The lateral revolution: How new technology makes spine surgery better

"Surgeons can achieve a good and strong fusion using the lateral approach, and the patient heals reliably," says David Raskas, MD, an orthopedic spine surgeon with Orthopaedic Sports Medicine & Spine Care Institute in St. Louis. "The PLIFs and TLIFs have a higher non-fusion rate than the lateral approach and that's a huge benefit. Additionally, the lateral approach allows you to treat lumbar scoliosis with a less invasive approach as well."

Less invasive surgical technique has proven several benefits in the literature over open procedures, and the lateral MIS surgeries are no exception. The benefits include:

•    Patients report less postoperative pain
•    Less blood loss and need for transfusions
•    Shorter hospital stays — even sometimes performed outpatient
•    Quicker recovery and return-to-work times

"The minimally invasive lateral approach certainly allows patients to return-to-work or s The minimally invasive lateral approach certainly allows patients a quicker return to work, and may aid in faster healing and improved quality of life than traditional open approaches," says Dr. Raskas.

Improving the lateral approach
While many device companies are introducing direct lateral systems, not all of them are differentiated; OsteoMed, on the other hand, has developed a new method of retraction and access to the lateral spine from the ground up, the first to allow dilation from the inside out.

"Many companies are not making their own retractors — they license or purchase them from third party members — OsteoMed however, came out with a novel way of accessing the spine with a very unique retractor system," says Harvinder Bobby Bhatti, MD, a spine surgeon at Atlanta Orthopaedic Institute. "In everything I've done with these retractors so far, patients have been very happy."

The system takes all aspects of lateral approach surgery into account, incorporating neuromonitoring, illumination and multiple options for positioning and docking, assuring surgeons that they will have the options they need.  Allowing safe passage provides for confidence when it comes time to insert the lateral interbody device, intended to span the disc space and provide solid contact for a successful fusion.

"With OsteoMed's introduction of the PrimaLIF they have taken a good surgery — the lateral — and made it even better," says Daniel D. Lee, MD, an orthopedic spine surgeon at Nevada Orthopedic & Spine Center in Henderson. "This new, radically different retractor allows for better, more physiological retraction of the psoas hence better visualization and less play for the surgeon. Instead of dilating the psoas from a large diameter leaving behind great wads of psoas muscle that need cutting, cauterizing or even redoing the retractor, the PrimaLIF retracts from a single point negating these other issues."

This technology is part of the larger evolution in the field and will continue to grow over the next several years. "We are getting better and better at using different types of cages," says Dr. Bhatti. "The OsteoMed system allows us to insert a larger cage even if there is a small space available through the indirect lateral insertion. We are accessing the spine in a more convenient way now and it has made this technology popular, especially with younger surgeons."

Beating the learning curve
Technology advancement creates great opportunities for better patient outcomes, so why aren't all spine surgeons using these new techniques? For experienced surgeons, it takes time away from their practice — and revenue production — to learn new techniques, and it can be difficult to master multiple systems. They have to select the technology most likely to produce good outcomes for their patients.

However, fellowship-trained spine surgeons with minimally invasive experience have an advantage.

"Learning and utilizing the lateral approach was very straightforward given the experience I had with anterior exposure of the spine through a retroperitoneal or transperitoneal approach," says Dr. Lee. "The transition was smooth and I felt comfortable to do these procedures without a vascular surgeon. If a spine surgeon has limited experience with anterior exposures, then the transition might be more challenging."

Anecdotally, Dr. Lee says he's observed the lateral approach more easily implemented and mastered than most minimally invasive techniques, such as tubular discectomy. Surgeons that go through the course with an open mind and follow the steps for the procedure can be successful.

"There is a learning curve to it, like there is for any new system, and the imaging is slightly different," says Dr. Raskas. "But the way I see it, technology is advancing and we have improved retractors that allow for better visualization and physicians are excited."

The procedure could become more difficult as the surgeon goes beyond the L3-L4 level, but Dr. Lee reports seeing the technology used with levels in the thoracic spine to L4-L5 and corpectomies performed through the same retractor and approach successfully. However, it doesn't matter how good the surgeon is if the surgery is performed on the wrong patient.

"The most important decision a spine surgeon will make is to select the right patient for the surgical intervention," says Dr. Lee. "The selection process translates into indicating the appropriate spinal pathology for surgery without other major psychiatric, lifestyle or medical comorbidities that might contraindicate against surgical intervention."

Organizing the surgical plan is also important, especially for the first several procedures surgeons perform with new technology. The plan should be based on evidence-based outcomes to optimize the patient's treatment and experience.

Maximize patient satisfaction
That patient experience will become even more important as time goes on. Not only are the surgeons' reputations and future word-of-mouth referrals on the line, but also their payment. Payers are moving toward "value-based care" and "pay-for-performance" models like bundled payments and accountable care organizations that ask surgeons to assume risk for patient outcomes. They also give patients a chance to provide subjective feedback on their experience — not just outcomes — and their satisfaction could factor into compensation in the future.

"The number one benefit to patient satisfaction from the lateral approach is less pain after the operation," says Dr. Raskas. "These patients come into our office a few weeks after surgery for their follow-up and they are happy to be able to take care of themselves. They can drive themselves around, go to church, parties and see their friends."

The lateral approach has also made treating obese patients easier, says Dr. Bhatti. There is less blood loss than with other techniques and patients aren't laying on their stomachs during the procedure — as they are with TLIFs — which can cause issues later on.

"This approach helps with their breathing after surgery and the infection risk is lower," says Dr. Bhatti. "Due to the simplicity and repeatability of the OsteoMed system, I feel it may contribute to a higher success rate of fusion, which makes a difference in patient satisfaction. But we have to give patients the right expectations and address the risks upfront to really direct their overall experience."

Studies show the environment also has a huge impact on patient satisfaction, and patients are happier when their surgeries are performed in outpatient ambulatory surgery centers than hospitals. The ASCs are smaller, more intimate facilities where staff members are often able to take a more individualized approach to patient care. In recent years, the minimally invasive revolution in spine surgery allows surgeons to perform cases in the outpatient setting, and many are now using ASCs — sometimes even developing their own spine-focused centers.

"Now even some two-level procedures can be done in ambulatory surgical facilities with 23-hour stays," says Dr. Raskas. "I think that as time goes on, more surgeries will move to outpatient ASCs."

This article is sponsored by OsteoMed.

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