Becker's Spine Review

9 SPINE SURGEONS Cost of total disc replacement in the 30 largest US cities By Carly Behm D allas and Fort Worth, Texas, are the most expensive cities in the U.S. to under- go total disc replacement surgery, according to Healthcare Bluebook, which helps patients shop for affordable care in their area. e price for total disc replacement includes facility, physician and anesthesia fees and is calculated based on the amount health plans have paid on medical claims. Here are the average prices for total disc replacement in 30 of the most populous cities in the U.S., based on data from the Census: 1. Dallas: $43,564 2. Fort Worth, Texas: $43,564 3. Seattle: $39,993 4. San Jose, Calif.: $39,346 5. San Francisco: $39,346 6. Milwaukee: $37,868 7. Indianapolis: $37,195 8. Denver: $33,843 9. Portland, Ore.: $32,750 10. Columbus, Ohio: $30,954 11. New York City: $32,521 12. Nashville, Tenn.: $28,400 13. Charlotte, N.C.: $27,636 14. Phoenix: $26,947 15. Philadelphia: $26,690 16. Austin, Texas: $26,549 17. Louisville, Ky.: $26,169 18. Detroit: $25,819 19. El Paso, Texas: $25,793 20. Memphis, Tenn.: $24,967 21. Los Angeles: $24,878 22. Washington, D.C.: $24,808 23. Boston: $23,771 24. Chicago: $23,489 25, Oklahoma City: $23,282 26. Houston: $22,705 27. Jacksonville, Fla.: $22,689 28. San Diego: $22,554 29. San Antonio: $21,694 30. Las Vegas: $21,126 n • In patients undergoing hemorrhoidectomy, a total of 266 mg (20 mL ) of EXPAREL was diluted with 10 mL of saline, for a total of 30 mL, divided into six 5 mL aliquots, injected by visualizing the anal sphincter as a clock face and slowly infiltrating one aliquot to each of the even numbers to produce a field block. Local Analgesia via Infiltration Dosing in Pediatric Patients The recommended dose of EXPAREL for single-dose infiltration in pediatric patients, aged 6 to less than 17 years, is 4 mg/kg (up to a maximum of 266 mg), and is based upon two studies of pediatric patients undergoing either spine surgery or cardiac surgery. Regional Analgesia via Interscalene Brachial Plexus Nerve Block Dosing in Adults The recommended dose of EXPAREL for interscalene brachial plexus nerve block in adults is 133 mg (10 mL), and is based upon one study of patients undergoing either total shoulder arthroplasty or rotator cuff repair. Compatibility Considerations Admixing EXPAREL with drugs other than bupivacaine HCl prior to administration is not recommended. • Non-bupivacaine based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. • Bupivacaine HCl administered together with EXPAREL may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. Therefore, bupivacaine HCl and EXPAREL may be administered simultaneously in the same syringe, and bupivacaine HCl may be injected immediately before EXPAREL as long as the ratio of the milligram dose of bupivacaine HCl solution to EXPAREL does not exceed 1:2. The toxic effects of these drugs are additive and their administration should be used with caution including monitoring for neurologic and cardiovascular effects related to local anesthetic systemic toxicity. • When a topical antiseptic such as povidone iodine (e.g., Betadine ® ) is applied, the site should be allowed to dry before EXPAREL is administered into the surgical site. EXPAREL should not be allowed to come into contact with antiseptics such as povidone iodine in solution. Studies conducted with EXPAREL demonstrated that the most common implantable materials (polypropylene, PTFE, silicone, stainless steel, and titanium) are not affected by the presence of EXPAREL any more than they are by saline. None of the materials studied had an adverse effect on EXPAREL. Non-Interchangeability with Other Formulations of Bupivacaine Different formulations of bupivacaine are not bioequivalent even if the milligram dosage is the same. Therefore, it is not possible to convert dosing from any other formulations of bupivacaine to EXPAREL and vice versa. Liposomal encapsulation or incorporation in a lipid complex can substantially affect a drug's functional properties relative to those of the unencapsulated or nonlipid-associated drug. In addition, different liposomal or lipid-complexed products with a common active ingredient may vary from one another in the chemical composition and physical form of the lipid component. Such differences may affect functional properties of these drug products. Do not substitute. CLINICAL PHARMACOLOGY Pharmacokinetics Administration of EXPAREL results in significant systemic plasma levels of bupivacaine which can persist for 96 hours after local infiltration and 120 hours after interscalene brachial plexus nerve block. In general, peripheral nerve blocks have shown systemic plasma levels of bupivacaine for extended duration when compared to local infiltration. Systemic plasma levels of bupivacaine following administration of EXPAREL are not correlated with local efficacy. PATIENT COUNSELING Inform patients that use of local anesthetics may cause methemoglobinemia, a serious condition that must be treated promptly. Advise patients or caregivers to seek immediate medical attention if they or someone in their care experience the following signs or symptoms: pale, gray, or blue colored skin (cyanosis); headache; rapid heart rate; shortness of breath; lightheadedness; or fatigue. Pacira Pharmaceuticals, Inc. San Diego, CA 92121 USA Patent Numbers: 6,132,766 5,891,467 5,766,627 8,182,835 Trademark of Pacira Pharmaceuticals, Inc. For additional information call 1-855-RX-EXPAREL (1-855-793-9727) Rx only March 2021 Payer enacts coverage for 1, 2-level disc replacement in Utah, Idaho By Carly Behm A third-party payer established positive coverage for one- and two- level lumbar disc replacement with Centinel Spine's Pro- disc L, the devicemaker said April 5. The payer, which isn't named, represents 837,000 patients across Utah and Idaho, according to a news release. Its policy provides coverage for patients with symptomatic degenerative disc disease who are treat- ed with the Prodisc L. Centinel Spine's Prodisc L is the only total disc replacement system in the U.S. approved for two-level use in the lumbar spine n

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