10 Spine Surgeons on Bringing Innovation to the Operating Room


Ten spine surgeons talk about the methods for bringing new techniques or innovations to the operating room. Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses. Next week's question: In what ways (if any) are you preparing for ICD-10?

Please send responses to Heather Linder at hlinder@beckershealthcare.com by Wednesday, May 8, at 5 p.m. CST.

Robert Watkins, Jr., MD, Co-Director of Marina Spine Center, Marina Del Rey (Calif.) Hospital: One of the great benefits of practicing spine surgery in America is the wide range availability of new technology. Innovative technology allows spine surgeries to be performed less invasively, more safely, and with enhanced outcomes. At the Marina Spine Center, our methodology for utilizing new technology consists of evaluating the existing research, trialing the instrumentation in a lab and discussing the technology with other surgeons and engineers.

Ultimately, the final test question that determines whether we will introduce a new technology to our practice is "Would we want this new technology used on us if we were a patient?" If the answer is "yes" then we discuss the technology with our patients and make a joint decision on whether to use it in the surgery. We review our results on a regular basis. Hopefully, we will continue to have access to the greatest technology in the world to treat our patients in the future.

Jeffrey Wang, MD, UCLA Spine Center: For me, it is a combination of multiple factors. First, the new technology needs to make sense. Next, I need to see some evidence of efficacy. Whether it's ideally randomized controlled prospective studies or some high quality independent preclinical studies, the evidence needs to be in existence. The cost then needs to be justified to provide an appropriate cost/benefit ratio. Next, I work with the hospital to ensure that the charges for the new technology seem appropriate, and compare it to the currently available technologies to ensure that relative pricing is appropriate.

The key is to work with the hospital and the new technology evaluation committee to vet the process, ensure that it is reasonable and confirm a small trial of the technology. Then, after a reasonable number of procedures are finished, we review the results to ensure that it is safe, effective and that there were no hidden costs. I think surgeons need to work within the current systems that are in place at their institution in order to create a reasonable, logical process to bring new technology into the operating room.

Kern Singh, MD, Rush University Medical Center, Chicago: I have created a healthcare incubator involving several physicians, private equity manager and a patent attorney. Costs are contained by not charging for sweat equity. No outside funding is raised and products are developed through collaborative efforts.

Jeffrey Goldstein, MD, Director of Spine Service, NYU Langone Medical Center's Hospital for Joint Diseases: When considering new technology, I am looking for innovative approaches to treat patient problems or solutions which address deficits in present treatments. Occasionally new technology is so innovative that it "reinvents the wheel" such that it accurately identifies and solves a problem that I didn't know existed by thinking outside of the box. Other technologies may look at a problem which has a treatment which is technically challenging and look for alternative treatments which are potentially safer. An example would include osteotomies for sagittal malalignment and alternatives such as hyperlordotic interbody devices.

Operating room committees would prefer revolutionary devices or procedures which come without a premium price as opposed to evolutionary technology. From a financial perspective, technology that provides equal or better patient care outcomes at lower costs is certainly appealing. The problem often is that new technology comes with a price. Companies with existing presence in the marketplace anticipate a premium for research and development, even for evolutionary changes. New companies can gain entrance into the marketplace by providing a new technology and discounting it against the market leaders.

Richard Kube, MD, Spine Surgeon, CEO and founder of Prairie Spine & Pain Institute, Peoria, Ill.: We are constantly analyzing new techniques and technologies. When we have identified something we want to implement, we spend time getting comfortable with the product. This could mean literature, case simulation or cadaver labs. We try to have a reasonable knowledge of what we will be facing prior to going to the operating room. We also see that our OR staff has comprehensive training and a level of comfort before bringing new things to the OR. Once we feel we have all done our homework and can safely implement with a live case, we bring in the new procedure. We look for support from the vendor when we go live, and we allow for extra time so that we can be very methodical.

Andrew Cordover, MD, Spine Surgeon, Andrews Sports Medicine and Orthopaedic Center, Birmingham, Ala.: As we care for patients, it's important that physicians and surgeons use the best possible technique for each individual patient. My methodology includes discussing with each patient the options they have and deciding together what operation and technique is best for them. I think there is a time and place for innovative operations, and I certainly use these when applicable. But I also find it necessary to examine every aspect of a patient's life, including the recovery time, financial impact and rehabilitation needs of each procedure. This is an important aspect of our job that can be sometimes left behind in the excitement of new and innovative operations.

Walter Eckman, MD, owner of Aurora Spine Center, Tupelo, Miss.: The most important point is to avoid fads and the latest procedure du jour. We see so much confusion in the spine surgery world by newly-proposed treatments and surgery which end up failing when tested by time. Many of these are playing on trends such as the fascination with minimally invasive surgery, yet I think could be inadequate when tested against our knowledge and experience. One of the biggest flaws is surgeons relying on company representatives bringing them "new and fascinating" devices. Realize that these folks are salesmen and generally do not have any ability to truly evaluate the technology they are trying to bring. Sometimes company-aligned physicians promote new ideas which are based more on potential financial return for them.

It is vitally important that we learn and develop new ways to do things, and yet we have to use a lot of judgment and common sense to choose changes to be made. In addition, for the sake and safety of our patients we have to be prepared to follow the results of new techniques in our own hands with enough uses to know the value. (To get a feeling for this responsibility each surgeon should try to do a power analysis for one or two proposed changes to see how many cases are needed to evaluate the results. Fear false contentions.) In spite of these difficulties we all have to strive to change what we do for the better. A stale spine practice is going to be a dying spine practice.

Amir Vokshoor, MD, Neurological Spine Surgeon, DISC Sports & Spine Center, Marina Del Rey, Calif.: As minimally invasive techniques in spine surgery have progressed, many innovative technologies have been introduced to enhance the precision of the surgery, add a factor of safety (i.e., addition of surgeon-driven neuromonitoring), and minimize the approach-related morbidity of these surgeries.

For me, it is of utmost importance to utilize a patient-safety oriented algorithm to introduce these technologies into the operating theater. From a technical standpoint, I look at how seamless and intuitive the new technology is to the average surgeon, which can be incorporated into their practice easily. I also evaluate the overall cost of the new technology in as comprehensive of a manner as possible. If we were to use the simplest method to evaluate new innovations, I would designate:

1. Is it making a surgery any easier (surgeon-friendly with an understandable learning curve) than the traditional approach?
2. Is it providing the patient with any additional corridor of safety or providing less anesthetic time or lessening the approach-related morbidity when compared to the traditional methods?
3. What is the overall cost consideration of this as opposed to other innovative technologies?

If they are providing additional precision safety or lessening the operative time, they should also, ideally, make the overall care of the patient cost-effective. And they often do, in a true comprehensive analysis including length of stay, blood loss, the rate of reoperation and/or complications. This is a very difficult factor to analyze or prove in a complex healthcare environment. I think an honest analysis of the cost-benefit ratio in the operating room is a key factor in any method of introducing new innovative technologies.

A great example of the above methods is the addition of intraoperative navigation to introduce higher levels of precision in spinal surgery for deformities. Although this may initially increase the cost of the operation, and even possibly the time anesthetic, the overall cost reduction with regards to decreasing complications from malpositioning of hardware, as well as decreasing fluoroscopy exposure time for the operating room staff, may be a worthwhile endeavor. This, however, could prove to be a very complex cost-benefit analysis.

Dr. Neel Anand, MD, Director of Spine Trauma, Cedars-Sinai Spine Center, Los Angeles: First, we need to evaluate the technique for the potential clinical value it brings to spine care. Then I would determine based on my experience whether this would be safe and judicious after participating in several cadaver labs with the instrumentation or technology. I would then apply to the OR committee at the hospital and request permission to use the instrumentation or technology. Finally, if all things go smoothly and the technology shows incremental benefit to what we are already using, then I would begin to use it more frequently as part of my regular surgical armamentarium.

Purnendu Gupta, MD, Medical Director, Chicago Spine Center at Weiss Memorial Hospital: As a medical student, I was captivated by the field of spine surgery due to the many innovations and vast frontier of techniques that were emerging. Even today we are learning more about the intriguing complexity of spine surgery and developing better techniques for treatment of various spinal disorders.

When innovative techniques emerge, my first approach is to understand the research behind the techniques and the existing clinical experience and case series reported by the innovator. Many times this occurs informally or formally at one of our scientific meetings — North American Spine Society, Scoliosis Research Society or International Meeting on Advanced Spine Techniques. Discussions and forums at these meetings are a good initial glance at a new technique.

Before embracing a new technique in the operating room, I consider visiting the surgeon innovator or attending a workshop with hands-on training. From this step forward, I think it is important to very carefully select the right patient. Many times wonderful techniques come out but are used without the appropriate surgical indications, which can lead to poor results.

In the operating room, it is essential that the staff be well prepared and appropriately versed in any new equipment that may be necessary. Many times before performing a new technique, we may do a trial run in the cadaver lab at a medical school.

And lastly, when the technique is implemented, it is extremely important to critically evaluate the outcome. When embracing new technology and techniques, we should always confirm that we are improving patient care and outcomes. In the final analysis of a new technique we should look at the long-term outcome at two years and at five years, which will ultimately give us a rigorous review of success.

More Articles on Spine:
5 Orthopedic & Spine Practices Expanding or Merging
5 Ideas for Spine Practice Growth in Today's Healthcare Market From Dr. Michael Hisey
ISASS Surgeons Present Study of Fusion as Back Pain Treatment Option

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