Donald R. Johnson, II, MDDonald R. Johnson, II, MD

Medical Director

Southeastern Spine Institute

MUSC Board of Trustees

Past Chairman

Advancements in Spinal Surgery

Advancements in Spinal Surgery

What’s New ?What Works?

What Can Get An Injured Worker Back To Work

What Saves Money?

Spinal AnatomySpinal Anatomy

Spinal Stenosis(Narrowing)

Spinal Stenosis(Narrowing)

• Spinal stenosis is the narrowing of the bony ring that surrounds the spinal cord. Causes include:– Bone spurs

– Disc degeneration

– Arthritis

– Congenital

• This condition is most common in elderly people, who have had years of wear-and-tear on their spines

Spinal StenosisSpinal Stenosis Stenosis of the spine can cause pain in the

back as well as in other parts of the body.

• Primary symptom is decreasing ablilty to walk- better with cart in store and better after sitting and bending over

• Can lead to paralysis and bladder/bowel control

Traditional Surgery Laminectomy

Traditional Surgery Laminectomy

Usually Multiple Levels

Interspinons Distraction for Spinal

Stenosis

Interspinons Distraction for Spinal

Stenosis

FLEXUS Interspinous Spacer

FLEXUS Interspinous Spacer

Competitive ProductsCompetitive Products

Medtronic

X-STOP

Paradigm Spine

Coflex

Abbott Spine

Wallis

Medtronic

DIAM

Surgical TechniqueSurgical Technique

FLEXUS Surgical TechniqueFLEXUS Surgical Technique

• Patient PositionPatient Position• Prone and in flexion Prone and in flexion

• IncisionIncision• 2-3 cm length2-3 cm length• MidlineMidline• Separate paraspinal muscleSeparate paraspinal muscle

on right sideon right side

FLEXUS Surgical TechniqueFLEXUS Surgical Technique

• Interspinous PerforatorInterspinous Perforator

• Create starting hole through Create starting hole through interspinous ligamentinterspinous ligament

FLEXUS Surgical TechniqueFLEXUS Surgical Technique

• Dilator – KEY PREPARATION STEPDilator – KEY PREPARATION STEPSeparate the bones(spinous processes)Separate the bones(spinous processes)

3 Step Insertion Technique – Trialing3 Step Insertion Technique – Trialing

1.1. Insert horn of trial through interspinous ligamentInsert horn of trial through interspinous ligament

2.2. Push trial past midlinePush trial past midline

3.3. Rotate trial 90° Rotate trial 90°

3 Step Insertion Technique – Trialing3 Step Insertion Technique – Trialing

Final PositionFinal Position

Discogenic IssuesDiscogenic Issues

• Discogenic Pain– Caused by a damaged disc. While

this pain can be felt directly in the lower back, it may also be felt outside of the area of the damaged disc, such as in the buttocks or upper thighs.

– Specific movements that put stress on this damaged disc can worsen the pain.

Discogenic IssuesDiscogenic Issues

• Pinched Nerve– Also know as radiculopathy, or sciatica,

occurs when there is pressure on a nerve to cause irritation and inflammation.

Discogenic IssuesDiscogenic Issues

• Bulging or Herniated Disc – Herniated Disc occurs when the jelly-like

center (nucleus) of the disc ruptures

– Causes material to be pushed outside of the outer ring of the disc

– Pressure on the spinal cord and nerve roots cause pain, weakness, and/or numbness to certain areas of the body

Degenerative Disc Disease (DDD)Degenerative Disc Disease (DDD)

• DDD is a slow deterioration of the cushions located between vertebrae.

• Since these discs act as a shock absorber between each vertebra, the reduction or loss of disc height can cause pain.

• The so-called “degenerative disc” is not getting enough nutrients and will not be able to repair itself once injured.

Degenerative Disc Disease (DDD)starts as an annular tear

Degenerative Disc Disease (DDD)starts as an annular tear

• If the outer ring, or annulus fibrosis, tears it can cause back pain.

• The inner core of a disc, or the nucleus pulpous, is very soft and can cause severe leg pain if it comes into contact with the surrounding nerves.

Spondylolisthesis (Spinal Bone Slippage)

Spondylolisthesis (Spinal Bone Slippage)

• Occurs when one vertebra slips forward in relation to an adjacent vertebra, usually in the lumbar spine.

• Symptoms include pain in the low back, thighs and/or legs, muscle spasms, weakness, and/or tight hamstring muscles.

Spondylolisthesis (Spinal Bone Slippage)

Spondylolisthesis (Spinal Bone Slippage)

• May result from the physical stress placed on the spine - lifting of heavy items, weightlifting, football, gymnastics, trauma, and general wear and tear.

• As the vertebral components degenerate, the spine’s integrity is compromised.

SpondylolisthesisSpondylolisthesis

• Depending on how far the vertebra has slipped, doctors label spondylolisthesis in four grades, I (one) being the least amount of slippage, all the way up to IV (four), which is the most slippage.

• Not all cases of spondylolisthesis require surgery.

Spinal FusionSpinal Fusion• Spinal fusion is a surgical procedure in which two

or more of the vertebrae in the spine are united together so that motion no longer occurs between them.

• Between the vertebra- termed INTERBODY!

• Usually a box(cage) filled with a bone “glue” May be supported by screws(pedicle) to allow glue in boxes to heal by keeping the bone and boxes still.

Spinal fusion can restore stability, correct alignment & reduce pain.

Interbody Fusion ApproachesInterbody Fusion Approaches

Posterior Lumbar Interbody (PLIF) Fusion

Posterior Lumbar Interbody (PLIF) Fusion

• Direct decompression• Exposes spinal cord elements• Retraction risks to nerves

Transforaminal Lumbar Interbody (TLIF) Fusion Transforaminal Lumbar Interbody (TLIF) Fusion

• Avoids spinal sac• Direct decompression possible• Potential nerve irritation

Anterior Lumbar Interbody (ALIF) Fusion

Anterior Lumbar Interbody (ALIF) Fusion

• Excellent visualization of disc space

• Avoids spinal cord

• Approach risks to organs and vascular structures

Extreme Lateral Interbody (XLIF)Fusion

Extreme Lateral Interbody (XLIF)Fusion

Approach for L4-L5 and above

• Reduces muscle trauma

• L5-S1 not accessible because of pelvis

Traditional Surgical ApproachesTraditional Surgical Approaches

BackFront Back

XLIF®

Surgical ApproachXLIF®

Surgical Approach

•eXtreme Lateral Interbody Fusion (XLIF)

•Advantages:

Does not require entry through back muscles, bones, or the retraction of major blood vessels

Side

Disc Degenerationbefore XLIF

Restoration of Heightafter XLIF

• Symptoms– Pain in the back, buttocks, or leg

• XLIF Correction– Reduces motion between the vertebrae

– Corrects alignment

– Restores proper disc height

– Alleviates pain

XLIF®

Indication – Degenerative Disc Disease (DDD)

XLIF®

Indication – Degenerative Disc Disease (DDD)

XLIF®

Indication – Spondylolisthesis

XLIF®

Indication – Spondylolisthesis

•Symptoms– Impingement of nerves and fatigue of back muscles

•XLIF Correction– Reduces motion between vertebrae, corrects

alignment, and restores disc height

Spondylolisthesis(Malalignment)

before XLIF

Restoration of Alignmentand Disc Height after XLIF

Degenerative Scoliosis before XLIF

Restoration of Alignmentafter XLIF

XLIF®

Indication – Degenerative Scoliosis

(Curvature)

XLIF®

Indication – Degenerative Scoliosis

(Curvature)•Symptoms

– Back and/or leg pain due to muscle fatigue and nerve impingement

•XLIF Correction– Restores proper alignment and disc height

Axial Lumbar Interbody (AxiaLIF) Fusion

Axial Lumbar Interbody (AxiaLIF) Fusion

• Has ability to spare 100% of Annulus• Preservation of Tissues & Muscles• Dynamic Decompression via Distraction

AxiaLIF Pre-Sacral FusionAxiaLIF Pre-Sacral Fusion

Unique Features

• Only interbody graft option where:– No muscle is dissected– No ligaments are cut– The disc annulus is preserved

Distraction

AxiaLIF Immediate Results AxiaLIF Immediate Results

Pre Op Post Op

Patient Ms. C. F.Patient Ms. C. F.

Dx: Adult Lumbar Scoliosis

1. Lateral diskectomy L1-5

2. Xlif fusion L1-L5

3. Placement of plastic cage with bone glue

Pre-op XraysPre-op Xrays

Right BendingLeft Bending

Pre-op LMRI FrontalPre-op LMRI Frontal

Pre-op Side ViewPre-op Side View

Percutaneous (thru the skin) Pedicle

Screw Fixation

Percutaneous (thru the skin) Pedicle

Screw Fixation

Pre-Op Cross SectionPre-Op Cross Section

2 Week Post-Op2 Week Post-Op

Patient Ms. C. G.Patient Ms. C. G.

Dx: Adult Degenerative Scoliosis

1. Xlif at multiple levels

2. Percutaneous screws and rods

Pre-op XraysPre-op Xrays

Pre-Op MRI FrontalPre-Op MRI Frontal

Pre-Op MRI Side ViewPre-Op MRI Side View

Pre-Op MRI Cross SectionPre-Op MRI Cross Section

1mo Post-Op1mo Post-Op

7mo Post-Op7mo Post-Op

Patient Mr. T.A.Patient Mr. T.A.

Dx: Degenerative Disc Disease L5-S1

1. Axialift

Pre-Op XraysPre-Op Xrays

Pre-Op MRI Side ViewPre-Op MRI Side View

Pre-Op MRI Cross ScetionPre-Op MRI Cross Scetion

2 week Post-Op2 week Post-Op

6mo Post-op6mo Post-op

Patient Mr. M.B.Patient Mr. M.B.

Dx: Degenerative disc disease with disc space collapse L3-4, L4-5, L5-1.

Dx: Annular tear with provocative discogram.

1.Xlif L3-L4, L4-L52. Percutaneous pedicle fixation L3, L4, L5, S1 3. Axilift L5-S1

Pre-Op XraysPre-Op Xrays

2wk Post-Op2wk Post-Op

IntraoperativeNeuro-Monitoring

IntraoperativeNeuro-Monitoring

Cell Mediated Disc TherapyCell Mediated Disc Therapy

FDA StudyFDA Study

• Starting March 1st- first FDA approved study of injection of cells to regrow and heal an injured disc

IsotechIsotech

Davis Adkisson, Ph.D.Founder & Chief Scientific Officer

from Summerville, SC

Outpatient Spine Surgery-Procedures currently being

done at SSI

Outpatient Spine Surgery-Procedures currently being

done at SSI

• Interspinous distraction

• Laminectomy/discectomy-single and multiple levels

• Anterior cervical fusion- 1and 2 levels

Anterior Cervical FusionAnterior Cervical Fusion

• 32 Cases

• 3.5 Postop stay in RR before DC-no readmissions

Planning: as OUTPT Procedures at SSIInterbody Fusions

Planning: as OUTPT Procedures at SSIInterbody Fusions

• Anterior lumbar fusion (ALIF)

• Posterior lumbar fusion (PLIF)

• XLIF

• Axialif

• Percutaneous pedicle screws

• Average operative time 1 hr at SSI

Cost Savings Vs HospitalCost Savings Vs Hospital

Based on EOBs obtained from pts is 50-66% cheaper to

commercial payers

2010 Workers Comp Fee Schedule

2010 Workers Comp Fee Schedule

(not ▲’d since 2003)-medical provider cost index up 28%

Using Medicare Relative Valve Units

(RVU’s)Good way to measure many different accounting metrics-but is system appropriate for the young injured worker?

Using Medicare Relative Valve Units

(RVU’s)Good way to measure many different accounting metrics-but is system appropriate for the young injured worker?

Medicare Spine Surgery-most common spine surgeries

Medicare Spine Surgery-most common spine surgeries

• Spinal Stenosis X-stop or multiple level laminectomies

• Compression fx Kyphoplasty• Degenerative Scoliosis Long

Fusions with Screws

Workers Compensation- most common spine surgeries

Workers Compensation- most common spine surgeries

• Herniated disc lam/disc or anterior cervical fusion or cervical ADR

• Annular tear lumbar disc replacement or interbody fusion or cell mediated therapy

• Degenerative disc with foraminal stenosis interbody fusion ± screws

• Spondylolisthesis laminectomy and fusion ± screws

Medicare not appropriate template for injured worker-

especially for spinal care

1. Whats valued in Medicare may not be valued for injured

worker2.Diseases/Medical conditions of

spine are different

Medicare not appropriate template for injured worker-

especially for spinal care

1. Whats valued in Medicare may not be valued for injured

worker2.Diseases/Medical conditions of

spine are different

Impact of New WC Fee Schedule on SSI

(8-10% of pts)

Impact of New WC Fee Schedule on SSI

(8-10% of pts)

• Office visits 12.9%

• EMG/Nerve 28.8%

• Injections 6.7%

• Spine Surgery decreased 10.0% !

Thoughts & ConsiderationsThoughts & Considerations

• Incentive to prolonged nonop care for injured spinal pts

• Disincentive for surgeons to see

• Time equals money in WC system

• May cause delays of definitive treatment and cost to entire system

• Issue of surgery for injury worker needs to be addressed by all parties in system

• Spine cases are the most common and expensive cases in WC