Lateral approach ADR, revisions, fusions
 

For the lunch breakout session on Friday, Diane and I attended Nuvasive's sesson on:

XLIF Approach - a Strategy for Degenerative Conditions and Safer TDR Revision

There were some amazing cases shown, all using Nuvasive's MAS (Maximum Access Surgery) platform that supports a set of products that allows eXtreme Lateral access for disc spaces from the throacic spine down to to L4-5. L5-S1 is not accessable (for the purposes of ADR or ADR revision) with this system. I'll get more details soon.

I first saw this system at a hands-on session at IITS (International Intradiscal Therapy Society) meeting in San Diego in 2005. At the time, there was no talk about lateral ADR. In 2006 at SAS and NASS, we started to see lateral disc designs including a PEEK lateral disc called Nubac. The small footprint and lack of fixation makes us worry about subsidence and migration.

During Fridays session, Dr. Pimenta presented some early experiences with a lateral disc (not Nubac) that seems very promising. I believe that we'll see even more working designs for lateral discs very soon, and we may already have them. Both ProDisc and Maverick come in oblique versions with and angled keel. I haven't seen them yet, but I would be surpised to discover that lateral versions of these implants don't already exist. LDR's Mobi-L has a keel that can be positioned for a lateral approach.

Other aspects of the lateral approach seemed (to me) to be be even more important that the potential application for a lateral disc. Dr. Pimenta presented several cases of large multi-level XLIF fusions for some extreme cases, including a 7-level procedure in a scoliotic patient. The very wide XLIF cages provide excellent stability and the easy approach allows the patients to go home VERY early. The 7-level procedure was done on a woman in her 70's and she asked to be released from the hospital the day following her surgery. Patients are up and about within a few hours of their surgery and many go home the same day. Anyone who's been through a traditional fusion will appreciate how incredible that is. Insurance companies and hospitals will appreciate the cost implications of faster surgeries with shorter hospital stays and lower medication use.

I was very impressed by the images of an L3-4 Maverick explantation via the XLIF approach. Dr. Pimenta's brilliant solution to this very complex and dangerous (via anterior approach) situation was amazing to watch. Low invasive lateral access. Osteotomy to remove a portion of the vertebral body to allow lateral removal of the upper plate. Removal of the lower plate. REPLACEMENT of the bone removed! Insertion of the XLIF cage. XLIF plate stabilizing the fusion on the access side. Minimally invasive placement of posterior instrumentation.on the side opposite side. AMAZING!!!

I look forward to getting much more info about this system... stay tuned.

Mark

PS... a quick google search yielded these results for XLIF:

http://www.texasspinecenter.com/en/cms/?341

http://www.freshnews.com/news/biotec...cle_32852.html

http://www.or-live.com/tgh/2330/index.cfm

Very interesting. Thanks Mark.

Dr. Regan told me about three years ago that he just returned from Brazil to learn a lateral ADR approach I think for higher lumbar levels. He was at work, bright and busy-tailed, despite that he flew in the night before e.g. no signs of jet lag/burnout.