Cervical Arthroplasty

A prior study published, evaluated patients two years following spine surgery and their participation in the Bryan Cervical Disc Trial. In addition to this study, a more recent study I participated in evaluated Bryan Cervical Disc study patients five years following their spine surgery.

This study concluded that patients still continued to have excellent spine surgical outcomes five years postoperatively in both study groups – arthroplasty (artificial cervical disc) and ACDF (spinal fusion). Additionally, those patients that had arthroplasty and received the Bryan cervical disc show significant improvement and less neck pain than those in the control group (spinal fusion). In respect to complications and a second spine surgery – both groups had low adverse effects. 

To read the abstract of this cervical disc replacement study, visit this link.

I recently co-authored a chapter on instrumentation that was published in a book entitled Cervical Spine Trauma. This chapter was entitled Cervicothoracic Junction Instrumentation. 

Additionally, I recently wrote a chapter for a Brazilian spine society book. The chapter was on degenerative disc disease, and was included in “Conceitos Avancados em Doenca Degenerativa Discal Lombar”.

In addition to patient care and research, physicians with Indiana Spine Group lecture nationally and internationally as well as publish.  A few recent publications include the following:

• A book chapter co-authored by Kevin Macadaeg, MD, and Rick Sasso, MD, et.al. This chapter was on neck pain and was entitled, “Treatment of Axial Neck Pain”. This was published in Arthritis and Arthroplasty: The Spine, edited by Shen and Shaffrey.  To purchase this book, visit this link.  

• A chapter co-written by spine surgeons Rick Sasso, MD, and Paul Kraemer, MD, entitled “Rigid versus Dynamic Cervical Plates: Indications and Efficacy”. This chapter was published in a book entitled Controversies in Spine Surgery: Best Evidence Recommendations, edited by Vaccaro and Eck. This book is available online.

In mid-October, I was a faculty member at a continuing education meeting held at the Orthopaedic Learning Center outside of Chicago. This meeting was sponsored by The American Academy of Orthopaedic Surgeons and theLumbar Spine Research Society. The focus of this continuing medical education meeting was “Contemporary Techniques in Spinal Surgery”.  I was a lecturer and lab instructor at this spine surgery education meeting. 

One topic that I lectured on was related to the surgical technique for a spinal fusion (C1 lateral mass screw, C2 laminar screw technique for posterior C1-C2 spinal fusion). Additionally, I participated in a debate about cervical disc replacement (arthroplasty) versus fusion. In this debate, I was pro cervical disc replacement. A few of the continuing medical education spine surgery labs that I instructed included: anterior cervical discectomy, laminoplasty, high cervical and upper thoracic dissection and laminoplasty.

Congratulations to Rick Sasso, MD, a spine surgeon with Indiana Spine Group, who was recently published in a new book. Dr. Sasso co-authored a chapter in the new publication Cervical Spine Trauma (2010, Rothman Institute, Philadelphis, PA). This chapter is entitled Cervicothoracic Junction Instrumentation.

In a recent blog entry, I highlighted information from a study that I participated in and an article I co-authored, “Quality of Spinal Motion with Cervical Disc Arthroplasty.” This blog entry will define a few key terms used in that abstract/study.

Kinematic Study – This is the study of the motion of the body, not taking into consideration the effects of mass or force on the motion.

Cervical Arthroplasty – Refers to the spine surgery procedure where a damaged cervical disc is removed and replaced by an artificial cervical disc. 

Spinal Fusion – Often this procedure is referred to as ACDF, standing for anterior cervical discectomy and fusion. This is the spine surgical procedure where a damaged cervical disc is removed. To preserve the space within the vertebral bodies a bone graft is then placed where the damaged disc was removed. This bone graft is either from the patient’s hip bone (iliac crest) referred to as an autograft donation or from a bone bank (allograft). Then a spinal plate and screws are attached to the vertebral bodies immediately above and below the graft. 

An article that I co-authored, published in the Journal of Spinal Disorders & Techniques, summarized a study on cervical spinal motion at the adjacent discs (adjacent segment motion) following spinal arthroplasty with a Bryan Cervical Disc as compared to a spinal fusion.  Radiographic analysis was used to measure this motion prior to surgery, and at designated intervals post-surgery. 

For an abstract of this study, visit this link. 

I recently co-authored a book that is now available on Amazon or through the publisher.  The book, entitled Spinal Arthroplasty: The Preservation of Motion, provides detailed information about spinal arthroplasty.  This medical education book includes information about cervical artificial discs and lumbar artificial discs that are used in the spine surgical treatment of cervical and lumbar degenerative disc disease.

A few chapter titles include: 

• History of Spinal Fusion
• History of Motion-Sparing Surgery
• Spinal Anatomy
• Spinal Biomechanics
• The Effects of Fusion and Motion Sparing Procedures on the Biomechanics of the Spine
• Biomaterials in Spinal Arthroplasty
• Total Disc Arthroplasty: Clinical Indications and Surgical Approach
• Cervical Arthroplasty: Biomechanics, Design Considerations, Clinical Outcome
  

Congratulations to Rick Sasso, MD, who recently co-authored a book
on spinal arthroplasty! This book entitled, Spinal Arthroplasty: The Preservation of Motion, is an ideal medical education resource for orthopaedic surgeons, spine surgeons, residents/fellows and health science libraries.

The book provides state-of-the-art information on everything related to spinal arthroplasty; including relevant spinal surgical anatomy, biomechanics, clinical indications, spinal imaging, and a complete overview of artificial disc implants - both cervical and lumbar. The publisher describes this book as “Lavishly illustrated with high-quality surgical and anatomical art and images, this landmark text brings this exciting and innovative technology to the forefront of spinal surgery with authority and style!"
 
This book is now available on Amazon and from the publisher. Also, the publisher link provides a complete Table of Contents. 

In a prior blog entry, I highlighted a few of the talks I participated in at the annual Scoliosis Research Society meeting. The acronym for this annual continuing medical education meeting is IMAST, and stands for International Meeting on Advanced Spine Techniques.

This international meeting brings experts on spine surgery from all over the world to discuss the latest surgical techniques, devices as well as it provides a forum to provide the latest on research in progress.

The overall educational objectives of this meeting are listed below.

At the completion of this program, participants should be able to:

1. Assess the most recent advances in surgical techniques for the treatment of spinal disorders and when to use them, in the interest of providing optimal patient care.

2. Analyze the indications and potential complications for various spine fixation systems including spinal arthroplasty.

3. Recognize emerging technology that has the potential to improve patient outcomes for specific indications and populations.

4. Understand when it may be appropriate to use biologic options to enhance spinal fusion.

At a recent annual continuing medical education meeting sponsored by The Scoliosis Research Society, I was an invited instructor. This conference was the 17^th International Meeting on Advanced Spine Techniques and was held in Toronto. This educational meeting is considered one of the premier international spine meetings held annually for spine surgeons, and it is an honor to be asked to be one of the limited faculty members.

At this meeting, I presented the results of a spine research study for an investigational device that I am participating in. This study is related to the cervical spine and deals with cervical motion technology. A few other continuing medical education activities that I participated in included:

·         Gave a presentation on occipitocervical fixation and biomechanics.

·         Moderated a round table discussion on cervical reconstruction.

·         Participated in a fundamentals session on the cervical spine and discussed posterior cervical decompression and fusion.

Congratulations to Rick Sasso, MD, a spine surgeon with Indiana Spine Group, who was just awarded his eighth patent!  This is patent number 7,727,266 for a method and apparatus for retaining screws in a plate.  
 

This patent is for an anterior cervical plate, now called Venture.  This plate is used in spine surgery for patients suffering from a herniated disc or stenosis (disc degeneration), or after trauma, tumors or other conditions causing neck instability.  The plate is used to stabilize the cervical spine after removing the disc. 

Below is an abstract of this patent:

A retention system for maintaining a screw to a vertebral plate. One or more screws extend through apertures within the vertebral plate. A cavity is positioned adjacent to and overlaps into the aperture. A ring is positioned within the cavity and held in position by a cap. The cap attaches to the plate to prevent removal of the ring. The ring is deflectable between a first shape to allow the screw to be inserted and removed from the aperture, and a second shape to prevent screw back-out from the aperture. A method of using the system is also included and comprises positioning the ring within a cavity in the plate, maintaining the position of the ring to the plate by attaching a cap, inserting a screw through the aperture and attaching the plate to a vertebral member, and positioning the ring over the screw head and preventing the screw from backing-out.

One spine surgery research study that I participated in - compared the post-operative results of cervical arthroplasty and arthrodesis on approximately 500 patients. The objective of this study was to compare any side effects of patients undergoing a cervical arthroplasty with the implantation of a Bryan Cervical Artificial Disc to those patients that underwent a spinal fusion.

In this study, of which there were 31 institutions where patients underwent spine surgery, there were 242 patients who received the Bryan Cervical Artificial Disc and 221 patients that underwent cervical discectomy and spinal fusion. Patients that participated in this study were over 21 years of age, had single level cervical degenerative disc disease causing radiculopathy or myelopathy as well as a few other clinical indicators. Once identified, these patients were evaluated before spine surgery and post-operatively at regular intervals beginning one and one half months following spine surgery up to 2 years. 

This study concluded that both procedures are safe, and that there is not a significant difference in adverse effects with the newer arthroplasty procedure utilizing the Bryan Cervical Artificial Disc when compared to the traditional surgical option of spinal fusion.

 To read the complete study,link here.

At Indiana Spine Group’s Back Talk continuing medical education symposium, as highlighted in a previous blog entry , there are two educational tracks that will be available for conference attendees on day one.  In addition to the general track discussed in the prior blog, there is a more in-depth track entitled, More Specifics | Spinal Diagnostics and Treatment. 

In this education track there will be a few sessions focusing on the diagnosis of spinal disorders and abnormalities.  One session titled Spinal Imaging | Technology and Diagnosis, will be presented by Stephen Pomeranz, MD. Dr. Pomerance is a radiologist. In this session, Dr. Pomeranz will provide an in-depth look at spinal imaging technologies and highlight the latest developments in spinal imaging technology and their applications in spinal diagnostics.  Additionally, using case studies, he will review radiological finds and diagnostic indicators. 

The second session of this educational track will focus on The Electrodiagnostic Evaluation, and will be presented by physical medicine and rehabilitation specialist Dr. Shashank Dave.  During his presentation, Dr.Dave will discuss the role and application of electromyography in the diagnosis of spinal disorders and diseases.  Additionally, he will review case studies which utilize electromyography and identify specific diagnoses. 

Another session presented for the in-depth track will focus on Diagnostic and Therapeutic Injections of the Spine.  This will be presented by minimally invasive spine specialist John Arbuckle, MD.  During this session Dr. Arbuckle will review and differentiate between the different type of therapeutic injections and will review the treatment efficacy of injections, the clinical protocols, indications and expected outcomes. 

The last session of this continuing education track will highlight spine surgery, and is entitled Surgical Perspectives | Fusion vs Arthroplasty, presented by spine surgeon Rick Sasso, MD.  During this session, Dr. Sasso will provide a detailed analysis of spinal fusion and arthroplasty and he will discuss motion preservation modalities for the treatment of generative disc disease.  He will highlight lumbar and cervical artificial discs as well as review research studies and discuss patient selection, indications and expected outcomes. 

While at the American Academy of Orthopaedic Surgeon’s annual continuing medical education meeting, I also gave a few other talks/podium presentations.  These presentations were:

"Does smoking have an impact on fusion rate in single level ACDF with allograft and plate fixation?"

“Does early return to work following arthroplasty and ACDF

result in adverse outcomes?"

While at the annual meeting of the American Academy of Orthopaedic Surgeons (AAOS) in New Orleans, in addition to presiding as President of the Federation of Spine Societies spine specialty day, I also gave a few talks on cervical radiculopathy.

The first session that I moderated was on the current concepts in cervical radiculopathy.  The objective of this continuing medical education session was to provide the most up-to-date information on the pathophysiology, diagnosis and treatment of cervical disc disorders, including the role of selective nerve root sleeve injections and artificial disc replacement.

Another session that I served as a faculty member for was the spine instructional course lecture entitled, “The Degenerative Cervical Spine: What You Need to Know.”  This presentation provided an overview of cervical degenerative diseases and addressed the patient evaluation and treatment options, including anterior, posterior and non-operative options.

The American Academy of Orthopaedic Surgeons (AAOS) held their annual continuing medical education meeting in New Orleans, in early March.  In addition to attending the annual continuing medical education meeting, I also had the honor of coordinating and hosting the spine specialty day. The spine specialty day presented a common forum by the Federation Societies, of which I am the president.  The Federation Societies is comprised of four spine-focused organizations, and includes the Cervical Spine Research Society, North American Spine Society, Scoliosis Research Society and the American Spinal Injury Association.  

A few of the educational objectives for the day included discussing the current concepts in the diagnosis and management of spinal disorders, and to review and update the clinical results and complications of the new technologies and concepts.  The information was presented in the form of instructional presentations, discussions, papers and debates. 

Highlighted topics were presented by each society within the Federation.  During the day in the North American Spine Societies section, I presented a talk on cervical disc replacement, and for the American Spinal Injury Association I discussed spinal cord injury and the appropriate time for decompression. 

In May 2009, the Bryan Cervical Artificial Disc received FDA approval.  This approval was previously written about in Dr. Sasso’s blog.  The cervical artificial disc provides an alternative spine surgical treatment for cervical degenerative disc disease.

Dr. Rick Sasso, a spine surgeon with Indiana Spine Group, has been a principal investigator in the studies with this spine surgical device – the Bryan Cervical Disc.  A few of abstracts of his published research studies regarding the cervical disc are available on the U.S. National Library of Medicine / National Institutes of Health web site. 

These include:

• Cervical kinematics after spinal fusion and bryan disc arthroplasty 
  
• Motion analysis of bryan cervical disc arthroplasty versus anterior discectomy and spinal fusion: results from a prospective, randomized, multicenter, clinical trial 
  

Earlier this year, Dr. Rick Sasso and I were asked to write a spine continuing education chapter on “Controversies in Cervical Spine Surgery”, specifically about a newer spine surgical technology known as dynamic plating for cervical fusions.  Traditional plates, known as static plates, have a high success rate, but in reviewing the published reports of direct comparisons between the two plates, the dynamic plates have a slightly higher percentage which fuse.  It may be even more beneficial in longer fusions.

I have switched my practice to essentially using only the dynamic plates for cervical spinal fusions.  I have been very happy with the  results.  As with all new technology, it is important to carefully monitor results and compare them against established techniques.  I'm keeping an eye on continuing trials even as I incorporate this technology into my own practice.

(This blog entry was written by Paul Kraemer, MD; a spine surgeon with Indiana Spine Group). 
 

In October, I was a faculty member at the 8^th Annual Symposium on “Innovative Techniques in Spine Surgery.” This continuing education meeting, hosted in Phoenix, addressed the innovative and emerging technologies of spinal surgery including; arthroplasty, minimally invasive procedures, motion sparring technologies and biologics.  At this meeting I gave a talk on Lumbar Artificial Disc Replacement, and presented the results of the FDA studies for the Cervical Artificial Disc.

This education program was sponsored by the Organization of Spinal Teaching and Research.  The purpose of this group is to facilitate education and discussion among spine care providers and industry and this organization includes leaders in the field of spine surgery and technology that utilize the most advanced and effective technology available for the treatment of spinal disorders.