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13 ORTHOPEDICS The report card spine surgery has been waiting for By Sophie Eydis F or years, spine surgery has been judged by what happens early. How long was the hospital stay? Were there complications? Did the patient need another operation? Did pain improve in the first year? Praveen Mummaneni, MD, believes those questions miss the larger story. As the Joan O'Reilly distinguished professor in spine surgery, co- director of the UCSF Spine Center and vice chair of neurosurgery at the University of California San Francisco, Dr. Mummaneni has helped build one of the clearest long-term views the field has ever had into what happens aer spine surgery. rough the Quality Outcomes Database and related spine registries, surgeons are now following thousands of patients for five years, long enough to evaluate not only whether surgery works, but whether its benefits last. e findings, he said, challenge some of the most persistent assumptions about spine surgery. "I think the key lasting impact is that, in the appropriately selected patient, if you do surgery, not only do you benefit them for a year or two, you're benefiting them for more than half a decade," Dr. Mummaneni told Becker's. at matters because spine surgery remains one of medicine's most scrutinized specialties. It is oen described as costly, overused and vulnerable to inconsistent outcomes. Dr. Mummaneni does not dismiss the need for accountability. But he believes the five-year data shows a more nuanced reality. For many appropriately selected patients, spine surgery is not a short-term intervention. It is a durable one. e myth patients bring into the exam room Patients oen arrive in Dr. Mummaneni's clinic already afraid of what surgery will mean. ey worry they will never work again. ey worry they will never golf, bike, swim or return to the activities that matter to them. ey worry spine surgery will leave them worse, not better. For years, surgeons had limited long-term data to counter those fears. Now, Dr. Mummaneni said, the conversation is different. "I tell them, actually, what you're telling me is not factually correct," he said. "We followed patients who have your problem for five years, and those patients are actually able to do a lot of activities and go back to work, and they get off their narcotics." at may be one of the most important shis the database has enabled. It gives surgeons evidence to reset expectations before the operation ever happens. "e expectation should be that you're going to have surgery, that you're going to resume an active and healthy lifestyle, and that you're going to go back to work, and you're going to get off the opiates," Dr. Mummaneni said. For him, that is not optimism. It is data. e QOD findings show patients returning to work, reducing opioid use, maintaining improvements and avoiding high rates of reoperation years aer surgery. ose outcomes, he argues, should change how patients, physicians, payers and policymakers understand the value of spine care. e patients many policies might leave behind e five-year data has also challenged Dr. Mummaneni's assumptions about patient selection. Like many surgeons, he once expected patients with obesity, smoking histories or significant medical comorbidities to experience limited improvement aer surgery. e registry told a different story. "Even patients who have a high BMI and obesity are making measurable gains," he said. "Even smokers are making measurable gains." ose gains are not identical to those of younger, healthier patients. A 35-year-old nonsmoker in good health may experience a larger improvement than a medically complex patient with obesity or tobacco use. But that does not mean higher- risk patients fail to benefit. at distinction is critical as healthcare systems and payers increasingly use risk factors to determine surgical eligibility. Blanket restrictions may appear responsible from a population-health perspective. But Dr. Mummaneni believes they can become dangerous when applied too rigidly. "What do you do if you're one of those people and you have myelopathy and you can't walk?" he said. For him, the lesson is not that every patient should have surgery. It is that patients should not be reduced to a risk factor. Minimally invasive surgery's real advantage Dr. Mummaneni has spent much of his career advancing minimally invasive spine surgery. e QOD data has helped clarify what those procedures do, and do not, change over time. In patients undergoing transforaminal lumbar interbody fusion for grade-1 spondylolisthesis, minimally invasive surgery offered clear early advantages compared with open surgery. Patients le the hospital sooner and required fewer blood transfusions. e longer-term findings were equally important. "e minimally invasive surgery patients got out of the hospital faster, had less blood transfusions, and in the long term, the outcomes of open and minimally invasive surgery were essentially equivalent," he said. In other words, minimally invasive surgery produced short-term recovery benefits without sacrificing durability. At one year, two years and five years, the patient-reported outcomes and reoperation rates were similar between open and minimally invasive approaches. For health systems, that kind of finding is valuable because it separates marketing from measurable benefit. Minimally invasive surgery may not necessarily produce superior long-term outcomes in every case, but when applied appropriately, it can improve the early recovery experience while preserving long-term results. at is the kind of distinction large registries are built to detect. e preoperative diagnosis surgeons cannot ignore Some of the most important changes in Dr. Mummaneni's practice now happen before surgery. If a woman over age 65 comes to his clinic, one of his first steps is to evaluate bone density. "I never used to do that," he said. e reason is straightforward. Undiagnosed osteoporosis can undermine even a technically sound fusion. Poor bone quality can increase the risk of implant failure, nonunion and revision surgery. "e number of people with osteoporosis is tremendously high," Dr. Mummaneni said. "If you don't treat it, they're going to fail their fusion."