Neel Anand, MD, director of spine trauma, minimally invasive surgery at Cedars-Sinai Spine Center in Los Angeles, discusses the biggest challenges and advances in spinal trauma treatment, as well as where the field is headed in the future.
Q: What is the biggest challenge for surgeons treating spinal trauma cases?
Dr. Neel Anand: The biggest issues we have are patients with multiple injuries — not just to the spine, but also to the pelvis, abdomen or chest. The organs take precedence and in the meantime we have to keep the spine stable while those things are being taken care of. The biggest challenge is the speed with which we can get to the patients to handle a spinal cord injury. The sooner we can get to the patient and stabilize and decompress them, the better their outcome will be. The window is three hours; getting someone into critical care within three hours can be challenging.
Then there is a challenge of having facilities prepared to accept spinal trauma patients. The biggest issues we have here, is dealing with patients who have significant blood loss and multiple injuries; you need big centers that can handle major trauma patients and sometimes those aren't very close. Once patients get to the hospital, we need to make sure we're managing the situation; we need to stabilize the spine and get the pressure off the spinal cord as soon as possible and stabilize the spine. To do that, you need the resources at a Level 1 trauma center to get those services going. It can be very difficult at a community hospital.
Q: What are the biggest innovations in spinal trauma over the past few years?
NA: There are three major things that have changed: we are able to augment osteoporatic fractures in elderly patients with percutaneous intervention — vertebroplasty or kyphoplasty — which began about 10 years ago; the other update would be minimally invasive fixation or similar techniques for these patients. We are able to do minimally invasive surgery to reconstruct the spine; the third change would be biologics for fusion. Biologics is still in the research phase right now, but down the line there will be stem cell therapies available for spinal cord injury.
Augmentation has been around for a while, as has minimally invasive stabilization and reconstructive techniques that have developed over the last three to five years. The two things we do are protect existing structures and reconstruct, the spine. We traditionally had to open the spine to stabilize it for screws and rods, but today we can put those in percutaneously without damaging muscles. We are also able to take the entire fractured vertebral body and replace it through a minimally invasive approach. A lot of minimally invasive technology in the thoracic and lumbar spine is able to help people today.
Biologics, such as BMPs and other bone extenders, make a big difference with trauma patients. We used to take bone from the iliac crest to promote fusion, and that incision traditionally has hurt. Biologics help us move away from that.
All these things have changed how we manage global spine trauma.
Q: Are most surgeons able to treat patients with these advances today?
NA: The minimally invasive stabilization goes beyond research and is something we do every day, but it's only applicable to a portion of the patients with spinal fractures. Some patients still need to be handled traditionally, so it's a growing field. As surgeons feel more comfortable doing minimally invasive techniques, it will become more popular. It's something we talk about at the meetings and it's an evolving forefront. People want to see the same results as they would get with open surgery, and they will as long as you select the right patients.
Q: Are there any other developments that have helped you treat patients with spinal cord injury?
NA: Imaging technology has improved so we have a better understanding of fractures from the MRI. We know what is unstable and it helps us determine the best pathway for fracture management.
Q: What is on the horizon for patients with spinal cord injury?
NA: There have been drugs that are now being looked at for patients with spinal cord injury. The future would be eventually chemotherapeutic or a pharmacological way of handling a spinal cord injury; I think that will impact the future more than stem cell treatment. Once you have a spinal cord injury you can restrict the amount of injury with good spinal cord therapeutic agent. That is very promising.
Other options available could be IV or local application of topical agents, which are being worked on right now. These would be for patients where the mechanical damage is already done to prevent further damage.
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Innovation in Spinal Trauma Treatment: Q&A With Dr. Neel Anand of Cedars-Sinai Spine Center FeaturedWritten by Laura Miller | July 11, 2012
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