There is an array of spine technologies and surgical techniques that have evolved over the years. But spine surgeons say there are some that remain underrated.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.
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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CST Wednesday, March 27.
Editor's note: Responses were lightly edited for clarity and length.
Question: What is the most underrated technology or technique in spine?
Hansen Bow, MD, PhD. UCI Health (South Orange, Calif.): I believe the most underrated technology or technique in spine surgery is use of the interoperative ultrasound. The intraoperative ultrasound is frequently used in brain surgery to locate brain tumors, evaluate the extent of tumor resection and find trajectories for placement of intraventricular drains. In conversations with my spine surgery colleagues, use of the intraoperative ultrasound is less well known. In my practice, I frequently use it to make sure my laminectomy is sufficient in preparation for accessing intradural pathology. I also use it in the context of trauma to determine whether a patient needs a trans-pedicular decompression for a burst fracture. For spinal oncology, I use the ultrasound to verify that a separation surgery has created enough space between the spinal cord and the tumor. Another use that I found helpful is when I need to debulk an extradural cervical tumor using a posterior approach. I use both the ultrasound and navigation to identify the location of the vertebral artery, enhancing the safety of the operation.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The most underrated technique in spine is being able to put pedicle screws in without navigation, using fluoroscopy only. I am afraid with the democratization of spine and the advent of robots will unfortunately result in residents and surgeons not knowing what to do when the robot flames out. I encourage anyone training to learn how to place pedicle screws with the navigation program in their brain, as well as in the computer.
Osama Kashlan, MD. Weill Cornell Medicine (New York City): The most underrated technology in spine is a tie between Bendini from NuVasive and Corus/Cavux from Providence Medical Technologies. The reason they are underrated is that I do not believe their adoption reflects how useful those technologies are for our patients. As per NuVasive’s website, the Bendini is a spinal rod bending system that expedites manual rod manipulation via computer-assisted bend instructions. Historically, rod bending took a substantial portion of operative time in my hands. Moreover, many times the manually bent or prebent rods fit well in some parts of the construct but not others. In those instances, a substantial amount of force was needed to get a rod into a specific tulip head. This was especially true in long segment minimally-invasive cases. Finally, in the past it was very important for a surgeon to have all tulip heads line up to make the rod bending easier. After I switched to using the Bendini, these problems have become non-issues. Rod bending is straightforward and smooth. Equal force is placed over all tulip heads almost every time. I place screws wherever I feel purchase is best without thinking about how the screw heads will line up in the final construct because the Bendini will do all the work! With regards to Corus/Cavux, this technology is like no other technology on the market for achieving a posterior cervical fusion in a minimally-invasive manner. In that way, the facet cages can be placed to treat non-union after anterior cervical fusions. They can also be used to back up multilevel anterior cervical fusions without having to do an open posterior procedure. I have also used these facet cages in open approaches in three ways. First, they can be used to augment facet arthrodesis at C1-2 when performing a C1-2 fusion. Second, they can be used in situations when there is intraoperative concern regarding the strength of traditional posterior fixation as added support to the construct. Lastly, they can be used in any posterior instrumented procedure as a method to achieve indirect foraminal decompression of any symptomatic level.
Jason Liauw, MD. Hoag Orthopedic Institute (Laguna Hills, Calif.): While there has been much well-deserved fanfare on enabling technologies in spine, I think one of the more underrated technologies/techniques in spine is endoscopic approaches to spine surgery. From the courses I have seen, endoscopic spine surgery is the pinnacle of extreme minimally invasive spine surgery. However, procedurally it takes a significant amount of training and expertise which is probably why it hasn't been adopted in every practice. I think that as the technology improves, endoscopic spine surgery including endoscopic spine fusion can really impact the future of spine surgery.
Yoav Ritter, DO. HCA Florida University Hospital (Davie, Fla.): Minimally invasive lumbar decompression (MILD) would have to be one of the most underrated procedures. This procedure uses small incisions compared to traditional spine surgery. This procedure is not expensive and the recovery time is less.
Steven Vanni, DO. HCA Florida University Hospital: Use of motion-sparing devices associated with lumbar laminectomies such as Coflex procedures is very underrated.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): To the chagrin of this practitioner, there are two underrated and underused technologies used in current neurosurgical practice: both generational, possibly linked to training biases and both complementary tools shown time and time again, to be fortuitous in a number of legal decisions.
Surprisingly, there are those who choose not to use the intraoperative microscope and likewise, choose not to perform intra-operational neurological monitoring. Case dependent of course, the more complex surgical situation will welcome the safest and most efficacious methods of task completion. Job one for all readers is puissant assurances and effectual recourse as they apply to all patient outcomes.