Lower back pain is one of the most common patient complaints. A new minimally invasive procedure at Duke Health promises relief to some patients. When the spine’s multifidus muscle atrophies, the resulting instability compounds lower back tightness and pain. The multifidus can be difficult to activate through physical therapy, but a restorative neuromodulation technique can stimulate the muscle to rebuild strength.

“We’ve used electronic stimulation in spinal care to modulate pain for quite some time,” says orthopaedic surgeon Peter G. Passias, MD, associate chief of the Duke Spine Division. “This is a relatively new procedure that’s novel in that it directly stimulates the muscle. We’ve found some regeneration correlatives of clinical improvements in pain and function.”

For patients with chronic low back pain who have failed conservative, noninvasive management, consider referral for evaluation. “I would advocate for patients to be evaluated at our Spine Center,” Passias says. “We have robust evaluation processes with the means and expertise to care for all types of back pain.”

If patients experience continuing lower back pain without a clear neurological or orthopaedic etiology, an MRI can help diagnose multifidus atrophy in the lumbar region. A same-day, minimally invasive procedure places a small controller in the pelvis with leads running to segments of the multifidus.

After the minimal recovery, the leads are programmed to stimulate the multifidus to contract and relax, strengthening the muscle over time. Rather than neuromodulation to override pain perception, the restorative technique helps rebuild the muscles that support the spine.

“To the patient, it can feel like exercising the lumbar area. They continue the regimen at home and typically see relief in three to six months,” Passias says. “Our studies have shown symptomatic and functional improvement, and five-year follow-up has seen steady improvement.”

The procedure is performed by Passias, orthopaedic surgeon Joe T. Minchew, MD, and neurosurgeon Nandan Lad, MD, PhD. It is offered at all Duke hospitals in the Triangle and is projected to be performed at Duke ambulatory surgical centers in the future.

“We pride ourselves on treating not only everyday conditions but ones that escalate to more complex levels of care,” says Passias. “Simple problems can become complex if not treated appropriately initially.”

Passias emphasizes that the support of the full system across all disciplines is key to patient outcomes. “Many people are involved in the process of undergoing surgery and recovery, from skilled providers in radiology, anesthesia, nursing, ICU, floor care, and postoperative rehabilitation. A center like Duke can coordinate care and offer expertise at all levels.”

Duke Orthopaedics is using artificial intelligence (AI) to improve patient care from expedited referrals to ambient transcription to treatment suggestions. Orthopaedic trauma surgeon Christian A. Péan, MD, MS, serves as the executive director of AI and information technology innovation for Duke Orthopaedic Surgery. “As artificial intelligence is being used increasingly, we want to make sure that we’re using it in a way that prioritizes access and excellence first and foremost,” Péan says.

The university’s long history of research into AI and machine learning makes Duke Health uniquely suited to developing and using AI solutions. “We have a raft of expertise and experience in developing these systems,” says Duke Health orthopaedic spine surgeon Brett Rocos, MD. “With the cases we see, we can feed these models a wide range of information, making it incredibly clever.”

The department is using AI to help expedite referrals and increase access. “We are really committed to expanding our digital front door,” says Péan. “We’re collaborating closely with care organization partners to use AI to more rapidly schedule patients, in order to help us document and find patients the right specialists at the right time.” He adds that AI also helps Duke providers communicate with referring physicians quickly and clearly.

“We encourage any and all providers to send patients to Duke,” Rocos adds. “No problem is too big or too small for Duke.”

Although implementation is still in the early stages, Rocos notes that the department is already using AI to assist decision making: “AI doesn’t replace the surgeon, but it can aid in surgical decision making. It’s like GPS in a car: the surgeon is still driving and choosing if these directions are the correct decision.”

This assistance helps while planning and performing surgery. “In spine, we’re using AI capabilities to make real-time decisions,” Rocos explains. “These systems can evaluate patients then and there while they’re asleep in front of us. AI systems use precise measurements to tell us when we’ve done enough to correct the patient’s spine. We can get the results we want without additional risk.”

Rocos reports improved outcomes and reduced procedure times among the benefits. “We’ve been able to do less surgery to reach the same goals, leading to shorter recoveries and shorter stays.”

Both physicians agree that governance and safeguards are vital to implementing AI in a clinical setting. “It’s still humans touching the patient and making the ethical decisions,” Rocos says. “We want to keep that human connection.”

Péan agrees that humans still need to take the lead: “I like to say that with AI, you don’t really ‘trust but verify.’ You verify and then trust, and only in that order.”

As AI is used across the medical field, Péan concludes, “[All physicians] have to be careful to balance our enthusiasm for using it to improve patient care with really thoughtful guardrails to make sure that we’re using it safely and responsibly. You need to have a really firm governance structure in place to vet any of these tools that we’re using, and we’re certainly doing that at Duke.”

Duke Health continues to advance spine surgery with minimally invasive procedures, including robotic, tubular, and endoscopic approaches. Endoscopic surgery, which can be performed as an outpatient procedure, in particular helps patients return to the activities of daily life faster, according to spine neurosurgeon David Huie, MD, MS. “With lower postoperative pain and quicker ambulation, patients can get up and get back to their lives faster. The recovery process doesn’t take as long,” he says.

Endoscopic spine surgery uses small incisions of about 1 cm to insert a camera and instruments into the spine. The procedure is most commonly used for decompression procedures with conditions including herniated discs, pinched nerves, and spinal stenosis, but indications for endoscopic procedures are always expanding. Endoscopy is also used for awake spine surgery by Duke neurosurgeons including spine surgeon Muhammad M. Abd-El-Barr, MD, PhD.

Duke Health’s spine neurosurgery team uses cutting-edge approaches to minimize patients’ pain and maximize surgical effectiveness. The team is also looking at new ways to use endoscopic surgery. “The techniques and surgical indications are growing,” says Huie. “Within endoscopic, one part has been performing less invasive versions of the surgeries we’ve already been doing, while another is utilizing the endoscope to perform operations that we were previously unable to do. The small size of the endoscope allows us to access areas of the spine that were previously more difficult or impossible to get to.”

Some aspects of surgery are currently considered too large for endoscopy. Procedures involving large portions of the back would take prohibitively long with present endoscopic techniques, but Huie anticipates a future where parts of those procedures could be done endoscopically. “Addressing problems such as deformity and oncology are some of the next things the field is working on,” says Huie.

Endoscopic spine surgery is only offered at a few advanced centers in the country. The expertise required to perform the surgery takes years of training, but Duke Health has multiple experienced endoscopic spine surgeons.

The decision to refer can be difficult. MRIs frequently aid surgeons in making a diagnosis, and Duke Health’s physicians are willing to consult with providers considering referral. “If there are any concerning imaging findings or symptoms, we’re happy to help,” says Huie. “We can look at imaging and determine whether they should see a nonsurgical provider first.”

Duke Health is expanding chiropractic care for patients with more access and more providers, offering a wide breadth of expertise from traditional chiropractic treatments to cutting-edge therapies. Seeing a chiropractor within the Duke system also enables patients to receive more advanced care or participate in clinical trials if necessary, says Duke chiropractor Justin Goehl, DC, MS.

“Our team has over 40 years of hospital- and multi-specialty experience,” says Goehl. “We’re all delivering quality of care that follows recommended guidelines. We’re dedicated to getting the patient to the right provider at the right time, whether that’s us, physical therapy, surgery, or another specialty.”

“Spine-related pain impacts patients’ quality of life,” says spine surgeon Christopher I. Shaffrey, MD, chief of the Duke Spine Division. “For a lot of people, chiropractic medicine makes them feel better quickly, and, as physicians, chiropractors can recognize if there’s something more serious going on that may require additional treatment.”

Current guidelines for spine-based conditions recommend conservative care as a first-line treatment before escalating to advanced imaging or surgery. This helps to reduce unnecessary or invasive procedures, as well as the likelihood of progression to chronic lower back pain. Treatment options include:

• Spinal mobilization/manipulation
• Myofascial release therapy
• Use of passive modalities and therapies
• Mechanical diagnosis and treatment
• Exercise guidance and home care suggestions

Although some think chiropractic treatment is a lifetime commitment, Goehl says the goal is to improve patients’ quality of life, reduce repeat injuries, and discharge them as soon as appropriate.

Shaffrey and Goehl agree that seeing a chiropractor can help patients with not only quality of life but also identifying conditions that may need more aggressive treatment. “We’re trained to evaluate all spine-related conditions and determine what treatment is appropriate,” says Goehl. “If someone comes in with a red flag for a surgically treated condition, we can identify that and help them get the appropriate care.”

Seeing chiropractors embedded within a larger hospital system offers patients significant benefits. “Providers can send patients to Duke with any spine-related complaint, and we’ll evaluate them and help identify the best avenue for their condition across multiple modalities, whether that’s chiropractic or another therapy,” says Goehl. Duke chiropractors also have access to all of the patient’s electronic health record, reducing the need for unnecessary testing or redundant imaging.

Duke’s comprehensive spine health program reduces uncertainty for referring providers. “If you’re not sure what conservative care option is right for a patient, we have a decision tree,” says Goehl. “We can evaluate the patient and help determine their needs. We’re here to help.”

Duke Health is growing its spine services through innovative research and adding new providers. “We want to be the leading comprehensive spine group in the Southeast and one of the leading groups in the country,” says spine surgeon Christopher I. Shaffrey, MD, chief of the Duke Spine Division, which combines the expertise of the departments of neurosurgery and orthopaedic surgery at Duke.

The new physicians complement the spine division’s breadth and depth with several experienced and well-known surgeons. “We’ve brought in people to facilitate engagement, access, and the ability to address simple to complex conditions across the Duke spectrum,” says Shaffrey.

The world’s second spine navigation unit recently came to Duke to improve instrumentation accuracy in endoscopic spine surgery. Spine tumor treatment, oncology, and osteofragility fractures are also leading areas of research. “Our surgeons are helping develop the latest and best treatments and technologies,” says Shaffrey.

The experienced physicians joining the staff add to treatments for complex spinal conditions, including awake spine surgery, severe scoliosis surgery, spine revision surgery, and chiropractic options. The new hires also increase access for patients, with more appointments in more locations throughout Durham and Wake counties.

Patients coming to Duke Spine don’t always start with surgery. “It’s very important that we engage people and look for the simplest treatment to take care of a substantial number of symptoms,” says Shaffrey. “This can help with optimization and insurance approvals, but more importantly, it gets patients healthier for surgery if it’s required.”

In this effort, the Duke Spine Health Program is adding more chiropractors and other nonoperative options for care. “Spine-related pain impacts patients’ quality of life,” Shaffrey says. “For a lot of people, chiropractic medicine makes them feel better quickly, and, as physicians, chiropractors can recognize if there’s something more serious going on, requiring additional treatment.

“Duke has been very forward thinking in bringing this group of capabilities together. The goal is to have any patient with any condition in the U.S. referable to Duke to have outstanding, cutting-edge treatment.”