Donald R. Johnson, II, MD

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Donald R. Johnson, II, MD

• Medical Director
• Southeastern Spine Institute
• MUSC Board of Trustees
• Past Chairman

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Advancements in Spinal Surgery

• Whats New ?
• What Works?
• What Can Get An Injured Worker Back To
  Work
• What Saves Money?

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Spinal Anatomy
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Spinal Stenosis(Narrowing)

• Spinal stenosis is the narrowing of the bony ring
  that surrounds the spinal cord. Causes include
• Bone spurs
• Disc degeneration
• Arthritis
• Congenital
• This condition is most common in elderly people,
  who have had years of wear-and-tear on their
  spines

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Spinal Stenosis

• Stenosis of the spine can cause pain in the
  back as well as in other parts of the body.
• Primary symptom is decreasing ablilty to walk-
  better with cart in store and better after
  sitting and bending over
• Can lead to paralysis and bladder/bowel control

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Traditional Surgery Laminectomy

• Usually Multiple Levels

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Interspinons Distraction for Spinal Stenosis
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FLEXUS Interspinous Spacer
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Competitive Products
Paradigm Spine Coflex
Medtronic X-STOP
Medtronic DIAM
Abbott Spine Wallis
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• Surgical Technique

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FLEXUS Surgical Technique

• Patient Position
• Prone and in flexion
• Incision
• 2-3 cm length
• Midline
• Separate paraspinal muscle
• on right side

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FLEXUS Surgical Technique

• Interspinous Perforator
• Create starting hole through interspinous
  ligament

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FLEXUS Surgical Technique

• Dilator KEY PREPARATION STEP
• Separate the bones(spinous processes)

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3 Step Insertion Technique Trialing

• Insert horn of trial through interspinous
  ligament

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3 Step Insertion Technique Trialing

• Push trial past midline
• Rotate trial 90

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Final Position
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Discogenic Issues

• Discogenic Pain
• Caused by a damaged disc. While this pain can be
  felt directly in the lower back, it may also be
  felt outside of the area of the damaged disc,
  such as in the buttocks or upper thighs.
• Specific movements that put stress on this
  damaged disc can worsen the pain.

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Discogenic Issues

• Pinched Nerve
• Also know as radiculopathy, or sciatica, occurs
  when there is pressure on a nerve to cause
  irritation and inflammation.

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Discogenic Issues

• Bulging or Herniated Disc
• Herniated Disc occurs when the jelly-like center
  (nucleus) of the disc ruptures
• Causes material to be pushed outside of the outer
  ring of the disc
• Pressure on the spinal cord and nerve roots cause
  pain, weakness, and/or numbness to certain areas
  of the body

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Degenerative Disc Disease (DDD)

• DDD is a slow deterioration of the cushions
  located between vertebrae.
• Since these discs act as a shock absorber between
  each vertebra, the reduction or loss of disc
  height can cause pain.
• The so-called degenerative disc is not getting
  enough nutrients and will not be able to repair
  itself once injured.

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Degenerative Disc Disease (DDD)starts as an
annular tear

• If the outer ring, or annulus fibrosis, tears it
  can cause back pain.
• The inner core of a disc, or the nucleus pulpous,
  is very soft and can cause severe leg pain if it
  comes into contact with the surrounding nerves.

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Spondylolisthesis (Spinal Bone Slippage)

• Occurs when one vertebra slips forward in
  relation to an adjacent vertebra, usually in the
  lumbar spine.
• Symptoms include pain in the low back, thighs
  and/or legs, muscle spasms, weakness, and/or
  tight hamstring muscles.

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Spondylolisthesis (Spinal Bone Slippage)

• May result from the physical stress placed on the
  spine - lifting of heavy items, weightlifting,
  football, gymnastics, trauma, and general wear
  and tear.
• As the vertebral components degenerate, the
  spines integrity is compromised.

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Spondylolisthesis

• Depending on how far the vertebra has slipped,
  doctors label spondylolisthesis in four grades, I
  (one) being the least amount of slippage, all the
  way up to IV (four), which is the most slippage.
• Not all cases of spondylolisthesis require
  surgery.

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Spinal Fusion

• Spinal fusion is a surgical procedure in which
  two or more of the vertebrae in the spine are
  united together so that motion no longer occurs
  between them.
• Between the vertebra- termed INTERBODY!
• Usually a box(cage) filled with a bone glue
  May be supported by screws(pedicle) to allow glue
  in boxes to heal by keeping the bone and boxes
  still.
• Spinal fusion can restore stability, correct
  alignment reduce pain.

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Interbody Fusion Approaches
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Posterior Lumbar Interbody (PLIF) Fusion

• Direct decompression
• Exposes spinal cord elements
• Retraction risks to nerves

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Transforaminal Lumbar Interbody (TLIF) Fusion

• Avoids spinal sac
• Direct decompression possible
• Potential nerve irritation

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Anterior Lumbar Interbody (ALIF) Fusion

• Excellent visualization of disc space
• Avoids spinal cord
• Approach risks to organs and vascular structures

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Extreme Lateral Interbody (XLIF)Fusion

• Approach for L4-L5 and above
• Reduces muscle trauma
• L5-S1 not accessible because of pelvis

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Traditional Surgical Approaches
Back
Front
Back
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XLIF Surgical Approach

• eXtreme Lateral Interbody Fusion (XLIF)
• Advantages
• Does not require entry through back muscles,
  bones, or the retraction of major blood vessels

Side
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XLIF Indication Degenerative Disc Disease
(DDD)

• Symptoms
• Pain in the back, buttocks, or leg
• XLIF Correction
• Reduces motion between the vertebrae
• Corrects alignment
• Restores proper disc height
• Alleviates pain

Disc Degenerationbefore XLIF
Restoration of Heightafter XLIF
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XLIF Indication Spondylolisthesis

• Symptoms
• Impingement of nerves and fatigue of back muscles
• XLIF Correction
• Reduces motion between vertebrae, corrects
  alignment, and restores disc height

Spondylolisthesis(Malalignment)before XLIF
Restoration of Alignmentand Disc Height after
XLIF
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XLIF Indication Degenerative
Scoliosis(Curvature)

• Symptoms
• Back and/or leg pain due to muscle fatigue and
  nerve impingement
• XLIF Correction
• Restores proper alignment and disc height

Degenerative Scoliosis before XLIF
Restoration of Alignmentafter XLIF
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Axial Lumbar Interbody (AxiaLIF) Fusion

• Has ability to spare 100 of Annulus
• Preservation of Tissues Muscles
• Dynamic Decompression via Distraction

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AxiaLIF Pre-Sacral Fusion

• Unique Features
• Only interbody graft option where
• No muscle is dissected
• No ligaments are cut
• The disc annulus is preserved

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AxiaLIF Immediate Results

• Pre Op

• Post Op

Distraction
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Patient Ms. C. F.

• Dx Adult Lumbar Scoliosis
• 1. Lateral diskectomy L1-5
• 2. Xlif fusion L1-L5
• 3. Placement of plastic cage with bone glue
  

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Pre-op Xrays

• Right Bending

• Left Bending

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Pre-op LMRI Frontal
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Pre-op Side View
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Percutaneous (thru the skin) PedicleScrew
Fixation
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Pre-Op Cross Section
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2 Week Post-Op
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Patient Ms. C. G.

• Dx Adult Degenerative Scoliosis
• Xlif at multiple levels
• Percutaneous screws and rods

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Pre-op Xrays
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Pre-Op MRI Frontal
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Pre-Op MRI Side View
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Pre-Op MRI Cross Section
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1mo Post-Op
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7mo Post-Op
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Patient Mr. T.A.

• Dx Degenerative Disc Disease L5-S1
• 1. Axialift

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Pre-Op Xrays
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Pre-Op MRI Side View
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Pre-Op MRI Cross Scetion
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2 week Post-Op
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6mo Post-op
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Patient Mr. M.B.

• Dx Degenerative disc disease with disc space
  collapse L3-4, L4-5, L5-1.
• Dx Annular tear with provocative discogram.
• 1.Xlif L3-L4, L4-L5
• 2. Percutaneous pedicle fixation L3, L4, L5, S1
• 3. Axilift L5-S1

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Pre-Op Xrays
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2wk Post-Op
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IntraoperativeNeuro-Monitoring
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Cell Mediated Disc Therapy
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FDA Study

• Starting March 1st- first FDA approved study of
  injection of cells to regrow and heal an injured
  disc

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Isotech

• Davis Adkisson, Ph.D.Founder Chief Scientific
  Officerfrom Summerville, SC

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Outpatient Spine Surgery-Procedures currently
being done at SSI

• Interspinous distraction
• Laminectomy/discectomy-single and multiple levels
• Anterior cervical fusion- 1and 2 levels

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Anterior Cervical Fusion

• 32 Cases
• 3.5 Postop stay in RR before DC-no readmissions

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Planning as OUTPT Procedures at SSIInterbody
Fusions

• Anterior lumbar fusion (ALIF)
• Posterior lumbar fusion (PLIF)
• XLIF
• Axialif
• Percutaneous pedicle screws
• Average operative time 1 hr at SSI

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Cost Savings Vs Hospital

• Based on EOBs obtained from pts is 50-66 cheaper
  to commercial payers

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2010 Workers Comp Fee Schedule

• (not ?d since 2003)-medical provider cost index
  up 28

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Using Medicare Relative Valve Units (RVUs)Good
way to measure many different accounting
metrics-but is system appropriate for the young
injured worker?
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Medicare Spine Surgery-most common spine
surgeries

• Spinal Stenosis ? X-stop or multiple level
  laminectomies
• Compression fx ? Kyphoplasty
• Degenerative Scoliosis ? Long Fusions with Screws
  
  
  

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Workers Compensation- most common spine surgeries

• Herniated disc ? lam/disc or anterior cervical
  fusion or cervical ADR
• Annular tear ? lumbar disc replacement or
  interbody fusion or cell mediated therapy
• Degenerative disc with foraminal stenosis ?
  interbody fusion screws
• Spondylolisthesis ? laminectomy and fusion
  screws

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Medicare not appropriate template for injured
worker-especially for spinal care 1. Whats
valued in Medicare may not be valued for injured
worker2.Diseases/Medical conditions of spine are
different
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Impact of New WC Fee Schedule on SSI (8-10 of
pts)

• Office visits ? 12.9
• EMG/Nerve ? 28.8
• Injections ? 6.7
• Spine Surgery decreased 10.0 !

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Thoughts Considerations

• Incentive to prolonged nonop care for injured
  spinal pts
• Disincentive for surgeons to see
• Time equals money in WC system
• May cause delays of definitive treatment and ?
  cost to entire system
• Issue of surgery for injury worker needs to be
  addressed by all parties in system
• Spine cases are the most common and expensive
  cases in WC