Note: This list is not an endorsement of included hospitals or associated healthcare providers. The following content should be used for informational purposes only and is not intended to substitute professional medical advice. Hospitals cannot pay to be included on this list and are presented in alphabetical order.

Abbott Northwestern Hospital (Minneapolis). Every year, more than 2,000 major neurological surgeries and more than 1,000 neuro-interventional procedures occur at Abbott Northwestern's Neuroscience Institute, making it a leader in neurosurgery and spine care in the Twin Cities and Midwest. U.S. News & World Report ranked Abbott Northwestern 27th in the nation for neurological and neurosurgery care for 2012-13, and its Neuroscience Institute continues to grow, with more than a dozen neurosurgeons on its staff.

Abington (Pa.) Memorial Hospital. With four full-time neurosurgeons and a growing neurosciences center, Abington Memorial Hospital is carving out its neurosurgery niche just north of Philadelphia. Ranked by CareChex as a top spinal surgery hospital in 2013 and labeled as a Blue Distinction Center for Spine Surgery, Abington was also the first in its area to offer minimally invasive AxiaLIF surgery, in which neurosurgeons conduct lumbar fusions by approaching the spine alongside the tailbone. In 2012, the hospital also conducted its fourth annual Pursuit of Neurovascular Excellence program to educate physicians on strokes and other neurological disorders.

Advocate Good Samaritan Hospital (Downers Grove, Ill.). A Blue Distinction Center for Spine Surgery, the 326-bed Advocate Good Samaritan is also a high-performing neurosurgery hospital, according to U.S. News & World Report's 2012-13 rankings. Advocate Good Samaritan's spinal and neurosurgery team is comprised of three board-certified neurosurgeons and orthopedic surgeons, and its Level 1 trauma center provides comprehensive, specialized care for patients with complex spinal injuries.

Aurora St. Luke's Medical Center (Milwaukee). Aurora St. Luke's Medical Center is one of the highest-performing neurosurgery hospitals in the Milwaukee area, as defined by U.S. News & World Report. Aurora St. Luke's, a cornerstone of Aurora Health Care, is a recipient of HealthGrades' 2012 and 2013 Neurosurgery Excellence and Neuroscience Excellence Awards. The hospital's spine experts specialize in several conditions, including herniated discs, lumbar stenosis and spinal tumors.

Avera McKennan Hospital & University Health Center (Sioux Falls, S.D.). Within the Dakotas, Avera McKennan Hospital is among the best in neurosurgery, spine procedures and neuro-interventional procedures. The hospital, which includes the Acute Spine Center and the Avera Neuroscience Institute, performs more than 600 major neurological surgeries annually. HealthGrades named Avera McKennan Hospital as the best hospital in South Dakota for neurosurgery and treatment of stroke in 2013, and CareChex has bestowed similar high rankings for the hospital's major neurological surgeries.

Banner Good Samaritan Medical Center (Phoenix). According to CareChex's quality rankings for major neurological surgeries, few hospitals compare to Banner Good Samaritan Medical Center, which was rated third in the country in its most recent rankings. In addition, HealthGrades recognized the 668-bed hospital with Neurosurgery Excellence and Neuroscience Excellence Awards for two straight years. Banner Good Samaritan's Neuroscience Clinic opened in 2000 and is a certified center of excellence for ALS, better known as Lou Gehrig's disease, and for peripheral neuropathy.

Barnes-Jewish Hospital (St. Louis). The Barnes-Jewish Hospital Neuroscience Center of Excellence contains one the largest neuro-intensive care units in the country and has consistently been ranked among the elite neurosurgery programs in the nation. For 2012-13, U.S. News & World Report placed Barnes-Jewish ninth in the country in neurosurgery and neurology, as it is at the vanguard for both past and future neurological and spine breakthroughs. Washington University neurosurgeon Neill Wright, MD, developed translaminar fixation, a cervical spine surgery, at Barnes-Jewish Hospital in 2003.

Baylor University Medical Center (Dallas). Baylor University Medical Center and its Neuroscience Center are ranked among the best in Texas. Baylor, a Truven Health Analytics 100 Top Hospital in 2012, is ranked in the top 75 of all hospitals in the country for major neurological surgeries, according to CareChex's 2013 quality ratings. Baylor also has a Skull Base Center, one of the few places in the state that offers comprehensive treatments for complex conditions of the skull. Michael Heggeness, MD, PhD, a professor of orthopedic surgery at the Baylor College of Medicine, is the immediate past president of the North American Spine Society.

Baystate Medical Center (Springfield, Mass.). Five neurosurgeons lead Baystate Medical Center's Division of Neurosurgery, which is affiliated with the Tufts University School of Medicine and treats several different adult and pediatric neurosurgical diagnoses. This year, CareChex rated Baystate among the top 80 hospitals in the nation for major neurological surgery quality, and Baystate — a Blue Distinction Center for Spine Surgery — also received HealthGrades' 2013 Neurosciences and Neurosurgery Excellence Awards.

Beaumont Hospital (Royal Oak, Mich.). Beaumont Hospital's Neuroscience Center of Excellence, which covers a full array of some of the most advanced spine and neurosurgical procedures, is led by Fernando Diaz, MD, PhD, a renowned neurosurgeon who is considered to be a top physician in the Detroit area by both U.S. News & World Report and Detroit Magazine. Beaumont, ranked in the top 40 across the country for neurosurgery by U.S. News, offers a spine reconstruction program and also has a spine fracture clinic, which provides the latest minimally invasive spine surgeries for patients with traumatic spine fractures.

Beth Israel Deaconess Medical Center (Boston). Beth Israel Deaconess Medical Center's Division of Neurosurgery and Spine Center continue to be nationally ranked by Truven Health Analytics and Blue Cross Blue Shield. BIDMC neurosurgeons are internationally renowned for their studies and practice of deep brain stimulation. In addition, researchers from the hospital published a study in 2011 that found spine surgeons can save more than $126 million in surgery costs each year by implementing a simple intraoperative waste awareness program.

Bon Secours St. Francis Hospital (Charleston, S.C.). Bon Secours St. Francis Hospital, a 204-bed hospital within Roper St. Francis Healthcare and the Carolinas HealthCare System, provides some of the most acclaimed neurosurgical and spinal treatment in the area. The 18-bed Neuro-Spine Center at BSSF, which includes six full-time neurosurgeons, has been recognized as a Blue Distinction Center for Spine Surgery. In 2013, CareChex rated BSSF in the top 15 hospitals in the country for quality in both spinal surgery and spinal fusion procedures.

Brigham and Women's Hospital (Boston). Neurosurgery and spine procedures continue to be a forte for Brigham and Women's Hospital, once home to Harvey Cushing, MD, whom many consider to be the father of neurosurgery. The hospital, ranked 20th in the country by U.S. News & World Report for neurosurgery, has a multidisciplinary staff of 13 clinical faculty and more than 100 other department members. In 2009, Brigham and Women's neurosurgery department performed more than 2,600 procedures. The program operates with a research budget of roughly $10 million per year.

Brookwood Medical Center (Birmingham, Ala.). In CareChex's 2013 quality rankings, Brookwood Medical Center ranked among the top 40 hospitals in the country for spinal fusion and among the top 150 for spinal surgery. Blue Cross Blue Shield also named Brookwood a Blue Distinction Center for Spine Surgery. Several of the area's leading neurosurgery physician practices, such as Birmingham Neurosurgery & Spine Group and Norwood Clinic, include physicians who are active staff members at Brookwood.

Cape Fear Valley Medical Center (Fayetteville, N.C.). Four full-time neurosurgeons staff the Cape Fear Valley Medical Center neurosurgery and neuroscience department. Cape Fear neurosurgeons offer some of the most expansive treatments in the Fayetteville area for brain tumors, aneurysms, spine trauma, complex spine disorders, neurosurgical pain management, movement disorders and epilepsy, among others. CareChex ranked Cape Fear as a top 50 hospital for major neurological surgeries this year.

Carle Foundation Hospital (Urbana, Ill.). Carle Foundation Hospital has built its neurosurgery and neurosciences program to become a leader within Illinois. For the past two years, the 345-bed hospital has received the Neurosurgery Excellence and Neurosciences Excellence Awards from HealthGrades, and CareChex also rated Carle within the top 70 hospitals in the country for major neurological surgery quality. Carle's board-certified neurosurgeons provide care within many areas, and they also collaborate with the Carle Spine Institute, which is a new 17,000-square-foot regional center of excellence managed by spine surgeons and physical medicine physicians.

Centra Lynchburg (Va.) General Hospital. The 358-bed Centra Lynchburg General Hospital is the flagship of Centra Health, and it was one of the first hospitals in Virginia to receive The Joint Commission's national certificate of distinction for primary stroke centers. Centra Lynchburg is one of the top 80 hospitals in the country for spinal surgery quality, according to CareChex's 2013 rankings, and hospital neurosurgeons perform roughly 450 neurosurgery procedures annually. U.S. News & World Report also rated Centra Lynchburg has a high-performing neurosurgical institute for 2012-13.

Cedars-Sinai Medical Center (Los Angeles). Keith L. Black, MD, continues to head the Cedars-Sinai Department of Neurosurgery, which offers a wide array of services, including treatment of spinal cord dysraphia, spinal deformities and oligodendroglioma tumors. Dr. Black has published more than 260 peer-reviewed articles and is a founding member of the North American Skull Base Society. Michael J. Alexander, MD, professor and vice-chairman of the Department of Neurosurgery, also is the current president of the Society of NeuroInterventional Surgery. For 2012-13, U.S. News & World Report ranked Cedars-Sinai 19th in the country for neurosurgery.

Cleveland Clinic. The multidisciplinary Cleveland Clinic Neurological Institute treats and researches some of the most complex neurological disorders and has advanced innovative neurosurgeries, such as epilepsy surgery, stereotactic spine radiosurgery and interstitial thermal therapy for brain tumors. U.S. News & World Report pegged Cleveland Clinic fifth in the country for neurosurgery in its 2012-13 rankings, and the hospital has consistently remained in the top 50 hospitals for neurosurgery over the past decade. Peter Rasmussen, MD, who is the director of Cleveland Clinic's Cerebrovascular Center, also is the vice president of the Society of NeuroInterventional Surgery.

Dartmouth-Hitchcock Medical Center (Lebanon, N.H.). Dartmouth-Hitchcock Medical Center, the only academic medical center in New Hampshire, received HealthGrades' Neurosurgery Excellence and Neurosciences Excellence Awards each of the past two years, citing superior outcomes in stroke, neurosurgery, spinal cord and other conditions that affect the nervous system. Dartmouth-Hitchcock's spine center was also part of the five-year Spine Patient Outcomes Research Trial, or SPORT, funded by the National Institutes of Health. SPORT looked at the most common back conditions and compared surgical and non-operative treatments.

Delray Medical Center (Delray Beach, Fla.). The 493-bed Delray Medical Center has become one of the top neurosurgical and spine providers in Palm Beach County. This year, HealthGrades recognized Delray with several awards, including Neurosciences, Neurosurgery and Stroke Excellence Awards. The hospital is five-star rated in neurosciences and is among the top 10 percent of hospitals in Florida for neurosurgery and spine procedures. Altogether, Delray offers several different services in its Advanced Neuroscience Center, including spine surgery and neurotrauma.

Dublin (Ohio) Methodist Hospital. Dublin Methodist Hospital is a 92-bed community hospital with robust neurosurgery services that break the mold for an organization its size. Dublin Methodist pools its resources with parent organization OhioHealth, which will be opening a 224-room Neuroscience Institute in two years. Neurosurgeons, spine surgeons and brain tumor specialists highlight Dublin Methodist's program, which is a Blue Distinction Center for Spinal Surgery.

Duke University Hospital (Durham, N.C.). The Division of Neurosurgery at Duke University Hospital — a Blue Distinction Center for Spinal Surgery and a top 50 hospital in both adult and pediatric neurosurgery, according to U.S. News & World Report — has 13 active staff neurosurgeons. Duke has several special clinical neurosurgery programs and has performed some of the most extensive studies in the country on brain and spinal cancers. Duke's Brain Tumor Center is one of the largest such centers in the field, and in 2012, the center received a $2.5 million private fund to research glioblastoma, the most common type of malignant brain tumor.

Edward Hospital (Naperville, Ill.). Edward Hospital's Neurosciences Institute features several independent neurosurgeons, spine surgeons and orthopedic surgeons who treat a wide range of conditions. Edward, a Blue Distinction Center for Spinal Surgery, offers advanced spinal fusions using low-profile plating systems for anterior cervical surgery, and in some instances, Edward physicians offer same-day microdiskectomies. The Neurosciences Institute also partners with the Chicago-based Northwestern Medical Faculty Foundation, the multi-specialty physician group affiliated with Northwestern University's medical school.

Emory University Hospital (Atlanta). More than two dozen neurosurgeons make up Emory's Department of Neurosurgery, and each neurosurgeon also has an additional area of interest, expertise or training. The 591-bed Emory University Hospital is ranked 26th in the country for neurosurgery services, according to U.S. News & World Report, and CareChex also ranked Emory 31st in the nation for spinal surgery quality. Emory offers brain tumor trials through the Winship Cancer Institute, the first medical facility in Georgia to earn National Cancer Institute Cancer Center designation.

Evanston (Ill.) Hospital. Evanston Hospital and NorthShore University HealthSystem's Neurological Institute has more than 50 physicians on staff, and it recently made headlines when its researchers unveiled a new study about identifying chronic traumatic encephalopathy — a neurological degenerative disease associated with suffering multiple concussions and other head injuries — in living patients. U.S. News & World Report ranked Evanston Hospital as a high-performing hospital in its neurosurgery and neurology adult specialty category, and in 2012, HealthGrades awarded the hospital a Neurosciences Excellence Award.

Exempla Saint Joseph Hospital (Denver). The 376-bed Exempla Saint Joseph Hospital, part of Sisters of Charity of Leavenworth Health System, has been rated as one of the top spine hospitals this year by numerous ranking agencies. CareChex rated the hospital highly for its spinal surgery quality, and HealthGrades gave Exempla Saint Joseph its Spine Surgery Excellence Award while also naming it one of the top specialty spine care hospitals in America. Exempla Denver Neurologic + Spine Associates works exclusively with the hospital, and the group's physicians provide care for spine conditions, tumors and cerebrovascular diseases.

Florida Hospital (Orlando). Florida Hospital, consistently ranked by U.S. News & World Report as a top hospital within the Orlando metropolitan area, treats more neuroscience patients than any other hospital in the country. The Florida Hospital Neuroscience Institute was created in 1998 and is home to several complex neurological surgeries and research on numerous movement disorders. Florida Hospital neurosurgeons perform more than 1,500 complex spine surgeries annually, and Orlando magazine also recognized several Florida Hospital neurosurgeons as some of the highest-rated in the area by their local peers.

Geisinger Medical Center (Danville, Pa.). Geisinger Medical Center — one of only 15 major teaching hospitals to make Truven Health Analytics' 100 Top Hospitals List in 2012 — has an award-winning neurosciences institute. GMC houses two of the three fellowship-trained neurosurgical oncologists in Pennsylvania, and its Brain & Spine Tumor Institute has made several advances in neuro-oncology, with a team led by Steven Toms, MD, and Michel LaCroix, MD.

Greater Baltimore Medical Center (Towson, Md.). Rated among the top 50 hospitals in the United States for spinal fusion and spinal surgery quality, Greater Baltimore Medical Center's Department of Neurosurgery has become a staple in Maryland. Fourteen neurosurgeons comprise the hospital's specialty neurosurgery group, Greater Baltimore Neurosurgical Associates. GBMC's primary areas of excellence include lumbar spine surgery, cervical spine surgery, craniotomies for tumors and aneurysms and minimally invasive surgeries around the pituitary and skull base.

Gundersen Lutheran Medical Center (La Crosse, Wis.). In CareChex's 2013 quality rankings, Gundersen Lutheran Medical Center was considered to be among the top 75 hospitals in the country for major neurological surgery and among the top 150 hospitals for spinal surgery. HealthGrades also gave the hospital a Neurosciences Excellence Award in 2012. Gundersen Lutheran neurosurgeons offer several modern spine surgeries, such as disc arthroplasty and stereotactic radiosurgery, and the hospital's neurosciences center also focuses on treating debilitating back pain and deep brain stimulation for Parkinson's disease.

Hackensack (N.J.) University Medical Center. Hackensack University Medical Center has become one of the nation's top hospitals over the past decade, especially within the field of neurosurgery. For two straight years, the academic medical center has received the Neurosciences Excellence and Neurosurgery Excellence Awards from HealthGrades, and U.S. News & World Report ranked HackensackUMC 39th in the nation for adult neurosurgery and 25th for pediatric neurosurgery. Arno Fried, MD, who started his own advanced neurosurgery practice within the hospital, serves as chairman of HackensackUMC's Department of Neurosurgery and director of Pediatric Neurosurgery.

Harper University Hospital (Detroit). One of the oldest tertiary hospitals in the country, Harper University Hospital — part of Vanguard Health Systems' Detroit Medical Center — offers the most neurosurgical options of any hospital in Michigan, according to its website. It is a teaching hospital for the Wayne State University School of Medicine and has six full-time neurosurgeons, as well as neurosurgical fellows and residents. In U.S. News & World Report's 2012-13 hospital rankings, Harper University Hospital placed 34th in the country.

Henry Ford Hospital (Detroit). Henry Ford Hospital, a 2012 recipient of HealthGrades' Neurosciences Excellence Award, is a national leader in spine and neurosurgical care. It was the first hospital in Michigan to provide minimally invasive spine surgery and the first hospital in the United States to provide radiosurgery for spine cancer. Henry Ford Hospital also has committed more than $178 million in neurosurgical research studies, and its neuroscience institute has tallied more than 550,000 patient visits over the past 16 years.

Hospital for Special Surgery (New York City). The Hospital for Special Surgery is best known for its orthopedic program, which U.S. News & World Report ranked first out of all hospitals in the country yet again in 2012-13. However, U.S. News also ranked HSS's neurosurgery and spine care as 10th best in the country, up from last year's position of 19th. CareChex rated HSS as the fourth-best hospital in the country for spinal fusion quality. HSS's Spine Care Institute has 16 neurosurgeons who treat an array of conditions and disorders, including several spine fractures and ankylosing spondylitis.

Hospital of the University of Pennsylvania (Philadelphia). Neurosurgeons at Penn Medicine perform more than 5,000 operations annually, a majority of which are performed at Hospital of the University of Pennsylvania. U.S. News & World Report ranked the Magnet-designated hospital 21st in the country for neurosurgery, and HUP's 13 clinical neurosurgeons on staff have been a major force in its successes. Neurosurgery was originally established in the hospital in 1936 under the Department of Surgery, and today, Penn Neurosurgery receives more than $3 million in research funds — a majority of which is from the National Institutes of Health — to study brain, spine and nervous system diseases.

Indiana University Health Methodist Hospital (Indianapolis). IU Health Methodist Hospital, the flagship of IU Health, has a neurosurgery and neurology program for both adult and pediatric specialties that is ranked among the top 25 in the country by U.S. News & World Report for 2012-13. IU Health's Neuroscience Center is the crown jewel of the system, and a recent $27 million renovation at IU Health Methodist expanded six neurosurgical suites and added two more. The Magnet-designated hospital also has cutting-edge technologies — IU Health Methodist was the first hospital in Indiana to use an intraoperative MRI scanner and the NICO Myriad device, which is used to remove brain and spine tumors in hard-to-reach areas.

Johns Hopkins Hospital (Baltimore). Johns Hopkins Hospital, considered one of the top hospitals in the country, is a leader in numerous specialties, including neurosurgery and spine. For 2012-13, U.S. News & World Report ranked Johns Hopkins first in the country for comprehensive neurosurgery treatment. Johns Hopkins was the first hospital to pioneer a neurological critical care unit, and its physicians perform some of the newest and most complex neurosurgical procedures. Ben Carson, MD — the director of Johns Hopkins' Division of Pediatric Neurosurgery and a Presidential Medal of Freedom recipient — is internationally known as the first surgeon to separate conjoined twins, who were joined at the back of the head.

Kansas Spine Hospital (Wichita). The 38-bed Kansas Spine Hospital is a physician-owned hospital and has nine physician owners, all of whom are neurosurgeons, orthopedic surgeons or anesthesiologists. Physicians at Kansas Spine perform spinal surgeries, orthopedic surgeries and pain management procedures. In its 2013 rankings, CareChex ranked Kansas Spine third and fourth for spinal fusion and spinal surgery quality, respectively.

Keck Hospital of USC (Los Angeles). Keck Hospital of USC, the 411-bed teaching hospital of the University of Southern California's Keck School of Medicine, is nationally ranked in three specialties by U.S. News & World Report, one of them being neurosurgery. The hospital offers several unique, comprehensive neurosurgery centers of excellence, including the Brain & Spine Tumor Center, the Brain Aneurysm Center and the USC Neurosurgical Back and Spine Center, which features spine surgeons specializing in six procedures.

Lovelace Medical Center (Albuquerque, N.M.). Lovelace Medical Center, the flagship facility of Lovelace Health System, has 263 licensed beds and recorded almost 11,000 surgical cases in 2011, many of which were neurosurgery-related. This year, CareChex highlighted Lovelace as a top hospital for quality in both spinal fusions and spinal surgeries. In 2011, Lovelace received HealthGrades' Spine Surgery Excellence Award, which recognized the hospital for low spine surgery complication rates and proficiency in treating spinal stenosis and performing other back and neurosurgical procedures.

Massachusetts General Hospital (Boston). The 907-bed, Boston-based stalwart is the third-oldest general hospital in the United States, and Massachusetts General Hospital's Department of Neurosurgery utilizes almost 10 percent of the hospital's beds. MGH records roughly 2,300 neurosurgery admissions every year, with an average daily census of 42 inpatients. Like its sister facility, Brigham and Women's Hospital, both of which are part of Partners HealthCare, MGH has tallied many medical firsts in the field of neurosurgery and spine. William Mixter, MD, was MGH's first chief of neurosurgery in 1933, and he was a pioneer of minimally invasive neurosurgery. Also, the first discectomy for a herniated intervertebral disc and the first successful stabilization of atlantoaxial instability of the cervical spine were performed at MGH.

Mayo Clinic (Rochester, Minn.). Ranked second in the country for neurosurgery in 2012-13 by U.S. News & World Report is Mayo Clinic. Mayo has more than 20 neurosurgeons who perform more than 3,500 neurosurgical procedures every year — including Gamma Knife-based surgeries, complex spinal reconstruction and spinal tumor surgeries. In addition to several awards for neurosurgical and spine excellence, Mayo Clinic conducts cutting-edge treatment and research for many brain, nerve and spinal clinical trials. In 2012, Mayo researchers found a new way to monitor real-time chemical changes in the brains of patients undergoing deep brain stimulation.

Memorial Hermann Memorial City Medical Center (Houston). Part of Houston's renowned Memorial Hermann Health System, the Memorial City facility has 426 licensed beds and an award-winning neurosurgical department. The hospital has received Neuroscience Excellence and Neurosurgery Excellence Awards each of the past two years from HealthGrades, and CareChex named Memorial Hermann a top-10 hospital for major neurological surgery quality. The hospital offers an array of services, such as brain and spine cancer care from specialized neuro-oncologists. Memorial Hermann is also affiliated with Mischer Neurosurgical Associates, a physician practice that offers comprehensive spine treatment.

Mercy Regional Medical Center (Lorain, Ohio). The 328-bed Mercy Regional Medical Center, part of Cincinnati-based Catholic Health Partners, has been a regional leader in spine and neurological surgeries for the past several years. In 2012 and 2013, the hospital earned HealthGrades' Spine Surgery Excellence Award, and HealthGrades named Mercy Regional as one of the 100 best spine surgery hospitals in the United States. CareChex has also recognized Mercy Regional, which has a neurological and orthopedic center of excellence, for its spinal surgery quality.

The Methodist Hospital (Houston). Methodist Hospital, ranked as the top hospital in Texas and 17th in the country for neurosurgery by U.S. News & World Report for 2012-13, has a leading Neurological Institute that was founded in 2004, but its history stretches much further. Physicians at the 1,119-bed Methodist performed the country's first spinal instrumentation surgery and first removal of a spinal cord tumor in the early 1960s. In November 2012, Methodist Neurological Institute Director Stanley Appel, MD, and a team of researchers received a Moran Foundation Award for showing how T lymphocytes could slow down ALS, or Lou Gehrig's disease.

Mission Hospital (Asheville, N.C.). Mission Hospital is considered a national leader in spine procedures, as evidenced by its three Spine Surgery Excellence Awards from HealthGrades and high neurosurgery rankings from CareChex. Mission's Neurosciences Institute encompasses its Spine Center, which performs more than 2,500 spine procedures every year. In October 2012, the hospital's parent organization, Mission Health, announced a partnership with Carolina Spine and Neurosurgery Center, which expanded the system's neurosurgical prowess into western North Carolina.

Mount Sinai Hospital (New York City). U.S. News & World Report ranked New York's Mount Sinai Hospital 15th in the country for neurosurgery services in its most recent listing, and Mount Sinai continues to hold its place on the cutting edge in the field. In October 2012, Mount Sinai's Department of Neurosurgery became the first neurosurgery department in the United States to use a virtual reality simulator to help train, assess and prepare neurosurgery residents for surgery. The Department of Neurosurgery was established in 1914 and has built several renowned programs and centers, including the Mount Sinai Brain Tumor Program, the Mount Sinai Clinical Center for Cranial Base Surgery and the Center for Spinal Disorders.

Munson Medical Center (Traverse City, Mich.). Munson Medical Center is a nationally recognized hospital with 391 beds that has offered neurosurgery services since 1962. Munson's four neurosurgeons treat brain and skull base tumors, and perform numerous types of spinal surgeries, including those for spine fractures and degenerative disks, and kyphoplasty. Munson also has some of the highest satisfaction rates among neurosurgery patients, who have consistently rated the hospital's services in the high 90th percentile. This year, U.S. News & World Report rated Munson as a high-performing neurosurgery hospital, and CareChex ranked the hospital 56th in the country for spinal surgery quality.

Naples Community Hospital (Naples, Fla.). Naples Community Hospital, a member of the Mayo Clinic Care Network, was recognized as the best hospital in its region by U.S. News & World Report in its 2012-13 rankings, and it has received five-star ratings from HealthGrades for the past eight years. CareChex ranked its neurosurgery program 58th in the country and its spinal surgery program as 65th best in the nation.

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The Nebraska Medical Center (Omaha). The Nebraska Medical Center has 627 acute-care beds and is the largest healthcare facility in the state. The academic medical center also includes an award-winning neurosurgery program that features six staffed neurosurgeons and specializations in neuro stimulation, trigeminal neuralgia and more. Nebraska Medical Center's Spine Center treats more than a dozen common conditions and also covers some of the most complex spinal disorders within the Nebraska, Iowa, South Dakota and Missouri region.

NewYork-Presbyterian Hospital (New York City). When former Secretary of State Hillary Clinton was treated for a blood clot that formed after a fall-induced concussion, she was admitted to NewYork-Presbyterian Hospital and treated by its neuro physicians. U.S. News & World Report ranked NewYork-Presbyterian's neurosurgery program as one of the top five in the nation this year. NewYork-Presbyterian neurological surgeon Philip M. Meyers, MD, is the president-elect of the Society of NeuroInterventional Surgery.

North Shore University Hospital (Manhasset, N.Y.). The Cushing Neuroscience Institute of North Shore-Long Island Jewish Health System hosts a 16-bed neurosurgical ICU. North Shore's neurosurgery department averages 30 endoscopic pituitary and skull base surgeries each year. The neurosurgery program was rated as one of the nation's top 50 by U.S. News & World Report in its 2012-13 rankings.

Northwestern Memorial Hospital (Chicago). Northwestern University's Feinberg School of Medicine's neurosurgery department was rated the highest in Illinois and number 11 nationwide by U.S. News & World Report. Its functional neurosurgery program at Northwestern Memorial Hospital treats movement disorders, epilepsy, degenerative conditions, neurological injuries and psychiatric disorders. Northwestern Memorial also includes highly regarded programs for spinal injury, deformity and neuro-oncology.

Novant Health Forsyth Medical Center (Winston-Salem, N.C.). Forsyth Medical Center's Stroke & Neurosciences Institute specializes in back and spine care, and this year, the 921-bed hospital received accolades for its neurosurgical procedures. CareChex ranked Forsyth, which is part of Novant Health, among the top 50 hospitals in the nation in both spinal surgery and spinal fusion quality. Donald V. Heck, MD, a physician at Forsyth, is the treasurer of the Society of NeuroInterventional Surgery.

Ochsner Medical Center (New Orleans). Ochsner Medical Center employs four full-time neurosurgeons who, along with affiliated neurosurgeons, perform upward of 1,000 surgeries annually. The department specializes in both adult and pediatric neurosurgery, as well as surgical programs for spinal trauma and deformity. Ochsner ranked 15th in the country for its neurosurgery quality, according to CareChex, and among the top 50 hospitals in the country for the specialty by U.S. News & World Report in its most recent rankings.

The Ohio State University Wexner Medical Center (Columbus). The Comprehensive Spine Center at the Ohio State University Wexner Medical Center, which is considered to be a high-performing neurosurgery hospital and the best within the Columbus, Ohio, region, treats spinal conditions spanning from the cervical to lumbar spine, and needs ranging from pain management to spinal surgery and rehabilitation. OSU Wexner's Cranial Base center excels in minimally invasive endoscopic-endonasal approach procedures.

Owensboro (Ky.) Medical Health System Hospital. Owensboro Medical Health System features a 30-bed neuroscience unit that features advanced diagnostic and minimally invasive technology, including intra-operative ultrasound, balloon kyphoplasty and image-guided neurosurgery. CareChex ranked Owensboro 40th for neurosurgery and within the top 200 hospitals for spinal surgery in the country. HealthGrades recognized Owensboro for its neurosurgery and stroke care excellence through its partnership with the University of Louisville Medical Center.

Penn State Milton S. Hershey Medical Center (Hershey, Pa.). Milton S. Hershey Medical Center's Spine Center is home to the orthopedic spine surgeon who performed neck surgery on Denver Broncos quarterback Peyton Manning in 2011. Seven of the hospital's neurosurgeons were named "Best Doctors in America," and CareChex ranked both the hospital's spinal and neurological surgery programs within the top 200 nationwide in its most recent rankings.

Providence St. Vincent Medical Center (Portland, Ore.). Providence St. Vincent Medical Center's Brain and Spine Institute is home to one of only 20 intraoperative MRI suites worldwide, which allow MRI equipment to be moved to the patient multiple times during surgery without sending the patient into a traditional MRI machine. The institute offers telestroke services to 19 hospitals in Oregon and Washington and is engaged in clinical research to treat neurological and spinal conditions, including multiple sclerosis, Alzheimer's disease and ALS. CareChex ranked its spinal surgery program 30th in the country.

Ronald Reagan UCLA Medical Center (Los Angeles). U.S. News & World Report has listed Ronald Reagan UCLA Medical Center among the top 10 neurosurgery programs in the nation for 20 consecutive years, with subspecialties including brain and pituitary tumors, traumatic brain injury, stroke and movement disorders. Its neuroscience and stroke unit hosts 26 beds and 11 additional acute, inpatient rehabilitation beds. Ronald Reagan UCLA's spinal surgery program was also rated 108th by CareChex.

Rush University Medical Center (Chicago). Named the 25th best neurosurgery program in the U.S. by CareChex and number 17 by U.S. News & World Report, Rush University Medical Center evaluates more people with memory and cognitive problems, such as Alzheimer's disease, annually than any other federally funded research institution. Its host of neurosurgical subspecialties includes neuro-ophthalmology, deep brain stimulation to treat symptoms such as Parkinson's tremors and minimally invasive treatments for carotid artery disease. Rush's Spine and Back Center is one of the nation's leaders in degenerative disease treatment and spinal cord trauma and infection surgery.   

Scottsdale (Ariz.) Healthcare Shea Medical Center. CareChex ranked Scottsdale Healthcare Shea Medical Center 51st in spinal surgery this year, and its sister facility, Osborn Medical Center, was rated among the top 60 for neurosurgery quality. The health system conducts neurologic research related to new surgical, drug and device treatments for skull, spine, brain and nervous system disorders. Several of the department's neurosurgeons were trained by Barrow Neurosurgical Associates, which is part of the award-winning Barrow Neurological Institute at St. Joseph's Hospital and Medical Center in Phoenix.

Scripps Green Hospital (La Jolla, Calif.). Scripps Green Hospital's spinal surgery program features advanced techniques such as kyphoplasty, laminectomy and spinal fusion. CareChex recognizes Scripps Green Hospital's spinal program as one of the top 100 in the nation. The hospital also offers neurosurgical procedures including gamma knife treatments for brain tumors, hydrocephalus treatments, vagus nerve stimulators for epileptic patients and pallidotomies for Parkinson's-related tremors.

Shands at the University of Florida (Gainesville). The neurosurgery department of Shands at the University of Florida features four labs for stereotactic radiosurgery, surgical research and training, neural stem cell treatments and epilepsy neurophysiology. UF&Shands is considered a center of excellence in the treatment of Parkinson's and other neurologic movement disorders, and U.S. News & World Report ranked the hospital 37th in the nation for adult neurosurgery and 49th for pediatric neurosurgery.

St. Alexius Medical Center (Bismarck, N.D.). The Neurosurgery and Spine Center at St. Alexius features three neurosurgeons specializing in spine, cranial and peripheral nerve surgical treatments for issues like trauma, tumors and degenerative diseases. Both its neurosurgery and spinal surgery programs fell within the top 150 nationwide by CareChex, ranked 33rd and 142nd, respectively.

St. David's Medical Center (Austin, Texas). The NeuroTexas Institute at St. David's HealthCare offers award-winning minimally invasive procedures to treat conditions ranging from spinal stenosis to cerebral aneurysms. The professional home to seven neurosurgeons, HealthGrades awarded the institute five stars for neurosurgery and stroke treatment for the past two years, placing it in the top 5 percent of such programs nationwide and third-best in Texas for neurosurgery. CareChex also ranked St. David's in the top 200 spinal surgery programs.

St. Elizabeth Edgewood (Ky.). A member of St. Elizabeth Healthcare system, St. Elizabeth Edgewood offers neuro-oncology and spinal surgery centers. It specializes in metastatic cancers of the brain, spinal cord and nervous system, and treats complications arising from such cancers such as hydrocephalus, thromboembolism and paraneoplastic syndromes. Its spine center boasts three neurosurgeons and offers services along the spine care continuum, from radiology and pain management to orthopedic surgery.

St. Francis Hospital (Roslyn, N.Y.). Ranked 36th in the nation by U.S. News & World Report, the neurosurgery department contained within St. Francis Hospital is at the forefront of neurosurgical practice and innovation. Led by Chief of Neurosurgery Richard Johnson, MD, the department performs minimally invasive spinal surgery to treat infection, injury and degenerative conditions of the spine and nervous system.

St. Joseph's Hospital and Medical Center (Phoenix). The Barrow Neurological Institute at St. Joseph's Hospital and Medical Center clocks in at 13th in the nation for neurosurgery programs, according to U.S. News & World Report. The institute says its residency program in neurosurgery is the largest and most sought-after in the world. Its wide pallet of neurosurgical and spine treatments spans the full spectrum of disorders and ailments from skull to spine to neuroimmunological maladies.

St. Luke's Episcopal Hospital (Houston). St. Luke's Episcopal Hospital hosts a 42-bed neurological acute-care unit and 20-bed neurological intensive care unit in its NeuroScience Center, ranked 35th in the nation by U.S. News & World Report. The hospital's Neurovascular Center combines specialists from multiple specialties to design and coordinate treatment for a range of neurovascular disorders.

St. Luke's Hospital (New Bedford, Mass.). St. Luke Hospital's Brain & Spine Center treats neurological and spinal conditions ranging from headaches and carpal tunnel syndrome, to peripheral neuropathy and vertebral compression fractures. St. Luke's falls under the umbrella of the Southcoast Hospital Group, whose neurosurgery program was ranked 86th in the country by CareChex.

St. Vincent Healthcare (Billings, Mont.). St. Vincent Healthcare, part of the Sisters of Charity of Leavenworth Health System, offers comprehensive cerebral and cervical neurosurgery procedures. The hospital also offers full stroke services. CareChex ranked St. Vincent's neurosurgery program 53rd and also placed the hospital within the top 150 for spinal surgery.

St. Vincent Indianapolis Hospital. St. Vincent Indianapolis Hospital's Neuroscience Unit has dedicated neurosurgical operating rooms and intensive care units. The Spine Center, ranked number one in Indiana by HealthGrades for spinal surgery, performed the world's first artificial lumbar disc replacement and the country's first artificial cervical disc replacement. U.S. News and World Report ranked its neurosurgery program 44th in the nation in its most recent rankings.

St. Vincent Infirmary Medical Center (Little Rock, Ark.). The Arkansas Neuroscience Institute at St. Vincent Infirmary Medical Center is directed by neurosurgeon Ali Krisht, MD, who is the chief editor of medical journal Contemporary Neurosurgery. He is highly specialized in vascular microsurgical procedures and the acute treatment of strokes. St. Vincent holds the number eight spot for best spinal surgery program and the 24th spot for neurosurgery quality from CareChex.

Stanford Hospital and Clinics (Palo Alto, Calif.). The Stanford Brain Tumor Center touts the latest chemotherapy and immunotherapy protocols and a premier radiosurgery program. Stanford is the original site where John Adler, MD, developed the CyberKnife and where it was first used on a patient in 1994. To date, the center has treated 5,500 patients via CyberKnife. U.S. News & World Report recognized Stanford's neurosurgery program as 31st in the nation.

Tampa (Fla.) General Hospital. Tampa General Hospital's neurosurgery department is home to a Level 4 epilepsy center. Additionally, its spine surgeons perform minimally invasive treatments for vertebrae fractures and spinal disorders, such as percutaneous vertebroplasty. Tampa General's neurosurgical department ranks 47th in the country, according to U.S. News & World Report's most recent rankings.

Texas Health Presbyterian Hospital Dallas. Texas Health Presbyterian Hospital Dallas, the flagship facility of Texas Health Resources, offers Joint Commission-accredited stroke care, Gamma Knife radiosurgery, specialized spine care and intraoperational MRI imaging. CareChex ranks Texas Health Presbyterian's neurosurgery program 18th in the country and placed the hospital within the top 200 for spinal surgery.

Thomas Jefferson University Hospital (Philadelphia). The Regional Spinal Cord Injury Center of the Delaware Valley, a collaboration between Thomas Jefferson University Hospital and Magee Rehabilitation Hospital, is listed as one of 14 Model Spinal Cord Injury Centers by the National Institute on Disability and Rehabilitation Research, with a far-below-average mortality rate of 5 percent for acute spinal trauma patients. Independence Blue Cross recognized the hospital for spine surgery excellence. The Jefferson Hospital for Neuroscience was also designated by U.S. News & World Report as a high-performing program and boasts some of the highest neurological patient volumes in the Philadelphia region.

UCSF Medical Center. The highest-volume brain tumor program in the country belongs to UCSF Medical Center. Its adult neurosurgery program is sixth in the country, according to U.S. News and World Report, and its pediatric neurosurgery program was ranked 36th. Approximately 1,000 clinical trials in neurological and neurosurgical research are currently under way at the hospital.

University Hospitals Case Medical Center (Cleveland). The Case Medical Center features 15 centers of excellence under its neurosciences umbrella. Surgeons of the Spinal Neurosurgery Center at UH Neurological Institute treat spinal conditions ranging from arthritis to spinal stenosis, and its Neurocritical Care Center treats patients in its Reinberger Neuroscience Intensive Care Unit with innovative treatments, such as induced hypothermia to help protect brain cells from dying.

University of California San Diego Medical Center. Across its affiliated hospitals, the University of California San Diego includes 31 neurosurgeons, some of them residents-in-training. The hospital's subspecialties include brain aneurysm, peripheral nerve, trigeminal neuralgia and pediatric neurosurgery. CareChex ranked UC San Diego's neurosurgery program 67th in the country this year, as well.

University of Chicago Medical Center. The Section of Neurosurgery at the University of Chicago is ranked 37th in the country, according to the 2012-13 rankings from U.S. News & World Report. University of Chicago is home to 11 neurosurgeons with subspecialties in neuro-oncology, craniofacial and congenital anomalies, and pediatric neurosurgery. Eight physicians are dedicated to University of Chicago's neurovascular surgery team alone.

University of Kansas Hospital (Lawrence). The University of Kansas Hospital's Center for Advanced Brain & Neurological Care is a Level 4 epilepsy center and home to the neurosurgery program U.S. News & World Report's ranked 22nd in the country this year. Neurosurgical subspecialties at University of Kansas Hospital include pediatric neurosurgery, neuro-oncology and a host of spinal surgery treatments performed at the hospital's Marc A. Asher, MD, Comprehensive Spine Center.

University of Kentucky Albert B. Chandler Hospital (Lexington). The Kentucky Neuroscience Institute, part of the UK HealthCare network, brings together leading neurosurgeons to deliver neuro-oncological and stroke care to the region. UK Chandler Hospital's UK Gamma Knife Center is the only facility in the state to offer the surgical procedure. U.S. News & World Report also recognized UK as a regional leader for neurosurgery in its 2012-13 rankings.

University of Iowa Hospitals and Clinics (Iowa City). Ranked 24th in the country for both adult and pediatric neurosurgery, University of Iowa Hospital and Clinics' Department of Neurosurgery was also designated best in the state by U.S. News & World Report this year. The UI Department of Neurosurgery treats spinal trauma, peripheral nerve conditions and degenerative conditions of the spine and nervous system.

University of Maryland Medical Center (Baltimore). The Department of Neurosurgery at the University of Maryland School of Medicine offers specialized treatments, including thrombolytic therapy, experimental chemotherapy, intrathecal baclofen pump treatment for spasticity and various spine surgery procedures. Physicians within the hospital's neurosurgery program perform more than 1,600 adult and pediatric surgeries each year and provide expert neurotrauma care at its Shock Trauma Center. U.S. News & World Report ranked the University of Maryland Medical Center 48th nationwide for neurosurgery excellence in 2012-13.

University of Michigan Medical Center (Ann Arbor). Neurosurgeons at the University of Michigan Medical Center are actively engaged in research dealing with gene therapies, brain conditioning to lessen brain injury and innovative neuro-oncology studies to better understand, treat and prevent cancer of the nervous system. As part of a program called Project Shunt, department members have traveled to Guatemala to perform neurosurgical treatments for neural tube defects each year since 1997. U.S. News & World Report ranked the adult neurosurgery program 30th in the country and 21st in pediatric neurosurgery this past year.

University of Minnesota Medical Center, Fairview (Minneapolis). The University of Minnesota Medical Center's Department of Neurosurgery provides neurological care at its hospitals throughout the Twin Cities region and through its clinical practice, UM Physicians Neurosurgery. A leading research institution, the academic medical center is currently studying possibilities in deep brain stimulation and radiosurgery. U.S. News & World Report ranked the program 25th best in the nation for neurosurgery in its 2012-13 rankings.

University of Pittsburgh Medical Center. The University of Pittsburgh Medical Center's neurosciences department includes 10 clinical divisions, including cognitive disorders and women's neurology. UPMC is host to several neurological institutes, including the Alzheimer's Disease Research Center, UPMC Stroke Institute and others devoted to Parkinson's, ALS and complex spine and neurosurgical conditions. U.S. News & World Report ranked the program seventh-best in the nation for 2012-13.

University of Rochester (N.Y.) Medical Center. The neurosurgery residency program at the University of Rochester Medical Center ranks among the top 10 when it comes to National Institutes of Health funding. A team of physicians make up the Integrated Spine Care comprehensive program offered at URMC, and they perform procedures such as cervical laminectomy and all kinds of thoracic spine surgeries, with an emphasis on minimally invasive surgery. The system clocks in at 46th for adult neurosurgery and 44th for pediatric neurosurgery, according to U.S. News & World Report's 2012-13 rankings.

University of Texas Southwestern Medical Center (Dallas). The University of Texas Southwestern Medical Center Neurosurgery Department includes 17 neurosurgical adult subspecialists in cerebrovascular, spine, skull base, functional and trauma procedures, with five more neurosurgeons at its Children's Medical Center of Dallas. Its cerebrovascular program treats the most complex cases in the five-state area, and its Epilepsy Center performs the most surgeries of any epilepsy center in Texas. U.S. News & World Report rated UT Southwestern's neurosurgical care 43rd overall in its most recent rankings.

University of Washington Medical Center (Seattle). The Department of Neurological Surgery at the University of Washington Medical Center is a major contributor to clinical research in the field and one of the largest funding recipients from the National Institutes for Health. The institution is actively engaged in studying concussion treatments for veterans, computer-assisted brain function recovery after injury and treatments for tumors and aneurysms. U.S. News & World Report placed UW Medical Center's neurosurgery program 16th in the country.

University of Wisconsin Hospital and Clinics (Madison). There are 12 neurosurgeons at the University of Wisconsin Hospital and Clinics, and the hospital's neurosurgery program ranks 40th in the nation, according in U.S. News & World Report. Daniel Resnick, MD, an associate professor of neurosurgery at the UW School of Medicine and Public Health, was elected in October 2012 as president of the Congress of Neurological Surgeons.

Utah Valley Regional Medical Center (Provo). Utah Valley Regional Medical Center, part of Salt Lake City-based Intermountain Healthcare, employs three neurosurgeons to deliver neurological and spinal surgical care, ranked 69th and 214th in the nation, respectively, by CareChex. The hospital features a neurological trauma and intensive care unit. U.S. News & World Report named the hospital the best in northern Utah for spine and neurosurgical procedures.

Vanderbilt University Medical Center (Nashville, Tenn.). Vanderbilt University Medical Center's Department of Neurological Surgery offers seven subspecialties, such as vascular, peripheral nerve and pediatric neurosurgery, and its Spine Center features five neurosurgeons on faculty. The Vanderbilt Brain Institute joins multidisciplinary experts together to research neuroscience and innovative treatments. U.S. News & World Report ranked Vanderbilt's neurosurgery program 33rd for adults and 41st for pediatric neurosurgery in its most recent rankings.

Via Christi Hospital (Wichita, Kan.). The Neurocritical Care Unit at Via Christi Hospital's 20-bed neurosurgery department utilizes video EEG monitoring for epilepsy and includes four negative-pressure ventilation rooms. Neurosurgeon Bassem El-Babbout, MD, heads the pediatric neurosurgery program to treat disorders including cerebral palsy, epilepsy and Tourette syndrome. HealthGrades placed Via Christi among the top 5 percent of hospitals for neurosurgery and stroke care in 2012, and CareChex ranked it 13th for neurosurgery and 100th for spinal surgery.

Wake Forest Baptist Medical Center (Winston-Salem, N.C.). Wake Forest Baptist Medical Center has 11 neurosurgeons between its adult and pediatric neurology and spine subspecialties, which range from comprehensive epilepsy care, neuro-oncology and stroke care. Wake Forest Baptist's specialty centers include the ALS Center and Movement Disorders Center. U.S. News & World Report ranked its neurosurgical services as 42nd in the nation.

Wesley Medical Center (Wichita, Kan.). Neurosurgeons and spine specialists at Wesley Medical Center perform neurosurgical treatments for common conditions such as Alzheimer's and Parkinson's diseases, as well as surgical treatments for disorders of the spine. CareChex ranked Wesley's neurosurgery program among the top 100 in the nation.

Yale-New Haven (N.H.) Hospital. Yale-New Haven Hospital offers stereostatic radiosurgery treatments and Gamma Knife therapy in its surgical neuro-oncology and neurovascular programs. The hospital is currently engaged in research sponsored by the National Institutes for Health, including studies on the development of advanced MRI and imaging techniques for use in neurological surgery and treatment, as well as primate studies analyzing outcomes of injections into the striatum, which are slotted for a phase I clinical trial in the near future.

Seth Gasser, MD, director of sports medicine at Florida Orthopaedic, will lead the institute in its involvement with the Buccaneers.

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The ALIF device includes counter-rotating titanium blades that deploy into adjacent vertebrae and lock the device in place, according to the release. Alphatec launched the device in Europe last month.

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The Boston-area subsidiary will focus on the PROW FUSION and eSPIN devices with the goal of launching a full line of products in 2014, according to the release.

NLT Spine specializes in non-linear technology for less-invasive implantation of large spine devices and instruments. The platform can be used for up to 95 percent of the spinal procedures performed in the U.S., according to the release. The company holds 18 patent families and more than 100 single-issued and pending patents worldwide.

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Q: Where is the spine field now and what technology could be a disruptive influence on the market going forward?

Dr. Lawrence Dickinson: Right now, I think our field is limited in our treatment options with much of the focus on spinal fusion in the United States. Surgeons are removing movement segments in the spine for people who have diseases that are more related to problems with the irrigation of the ligaments and osteostructures of the spine.

I am currently using the iO-Flex system (Baxano Inc),  a tool that maximally preserves the anatomy, particularly the facet joint anatomy of the spine and allows surgeons to very comprehensively decompress the nerve elements in a way we can avoid fusions for some people who are currently subjected to large structural reconstruction operations like fusions.

Q: What advantages does the iO-Flex technology afford surgeons? How is it different from other minimally invasive systems?

LD: iO-Flex is able to help surgeons decrease failure rates because we are preserving the midline anatomy and a vast majority of the facet complex. This is a mini open midline laminectomy that allows surgeons to pass a flexible micro-shaver that removes ligament and bone from the central surface of the superior articulating process of the affected level, thus decompressing the lateral recess all the way out to the far lateral foramen.

I've been excited to work with Baxano on post-market prospective trials for stenosis patients in order to further demonstrate the clinical and economic benefits of the tool in decompression surgery. The original idea for the procedure was doing the operation percutaneously, but the available tools are not percutaneous as you still need to visualize the thecal sac. I perform the procedure minimally invasively through a unilateral METRx tube approach and am able to get a profound decompression that is somewhat revolutionary.

Q: How can surgeons incorporate this technology into their practices? How much time and resource allocation does it take?

LD:  The most important factor for surgeons before learning the devices is to become facile with fluoroscopy because this procedure involves radiographic documentation of where you pass the device and understanding of the facet and lateral spinal anatomy. There is some training involved and surgeons can go through a didactic and lab to learn the devices. There are also technical representatives in the operating room with the surgeon to help the staff implement the tools.

It's also necessary to conduct neurophysiological monitoring on each case. Not all surgeons currently do neurophysiological monitoring with simple decompressions.

The system is FDA cleared and the company has also been careful in assessing the surgeons’ skill before working with them to implement this technology. I've seen some patients on bed rest come in for spine surgery and literally with a 20-minute procedure they were able to stand up and walk out. This revolutionized how we take care of acute care issues, yet if you don't have the right technician, you can have bad results or an incomplete recovery.

Q: How do you think costs could be mitigated on this technology in the future? How does the technology fit within reimbursement and would it make sense for every hospital?

LD: I think from a resource perspective decreasing failure rates and avoiding spinal fusions for some patients will offer significant savings in our healthcare system. For the hospital, fast patient recovery helps mitigate the cost of the device, but the current economics can make some institutions hesitate in using technology like iO-Flex. As we move forward with healthcare reform and we evolve from cost-based to value-based purchasing, the incentives will shift from quantity to quality. In this new environment, technologies like iO-Flex that have equal or better outcomes for less cost, will become part of every surgeon's practice. In fact, one of the most likely quality models that will be evaluated shortly could be a bundled payment for a condition such as symptomatic stable grade I spondylolisthesis for 12-month care. A minimally invasive decompression would likely be the most effective choice for many patients.  

Q: What is the biggest roadblock to this technology becoming more pervasive?

LD: The short-term economics can make some institutions hesitate in allowing the technology to be used. Currently our government has rules and regulations about safety of devices, but because surgeons haven't taken enough time to advocate for individual outcomes measures, the federal government supports looking at the epidemiology of conditions and treatment. The insurance companies are more focused on cost cutting. It will take time for the environment to shift to make the technology more pervasive.

Q: Where do you see minimally invasive spine surgery heading in the future? Where is the biggest opportunity for growth?

LD: I think the most exciting developments will come from stem cell innovation. We may be able to reverse degenerative diseases with some types of minimally invasive procedures, such as injection therapy into the joint for internal repair. Up until now, we've been fixated on taking out the injured part and putting something else in; we'd love to go in and have a confident gene product that would allow renewed function in the joint. If we are able to get to the point where stem cell technology can repair spinal cord injury it would be the Nobel Prize in our field.

Surgeons are doing phenomenal work in spinal cord regeneration that is very exciting with stem cell technology. For me, adding new biologics in the field will be profound and revolutionize this idea that we are physioscientists that are returning and regenerating the anatomy. In the future we will have the capacity to have good biologics for everything: bone, ligament and cartilage regeneration.

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The pain management market is currently valued at $52 billion. The opioid segment of the market is growing at a rate of 20 percent and will constitute 43 percent of the pain management market by 2018, according to the report.

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Dr. Khan is a board-certified orthopedic surgeon with Resurgens Orthopaedics in Johns Creek. His area of expertise is arthroscopic and reconstructive surgery of the shoulder, elbow and knee, according to the report.

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Mako Surgical has appointed Christopher Marrus as senior vice president of sales.

Smith & Nephew named Julie Brown as its chief financial officer, after the resignation of the previous CFO, Adrian Hennah. Michael Friedman, MD, has joined the company's board of directors as a non-executive director.

Alan Milinazzo joined InspireMD as the company's president, chief executive officer and a member of the board.

Max Reinhardt has taken over for Namal Nawana as the worldwide president DePuy Synthes Spine, a Johnson & Johnson subsidiary.

Michael Dormer will be joining EOS Imaging as a chairman of the board of directors.

NLT Spine has appointed Peter Wehrly to its board of directors.

Tornier CEO Douglas Kohrs has retired. David Mowry, chief operating officer, will stand as the interim president and CEO.

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The Commission hopes the changes will reduce health spending and improve quality of care. The Commission is chaired by Steven Schroeder, MD, distinguished professor of health and healthcare division of general internal medicine in the department of medicine at the University of California, San Francisco, and heart transplant surgeon and former Senate Majority Leader William Frist, MD.

The recommendations include:

1. Payors eliminating stand-alone fee-for-service payment to medical practices
2. Transitioning to quality and value-based models of care
3. Continue recalibrating fee-for-service payments
4. Increased annual updates for evaluation and management codes and freezes on updates for procedural diagnosis codes for up to three years for Medicare and private insurers
5. Eliminating higher payment for facility-based services that can be performed in lower-cost settings
6. Always incorporate quality metrics in fee-for-service contracted reimbursement rates
7. Small practices should be encouraged to form virtual relationships through fee-for-service reimbursement.
8. Focus fixed payments on areas with significant potential for cost savings and increased quality.
9. Fixed payment systems should include measures to safeguard access to high quality care, strong physician commitment and assess the quality of risk-adjustment indicators
10. Eliminate the Sustainable Growth Rate
11. Pay for SGR repeal with cost savings from the Medicare program after cutting physician payments and reducing inappropriate service utilization
12. More diversity of membership and transparency with decision making in the Relative Value Scale Update Committee, and the Centers for Medicare and Medicaid should develop an alternative method to update relative values that is open and evidence-based

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1. Milagro Advance Interface Screw from DePuy Mitek.

2. NuVasive Long Lateral Spinal System from NuVasive.

3. EasySpine System from LDR Spine.

4. Anterior Cervical Plate System from Weigao Orthopaedic Device.

5. Parcus Draw Tight 1.8MM Single-Load Suture Anchor from Parcus Medical.

6. Augment and Bone Screw from United Orthopedic.

7. Pass LP Spinal System from Medicrea International.

8. Profemur Z Classic Stems from Wright Medical Technology.

9. Maxim Surgical X-Treme Interbody Fusion System from Maxim Surgical.

10. Reliance Spinal Screw System from Reliance Medical Systems.

11. Xiphos from DiFusion Technologies.

12. Spectrum Spine Laminoplasty Plating Systems from Spectrum Spine.

13. Spineology Spinous Process Plate from Spineology.

14. Espine from NLT Spine.

15. Gibralt Occipital Plate Screws from Exactech.

16. Range Spinal System, Small Stature Components from K2M.

17. Intervertebral Body Fusion Device from Dio Medical.

18. Integra Proximal Humeral Plate System from Ascension Orthopedics.

19. A200 Knee System from Renovis Surgical Technologies.

20. SpeedLock Hip Knotless Fixation Implant from ArthroCare.

21. Illico MIS Posterior Fixation System from Alphatec Spine.

22. Triathlon All-Polyethylene Condylar Stabilizing Tibial Implants from Howmedica Osteonics.

24. MotionLoc Screw for NCB Polyaxial Locking Plate System from Zimmer.

25. Synster (Cervical ALIF, PLIF, PTLIF and TLIF) from BM Korea.

26. SpineFroniter PedFuse Pedicle Screw System from Spine Frontier.

27. TwinFix TI 3.5MM Suture Anchor with Two Unltrabraid Suture from Smith & Nephew.

28. Cinchlock Knotless Suture Anchor from Pivot Medical.

29. Lucent from Spinal Elements.

30. Zimmer Persona Personalized Knee System from Zimmer.

31. U-Motion II Acetabular System from United Orthopedic.

32. Persona Natural Tibia Baseplates from Zimmer.

33. CD Horizon Spinal System from Medtronic Sofamor Danek.

34. Vertex Reconstruction System from Medtronic Sofamor Danek.

35. Polaris Spinal System-Ballista II Percutaneous Screw Placement System from Biomet Spine.

36. Orthocord from DePuy Mitek.

37. Piccolo Composite Plate System from CarboFix Orthopedics.

38. SImmetry Sacroiliac Joint Fusion System from Zyga Technology.

39. Ankle Trauma System from OrthoPro.

40. Synthes Patient Specific Plate from Synthes.

41. Intervertebral Body Fusion Device from Dio Medical.

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1. Consider vendor contracts. Carefully choose which vendors to form the strongest relationships with as you transition cases into an ASC. There may be five main implant vendors occupying the outpatient spine space, but it would benefit you to trim your preferences down to two. "Create a loyalty to one or two vendors to help with pricing," says Marcus Williamson, president of the spine division of Symbion Health Care. "As you look at the cost of the implants, for you and your patients' out-of-pocket expense, you want to work exclusively with fewer than three vendors for surgical cases.

Vendors can also help introduce spine surgeons into the market. "If they have a cervical fusion product, implant or cement, they can co-brand the device with you, which helps you make an introduction into that market," says Mr. Williamson. There are three types of outside-the-house arenas surgeons focus on as they break through into the market:

•    Direct-to-physician — vendors can help coordinate meetings or lab that physicians receive educational credits because vendors have the CEU designation for diagnosing and treating conditions.
•    Direct-to-patient — vendors can co-brand the surgeon's name with their marketing materials for direct-to-consumer efforts.
•    Direct to health plan — vendors can work with you to present information about procedures and technology used during spine surgery for better coverage and the patient's utilization of benefits in the surgery center setting.

2. Understand how payor contracts impact the center. Surgery centers are increasingly seeking in-network contracts with private payors to ensure long lasting success of the ASC. There are a few steps surgery centers can take to make sure they attract the best contracts available:

• Document outcomes to prove surgery can be successful in an ASC
• Demonstrate strict infection control protocols
• Provide your complication rate and risk management protocols
• Show the companies you are meeting clinical and financial benchmarks
• Emphasize cost savings associated with performing cases in the surgery center

"We just had a four-hour tour with a major private payor to go through our protocols and records," says Robert S. Bray, Jr., MD, neurosurgeon and CEO of DISC Sports & Spine Center in Marina del Rey, Calif. "The company's representative decided they wanted to work with us. It's this type of detail that has to be developed because that's where the future of surgery lies. We are raising the bar for surgery centers so there's no question these high acuity cases can be performed here."

3. Patient selection. Selecting the appropriate patient for spine surgery in the ASC is crucial for optimizing your success rate. Patients who have comorbidities, such as cardiac problems, shouldn't be brought to the ASC. Fred Naraghi, MD, director of the Comprehensive Spine Center in San Francisco, also steers patients with a body mass index of more than 30 or a significant dependence on pain medication (taking more than eight narcotics per day) to the hospital setting. These patients are at a higher risk for complications, so it's too risky to perform their surgeries in an ASC.

"For every case it is different, but as a rule I tend to have lower risk patients for outpatient spine surgeries," says Dr. Naraghi. "An important part of that is pain management for the patient. If the patient has a high pain management requirement, I would be very careful about doing those procedures as outpatient procedures because controlling the pain is going to be hard."

4. Training ASC staff. Spine surgery is a different type of procedure than most procedures performed in the ASC, and surgeons must make sure the staff members are experienced and prepared to work with them. Even after you begin bringing spine cases to the ASC, you must train your staff on each new type of procedure before performing the case. Dr. Naraghi holds an in-service day at his ASC before bringing a new procedure to the facility so the staff will understand the different components of the surgery.

"It's common to have an in-service and ask the device company to bring in the equipment for the procedure so you can do a dry run and make sure everyone understands what will happen when the patient arrives," he says. "When a new procedure starts in the ASC, you might be missing something and that could mean the case might not go smoothly. Have a checklist for the procedure and make sure the components can adapt to the ASC. Once you start ahead of time, you can find the kinks and it isn't an issue; but if problems occur during the actual surgery, it could be a major complication."

For example, if a wrong-sized cannula is pulled for the case and the surgical team doesn't realize it until the surgery has begun, finding the appropriately sized cannula will take time and the patient will most likely need admittance to the hospital.

5. Schedule cases early in the day. Spine cases scheduled late in the day can have a negative effect on staffing costs. "Schedule cases early in the day to give the patient additional time to recover if they are same day cases," says Ken Pettine, MD, co-founder of Colorado's Rocky Mountain Associates in Orthopedic Medicine in Loveland, Colo. "[That way], they do not require an overnight stay, [meaning] you have to call in a night shift." If you schedule spine cases early in the day, surgeons will still be able to complete a case that becomes unexpectedly difficult.

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Outpatient lumbar discectomy more effective than inpatient.
A study of 4,310 single lumbar discectomy cases found that the patients treated with outpatient surgery had lower overall complication rates than those patients that underwent the procedure in an inpatient setting. Of the patients studied, 61.7 percent stayed in an inpatient hospital after the lumbar discectomy and 38.3 percent had the procedure done in an outpatient setting. Overall complication rate for the outpatient setting was 3.5 percent, compared with 5.4 percent for the inpatient setting.

Drs. John Ehteshami, Abram Burgher joined Spine Treatment Centers of America.
John Ehteshami, MD, and Abram Burgher, MD, joined Spine Treatment Centers of America in order to provide patients in the Phoenix and Scottsdale region with neck and back pain relief. Dr. Ehteshami and Dr. Burgher will perform minimally invasive spine surgery at the Freedom Pain Hospital in Scottsdale, Ariz.

Aesculap Implant Systems' PL-AGE System is now for sale.
Center Valley, Pa.-based Aesculap Implant Systems' PL-AGE System is now available for commercial use.

Dr. Stephen Cook named Precision Spine Director.
Stephen Cook, PhD, joined the board of directors of Parsippany, N.J.-based Precision Spine. Dr. Cook is the president and chief scientist at the Fellowship of Orthopaedic Researchers in Metairie, La.

NLT Spine opens U.S. subsidiary.
Israel-based NLT Spine has opened a U.S. subsidiary to increase commercialization of its device technology platform. The Boston-area subsidiary will focus on the PROW FUSION and eSPIN devices with the goal of launching a full line of products in 2014, according to the release.

GOP & Dems' budgets both impact healthcare.
Rep. Paul Ryan (R-Wis.) led the design of the GOP's budget proposal, which would balance the federal budget in 10 years with $4.6 trillion in spending cuts through 2023. Much of that includes repealing funding for key features of the health law, including the health insurance exchanges and Medicaid expansion funding. It would also privatize Medicare using federal subsidies and terminate financial regulatory laws implemented during the Obama administration.

The Democrats are shooting for a $100 billion economic stimulus initiative for job training and infrastructure projects, paid for by closing tax loopholes amounting to nearly $1 trillion in added revenue. At the same time, they would cut an additional $1 trillion from federal spending. Dems have defended federal entitlements like Medicare and Medicaid.

Dr. Richard Kube performed Coflex Interlaminar Implant procedure.
Richard Kube, MD, was one of the first doctors in the US and the first surgeon in Illinois to perform a procedure with the Coflex Interlaminar Implant, which functions as an alternative to spinal fusion. Dr. Kube, board certified orthopedic surgeon and founder of Prairie Spine and Pain Institute in Peoria, Ill., performed the minimally invasive, outpatient procedure at Southern Illinois Surgery Center in Marion.

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Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses. Next week's question: In which spinal technologies do you see the most potential to positively impact patient care?

Please send responses to Heather Linder at hlinder@beckershealthcare.com by Wednesday, March 20, at 5 p.m. CST.

Jeffrey Goldstein, MD, Director of Spine Service, NYU Langone Medical Center's Hospital for Joint Diseases: Initially changing to an EMR will slow you down. However, not only is it a requirement in order to meet the meaningful use standards, but also it should make your documentation more complete. Be careful not to become complacent. It is useful to take the time to build templates to help you document the work that you do and to help you communicate to your colleagues. Templates can help to remind you to query your patients for information and complete parts of your examination and evaluation. Ultimately, an EMR will help you to be more efficient and complete. It will also give you the opportunity to document the full extent of the work that you have completed and the complexity of the decision making processes you have utilized and elevate the care you provide to your patients.

Vincent Arlet, MD, Orthopedic Spine Surgeon, KneeFootAnkle Center of Kirkland (Wash.): Learning an EMR takes time, and you will need physician extenders to help you with it. The learning curve is long and, no matter your proficiency, can be a waste of time.

Jeffrey Wang, MD, UCLA Spine Center: The most challenging part is the most obvious one — learning a new way to do things that one has done in a different way for a long time. Those who are used to electronics, computers and navigation on a Web-based platform will adapt much easier. For those who have not embraced technology, it will be slightly more difficult. The first step is to accept that this is the way of the future. One cannot fight or complain too much. You just have to learn it. Once one accepts that this is needed, it is easier each day. From personal experience, I can say that one should try to keep an open mind and expect difficulties. When encountering those difficulties, embrace it rather than complain. It will be easier. You have to spend the time to learn it well.

Richard Kube, MD, Spine Surgeon, CEO and founder of Prairie Spine & Pain Institute, Peoria, Ill.: I believe it is the same challenge as with the rest of medicine or any other business – the staff. Whether you are converting from paper to an EMR or converting between EMR systems, this is an enormous undertaking. Folks usually concentrate on the technical components of these types of projects. Certainly there are challenges of finding the right system with the desired features and the right price. But it is also important to find the right people to implement the go live date. I think it is critical to remember that this is an enormous project, and it will stress many of your existing staff to second-guess what they are doing as your employee. This is a big picture change for your business and most employees are not in a position to have enough information to truly understand the big picture and how it affects their daily routine. Adequate training must be provided to increase staff comfort level with implementation. It is important to allow those individuals to see small wins as the system rolls out so that they can believe that the new system will make a positive impact on them individually. Then they can get behind your vision for change. This makes all of the difference when doing a project with staff engaged as a team of believers and supporters versus a league of saboteurs. You will need all hands on deck to implement such a program efficiently.

Ara Deukmedjian, MD, Neurosurgeon and CEO, Deuk Spine Institute, Melbourne, Fla.: Most physicians find themselves spending more time documenting and scanning after they begin using the EMR than they spent charting before the switch. Documenting the key components of the history and physical examination may actually take much longer with the EMR than using a chart. Many of our physicians found our clinics became less productive, and we saw fewer patients with the EMR. I have heard this same complaint from others. Our EMR system is Nextgen, a Medicare-certified system. Another problem was the cost of the system and maintenance of the database, HIPAA, upgrades, recurring monthly costs and license fees and more. It gets expensive very quickly. New versions aren't free either.

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Dr. Yeung pioneered the now FDA approved Yeung Endoscopic Spine Surgery system and continues to explore the development of minimally invasive spine surgery.

Dr. Yeung earned his medical degree from the University of New Mexico School of medicine. He interned at the Banner Good Samaritan Medical Center and completed his residency at Maricopa Medical Center, both in Phoenix.

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Dr. Altchek performed the ulnar collateral ligament reconstruction at the Hospital for Special Surgery in New York.

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Dr. Akizuki will perform the non-invasive procedure in order to repair a torn meniscus in Mr. Pill's right knee.

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The minimally invasive spine device maker aims to use funds from the sale to advance its platform for spinal stenosis treatments, according to the release. The scale and scope of the deal are not disclosed, and will include cash and contingent payments as well as a long-term licensing agreement.

VertiFlex is currently conducting an investigational device exemption trial for its Superion Interspinous Spacer system.

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1. Watch surgeons who tend to over or underestimate surgical times. Schedules are tight at surgery centers, so it becomes a problem when a surgeon grossly over- or underestimates surgical times; it disrupts the surgery schedule when cases run over and delays the following cases. Surgeons get upset and patients are frustrated.

"I conducted a QA study when we were encountering surgeons who were estimating inaccurate times," says Mr. Bernhardt. "We had a group of surgeons that were underestimating them, and with our limited schedule, following those surgeons was creating inefficiencies. We monitor them closely and direct our schedulers to add time to those surgeons' cases."

Mr. Bernhardt might add 30 minutes to a surgeon who is consistently slower than estimated times so the schedule is more appropriate. "There can be no gaps in between cases," he says. "We look at our schedules daily and weekly and I have the power to readjust them and move the surgeries around so they flow smoothly and have no gaps."

2. Allow for early starts. Instead of adding cases at the end of the day, Mr. Bernhardt allows surgeons to add additional cases in at the beginning of the day to keep clinical times moving smoothly. This allows staff members to anticipate when they will be leaving the center each day. Also everyone must agree to the meaning of 'Start Time.' Their start time is when the patient enters the OR room.     

"We have three early start rooms, which will normally start at 7:30 am," says Mr. Bernhardt. "Surgeons can add cases before their clinical hours; I oftentimes add a microdiscectomy or a quick arthroscopy in the morning. We can do two cases at 6:30 am and one case at 7 am starting time. The flexibility is in the schedule and not having any gaps during the day, you can allow early cases in the morning to drive additional patient volume."

3. Optimize OR selection. Coordinate operating rooms so similar cases follow each other. The goal is to minimize the movement of equipment. For example, Main Street Specialty Surgery Center can do all shoulder surgeries in one room and all knee surgeries in another. You can coordinate even further by doing all left side surgeries first before switching to the right side. Another way is to do all the knees in a row and then do the shoulders.

"You have to schedule similarities in the operating rooms so things flow smoothly," says Mr. Bernhardt. "We are a multispecialty ASC, so for example we put all the general surgeries in one room and line up hand surgery cases in another. Managing the surgical schedule can create efficiencies every day."

4. Maintain a consistent staff. Build a quality team at the surgery center and maintain the same staff members for as long as possible. Surgeons appreciate working with the same team from year to year, and knowledgeable employees are more efficient and effective than new hires.

"We put the same people with the same surgeons 80 percent of the time, and we cross train staff members to back up our team," says Mr. Bernhardt. "They easily shave 10 minutes from each case just because we have a consistent staff."

The staffing must also be adequate, which can come to a great expense to the ASC. However, moving patients through efficiently can improve ASC revenue and enhance the bottom line in the long run.

5. Assign float staff for room turnover. In an attempt to run a lean business, many surgery centers charge their regular staff with room turnover. However, with a limited team, turnover times are slower. Instead, ASCs can designate "float" staff to move from room to room and help with turnovers as necessary.

"We try to have extra staff members in the hallways so people who were working on the cases in those rooms don't have to come back and turn over their rooms," says Mr. Bernhardt. "The minute the circulating nurse transports the patient, our float staff comes in and cleans the room, and then opens it up for the next case. Our average room turnover is three to six minutes. ASCs try to cut costs and expect the room staff to clean their own rooms, but their turnover times are abysmal."

Quick turnover times are crucial, because they are one of the big advantages many surgeons see for surgery centers over hospitals. Mr. Bernhardt also has surgical techs and support techs available to help with room turnovers because they ensure the equipment is ready for the next case.

"Our surgeons want to flip from one room to another if we have extra rooms — they'll do a shoulder and then flip to the knee," says Mr. Bernhardt. "If we aren't running all five operating rooms, we flip rooms. That requires a commitment from the staff to help them does that. It costs a little more to hire these employees, but their help pays for itself."

6. Standardize equipment trays and sterilization. Poorly-managed supplies and equipment leads to increased sterilization and slow turnaround times. When supplies and equipment are standardized ASCs can move through cases more efficiently. Many surgery centers have just enough trays available to complete a few cases before the sterilization process begins. This slows down the turnovers and may end up costing the ASC more in the long run due to decreased efficiency.

"ASC's sometimes for budgetary reasons and don't have enough trays, so they are forced to sterilize those trays for turnovers. This can create problems with turnover times and infection control," says Mr. Bernhardt. "You might have to have enough trays to get well into the third case before beginning the sterilization process. We rarely have to delay a case because of sterilization issues."

Mr. Bernhardt also uses standardized custom packs and automated fluid removal. "You can't have pails or bottles of contaminated fluid carried down the hallway; you have to have automated draining systems," he says. "This is especially important if you have orthopedics cases in your ASC."

7. Use technology to decrease paperwork and tailor paperwork to different specialties. Part of the standardization at Main Street Specialty Surgery Center is patient forms; many providers are frustrated with the time and effort it takes for charting. Mr. Bernhardt tries to minimize the writing by tailoring their forms to specialty and utilize charting by exception. He also uses online ordering to reduce paperwork and streamline materials management.

"Our preop forms are engineered to help reduce interview times. Our GI and pain procedures have forms that are tailored for them specifically," he says. "We want to tailor the form to fit the process and not have a generic form that asks questions that may not be relevant. Every ASC should review their forms annually to simplify and reduce redundancies."

The center also tries to limit staff paperwork so they can meet regulatory requirements without adding extra paperwork. Each OR includes a laminated poster of the Surgical Safety Checklist. When the surgical staff completes the safety checklist it is checked off on the nursing intraoperative form. This process eliminates adding another form to the chart.      

Mr. Bernhardt also uses Supply Management Online and McKesson's Data Transfer to manage costs, optimize inventory, and to help his materials management save time and to be as efficient as possible.       

8. Promote teamwork and leadership. Team leaders report to the Director of Nursing (DON). They carry out the plan as directed by the DON. Team leaders at the surgery center are in charge of making sure everyone knows the plan for the day. They make the assignments and oversee the schedule. Team leaders gather their team every night to make sure surgical equipment and trays are ready for the next day.

"Everybody is a niche player on our team," says Mr. Bernhardt. "I try to look where they add the most value. So even if someone isn't as strong overall as someone else, there is an area where they will excel and add value to the team. I try to instill that in our culture."

9. Communicate constantly with staff members. Team leaders should have constant communication with their staff members during the day so everything runs smoothly. If a patient arrives late, everyone on the team communicates to know the case should be fast tracked and people can rotate over to get the patient in as quickly as possible.

"We use the SBAR communication process as part of our culture here," says Mr. Bernhardt. "We want to communicate about potential issues before they happen, not while they are happening. We need to anticipate problems and avoid them instead of just responding after they occur. I try to empower my employees, so they can think independently and creatively. My door is open to any employee who wants to talk and have some 'Boss Time.'"  

10. Address problems immediately. The efficiency of an organization is directly related to the morale of the employees. Employees will be motivated and loyal when they are treated with respect, challenged by their work, and have access to management. Main Street Specialty Surgery Center has an open door policy to immediately address staff issues that haven't been resolved thru the normal chain of command. When someone isn't behaving appropriately, or has an issue that they want addressed, it's important to work with this employee instead of letting the problem fester.

"When someone has a problem, I try to talk to that person immediately. One of the worst things to do is let someone ruminate with their issue. Anger and resentment almost always increase," says Mr. Bernhardt. "You have to be interactive and preemptive when someone comes into the office with a problem, they might not want to address the issue directly because they know something negative may happen, but a manager must be a coach and a counselor in order to resolve their issues."

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Q: What alternatives to cervical spinal fusion exist in the spine surgery market?

Joe Ross: There are a few procedures to treat cervical pathologies that do not include fusion. These include cervical disc replacement, foraminotomy and laminoplasty, as examples. For patients with degenerative disc disease with radicular symptoms for which surgery is indicated, the primary alternative to fusion for the foreseeable future is artificial disc replacement. There are several ongoing device trials for cervical disc replacements, including the Mobi-C from LDR.

Q: How will surgeons be able to differentiate the new discs coming on the market?

JR: While there are some similarities to a few devices, either available or anticipated to be available in the U.S., there are some distinct design differences. These differences include materials, fixation features and the way in which motion is provided by the device. Regardless of the specific design features however, another very important consideration when evaluating the devices will be the clinical evidence to support safety and efficacy of the individual device as it relates to its approved indication. Physicians will need to absorb this evidence, along with the approved indications, in order to make a personal determination of what is best for their patient population.

Q: How can motion preservation technology benefit the patient?

JR: When a patient receives a fusion today, normal motion is of course largely eliminated at the operative levels.  And in addition to that segmental loss of motion, it is theorized that fusion may transmit increased stress to levels above or below the fused segment(s), and thereby accelerate, or fail to slow further spine degeneration. Potential benefits of disc replacement or motion preservation techniques include more normal motion maintained at the surgical levels, less adjacent level degeneration and fewer additional surgeries in the future. If these potential benefits are proven to be real, then cervical disc replacement could be as revolutionary to cervical spine surgery as hip and knee replacements have been to large joint replacement.

From my personal view, the positive evidence for disc replacements is becoming increasingly clear. With initial studies we saw some trend that appeared to favor cervical disc replacement when compared to ACDF, and now subsequent studies and long-term data is being presented at meetings and published in journals that further supports the safety and efficacy of cervical disc replacements, including potential advantages of lower reoperation rates and lower rates of adjacent segment degeneration. It is important of course to continue to monitor the objective, peer-reviewed clinical evidence. However, I am encouraged that the long-term studies of certain discs being reported seem to be painting an increasingly positive picture.

Q: How big is the field for disc replacement surgery today? Do you see it growing in the future?

JR: Cervical disc replacement is an established, but still emerging market in the United States. Reimbursement coverage is becoming more widespread, and there are an increasing number of choices for physicians when it comes to the cervical disc, as evidenced by two recent approvals of new devices. There are currently five discs approved in the United States for cervical disc replacement, and a few others are expected over the next couple of years, including the Mobi-C from LDR. At that point, there will be a number of options for surgeons. Beyond that though, there is not a great deal on the horizon, and any future products not already undergoing clinical trials will of course be subject to the rigorous, multi-year, study requirements for new technologies.

Q: How can spine surgeons incorporate non-fusion technologies into their practice?

JR: Surgeons must first look at the available evidence and decide whether non-fusion technologies can benefit the patients they treat. If they then decide to incorporate cervical disc replacement into their practices, they can take advantage of the numerous training courses offered around the country. Each manufacturer provides training at various locations for surgeons to familiarize themselves with the techniques and indications for use specific to their device.

Q: What is reimbursement like for cervical disc replacement? Are there any hurdles?

JR: The reimbursement environment for cervical disc replacement is improving but can still be variable by geography. It is always very helpful to be knowledgeable regarding the local payor mix and their individual coverage policies. It is interesting to note that recent coverage policies have been very specific to approved indications and approved devices, which may make it important for physicians to match their patient's surgical need to a device having that approved indication. Overall, I see the trend as being very positive for cervical disc coverage.

Q: What non-fusion technology should spine surgeons look for in the future? Where is the field heading?

JR: The primary new, non-fusion technology for the cervical spine for the foreseeable future remains the cervical disc. The clinical trial requirements in the United States can take six to eight years or more, therefore a next generation of solutions seems quite far out on the horizon.

That said, one significant development may be the expansion of indications to include two level disc replacement via the anticipated two level approval of LDR's Mobi-C Cervical Disc. This will be a important event given the prevalence of two level pathology, and may significantly increase the number of patients eligible to be treated on-label with cervical disc replacement.

Overall, when you consider the growing library of supportive short and long term evidence for cervical disc replacement, new device approvals, the potential for expanded indications and an improving reimbursement environment, the field of non-fusion surgery for the cervical spine is very exciting both for patients and physicians.  

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