Is Your Spine Practice Principle-Based?

A principle-based spine surgeon chooses the best technique for each patient instead of the surgery technique at which they’re best.

Peer Reviewed

At a time when new technologies and techniques for spine surgery are emerging at a rapid pace, it can be easy to slip into a technology-based practice. Specialize too narrowly, however, and you risk doing your patients a disservice.

Principle based practiceA principle-based spine surgeon chooses the best technique for each patient instead of the surgery technique at which they’re best, says Ali A. Baaj, MD.

With this in mind, Ali A. Baaj, MD, (@alibaajmd) recently tweeted “Regardless of your favorite spine alphabet soup (XLIF, OLIF, PLIF, etc), a principle-driven practice is more sustainable than a technique-driven one.” SpineUniverse spoke to Dr. Baaj about the advantages of principle-based practice and the top 3 strategies for implementing this type of practice.

Dr. Baaj is the inaugural chief of spine surgery and associate professor of neurological and orthopedic surgery at the University of Arizona, Banner University Medical Center in Phoenix, Arizona.

Q: What is a principle-based practice?

Dr. Baaj: A principle-based practice offers personalized care that incorporates disease pathology, anatomy, pathophysiology, and biomechanics into the individualized selection of the best technique or technology for each patient’s unique case. A principle-based practice is one in which the spine surgeon adapts technologies and techniques to the individual patient’s condition, and not the other way around.

For example, in the case of a patient with a cervical spine condition, a principle-based approach examines that patient’s condition, biomechanics, and pathology to determine the best way to achieve optimal outcomes. In some cases, the best approach is an anterior cervical fusion, but in others, the best approach may be an artificial disc technology, posterior fusion, laminectomy or laminoplasty. We can only select the best technique if we focus on the principles of spine surgery.

Embracing new technologies and innovative techniques in spine surgery is an exciting part of what we do. However, it is essential that all spine surgeons, and particularly those who are early into practice, remember that principles are the most important aspects of care to focus on.

Q: What is technique-based practice?

Dr. Baaj: A technique-based practices is one in which a spine surgeon specializes in a certain technology or technique and tries to apply that approach to most patients they treat.

Take a spine surgeon who specializes in anterior cervical fusions and uses this approach in a majority of cases. While this technique is a good one, it may not be the best choice for all patients. Thus, surgeons practicing technique-based practice would best serve their patients by expanding their skill set through additional training or fellowship to learn how to implement new technologies and techniques. This applies to surgeons at all stages of their careers, and particularly to surgeons early in their careers. 

As a teacher and academician, I advise my trainees to not pigeonhole themselves by focusing on one technique, but rather to focus on understanding the principles of spine pathology, and then try to employ as many techniques as they are trained in. Important principles of spine surgery include decompression, stabilization, and deformity correction, while ensuring that we are not creating an iatrogenic problem for the patient.

Whether you become a spine surgeon through a neurosurgery or orthopedic surgery track, you are going to have exposure to a wide variety of techniques and technologies, and you will want to make sure that you are able to employ as many as possible, and not corner yourself into one technique.  Techniques and technologies always evolve, and one should stay nimble and be able to adapt these as needed.

Q: What are the advantages of a principle-based practice?

Dr. Baaj: The advantage of focusing on a principle-based practice is that spine surgeons are not limiting their treatment options, are thinking about the patient as a whole, and are focusing on the basic fundamental principles of spine surgery. The disadvantage of a technique-based practice is that surgeons may be limiting the options for patients and possibly overtreating or undertreating patients based on the technique or the style that the surgeons favor.

I have been practicing as a spine surgeon, including training, for approximately 17 years and believe that a principle-based practice is more fulfilling and offers greater longevity. Patients are happier if you focus on their disease pathology and give them options in terms of techniques or technologies. In this way, your patient will trust you and appreciate that you are involving them in the decision-making process and not trying to force one specific technique on them.

Q: Can you give an example of how having a principle-based practice can improve outcomes from spine surgery?

Dr. Baaj: Let’s consider lumbar degenerative spine disease, a ubiquitous condition. If you specialize in an open laminectomy and fusion and take this approach with all patients, you are missing the subset of patients who may benefit from a minimally invasive procedure or an anterior procedure to restore a disc height and improve the lumbar lordosis. Other patients may benefit from spinal decompression alone.

With all of these different techniques and beneficial new technologies on the market—including instrumentation and implants—we should still focus on the principles of spine surgery and determine how to leverage the technologies to meet patients’ needs. How do we decompress? How do we best realign the spine? How do we best correct the deformity?

You want to be able to provide different techniques based on the specific pathology that that unique patient has, and don’t want to deprive patients of surgical options.

Q: What are the top 3 ways to make a spine practice more principle-based?

Dr. Baaj: The top 3 strategies for maintaining a principle-based practice are as follows:

  1. Have a sound understanding of spinal biomechanics.
  2. Stay current with the literature on spine disease pathology. Even our own understanding of the principles of spine surgery evolve over time. For example, many years ago we were performing open, complex spine surgery on metastatic spine tumors all the time, whereas now with improvement in radiation and systemic therapies, we are able to perform less invasive procedures for patients with much more acceptable surgical footprint.
  • Stay current on new techniques and technologies to offer quicker surgeries that are effective and safe. We want to focus on a principle-based practice, but still want to ensure that we are learning and employing new techniques and technologies. We don’t want to treat spinal conditions or spinal disease the same way we were doing it 20 or 30 years ago.

Q: What innovations do you hope to integrate into your principle-based practice?

Dr. Baaj: I am excited about advancements in neuronavigation and robotics, virtual reality/augmented reality, and artificial intelligence.  I think these technologies are going to be key in the future. The continually expanding minimally invasive spine market also is of interest. I am eager to expanding the use of these innovations into my practice so that I can address the fundamentals of spine conditions in even safer ways. Having said that, I am keen to continue focusing on the principles of spine disease and to apply such innovations in the appropriate clinical context.


Dr. Baaj is a consultant for DePuy Synthes.

Updated on: 10/09/20
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