In spine surgery, timing matters. Technique matters. Patient selection matters.
What has changed over the past few years is who shows up for surgery, and how prepared they are when they arrive.
Glucagon-like peptide-1 receptor agonist (GLP-1) medications have moved quickly from being primarily diabetes drugs to something many of my patients have either tried or are actively taking. National spending on GLP-1 medications increased more than fivefold between 2018 and 2023, rising from $13.7 billion to $71.7 billion in inflation-adjusted dollars, according to recent data in JAMA Network Open. That kind of growth signals more than a trend. It reflects a structural shift in how obesity is being treated in this country.
As a board-certified neurosurgeon, I do not prescribe these medications, but I am seeing their downstream impact in my clinic. Increasingly, patients come to consultation having already lost weight medically or actively working on it. Five years ago, most had tried dieting and exercise alone before considering surgery. Now it is far more common to see measurable metabolic improvement before we even begin discussing an operative plan.
That changes the risk conversation.
When weight becomes a surgical risk factor
Obesity is not a character issue in my office or simply a number. It is a physiologic variable that carries measurable surgical implications.
Higher body mass index is associated with increased wound complications, infection, anesthesia challenges and longer hospital stays across surgical specialties. Data from a recent multicenter analysis in Cureus found that obese patients undergoing elective surgery had higher rates of surgical site infection and pulmonary complications, along with longer operative times and hospital stays than normal-weight patients. In spine surgery, excess weight also affects positioning, blood loss and wound healing, all of which influence complication risk and recovery.
Those clinical realities have economic consequences. A 2025 systematic review in the Journal of Managed Care & Specialty Pharmacy found that direct medical costs for people living with obesity were up to three times higher than for individuals at normal weight, with costs rising further when conditions such as type 2 diabetes or hypertension were present.
In practice, body mass index (BMI) is less than likely the only factor. It is usually part of a broader metabolic picture that may include diabetes, sleep apnea or cardiovascular strain. When those conditions overlap, surgical risk tends to rise accordingly.
Modest weight loss can shift outcomes
There is a misconception that unless a patient achieves dramatic weight loss, nothing meaningfully changes. In practice, that isn’t always true.
Even modest reductions in BMI have been associated with lower annual health care spending, with employer-sponsored insurance data in JAMA Network Open linking a 5 percent BMI reduction to projected savings of roughly 7 to 8 percent. Similar trends were observed in Medicare populations.
Five percent is not a cosmetic transformation. But physiologically, it can matter.
In surgical terms, even modest weight reduction can improve blood pressure control, stabilize glucose levels and improve baseline mobility. Those improvements are associated with lower infection risk, fewer wound complications and often a steadier recovery. In some cases, that translates into shorter hospital stays and fewer unplanned readmissions.
Weight loss does not eliminate surgical risk or guarantee a perfect outcome, but it can meaningfully improve the margin for safety.
Honest conversations in a post-GLP-1 world
The cultural tone around weight has also shifted.
When patients arrive having already pursued medical weight loss, the discussion is often less defensive and more practical. We can talk about BMI as a surgical variable rather than a personal failure. That makes it easier to focus on what matters: reducing risk and protecting outcomes.
The conversation must remain honest and free of stigma, recognizing that obesity is a disease state with measurable physiologic consequences and that addressing it before surgery is about safety, not appearance.
At the same time, guardrails are important. Recent reporting has highlighted high discontinuation rates for GLP-1 medications, particularly among older adults, with cost and side effects cited as common reasons. Concerns have also been raised about lean mass loss. Recent reporting in The New York Times has highlighted discontinuation trends and questions around muscle preservation.
For surgeons, the goal is not simply weight reduction but metabolic optimization while preserving strength. Muscle loss in older adults can increase frailty and fall risk, which directly affects postoperative recovery, so attention to protein intake, resistance training and coordination with primary care or endocrinology becomes part of responsible preparation.
This is not about prescribing lifestyle advice, but making sure the patient is physiologically prepared for the stress of surgery.
Why “sooner” does not always mean safer
Patients understandably want relief, and when pain is persistent or function is limited, the instinct is often to move quickly. There are certainly situations where prompt surgery is necessary, particularly when progressive neurologic deficits are involved.
But in elective spine surgery, there are cases where a short period of medical optimization can meaningfully change the risk profile. If a patient can achieve even a 5 to 10 percent reduction in body weight while stabilizing metabolic markers and improving conditioning, the procedure itself may be safer and recovery more predictable.
Taking time to optimize is not about delaying care but about aligning a patient’s physiology with the demands of surgery. In many ways it is similar to coaching, where you would not send an athlete into a high-stakes game without preparation. Surgery is a controlled physiologic stress, and reserve matters.
The downstream cost implications
Complications are not just clinical events; they carry financial consequences. Readmissions, wound issues, prolonged hospital stays and extended rehabilitation all increase total spending for health systems and payers. The Journal of Managed Care & Specialty Pharmacy review showed how costs rise as obesity severity increases and climb further when metabolic conditions overlap, while a 2024 analysis in JAMA Network Open suggested that even modest reductions in BMI are associated with projected savings.
From a surgeon’s perspective, those figures reflect what happens at the bedside. When complication rates decrease, downstream costs often follow. Fewer infections mean fewer additional procedures. Shorter hospital stays reduce resource use. A steadier recovery lowers the likelihood of unplanned care. Medical weight management before surgery, including GLP-1-enabled approaches when appropriate, may therefore improve individual outcomes while also reducing the cumulative cost burden tied to surgical complications.
Staying in the surgical lane
It is important to stay within scope. My responsibility is not to promote or oppose a specific medication, but instead to evaluate surgical risk, counsel patients clearly and operate when the expected benefit outweighs that risk. What has changed is that more patients now have access to tools that can improve surgical readiness before they enter the operating room.
When used thoughtfully, with attention to muscle preservation and long-term sustainability, medical weight loss can actually lower complication rates, support a steadier recovery and reduce downstream strain on both patients and health systems. Preparation doesn’t guarantee perfection, but in spine surgery, it often makes the difference between a difficult course and a predictable one.
Photo: Peter Dazeley, Getty Images
Brian McHugh, MD, FAANS, FACS, is a board-certified neurosurgeon serving the New York City metro region. He completed his neurosurgical residency at Yale University and advanced fellowship training in complex and minimally invasive spine surgery at the Hospital for Special Surgery in New York City where he served as the John Cobb Fellow in Adult and Pediatric Spinal Deformity. Dr. McHugh specializes in treating degenerative spine disease, spinal deformity, and complex spinal conditions, with a focus on patient-centered, evidence-based care.
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