Becker's Spine Review

9 SPINE The spine cases 9 surgeons are most proud of: Drs. Alok Sharan, Peter Derman & more By Alan Condon F rom complex cases on patients with comorbidities to how novel spine surgery pro- tocols or techniques helped achieve a positive outcome, nine spine surgeons from health systems and private practices around the country detail the surgeries of which they are most proud. Editor's note: Responses were lightly edited for clarity and length. Question: Can you detail a recent spine surgery that you are particularly proud of? What was challenging about the patient's condition? How did you ap- proach the surgery and what was the outcome? Peter Derman, MD. Texas Back Institute (Plano): A young man in his twenties came to me with pain radiating down his lower extremity and a partial foot drop due to a forami- nal disc herniation at L5-S1. Symptoms persisted despite attempted conservative care. He was told by two other surgeons that accessing the herniation and decompressing the nerve would necessitate fusion. He was understandably hesitant to undergo such an operation, so he came to me for another opinion. I reviewed the imaging, which revealed that he in- deed had a narrow pelvis; this would have been an impediment to an isolated decompres- sion if performed via open or even tubular techniques. However, there was enough of a corridor to access the herniation endoscopically. I per- formed an outside-in endoscopic foraminal discectomy on him, which went smoothly. He had complete resolution of his pain and weakness, took no narcotics after surgery and had essentially zero downtime. Importantly, this young patient was able to avoid a fusion surgery and the risk of future adjacent segment issues. I never cease to be amazed by how quickly patients bounce back after endoscopic spine surgery. Smaller incisions, minimal muscle disruption and less (if any) bone resection al- low for rapid recovery. However, spinal endoscopy really shines in cases like this in which it fundamentally changes the operation I am able to offer and allows patients to avoid fu- sion altogether. Alok Sharan, MD. NJ Spine and Wellness (East Brunswick, N.J.): About seven years ago I had a patient who came to me and needed a spinal fusion. She previously had shoulder surgery under general anesthesia and was scared of undergoing surgery due to the effects of general anesthesia on her body. At that time, I discussed the awake spine surgery pro- tocol that we developed and how she would be a perfect candidate to undergo an awake spinal fusion. As she was a widow with a daughter who lived more than an hour away, she was very worried about the post-operative recovery, especially because she would be by herself. When we discussed the benefits of the awake spinal fusion procedure, including reduced likelihood to develop delirium or confusion after surgery, she enthusiastically signed up for the surgery. We performed an L4-5 awake spinal fusion on her. She did incredibly well and experienced minimal pain after surgery. She was able to regain her independence soon after and was happy that she avoided general anesthesia. Ever since then, we have continually evolved and improved our awake spine surgery protocol. This patient's story was the birth of our awake spinal fusion program. Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: About a year ago, I saw a patient who had an isthmic spondylolysis repair about 5 years previous using only posterior pedicle screws. Initially, she did well but developed a progressive slip at the level above and a pseudoarthrosis at the index level. It was required to perform a posterior- • 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

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