Vertiflex setup - clinic or ASC?

[mja75]

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Hey guys, would you recommend doing Vertiflex in the clinic? Ideally Id do them in ASC but wondering about the safety of doing them in a regular procedure room in clinic. Do you find yourselves needing Bovie?

 

[BobBarker]

You can only perform vflex in the HOPD and ASC due to CPT location restraints.

But never use bovie

 

[mja75]

You can only perform vflex in the HOPD and ASC due to CPT location restraints.

But never use bovie

I appreciate your input. Why do you recommend against Bovie?

 

[BobBarker]

It isn’t necessary. the final dilator tamponades the majority of the bleeding. You can’t see to bovie down by where the device is. I just dump some local with epi in the hole and close.

 

[deleted993114]

It isn’t necessary. the final dilator tamponades the majority of the bleeding. You can’t see to bovie down by where the device is. I just dump some local with epi in the hole and close.

I am somewhat conflicted about learning about this procedure and performing it. The article I could find with a head-to-head comparison of X-stop vs Vertiflex showed they are about the same. We (with one of our neurosurgeons) did several X-stops in the past and they did not seem to work well. With a procedure that shows equivalence to X-stop, I don't know when I would ever do it, but is just one of those things that it is good to know how to do.

Medtronics dumped X-stop for a reason and I am just wondering if Vertiflex will suffer the same fate.

Interestingly, when we went to learn about X-stop, the MRI images shown for their cases did not meet criteria for lumbar stenosis. In fact, looking at the MRIs, I remarked that I probably would not have even done a lumbar epidural steroid on them.

Jim Weisntein's article on surgical vs conservative care clearly showed a lumbar lamy to be superior (and he hates all spine suregery). I just wonder when we have a highly effective, easy surgery like a lumbar lamy for stenosis whether some of these new devices for treating stenosis are akin to perfecting methods of making sealing wax.

 

[SSdoc33]

Jim Weisntein's article on surgical vs conservative care clearly showed a lumbar lamy to be superior (and he hates all spine suregery). I just wonder when we have a highly effective, easy surgery like a lumbar lamy for stenosis whether some of these new devices for treating stenosis are akin to perfecting methods of making sealing wax.

short term superiority of laminectomy -- 2 years -- but no difference in ODI. no mention of adjacent level disease, post operative spondylolisthesis, etc.....

 

[drusso]

I am somewhat conflicted about learning about this procedure and performing it. The article I could find with a head-to-head comparison of X-stop vs Vertiflex showed they are about the same. We (with one of our neurosurgeons) did several X-stops in the past and they did not seem to work well. With a procedure that shows equivalence to X-stop, I don't know when I would ever do it, but is just one of those things that it is good to know how to do.

Medtronics dumped X-stop for a reason and I am just wondering if Vertiflex will suffer the same fate.

Interestingly, when we went to learn about X-stop, the MRI images shown for their cases did not meet criteria for lumbar stenosis. In fact, looking at the MRIs, I remarked that I probably would not have even done a lumbar epidural steroid on them.

Jim Weisntein's article on surgical vs conservative care clearly showed a lumbar lamy to be superior (and he hates all spine suregery). I just wonder when we have a highly effective, easy surgery like a lumbar lamy for stenosis whether some of these new devices for treating stenosis are akin to perfecting methods of making sealing wax.

Sounds like you're making an argument for MILD.

 

[pmrmd]

Jim Weisntein's article on surgical vs conservative care clearly showed a lumbar lamy to be superior (and he hates all spine suregery). I just wonder when we have a highly effective, easy surgery like a lumbar lamy for stenosis whether some of these new devices for treating stenosis are akin to perfecting methods of making sealing wax.

Sometimes a laminectomy isn't the answer. Someone with stenosis and a grade 1 slip, who the surgeon would want to instrument with the lami. Vertiflex is the easy choice here. Two level stenosis that surgeon may want to instrument? Vertiflex first. 80 year old patient? Vertiflex. Bad COPDer or other comorbidity? Vertiflex.

I send people for lami when its the right decision for them and it makes sense to do so.

 

[deleted993114]

Sounds like you're making an argument for MILD.

In my opinion, and according to the literature, neither one of these treatments is an effective answer for lumbar stenosis. We have a lumbar laminectomy, which is far superior to conservative care, as a reliable, effective option for patients with stenosis.

For anyone who has scrubbed in on a lumbar lamy, the reason these minimally invasive procedures do not work becomes obvious rather rapidly.

I am all for new procedures, but the pain community has the bad habit of implementing "new" treatments in the absence of a reliable body of medical literature. Thus, we move from one failed procedure to another, contributing to the lack of credibility that pain management has acquired.

 

[deleted993114]

Sometimes a laminectomy isn't the answer. Someone with stenosis and a grade 1 slip, who the surgeon would want to instrument with the lami. Vertiflex is the easy choice here. Two level stenosis that surgeon may want to instrument? Vertiflex first. 80 year old patient? Vertiflex. Bad COPDer or other comorbidity? Vertiflex.

I send people for lami when its the right decision for them and it makes sense to do so.

I 100% disagree.

1. Vertiflex has been shown to be "not inferior" to X-stop (which did not work).
2. If someone has a spondylolithesis and stenosis, they need a decompression and fusion if they have persistent symptoms. Why? When there is still movement from the slip, there will be a progression of stenosis, necessitating surgery at some point. Why in the world would you want to put in a marginally effective device when you can do the definitive treatment.
3. Poor health is not a reason to implement a marginally effective treatment. I have never seen a single X-stop patient improve long term (and God knows we did a bunch)
4. Put a stim in those patients who are not candidates for a lamy (for whatever reason). At least you can control their neuropathic pain.

It would be helpful to attend NASS meetings, as you hear more evidence based, rational treatments for pathology of the spine.

 

[Ducttape]

just as a side note, and you read articles too, but "not inferior" is much easier to prove and what is required by FDA to approve new treatments. ergo that phrase as opposed to "clinically superior" to standard care.

 

[pmrmd]

I 100% disagree.

1. Vertiflex has been shown to be "not inferior" to X-stop (which did not work).
2. If someone has a spondylolithesis and stenosis, they need a decompression and fusion if they have persistent symptoms. Why? When there is still movement from the slip, there will be a progression of stenosis, necessitating surgery at some point. Why in the world would you want to put in a marginally effective device when you can do the definitive treatment.
3. Poor health is not a reason to implement a marginally effective treatment. I have never seen a single X-stop patient improve long term (and God knows we did a bunch)
4. Put a stim in those patients who are not candidates for a lamy (for whatever reason). At least you can control their neuropathic pain.

It would be helpful to attend NASS meetings, as you hear more evidence based, rational treatments for pathology of the spine.

I would say:
1. Do a case or two and judge the outcome. It works and works well.
2. Listhesis is usually stable. I would ask you why in the world you would subject someone to fusion/instrumentation/bracing for 3 months/8 weeks of P.T./etc instead of a 30-45 minute procedure that provides a similar outcome?
3. You are doing your patients of marginal health a disservice if it’s surgery or nothing.
4. You won’t do a stim anymore for claudication after Vertiflex. You won’t want to put your patient through that hassle and difficulty.

Your entire post is based on presumption of equating one treatment with an entirely different one.


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[lobelsteve]

I would say:
1. Do a case or two and judge the outcome. It works and works well.
2. Listhesis is usually stable. I would ask you why in the world you would subject someone to fusion/instrumentation/bracing for 3 months/8 weeks of P.T./etc instead of a 30-45 minute procedure that provides a similar outcome?
3. You are doing your patients of marginal health a disservice if it’s surgery or nothing.
4. You won’t do a stim anymore for claudication after Vertiflex. You won’t want to put your patient through that hassle and difficulty.

Your entire post is based on presumption of equating one treatment with an entirely different one.


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doing a case or two is complete bs. Thats not science

 

[pmrmd]

doing a case or two is complete bs. Thats not science

True.


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[Ferrismonk]

Effectiveness of surgery for people with leg or back pain due to symptomatic spinal stenosis | Cochrane

www.cochrane.org

 

[Ducttape]

better yet is to review the SPORT study.

Systematic Review of Outcomes Following 10-year Mark of Spine Patient Outcomes Research Trial (SPORT) for Spinal Stenosis - PubMed

3.

www.ncbi.nlm.nih.gov

we have reviewed this in the past. originally released in 2006-2008, there was variability but there appeared on the initial analyses to be no difference between surgical intervention and non-operative intervention.

when the formal reports did come out, for spinal stenosis arm, there was clinically significant benefit. (the other 2 arms were disc herniation and degenerative spondylolisthesis)

follow up studies done by the same authors at 4 years showed persistent benefit, but at 8 years there was crossover so that there was not clinically significant difference between operative and non-operative candidates.

this was not a randomized study because patients obviously knew they were having surgery.

 

[PinchandBurn]

I 100% disagree.

1. Vertiflex has been shown to be "not inferior" to X-stop (which did not work).
2. If someone has a spondylolithesis and stenosis, they need a decompression and fusion if they have persistent symptoms. Why? When there is still movement from the slip, there will be a progression of stenosis, necessitating surgery at some point. Why in the world would you want to put in a marginally effective device when you can do the definitive treatment.
3. Poor health is not a reason to implement a marginally effective treatment. I have never seen a single X-stop patient improve long term (and God knows we did a bunch)
4. Put a stim in those patients who are not candidates for a lamy (for whatever reason). At least you can control their neuropathic pain.

It would be helpful to attend NASS meetings, as you hear more evidence based, rational treatments for pathology of the spine.

Spondylolithesis doesnt necessarily translate into needing surgery and instrumentation. I talked to a neurosurgeon that does both functional neurosurgery and deformity . He also does vertiflex.

He stated Spondy Grade 1 and on ext/flex films if theres less than 3mm movement vertiflex all day long (with mild to moderate stenosis). Grade 2 and beyond is potentially surgical. Also if Grade 1 but with more than 3mm of translational movement, go surgical. IF severe stenosis--potential surgical as well.

So I think it really depends.

I think there's very little downside and the potential for the ESIs to last longer and potentially obviate the need for ESIs for awhile. In the right patient, it could be beneficial.

 

[thecentral09]

I would be curious what others who are doing this routinely are seeing results/ complications wise