Becker's Spine Review

13 SPINE SURGEONS Biggest spine industry change? Reimbursement — Dr. John Peloza explains spine trends, challenges & opportunities By Mackenzie Garrity J ohn Peloza, MD, is a spine surgeon and medical director of Dallas-based Center for Spine Care. In an interview with Becker's Spine Review, Dr. Peloza discussed spine industry trends and opportunities he is seeing in his practice and as a spine leader. Question: What trends are you current- ly experiencing in the spine industry? Dr. John Peloza: A number of forces are in- fluencing spine surgery today. e most im- portant are cost and quality, which determine value. Back and neck pain are very common conditions in the population with approxi- mately 5 million adults in the U.S. with some degree of disability. Advances in surgical tech- niques, implants, anesthesia and medical man- agement of comorbid conditions have made spine surgery more consistently successful and available to patients that otherwise would not be considered surgical candidates. Following the example of total hip and knee arthroplasty, a major trend is moving spine surgery from the general hospital to the am- bulatory setting. is is not a new idea and is a proven concept for cervical anterior cervi- cal discectomy and fusion/lumbar total disc arthroplasty, posterior cervical discectomy, lumbar discectomy/laminectomy and now minimally invasive spine lumbar fusion. e outcome data is excellent without an increase in complications. e cost of ambulatory sur- gery is significantly less than in-patient sur- gery with equivalent outcomes resulting in a significant increase in value for the patient and payers. is is an irreversible trend. It is necessary to master minimally invasive surgical techniques in order to perform con- sistently successful outpatient surgery. Mini- mally invasive spine surgery is not just small incisions and the use of a microscope. It is a diagnostic and surgical strategy that utilizes specific, precision diagnostic modalities com- bined with surgical technologies/techniques as well as highly trained surgical teams. e result is treating the pathology without dam- age to the normal tissue. MIS surgery can now be performed in a range from the simple metachromatic leukodystrophy to deformity. e greater the magnitude of the surgery, the more potential benefit achieved by minimally invasive techniques. Other trends that compliment minimally in- vasive spine surgery are surgical approaches, particularly the anterior to psoas approach. is approach has all the advantages of the traditional anterior and lateral approach without the disadvantages – vascular and neurologic respectively – of those approach- es. Transforaminal approaches with or with- out fusion implants are now safely performed through a tubular retractor, especially with curved and shielded burrs. is approach de- compresses the spinal canal from the far lat- eral to the entry zone of the foramen and the lateral recess without destabilizing the facet joint or pars. End plate osteophytes can also be removed. e approach can be combined with a midline minimally invasive surgery approach to address the central and lateral recess stenosis. Intraoperative navigation of implants and tu- bular retractors is another technology that is here to stay. e O-arm has been in service for years and is in operating rooms all over the country. Other systems are available and are equally effective. is makes implant placement much more accurate and rapid, which enables complex deformity and revi- sion surgery safe and rapid with less blood loss and dissection. Navigation is now being combined with robotics to refine spine sur- gery. At this time, the navigation is the key technology and the robotic contribution does not justify the cost. However, I expect future robotic advances may change this outlook. New metallurgic and manufacturing technol- ogies are revolutionizing design and utiliza- tion of spinal implants. is includes surface treatments that allow bone cells to adhere and grow into the metals. 3-D printing and subtraction processes can make surface and internal architecture of the implants in any shape and configuration rapidly within fine tolerances while being much more cost effec- tive. Another advance is an implant internal architecture based on trusses or arches that change length (strain) on a nano scale to induce a cell signal to make more cells and attract additional cells (stem cells) into the implant. ese technologies make fusion sur- gery much more predictably successful. Biologics continue to advance and are espe- cially useful in minimally invasive spine sur- gery. We rarely require the old techniques of harvesting large bone gras from the patient. ese technologies include allogras, carriers, growth factors, and stem cells. e use of stem cells for tissue repair or regeneration is still in early trials but the results are promising. Another important element in spine sur- gery is peri-operative and postoperative pain control. We try to avoid or use as little opiate medication as possible. We give a pre- operative cocktail of anti-inflammatory and neuropathic drugs and continue these post- operatively for several days. We also utilize a long-acting local anesthetic in the so tissues of the wound at surgery. Non-narcotic pain medication is used post-operatively as well. e minimization of opiate medication al- lows the patient to be more awake and alert which facilitates post-op rehab and recovery. Our opiate addiction and weaning issues have decreased significantly. e most significant advance in pain modal- ities is dorsal column stimulation. is used to be a salvage technique most appropriate for unilateral neuropathies, damaged nerves, and complex regional pain syndromes. It was poor at relieving axial back pain and success was considered a reduction in pain medicine usage. Overall, this technology usually de- livered disappointing results. New implants and especially new computer soware has radically changed surgical outcomes. DCS now relieves back and bilateral leg pain sig- nificantly and predictably. Because of the new technologies and tech- niques, surgical outcomes have never been better. More patients with more spinal pa- thologies can be treated with confidence. at also means patients with more co-morbidities and advanced age can now be treated as op- posed to the past. ese patients have some of the best outcomes in terms of improvements

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