1. Lateral interbody spine surgery. One of the most rapidly growing fields in spine surgery over the past five years is the lateral approach to the thoracic and lumbar spine. This allows excellent access to the disc space with less retraction of the spinal nerves than a posterior approach and with less retraction of the abdominal organs and vessels than an anterior approach. Instrumentation and prosthetic devices are being developed to allow stand-alone lateral interbody fusions, vertebral body replacement and artificial disc replacement.
2. Motion preservation spine surgery. Artificial disc replacement and dynamic posterior stabilization systems have been in widespread use in the United States and mainly Europe for many years. The artificial disc replacement has been shown to be effective in the cervical and lumbar spine. In addition to the lack of coverage from many insurance carriers, one of the main obstacles for motion preservation technologies is our lack of understanding about how much stability versus motion is optimal at each spinal level. Patients undergoing an artificial disc replacement may still have postoperative pain due to facet joint arthralgia, and those undergoing posterior systems may still have discogenic pain. As we gain biomechanical understanding in the future, "smart" technology may allow a prosthetic device to accommodate the specific demands of an individual spinal level.
3. Image-guided spine surgery. Currently, intraoperative three-dimensional fluoroscopic imaging combined with light-emitting devices and camera computer systems allow spinal surgeons to place instrumentation into the spine with real-time navigation on a three-dimensional image of the spine. These systems have proven to be accurate, safe and efficient. Future advancements will include the incorporating of magnetic resonance imaging for soft tissue visualization, smaller size for better ergonomics, better quality imaging and eliminating the need for cameras (and the associated line-of-site issues) potentially with the use of electromagnetic technology.
4. Robotic spine surgery. Robotics is just starting to penetrate the field of spine surgery. Current robotic applications require preoperative planning, complex mounting of the device to the spine, and questionable accuracy. In the future, integration of intraoperative MR and CT imaging with robotics will allow greater precision and safety for spine surgery. The key advances still to be made are integration of the imaging with the robotics, proven accuracy of the system and ease of use.
5. Biologics. Proven stem cell therapy is still far from clinical application. One of the main limitations is that it will be difficult for stem cell therapy to effectively treat a biomechanically unstable spinal segment. If treatment is reserved for biomechanically stable segments, then there is potential for a large number of asymptomatic discs to undergo unnecessary treatment. The indication for treatment will be a challenging issue. Biologic substitutes for spinal fusion have already shown to be very effective and will continue to expand and hopefully lower costs.
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