Minimally invasive spine surgery in socioeconomically disadvantaged populations—a narrative review

Introduction

Minimally invasive spine surgery (MISS) has gained popularity over open spine surgery, with benefits that include reduced blood loss, shorter hospital length of stay and similar postoperative outcomes (1-5). While such benefits were described within a broad population base of variable socioeconomic status, considerably less is known about the impact of MISS on a socioeconomically disadvantaged patient population. This discrepancy may be due in part to an underestimation by spine surgeons of MISS utilization, causing a relative neglect of research focus in the area. One international survey study demonstrated that a higher percentage of spine surgeons—regardless of geography—stated they utilized MISS techniques compared to the percentage of those who stated they believed MISS was considered “mainstream” (6). To better address and explore MISS access and outcomes in socioeconomically disadvantaged patient populations, we surveyed current literature under a Social Determinants of Health (SDoH) framework. SDoH describes the various non-health factors that contribute to immediate and long-term health and wellbeing (7). There is a plethora of factors that may contribute to SDoH in patients. For the purposes of this review, we chose to consolidate them into the domains of race, insurance status, economic status, education, and geography/environment. Significant departures from what is considered the expected population norm or minimal level necessary for adequate living in any of these areas is termed Socioeconomic Disadvantage or Deprivation. To objectively define the cutoff for disadvantage or deprivation, prior studies have generated validated tools which define and incorporate representative variables within each domain of SDoH to establish scores and indices for statistical comparison, such as the Area of Deprivation Index (ADI) or Social Deprivation Index (SDI) (8-11).

Our aim was to explore the current literature surrounding spine surgery and MISS in socioeconomically disadvantaged groups, identify gaps, and highlight future directions. We present this article in accordance with the Narrative Review reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-63/rc).

Methods

The dimensions of social determinants of health analyzed within open spine surgery and MISS included: race, insurance status, economic status, education, and geography. A literature review using PubMed, Embase, and Google Scholar for articles published between June 1994–May 2025 was performed using search keywords “Minimally Invasive”, “MIS”, “Spine”, “Orthopedic”, “Outcomes”, “Disparity”, “Disparities”, “Differences”, “Access”, “Disadvantaged”, “Race”, “Insurance”, “Environment”, “Geographical”, “Geography”, “Medicaid”, “Medicare”, “Health Literacy”, Accessibility”, “Financial Stability”, “Socioeconomic”, “Insurance Payor Group”, “Vulnerability” (Table 1). Article abstracts were assessed for relevancy, and articles were excluded if they failed to address one of the above-defined categories of SDoH and orthopedic spine surgery. A manual review of bibliographies of applicable articles was conducted to find additional relevant articles. Additional queries were done to answer additional questions within the realm of social determinants of health on outcomes of spinal surgery as necessary for background context.

Discussion

Race

Structural and interpersonal racism contribute to racial disparities in all facets of healthcare. The odds of adequate access to care, length of care, and explanation of care provided were shown to be lower in areas with established provider and state-level racism (12). Nonwhite patients are significantly more likely to report worse health status than White and Asian patients, are more likely to be uninsured, and are more likely to delay care due to cost despite higher rates of comorbidities and avoidable hospitalizations (13-15). Regardless of etiology, race directly impacts healthcare access and delivery and is well documented in the spine surgery population.

Despite a higher prevalence of disabling low back pain, nonwhite patients consistently experience worse outcomes after spine surgery (16). Black, Hispanic, and Asian American patients are less likely to undergo fusions compared with white patients despite an equivalent preoperative diagnosis. This difference may be due in part to an overrepresentation of nonwhite patients seeking care at low-volume hospitals, although additional contributing factors are likely at play (17-19). A recent meta-analysis also reported that black patients undergoing any spine surgery—open or MISS—have a higher post-operative mortality rate, longer hospital stays, and have higher rates of nonhome discharge (20). Rates of readmission and reoperation are also higher in nonwhite populations (21,22).

Existing literature on the intersection of race and MISS is sparse. One single-center study reported that African American patients undergoing transforaminal lumbar interbody fusion (TLIF) MISS were more likely to have an extended hospital stay compared with Caucasians (23). In contrast, a different work on patients receiving a MISS-TLIF from an institution with significant experience working with a minority predominant population found no differences in hospital stay, discharge disposition, or postoperative complications (24). This work suggested that comparable outcomes can be obtained in a system geared towards taking care of the diverse needs of a minority predominant population. Indeed, studies have shown that while Black and Hispanic patients are less likely to receive MISS, they are also more likely to be treated by low-volume hospitals and providers, further reinforcing how structural barriers likely play a pivotal role in access (25,26).

However, to date there are no large-scale, multicenter studies or meta-analyses on MISS that look at race as the primary variable of interest. Given the favorable intraoperative variables and comparable postsurgical outcomes of MISS compared with open spine surgery, it is necessary to establish whether patients of different racial backgrounds reap similar benefits, and whether MISS may help decrease the racial discrepancy evident in spine surgery. In addition, more should be done to address gaps in the literature about how other minorities fare in both open spine surgery and MISS. Studies are beginning to explore these questions in the American Indian, Alaskan Native, and Pacific Islander population (27). More work in this area should be encouraged to more accurately assess and act to reduce the racial care gap in US healthcare.

Insurance status

Medical insurance status strongly influences coverage and quality of care. Uninsured adults often receive less adequate care and have worse health outcomes than those with public or private insurance, which may be due to worse disease progression on presentation (28,29). While Medicaid patients have lower quality or unfavorable care compared with privately insured patients, Medicare patients have favorable provider access, care satisfaction, and less medical debt (30,31).

Disparities in spine surgery access and outcomes exist across many procedure types. High-deductible commercially insured patients have reduced access to cervical spine surgery (32). Anterior cervical discectomy and fusion (ACDF) patients utilizing Medicaid had worse outcomes than privately insured patients, and similar payor group patterns have been found in patients who underwent lumbar spinal fusions (33,34). While Medicaid patients who underwent lumbar laminectomy and fusion had significantly lower 2-year reoperation rates than commercially insured patients, this may be due to a lower likelihood of pursuing aggressive procedures or Medicaid patients not pursuing beneficial procedures for longer periods of time (35). A systematic review and meta-analysis performed in part by our group demonstrated that Medicare and Medicaid patients have a greater likelihood of morbidity and poor outcomes across all spine surgeries compared to privately insured patients (36).

There is no literature that directly assesses how insurance status affects the access to and outcomes of MISS. Given trends in minimally invasive surgery (MIS) utilization across other surgical specialties, along with documented insurance-based disparities in MIS access and outcomes, MISS is likely to demonstrate similar utilization patterns across payor types. The existing body of literature may not explicitly exclude MISS procedures in their analysis, and surgeon- and center-specific trends in MISS vs. Open spine surgery may impact findings. Additionally, payor groups may disincentivize MISS procedures even when patients are adequate surgical candidates or MISS is preferentially indicated due to relative procedural cost, which may further drive discrepancies in MISS utilization (37,38). Taken together, the relationship between healthcare access and MISS outcomes remains inconclusive. As healthcare systems continue to pursue equitable and value-based outcomes, a better understanding of how payor status influences access to and recovery from MISS is essential.

Economics and economic status

A patient’s insurance status, financial stability, and economic opportunity can significantly impact their ability to access high quality healthcare services. Patient economic status has been shown to impact their likelihood of a 90-day postoperative readmission, influences their length of hospital stay, impacts their likelihood of a postoperative complication, and can contribute to post-operative pain levels (39-41). There are limited prior publications on the impact of economic disparities specifically in minimally invasive spinal surgeries. Prior work has reported that patients with government insurance (Medicaid and Medicare) have a greater risk of perioperative morbidity than patients with private insurance and worse three- and twelve-month postsurgical outcomes, despite higher rates of indication for spine surgery (36,42,43). Interestingly, even within government insurance, state-specific inequity in access to spine surgeons has been demonstrated when comparing traditional Medicaid to Medicaid Advantage plans (44).

Perioperative and postoperative outcomes like post-operative pain, hospital stay length, and complication rate play central roles in establishing access to spine surgery, as favorable outcomes in these metrics impact the cost-efficacy of instituting procedures. Despite studies demonstrating MISS patients may have less post-operative pain, reduced hospital stays, and lower complication rates compared to open cases, its financial stability and accessibility to care remain under-analyzed (45). MISS appears to be cheaper to the hospital than open spinal surgery procedures, although disposable costs increase its up-front price; however this has mainly been demonstrated in posterior lumbar interbody fusion (PLIF) and TLIF MISS procedures (46,47). Further, though MISS has been shown to have lower total costs, it is reimbursed less than open procedures, suggesting a key implementation barrier to hospitals (41,47). Additionally, hospitals or regions without sufficient funding, limited medical technology, or adequate mentorship in MISS techniques make its implementation less likely (48). Additional research should be performed to further elucidate the relationship between the economic feasibility of implementation and access to MISS, especially focusing on how different MISS procedures and their associated implementation and utilization costs may benefit those with economic disadvantage. Findings in these areas might influence what surgical approaches physicians and hospitals might offer to this patient population that both maximize patient-related outcomes as well as promote cost-efficacy for both parties.

Education

Education heavily influences a patient’s ability to understand surgical risks and adhere to postoperative guidelines. Higher levels of education are positively correlated with patient health outcomes and lifespan, and lower education has been shown to limit accessibility to open spine surgery (49,50). Education enhances health outcomes by advancing health literacy, increasing accessibility to resources, encouraging healthier behaviors, and providing psychosocial benefits (51). Lack of college education has been correlated with higher pre-operative pain levels in spine surgery, while patients with higher education levels may also be more likely to return to work earlier after open lumbar surgery and have higher post-operative satisfaction (52-54). However, contemporary research surrounding the relationship between education and MISS is limited. MISS studies acknowledge that education is a significant confounding variable, however the specific effect that education level has on MISS postoperative outcomes has not been quantified (55). Further understanding the impact of varying education levels on MISS might lead to further optimization and improvement of postsurgical outcomes (56).

One possible route for exploration might be how education impacts pain management. Prior studies in open spine surgery show lower education levels correlate to greater post-operative pain, and patients suffering from cervical spondylotic myelopathy with education levels of high school or lower experienced greater pain and increased duration of symptoms prior to surgical intervention (57-59). This suggests that educational disadvantage may hinder how patients interpret their pain, possibly influencing when they seek surgical management, as well as postoperative pain control. Future efforts might consider exploring educational tools or enhanced education by physicians to address pain perception and disease management in patients with degenerative spine disease.

Environment and geography

Where patients live imparts environmental pressures that alter their access to healthcare and influence their comorbidity burden. Body mass index (BMI), activity level, type II diabetes mellitus, and poor health outcomes disproportionately affect patients living in socioeconomically challenged environments (60-62). Retrospective reviews and recent meta-analyses demonstrate that these comorbidities—especially inflammatory comorbidities like type II diabetes mellitus, hypertension, and chronic obstructive pulmonary disease (COPD)—may be associated with the development of spine pathologies like intervertebral disc degeneration (63-65).

Geographic location doesn’t just impact the development of spine pathology—it also impacts treatment approaches. Multiple studies have found variability in surgical approach preference in cervical and lumbar spine surgery based on geographic location. Lumbar fusions are more likely to be performed in the Southern US, whereas cervical fusions may be more likely to be performed in both the Southern and Northwest US. The authors attributed these geographic differences to disease prevalence, spine surgeon density, and surgeon knowledge and experience (66-68). Hospitalization and surgery rates for low back pain have also been found to be preferentially higher in the Southern US, suggesting a geographically dependent burden of disease (69). Despite this, there is a paucity of research regarding MISS and geography. However, geographic discrepancies in disease burden and surgical management should be explored to understand whether environmental factors or associated comorbidities affect MISS utilization.

Limitations of the study

There are several major limitations to the present review. First, given the present work is a narrative review, it likely does not fully capture all available literature regarding MISS in socioeconomically disadvantaged patient populations. Our review limited its scope to a review of three databases and thus may miss research published in others. While efforts such as bibliography searching and additional querying of relevant SDoH and MISS topics were employed to attempt to address this, it is possible we did not generate an exhaustive review encompassing the full breadth of available literature on the subject.

Secondly, the authors elected to analyze socioeconomic disadvantage through SDoH, and in doing so attempted to compartmentalize a broad topic into discrete, searchable categories. Given this, it is possible we did not capture all available research on MISS in socioeconomically disadvantaged populations, as there are many facets to the subject not necessarily described under the chosen subtopics. Our hope in choosing the above categories was to utilize sufficiently broad topics which incorporated the majority of facets to socioeconomic disadvantage, however we acknowledge this was likely not sufficient to capture all available literature.

Finally, given this article is a narrative review, it did not attempt to perform a quantitative analysis or synthesis of date to measure true effect sizes of results. In doing so it is not possible to make objective assessments of the strength of findings across the reviewed studies, and our analysis and conclusion are limited to descriptive and interpretive claims.

Future directions

This review explores the current literature available on how SDoH impacts care regarding MISS. However, the present narrative review is unable to draw definitive conclusions and provide evidence-based recommendations which might direct future research or help guide institutional or government-level direction on alleviating disparities. As such, it would be of great interest and benefit to query national registry databases and perform a nationwide analysis using validated social deprivation tools such as the ADI or SDI. Doing so would allow us to better understand the current landscape of MISS in socially disadvantaged populations and allow us to make targeted recommendations to alleviate gaps. Further, future studies should attempt to stratify amongst various MISS techniques [e.g., TLIF, posterior spinal fusion (PSF), anterior lumbar interbody fusion (ALIF)], allowing us to better understand how the unique economic, financial, and geographical differences guiding their utilization may impact the socially disadvantaged population.

Conclusions

SDOH is a major contributory framework that influences how we approach healthcare. Despite an extensive body of research that attempts to understand the relationship between spine surgery technique and the outcomes and categories that contribute to SDOH, these works have not focused on the MISS population. The increasing prevalence of MISS warrants a similar increase in the body of literature looking at how patients from disadvantaged socioeconomic backgrounds might benefit.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Surgical Journal for the series “Advances in Minimally Invasive Spine Surgery”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-63/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-63/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-63/coif). The series “Advances in Minimally Invasive Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. M.S.F. serves as an unpaid editorial board member of AME Surgical Journal from February 2025 to January 2027 and served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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