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"One of the great things about living in America and the new technologies is we've been able to take the same conditions with the same indications for surgeries and make them safer and better," said Dr. Robert Watkins, orthopedic spine surgeon and codirector of the Marina Spine Center in California. "In the last five to 10 years technology has improved so much we can safely perform the surgery and have a higher chance of helping people with their pain."

The number of actual procedures, though, is fairly limited. "The available options have not changed," said Dr. Marjorie Eskay-Auerbach, president of Spine Care and Forensic Medicine in Tucson, Ariz. "With the exception of disk replacement, the options are the same but the approaches can be different."

Lateral interbody spine surgery. This technique allows surgeons to do a spinal fusion by going through the patient's side. Fusions are most effective if the disk is removed and replaced with bone material, allowing the bone to grow across the disk space.

"We can do that from the front, side, or the back," Watkins said. "Twenty years ago, it was all done from the back, but it's harder to get to the disk from the back. The nerves are in the way, and it's more dangerous."

Through the front works well for some patients. "But you have major blood vessels that have to be moved," Watkins said. "For certain conditions, it can be difficult."

For the last several years, the lateral position has become popular. "We don't have to move major vessels and if the patient is overweight, it's not an issue," Watkins said. "We still get great access to the disks. We can clean it out and get pieces of bone in there."

While not appropriate for all spinal fusions, the lateral approach works well for many patients, Watkins said.

Motion preservation spine surgery, or artificial disk replacements. The benefit to these is that unlike fusions, they allow for motion to occur at the disk space, Watkins explained. The downside is that it is unclear how much stability versus motion is optimal at each spinal level, meaning patients may still experience pain following this procedure.

"It remains controversial," Eskay-Auerbach said. "Artificial disk results have been pretty good in cervical, but in lumbar are very iffy, so it hasn't been received as well."

However, the procedure could eventually be advanced with so-called smart technology. "That refers to microchips in the device that can transmit information like pressure, weight bearing motion -- so there's a small sensor in the device that can tell the doctor what forces are going on in the prostheses inside the patient," Watkins said. "It's not used at all right now but may be in the future."

Image-guided spine surgery gives the physician "a three-dimensional picture of the patient's spine in the operating room," Watkins explained. Spinal surgeries have been enhanced by the use of pedicle screws for decades because they provide the stability a surgeon needs to correct a problem.

"The downside is, if you miss the bone and hit the nerve, people get nerve damage, which causes pain and weakness," Watkins said. "We use a computerized system to do it safer."

Robotic spine surgery. Using robotics can result in precise movements and accuracy. However, there is no practical application for it in spinal surgery.

"Robotics is really going to rely on intraoperative imaging, whether it be X-rays, CT scans or MRIs. So you're going to need some type of image to guide the robot," Watkins said. "Right now there is no intraoperative MR imaging. Plain X-rays don't show nerves, just bones."

Watkins says it will likely be 10 to 20 years before the technology is available and affordable to make robotics practical for spine surgeries.

Biologics. Biologic substitutes for spinal fusion have been shown to be very effective, Watkins said. "One of the biggest most effective biologics products is bone graft substitutes," he said. "Instead of having to take a patient's own bone from his pelvis, which often hurts, we're able to use biologics and bone graft substitutes that are synthetically made."

The downside is the expense. "Reimbursement to hospitals for Medicare patients is so low that if the hospital allows their surgeon to use biologics for fusion, the hospital usually loses money on that surgery," Watkins said.

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February 17, 2011

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