Advent of New Spine Surgery Approaches & Technologies

Podcast Transcript

Dr. Alex Rae-Grant: Neuro Pathways, a Cleveland Clinic podcast for medical professionals exploring the latest research discoveries and clinical advances in the fields of neurology and neurosurgery. Welcome to another episode of Neuro Pathways. I'm your host, Alex Rae-Grant, neurologist in Cleveland Clinic's Neurological Institute. In an effort to explore the latest advances in neurological practice, today we're talking with Dr. Mike Steinmetz about the latest developments in spine surgery, specifically minimally invasive spine surgery. Dr. Steinmetz is the Chairman of the Department of Neurosurgery and spine surgeon in the Center for Spine Health in Cleveland Clinic's Neurological Institute. Mike, welcome to Neuro Pathways.

Dr. Steinmetz: Thanks Alex. Happy to be here.

Dr. Alex Rae-Grant: Before we start Mike, tell us a little about yourself, where you're from, where you trained, and when did you begin your career at the Cleveland Clinic?

Dr. Steinmetz: Sure so I grew up in the Southwest. I lived the majority of my young life in El Paso, Texas. Never thought I'd ever leave the Southwest, but came up to the Cleveland Clinic to train in neurosurgery and put roots down and been here ever since. So I arrived here in 1999, left after residency to do a fellowship in Wisconsin, came back, and have never looked back. I'm going on 20 years here at the Cleveland Clinic.

Dr. Alex Rae-Grant: And I'm sure you're enjoying the weather.

Dr. Steinmetz: The weather is great. Yeah. It was a big change coming from the Southwest-

Dr. Alex Rae-Grant: Lots of change.

Dr. Steinmetz:  ... but now it's home.

Dr. Alex Rae-Grant: Kind of used to it.

Dr. Steinmetz: That's right.

Dr. Alex Rae-Grant: Well good. Well let's start off broadly. Can you define the term minimally invasive spine surgery for the audience?

Dr. Steinmetz: That's a great question and it's often misunderstood even amongst us in spine surgery and we really try to define what that means. But in a big picture view, what minimally invasive spine surgery is, really a difference compared to traditional surgery in just the approach. So what we're trying to do is to be minimally disruptive to the muscles and soft tissues of the spine, but to gain access to the spine. So in essence, we can do any type of surgery we could do open, but through a much, much smaller corridor to minimize the damage. Now what's important about this is when you talk to patients, they often view this as the skin incision. They want to have a “Band-Aid surgery”, a few millimeter incision, and that's minimally invasive, but for us the skin incision really doesn't hurt. It's not that relevant. It's really what we do to the muscles down below. In a traditional operation, you've got to strip the muscle off the spine, it can be very damaging, but in a minimally invasive approach, we dilate up the muscles slowly so we have minimal damage to create that corridor.

Dr. Alex Rae-Grant: Mike, we know that back pain is one of the most widespread health problems affecting many Americans. Can you describe what spine conditions are suitable for minimally invasive spine surgery versus open approaches?

Dr. Steinmetz: Sure. Again, another great question. Now you can pretty much do almost any surgery that we would do in a traditional open way, in a minimally invasive fashion, but if you've got this hammer so to say, with minimally invasive, not every patient is that nail for them. So there are differences with these approaches that we can do safely and it depends on what the patient is presenting for. So let me give you a classic example with a patient. I saw a patient who had a pretty significant spinal deformity and had very bad back pain. So to treat that with surgery, that involves reconstructive spine surgery with a lot of screws, rods, removing bone through an osteotomy. That is not a classic minimally invasive surgery. That's, in fact, a maximally invasive surgery. But what the patient came to me for was a minimally invasive endoscopic foraminotomy, which is what they were told they needed. So it's not an issue of could it be done for the patient, it was just the wrong operation for that patient. Hopefully I'm answering that correctly. We can almost do anything open, minimally invasive, but there are specific indications for it, when it works well, when it shouldn't be done from a safety standpoint, so we've got to individualize that patient and the technique. It's not a one trick pony, so to say, you've got to be able to customize it for the patients. And that's why coming to a center like ours, putting in a plug for our spine center where we do open and minimally invasive, we can try to design the correct operation for that patient, and if we can do it minimally invasive, we sure will offer it.

Dr. Alex Rae-Grant: So I can imagine with what you've said, if I had to have a spine surgery, I would think with the less traumatic approach that you guys do with minimally invasive, I'd be feeling better after the operation and be up and moving better. Is that the main benefit of the minimally invasive surgery? Are there other benefits we should talk about?

Dr. Steinmetz: Sure. I think what you just said is probably the biggest benefit of it, is theoretically, if I approach your spine in a less damaging corridor, I should lose less blood with the surgery and be less traumatic. So the thought is you'd have less pain in kind of that perioperative early outcome time point where you're up earlier, you're moving faster with less pain, I can get you back to work or get you back to life faster. So those truly are the biggest benefits. Now in the literature, people have shown less blood loss, less pain medication usage as well, but again, I think in my own anecdotal experience, it's getting patients up faster, out of the hospital quicker and not in big lumbar surgery, not as much blood transfusion as well.

Dr. Alex Rae-Grant: We always like to hear about the latest technology in medicine. What are some of the latest things that you have brought to bear in minimally invasive spine surgery?

Dr. Steinmetz: So there's probably two, if we're looking at the latest advances. One has been endoscopic spine surgery. Now, endoscopic spine surgery, meaning truly operating in the spine through an endoscope, has been around for many years, but it was largely, I'm going to call it a fringe procedure really, it wasn't done by traditional spine surgeons. It was kind of frowned upon because the techniques were done for probably not clear indications. The scope technology was not very good. The tools to be able to work through the endoscopes were not very good. And what we've seen probably in even the last five years has been some companies putting significant dollars in research and development into these endoscopic platforms. So now we have much better endoscopes, so our visibility and illumination is significantly greater, there's always been an issue of three-dimension or depth perception, but with modern endoscopes that's becoming less of a problem. And now we have a wide variety of tools that are available to work through the endoscope and allow us to apply this to a much greater number of patients and indications. My ability to not only do less invasive surgery, which is still cutting the skin, dilating up the muscles, putting a tubular retractor in and working through it, now I can do that through a much smaller endoscope. That is here now and we're using it. So what used to be kind of a fringe procedure and almost like shunned, is now being accepted and performed at big academic centers such as ourselves. And I think with R&D from industry, I think we're going to see a much greater application of these technologies moving forward. And again, I think there, you're talking about being able to do surgeries including fusion surgeries in a patient completely awake, so you can almost avoid general anesthesia with some of these. And so I think that that is on the forefront and that's going to continue to advance.

Probably the second biggest advance is robotics and we are way behind the other surgical subspecialties with robotics. The robots we have available in spine now, and there's probably three in the US that are available currently, are very basic. They're really a guidance arm that allows you to put screws in and it's very simplistic. But what we have today is not what these will be used for probably even five years from now. So we think about how we access the spine, how we get there through the abdominal corridor, through the spine, doing this minimally invasive, it's still a little bit challenging because we're doing it by hand. We're using often fluoroscopic imaging to do that. Now we're at a point where we could simulate or plan this operation on a robot and then use the robotic technology to gain access to the spine in a very minimally disruptive way, and then help us guide surgery. We could probably be able to drill bone safer, certainly place our hardware safer, our screws and rods, which is what it can do now. So I think this technology is just advancing significantly. What we can do today, very simple. What we're going to do five years from now, will be probably much more complex than it is now. We're just on the forefront. We just took one baby step into robotics and this is going to take off moving forward.
And I think the last thing, and these aren't the only three, but I think the other thing that is gaining a lot of foothold in spine as well as other subspecialties is the use of artificial intelligence. You know, spine is still one of those practices where it often has some of the art of medicine and not just a science, right? It's trying to take a patient, try to correlate the imaging to their symptoms, see if there's surgical design or surgery to treat it, and you're often guessing to some extent about some of these pathologies. With the advent of artificial intelligence and large patient data registries like we have at Cleveland Clinic, we can truly develop population-based predictive algorithms or predictive, software platforms that can help us take a patient in and before we even start talking with them, know, with fairly high degree of certainty if we did an operation, is it going to be effective? Maybe another surgeon in our group is more effective based on the predictive analytics, maybe doing it at one of our different hospitals in the main campus, so the power we have in being able to predict accurately patient outcomes with our interventions is only going to grow astronomically. So I think to me, those are three huge forefronts of spine surgery and really going to change the way we practice.

Dr. Alex Rae-Grant: It's really kind of an exciting time in that field.

Dr. Steinmetz: I think it is. Yeah. We were stagnant for a long period of time and the only thing that changed was really the technology, right? We've still, you know, choosing patients the same way, doing the same thing, but with some advances in how we do it. With the advent of robotics and predictive analytics, I think it's really going to change not only what we do, but how we choose those patients in a better way. And that's going to change our field forever.

Dr. Alex Rae-Grant: And so if I were a referring physician, what might be sort of the most appropriate patient type to be sending off to you guys to look at? Is there a particular group of people who particularly will benefit from this approach?

Dr. Steinmetz: From a surgical approach you mean?

Dr. Alex Rae-Grant: Yeah, yeah.

Dr. Steinmetz: Well, again, I think the patients that do the best in surgery are ones that have typically a condition that has been relatively short lived, differentiating, being someone who has three months of pain versus somebody with 15 years of pain that's now likely a chronic pain syndrome. So somebody who's condition is rather acute or sub-acute, who has had an adequate trial of conventional therapy, physical therapy, medications, injections, and is motivated to get better. That is probably the ideal candidate for surgery. And I contrast that with a patient who perhaps has been out of work for multiple years, who's on narcotics, who's had 15, 20 years of pain, that patient more likely has a chronic pain syndrome. We always say no matter what the pathology is, outside of a tumor or infection, but on the degenerative end and that patient surgery can't fix that problem. You need an advent of probably pain psychology and other modalities to try to get that patient better.

Dr. Alex Rae-Grant: And I know we've talked about surgery specifically in this segment, but obviously the spine center has those other capabilities and often does not approach things from a surgical point of view.

Dr. Steinmetz:  That's exactly right. If you look at the number of patients that come through our spine center, only a minority of those actually go on to have spine surgery. I think that's really what we try to highlight with our interdisciplinary spine team where we've got physical medicine and rehab doctors, we have interventionalists, we have general neurologists, pain psychologists, and those of us on the surgical realm. Number one is we can offer a patient almost anything they need from that, but also if someone comes through the door and sees me at surgery for a surgical opinion, but I think they should see a pain psychologist first and have other conservative modalities, those people are right here as well and willing to take him in and we keep them within our team and we're all talking to each other. And we think that approach is best for these spine patients.

Dr. Alex Rae-Grant: Anything else as a take home point for our audience? Anything else we should have them take away from this conversation?

Dr. Steinmetz: From the minimally invasive realm, I think that, again, these technologies are advancing. I think the main take home for that is these approaches are good for a number of patients, but they're not good for every patient. And so sending somebody on strictly for minimally invasive surgery, the patient may be offered it, but they may not because there's a more appropriate, safer approach to take. Technology is really advancing. It's a really exciting time. I think that what we can do and how we can predict it is really going to change moving forward and again, our team is multidisciplinary and happy to see anybody. We'll get them plugged in the system and be able to try to give them the most appropriate treatment even if it's not surgery.

Dr. Alex Rae-Grant: Well, thanks Mike. Thank you so much for joining us. I really appreciate your time and insights.

Dr. Steinmetz: My pleasure.

Dr. Alex Rae-Grant: This concludes this episode of our Neuro Pathways podcast. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast. Subscribe to the Neuro Pathways podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinics Neurological Institute on our Consult QD website, consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD, all one word. That's @C-L-E Clinic M-D on Twitter.

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