Nine spine surgeons discuss total disc replacement and how they see the procedure developing in the future.
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.
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Note: The following responses were edited for length and clarity.
Question: How do you see total disc replacement developing in spine over the next five years?
Mark Mikhael, MD. NorthShore Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): I anticipate the number of cervical disc replacement cases to increase significantly over the next five years. There has already been an uptick in the last few years. The increase is likely due to published 15-year data showing CDR being more cost-effective and having a lower reoperation rate and better outcomes compared to anterior cervical discectomy and fusion. Despite these findings, many spine surgeons have been reluctant to adopt this procedure. But I expect more surgeons will recognize disc replacement's motion sparing technology as a better option for patients compared to the historically effective discectomy and fusion.
As surgeons gain more experience, they can expand to more levels and even skip levels in combination with fusions. I see surgeons broadening their patient selection beyond younger adults with limited arthritis. There are so many people with neck disc herniation as well as arthritis with bone spurs who can benefit from CDR. Fusions will never go away, but as more surgeons become aware of the long-term benefits of CDR and more experienced in performing it, more patients will likely benefit from it by 2025.
Neel Anand, MD. Cedars-Sinai Spine Center (Los Angeles): In five years, at least in the cervical spine for patients between 20 and 65, I think that total disc replacement will be the standard of care. Hybrid constructs in the cervical spine, where fusion is performed at a severely degenerated level and an artificial disc replacement at a less degenerated level will become commonplace too.
With the growing variety of cervical discs available, surgeons will also be afforded the incredible opportunity to choose the disc that best fits a particular patient's anatomy. In the lumbar spine, I believe artificial disc replacement will still be done selectively. I don't see much development over the next five years here, but I remain hopeful.
Fred Naraghi, MD. Klamath Orthopedic Clinic (Klamath Falls, Ore.): CDRs have an outstanding outcome and are likely going to be used more. Lumbar disc replacements, on the other hand, have a less predictable positive outcome.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Total disc replacement has the ability to preserve spine range of motion and minimize the chance of adjacent segment degeneration as well as the need for more spine surgery in the future. It also allows patients to recover and return to work and function faster. It has been shown to be very effective in the cervical spine. The data for lumbar spine disc replacement is not as robust, but I am sure as the implant design and techniques evolve, it will be shown to be just as effective as CDRs.
Over the next five years CDR will become more prevalent and offered to more patients. This will result in better surgical outcomes, postoperative function, quicker recovery and return to function as well as lower risk of subsequent surgeries in the future.
The main barriers for broader use of this technology remain insurance denials, low reimbursement rates and lack of surgeon training and acceptance. I hope these issues will continue to improve so that we can offer this amazing technology to more of our patients and improve their outcomes.
Harel Deutsch, MD. Rush University (Chicago): For the cervical spine, I believe growth will be significant in the next five years where more disc replacements will be done than fusions. For the lumbar spine, I foresee a slow growth because of lack of incentives for surgeons to do the procedure.
James Chappuis, MD. Spine Center Atlanta: I am in favor of the development of total disc replacement in the cervical spine. However, I still have significant concerns about its use in the lumbar spine. The main reason is because trying to revise a total disc replacement in the lumbar spine is almost always impossible anteriorly and the outcome for posterior fusions in that setting is also less than ideal. Additionally, the results of a one-level anterior lumbar interbody fusion today are extremely positive, and I would be concerned that long-term disc replacements would not be able to match those results.
Brian Gantwerker, MD. Craniospinal Center of Los Angeles: In our middle-aged and healthy 60-something patients, Medicare will be reconsidering their current local coverage determinations. Invariably, they will accept the good data out there that suggests patient outcomes are better and the long terms costs, related to reparation and adjacent segment disease is less. There will be a tipping point when most carriers will need to cover them and no longer be able to roll out the old 'experimental' excuse.
Payam Farjoodi, MD. MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): CDR has already been shown to be an effective treatment, and I believe we will continue to see an increase in the number of these procedures performed. More and more patients are educating themselves and requesting alternatives to fusion with CDR being an excellent one.
I feel there is also potential for lumbar disc replacement to increase in popularity, however we need to do a better job of determining the best indications for this procedure. The lumbar spine is more difficult to treat as our outcomes for lumbar versus cervical fusions demonstrate. I hope we can use good data to accomplish this in the next five years and make lumbar disc replacement an effective and reproducible surgery.
Issada Thongtrangan, MD. Microspine (Phoenix): I feel CDR will gain more popularity as the outcomes are superior to ACDF. However, I am not certain that is the case with lumbar artificial disc replacement.