Becker's Spine Review

Sign up for Becker's Orthopedic, Spine Business & Pain Management E-Weeklies at www.BeckersOrthopedicandSpine.com or call (800) 417-2035 "Disc regeneration seeks to bring the cushion of the spine back to its normal state," says Dr. Patel. "These techniques are being researched and there have been some attempts at performing them, but we don't have any solid clinical evidence that will promote the idea we should change the way we treat spinal surgery at this point in time." Biologics has permeated the market with bone morphogenic proteins and other similar synthetic fusion materials. Device companies are working on creating a material that allows bone graft substitutes to achieve fusion without harvesting bone from the patient's iliac crest. "I have actually converted the majority of our procedures where we had used BMP to using some of the ceramic based substitutes," says Dr. Ball. "Some are usable by themselves and others are used in conjunction with a demineralized bone matrix. I think that is really where people are going; going back to using allograft or autograft because there has been evidence in the literature of the potential complications and side effects of BMP." BMP has also been very expensive in the past and surgeons are now encouraged to use other options in the future. 5. Lateral approach is gaining steam. More procedures are looking for a lateral approach to the spine, and device companies are developing new lateral systems to meet these needs. Initial minimally invasive procedures approached the spine anteriorally or posteriorally, but there have been some proven benefits to the lateral approach when possible. "The biggest trend in minimally invasive surgery right now is the lateral approach," says Jennifer Sohal, MD, a spine surgeon with St. Vincent Spine Institute in Los Angeles. "It has been very effective in decreasing postoperative pain and allowing surgeons to perform more complex procedures with less morbidity." Dr. Jennifer Sohal Even high acuity procedures such as scoliosis repair are now accessible through a lateral approach. However, the technique has not become a standard of care yet. "It's still in the early stages, but I think more people are increasing their skill level in these techniques," says Dr. Sohal. "We'll see more training opportunities available and surgeons will become more comfortable selecting the right patients for the procedure. Minimally invasive techniques are not replacing all open techniques; it's just another tool in the toolbox." 6. Intraoperative neuromonitoring and neurophysiology. Along with minimally invasive instrumentation and implants, a new need for advances in neuromonitoring and neurophysiology has emerged. Surgeons want to perform these procedures safely for their patients, and an extra person gauging the quality of the procedure can really make a difference. "An area of advancement in the future is going to be neuromonitoring so surgeons can make sure they aren't doing any nerve damage during these procedures," says Dr. Nottingham. "We'll also need a way to package this technology so it can come at a reasonable cost to the ASC or hospital. It will be in the interest of companies to develop models for leasing and temporary rental programs so that these technologies can be used in a more economical manner." Lawrence Dickinson, MD, a spine surgeon with Pacific Brain and Spine Medical Group in Castro Valley, Calif., has added a neurophysiologist to his practice, which he has found improved the quality of his procedures. He uses the Baxano system to perform minimally invasive spine surgeries and has seen the advantage of using a neurophysiologist in the operating room, even if it adds expense to the case. "I think adding a neurophysiologist is an advantage and the patient will never complain about Dr. Lawrence Dickinson 9 someone guarding the nervous system," he says. "This person is in the room telling the surgeon if he is irritating the nerve root. Additional safety is helpful in the long run because it prevents complications, whether you are using a device or not. I started using electrophysiology and improved my practice." 7. Computer navigation could have a place going forward. Computer assistance and robotic guidance for orthopedics and spine have been a contentious issue for the past few years; the equipment is expensive and surgeons question whether it actually improves the procedure enough to warrant that cost. However, there is a market for this technology and future iterations could make an impact on spine care. "Surgeons are able to use navigation to assist in surgery, decreasing operative time and need for revision surgery," says Dr. Sohal. "It involves obtaining an intraoperative CT scan to create a model of the spine on which we can project our operative plan." Mazor, a robotic spine technology company, has published results from individual surgeons on their accuracy placing pedicle screws. "I think we have navigational systems working now, but there will be continued improvement there," says Dr. Nottingham. "The technology continues to reduce our element of error and the amount of radiation used to produce images." 8. Physician-owned ambulatory surgery centers are more common in spine. There is an opportunity for more spine surgeons to become investors in ambulatory surgery centers if they can move their cases into the outpatient setting. Spine practices in unsaturated markets are able to open their centers and have more control over their cases. "Our ASC is really staying on the forefront of minimally invasive spine technology," says Dr. Nottingham. "There is a keen interest of the management and ownership to really develop quality outpatient spine surgery services, so it's been a real pleasure working with them. Some ASCs don't show that level of interest because it really takes commitment to develop an outpatient spine service." Spine surgeons must partner in outpatient surgery center endeavors and commit to performing cases there to make the investment successful. "If there is teamwork amongst the surgeons and administration, the program will come into existence and become one of quality service," says Dr. Nottingham. "If you bring in the appropriately selected cases, you will have the monies to purchase the navigational, neuromonitoring and anesthesia systems along with any other instrumentation needed. The critical element is getting interested parties together." n

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