Where is Spinal Fusion Headed? Q&A With Dr. Mark Crawford of ABQ Health

Mark Crawford, MD, is a spine surgeon with Albuquerque, N.M.-based ABQ Health Partners. His practice focuses primarily on adult spine degeneration; he has been performing spinal fusions for 15 years. Throughout Dr. Crawford's years of practice, he has seen many changes in the way fusions are performed and the devices used to assist the procedures.

Here's Dr. Crawford's take on how fusions are changing and what challenges remain.

Question: What are the biggest changes you've seen in spinal fusion?

Dr. Mark Crawford: I've seen a lot of change with the introduction of new biomaterials.  Spine surgeons have been performing the same type of fusion procedure for a very long time. While the procedure has primarily stayed the same, spinal fusion devices are rapidly evolving as physicians and vendors recognize the role of new biomaterials in the fusion process.  Some biomaterials, such as silicon nitride, can provide distinct advantages to surgeons and patients in comparison to Titanium and PEEK-based devices.

I've been using silicon nitride implants for interbody fusions for the past three years. Silicon nitride is bioactive in that the bone can grow into the device itself, as opposed to PEEK, which is a plastic spacer that doesn't actively participate in the fusion process. There have been some cell culture studies that have shown grown osteoblasts on silicon nitride and titanium and PEEK. The osteoblasts are much more biologically active on the silicon nitride, meaning that silicon nitride actually helps increase the bioactivity going on as part of the fusion.

Silicon nitride has also been shown to have significantly improved anti-infective properties. It also has great radiographic characteristics, as opposed to metal, and shows no artifact at all on an MRI or CT. This makes post-op imaging much easier and more effective.

Q: What will future spinal fusion techniques look like? Will they be solely reliant on biomaterial?

MC: The whole role of biomaterials is still in its infancy. As it grows, we may have better ways to obtain fusion or even repair discs, eliminating the need for fusion. Surgeons are still doing the same procedure as 100 years ago, except with vastly improved devices. But we are still trying to achieve a bony fusion. Fifty years ago we used to do fusions for hip and knee arthritis. We now do joint replacements. Unfortunately, we have not seen the same results with disc replacement in the spine and continue to rely on fusion to obtain pain relief.

Q: How do you approach novel technologies?

MC: We are definitely incorporating evidence-based medicine more and more. Even the most recent studies that looked at the data on the Medtronic Infuse found that bone grafting is still as good as Infuse. Device companies keep coming out with more expensive things, but surgeons keep coming back to a patient's own bone as the most effective means to obtain fusion.  

I have no specific time frame for adopting a new device. If something is innovative, reduces patient risk and makes the procedure more effective, I'm more likely to adopt it. Most importantly, I want to deliver safe patient care. That means exploring innovative devices that are proven safe and effective.

Q: What role do reimbursement challenges play in your practice?

MC: The finances are becoming more and more important, and payers are paying a lot more attention to what's being utilized. In many cases, they are influencing that by refusing to pay for devices that haven't shown clinical efficacy. The payer is playing a bigger role in this and that is likely to continue.

I think in some of those difficult situations where you think the patient will benefit, get on the phone and call the medical director [at the insurance company]. Have a one-on-one about what you're trying to accomplish and what the situation is. Most times I've found that's effective. They are not trying to regulate care; they are just trying to make sure that it's financially efficient, with good reason. With a specific case that warrants something that is not traditional, having that conversation can often solve the problem.

Q: How do you approach patients who need a fusion surgery?

MC: The most important part of the whole process is to spend time with patient and make sure that everything in the non-operative realm has been tried and failed before even considering fusion surgery. Then you must get the patient to have reasonable expectations regarding the outcome. Fusion is not perfect, but it can solve the majority of the patient's problems or decrease the need for medications and increase quality of their life, then everybody is a lot more satisfied.

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