Many of the new techniques and equipment developed over the past few years for spine surgery have leaned toward the minimally invasive approach, which is gaining in popularity across the country. However, most physicians are still performing the open surgeries they have perfected over the years, and healthcare reform could stall technological advances in the coming years due to uncertain reimbursements and increased fees on device makers. As we approach 2011, industry leaders weigh in on the future of spine surgery.
1. Healthcare reform's impact on spine surgery. In the current atmosphere of anxiety regarding the "unknowns" of healthcare reform, many spine surgeons are opting to proceed with their practice cautiously. An increase in patient volume due to growth in the aging population coupled with diminishing reimbursement rates means spine surgeons will be looking for less costly surgery systems that are easy to use, says Chris Zorn, vice president of Spine Surgical Innovation. Physicians who are working in hospital settings must justify their spending, which could lead to a decrease in purchasing new and complex technologies that facilities are currently willing to purchase. While technology may continue to advance, physicians may not have the resources to learn new procedures or gain access to the equipment.
"Generally speaking, spine, like many other surgical areas, has certain things that become trendy, but my observations are that physicians worldwide are sticking to the basics," says Mr. Zorn. "We live in a world of trying to keep it simple, keep the learning steps simple, minimize the impact of surgery on the budget as well as the impact of the procedure on the staff, surgeon and patient's time."
2. Minimally invasive spine surgery vs. open surgery. Loosely defined, minimally invasive surgery means physicians are performing a procedure with a smaller incision than is used in an open procedure, and physicians dilate the muscles surrounding the spine for the least amount of muscle and nerve damage. "Spine surgery has never been one that has been amenable to smaller instrumentation and smaller incisions, but now all that's changing," says Michael Weiss, DO, a spine surgeon and chief of spine surgery at Laser Spine Institute Scottsdale (Ariz.). "The bigger benefit starts to come because you do less soft tissue destruction to get to the bone."
Some physicians consider specific fusion procedures as minimally invasive while others bill minimally invasive techniques as the alternative to fusions. The length and depth of an incision that constitutes a "minimally invasive" incision remains undefined, says Mr. Zorn, and will most likely be a topic of continued debate. A better definition of would be "less invasive" surgery, says Mr. Zorn.
The popularity of minimally invasive procedures has been increasing over the past few years. In some communities, educated patients are beginning to request physicians perform "minimally invasive" surgery, says Dr. Weiss, and physicians without the ability to perform such procedures might lose out.
However, Mr. Zorn says physicians should consider their practice region before deciding to train on minimally invasive techniques. "If every surgeon in the region is already minimally invasive oriented, the other surgeons have to keep up," says Mr. Zorn. "If no other surgeons in the region are doing minimally invasive stuff, there is less competitive pressure on surgeons to change."
3. Endoscopic technology. Advances in spine surgical technology have made it possible to gain access to the patient's pathology through endoscopic instruments, says Dr. Weiss. The small scopes allow physicians to see the patient's pathology on a screen as they work within the enclosed area. The scopes navigate the physician away from nerves and arteries during the surgery. Physicians use cannula tubes running parallel to the endoscope so physicians can reach the surgical site without making a large incision. Imaging technology will continue to advance, as the newest endoscopic technology is able to project images on HD visualization screens, further magnifying the patient's pathology.
While Mr. Zorn also projects continued technological advancement in minimally invasive spine surgery instrumentation, he says the technology will grow faster than is consumable by spine surgeons. "The technological advances are faster than any gifted surgeon can keep up with," says Mr. Zorn. "Surgeons have to be on the look out for systems that are effective, easy and less costly because they need to justify everything they buy these days."
4. Spine surgery education labs. In communities where physicians are beginning to perform minimally invasive spine surgery, the other physicians will begin to explore minimally invasive spine surgery training programs. The problem is that training in these procedures requires a large amount of time, and there is a significant learning curve, says Dr. Weiss. Physicians must learn about the procedure and practice performing it several times before they are able to treat patients effectively. "Minimally invasive surgery is not something that the typical orthopedic or neurosurgeon can get good at after a weekend course," says Dr. Weiss. "It really takes a significant number of surgeries before the surgeon is really comfortable performing them."
Spine surgery education labs and programs are beginning to spring up around the country to train surgeons in minimally invasive procedures. The Advanced Spine Institute & Minimally Invasive Spine Center at Alvarado Hospital in San Diego is one such program that includes education labs for physicians to practice the procedures on cadaver spines in operating rooms that mimic traditional hospital and ASC operating rooms. Other physicians around the country trained in minimally invasive spine surgery offer training programs to mentor surgeons as they learn the technique.
Mr. Zorn says physicians affiliated with academic research centers are the surgeons most likely learn minimally invasive techniques in the future because these physicians have more of an emphasis on procedural development. In the coming healthcare climate wrought with uncertain reimbursement rates and the potential for an increase in patient volume, physicians busy serving in the operating room all day and managing a robust practice will need to search for minimally invasive systems with simple ease of use, short learning curve and high value. The physicians will invest in low-cost systems with that demonstrate beneficial patient outcomes.
5. Development of minimally invasive disc replacement procedures. The future of spine surgery will include minimally invasive disc replacement, says Dr. Weiss. Physicians currently go through the pelvis and have to sidestep organs in order to implant the new disc, which is a big procedure. However, the development of new technology could mean that physicians conduct minimally invasive disc replacements through anterior or posterior procedures. New systems would have to have the capability to get the instruments through small tubes to conduct the operation.
Randall Dryer, MD, a spine surgeon with Central Texas Spine Institute, performing surgeries at Northwest Hills Surgical Hospital, a Surgical Care Affiliates facility, has been conducting research on two level artificial disc replacements in the neck. Cervical disc arthroplasty will have implications on the future of spine surgery. "The purpose of these operations is to relieve pain and restore function while minimizing the likelihood of degeneration at adjacent levels," says Dr. Dryer. "Many patients undergoing these procedures are quite young, so the opportunity to limit future pathology is significant."
Right now, Dr. Weiss says researchers and device companies are focused on improving modern instrumentation to help physicians perfect the minimally invasive techniques and ensure these techniques are reproducible before moving on to performing more types of surgery through smaller incisions.
6. Active patient recovery. As minimally invasive surgery and pain medicine make advancements, patients are able to play an active role in their recovery process. Dr. Weiss says that some patients receiving minimally invasive surgery are able to walk and receive physical therapy the same day of their outpatient surgery. These patients are likely to return to work three to four weeks, or around six weeks for labor intensive jobs, which is faster than in the past. Incisions of an inch or less and local anesthesia contribute to the shortened recovery time for patients.
7. Disc regenerating material. The use of stem cells to treat injuries and medical disorders has gained ground in orthopedics over the past few years and spine surgery is slowly following this trend. Some physicians have begun harvesting stem cells from the patient to use as regeneration material during spine surgery. California's Geron Corp. recently became the first company to test embryonic spine cell procedures on a human patient, attempting to reverse paralysis due to spinal cord injury. However, the use of stem cells in spine surgery is still in its infancy and many physicians are weary of employing the technique without extensive clinical research and knowing the long-term affects.
In the mean time, Dr. Weiss says research will continue on regeneration material such as bone morphogenic proteins for use in regenerating disc material. Several leading device makers have received clearance for bone grafting substitutes developed to enhance spine surgery. In the future, he says companies will develop an artificial-type disc that is not metal or plastic to use during disc replacements.
Read more coverage about spine surgery:
- 10 Articles for Successful Spine Practice Management
- 6 Ways to Avoid Denied Claims for Spine Surgeons
- Improving Patient Satisfaction: Endoscopic Spine Surgery
1. Healthcare reform's impact on spine surgery. In the current atmosphere of anxiety regarding the "unknowns" of healthcare reform, many spine surgeons are opting to proceed with their practice cautiously. An increase in patient volume due to growth in the aging population coupled with diminishing reimbursement rates means spine surgeons will be looking for less costly surgery systems that are easy to use, says Chris Zorn, vice president of Spine Surgical Innovation. Physicians who are working in hospital settings must justify their spending, which could lead to a decrease in purchasing new and complex technologies that facilities are currently willing to purchase. While technology may continue to advance, physicians may not have the resources to learn new procedures or gain access to the equipment.
"Generally speaking, spine, like many other surgical areas, has certain things that become trendy, but my observations are that physicians worldwide are sticking to the basics," says Mr. Zorn. "We live in a world of trying to keep it simple, keep the learning steps simple, minimize the impact of surgery on the budget as well as the impact of the procedure on the staff, surgeon and patient's time."
2. Minimally invasive spine surgery vs. open surgery. Loosely defined, minimally invasive surgery means physicians are performing a procedure with a smaller incision than is used in an open procedure, and physicians dilate the muscles surrounding the spine for the least amount of muscle and nerve damage. "Spine surgery has never been one that has been amenable to smaller instrumentation and smaller incisions, but now all that's changing," says Michael Weiss, DO, a spine surgeon and chief of spine surgery at Laser Spine Institute Scottsdale (Ariz.). "The bigger benefit starts to come because you do less soft tissue destruction to get to the bone."
Some physicians consider specific fusion procedures as minimally invasive while others bill minimally invasive techniques as the alternative to fusions. The length and depth of an incision that constitutes a "minimally invasive" incision remains undefined, says Mr. Zorn, and will most likely be a topic of continued debate. A better definition of would be "less invasive" surgery, says Mr. Zorn.
The popularity of minimally invasive procedures has been increasing over the past few years. In some communities, educated patients are beginning to request physicians perform "minimally invasive" surgery, says Dr. Weiss, and physicians without the ability to perform such procedures might lose out.
However, Mr. Zorn says physicians should consider their practice region before deciding to train on minimally invasive techniques. "If every surgeon in the region is already minimally invasive oriented, the other surgeons have to keep up," says Mr. Zorn. "If no other surgeons in the region are doing minimally invasive stuff, there is less competitive pressure on surgeons to change."
3. Endoscopic technology. Advances in spine surgical technology have made it possible to gain access to the patient's pathology through endoscopic instruments, says Dr. Weiss. The small scopes allow physicians to see the patient's pathology on a screen as they work within the enclosed area. The scopes navigate the physician away from nerves and arteries during the surgery. Physicians use cannula tubes running parallel to the endoscope so physicians can reach the surgical site without making a large incision. Imaging technology will continue to advance, as the newest endoscopic technology is able to project images on HD visualization screens, further magnifying the patient's pathology.
While Mr. Zorn also projects continued technological advancement in minimally invasive spine surgery instrumentation, he says the technology will grow faster than is consumable by spine surgeons. "The technological advances are faster than any gifted surgeon can keep up with," says Mr. Zorn. "Surgeons have to be on the look out for systems that are effective, easy and less costly because they need to justify everything they buy these days."
4. Spine surgery education labs. In communities where physicians are beginning to perform minimally invasive spine surgery, the other physicians will begin to explore minimally invasive spine surgery training programs. The problem is that training in these procedures requires a large amount of time, and there is a significant learning curve, says Dr. Weiss. Physicians must learn about the procedure and practice performing it several times before they are able to treat patients effectively. "Minimally invasive surgery is not something that the typical orthopedic or neurosurgeon can get good at after a weekend course," says Dr. Weiss. "It really takes a significant number of surgeries before the surgeon is really comfortable performing them."
Spine surgery education labs and programs are beginning to spring up around the country to train surgeons in minimally invasive procedures. The Advanced Spine Institute & Minimally Invasive Spine Center at Alvarado Hospital in San Diego is one such program that includes education labs for physicians to practice the procedures on cadaver spines in operating rooms that mimic traditional hospital and ASC operating rooms. Other physicians around the country trained in minimally invasive spine surgery offer training programs to mentor surgeons as they learn the technique.
Mr. Zorn says physicians affiliated with academic research centers are the surgeons most likely learn minimally invasive techniques in the future because these physicians have more of an emphasis on procedural development. In the coming healthcare climate wrought with uncertain reimbursement rates and the potential for an increase in patient volume, physicians busy serving in the operating room all day and managing a robust practice will need to search for minimally invasive systems with simple ease of use, short learning curve and high value. The physicians will invest in low-cost systems with that demonstrate beneficial patient outcomes.
5. Development of minimally invasive disc replacement procedures. The future of spine surgery will include minimally invasive disc replacement, says Dr. Weiss. Physicians currently go through the pelvis and have to sidestep organs in order to implant the new disc, which is a big procedure. However, the development of new technology could mean that physicians conduct minimally invasive disc replacements through anterior or posterior procedures. New systems would have to have the capability to get the instruments through small tubes to conduct the operation.
Randall Dryer, MD, a spine surgeon with Central Texas Spine Institute, performing surgeries at Northwest Hills Surgical Hospital, a Surgical Care Affiliates facility, has been conducting research on two level artificial disc replacements in the neck. Cervical disc arthroplasty will have implications on the future of spine surgery. "The purpose of these operations is to relieve pain and restore function while minimizing the likelihood of degeneration at adjacent levels," says Dr. Dryer. "Many patients undergoing these procedures are quite young, so the opportunity to limit future pathology is significant."
Right now, Dr. Weiss says researchers and device companies are focused on improving modern instrumentation to help physicians perfect the minimally invasive techniques and ensure these techniques are reproducible before moving on to performing more types of surgery through smaller incisions.
6. Active patient recovery. As minimally invasive surgery and pain medicine make advancements, patients are able to play an active role in their recovery process. Dr. Weiss says that some patients receiving minimally invasive surgery are able to walk and receive physical therapy the same day of their outpatient surgery. These patients are likely to return to work three to four weeks, or around six weeks for labor intensive jobs, which is faster than in the past. Incisions of an inch or less and local anesthesia contribute to the shortened recovery time for patients.
7. Disc regenerating material. The use of stem cells to treat injuries and medical disorders has gained ground in orthopedics over the past few years and spine surgery is slowly following this trend. Some physicians have begun harvesting stem cells from the patient to use as regeneration material during spine surgery. California's Geron Corp. recently became the first company to test embryonic spine cell procedures on a human patient, attempting to reverse paralysis due to spinal cord injury. However, the use of stem cells in spine surgery is still in its infancy and many physicians are weary of employing the technique without extensive clinical research and knowing the long-term affects.
In the mean time, Dr. Weiss says research will continue on regeneration material such as bone morphogenic proteins for use in regenerating disc material. Several leading device makers have received clearance for bone grafting substitutes developed to enhance spine surgery. In the future, he says companies will develop an artificial-type disc that is not metal or plastic to use during disc replacements.
Read more coverage about spine surgery:
- 10 Articles for Successful Spine Practice Management
- 6 Ways to Avoid Denied Claims for Spine Surgeons
- Improving Patient Satisfaction: Endoscopic Spine Surgery