John Peloza, MD, is a spine surgeon and medical director of Dallas-based Center for Spine Care.
In a recent 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.
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Question: What trends are you currently experiencing in the spine industry?
Dr. John Peloza: A number of forces are influencing spine surgery today. The most important are cost and quality, which determine value. Back and neck pain are very common conditions in the population with approximately 5 million adults in the U.S. with some degree of disability. Advances in surgical techniques, implants, anesthesia and medical management 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 ambulatory setting. This is not a new idea and is a proven concept for cervical anterior cervical discectomy and fusion /
lumbar total disc arthroplasty, posterior cervical discectomy, lumbar discectomy/laminectomy and now minimally invasive spine lumbar fusion. The outcome data is excellent without an increase in complications. The cost of ambulatory surgery is significantly less than in-patient surgery with equivalent outcomes resulting in a significant increase in value for the patient and payers. This is an irreversible trend.
It is necessary to master minimally invasive surgical techniques in order to perform consistently successful outpatient surgery. Minimally 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 combined with surgical technologies/techniques as well as highly trained surgical teams. The result is treating the pathology without damage to the normal tissue. MIS surgery can now be performed in a range from the simple micro-lumbar discectomy to deformity. The greater the magnitude of the surgery, the more potential benefit achieved by minimally invasive techniques.
Other trends that compliment minimally invasive spine surgery are surgical approaches, particularly the anterior to psoas approach. This approach has all the advantages of the traditional anterior and lateral approach without the disadvantages – vascular and neurologic respectively – of those approaches. Transforaminal approaches with or without fusion implants are now safely performed through a tubular retractor, especially with curved and shielded burrs. This approach decompresses the spinal canal from the far lateral 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. The approach can be combined with a midline minimally invasive surgery approach to address the central and lateral recess stenosis.
Intraoperative navigation of implants and tubular retractors is another technology that is here to stay. The 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. This makes implant placement much more accurate and rapid which enables complex deformity and revision surgery safe and rapid with less blood loss and dissection. Navigation is now being combined with robotics to refine spine surgery. 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 technologies are revolutionizing design and utilization of spinal implants. This 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 effective. 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. These technologies make fusion surgery much more predictably successful.
Biologics continue to advance and are especially useful in minimally invasive spine surgery. We rarely require the old techniques of harvesting large bone grafts from the patient. These technologies include allografts, carriers, growth factors, and stem cells. The use of stem cells for tissue repair or regeneration is still in early trials but the results are promising.
Another important element in spine surgery is peri-operative and post-operative pain control. We try to avoid or use as little opiate medication as possible. We give a preoperative cocktail of anti-inflammatory and neuropathic drugs and continue these postoperatively for several days. We also utilize a long acting local anesthetic in the soft tissues of the wound at surgery. Non-narcotic pain medication is used post-operatively as well. The minimization of opiate medication allows the patient to be more awake and alert which facilitates post op rehab and recovery. Our opiate addiction and weaning issues have decreased significantly.
The most significant advance in pain modalities is dorsal column stimulation. This 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 delivered disappointing results. New implants and especially new computer software has radically changed surgical outcomes. DCS now relieves back and bilateral leg pain significantly and predictably.
Because of the new technologies and techniques, surgical outcomes have never been better. More patients with more spinal pathologies can be treated with confidence. That also means patients with more co-morbidities and advanced age can now be treated as opposed to the past. These patients have some of the best outcomes in terms of improvements in quality of life. They also have more frequent complications that increase costs. There are risk stratification models being utilized to identify a more appropriate surgical treatment of individual patients in order to minimize risk.
This brings us to one of the biggest trends in spine surgery and that is reimbursement. There is no doubt that reimbursement is going to change. This will affect hospitals, surgeons, vendors patients, payers and employers as well as government. There are many interests involved so where it leads will be difficult to predict. Fee for service medical care will decrease and some sort of managed care with a fixed total payout will be more likely. Presently, bundled payment models are being developed and implemented with mixed results. If a single payer government system evolves, then rationing will be the main characteristic of the medical system and we can forget about almost everything previously discussed.
It is an exciting time to be a spine specialist with many new and effective treatments to offer more patients. Patients need not suffer in pain as in the past. People can recover quicker and return to an active lifestyle not seen in the past. The scientific and technological progress is moving ahead very well. The main challenge is financial, and I have confidence in the free market for solutions.