Becker's Spine Review

8 Sign up for Becker's Orthopedic, Spine Business & Pain Management E-Weeklies at www.BeckersOrthopedicandSpine.com or call (800) 417-2035 8 Big Trends in Minimally Invasive Spine Surgery (continued from page 1) "Minimally invasive techniques were historically used for diagnosis only. But technology advances have allowed us to improve the treatment of spine disorders using the same techniques for surgery," says Nimesh H. Patel, MD, a neurosurgeon at the Methodist Moody Brain and Spine Institute in Dallas. "It's one of the biggest advantages for patients because we are able to do spinal procedures with smaller incisions, which means less pain and blood loss. Hospital stays are also shorter." Shorter hospital stays and reduced risk of infection have a huge economic impact on the cost of care for people with spine issues, which is one of the biggest costs to our system today. Device companies and insurance providers are slowly coming on board with these new techniques as they are proven safe and effective in the literature. "There is some data that shows less cost associated with minimally invasive procedures and patients are able to return to work more quickly as well," says Dr. Patel. "But, there is a cost associated with purchasing the equipment, so it can be a double-edged sword. However, data has shown there are more benefits and less cost overall to perform minimally invasive procedures on the appropriately selected patients." Here, spine surgeons who are experienced with minimally invasive procedures discuss their evolution and where we are likely to see this trend headed in the future. 1. Complex procedures are now minimally invasive. Simple procedures, such as discectomies, were among the first to transition into a minimally invasive approach, and now surgeons are performing minimally invasive fusion procedures on a regular basis. However, more recent technological development has allowed even more complex procedures, such as scoliosis correction, to fall under the minimally invasive umbrella. Dr. Nimesh Patel "Traditionally scoliosis is known as a very difficult surgery on the physician and the patient," says Dr. Patel. "Now we are able to access the spine from a lateral approach and perform scoliosis surgery with significantly less blood loss and pain. Patients can mobilize the next day and their hospital stays have decreased." While the more complex minimally invasive procedures are still relatively new, they could become more popular on the horizon if quality and cost can stand the test of time. However, the minimally invasive approach isn't right for all patients and there will likely be a subset that will still need the traditional open procedures going forward. "Every patient is unique, and minimally invasive surgery can help some patients but not all," says Dr. Patel. "For some patients, the more traditional procedures may yield the best results. The key is finding a surgeon who is experienced in minimally invasive techniques and who relies on proven medical data to support the surgical reliability and safety of the techniques." 2. Outpatient spinal fusions are more common. As more surgeons are learning minimally invasive techniques and the technology develops for fusion procedures, more of those cases could be performed in the ambulatory surgery center setting. Anterior cervical discectomies and fusions are performed regularly in some ASCs, and additional procedures could make the transition in the future. "Where we are trying to push the envelope a little more is in fusions," says Paul Nottingham, MD, a spine surgeon in Walnut Creek, Calif. "We can do some lumbar fusions in the outpatient setting. Single level transforaminal lumbar interbody fusions have also worked well in the ASC for painful degenerative discs. I think we are going to try to gain better constructs on a singlelevel lumbar fusion and a better alignment for TLIFs in the outpatient setting." Dr. Paul Nottingham Insurance companies reimburse outpatient facilities at a lower rate than hospitals, in most cases, and ASCs generally have a lower infection rate than inpatient facilities. 3.  Artificial disc technology in limbo. Motion preservation has been a trend in orthopedics for years, and disc replacement technology was designed as a step up from fusions in the field. However, attempts at lumbar disc replacements are largely considered failures and recent studies question whether cervical disc replacements reduce the risk of adjacent segment disease. "This goes back to an overall healthcare question: how do we obtain the fountain of youth and stop ourselves from aging?" says Dr. Patel. "One of the things we are looking toward in spine surgery is motion preservation. Currently the dogma is too much motion creates too much pain and is unstable, so a fusion is required. However, fusion is the opposite of what the body wants to do — it wants to preserve motion." In orthopedics, knee and hip surgery has evolved from early fusion techniques to joint replacements, which are now the standard of care. "We have some development in implant technology that allows us to perform motion restoration procedures like artificial disc replacement or even instrumented fusion or arthrodesis procedures," says Hieu Ball, MD, an orthopedic spine surgeon in Walnut Creek, Calif. "We are looking to do things in a less traumatic way than in the past." 4. Biologics and disc regeneration. Moving forward with motion preservation, surgeons and scientists have set their sights on biological solutions and disc regeneration. Early technologies are still in the beginning stages and clinical trials, but this area shows the most promise in combating some of the highest pain and cost generators in the country. Dr. Hieu Ball

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