Current Spine Procedures

Transcription

1 SPINE BOOT CAMP: WHAT YOU DON T KNOW MAY COST YOU! David Abraham, M.D. The Reading Neck and Spine Center Reading, PA Current Spine Procedures Epidural/Transforaminal Injections Lumbar Procedures Laminectomy Discectomy?Fusions Current Spine Procedures Cervical Procedures Cervical Laminectomy Cervical Discectomy and Fusion Spine Fractures Kyphoplasty vs Vertebroplasty 1

2 Current Spine Procedures Cervical Arthroplasty X-Stop Decompression of the Lumbar Spine Current Techniques: Steroid Injections Cervical Facet Injections Epidural Injections Transforaminal---?Safety Pros: Fast, Effective, Profitable ($900 - $1200) Cons: Safety Current Techniques Steroid Injections Lumbar Midline Epidural Injections Transforaminal Injections Facet Injections Pros: Fast, Effective, Profitable, Safe Cons:?Proof 2

3 Lumbar Procedures Lumbar Laminectomy Removal of bone and soft tissue to relieve pressure on a spinal nerve, unilateral or bilateral With or without discectomy minutes, 1 inch incision, minimal blood loss, minimal equipment, profitable Medicare Expect $4-8K/case (code for spinal stenosis) Lumbar Procedures Lumbar Fusions Limited role in ASC 23 hour stay Expect $10-20K Small volume, increased risk Watch implant costs! Cervical Procedures Cervical Laminectomy Posterior exposure, older approach, limited volume Anterior Cervical Discectomy and Fusion Removal of Disc, allograft, plate Common,1-2 hours, 1-2 levels, safe Expect $8-14K, watch implant costs! 3

4 Spine Fractures Kyphoplasty vs Vertebroplasty Injection of PMMA (cement) into a fractured vertebral body +/- Balloon Common, Effective (>90%), fast Balloon cost = $3500, Reim = $3750? 2 C-arms Frail Patients Spine in the Future Cervical Arthroplasty FDA approved, 1 hour, safe Problems Insurance, Medicare, Private Coding, not a fusion Physician reimbursement Costs of implants X-STOP Interspinous Process Decompression System Rev 1 4

5 CLINICAL PRESENTATION OF LSS Extension provokes symptoms Pain/weakness in the legs Patients lean forward while walking to ambulate more comfortably Sitting relieves symptoms EPIDEMIOLOGY OF LSS LSS is the most common reason for spine surgery in older people 2 More than 125,000 laminectomy procedures were performed for LSS in The financial impact and lost work hours reaches billions of dollars each year in this country 4 1. Murphy et al, BMC musculoskeletal Disorders, 2006, Jennis et al, Spine Murphy et al, BMC musculoskeletal Disorders, Szpalski, European Spine Journal, The Ortho FactBook ; U.S. 5th Edition; Solucient, LLC and Verispan, LLC 4. Knowledge Enterprises, Inc. PATHOANATOMY LSS Disease Characteristics Disc Bulge/Herniation Hypertrophied Ligamentum flavum Narrowed Spinal Canal Narrowed Lateral Recesses Hypertrophied Facets Stenotic Normal Neural Compression 5

6 PATHOANATOMY Neurogenic Intermittent Claudication Decrease in Extension Increase in Flexion NATURAL HISTORY OF LSS The degenerative process is very slow Symptoms may remain unchanged or even improve in majority of patients However, patients with severe symptoms may deteriorate OTHER TREATMENT ALTERNATIVES Non-Operative Care Epidural injections Physical therapy NSAIDs other drugs Lifestyle modification Surgical Decompression Laminectomy Laminectomy with fusion Laminotomy/facetectomy - Minimally Invasive Techniques X- STOP IPD 6

7 X-STOP IMPLANT DESIGN Adjustable Wing Implant limits extension at treated segment Tissue Expander Oval Spacer Fixed Wing Inserted laterally Oval Spacer Wings prevent lateral and anterior migration Tissue Expander CANAL DIMENSIONS Axial MRI slices of extended cadaver specimens showed Canal area: 18% Canal diameter: 10% Subarticular diameter: 50% Pre-Implant Post-Implant Richards Spine 2005 INSERT DILATOR THROUGH INTERSPINOUS LIGAMENT 7

8 POSITION IMPLANT Align the spacer assembly instrument handle with the interspinous space (extend the incision caudal if necessary) Orient the tissue expander at 45 o to the interspinous space to make insertion easier Use your left index finger to guide the implant through the pilot hole Leave the insertion instrument attached during fluoroscopy CONFIRM ANTERIOR POSITION w/ Intra-Op Fluoro REVIEW THE OUTCOME Pre-Op Post-Op Tight Foramen Collapsed Increased Foramina Height 8

9 SUMMARY Minimally invasive Outpatient surgical setting minutes skin-to-skin Short learning curve Minimal morbidity General anesthesia Little or no resection of bone or soft tissue Use does not preclude other treatment options May avoid the need for fusion Summary Novel approach to old problem Not approved for use in ASC by Medicare Blues approval under radar Future potential is huge! The Future of Spine Care in the ASC is Bright! 9