The Power of An Integrated Spine Care Mission

WHAT ARE ASPIRATIONAL PRACTICES FOR MANY ARE DAILY FARE AT THE OBI SPINE CENTER

Progress in joint replacement procedures has led to ever-shorter surgeries and broadened options, yet innovations in treating spine pathology – the leading cause of pain in adults the world over – has remained in the risk-averse shadows. Too often, these patients travel on diagnostic or treatment odysseys before receiving appropriate personalized treatment.

Spine practitioners at the O’Donnell Brain Institute (OBI) Spine Center are working to properly align treatment to the needs of the individual patient. As part of a truly transformative perioperative program, they are leading the way in integrating novel techniques and devices to bring the best interventions out of the shadows.

“The fact that we have one of the most integrated spine care programs in the country allows us to evaluate and treat patients holistically, without a subspecialty bias,” says Nader Pouratian, M.D., Ph.D., Chair and Professor of the Department of Neurological Surgery. “If core strength-building and lifestyle changes help, great! But if an intervention – whether an injection or surgery – is in the patient’s best interest, I believe there is no place where the risks of adverse events are better mitigated.”

PAIN MANAGEMENT WITHIN ERAS

Established in 2016, the OBI Spine Center, which encompasses four specialties – neurosurgery, physical medicine and rehabilitation, orthopaedic spine surgery, and anesthesiology – is one of few medical centers in the country to apply Enhanced Recovery After Surgery (ERAS) to spine surgery. Leading the OBI’s advances in perioperative optimization is Salah Aoun, M.D., Director of ERAS, who has authored more than 80 publications on the topic in the past two years.

“ERAS is the quintessential crystallization of our Spine Center’s efforts to improve surgical patient management,” he says. “What defines success for the patient is largely whether they are prepared beforehand and monitored afterward. Many spine services will involve perioperative difficulties, so our patients see pain management doctors in advance to optimize their narcotic regimen before and after surgery. Then, every patient undergoing a complex surgical reconstruction sees a psychiatry practitioner to make sure they understand the goals and timeline for healing.”

Patients with first-tier procedures such as anterior cervical fusion disc replacement, small discectomies, and small laminectomies in the lower back require only an overnight stay and rarely have complications. ERAS makes the largest impact on the middle tier of procedures, such as short segment fusions and short 360s. Patients with these procedures generally stay in the hospital for two days and have a higher risk of complications and narcotic dependence.

The OBI also integrates ERAS to improve outcomes in its most complex surgeries, such as scoliosis reconstruction.

Through ERAS, surgical candidates can meet patients who have had their procedure, hear their testimonials, and watch videos that feature their practitioners’ work. Addressing the balancing act of pain management, while minimizing narcotic intake, starts with a six-week prehab, so patients know what’s expected of them after surgery, boosting their motivation to walk early and commit to rehabilitation.

BEATING NARCOTICS TO THE PUNCH

One of the Spine Center team’s strategies for managing pain in patients with spine deformities is administering epidural analgesia and long-lasting incisional blocks after surgery. Compared with a typical pain regimen, this can make a huge difference in patients avoiding narcotic dependency.

“It’s been remarkable – at three months and six months, they just aren’t renewing their narcotics scripts,” Dr. Aoun says.

The Spine Center team was the first to adapt a joint replacement epidural anesthetic called Exparel to complex spine surgery patients. Exparel consists of microsomal lidocaine or Marcaine enclosed in tiny fatty molecules that release over time. Its use significantly reduces pain for four days so that patients are able to walk, which reduces wound infections, blood clots, constipation, and urine retention.

“These patients require less pain medication both during and after surgery,” Dr. Aoun says. “We are tracking all that data through our patient-controlled anesthesia (PCA) software. It makes a huge difference in reducing narcotic dependence.”

Spine Center researchers are continuing to gather data to publish results on the anesthetic’s effectiveness and are establishing a general use protocol on Exparel for both neurosurgery and orthopaedic surgery.

The team is also using epidurals in a novel way with patients undergoing highest-tier procedures such as scoliosis corrections, resection of tumors requiring anterior and posterior access, and multilevel fusion. This enables patients to walk in the first few postoperative days without oral narcotics.

ERAS IN THE OR

Dr. Aoun says the operative time for big cases has dropped from as long as 12-15 hours to 4-6 hours, thanks to the just-in-time effect built into the ERAS program.

“We are making sure that every time we look at a case, we know how many hours it should take, and we have a process for making sure all the tools, equipment, and staff are at the ready,” Dr. Aoun says. “On our scoliosis team, we have the same three people who do the instrumentation. From techs to nurses to surgeons, there is a lot of pride that goes into reaching our goals.”

For patients undergoing highest-tier surgeries, the OBI has also made a groundbreaking leap by establishing two dedicated ICUs within the institute, making it one of a handful of spine centers in the nation to provide this level of care. The team is conducting research through these ICUs, including several traumatic brain injury trials to optimize decompression and medication management.

INNOVATIVE INTERVENTIONAL AIDES

For patients with complex spine deformities, the center is pioneering new enhancements in surgical techniques and aides. One of these utilizes life-size 3D prints of the spine that enable Dr. Aoun and his team to more precisely plan and execute procedures.

“Instead of wasting an hour and a half figuring out where we’re going to put the screws to line up the vertebra, this model acts as a reference I hold in my hands and can move 360 degrees,” Dr. Aoun says.

The Spine Center is one of the first to offer the new Intracept radiofrequency ablation procedure for vertebrogenic low-back pain and currently performs seven to eight of these procedures per month.

Robotic techniques still play a narrow, but valuable, role in Spine Center surgeries, primarily helping with precise placement of hardware in areas of high risk for displacement, such as the L5 S1, where the bone angle and hardness make manual placement precarious.

MICRO-ETCHED ‘BONE’ AND CUSTOM RODS

The Spine Center is at the forefront of trials for implant materials that are revolutionizing spine surgery.

One is a two-year trial on a Medtronic implant technique, where an artificial vertebra or other bone replacement is micro-etched to resemble bone on a microscopic level. When fusion takes place, instead of overproducing inflammatory agents to help colonize cells, this material sidesteps the inflammatory phase in healing.

“The body thinks the hardware is just a bone graft,” Dr. Aoun says. “Now, the same technology is used in screws as well.”

This technique may also be a solution for smokers, older patients, and those with poor bone integrity, whose bodies don’t produce the inflammation necessary to engender fusion healing. Dr. Aoun is scanning cervical spine patients at three months to compare progress against those implanted with unetched titanium or plastic materials.

In another innovation, the Spine Center is in phase 2 trials on implanting custom rods. Patient images are sent to the rod manufacturer beforehand, where they calculate the degrees that the patient is off alignment, prepare a plan that accounts for the curve and line-up of the screws, and then manufacture rods to fit the specific patient. During the procedure, the surgeons can make changes if needed and later send postsurgical X-rays to compare actual and expected outcomes for continuous improvement and self-monitoring.

DISCS ENABLING NATURAL MOTION

More pliable discs are also finding their way into the Spine Center surgical suite. The spine team is providing feedback on new cervical discs that mimic the natural disc. Instead of sliding into flexion and extension, they enable the joints to move 360 degrees and in unison.

“We are seeing a significant improvement in neck pain, which should reduce the risk of surgery in the future. In a younger person with a herniated disc, this implant winds the clock back to before the herniation,” Dr. Aoun says.

RESEARCH FOR SPINAL CORD INJURY AND TBI

The OBI is currently participating in two stem cell trials. In one phase 1 safety study, stem cells are injected into the spinal cord of patients with paraplegia, and thus far the study has proceeded without safety concerns. In a second trial, the team is working with colleagues at Parkland Memorial Hospital testing anti-inflammatory interleukin molecules within 48 hours of acute spinal cord injury to see if nerve damage is mitigated or even reversed.

Also in conjunction with Parkland, the Spine Center is in several ICU-related trials. One is looking at when to decompress a patient with traumatic brain injury (TBI) and when to give them medication or transfusions.

“When someone comes in with a TBI, we have found that transfusing these patients at higher blood volume increases their chances of living longer, more functional lives,” Dr. Aoun says. “This led to our publishing new transfusion guidelines on TBI and spine fusion.”

INTERDISCIPLINARY DYNAMICS

In an enterprise that serves more than 2,300 patients per month, Kavita Trivedi, D.O., Medical Director of the Spine Center, heads operations and helps practitioners keep up with the new evidence-based research in the field.

“I feel very passionate about providing good spine care to patients. A lot of people have come to us having undergone multiple spine surgeries without an improvement in their initial symptoms or perhaps having gone without any meaningful treatment before finally coming to us,” Dr. Trivedi says. “Many of these patients may benefit from different types of physical therapy, injections, nerve blocks, radiofrequency ablations, or minimally invasive surgeries.”

Of utmost importance to the center’s mission to provide integrative, holistic spine care is ensuring communication among nonsurgical and surgical providers alike.

“We all have the same values and priorities of conservative care, when possible,” Dr. Trivedi says. “Most spine patients don’t need surgery, so if we can get that patient better without it, that is our initial goal.”

An advantage of being under one roof is the ease of having weekly meetings to discuss patients and lend expertise on cases.

THE POWER OF PATIENT PREPARATION

The communication priority Dr. Trivedi promotes is pervasive throughout the center.

“If you don’t educate patients about what’s causing their symptoms, they’re not going to be compliant with your recommendations,” Dr. Trivedi notes.

She adds that this starts with a holistic initial evaluation, looking at root causes of spine problems and their connections with other problems such as shoulder, hip, or knee pathologies.

“Depending on what they have, the first line of treatment may be something like physical therapy, but there are different types of treatment for spine issues,” she says. “The thing I always ask my patients is, ‘What are you not able to do in your normal life that you want to do?’ It may be ‘I can’t play soccer with my kid,’ or ‘I can’t work,’ or ‘I can’t go to a movie with my girlfriend.’ That gives us a goal. I also ask them what approach they want to take, because if they don’t believe in what they’re doing, they’re not going to do it, and then they’re not going to get better.”

The team offers several community lectures per year, presented by one of the providers, where patients, families, and others can learn about spine and musculoskeletal health. Dr. Aoun leads an online course for patients with a spine deformity such as scoliosis, explaining how the surgery is going to be done and what to expect before and after.

“It’s a good time to be a patient at the OBI – the gadgets are great, and patient care has undergone a sea change. I think we have an exciting 20 years ahead, building on these innovations,” Dr. Aoun says.