Donald R. Johnson, II, MD Medical Director Southeastern Spine Institute MUSC Board of Trustees Past...
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Transcript of Donald R. Johnson, II, MD Medical Director Southeastern Spine Institute MUSC Board of Trustees Past...
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 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
Competitive ProductsCompetitive Products
Medtronic
X-STOP
Paradigm Spine
Coflex
Abbott Spine
Wallis
Medtronic
DIAM
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
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.
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
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
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
Percutaneous (thru the skin) Pedicle
Screw Fixation
Percutaneous (thru the skin) Pedicle
Screw Fixation
Patient Ms. C. G.Patient Ms. C. G.
Dx: Adult Degenerative Scoliosis
1. Xlif at multiple levels
2. Percutaneous screws and rods
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
FDA StudyFDA Study
• Starting March 1st- first FDA approved study of injection of cells to regrow and heal an injured disc
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