Nima Salari, MD, is not opposed to spinal fusion. He is opposed to making it the starting point.
Before immobilizing a segment of the spine, the spine surgeon at Phoenix-based Desert Institute for Spine Care considers whether the same problem can be treated while preserving more of the patient’s muscle, ligaments, bone, stability and motion.
Sometimes that means removing a small fragment of disc through an endoscope. Sometimes it means performing a limited decompression or replacing a damaged disc. Even when fusion is necessary, a less invasive approach may reduce the healthy tissue disrupted to complete it.
The objective is not to perform the smallest operation possible. It is to know how much surgery is enough.
“The focus of my practice has been preserving what matters,” Dr. Salari told Becker’s.
That philosophy is becoming more consequential as spine surgery accumulates new implants, imaging systems and increasingly specialized techniques. Each advance expands what surgeons can do. It does not automatically clarify what they should do, or which patients should receive it.
The next major step in spine surgery may therefore be less about inventing another procedure than becoming more precise about the amount of surgery each patient needs.
Fusion is a tool, not a starting point
The movement toward minimally invasive and motion-preserving surgery can make fusion sound like an outdated operation. Dr. Salari rejects that framing.
Patients with instability, deformity, weak bone or advanced arthritic changes may not be appropriate candidates for motion preservation. In those cases, fusion can provide stability the spine can no longer maintain on its own.
The problem arises when fusion becomes the default rather than one option in a broader surgical toolbox. Dr. Salari sees that toolbox as a continuum.
A focal disc herniation may be treated endoscopically. Spinal stenosis may require a limited decompression. An artificial disc may preserve movement in an appropriately selected patient. Greater instability or deformity may require fusion.
“When I can, I try to utilize the breadth of tools that are available to us today,” he said. The least invasive operation is not automatically the right one. A small procedure can fail if it leaves the primary pathology untreated. A motion-preserving implant can perform poorly if the patient’s anatomy cannot support it.
Preservation is not simply minimalism. It is matching the scale of the operation to the scale of the problem.
What does ‘minimally invasive’ actually mean?
The phrase “minimally invasive” has become nearly ubiquitous in spine surgery. Its meaning is less consistent.
An operation may be described as minimally invasive because its incision is smaller than that of a traditional open procedure. But that label alone does not tell patients how much muscle must be dilated, how much bone will be removed or which tissue planes will be disturbed.
Dr. Salari describes some of his endoscopic procedures as “ultra-minimally invasive” because they are performed through an incision approximately 7 or 8 millimeters long. The surgeon uses dilation to create a narrow path to the pathology rather than opening a broad surgical corridor.
“You’re not removing any tissue or disrupting any of the tissue planes until you get to where you need to be,” he said. “You have a very focal, finite area that you are ultimately impacting.”
Traditional minimally invasive procedures may still use larger tubes and require more muscle dilation or bone removal to reach the same area. Both approaches may be less invasive than open surgery, but they are not necessarily equivalent.
“A lot of times, I feel like there are these catchphrases and buzzwords being utilized,” Dr. Salari said. “They don’t necessarily mean what the intent is at the end of the day.”
That ambiguity matters because patients increasingly arrive having researched procedures through websites, videos and social media. Different operations may be promoted using the same language despite meaningful differences in their approach and recovery.
“Language does matter,” he said. “It does matter how you describe it.”
The important question is not whether an operation carries a minimally invasive label. It is what the surgeon must disturb to complete it.
The operation is only as good as the indication
Cervical artificial disc replacement has developed a substantial clinical evidence base, but strong results do not make the procedure appropriate for every patient.
“You have to choose the right patient,” Dr. Salari said. Clinical trials typically use strict criteria to determine who can participate. Those boundaries help produce consistent results by excluding patients whose anatomy or medical conditions make failure more likely.
When the procedure moves into broader practice, surgeons must decide how closely to remain within those criteria. A patient with good bone quality, preserved alignment and healthy facet joints is different from one with osteoporosis, significant cervical kyphosis or advanced facet arthritis.
Preserving motion in the wrong patient can preserve pain or instability.
“If you stay within the parameters of how these studies were conducted, while using sound clinical judgment to deviate when appropriate, I think that’s when the results are most reproducible,” Dr. Salari said.
The principle extends beyond artificial discs. Endoscopic surgery, limited decompression and other less invasive procedures work best when the pathology can be treated adequately through the narrower approach. Expanding a technique into unsuitable anatomy may produce disappointing outcomes that reflect poor patient selection as much as a limitation of the procedure itself.
Optimization also begins before the operation.
“Bone health is critical, but so is overall tissue health. Factors like protein intake and albumin levels give the body the resources and building blocks it needs to heal,” Dr. Salari said.
The technique may be sophisticated. The patient’s body still has to integrate an implant, heal tissue and sustain the result.
Why endoscopic surgery has not spread faster
The obstacles to endoscopic spine surgery are not only clinical. They are educational and economic.
Many surgeons do not receive extensive endoscopic training during residency or fellowship. Adopting the technique may require a practicing physician to learn a new visual orientation, unfamiliar instruments and a narrower working corridor while maintaining an active clinical practice.
“Surgeons do not necessarily get that training in fellowship or residency,” Dr. Salari said.
The early cases can take longer than the surgeon’s established microscopic or open procedure. That is not necessarily a weakness in the technique. It is part of learning to perform it safely. Hospitals and ASCs must also purchase endoscopic towers and specialized instruments, prepare operating room teams and accommodate longer procedure times during the learning curve.
Reimbursement may remain essentially unchanged. The surgeon and facility must therefore absorb new training, equipment and time costs without receiving additional payment for the investment.
“There’s the opportunity cost on one end, and then the ability to implement this on the other,” Dr. Salari said. Those economics help explain why promising procedures do not spread automatically, even when patients may benefit from reduced tissue disruption and faster recovery.
Dr. Salari believes health systems should approach adoption as a program rather than an individual surgeon’s side project. They can support physician training, invest in systems that several surgeons will use and develop enough procedural volume to make the equipment sustainable.
“There has to be some additional investment made,” he said. The business case should not begin with whether the organization can advertise endoscopic spine surgery. It should begin with whether the organization can support surgeons through the training and learning curve required to perform it consistently.
Purchasing the technology is the easiest part. Building the clinical capability is harder.
The danger of building around a tool
Investment creates another risk. Once a hospital or ASC purchases an expensive platform, the organization has an incentive to use it. Surgeons may also build their reputations around a particular procedure.
That can subtly reverse the order of clinical decision-making. Instead of beginning with the patient’s condition and choosing the appropriate treatment, the program begins with the technology and looks for patients who might fit it.
Dr. Salari described the value of maintaining a “quiver of arrows,” a range of techniques that allows the operation to follow the pathology rather than forcing the pathology into a preferred operation.
More options, more restraint
Dr. Salari expects lumbar disc replacement to gain broader adoption as longer-term evidence clarifies which patients benefit.
“Over the next decade, I think lumbar disc replacement will see wider adoption as more data emerges on its efficacy,” he said.
Dr. Salari does not expect one operation to replace all the others. Instead, he sees the field moving toward more precise patient selection. Some patients will need fusion. Some will benefit from an artificial disc. Others may need only a small fragment of disc or bone removed through an endoscope.
Progress, in his view, will not come from proving that one technique is universally superior. It will come from becoming better at knowing when each is enough.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
