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15 Technology & Innovation E ndoscopic transforaminal decompressive surgery is one of the up- and-coming technologies that could change how traditional spine surgery is performed. Anthony Yeung, MD, founder of Desert Insti- tute for Spine Care in Phoenix, developed the Yeung Endoscopic Spine Sys- tem and all members of his practice perform it. "Technologies disrupting conventional spine care involve a technique to first identify the patho-anatomy of pain generators through diagnostic and thera- peutic injections," says Dr. Yeung. "This preliminary method confirms diag- nosis correlating the imaging study with surgical MIS treatment." "Selective endoscopic discectomy" is the term coined for intradiscal decom- pression and foraminoplasty of the subarticular and lateral recess for the fo- raminal approach. The diagnostic and therapeutic injections through the fo- ramen outline patho-anatomy fluoroscopically and augment imaging studies before providing evidence of the therapeutic part of the injection with a transforaminal steroid. The transforaminal steroid provides pain relief and helps predict outcomes for surgically decompressing, ablating and irrigating the source of intradiscal and foraminal pain. "The surgical philosophy is to focus on the elimination of pain directed to- ward the patho-anatomy in a degenerative spine rather than just focusing on correcting deformity or instability as a first line treatment," says Dr. Yeung. "The decompression can be confirmed in a postoperative MRI or CT scan." The traditional treatments for spine conditions focus on correcting the imag- ing abnormality exclusively. These treatments are effective in the appropriate patients but only after a more extensive surgical option as the first line of treatment fails, says Dr. Yeung. He has focused and practiced this philosophy and the endoscopic technique of transforaminal decompression, ablation and irrigation through the endo- scope for more than two decades — since 1991. "Surgical results can be predicted to resolve or mitigate the painful course of a degenerating spine to a less painful or non-painful final outcome over time," says Dr. Yeung. "The technique is being adopted all over the world, especially in Asia." But will the procedure have staying power in the United States? That depends on several factors, including data collection and payer reimbursements. "Payers have realized that the high cost of surgical spine care cannot continue unabated," says Dr. Yeung. "Techniques that simply eliminate the cause of pain in measured steps will stick because they work in experienced endo- scopic surgeons' hands and are cost-effective, as validated in the literature." Practices that are currently focused on procedures with expensive hardware and implants will see reimbursement decreases without a similar decrease in implant price. As a result, Dr. Yeung sees effective non-fusion decompressive procedures becoming more prevalent because these procedures demonstrate as cost-effectiveness. "Patients are seeking nonfusion alternatives as they discover new options in this technology advancing MIS spine care method to mitigate pain," says Dr. Yeung. "They seek solutions to eliminate their pain while the natural process evolves to a less painful state. Many of these alternatives are touted on the internet, but some of it is marketing hype." The technologies that have these qualities will likely have longevity in the marketplace: • Provide pain relief • Alter the painful phase of degenerative processes • Decrease reliance on expensive implants and hardware "Even successful surgery isn't forever, as evidenced by adjacent level problems and artificial components having a timeline of wear and tear," says Dr. Yeung. "We need to focus more on decompression first, without hardware as the first line of treatment and add hardware as a staged procedure when needed dur- ing the aging or degenerative process." For patients, it's critical to find surgeons with experience and proven out- comes instead of those who only have "marketing hype." Endoscopic technol- ogy isn't the only area to watch. Going forward, there will also be big oppor- tunities for development in biologics. "The areas of biologics from natural tissues, such as stem cells that can bypass the regulatory issues controlled by the FDA, present an important area of ad- vancement," says Dr. Yeung. "Studies of its efficacy are beginning to surface. Training opportunities in residency programs, currently absent, will rapidly advance this field. Most advancements currently are from the private sec- tor. Their visibility, however, is being validated more and more in the spine literature." n Why Endoscopic Spine Surgery is the Next Tech Disruptor By Laura Dyrda than with PEEK implants. Since beginning to use titanium, he hasn't seen a pseudoarthrosis case. "I've done revisions from other surgeons where I took out PEEK interbody spacers and found there were no fusions around the implants and then re- vised them with Titan titanium spacers," he says. "I've only seen one case where the titanium spacer backed out, and that's in two years of using them." Titanium is quickly becoming the material of choice among spine surgeons, according to Dr. Colle. "There is continued research and study of the interface between titanium and bone," says Dr. Colle. "I think it's going to become more widely accepted. The Europeans now can't get enough titanium and they don't want PEEK anymore. Titan's research shows titanium interbody spacers are osteogenic to promote stem cells to behave in a way that promotes bone growth." There have been some companies updating their PEEK now with titanium spray. "They want to improve the PEEK with titanium, but I would say just to use implants like Titan's that are entirely titanium," says Dr. Colle. "If the titanium is what works, and engineering has made the product better, then surgeons should stick to that." Titan Spine is currently conducting research to demonstrate the potential for particulate debris production associated with titanium-sprayed PEEK implants during implantation. The company is also performing studies to counter the long-held belief that the modulus of elasticity of PEEK allows it to resist subsidence more effectively than titanium in- terbody fusion devices. The research will soon be published and presented at spine society meetings. Titan Spine is so confident in their interbody devices that they announced a warranty last year for a one- time, free replacement of any eligible Titan spine in- terbody fusion device if revision surgery is required for a non-union within five years of the warranty period. "Ultimately, the warranty demonstrates the significant confidence we have in our products and science validating our surface technology," says Titan Spine CEO Peter Ullrich, MD. n 1 Data on file at Titan Spine.