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14 SPINE SURGEONS Will disc replacement supersede spinal fusion? 8 spine surgeons weigh in By Alan Condon O n the back of two-year data comparing the M6-C cervical disc with anterior cervical discectomy and fusion published in e Spine Journal, eight surgeons discuss the future of total disc replacement in spine: Question: How do you see disc replacement developing in the next five to 10 years? Brian Cole, MD. Englewood (N.J.) Spine Associates: I think cervi- cal disc replacement is becoming the standard of care for treating de- generative cervical disease now. In my own practice, I perform many more replacement surgeries than fusions. is is primarily because of the outstanding clinical results in terms of pain relief, return to func- tion and patient satisfaction. Today we wouldn't think about fusing a knee or hip, so why are we fusing spines that aren't unstable? Adam Shimer, MD. UVA Health (Charlottesville, Va.): ere will undoubtedly be an increase in use of cervical disc arthroplasty rel- ative to ACDF over the next five to 10 years. With that said, this shi will be evolutionary as opposed to the historical revolutionary explosion of low-friction hip and knee arthroplasty. Hip and knee fusions are pretty terrible whereas ACDF is a darned good proce- dure. I believe three key facts limit rapid, widespread transition to cervical disc replacement: 1. ACDF is a good surgery with predictable outcomes and a long proven track record. 2. ere is more to 'think about' when choosing to do CDR. Just look at the FDA IDE inclusion criteria: DEXA scans, motion evaluation, no prior anterior or posterior surgery, no facet ar- thropathy. 3. e unknown as to what happens to CDRs 10, 20, 30 years down the line. ese are being used in younger patients and we just do not know the longevity of these devices. With increased use of CDR over the next five to 10 years we will see papers about not only the positive outcomes, but also more reports of complications and limitations. Frank Phillips, MD. Midwest Orthopaedics at Rush: I have been fortunate to have been close to this field for over a decade and par- ticipate in numerous cervical TDR FDA IDE studies. Cervical TDR is arguably one of the best studied procedures in spine care with numer- ous level 1 studies supporting its effectiveness in appropriately select- ed patients. We are seeing compelling data favoring their outcomes over ACDF with long-term (10 year) follow-up with first generation design prosthesis, and now excellent data with second generation TDR designs that more closely mimic natural disc kinematics. In addition, a number of FDA IDE studies with novel disc designs for both one- and two-level indications are starting up. Given the quality of the evidence, most payers are now routinely covering cer- vical TDR which favorably impacts clinical adoption. As younger surgeons are increasingly exposed to TDR in their training, I would anticipate this becoming an integral part of their treatment algo- rithms for cervical radiculopathy and myelopathy. I expect that all major spine manufacturers will participate in this space, likely by acquisitions of approved TDR prostheses from smaller companies. Although many indications for cervical fusion remain, with the con- fluence of events outlined, I anticipate cervical TDR continuing to grow over the next five to 10 years. Todd Lanman, MD. Lanman Spinal Neurosurgery (Beverly Hills, Calif.): Spine arthroplasty or artificial disc replacement will expand in its usage dramatically over the next 10 years compared to fusion. Nine artificial cervical discs have been FDA approved. ree have al- ready been retired from use as newer devices are continually being developed and tested. ere are currently three clinical trials begin- ning shortly for new types of artificial discs for the neck and low back. Artificial disc replacements will become routinely used, superseding fusion as the standard of care over the next five to 10 years. e par- allel is quite similar to that which was seen in the past with severe arthritic and degenerative hips and knees, where these were routinely being fused. Now, no one would even contemplate having their knees or hips fused. ey would opt for an artificial hip or knee replacement. In fact, artificial discs for the spine offer even better long-term data demonstrating they will not fail for likely over 70 years. ese im- plants, if placed properly by an experienced spine surgeon, provide excellent relief of cervical or neck pain, arm pain, and low back pain and leg pain in the lumbar region. ey maintain mobility and mo- tion of the spine, which is an imperative component to maintaining an active, functional lifestyle. Adam Bruggeman, MD. Texas Spine Care Center (San Antonio) and CMO of MpowerHealth (Addison, Texas): e future of disc replacement will depend on studies looking at more commonly per- formed surgeries, such as those on patients with prior fusions at other levels and those with multiple levels that need to be performed. Over the next five to 10 years, I see further adoption of disc replacement as well as additional studies looking at more common situations seen in day-to-day practices. I also anticipate implant designs will adjust for these evolving indications to include multiple options to address stability as well as endplate variations. Brian Gantwerker, MD. Craniospinal Center of Los Angeles: We are coming to a time when cervical arthroplasty will become as prev- alent and reproducible as knee and hip replacements. Disc replace- ment has become a legitimate alternative to cervical fusion and, in many cases, is a better choice. Although the exact 'special sauce' of semi-constrained, constrained, keel, no-keel remains to be elucidated, many patients have and will continue to benefit from motion-preser- vation surgery. ere are many different choices in the arthroplasty market; most coming from big box spinal instrumentation companies. ere are some smaller, boutique companies and the competition fostered will undoubtedly make the tech increasingly reliable and less expensive. Since most insurance companies will remunerate for this legitimate