Spine Surgery in 2065

Michael Y. Wang, MD, FACS
Praveen Mummaneni

There have been tremendous advances in spinal surgery over the past fifty years. Fifty years ago rigid three-dimensional fixation of the spinal column could not be accomplished, anterior cervical approaches were still being developed, and fracture treatment consisted largely of prolonged bed rest. As recently as the 1990s, residency training in neurosurgery consisted primarily of decompression surgery; instrumentation procedures were limited to trauma and tumor cases, spinal deformity was not on the neurosurgical horizon, and understanding of issues like spinal balance, spinal biomechanics, and bony fusion were rudimentary at best.

Spinal surgery today is far more advanced than it was 25 years ago. We now have the ability to offer surgery to many more patients than we did previously. It was not atypical in the 1990s to tell patients they had a complex spinal problem and there was no surgical solution for it. During residency training in the 1990s we could not imagine offering an operation to a 70-year-old patient debilitated with decompensated kyphoscoliosis or a post-traumatic spinal deformity, for example. Today, medical horizons have expanded enormously with the availability of new and more advanced instrumentation systems.

In the next 50 years, neurosurgeons will need to treat an aging and more active population. It is now not uncommon to see patients working a full-time job well into their 70s and living actively into their 90s. By 2050 the U.S. Census projects that there will be 4.2 million centenarians, and by 2065 the U.S. population forecast is for 500 million people with mean lifespans of nearly 90 years (Figure 1). If this population forecast is realized, it will reset the limits of spinal surgery.

Figure 1: U.S. Census projection of the number of centenarians.

Medical treatments for osteoporosis will likely advance to offset the bane of osteoporosis and its related fracture patterns. Diagnosis of spinal pathology will be enhanced with more sophisticated radiology imaging (high tesla MRI and low radiation CT for example). We’ll have the ability and the means to view these images on smartphones, smart watches, or monitors anywhere at any time. Typically, the expansion of digital technologies makes their acquisition more affordable over time. For example, during the past decade we have seen the price of LCD televisions drop by over 80 percent. Cost reductions from technological advances will be needed throughout medicine and spinal surgery to make the treatments economical for a larger and aging population.

Furthermore, patient recovery from surgery will become quicker with the implementation of new generations of minimally invasive access pathways and instrumentation designed to limit blood loss and tissue disruption while obtaining decompression and, when needed, spinal fixation and correction of deformity. New biologics will likely enhance spinal fusion in the setting of osteoporosis.

Some have proposed that treatments at the molecular and cellular levels may offset the need for some surgery in the future. While we cannot accurately predict the full impact of such treatments now, encouraging entrepreneurial innovation is important if we hope to see how far current boundaries can be pushed in the next half-century. Non-fusion alternatives for treating degeneration of the intervertebral disc and facet joints would be a welcome addition to our armamentarium and will still likely require the services of spinal surgeons or injection specialists to place biologic therapies in their appropriate anatomic location. However, such treatments, if available, will not eliminate the need for spinal surgery to treat trauma, deformity, tumor, and degenerative disease. The future of spinal surgery is bright, as the next generation of spinal neurosurgeons will undoubtedly translate new technological developments for the improvement of patient care (Figure 2)

Figure 1: U.S. Census projection of the number of centenarians.