Becker's Spine Review

46 20 innovations in spine to know | 2020 T he spine field is rapidly changing. In- novation in spinal surgery techniques, material and patient decision making have led to better outcomes. However, the next wave of disruptive technologies will need to provide clinical significance as well as cost-effectiveness. Navigation and image guidance. Image guidance and navigation technologies are dis- rupting the traditional method of performing spine surgery for more precise procedures us- ing less radiation. e FDA approved Joimax's Intracs system for electromagnetic navigation tracking and control during spine surgery. Surgeons can use the technology to perform procedures with minimal X-ray control and the system can flatten the learning curve for endoscopic procedures. 7D Surgical also plans to launch a radia- tion-free machine vision-image-guided sur- gery system in the U.S. later this year. e system is designed to replace standard fluo- roscopy and uses visible light to register spinal segments in seconds. Finally, Alum Bioscienc- es is also studying the use of a nerve imaging drug during spine surgery. e company's ALM-488 peptide-dye conjugate is designed for the fluorescent highlighting of nerves during head and neck procedures. Robotics. Medtronic leads the spinal robotics market with the Mazor X Stealth Edition tech- nology, which was used at more than 50 U.S. hospitals for 1,000-plus procedures in its first year. e robotic technology includes analyti- cal tools, precision guidance, optical tracking and intraoperative verification and connec- tivity technologies. Globus Medical also has a robotic spinal system on the market, Excelsius GPS, and Zimmer Biomet has Rosa Spine. NuVasive has been working on spinal robotic technology called e Pulse, which is an open imaging platform with integrated Siemens 3D mobile C-arm. However, the release of Pulse was delayed during the pandemic, CEO Chris Barry said during the company's second quar- ter earnings call in August, but robotics re- mains a key part NuVasive's strategy. "e future for robotics is bright. In addition to trajectory guidance to place hardware and perform complex preoperative planning pro- cedures, robots are soon going to be able to have greater autonomy in the OR, I hope," said Kornelis Poelstra, MD, PhD, of e Ro- botic Spine Institute of Silicon Valley in Los Gatos, Calif. "We must discuss these advances together with regulatory bodies such as the FDA, but this autonomy will not be far off. Robotic systems should be able to nearly au- tonomously place hardware, further reducing outliers and human error, help us with discec- tomy procedures and end plate preparation in a more predictable form as well as with de- compression surgery or the spinal canal. Uti- lizing advanced learning, I am confident that we can start manipulating muscle and fascia and have robotic assistance soon that will help us open and close surgical approaches." Cervical disc replacement. e cervical arti- ficial disc replacement procedure has evolved over the past two decades into a sleek surgery that shows comparable, if not better, out- comes to spinal fusions. e Prestige LP, M6 and Prodisc-C are among the most common cervical discs and they have long-term data showing their efficacy. Todd Lanman, MD, a spine surgeon in Beverly Hills, Calif., said surgeons are beginning to use artificial disc replacements for more procedures and he sees them becoming part of his revision strategy in the future. "I believe fusion will be considered archaic, particularly cervical, because the data is so clear that ADR is superior to fusion in almost every outcome measure," said Dr. Lanman. "Over a 10-year follow-up period re-surgical rates are half as much, so you're going to see new artificial discs created with even better designs and functionality, and surgeons are going to more rapidly move toward artificial discs. Many surgeons, particularly on the East Coast, still fuse a lot of patients. I think more disc replacements are done on the West Coast with people living more active lifestyles in a better climate." e M6-C disc has differentiated itself with a viscoelastic insert mimicking the normal disc, which could improve the biomechanics of the replacement. "As opposed to fusion where the placement is not pivotal as long as you get bone to heal, in artificial discs the placement has to be close to perfect because imperfec- tions can lead to dysfunction of the spine joints leading to pain and early arthritis," said Fabien Bitan, MD, of Atlantic Spine Center in Edison, N.J. Lumbar disc replacement. Lumbar disc re- placements present different challenges than cervical disc replacements, but a 2018 study in Global Spine Journal suggests they can be effective. In a meta-analysis of four studies comparing lumbar disc replacement to fu- sion, researchers found patients who under- went disc replacements reported lower dis- ability, significantly lower reoperation rates and higher patient satisfaction than fusion. Insurance companies are beginning to take notice of the results and in some cases cover- ing the procedure. In April, the FDA approved Centinel Spine's prodisc L lumbar total disc replacement device for two-level indications. e disc includes two cobalt chrome alloy endplates and an ultra-high molecular weight polyethylene inlay. Endoscopic spine surgery. e endoscopic spine technique has been evolving for nearly three decades, but remains rare in the U.S. It is a more technically challenging procedure than other techniques, but it has been associ- ated with good outcomes. Raymond Gardoc- ki, MD, of Memphis, Tenn.-based Campbell Clinic Orthopedics, sees endoscopic surgery as having huge potential in the future. "It currently is a very small part of the market, but it has the greatest benefit and it's applica- ble to the largest number of patients," said Dr. Gardocki. "We have technologies yet to be de- veloped in endoscopic surgery that are going to allow us to do lumbar and cervical fusions outpatient in addition to the discectomies and decompressions we can already do. Instru- mentation and expandable cages — things that can be applied through a very small por- tal and expanded — are yet to be developed and I think that's where you're going to see ev- eryday degenerative spine treatment change." ere is also emerging literature on endoscop- ic assisted lumbar fusion. "Some aspects of spine surgery are currently performed with- out the benefit of direct visualization such as pedicle cannulation and endplate prepara- tion," said Kris Radcliff, MD, of Rothman In- stitute in Philadelphia. "Some surgeons have been able to utilize endoscopic guidance to fa- cilitate those aspects of surgery. I believe that endoscopic assisted lumbar fusion techniques may be the first exposure of many surgeons to endoscopic spine surgery, as the indications are identical to current spine fusion indica- tions." Stem cells. ere are many differing opinions on stem cell treatment in spine surgery, with the most pervasive being cautious optimism. Sponsored by:

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