A. Jay Khanna, MD, MBA is an associate professor of Orthopaedic Surgery and Biomedical Engineering at The Johns Hopkins University and serves as the co-director of the Division of Spine Surgery at Johns Hopkins Orthopaedic Surgery at Good Samaritan Hospital. In addition, he serves as the clinical director of the Johns Hopkins Center for Bioengineering, Innovation and Design (CBID). Dr. Khanna discusses what he views as the four greatest opportunities for spine surgery in the immediate future.
1. Minimally invasive spine surgery
Much of the spine surgery that we currently perform — and that has been developed by generations of surgeons before us — is relatively invasive. The spine is a deep structure and somewhat difficult to access. We often end up creating a great deal of collateral tissue damage to get down to the area of interest. For surgery on the lumbar spine, for example, we may have to make an 8- to 12-inch incision to get down to a much smaller region in the spine. That additional exposure creates a substantial amount of risk, potential morbidity and cost.
The field of minimally invasive spine surgery is still in its early stages, and I believe it will continue grow in popularity, both from a surgeon and a patient standpoint. I compare this to the evolution of a number of other procedures that were performed in open fashion 10-15 years ago and are now frequently performed in a minimally invasive fashion; laparoscopic cholecystectomy, arthroscopic rotator cuff repair and arthroscopic ACL reconstruction are several examples.
Minimally invasive procedures have the potential to reduce hospital stays, improve patient recovery and decrease risk to the patient. However, the procedures tend to be more expensive (due to the instruments and implants we use to perform them), rely on techniques that can take some time and experience for surgeons to learn and require fluoroscopic guidance; in addition, the overall long-term efficacy is not yet fully understood. There is also difficulty achieving fusion because we do not expose the posterior aspect of the spine, as with minimally invasive pedicle screw placement, for example. Another downside for surgeons is that working through a small portal may limit our ability to address certain complications if they occur and may lead to inadequate decompression of neural structures.
Minimally invasive spine surgery is still relatively early in its development. As surgeons address and resolve some of the challenges we are currently facing, I anticipate that minimally invasive procedures will evolve to the point where a larger proportion of spine surgeries will be performed using these techniques.
2. Cost containment in spine surgery
I believe that increasing healthcare costs are the biggest threat to the future of spine surgery — we all know that continuous increases are ultimately unsustainable. One of the largest sectors of the total healthcare spending is medical devices. Spine surgery has seen a disproportionate growth in the cost of implants and biologics over the last 10 years, and this clearly cannot continue. I believe that new models must be created to help contain the cost of providing spine surgical services, including those related to devices such as pedicle screws, interbody devices, and plates and biologics, such as BMP (bone morphogenetic protein).
It is imperative that we address costs with regard to hospital stays, and I believe that this is where minimally invasive procedures and the shift to outpatient care come into play. One area that people tend to scrutinize is surgeons' professional fees — my impression is that these fees are as low as they can get. It's imperative to continue to incentivize the most talented people to practice orthopedic, spine and neurosurgery. A surgeon's professional fees comprise a very small part of the total expenditure on spine surgery services, and there is very little room for these fees to be reduced; of course, I am probably biased in this regard.
In addition to advances in device technology, I believe that new business and distribution models could save the system money in the long run. Many orthopedic and spine device companies are very management- and distribution-channel heavy. A careful evaluation of organizational structure and a move toward leaner and stronger companies would go a long way toward helping the bottom line.
3. Increased use of biologics in spine surgery
Biologics are a hot topic in spine fusion surgery. There are three main factors to consider with biologics: efficacy, in terms of ability to reliably achieve fusion; safety, morbidity and the impact on the patient; and cost. Many products on the market perform well in two of these areas, but we have not yet found the product that achieves all three.
Iliac crest bone graft is thought to be the "gold standard" in spine fusion surgery, but many surgeons don't like to use it frequently because of patient morbidity and pain, and the additional time and effort required to harvest bone from the iliac crest. BMPs have been widely popularized and used over past several years, but there are some lingering concerns about safety, especially in the cervical spine. They are also very expensive.
I do think biologics can help achieve fusion. Many companies, scientists, and surgeons are working on this problem, and I'm confident we will see better options in the next 5-10 years.
4. Image guidance safety and radiation dose reduction
Many spine surgical procedures, especially minimally invasive spine procedures, require the use of image guidance or fluoroscopy. One minute of fluoroscopy in a 70kg patient has the equivalent radiation dose of 150 chest x-rays. Typically, we use about 10-30 seconds of fluoroscopy for a spine case, but some surgeons may occasionally use up to 3-4 minutes, especially for minimally invasive procedures. Surgeons, especially those who use fluoroscopy for their cases, experience a large amount of radiation exposure. This includes surgeons who perform disproportionate amounts of minimally invasive spine surgery, orthopedic surgeons who treat hip fractures and surgeons who handle other trauma cases.
Research in this area has increased in the past several years, and we are now beginning to understand the impact of such radiation exposure on cancer rates as well as other adverse outcomes, such as cataracts, in orthopedic surgeons, interventional radiologists and interventional cardiologists.
We need to maximize safety for the patient and OR personnel during minimally invasive spine procedures and even routine spine surgery, so many surgeons use fluoroscopy. We also have to make sure the patient is protected from high radiation doses. So what is the best way to resolve those two issues? This is where the field of image guidance in spine surgery is taking us. I expect to see new, advanced image guidance technologies being developed that allow for excellent visualization in the operating room while drastically decreasing radiation dose.
The major concern that many surgeons have is that these technologies are cumbersome and can severely affect workflow in the operating room. I believe that the main challenge is to find image guidance technologies that decrease radiation dose to the patient, surgeon, and operating room staff; optimize or improve safety and accuracy; and have no negative impact on workflow in the operating room.
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