Innovation and fundamentals: why old-school surgery still matters

Revisiting the basics in an era of innovation

Every conference, every journal, every industry presentation promises greater precision, fewer complications, and better outcomes. Yet in quieter moments, during training, in the OR, or when discussing complications, an important question sometimes emerges: Are we forgetting the basics?

You probably know about Scott's Parabola—where new methods are adopted too fast, only to be dropped when they don't work or hurt patients. Spine surgery has, for example, seen that before with things like Intradiscal Electrothermal Therapy (IDET).

Old-school surgery is not something that's outdated and unsafe. It's about having a deep grasp of anatomy, having a clear understanding of how the anatomy really works, careful exposure, skilled hands, and good decision-making.

These are the ideas that modern improvements are grounded upon. I believe that improvements and basics should go together. Old-school surgery still matters because it's key to safety, being able to adapt, training, and good results for patients.

What “old-school” surgery actually means

Old-school is often misunderstood. It does not mean ignoring proven innovations, rejecting small incisions, disliking technology, or favoring unnecessarily large exposures and prolonged procedures. Instead, it represents something far more essential.

Old-school surgery is about mastering anatomy with absolute precision, understanding biomechanics beyond algorithms, remaining comfortable with open surgery when necessary, trusting judgement over machines, adapting strategies when conditions change, and solving problems decisively.

Technology is a remarkable tool—but it must never substitute for thinking.

No machine is able to replace a surgeon who really knows anatomy. New tools can fool you into believing that everything is safe. Navigation provides coordinates; robots ensure direction and X-rays to indicate position.

But what if:

• The registration is wrong?
• Things are out of place because of issues or surgery?
• The system crashes?
• The anatomy is strange due to trauma, infection, or a tumor?

Anatomy: the one skill that cannot be outsourced

No machine can replace a surgeon who truly understands anatomy. Navigation provides coordinates. Robots assist with trajectories. Imaging confirms positions. These systems are immensely helpful—but they are also vulnerable.

Registration errors occur. Anatomy shifts during surgery. Systems crash. Patients present with distorted anatomy from trauma, infection, tumors, or previous operations. In these moments, only anatomical mastery prevents catastrophe.

Traditional training emphasized tactile and visual learning: feeling for bone landmarks, recognizing subtle variations, understanding soft tissue behavior, and appreciating how pathology alters normal structures. These skills allow surgeons to change plans when necessary, recognize danger early, and work safely even without technological assistance.

Tech is supposed to help you understand anatomy, not replace it. I believe knowing anatomy well is a very good foundation for surgery.

Biomechanics: fashion changes, physics does not

Surgery is not merely about decompression, implants, or motion preservation. It is fundamentally about load sharing, alignment, and long-term mechanical behavior. Implants have evolved dramatically, yet the principles governing success remain unchanged.

When biomechanics are ignored, fusions fail. Adjacent segment disease often reflects alignment and load distribution issues. Screw loosening is rarely a hardware problem—it is usually a planning problem.

Old-school training taught balance long before it became fashionable, reinforced the critical role of alignment, and highlighted the consequences of over- or under-instrumentation. Surgeons grounded in biomechanics select implants thoughtfully, avoid unnecessary hardware, and tailor procedures to patients rather than catalogues.

Old-school training focused on:

• Balance long before it was fashionable.
• How alignment is the difference between you and the results.
• What should happen when you use too much hardware or too little.

Open surgery vs MISS: smaller is not always safer

Minimally invasive approaches have transformed modern surgery. Smaller incisions frequently reduce blood loss, accelerate recovery, and shorten hospital stays. These are real victories.

But smaller does not automatically mean safer.

Limited exposure can compromise visibility. Complex revisions, distorted anatomy, tumors, infections, and major complications often demand direct visualization and manual control.

Old-school training emphasized wide exposure, when necessary, meticulous identification of neural structures, hands-on hemostasis, and careful tissue handling. A surgeon who lacks comfort with open surgery is inherently limited. When complications arise, solutions are rarely minimally invasive.

Repairing failed surgery requires confidence, dexterity, and the ability to manage scar tissue, bleeding, dural tears, and instability—skills that cannot be learned exclusively through tubes or scopes.

Decision-making: the most critical skill of all

Technology can assist in performing surgery. It cannot decide whether surgery should be performed at all.

I have concerns that one of the unintended risks of modern minimally invasive techniques is the potential to lower the threshold for intervention. When procedures appear easier and less disruptive, overtreatment becomes a real concern.

Historically, surgeons were trained to observe patients carefully, correlate imaging with symptoms, and consider non-operative alternatives. Now that we can do more with technology, it’s more important than ever to hold back when it matters.

Judgement is built through experience, mentorship, reflection, complication analysis, and long-term patient follow-up. These elements remain irreplaceable, regardless of AI or protocol-driven systems.

Training the next generation: are we cutting corners?

Perhaps the greatest challenge lies in education. Trainees may insert screws using navigation before mastering freehand techniques. They may become proficient in minimally invasive methods without developing competence in open surgery. Software planning may replace deep biomechanical reasoning.

But what happens when technology is unavailable, unreliable, or misleading?

Surgeons trained on fundamentals can transition between techniques, operate safely in resource-limited environments, and adapt when conditions deviate from plans. Training programs must ensure that innovation complements, rather than replaces, foundational skills.

Complications: where fundamentals truly matter

All surgeons encounter complications. The difference lies in recognition and response.

Experience cultivates an instinct for when something is not right, sensitivity to early signs of neural risk, and pattern recognition that is difficult to quantify but vital for safety.

When major complications occur—vascular injuries, dural tears, neurological compromise—surgeons must act decisively, often requiring immediate exposure and direct repair. This is where old-school training proves indispensable.

Innovation, evidence, and the passage of time

Not every new technology ultimately delivers on its promise. Surgery has witnessed cycles of rapid adoption followed by abandonment when outcomes disappoint.

Many modern innovations lack long-term data. Some generate early enthusiasm yet require refinement and cautious implementation. Meanwhile, established techniques endure precisely because they work.

Old-school surgeons often:

• Have an instinct for when something doesn't feel right.
• See signs early that a nerve is at risk.
• Use their gut from having seen previous patterns.

These things are hard to quantify, but they are essential to preventing things from getting bad. When major problems occur, such as blood vessel damage, tears, or nerve injuries, you invariably need to make a cut fast, fix things directly, and stay calm. It's in these scenarios that old-school training pays off.

True progress lies not in replacing the old with the new, but in integrating innovation with proven principles.

Culture, mentorship, and professional identity

Old-school surgery was never solely about technique. It fostered responsibility, humility, mentorship, and long-term patient relationships.

Modern systems—with shorter training periods, increasing efficiency pressures, and rapidly shifting clinical environments—risk diluting these values. Preserving them is as important as adopting new tools.

Rethinking the term “old-school”

Perhaps “old-school” is the wrong phrase altogether.

What we are really discussing are fundamentals: enduring principles, timeless skills, and judgement that cannot be automated. Innovation should build upon these foundations, not replace them.

Conclusion: progress requires foundations

Surgery must continue to improve. Stopping would be wrong. But advancement without fundamentals risks creating surgeons who are technologically proficient yet vulnerable when precision, anatomy, or judgement are tested. 

Old-school surgery still matters because anatomy matters, biomechanics matter, judgement matters, complications still occur, and patients remain human beings rather than technical challenges.
Technology will evolve. Techniques will change. Hardware will improve.

The best surgeons will be at the cutting edge of new ideas as well as old basics. In the long term, tech will change, screws will change, and the way we do these things will trend. Yet the core principles of safe, thoughtful, patient-centered surgery remain constant. Old-school surgery is not a relic of the past. It is the foundation of the future.