Kris Radcliff, MD, is a fellowship-trained spine surgeon with Philadelphia-based Rothman Institute, focusing on minimally invasive spine surgery and artificial disc replacement.
He was recognized as one of SpineLine's '20 Under 40' spine surgeons at the North American Spine Society Annual Meeting last year.
Here, Dr. Radcliff discusses pressing issues in spine, robotics and key considerations when becoming an early adapter of a device or implant.
Question: What area of spine do you find most pressing in 2019?
Dr. Kris Radcliff: It's really important that we do robust clinical outcomes research to demonstrate the value of spine surgery to our colleagues, payers and our patients. There is a misconception among many payers, medical providers and patients that "spine surgery doesn't work and that you should never have spine surgery." It's important that we get the message out there that, for properly selected patients, spine surgery is an excellent option and associated with improved quality of life even compared to nonsurgical treatment.
Part of the misconception lies in misunderstanding the goals of spine surgery. Ten or 15 years ago, the joint replacement surgeons had a similar awakening with some questions about the outcomes of knee replacement surgery. For example, can patients resume deep knee flexion following knee replacement? With transparency and education, surgeons were better able to understand the patient's goals and to ensure that patient goals aligned with surgical goals.
There is significant public ambiguity about the goals of spine surgery. How well does spine surgery work for axial pain? Should a secondary surgery be viewed as a progression of the disease process or a failure of the first intervention? Is it better to have a more intense initial surgery if that can prevent further problems in the future?
We need to do a better job of clarifying patient goals and provider goals after spine surgery. When all parties are on the same page about goals and outcomes, it is more likely that patients will be satisfied with the outcome of treatment.
Q: Is there any spine device you see as becoming particularly innovative in the near future?
KR: I think that robotics is very exciting as there is the potential to reduce the invasiveness of some spine procedures. With robotics and navigation, the surgeon does not have to create as wide of an exposure to identify landmarks to place screws and anchors. To my knowledge, robotics is only available to accompany spinal fusions. We don't have an elegant robotic tool to do a better microdiscectomy or laminectomy. The critical part of the outcome of most spine surgeries is doing a good decompression and taking the pressure off the nerves. In most degenerative cases, the instrumentation is really just the insurance to prevent future problems. In the future, hopefully, robotics will have a role in all of the different aspects of spine surgery but right now it's really only focused on instrumentation.
Artificial disc replacement also continues to evolve and become more sophisticated. As a spine community, we have increasing understanding of the relationship between segmental motion and outcome. Specifically, disc replacements that are oversized do not move as well. As a result, oversized disc replacements tend to develop more heterotopic ossification and have an increased risk of adjacent segment degeneration. This is particularly an issue in women who have on average smaller stature and therefore smaller discs than men. The early disc replacements had limited sizing options because of the material limitations. This was also an issue that our colleagues who do knee replacement encountered over a decade ago.
New disc replacements are emerging with novel shapes and materials that enable a larger range of sizes to accommodate patient anatomy. The current and next generation of artificial disc replacements have robust clinical outcome literature that demonstrates that properly selected patients who receive disc replacements have excellent outcomes and low rates of adjacent segment disease.
Finally, there is increasing attention on the mechanobiology of spine implants. Spine cages are not only expected to function as static spacers, but also to have a biological effect and actively contribute to the fusion process. New spine implants have sophisticated, carefully engineered structural properties that modulate cell biology with controlled mechanical deformation and surface features.
Q: Robotics in spine is playing catch up to other areas of healthcare. How far do you see robotics developing in spine? Is there an apprehension among some physicians to adapt robotics in the field?
KR: I see the goal of robotics as narrowing the bell curve of our performance. They've done a lot of studies on this in joint replacement. So, there's a certain amount of variability in the alignment of a hip or knee after a joint replacement relative to ideal alignment. If you look at someone in the first year of their practice, the range of alignment relative to ideal is pretty wide. Occasionally you get the joints perfectly aligned and occasionally the alignment is really suboptimal, which is either varus or valgus. In joint replacement, robotics has been able to narrow the bell curve of alignment which means that there is increased precision and reproducibility.
I think that some of the apprehension occurs among surgeons who are already technically proficient. I think that a similar thing happens in spine surgery when you start off in your first couple of years of practice — there's some variability in your accuracy of screw placement and how well you perform a decompression and so forth. At some point, you get past the steep part of the learning curve and thus you already have a pretty well defined, reproducible product. There is an article along these lines in the Journal of Bone and Joint Surgery this month that robotics does not offer as much advantage to surgeons who are already proficient in unicompartmental arthroplasty.
Q: As a spine surgeon in private practice, what do you consider when becoming an early adapter of a new implant or device?
KR: I look a lot at the research. For implants and biologics, I want to see some favorable publication history before I'm willing to put it in my patients. At the very least I'd like to see in vitro studies and in vivo studies. In terms of instruments and navigation, I think that's much more of a trial and test drive process, so that's where I'd like to try something out at a meeting or a conference or lab. Society for Minimally Invasive Spinal Surgery and the International Society for the Advancement of Spine Surgery both have very good cadaver labs that accompany the meetings and thus you can get a feel for a lot of new devices.
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