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Patients often fall victim to the myth that spine surgery will force them to give up the activities they love, said Grant D. Shifflett, M.D. The minimally invasive and complex reconstruction spine surgeon studied golfers with one- and two-level lumbar fusions when he was a fellow. Most patients were able to return to the game and play it better, said Dr. Shifflett, an avid golfer himself.
“Patients need to know that they can have these operations done well and get back to the hobbies they want to do,” said Dr. Shifflett, a surgeon at DISC Sports & Spine Center in California. “When you have research and education behind that narrative, it’s even more impactful.”
Of course, education also comes into play when talking to patients about specific procedures. Dr. Shifflett has focused much of his practice on total disc replacement and minimally invasive surgical techniques. Nearly 90% of his cervical practice and 10% to 20% of his lumbar practice is total disc replacement. He expects these percentages to increase as implants and technologies evolve. Further, Dr. Shifflett said that patients are more knowledgeable about motion-preserving procedures and request them, which helps when the surgery is suitable for the patient and their indications.
We spoke to Dr. Shifflett about his experience and his advice for spine companies on the next generation of technology.
We’re hearing a lot of buzz about motion-preserving implants, but obviously fusion will never completely go away. What excites you about implant designs that might provide greater stability and alignment in patients who have complex pathologies?
Dr. Shifflett: Fusion definitely has a role for certain patients and pathologies. There’s a methodology for making surgeries minimally invasive or minimally intrusive while also restoring optimal biomechanics for the best short- and long-term outcomes. Truthfully, however, I think the indications for fusion are becoming less common.
We’re moving toward motion preservation to restore the spine’s alignment and mechanics while maintaining its mobility. Better techniques and more confidence in the procedures are allowing surgeons to perform surgeries that push the envelope without making compromises.
What are the barriers to greater adoption of motion-preserving procedures?
Dr. Shifflett: If you aren’t trained in motion-preserving techniques, they are challenging to adopt. It’s hard to add a new procedure to your practice when you’ve done things a certain way for years.
There’s a philosophical side, too. Some of our thinking is backward and outdated. Dogma can cloud your judgment about whether you can safely perform a minimally invasive procedure. Surgeons must also become more comfortable with the technology used to perform the procedures. They get comfortable with what works best in their hands, but that may not always be the best thing for the patient. Surgeons who aren’t willing to adapt and try new things are a barrier.
We’ve seen more artificial discs enter the market, with more in development. Does this newer generation offer benefits that may help restore the natural biomechanics of the spine?
Dr. Shifflett: The newer implants have materials that mimic the natural properties of the disc, and the sizes and angulation of the discs give surgeons more options to fix the patient’s defects and feel comfortable with intraoperative decisions. The techniques available for achieving early- and long-term fixation have evolved.
It’s hard to blame technology for the lack of cervical arthroplasty adoption. Nearly every patient is a candidate for cervical disc replacement. Surgeons have a cadre of options, materials and methods of implantation and fixation that address most concerns about disc replacement. The options in the U.S. for lumbar disc replacement are limited, but those that are available function very well, too.
How can device companies enhance the design of instruments or implants to advance minimally invasive surgery, especially as more cases move to the ASC setting?
Dr. Shifflett: It’s often clear that the person who designed an implant or instrument has not operated on a patient or been intimately involved with patient care, because the way the product is intended to be handled doesn’t make sense. Surgeon engagement is needed throughout the entire design process. Implement surgeon feedback so that when surgeons perform a procedure, they’re comfortable and confident using your product.
There’s also a need for implant companies to possess a better understanding of the problems that we face when treating patients. That understanding can help them model their implants and instruments. Tools don’t need to be cool and slick. They need to be functional, usable and outcomes driven.
Dr. Grant Shifflett of DISC Sports & Spine Center believes the indications for spinal fusion will decrease as implent technology evolves.
What attracted you to minimally invasive and motion preservation procedures?
Dr. Shifflett: The technology and approaches are interesting. I also empathize with my patients. I think, what would I want if I was going to have surgery? Patients get back on their feet quicker, they’re happier and their outcomes are better with less invasive procedures.
Also, surgeons can perform these procedures in a surgery center. I’m not interested in subjecting my patients to lengthy hospital stays. They’re injured, not sick. They come to our surgery center, we fix their problem and get them mobilized quickly. It’s a cleaner, more efficient and more predictable process.
There is a movement toward preemptively treating orthopedic pathologies to prevent more serious conditions in the future. Does that apply in the spine space?
Dr. Shifflett: Definitely. While we don’t currently do this, patients ask about it all the time.
The challenge is figuring out whether a patient is going to become symptomatic from their disease. An older patient with a horrendous-looking spine might have never needed surgery because they didn’t have physical symptoms. Did that person need preventative treatment? No.
Yet, someone with an impending blockage in their heart wouldn’t want to wait to have a heart attack before having it treated. When patients have an asymptomatic condition like spinal cord compression that will only get worse, surgeons must figure out who should undergo prophylactic or preventative spine surgery to preserve their motion and functionality and limit their neurological deterioration — especially as patients age.
We didn’t think like that when fusion was the only treatment option, because you’d do more harm than good if you fused asymptomatic patients. As disc replacement evolves, should we preemptively replace the discs of patients who have degenerative pathological discs or cysts in their necks? Would we be able to preserve other levels of the spine if we preemptively treat pathologies? The answers will not be borne out academically or in the literature. Theoretically, they will be answered in practice as spine surgery advances.
Patients often fall victim to the myth that spine surgery will force them to give up the activities they love, said Grant D. Shifflett, M.D. The minimally invasive and complex reconstruction spine surgeon studied golfers with one- and two-level lumbar fusions when he was a fellow. Most patients were able to return to the game and play it...
Patients often fall victim to the myth that spine surgery will force them to give up the activities they love, said Grant D. Shifflett, M.D. The minimally invasive and complex reconstruction spine surgeon studied golfers with one- and two-level lumbar fusions when he was a fellow. Most patients were able to return to the game and play it better, said Dr. Shifflett, an avid golfer himself.
“Patients need to know that they can have these operations done well and get back to the hobbies they want to do,” said Dr. Shifflett, a surgeon at DISC Sports & Spine Center in California. “When you have research and education behind that narrative, it’s even more impactful.”
Of course, education also comes into play when talking to patients about specific procedures. Dr. Shifflett has focused much of his practice on total disc replacement and minimally invasive surgical techniques. Nearly 90% of his cervical practice and 10% to 20% of his lumbar practice is total disc replacement. He expects these percentages to increase as implants and technologies evolve. Further, Dr. Shifflett said that patients are more knowledgeable about motion-preserving procedures and request them, which helps when the surgery is suitable for the patient and their indications.
We spoke to Dr. Shifflett about his experience and his advice for spine companies on the next generation of technology.
We’re hearing a lot of buzz about motion-preserving implants, but obviously fusion will never completely go away. What excites you about implant designs that might provide greater stability and alignment in patients who have complex pathologies?
Dr. Shifflett: Fusion definitely has a role for certain patients and pathologies. There’s a methodology for making surgeries minimally invasive or minimally intrusive while also restoring optimal biomechanics for the best short- and long-term outcomes. Truthfully, however, I think the indications for fusion are becoming less common.
We’re moving toward motion preservation to restore the spine’s alignment and mechanics while maintaining its mobility. Better techniques and more confidence in the procedures are allowing surgeons to perform surgeries that push the envelope without making compromises.
What are the barriers to greater adoption of motion-preserving procedures?
Dr. Shifflett: If you aren’t trained in motion-preserving techniques, they are challenging to adopt. It’s hard to add a new procedure to your practice when you’ve done things a certain way for years.
There’s a philosophical side, too. Some of our thinking is backward and outdated. Dogma can cloud your judgment about whether you can safely perform a minimally invasive procedure. Surgeons must also become more comfortable with the technology used to perform the procedures. They get comfortable with what works best in their hands, but that may not always be the best thing for the patient. Surgeons who aren’t willing to adapt and try new things are a barrier.
We’ve seen more artificial discs enter the market, with more in development. Does this newer generation offer benefits that may help restore the natural biomechanics of the spine?
Dr. Shifflett: The newer implants have materials that mimic the natural properties of the disc, and the sizes and angulation of the discs give surgeons more options to fix the patient’s defects and feel comfortable with intraoperative decisions. The techniques available for achieving early- and long-term fixation have evolved.
It’s hard to blame technology for the lack of cervical arthroplasty adoption. Nearly every patient is a candidate for cervical disc replacement. Surgeons have a cadre of options, materials and methods of implantation and fixation that address most concerns about disc replacement. The options in the U.S. for lumbar disc replacement are limited, but those that are available function very well, too.
How can device companies enhance the design of instruments or implants to advance minimally invasive surgery, especially as more cases move to the ASC setting?
Dr. Shifflett: It’s often clear that the person who designed an implant or instrument has not operated on a patient or been intimately involved with patient care, because the way the product is intended to be handled doesn’t make sense. Surgeon engagement is needed throughout the entire design process. Implement surgeon feedback so that when surgeons perform a procedure, they’re comfortable and confident using your product.
There’s also a need for implant companies to possess a better understanding of the problems that we face when treating patients. That understanding can help them model their implants and instruments. Tools don’t need to be cool and slick. They need to be functional, usable and outcomes driven.
Dr. Grant Shifflett of DISC Sports & Spine Center believes the indications for spinal fusion will decrease as implent technology evolves.
What attracted you to minimally invasive and motion preservation procedures?
Dr. Shifflett: The technology and approaches are interesting. I also empathize with my patients. I think, what would I want if I was going to have surgery? Patients get back on their feet quicker, they’re happier and their outcomes are better with less invasive procedures.
Also, surgeons can perform these procedures in a surgery center. I’m not interested in subjecting my patients to lengthy hospital stays. They’re injured, not sick. They come to our surgery center, we fix their problem and get them mobilized quickly. It’s a cleaner, more efficient and more predictable process.
There is a movement toward preemptively treating orthopedic pathologies to prevent more serious conditions in the future. Does that apply in the spine space?
Dr. Shifflett: Definitely. While we don’t currently do this, patients ask about it all the time.
The challenge is figuring out whether a patient is going to become symptomatic from their disease. An older patient with a horrendous-looking spine might have never needed surgery because they didn’t have physical symptoms. Did that person need preventative treatment? No.
Yet, someone with an impending blockage in their heart wouldn’t want to wait to have a heart attack before having it treated. When patients have an asymptomatic condition like spinal cord compression that will only get worse, surgeons must figure out who should undergo prophylactic or preventative spine surgery to preserve their motion and functionality and limit their neurological deterioration — especially as patients age.
We didn’t think like that when fusion was the only treatment option, because you’d do more harm than good if you fused asymptomatic patients. As disc replacement evolves, should we preemptively replace the discs of patients who have degenerative pathological discs or cysts in their necks? Would we be able to preserve other levels of the spine if we preemptively treat pathologies? The answers will not be borne out academically or in the literature. Theoretically, they will be answered in practice as spine surgery advances.
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Carolyn LaWell is ORTHOWORLD's Chief Content Officer. She joined ORTHOWORLD in 2012 to oversee its editorial and industry education. She previously served in editor roles at B2B magazines and newspapers.
