Here four spine surgeons weigh in on the future of biologics in spine.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses. Next week's question: Are you performing image-guided spine surgery? What are the challenges and benefits?
Please send responses to Heather Linder at hlinder@beckershealthcare.com by Wednesday, July 17, at 5 p.m. CST.
Kern Singh, MD, Rush University Medical Center, Chicago: Unfortunately, the market is inundated with biologics with very limited basic science data supporting the efficacy. Physicians are asked to make expensive decisions with little information regarding the biologics' safety and efficacy. Clearly, biological agents will allow us to provide less invasive care. However, we need more stringent pre-clinical studies to allow physicians to better evaluate what biologics do work and in what capacity.
Walter Eckman, MD, Owner of Aurora Spine Center, Tupelo, Miss.: Biologics will be very important for fusions because there is a great need for lower costs and higher fusion rates with little or no added morbidity.
Jeffrey Carlson, MD, President, Orthopaedic and Spine Center, Newport News, Va.: Biologics are adding significant improvements in spine surgery. However, there is cautious optimism. There are two basic driving forces in the use of biologics — surgeons who find the improved patient outcomes and those of the health system concerned about the economics. Surgeons have found biologics to provide an improvement in their abilities to achieve successful fusions. Adding a substance that is able to enhance the fusion rates and in turn improve the function of patients, decrease the need for revision fusion related to non-union and save time in the operating room is ideal. There have been some concerns recently about mis-information related to complications in the use of biologics, but for the most part physicians that use biologics have found them to be a great adjunct. As with any procedure, device or material, surgeons need to use their best judgment to have the optimal outcomes for patients.
Health systems have struggled with the economics of biologics in spine surgery. Spine surgery in general has come under intense scrutiny as hospitals and insurers try to balance their books. There is some trade-off in the use of an expensive product that provides a better outcome, but most health systems don't reap any benefits related to patients doing well. The hospitals should show some improvement in their bottom line if there is less operative time per case, so the surgeon could perform more surgery or the hospital staff members use less overtime. The health insurance, of course, will save money in the longer term if the patients are not returning for revision surgeries. This is somewhat of a difficult quantity to calculate, as not all non-unions will need surgery.
The future of biologics seems related to these two forces. As more biologics are developed, they will also become less expensive to use and have more focused indications and usage. This should produce better outcomes medically, fewer complications and improved economics for all involved.
Raj Rao, MD, Orthopedic Spine Surgeon, Medical College of Wisconsin, Milwaukee: The use of bone morphogenetic proteins will, and probably ought to be, on the back shelf for a while, given the most recent information we have on the product efficacy and safety issues. Surgeons will still be tempted to use BMPs for minimally invasive indications and for difficult host fusion conditions, but this ought to be after a fully informed discussion is carried out with the patient. Research in ceramics and other bone graft extenders will likely see an upswing over the next few years.
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