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44 F ive spine surgeons discuss exciting innovations in spine surgery, roadblocks to innovation and the best opportunities for growth over the next five to 10 years. Question: What are some of the most exciting innovations in spine surgery at the moment? Samuel Cho, MD, Mount Sinai Hospital (New York): There are several in- novations. In the cervical spine, artificial disc replacement has been shown to have equivalent clinical efficacy compared to ACDF. The investigators are following patients long-term to see whether this motion preservation tech- nology can decrease the incidence of adjacent segment disease. Minimally invasive spine surgery now has some evidence to support that its use results in similar long-term clinical outcome compared to traditional open procedures but with shorter hospital stay and quicker recovery. It has also been shown to be cost effective in a couple of papers. On the other hand, it exposes the surgical team to greater radiation. Biologics are another exciting field. Many companies are coming up with stem cell-based products such as bone graft substitutes. Its efficacy is yet to be proven. Jeffery Carlson, MD, President, Managing Partner, Orthopaedic and Spine Center (Newport News, Va.): The advancement of bone graft and bone graft substitutes are making great strides. Manufacturers are making products that are becoming more advanced. These products will continue to push the envelope of fusion technology. The "Gold Standard" autograft bone is now being challenged by visionary companies that are enhancing bone proteins, collagen platforms and stem cells. These creations will eventually prove to be better than autograft bone as the technology advances to exactly reproduce autologous bone, then enhance the matrices to make grafts that can exceed the potential of autograft bone. Mick Perez-Cruet, MD, MSc, Chief, Spine Surgery, Department of Neuro- surgery, William Beaumont Hospital (Royal Oak, Mich.): What interests me is minimally invasive spine surgery and how innovations in MIS are be- ing developed. I think, in general, we are developing certain technology for more focused care so that patients are recovering quicker and with better outcomes. We are treating a variety of pathologies of the skull base, cervical, thoracic and lumbar spine using MIS techniques and technologies. I've been doing this for quite a while and we are definitely seeing long-term improvements that are lasting and satisfied patients who are receiving those treatments. Thomas Schuler, MD, FACS, CEO, Virginia Spine Institute (Reston): Devel- opments in artificial disc technology, regenerative treatments for the disc and spinal structures as well as advancements in minimally invasive spine surgery are positively benefiting patients. Hybrid cervical arthroplasty/fusion is a monumental improvement for our patients. The PRP injections and the stem-cell injections used intradiscally to repair the disc and ligament helps patients avoid surgery or postpone sur- gery. These non-operative options are helping improve patients' daily lives and function. Q: What are some new technologies you are using in your work? Roger Hartl, MD, Chief, Spinal Surgery, NYP/Weill Cornell Medical Center (New York): I use a lot of 3D navigation for spinal surgery cases. The technol- ogy has been available in the last 10 years, but it has evolved, and it has now become more user-friendly. Dr. Schuler: We're using posterior Mazor robot-guided surgery, lateral in- terbody fusions with plate fixation and anterior spine reconstruction to ad- vance minimally invasive spine procedures. These approaches are improving patient outcomes. Stem cell injections for disc regeneration and complex cervical hybrid ar- throplasty-fusion operations are providing our most exciting advances for patients. Dr. Cho: I utilize artificial disc replacements and minimally invasive tech- niques when appropriate. I am waiting for more evidence on stem cell tech- nology. Dr. Perez-Cruet: We are using MIS technologies that reduce cost while im- proving fusion rates, facilitating MIS procedures and reducing radiation exposure to surgeons. Many of these have been developed working with Thompson MIS. Q: What are some of the roadblocks to innovation in spine sur- gery? Dr. Hartl: The lack of spine surgeons who are interested in conducting spinal research. We have a great lack of understanding about what is causing degen- erative spine and why it causes pain. The research that is necessary to under- stand these pathologies better, but not a lot of spine surgeons are interested in doing it. Also, there is a lack of infrastructure in which to conduct this research. Innovation in Spine MIS, Biologics & More: Can Anything Stem the Flow? By Anuja Vaidya ©2013 Medtronic Sofamor Danek USA, Inc. All Rights Reserved. PMD012500-1.0 BRIEF SUMMARY OF INDICATIONS, CONTRAINDICATIONS, AND WARNINGS FOR: INFUSE® BONE GRAFT/LT-CAGE® LUMBAR TAPERED FUSION DEVICE, INFUSE® BONE GRAFT/INTER FIX™ THREADED FUSION DEVICE, INFUSE® BONE GRAFT/INTER FIX™ RP THREADED FUSION DEVICE The INFUSE® Bone Graft/Medtronic Titanium Threaded Interbody Fusion Device is indicated for spinal fusion procedures in skeletally mature patients with degenerative disc disease (DDD) at one level from L2 – S1, who may also have up to Grade I spondylolisthesis or Grade 1 retrolisthesis at the involved level. The INFUSE® Bone Graft/ LT-CAGE® Lumbar Tapered Fusion Device is to be implanted via an anterior open or an anterior laparoscopic approach. INFUSE® Bone Graft with either the INTER FIX™ or INTER FIX™ RP Threaded Fusion Device is to be implanted via an anterior open approach. The INFUSE® Bone Graft/Medtronic Titanium Threaded Interbody Fusion Device consists of two components containing three parts– a metallic spinal fusion cage, a recombinant human bone morphogenetic protein and a carrier/scaffold for the bone morphogenetic protein and resulting bone. These components must be used as a system for the prescribed indication described above. The bone morphogenetic protein solution component must not be used without the carrier/scaffold component or with a carrier/ scaffold component different from the one described in this document. The INFUSE® Bone Graft component must not be used without the Medtronic Titanium Threaded Interbody Fusion Device component. NOTE: The INTER FIX™ Threaded Fusion Device and the INTER FIX™ RP Threaded Fusion Device may be used together to treat a spinal level. LT-CAGE® Lumbar Tapered Fusion Device implants are not to be used in conjunction with either the INTER FIX™ or INTER FIX™ RP implants to treat a spinal level. The INFUSE® Bone Graft/Medtronic Titanium Threaded Interbody Fusion Device is contraindicated for patients with a known hypersensitivity to recombinant human Bone Morphogenetic Protein-2, bovine Type I collagen or to other components of the formulation and should not be used in the vicinity of a resected or extant tumor; in patients with any active malignancy or patients undergoing treatment for a malignancy; in patients who are skeletally immature; in pregnant women; or in patients with an active infection at the operative site or with an allergy to titanium or titanium alloy. There are no adequate and well-controlled studies in human pregnant women. In an experimental rabbit study, rhBMP-2 has been shown to elicit antibodies that are capable of crossing the placenta. Women of child bearing potential should be warned by their surgeon of potential risk to a fetus and informed of other possible orthopedic treatments. The safety and effectiveness of this device has not been established in nursing mothers. Women of child-bearing potential should be advised to not become pregnant for one year following treatment with this device. Please see the package insert for the complete list of indications, warnings, precautions, adverse events, clinical results, definition of DDD, and other important medical information. The package insert also matches the sizes of those sized devices that are indicated for use with the appropriate INFUSE® Bone Graft kit. CAUTION: Federal (USA) law restricts this device to sale by or on the order of a physician with appropriate training or experience.