Brian, R. Gantwerker, MD, is a board-certified neurosurgeon, specializes in the treatment of brain tumors, as well as degenerative diseases and injuries of the spinal cord.
A Chicago native, Dr. Gantwerker earned his medical degree from Rush Medical College in Chicago. He has been in private practice for over nine years at The Craniospinal Center of Los Angeles, in Santa Monica and Encino, Calif.
Dr. Gantwerker provides his insight into the evolution of spinal fusions, implant surface technology and the future of 3D printing in spine.
Question: How do you see spinal fusions evolving in the future?
Dr. Brian Gantwerker: I think spinal fusions will continue to miniaturize and be done more in the outpatient setting. Cost pressures will drive these cases more to efficient hospitals and outpatient surgery centers. The increased burden however, of prior authorization (PA) will reduce the number of fusions done in the private sector.
I think fusion numbers will go up in the academic setting and higher risk cases will not be taken on by private practice doctors who are fatigued from getting on the phone for 45 minutes to wait to do a peer-to-peer for a PA. This will lead to a further increase in the cost of fusions. The academic centers will (and rightfully so) demand higher reimbursement and get it. Insurers will balk more and more and create increasingly stringent guidelines — which may or may not be grounded in peer-reviewed science. Ultimately, we will see a turn away from the chants of “T10 to Pelvis” and “titanium deficiencies” as insurers will pay less and less often for them, regardless of demonstrable patient need.
The future in instrumented spine surgery will rely more and more on arthroplasty and decompressive procedures. There are trends towards less future operations and better outcomes. The hard part will be being able to discern studies sheltered from the sway of the industry. In my experience, trending away from fusions and favoring arthroplasty, hybrid constructs, and decompressions has been worse for my bottom line, but make for happier patients with better quality of life.
Q: Where do you see the biggest opportunities for implant technology to make a difference in procedure outcomes?
BG: The advantage of hybridized implants with titanium impregnated surfaces and PEEK cores or porous metal surfaces in my mind have yet to prove superior to PEEK. In the cervical spine, there has been at least one study I have seen that has shown inferiority of PEEK. I have seen some PEEK failures in the cervical spine, but it was hard to tease out whether it was kind of allograft or the implant itself. If there can be a side-by-side independent study with similar endpoints including radiographic fusion as well as VAS and SF-36 outcomes tracking, one could be convinced in either direction.
From an engineering standpoint, it makes sense to have a crenelated surface that will interdigitate with the bone; it takes more than some pretty color microscope pictures showing bone “growing” into the titanium to convince me of their efficacy. At the end of the day, there are business and advertising opportunities for the industry, but making a difference in clinical outcomes remains divorced from surface technology claims.
Q: How do you think 3D printing will fit in spine moving forward?
The initial promise of custom-printed individual patient implants has fallen down the black hole of cost. What is happening now is there are 3D printed cages that offer a porous metallic environment that promises higher rates of fusion. Clinical studies have yet to bear out their superiority. In cranial surgery, we have been using custom implants for reconstructions for almost 20 years. It works great, looks good, and most of the time, it fits. In spine it is nearly impossible to custom-print an implant due to unanticipated factors in surgery — such as bone quality, having to take more or less bone off than anticipated and surgical tech issues intraoperative — that it's been slower to catch on.
Where it can and should shine is potentially having a 3D printer intraop that can construct a custom cage based on intraop CT scans or imaging. Whether we will get there anytime soon, and if we can get paid or the hospital get paid to do it, remains to be seen. I do hope it finds its niche in helping us do our actual jobs, rather than being ballyhooed as the latest and greatest.
Learn more about key trends in spine surgery at the Becker's 17th Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference, June 13-15 in Chicago. Click here to learn more and register. For more information about exhibitor and sponsor opportunities, contact Maura Jodoin at mjodoin@beckershealthcare.com.
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