Spinal Fusion Surgery

This spine wellness blog entry will address more about the effects of smoking and your spine’s health.  In this Spine Universe article, it summarizes the negative effects of smoking and its impact on the spine surgery procedure of spinal fusions. 

A general definition of a spinal fusion is that it is a spine surgical procedure that joins bony segments of the spine (vertebrae) – this spine surgery can be performed at the lumbar, thoracic or cervical areas of the spine.  As a part of the healing / fusion process of this spine ssurgery there needs to be new bone growth.  Many factors can affect the success of a spinal fusion and can include the patient’s overall health, other medical conditions and smoking. Research has shown that habitual cigarette smoking results in less successful spinal fusions when compared to similar spine surgical procedures performed on nonsmokers.  Additionally, another study indicated that individuals that smoked had a higher post-operative infection rate than nonsmokers. 

Many times with scoliosis - no treatment is needed.  Once a patient is diagnosed with scoliosis it is important to observe and monitor the curve during the patient’s growing years.  Factors that affect what type of treatment is recommended include the age of the patient and how much growth they have left, the degree and pattern of the curve, and the type of scoliosis. 

Treatment options may range from observation to surgery.  If it is decided that the patient will be observed; they will be evaluated approximately every six months while the patient is still growing.  At this time, the degree of the curve will be assessed.

Bracing is a treatment option to prevent the curve from progressing.  This is recommended if the patient has an idiopathic curve, is still growing and:

• Has a curve greater than 25 degrees,
• Has two more years of potential growth remaining and the curve is between 20 and 29 degrees, (and if female has not had her first menstrual period) or
• Has a curve that is between 20 and 29 degrees and is progressing.   

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). 
 

A lot of patients ask me about the differences with arthroplasty (cervical artificial disc) and spinal fusion; as well as how does the cervical artificial disc work. A few years ago, I was interviewed by Barbara Lewis on Sound Medicine. This segment titled, “New Artificial Cervical Discs”, can be heard by visiting this link. 

A few topics discussed during this interview included:

• Comparison of a spinal fusion to cervical artificial disc,
• More detailed information about the cervical artificial disc,
• Comparison of cervical artificial disc to artificial hip and knee,
•  The future of cervical artificial disc.

Previously, I blogged about the research results of a spine patient study – which evaluated the clinical outcomes of patients who received a Bryan Cervical Disc compared to those that had a standard spinal fusion at 24-months post-operatively. I recently completed a new study, which evaluated these patients 48-months post-operatively. This study will soon be published.

In this study – the functional outcomes of patients at 48-months (4 years) following their spine surgery was evaluated. This study had two groups of patients – one group received a spinal fusion (Anterior Cervical Discectomy and Fusion - ACDF) and the other group received the Bryan cervical artificial disc prosthesis. This spine surgery was for the treatment of radiculopathy and myelopathy, after minimally invasive spine procedures were determined ineffective.

There were 47 patients enrolled in this spine study. Of this group, 21 were enrolled in the Bryan cervical disc arm of the study and their mean age was 40.  In the group that received a spinal fusion (control group), there were 26 participants and their mean age was 43.

This study concluded that patients that received the Bryan Artificial Cervical Disc at 48-months, when compared to the control group:

•     Had less neck and arm pain,
•     Greater mobility,
•     Less adjacent segment degeneration, and
•     Lower secondary operation rate.

An article in Science Daily entitled “Artificial Disc Replacement As Good or Better Than Spinal Fusion, Study Suggests”, highlights a published study that I co-wrote. 
 

In this article in Science Daily, co-author K. Daniel Riew, MD – a cervical spine surgeon at Washington University Orthopaedics and Barnes-Jewish Hospital, stated that one of the most important findings of the study was that people who received the Bryan Cervical Disc were able to preserve all of their motion.

 

I was recently interviewed for a news story that announced the FDA approval of the Bryan™ Cervical Disc. The Bryan Cervical Disc is an artificial disc used in cervical arthroplasty. 

This story also appeared on their web site which generated a few reader’s comments/questions. This blog entry – will address some of those questions. 

Blogger question: Can it be used in the lower back?

The Bryan Cervical Disc can only be used in the cervical (neck area) spine. There are two FDA approved artificial discs for the lower back (lumbar spine). They are: CHARITE Artificial Disc, approved by the FDA in 2004 and the ProDisc. Artificial lumbar discs are a surgical option for some patients who are being treated for degenerative disc disease or other related spinal conditions. These links provides more information about the artificial lumbar disc - (article one and article two).

Blogger question: Does this work for someone who has had a fusion done 10 years ago?

The answer to this is no. When a spinal fusion is performed, two bones are “fused” together; meaning that they are attached. In that this procedure is done with the goal of a permanency – it can not really be undone to have cervical arthroplasty performed. 

In blog discussions about the cervical artificial disc, specifically the Bryan Cervical Disc, it was announced that this disc has now received FDA-approval.  One key advantage of cervical arthroplasty and the Bryan Cervical Disc is that patients maintain their natural neck motion as compared to a spinal fusion. (Spinal fusion is the current standard spine surgical treatment for degenerative disc disease.)  

A study that I participated in and co-authored, specifically evaluated the patient’s motion – comparing post-operative neck motion. Patients who received the Bryan Cervical Disc in cervical arthroplasty were compared to those that underwent a spinal fusion and anterior discectomy. 

In a prior blog, the recent FDA-approval of the Bryan Cervical Disc ™ was announced. One of the advantages of this device and cervical arthroplasty, as a spine surgical treatment for degenerative disc disease, is that patients can return to work and their normal activities in a relatively short period of time. Generally, this time period is quicker when compared to a spinal fusion – which is the current standard spine surgical treatment to this newer procedure and technology. At this time, spinal fusion is the standard surgical treatment.

A study recently published in Neurosurgery, concluded that patients that underwent cervical arthroplasty returned to work on average about three months sooner than those patients that underwent a spinal fusion and cervical discectomy. The patients who received the cervical artificial disc returned to work in a median time frame of 101 days following their spine surgery (cervical arthroplasty) as compared to 222 days in the group that underwent the spinal fusion and cervical discectomy.  

We are excited to highlight another silver sponsor of Back Talk, Indiana Spine Group’s continuing medical education program – Globus Medical.

Globus Medical is dedicated to providing the most advanced, simple to use, highest quality spinal products. Their spinal products include the areas of fusion, minimally invasive surgery (MIS), biomaterials and motion preservation. Since its founding in 2003, Globus Medical continues to develop new technologies to improve patient outcomes. 

The ultimate goal of Globus is to utilize superior engineering and technology to achieve pain free active lives for all patients.

This blog entry will highlight Rapp Medical Systems Inc. | Medtronic Spinal & Biologics, a silver sponsor of Back Talk. Back Talk is the continuing medical education program that Indiana Spine Group is sponsoring for primary care physicians and practitioners. 
 

Rapp Medical Systems Inc. is a local medical product distributorship representing Medtronic Spinal and Biologics. Working with physicians, their mission is to provide superior products and service which will enable our physician partners to provide the highest level of patient care possible.

Medtronic Spinal and Biologics, is a division of Medtronic which focuses on spinal and  musculoskeletal therapies. Their key product areas include:

• Minimal Access Spine Technologies (MAST™) for treating painful conditions of the spine, such as degenerative disc disease.
• Fusion systems¹ that correct and stabilize abnormal spine curves.
• Artificial cervical discs² to replace damaged or degenerated discs in the neck. Our latest disc is made of surgical-grade stainless steel and allows motion so patients can go back to doing everyday activities they love.
• Infuse^® Bone Graft,³ a biologic that stimulates the body to regrow bone and is used to treat certain spinal, tibial, and maxillofacial conditions. Infuse Bone Graft eliminates the need to harvest bone from another area of the patient's body, thus eliminating an additional, often painful, surgery.

For more information, visit Medtronic Spinal and Biologics and for consumer education information visit their patient education site. 

In March, I attended and presented at the annual continuing medical education meeting of the American Association of Neurological Surgeons in Phoenix. This meeting was entitled,  The Backbone of Spinal Surgery: Evidence, Appraisal and Advocacy. At this meeting, I co-presented a special course entitled – New Developments in Arthroplasty. 

The overall objective of this course was to review the indications for cervical and lumbar arthroplasty. (Arthroplasty is the procedure that utilizes a cervical artificial disc or lumbar artificial disc – and this artificial disc is used as an alternative to spinal fusion). 

The overall course objectives were as follows:

·         Have an understanding of the indications and contraindications for arthroplasty.

·         Discuss the associated complications and management strategies for them.

·         Gain a better understanding of the biology and biomechanics of the devices.
 

In this study, patients diagnosed with cervical radiculopathy or myelopathy that required surgical intervention were randomly selected. Patients either had cervical artificial disc (Bryan artificial disc) or anterior cervical discectomy and fusion. The study then followed the patients for two-years to determine their functional outcome and radiographic results. 

In summary, this study concluded that the Bryan artificial disc replacement was a comparable surgical alternative to an anterior cervical discectomy and fusion for patients suffering with 1-level cervical disc disease. (1-level is where only one of the spinal discs is affected). Following surgery, both groups showed improvement in their functional outcomes. In respect to the patient’s range of motion, at two-years – those patients that underwent the Bryan artificial disc replacement had a greater range of motion than those that underwent the anterior cervical discectomy and fusion. This study did demonstrate that the artificial disc replacement is a comparable procedure to the spinal fusion. Further studies are underway, to determine longer term results of this investigational device.

Another study that I participated in has recently been completed, and the results published. This study compared the results of Bryan artificial disc replacement to anterior cervical fusion, two years following spine surgery. This study is entitled, Artificial Disc versus Fusion | A Prospective Randomized Study with 2-Year Follow-up on 99 Patients.  

This study evaluated 99 patients for a two-year period. Patients were from three spine surgical centers that were involved in the US FDA Investigational Trial for the Bryan artificial cervical disc. One of the centers involved in this investigational trial was Indiana Spine Group. I was honored to implant the first Bryan cervical artificial disc in the US, in May 2002.

Recently, I had the honor of being the co-chairman of an annual spine meeting hosted by the American Academy of Orthopaedic Surgeons.  The focus of this meeting was “Contemporary Techniques in Spinal Surgery 2008”.

At this meeting I gave presentations on spinal decompression and reconstruction techniques, including; ACDF, corpectomies and struts.  I also presented information that compared the cervical artificial replacement procedure with the spinal fusion.  Additionally, I was a lab instructor – which provided hands-on training to orthopaedic surgeons. A few procedures reviewed included X-Stop – a procedure which utilizes a device in spine surgery for lumbar spinal stenosis; XLIF – this is a minimally invasive spine surgery procedure used to treat back pain that is caused by degenerative disc disease. 

In the recent issue of Spine, an article that I co-wrote was published. This article is entitled, Comparison of BRYAN Cervical Disc Arthoplasty with Anterior Cervical Decompression and Fusion: Clinical and Radiographic Results of a Randomized, Controlled, Clinical Trial.

This article summarizes the results of a two-year clinical research study, following spine surgical patients that either had a spinal fusion or a cervical artificial disc implanted.  In conclusion, the study showed that cervical disc arthoplasty is a viable spine surgical alternative for patients suffering from single-level cervical disc disease.  

For more information, here is the abstract to the study.

A prior blog entry highlighted a research study that Dr. Renkens, a neurosurgical spine surgeon with Indiana Spine Group, was participating in for lumbar disectomy.  Dr. Renken’s is also participating in a clinical research study for the surgical treatment of spinal stenosis. 

Spinal stenosis is a degenerative spine disease where one or more areas of the spine narrows.  Usually affecting individuals in their 50’s and 60’s, spinal stenosis is most often caused by osteoarthritis-related bone damage.
 
Symtpoms include pain or numbness in the lower legs, back, neck, shoulders or arms, a loss of sensation in extremities, tingling or weakness.  Depending on the severity of the spinal stenosis – treatment may range from physical therapy to surgery.  

The study that Dr. Renkens is participating in is for more severe cases of spinal stenosis – where surgery is required.  The name of this study is A Prospective and Randomized Controlled Trial to Evaluate the Safety and Effectiveness of Total Facet Arthoplasty in the Treatment of Degenerative Spinal Stenosis.  In this study, Dr. Renkens will be using the Archus Total Facet Arthoplasty System (TFAS), which is a non-fusion spinal implant for the treatment of patients with moderate to severe spinal stenosis.  This TFAS, provides an alternative treatment for spinal stenosis as an alternative to spinal fusion – which is one spine surgical treatment for spinal stenosis. 

For more study information, click here.