Transcription:

Dr. Andrew Wilner: Welcome to GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm your host, Dr. Andrew Wilner. I invite you to listen in, as we discuss minimally invasive spine surgery with Dr. Wayne Olin, Associate Professor at The George Washington University School of Medicine & Health Sciences and Director of Interventional and Endovascular Neurosurgery at The George Washington University Hospital. Welcome, Dr. Olan.

Dr. Wayne Olan: Thank you very much for having me.

Dr. Andrew Wilner: Dr. Olan, I'm a neurologist and I see a lot of patients with neck and back pain. Some of them need surgery, although frankly, I'm not always sure which ones. I'm looking forward to learning about new surgical approaches at The George Washington University Hospital that might help my patients.

Dr. Wayne Olan: I look forward to talking to you and hopefully, you know, educate and as well as, you know, tell some people about some of the options that are available to them if they encounter some of these situations.

Dr. Andrew Wilner: That's great. So let's start with something simple. What is minimally invasive spinal surgery?

Dr. Wayne Olan: Most of what I do is image-guided. And if you sort of want to lump it in, it's image-guided without stitches., So, you know, band-aid when you're finished. Usually needle-based or at least needle-driven, so everything can go through a needle. No incision, no real recovery. The patients usually do very, very well. And almost everything we do from that standpoint is same day, even if we leave a device in place or put in an implant.

Dr. Andrew Wilner: Woah. So, I mean, that sounds great, but what kinds of surgery, I guess, can you do with such a tiny little hole?

Dr. Wayne Olan: Well, most of what we do, to put it into sort of a larger umbrella, under an umbrella, would be like the degenerative spine, so spinal stenosis, we do releases for spinal stenosis. We will do minimally invasive pain management procedures, which are needle-based. We are also one of the busiest centers in the country for fixing vertebral compression fracture, either from osteoporosis or from trauma or neoplastic or tumor-based. And that's all needle-based therapies. The devices can fit through needles and then you can get them to go and do what you need them to do. But the delivery that we use is really minimally invasive, smaller than your pinky.

Dr. Andrew Wilner: That sounds great. Now, I trained in medical school quite a while back. And what I remember about vertebral fractures is you just didn't do anything for them at all. So what do we do now?

Dr. Wayne Olan: Yeah, that's old school. And you and I probably trained right about at the same time, but especially for osteoporotic compression fractures, that's become -- and the data clearly supports that, the worst thing you could do is to do nothing. For patients with osteoporosis, the key is getting them back moving around, doing the things that they need to be doing. The worst thing you do for somebody with osteoporosis and the data supports it is put them at bedrest because all that does is maximizes and makes their osteopetrosis worse. So we want to get these fractures fixed, get these patients back up to their life as quickly as we can.

Basically, it's a very simple procedure and sort of it's developed over time to now we're finally reducing these fractures. We're not just fixing them and taking the pain away, but we're restoring the configuration of vertebral height after those vertebral bodies may have been compressed, which really helps significantly to prevent other fractures down the road. So we're not only fixing the fracture, taking the patient's pain away, but we're also preventing them from having to go through this again.

Dr. Andrew Wilner: Do you inject glue or is there some kind of gadget that elevates the height? What goes on in there?

Dr. Wayne Olan: Yeah, we try not to call it a gadget. It's a device. It depends, but if we're going to reduce the fracture, the evolution was initially just a cement and the same bone cement that's been used for years and years and years for hip fractures and joint replacements. You put the cement into the vertebral body through a needle and essentially put a cast on that vertical body from the inside to keep it from moving. The evolution of that was to then add a balloon there prior to putting the cement to make a cavity for the cement, but as well as to try to elevate the vertebral body. Although you were able to make a cavity, the reduction was not quite as predictable, the elevation or the restoration of the height wasn't quite as predictable as we would have hoped. And what's recently developed was a device called SpineJack, which really does what it says like it sounds like it does. It functions almost like two carjacks one on top of the other, one going up, one going down at the same time. And what's nice about it is you leave this product in; where the balloon, you used to take it out, so the pressures that were on that vertebral body would be still effective. Here, the implant stays in. So the reduction that you get and the restoration of the height, you maintain, and then you put the cement in through the jack. So not only do you reduce and restore the fracture, you then can go fixate it at the same time.

Dr. Andrew Wilner: Wow. I mean, that sounds such an attractive solution that I think I want one. I mean, it sounds like it actually works.

Dr. Wayne Olan: It really does work. I mean, the data supports it. This is not experimental. Thousands and thousands of cases have been done using it. And it's very reliable. The nice thing is too, you know, these people come in and they're in debilitating discomfort and I mean debilitating. They can no longer live their lives. They can't do anything that they had previously done. And the majority of these patients were independent and they're at, you know, a time of their life where now they're thinking they're taking on becoming dependent, becoming dependent on their family and may require help. It's a terrifying time and, you know, we call these kinds Bible boat results. The patient's pain relief is almost immediate and the restoration back to their lifestyle is almost immediate. And there's really no recovery. They go home two hours later. I mean, like I said, we call it like a Bible boat kind of result. And it's been phenomenal. From my standpoint, and I know you understand this as a physician as well, it's one of the most rewarding things we could do where we provide somebody, basically give them back their life.

Dr. Andrew Wilner: Oh, that's fantastic. Now, I heard about another device called a Superion. What is that?

Dr. Wayne Olan: Superion is a really, really interesting, again, minimally invasive product that gives you maximum results. Spinal stenosis is another degenerative problem. As people age, the vertebral bodies kind of collapse a little bit on each other. And the canal that carries all your nerves gets really narrow. And a lot of times that's not necessarily from a disc pushing forward, but it's from other things crowding it as the vertebral bodies sort of collapse and the disc gets narrow in between the vertical bodies, so you just lose room. What Superion does, it's a device that goes in from the back and it goes in between the spinus processes, which are those little things in the back of your vertebra, behind the spinal canal. And it looks like wings, like two sets of wings, one going up and going down and you're able to kind of tap it in gently. And then you open up the wings that hold it into place and it elevates the vertebral bodies back and provides that room between them. Again, the results have been just phenomenal.

I mean, a lot of this is about patient selection and you've got to put it in the right patient. But I mean, we had a guy Thursday. We did a case on Thursday. His daughter was getting married Saturday night and he sent pictures of him dancing at her wedding. There's really no recovery because we don't have a lot of tissue to dissect down through. It's all needle-based therapies. So there's not a lot of recovery. There's no stitches. There's nothing I have to take out. And the patients do phenomenal. Patient selection though is still really the key, right? You still got to pick the right patient to do these procedures on. So for degenerative spinal stenosis, you know, these patients have have really done phenomenal and it really gives them an option that's "non-surgical" In fact, the data from Superion is better than the data from surgery.

Dr. Andrew Wilner: Now, how do you see what you're doing if there's only a tiny little hole?

Dr. Wayne Olan: That's a great question. So, you know, as my children like to say, it's almost like -- and I don't want to discount how important it is -- but it's like playing a video game. I am an interventional neuroradiologist by training and we do these in a $2.2 million biplane, what we would call procedure suite. So I have cameras in the AP or straight and lateral side to side mode where I can see every dot. Basically, I'm seeing through the patient. And so it's all done with image guidance.

Dr. Andrew Wilner: So it's like a fancy fluoroscopy.

Dr. Wayne Olan: Very, very, very fancy.

Dr. Andrew Wilner: I guess, someday you'll use 3D MRI, right? Or something like that.

Dr. Wayne Olan: You might. I mean, I think there's been a toy around with that. The problem with MRI in that respect is, one, all the devices would have to change because the magnet, the artifact from metal even if it's not a magnetic product really degrades the image. And two, you know, these procedures we're talking about right now take 20 to 30 minutes. An MRI does sound wonderful, but, you know, image guidance is great, but I'm not really looking for the soft tissues really here. I'm looking mostly at the bones and so x-ray and CT are still sort of the gold standard and the best way of seeing calcium-based materials. MRI's great for soft tissues. The other thing I'd be reluctant to do is take a 20 to 30-minute procedure and make it last three hours, because the MRI takes time to develop and process the image; where fluoroscopy, I step on the pedal, I see what I'm seeing.

Dr. Andrew Wilner: Oh, that's fantastic. Well, to wrap up here, when should a referring physician consider sending a patient for this type of procedure or, in other words, how does it work? You know, as an internist or family practice guy, and I have a patient and a bunch of, you know, a collapsed vertebrae and their back hurts, I mean, do I send them to a neurosurgeon and orthopedic surgeon, an interventional neuroradiologist? How do I know where they go?

Dr. Wayne Olan: Well, I mean, for vertebral augmentation or as we were talking about for vertebroplasty/kyphoplasty, which SpineJack, that device is part of the sort of kyphoplasty umbrella, we're easy to find. And you know, there are only certain physicians. Their subspecialty doesn't necessarily matter. You'll have neurosurgeons, orthopedic surgeons or interventional neuroradiologists who could do these procedures, interventional radiologist as well. And, you know, the procedures thankfully are not very difficult to do, but the key is the image guidance. So you'd like to send it to somebody who has very, very good image guidance, because that's where the safety is.

Usually, it's looking at, you know, now a lot of stuff is internet based, so it's easy to find people. If you're in DC and you search kyphoplasty, I'm coming up. So it's easy to find. With respect to the spinal stenosis patients, that can be a little bit more complex because there are real surgical alternatives. For most of the vertebral compression fractures, there really isn't and the old alternative was bracing, which the data has really bore out is possibly the worst thing you could do to somebody, just putting them in a brace if they're known to have osteoporosis. So with respect to the spinal stenosis diagnosis, a lot of times those patients are getting sent for injections or other evaluation, again, minimally invasive. And if they do well, even in the short term from the injection, if the injection gives them relief for a year, well, you're not going to do anything other than another injection. But say, the injection only gives them a week or two of relief, now you start to consider a surgical option. And there's no question, Superion is something to consider in these patients with degenerative spinal stenosis, especially 90% of the time, the levels are L3-4 or L4-5. And, you know, the criteria for the procedure are fairly simple. So it's an easy evaluation. And again, it's like, you know, anything, you got to just keep educating people and making sure that they have the opportunity and have the ability to seek out the best care for their patients.

Dr. Andrew Wilner: Any last words of advice or anything you'd like to share before we close?

Dr. Wayne Olan: Not much. First and foremost, I really appreciate you having us on again. Part of the success comes from like, we just talked about, spreading the word. So hopefully, some people hear it and if, you know, it provides an option for them, it's a real privilege for me to have been out here and on the phone with you and going over this. Like I said, one of these procedures have really given us the opportunity to change people's lives. And at the end of the day, you know, that's why we went into this, and I'm thankful to be able to provide it.

Dr. Andrew Wilner: Well, that's great, Dr. Olan. Thanks very much for this informative discussion. It's great to know that there are proven techniques for effective and less painful spine surgery, which can help patients live more active lives. Thanks again.

Dr. Wayne Olan: I really, really appreciate you having me on. Thank you so, so much.

That concludes this episode of GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. To refer your patient please call 1-888-4GW-DOCS. If you have a question for one of our specialists please email physicianrelations@gwu-hospital.com

Disclaimer: Physicians are independent practitioners who are not employees or agents of The George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians.

Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you.