5 Things that Changed my Spine Practice over 20 years

I’ve been a physician for over 30 years and spine surgeon for over 20 years. These are the five  things that changed my practice over the past 25 years.

I graduated medical school in 1989. I finished my 2nd neurosurgical fellowship in 2000 and have been in practice since.  A lot has changed since I went into practice. These things made the biggest impact on my practice:

1. Navigation


When I went into practice, pedicle screws were placed with landmarks and fluoroscopic confirmation.  A few years down the line and we used live fluoroscopy. The O-Arm turned up about 10 years ago and totally changed my practice (https://www.medtronic.com/us-en/healthcare-professionals/products/neurological/surgical-imaging-systems/o-arm.html). Every thoracolumbar screw I place is now navigated as well as C1 and C2 screws. As spine surgeons we were late to the party. The intracranial neurosurgeons had navigation available before the turn of the century but translating that to the spine was cumbersome, slow and had a lot of dead ends. We are in a good place. Robotics would be nothing without navigation.


2. BMP


I will argue that the biggest innovation in minimally-invasive surgery was BMP (recombinant Human Bone Morphogenetic Protein-1, rhBMP-2, https://www.medtronic.com/us-en/healthcare-professionals/products/oral-maxillofacial-dental/bone-grafting/infuse-bone-graft.html). It makes bone grow. Overnight we stopped taking iliac crest graft. Our incisions shrunk. Issues did crop up, which included swallowing issues in the cervical spine and osteolysis before osteogenesis, but  overall, it has been a game changer. Our incisions became smaller. Even with some backlash, we never went back to crest. Local bone with BMP has become my goto which means I don’t have to explain where allograft comes from and the fusion rates in the lumbar spine, in my hands  have been >95%, with smaller incisions and shorter lengths of stays. Nice thing is a little goes a long way- I now use XXS per level in the lumbar spine. Game changer.


3. Indirect Decompression

As a neurosurgeon we were always taught to directly decompress every time and we get good at it but the following changes happened to my practice that have made me do more indirect decompressions or rely more on it in conjunction with direct decompressions:


3.1 Anterior cervical surgery


No more cloward dowels. No more crest. Bigger cages. Distract the foramina. Less worry about how good my foraminotomy is. Less subsidence with porous titanium. It’s been great.


3.2 Anterior and lateral lumbar fusions



Wonderful for adjacent segment disease or postlaminectomy foraminal collapse. Anteriors and laterals have been a great addition to the toolbox especially, if I can do it all single incision and single position.

3.3 Navigated MIS TLIFs

I will  now often only decompress the symptomatic side now from a Wiltse approach and rely on distraction and reduction to give me contralateral indirect decompression, even with bad central stenosis. The best of both worlds, direct and indirect decompression. Could not work without navigation and BMP.


4. Vancomycin Powder


The data is all over the place but most surgeons use vancomycin in their posterior lumbar wounds and it does look like infection rates dropped a lot to the pre-vancomycin days. Yes, there may be issues of antibiotic resistance but for now this seems to have done a lot of good. I do less washouts for sepsis.


5. On-Q Pain Pumps

When i started practice, posterior cervical surgeries stayed in hospital for a week and had miserable neck pain. Lumbar fusions were not far behind. I started placing paraspinal pain catheters with infusions of ropivacaine and it’s been a game changer. There is something about infusing local anaesthetic into paraspinal muscles that really helps in the first 48 hours with no rebound. Pain, next day, invariable, 4 out of 10. Less neck pain and patients out of hospital within 2 days. As a spine surgeon, take a look (https://avanospainmanagement.com/solutions/acute-pain/on-q-pain-relief-system/)/


I am sure every field has game changing innovations that have stood the test of time. Your list may differ to mine. If you would like to comment, add to the list or give yours, please comment below.

2 responses to “5 Things that Changed my Spine Practice over 20 years”

  1.  Avatar

    Great post Lali! Clear and concise for both medical professionals and the general population.

    1. Lali Sekhon Avatar
      Lali Sekhon

      Thanks for reading and commenting!

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