Monday, April 2, 2012

MIS - Missing In Surgery

As Michael Buble would sing;

It's a new dawn, it's a new day, it's a new life for me

Yes fellow Spineophiles, TSB must pose the $640 million dollar question, is the state of Minimally Invasive Surgery moving fast enough?  Based on recent marketing data, it seems that MIS is not moving fast enough. Why? Considering that preserving the patients biology has become a priority, one would believe that more companies would be following NuVasive's lead.  It is estimated that by the year 2015, an estimated 30% of all spinal procedures will be performed utilizing an MIS or minimally open approach.  Today, at least nine companies are vying for a piece of the pie in MIS. Where are the rest of the laggards?  NuVa is the market leader, followed by Medtronic, DePuy/Synthes, Stryker, Zimmer, Globus, Trans1, and the infamous Others.

Contingent on the patients diagnosis, MIS can reduce operative time, contribute to early mobilization, reduce one's hospital stay, and reduce post operative pain.  Yet, the biggest factor that has contributed to the increase in MIS is preservation of the patient's biology.  Granted not every patient is a candidate for MIS.  Yet, one must admit that by not stripping or de-vascularizing the soft tissues, the end result is a happier patient.  Patients heal faster, and there is a decrease in infections at the site of the surgery.

So why don't more surgeons take to learning a technique that enhances the potential outcome? Some of the retractor systems are simple to use with an inordinate amount of flexibility. Could it be that some surgeons are not flexible? Could it be that the older surgeons are not willing to learn something new?  Could it be that its just simpler to filet someone open, and get it over as quickly as possible?  Recently, TSB watched a young surgeon perform an MIS procedure with as much depth and quickness as those surgeons using an open approach.  As open procedures start to decline, an educated public will benefit from MIS growth.

If Nuvasive, Medtronic and DePuy have over 90% of the Lateral and MIS market, where are all the innovative start-ups, and why do they have an inability to execute?  Anything above L5-S1 is game for a lateral approach, though there has been some skepticism surround L4-L5.  But the question that must be posed to our readers is, what will it take for a competitor to come in and disrupt the current leaders in the marketplace?  Does anyone believe that the new VEO Lateral Fusion System can disrupt the current market?

So who has the best MIS system?  Is it AlphWreck?  DePuy?  Medtronic? NuVasive? Stryker? Globus? K2M?  Lanx?  Pioneer?  Or could it be, Trans1?  You be the judge, let our readers know.

83 comments:

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  2. It all has to do with your definition of MIS. Nobody has a good answer so the 30% you mentioned is too low. Everyone claims they are doing less invasive surgery.

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  3. To call Nuvasive the leader in MIS is ridiculous. MDT has been pioneering that market segment since the days of MED (how painful was that). Nuvasive may be the leader in laterals, but not the leader in MIS.

    Two factors in the slow progress for MIS is that the docs are not reimbursed any differently for a perc TLIF than an open and inertia is our biggest enemy. With no financial benefit and longer case times during the learning curve, docs may not want to invest the time required. Another factor is the increased cost of the implants, plus disposables and monitoring costs that may not be needed for an open fusion. We all know that it is a challenge to introduce new costs to the hospital, with no increase in reimbursement.

    Another factor may be the experiences of some docs who tried MED and Metrx early, and didn't see an appreciable post op benefit to the patients to justify the technology.

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    1. Yes Medtronic was fisrt, but clearly still has the same products as when METRIX and Sextant was launched 10 years ago... Nuvasive has evolved.

      Products and instrumentation has evolved. Unfortunately, Gary Michelson and KF has MDT by the nuts on any patent thus no inovation.

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  4. I can tell you one thing. Spine select's MIS TLIF has to be one of the biggest frauds in the business. Charging more for the implant and plastic working channel along with encouraging doctors to send the patient home the same day. The implant is so small and poor disc clean out will lead to a revision faster than a laser spine patient.

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    1. Hmmm... are you a distributor they fired or that fat sales rep they fired? Or, have they just taken all of your (probably limited) business? My surgeons love SpineSelect's system. And, they're the only MIS system I have seen with REAL outcomes data! Don't hate on true innovation just because it's not in your bag...

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  5. Zimmer's mis rocks in Detroit! 9 new products!

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  6. Who is Joel Olmgren? A distributor or a direct salesmen?

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    1. Having dealt with him on a number of occasions, all I can say is stay away

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  7. I would not consider NuVasive's MAS TLIF a MIS leader. The system in its current state seems over complicated and not well thought out. Most Surgeons that I have worked with that do MIS want an option for MIS Decompression, which the NuVasive system can not do w/o using Pedicle Screws. I am not sure if NuVasive is following this market, as they seem to be quite happy with their platform and continue to abstain from saying that it is MIS.
    Medtronic would seem to be the market leader, with DePuy following. Metrix, Spotlight, Sextant, Viper are all well thought out systems for delivering results.
    If Fusion is the goal and both procedures provide fusion within one year, reimbursement been equal the benefits are the immediate patient results (Less Blood Loss, Less chance of infection, Quicker Recovery). I see a lot of big MIS TLIF guys starting to rethink their procedure, as Infuse is being cut out. More thoughtful discectomy and better preparation has to be made for the MIS TLIF, from what has been getting by in the past. Seems like Surgeons just did some quick disc work, use their disc shavers, shove a 10mmx25mmx8mm Oblique spacer in with some Infuse and get good fusion. Has the abandonment of Infuse led to a bigger difference in Fusion rates between mini open and tube based fusions?

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    1. Good question. I don't think we will know the answer to this question for 1-2 years. Infuse allowed surgeons to perform MIS fusions relying on a anterior, interbody fusion. Some surgeons burr the facet joint and "spot weld" it with their choice of biologics.
      Now that less surgeons are using Infuse and still relying only on a interbody fusion or interbody with facet fusion(no posterior lateral and more difficult discectomy through a tube), it would seem that fusion rates would decrease. Further, most surgeons use whatever DBM/Ceramic product the metal rep is carrying. It will be interesting....

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    2. 3:54pm and 4:22pm,

      I agree with what you guys are saying about InFuse allowing for less thorough disc prep thus being better suited for MIS, but on the other hand, InFuse also dramatically increases the rate of subsidence due to osteolysis at the endplates. Of course there are many schools of thought on this, but some surgeons would argue that InFuse is not well-suited for any variation of TLIF or PLIF (i.e. Open or MIS) because the surface area of the implant(s) is not great enough to overcome the immediate osteolytic nature of InFuse.

      For better or for worse, I think that we're probably going to continue to see a trend more towards ALIF/XLIF 360's, and a decline in TLIF/PLIF's. At least for now, the reimbursement is better, and the fusion rates are better too. With that said, I'm certainly open to criticism. What do you guys think?

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    3. Disc prep through a tube is one of the biggest challenges. When you also consider that infuse is being squeezed out by hospital/surgeons due to cost, bad press, etc, a meticulous disc prep is vital. This seems to be a new opportunity. This will not change the world but is an undeserved segment of the industry. It seems like there are three products thus far with more surely to follow. I have seen the Medtronic shaver and Hydrocision Spine Jet. They seem to remove disc okay. I have heard about Spineview's inspire. It apparently also preps the endplate and has no capital equipment which seem to be advantages. If this thing works and I can get it, I could see some opportunities for taking advantage of the pressure on infuse and adding other biologics. Does anyone have any experience with this device and is it combined with other biologics cost neutral or better to infuse? That would be interesting.

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    4. Spineview's Inspire is an interesting product. I think the major road block comes with the surgeon not having a way to know if he/she has performed a complete discectomy (or as complete as they would like) or not. They put the enhanced likelihood of fusion in the hands of a spinning wire with an auger that pulls out disc material without knowing whether what they pulled out was indeed nucleus or just shredded up endplate or weak, degenerated annulus. In theory it sounds effective. And it may be. But I think going along with hesitations to MIS for many surgeons, there's a matter of trusting your instrumentation whether you can see it in plain view or not, that will result in mediocre desirability for disc prep products like these. Not to mention that it looks and feels like a Bob the Builder hand drill that is disposable. Nothing like tossing a brand new toy in the trash after one use day in and day out.

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    5. I have surgeons using enSpire. Yes, it took a case or two for them to trust it at first. They went in with curettes and pituitaries after the first cases to confirm the job it did. Now they won't do cases without it. Cleans the endplates and for some reason, it doesn't cut annulus. One of them saw it at NASS and says it is the first truly new technology he has seen in recent memory. No complaints here.

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    6. Sounds like a cool gig then. On average how long would you say an average discectomy takes using it?

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    7. 5 min give or take. They also feel that they are getting fusion on contralateral side, able to put more graft in and getting more robust fusion, easier to place cages, safer due to less instruments going past nerves. One feels that this has solved the infuse osteolysis issue as he no longer breaks endplates with scrapers. Apparently infuse only reacts that way when exposed to cancellous bone. Two guys have stopped using infuse for TLIF and XLIF respectively because they no longer feel they need it. Disclaimer: I am paraphrasing multiple comments by multiple docs. One of my guys feels he did just as good of job but this is just faster.

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    8. The disc prep devices look interesting and they probably do a descent job. I am not a fan of adding more cost to already inflated MIS product prices, but who knows. My point is, Surgeons will have to re-educate themselves on thoughtful disc preparation and fusion techniques as the reliance on the Super Fuse InFuse is going away. It may be up to the Attending Surgeons to step up, like so many do, and educate heavily on the basics of disc preparation and interbody fusion. It will also be imperative to focus on PSF and techniques. MIS Surgeons seemed to rely heavily on the interbody fusion, as another poster pointed out, and less on a good PSF. We need to look at both to get the results.
      I know a few Surgeons who read this board, what are the thoughts?

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  8. "Could it be that some surgeons are not flexible? Could it be that the older surgeons are not willing to learn something new?"

    It could be attendings are letting residents do all of the work and refuse to learn anything new therefore teach them anything new. It could be that surgeons do not want to take the time to learn anything new.

    ditto 1:03

    How about SYNTHES MATRIX

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    1. What about Matrix?
      Should we all stand up and clap for the arrival (in the works since 2006. Pathetic) of another me too Pedicle screw system. Synthes Matrix has nothing that other companies haven't already had for 5 years. Pop on heads - not unique, OrthoFix has.
      By the way, who the hell wants your pop on heads when you have trouble keeping the pre-assembled Pangea heads on the screw shanks. Also, word is the Matrix heads have disassembled as well.
      And you still can't make a good reducer that doesn't stay connected or at times gets stuck and the surgeon spends 20 minutes trying to disengage.
      How are those cross threading caps working out? We can all hear the titanium squeak from here. You boys and girls would do well to heave Matrix and wrap your arms around Expedium.

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    2. Dat's Right!!!!

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    3. Matrix seems to be very solid you seem a bit sour must be losing business to Sinthese! Surgeon tells me dual core screw design is tough to compete against. Also the screw has a threaded head.
      One major difference is transconnector is easy to use.

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    4. On the contrary, why do you think I know so much about Matrix. The surgeons that switched to it (from Pangea) after waiting patiently for years were not enthused. First, the problems as outlined above along with a screw holding design that comes loose during insertion. I now have these surgeon's business and they were the ones to describe all the issues from their perspective - not from the PD manager who says it was never an issue during the development phase and gives the standard answer "your surgeon is creating the error".
      Good luck competing against the more truly innovative pedicle screw systems out there such as NuVasive's new MIS system, MDT's Solera and K2M's Everest.

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    5. I was taking some Pangea business and the doc gave the Synthes rep a chance with Matrix. Once. He said it was horrible and after looking at it, he is right. What is up with the engineers making the screw driver, set screw starter and final tightener all the same instrument and only putting 2 in the tray? Having to assemble the driver a couple of times per case, the assemble the final tightener because they all use the same inner shaft? The MIS technique online shows that they really missed the mark. Ridiculous, large instruments for MIS. After the merger, you will no longer see any synthes pedicle screw systems. They will all be amazed with Expedium, not because it is amazing, but because the synthes systems are all so amazingly bad.

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    6. Sounds like a disgruntled Ex-employee of Synthes if you ask me! I would love to know what amazing pedicle screw system has helped you overcome your non-compete and easily take Pangea oops I mean crappy Matrix business away! You sound like an old record on here. I wonder if anyone even misses you?

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  9. With the new coding released making TLIF part of posterior spinal fusion (as opposed to its own free-standing code as it has been), I'll say that traditional MIS will take a hit. Surgeons are already telling me, "If I cant bill for TLIF, I wont do a TLIF". We all know MIS TLIF relies on interbody fusion with little or no decortication being done. This should in turn help grow the lateral portion of MIS.

    I still see MIS as an option in some trauma, but overall I dont see too many more strides in this area. Its a lot of smoke and mirrors

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    1. Have to go back to disc prep. If anyone thinks they are getting a good clean out doing a PLIF, TLIF, XLIF, I would suggest they borrow a small arthroscope and take a look at how they are doing. It's very humbling. All are in-direct visual approaches. ALIF is not, but has it's complications and detractions as well. I am amazed at the number of ALIF with plates are being done. They provide some protection in extension, but flexion is like it ain't even there.

      Somebody made the comment the XLIF provides a better fusion. Sure would like to see those studies - and the related outcomes. Oh yeh, I did see some of them. They are far from definitive, and if you believe most of the papers on how fusions are assessed (CT and Flex/Ext x-ray), read Resnick"s series from 2005, think it's number 4. You don't have a great chance of determining fusion from any current radiological test. And outcomes on XLIF - show me the money. It ain't there. Lot's of improvement results, but from what. Sorry a 10% improvement is NOT clinically significant, especially considering the starting point. Most of the data is class 3 at best, and should more likely be considered observational.

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    2. 7:36pm, you don't have a clue if you think that XLIF is an "in-direct visual approach". The surgeon looks directly at the disc space for almost the entire procedure. This statement alone discredits the rest of your comment since you clearly know nothing about XLIF.

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    3. Next time your in an XLIF, put a small scope in there to see what you can see. You will be surprised at what is missed. Sure, better than a TLIF or PLIF, but still not great, and certainly not compared to an ALIF. Don't get me wrong, I am not against XLIF or any procedure. Just hate to see people making wild claims without consideration. And, clearly, you don't know enough about XLIF so don't through stones.

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  10. MIS surgery will not be a big deal until reimbursement is dictated by results i.e shorter hospital stay, blood loss and better patient recovery. There is no benefit financially to the surgeon so in smaller markets where referral patterns are long time established outcomes don’t mean much. Only thing that will generate more MIS will be reimbursement

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  11. The VAST majority of TLIFs exist for poorly indicated back pain fusions or degen stenosis that could be decompressed without a fusion. Once the payors work this out (they are figuring it out), TLIFs will decline in volume. Degen spondys do NOT need a TLIF, just another 1500 bucks in the surgeon bill because it is easy to do. No added benefit. 559 has it figured out pretty well, I think.

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  12. I've seen a lot of young surgeons adopting the lateral fusion procedure vs. their traditional Tlif's & Alifs. Also it's very good for adult deformity. As the patient becomes more educated on a lateral approach vs. an alif(L1-5) I think it will make even more older surgeons wanting to be trained or learn the procedure. Globus will have an expanding lateral cage soon and LDR will release their lateral cage with anchoring plates similar to their alif and cervical products. Cages & retractors is where the growth in spine will come from not another screw system.

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    1. Is this guy (girl?) for real? 9:06pm, your comment sounds like a high school book report on lateral fusion. You clearly don't have a clue about lateral access surgery.

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    2. Thanks for considering this a book report, I did not spend nearly the time and effort on this post as a report but it might have been longer than most books you read. You must be a cheetah and you pioneered the procedure, I don't care either way, a shit ton of retractors and cages are on the way so buckle up.

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    3. Your an idiot, Globus has had an expanding lateral cage for months now, they also have an anchored lateral cage with two HA coated screws. Spend more time researching your competition. FYI, hospitals and surgeons are not to impressed with the new tech or its price tag.

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    4. Sorry, i have not seen the globus expanding lateral cage used anywhere. I knew it would be coming out soon but figured I would have seen it by now due to it being innovative. Also do you not agree that the lateral procedure is new tech with a higher price tag that requires no assisting surgeon.

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    5. Dude, seriously stop responding to this clown. He obviously has no clue what he's talking about, and seems to be fishing for information. Smells like a lawyer...or a recruiter.

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    6. I've seen the Globus cage (and more importantly the Globus reps). The issue with MIS/Lateral surgery is not technology since every company has an option - its the rep's comfort with presenting said option as a viable alternative to an open procedure. We all know its easier to sit in the back of the room and charge for pedicle screws vs taking an active role in educating our surgeons

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  13. TSB "watched a young surgeon do a MIS case".
    TSB we will need to know the outcome of the case.
    Every case looks good for a while.

    Nothing ruins a case like followup.

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    1. Amen - nothing looks better than immediate postops of some stem to stern lateral fusion case with mastergraft or some other dense material in the cage that makes it look fused - with horrendous looking "perc" screws. There's a reason why Anand isn't all over the podium at "real" meetings with considerable followup.

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    2. Funny you should mention that name. Anand is a classic example of the breed of surgeon that fortunately is dying out, thanks to the weeding done by Grassley et al. I don't believe a single word he utters about product performance, safety and patient success. Even if in his NASS 2010 disclosure he underreports, it still is telling enough:

      Anand, Neel: Royalties: Medtronic (E), NuVasive (E); Stock
      Ownership: Trans1 (Unknown), Globus (Unknown);
      Private Investments: Paradigm Spine (Unknown), Bonovo
      Orthopaedics (Unknown), Pearl Diver (Unknown);
      Consulting: NuVasive (D); Speaking and/or teaching
      arrangements: Medtronic (D), Globus Medical (C), Applied
      Spine Technologies (B), Pioneer Surgical Technology (B),
      Trans1 (B), Zimmer (B); Trips/Travel: Medtronic (Consulting
      disclosed); Scientific Advisory Board: Applied Spine (10,000
      options), Atlas Spine (10,000 options), Globus Medical
      (150,000 options); Grants: Zimmer (E, Paid directly to
      institution/employer).

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    3. 7:05 NFL not on that list?

      http://www.nfl.com/videos/nfl-network-total-access/09000d5d826d97b3/Manning-s-injury-explained

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  14. Great post 559 hit the nail on the head. TSB, would be good to hit on the coding changes we are encountering as healthcare continues to change. We know Acdf is 1 code now. Tlif and PSF are now one code. Allograft is being blended into the whole procedure. These codes will severly affect our business going forward

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  15. LES is the new MIS www.les-society.org

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    1. Ha!! Good luck getting surgeons to attend faux society "workshop"!!

      I like how it says at the bottom of the website, "LES Society is a division of the Society of Facet Surgical Techniques and Technologies, Inc. (SOFAST), a Florida nonprofit corporation." Is there really a Society of Facet Surgical Techniques and Technologies? What surgeon in his right mind would join a society like that? One that is getting PAID!! That's who!! Haha...this industry has gotten so ridiculous that you almost can't do anything but laugh when you hear about stuff like this.

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  16. MM should know that MIS through a tube will never be broadly adopted by surgeons for the following reasons:
    1) You can’t see your landmarks, in general surgeons like to see what they are doing…
    2) Mediocre endplate prep at best and now no more Infuse to hide a poor prep job…
    3) Longer surgery times and too much radiation exposure by surgeon, staff and patient, not to mention surgeon radiculopathy from wearing lead so long, if they wanted excess radiation exposure they would’ve been cardiologists
    4) Did I mention no increase in reimbursement
    Medtronic did extensive market research on this using conjoint analysis (= tricky ways to figure out what the customer really wants when he won’t tell you because he is too macho). They figured out that the surgeon wants minimally invasive but doesn’t care about going through a tube and sure doesn’t want the above as tradeoffs. Medtronic’s response to this was to launch the MAST MIDLF procedure at NASS which they evidently put into a witness protection program because it hasn’t been seen since, another genius move from Memphis

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    1. Ah, yes you can see the landmarks, move the damned tube. MIS endplate prep is no better or less than open TLIF or PLIF, if you have more op time and exposure time, you are not doing it right.

      Keep thinking short sited and you will reach your goals.

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  17. Change of subject...Anyone know how Paradigm Spine is doing these days and where have some of its former management team like Chris Hughes and Chris McAuliffe surfaced since they both departed? They both seemed like a good team together....Just Curious

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    1. Hughes is riding the POD wave at PDP

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    2. Chris is/was a good guy...too bad he sold out. Apparently the end is near.

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    3. What end is near? Paradigm Spine's or Chris'?

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    4. Yep, PDP is trying to pass itself off as a non-POD, but at the end of the day they still have surgeon owners/investors that are using the products

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    5. No Paradigm end is near too. Word is all their top guys left or are leaving soon. They have completly run out of money. Too many expensive cigars apparently. Even if their coflex device gets approval, they will not have enough $$$ to actually hire "A" players again to sell it. Have heard they have been through 2 rounds of cutbacks in the last year and the products they do have are horrible. Sinking ship.

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  18. Has anyone seen the new system from Interventional Spine called the PerX360 with Opticage?

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  19. You mean.... Biomet? .... Going Public? Again...?...

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  20. Who is getting Royalties on the Viper system?

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  21. D. Greg Anderson, MD
    Thomas Jefferson University Hospital
    Rothman Orthopaedics

    Robert Heary, MD
    University of Medicine
    & Dentistry New Jersey
    Newark, New Jersey

    Carl Lauryssen, MD
    Tower Orthopedic &
    Neurosurgical Spine Institute
    Beverly Hills, CA

    Tony Tannoury, MD
    Boston University Medical Center

    Professor Cornelius Wimmer, MD
    Behandlungszentrum Vogtareuth
    (Vogtareuth Treatment Center)
    Vogtareuth, Germany

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    1. You need to check out the Viper 3d system/surgery technique. They have about 25 contributing surgeons on that.

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    2. DePuy . the distribution model. get a consultancy/ royalty agreement and watch those numbers come rolling in. The Big East is doing well

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  22. I may be wrong, but I think those are the surgeon designers. Viper is based on Expedium and I believe that came from Lutz Biederman. So the IP royalties are probably going to his company.

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  23. Hilarious that you don't think the "surgeon designers" aren't getting IP royalties for that stuff...that's how it works.

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    1. Surgeon designers may get some royalty consideration for saying tweak this or that but the bulk of royalties goes to the patent holder. In this case, I believe Biederman is getting the F You money.

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  24. Who says you can't get to L5-S1 with the MIS lateral approach? Just drill straight through that pesky ilium!

    http://www.spinefrontier.com/resources/TILT-Sale-Sheet.pdf

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    1. I would hate to be the first surgeon that has to defend that in trial. Where is the ground to stand on?

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    2. why wouldn't that work?

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    3. @9:14 I would be hesitant to say it definitely would not work, but at what potential risk? The morbidity of drilling a hole through the Ilium to facilitate a XLIF spacer, seems careless. Please also reference the Plexus at 5-1, it is like a spider web. 4-5 XLIF is difficult enough to navigate, unless you have a skilled Surgeon with the right equipment. L5-S1 would be a catastrophe, in the majority of cases. Why would you do this when ALIF is a perfectly reasonable approach to 5-1? Again, I wouldn't want to be the first surgeon to defend that. The only reason I could see to do this, would be if the patient has had previous abdominal surgery and/or a few posterior I would rather navigate posterior scare tissue rather than proceed with this Sx. Other than that this is a code chaser procedure with little benefit and unacceptable risk. As always, in my humble opinion.

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    1. http://www.frontiersman.com/news/marijuana-conviction-stands-on-appeal/article_535f6240-478b-5bde-ad42-70eda7a18c04.html

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    2. Shane Neuharth lost his fight with the FEDS

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    3. LDR and Amendia should be so proud of their representation.

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  26. Shane Neuharth should start a smoke room campaign for his spine surgeons. I heard he sparks it up with a few docs now and then. Being stoned in a case would be scary.

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  27. Stryker's MANTIS is legit.

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  28. surgeons dont take the time because most of them are lazy fat asses! They would rather cut a pat open 5-6cm to place in 4 screws and two rods "saving them time" as they put it.
    Nice!!!

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  29. On the other end of the spectrum, there is a doc in my territory that does six level xlif and ten levels of MIS screws. Two day staged surgery. Eight plus hours for pedicle screws that could be done open in just under three. He is ego is so big he proudly shows it to everyone on his iPhone. This not what s best for his patient or good use of healthcare dollars.

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  30. Is he in Chicago by chance?

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    1. Not Chicago. But it looks like there is one of the egomaniacs in every city.

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  31. Saw some Amendia cases with their oblique MIS approach I think they call it the OLLIF. Sketchy as hell, but looks cool. Almost an exact rip-off of an Optimesh case, but with a massive PEEK cage being pounded past an unprotected nerve root.

    Let me repeat that: A massive PEEK cage being pounded past an unprotected nerve root.

    I asked the rep if the cage touches the nerve root as it passes. He said "almost certainly." So what was protecting the nerve root? He said it was the shape of the cage. Oh, right. So it's not a direct blow on the unprotected nerve root, it's multiple indirect blows... unless the nerve gets snagged by the passing cage.

    And do patients do well? They started doing cases with this piece of shit 4 years ago. If it worked worth a shit, you'd probably have some non-consultant surgeons using it by now. But no. Or maybe something would be published about it. But no. Seriously, I did some searching and couldn't even find a poster. Hell, there's more data out there on Optimesh.

    As far as their MIS screws-- let's just say the reason I saw the case is that I was there for the metal part. The surgeon said the Amendia screws were among the worst he'd ever seen.

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