Marc Cohen, MD, a spine surgeon based in New Jersey, discusses the biggest trends in spine research and technology, and where the field is headed in the future. Dr. Cohen has a special interest in minimally invasive micro spine surgery and endoscopic laser spine surgery.Q: What does the future hold for spine-related research?
Dr. Marc Cohen: When you talk about the future for research in the spine world, the reality is that the interest of medical care used to be on the clinical research and outcomes, but now — with the changing healthcare environment, costs and restraints — the focus for all research is turning toward evidence-based medicine. Evidence-based medicine measures the patients' symptoms, functional status and patient satisfaction. The problem is that the technology of today has to be justified with healthcare costs and weighted with the evidence-based outcomes.
Q: Traditionally, academics have been most involved in research. Is that still true?
MC: You don't have to be in academia to conduct research today. I'm in private practice and I collect patient outcomes data with new devices and provide that information to registries that act as a database of documented information contributing to evidence-based medicine. These studies show hospitals and payors that new technology or techniques have merit and patients do better after treatment; therefore, the technology should be reimbursed.
The problem is today, guidelines and protocols are being controlled by insurance carriers and they set their own standards; they gather their own information, which is different than protocols physicians develop. Physicians and surgeons have the training and knowledge about their patients, and they are the ones with the expertise about which treatments are best. The problem is cost control by payors and government; they use their own data which makes gaining coverage an uphill battle for surgeons.
Q: How has this new focus impacted spine research and technology development?
MC: Technology and research is affected because every new development needs more justification; many decisions are based on cost analysis. Technology will be hard to bring into this country and hospital because the cost is so great. Government and insurance carriers are squeezing physicians and hospitals, which are scrutinizing new devices and weighing outcomes against cost.
The only way for surgeons to deal with this situation is by being an active player; they need to provide their own data for patient outcomes into their specialty societies. It will be important for spine surgeons to become involved in their medical and spine societies. They need to participate in initiatives to take back control and set guidelines for appropriate medical care for spine patients.
Q: What new technologies will be most successful in the future?
MC: I believe the future is in minimally invasive techniques. I think the technology is out there now for less invasive surgery, and spine surgeons can perform better procedures using modern technique. Minimally invasive surgeries mean less tissue damage, smaller incisions and quicker recovery times. In the future surgeries should be done more efficiently to cut costs.
I also see more specialty hospitals and spine centers, and more surgeries performed by physicians with a special focus on the spine. The protocols, outcomes and efficiency will all be better as a result of more research and development in spine surgery. This will cut costs and make surgeons and payors happy.
Q: Where do you see the most opportunity for development in spine technology? Are there any developments you are particularly excited about?
MC: The future technology will include endoscopic surgery, allowing routine spine surgical procedures through a smaller incision. The other technology that will develop is the use of artificial disc replacement, which has merit. I think data and evidence-based medicine is coming now in the cervical spine, and outcomes have been effective. However, some insurance companies still consider artificial disc replacement an experimental procedure.
It would be good to see whether artificial discs can be used at multiple levels in the future. Most surgeons only use it on one level. In the future, it will be interesting to see whether multiple levels can be used; then we can use artificial discs instead of hybrid surgery or open fusions.
Looking away from surgery, technology has to do with patients who have back pain. Technology will evolve so physicians can change the physiological and pathological state in the patient using stem cells and gene therapy. Spine surgeons have to pioneer research with pain physicians so they can reach patients undergoing treatment for painful discs in the early stages; these patients may be able to undergo a biological injection before the spine procedure. It has to be a combined effort to help the patients and avoid open surgical intervention.
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