Primer on Fusion Techniques

Thanks everyone for being still here. I'm Christopher Hofstra. Sig, thanks for moderating this. I'm Peter, uh, great to follow you here. Um, so I'll be talking about fusions, uh, using endoscopic technique. Um, here are my disclosures.

Uh, again, I also do teaching for Troy Mac and the AO Spine.

Uh, here are the learning objectives. So, uh, I want to talk about the adjunct technologies that can help us to facilitate endoscopic fusions, get to know indications, uh, get to know, uh, the challenges that we have currently, and, and explore as a, uh, current opportunities to advance the field.

So we've all have seen this, uh, you know, how the field has advanced and we've seen fantastic talks on that, so I'm not going to, uh, spend a lot of time on that, but the field is moving forward, big data, cost effectiveness, all of this we're striving to, uh, and here's the value proposition for, for endoscopic fusion. So fusion procedures can be standardized. We can treat a much wider variety of, of, of pathologies.

Uh, robotic and techno robotic and navigation Technology, it really comes in hand in hand, uh, and the most important thing is the tremendous amount of of cost cutting. So in, uh, Doctor Wang's experience, the delta of cost cutting is almost $60,000 per piece. Uh, again, that is including Awake Surgery, ERIS Technology, all the stuff, all the good stuff that we've seen putting in one box.

Um, you know, the Approach that we typically do for this is, uh, a trans-SAP Approach. The reason we, we, we choose that is so that we don't, uh, blindly go into the foramen into the Camden strangle anymore, and this has helped us tremendously to avoid postoperative paresthesias, which is, uh, which is, which can be a concern with this Approach.

Um, the second thing that is really important is foraminoplasty, and, and foraminoplasty is a stupid word. I'm sure everybody in the audience is right now. What the heck? foramina, what? Plastic? I don't like plastic. I like solid metal. Um, so it has nothing to do with plastic, um, but it, it means to open up that foramen. Why don't they call it a foraminotomy? Because a foraminotomy means also that you remove scar tissue, yellow ligament from the nerve root. This is just opening the bony area. So it kind of makes sense. I don't like the name either. Let's come up with something better, but it, it makes sense.

Um, discectomy, there's a lot of work that is being done there right now. discectomy tools are in development. Uh, the last couple of labs I've done with industry, uh, between an MIS and an endoscopic discectomy, the volume is very, very similar already. And down there you see.

One thing that we can't do open, we cannot do with MIS or any Other technique, we can actually move the endoscope into the disc space and make sure that we have nice, you know, end plate that is there and if there's something left, then you can drill it off and just have a nice preparation of the end plate.

Cages, that's where everybody's going to, uh, you know, like get happy here right now. There's a, there's a wide variety of cages. Uh, you see, uh, expandable two-dimensional expandable cages, but I think my prediction in endoscopy is going to be 3 dimensional. Uh, and the reason for that is your working channel is 8 millimeters in diameter. So there's just not as much space that you have to get in there.

Uh, so interesting concepts is the spinal elements, one, the Optimme cage, um, and the flare hawk Technology. Uh, all of this very, very interesting technologies, and I think they're going to change the field. Off-state biologics, we've learned a lot about it, right? Cages and screws are internal braces. Uh, the quicker fuses, the less brace we need. Um, and so typically I use for these, uh, uh, extra small BMP, so, uh, roughly 2 mg of BMP.

Navigation Robotics, this is really a Technology that uh lives with that. um, it helps us to very quickly uh Approach the target, uh, and target, um, I don't know it's not starting so here we go. You see it up there. It helps you with driving the needle in, uh, it flattens the Learning curve because it's a point and shoot, uh, type of technique, um, and it can also be, um, combined with, um, robotic assistance and that's.

One of my fellows, uh, Doctor, uh, Sai Hassan, he combined that with the, uh, with the Globus robot, uh, and used it to kind of really get just his endoscope right there. So there's no more thinking again like we've heard before, you just plan it, you execute it, you see you're right there, so.

It really is a fantastic Technology to combine with that. And you see how the robotic arm comes in there and it gets him right into the Camden Strangle. So, no more little needles and, and all of that. It just gets you right there. And that's one thing that we have.

Uh, we've heard a lot about this today is, uh, endoscopic Technology lends itself for being performed in the ASC, uh, as well as changing the way we take care of our patients. Uh, and, and, and PETA is part of this. So, first of all, we've standardized all these procedures, so it's all defined with the same name. It's kind of like all, you know, with the AO we have, uh, put a curriculum together sort of just to know what we're speaking about.

Uh, and then what we do here is, uh, we can then sign up the patients in a, in a cloud-based database, and all my patients are in there. That's why it's blacked out.

Um, and then one thing I really like a lot is, uh, when I have my patients signed up there, I see exactly, uh, how their Pain is doing, and I see that I can show you all my last 100 patients, they're in my, my smartphone right now as we speak, um, and in addition to that, Peter, you've not seen this is, this is our new data right now. We're also collecting all the walking data, activity data from the, from the iPhone, so.

Um, one thing that I think this has really given me a lot of satisfaction being a surgeon because I know every day how my patients are doing. And before that it was just like, oh, I did 5 cases yesterday. I haven't heard from them, they're probably doing fine. Um, but now I see, you know, next day, I'm just, you know, you know, reading the newspaper and just check it and, and it's been really awesome to see how patients are doing. So every day they filled it out, the 7 1st days, and then we get good data there.

Which is, as we've heard, really important. Uh, the Other nice thing we're doing, um, I do roughly 150, uh, endoscopic cases, so roughly 5% of my fusions are endoscopic. So I'm not, you know, uh, this is for me of the beginning there. Uh, but, um, my post-operative care, um, you know, my, I have roughly 150 endoscopic patients and, and for 99%, the, the, the follow-up is not virtual. So they just fill out certain questions and then they send me a picture of their wound.

I know how they're doing from the outcome. If they have a question, they can text text it to me in a chat in there. So overnight my, my clinic has, you know, been elevated of 300 visits because normally these patients came back twice, um, and so I've, you know, saved, I've freed up my clinic of, of, of 300 patient visits roughly, which is huge.

Um,

And then one thing is, uh, that we have done now uh as we have heard from the previous, uh, speeches, one thing that is that allows.

You know, having this cloud-based Approach that now you can actually collaborate with your with your colleagues. So for example, Peter is part of this and he's seeing his patients exactly the same. He has the same platform, um, and then we can uh in the near future analyze our data together and and have predictors who's doing well, who's not doing well, what cage is the best, you know, what do we have to do, what are the fusion data, so and it's all set up and so we have a really awesome group of people working together on this.

Um, and it has been, uh, an amazing, uh, you know, like travel so far. So.

This

So indications for endoscopic fusion. So I'll be very generous. I'm not going to show you crazy cases. I'll just show you cases where I think it's reasonable to use this Technology today.

I think I do a lot of thoracic discs, and if patients have thoracic Pain and instability there, I think endoscopic fusion is perfect. I would bring that. I would debate anybody on this any second.

Um, I think right now the endoscopic fusions are good at the thoracol lumbar junction where you don't need any low doses or very minimal.

In the lower lumbar Spine, I offer it if a patient has a lot of comorbidities and has a balanced Spine. And I'll show you an example of this. So these are the cases right now that I, I, I kind of do for that. So here, for example, 52 year old female.

She had this fall. She was in a boat. She's very wealthy. She fell on a boat and then since that time she had this, her Pain diagram is obviously crazy as you can see there, but she had back Pain. She had the synovial cyst and, and awkwardly at T11, T12, she had this right-sided facet joint which was fractured and also asymmetric in appearance. So we did a T11, T12, T11 endoscopic on her, and as you can see, the Pain improved to a 3 out of 10.

Uh, one year afterwards she had a solid fusion there. Um, again, one thing that I obviously you will see, you see the subsidence of the cage that is one of the limitations right now. Um, I typically don't use expandable cages in the thoracic Spine anymore, but at the beginning we use those. Very quick Other example here right now, 74 year old male, uh, past medical history longer than in the slide, diabetes, asthma, rheumatoid, whatever, very sick.

And everything he had, we did a laminectomy on him, a discectomy, a foraminotomy, and then he just had this intractable Pain, and you can see that disc is totally worn out. He was balanced on X-rays. We've got Scoli films, and he just needed this level of fuse. And so we did an endoscopic fusion. Patient got out of the hospital the next morning. I don't have to worry about infections, and this is good enough.

Limitations, a lot of them, um, you know, I think the endoscopic stuff, it's less destabilizing. You can do it in very large patients, which is good. The tube is as long as you want it to be. You can see the disc prep. Um, the duotomy rate is, is lower. You can do it awake if you have anesthesia supporting this, uh, faster recovery. Disadvantages, you have to train and practice this. Um, equipment is initially expensive, even though not more expensive than the microscope.

Uh, the foraminoplasty needs to be done, so that's a little bit of additional work so that you don't irritate the nerve root.

No central spinal canal decompression. Now this is changing actually because we're doing more and more interlaminar fusions too, which are actually to some degree safer, uh, and this smaller cage footprint is which is going to be overcome by three dimensional cages, um, and again right now the biggest thing for me is, you know, the data on the doses and fusion rates is still pending, and this is why we have this Research group, uh, and we're going to collect the data, but we're needing big data for, for, for putting this and seeing what the limitations are and where we can go with this.

The burden of proof, um, actually, I used it from you list, so we have to restore segmental loosis. It's a recent endoscopic cage where I added like roughly, you know, 10 degrees of loosis there, but again you see a little of subsidence of the cage, but we still got additional 10 degrees.

Um, you have to demonstrate a durable clinical outcomes down there. The, the same patient that you see up there is her, the, the Spine healthy follow up so you can see the patient reports the outcomes and you see it's not, patients are not like they are, um, it's still Surgery, so they still have a couple of weeks where they don't feel well, uh, and they're, it's, it's, it's very, very frank that it's also you see the same thing in the, in the stepping pattern too, so they need a couple of weeks and months to get over this.

Uh, we have to show and demonstrate that we have the same fusion rates as MIST lifts, um, and to develop a system for L5-S1, which brings me to the conclusions. Um, so I think there's a lot of adjunct technologies which make this, uh, Technology better, faster, and doable for any surgeon.

Um, the, the tech endoscopy part is much, much simpler than the decompressions. Um, current Technology, um, have, I think, competitive solutions for the thoracic and thoracollumbar segments. I think the 3D expandable cages are going to be a game changer for the lower lumbar Spine, and we just have to work together to develop these tools, adjuncts, and sort of provide good follow up data. Thank you so much.