Arthrodesis of the Spine by the Non-Spine Surgeon

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buddababa

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www.cns.org

AANS/CNS Position Statement on Arthrodesis of the Spine 8.21.21

Patient safety and optimal outcomes are maximized by team-based treatment of patients with either trauma or degenerative diseases of the spine involving a collaborative relationship between neurosurge
www.cns.org www.cns.org


It was only a matter of time until the spine surgeon spoke out against what is happening in our pain management world right now with the spinal simplicity and other "fusion devices."
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buddababa said:
www.cns.org

AANS/CNS Position Statement on Arthrodesis of the Spine 8.21.21

Patient safety and optimal outcomes are maximized by team-based treatment of patients with either trauma or degenerative diseases of the spine involving a collaborative relationship between neurosurge
www.cns.org www.cns.org


It was only a matter of time until the spine surgeon spoke out against what is happening in our pain management world right now with the spinal simplicity and other "fusion devices."
Click to expand...

This was a very hot-button topic among KOL's.
 
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Good. About time.

we/pain docs went from complaining about surgeons over-utilizing fusions to doing it ourselves Bc companies would train us and we could bill for it.

I see multiple LinkedIn posts per day of pain docs doing a fusion for axial low back pain. High-fiving about “stabilizing spines”. And multiple 2nd opinion consults/month in my office for same. Fusion for axial pain, with rare exception, doesn’t work well when surgeons do it. Why the f would it work when a pain dr does it… poorly…

I just saw a consult yesterday for a 2nd opinion. Healthy 70yo with a mobile spondy and 2 level severe stenosis. Severe neurogenic claudication. Can’t walk a half block. She wanted to see if there was anything else that can be done for her. She “already had a fusion” and her pain dr had rec’d scs trial as next option. She had one of those new doodads implanted bw her spinous processes. She was very happy to hear that her problem can actually be fixed. Surgical consult Monday.
 
I wonder how many patients who would have done well with a mini-lami end up with these fusion devices instead. The incision is probably about the same size.
 
I agree pain physicians should not be doing percutaneous fusion, I don’t think anybody really should be.

but the position statement is ridiculous, there’s hundreds of neurosurgeons and ortho surgeons who will operate and fuse multiple levels when a one level lami might suffice. Adjacent level disease, please, there’s more than one surgeon in my immediate area that routinely does a L2-S1 fusion.
 
Also, where is the consensus statement that neurosurgeons should be doing epidurals?
 
Taus said:
Good. About time.

we/pain docs went from complaining about surgeons over-utilizing fusions to doing it ourselves Bc companies would train us and we could bill for it.

I see multiple LinkedIn posts per day of pain docs doing a fusion for axial low back pain. High-fiving about “stabilizing spines”. And multiple 2nd opinion consults/month in my office for same. Fusion for axial pain, with rare exception, doesn’t work well when surgeons do it. Why the f would it work when a pain dr does it… poorly…

I just saw a consult yesterday for a 2nd opinion. Healthy 70yo with a mobile spondy and 2 level severe stenosis. Severe neurogenic claudication. Can’t walk a half block. She wanted to see if there was anything else that can be done for her. She “already had a fusion” and her pain dr had rec’d scs trial as next option. She had one of those new doodads implanted bw her spinous processes. She was very happy to hear that her problem can actually be fixed. Surgical consult Monday.
Click to expand...

I’m glad I’m not the only one that finds the trend in fusions odd. Plenty of people complain on this forum about fusions that surgeons have done to being the ones doing fusions. Vertiflex and mILD is one thing but minuteman and the like seem like overkill.

If you want to fuse, Why not just do percutaneous pedicle screws instead (Medtronic- did them in fellowship 11 years ago with neurosurg)? If you can do a Kypho you can do pedicle screws.
 
You have to have some judgement. I do a few of these cases per month. I have seen the LinkedIn posts and see that there are many doctors placing these in patients I would not. I try not to comment. I have a couple times but have been ignored. One was on a vertiflex that the patient looked to have the spine of a 30 year old, then more recently (somewhat related) they were talking about doing a kyphoplasty on a 34 year old alcoholic. Sometimes they are so eager to post cases, they post a HIPAA violation for the world to see.
 
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And I disagree with the position statement. I’m doing these cases as a last option. The patients are overall very old. These devices are much less likely to create adjacent segment disease than a pedicle screw construct as the fixation is less rigid, but it really doesn’t matter as the patients won’t live that long. The mantra about not being able to deal with complications is the same as what they used to use against the cardiologists and gastroenterologists
 
buddababa said:
www.cns.org

AANS/CNS Position Statement on Arthrodesis of the Spine 8.21.21

Patient safety and optimal outcomes are maximized by team-based treatment of patients with either trauma or degenerative diseases of the spine involving a collaborative relationship between neurosurge
www.cns.org www.cns.org


It was only a matter of time until the spine surgeon spoke out against what is happening in our pain management world right now with the spinal simplicity and other "fusion devices."
Click to expand...

How does such a statement affect anyone or anything ? Really asking, not rhetorical.
 
BobBarker said:
The mantra about not being able to deal with complications...
Click to expand...
Right, as if these folks are managing the sequalae from their surgical misadventures.

Does neuro/ortho spine have training to fix a pedicle screw in the aorta or a hernia from an XLIF?

It's a team sport. I agree with the sentiment that this may be overutilized, that there should be clearer criteria for using device X or surgery Y, and more education about indications/contraindications/considerations would be helpful.
 
ateria radicularis magna said:
How does such a statement affect anyone or anything ? Really asking, not rhetorical.
Click to expand...

It's a shot across the bow and it will not be tolerated. It's time for pain doctors to step up and open their hearts, minds, and most importantly their wallets to shut down this kind of fear-mongering/turf wars. Time to speak with one voice.
 
I’m sure if you look hard enough you’ll find similar position statements by STS on interventional pulmonologists doing EBUS and placing bronchial stents and taking biopsies and by Cardiac surgeons about Intv cards and vascular surgeons about IR.

the thing that separates those interventionalists from us is, sadly, data. Say what you will about ASPN or NANS but at least they are pushing the envelope by trying to get data supporting the efficacy of these procedures and long term benefit compared to open surgery. Do they have financial motives and is the data shoddy and industry sponsored, yes absolutely. But that exists with IP, Cardiology, IR, etc too I’m sure.
 
Propofool123 said:
the thing that separates those interventionalists from us is, sadly, data.
Click to expand...
Unfortunately in my opinion, the data aren't the issue, it's the phenotype and end points.

Cardiac function, vascular flow, or incidence of pneumothorax for example are objective and cleanly correlated endpoints or markers.

Pain, function, disability, and need for further spine surgeries are either not objective or cleanly correlated due to the other factors that go into them. The decision to have another spine surgery for a painful radic for example is dependent on the surgeon preference and patient psychology, as much as it is on the imaged pathology or disability described.
 
Propofool123 said:
I’m sure if you look hard enough you’ll find similar position statements by STS on interventional pulmonologists doing EBUS and placing bronchial stents and taking biopsies and by Cardiac surgeons about Intv cards and vascular surgeons about IR.

the thing that separates those interventionalists from us is, sadly, data. Say what you will about ASPN or NANS but at least they are pushing the envelope by trying to get data supporting the efficacy of these procedures and long term benefit compared to open surgery. Do they have financial motives and is the data shoddy and industry sponsored, yes absolutely. But that exists with IP, Cardiology, IR, etc too I’m sure.
Click to expand...

Why should one physician specialty define another physician specialty's scope of practice?
 
Orin said:
Unfortunately in my opinion, the data aren't the issue, it's the phenotype and end points.

Cardiac function, vascular flow, or incidence of pneumothorax for example are objective and cleanly correlated endpoints or markers.

Pain, function, disability, and need for further spine surgeries are either not objective or cleanly correlated due to the other factors that go into them. The decision to have another spine surgery for a painful radic for example is dependent on the surgeon preference and patient psychology, as much as it is on the imaged pathology or disability described.
Click to expand...

that’s a very fair point.
 
ateria radicularis magna said:
For those performing vertiflex or minuteman or zip or the others, will this statement change your practice?
Click to expand...

I don’t think that Vertiflex falls into the same category. It’s a distraction device. I can’t imagine that device is the target of this position statement. Perhaps if MM, ZIP, etc had an indication for LSS and not billed using a fusion code this wouldn’t be an issue. But then again no one would be putting those devices in if it wasn’t for the $$$.
I’m certain that part of what fueled this statement is all the KOLs talking trash about surgery and calling themselves surgeons. They are all so caught up in self promotion on social media. There is little exchange of useful information. If you are connected with spine surgeons on LinkedIn have a look at their posts. Difficult cases and useful discussion amongst colleagues regarding options, etc.
 
drusso said:
It's a shot across the bow and it will not be tolerated. It's time for pain doctors to step up and open their hearts, minds, and most importantly their wallets to shut down this kind of fear-mongering/turf wars. Time to speak with one voice.
Click to expand...
drusso said:
No. They wanted to help patients.
Click to expand...

... so start a new society instead?
 
NJPAIN said:
I’m certain that part of what fueled this statement is all the KOLs talking trash about surgery and calling themselves surgeons. They are all so caught up in self promotion on social media. There is little exchange of useful information. If you are connected with spine surgeons on LinkedIn have a look at their posts. Difficult cases and useful discussion amongst colleagues regarding options, etc.
Click to expand...

I do wish there was more of that thought-provoking intellectual conversation on LinkedIn and other social media. We just look like salespeople when docs post a picture holding the packaging of the stim/device they just implanted standing next to their rep. It’s a bad look for the entire field.

At the last ASPN meeting during the panel discussions there was good conversation about all of these different devices. I just wish that some of the people on the stage would’ve asked those heavy hitting questions about the effectiveness of these therapies or critiqued the research being cited.
 
Propofool123 said:
I do wish there was more of that thought-provoking intellectual conversation on LinkedIn and other social media. We just look like salespeople when docs post a picture holding the packaging of the stim/device they just implanted standing next to their rep. It’s a bad look for the entire field.
Click to expand...
I find bragging about doing your first case really bizarre. Patients don’t want to see that they’re your test case…
 
Taus said:
Good. About time.

we/pain docs went from complaining about surgeons over-utilizing fusions to doing it ourselves Bc companies would train us and we could bill for it.

I see multiple LinkedIn posts per day of pain docs doing a fusion for axial low back pain. High-fiving about “stabilizing spines”. And multiple 2nd opinion consults/month in my office for same. Fusion for axial pain, with rare exception, doesn’t work well when surgeons do it. Why the f would it work when a pain dr does it… poorly…

I just saw a consult yesterday for a 2nd opinion. Healthy 70yo with a mobile spondy and 2 level severe stenosis. Severe neurogenic claudication. Can’t walk a half block. She wanted to see if there was anything else that can be done for her. She “already had a fusion” and her pain dr had rec’d scs trial as next option. She had one of those new doodads implanted bw her spinous processes. She was very happy to hear that her problem can actually be fixed. Surgical consult Monday.
Click to expand...
Hopefully she isn’t seeing Alex vacarro for her sake and probably yours
 
My first consult this am…. 50yo. Has L45 gr1 listhesis with severe stenosis (degenerative superimposed on congenital stenosis). Has had a mild and Vertiflex combo…. Was getting shots q2mo last several years. At least the bs pain creams, in house dme and uds didn’t physically harm patients or deprive them of proper medical care. This is disgusting.
 
Taus said:
My first consult this am…. 50yo. Has L45 gr1 listhesis with severe stenosis (degenerative superimposed on congenital stenosis). Has had a mild and Vertiflex combo…. Was getting shots q2mo last several years. At least the bs pain creams, in house dme and uds didn’t physically harm patients or deprive them of proper medical care. This is disgusting.
Click to expand...

She is fortunate to be in your office. You know that she was headed either to someone who would remove the Vertiflex and replace with a posterior interspinous fusion device or stim and “ save” her from a fusion. Frequently a structural problem requires a structural fix.
 
Taus said:
My first consult this am…. 50yo. Has L45 gr1 listhesis with severe stenosis (degenerative superimposed on congenital stenosis). Has had a mild and Vertiflex combo…. Was getting shots q2mo last several years. At least the bs pain creams, in house dme and uds didn’t physically harm patients or deprive them of proper medical care. This is disgusting.
Click to expand...

She could be Zipped?
 
BobBarker said:
So you think a L4/5 fusion and decompression is going to fix this?
Click to expand...
BobBarker said:
So you think a L4/5 fusion and decompression is going to fix this?
Click to expand...
Yes. Yes I do. Not all surgeons suck. Not all patients end up the messes we see in chronic pain. This patient should do great with a single lami and mis fusion.
 
lobelsteve said:
Yes. It is the standard of care for this.
Click to expand...
I’m playing devils advocate. I send a large amount of surgical referrals out. I think if she isn’t incredibly tight at L4/5 there was really no harm in the mild/Vflex conservative treatment. Worth a try vs fusing a 50 year old and the inevitable adjacent segment disease. Congenital stenosis is tough and she will have multiple spine surgeries in her lifetime.
 
ateria radicularis magna said:
For those performing vertiflex or minuteman or zip or the others, will this statement change your practice?
Click to expand...
Not really. I work in a multidisciplinary clinic with 3 neurosurgeons, 2 interventional pain, and 1 physiatrist that does med management. I have approached the surgeons on every Vertiflex I have done to see if they wanted to do a lami, ect. Most of mine are >75 years with multiple comorbidities and the surgeons generally don't want to touch them. I can do the case in 15-30 min under sedation.

In fact, they have referred patients to me for the procedure.

I don't do a lot (I think 12 so far) and am pretty selective. I try to stay in my lane but have great partners who see the benefit.
 
jj337 said:
Not really. I work in a multidisciplinary clinic with 3 neurosurgeons, 2 interventional pain, and 1 physiatrist that does med management. I have approached the surgeons on every Vertiflex I have done to see if they wanted to do a lami, ect. Most of mine are >75 years with multiple comorbidities and the surgeons generally don't want to touch them. I can do the case in 15-30 min under sedation.

In fact, they have referred patients to me for the procedure.

I don't do a lot (I think 12 so far) and am pretty selective. I try to stay in my lane but have great partners who see the benefit.
Click to expand...
I agree with you on this situation. Vertiflex for old claudicators is not arthrodesis and not who many pain docs are putting in bs fusions for
 
Agast said:
Well this is terrible. One of our spine surgeon's patient just had what sounds like a minuteman done poorly by a local pain physician. Next day to ER, found to have internal bleeding. Expired within 3 days of procedure in kidney failure needing dialysis with GI bleeding. Lawsuit likely pending.
Click to expand...

Wow that’s awful
 
Agast said:
Well this is terrible. One of our spine surgeon's patient just had what sounds like a minuteman done poorly by a local pain physician. Next day to ER, found to have internal bleeding. Expired within 3 days of procedure in kidney failure needing dialysis with GI bleeding. Lawsuit likely pending.
Click to expand...
Wow. Terrible indeed. Sorry to hear. How tf that happen? Wasn’t an alif…
 
Agast said:
Well this is terrible. One of our spine surgeon's patient just had what sounds like a minuteman done poorly by a local pain physician. Next day to ER, found to have internal bleeding. Expired within 3 days of procedure in kidney failure needing dialysis with GI bleeding. Lawsuit likely pending.
Click to expand...

Yikes
Doug Beale said “you have more chance of putting this in the brain than in the kidney”. I guess that’s not true. Regardless it would be very educational to know where/how this went wrong.
 
Agast said:
Well this is terrible. One of our spine surgeon's patient just had what sounds like a minuteman done poorly by a local pain physician. Next day to ER, found to have internal bleeding. Expired within 3 days of procedure in kidney failure needing dialysis with GI bleeding. Lawsuit likely pending.
Click to expand...
Didn’t see this and I binge watch Linkedin.
 
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