Facet Fusion Technology: Does it really Work?

Recently one of our readers e-mailed TSB and inquired whether there was any existing literature/white papers pertaining to facet fusion devices. This post pertains solely to machined allograft products that have been in use for two to three years. This alternative treatment to fusion is relatively new, so, TSB went in search of data that would potentially substantiate the clinical efficacy of these products, address the many concerns that have been raised implanting a cortical allograft within the facet joint, and whether there was a selection criteria that would make orthopaedic and neuro-spine surgeons, interventional radiologists and pain management physicians comfortable with these products as an alternative modality of treatment to traditional fusion techniques.

So what did we find?

The first clarification that must be made is that bone dowels or wedges are not as new as some marketing platforms claim. Bone dowels and wedges of different shapes and sizes have been around for many years, especially in orthopaedics. To claim that the allograft will "eliminate" facet pain is a bit disingenuous. Maybe, if the primary source of pain is facet degeneration, but, back pain can be and is usually accompanied by secondary, and at times, even tertiary drivers. Therefore the key to any successful surgery is patient profiling, in addition to pre-operative planning. In many respects, it's similar to laser surgery. Yet, before any of this is considered, the majority of patients prefer to be treated conservatively. This runs the gamut from administering pain medication, "hand grenading" the facet joint with a combination steroid/anesthetic injection, PT, and a good old fashion facet rhizotomy where a needle or catheter is inserted into the area where the sensory nerves meet the joint sending an electric current utilizing heat to stun or ablate the nerves utilizing fluoroscopy. So by the time the patient is desperate for surgery, the physician has extinguished conservative therapies.

But what about the osteogenic characteristic of the allograft used to manufacture these implants? Most orthopaedic surgeons are skeptics using a cortical graft, and in all likelihood will never be proponents, or, advocates of this procedure, unless they are a paid consultant. Neurosurgeons seem to like this product, yet, one must question the philosophical difference between these two disciplines. So the question must be raised, where is the retrospective data substantiating facet fusion using a cortical allograft? Considering that it is nearly impossible to develop a cancellous graft for facet fusion applications, yes, TSB knows that some will argue that it can be done, but at what cost? And, where will one harvest from? The industry would love to see the published data in addition to what financial interest these physicians have in driving the revenue for some of these companies. With the Spine Technology Summit in NOLA next week, this would have been a perfect forum to showcase results.

But the biggest challenge that any of these companies have is the selection criteria. Not one of these companies can specifically provide an established criteria as far as patient selection. Facet pain is a broad generalization. So, in the spirit of debate, have any of our readers had success selling these products? What have been some of the clinical indications? And, which specialist seem to like the use of this device? Sometimes, it's not just about the money, at the end of the day it comes down to outcomes. TSB wants to know if our readers can shed a little light on this topic.

You know the old expression that if one cannot get one's way, one must adjust to the inevitable. Therefore, if the mountain cannot come to Mohammed, Mohammed must go to the mountain.