John C. Liu, MD

A study in The Spine Journal recently looked at spinal manipulation and mobilization to manage chronic low back pain and its findings were met with mixed reactions. Orthopedics Today invited spine specialists to discuss the study and similar issues raised in a Forbes article published about the same time.

The use of intraoperative neuromonitoring during spine surgery is widely variable for different procedures, as well as in the parts of the United States in which it is used. Some spine surgeons use intraoperative neuromonitoring in all cases, even straightforward lumbar decompressions. Other surgeons only use it during high-risk deformity surgeries. In addition, some surgeons may not use it at all as they believe it is not predictive of injury and adds little to the safety of spine surgery.

According to the CDC National Center for Health Statistics, the number of outpatient surgery visits in the United States increased from 20.8 million in 1996 to 34.7 million in 2006. The types of surgery involved are primarily endoscopic general surgery, ophthalmology, gynecology and orthopedic surgery, among others. Despite an increase in overall spine surgeries during the same period, outpatient spine surgery represents a minority for most spine practices in the United States.

When the Charité artificial disc received FDA approval for clinical use in 2004, most spine surgeons thought lumbar artificial disc replacement was going to change spine surgery. They believed the issues of adjacent-level degeneration and reoperations would be issues of the past and this new, exciting technology offered the ability to maintain normal motion in the lumbar spine, which sounded natural and how things should be, instead of creating a rigid lumbar segment.

Spine surgery is a challenging profession. Even though our knowledge of the spine continues to increase with ongoing research, there remains a significant gap in our understanding of how the spine works. Correct diagnosis and meticulous execution of the surgical plan continues to be the hallmark of a successful surgery and satisfied patient. When that falls short, however, failed back surgery syndrome results.

Spine surgeons see chronic pain and opioid use on a regular basis. The number of patients who present already taking opioid pain medications for a variety of spine-related problems has increased rapidly in recent years. In my own practice, at least 50% of new consultations are patients who have been taking opioid pain medications for at least 3 months.

The National Transportation Safety Board recently announced that the crash of Asiana Airline flight 214 resulted from the crew being too reliant on the technology. In addition, the copilots were reluctant to question moreseasoned pilots.