Becker's Spine Review

44 Executive Briefing SPONSORED BY O ver the past few decades, rates of spinal fusions have steadily risen. However, pseudarthrosis rates— an indicator of unsuccessful spinal fusion — have not improved enough in the past 20 years to reduce the overall non-unions. 1 2 With a growing number of spinal fusions, a constant pseudarthrosis rate means that each year there are more non-unions, many of which require revision surgery. The current rate of pseudarthrosis means U.S. patients experience approximately 149,000 non-unions each year. Among these non-unions, about 92,000 require revision surgery, which has negative implications for patients, provider organizations, surgeons and payers. 3 Patients experience longer rehab times, surgeons' performance metrics decline, and payers and providers have to flip the bill for these additional procedures. As the number of spinal fusions continue to rise, it's important for healthcare organizations to ensure these procedures evolve in a way that is clinically beneficial to patients — the status quo is simply not good enough. With a myriad of innovative technology available to help improve spine surgery, surgeons and administrators have to decide which solution is best positioned to improve fusion quality? To better understand how innovative leaders are answering this question, Becker's Spine Review recently spoke with three leading spine surgeons: • Alpesh Patel, MD, Co-Director for Northwestern Center for Spine Health, Professor of Neurosurgery and Orthopedic Surgery at Northwestern Feinberg School of Medicine in Chicago • Ernest Braxton, MD, Partner at Vail-Summit Orthopaedics & Neurosurgery in Vail Colorado • Joseph Osorio, MD, PhD, Director of Spinal Oncology and Deformity Surgery and Assistant Professor of Surgery at UC San Diego Health The following article is based on the experiences of these three surgeons. The path to better fusions Currently, spine surgeons who want to improve fusions have several approaches to consider: New methods of patient selection, further surgical education and training, and the integration of emerging technologies and disciplines like osteoimmunology and bone grafts that can modulate human immune response. All three surgeons interviewed by Becker's expressed a similar focus on osteoimmunology and bone graft technology. For this reason, each are acutely aware of the FDA-cleared MagnetOs™, biphasic calcium phosphate bone graft from Kuros and its promising results in spinal fusions. MagnetOs is capable of polarizing macrophages from the M1 pro-inflammatory to the M2 pro-healing phenotype. It stimulates bone growth even in soft tissue due to its NeedleGrip™ surface technology. For years, spine surgeons have been aware the immune system can influence the way a bone heals and the spine fuses. "The immune system can work against you in spine surgery — that is very apparent," Dr. Braxton said. "What we're discovering now is that the immune system can actually work for you to help with healing and to accelerate a more stable construct." How spine surgeons view the immune system in relation to their work is changing. The emerging field of osteoimmunology explores the link between the immune and skeletal systems. Dr. Patel offered several examples of situations where the immune system and skeletal system interact. "Where the immune system is suppressed because of medical issues, like diabetes or patients on chronic steroids for medical issues like rheumatoid arthritis, we know that their skeletal system is pretty severely impacted from those conditions, both at baseline and even more so after surgery. These patients have a high rate of non-union implant failure. These examples paint a pretty good picture of how the immune system and the skeletal system interact with each other." As an adult spinal deformity surgeon, Dr. Osorio is well aware of the links between the immune and skeletal systems. He said there is evidence that medications such as steroids, nonsteroidal anti-inflammatory drugs and disease-modifying antirheumatic drugs augment patients' immune response. "All these medications will blunt the immune system, and we know from the literature that patients don't fuse as well when they are taking these medications," he said. "In my mind, that's really the reason why we've had this explosion in the field of osteoimmunology." Dr. Braxton offered a succinct summary of the interplay between the immune system and the skeletal system. "We know that the immune system plays a pivotal role in healing. In fact, bone healing is really fusion," he said. Dr. Patel said the spine surgery field is at an inflection point in terms of integrating biologic products, such as Kuros' MagnetOs, to help benefit patients. Harnessing the immune system = more predictable spine fusion healing Dr. Patel said that early in his training, 15 or so years ago, spine surgeons didn't spend much time thinking about linkages between the immune and skeletal system. The prevailing view was, "We can overpower the immune system." A new era in spinal fusion: 3 surgeons weigh in on the emergence of osteoimmunology and bone graft technology

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