Dr. Laratta: This is supposed to be a debate, but I think you’re 100% correct that the gold standard for spinal deformity is a posterior approach. The anterior approach is interesting; I think it can provide a lot of benefit in specific situations.
As minimally invasive surgeons, we live and die by the interbody fusion. We have to realize that it may cut down on BMP costs, but we have to be stewards when it comes to how many cages we use, and what is most cost effective in light of the healthcare economy that we have right now.
Moderator Haid: Joey and Avery, I’d like to thank you once again for your discussions today. I think you both have done an excellent job of highlighting the pros and cons of each technique. Let me first start by saying there is not one unique, proper way to do this technique. This can be done in a variety of approaches, both open, minimally invasive and hybrid.
What’s most important is that each surgeon chooses his or her own approach and for what they feel comfortable. I continue to evolve in my practice with what I do anterior, or lateral, or posterior, or combined. The one thing that we all know if we had the same discussion two years from now, we would each share an evolving perspective about this.
I first found it interesting that you both talked about aquatic therapy and I ask patients if they get into a swimming pool. I’ve had a procedure, anterior and posterior for degenerative lumbar disease. And I found it amazing that when I went down to see my parents in Florida, if I got into a swimming pool, my pain would just go away. It is good to understand if the pain is weightbearing, or non-weightbearing. Joey another thing you’ve talked about is compensation and decompensation. When I see people in my office, I make a point of making them walk into my computer room and I make them stand there. I don’t go to their particular patient room and watch them sit down. My nurse walks a patient down the hall, and I look at how they walk. Then I make them stand up while I examine them and ask them questions. Invariably, you’ll see people start to bend over, lean on a counter, or ask to sit down.
Having them walk for five minutes and take a new set of X-rays where they’re no longer able to maintain that compensatory posture, is absolutely key. I’m going to bring that into my practice quite frankly. I think it’s also clear that when you look at the literature, anterior approaches provide improved lordosis and sagittal balance.
I’ve taught around the world with Juan Uribe and Chris Shaffrey about this. It’s clear from the literature that an ALIF offers greater restoration of sagittal alignment and lumbar lordosis. If there’s one place where you have to get lordosis, it’s at L5-S1.
