Total Joint Replacement for the Lumbar Spine

An alternative to spinal fusion for leg and back pain.


Is This For Me?

If any of these sound like you, you’re in the right place.

  • “My doctor recommends fusion surgery, but I’ve heard stories that concern me.”
  • “Pain controls my life! I want to be healthy and active again.”
  • “Aren’t there more advanced solutions available?”

What's the procedure?


The BalancedBack procedure is the first “total” joint replacement for the lumbar spine. It represents a major advancement in how leg/back pain is treated, and follows closely in the footsteps of other total joint replacements, such as hips and knees.

The procedure addresses the same pathologies as fusion, but with one important difference: BalancedBack preserves range of motion, natural balance, and helps protect adjacent levels from breakdown.


What are the results?

The goal of the BalancedBack project is to replace fusion for the vast majority of degenerative spinal conditions.

We are a dedicated team of healthcare innovators, with some of the leading experts on spine care in the world.

Here is an overview of our track record:

86 Patients Treated
122 Levels
18-79 Age Range
2.7x Improvement over Fusion

Where is the procedure available?

The BalancedBack procedure is available at CTMH Doctors Hospital in Grand Cayman by a team of fellowship-trained US surgeons.

Scott Hodges, DO

Hodges, DO

Scott Hodges, DO

Hodges, DO

Dr. Hodges is a board-certified and fellowship-trained spine surgeon with more than 25 years of clinical experience. He has completed over 15,000 spine surgeries throughout his career, with a special interest in spine motion preservation techniques. Dr. Hodges entered private practice in 1994 with the Center for Sports Medicine and Orthopaedics in Chattanooga, Tennessee, where he works alongside a team of medical professionals specializing in orthopedic surgery and sports medicine.

Dr. Hodges is a pioneer in joint replacement and also holds an interest in minimally invasive surgery (MIS) for the spine. He was an early adopter of navigationally-assisted MI and has served as a faculty member and chairman of numerous educational programs for over two decades. Dr. Hodges’ current research focuses on spinal mobility before and after surgical intervention. He is an active innovator with over 50 patents for spine/orthopedic devices, and currently serves as chairman of the research committee for the American Osteopathic Academy of Orthopedics.

Dr. Hodges is a native of North Carolina. He received his undergraduate degree in biology from Southern Adventist University and graduated cum laude from the University of Health Sciences in Kansas City, Missouri. He also served in the United States Air Force achieving the rank of major.

Craig Humphreys, MD

Humphreys, MD

Craig Humphreys, MD

Humphreys, MD

Dr. Craig Humphreys is a board-certified, fellowship-trained orthopaedic surgeon who has been performing spine surgeries for more than 20 years. In 2011 he founded Kenai Spine, a regional spine center of excellence for the treatment of back and neck problems, with offices located in Soldotna and Anchorage, Alaska. It is the only spine center in the state of Alaska that appears on, the national listing of credentialed spine centers. Dr. Humphreys was elected president of the Alaska Medical Board in 2017.

Dr. Humphreys’ philosophy, and that of Kenai Spine, is to explore and exhaust all non-surgical options for patients in advance of spine surgery. For patients requiring surgical intervention, Dr. Humphreys has developed new devices and techniques, including motion preservation options to advance healthcare. Dr. Humphreys is volunteering and collaborating with CURE International in Kenya/Africa in its efforts to develop spine care in underserved areas of the world.

Dr. Humphreys grew up in Alaska. He received his undergraduate degree from the University of Notre Dame, and attended Loyola University Stritch School of Medicine and Loyola University Medical Center for his internship and residency program. He practiced at the Center For Sports Medicine and Orthopaedics in Chattanooga, Tennessee, prior to founding Kenai Spine.

Marcella Madera, MD

Madera, MD

Marcella Madera, MD

Madera, MD

Dr. Madera is an expert in surgical treatment of conditions of the spine, including degenerative spine disease, spine tumors, and degenerative deformity. Fellowship trained under world-renowned spine surgeons at Johns Hopkins, Dr. Madera has expertise in all spinal approaches and techniques, including both open and minimally invasive surgery (MIS), endoscopic spine surgery, disc/joint replacement, and regenerative/stem cell procedures for spine disease. She is board certified by the American Board of Neurological Surgery, and currently practices at Austin Integrative Spine in Lakeway, Texas. Dr. Madera is also licensed in the Cayman Islands and practices at NovoClinic Cayman, with surgical privileges at CTMH Doctors Hospital.

Dr. Madera is passionate about reconstructive and regenerative spine care, and takes a holistic approach to treatment. She believes the body’s natural healing ability can be harnessed to treat spine disease in conjunction with advanced surgical instrumentation. Dr. Madera has traveled extensively throughout Europe and the US to learn progressive surgical techniques and regenerative medicine practices, and is one of the only spine surgeons in the country to offer cell-based treatments using a patient’s own harvested cells to promote healing.

Dedicated to advancing spine care, Dr. Madera is actively involved in a number of technology development and research projects. She serves as a mentor for students before and during medical school and is an Assistant Professor of Neurosurgery at the University of Texas Dell Medical School in Austin.

Nathan Schatzman, MD

Schatzman, MD

Nathan Schatzman, MD

Schatzman, MD

Dr. Nathan Schatzman is a specialized cardiac anesthesiologist practicing in Chattanooga, Tennessee. Dr. Schatzman attended Harvard College in Boston, then went on to earn his medical degree at Baylor College of Medicine in Houston, Texas, where he graduated in 1989. Dr. Schatzman has 28 years of diverse experience across the field of anesthesiology. Dr. Schatzman is also fully licensed and insured to practice medicine in the Cayman Islands at NovoClinic Cayman, with surgical privileges at CTMH Doctors Hospital.

Marcus James, RN

James, RN

Marcus James, RN

James, RN

Marcus James received his Bachelor’s degree in nursing from the University of West Georgia, after which he completed two additional surgical assistant programs, one in Chattanooga, TN, and one in Los Angeles. He has extensive surgical experience, having started his nursing career in an operating room about 20 years ago. He began by working on general orthopedics cases and some neurosurgical procedures; after about seven years he moved into spine surgery exclusively.

Marcus currently works as Dr. Scott Hodges’ first assist at Memorial Hospital in Chattanooga. He also works alongside Drs. Hodges and Humphreys on BalancedBack surgeries in the Cayman Islands. As the RN first assistant he facilitates every procedure, providing direct patient care during surgery as well as in the pre- and post-operative stages.

Don Duff, FNP, DC

Duff, FNP, DC

Don Duff, FNP, DC

Duff, FNP, DC

Dr. Don Duff has more than 35 years of healthcare experience. He began his spinal health career in private practice as a chiropractor in Chattanooga, Tennessee, in 1990. While working extensively with orthopedic spine surgeons, Dr. Duff utilized his expertise in conservative spine management to provide appropriate alternatives to surgery when indicated. He also developed postoperative rehabilitation protocols to help patients manage their surgical recoveries and optimize outcomes.

Dr. Duff graduated in 1984 with a Bachelor of Science in Nursing from Southern Adventist University, then completed his Doctor of Chiropractic training at Life University. He later completed graduate training at Southern Adventist, earning the Family Nurse Practitioner (FNP) credential. Dr. Duff currently has a dual practice as part of a group of spine care associates in Tennessee, and at NovoClinic in the Cayman Islands.

An advocate of a multidisciplinary approach to spinal care, Dr. Duff frequently presents at academic meetings and teaches across a variety of specialties, including co-development of a 12-hour CME course on the continuum of care for spinal health.

Donna Duff, FNP

Duff, FNP

Donna Duff, FNP

Duff, FNP

Donna has practiced nursing in a variety of intensive care settings for over 30 years, as a nurse and certified family nurse practitioner. She has experience in internal medicine, intensive and emergency care, rehabilitation, and acute post-op pain management for orthopaedic patients. Donna currently works in endocrinology, with a dual practice screening surgical candidates for NovoClinic Cayman.

Donna completed her undergraduate and graduate nursing training at Southern Adventist University, where she also served as an adjunct faculty member for 10 years. She is passionate about health care education, and strongly believes that compassionate care delivery plays a critical role in both short- and long-term outcomes.

Marissa Koscielski


Marissa Koscielski


Marissa Koscielski graduated from the University of Notre Dame with an undergraduate degree in math and a concentration in neuroscience. She then attended the same university’s ESTEEM program, one of the world’s premier graduate programs in technology and entrepreneurship. Marissa’s theoretical math background combined with her interests in neuroscience, pathophysiology, and the different models of health care delivery led her to the medical space, where she now looks for new ways to innovate. Recently, Marissa played a key role in the conception, design, and development of two medical devices: a syringe stabilizer created to help administer self-injections, which is currently undergoing the FDA approval process, and new rehabilitation technology for lower limb amputees and stroke patients, a project that is in development.

In her clinical administrator role, Marissa works on everything from guiding patients through the surgical process to handling data collection and reporting related to BalancedBack. She also helps the company maintain regulatory compliance for clinical operations.

Patient Stories

Learn about the experience from real BalancedBack patients.

Don H - BalancedBack Patient

Don H.

"Within three hours of the [BalancedBack] surgery, I was up standing."

Corey H - BalancedBack Patient

Corey H.

"Over the last five or six years, I don't remember a day that I've gotten out of bed and not hurt."

Michael B - BalancedBack Patient

Michael B.

"I had an 18 degree curvature of the spine and I realized when I looked in the mirror, I couldn't stand straight."

Travis T doing archery

Travis T.

"I would say this is the best I've felt—five days after surgery—than I have in the last two months."

Stephanie W skiing

Stephanie W.

"I would never have thought that I would feel this good, so quickly, and actually be able to ski after having back surgery."

Carol S - BalancedBack Patient

Carol S.

"For six months [before BalancedBack] I ended up sleeping in a camping recliner. Walking seemed to be the only thing that would give me semi-relief."

BJ B - BalancedBack Patient


"BalancedBack has given me my life back."

Ronnie B - BalancedBack Patient

Ronnie B.

"When I woke up from anesthesia, I had absolutely, absolutely, no back pain whatsoever."

Harvey F - BalancedBack Patient

Harvey F.

"I kept on working and just pushed through the pain... until about three to four years ago when [the pain] started catching up to me."


Manuel N.

"Now that I have come to the realization that I was the first in the world to have this done, it is a big deal to me."

Samantha's BalancedBack story

Samantha C.

“I am completely 100% back to my routine from years and years ago when my back was good."

What do I need to know?

  • The procedure is private pay. The cost for a single level is $56,500, two levels is $67,000 (including all travel and accommodations for the patient and one companion).
  • To begin the screening process, you will be sent a medical questionnaire. We will require all current imaging.
  • The surgery is performed at CTMH Doctors Hospital in the Cayman Islands.
  • The BalancedBack procedure is part of a Health Practice Commission regulated clinical study.
  • We require all patients to wean off opioids and cease smoking prior to surgery.

The Clinic Experience

What happens before surgery?

The day before your scheduled surgery, you’ll fly to Grand Cayman. From the moment you land, we’ll be with you every step of the way. Our concierge service takes you from the airport to NovoClinic for a final checkup, then on to your condominium on Seven Mile Beach.

What happens on the day of surgery?

On the morning of your surgery, we’ll take you and your companion(s) to CTMH Doctors Hospital, a small, private hospital just a few minutes from your condo. Since this is a total joint replacement and not a fusion, you will be up and walking shortly after the procedure to enhance your mobility and speed recovery. In many cases, you will be ready to go back to the condo the same day.

What happens after surgery?

A safe surgery is our #1 goal, but we also take pride in a superior vacation experience in the days following your surgery. You’ll soon be back at your condo, eating good food, smelling the salt air, and walking as much as possible. We believe that the post-operative period is important for your long-term recovery, and have structured our program to maximize your chances of a successful outcome. Our clinicians will work hard to minimize your post-operative discomfort, and will check on you several times per day.

After 5-7 days post-op, you’ll be ready to fly home. Our staff will escort you to the airport, manage your luggage, and see you onto the plane. We’ll coordinate with your primary care physician back home for follow-up visits and physical therapy as needed. Our goal is to help you regain full function and live pain-free.

Frequently Asked Questions

Why do I have to travel for surgery?

Every country has its own regulatory paradigm. Due to the pace of the Food and Drug Administration (FDA) approval process, anti-innovation efforts to control skyrocketing healthcare costs, and a politicized insurance system, the US is often slow to adopt new medical technology.  

In contrast, the British territory of the Cayman Islands provides a first-class healthcare, financial, and tourism economy efficiently regulated by the Health Practice Commission (HPC). Each of our US-based, fellowship-trained providers is licensed to practice in Cayman, as well as the US. The team travels with you to Cayman for surgery, where HPC regulates the use of BalancedBack.

Destination healthcare is an emerging trend. More and more people are taking control of their own healthcare, seeking safe, effective, and affordable solutions to their medical conditions outside of the United States system.

How much does the BalancedBack procedure cost?

The total cost is $56,500 USD for a single level and $67,000 for a two-level procedure. That includes travel and accommodations for the patient and one companion, surgical care, and local ground concierge service. There is no cost for your initial consultation with our clinical team. 

Does insurance cover a total joint replacement?

The BalancedBack procedure is not covered by insurance. Certain self-insured plans may provide for reimbursement, but the procedure is private pay.

What is the recovery period?

Recovery from any surgical procedure will depend on your individual condition. Our rehabilitation specialist will discuss your goals with you before surgery, and design a recovery program to help you reach them.

In general, BalancedBack patients are ambulating the same afternoon or evening after surgery, and are discharged from the hospital the next day. Patients spend an average of five days recovering on Seven Mile Beach before traveling home, with daily physician visits and rehabilitation sessions. Most patients begin a more aggressive physical therapy program at week six, and return to unrestricted activity at about three months.

How long will I be in the Caymans?

Patients typically arrive in Grand Cayman one or two days ahead of their scheduled procedure, and travel home five to seven days after surgery. The length of stay can be shortened or extended based on your individual condition, but 7-9 days total is typical. Please note that pricing is not influenced by length of stay. It is our goal to design the optimal destination healthcare experience based on your travel distance, time off work, travel preferences, and individual condition.

What is the experience like?

We work hard to provide the highest-quality care from the time you arrive on the island until you’re safely back home. It all starts with understanding your individual condition and determining if the BalancedBack procedure is right for you. If the answer is yes, our team will customize travel arrangements to make your trip easy. We select routes, flights, and seats based upon our experience. When you land in Cayman, our airport concierge representative will meet you at your airplane and expedite you through customs. They will bring you to our local concierge curbside, who will take you to your condo on Seven Mile Beach, manage your luggage, and remain available to help you with small requests throughout your stay, like groceries, dinner reservations, or other needs. At your hotel, you will receive a welcome bag telling you what to expect during your stay, the names and contact information of our team members, and other useful items and information.

After settling in, you will complete one last pre-operative visit at NovoClinic prior to your surgery that includes pain and disability scores, baseline pre-operative X-ray, and a neurologic exam. Our team will manage transport to and from CTMH Doctors Hospital for you and your traveling companions during your surgery stay. Our goal is to get you out of the hospital and back to your room on Seven Mile Beach as quickly as possible, where our clinicians and rehab specialists will visit you several times daily to aid with your mobility and minimize any post-surgical discomfort.

A safe surgery is our number-one goal, but we also take pride in a superior vacation experience in the days before and following your surgery. We believe the postoperative experience is important for your long-term recovery, and have structured the entire program to maximize your chances of a successful outcome.

On the day of departure, our ground concierge will meet you at the hotel, manage your luggage, and bring you to the airport, expediting you through security and staying with you until you are comfortably seated on the airplane. From there, the airline will assist you with connections and luggage to your local ground transportation home. (For your comfort, we request special assistance from the airline on departure.)  

Even after you arrive home, you’ll interact with a NovoClinic team member to coordinate future care through your primary care physician, physical therapist, or other providers as needed. Our goal is to help you regain full, pain-free motion, and the outcome you expect.

Can I make my own travel arrangements?

We prefer to arrange travel, simply because we know what is easy and hard for people with your healthcare condition. If you are a savvy traveler and prefer to make your own arrangements, let us know and we’ll tailor a program to meet your needs. People often ask to use airline miles or other loyalty programs, or elect private air travel over commercial flights in certain circumstances. Whatever your request, we have likely managed it before and will be happy to help meet your needs.

Can I bring someone, and will it increase the cost?

We strongly encourage you to bring a friend, spouse, or significant other. It makes the experience more pleasant for you, and it’s a good opportunity for both of you to enjoy the beauty of the Cayman Islands. When patients come to Cayman a day or two early with someone they trust, we see the natural anxiety of traveling for care melt away.

The cost of the procedure includes companion costs for accommodations, but not travel.

Is my medical information confidential?

Yes. We value your privacy, and voluntarily comply with HIPAA standards.

How is BalancedBack different than an anterior disc replacement?

An anterior disc replacement only treats the disc.

BalancedBack replaces the function of the entire joint—both the disc and facet joints—with a new motion device.

Only 2% to 5% of patients have the right indications for an anterior disc replacement—that means they have facet joints in good condition and no other pathologies that need to be addressed to relieve pain, such as pinched nerves or spinal stenosis. A BalancedBack Total Joint Replacement, in contrast, is a good option for more than 50% of potential patients.

Ready to have 
your case reviewed?