Minimally invasive spine surgery is advancing, and single-position techniques will significantly push patient care forward, according to two spine leaders with Och Spine at NewYork-Presbyterian in New York City.
Andrew Chan, MD, and Dean Chou, MD, spoke with Becker’s about lateral transpsoas and antepsoas approaches and where they fit in the larger spine care landscape.
Note: This conversation was lightly edited for clarity and length.
Question: How has mastering lateral transpsoas and antepsoas approaches changed your decision-making with complex spine cases?
Dr. Andrew Chan, director of minimally invasive scoliosis surgery: It’s completely changed the game. We are always trying to do something as efficacious or more, but more minimal. That’s exactly what lateral surgery is. Traditional spine surgery involves opening up the patient with a big midline incision in the back with muscular dissection and going out wide by taking down the bone joints. If we’re doing an interbody fusion, we’re placing a cage through that way, as opposed to doing that in lateral access surgery where we can use a 1-inch incision on the side to put in a very large cage. We can use cages that are much bigger than the ones you can put in from the back so it’s more biomechanically stable, and it lets increase the disc height and the central canal’s size as well because we’re often treating stenosis with just that cage.
It’s not just about the small incision size, but we’re not opening up the back muscles. We’re not tearing down the ligaments and different things in the back to do that, so that we’re preserving all those structures at the same time. There’s a lot of advantages there that make this more efficacious, but then less invasive.
Dr. Dean Chou, chief of spine division: Lateral surgery has changed the whole game of how surgery makes the patients better. In terms of spine surgery, I’ve operated on [active patients], and all these very high functioning people go back to great lives. I think that having the lateral approach makes it so much less invasive and so much less than the orbit of a procedure. And it makes sense, because it’s basically a natural corridor of the human body. But at the same time, you get huge surface coverage to really reconstruct the anterior column of the spine. And to take a step back, as you know, the majority of the way that the human torso is born by the anterior column of the spine. So you want something really strong to hold up the torso.
Q: Where do you see the biggest learning curve for surgeons who want to transition to performing these procedures and minimally invasive surgery as a whole?
AC: Most traditional surgery is with the posterior approach. So when you are doing this from the side, it’s a whole new anatomy. And if you’re doing it the way that Dr. Chou and I can do here at NewYork-Presbyterian where we can have people in a single position, it’s a whole new position. There’s a lot of things that you’re going to need to learn and make sure to do safely. That’s one of the big things that people will need to do before they can adopt this procedure.
DC: I think the learning curve is very doable, and it’s very feasible, even for surgeons who are in practice. I learned all my minimally invasive techniques after I was done with the training. I think having the fundamentals of spine surgery first are critical, whether it’s open or interior posterior. But I do think that afterwards, if people really want to learn and adopt these techniques, it can be done in a very safe, safe manner.
Q: Is there anything unique at Och Spine that has helped you leverage these techniques and grow?
AC: It’s the willingness of NewYork-Presbyterian and Och Spine to find to adopt new technologies to work with because there’s only certain vendors that do the lateral approach surgeries at a high level. A lot of places, especially in the current climate, are trying to clamp down on the number of companies that can represent spine instrumentation at certain hospitals. Sometimes, if you don’t make the cut at a hospital, you may not have one of the large lateral companies that can be accessible to the surgeon at all. So it’s nice that we work at a place that is pretty open to new technology if it’s going to be better for the patient.
DC: I think the vision of NYP and Och Spine is that it wants to be comprehensive with the breadth and depth of different specialties in spine. That really helps because if we’re known for one procedure but not another, they make sure that they develop or hire or grow so that we’re experts in all of these fields. Having the willingness to cover the entire gamut of spine, nonoperative and operative is a really nice vision.
Q: What other kinds of advancements do you think will best accelerate lateral and single position spine surgery in the next year and then in five years from now?
AC: Something recent is we have the ability to use patient-specific cages in these lateral surgeries. We have nice, broad implant coverage with wide cages and tall cages, but now we can have them fit perfectly at the end plates and design the perfect amount of lordosis we want in the spine.
The other thing that’s very important for some of the types of lateral surgery we’re doing is neuromonitoring. The vendors help out with this, and we’re improving our technologies with the neuro monitoring so that we can make these lateral approaches even safer. Year by year, we’re improving on the system and the ways we’re monitoring it. We have a very high-level neuromonitoring team, and they’re our partners in the operating room. Without a very high functioning team, that is very accurate, communicates in real time and is very meticulous, some of these surgeries would not be doable.
DC: The other thing is to really push this forward, is having really good outcomes data. And I think that is critical. Dr. Chan is a prolific, highly published person already. Having data outcomes and peer-reviewed literature showing that these procedures are advancing healthcare and spine surgery is so critical. That’s part of why Och Spine is so important, because of the collaborative nature of having multiple people working together to get these outcomes.
Q: How do you see lateral and single-position techniques fitting in the broader conversation we’re having about value-based care and spine?
AC: That’s basically the equation of value over cost if we want to boil it down. One, you have to prove that this is more efficacious. So far, we’ve given you all the rationale for why we think it is. Then the further advantages are what it could do in terms of efficiency and cost to further make that advantageous. That’s one of the things that single position surgery is really helpful for and that’s whether you do it in the direct lateral position or the prone position. There’s an increased efficiency in the operating room. You’re eliminating that turn and flip of the patient, and depending on your move team that could be anywhere from minutes to hours. What can happen is that if you shorten that OR time, the anesthesia time, you can potentially do another surgery in a given day.
DC: Because you’re doing these procedures with less time and less anesthesia and less morbidity, hopefully the patients go home sooner and length of stay is going to decrease. I think that will also help increase value to the whole health system. But I think on multiple fronts, it’s overall, going to be a positive benefit.
