Fifteen spine surgeons discuss the most important technological and technique-based innovations in spine care over the last 10 years.
Question: What technique, developed in the last decade, changed the way spine care was delivered?
Edward H Scheid Jr., MD. President, Founder of Capital Region Neurosurgery & President, Capital Region Special Surgery (Slingerlands, N.Y.): The development of minimally invasive lateral interbody fusion techniques.
The procedure, originally developed as XLIF, has led to a paradigm shift in how patients with degenerative deformities in the lumbar spine are treated. By allowing a surgeon to correct coronal imbalance with lateral grafts placed via a minimal approach, XLIF and other lateral fusion techniques have opened up an opportunity to treat patients more effectively, and allow fusions to be performed without long incisions and large posterior constructs.
Charla Fischer, MD. Assistant Professor of Orthopedic Surgery at Columbia University Medical Center (New York): The development of minimally invasive spine surgery has revolutionized spine care for many reasons. As a surgeon, I am now able to treat conditions of the spine with the same principles that have been developed over many years, while preserving the healthy soft tissue of the back. This allows for shorter hospital stays, faster return to work and activities and less postoperative pain. Additionally, this technique maintains the maximum amount of normal healthy tissue, and this will help the patient avoid additional spine surgeries in the future.
The development of a multidisciplinary approach to spine patients has truly revolutionized the way spine care is delivered. This allows for collaboration of spine specialists in physical therapy, pain management, nonoperative interventionalists, medicine, anesthesia, spine surgery and psychiatry/psychology. Now patients are able to maximize the nonoperative options before meeting with a surgeon. Patients who may benefit from surgery are carefully screened from the risk/benefit perspective and medically optimized for surgery. Current spine care allows for thorough understanding of patient expectations and risk of complications from a multidisciplinary team perspective.
Michael Perry, MD. Co-founder and Chief Medical Director of Laser Spine Institute (Tampa, Fla.): As I consider the techniques and advancements that have led to a change in spine care delivery, I'm immediately drawn to those that help to improve the patient experience. In tandem with the advent of new devices and procedures that no longer require invasive, lengthy incisions, minimally invasive spine surgery has changed the way both surgeons and patients perceive spine surgery. This model's shift from the hospital to an outpatient facility has not only helped to comfort patients, but it's kept them safer, with complication and infection rates shrinking drastically when comparing an ambulatory surgery center with a hospital. It's also getting patients back to work and the things they love most, faster and with a gentler recovery.
Biologics is another area primed for growth within the spine space. While research is still in its infancy, particularly related to stem cells, many feel that biologics will ultimately be viewed as an early treatment modality. The clinical application will be varied, including usage for preventive therapy, but there's no doubt that healing and regeneration from biologics will play an increasingly important role in spine care and the patient experience.
Frank La Marca, MD. Chief, Spine Section of the Department of Neurosurgery at the University of Michigan Health System (Ann Arbor): I feel that the development of minimally invasive lateral approach techniques to the spine has contributed greatly, over the last 10 years, to the advancement of spinal surgery and has revolutionized how we treat patients, not only with common degenerative spinal pathology but also with more complex spinal deformity problems. These surgical techniques, such as lateral interbody arthrodesis with or without anterior longitudinal ligament release, are not new per se but thanks to the introduction of minimally invasive approaches have become more accessible to a broader number of surgeons and often eliminated the need for an assistant surgeon to help in the surgical exposure.
These techniques along with novel device implants have also been shown to yield significant clinical benefits as compared to open surgical techniques resulting in an increased overall value for the healthcare system.
Richard Nachwalter, MD, and Carl Giordano, MD. Spine Surgeons at Atlantic Spine Specialists (Morristown, N.J.): There are few things that develop that are truly revolutionary. Most techniques are more evolutionary, that is, small advances. We are always striving to make incisions smaller and surgery safer. The development of image guidance, the ability to view in real time spinal implants as they are being inserted, has achieved both of those goals. We can now make surgery smaller and safer.
Jae Lim, MD. Principal Surgeon at Atlantic Brain & Spine (Fairfax, Va.): I believe minimally invasive surgery for the spine has undoubtedly changed the way spine care has been delivered in the past decade. This includes robotics, but also intraoperative image systems, endoscopes, tubular retractors, novel spinal access approaches and interbody implants that accelerate fusion/healing to name a few. I think future direction will be in restorative spinal surgery, which is a focus on procedures to replace or strengthen the different parts of the spinal column. With the upcoming advances in nanotechnology and 3-D printing, surgeons will be able to increasingly rebuild the spine rather than simply resecting and fusing.
James J. Lynch, MD. Founder of SpineNevada (Reno, Nev.): The single most influential technique developed in spine during the last decade in my opinion is the lateral approach to the lumbar spine. This procedure technique was developed and promoted initially by NuVasive 10 years ago and is commonly known as XLIF or extreme lateral interbody fusion. Due to its phenomenal game-changing effect and the disruptive technology on how we view, interpret and treat lumbar spine conditions in degeneration, deformity and trauma, the procedure has been more recently adopted by other spine companies and use the acronyms ELIF and DLIF.
No other procedure has contributed to improved patient wellbeing by minimizing the approach to fusion techniques and certainly changing the way surgeons address global alignment strategies and overall sagittal balance issues by avoiding more outdated, scoliosis, open, destructive surgical procedures. This procedure has resulted in marked improved patient outcomes in the last decade.
Mark Nolden, MD. Spine Surgeon at NorthShore Orthopaedic Institute (Chicago): Minimally invasive procedures for spinal decompression surgery have enabled specialists to deliver more outpatient care. This has led to a quicker recovery for patients and less of a need for postoperative rehabilitation.
Todd Lanman, MD, Lanman Spinal Neurosurgery, Beverly Hills, Calif.: Over the past decade, artificial disc replacement has become an attractive option for patients with degenerative disc disease who would benefit from surgical treatment. Artificial disc replacement is now a compelling rival to the current standard of care for this patient population, vertebral disc fusion. In fact, I anticipate artificial disc replacement may eclipse vertebral fusion in the very near future since replacement provides similar symptom relief to fusion with one important advantage: preserved range of motion in the spine.
We now have data from clinical trials showing cervical artificial disc replacements — devices that are placed in the neck — provide superior outcomes to vertebral fusion surgery. This is true whether a patient needs treatment at one or even two vertebral levels. People with lumber disc disease, that is, disease in the spinal bones of the lower back, also benefit from artificial disc replacement. Studies have now shown that lumbar disc replacement provides at least equivalent symptom relief to fusion, again with the added benefit of preserved spinal motion.
Given the documented successes of artificial disc replacement over the past decade and the superior functional outcomes it provides, I expect that within the next 10 years artificial disc replacement will become the new standard of surgical care for most patients with symptomatic degenerative disc disease.
Barry Ceverha, MD. Medical Director, Operative Program at Center for Spine Health at Orange Coast Memorial Medical Center (Fountain Valley, Calif.): There have been many new applications in spinal technology — spinal instrumentation, biological products, the progression of MIS surgery and so on. I feel that surgical navigation remains at the forefront of new technology. This technology enhances patient safety, demonstrates better outcomes and reduces cost by reducing OR time and allowing more accurate placement of hardware. Intraoperative CT guidance with enhanced imaging will allow even more accuracy and will open new windows of application.
Brian R. Gantwerker, MD. Spine Surgeon at The Craniospinal Center of Los Angeles: By far, the lateral interbody technique has totally changed the way most of us practice. It has allowed us to look at the spine as a true three-dimensional construct and to start really thinking about how to change coronal and some sagittal issues. With practice, really challenging cases can suddenly look accessible and doable from a surgical perspective. It has granted access to regions of the spine that were once a struggle to get to from the posterior approach. That being said, nothing beats a great vascular access surgeon for the anterior lumbar approach. I am fortunate enough to practice with some tremendously talented vascular surgeons who have made anterior access into an art form.
J. Brian Gill, MD, MBA. Spine Surgeon at Nebraska Spine Hospital (Omaha): There have been several innovations that have forwarded the field of spine surgery including image guidance, which has helped to facilitate MIS surgeries, bone graft substitutes, such as BMP and stem cells, and disc arthroplasty procedures as this has afforded an alternative to fusion procedures generating a discussion on motion preservation technologies and how they fit into the spine surgeon's armamentarium.
Vladimir Sinkov, MD. Spine Surgeon at New Hampshire Orthopaedic Center (Nashua): Minimally invasive techniques in general have changed spine care tremendously in the past 10 to 15 years. Most of those techniques have actually been developed earlier than that, but the recent advances in instrumentation, implants, imaging and neuromonitoring have made it possible for most spine surgeons to adapt and embrace them. The technique that has changed my practice the most is the lateral lumbar interbody fusion with direct visualization of the psoas. It allows for the least invasive way to fuse the thoracolumbar spine while performing the surgery safely. My outcomes have improved [and] length of hospital stay has decreased. I can offer this surgery to patients who would not be able to tolerate the traditional open lumbar fusion due to their health, anatomy or history of previous spine procedures.
Azadeh Farin, MD. Neurosurgeon at Long Beach (Calif.) Memorial Medical Center: Spine care has changed dramatically in the last decade, prompted by several factors, including needs of an aging, more sophisticated, active, demanding and medically complex population which is living longer. Together these factors encourage the development of a myriad of new surgical techniques, medical devices and biomaterials including expandable cages, motion-preservation devices, alternative approaches to the spine and techniques for correction of spinal deformity, minimally invasive approaches, stem cell biologics, 3-D printing, rapid prototyping, transition to single use sterile packaging and nanotechnology for surface preparation.
Many of these developments successfully address unmet clinical needs and offer options to patients who before had very few to improve their quality of life. These advantages further include advances in patient safety, cost controls and information technology, outcomes collection and surgical animations — although not every new phenomenon has demonstrated clear advantages over older products and techniques. Measures meant to increase patient satisfaction, include the common use of intraoperative neuromonitoring and increased use of the intraoperative microscope to help ensure safer surgeries. Additionally, the evolution of a growing number of spine surgeries from the hospital operating room to an increasing number of ambulatory surgery centers is resulting in decreased lengths of stay and cost.
Bryce A Johnson, MD. Orthopedic Spine Surgeon, Saddleback Memorial Medical Center (Laguna Hills, Calif.). Over the last decade, both the refinement of tubular or minimally invasive surgery based retractor systems and instruments as well as the advancement of multimodal pain management have really propelled the movement for faster recovery and shortened stay postoperatively. Although their development began prior, minimally invasive techniques have experienced increased interest over the last decade.
The goals of surgery remain the same as open surgery with thorough neurological decompression and stabilization, if necessary, of paramount importance. However, with lessened collateral damage, we have seen decreased postoperative pain and narcotic utilization, and, therefore, a faster recovery. This effect has been helped with advancements in multimodal pain management in the perioperative period. The more widespread use of IV acetaminophen and the judicious use of short-or long-acting local anesthetics have furthered the decrease in narcotic use postoperatively. As a result, patients are mobilizing faster and being discharged earlier.