THIS WEEK'S ARTICLES
Kyphoplasty Can Provide Path to Relief for Patients With Painful Spine Fractures - Sponsored Content
A New Home for Cutting-Edge Spine Surgery
DISC Sports & Spine Center announces plans for its most advanced outpatient facility yet.
Patients looking for the latest technology and top-caliber spine care will soon have another option in the Los Angeles area. DISC Sports & Spine Center, a longtime provider of outpatient spine surgery, is currently constructing a brand-new 11,000-square-foot ASC in Marina del Ray, Calif., with an anticipated opening in early 2023.
The facility will be DISC's most technologically advanced center yet, and capable of hosting 1,000 complex spine cases per year. Amenities will include two state-of-the-art ORs outfitted with Zeiss microscopes, a PACU bay, four private patient rooms including a luxury suite, an inviting family lounge, a private consult room, a modernly designed waiting room, 2,000 square feet of administrative space, digitally integrated OR feeds, collaborative workstations and conference space for teaching purposes.
To be located in a space adjacent to DISC's existing musculoskeletal clinic in Steelwave's Marina Park, DISC plans to combine "the latest advances in minimally invasive technology and medical infrastructure with a world-class surgical team to elevate the patient experience in a safe, modern setting," according to a press release.
DISC is no stranger to cutting-edge ASCs constructed in aesthetically appealing ways that make patients feel as if they're checking into a hotel instead of undergoing an operation. Its 12,000-square-foot, two-OR DISC Surgery Center at Newport Beach, a destination for spine patients from across the country, has the look and feel of a five-star hotel, says DISC Chief Operating Officer Karen Reiter. "Behind the beautiful facade lies the framework of a technologically advanced facility designed to deliver state-of-the-art spinal care," she says. Take, for example, the facility's HVAC unit, a sealed system that covers the entire ASC. "Every air exchange goes through pre- and post-HEPA filters and is treated with ultraviolet light," says Ms. Reiter. "The advanced system was a significant expense that goes unseen, but it has contributed to our zero infection rate."
DISC launched its first ASC in Marina del Rey 16 years ago. "Over these past 16 years, we have embraced a fierce commitment to constantly evaluate, learn, innovate and fine-tune every part of the patient experience, whether the cases are simple or complex," says founding director Robert S. Bray, MD, a neurological spine surgeon. "Our new facility is the product of all of this — an ASC upholding DISC's superior quality while creating a model that is truly the future of high-acuity outpatient spine for the U.S."
Cleveland Health System Adds Robotic Guidance Platform
Technology enhances its effort to provide maximum accuracy and efficiency in spinal surgery.
University Health's (UH) St. John Medical Center and Cleveland Medical Center has become the first health system in greater Cleveland to acquire the Mazor X Stealth Edition Surgical Robotic Guidance Platform. The platform will first be used at UH St. John Medical Center by neurosurgeon Dustin Donnelly, MD, PhD, who specializes in spine surgery.
The Mazor X's robotic arm enables precise placement of surgical tools while providing 3D visualization of the surgical area of the spine. The idea behind the purchase is to help the surgeon operate with greater precision, efficiency and confidence, with the goal of improving subsequent outcomes. "Robotics is an enabling technology that allows us to maximize accuracy and efficiency across the spectrum of spinal surgery, from percutaneous and other minimally invasive approaches to complex deformity correction," says Dr. Donnelly.
The platform enables the health system's surgeons to plot an optimal surgery in a 3D simulation using the patient's own CT imaging. Computer analytics provide the surgeon with data for the preoperative planning, as well as guidance during the procedure.
Nicholas Bambakidis, MD, chairman of the Department of Neurosurgery and director of the UH Neurological Institute, says that although minimally invasive procedures are becoming more common for spine, they can also present a challenge to surgeons due to limited views of the patient's anatomy. "The Mazor X helps to overcome this challenge with a 3D comprehensive surgical plan, giving the surgeon more complete information and visualization before the surgery begins," he says.
Kyphoplasty Can Provide Path to Relief for Patients With Painful Spine Fractures
Balloon kyphoplasty produces better pain relief and quality of life for patients with acute VCF compared to patients treated with non-surgical management.
Optimizing treatment of patients with painful vertebral compression fractures depends on promptly identifying which patients could benefit from an interventional procedure. That's according to Dr. Joshua Hare, an anesthesia and pain management physician practicing with Elite Pain Consultants in Dalton, Ga., and Cleveland, Tenn. Hare sees patients with painful VCFs from a variety of sources, from primary and urgent care to emergency department follow-ups. What the patients all have in common is what Hare calls intense, severe back pain.
In an outpatient setting, Hare said patient care begins with conservative measures including anti-inflammatory medications, muscle relaxers or over-the-counter pain relievers.
"If the pain kind of persists, ultimately, they end up getting an X-ray, and. a lot of times, we'll pick up the initial deformity on an X-ray," Hare said. "And then we'll kind of accelerate our treatment. We realize we're not just treating a run-of-the-mill lower-back pain or mid-back pain — we actually have a more serious issue. So, at that point, we'll move on to things like bracing, potentially some physical therapy, and, again, continuance of conservative medicines. If those things don't get them better and they're continuing to have severe pain — greater than 5 out of 10, inhibiting their daily activities, and not able to complete a course in physical therapy or just having chronic, persistent severe pain — we think about proceeding with some sort of vertebral augmentation like balloon kyphoplasty."
Balloon Kyphoplasty is a minimally invasive surgical procedure for the treatment of spinal fractures due to osteoporosis, cancer or non-cancerous tumors. These spinal fractures, also called VCFs, occur 800,000 times a year in the United States.1 Over the years, studies comparing balloon kyphoplasty to non-surgical management have shown balloon kyphoplasty produced better pain relief and quality of life for patients with acute VCF compared to patients treated with non-surgical management.2-4
Although the complication rate for Balloon Kyphoplasty is low, as with most surgical procedures serious adverse events, some of which can be fatal, can occur including heart attack, cardiac arrest (heart stops beating), stroke and embolism (blood, fat or cement that migrates to the lungs or heart). Other risks include infection; leakage of bone cement into the muscle and tissue surrounding the spinal cord and nerve injury that can, in rare instances, cause paralysis; and leakage of bone cement into the blood vessels resulting in damage to the blood vessels, lungs and/or heart.
Hare said he educates referral sources about how his team is prepared to treat patients with painful VCFs. "If a referring physician gets an X-ray to our office, send the patient over. We'll get them in quickly and we'll manage the entire situation."
A vertebral augmentation procedure doesn't mark the end of the care pathway, Hare said. Patients with painful VCFs are referred for post-fracture care to the hospital's Healthy Bones Clinic. "It does the entire gamut of osteoporosis treatment from basically from soup to nuts," Hare said, "so we put those folks into that immediately. Because we really want them to avoid having this kind of continual process of fractures. Once a patient has an osteoporotic compression fracture, their risk of getting a second one goes up dramatically.5"
1. Medtronic Data on File - Business Insights & Analytics Sept 2019
2. Berenson J, Pflugmacher R, Jarzem P, et al. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol. 2011 Mar;12(3):225-35.
3. Boonen S, Van Meirhaeghe J, Bastian L, et al. Balloon kyphoplasty for the treatment of acute vertebral compression fractures: 2-year results from a randomized trial. J Bone Miner Res. 2011;26(7):1627-1637.
4. Van Meirhaeghe J, Bastian L, Boonen S, et al. A randomized trial of balloon kyphoplasty and nonsurgical management for treating acute vertebral compression fractures: vertebral body kyphosis correction and surgical parameters. Spine. 2013;38(12),971-983.
5. Lindsay R, Silverman S, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001;285(3):320-323
Eyes Wide Open During Spine Surgery
‘Awake' procedures can improve outcomes in a select patient pool.
A review of literature about awake spine surgery shows the procedures can benefit a large group of people, although patient selection is a key ingredient to success.
The review, published in Surgical Neurology International, notes that awake neurosurgery was once limited to craniotomies, but over the past two decades the list has grown incrementally to include laminectomies/diskectomies, anterior cervical diskectomy and fusions (ACDFs), lumbar fusions and dorsal column (DC) stimulator placement. This expansion was driven by surgeons pushing for new techniques that could produce lower financial burdens, faster recovery times and better outcomes for patients.
The review says the literature shows that avoiding general anesthesia by performing awake lumbar laminectomies with local anesthesia results in shorter surgical times, fewer incidences of PONV, less urinary retention and spinal headaches and shorter hospital stays. The results were largely the same for lumbar fusions, showing improved postoperative function and fewer side effects overall compared with patients who were given general anesthesia.
Awake DC stimulator placements, meanwhile, show mixed results. Spontaneous patient movement is associated with the procedure's nearly 30% failure rate, about twice that of patients who received general anesthesia. However, the review found that some surgeons benefit from getting real-time feedback from patients as they test their affected nerves. The literature showed no significant differences in outcomes with awake ACDFs, save that patients who underwent general anesthesia reported a higher pain tolerance.
The review found that candidates for awake spine surgery should be able to receive spinal anesthesia, which also means they must be able to tolerate being in the prone position for the entirety of the surgery. Patients with high BMIs, COPD, difficult airways, anxiety and obstructive sleep apnea should be excluded, the study found.
"At present, the field of spinal surgery neglects to provide suitable options for patients who are otherwise not eligible for general anesthesia," concludes the review. "However, awake spine surgery can attend to this patient population and make surgery more accessible to a wider patient population. Its advantages lie in its ability to provide live neural feedback during surgery and reduce the side effects associated with general anesthesia."
Tapping Into What Spine Surgeons Think of Telemedicine
Virtual visits for spine have their pros and cons.
A recent international study performed at the height of the COVID-19 pandemic examined how nearly 500 spine surgeons in various countries perceive the challenges and benefits of virtual care.
The leading challenges reported by surgeons globally were decreased ability to perform physical examinations (38.6%), possible increased medicolegal exposure (19.3%) and lack of reimbursement parity compared to traditional visits (15.5%). For North American spine surgeons, however, decreased ability to perform physical examinations was listed as a challenge by 62.2%, lack of reimbursement parity was cited by 31.1% and unclear billing codes was cited by one-third of respondents. Other challenges reported included regulatory barriers and various technical issues.
"North American providers encountered the most challenges, but also were the most optimistic about benefits," says the study published last year in European Spine Journal. Those benefits specifically: increased convenience for both patient and provider, and patient satisfaction. "Our study echoed this duality, underscoring the importance of addressing the shortcomings of telemedicine to sustain adoption," states the study.
The surgeons surveyed also submitted what they perceived as their patients' challenges with telemedicine, led by lack of technological literacy (24.1%), lack of access to a camera (17.8%), lack of access to Internet (17.6%) and concern for paying for care received over telemedicine (11.9%). North American surgeons, interestingly, reported the highest rates of these perceived challenges.
Respondents agreed that telemedicine increases access to care for rural patients, provides societal cost savings and increases patient convenience, but only slightly agreed that telemedicine increases provider convenience and decreases overhead. Video visits were perceived as superior in terms of perceived patient satisfaction and provider convenience compared to audio-only phone visits; many surgeons believe the video component improves personalization and the ability to observe the patient. The study also found that the more telemedicine visits surgeons performed, the more convenient they found them.
The study says significant groundwork must be laid to optimize remote physical examination maneuvers and achieve legal and reimbursement clarity before widespread implementation of telemedicine is feasible. It points positively to efforts to establish guidelines for conducting effective virtual spine examinations. "With the increasing integration of telemedicine into electronic medical record systems, proper training and standardization of practices, technological difficulties may not be a major hindrance to effective spine telemedicine use," the study says.
The study also showed that only about one in every five spine surgeons had other physicians or trainees present during telemedicine visits. "The feasibility of the multidisciplinary examination is clearly improved with virtual consults; however, improved coordination and collaborative logistics are necessary to integrate such visits into routine clinical care," the study notes.
"Our results provide insight into the pros and cons of telemedicine, which we hope will aid payers, hospital systems, administrators, researchers and surgeons in determining whether and how to best integrate effective telehealth care after the pandemic," the study concludes.