“What makes our new center unique is that we offer a ‘one stop shop’ where a patient can be seen by a surgeon and other experts as needed, get updated imaging and other tests, receive a diagnosis and be given a treatment plan tailored to their specific needs all on the same day,” says Han Jo Kim, MD, director of the new center and HSS spine surgeon. He adds that other centers could take weeks or even months to line up all the necessary appointments and provide a care plan recommendation.

Spine care at the CSSC is bolstered by a combination of highly specialized experts across multiple specialties and a decade of HSS-led research on advanced surgical techniques and recovery pathways. This has helped them transform the most challenging spine surgeries into much more straightforward operations with lower complication rates and faster recovery times.

“We have shortened the time it takes to do these surgeries, reduced complications, decreased patients’ length of stay in the hospital and shortened their recovery time, allowing patients to get back to what they love most,” says Dr. Kim.

The range of specialties the CSSC offers include anesthesiology, infectious disease, interventional radiology, metabolic bone, neurology, pain management, physical therapy, physiatry, and spine surgery. Care navigators help make the care experience easier by guiding patients through next steps, coordinating appointments and when possible, arranging visits with the appropriate physicians and receive any necessary imaging on the same day.

“We are integrating clinical triage so we can get the right patient to the right physician the first time for the care they need, as well as ensure a smooth experience for the patient and the physicians involved,” says HSS spine surgeon Andrew Sama, MD, co-chief of HSS Spine.

This streamlined approach is particularly helpful for the over 1,000 patients who travel to HSS annually from out of state or out of the country to see our surgeons, nearly 500 of whom receive surgery here.

“We want to meet patients where they are, and if they’re traveling a far distance, it’s especially important to make the most of their time here,” says HSS spine surgeon Sheeraz Qureshi, MD, MBA, co-chief of HSS Spine.

CSSC care is available to adult and pediatric patients at HSS locations in Manhattan, Long Island, Brooklyn, Queens, New Jersey, and Connecticut. “HSS has invested a lot into our regional sites so that we can bring complex spine care to the communities we serve,” adds Dr. Qureshi. This builds on the recently opened multidisciplinary Spine Center in Paramus, which expands access to world-class spine care through a collaborative approach and state-of-the-art facilities.”

Another focal point of the CSSC at HSS is the development of a clinical registry to detect and study genetic indicators of risk for a variety of postoperative complications.

“This is next-level precision medicine, where we are using a person’s genetic makeup to mitigate certain risks or complications that they are likely to face after surgery,” explains Dr. Kim. “For example, if we find that somebody is genetically prone to infection or blood clots, we can give them medication to minimize or prevent those risks and ensure they have the smoothest recovery possible.”

To learn more or to request an appointment by submitting your case to the CSSC at HSS, please visit: https://www.hss.edu/departments/spine/complex-spine-and-scoliosis-center

Patient Success Story:

For 20 years, Long Island resident Susan had been living with diffuse idiopathic skeletal hyperostosis (DISH), an osteoarthritic condition that causes ligaments and tendons in the spine to calcify, leading to stiffness and pain. In 2023, after two traumatic falls, Susan endured a spinal cord injury, leaving the 57-year-old unable to lift her head. She scheduled an appointment with Dr. Kim for an evaluation for reconstructive surgery.

“I was totally looking down, and I couldn’t lift my head to see ahead of me. I was very limited, and it was challenging to get around with my walker. I would have been miserable if I had to live the rest of my life like that,” says Susan.

“I knew from my research that Dr. Kim was a superior surgeon, but I was also impressed with how he spoke to me and not at me, and used words I could understand,” Susan recalls. “I felt a connection with him right away and was relieved when he said he could help me.”

Susan had surgery in June of 2025 and after six weeks of recovery and rehabilitation, she says her life has changed for the better.

“Dr. Kim corrected my posture immensely so I can stand up straight, look forward, and see people ahead of me now. My chin is up!” she says. “He changed my appearance and made me look healthier, so I don’t appear distorted or in pain. I’m deeply grateful for what he’s done. Dr. Kim and the care team at HSS made such a meaningful difference in my life.

While Susan has some lingering weakness from the prior spinal cord injury and DISH, having surgery with Dr. Kim has improved her quality of life, allowed her to continue living independently and given her the chance to help care for her aging parents.

Today at the American Academy of Orthopaedic Surgeons (AAOS) 2021 annual meeting, details of an enhanced recovery pathway developed for these patients were presented and the improvements that patients saw after being treated with this approach were described. The results of the investigation into its effectiveness were also published in January 2021 in The Spine Journal.

“In today’s healthcare environment, we’re all looking for ways to decrease costs and improve the quality of care we deliver,” says HSS spine surgeon and principal investigator Han Jo Kim, MD. “We wanted to see which factors were modifiable in the care of these patients, to help us decrease the time spent in the operating room and patients’ length of stay and minimize complication rates.”

The team started using its enhanced recovery pathway in February 2019. The study reports data from 40 patients who underwent fusions of at least five vertebrae in the lower back using the new protocol. Although spinal fusions of five or more vertebrae are considered complex procedures, they are relatively common and used to treat a number of conditions.

“Traditionally, these patients stayed in the hospital for at least seven or eight days,” Dr. Kim says. “This procedure has a high reported complication rate, and a high rate of revision surgeries, 90-day readmissions and dependence on rehabilitation facilities upon discharge. For those reasons, we thought it would be an important operation to evaluate when we started targeting methods to improve complex spine surgery.”

One key component of the new treatment pathway was always using the same surgical team, including surgical technicians, nurses and anesthesiologists. After surgery, the same physical therapy team cared for all the patients in the study, and patients were mobilized three times a day. Rigorous patient selection was also important for ensuring that patients could fully benefit from the optimization.

During surgery, the team focused on minimizing blood loss and keeping the time spent in the operating room as short as possible. When feasible, powered surgical instruments were used. The surgeries were done in four stages of one hour each, so that all members of the team would know how to anticipate the next phase of the operation.

Several changes were made postoperatively as well. The regimen for pain medication was modified to reduce the complications seen from narcotics. The patients were prompted to get out of bed the same day as their surgery, instead of waiting until the next day. And physical therapy sessions were increased from twice a day to three times a day.

When compared with matched patients treated without the optimized pathway, the study population achieved remarkable results. No patients went to the intensive care unit following surgery, compared with a usual rate of 30%. Hospital stays were decreased from an average of 7.3 days to 4.5 days. A higher rate of patients were discharged home versus to a rehabilitation facility (95% versus 65%). Overall patient outcomes at one year were equivocal.

“HSS is uniquely positioned to execute a program of this kind, because everyone here is dedicated to orthopedic surgery and care. That enables us to create and initiate optimized pathways,” Dr. Kim says. “Not every hospital has the infrastructure and resources to build this type of program, but we wanted to share what we did so other centers could model it. Ultimately, the goal is to improve the quality of care that we provide for patients and to decrease the costs by instituting such pathways across multiple healthcare systems in the country that care for complex spine patients.”

Spinal fusion is among the most commonly performed orthopedic surgeries in the United States, with more than 400,000 patients undergoing the procedure each year. Although most cases are successful, as many as 45 percent of patients experience complications after the operation, often resulting from the bone’s inability to tolerate the hardware surgeons use to support the skeleton. 

The most widely used technology to evaluate patients’ bones before spine fusion surgery is called dual x-ray absorptiometry, or DXA. DXA imaging gives physicians a rough sense of the strength of a person’s bone, but it is not foolproof. In some cases, surgeons find that patients whose DXA scans appear normal have bones that are so weak that the appliances they use during spinal fusion are at risk of failure. 

The HSS researchers hypothesized that a more sensitive measure of bone quality could identify abnormalities in the skeleton that DXA does not detect, and that these defects would be linked to postoperative complications. 

For the new study, the team led by Emily Stein, MD, an endocrinologist and bone specialist, along with spine surgeons Han Jo Kim, MD, Matthew Cunningham MD, PhD, and Frank Schwab, MD, turned to a cutting-edge technique for assessing bone called high-resolution peripheral quantitative computed tomography (HR-pQCT). HR-pQCT can separately measure how much bone is in the outer (cortical) and inner (trabecular) compartments and measure on a microscopic level how the inner trabecular bone network is organized, including the number, thickness and spacing between the parts of that network called trabeculae. These measurements—known broadly as the microarchitecture—may provide a much more robust assessment of skeletal health than DXA, particularly in this population of patients who frequently have changes in the area of the fusion which undermine the utility of DXA. 

“DXA provides a two-dimensional measure of bone density, or the amount of bone present, whereas HR-pQCT provides a true three-dimensional measurement of the bone density,” Dr. Stein said. “This provides additional information about the structural features of bone that can be leading to weakness or fragility.”

The study included 54 men and women scheduled for spinal fusion at HSS between December 2017 and December 2019. Patients underwent conventional DXA scans, as well as HR-pQCT scans of the radius (forearm) and leg bone (tibia).

Of the 54 patients in the study, 14 experienced complications within the first six months of surgery, including broken rods, loosened bone screws, fractures and abnormal bending of the spine. Although the number of people in the study was small, the researchers found that those with abnormalities on HR-pQCT were significantly more likely to experience complications than those without such defects -- abnormalities that were not evident on DXA imaging. These abnormalities involved lower bone mineral density in the trabeculae (the spongy tissue in the center of bones), fewer and thinner trabeculae, as well as thinner cortices.

“We used HR-pQCT to show for the first time that abnormalities in the microscopic structure of bone are directly related to the development of complications after fusion. Our study identified several abnormalities in patients who had complications,” Dr. Stein said.

For the moment, HR-pQCT is a research tool that’s not widely available to surgeons. “I think that it does provide a lot of additional information that we’re not getting from DXA. On DXA, the spine is almost always going to look fine, which can be misleading,” noted Dr. Stein. 

Dr. Stein’s group is expanding their study to include more patients. “Spinal fusion surgeries are so invasive, the potential for complications is high,” she explained. “We want to have the most optimal strategies for lowering complications in our patients, and that begins with understanding who is at risk and why. In our future work with additional patients, we hope to be able to define which features, or group of features of the bone structure is most important in contributing to surgical success. This will help us to devise the most targeted treatment strategies for our patients.”

Dr. Stein's team published their findings in the journal Bone, and made available online first on November 4, 2020.

Philip Louie, MD, who recently completed a spine surgery fellowship at Hospital for Special Surgery (HSS), has given the subject a lot of thought. “Peak performance is the ability to achieve optimal outcomes or performance of a given task in a consistent manner. Although commonly studied in athletes and musicians and promoted in other careers as well, peak performance is rarely considered for those undergoing the rigors of surgical training,” he said.

A classically trained musician and former varsity athlete himself, Dr. Louie thought about how he could apply his preparation in these areas to surgical residency training and help others achieve peak performance. Long interested in the kind of growth mindset that drives long-term success, he majored in business before attending medical school to gain new insights and learn to “think outside the box,” he said.

Dr. Louie and colleagues at HSS set out to review the current literature on residency training and to discuss the value of assessment tools and critical performance measures. In an article published in the Journal of the American Academy of Orthopaedic Surgeons, the HSS physicians offer practical advice for both educators and trainees on reaching peak performance.

“Residency is a crucial period of training where foundations for future success are established by habit and daily practice,” said Michael McCarthy, MD, a former spine surgery fellow at HSS and co-author. Dr. McCarthy, a former college football player and history major, cited the intensity of Division I athletics and the diversity of thought and opinion in his studies as the foundation and impetus to explore achieving peak performance in training. “We believe the same tools that enable those in other fields to be at their best could equip surgical trainees with the tools necessary to achieve peak performance. It’s crucial for physicians seeking to perform at the top of their game and will ultimately benefit patients.”

The HSS physicians say peak performance is essential in an evolving health care landscape that demands optimal clinical outcomes and value-based medicine. The COVID-19 pandemic is also placing unprecedented demands on physicians. Coronavirus cases surged while Drs. Louie and McCarthy were in the middle of their spine surgery fellowship. The attributes they discuss in their article − perseverance, grit and stoicism − were essential when, almost overnight, HSS went from an orthopedic specialty hospital to a “surge” center treating coronavirus patients to take the load off overwhelmed neighboring hospitals.

“During that stressful time, when New York City was the epicenter of the pandemic and we cared for COVID patients in the ICU, the important thing was to take a step back and remember why we decided to enter medicine,” Dr. Louie notes. “We had been given the gift of opportunity, and it was our duty to persevere and make the most of it and play our role in guiding our communities through the crisis. What we gained from collaborating with other healthcare professionals and caring for patients in their time of greatest need will last far beyond the pandemic.”

When the crisis was under control in New York City, HSS transitioned back to a dedicated musculoskeletal center, resuming elective surgeries in the beginning of June.

In their article, Drs. Louie and McCarthy outline several key areas and recommendations to achieve peak performance, including growing self-awareness through mindful activities. “We realize that some of these concepts are off the beaten path for orthopedic trainees, but they’re important nevertheless,” said Dr. McCarthy. “When you’re used to focusing on evidence-based medicine, these can seem like nebulous concepts, a skill set difficult to grasp for detailed-oriented surgeons.”

They break down their recommendations on reaching peak performance into five key areas that encompass both physical and mental skills:

1 - Translating Practices from Peak Performers in Other Fields

• Refine physical skills through improving mental engagement during a task. Practice focusing solely on the task at hand.
• Develop a program for deliberate practice in which you can undergo critical assessments to allow for graduated improvement.
• Grow self-awareness through mindfulness activities to promote “flow” states. The term “flow” is best described as a state of full engagement, control, concentration and action awareness occurring during an activity perceived as highly rewarding and characterized by clear goals.
• Create and consistently review step-by-step notes on specific techniques to develop proficiency that can be translated directly to intraoperative opportunities.

2 - Goal Setting and Accountability

• Align goals with values, create a plan and visualize the goals.
• Identify an accountability partner or system.
• Anticipate obstacles and possible solutions.
• Ensure work-life balance.
• Reward goal accomplishment.

3 - Developing Technical Skills

• Seek opportunities outside the OR for skill acquisition. Evaluate how other departments in the hospital may be training their residents.
• Encourage the program director to consider new technologies, such as bioskills simulations and virtual reality training.
• Upon seeking feedback on surgical techniques and proficiency, identify activities that can improve areas requiring additional practice.

4 - Perseverance and Grit

• Believe in constant change and grow.
• Understand that frustrations are part of the process.
• Focus on productivity.
• Look for ways to make work more meaningful.
• Practice deliberately.
• Consider the principles based on Stoicism during long periods of difficulty or moments of crisis.

5 - Mentorship

• Monitor, track and measure the results of the mentorship relationship.
• Define the strategic purpose of the mentorship.
• Identify a strong match based on the skills of the mentor and the needs of the mentee.

Both Drs. Louie and McCarthy underscore the importance of mentorship and say they appreciate the “amazing” mentors they had at HSS: spine surgeons Todd J. Albert, MD, and Han Jo Kim, MD. But many residents and fellows at other hospitals are not as fortunate, Dr. Louie notes. “A lot of mentors don’t put time into the relationship. They only meet with the trainee twice a year,” he says. “I think mentorship needs to be much more formalized. You need to ensure a good match and set formal strategic goals on both sides of the mentorship. There needs to be accountability and checkpoints over time as to how the relationship is going and what can be done to improve it.”

Drs. Louie and McCarthy recently completed their fellowship training, but they plan to continue to collaborate with doctors at HSS to establish an initial curriculum based on the principles and strategies they outline in their paper. They believe educators should aim to equip surgical residents with the tools necessary to achieve peak performance during training, so they can apply what they learn throughout their careers.

# # #

Journal of the American Academy of Orthopaedic Surgeons – September 1, 2020

“Reaching for Peak Performance During Surgical Training: The Value in Assessment Tools and Critical Performance Measures”

Louie, Philip K. MD; McCarthy, Michael H. MD, MPH; Albert, Todd J. MD; Kim, Han Jo MD