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Donald R. Johnson, II, MD
Medical Director
Southeastern Spine Institute
MUSC Board of Trustees
Past Chairman
Advancements in
Spinal Surgery
What’s New ?
What Works?
What Can Get An Injured
Worker Back To Work
What Saves Money?
Spinal Anatomy
Spinal Stenosis
(Narrowing)
• Spinal stenosis is the narrowing of
the bony ring that surrounds the
spinal cord. Causes inc...
Spinal Stenosis
Stenosis of the spine can cause pain in the
back as well as in other parts of the body.
• Primary symptom ...
Traditional Surgery
Laminectomy
Usually Multiple Levels
Interspinons
Distraction for Spinal
Stenosis
FLEXUS
Interspinous Spacer
Competitive Products
Medtronic
X-STOP
Paradigm Spine
Coflex
Abbott Spine
Wallis
Medtronic
DIAM
Surgical Technique
FLEXUS Surgical Technique
• Patient PositionPatient Position
• Prone and in flexionProne and in flexion
• IncisionIncision...
FLEXUS Surgical Technique
• Interspinous PerforatorInterspinous Perforator
• Create starting hole throughCreate starting h...
FLEXUS Surgical Technique
• Dilator – KEY PREPARATION STEPDilator – KEY PREPARATION STEP
Separate the bones(spinous proces...
3 Step Insertion Technique – Trialing
1.1. Insert horn of trial through interspinous ligamentInsert horn of trial through ...
2.2. Push trial past midlinePush trial past midline
3.3. Rotate trial 90°Rotate trial 90°
3 Step Insertion Technique – Tri...
Final Position
Discogenic Issues
• Discogenic Pain
– Caused by a damaged disc. While
this pain can be felt directly in the
lower back, it...
Discogenic Issues
• Pinched Nerve
– Also know as radiculopathy, or sciatica,
occurs when there is pressure on a
nerve to c...
Discogenic Issues
• Bulging or Herniated Disc
– Herniated Disc occurs when the jelly-like
center (nucleus) of the disc rup...
Degenerative Disc Disease (DDD)
• DDD is a slow deterioration of the cushions
located between vertebrae.
• Since these dis...
Degenerative Disc Disease (DDD)
starts as an annular tear
• If the outer ring, or annulus fibrosis, tears it
can cause bac...
Spondylolisthesis
(Spinal Bone Slippage)
• Occurs when one vertebra slips forward in
relation to an adjacent vertebra, usu...
Spondylolisthesis
(Spinal Bone Slippage)
• May result from the physical stress placed
on the spine - lifting of heavy item...
Spondylolisthesis
• Depending on how far the vertebra has slipped,
doctors label spondylolisthesis in four grades, I
(one)...
Spinal Fusion
• Spinal fusion is a surgical procedure in which
two or more of the vertebrae in the spine are
united togeth...
Interbody Fusion Approaches
Posterior Lumbar Interbody
(PLIF) Fusion
• Direct decompression
• Exposes spinal cord elements
• Retraction risks to nerves
Transforaminal Lumbar
Interbody (TLIF) Fusion
• Avoids spinal sac
• Direct decompression possible
• Potential nerve irrita...
Anterior Lumbar Interbody
(ALIF) Fusion
• Excellent visualization of disc space
• Avoids spinal cord
• Approach risks to o...
Extreme Lateral Interbody
(XLIF)Fusion
Approach for L4-L5 and above
• Reduces muscle trauma
• L5-S1 not accessible because...
Traditional Surgical Approaches
BackFront Back
XLIF
®
Surgical Approach
•eXtreme Lateral
Interbody Fusion
(XLIF)
•Advantages:
Does not require entry
through back muscles...
Disc Degeneration
before XLIF
Restoration of Height
after XLIF
• Symptoms
– Pain in the back, buttocks, or leg
• XLIF Corr...
XLIF
®
Indication –
Spondylolisthesis
•Symptoms
– Impingement of nerves and fatigue of back muscles
•XLIF Correction
– Red...
Degenerative Scoliosis before
XLIF
Restoration of Alignment
after XLIF
XLIF
®
Indication –
Degenerative Scoliosis
(Curvatu...
Axial Lumbar Interbody
(AxiaLIF) Fusion
• Has ability to spare 100% of Annulus
• Preservation of Tissues & Muscles
• Dynam...
AxiaLIF Pre-Sacral Fusion
Unique Features
• Only interbody graft option where:
– No muscle is dissected
– No ligaments are...
Distraction
AxiaLIF Immediate Results
Pre Op Post Op
Patient Ms. C. F.
Dx: Adult Lumbar Scoliosis
1. Lateral diskectomy L1-5
2. Xlif fusion L1-L5
3. Placement of plastic cage ...
Pre-op Xrays
Right Bending Left Bending
Pre-op LMRI Frontal
Pre-op Side View
Percutaneous (thru the skin
Pedicle
Screw Fixation
Pre-Op Cross Section
2 Week Post-Op
Patient Ms. C. G.
Dx: Adult Degenerative Scoliosis
1. Xlif at multiple levels
2. Percutaneous screws and rods
Pre-op Xrays
Pre-Op MRI Frontal
Pre-Op MRI Side View
Pre-Op MRI Cross Section
1mo Post-Op
7mo Post-Op
Patient Mr. T.A.
Dx: Degenerative Disc Disease L5-S1
1. Axialift
Pre-Op Xrays
Pre-Op MRI Side View
Pre-Op MRI Cross Scetion
2 week Post-Op
6mo Post-op
Patient Mr. M.B.
Dx: Degenerative disc disease with disc space
collapse L3-4, L4-5, L5-1.
Dx: Annular tear with provocativ...
Pre-Op Xrays
2wk Post-Op
Intraoperative
Neuro-Monitoring
Cell Mediated Disc Therapy
FDA Study
• Starting March 1st
- first
FDA approved study of
injection of cells to
regrow and heal an
injured disc
Isotech
Davis Adkisson, Ph.D.
Founder & Chief Scientific Officer
from Summerville, SC
Outpatient Spine Surgery-
Procedures currently being
done at SSI
• Interspinous distraction
• Laminectomy/discectomy-
sing...
Anterior Cervical Fusion
• 32 Cases
• 3.5 Postop stay in RR before DC-
no readmissions
Planning: as OUTPT
Procedures at SSI
Interbody Fusions
• Anterior lumbar fusion (ALIF)
• Posterior lumbar fusion (PLIF)
• ...
Cost Savings Vs Hospital
Based on EOBs obtained from
pts is 50-66% cheaper to
commercial payers
2010 Workers Comp
Fee Schedule
(not ▲’d since 2003)-medical
provider cost index up 28%
Using Medicare
Relative Valve Units
(RVU’s)
Good way to measure many
different accounting metrics-
but is system appropria...
Medicare Spine Surgery-
most common spine surgeries
• Spinal Stenosis  X-stop or multiple
level laminectomies
• Compressi...
Workers Compensation-
most common spine surgeries
• Herniated disc  lam/disc or anterior
cervical fusion or cervical ADR
...
Medicare not appropriate
template for injured worker-
especially for spinal care
1. Whats valued in Medicare
may not be va...
Impact of New WC
Fee Schedule on SSI
(8-10% of pts)
• Office visits  12.9%
• EMG/Nerve  28.8%
• Injections  6.7%
• Spin...
Thoughts & Considerations
• Incentive to prolonged nonop care for
injured spinal pts
• Disincentive for surgeons to see
• ...
New Advances in Spine Surgery
New Advances in Spine Surgery
New Advances in Spine Surgery
New Advances in Spine Surgery
New Advances in Spine Surgery
New Advances in Spine Surgery
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New Advances in Spine Surgery

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New Advances in Spine Surgery

  1. 1. Donald R. Johnson, II, MD Medical Director Southeastern Spine Institute MUSC Board of Trustees Past Chairman
  2. 2. Advancements in Spinal Surgery What’s New ? What Works? What Can Get An Injured Worker Back To Work What Saves Money?
  3. 3. Spinal Anatomy
  4. 4. Spinal Stenosis (Narrowing) • Spinal stenosis is the narrowing of the bony ring that surrounds the spinal cord. Causes include: – Bone spurs – Disc degeneration – Arthritis – Congenital • This condition is most common in elderly people, who have had years of wear-and- tear on their spines
  5. 5. Spinal Stenosis Stenosis of the spine can cause pain in the back as well as in other parts of the body. • Primary symptom is decreasing ablilty to walk- better with cart in store and better after sitting and bending over • Can lead to paralysis and bladder/bowel control
  6. 6. Traditional Surgery Laminectomy Usually Multiple Levels
  7. 7. Interspinons Distraction for Spinal Stenosis
  8. 8. FLEXUS Interspinous Spacer
  9. 9. Competitive Products Medtronic X-STOP Paradigm Spine Coflex Abbott Spine Wallis Medtronic DIAM
  10. 10. Surgical Technique
  11. 11. FLEXUS Surgical Technique • Patient PositionPatient Position • Prone and in flexionProne and in flexion • IncisionIncision • 2-3 cm length2-3 cm length • MidlineMidline • Separate paraspinal muscleSeparate paraspinal muscle on right sideon right side
  12. 12. FLEXUS Surgical Technique • Interspinous PerforatorInterspinous Perforator • Create starting hole throughCreate starting hole through interspinous ligamentinterspinous ligament
  13. 13. FLEXUS Surgical Technique • Dilator – KEY PREPARATION STEPDilator – KEY PREPARATION STEP Separate the bones(spinous processes)Separate the bones(spinous processes)
  14. 14. 3 Step Insertion Technique – Trialing 1.1. Insert horn of trial through interspinous ligamentInsert horn of trial through interspinous ligament
  15. 15. 2.2. Push trial past midlinePush trial past midline 3.3. Rotate trial 90°Rotate trial 90° 3 Step Insertion Technique – Trialing
  16. 16. Final Position
  17. 17. Discogenic Issues • Discogenic Pain – Caused by a damaged disc. While this pain can be felt directly in the lower back, it may also be felt outside of the area of the damaged disc, such as in the buttocks or upper thighs. – Specific movements that put stress on this damaged disc can worsen the pain.
  18. 18. Discogenic Issues • Pinched Nerve – Also know as radiculopathy, or sciatica, occurs when there is pressure on a nerve to cause irritation and inflammation.
  19. 19. Discogenic Issues • Bulging or Herniated Disc – Herniated Disc occurs when the jelly-like center (nucleus) of the disc ruptures – Causes material to be pushed outside of the outer ring of the disc – Pressure on the spinal cord and nerve roots cause pain, weakness, and/or numbness to certain areas of the body
  20. 20. Degenerative Disc Disease (DDD) • DDD is a slow deterioration of the cushions located between vertebrae. • Since these discs act as a shock absorber between each vertebra, the reduction or loss of disc height can cause pain. • The so-called “degenerative disc” is not getting enough nutrients and will not be able to repair itself once injured.
  21. 21. Degenerative Disc Disease (DDD) starts as an annular tear • If the outer ring, or annulus fibrosis, tears it can cause back pain. • The inner core of a disc, or the nucleus pulpous, is very soft and can cause severe leg pain if it comes into contact with the surrounding nerves.
  22. 22. Spondylolisthesis (Spinal Bone Slippage) • Occurs when one vertebra slips forward in relation to an adjacent vertebra, usually in the lumbar spine. • Symptoms include pain in the low back, thighs and/or legs, muscle spasms, weakness, and/or tight hamstring muscles.
  23. 23. Spondylolisthesis (Spinal Bone Slippage) • May result from the physical stress placed on the spine - lifting of heavy items, weightlifting, football, gymnastics, trauma, and general wear and tear. • As the vertebral components degenerate, the spine’s integrity is compromised.
  24. 24. Spondylolisthesis • Depending on how far the vertebra has slipped, doctors label spondylolisthesis in four grades, I (one) being the least amount of slippage, all the way up to IV (four), which is the most slippage. • Not all cases of spondylolisthesis require surgery.
  25. 25. Spinal Fusion • Spinal fusion is a surgical procedure in which two or more of the vertebrae in the spine are united together so that motion no longer occurs between them. • Between the vertebra- termed INTERBODY! • Usually a box(cage) filled with a bone “glue” May be supported by screws(pedicle) to allow glue in boxes to heal by keeping the bone and boxes still. Spinal fusion can restore stability, correct alignment & reduce pain.
  26. 26. Interbody Fusion Approaches
  27. 27. Posterior Lumbar Interbody (PLIF) Fusion • Direct decompression • Exposes spinal cord elements • Retraction risks to nerves
  28. 28. Transforaminal Lumbar Interbody (TLIF) Fusion • Avoids spinal sac • Direct decompression possible • Potential nerve irritation
  29. 29. Anterior Lumbar Interbody (ALIF) Fusion • Excellent visualization of disc space • Avoids spinal cord • Approach risks to organs and vascular structures
  30. 30. Extreme Lateral Interbody (XLIF)Fusion Approach for L4-L5 and above • Reduces muscle trauma • L5-S1 not accessible because of pelvis
  31. 31. Traditional Surgical Approaches BackFront Back
  32. 32. XLIF ® Surgical Approach •eXtreme Lateral Interbody Fusion (XLIF) •Advantages: Does not require entry through back muscles, bones, or the retraction of major blood vessels Side
  33. 33. Disc Degeneration before XLIF Restoration of Height after XLIF • Symptoms – Pain in the back, buttocks, or leg • XLIF Correction – Reduces motion between the vertebrae – Corrects alignment – Restores proper disc height – Alleviates pain XLIF ® Indication – Degenerative Disc Disease (DDD)
  34. 34. XLIF ® Indication – Spondylolisthesis •Symptoms – Impingement of nerves and fatigue of back muscles •XLIF Correction – Reduces motion between vertebrae, corrects alignment, and restores disc height Spondylolisthesis (Malalignment) before XLIF Restoration of Alignment and Disc Height after XLIF
  35. 35. Degenerative Scoliosis before XLIF Restoration of Alignment after XLIF XLIF ® Indication – Degenerative Scoliosis (Curvature) •Symptoms – Back and/or leg pain due to muscle fatigue and nerve impingement •XLIF Correction – Restores proper alignment and disc height
  36. 36. Axial Lumbar Interbody (AxiaLIF) Fusion • Has ability to spare 100% of Annulus • Preservation of Tissues & Muscles • Dynamic Decompression via Distraction
  37. 37. AxiaLIF Pre-Sacral Fusion Unique Features • Only interbody graft option where: – No muscle is dissected – No ligaments are cut – The disc annulus is preserved
  38. 38. Distraction AxiaLIF Immediate Results Pre Op Post Op
  39. 39. Patient Ms. C. F. Dx: Adult Lumbar Scoliosis 1. Lateral diskectomy L1-5 2. Xlif fusion L1-L5 3. Placement of plastic cage with bone glue
  40. 40. Pre-op Xrays Right Bending Left Bending
  41. 41. Pre-op LMRI Frontal
  42. 42. Pre-op Side View
  43. 43. Percutaneous (thru the skin Pedicle Screw Fixation
  44. 44. Pre-Op Cross Section
  45. 45. 2 Week Post-Op
  46. 46. Patient Ms. C. G. Dx: Adult Degenerative Scoliosis 1. Xlif at multiple levels 2. Percutaneous screws and rods
  47. 47. Pre-op Xrays
  48. 48. Pre-Op MRI Frontal
  49. 49. Pre-Op MRI Side View
  50. 50. Pre-Op MRI Cross Section
  51. 51. 1mo Post-Op
  52. 52. 7mo Post-Op
  53. 53. Patient Mr. T.A. Dx: Degenerative Disc Disease L5-S1 1. Axialift
  54. 54. Pre-Op Xrays
  55. 55. Pre-Op MRI Side View
  56. 56. Pre-Op MRI Cross Scetion
  57. 57. 2 week Post-Op
  58. 58. 6mo Post-op
  59. 59. Patient Mr. M.B. Dx: Degenerative disc disease with disc space collapse L3-4, L4-5, L5-1. Dx: Annular tear with provocative discogram. 1.Xlif L3-L4, L4-L5 2. Percutaneous pedicle fixation L3, L4, L5, S1 3. Axilift L5-S1
  60. 60. Pre-Op Xrays
  61. 61. 2wk Post-Op
  62. 62. Intraoperative Neuro-Monitoring
  63. 63. Cell Mediated Disc Therapy
  64. 64. FDA Study • Starting March 1st - first FDA approved study of injection of cells to regrow and heal an injured disc
  65. 65. Isotech Davis Adkisson, Ph.D. Founder & Chief Scientific Officer from Summerville, SC
  66. 66. Outpatient Spine Surgery- Procedures currently being done at SSI • Interspinous distraction • Laminectomy/discectomy- single and multiple levels • Anterior cervical fusion- 1and 2 levels
  67. 67. Anterior Cervical Fusion • 32 Cases • 3.5 Postop stay in RR before DC- no readmissions
  68. 68. Planning: as OUTPT Procedures at SSI Interbody Fusions • Anterior lumbar fusion (ALIF) • Posterior lumbar fusion (PLIF) • XLIF • Axialif • Percutaneous pedicle screws • Average operative time 1 hr at SSI
  69. 69. Cost Savings Vs Hospital Based on EOBs obtained from pts is 50-66% cheaper to commercial payers
  70. 70. 2010 Workers Comp Fee Schedule (not ▲’d since 2003)-medical provider cost index up 28%
  71. 71. Using Medicare Relative Valve Units (RVU’s) Good way to measure many different accounting metrics- but is system appropriate for the young injured worker?
  72. 72. Medicare Spine Surgery- most common spine surgeries • Spinal Stenosis  X-stop or multiple level laminectomies • Compression fx  Kyphoplasty • Degenerative Scoliosis  Long Fusions with Screws
  73. 73. Workers Compensation- most common spine surgeries • Herniated disc  lam/disc or anterior cervical fusion or cervical ADR • Annular tear  lumbar disc replacement or interbody fusion or cell mediated therapy • Degenerative disc with foraminal stenosis  interbody fusion ± screws • Spondylolisthesis  laminectomy and fusion ± screws
  74. 74. Medicare not appropriate template for injured worker- especially for spinal care 1. Whats valued in Medicare may not be valued for injured worker 2.Diseases/Medical conditions o spine are different
  75. 75. Impact of New WC Fee Schedule on SSI (8-10% of pts) • Office visits  12.9% • EMG/Nerve  28.8% • Injections  6.7% • Spine Surgery decreased 10.0% !
  76. 76. Thoughts & Considerations • Incentive to prolonged nonop care for injured spinal pts • Disincentive for surgeons to see • Time equals money in WC system • May cause delays of definitive treatment and  cost to entire system • Issue of surgery for injury worker needs to be addressed by all parties in system • Spine cases are the most common and expensive cases in WC

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