Lawrence Dickinson, MD, an neurosurgeon with Pacific Brain & Spine Medical Group in Castro Valley, Calif., discusses minimally invasive spine surgery and where he sees the field heading in the future. Q: Where is the spine field now and what technology could be a disruptive influence on the market going forward?
Dr. Lawrence Dickinson: Right now, I think our field is limited in our treatment options with much of the focus on spinal fusion in the United States. Surgeons are removing movement segments in the spine for people who have diseases that are more related to problems with the irrigation of the ligaments and osteostructures of the spine.
I am currently using the iO-Flex system (Baxano Inc), a tool that maximally preserves the anatomy, particularly the facet joint anatomy of the spine and allows surgeons to very comprehensively decompress the nerve elements in a way we can avoid fusions for some people who are currently subjected to large structural reconstruction operations like fusions.
Q: What advantages does the iO-Flex technology afford surgeons? How is it different from other minimally invasive systems?
LD: iO-Flex is able to help surgeons decrease failure rates because we are preserving the midline anatomy and a vast majority of the facet complex. This is a mini open midline laminectomy that allows surgeons to pass a flexible micro-shaver that removes ligament and bone from the central surface of the superior articulating process of the affected level, thus decompressing the lateral recess all the way out to the far lateral foramen.
I've been excited to work with Baxano on post-market prospective trials for stenosis patients in order to further demonstrate the clinical and economic benefits of the tool in decompression surgery. The original idea for the procedure was doing the operation percutaneously, but the available tools are not percutaneous as you still need to visualize the thecal sac. I perform the procedure minimally invasively through a unilateral METRx tube approach and am able to get a profound decompression that is somewhat revolutionary.
Q: How can surgeons incorporate this technology into their practices? How much time and resource allocation does it take?
LD: The most important factor for surgeons before learning the devices is to become facile with fluoroscopy because this procedure involves radiographic documentation of where you pass the device and understanding of the facet and lateral spinal anatomy. There is some training involved and surgeons can go through a didactic and lab to learn the devices. There are also technical representatives in the operating room with the surgeon to help the staff implement the tools.
It's also necessary to conduct neurophysiological monitoring on each case. Not all surgeons currently do neurophysiological monitoring with simple decompressions.
The system is FDA cleared and the company has also been careful in assessing the surgeons’ skill before working with them to implement this technology. I've seen some patients on bed rest come in for spine surgery and literally with a 20-minute procedure they were able to stand up and walk out. This revolutionized how we take care of acute care issues, yet if you don't have the right technician, you can have bad results or an incomplete recovery.
Q: How do you think costs could be mitigated on this technology in the future? How does the technology fit within reimbursement and would it make sense for every hospital?
LD: I think from a resource perspective decreasing failure rates and avoiding spinal fusions for some patients will offer significant savings in our healthcare system. For the hospital, fast patient recovery helps mitigate the cost of the device, but the current economics can make some institutions hesitate in using technology like iO-Flex. As we move forward with healthcare reform and we evolve from cost-based to value-based purchasing, the incentives will shift from quantity to quality. In this new environment, technologies like iO-Flex that have equal or better outcomes for less cost, will become part of every surgeon's practice. In fact, one of the most likely quality models that will be evaluated shortly could be a bundled payment for a condition such as symptomatic stable grade I spondylolisthesis for 12-month care. A minimally invasive decompression would likely be the most effective choice for many patients.
Q: What is the biggest roadblock to this technology becoming more pervasive?
LD: The short-term economics can make some institutions hesitate in allowing the technology to be used. Currently our government has rules and regulations about safety of devices, but because surgeons haven't taken enough time to advocate for individual outcomes measures, the federal government supports looking at the epidemiology of conditions and treatment. The insurance companies are more focused on cost cutting. It will take time for the environment to shift to make the technology more pervasive.
Q: Where do you see minimally invasive spine surgery heading in the future? Where is the biggest opportunity for growth?
LD: I think the most exciting developments will come from stem cell innovation. We may be able to reverse degenerative diseases with some types of minimally invasive procedures, such as injection therapy into the joint for internal repair. Up until now, we've been fixated on taking out the injured part and putting something else in; we'd love to go in and have a confident gene product that would allow renewed function in the joint. If we are able to get to the point where stem cell technology can repair spinal cord injury it would be the Nobel Prize in our field.
Surgeons are doing phenomenal work in spinal cord regeneration that is very exciting with stem cell technology. For me, adding new biologics in the field will be profound and revolutionize this idea that we are physioscientists that are returning and regenerating the anatomy. In the future we will have the capacity to have good biologics for everything: bone, ligament and cartilage regeneration.
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