The evolution of percutaneous spinal fusion
The human spinal column is composed of 33 vertebrae that articulate with each other via bony joints which include the outer margins of the vertebrae and the superior and inferior articulating processes of the facet joints. In addition the majority of the surface area of the bony vertebrae is connected through a strong collageno-viscoelastic ring that bears some similarities to the configuration of a donut. The elements are surrounded by a complex intertwining of muscles and ligaments that provide for both stability and motion allowing the units to move in a rhythmical fashion that permits the human being to flex, extend, rotate and twist his spine. The anatomical and functional relationships of the spinal unit include a critical area called the transforamen through which nerves exiting from the spinal cord and canal are able to distribute themselves within the musculoskeletal structures of the arms and legs. It is this very particular region of the anatomy that has provided the inspiration and actual anatomical means through which the protected tissues of the spinal column could be safely reached.
Dr .Parviz Kambin first identified this region in the 1970s and was able to delineate the margins of what he called Kambin’s triangle but more importantly he recognized that it provided a relatively safe portal through which surgical tubes, dilators and instruments could be passed for the purposes of addressing spinal pathology. This recognition changed the paradigm of spine surgery because it now became unnecessary to perform wide open aggressive back dissections that quite often resulted in far greater collateral damage to the surrounding muscles and ligaments which frequently left patients in a worse state than before the surgery. His pioneering work and persistence in the 1970s provided the foundation from which the field of percutaneous spine surgery began to evolve and which today is represented by the fact that most lumbar interbody discectomies and fusions are performed using this approach.
In 2005 the first ever outpatient lumbar interbody fusion was successfully performed in NJ, USA on a 55 year old male construction worker. The procedure was carried out under fluoroscopic guidance and interpretation and the patients were discharged home two hours after the surgery. This radical shift from the usual three to five stay hospital admission and increase incidence of hospital acquired infection was another major shift in the spine surgery paradigm as it essentially proved that what were once considered ‘complex’ case only treatable in the hospital setting could now be successfully and safely treated in the outpatient setting with the use of an ambulatory surgical center. As a consequence of the case performed in 2005 in NJ at least four other innovative spine device companies in the US began research and development on the creation of a device similar to the one used in 2005 and with specifically the ability to insert a collaped lumbar interbody device through a the transforaminal space using a small skin incision and a 9mm portal. These devices copied the exact surgical principles that inspired the surgeon in NJ in 2005 to first conceptualize the possibility of performing a lumbar interbody fusion through a 9mm portal and with less than 50 cc blood losses.
The companies in order that produced devices suitable for percutaneous lumbar fusion were
Amendia
Globus
Alpatec
Joimax
Of course the first device used in 2005 was the optimesh graft produced by Spineology.
The next ten years will see the spine market experience more of these percutaneous devices employed in the treatment of degenerative spinal disease with a general trend towards an increasingly less invasive technique. Improved imaging tools and their advanced portability will enable the dissemination of these approaches to wider regions of the global population.
New Jersey should be proud of the fact that it was the first place to perform this historic procedure, which has irreversibly changed the course of spine surgery and turned this specialty from the boogey man onto the cape crusader. NJ is more than the shore, bad haircuts and shifty political leaders. It is about medical innovation and the discovery that lumbar interbody fusions could be done safely and effectively in an ambulatory surgical setting, does in my opinion, make it more deserving of a reality TV show than one with some teenagers with overly coiffured nests.
