Episode 7: Dr. Verma Discusses Artificial Disc Replacement with Dr. Jason Cuellar

Description:
Dr. Verma sits down with his longtime friend and fellow spine surgeon, Dr. Jason Cuellar, to discuss artificial disc replacement, spine surgery innovation, and the future of motion-preserving procedures.

From the episode:

“Dr. Jason Cuellar is an experienced orthopedic spine surgeon based in Florida, with practice locations around Palm Beach, Jupiter, and the Miami area.

In this episode, Dr. Verma and Dr. Cuellar explore various topics in spine surgery, including cervical and lumbar arthroplasty, artificial disc replacement, fusion surgery, patient selection, recovery expectations, revision risks, insurance challenges, and the barriers surgeons face when adopting newer spine surgery techniques.

Dr. Cuellar shares his background, including his training at UC Davis, Stanford, NYU Hospital for Joint Diseases, and Cedars-Sinai Medical Center. He also discusses how his career became focused on artificial disc replacement and motion-preserving spine surgery.

The conversation gives patients and listeners a deeper understanding of how spine surgeons evaluate candidates for disc replacement versus fusion, why careful patient selection is so important, and how modern surgical techniques are helping patients maintain mobility and return to active lifestyles.

Dr. Verma and Dr. Cuellar also discuss the future of spine surgery, including emerging technologies, new implant options, and the importance of educating both surgeons and patients about alternatives to traditional fusion surgery.” 

Explicit content:
No

Promotional content:
No

Transcript

SPEAKER_01 0:09

Guest is an old friend of mine, uh, Jason uh Quailar. He and I actually went to NYU together. I was a medical student while he was a resident. I always looked up to him, and we followed each other's careers pretty closely over the last, I think, 10 or 15 years. And Jason has really done a great job of building his practice around innovation in arthroplasty, both cervical arthroplasty and lumbar arhoplasty, and he's based out of Palm Beach. Yeah, Palm Beach, Jupiter, and a little bit in Miami. Okay, Palm Beach, Jupiter, and close to Miami in Florida. And he's just an exceptional surgeon. I had the opportunity to actually uh spend a day with you in March trying to, you know, learn some of the nuances of lumbar disc orthoplasty that maybe I haven't seen myself or look and see how you'd put these orthoplastys in on difficult cases. And I really appreciated that time together. And I I can tell you're an expert. So I'm gonna let you jump in. Tell us about your background, your training. I know you're an MD PhD, which means you're brilliant, but also how did you get so interested in orthoplasty? What was the path and what have you learned kind of going down this path as a surgeon?

SPEAKER_00 1:25

Sure. Uh so I started out in California from UC Davis for undergrad and PhD and Stanford for medical school. And then I went to NYU Hospital for Joint Disease, where I met you, where I was doing my orthopaedic surgery residency. And uh I learned from a lot of great spine surgeons there. We did a lot of uh, I put in a lot of screws and did a lot of decompression, uh, did a lot of big, you know, fusion surgeries, but pretty much no arthroplasty until I came to Cedar Steinheim Medical Center in Los Angeles, where I did my fellowship with Todd Lannman and Hun Be and Mike Croft, you know, just to name a few of the excellent surgeons that I work with that did that did quite a bit of arthoplasty, especially Dr. Landman, who I eventually joined and practice at after fellowship. And I spent uh almost seven years with him. And you know, we we pretty much did did every surgery together. And, you know, I think I did uh over a thousand surgeries out there with him, and uh, you know, a majority of those were actually orthoplasty. So, you know, at this point I've done over 1,600 artificial disc replacements, and it's become my kind of my focus, my specialty or subspecialty, or super, you know, super specialized, you know, focus. Yeah. And it's uh it's kind of my thing now, you know. I mean, I was talking to Dr. Armin Kottacherian out in uh Park City a few weeks ago, and you know, he and I both were were kind of discussing how you know we tell other surgeons now that like 90 to 95 percent of our practice is artoplasty, and they say, Oh, that's not possible. And we're like, Yeah, actually it is. Look at my schedule. You know, it's uh it's possible, and that's what I love to do, you know, for for a variety of reasons, but you know, foremost because patients get great outcomes.

SPEAKER_01 3:11

Yeah, I've seen that myself. You know, you can put the patient through a much easier recovery, avoiding big open spine surgery. You know, those incisions on the back are just really tough to recover from. And the more you're able to do in the anterior column or through the lateral space, I think the easier the surgery is. And and more and more if you've got the right vascular surgeons, you can put arthroplastys rather than fuse people. One of the things I liked about your practice is you're doing arthroplasties on cases where it might be a little more technically difficult to get the arthroplasty in there, maybe the facet joints aren't perfect, but you've got enough experience that I think you're you're able to know who the good candidates are and who are. In your own words, how have things changed over the last five to ten years in practice? Just in your practice and also what you've seen around you in terms of like cervical and lumbar orthoplasty, and when are the situations where you'll still sort of try to avoid it and try to do maybe a mentally invasive fusion? Sure.

SPEAKER_00 4:14

I mean, it's definitely been something, you know, that's sort of evolved over time. You know, obviously I wasn't the first one to do a lumbar orthoplasty, and you know, it's it's been around for now 35 years. And so, you know, I've learned from you know the great surgeons like you know, adventure of of of the protist Thierry Marnay in France and you know, my mentor and partner, Dr. Todd Laman, and you know, really pushing the um the indications, I think, where you know you start out just with the one and two level, you know, mild to moderate dis regeneration, you know, patient with you know perfect facet joints, and then you know, you see that those work and you sort of advance to the next level where you're doing more collapsed discs. And then, you know, eventually get to the point where you're doing patients that have multi-level severe collapsed, you know, bone-on-bone discs with with you know some you know, some moderate facet joint arthritis. And and so we just kind of slowly, you know, push the indications, you know, of course, with you know, with caution, you don't, you know, you really don't want a failure, obviously. And so I think you have to do that, you know, very responsibly. And uh, you know, because a failed lumbar arthroplasty is is a big mess. It's you know, it's a disaster. And, you know, and uh unfortunately I think some surgeons have you know experienced you know the one disaster maybe of their own or someone else, and they're like, well, I I I don't want to catch it ever again. You know, so you do have to be careful. And so you know, there are there are definitely some patients, you know, that I avoid. And you know, of course, of course, a truly uh unstable patient where you have you know grade two spondular thesis, you know, I think any spondulisthesis at L5S1 for me is a no-go. You know, any sort of parish fracture at L5S1 is is an absolute no. I have done patients with unilateral parge fractures at 3.4 and 4.5, they're 3-4 or 4-5, not you know, both levels, but you know, one at a time if they've got a you know one-sided unilateral, you know, non-displaced parish fracture, old, old facet fracture, up at those upper levels where there's you don't have the shear force that you have at L5S1. And these are patients with a degenerative discs that have failed medial branch blocks. And so it, you know, if you're ruling out the facet as the source of pain, obviously, you know, you're not gonna want to do orthoplasty on someone that you think is whose pain is just facetogenic, right? And that can be difficult to know for sure. But, you know, and you and and I think that this is it is very important to have a very detailed conversation with the patient ahead of time. And, you know, those cases that I've done with, you know, unilateral facet or parse fractures or advanced degeneration. I've had a conversation with the patient and say, look, you know, and these are usually patients that really refuse to have a fusion, do not want a fusion, and you know, they found me maybe on their second, third, or fourth opinion, and they said, hey, look, you know, I think it's coming from your disc and maybe some, you know, foramenal loss of height, you know, stenosis. And I think the orthoplastsy will take care of it, but there's a small chance that you know you may still have some post-op back pain from if the facet joint is a is a contributor. And I said, Well, you say so you may need facet joint, you know, radio frequency ablations, post-op. I've only really had to do that one time and in the early post-op period and the pain resolved eventually.

SPEAKER_01 7:46

So and for any audience here, you know, when we're diagnosing back pain, we look at the MRI and the x-ray, and we need to feel pretty confident the majority of the pain is related to either nerve compression or what we call discogenic disease, where we really think it's the disc that's the main driver of pain. And then we always will look at the x-rays to make sure the level isn't uh grossly unstable, not slipping out of place on an x-ray. And then usually we'll take some sort of look at the facet joints, either uh with quality x-rays or a CT scan. If the joints in the back look healthy, you know, presumably that's that's a candidate that you might consider uh an artoplasty on. Is that is that correct?

SPEAKER_00 8:25

Yeah, absolutely. And you know, as you mentioned, you know, we want to stay away from certain patients. And so, you know, I think the obviously patients that are truly unstable, you have to avoid patients with with osteoporosis, you know, patients that have abnormally large bones. So, you know, I I only I've only had a couple of only had two postdoc failures and from subsidence, and those are people that were have really big bones. So now I measure everyone. So I'm these these are the guy, you know, talking about the guy that's six foot five, two fifty with with you know vertebrae that are giant. And and so now I measure every disc space, and I don't want to do a really big patient because you know the the Pro Disc, which is the implant I use, it's the only one we have right now at the time. Well, I think it's the best implant, but it's what we have in the US. You know, they it's made for the average size patient, right? So if you have a really big person or a really small person, the implant may not fit them well. And I think so you have to really take that into consideration as well. You know, I've you know, you get the woman who is you know four foot eleven and 105 pounds, you know, you know, I've got a so I I always measure the the normal disk spaces above, I measure uh as far as the height and I measure the you know disk space, you know, A to P length and the width. And you know, I know the implant sizes. And so if a woman has a it's usually at the sacrum where it's a problem, if you know her sacrum is 25 millimeters deep, and I know that the smallest pro disc is you know 27 millimeters, I'm gonna warn her and say, look, you know, you you may be too small for the smallest pro disc implant, and we we may need to fuse you, and and and sometimes it comes down to intraoperative decision, but you have to have the conversation with the patient. So those are the patients that I'm avoiding. And and then obese people, you know, no, yeah, yeah, not trying to offend anyone, but you know, if you have a BMI over 35, you know, the bone, the bone may not support the implant, and the surgery itself is is more dangerous.

SPEAKER_01 10:20

So that those are the people that I've learned. I counsel my patients the same way. If they're older and osteoprotic, I think it's probably safer to just do a minimally invasive fusion. And if you are a large patient with a BMI over 35, I've seen strange failures in that subcategory of patients, implant failures, fractures, things like that. So I think more instrumentation rather than less might give you a more reliable outcome. I do agree with that.

SPEAKER_00 10:48

Or as I was just gonna say, I I have had patients successfully lose weight and and be treated for osteoporosis and you know, there's their techniques using cement and whatnot. So we can, if a patient is really determined, um, you know, sometimes we are able to overcome some of those problems. Yeah.

SPEAKER_01 11:04

What is when when patients come in and they're debating the fusion versus the arthroplasty, what are the types of conversations that you have with patients? I assume, like like many of us, you you kind of let the patient decide what they want and you give them the pros and cons of fusion versus arthroplasty. What in your opinion is is like if you have a typical 40-year-old patient, you know, the pros of fusion versus the pros of orthoplasty, and then the cons of fusion and the cons of arthoplasty, and kind of go over that conversation with us, share our way in as well.

SPEAKER_00 11:37

Yeah, and you know, it depends on a lot of different factors. It depends on the levels, for example. So, you know, let's say if a patient has, you know, two-level disease and you know it's an L45 and L5S1, and you know, we're deciding between, I mean, for for me, that's a very common scenario. We're deciding between a two-level disc replacement and a hybrid. So we're at we're on fusing 5.1 and doing an orthoplasty at 4.5. Um, so you know, that conversation there is, you know, the the the pro that the advantage of having the two-level disc replacement is your overall motion is going to be better and your recovery is going to be faster with the disc replacement. And, you know, your return to work, you know, data has shown that that's you know faster. You know, so those are those are the advantages of, you know, for example, a two-level disc replacement versus the hybrid. The hybrid does very well, but you know, it does take longer for that fusion level to heal. You know, it could be up to a year. And then there's a small, you know, percentage of people that don't successfully fuse at the L5S1, and then you have to go back and add screws, you know, posteriorly. Because a lot of times I I if I'm going to do a hybrid, I usually do it all from the front. I don't put screws in the back.

SPEAKER_01 12:54

Yeah, in our practice, we'll do one set of unilateral screws in the back just to share it up. It it maybe adds a little bit of discomfort from that incision. You have to flip the patient, but I feel a little bit better with a little bit more fixation in there just to make sure it fuses. But yeah, I have the same concerns. And the one of the things I tell patients is, you know, the implant is hard to get out. You know, if for some reason you have ongoing back pain, or you know, one of the concerns I sometimes have is subsidence. It's a really collapse level, an art osteoporotic patient. Maybe that implant will settle in a position that we don't want it in. What do you tell patients about revision rates of the two different procedures?

SPEAKER_00 13:34

Sure. So you you know the revision rate, and you know, I really have to stress careful patient selection. You know, if you carefully you know select the patient and you're not doing the osteoporotic patient without treating them for six months with Forteo, for example. But you know, if you carefully select the patient, then the revision rate of a well executed lumbar disc replacement should be less than one percent in Ishigan.

SPEAKER_01 13:58

And that's the data that really drives a lot of the surgeons to want to do at least lumbar or cervical disc replacement, is the revision rate is is pretty low. And in the cervical spine, we have I think good tenure data that shows that the adjacent segment revision rate is lower if you do a disc replacement. And we all kind of know that now. With lumbar orthoplasty, I think it's harder to get a really good quality study. And we'll go into why if you want to discuss it. But I think it is a little bit harder to get that data, but for sure, probably the revision rate is lower than a fusion. With a fusion, you're probably transferring stress to the adjacent level. That level may break down more quickly over time for a younger patient that's relevant. And that risk we think is about 3% per level per year. That's kind of been famously quoted many times. Would you uh sort of counsel patients the same way?

SPEAKER_00 14:53

Yeah, exactly. And and you know, a good example is is let's say if a patient just has a problem at L5S1, that's the only level they have a problem at. And then so, you know, you're talking about a one-level fusion, and let's say let's compare ALIF at L5S1 to a disc replacement at L5S1. So, you know, L5S1 as an orthoplasty surgeon, you know, we'd like to say it's the easiest level to access, but it's the hardest level to do. You know, it's the it's the level most likely to fail after a lumbar disc replacement. And I'm not talking about a high failure rate, but we if you compare uh, you know, um the other levels, the L5S1 is definitely more difficult to do from a the technical standpoint, and it has more stress on it, you know, because of the angle of the pelvis, there's more shear force in the implant. So I carefully measure the sacral slope. And if if someone is above 45 to 50 degrees, I think that puts them at a higher risk of that level failing with an arthoplasty. So if you couple that with some facetrin arthritis, then I think, you know, in in that patient, it's a very distinct possibility that an A-lift may actually be, you know, have a higher rate of success in certain patients. And so then you're counseling the patient, well, look, the A-LIF may actually, you know, have a higher chance of doing better, but the catch is that you are gonna be at a higher risk of adjacent segment degeneration at the next level, right? So, you know, it it's hard to make that decision because at one level ALIF at all at L5S1 does great, you know.

SPEAKER_01 16:30

I and I think that's the tricky thing because that's a surgery where I will do a minimally invasive, and very rarely do I actually revise that surgery. It does pretty well. But I'm sure if you follow them out 10 or 20 years, you know, they're that adjacent level, at least radiographically, probably has some breakdown. Whereas the ADR level will probably not have the same amount of breakdown.

SPEAKER_00 16:54

Yeah. So I think that that's a case where so that's why I carefully evaluate, you know, the each patient. And if I think that there's any you know, risk factors for failure and it's only that one level, then you know, we may lean towards an ALIF.

SPEAKER_01 17:09

What do you uh counsel? Like what kind of literature do you quote when kind of guiding patients? Like in my practice, it's people are often pretty enthusiastic about lumbar disc replacement, but not everyone's a candidate. And you know, maybe we're a little bit more selective on on certain levels, but what literature do you rely on to sort of help patients and guide them to make the decision? Is like there are good comparative studies or there are longitudinal studies? What are you doing on?

SPEAKER_00 17:39

Arthoplasty in the spine is one of the most well-studied surgeries that we have. And, you know, there's the randomized control trials, there's both the both the pro-disc and the actavel studies. You know, the actavel sell you they compare pro-disc to actavel. And then there's the the original Pro-Disc trial, it was randomized control trial of anterior-posterior fusion with lumbar artoplasty. And the FDA trials, you know, they're very strict when when you talk about like their criteria for success. So unfortunately, when you look at like the outcomes, it doesn't look like they're very good. It's like 60% success rate, right? It looks it looks terrible. But but you know, for both groups in that shorter term, but it's because they're you know, a patient's considered a failure if anything happens. I mean, they you know, if they catch a cold in week two, that's like, oh, that's a failure, you know. I mean, anything happens, like literally, right? And that's considered a complication or you know, a failure. So they're very comparable data when you look at you know the first couple of years. But when you look longer term, five years, 10 years, you definitely see a higher rate of reoperation and adjacent segment degeneration in the fusion group compared to the um ADR. So that's one set of data. You know, I published some uh some papers with some other surgeons also looking at longer-term multi-level lumbar disreplacement, showing that they do well and they maintain their motion. You know, that's one set of data that's not you know randomized. And then there's and then there's a very long-term data that's that's published by Dr. Marnay's group, you know, up to 20 years with over a thousand patients and you know, very good, you know, very well collected data. You're showing that the JSON segment is generation and uh your rate's very low, ferry rate's f uh very low, and success rate is is good.

SPEAKER_01 19:32

So I think we're gonna do you know like over 97% success rate.

SPEAKER_00 19:37

You know, I should know that number, but I actually don't. I I I don't know the you know success rate for that.

SPEAKER_01 19:42

I struggle with that myself because every time I do a minimally invasive fusion, I feel like the success rate is in the 97, 98% rate. So I quote people that it's probably at least as as successful as a surgery. We just have to make sure we carefully select. And then I want to pivot into the barriers. So despite there being pretty good data for lumbar and cervical disc orthoplasty, lumbar disc orthoplasty is met with a lot of barriers to success, basically. It's difficult for uh surgeons across the country to really incorporate this uh surgery. Can you go into why that might be? And I I I can jump in as well, but I want to give you a chance.

SPEAKER_00 20:23

Yeah, this is something I've talked about recently a lot, especially on the spine pod podcasts I did a few months ago. We went into this a bit. I mean, you know, there's some reasons that are good and some reasons that are bad, and you know, what uh, or I should say acceptable and you know, not acceptable. You know, one reason that's acceptable, I guess you would say, is is just the lack of a good vascular surgeon to work with. And, you know, I was very blessed at all the places that I've trained at, you know, NYU, we had a great vascular surgeon, although we only used them for for anterior lumbar and biofusions. And then I got to Cedars and we had two really amazing vascular surgeons that we used for both ADRs and and A-lifts. And then now I'm in South Florida, where we have you know two very good surgeons and you know, I primarily use one that's that's really excellent. But but you know, uh other than you know, those centers I just mentioned, there aren't that many centers around the country that that have you know great access surgeons. I mean, they've got a great access surgeon at Texas Back Institute. I'm sure they have one, you know, John Hall out in Flagstaff, you know, you know, is a great lumbar ADR surgeon, and you know, Matt Gornett in St. Louis does them himself. I think. So, you know, there's a I mean, there are definitely pockets here and there where they've got you know great access surgeons, but a lot of you know, patients that come to me here for treatment for lumbar disc replacement, they say, well, no one in my area does them. And, you know, not having an access surgeon is is one reason. And then the other reason is I mean, there are a variety of other reasons. One unfortunate reason is is insurance. I really think a lot of the insurance you know companies are criminal. In that they oftentimes won't authorize them or make it very difficult, make it very difficult to get authorization. I've had, I've had some patients that I've had many patients come to me and have and have had to pay for the entire procedure out of pocket because they were too old, you know, they're over 60. The insurance company says, oh, we don't cover them if you're over 60. And and if if it's in their medical necessity policy like that, you can't appeal it. They just won't overturn it. They just, there's nothing you can do. You know, so there's age, insurance companies will deny it if uh oftentimes if you've had prior surgery at that level, even though that's completely unjustified, you know, they'll deny it. If you know, let's say if you're trying to get you know two levels approved and the radiology report says that you know there are three levels that have some pathology, even though you, as the surgeon, don't think it's that you know relevant, they'll try to deny it for that. And then you know, there's there's Aetna that lost a you know class action lawsuit for not covering lumbar ADRs, and now they're supposedly covering them, but they only cover one level, not two levels.

SPEAKER_01 23:01

You know, how they on the back end, you know, it's very hard to get reimbursed. Even if you do the surgery, there's no guarantee the insurance will pay you fairly. And then often uh whatever payment there is, you usually have to split that with a vascular surgeon. So it becomes very not cost effective. You really have to be a surgeon that's interested in this, pursue it. And I think there's some there's some ways to get around it, which some surgeons are finding different ways to get get around it, but it it's been a challenge, and I think it's too bad. It's just probably one of those areas where you know the innovation is great, but we just can't get the payers on board. And so I tell all of my Arthroplasty patients, like, we're gonna be a team on this, we're gonna work together to get your insurance to approve the procedure. And it'll probably be a lot of phone calls and peer-to-peers and appealing and things. I've never actually had a lot of success getting a hybrid approved. I think usually you have to get the two-level approved and then dictate something that says we had to do a fusion. Is that correct?

SPEAKER_00 24:01

Yeah, I mean, we have gotten some approved. You know, unfortunately, sometimes you know, the patients had to either pay out of pocket or they've had to pay out of pocket for that second level, you know, and maybe able to get the fusion approved and that to pay out of pocket for their disc replacement level. So there are different ways to do it, but it's not easy for sure. And that's another barrier, you know. I mean, if if the surgeon, you know, wants to, you know, wants to treat both levels and they feel like one level needs a fusion, one level needs a disc replacement. Now yeah, the insurance company is saying, oh, you can't do that, you know, playing medic, you know, playing doctor. So, you know, that's another barrier. And as you mentioned about reimbursement, you know, it's it's sad. And this is what I think one of the unacceptable reasons is you know, reimbursements for in-network surgeon, they actually pay less for the disc replacement to the surgeon than they do for a fusion. So you have some surgeons that are just taking the attitude of, well, I get paid less for a disc replacement. And by the way, it's actually more work. So, you know, why would you do that? Right.

SPEAKER_01 24:57

So yeah, that's that's a lot of the uh the mantra that I've heard kind of through training. But it's interesting, you've trained in Southern California and you practiced here. Now I've been in Southern California for seven years. There's definitely like geographic variation in how spine surgery is done. In Southern California, there's more innovation, I think, in the orthoplasty space. Just historically, surgeons have done more orthoplasty and they've innovated and pushed the boundary more and that trained a lot of people that believe in that same way of practicing. And even though I didn't train at Cedars, I my training, as you know, is more complex spine. It's just rubbed off of me over the years. I'm like, you know, we don't need to be doing as many fusions. And the ones we do, we're doing them as minimally invasive as possible. Uh-huh. So we're not disrupting the posterior elements and trying to give the patients a lower revision rate. Are there specific patient populations where you really feel like you know the arthroplasty, let's say lumbar orthoplasty in this situation outperforms a fusion? Like who's your ideal candidate? You're like, this is a great arthoplasty candidate.

SPEAKER_00 26:02

Yeah. I mean, uh, you know, I recently had some really fantastic patients in their 50s and 60s who are just, you know, super active guys, you know, you know, jujitsu, skiing, golf, you know, all these guys with multi-level, you know, I'm talking about three and four level uh disgeneration, you know, with with partially collapsed discs and an axial back pain, you know, plus minus a little bit of leg pain, you know, no prior surgery, you know, minor facet join arthritis who just failed all conservative treatment. You know, I've had multiple cases in the past you know, years or two years or whatever that where I've done you know three-level lumbar ADRs on them and they've gone back to golf and skiing and mountain biking and running. I mean, I had a patient, he's actually a you know, spine surgeon now in uh Park City, Utah, who just did a triathlon. He did a triathlon. I heard of a triathlon, eight months, you know, post-op from a three-level lumbar ADR. And I think he's like 62 or 3, something like that.

SPEAKER_01 27:06

And the reason that's important is that kind of outcome is not one you expect from a three-level fusion. So I think the differences between ADR and fusion really start to become very evident in a patient with like three-level disease in their 60s. If you do a three-level, even if you do it minimally invasive, they're not going to have that same level of function that you have to do.

SPEAKER_00 27:27

No, absolutely, absolutely. I think it's a big functional difference. I mean, it's not just the surgery and recovery and the adjacent stem degeneration is a big thing too. But you know, when you get more than two levels, I think you you really you really lose a lot of motion, you know, when you're gonna do that.

SPEAKER_01 27:41

Yeah, absolutely. Yeah, I think sometimes you can sit there and really debate the one level. Do I fuse it? Do I do disc replacement? When you start to look at multi-level disease and somebody is really fit and active, it's really hard to point them in the direction of fusion. I think that's that's I echo that. When you do these arthroplasties, what does a recovery typically look like? I can share some of my thoughts, but I want to give you a chance. I've noticed sometimes patients can get a little facet-related back pain because you're really taking these collapse levels, standing them up pretty tall. I've noticed they can get a little L5 ridiculopathy or a little irritation of the L5 nerve root. That one tends to always be the one that gets irritated. But then when I follow them out a couple of months, it seems to all go away and they're very happy. And then I tend to CT scan people uh to look at the implant and make sure there's no subsidence and no fractures or anything like that. And then I let them go. Uh, what's your protocol look like?

SPEAKER_00 28:37

Yeah, so you know, typically, and I agree with most of that. You know, typically for the first two weeks, they're just walking. You know, on the third week, I have them start, start back in the gym, but with some gentle exercises. So they're not, you know, I don't like them to bend for the first six weeks. So from weeks three to six, they're in the gym, but they're keeping the spine neutral. So they're doing some gentle leg work, some gentle ab work, some you can do a little exercise bike and elliptical, you know, a little, a little easy exercise to get things moving. So they're doing that for three weeks. And then when they hit the six-week mark, they're allowed to start bending and kind of doing everything except for running and jumping. So at six weeks, they're, you know, I say about 75% better. So they're feeling, you know, pretty good. And then they're really starting to rehab so really strengthen the perispinal muscles and the and the core muscles. And and usually by by three months, they're you know, about 90% recovered is what I normally say. And then I say, well, that last 10% can take people another month or it can take people another three months. You know, it's it's pretty variable, right? But most people are feeling pretty good by three or four months. Now, you you mentioned you know, nerve stretch pain, the facet joint joint pain. I do find that both of those pretty variable. So, you know, some people I do a lot of really collapsed discs, and you know, I'm really stretching them out and they wake up and they have no back pain and I'm like shocked. And other people have a lot of pain in the beginning that you know fades away pretty quickly. The nerve stretch, nerve stretch pain, I think it is, or that's what I call it, where they you know they get kind of a sciatic type of ridicular pain. I feel like that comes on, you know. I've been quoting patients about 20% of the time, and about 20% of my patients. That's I haven't I haven't actually studied it and and and you know looked at the actual interesting because you get it with fusions too.

SPEAKER_01 30:24

But with the fusion, sometimes you can be a little bit less aggressive on the foramenal height.

SPEAKER_00 30:29

Height, yeah, exactly. Yeah, yeah. With with A lift cage, you can use uh, you know, they have much smaller ones if you want. So with the ProDisc, we're kind of limited to the smallest one to 10 millimeter tall. But it oh classically, it starts at two weeks post-surgery. I don't know if you notice that. It's like they'll be feeling fine, and then like almost exactly two weeks, that leg pain starts.

SPEAKER_01 30:47

It really is kind of delayed, and it almost makes you like run in to go get an MRI, but you give them some steroids, you give them a little bit of time, and then it seems to settle down, especially if there's no motor weakness. If the patient has weakness in their foot, you obviously be a little more concerned. With the technique, you can describe this, but we go in through the disc space and we use a curette to release the uh posterior longitudinal ligament and even use a kerosene or a biting tool to release the ligament that's sitting over the nerve. That way, as part of the disc replacement surgery, you're actually freeing up the nerve both directly and indirectly, but you're also replacing the disc and addressing some of the back pain. Describe the technique that you sort of use to free up the nerve.

SPEAKER_00 31:32

Yeah, you know, that's correct. Once the disquectomy is done, you know, and all the disc is removed, then you know, I go to the back of the disc space and you use a micro curved corette to release that that posterior long ligament off of the bone. You know, it's not really necessary if the disc is not collapsed, but if it has any sort of collapse, you definitely want to release that, you know, prior to really forcefully spreading. So we have these intradiscal spreaders, these metal, they're like little carjacks that go into the disc space and yeah, sort of jack up the disc space. You know, before you put a fair amount of force on that spreader, you need to make sure the ligaments are released. So once the ligaments are released and you know able to really spread aggressively to restore the height, only then do I put the artoplasty trial in and then do the chisel and the implant. If you, you know, a common mistake I see with with surgeons new to the procedure is trying to put the trial in and using the trial to to you know restore height, that doesn't work.

SPEAKER_01 32:32

Yeah, and a lot of times you'll you when you try to put the trial in and you haven't released the back, you'll find that it it can kick out. It won't sit the way you want it to sit. And so that's usually an indication to go back in there with the curat and release things. And and that I think is maybe where this part of the procedure gets a little technical, right? And what we're talking about is, you know, we're replacing the uh disc right here with with uh with an artificial disc. But before we even put it in, we often go in with a curat and release the posterior longitudinal ligament. And then from the front, we have access to the nerves, the exiting nerves uh in the neuroforamen, and that allows us to address a patient's leg pain as well as their back pain. So I think it's actually a very powerful procedure that way. And just so everybody knows, when we do the artificial disc from the front, we're making an incision in the belly. And then usually that's where the vascular surgeon comes in. They retract the common iliac artery and vein and protect protect it from injury. So that's why we tend to only do this procedure when we have a vascular surgeon. At L5S1, the veins and arteries are a little bit more out of the way. At L45, the vein and arteries sitting directly on top of a disc, so it has to be mobilized off to the right side in most situations. And that means you want to be pretty sure that this is a level you want to do because it's going to be difficult to get it out once you kind of have the artery and vein back in the correct position. So that's some of the technical stop pickles with orthoplasty. Do you have a specific protocol for L4-5 as opposed to L5S1? Are you a little more conservative with that level or not? It doesn't really matter to you. As far as patient selection or the actual Yeah, as far as you know, choosing the 4-5 level. You know, for me, if I'm gonna do 4-5, I really look at 5-1 carefully. And I can't do reputation about it.

SPEAKER_00 34:22

Yeah, and also 3-4, because you know, if I'm gonna do 4-5, you're not gonna be able to access three, four in the future. You know, it's it's gonna be very difficult, if not impossible. So if 3-4 has some degeneration and I'm doing a four-five, I'm gonna talk to them about doing, you know, about possibly doing three, four, because I'm I'm gonna tell them, like, look, we may not be able to get to three, four in the future. I mean, luckily now, well, not now, but net, you know, probably next year at some point, we're gonna have the MODIS three-spine device, which is uh artificial disc replacement that can be inserted from the posterior aspect from the back. Yeah, that it's it's a very exciting thing we're gonna have. I I'm not sure it's gonna be as good or better than the than the current arthhoplasty option we have, but in those patients where you can't get to them from the front, and I've got a handful of patients where we've tried, you know, to go in the front. You know, let's say, I mean, I've had a few patients where they've had prior disc replacements or prior fusions at at L45 and L5, but someone we tried to do artoplasty at 3-4 and couldn't get to it.

SPEAKER_01 35:26

And there's nothing from the lateral space. I haven't heard of anything, right, in terms of because the L3-4 is a is a great level to get out of the lateral technique, but it's the ring thing.

SPEAKER_00 35:37

There is. I mean, there's there's the oblique pro disc that's in that's in France, uh, which is you know not an option here. There was an invasive laterally inserted disc replacement, which didn't make it to the market. Not really sure uh exactly why that you know it could have been an exciting option. And then there's a there there's the axiomed arthoplasty, which uh, you know, it's not approved. So there, you know, there are potential options in the future. I'm not sure if any of them are gonna pan out. Uh, but that would be that would be the best, you know, if you and and of course I've thought about you know, how can we design, how can we improve, you know, for example, the oblique pro disc, uh, you know, that's can we turn that into a direct lateral, you know, option?

SPEAKER_01 36:20

From a radiographic standpoint, direct lateral would be a lot easier to put the implant right where you want it. Yeah. When you're working oblique, it's a little easy to be a little bit off and the end plate or a little crooked.

SPEAKER_00 36:33

Yeah, the oblique is uh you have to be uh you have to good be good at geometry and really hang out and remember how to place it. And so it's uh I've seen it.

SPEAKER_01 36:42

I've never been an oblique lateral person. I've always been a direct lateral, and I find that you know, I actually I take the right side approach and I retract the vein, so I have a beautiful view of what I'm looking at. And I've always liked that for my fusions, but I do wish there was an option there for Arthur Plasty. Interesting. Why do you take the right side? Well, you know, I used to do it left side. That's how we were, I think, all trained you know, originally through new vasive. And then I actually watched uh uh another surgeon, Jeff Decke, down in HOI, and he does the right side. And he literally had his retractor, he was looking at the vein, retracting the vein. And I just it made a lot of sense to me. If you if there's a dangerous part of that surgery, it's that you're gonna injure the vein. And wouldn't it be better to be on the side of danger? Let's say you do injure the vein where you're right there, you can extend your incision, you can put your hand on it, you can call vascular surgeon, whatever. You're not gonna really injure it, just gently retracting it. The injury usually happens from the cob, you know, if you're on the left side. And if you get the vein on the right side and you're left side up, you'll have no access to the injury. So I switched about five, six years ago to right side up, and I've been very happy. And I think because I'm right side up, I feel more confident to do a wider exposure, and I put a wide 22 millimeter cage when I do need to fuse people. Even went to a lab where they're talking about doing osteotomies in the lateral space. I I think it is safer from the right side. It's better for the surgeon to be on the side of danger, I think.

SPEAKER_00 38:13

Interesting. So do you you do you actually look for the vein and try to retract it?

SPEAKER_01 38:17

I don't I leave a cuff of tissue. I take a little cuff of the psoas and bring it with the vein, and I make sure that it's not scarred down. I've had no retroperineal surgery, that the vein isn't scarred down, but then I can just slowly mobilize it and I have the retractor all the way around the front, uh, the vertebral body, and then I you know I've never had an issue doing it that way. So now it's sort of it's into bred into my DNA. I like to do it that way.

SPEAKER_00 38:41

Interesting.

SPEAKER_01 38:42

You want to switch gears and talk a little bit about cervical authorplastic. I was just gonna say we've gone a little down a rabbit hole with lumbar. And I think lumbar is uh in some ways more interesting because there's more controversy, you know. I think you know it's really exciting technology, it's just we can't get it to be in everyone's hands. With cervical, I feel like there's a more of a motion where all spine surgeons are moving towards doing more cervical orthoplasty infusion. Talk to me about that.

SPEAKER_00 39:09

Yeah, I've I've you've definitely seen that. I mean, there are still you know some resistant surgeons, and there are still I think I I guess what I see the most is is a lot of surgeons not doing it because of you know facet joint arthritis. And and I really feel like if you use the right implant, if you use a you know stable, you know, fixed core device, then I think the facet joint arthritis is is not that big a deal.

SPEAKER_01 39:35

Even if they have a lot of neck pain and they have facet joint arthritis, does that sway you more towards fusion or you still feel pretty confident that the orthoplasty will get them?

SPEAKER_00 39:45

I'm still pretty confident about it, you know, especially if like you know medial branch blocks and rhizotomies, you know, uh didn't work. You know, if you feel like it's a lot of you know rating pain from nerve impingement that can be causing that neck pain. And also the facet joints are really biomechanically abnormally loaded when the disc is collapsed, right? Yeah. So I really think that some of that is normalized when you when you uh you know when you replace the disc, right? So you know I but I do think that the implant is important. I mean, not to knock on my least favorite implants, but there are some implants that just really have poor biomechanics and they're really hypermobile.

SPEAKER_01 40:24

And I agree. I think without naming names, the disc replacement, any device, this is the lumbar, they tend to have a keel, basically like a like a sailboat. It keeps them upright. And I think for the surgeons and the patients, it tells them that the implants are not gonna shift in position. There's implants that don't have a keel, and there's implants that do have a keel. Give us your opinion on that.

SPEAKER_00 40:47

Sure. Well, you know, I I think keel versus versus non-keel and core are two separate issues. Yeah. And I can't, you know, I'm happy to talk about both. I think you know, the issue I was talking about earlier with the with with the unstable biomechanics, that's in the less constrained devices. So, you know, if you look at the Moby C, if you look at the the uh simplified and prestige LP, some of those are good devices, but but they definitely have more translational instability or or less you know constraint. Whereas if if you look at you know ball and socket devices, you know, like the ProDisc or like the um synergy discs that's coming out, you know, those discs have more or globus security, you know, more of a fixed core, where I think that that provides a little more stability, possibly a little bit less, you know, problem to the facet joint. Now, the keel keel versus no keel, that's a separate issue that I'm very interested in as well. Because even like, for example, you know, the the prodisc, which is the disc divine, you know, to name names, that's the disc I normally use, but even within the pro disc, there's you know, they all have all the pro discs have a fixed cord core, right? But they have they have keeled and now they have non-keel keeled versions of that. And I've used both. And and then for a lot of a lot of patients, I do prefer still the the keel device.

SPEAKER_01 42:07

Yeah, they have a small keel and they also have a big keel. Yep. In our practice, we use the small keel pretty much on everybody, unless it's like a revision or a very big patient, or maybe I'm worried that we might use the big keel. What do you do in your practice?

SPEAKER_00 42:22

I use mostly the big keel because it's just because of the way the technique of making the keel cut. And that's you know, with the with the original produce, you use the the drill, the milling bit. And I think that's actually less traumatic than using a chisel for the small keel. You're actually you know, you're hitting the spine. So yeah, so if you think that I don't really like about that technique either, yeah.

SPEAKER_01 42:45

So it's no it's very controlled, yeah. But yeah, I think a drill is is a little more elegant. I agree with you.

SPEAKER_00 42:50

Yeah, so you know, if they have another level that has some you know spinal cord compression or something, you don't want to. I mean, I'll do the discoctomy on that level first, but I rather avoid hitting it. I and uh you know, I I've done so many of the original pro discs, I'm I'm kind of used to that. I know some surgeons think it's you know faster to use the chisel rather than the milling bit, but I haven't really found a big difference. No, if you compare those two keel devices to the vivo, which which has has the the domed upper end plate with spikes and and no keel, I think that's a very nice implant for people that have that have the uh a domed upper implate, you know, in their disc.

SPEAKER_01 43:26

And another surgeon described it to me that like if they're gonna do a disc replacement where they're a little concerned that it might fail, like if you're doing it on a 65-year-old patient with a lot of arthritis, that that one would be easier to revise. I don't know if I totally love that logic. If you're worried about doing it, just do the fusion, in my opinion. But uh what's your opinion on that?

SPEAKER_00 43:46

Yeah, I don't like that logic either because I mean I found I I I find either one of them easy to get out. If you have to revise it, I don't really have a problem, you know, removing any of those implants. Um, so I don't like that thing. That's a great reason. The only reason I I kind of lean toward Towards the keel device is you're actually cutting the bone. I feel like that. So that that creates, I think, uh, you know, better healing environment for the osseous integration, and also feel like it's immediate stabilization. I do use the vivo sometimes if they have a really curved M plate, but I do still prefer the keel version.

SPEAKER_01 44:17

And then there's some other doing my little like analysis here in in Southern California over the last six years, I feel like people have moved away a little bit from a couple of the devices that were being used early on. And then now it seems like a majority are using either the ProDisc, some variety of the ProDisc, or the Simplify because of the MRI compatibility. And I like that too. I had a police officer I took care of recently, very severe stenosis, but he wanted any of his like early myelopyathic symptoms. And we did uh the simplify primarily because we want to be at the freedom to MRI them again and really be clear.

SPEAKER_00 44:55

And I have used the simplify for that reason for that reason as well. Has has great MRI imaging, you know, so did the the M6, but that's not available anymore. Yeah, but you know, the Simplify, I have used it, you know, in that situation. I'm not, you know, we don't have long-term data on that, and and the biomaterials are unique. So, you know, with with some of the other discs where we have you know the cobalt chrome on high molecular weight polyethylene, we know that that's gonna last 50, 75 years. You know, we don't we don't really know, but we know it's gonna last a long time. You know, we already have you know 40 years on it, and and we have lab testing showing it's gonna be 75 to 100 years. But that, you know, even though I really like Simplify imaging and you know that it's a low friction device because you have ceramic on peak, but that's also hard material on a soft material. So is that gonna last 75 years like the ProDisc? I I don't really know.

SPEAKER_01 45:50

Yeah, and we talked to patients about both of them, the pluses and minuses, it seems like, but everyone I sort of asked, they're kind of doing some combination of both, you know, and different, you know, ratios. But uh that's kind of where it is right now. And uh yeah, they let's talk about revisions. You said the cervical and I agree, they're pretty easy to revise. Some of the lumbar revisions that you had to do, and like obviously when you talk to patients, you're gonna probably tell them, well, you know, the worst case scenario is maybe we have to revise this. Either convert you to a fusion, if you're not happy, you have ongoing back pain, or either more challenging option, take it out and try to convert it to a fusion. What's been your experience with that and what can you share after the surgeons and patients?

SPEAKER_00 46:35

Yeah, well, I'll put it this way I never go into a lumbar orthoplasty with a backup plan of revising it. So if there's any possibility, that's not if I think there's a possibility it's not gonna work, I'm not gonna do it, right? You know, because I think that that's never something that you want to plan to do. I always tell patients I'm like, look, you know, we we don't want to go back, right? So we so we we want to do this right the first time. Because if we have to go back, you know, there's a possibility that even with the best the best you know vascular surgeon that we can't get back, right? And so if you have a and I I have done revisions and I I have removed them, and you know, it's definitely possible, but very difficult. I've taken some out from the front, you know, very, very hard to do and dangerous. Um I've taken some out from the side from the lateral, you know, probably my preferred way of getting them out. Yeah, but you can't do that at 5'1, right? And it's difficult at 4-5. I've done, you know, my you know, best experience was taking one out at 3-4, but with the produce is a big keel, which means I had I had to cut a big block of bone out. Yeah, it's essentially like a corpectomy.

SPEAKER_01 47:39

Yeah, half of L3 and L4 really to get it out.

SPEAKER_00 47:43

Yeah, well, just L3. So I had to take a block of bone of of L3, which I was able, and I was able to do a direct lateral antibiotifusion, and then I just actually took a cervical bone graft, it was a perfect size bone plug to fill that hole. Actually worked very well. It was a great result. So, you know, that was a good experience. You know, the the only other only other well, I've had let's see, two other failures, I guess. Only the uh two other failures I've had for for fracture were at L5S1, and I was able to go back, remove it, and yeah, you're below the bifurcation, it's a little bit easier. But I had one at L5S1 I wasn't able to get to.

SPEAKER_01 48:21

So that was one case. Then you end up doing like a posterior fusion with some for the for the audience bone morphogenic protein, probably to really make sure it fuses.

SPEAKER_00 48:29

Yeah, I mean, that was like the only one patient out of you know, 600 dudes I've done who, you know, still had a lot of back pain after the disc replacement, couldn't figure out why, tried to remove it during the diffusion, couldn't remove it. So we haven't done any other surgery, but because the disc replacement is still functioning fine. So, you know, I I tell patients I'm like, look, the the the success rates, you know, sure, 90-95%. You know, once in a while, the patient doesn't get better. We don't know why sometimes, and it's it's it's uh it's odd.

SPEAKER_01 48:58

I appreciate your candor because there is no perfect spine surgery, and you're trying to decide between two very good operations and tease apart who the best patients are, and it's not it's not always that easy. Some of the other technologies that are on the horizon and uh you know for motion preservation surgery, you can touch on them quickly since I think you're in this space where you're really interested. What's your opinion of like facet joint replacement and things like that? Is you know, this is kind of an innovating thing, innovative thing you're interested in.

SPEAKER_00 49:28

Yeah, so you know, I really think there's two other viable options, right? One is on the market, and that's called the the TOFS to bias bar premium spine, and that's already approved. That's I guess you would say more of a phosphate joint replacement. You know, I think that has limited utility. I mean, it's it's really for the patient that has a degenerative spondolysthesis with stenosis. And so you do a decompression, you do a fastectomy, and you can you can put that device in. And it's a you know, it's basically four screws, and instead of the fusion rods, it's a mobile device that goes in the back. Uh it's you know, it's kind of big and bulky, but I I do think the results have been pretty good. You do have to have the long trunk, right? Yeah, exactly. I mean, you do have to have a fair amount of disk space, though, you know, still there. And but you know, the the nice thing is it's easily converted to a fusion, you know. So if it fails, you basically just take out the little device and you already have the screws in place and you just you know add rods. I mean, so there's a pretty you know, it's pretty easy to bail out of that. The other you know procedure that's not approved yet, but you know, the FTA trial has been completed. I started with a trial when I was in LA, but that you know, I only enrolled one enrolled one patient, and then I moved to Florida, so I didn't I didn't get to finish it, but they enrolled all the patients that were done last year, and so now they're just kind of in their observational phase. That's the MODIS uh device by three spine. It used to be called balanced back. This was this is Dr. Scott Hodges and developed it. He he actually did a lot of them for many years in the Cayman Islands before it was approved in the US and before he did the FDA trial, and he was getting great results. And then, you know, as a as a study investigator, I was able to go and do the you know training and everything and see the you know, see the preliminary data and the biomechanical studies. And I think it's a great device. I mean, you know, basically it's put in as like a bilateral, you know, trans uh framinal lumbar antibody fusion, like a T lift on both sides, but instead of a fusion cage, you're putting in this orthoplasty device. And so it's kind of like a ball and a socket, but instead of one big ball and socket, it's two smaller ball and sockets. So it's technically challenging to do. You know, it's there's a lot of carpentry involved, and and I do think that's gonna be the main problem. But the sure that's one of the problems we're doing T-Lift briefly, you know, falling out of favor.

SPEAKER_01 51:45

Yeah, it's very difficult. Jason, I I really appreciate you taking this time. I consider you one of the the experts in in our age group when it comes to arthroplasty. You've done a lot, you've been really interested in arthroplasty for a long time, and I think your opinions are are really valuable. So thank you for sharing. Is there anything else you want to tell the listeners? No, I think we've covered a lot of ground.

SPEAKER_00 52:05

You know, thanks for having me on. I think you know the the future of artoplasty is is uh you know slow going, but I think it's very exciting, and you know, I think we just have to keep doing what we're doing and you know, training other surgeons and you know, teaching patients, educating patients that there are other options out there.

SPEAKER_01 52:22

How do people get a hold of you in Florida? You mentioned that you're um you're you're close to Miami, Palm Beach. Tell us how they get a hold of you. And you know, I think certainly in your area, there's nobody that's really, you know, quite the expert in orthoplasty, you know?

SPEAKER_00 52:38

Yeah, and the easiest way is just go to my website in www.quayar spines at C-U-E-L-L-A-R-Spine.com. And I've got a lot of educational videos on there about disc replacement. You know, people wanna wanna watch those that can you know help inform them as well.

SPEAKER_01 52:54

Yeah, and that's really the purpose of this is just to try to create uh a dialogue among leaders in our specialty and also just random topics that patients often ask me questions about and you know try to create some content online. And uh Jason's been a friend for so many years. It's been fun to see your career. Uh it's too bad you don't live in Southern California anymore because you're always fun to hang out with. But thank you for sharing and uh thanks for having me come down and visit you recently too. I look forward to seeing what's next. All right, all right, likewise. All right, take care. Take care.