ALPA Approach or XLIF?

[mmglobal]

I had a wonderful surprise yesterday. I got a message from Dr. Bertagnoli saying that he was going to be a LAX for a 5 hour layover on his way back from the MIIST conference in Hawaii. 4 hours of his undivided attention is tough to come by... there was no problem canceling other plans (was going to see David Beckham play for LA Galaxy... 5 goal game... would have been fun, but this was better!) So instead of Dr. Bertagnoli sitting in the airport for 5 hours, I picked him up and we had a wonderful afternoon and evening. (Manhattan Beach is great!)

This post comes along with all the standard "I'm not a doctor" disclaimers. I'm just posting my layperson's recollection of our conversations. Take everything I say with a grain of salt.

Unfortunately, several of my clients are dealing with ADR revisions. I asked him a question about the XLIF approach. He corrected me... XLIF is not an approach, it's the name of some devices and is frequently used in describing systems that support the ALPA (AnteroLateral transPsoas) Approach. I didn't realize it when we were speaking, but I've seen him do it. It was truly one of the most amazing surgeries I've seen... not because of the lateral approach step, but this was a very extreme case. The ALPA approach seemed so easy, it was a very small part of this procedure. Even so... I think you'll find Ken's story is VERY interesting.

Today, I've been looking around for info on ALPA and XLIF. Both are written up in a new book that I bought at SAS last month. (Motion Preservation Surgery of the Spine, Yue, Bertagnoli, McAfee, An) This book is amazing and seems to have everything in new spine tecnologies... very well presented. Both ALPA and XLIF are written up. Bertagnoli Pioneered ALPA back in the late 90's as a minimally invasive approach for prosthetic disc nucleus implantation. It turns out that the term XLIF is frequently used to refer to the approach in addition to the hardware. In any case... ALPA, XLIF look like excellent alternatives for procedures that can be performed from these minimally invasive lateral approaches.

Whenever Dr. Bertagnoli and I get together, there is never time to just relax... we played dueling laptops as I showed him a few of the extreme clients I'm working with. It never ceases to amaze me when I will show a case to 5 different surgeons (not just a quick look... often very extensive discussions... ordering more tests... more discussions), then... showing the same case again to the same surgeons, or to a new surgeon, something JUMPS out... significant findings. That happened yesterday for a couple of clients... Dr. Bertagnoli made some incredible finds.

[JeffreyD]

I just read Ken's story...That is really something. I've been studying this stuff for many years now, and am not usually surprised, but this entire surgical plan of attack and apparent solution is an eye opener!
I have been struggling for the last 1-1/2 years with intense pain and worsening problems in my low back. I have 3 artificial discs in my lumbar spine (and 2 in my cervical spine; those are great!), and my top-most lumbar Charite (L-3/4) is rotated and tilted.
My functionality is still better than before the ADR surgery, but the back and leg pain has become a nightmare. I work 40 hours per week as a graphic designer (praise God!!!), but the rest of the time, I'm pretty much laying on the floor or in bed.
Revision surgery may possibly be for me at some point in the future, so this intrigues me very much, as it may have some application to my problems.
Thanks Mark, for bringing this to light. I hope Ken continues to improve!
God Bless,
Jeff

[B13s]

Originally Posted by mmglobal

Unfortunately, several of my clients are dealing with ADR revisions.

It would be interesting to know how many % this is from all your clients. I hope it's not the usual 99% success rate you get from surgeons...

[mmglobal]

B13, that number might be interesting, but it would not be meaningful. These forums, like my client base have artificially inflated numbers of failures. A highly successful patient does not seek me out to tell me that they are doing wonderfully. The successful patients are not spending their days on the internet posting their woes.

I'm reviving the paremeterized surgical outcomes thread that I started 5 years ago and that will produce some interesting data. Even with that, the data should not be used for decision making process unless there is a way to 'grade' the patients. If a surgeon is unwilling to take a difficult patient and only 'cherry picks' his results will appear better. The surgeon who is willing to take the 'basket cases' may have results that don't look as good, but are actually far better in many ways.

Mark

[Tim]

Hi all
Remember the ALPA/XLIF approach is not applicable to the L5/S1 level. I assume revision at this level either involves a risky 2nd anterior approach to remove the offending ADR or a posterior gutter fusion with rods and screws leaving the ADR in place.
The XLIF is an exciting innovation either for straight fusion or ADR revision - unfortunately as it's pretty new there seems to be a shortage of real life cases on the web to read about. Hopefully over the next year we'll start to see some cases filtering through and then we'll get a real idea of how much of a step forward this really is.
If you visit the Nuvasive site or any of the sites provided by clinics using the XLIF you get the real impression this surgery is a walk in the park..
Here in the UK there are currently only 2 doctors who are trained in this procedure (although more are signed up to go over to the states for training in the near future). The doc I saw recently had at that time only done 1 procedure and I don't fancy being part of his learning curve. There seem to be far more surgeons in the US who are well practiced in this procedure.
Jeff I'm so sorry to hear of your ongoing problems. Have you talked to Dr Zeegers or any other surgeons to discuss your options?
Tim

[johnb]

I believe Job13 had this procedure done to remove her prodisc. Her experience is detailed in her thread. I also understand that there in a nerve that runs through the psoas and damage to that nerve is a potential complication during the procedure though it seems this literature points to a small chance percentage. http://www.spineuniverse.com/display...ticle4227.html

Johnb

[mmglobal]

Thanks John... great article.

At SAS in Miami last month, Diane and I attended the XLIF breakout session... 2 hours including unlimited Q&A... it was excellent. There was some discussion about how to minimize the risks of this complication. More talented and experienced surgeons will be able to reduce these risks.

Mark

[B13s]

Originally Posted by mmglobal

B13, that number might be interesting, but it would not be meaningful. These forums, like my client base have artificially inflated numbers of failures. A highly successful patient does not seek me out to tell me that they are doing wonderfully. The successful patients are not spending their days on the internet posting their woes.

I'm reviving the paremeterized surgical outcomes thread that I started 5 years ago and that will produce some interesting data. Even with that, the data should not be used for decision making process unless there is a way to 'grade' the patients. If a surgeon is unwilling to take a difficult patient and only 'cherry picks' his results will appear better. The surgeon who is willing to take the 'basket cases' may have results that don't look as good, but are actually far better in many ways.

Mark

What I mean how many of out your clients that had ADR's with you need revision, not counting the ones that contacted you just because of the revision having their ADR's implanted before.

[mmglobal]

That is a great question and will require some research. Off the top of my head, Off the opt of my head, I know 2 people who were my clients before their ADR surgery who had revisions. There may be more, but I'll have to look. My guess is that I know approximately 20 revision patients. Most would not have required revision had they done something different (gone to more careful/experienced surgeon.)

Give me some time to do research... if I haven't updated this in a couple of weeks... hunt me down.

[mmglobal]

I had breakfast yesterday with an XLIF surgeon from Los Angeles; Larry Khoo, co-director of spine at UCLA. One of the things we discussed was XLIF. Very interesting contrasts... he describes XLIF as "mini-ALPA" The instrumentation that Nuvasive has developed allow even smaller access.

I like Dr. Khoo. He got on my radar at SAS with excellent presentations about several minimally invasive procedures that have nothing to do with ADR. Also, I was researching a very complex FBSS case that includes AXIALIF and he came highly recommended. He's pretty amazing. I'm looking forward to spending more time with him.

All the best,

Mark

Mark