Becker's Spine Review

24 DEVICES & IMPLANTS How will total disc replacement develop in spine? 9 spine surgeons share insights By Alan Condon Nine spine surgeons discuss total disc replacement and how they see the procedure developing in the future. Note: e following responses were edited for length and clarity. Question: How do you see total disc replacement devel- oping in spine over the next five years? Mark Mikhael, MD. NorthShore Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): I anticipate the number of cervical disc replacement cases to increase significantly over the next five years. e rise is likely due to published 15-year data show- ing CDR as being more cost-effective with a lower reoperation rate and better outcomes compared to anterior cervical discectomy and fusion. Despite this, many spine surgeons are reluctant to adopt CDR. More surgeons will recognize CDR's motion sparing technology as a better option for patients compared to discectomy and fusion. I see surgeons broadening their patient selection beyond younger adults with limit- ed arthritis. Fusions will never go away, but as more surgeons become aware of the long-term benefits of CDR and more experienced in per- forming it, more patients will likely benefit from it by 2025. Neel Anand, MD. Cedars-Sinai Spine Center (Los Angeles): In five years, at least in the cervical spine for patients between 20 and 65, I think that total disc replacement will be the standard of care. Hy- brid constructs in the cervical spine, where fusion is performed at a severely degenerated level and an artificial disc replacement at a less degenerated level will become commonplace too. With the growing variety of cervical discs available, surgeons will be afforded the op- portunity to choose the disc that best fits a particular patient's anato- my. In the lumbar spine, I believe artificial disc replacement will still be done selectively. I don't see much development over the next five years here, but I remain hopeful. Fred Naraghi, MD. Klamath Orthopedic Clinic (Klamath Falls, Ore.): CDRs have an outstanding outcome and are likely going to be used more. Lumbar disc replacements, on the other hand, have a less predictable positive outcome. Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Total disc replacement has the ability to preserve spine range of motion and min- imize the chance of adjacent segment degeneration as well as the need for more spine surgery in the future. It also allows patients to recover and return to work and function faster. It's been shown to be very effec- tive in the cervical spine. e data for lumbar spine disc replacement is not as robust, but I am sure as implant design and techniques evolve, it will be shown to be just as effective as CDRs. Over the next five years CDR will become more prevalent and offered to more patients. is will result in better surgical outcomes, postoperative function, quicker recovery and return to function as well as lower risk of subsequent sur- geries in the future. e main barriers for broader use of CDR are in- surance denials, low reimbursement rates and lack of surgeon training. Harel Deutsch, MD. Rush University (Chicago): For the cervical spine, I believe growth will be significant in the next five years where more disc replacements will be done than spinal fusions. For the lum- bar spine, I foresee a slow growth because of lack of incentives for surgeons to do the procedure. James Chappuis, MD. Spine Center Atlanta: I am in favor of the development of total disc replacement in the cervical spine. However, I still have significant concerns about its use in the lumbar spine. e main reason is because trying to revise a total disc replacement in the lumbar spine is almost always impossible anteriorly and the outcome for posterior fusions in that setting is also less than ideal. Addition- ally, the results of a one-level anterior lumbar interbody fusion today are extremely positive, and I would be concerned that long-term disc replacements would not be able to match those results. Brian Gantwerker, MD. Craniospinal Center of Los Angeles: In our middle-aged and healthy 60-something patients, Medicare will be reconsidering their current local coverage determinations. Invari- ably, they will accept the good data out there that suggests patient outcomes are better and the long terms costs, related to reparation and adjacent segment disease is less. ere will be a tipping point when most carriers will need to cover them and no longer be able to roll out the old 'experimental' excuse. Payam Farjoodi, MD. MemorialCare Orange Coast Medical Cen- ter (Fountain Valley, Calif.): CDR has already been shown to be an effective treatment, and I believe the number of procedures per- formed will continue to rise. More and more patients are educating themselves and requesting alternatives to spinal fusion with CDR be- ing an excellent one. ere is also potential for lumbar disc replace- ment to increase in popularity, however we need to do a better job of determining the best indications for this procedure. e lumbar spine is more difficult to treat as our outcomes for lumbar versus cervical fusions demonstrate. I hope we can use good data to accomplish this in the next five years and make lumbar disc replacement an effective and reproducible surgery. Issada ongtrangan, MD. Microspine (Phoenix): I feel CDR will gain more popularity as the outcomes are superior to ACDF. How- ever, I am not certain that is the case with lumbar artificial disc re- placement. n Stryker appoints new president of joint replacement By Laura Dyrda Stryker named Don Payerle president of joint replace- ment, effective March 1. Mr. Payerle has previous experience as vice president and general manager of Sage and EMEA. He has man- aged territories, led teams and grown departments and functions as well as directed product development and launched products. He has experience creating a competitive advantage for business units and divisions during his career, ac- cording to the announcement from Stryker. n

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