UVA Ortho Grand Rounds with Sheeraz Qureshi (Spine Surgeon - HSS)

Thanks bobby um i'm going to have adam do the formal introduction but i really just wanted to thank dr uh karishi for coming down and we've known each other for a long time he's a colleague to all of us and a friend of the division i would love to have done this in person um to maybe had that night before with the fellows and the residents and then maybe taking you over to the Orthopedic center with the musculoskeletal center that doctor travels sort of vision that's going on but maybe next year um and adam if

you'd uh do the introductions in the talks that'd be great yeah thanks dr chobra and dr shen it's a really great pleasure not only myself but but the department and the university of virginia to welcome shiraz Qarashi to uh orthopedic grand rounds this morning uh shiraz and i are contemporaries he finished fellowship i believe one year before me yeah with henry bowman up at case western with one of my good friends paul goss but he um graduated from rutgers university and then went on to tufts to get his uh md and mba he's an associate

professor at Weill cornell medical college and hospital special surgeries he's the patty and jay baker chair and minimally invasive spine surgery he probably did a discectomy on patty baker and became uh the chair and they think he's amazing it's just a discectomy on a very uh wealthy uh new york socialite he's a research director for the spine division he's extensively funded by Csrs nas raf and nih he's had over 170 peer-reviewed publications over 20 book chapters uh frank and i insurance were just talking he's on innumerable committees and in leadership positions both nationally and internationally

and really um schraz is not only a great surgeon great guy but really i think uh extensively uh recognized as A real thought leader and minimally invasive spine surgery so we're excited to hear him give a couple talks on cervical disc arthroplasty and also his learning journey doing minimally invasive transferamil lumbar inner body fusions and i think this is really important just as spine moves out of the inpatient only setting into more Opportunities for outpatient so curious to ask him a few questions on his thoughts on that but i won't take any more time thanks

for oz and and take it away thank you so much i i really appreciate i'm so excited to be here i think of all the things that we do uh you know being involved in uh in being able to be part of uh visiting professor programs is really the best part of what we get To do uh getting to connect with uh with old friends and uh and seeing new places so you know adam and i and frank and i were talking about how great it is to be able to have some things over zoom

but uh but certainly these these are the things that it's great to do over zoom but uh but looking forward at some point to being able to uh come down and have you guys uh this way As well so but uh thank you so much for having me so uh i will share my screen [Music] here all right can you guys uh see my screen okay yes okay good shape thanks all right great thank you all right so um my my first uh talk this morning uh as adam uh mentioned is gonna be About uh

cervical disc replacement surgery it's a uh it's a surgery you know that that i really enjoy doing and i would say that uh amongst uh all of my disclosures the relevant one is uh is that if i needed uh a single level cervical surgery done i would choose a cervical disc replacement so i'm gonna put that out front there so that you guys can can know my biases Um i uh i did my spine fellowship with henry bowman and anytime i give a talk on uh minimally invasive surgery or motion sparing surgery i always wonder

what uh what dr bowman could think and uh you know whether uh whether he's uh turning over at his grave uh hearing me talk about this stuff and so i was a little you know worried about uh you know what Adam and frank would think about me as well but i had reached out to the fellows ahead of time and and i saw that adam's practice was about two percent deformity but he was doing a lot of fusions for lumbar back pain some disc replacement for primary disc herniations which i thought was interesting x-stops for

tumor surgery and uh you know even some coccygectomy's made Up his practice and obviously the s i joint fusion and i still call myself a deformity surgeon because exactly so so i didn't feel so bad and then i said well you know what about frank i hope he doesn't worry so i looked at some reviews and frank you got great reviews online you know this patient was super happy with then uh with the laser spine surgery for nine bulging discs so i thought that was really great Um adam's reviews were a little lower but like

i guess because he kept calling some guy named the caro and and trying to figure out what he should do as far as the surgery goes but so so anyway i didn't feel so bad about some of the things i'm going to be talking about today so uh but uh i thought i thought i'd put that out there up front but um i i think you know let's let's start With a with a common case that i think that we all see in our uh in our practices this is the patient is a mid-30s almost

40 year old guy he's had a uh short history of uh not only right upper extremity radiculopathy but but significant weakness um in a major muscle group in his dominant arm a three out of five in his uh Deltoid bicep um doesn't have any findings of spinal cord irritation uh these are the x-rays um that were obtained uh at the time of presentation uh that show uh you know pretty good disc space height at all of the levels um good lord doses we could see a little bit of retro less thesis of c4 on c5

to maybe indicate uh that there could be some disc Pathology in this patient despite his uh good disc height you can see he's got good flexion and extension and the mris on the parasagittal view show this right-sided disc fragment at c4c5 here are the axial views across the c45 level and we can see on the right side a disc herniation that's posterolateral a uh the right side of the cord but Really not causing any cord deformation or displacement but really you know uh impinging upon the uh right c5 nerve reach so if we think about

that patient and and we think about the different treatment options you know anytime you have a patient with uh with cervical radiculopathy you think about sort of doing nothing giving them time giving them anti-inflammatories maybe A selective nerve block or surgery and certainly if we thought about the cheapest treatment it would it would uh be you know sort of some advil and uh and give it time but in a patient who's got a weakness of the dominant arm that may not be the best option this is a study that's almost you know uh going to

be 20 years old in a few years but uh you know cervical spine issues are very common Uh we need to consider them as part of us of the pie uh of medical care because uh they are tend not to be so cheap um and there are multiple different treatment options and uh if we want to think about the ones that we can have the greatest impact on and provide care for we have to sort of defend uh why our options may be better than Others in some cases and when we're thinking about cervical degenerative

disorders we're not talking about this kind of a patient right this is a multi-level cervical myelopathy patient that we'd all agree need surgery we're really talking about this patient the single level cervical disc herniation with symptoms that are ongoing That are sort of relatively early stages but some neurologic issues that are having a significant disability on the patient that's the patient we're talking about this is the problem we're talking about so uh i i'm sure that the residents and fellows on the on the zoom today have seen many different treatment options for this same problem

i think this is sort of the tried and true the Gold standard acdf um posterior cervical foraminotomy i think is an excellent option for single-level cervical disc disease uh and then there's the uh cervical disc replacement surgery that we're going to focus on today but these are really from a surgical perspective the three options we had looked at sort of just the current trends in treatment for single level cervical radiculopathy And it's interesting as you'll see in in a lot of the studies that i'm going to talk about the comparator is always acdf and uh

and cervical disc replacement uh but as as uh as i think frank and adam might agree when we think about the patients that are good candidates for cervical disc arthroplasty there also often could be potentially candidates for a posterior cervical foraminotomy And what what what we found was that actually the trends and usage of acdf are not changing but as cdr uh utilization increases the biggest impact it's had is on cervical foraminotomy which in some ways may be a a cheaper and perhaps better alternative uh although i think that that's uh still yet to be

proven so there are many different types of Cervical disc replacements i i would say this is probably this one that we're showing here uh is the is the mo bc implant it's a unconstrained uh implant very easy to put in and probably the most commonly one used today uh i i have actually gone away from this as i will get into uh later on um this is another type of implant this is a More constrained implant that's put into place uh and has uh uh four keels um that go into the vertebra so provide a

little bit more stability it's a metal on metal implant as opposed to the one that we showed before which is a uh a poly implant with metal um so there there are differences amongst the different types of implants um so we're going to be talking about cervical Disc replacement in general but i think like in any um joint replacement uh or disc replacement conversation there is some tribology that we certainly don't know enough about when it comes to uh discartoplasty in terms of the differences in the different types of implants and that's certainly an area

that still needs to be better studied There are a lot of articles that have been published on uh on cervical disc replacement um and i would say important for the residents and the fellows on the call to know that cervical disc replacement may be the absolute best thing that's been studied in spine surgery um there have been multiple ide studies prospective randomized studies tons of patients with long-term follow-up And i just wanted to take the beginning of this of this lecture to sort of go over uh the different studies that have been done um and

and what they've all shown so this is just a listing of the uh of the different fda approved implants some of which aren't even used anymore brian disc is not used anymore uh i think the prestige st is not used anymore and it's just because companies Have made different decisions but these are at least at the time that i put the majority of this talk together were the uh where the main fda approved disk since then i think at least one more has been approved and if we look at the prospective randomized studies at the

time just amongst these disk replacement um uh implants you can see that that thousands of patients have been looked at Over the long term the inclusion and exclusion criteria for these uh different ide studies are extremely similar which is why i think although i will present them separately it is in a lot of ways safe to be able to lump these uh studies together to look them in a look at them in aggregate because they used very similar criteria uh votes for inclusion and exclusion and The control in all of the cases was sort of

what we would all consider as the gold standard the acdf uh most commonly with uh plate and and bone graft in order to have uh success in these uh in these ide studies uh the outcomes that were looked at both primary and secondary are listed here uh and for overall success you had to meet all of the criteria so that was Pretty critical especially i think in the nd uh ndi which is the next disability index criteria you had to meet um the parameters of success for improvement uh so if if you look at this

if you had a 14 point improvement in your ndi you were not considered to be an overall success so you had to meet these criteria which is what i think again adds a Little bit to how powerful these studies can be and if we go into the specific studies i think this was the first one that was published looking at the brian disc and i won't spend a lot of time on the specifics of the studies but really you know the important things to highlight here if you look at the two-year follow-up in these studies

both in the um Study yarn and the control arm you can see in a 95 and almost 90 percent um uh retention in terms of two-year follow-up and you can look at the overall success in on on both sides being being very significant uh of fusion and and disc replacement but that disc replacement outperforming at two years in this study uh this is a different implant Uh but again one of the earliest implants available um i think this was actually the first implant that was on the market the prestige showed excellent results compared to acdf

at 24 months where there was statistical superiority same thing with this implant which is the pro disk again subtle differences in these implants but you can see that the overall Outcomes in all of uh in all of these studies were quite similar uh at the two-year mark and these were all prospective uh randomized controlled studies as we got a little bit further out or we started to think about saying okay well what about two levels so this was an important study that was published looking at two level uh cervical disc replacement Uh looking at 330

patients with again randomized and showed that again cervical just replacement even at two levels uh maintains statistical superiority over acdf uh at the two-year mark this was four-year data so um initially it was one level at two years then it was one level looking out multiple years Then it was two levels looking at two years so really kind of build the literature building upon itself to look at you know multiple year results these are five-year results of of the uh of the randomized controlled trials and then even out to seven year results and you can

see uh that the outcomes um you know of overall success and improvement uh in those categories that defined Overall success were maintained uh and and were superior in appropriately indicated cases for cervical disc arthroplasty both at one or two levels so um i use that just to sort of build the case that i i would say that there is level one evidence uh to suggest uh that cervical disc replacement is an appropriate treatment for a patient with a single level cervical Reticulopathy the case that we uh that we made earlier so i think that you

know when we say that there's level one evidence i think all the studies would also show that there's level 1 evidence that acdf is an appropriate treatment as well and so the surgeons task in a scenario like this i'm sorry for the background noise but um but the surgeon's tasked in a problem like this when you've got Multiple good options for treatment which include non-surgical and surgical options is to try to figure out which procedure is going to result in the best outcome for the patient that you are dealing with that's in front of you

um you know i always say that percentages um and options are for everybody else but for any one patient there's usually One best option and there's going to be one outcome that's going to be either bad or it's going to be good it's pretty binary so we have to consider sort of the cost of health care when we think about these things uh because as as we all know um you know health care is expensive in this country um and and there's a little bit of an alignment issue because i would say that the goal

Of healthcare is not just to figure out the lowest cost treatment it's really to find the most the treatment that allows for the best value uh and so we have to think about cost we have to think about cost effectiveness and then ultimately we have to think about value and so when we're thinking about value again i think this particular topic really highlights at least for spine surgery what we're Talking about because it is a uh an indication and a pathology that can be treated potentially non-operatively often operatively and there are multiple good options so

when we're thinking about sort of value and think about what the goal posts sort of around which we define really good outcomes uh and and maybe in any particular patient which option provides the most value So this is just sort of how value is defined i'm sure you know everybody on this call is familiar with these terms we're really thinking about quality cost and time as being the key factors and so you know those studies that were done that i presented i think um you know highlight quality they highlight time because They're followed over a

period but but they don't necessarily highlight cost and so cost effectiveness can be very important when we're thinking about a topic such as this and specifically around cervical disc replacement because cost effectiveness or cost utility is really probably in this scenario becomes very important because you are comparing really good options um for for a particular problem that can Be extremely variable in terms of their cost so we've spent a lot of our um time looking at uh cost effectiveness around cervical degenerative disorders and but really specifically around cervical disc replacement uh this was just a

systematic review that was published uh several years ago now uh that i was involved with looking at uh Cost effectiveness in different cervical degenerative diseases and what we found was that there's probably no full economic evaluations and i think that this still holds true although our date this this papers from 2014 that actually look at the economics of operative versus non-operative management for cervical disc disease i think most of us use Clinical judgment on on who's a surgical candidate and who isn't but in terms of the economics of this they're not still very well understood

what we found in this study though was that for at least for surgical treatment and and i'll just highlight the part that's relevant to this uh to this talk that cervical disc replacement may be more cost effective than acdf for The treatment of cervical reticulopathy at one level we also found that posterior cervical foraminotomy may be more cost effective than acdf at least after two years for the same problem so our gold standard which is an excellent surgery and often you know again you have to take everything that i'm saying with the caveat that they're

again most patients who present with a single level Cervical issue may not be candidates for posterior cervical foraminotomy or disc replacement so this is sort of that very um sort of maybe small but i think uh getting bigger subgroup of patients that could be a candidate potentially appropriately for any one of these three options what we found in our own uh cost effectiveness studies was that Acdf in terms of quality adjusted life years uh was a little bit more expensive and cervical disc replacement although both were small numbers when you think about sort of what

the actual cost for quality society is willing to spend which can be upwards of 50 to 100 000. this was early data this study uh when we did similar modeling with five-year data what we found were that Both again are cost-effective and what we found here was that there are sort of parameters around this so as long as you can keep the cost of disk replacement below 20 000 it can be a dominant strategy if you can keep your complication rate below 5 it would be the dominant strategy but if suddenly the acdf cost was

able to fall below eighteen thousand dollars it became the dominant strategy so there Are some variables here uh around cost and around um uh the quality of the surgery that's being done that have an impact on this um we most recently looked at this at out to seven years and again we found that you know at the further out we get uh the more the more cost effective uh the surgical treatment of uh single level cervical Radiculopathy both with disc replacement and acdf proved to be so now we've sort of looked at the data i

would say clinically we would say that there's level one evidence that clinical effectiveness for cervical disreplacement exists and i think um i would say you know it's hard to put a level on this but doing systematic reviews and uh and doing um uh Modeling around cost effectiveness i think that we can also say that not only is the cervical dyscarthoplasty clinically effective but it's also a cost-effective option amongst the multiple options that are available for the treatment of single-level cervical disc disease so i would tell you in terms of my current decision making uh for

for patients who come in uh with cervical Disc issues if i see a patient who's got cervical degenerative disease and they've got facet arthropathy that results in a significant amount of neck pain i will do an acdf uh for this patient i primarily will use an integrated device for this uh as opposed to a plate and screws if i have a patient who's got a lateralized disc herniation with no cord abutment whether or not They've got myelopathy but i don't like to try to go after a fragment that's close to the cord but if there's

no cord abutment a lateral disc herniation and if there's sort of at the level i'm operating on if there's no kyphosis or minimal kythosis um i i would um i like a closer cervical foraminotomy for this and i would say um i'm increasingly using For aminotomy um but if there is a patient with one level disease and definitely if there's two level disease there's no facet arthropathy and symptoms are as we presented uh than the cervical disc arthroplasty for me is my go-to uh implant so we'll shift gears now um to some of the surgical

techniques around cervical disc replacement um because i i would say That cervical disc replacement i think similar to joint replacement and uh you know the hip the knee the shoulder etc elbow um the the surgical technique is very important it is uh it is not a forgiving surgery in that sense and i think some of the outcomes issues that some some people can highlight sometimes are because Um a lot of surgeons were doing cervical disc replacement the same way that they did acdf and uh and i and i can say that that probably can result

in less than optimal outcomes patient positioning is really important uh you do need fluoroscopic visualization uh for this type of a surgery in uh in both the ap and lateral planes i've gotten away from ap fluoroscopy Intraoperatively now until the until the end and i think as most of us get better at cervical disc replacement and do more of them uh most of us have probably gotten away from it uh but i do think that uh it's still an important thing i don't like to leave the or with a good ap image to make sure

that my implant is uh is well positioned this is an image of a Patient that we all worry about you know so this is a patient who's got a big neck and big shoulders um a c67 level that was being operated on can be very challenging to visualize um but there are tips and tricks by you know uh have uh working with the fluoroscopy unit to sort of really comb down the level of surgery but it's really important to be able to see uh both end plates uh that are involved In the surgery and you

want to be able to see from the front to the back of the disc space um and and have a good view because again the positioning of the implant uh it is critical in terms of the uh in terms of outcome here in terms of patient positioning you know oftentimes i'm sure when most of us are doing acdfs you guys are probably similar to me You know we put a role under the uh under the shoulders to get the neck extended to be able to have really good room to work but when we're doing a

cervical disc replacement you really want to avoid a a hyper extended or hyper flexed posture i don't think any of us would really have a hyper flex posture when we're operating but hyper extension is not uncommon uh and can lead if you're not Thinking about it to taking off more end plate uh posteriorly in the disc base which can ultimately then lead to hyphatic malalignment uh this these are images that i borrowed from a jaos article that jacob bukowski had published several years ago sort of just um defining what that how that happens and how

you end up taking more end plate posteriorly uh and then Post-operatively um when the patient uh starts to wait there you know the head the weight of the head you can go into kythosis because you've taken off more end plate posteriorly and and you haven't properly sized the implant so neutral possession of positioning of the neck is critical uh both for end plate preparation and prosthesis insertion um and you really want to have a neck Position that sort of looks like this you know it looks fairly straight and the end plates are pretty parallel and

uh and and i've really gotten away from doing any burr work uh we're trying to at least minimize uh burr work when i'm uh when i'm doing a cervical disc replacement otherwise it's a pretty standard uh approach for both spine surgeons Smith robinson approach there's self-retaining retractors placed i think most of us would use distraction pins uh i i certainly do uh this is what that looks like pin placement can be important here especially if you're using some implants that involve keels uh and especially if you're going at multiple levels uh because you don't want

to create a Stress riser in a keeled implant with multiple pins so oftentimes i will place my pins a little bit off-center and then be thoughtful around the distraction that's occurring to make sure that i'm still providing all my releases uh around the level of surgery appropriately at a single level it's a little bit less important but i do often Try to get the pins for a little further away from the area of the procedure in terms of decompression i would say that again the cervical disc replacement is a little bit less forgiving when we're

thinking about a decompression as compared to an acdf i think most of us would say well if there's uh bony osteophytes or uncle vertebral osteobytes and we're doing an acbf We're going to get a good decompression directly we're going to rely on an indirect decompression for some parts of it and ultimately when the when the fusion occurs there is this concept that the because the motion is stopped that there's some resorption of the uh osteophytes and the symptoms go away i think because you're preserving motion in the cervical disc replacement you really have to sort

of shift And and and i would say that most surgeons who start doing more cervical disc replacements probably do better direct decompressions even for their acdfs because you just get more comfortable sort of really going after all of the osteophytes and and cleaning out uh appropriately not only the central part of the dural sac uh but also the foramen bilaterally removing the disc i think is sort of Second nature for us and then identifying the uncle vertebral joints is important and especially as you start to expand your indications a little bit as i'll talk about

uh in some of the upcoming slides you know having an understanding of your uncle vertebral joints is very critical because if you start to drill away or bite away your upper vertebral joints and start to lose centering You can end up with an ap x-ray that shows that you're off to one side or another even by just a few millimeters and that positioning could have an impact on the patient's outcomes as we talked about it is critical to remove all of the osteophytes both posteriorly because we want to get the implant as sort of to

get full coverage from front to back as much as possible And then also out in the foramen as we talked about um in terms of the foraminotomy um i you know it's sort of a delicate balance you know most of us like to use a bur because it's less traumatic to the nerve root than multiple passes of a kerosene run sure uh but the bird does produce bone dust and if you're using a bur uh you want to make sure that you're irrigating away all the bone dust some Of the issues around complications uh that

are thought about traditionally for cervical disc replacement um are you know that that the level can fuse and uh and sometimes it can fuse around those uncle vertebral joints if there's been a lot of burr work done uh and and some of those uh some of that bone dust has kind of been left behind or not appropriately Cleaned out and the area can fuse or create painful motion um i tend to resect the pll in uh i would say close to 100 of my cases um there is some thought around uh implant properties and how

constrained an implant is whether or not you want to maybe maintain some of the pll uh but i i generally do resect the pll i Find that it allows me to balance that disc level a little bit better um in terms of having appropriate motion especially with a more unconstrained implant i i do not however do a complete resection of the incident uh as we sometimes will do uh for for acdf surgery where there's significant vertebral uh hypertrophy uh i that it is really important to maintain That lateral uh checkpoint uh for your disc arthroplasty

implant both when you're placing it and then for stability afterwards uh from side to side prosthesis sizing i think is one of the biggest things that the hurdles that you have to get over when you're doing a cervical disc replacement and are used to doing an acdf when we think about acdf surgery We think about the fact that we don't want to over distract the facet joints but we want to get sort of a big enough implant in or it's not often as big an implant in as we can get in terms of height without

over distracting the facet joints and we're not as worried in acdf at least traditionally in terms of coverage from anterior to posterior that is completely Reversed in a cervical disc replacement you do not want to overstuff a cervical discard the plasti in terms of height and you want to get the most coverage in terms of side to side and front to back so that you could try to get close to producing um uh more normal kinematics around the center of rotation of the Disk space um and so but but overstuffing an arthroplasty or putting an

arthroplasty that's too small from front to back are the most common things that i see when patients come in um with with a with sort of pain after a a disc replacement has been done so implant sizing is is really critical and it and it does vary um from implant to implant um this is the sizing For the ovc implant but it's just specific to that implant where you have some rotational checks some implants do require slots or keels as we talked about this is uh showing a prodisc implant visit which is a single large

keel at the top of the bottom um keels are also involved in other implants uh the one that i now most commonly use is called the prestige lp and it's got Four small keels at the top and bottom um the i i do place this implant and i do my acvs center fluoroscopy as well again just to make sure that we are getting full coverage from front to back and uh this is just another look at an implant um once that implant is placed i think it's important to get an ap fluoroscopy shot in order

to make sure that you're not off to one side or the other and that There are not rotational abnormalities uh and this is especially important for you when you're doing multiple levels you know making sure that you have a good ap x-ray that shows good coverage uh and good rotational placement and positioning are really important the comment that i made earlier about the uncle vertebral osteobytes i specifically chose this as a as an ap x-ray because you can see here Pre-operatively this patient's primary issues uh were right-sided around the foramen uh and there was some

bony changes in the vertebral joints and so it's really important when we're putting in this implant uh i like to look at the ap because we want to make sure that we've not only done a direct decompression but at least somewhat of an indirect decompression And so when i see this ap shot i really focus on sort of what that what the encore vertebral joints look like bilaterally and make sure that they're even and that they're lifted off of each other um because then i will feel good about what this person is moving that they're

not going to recollapse or still have persistent stenosis uh in the foramen where the issue was Standard closure i don't use bracing after surgery i also don't use drains uh for these uh for i don't use drains for any of my cervical patients at this point but you do want to get like with any anterior cervical surgery really really good hemostasis um i know adam had mentioned around outpatient procedures and things this is a procedure that at one in two levels i do do as an outpatient and i have a Protocol around that uh in

terms of how long patients stay and sort of what they have to do um [Music] in closing or in getting close to finishing here with with this talk i'll talk a little bit about some of the concepts around as the indications expand so um you know as as we've gotten better at doing cervical disc replacement we've also start started to get better At maybe uh using the arthroplasty and things that it wasn't traditionally in specifically indicated for so patients who may have uh what looks like some sagittal now alignment like you see with this patient

um and you know can an arthroplasty like this you know be successful and what we found um at least in a systematic review uh and also compared it to our own patients um Was that when we looked at at a single level traditional acdf standalone acdf uh which means an integrated device and no plate uh or a cervical disc replacement um you know there was not really a significant difference uh postoperatively in terms of that c2 to c7 cob angle so alignment after single level acdf in terms of what we achieve Is probably more just

based on how you do your surgery as opposed to the implant itself and so i thought that was something interesting myelopathy treatment with cervical dysarthroplasty i think this was an area of some controversy although i think now uh most of us would say that that this is a safe alternative uh in terms of doing myelopathy surgery although Not exactly the uh the purpose of this talk um that you can see here a patient with two uh you know um two disc herniations central cord compression um probably a little bit of loss of lordosis mostly based

on the on the cord compression who underwent a two-level cervical disc arthroplasty and we looked at this in terms of the effect of myelopathy on early clinical Improvement and compared again our our patient cohort against the national cohort and we found pretty equivalent results which showed that um patients with myelopathy um didn't improve quite as quickly as patients who had uh non-myelopathy complaints but uh but by six weeks they were as good and improved in their pre-operative complaints Degenerative disc disease i think is you know obviously a topic of uh of controversy in terms of

treatment you know should you be doing surgery at all in these patients who come in with a collapsed disc and uh all neck pain and it was uh funny because uh when i trained with uh henry bowman uh he was very against back pain surgery but he he was always would would joke and say neck pain surgery is totally different than Back pain surgery neck pain surgery works i'm not so sure about that i think it's just like doing surgery on cervical spine but i will say that you know oftentimes you'll see a patient such

as this image here who's got you know two very collapsed discs and uh and loss of lordosis across that segment and uh and primarily neck pain and sort of and we try to figure out you know Like we try to call something radiculopathy around the shoulder blades and things like that but i think most of us would agree that if you're going to do surgery on this patient it's really for neck pain this is a very collapsed disc you know it's going to be spondylotic it's going to be a challenging disc replacement and a lot

of people i can tell you one of my partners [Music] and i we're adam trained uh with uh todd albert he would uh every time we have a patient like this that's presented at conference he he he's like it is malpractice to get to do uh you know in a joking manner to do uh disc replacement on a patient like this because uh you know he wouldn't do it um you can see here you know again not a lot of Compression so this is a very controversial patient to do surgery at all and especially this

replacement surgery and i certainly don't want the residents or fellows on this talk to think that that they should do a surgery like this uh especially during their boards collection and you want to really make sure that you talk to the patient about how they're going to do Uh but i did do a disc arthroplasty on this patient and we've gotten a little bit more uh knowledgeable on which patients are going to do well but in a patient like that you really have to look at your radiographs because there is what we looked at sort

of um and published on the impact of that pre-operative arthrosis and what it does to the implant position it is very difficult Um to make sure that you maintain good landmarks and and place a good implant here there is that that surgery is a true reconstruction of that disc level similar to what you might do in a very arthritic knee uh and what we found here was that you've got to know you know what your uncle vertebral joints look like and if you don't know that there is a Tremendous amount of funko vertebral joint resection

that's going to need to be done that's a patient that will have probably a negative outcome and achieving good implant positioning we found was that the tighter the disc space was the harder it was to get a good implant placed uh and i think that's mostly because you have to spend a lot of time Releasing all of the you know not only the pll which we all release but really releasing the lateral annulus and the structures that have contracted around the ankle vertebral joints and then the overall positioning um we created a scoring system around

the ap and lateral fluoroscopy and what it looked like does impact uh the outcome um i'll finish just a little bit with with The complications and and i think there's some complications um that are uh you know consistent across surgeries but i'll highlight some of uh the complications that i think are particular to to some implants around disc replacement i don't have any um any bias uh as for any uh commercial bias in terms of a relationship with any uh with a company around cervical disc Arthroplasty this was an implant that i used called the

mobc very very commonly uh because again it was just it was indicated for two levels i like that it had the first fda approval it was easy to put in and you can judge rotational uh implant positioning on a lateral image which i really liked um but it is an unstable implant um i'm Sure all the spine surgeons on this call are familiar with a lumbar implant called charity which is no longer on the market and it sort of has a lot of qualities that are similar and uh and what i found over time as

i did more of these was that there was a level of instability and prosthesis motion even if you left the or with what you thought was a really good Surgery um that could be very unpredictable so you can see here um you know uh subsidence and and uh and sort of unilateral collapse of this implant um this is a patient who came in at one year post-op and you know they had complaints of neck pain and we got an x-ray this is what we saw so you know the these can be these do have an

impact and you can see the difference here in terms Of where we left the operating room and how slowly over time where this ended up at one year here's a patient who you know uh we listed this under infection only because when i swabbed the patient intraoperatively for when i did the revision it was a different case um [Music] they had uh staph epidermidis i'm sure that was just a skin Contaminant uh but and i think that this was an implant problem but this is the patient at two weeks postop so this is the improv

image of the cervical disc arthroplasty here's the two week image uh at where you could see maybe a little bit of a change from the pre-op positioning and then here's the six-week post-op image so this this patient came into me and Was had no symptoms he was asymptomatic doc i'm feeling good can i go back to overhead lifting and and as i'm having the conversation with him hey you're six weeks out you're feeling great i think it should be fine as i pull up the x-ray and i'm like change of plans i need to admit

you right now and we have to go back to the operating room um and uh these are just some of the Intraoperative photos of that of kind of removing the prosthesis uh i i did an acdf here so you know the salvage strategy which often uh people talk about maybe having to do a corpectomy or things like that i think with most of the implants now um the salvage strategy even for a catastrophic complication i didn't include the ct images but although it looked like a lot of bone loss anteriorly on that uh on the

Inferior end plate that was unilateral and i was able to do uh an acdf so um take home message here i think cervical disc replacement at least in in my opinion is the treatment of choice for patients who have one or two level cervical disc disease without facet arthritis i think the technique is really really important you have to include a meticulous decompression and you have To have an understanding of how you're placing this implant and what are the steps that you're taking up to that point because there are certain things that you could do

that are sort of like a okay well now we can't do a disk replacement anymore uh specifically around the vertebral joint what you're doing with the end plate the indications although they're expanding um You have to make sense of them right so even that patient that i talked about with that you're doing surgery for neck pain you're going to do those surgeries sometimes and you have to have a really good conversation around the patient and with yourself around what are the goals of the surgery and what is your surgery going to mean for short and

long term results and then Positioning and what kind of implant you're using have an understanding of the implant that you're using not all implants behave the same way they're not all made the same way and there are certain patients in certain areas certain slopes that you need to look at in alignment where you may want a more stable implant and you want to understand those implant Properties when you're thinking about cervical discarding plastic i'll stop there thank you i'll tell you that that's a great talk trash i really appreciate a couple things about that in

particular one is that um the amount of emphasis and time you put in your practice talking about value i think that's one of the things that's orthopedists we don't do a very Good job at and there's no question i don't do as good a job at that but your your effort in getting that literature out there is important because i think that's going to be a big part of insurance and and patience and and what outcomes are the second thing i appreciate is really the complications that you sort of put out there what what the

complications are What in your practice what what percentage is one and two level i feel like one is already challenging enough for me but two is really daunting um so what what what's your sort of thoughts on one and two level disc placements in your practice yeah that's uh that's a great question as i've started to do more foraminotomies frank i've most of my arthroplasties i would say now Are two level arthroplasties unless i'm treating a patient for single level myelopathy um from a large disc herniation and i and and you know i think because

the comparisons have primarily focused on single level um there the differences although still present are smaller um but but a lot of the studies have shown that you know at multiple levels To uh you know sort of being the the most levels that are at least fda approved um the differences both short and long term uh can be uh can be greater and so my practice um in my practice i would say i probably do more two level cervical disc replacements than i do one level cervical disc replacements right now um but uh but you

know but that i think it's It's more just a function of of my practice and and i like doing for am anatomies often for a lot of patients who might you know get an anterior surgery otherwise for one yeah i just want to echo frank's uh opinions on the talk i think it hit all the major points i think one of the challenges for cdr is that it is perhaps supplanting or replacing a Procedure that's historically pretty good take for example is counter distinction intermedullary nailing for long bone fractures right that was revolutionary right traction

versus plates and screws big open surgery so i think cervical disc replacement adoption we're talking about very fine differences in outcome And i agree that for two level disease the results are compelling one level i tell the residents they're pretty equivalent between an acdf and a cdr2 level uh is really where some of the differences came out and you touched upon that so i in speaking about wider spread adoption i think the technical aspects of the procedure are less much less forgiving like you say so It'll be interesting to see as we expand cervical disc

replacements maybe outside of the academic setting the more complications we see and they can be challenging complications a two-level unstable cervical disc is a bit of a pain to deal with you know just because you're ripping two out and doing that so i don't know if it was more of a statement than a question Um you know i guess it just speaks to where do you see cervical disc replacement going in terms of utilization over the next five and ten years yeah i think it's a really important point adam so so what i when i

have the conversation with my patients you know i say cervical disc replacement i think when we i mean we we weren't around when it was First being you know thought about but uh but as taking care of patients now you sort of say well i'm gonna do it because i'm gonna preserve motion and that's gonna reduce your adjacent segment disease right and i would are i we can argue that every day of the week there is probably no difference because how you're setting your center of rotation or the cervical disc Replacement it's not anatomic um

and so could it be it could be but it's very theoretical so i tell my patients the biggest difference is that there's no way that you could get a pseudoerectosis right and and to me both at one and two level if you're an appropriate candidate the reason that i would have it done on myself is because i think that that Pseudoarthrosis rate is under reported a little bit and the um and the studies that have been done around uh cervical disc replacement obviously with bias in them um have shown that the pseudo-reducers rate for ac

for even a single level acdf can be significant and is probably the most common reason that patients have a second surgery I think in terms of adoption you know it's an interesting thing because as much as we hate to think about this like you get paid less to do a cervical disc replacement right i mean so whether you're paid by rvus or whether you're paid by insurance reimbursement or whatnot at some point you know if it would be interesting if if sort of the system changed and and you were and we were Paid based on

how we on the problem that we took care of right that you were in a real like kind of value based system maybe like virginia mason in seattle or something where it's like hey you're getting paid to take care of this person with with cervical uh disc disease whether you're treating the non-operatively operatively you're doing A foraminotomy a disc replacement acdf here's your here's your piece of the pie and you figure out what the right thing to do is and if you do a good job you know more patients will come back to you and

you'll and you'll keep more of the money because you're gonna spend less so and that's where i think also going back to frank's point you know understanding the value and the Cost effectiveness not only in the short term because insurance and companies probably only care about this for a year or two years right they don't i mean the whole reason around two-year data i think is from that um we care about it in the longer term and uh you know for our patients and because we're in this for for a longer time and so i

think that that's where The adoption i think ultimately if it starts to come from patient and insurance demand if we're really believing that there is a value here that could be greater even though the clinical effectiveness like you said is probably similar um you know that may ultimately increase adoption but i do worry that you know oftentimes especially out in in the regular world outside of Academics that a lot of these decisions are based on well i get paid more to put a plate and a grafton and i can do it faster it's more predictable

why wouldn't i do it so sure uh fantastic talk thank you what are the struggles with insurance companies right now because any time you you know bring in a new implant that's probably more expensive and there's a very reliable procedure that has good outcomes that is less expensive What are your battles been here from an insurance and reimbursement standpoint because i'm sure it's it's not easy to get these approved no and i would say that even you know just five years ago like every disc replacement you were expecting a denial you know for a cervical

spine um you were expecting a denial and you'd have to you know again a reason why You know guys in in private practice may say well i'm not dealing with that i don't want to like have to like put another burden on my office or myself having to do with peer-to-peer and things like that i will say that um one of the pleasant things has been that as the literature has supported uh you know the value of cervical disc replacement um i don't have to i don't find And i'd be curious to hear um from

adam frank ahmed you know the guys on the call uh [Music] i don't find that these uh cervical disc arthroplasty surgery is really denied anymore as long as uh otherwise clinical criteria are met um you know with radiculopathy or myelopathy and i think that that's been a really Pleasant surprise the reimbursement though has been cut you know the code is uh you know it's a single code operation and things like that and so i think you know through our societies through nas through double aos double ans um and some combined efforts what you know what

we're trying to do is to say hey disc replacement acdf they they should Be reimbursed the same and that doesn't mean reinverse is less for acdf it means reimburse the support for disk replacement um and uh and and that's still to be determined so so the approval part of it has has gotten easier i would say uh reimbursement though has gotten worse charles great talk thanks so much uh quick question what do you see in regards to Changing motion dynamic over the years do you see any difference from a day one or first three versus

two or three years post-op yeah i mean i so it's a really good question because ultimately if you're doing a motion preserving surgery what you should really be interested in is have you preserve motion at the level that you've done the disc replacement and how it's impacted the areas above And below and i would say it's probably like the worst studied part of cervical disc replacement right uh and so um i i think that uh so we it we actually submitted for a csrs grant to looks specifically at that because we have a great kinematics

lab here at hss and and i would say the answer to your question is i i don't know um i will say just anecdotally um that patients seem to be able to do Better in some of the things like the you know getting their car out of the driveway and having to rotate the neck way over their shoulder um that's the part with acdf especially at two level that i find that patients lose a little motion in most patients don't complain about deflection extension issues as much so but but i think you know we need

sort of real live Patients to have some kinematic studies done to really get an understanding of if there is really you know motion that's occurring that's more close to anatomic through a disc replacement not only at the level of surgery but also at the adjacent levels as patients get for uh you know a year or two years out from discard the last day at the end of the hour why don't we um Take a couple adam can i can i ask a quick question yeah sure i'm sorry that's great it's uh show us dave voice

one of the orthopedic trauma surgeons here thanks really interesting talk as a non spine surgeon i'm still very interested in in the in the topic just a good presentation um i had a question when we talked to patients about uh You know fusion versus joint replacement say in the ankle i don't do ankle arthroplasty or foot ankle surgeons do but if i talk to someone who may be thinking about effusion versus arthroplasty and trying to decide where to send them you always say well no replacement can maybe preserve motion but then you got to take

care of it it's like it's an artificial joint you've got a you know it's it's something different For the rest of your life and so if you're looking at someone who's in their 50s and they're looking at say a disc replacement versus a fusion once it's fused it's kind of fused um you know you have that conversation about sort of they have to sort of take care of this now for the rest of their life is there some additional thing that they have to sort of think about going forward whether It's dental work or whether

it's just sort of thinking about the fact that you've got to really care for this joint as opposed to fusion where we kind of think of those as being more solid once they're fused they're kind of fused yeah it's a good question and i think that early on uh with cervical disc replacement sort of there was a lot of thought around Like where um and sort of what can you do what can't you do um as we've learned more and i've had longer follow-up with large amounts of patients with cervical disc replacement um what we

found is that you know it's different than an ankle or a knee uh in the sense that there's so much coupled motion in the cervical spine and even at the level that you're Replacing you still have two uh facet joints there that are still involved in movement um that the arthroplasty and the cervical spine at one or even two levels um doesn't wear at a similar pattern as like a large joint light um including the ankle um so so in that sense you know we feel pretty good about it that like hey once we put

this in even if you're 35 years old The the where part of this shouldn't be an issue as long as it's well done and and we understand it shouldn't be we don't know that definitively it could be but it shouldn't be um in terms of like how aggressive you could be afterwards in terms of activity and taking care of it from that sense you know Um i in in the national football league you if you have a disc replacement you're not coming back and uh you know if you have an acdf you can uh and

i would say most of that is just because of a fear of something happening around the implant that that is probably um it hasn't really been borne out but uh but you know could happen um and you know we just had this debate at one Of our national meetings uh where there is now you know disreplaced cervical distribution implants and somebody in the national hockey league and and in major league baseball and uh and other sports so the nfl is probably that last sport but i will say that in the military where guys are jumping

out of airplanes um cervical disc replacement um had and i think still is uh sort of the Treatment of choice uh because you don't have to wait for fusion or something like that so as far as the load that it can take seems to be um seems to be pretty that it can tolerate pretty high loads great thank you thanks russ a very good talk i learned a lot and josh lee here hi jeff i like i like the disc replacement very Much and right now i expand the indication a little bit um four uh

four weeks ago i did a surgery for a patient young patient with the collapsed disc in the two level uh three millimeter millimeter um disc height so i put in the five millimeter of the implant and the patient complained about uh neck Pain for about two weeks and then the pain goes away and what's your thought experience on the uh disc height that claps the disc what do you have any cut off for the disc height you know i don't i my partners will use 50 as they're cut off and i think that that's probably

what's most commonly used i am a little bit more aggressive i Would say in terms of saying you know if it's really purely disc height loss that the uncle vertebral joints look reasonable to me that i think i could release them without destabilizing then i will still do it and i think the patient that you're describing i actually tell my patients if i'm doing a collapsed disc that their neck pain can get worse Before it gets better and i think a lot of that is from the facet capsule so you know sometimes these patients don't

have to set arthritis but they've got contracted facet capsules and when you're distracting the disc you're also distracting or trying to open up the facet capsule and i think that that can generate pain uh because that capsule has been Contracted for so long around that joint and so i often will tell those patients that the back of your neck is going to hurt uh for a few weeks and it's really important to start to move early in those patients uh to start to introduce movement and uh and that pain i i'm gonna now that i'm

going to say this i'm sure today in my office i'm going to see somebody's got persistent pain but i haven't had a patient In that scenario who's had pain like beyond a month which is what i usually tell them it's going to be about great uh do you do any hybrid implant um you know i don't um unless i'm doing it above an already fused uh level you know so if there's a c67 fusion that was done a long time ago and now person comes back and has a soft disk herniation at c56 Uh i

will do a hybrid the reason i don't do hybrids like from the start uh is because i i i think it's a rare scenario where one level doesn't fit the criteria for a disc replacement but another one does um and you know i just haven't found that patient because i'm like oh if this level's got facet arthritis and a lot of uncle vertebral hypertrophy then That's the pathology the patient's kind of presenting with and it usually affects both levels similarly um so instead like i'll either do a single level acdf or a two level acdf

um i generally have i have not had experience doing hybrids but it's just i just haven't found the patient that it would be that that is the right indication you so very much yeah of course i think the feedback has been Uh phenomenal i was going to try to move along just in the interest of time charles do you mind just starting your second talk yeah let me uh oh to try them can i ask just a question before sure sure of course yeah um so that was a great topic for uh qureshi i'm the

spine fellow here and i did an observership with you two weeks in new york Hey how you doing it's good to see you again good good good to see you again um just a question about the adjacent um sigmund disease what does they like being doing this this replacement change your um implant choice for adjacent segment disease say that so does the does the does does the presence of cervical disc replacement change your implant choice in the future for autism Oh that's a good question you know i think again that that's something that we haven't

looked at as much and and i you know it's a really good question because i i will say i haven't had the scenario where a patient has had a disc replacement at least that i that i've done and that i could think of uh coming from elsewhere where they've Had like a an issue at the next level and and i think it's probably just it's coming you know we just uh i probably just haven't done them for for long enough just yet and and i think it probably would um and uh and i and i

would say that if there's like you know keeled implant let's say at two levels you know maybe that third level if i'm Going to do i might consider doing a non-keeled implant if i'm doing it above maybe which level is involved if the patient's had a c56 disc replacement now the issue is at c67 and they've got a lot of lordosis along that level i may choose to do something that is more constrained with the heel um so i i think it would be patient by patient but i i think it would be something that

that you would have to keep You know sort of think about and be thoughtful about in the in the treatment options if you're seeing somebody for an adjacent level issue next to a cervical dischargioplasty thank you so much a quick uh just a comment and i sure i was sorry to interrupt but uh i just uh residents faculty pas i have a special presentation for one of our residents after this next talk so uh please stay on the line for just two Minutes after uh dr crazy's done go ahead charles all right thank you so

much so um this uh so that this talk my next talk will be sort of around uh minimally invasive t-lift surgery um you know as uh adam had mentioned i uh i i uh my practice really focuses uh in the lumbar spine on minimally invasive procedures uh that i've been doing for quite some Time now and i think i you know it's sort of an evolution in practice like adam you know the fellowship that i did the m and mis did for maximum uh and as more and more patients demand minimally invasive procedures and this

technology has has advanced i think for most of us it's become an important part of our of our practices see if i could find my cursor here to try to advance this talk There we go uh so my i do have some relevant disclosures for this one i i do uh some consulting and that's the royalty uh with a company with globus who uh i'll be speaking about their robot um so i think with uh minimally invasive surgery especially around spine surgery as most i think the spine surgeons and the non-spine surgeons on this call

would say well What is it you know what's the definition and i would say that there's definitely a spectrum of invasiveness uh non-invasive being on one end maximally invasive or kind of traditional uh open spine surgery on one end and then minimally invasive tends to be this like big black box of a bunch of different things that are probably most often used as uh as Marketing tools as opposed to uh as opposed to actual surgical tools so i think we know what non-invasive is right a needle biopsy uh you know something that doesn't really cause

any collateral tissue damage would be considered non-invasive and then i i don't like to use the term maximal but you know we'll use it for the purposes of this Talk but you know traditional open surgery you know where you've gotta you know cut the muscle or at least detach the muscle and retract on it we'll call um sort of you know the collateral tissue damage that happens and the minimally invasive which was a term that was uh coined in uh in britain uh several decades ago now is really you know procedures where you're Minimizing kind

of the damage at the point of of entrance to where you're trying to get to we think about endoscopic procedures laparoscopic procedures arthroscopic procedures so um but in the spine it's a little bit less defined and i would say when we think about minimally invasive surgery probably the worst thing to happen to minimally invasive spine surgery uh in many ways was the laser Spine institute probably all remember advertisements such as this one and airplane magazines where you know they showed a picture of like a thin person in a beautiful area you know with a small

bandage and i would say that this has done more uh harm for minimally invasive surgery than good um the reality is minimally invasive surgery really you know can help all of our patients You know the elderly the obese and also the uh the thin and the beautiful so the naysayers you know i think would question the clinical effectiveness they would say that the results might be harder to reproduce in everybody's hands that the complications are underreported and then you know kind of everybody says uses the term minimally invasive because that's what patients want to hear

and i'm hoping that at the end of this talk you'll Sort of find that you know the adoption of minimally invasive techniques goes it really pushes us towards improved efficiency and outcomes and ultimately better patient care and the one thing that i would say is that you know hopefully what you'll take out of this especially for the residents and fellows on this call that when you get into practice um you know you can read the literature which you should And you should use that as a guide but your patience should bring the care that you're

providing should be the most important guide so follow your patients collect the outcomes because you know what works best in your hands might be different for a particular problem than what works in others and uh and in spine surgery there's a lot of ways to achieve good outcomes so you got to figure out what Works best in your hands so the keys to success are don't change your indications and understand what your goals of surgery are based on why you're doing surgery so when we think about spine surgery indications we think about doing surgery for

spinal stenosis right which i'll include herniated disc in that instability or deformity right and so if You're doing surgery for those reasons uh then i think that you will have success regardless of how you do the surgery and then your goals you want to decompress you want to stabilize and you want to be thoughtful of the alignment that you're providing to the spine and so if you can marry those things then you know that you will have a better chance at having a successful result and i would say in spine surgery In some form or

fashion we're but we're definitely behind the curve um you know compared to our partners and in other surgical specialties and even within you know orthopedic surgery and neurosurgery um you know having a big incision like this for cholecystectomy you know is is a almost never thing nowadays everything's done uh through small portals around the abdomen and even in Spine surgery um the thought of doing things less invasively is not new you know if we go back to the 60s 70s you know leaders in the field have thought about how to do things less invasively the

limitation has always been the surgical technology and that part has changed i would say uh at least for the first time that i know of i think a lot of my partners who are Senior to me would agree the technology that's available today is ahead of what the surgeons are ready to adopt and uh and that is a new place to be in spine surgery uh because the things that we could see both through illumination and imaging are just um at another level right now um and and really impacting the way that we do things

um i would say in the united States at least uh the birth of minimally invasive surgery was based around percutaneous pedicle screw placement through um this system called the sextant system uh which was introduced back in 2001 so it's still a relatively young field but not that young anymore um the tools vary and have changed so uh this is my uh sort of or And and the different tools that i i use the workhorse of minimally invasive surgery is this uh tubular uh retractor that's shown on the bottom of the screen here i'm so sorry

i can't seem to find my cursor but uh but i uh but i think you guys can see what i'm referring to um i think microscopic visualization is important and then whether you're using fluoroscopy Or intraoperative navigation or robotics and i'll touch on all of these um you know these are all tools in uh that we use in real time during surgery to help us with these so in terms of the things to consider you know you really want to achieve the same goals as open surgery so you want to think back to those am

i doing a decompression am i doing a fusion am i what do i think what am i doing for alignment And a lot of us get caught up in minimizing the size of the incision and you know that is sort of you know what it is but it's probably really the least important part of mentally invasive surgery it's really trying to minimize soft tissue disruption and then ultimately how to enhance post-op recovery so i'm going to focus on one minimally invasive procedure of the multiple that there are because i think It's probably the one that's

uh that's most uh often used to treat the pathology that most spine surgeons see every day so you see a patient here who's got spinal stenosis with spondylolisthesis l4 l5 there's a facet cyst coming off of the joint at the uh at the on the right side of the l45 level and this is a procedure that you know we can use in at a national meeting and A debate and say who would treat this with uh anterior surgery who would treat this with a posterior surgery who would just take out the cyst who would do

a fusion who would do this from the side etc so this is a hotly debated uh issue but for me you know it really sort of highlights the workforce procedure and minimally invasive surgery in the spine which is the minimally invasive Transformational lumbar in your body fusion so what that means is you know we're really trying to change sort of a big exposure where we're cutting the muscle doing a laminectomy exposing the neurologic structures to doing something through uh percutaneous openings smaller openings tubular retractors and and really trying to preserve uh the bony structures the

the muscle Attachments and the ligaments that sort of attach uh along the uh spine what we're doing here so just that for some of the non-spine surgeons calls so the doctor retractor that sits on the cassette joint and then here we're uh in the security so we've identified our facet joint we then go to an area called camden's triangle uh so what you're looking at here that White structure there is the dural sac and that one there is the disc so we're really accessing the disc space right next to the dural sac this video is

is from a few years ago most of the time when i do this procedure today i don't want to see the dural sac at all i take even a more lateral approach and that's been part of my learning curve in this Um disk space preparation is critical so you know we want to prep the disk space as uh as much as we can and then if you want to add a direct decompression after the implant is placed we can sort of walk by wanding the tube and working over the dural sac we can still do

um a full decompression but what we've done here is what's outside of this tube is the Spinous processes the other half of the lamina and all of the muscles on both sides as well as the inner spinous ligaments if there is pathology like i showed earlier this is that patient whose image i showed the set cyst you can have direct access to removal of that cyst um as needed so after again after the inner body takes in place you can go and deal with direct Pathology the rod has been passed through percutaneous screws um and

i think that this is uh you know the nice thing about a minimally invasive t-lip is it can be done in a lot of ways and when i first started doing the surgery i i used uh live fluoroscopy so one of the things that you see here uh draped in as a c-arm and that was a critical part of my surgery was the Ability to use a c-arm but here's just a video of multiple x-rays that are taken through a fluoroscopic surgery and every time the picture changes x-ray x-ray x-ray x-ray x-ray x-ray so you

can imagine there's my hands getting radiated uh you're going to see my fellow's hands in a second also getting uh radiated right there and so this was that you know A fluoroscopically based mist lift um you know has you know is is a great operation easy to do and uh i think is the way that most people do it but the radiation dosage uh to the surgeon to the patient to the or team uh can be quite significant uh as you go you know through the entire procedure uh from the start all the way down

to the finish of Putting in the screws and passing the rod so you can just imagine how much x-ray is being taken there so the other thing with x-ray is that oftentimes you know you can put screws where you don't want them to so this was a patient who's having an l5 s1 fusion done and you can see the l5 screws are sitting right in the facet joint on the right side and have violated at least a portion of the facet joint on The left side and so the accuracy of screw placement can also be

in question when using fluoroscopic guidance alone uh we looked at this so you know i sort of felt this uh as an issue as i was uh going through my learning curve of mist lift and so we went to a lab with some residents and fellows and uh and we put in percutaneous screws and A bunch of cadavers and then we dissected the cadavers and we found that you know it's pretty safe and accurate if you're thoughtful about it um but the traditional thought of placing screws at the three o'clock or nine o'clock position and

passing them in when it came to percutaneous screws um we sort of defined a different way to do it where you actually really want to start at the inferior lateral border of The pedicle you want to aim up and then you want to redirect your hand so it was it was certainly something that could be a little technically challenging in order to prevent facet joint violation and then again as we talked about a lot of radiation so we looked at uh at my own patients and published a study on this Looking at sort of the

radiation exposure in an mist lift and although you know we got better after the first 50 cases you could see that even when we were considered mature on our learning for a one case you know still had up to two minutes of live fluoroscopy time and so that that was pretty significant and i thought you know um that was kind of eye-opening for me um It sort of started my interest in uh in three-dimensional intraoperative imaging modalities and of which there are many and this is really where the field is exploding now so i then

shifted to using uh navigation i started with using sort of more traditional navigation and then more recently shifted towards doing something called the spine mass tracker which is a skin based uh Navigation uh where we place the tracker on the skin you can see with navigation so this is a setup for an mist lift in my practice where the um where the mask is sort of outside of the field so it's at the top of the picture here that yellow thing that's draped with iodine and then we can get a really good look and you

can see so that's Myself and my fellow and you can see there's no c arm draped in the field anymore and we've got a really good 3d view of exactly where the uh where that first jam td needle is called is going and i think it's a great teaching tool because um you know we can really do this surgery together and and the fellow or the resident can have a really good look at exactly what They're feeling and what that's translating to on a screen um in terms of being able to you know accurately place

pedicle screws in areas where that are traditionally difficult to visualize even on with x-rays such as the sacrum and getting towards uh good medialization and towards the sacral promontory i think that there are advantages and then working around large facet Joints such as shown here uh in order to get an accurately placed screw in a good position with the longest screw possible i think there are definite benefits to this 3d imaging i use it for docking my tubular retractor as well and i think that that allows for uh accuracy and just a good understanding of

where you know where you are right away we looked at this and this is a study that was published in the spine journal Just looking at the total time demand because i would say that you know when i um when i talk to my partners who now are you know i would say thankfully all believers um the biggest thing was i don't have time for that you know i got too many cases to do it takes too long and what we found was that you know the time demand difference from Fluoroscopy versus uh versus navigation

the difference was only five minutes um and it was statistically significant but i think five minutes is a pretty small amount of time and less than what i thought it would have been um and worthwhile especially when you think about the total radiation you see that fluoroscopy time in seconds uh you can see this is extremely Significant uh in terms of having 26 seconds of live fluoroscopy time and the total radiation dose you know is is statistically significantly different it's still higher than what we want it to be but remember part of this is the

spin that we can all step away from and doing these surgeries several times a day several times a week a month a year you know that radiation dose You know can be can can add up and then ultimately and importantly you know what about the pedicle screw violation like we showed earlier where you violate the facet joint and that violation you can see um in this regression analysis that you know with fluoroscopy compared to uh navigation you have twice the odds of core screw placement and poor screw placement here is specifically you know kind of

looking At that ascent joint violation some other issues that i've sort of gone through you know so this is a patient of mine um for i think this was my first or second mist lift and i guess i think i did everything wrong you know the patient's confined but you can see a broken guidewire um you know at that time we were using stainless steel guidewires you can see a really small Uh implant in the inner body space um and uh and i'm sure if we looked at the uh the lateral image which i don't

have here but it would show you know that the person is pretty flat-backed and things so um you know you want to think about all of the goals of this so you know one of the things that that i always hear about you know uh in terms of minimally invasive t-lift surgery Specifically versus traditional uh open surgery as well the fusion how do you get a fusion and i would say that you know again i've gone through the learning curve um this is not uh one of my patients but a patient that you know i

saw a few years ago had a minimally invasive surgery done elsewhere who clearly you know uh has a a significant pseudoarthritis screw loosening etc And and it sort of led me to sort of say boy how am i doing in this and when i and when i thought about you know sort of the different um ways to achieve fusion you know there's allograft and infuse and autographed and different implant types and and and i went back and i looked at my own patients and this uh is data that we published i think it finally got

published just uh just a Couple of years ago but but we weren't doing that great either you know i mean my fusion rates with uh kind of just allograft type phone material was was less than 70 percent and my fusion rate using infuse was better but it was still under 80 um and then the complications of infuse you know sometimes they are symptomatic sometimes they're not but this is a common one Or a foraminal bone growth so um you know maybe we're increasing our fusion rate but was that really helping our patient and so sometimes

you look at your own data and you realize you've got to go back you got to think back and i thought back to my fellowship and i thought i thought thought back to henry bowman and how we would take iliac crest autographed for everybody and so I went back to taking cresscraft and that small incision there you know is i figured out a way to use navigation and to do a minimally invasive approach where we didn't split any muscle we made a percutaneous opening over the top of the crest and then we passed this reverse

reamer that i think is often used by people in trauma and hand surgery and uh and reamed A you know from between the tables a large amount of autographed bone and uh and then used it with with different uh options this was a uh a uh minimally invasive uh disc prep instrument set that i had developed to help get like really uh nicely across the midline and really uh do a larger disc prep And then when we went back and looked at our fusion rays we found that if we combined iliac crest autographed bone with

some newer cage technologies we'll talk about our fusion rates finally went above 90 and this was all um cts at one year uh looking at fusion uh and comparing them uh in each of the groups what about alignment you know um a lot Of times with single level surgery we think we don't really think about alignment you say well you know that this is not a deformity right i mean this is like this person's fine and um you know what this has been looked at by a lot of authors one of my partners todd albert

he was at the rothman institute you know looked at this and uh and and even at a single level you know Where doses reconstruction is important uh and i think what we're finding is it's not only important for what the x-ray looks like but it does have an impact on outcomes and one of the things that we always think about we always talk about with our patients is around you know what does a fusion mean to um to the adjacent segments and the degeneration that occurs and i think reconstructing uh optimal Lordosis can potentially help

in that and i think we're going to show that with time so so here's the that same patient that i'm talking about you know i i think i had a pretty good result in the translational reduction of that spondylolisthesis um but i would say that if we really looked at the lordosis you know somebody said well i could do a better job than that if i did an a-lift surgery or if i Didn't open surgery because not only would i be able to get the translational correction but i would be able to really get the

lordosis better than what you got it there it's hard to argue that and what that ultimately means in this patient for their next disc l4 l5 you know time is going to tell but certainly it made me start to think about you know what can what can i be doing in my own practice To sort of do better with this so the first thing we did was you know we did a systematic review to see what's the literature out there on lordosis reconstruction with mistletoe and we found there's not much so then we did our

own study on this that was published a couple of years ago in uh in one of the neurosurgery journals and we found that you can control it you have to think About what the patient's got going in there's a very busy slide but really the basis of the information here is that by using certain types of cage technology especially expandable cages you can start to improve uh the amount of lordosis that you can restore but it does depend on how much orders the patient already has going in so here's a patient you know collapse disc

little low solar dose that's not Terrible but if we here we used an expandable cage we got it placed anteriorly in the disk space and that expandable cage allowed not only for restoration of the posterior disc height but also improvement at least in the uh lordosis even if slight here uh but we're not making um that worse certainly but expandable cages alone won't do the trick right i mean here's a patient Similar to the other one that i showed that i did use an expandable cage but that's where i got it to and you can

see again the lordosis is probably not optimal better but not optimal and so this was a paper that we recently published that looked at sort of the most important factor is not the amount of lordosis the cage is necessarily giving you know we say oh well let me use a 15 degree cage or a 10 degree cage or a 6 degree cage Those are sort of small differences but really the most important thing is where you're getting that cage in the disk space and getting it into that anterior third of the disk space into the

front of the disk space is really the most important thing when we think about lower doses and now that we've you know sort of make a conscious effort to do that i would say that we've gotten much better uh at the type of ordonic alignment we Can get and you can see here the pre and the post-op you know you can really get good lordosis reconstruction here and everything's being done through the inter-body space so for some of the non-spine surgeons on the call you know when an open surgery is done you can put these

cages in and then you can use your screws to compress across and get lower doses that doesn't happen unfortunately in minimally invasive Surgery despite what your reps might tell you i think the guys on the call would agree percutaneous screws you just can't do that here's another case of a patient who you know had a two level issue and you can see if we can get the implant anteriorly we can really get good more doses reconstruction uh and as well as getting good posterior disc height reconstruction without compromising The two things it doesn't always go

well so this is a patient uh you know one of my complications l45 spondylolisthesis happens to be a family member of one of a spine surgeon i know sort of what you would say home run operation you know l45 spinal stenosis monolith but as i look back on it i'm like oh boy you know tall disc um i didn't really check the guy's bone density screws are really small that i used and That cage is not even fully expanded is still barely touching the end plates and this is the patient at six weeks post-op you

can see loss of the reduction subsidence of the cage and i would say it's really really important to sort of even when you think you're good at this you know seeing your patients back can be very humbling Um and and this patient you know pretty much all of his symptoms came back um now we looked at this so this led us to i i wondered well how often does this happen is it really meaningful or is it a one-off and so we've looked at this recently this is uh data that's submitted for publication uh that

is in revision right now uh but what we found was that patients with Subsidence tend to be a little older um they definitely have lower bone quality which is why getting a sense of bone density is very important um and uh the larger the implant footprint is the less likely they're there to subside so filling that disk space becomes really important um and clinical clinically whether it's meaningful or not you know i would say again you know even though our data suggests that it may not be Very clinically meaningful i still think that you know

even if you see one patient where where they didn't have a good outcome like you know if you could do a better job it's worth following so there was no difference in fusion rates uh that we found um and uh but you know in the sf-12 physical functions for one year there was a significant difference in patients who had Subsidence um there's some technical challenges around using some of these kinds of cages that can provide the lordosis that can have a big footprint here's a patient who just had a this was a third time recurrent

disk collapsed disk we did a mist lift and you can see on that ap x-ray that cage did not go where you know lateral looks okay But on the ap it did not get where it needed to and this is what it looked like on the ct scan and i ultimately had to reposition this cage because it was irritating um he had some neurologic symptoms and i wasn't convinced it wasn't from that we've gotten better again with technology as far as this goes so i think this is where robotics uh plays a role in my

practice i've sort Of again i i have a commercial bias here in just a sense of the fact that i consult and get some royalty from a company who makes this robot but um but i would say i i am a hundred percent in on robotics when it comes to spine surgery i think we think about it um mostly with screw placement but i i think we all play screws pretty well I think the three-dimensional uh aspect of navigation married with the precision of robotics allows us to place it better but i think really you

know planning this case so this is just a picture of me with one of my fellows in the or we're doing an intraoperative plan and then placing four screws the clock is there so you could see putting you know doing the intraoperative planning and then placing The four screws so that's from the first picture over to the third picture you know doesn't take a lot of time this is just you know single levels of four screws um but what it does do is it really allows us to map out the perfect screw for each patient

so i found myself i was always i generally you know 6545 was my screw of choice um and now i really choose the screw that fits the pedicle the best Sometimes that's an eight five sometimes it's a sixty uh sometimes it is a six five by forty five the other thing that it allows me to do is sort of accurately kind of uh position some of my disk prep implants um so this is just showing the screw placement but here's uh the disk prep you can see i'm looking up at the screen there so i've

got a curette in the disk space but i've planned out where my inner body is Going to be and so i can really prep by seeing that overlay on the screen where my curetta is i'm making sure that i'm prepping where my inner body ultimately will go and then ultimately placing the inner body using that navigation guide and so i can watch exactly where the inner body goes in three dimensions um to avoid uh a scenario like i had Shown earlier where the implant you know was too lateral in the disk space in terms of

mist lift surgery you know i i think the biggest advantage here you know the thought that thought it always is always like okay it's great you know but like so what you know what does it really mean to the patient um maybe they get out of the hospital a day earlier maybe they go on the same day Uh but really does it matter at the end and i would say that you know the further the more we're looking at this the better we're getting at it we're finding that you know for things that are important

to patients when can i go back to driving when can i go back to work when do i not need pain medication for here so here's our data here uh again submitted for publication uh But not published yet but what we've found is that you know patients who have a single level fusion versus patients who have a single level decompression um you can see that that single level fusion the differences are not that great so in terms of return to driving a single level decompression we found in our average on average medium days uh in

our cohort was 14 days the fusion went back At 18 in terms of returning to work difference of uh of 12 days and in terms of getting off narcotics differences just a few days so you know i think um hopefully valuable information that we could uh know for ourselves and provide our cases sorry i'll go back here but uh so i'll finish off with the case you know uh and sort of to highlight kind of uh you know What we're hoping to achieve so the patient uh he'll you'll hear him but he's got essentially symptoms

of of a of neurogenics numbness in the right leg for the past 12 years and pain in the lower uh left side of my lower back also any weakness no weakness have any injections or physical therapy helped absolutely not thank you very much so You can see l45s stenosis spondylolisthesis sort of a classic patient that we are all going to take care of many many times a year uh we did a single level misp lift on this patient you know what everybody high fives about is the little incisions but that really doesn't matter i would

say it's the least important part of it but what is great is that you know this is our Part of our outpatient protocol so this is five hours after surgery [Music] so i think you know when done appropriately you know obviously within collaboration with some our anesthesia colleagues we're doing some specific blocks and things like that but starting to think about you know and doing outpatient single level fusion surgery Uh i think is becoming more uh more of a reality and i think that's where these uh techniques will really allow us to get to as

we continue to move forward so take-home points i would say in general minimally invasive techniques are safe and effective for the same problems that we deal with with open surgery i specifically use the term degenerative deformity here because i do not believe that minimally invasive techniques are a Good option right now for real deformity surgery uh i would say for the residents and fellows you know the spine surgery is you know a very discretionary surgery right a lot of ways to do it so and a lot of times when you should or shouldn't do it

and the art of spine surgery like any surgery but really i think it's my surgery it's so important is the indication that's the Art and use technology but use it on real pathology don't let the technology drive your surgery uh let the surgery drive what kind of technology you use and never compromise on the goals of surgery don't do a worse surgery uh just because you can use technology you know you gotta focus on what the goals of surgery are make sure you get them done that's how You're gonna have happy patients thank you sure

quick question do you have any um limitation in the patient's size i feel very i feel really difficult to miss when you go above 90 millimeter with it with the tubular lengths and and the triangulation is very difficult and the safety because compromise what do you do or you guys don't have any in new York i was gonna say you know i think one of the good things is uh you know with where i practice it it's rare for me to have uh to need a tube uh that's that's 90 millimeters uh but you know

we're often in a 70 millimeter tube um i i do think that there are some some limitations when it comes to size uh where it makes the surgery a little Bit more difficult triangulation becomes a little more difficult can the burr reach all the way down to where you need to get to becomes difficult um so you know there are advantages and disadvantages when you get done with that case and you're closing still four or five little openings as opposed to a giant incision uh in in a person uh who you know Is has a

large bmi um you know i think that's a real positive but it's a much more difficult surgery um and you know i i talked to my friends in chicago who like you know deal with uh or in the midwest who deal with these uh you know much bigger patients on a regular basis and i think you know like anything else there's a learning curve to that Uh and you sometimes need special instruments i think one of the things that i'll do sometimes is i'll make a bigger skin incision and then just drop and then make

the fascial opening sort of surface i'll put like a little wheat lander on the skin and then i'll make the fascial opening and i'll just drop like a 70 millimeter 60 millimeter tube still Um and then this way like it's just a skin opening that's a little bigger but i'm still working in a tooth that i'm comfortable with um but i but you know but in all honesty i will tell you that for me uh you know one of the benefits of practicing what i do is that it tends to be a less common occurrence

of you of having to use the big tubes great jaraz i want to thank you for Attending we're getting ready to break real quick to go to uh clinics and ors so i i hope you got our little gift package um i did thank you so much i loved it and uh i really appreciate you spending time this meeting this morning to educate our department really fascinating stuff you're doing up there and please say hello to everyone at hss we obviously have a lot of contacts with Your department so thank you very much any other

final questions great thank you uh hope we can do this in person sometime soon thank you so much thank you so i really had a great time thanks for everybody for sticking around i know it's always hard when i got or patients to get to like that thanks so much it was great thank you so much fascinating fascinating So uh everyone i just want to make a quick uh recognize someone and make something final uh jim burgess you're on the line right yes sir all right um this is actually a huge honor for me as

a supervisor i guess i'm supposed to uh make this uh final uh dr burgess has been promoted uh in are in the military um so i'm supposed to read this to make this uh final And uh also offer uh congratulations from the department uh jim so the president of the of the united states has reposed special trust and contra confidence in the patriotism valor fidelity and abilities of captain james michael burgess in view of these qualities and his demonstrated potential for increased responsibility he is therefore promoted in the united states army to the great of

major So congratulations james uh really fantastic obviously your uh your devotion to our military uh is is is incredible and and we're proud to have you as part of our department but i guess this makes it final that you are uh promoted through the rank of major once that was read so uh congratulations and i'm glad the members of our department could hear that Thank you congratulations all right everyone time to a break uh thanks spine division for uh for um for the arranging that conference really fascinating stuff obviously spine technology is is advancing quickly

but also it's very expensive so uh we'll see how that plays out but you had to take one jab at it you couldn't have just left it nice right it's fantastic but It's expensive that's all i'm saying that's all i'm saying is expensive looks expensive and i'm sure it is expensive so but anyway great talk so thanks everyone uh and have a good day and congratulations james