Emerging Spinecare Trends

The American Academy of Spine Physicians (AASP) developed this area of the website to consolidate topics on emerging trends in spinecare and topics which will have an impact on the future of spinecare. Posting of information is meant to inform and prepare members for evolving changes in spinecare with the hope that it will also generate interest and additional research on the subjects. The information is developed and/or compiled by a designated mulidisplinary panel of experts assigned by the AASP. The opinions and projections do not necessarily reflect the opinions of all members of the American Academy of Spine Physicans.

Introduction

This article was developed by the American Academy of Spine Physicians (AASP) to serve as an introduction to possible future developments and trends in spinecare. It was meant to generate interest and more research on the subject. The article was created by a designated mulidisplinary panel of experts and therefore the projections do not nessecary reflect the opinions of all members of the American Academy of Spine Physicans.

Overview

Spine disorders account for tens of millions of patient visits each year in the United States. The prevalence of spine and related disorders has grown to epidemic proportions. As people survive longer they develop and suffer form degenerative diseases of the spine. Back pain has become one of the most common reasons for seeing a physician. The growing elderly population will lead to a greater incidence of degenerative spine disorders and related complications. Degenerative disorders include spinal stenosis, hypertrophic arthropathy, intervertebral disc disease, sarcopenia, and osteoporosis. The rising occurrence and complexity of spine disorders will place unprecedented burdens on families, society, and healthcare system. The growing incidence of disorders such as diabetes and obesity will also contribute to the back pain epidemic.

One of the fastest growing concerns in healthcare is the provision of a timely diagnosis and adequate care for individuals with back pain and other spine disorders. Spinecare currently represents one of the more inefficient specialties of healthcare. The rising incidence of back pain and spinal disorders has no geographic boundaries, thus afflicting people of all nations. It is rapidly becoming a healthcare priority with significant personal, social and industrial ramifications. The increased demands will tax regional and world healthcare systems. A comprehensive solution will include the coordinated efforts of an International Spine Organization to help educate and integrate healthcare providers, other organizations, and the public. This parallels the path taken in other fields such as the American Diabetes Association and the American Heart Association, but with a global reach. There will be greater reliance on international databases for physican and public education.

The spine is intricate and complex and therefore often requires the care of one or more spine physicians or specialists. Expanding insights on spinal tissue repair, adaptation, remodeling, and plasticity will continue to influence the type of spinecare provided in the future. A growing appreciation for molecular mechanisms will facilitate an ongoing search for biological solutions. The spinecare of the future will be more predictive, preventive and personalized than it is today. Spinecare will be implemented earlier in the course of dysfunction and/or disease leading to better outcomes. Scientific and technological advances will redefine "early stage disease" and promote conservative intervention during "pre-disease" states.

Spine Informatics

Bioinformatics is the field of science in which biology, computer science, and information technology merge to form a single discipline. Spine informatics can be defined as the intersection of spine science, computer science, and a spine pathology database. This emerging field will strongly impact future spinecare. It will enable the discovery of new biological insights and be used to develop global databases from which unifying principles in spine physiology and pathology can be discerned. Spine informatics encompasses the technology and methods required to optimize the acquisition, storage, retrieval, and use of information in spinecare. Informatics tools include computers, merged databases, and communication systems.

Software programs will be designed to identify specific findings such as disease characteristics or structural features on imaging studies and map them to standard ontologies in an accepted lexicon. This will allow for quick and comprehensive retrieval of information on patients with spine disorders who have had imaging studies done. Major advances in spinecare will emerge secondary to broader development and application of informatics. It will help drive population-based prevention programs and community education.

Integrated Spinecare

Spinecare of the future will be integrated, predictive, personalized, and preventive all of which will be influenced by regional, national and global initiatives. This process requires informatics. Individual spine specialists will rely less on there own expertise and more on the collective insights and efforts of an integrated or team approach and databases of information.

Spinecare will no longer be practiced individually. It will be practiced in integrated groups where the care can be delivered more efficiently and the patient can receive greater benefits. Healthcare professionals of various disciplines will develop a growing appreciation for the complexity of the spine which will encourage interdisciplinary efforts. The prioritization of cooperative and conservative intervention will continue to improve the outcome of spinecare. The American Academy of Spine Physicians is dedicated to facilitating integrated and evidence-based spinecare by providing educational opportunities and resources to healthcare professionals and the public. The AASP will keep its members informed by acknowledging advances in technology and techniques and by implementing novel communications technology to promote the development of interdisciplinary spinecare networks.

Progress in technology and diagnostic protocols will provide physicians and other spinecare professionals an opportunity to render an earlier and more accurate diagnosis. The scientific advances will enhance our understanding of spine tissue properties leading to more reliable indicators of tissue recovery and measures of therapeutic outcomes. The insights will facilitate a growing appreciation for the complexity of the spine which will encourage interdisciplinary efforts. In the multidisciplinary spinecare model, well-defined clinical algorithms and guidelines will be used to help standardize care.

Integrated (multidisciplinary) spinecare teams will be comprised of two or more of the following:

-Chiropractic Physicians
-Neurologists
-Psychologists
-Rheumatologists
-Orthopedists
-Pain Specialists
-Anesthesiologists
-Exercise Specialists

-Neurosurgeons
-Psychiatrists
-Neuroradiologists
-Rehabilitation Specialists
-Basic Scientists
-Molecular Biologists
-Engineers
-Massage Therapists

Role of the Internet

In the future most individuals will go the intent to learn more about their spine, spine disorders and available spinecare. They will rely on the internet to locate spine specialists and multidisciplinary spinecare facilites. They will also the internet to compare the background, experience, and success of various professionals and facilities. A growing number of people will be willing to travel great distances to access superior spinecare. This trend renders online directories and professional profiles more important.

The coalescing global spinecare market will improve access to spinecare and spine information. The accessibility to and rapid dissemination of information on the internet fosters consumerism. The public and patients will be less apt to rely soley on the advice of a physican or single practice approach and will turn to the internet to check out the facts and to obtain a consensus opinion. The patient of the future will report to spinecare practices equipped with relevant information and high expectations.

The internet will increasingly provide for the efficient delivery of information, rendering international borders and time zones less restrictive. Every healthcare professional including public health professionals will have the opportunity to become part of extraordinary global initiatives and solutions. Global advancement and integration of spinecare will require free and easy access to knowledge. The internet will allow spinecare professionals to discover, share and create knowledge.

Evidence-Based Care

Evidence-based spinecare refers to purposeful use of the best available information when making decisions about the care delivered to patients with spine disorders. It requires the integration of clinical expertise with clinical evidence from published research and peer delivered consensus reports. Evidence-based care will enable members of the spinecare team to offer the greatest benefit for the least expense. Considerable emphasis over the last decade has been placed on improving methods of acquired and correlating evidence from systematic reviews for the purpose of developing evidence-based guidelines and measures. Future advances in technology, diagnostic methods, and spine informatics will facilitate further development of intuitive databases which will be used to develop clinical guidelines and algorithms. Evidence-based spinecare will continue to contribute to more informed decisions and improved spinecare outcome.

Spinecare Facilites (Centers of Excellence)

Spinecare is currently delivered through many settings such as standalone practices, group practices, multidisciplinary supergroups, and as part of hospital or large healthcare systems. In the future we will see less isolated spinecare practitioners. There will be greater integration and collaboration between practitioners and facilities. The majority of successful spine physicians and specialists will join forces as part of multidisciplinary spinecare centers of excellence. Some of this will be facilitated by hospitals and large corporate healthcare systems hoping to expand their market reach. Other groups will be developed by likeminded practitioners. The integrated spinecare program/system can offer more services and allow for staff members to specialize and refine their skills which will have a positive impact on treatment outcome. This results in a group comprised of highly specialized and skilled practitioners. This attracts patients and referrals from a larger geographic area thus taking patients from less efficient and less capable practitioners and/or facilites.

Larger spinecare facilites can afford to invest in leading-edge technology and can offer staff greater opportunities and benefits. They are also able to hire more qualified ancillary staff members thus freeing up spine physicians to focus on their areas of expertise or interest. Larger facilites also have greater negotiating power with third party payers. Integrated spinecare programs provide more efficient and comprehensive spinecare. They also have the tools to objectify treatment outcome and meet the growing demands for evidence-based care from patients and/or third party payers. This successful trend has become prevalent in the fields of orthopedics and cardiology.

The future healthcare delivery system will place even greater demands on spine physicians and specialists to provide quality care, while utilizing approaches which are cost efficient and effective. The restraints of dwindling revenues and advances in spinecare technology will further drive the development of niche programs and/or centers of excellence. Spine practitioners will have to collaborate or partner with healthcare systems and facilites to insure that adequate levels of reimbursement/profit are received. Spine physicians and specialists will have to become part of delivery systems that promote accountability, savings and state-of-the-art care.

The spinecare field is rapidly evolving. The emerging trend favors the development of large multidisciplinary spinecare centers of excellence. Some large established centers will develop satellite locations which will feed into the primary location. The international community is becoming more educated about the difference in the level of care between facilites not only within their own region or country but abroad. With the ability to access information about facilites anywhere in the world the public is more willing and able to travel to receive optimum spinecare. This trend will have an adverse impact on small spinecare centers and communities that do not have integrated centers of excellence.

In the multidisciplinary spinecare setting, well-defined clinical algorithms and guidelines will be used to deliver more standardized care. Improved documentation and objective outcome measures will be used to support treatment decisions. A practice continuum will be implemented to prioritize the most conservative treatment options. Failure at a conservative level of care will be required prior to advancing to the next more aggressive treatment option. The ultimate goal will be to offer the most conservative level of care for the greatest gain. Heathcare disciplines will be integrated in a manner that facilitates a seamless continuum of cost efficient spinecare. The multi-disciplinary approach will ensure a comprehensive approach and lead to high patient satisfaction.

The Future Spinecare Facility will prioritize;

-collaborative interdisciplinary care (integrated multidisciplinary care)
-multimedia educational opportunities for patients/families
-biological solutions for the care of back pain and spine disorders
-the preservation and restoration of spine function
-the use of objective biomarkers and benchmarks in functional assessment
-diagnosis and care of peripheral complications associated with spine disorders
-early detection and intervention with screening services

The Future of Diagnostic Imaging of the Spine

Advances in diagnostic imaging will transform the field of spinecare. Molecular imaging studies will direct emerging technology and foster further discoveries in spinecare. Molecular imaging techniques will be used to directly and indirectly monitor and record the spatiotemporal distribution of molecular or cellular processes in spinecare. There are many different imaging techniques which will be applied for the purpose of molecular imaging such as radiotracer imaging/nuclear medicine, MR imaging, MR spectroscopy, optical imaging, and ultrasound. Magnetic resonance spectroscopy (MRS) will likely emerge to become one of the most practical and safest forms of assessing spinal tissue biochemistry in vivo. Molecular imaging will have a huge impact on future spinecare. It will be sued to reveal the clinical biology of the disease process and it has the potential to help personalize a patient's care. The combination of magnetic resonance imaging (MRI) with MRS will yield the relationship between structure and molecular biochemistry in ways we can not achieve through other diagnostic methods.

The current use of MRS is contributing to a growing list of disease specific biomarkers. The term biomarker refers to a reliable measure of disease which can be used to detect a disease process, to monitor disease progression, and to assess treatment outcome. In the past biomarkers were primarily limited to blood tests and tissue biopsies. MRS is currently being used to assess biomarkers and biochemical relationships within neurological tissue of the brain, brainstem, and spinal cord regions. In the future it will likely be used to perform "in vivo" chemical mapping of the intervertebral disc, cerebrospinal fluid, the vertebral body (bone marrow) and for characterizing spinal tumors. .

Molecular imaging such as MRS will have a profound effect on the future of spinecare through its application in translational medicine, a phrase which refers to a continuum often known as the "bench to bedside" transition of basic research to clinical application. It is the process of moving research discoveries from the laboratory into clinical practice where the information can be applied to diagnose and treat patients. The phrase translational medicine is often used interchangeably with terms such as "Molecular Medicine" or "Personalized Medicine".

MRI will likely remain the modality of choice for detailed evaluation of most intraspinal pathology. Future diagnostic imaging of actual or suspected spinal cord compromise will likely include diffusion weighted imaging, spectroscopy, fiber tractography, and MR neurography. The spinal column will be navigated using advanced digital reconstruction virtual reality technology and tools. Imaging technology will allow for non-invasive biochemical assay of regions of the spine and the central nervous system. Future imaging will also provide better visualization of spinal and spinal cord vasculature. Expanded imaging field of view (FOV) combined with better tissue resolution will led to the discovery of subtle abnormalities at various stages of development. Greater use of quantitative imaging techniques will provide better measure of change. The full spine imaging study will become common place. Diagnostic imaging will continue to trend toward earlier detection of dysfunction and disease.

Diagnostic imaging advances will change the way we view and detect early stage spine disease. It will also have a profound impact on how we treat and monitor spine disorders and related complications. Molecular imaging will have a profound influence on how we diagnose disease. It will allow us to view molecules (metabolites) in vivo and tissue remodeling in disease. Molecular imaging will be used to reveal characteristic biosignatures of disease. Magnetic resonance spectroscopy (MRS) uses nuclear magnetic resonance techniques to reveal the biochemistry and metabolism within targeted regions of tissues such as the brain, brainstem and in the near future the spinal cord. MRS may eventually prove to be an effective method for identifying the location of pain in the spine. Before this can be realized in vivo chemical biomarkers for inflammation and the provocation of pain must be identified. MRS will be used to help evaluate and follow the underlying mechanisms of osteoporosis.

When MRI and MRS are performed together we learn about how the tissue looks and what is going on chemically within the tissue. In general abnormal chemistry precedes the development of structural pathology; therefore, MRS may be used to identify early stage pathology and pre-disease states. Bioinformatic databases will be used to define the correlates between metabolite levels and metabolite ratios and their relationships to health and disease. The current list of chemicals detectable with MRS is limited but the list is growing. MRS and related technology will provide us with a practical non-invasive window into the spine revealing metabolite levels, chemical shifts, and chemical signatures indicative of disease or other abnormalities.

Diagnostic imaging will continue to play an increasing important role in spinecare. MRI will likely remain the best overall modality for this purpose for years to come. Future applications will include faster scanning speed (data acquisition time) speed, broader fields of view, sophisticated image postprocessing (data manipulation) and improved tissue resolution (signal to noise ratios). Additional advances will include multicoil and multichannel data acquisition leading to better spatial resolution.

Advanced imaging and formatting capabilities will give spine specialists the ability to virtually fly through and investigate areas of interest. Software will be used to segment tissues, acquire quantitative measurements, and to perform in vivo biochemical mapping of selected tissues or pathology. In the future regional imaging surveys of the spine will be replaced by full spine imaging with subsequent focused assessment. Complex "add on" protocols will become a routine part of profiled image sequencing. The growing trend will be in the direction of quantitative imaging and expanded field of view (FOV).

Specilialized MRI protocols such as diffusion-weighted imaging (DWI), diffusion tensor imaging (DTI) and tractography, perfusion, MR spectroscopy (MRS), MR angiography (MRA), and functional MRI (fMRI) sequencing and acquisitions have become routine in the assessment of the brain for strokes, tumors and inflammatory lesions. In the near future these approaches will be equally promising for evaluation of the spinal cord.

Post image processing will become an invaluable tool of the radiologist and surgeon. The data and reports will also be accessed by other members of the spinecare team through electronic healthcare record systems. Software will become more capable of integrating functions currently available such as volume rendering, virtual endoscopy, surface modeling, tissue segmentation, data sorting as well as offer different methods for making quantitative measurements within the region of interest (ROI).

Future Imaging of the Spinal Cord

Chronic spinal cord compression represents one of the most common causes of muscle weakness and paralysis in the elderly. People are living longer; therefore, there is a rising incidence of degenerative narrowing of the spinal canal (spinal stenosis) which can lead to slow and clinical silent progressive spinal cord compromise. It often goes undetected until there are obvious clinical deficits. This typically occurs after a significant number of spinal nerves are compromised, often permanently. Surgical decompression of the spinal cord is usually not performed until there is some degree of permanent neurological compromise. In the future new imaging techniques will be used to help identify spinal cord compromise earlier.

In the future emphasis will be placed on identifying high risk patients before there is obvious loss of spine functions. This will be accomplished by using various methods including MRS for assessing for "in vivo" chemical evidence of spinal cord cellular compromise within the narrowed region of the spinal canal. This will involve identification of ischemic biomarkers, inflammatory biomarkers, and biomarkers of demyelination and/or axonopathy.

In the field of magnetic resonance imaging (MRI) the use of stronger magnets will improve a signal-to-noise ratio which improves imaging quality and reduces data acquisition (scan) times. The improved imaging capacity will reveal more subtle pathological and structural details not otherwise detectable. It will allow for visualization of inracanicular and intraneural tissues. Advances in diffusion-weighted imaging (DWI) will be used to asses those at risk for ischemic injury within the spinal cord and other spinal structure. A derivative technique, diffusion tensor imaging (DTI) will be used to evaluate scalar properties of the diffusivity of extracellular water molecules within white matter fiber tracts. The dataset is will more routinely be used for 3-D reconstruction of white matter tracts in the spinal cord. DWI will be used to asses the altered matrix of neoplastic tissues within or adjacent to the spinal cord. In the future a needless biopsy using MRS will help characterize the lesion.

The nerve fibers of white matter tracts have properties which direct the diffusion pattern of water. The proposed mechanisms of underlying diffusion anisotropy include the myelin sheath, the axonal cytoskeleton, local susceptibility artifacts and fast axonal transport. The diffusion pattern of water can be measured and turned into an image. The current clinical application of diffusion-weighted imaging (DWI) of the human spinal cord is limited by a few technical challenges. These challenges will be overcome in the near future.

Fractional anisotropy (FA) will routinely be used to perform specific spinal cord fiber tract studies. FA refers is derived from DTI computations and represents the global anisotropy of tissues. These studies will be used to characterize myelination, axonal thickness, collective nerve fiber/fiber tract volume, and spinal intraparenchymal morphological parameters. Changes in fractional anisotropy and mean diffusivity may become sufficient enough to differentiate between potentially reversible edema and irreversible gliosis in the spinal cord in patients who have spinal canal narrowing secondary to spondylosis. The determination of eiginvalues will be used to help stratify subgroups of patients with spinal cord compression, a step which will help determine the best treatment options. DWI will also be used to assess structural integration of the vertebral body including the subchondral endplate region adjacent to the intervertebral disc.

In vivo magnetic resonance spectroscopy (MRS) (proton spectroscopy) will be used to measure metabolite concentration, biochemical ratios, and to perform metabolic mapping of the spinal cord and other spinal tissues. A growing number of metabolites can be identified with MRS, many within the central nervous system. Spinal cord spectroscopy has the potential to add metabolic information to the routine spinal cord MRI. Currently, spinal cord spectroscopy remains challenging due to technical factors such as magnetic field inhomogeneities, CSF pulsation and the relatively small field of view. These factors limit the quality of the acquired data although these challenges will soon be overcome. Metabolite quantification in the spinal cord will offer new opportunities for clinical correlation and research. For example, the metabolite N-acetyl aspartate (NAA) has been shown to be a biomarker of axonal integrity within the central nervous system. Its levels correlate well with motor disability. MRS may be used to assess the pre-myelopathic state.

In the future acquired spectroscopy data may be merged with magnetic resonance angiography (MRA) data to help detect early disease/compromise. Intraparenchymal assessment of blood flow could be correlated with region specific ischemic biomarkers. This can further be correlated with the diffusivity of water within white matter tracts along with the evaluation of segmented spinal tract morphology and volumetrics.

Some functional MRI (fMRI) studies of the spine have been performed with limited success due to technical challenges which will likely be overcome in the future. It the challenges are overcome future fMRI studies may be used to help investigate the spinal cord processing of pain stimuli. Progression to the use of perfusion-based fMRI could help reveal ischemic regions within the spin cord which are vulnerable for progression to infarction. In the future perfusion based fMRI may be correlated with the use of MRS to evaluate for metabolites which serve as ischemic biomarkers.

Magnetic resonance myelographic (MRM) will be perfected to provide a non-invasive method for assessment of nerve root sheaths, the effect of intradural adhesions/masses on CSF flow and to evaluate other perineural pathology. Emerging techniques will be applied to imaging the intervertebral disc and related pathology. The dynamics of intradiscal metabolite concentration and water diffusivity will be revealed which will help determine the prognosis and stability of disc degeneration and disruption. All of these advances will improve the post-operative imaging workup. Improved 3D reformatting will enhance the detection of tissue and instrument displacement as well as the presence of scar as well as recurrent and/or residual pathology. DTI hat high field strength shows promise in the assessment of all spinal cord pathologies.

Future Role of Traditional and Virtual Organizations

In the future, consumers will be influenced less by individual physicans and traditional marketing approaches. They will increasingly turn to national organizations and consensus opinions for information about spinecare and products which can be used to improve the health of their spine. Healthcare professionals will also turn to organizations to help them integrate with other spinecare professionals and with facilites that offer spinecare. Select organizations will rise to a position of greater influence (cultural authority) and serve to integrate other less capable or specialty organizations. Successful professional organizations will develop virtual divisions and/or departments to perform tasks and provide access to resources. These might be referred to as virtual organizations or virtual divisions of organizations.

The development and application of virtual organizations (VO) in spinecare will enhance discovery and innovation by bringing professionals and resources together across institutional, geographical and cultural boundaries. In the future VO's will be used to facilitate the application of leading-edge transformative research and learning within and across all fields of spinecare.

Complex, networked socio-technical systems will be supported by advanced cyberinfrastructure allowing VO's to integrate professionals and informational resources. This process will foster effective data streaming thus enabling new approaches to scientific inquiry and education. It will allow remote access to experimental tools, observational instruments, simulation systems, and to spine disease modeling.

Virtual organizations extend beyond traditional "brick and mortar" institutions, and can therefore provide flexible boundaries facilitating professional integration and sharing of information from distances never before possible. VO's will be explored as primary mechanisms for enhancing innovation and broadening participation in spinecare networks. These socio-technical systems will be leveraged to generate and accelerate transformative research. The process will require successful integration of specialists with expertise in spine informatics, spine pathology, network science, artificial intelligence, statistical physics, software/hardware design, information privacy and security, operations research, and organizational studies.

Redefining and Restaging Disease

Advances in spine research and molecular imaging will redefine early stage spine disease. In vivo molecular imaging will also change the way we stage spine disease including spinal tumors. Emphasis will shift from anatomical (structural) imaging to integrated anatomical and in vivo biochemical imaging. Biochemical evidence of spine disease will likely precede structural pathology and classic signs and symptoms. Molecular imaging will be used to identify the molecular (biochemical) borders of tumors/lesions in contrast to focusing on structural boundaries of pathology. In most cases the biochemical borders of a lesion will extend beyond the more obvious structural borders seen on routine imaging studies. The future will bring about a more aggressive search for chemical and genetic biomarkers of disease. This will include biomarkers acquired through lab work, imaging and biopsies. Disease biomarkers will be correlated to help stratify the stages of spine disease.

Future Role of Physicians and Spine Specialists (Spinecare Team)

There has never been a greater need for spine physicians and spine specialists of various disciplines to prepare for the future and begin working with one another. Successful spinecare requires collaboration, networking and integration at many different levels. In the future physicians will strive for excellence and will do what is necessary to distinguish themselves and enhance their role in spinecare. This process will include acquiring additional training credentialing. New graduates will look for opportunities in multidisciplinary spinecare facilites and centers of excellence rather than small isolated practices.

Integrated spine centers will prioritize hiring of physicians and support staff who are well trained, credentialed, and experienced in various levels of spinecare. Emphasis will be placed on hiring staff which prioritize the delivery of conservative care because the majority of patients seen in these facilities will not require invasive or surgical intervention. This trend will enhance the role of the chiropractic physican, physical therapist, and physical medicine specialists. In the future the chiropractic physician may assume the role of a primary spinecare clinician. The future will also offer unique interdisciplinary residencies, fellowships and credentialing opportunities.

Physicians of the future will have a greater responsibility to direct their patients to online "need-to-know" information about their spine disorder and reasonable treatment options. Physicians will be encouraged to recommend patients with one or more chronic spine disorders to become a member of a national and/or international organization so they can stay informed and learn more about how they can help themselves. The future will bring new standards of care and will expand the responsibilities associated with informed consent.

Future Non-Operative Treatment Emphasis

In the future, priority will be placed on the delivery of conservative methods of treatment which promote favorable tissue repair and neuromuscular performance. Physical rehabilitation will focus on improving stability and function using techniques such as unstable base training, core muscle strengthening, enhanced coordination methods, and approaches which improve reaction time. Surgery will prioritize the use of motion preserving implants while moving toward the application of biological solutions to promote functional tissue regeneration and repair. Spine surgery will be used to set the stage for functional restoration includes novel approaches for providing biological scaffolds for tissue repair and adaptation.

Non-operative spinecare will require a more diverse team of individuals than invasive or operative care. Future spinecare settings which provide the full spectrum of care will have to have an integrated multidisciplinary team. Non-operative spinecare of the future will incorporate physical performance testing. This may be done in human performance labs developed as part of centers of excellence. They will likely include a gait lab as well as methods for objectively evaluating neuromuscular performance. The later will be used to help identify and monitor performance (fatique) induced muscle weakness (paresis) secondary to spinal cord and/or spinal nerve compromise. Protocols will be incorporated to stress the neuromuscular system so that neurological deficits associated with a spine disorders can be identified early. Physical performance testing facilities and/or protocols will become an important part of conservative treatment approaches. It will help serve as an important part of the foundation for evidence-based non-operative spinecare.

Future non-operative treatment approaches will place greater emphasis on weight management and clinical nutrition. Nutritional and nutraceutical approaches will be used to reduce inflammation and to promote favorable tissue anabolism. In some cases these approaches will be used with conservative pharmaceutical measures. Greater emphasis will be placed on the evaluation and treatment of spinal segment mobility. The approach will not be limited to looking for gross spinal instability which requires surgical stabilization.

In the future greater emphasis will be placed on soft tissue subsequently exercise/fitness specialists and massage therapists will become an important extension of the spinecare team. A healthy spine is dependent upon adequate muscular strength, muscular endurance, optimum body composition, cardiovascular endurance, segmental stability and overall flexibility. It is well accepted that the tissues of the spine repair and remodel based upon the stresses placed upon them. Proper posture and exercise facilitates a favorable tissue remodeling process. In the future healthcare professionals will develop a growing appreciation for the effect of exercise on tissue remodeling and neuroplasticity both of which will influence on the outcome of spinecare.

Invasive intervertebral disc treatment will incorporate various methods to help repair and seal the annulus while preserving segmental motion. Future approaches will incorporate advances in molecular therapy, gene therapy, as well as various cell-based therapies. Diffusion tensor imaging (DTI) will be used to assess water movement and the integrity microarchitecture within the intervertebral disc. Advanced imaging such as MRS and DTI will help direct minimally invasive approaches.

Future Invasive Care (Spine Surgery)

Spine surgery represents intervention into a complex and intricate 3D space surrounded by vital and delicate structures. Future breakthroughs in surgical planning will lead to better surgical outcomes. Computers will increasingly being utilized to help surgeons plan and participate in preparatory virtual sessions before spine surgery. Preoperative imaging data will be reformatted to digitally recreate internal spine environments in multiple dimensions. Computer generated models will be used to predict morphological characteristics after surgery and will also be used to predict spinal tissue function and mechanical stability.

Integrated data from imaging procedures will continue to be used to guide delicate stereotactic procedures. They will simply become more controlled and precise. The surgical field is relatively small and structurally complex therefore a digitally reconstructed landscape using both endoscopic and macroscopic views will be used to help plan and guide procedures. Increasingly powerfull hardware and software will be used in the future to fuse datasets from multimodality imaging sources such as CT, MRI and PET. The datasets will be used to develop computer simulated perspectives and assist neuronavigation systems. Advanced surgical planning is and will remain one of the most important steps for improving the outcome of spine surgery. The future operating suite will include robotic options, real-time virtual imaging of the surgial field and advanced stereotactic navigation equipment.

Prior to entering the operating room spine surgeons will be able to use a virtual system to explore and plan their surgical approach using imaging datasets. It will incorporate seamless integration of multimodality images such as CT, CTA, PET, MRI, and MRA. The operating room of the future will be integrated, offering customized connectivity to imaging derived datasets and navigation methods. The operating room staff will be able to access and display information whenever the surgeon needs it. Sophisticated hardware and software will be integrated to provide a detailed real and/or virtual view of the operative landscape and defined regions of interest. The spine surgeon will be able to look at the spine from any angle in multiple dimensions. The efficiency of the surgial workflow will improve dramatically.

Spine surgeons of the future will be able to access imaging derived biochemical maps of spine tissues matched with tissue segments. This information may be used to evaluate histoanatomic integrity and the biochemical basis of structural stability, process which will help guide the placement of stabilizing devices and /or arthrodesis.

Biological Solutions

Multidisciplinary spinecare will lead to greater application of conservative treatment measures and biological solutions. This will play a particularly important role in the treatment of spine disorders associated with aging and related degenerative changes. The term biological solutions refer to the use of the body's natural physiological processes and innate ability to recover. The approach encompasses a broad spectrum ranging from biochemical manipulation with clinical nutrition to surgical implantation of grafted tissue, biological tissue scaffolding or other supportive materials.

In the near future the list of biological solutions will include proteonomic and genomic intervention. Surgery will be used to deliver materials and products which can be implanted to synergistically work with or to replace diseased or degenerated tissues of the spine. Predictive multidimensional imaging reformatting and reconstruction will be used to predict how the treated area of the spine will look and function. The use of biologic material during spine surgery will represent one of the most exciting developments in future spinecare.

A Few Future Predictions

• Development of larger more integrated spinecare groups
• Expanded screening services
• Better reimbursement for larger groups who can leverage contract negotiations
• Greater public reliance on the internet to research treatment options and to locate professionals and facilities
• Greater willingness for the public to travel to obtain the best spinecare
• Advances in the implementation of telemedicine
• Greater use of physician assistants of various types
• Expanded large facility marketing and networking
• Full body spine imaging
• Use of integrated structural and molecular imaging
• Greater reliance on networking resources of national organizations
• Trending towards biological solutions

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