Chair of Neurosurgery at Allegheny Health Network, Donald Whiting, MD, talks about a new way to perform spinal fusions.
Interview conducted by Ivanhoe Broadcast News in 2023.
What is spinal stenosis?
Whiting: Spinal stenosis is a condition where your spinal canal, which is the area where the nerves go down behind the vertebrae in the spine travel and the bone protects the nerves as a spinal cord goes down. There’s joints made up of discs and then joints in the back of the spine that help you move. Over time, those joints wear down, just like a knee or a shoulder world, and you get bone rubbing on bone. With a knee or a shoulder, as the joint gets bigger, it just stretches the skin. But in the spine, as those joints get bigger, they start narrowing down the spinal canal, like rust building up in a water pipe. And eventually it gets so narrow that the nerves get pinched and people get symptoms.
What might cause something like this?
Whiting: Spinal stenosis is typically caused from wear and tear of the joints in the spine, gradually wearing down and building bone spurs around them. Just from the surfaces that are normally the gliding surfaces wearing down, as the bone spurs build up, it just causes pressure on the nerves.
And I know in Nathan Snyder’s case, he mentioned this may have been caused just by being an athlete for so many years. Are there people who are more prone to something like this?
Whiting: Yeah, that’s a really good question. Spinal stenosis is typically a wear and tear condition of the joint in the spine, but it can be sped up by strenuous physical activity. For example, athletes, football players who have a lot of pressure on their spine and on their neck get a smaller spinal canal and stronger bone, which then makes the canal narrower from the beginning. And then the arthritis building up doesn’t need as much arthritis to cause symptoms. Sometimes people are born with small spinal canals, congenitally, it’s not traumatic per se more wear and tear, but it really depends on how you’ve developed over time.
And when your patients come to you, what are they saying their symptoms are? What kind of pain are they in?
Whiting: The symptoms from spinal stenosis typically are symptoms of nerve type symptoms down the legs. So they’ll have symptoms of numbness or pain, or the feeling of fatigue. The thing about it is what’s typical about spinal stenosis is when you sit down, it goes away. When you stand up or you walk a distance, it starts getting worse and worse. So it’s gravity related to some degree, and the more you move, the worse it is.
So traditionally, what treatments are available outside of the top treatment? What were the options?
Whiting: For spinal stenosis and symptoms of back pain with spinal stenosis? Typically we start with physical therapy, anti inflammation medicines, muscle relaxants, sometimes steroid injections, and then we’ll move on to surgical options. As far as the surgical options for purely spinal stenosis, which is just the narrowing of the vertebrae, the spinal canal do what’s called a laminectomy, which is unroofing that spinal canal and freeing up the nerve like clearing rust in a water pipe to make it open again. But with spinal stenosis and slippage of the vertebrae, similar to what Nathan had. If you just do that, the vertebrae slipped further. So typically, we would do a spine fusion, in that case with screws and rods and bone graph to get those vertebrae to go together. That’s where this device is a difference maker.
And can you explain to us what is TOPS? And if you need me to grab the model there, I could do that for you. But what are we talking about here? What’s this mean?
Whiting: I’ll do it without the model and then we can do it. So the tops device maintains motion. So as we said, with spinal stenosis there’s narrowing, and we take the pressure off to free up the nerves. But if there’s spinal stenosis, as well as slippage called spondylolisthesis, which were one vertebrae, has slipped forward on the other because those joints have worn down so much that they’re loose. Then after we take that pressure off, if we don’t do anything further, the bones will slip further. People have chronic back pain and need further surgeries. Typically, we do the spine fusion to stop that motion, but that spine fusion actually does stop the motion at that level, which puts more stress on the one above and below, and they can wear down faster, leading to more and more surgeries. That’s what’s called adjacent segment disease. With the tops device, this is a device where it stabilizes those vertebrae when they’re slipped after the decompression, after you take the pressure off. But it doesn’t fuse them, so there’s still motion. Then there’s less wear and tear on the levels above and below, and less a need for further surgery down the road. So the device itself maintains motion instead of fusing the joint, which is a huge development.
Are there any risks with the TOPS procedure?
Whiting: The TOPS procedure has the same risks that somebody would have with a spine fusion. So the TOPS procedure has the same risks as a spine fusion, with the exception of potentially the joint itself wearing down. But really in the studies that have been done, there’s no sign that that would wear down over time. Eventually, it may will over years and years, But at that point, that’s the only difference that would be the difference as far as risk between the fusion and the TOPS device.
And then how long will this last and will it need to be replaced?
Whiting: I can say. So the TOPS device at this point has lasted in studies for up to 10 years. But there is no upper limit yet because none of had to be replaced yet from wearing down. It is just released by the FDA and just commercially available. So over the years, we’ll be determining that, but at least 8-10 years, if not into infinity right now.
What is this made out of?
Whiting: The tops device is made out of titanium end plates that connect to the screw. So the tops device is made of titanium end plates with what’s called peak polyethylene ether cage, which is a surgical plastic and then a polyurethane wrapper. So it’s titanium on the top and bottom, a tethering surgical plastic cable and then polyurethane around it. And then we put saline fluid in it so that it can move like a joint. And then that device hooks onto the screws that are in the vertebrae that we put in just like we do a fusion.
What are the three major benefits of this procedure?
Donald Whiting: With the TOPS device compared to a fusion, the major benefits are that it maintains motion, so you have less wear and tear on the levels above and below. Less chance of needing surgery at adjacent levels. Because maintenance of motion is part of this, people can see improvement of their back pain and their leg symptoms over time, progressively. And our studies show that even in the third, fourth, and fifth years after surgery, because they’re active and still have motion, they have progressive improvement of all of their symptoms. We don’t see that with fusion. And then the third major benefit is the fact that, with this, you can take the pressure off of the nerves without worrying about causing more pressure above or below the adjacent same with disease.
And back pain can really have an impact on people’s quality of life. You’re giving people their life back with this. So with that being said, can you just tell us about your relationship with Nathan Snyder? What kind of condition he was in when he came to you and where he is now?
Whiting: Sure. Nathan Snyder, when he came to me, was really debilitated for him. So he couldn’t really run, he couldn’t do the activities that he did. And he really was a road warrior. He was a athlete, a marathoner, very physically fit in doing every physical fitness activity you could at a high level. And this really put him down. The options that he had once he didn’t respond to medical management was a fusion with the decompression for the stenosis or this. And this was a study at the time. He decided to enter the study and what he found was soon after the surgery, he had all of his flexibility back symptoms were better, his symptoms were battery is getting back to his training and getting back to all of his usual activities very quickly. With effusion, typically people need to heal, bones need to grow together. So it takes three to six months to really start building yourself back up. In this case, within a month, he was back doing things, within six months, he was back in the groove of where he was months and months before.
Interviewer: Wonderful.
So, fusion wouldn’t really let Nathan be who he really wanted to be as far as working out, right?
Whiting: Yes. So with Nathan, and frankly, with all of the patients that we’ve done this procedure on as part of the study, they really got their life back very quickly, and in a way that they really wanted to on their terms. So for Nathan, he’s back to doing tough matters, and he’s doing all of those things five years out of surgery, and continuing to do better and better. I’ve had a number of other patients at different ages and activity levels who’ve gone back to doing activities at high levels. I have one guy who’s a retired executive who golfs really six out of seven days a week, month after month after month after the surgery when he couldn’t do that before. So it really does give you that pain relief, that stability, that ability to get stronger, which we don’t typically see when people have fusions.
Is there anything else that you wanted to add about this procedure. Anything that we missed that you want to mention?
Whiting: I think I can just sum it up, I guess, a little bit. I think up until this point, the best we had available for people was a spine fusion. And there’s a lot of trepidation with people with spine fusions, because there’s a lot of concern about the levels above or the levels below wearing down. Then starting to have surgery at the next level, and then the next level, and becoming a cascading progressive event that once you start it, it continues on and on. I think this is the first time it can truly give people motion back to minimize that wear and tear, and that adjacent level continuing doing more and more surgical levels over time. But more importantly, they get back to their life quickly. They get back to their life in a more fully interactive way like they never could with a fusion.
Interviewer: Perfect. I’m good.
Interviewer 2: [inaudible 00:12:48]
Donald Whiting: Sure. Thank you.
Interviewer 2: I’m going to share- I’m going to do this twice. Not because you’re going to do anything wrong, but I’m shooting the medium shot, and then I’m going to do tutorial.
Donald Whiting: This is a good level.
Interviewer 2: I mean, we can either tell us about it or we can hit you with the question.
Interviewer: Yeah, I have a few questions, but just first tell us what’s in your hand. What are we looking at?
Donald Whiting: Sure. This is a spine model, made it out of acrylic. Simulates the spine. The spinal canal is the area that goes down this area. That’s where the nerves go. And the disc in the front, and then there’s joint on either side in the back that help give you motion. They wear down causing bone spurs to build up which makes spinal stenosis more and more narrowing of that spinal canal. So when we have that, we remove the bone to unroof and free those nerves up. When the bones already have some slippage of the vertebrae, by removing this bone, it destabilizes it more, so you need to do something to stabilize those vertebrae, and that’s where this device comes in. So typically, whenever somebody has slippage and stenosis, and we do the surgery, we would put screws into the vertebrae on either side, and connect them with a titanium rod, and put bone down to get them to grow together, just like as if you broke a bone. In this case, we do everything exactly the same as far as the surgery, when we would do it for fusion. Removing the bone spurs and the pressure, putting the screws in. But instead of making that grow together with a fusion, we put this joint in. The joint has a titanium top that connects into the screws on either side. It has a polyurethane retainer. Inside of there is a peak, which is surgical plastic ribbon cable that tethers it, and then there’s saline or water in there that helps it move, so it actually can expand and compress. And it gives you motion where fusion does not. So that’s really the device in a nutshell, and it really is self-contained, goes right on, gives the motion, whereas previously, we would just fuse that together, and never move.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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