Becker's Spine Review

34 Thought Leadership Dr. Daniel Birk: Spinal fusion will become mostly obsolete in 10 years By Laura Dyrda D aniel Birk, MD, director of the Neurosurgery Spine Center at Stony Brook (N.Y.) Medicine, discussed the biggest challenges and opportunities in spine device development today. Question: What emerging technol- ogy or technique do you think will have the biggest impact on the spine field five years from now? Dr. Daniel Birk: Today, the cutting-edge spine surgeon utilizes an array of synergistic technologies to achieve minimally in- vasive decompression or fusion, including tubular retractors, endoscopes, image-guided navigation, robotics and biologically enhanced arthrodesis. Instrumented fusion is reaching a zenith of sophistication. e next five years are going to see MIS, robotic and biologic technologies become pervasive. Combined with an understanding of sacro-pelvic parameters and sagittal balance, the art of pedicle screw-based instrumented fusion is close to being perfected. Due to economic inertia and regulatory challenges, the funda- mental techniques and technologies of spine surgery will not be significantly different five years from now. Instead, I foresee the continued refinement and proliferation of the current paradigm in the short term. Q: Where do you see the biggest room for innovation in spine? DB: is state of affairs is analogous to the end of World War II when pis- ton-powered aircras were reaching peak development just at the same mo- ment the jet engine made its debut and rapidly made piston aircra obsolete. Similarly, titanium implants and arthrodesis technology will achieve their maximum potential in the next five years just as disruptive innovations and treatment strategies are emerging through new basic science discoveries, proof-of-concept prototypes and clinical trials. New kinodynamic models of spine biomechanics will combine with advanc- es in material science, robotics, additive manufacturing, computer vision and nanotechnology. Novel diagnostic modalities will accompany groundbreak- ing insights into spine pathophysiology. Today, I am unable to offer my pa- tients spinal restoration. However, in 10 years, I predict that fusion surgery, and the associated complications, will become mostly obsolete and will give way to dynamic and adaptable spine technologies that restore and maintain spine physiology without rigid fixation or titanium implants. n Dr. Brian R. Gantwerker: Spinal fusions, 3D printing and the future of spine surgery By Alan Condon B rian, R. Gantwerker, MD, is a board-certified neurosurgeon, special- izing in the treatment of brain tumors, as well as degenerative diseases and injuries of the spinal cord. A Chicago native, Dr. Gantwerker earned his medical degree from Rush Medical College in Chicago. He has been in private practice for over nine years at e Craniospinal Center of Los Angeles, in Santa Monica and Encino, Calif. Dr. Gantwerker provided his insight into the evolution of spinal fusions, im- plant surface technology and the future of 3D printing in spine. Question: How do you see spinal fusions evolving in the future? Dr. Brian Gantwerker: I think spinal fusions will continue to miniatur- ize and be done more in the outpatient setting. Cost pressures will drive these cases more to efficient hospitals and outpatient surgery centers. e increased burden, however, of prior authorization will reduce the number of fusions done in the private sector. I think fusion numbers will go up in the academic setting, and higher risk cases will not be taken on by private practice [physicians] who are fatigued from getting on the phone for 45 minutes to wait to do a peer-to-peer for a PA. is will lead to a further increase in the cost of fusions. e academic centers will (and rightfully so) demand higher reimbursement and get it. In- surers will balk more and more and create increasingly stringent guidelines — which may or may not be grounded in peer-reviewed science. Ultimate- ly, we will see a turn away from the chants of "T10 to Pelvis" and "titanium deficiencies" as insurers will pay less and less oen for them, regardless of demonstrable patient need. e future in instrumented spine surgery will rely more and more on ar- throplasty and decompressive procedures. e hard part will be being able to discern studies sheltered from the sway of the industry. In my experience, trending away from fusions and favoring arthroplasty, hybrid constructs and decompressions has been worse for my bottom line, but make for happier patients with better quality of life. Q: Where do you see the biggest opportunities for implant technology to make a difference in procedure outcomes? BG: e advantage of hybridized implants with titanium impregnated sur- faces and PEEK cores or porous metal surfaces in my mind have yet to prove superior to PEEK. In the cervical spine, there has been at least one study I have seen that has shown inferiority of PEEK. I have seen some PEEK fail- ures in the cervical spine, but it was hard to tease out whether it was the kind of allogra or the implant itself. If there can be a side-by-side independent study with similar endpoints, including radiographic fusion as well as visual analog scores and Short Form health survey of 36 questions, one could be

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