Becker's Spine Review

19 THOUGHT LEADERSHIP hands, one can resect excessive bone, slip and injure the esophagus or vertebral arteries, or under-decompress particularly the foramen. Ideal- ly, robotic guidance will lead to more efficient, safer and effective surgery and also facilitate better placement of artificial disc replacements. My main challenge in anterior cervical surgery remains the poor bone quality of the cervical vertebral bodies. e unicortical, cancellous screws uniformly have poor purchase. Other types of spine surgery in- volve fixation in cortical bone with pedicle screws. We need improved screw designs and osseodensification methods to improve the fusion rate and long-term outcome. Ciro Randazzo, MD. NorthEast Regional Surgery Center (Paramus, N.J.): e three biggest changes that I expect to come to ACDF in the near future in- clude: movement away from ACDF to anterior cervical discectomy with disc replacement rather than fusion; migration of these cases from the hospital to the surgery center; and the use of standalone devices rather than anterior plat- ing. Unlike other spinal surgery, I do not see a significant increase in the use of robotic surgery or navigation for anterior cervical surgery. Harel Deutsch, MD. Rush University (Chicago): I believe artificial cer- vical disc replacement will replace most ACDF procedures in the future. Implants will continue to improve for artificial discs. Ten-year data has shown us that artificial disc is superior to fusion. We will still be doing some fusions, but I believe 90 percent of current ACDF surgeries will be artificial disc replacements. Jonathan Stieber, MD. NYU Langone Health (New York City): ACDF has changed only modestly since its introduction in the 1950s. Implants have evolved to become very low profile while affording improved sta- bility. I expect advancements in interbody implant technology and bio- logics will further improve the reliability of fusion and minimize the risk of pseudoarthrosis. Advanced technologies including the incorporation of hydroxyapatite and porosity will continue to evolve to enhance both on-growth and in-growth for higher fusion rates. As artificial disc replace- ment undergoes further study, three- and four-level arthroplasties are like- ly to become more commonplace. Hybrid surgeries will also find greater acceptance as the data leads to payer coverage for these procedures. Grant Shifflett, MD. DISC Sports & Spine Center (Newport Beach, Calif.): I think the major development with ACDF over the next 10 years is simply that they won't be performed very oen. But when they are performed, the technology will continue to shi away from PEEK and toward more biologically friendly materials. Radiopacity of current metallic implants is a barrier in ACDF surgery and I believe innova- tion will strive to overcome this, allowing surgeons to perform these surgeries with greater success. Lumbar disc replacement and other mo- tion-preserving technologies in the lumbar spine are highly effective in many scenarios but remain inadequate in many patients with a variety of lumbar pathologies. By contrast, the overwhelming majority of patients presenting with cervical disease can be treated with motion-preserving technologies. ACDF is not going to go away entirely, but the future of this surgery is certainly imperiled by advancing technology. ere is a firm evidence basis for ACDF to be safely performed in outpa- tient facilities, and there will be continued economic pressure to make the procedure competitive in that setting. e anterior plate and inter- body spacer procedure will continue to be simplified, such as individual sterile wrapping with construct pricing and standalone spacers with in- trinsic fixation. ACDF will be challenged in this milieu by cervical disc replacement, which will continue to make inroads in the younger, more active population with one- and two-level disease. Furthermore, in the next decade, the indications for cervical disc replacement will likely ex- pand to include hybrid cervical disc replacement/fusion and three-lev- el indications. ere will be continued evolution and sophistication of disc replacement devices, and ACDF will adapt by becoming even more streamlined, cost-effective and efficient. Conversely, ACDF will retain primacy in the inpatient setting. ese indications include trauma, tumor, infection and deformity. In the inpa- tient setting, ACDF will need to adapt to an older population with signif- icant comorbidities including osteo-penia/-porosis, multilevel disease and deformity. ACDF plates will allow for straightforward load sharing and simplified application techniques. Interbody spacers will continue to evolve with fusion-friendly materials, such as 3D-printed metals and multiple lordotic options. Finally, common sense and evidence basis will ultimately prevail and certain insurers will no longer classify interbody spacers — which have been used safely and effectively for the past two decades — as "investigational." Ultimately, ACDF is here to stay. Brian Gantwerker, MD. e Craniospinal Center of Los Angeles: I think ACDF's future in the next decade is stable overall. Like many ar- rows in the quiver of spine surgery, it will always have a place in the armamentarium of spine surgeons. Especially in the setting of infection and disc-disruptive trauma, fusion remains the gold standard. In many cases of degenerative disease, where the patient's facet joints no longer function, anterior cervical fusion is usually the best treatment. I think now that most payers have relented and are paying for artificial disc replacement and patients are doing very well from them, we will see it more widespread. Artificial disc replacement instrumentation will continue to improve as new models are released and longer-term data is revealed on which bear out as superior. And now that many surgeons have had more experience in patient selection and postoperative man- agement, it will be much more widespread. I do hope that fusion does not fall completely out of favor as it is an important bail-out in the case of a failed arthroplasty. In short, we will always need both. Domagoj Coric, MD. Carolina Neurosurgery & Spine Associates (Charlotte, N.C.): ACDF will continue to be a workhorse procedure over the next 10 years. e two biggest factors affecting the development of ACDF will be the continued movement of the procedure to the ASC setting and the increasing adoption of cervical total disc replacement. ese factors will bifurcate the development of ACDF into an outpatient procedure as well as a complex, inpatient procedure. omas Lous, MD. Austin (Texas) Neurosurgical Institute: e ACDF procedure has achieved excellent outcomes for many years. While I expect nuanced improvements in instrumentation and biologics over the next 10 years, I do not foresee major changes in how the procedure is performed. I expect its acceptance as mostly an outpatient procedure will continue to grow and there will be a more widened application of its use in the outpatient setting for three-and four-level procedures also. While there is some growth in cervical artificial disc replacement appli- cation, I still expect ACDF to play a major role in treatment of cervical spine disorders. Compared to other spinal fusion procedures, I expect ACDF to continue to be considered one of the most highly successful procedures in our armamentarium. Issada ongtrangan, MD. Microspine (Scottsdale, Ariz.): I anticipate that there will be more movement toward cervical disc replacement in- cluding multilevel or hybrid cases. Many data have shown the noninfe- riority outcomes of cervical disc replacement compared to ACDF and even superiority outcomes in multilevel diseases. I think surgeons will do less traditional ACDF using anterior cervical plates and move toward the standalone device that can restore the lordotic alignment with excellent fixation and can be done efficiently in the ASC setting. As far as endoscop- ic cervical spine surgery, I think there will be less adoption of endoscopic anterior cervical procedures compared to endoscopic posterior cervical

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