Dr. Coric - ACDF

Speaker 1Now we're gonna, uh, move on to Doctor Kork.

Speaker 2Appreciate it and uh thanks for having me and uh Roger, thanks for the great presentation. Uh, we can go to the next slide.

Speaker 2So this is, uh, my disclosure, this is our crew in Charlotte, kind of an always an outdated photo because we always have new guys coming in. We're up to about 40 neurosurgeons in, in Charlotte and Greensboro area. Uh, and, uh, and so we're we've, we're always trying to stay on the cutting edge and, uh, let's go to the next slide.

Speaker 2So again, briefly to go back over the the the case, there, there was neck Pain, uh, um, as presented. There was some component of neck Pain and if we look at the MRI it does show that there is a fairly large size foraminal disc herniation like Roger was talking about, uh, you, you know, sometimes you can get a CT scan called the bony anatomy. You don't need that here because you get a pretty good shot at the facets which look pretty good and you got a, uh, a good sized soft disc.

Speaker 2Herniation. So let's go to the next slide. And then, uh, the full, the full picture you showed, uh, previously, Paul, and, uh, and again I wanna thank you for picking the perfect patient for ACDF, uh, because this is a workman's comp case. Uh, there is axial neck Pain in addition to the radiculopathy, uh, and Roger talked about the loss of, uh, the normal, uh, curvature, but there was clearly a loss of Bordeaux.

Speaker 2as well as uh as well as focal uh spon more than focal spondylosis, the, the, uh, moderate spondylosis, at least moderate 56, and at the Other levels that you showed previously, there was kind of mild to moderate multilevel disease and I'm not sure if this has been mentioned or not, but, uh, this is a workman's compensation case. So let's go to the, uh, next

Speaker 1slide. Now, don't hold back. Tell us how you really feel.

Speaker 2Yeah,

Speaker 2My, my friends rarely accuse me of being an internalizer, so I'll try to just throw it right on out there. So if we go to the next slide.

Speaker 2All right, not seeing it. I'm seeing the kind of telephone screen, 6 telephone screen there.

Speaker 2Hm,

Speaker 1it's your, uh, ideal indications.

Speaker 2So if we look at the ideal indications, uh, there, these are all different procedures, and these are all procedures that we do that I do personally, uh, and, uh, and I think that there are really 3 great procedures, but they're all out there.

Speaker 2Ideal indications. ACDF is better for moderate and moderate to severe spondylosis, better for multilevel disease, better for patients that have a loss of lordosis, and certainly better for facet disease. And, uh, and then cervical arthroplasty, which, which Rick will talk about. Doctor Guyer certainly has a huge experience with this, and I think a lot of the literature he'll quote, uh, I was involved with some of that with him as well, but this is a relatively limited.

Speaker 2Uh, relatively limited, uh, um, indication list in terms of exactly, uh, what the indications are from an ideal perspective. And if we look at, uh, we look at cervical foraminotomy, it's even more limited. Like Roger said, it's really prone to unilateral Pathology, one level disease, and you really need to have a clean radiculopathy with little or no axial neck Pain.

Speaker 2So, uh, as we go down from ACDF we see the kind of workhorse procedure and we see some more limitations with cervical arthroplasty and we see the most amount of limitations for posterior cervical foraminotomy. Let's go to the next slide, please. So, if we talk about the, the actual, um, the case that's been presented here and Roger's already spoken about cervical foraminotomy, it is, uh, what are the the.

Speaker 2Downsides of it. Well, it's not ideal for a Primary component of axial neck Pain, and it's technically challenging to safely resect a large foraminal soft disc from a posterior Approach. Roger touched upon it. Unfortunately, most of us aren't master technicians like Roger, and, uh, and it is difficult to drill down the pedicle, and we do it sitting cervical. Roger talked about doing it prone, but you're getting blood welling up in the wound, drilling down the pedicle, you're trying to identify.

Speaker 2The sensory root from the motor root, you're getting into the axilla, poking around with the nerve hooking you're trying to get that hunk of crab meat out of there, and the reality is that this is a technically challenging procedure in the best of hands as far as cervical radiculopathy, as as far as cervical radiculopathy being treated with the arthroplasty, again, this is not a definitive procedure. This is a workman's comp case, and, and with, with arthroplasty, there's always something you can do.

Speaker 2Beyond your arthroplasty, in Other words, even if you have a perfect looking X-ray and the patient isn't doing well, they can, they can say, well, I want, I wanna go to, I wanna do the definitive procedure, so you're looking to do a next procedure after doing the kind of a middle procedure. Uh, it does not do well with patients with loss of loosis and even moderate spondylosis. This is a procedure that is ideally treated for early to moderate, uh, degenerative disc disease as patients.

Speaker 2Probably a little bit more advanced than that. And then if we look at the negatives for ACDF, my friend Doctor Guyer is gonna talk about the loss of motion and about the adjacent level disease that you can see with ACDF. So let's talk about some of those issues. Let's go to the next slide. And so if we look at the, the probe for posterior cervical lamino foraminotomy, Doctor Hartle is exactly right. It is a minimally invasive procedure and it is a motion preserving procedure.

Speaker 2We find it ideal for highly motivated individuals like athletes and professionals. Our experience, and most notably Tim Adamson, who was one of the pioneers, not the pioneer in this field. We've had excellent results with NASCARR, uh, and NFL athletes, highly motivated athletes. I don't know what kind of patients is treating in New York, but it's been not been my experience that workman's comp and litigation patients are quite as highly motivated as professional as professionals.

Speaker 2To get back to uh their their exact level of activity prior this is one of our my actual cases where we do it like Paul said sitting cervical with the laminal foraminotomy with two go to the next slide. So let's talk about some of the negatives for posterior laminal foraminotomy. It does not address and really may potentially accelerate the underlying degenerative process and, and additional.

Speaker 2Like, like I've previously been discussed, it's technically demanding in the best of hands, and like we, like I said, we all can't be Roger, uh, and this is quickly becoming a lost art. It's not something that you see residents familiar with, uh, and drilling around down the pedicle and working around that nerve root, especially when you have a large pyramidal fragment like we talked about. It generally involves manipulation of the root and, uh, uh.

Speaker 2And kind of predisposed towards neuropractic injury and some of the things that led to the.

Speaker 2Ad adaptation of the Anterior approach to begin with. Again, this is our setup for, uh, posterior cervical laminal foraminotomy, uh, which we do sitting cervical and one of, one of, one of our patients. So let's turn both barrels to Doctor Guyer and so let's get to the, uh, cervical, uh, uh, arthroplasty. Next slide. So ideal indications include radiculopathies.

Speaker 2Secondary to soft disc disease and if you kind of look at this slide, you can see how all the discs look the exact same. There's not a a real focal spondylosis and it's a soft disc herniation, so this is kind of the ideal indication. Let's go to the next slide. Some of the contraindications to cervical arthroplasty uh are directly related to the complications you can see when you're dealing with patients with advanced spondyli.

Speaker 2Closis you're predisposed towards teterotopic ossification. If you're dealing with patients with osteoporosis, you can see some guidance. And if you're dealing with patients with multilevel disease or global kyphosis, you can run into Other problems. So let's go to the next slide and let's see some of the complications we can see. And this is what I mean when I'm talking about we're not necessarily doing a definitive procedure. These are some of the problems that you can have and let's go into some of these.

Speaker 2Individual cases and so these are all cases, luckily they aren't all necessarily my arthroplasty cases, but they're all cases that I've seen in my clinic and this is a patient who came in with a displaced inferior artificial disc and you see the final common pathway is ACDF X slide you see an expulsion patient again with the entire arthroplasty, uh, expulsed into the prevertebral space.

Speaker 2Next slide, you can see osteolysis, which is uh which is an eroding away the end plate and typically the the answer for this procedure is the answer to this complication is an anterior cervical discectomy infusion. Next slide. Then we see heterotopic ossification. This is actually one of my patients, and you can see over the years how the patient became a little kyphotic to begin with and ultimately developed a solid fusion over a period of.

Speaker 2Several years and that is something that you can see with every arthroplasty device, no matter what your technique is, we see it across the board and it is a potential complication, although not clinically relevant. It really doesn't do any better than having an uh than a fusion to begin with. Next slide. And then here's an interesting case because let's look at that MRI and, and it doesn't have quite as prominent a foraminal disc herniation, but there's some foraminal stenosis.

Speaker 2And this patient is a 38-year-old, and if you look at the spondylosis and the lack of lordosis, this is a hauntingly similar, uh, case to the one that's been presented by Doctor Pell, and it's actually a C6 radiculopathy as well. There's some axial neck Pain and there's loss of that normal lordosis with a little bit of focal spondylosis. Is any of this sounding familiar, Doctor Dyyer? So, uh.

Speaker 2slide. Look at the intraoperative pictures. They look perfect intraoperatively. Look at that artificial disc and then let's go to the next slide. And then what we see here is a little bit of preload of the artificial disc. The disc is thrown into kyphosis and then look at the CT scan with the disc and kyphosis. This is a workman's comp litigation patient. The patient's radiculopathy is completely resolve.

Speaker 2Resolved, but they have axial neck Pain. They have a picture that looks like this, so what are you gonna have to do? Next slide, please. You're gonna have to revise it to the more definitive procedure, which is an ACDF despite the fact that the patient's radicular symptoms are completely resolved because your X-rays don't look perfect and there is something else that you can do. Let's go to the next slide. So let's talk about some of the.

Speaker 2Pros of arthroplasty and so you utilize that same familiar Anterior approach. It also is minimally invasive and motion preserving, but what is, what is the negative of it? It is certainly a more novel procedure and it's more technically challenging. The vast majority of Spine surgeons are already expert ACDF technicians. And so, and then first and foremost, especially in a workman's comp case, it's just not a definitive procedure.

Speaker 2And so if something goes wrong or or the X-rays don't look perfect, there is something else you can do, and that something else is ACDF. So, let's go to the next slide. So, for this particular workman's comp patient with the paracentral foraminal disc with neck Pain, moderate spondylosis, loss of lordosis, the most definitive procedure, ACDF is the procedure of choice. It's not called the gold standard for nothing. And

Speaker 1I'm gonna do a sound effect. This is the you dropping the mic.

Speaker 2All right, we got a little more, we got a little more if you guys can take it. So let's go to the next slide. So we see what's our, what are the advantages. It's a definitive workhorse procedure. It is every virtually every Spine surgeon is an expert technician in this particular procedure. It also is minimally invasive.

Speaker 2We've done several thousands of these Outpatient, 12, and even 3 levels excellent results and what are the, what are the cons again, the loss of motion, the adjacent level reoperation. So let's, let's talk about that a little bit, shall we, Rick? Next slide. Are you gonna give my entire talk?

Speaker 2So, uh, so if we look at adjacent levelvel disease, let's look at the Hildebrand seminal article from, uh, 1999. And in that article, he describes adjacent level, uh, symptomatic disease, which is a combination of reoperation and the presence of this non-validated criteria of on two consecutive office visits to have uh uh adjacent level.

Speaker 2Symptoms referable to one of the levels above and below. So this is a totally vague and non-validated uh criteria. Let's go to the next slide. If you, if you look at that paper and you look at Alan's numbers, you'll see that the actual adjacent level reoperation rate, which is all which the actual thing that we care about, is incredibly small. It actually has an annual rate of.

Speaker 20.66% per year. So annual rate of reoperation, less than 1%, uh, really 0.7%. So the rate of actual reoperation following ACTF incredibly small and not the 3% that we quote reflexively from Hildebrand's article because he includes this non-validated criteria. So let's go to the next slide.

Speaker 2So if we really look at adjacent level reoperation, it's a multifactorial etiology. There's so many different things that go that go into it. So at the end of the day, the choice of actual arthroplasty versus ACDF versus foraminotomy is just one of those factors, and you could certainly have adjacent levell disease with all the procedures that we discussed today. Go to the next slide.

Speaker 2So, let's get back to the loss of motion. Rick's gonna talk about this, but approximately 50% of the cervical Spine motion occurs from the occiput to C2. The remaining 50% is split amongst the Other levels. So let's do some math that even my buddies in orthopedic Spine Surgery could probably do. Boom. 56 divided by 15 is about 8% per level, and at 8% per level is difficult to.

Speaker 2Argued that the loss of motion at a single level is gonna result in any kind of clinically meaningful limitation of range of motion. And so this is not the C2 to T2 that we're seeing here again. This is another one of my cases, but this guy has a loss of motion. He'll take that loss of motion. But when you have one level ACDF, you're just not gonna get a clinic clinically significant loss of motion. Let's go to the next slide. So Roger touched upon this a little bit. So this is a work.

Speaker 2' s comp case and let's look at the RVUs that are associated with each of these procedures. So we get about 75 for ACDF, 45 for cervical arthroplasty, and 35 for posterior cervical foraminotomy. So we're getting paid significantly less to do more technically demanding procedures, which are actually less definitive. Makes sense. Like, right, Roger and Rick? Sounds right to me. Let's go to the next slide.

Speaker 2So this is a slide that talks about our experience at the Surgery center. So you're saying it's all about the money. Well, if you do this in the Surgery center like we've been doing for the past 10 years, for ACDF, you, you save anywhere from about 30 to 40% from your hospital charge, and these charts are from a published paper that Matt McGurk did for us that where, where we looked at the outcomes Inpatient and Outpatient. The clinical outcomes are exactly the same, and yet you're.

Speaker 2Saving 30 to 40%, which translates into about 78, 9000 per case, way in excess of a couple of extra RVUs that the surgeons. So let's go to the next,

Speaker 1uh, wait a second. So why, why do you think that Inpatient ACDFs take longer to go back to work than Outpatient ACDFs? You're doing the same operation.

Speaker 2They don't, they, they didn't, it is an expectation kind of thing as we know.

Speaker 2Expectations when we started doing these 14 years ago, everyone was like, My God, how can you do ACDS as an Outpatient? Now it's become commonplace because the expectation is set. For instance, when I do my Outpatient ACDFs, I don't use the collar. I don't tell the patient they can't do anything for a for a month. I tell them just like with my arthroplasty patients, start moving your head right away. No collar. You're not going to be out of work for a month. You're going to be, I want you driving after about a week.

Speaker 2Or two as soon as you get off of muscle relaxers and narcotics, and I want you back to work in the same, I tell them the same things I tell my foraminotomy patients and my arthroplastic patients, which are, you know, mobilized early and, and off and get back to work sooner and that there's a self-fulfilling prophecy. If you slap someone in the collar for 2 months and you tell them they can't move their neck, they're gonna get to work a lot, a lot later than, than if you do a foraminotomy or an arthroplasty and you tell them.

Speaker 2They could, they could do things right away. So in conclusion, Spine surgeons really do have 3 efficacious and minimally invasive procedures to treat cervical radiculopathy. And again, in deference to my esteemed colleagues, all three really have an excellent firm evidence basis for usage, but it's at best a moot point and at worst counterproductive to attempt to debate which procedure is theoretically superior. They're all.

Speaker 2Great procedures. The focus needs to be on maintaining competency in all three and matching the individual patient to the proper technique. The next slide, so to minimize failed Surgery, it comes down to Patient Selection, Patient Selection, Patient Selection, and for this particular patient, ACDF is the is the most definitive and best procedure. This interesting patient at the bottom here is also one of my patients who actually.

Speaker 2He has undergone all three of the stated procedures all in one patient. He has a cervical arthroplasty. He has a cervical foraminotomy at the middle level and the lower level, and he has ACDF at the lower level. So this patient actually has all three proving that they're all good Operations. Patient is an actual tennis coach who's still playing tennis at age 60+. Next slide, that's it, fellas. I appreciate your attention and thanks for having me.

Speaker 1Well, thank you very much. I think that your point that we should

Speaker 1Master all three techniques and and utilize them, uh, and have each of those arrows in our quiver, I think is a very, very, very good point. So what do you think, how do you think, uh, Cam Newton's going to do up in New England this year?

Speaker 2You can have

Speaker 2them.

Speaker 2We're not going to miss him.

Speaker 1So I do have a question if nobody else has any questions for Dom.

Speaker 1So if you're doing a cervical arthroplasty, do you treat that person differently in terms of Return to work, single level ACDF and single level arthroplasty?

Speaker 2No,

Speaker 2no collar, get back to, you know, don't drive or take it easy for about a week or two at the most, and then, uh, um, get back as soon as you can. And typically I feel like my Return to work numbers personally are very similar for arthroplasty and ACDM.

Speaker 2And, and, and it's interesting because all kidding aside, Rick and I have collaborated on numerous things. The last two studies, arthroplasty studies that we've been co-investigators for, for this, for the country have been the N6 study and the simplified study, two really modern generation.

Speaker 2Discs and every one of the patients that we enrolled in those studies were done Outpatient and like I said, we routinely do 1 and 23 level ACDS Outpatient, same situation and virtually all our cervical foraminotomies are Outpatient.

Speaker 1Excellent.