Posterolateral Arthrodesis for the Lumbar Spine: Minuteman - Chad Stephens, D.O.

本站添加: 2026-05-30

[00:00:03]My back on. Thanks for the shout out to Al. I forgot about mentioning Al's line.

[00:00:07]Al gets credit for the greater trochanteric procedure. So, I was I was in uh um Australia and talking to a um I guess he would be a sports orthopedist there. And um many years ago we we were talking about how they were starting to do greater trochanteric work and how it might come to America and then uh fast forward a few years later and Al kind of promotes the Al's line and I guess that going so. Um okay, we're going to start spinal simplicity. Um again, uh for you fellows in the audience, um as you're starting to to ascend up the ladder, so to speak, of getting more involved in teaching or getting more involved in patient selection and and helping your APPs learn what they're looking for and things like that. One things you want to do is find good mentors. And so, the man at the podium, Doug Beal, called me one night and um he knew that I was doing another procedure and I'd gotten kind of less than pleased with the results of it. And he told me to get on this call for a minute, man. And um he got me on this this call and I was like, "Well, where where the heck's Doug?" And they're like, "Oh, Doug Doug's not here.

[00:01:14]He just got you on the call." And so, I but I I had a chance to jump on this call. It was during COVID time and one things I figured out is that man, there's there's a lot of patients that are running through my office every day that could benefit for me paying attention to this, but I was like, "Man, this this lateral approach thing, this is something I didn't learn in fellowship. It's not something that's exactly um up in my list of things I think I can just go do tomorrow." And so, at first I kind of turned it off for a minute and then um if you need any of you are married or dating, um I have what I call the wife test and I went to went to bed that night and my wife said, "Well, what did you think about the webinar you had tonight?" And I'm like, "Ah, it's a pretty cool device. Awesome device, actually, but I don't know if it's for me."

[00:01:56]And she put this drop on me that I'll never forget. She said, "Chad, if not you, then who?"

[00:02:02]And I said, "Well, that's then sit well with me because she's like, you always wanted to try to help move the pain space forward. This sounds like a procedure that would. So, what are you running from? What are you afraid of?"

[00:02:12]And I was like, "You know what? I'm kind of I'm kind of listening to my wife and I think she's making sense." And so then, uh fast forward a few weeks, I get trained and um actually CEO of the of the product came out and trained me. And that's why we give this device here.

[00:02:27]This is called the Todd. So, everybody who I have taught, and that's a lot lot of people throughout the US and around the world, they all call this the Todd.

[00:02:34]And the reason is because we're going to use this to support our hands our our device and our hands out of the out of the radiation. And so, I would say Todd thinks of everything. But um so, anyway, I got started doing this procedure and now that I've done hundreds and hundreds of them, there's been a lot of patients in our area that are getting a lot of benefit from it. And I think it's really important we go through the patient selection, but I want to first go through and show you the device, show you the placement, and then I'll kind of tell you what the patients look like kind of got to do in the last little uh segment. But um I definitely want to talk to you about the patient selection because there are a lot of these patients running through your office.

[00:03:08]So, um essentially, this is all laid out here if you want to kind of hone in on this, Ben.

[00:03:13]Okay. So, you have a marking pen.

[00:03:16]You have a long guide wire. This one you notice has a business end, it's a pointed end. You have the extension guide wire. And then we go to our dilators. We have our first dilator, second dilator, third dilator, sleeve one, sleeve two. And what you'll notice is that with sequential dilation, what happens is um we're opening up a space so that we can get in the rest of the product, but what it's doing is it's it's opening uh up the space that is going to allow the implant, even though it may be a kind of a tight space. And you may think, "Okay, what do I do? Can I do this procedure on people that have like kissing spines processes or Baastrup's disease?" And the answer is yes, you can because you'll still have an opening kind of right here at the front and to your right behind your facet shadow. So, you can still do those patients. So, I'm going to go through the patient selection a minute. Then we have this guy right here and this works as um a couple things. Number one, when you're doing any kind of surgery, the AO principles from the Swedish doctors um that came together talking about the things that promote fusion, they're talking about the importance of decorticating. And this helps to decorticate at the two sides of the spinous processes and fix it for uh better fusion. But what it also does not just decorticate, it also has a sizing component. You may not be able to see it. It's got a little gunk in it right now, but each of these little sizes 8, 10, 12, 14, 16 is going to be a sizing um I'm going to work through. So, you'll notice it's it's kind of got these um these lines here. So, what happens is once you kind of get across midline, then you just keep turning this clockwise and it kind of does all the work of getting across to the other side until we find our space where we feel like our size is correct. What this is used for is for taking a facet down that is really hypertrophic. We talked about in the last segment about hypertrophic facets. This is a very aggressive tool that does a really nice job. You can see the teeth on it of just doing a little 10-2 debridement of a facet joint if for some reason you can't get your dilators across the line. This again is is going to cause a really nice amount of decortication. It's going to help prepare It's going to cause a little bit of bleeding. Our surgical colleagues that we teach with when I'm doing these labs often you really stress using this every single time. The pain doctors tend to not use this quite as much if their case is going smoothly just because of the extra bleeding we don't really want to have. But anyway, this is going to um be used in some situations. And then I already told you what the Todd was. This is the Todd. So, to start this out, I do them just the way I was taught back in 2020. And that is you take an AP picture.

[00:05:44]Picture, please. Oh, by the way, this is Jim Hyde. Jim is here to help in this one and Jordan Stickler will be here for the next one, but Jim is the local distributor for this product and Madison Mountain is the group he works with.

[00:05:56]Jim knows everybody and their dog in this area, so he's a great contact. But, we pulled him in today to get him some exposure to this lab. So, thank you for having Jim and I here today. So, the first thing we do, and this is going to seem super simplistic to all you fellows and people that are in your training out there. Image, please, Anthony.

[00:06:16]I used to do a lot of Vertiflex procedures and teach it around the country and one of the things I found is that a lot of times people would get the picture on their AP right, make their incision, and they get to their lateral and they were at completely the wrong place. So, I'm not even trying to go plates places deep or anything. All I'm trying to do is say, "Okay, this is the level I'm planning on going into." And I just take it down a little bit, just put it there. Then what I do is I take a line that goes from there.

[00:06:48]Picture take a picture, Anthony, please.

[00:06:50]That's going to show the approach angle I'm going to take and it's about right there.

[00:06:54]And I'm going to take this line, I'm going to take it and walk it all the way out to the flank.

[00:06:59]Okay? And we're going to a lateral.

[00:07:01]The reason for that is because we want to make sure like you can see the iliac crest kind of in the way there a little bit.

[00:07:07]It shouldn't be much of a trouble for this, but if you were doing like an L45 or L5S1, there's other techniques you can use, but um it's sometimes pretty helpful to like this person has pretty equal heights on their iliac crest. Sometimes if a person has a really high iliac crest, it's nice to come in and and move one down by kind of crossing the crisscrossing their legs and pulling the hip down or just go to the other side of the body and work on it. And now we'll take a picture here. This is going to be a lateral picture. We want to be right our line is going to be right behind that facet shadow. And that's important because the more anterior we are, the better the implant's going to be. If If you can move Anthony if you can give me just a little bit more room this way. Um, is that as far as you can go? That's all right. No, that's okay.

[00:07:49]Just stay where you are. And so that that's helpful for us because we want to be with at the strongest part of the spinous process. So I'm going to come in here, make my incision as big as the the largest dilator. Just stay where you are for a second. This is Oops, sorry. This is the largest dilator. So I'm going to make my incision so that it will go through and then I'm going to take my guide pin on the business end and walk this down. Again, I've already drawn a line here and I know where this needle is. So I have an idea in my mind of where I want to kind of tap or just give me a forcep.

[00:08:19]So this gives me an idea of where I'm headed.

[00:08:22]Picture, please.

[00:08:24]So I'm a little bit too anterior. So I'm going to back up my angle just a little bit. Picture, please.

[00:08:29]A little bit too anterior still. Going to back it up.

[00:08:32]Picture, please.

[00:08:34]That looks better. That looks like it's headed for the right place. So now we're I'm feeling bone so I'm near that facet.

[00:08:39]We're going to go ahead and go to the AP view.

[00:08:42]Let me see if I I'm going to try to get this to go just across the midline to about the contralateral pedicle.

[00:08:52]Yeah, and I'm pretty good. So I'm going to walk it on across there.

[00:08:55]Image, please.

[00:08:57]And it's nice uh about as far as I want to go. So I try to talk in football terms but yeah, I want to be about the 50-yard line because when I open up the wings to this device, it's going to open up um in between and I want it to have equal bite on both the spinous processes. So then we're going to go with each of these sequential dilators and we're going to walk these forward till you get just about Image, please.

[00:09:21]Right about to that spinous process and then each of these are going to stack on top of each other kind of like a a wedding cake or a birthday cake.

[00:09:30]You're going to try to run on me image there.

[00:09:33]Perfect. This is the the dilator.

[00:09:36]They're stacking so I can see how we're doing here.

[00:09:40]Image, please.

[00:09:41]Perfect, right up against there, and then the first sleeve is going to go on right here.

[00:09:48]Image, please.

[00:09:50]Just a touch further. The facets are a little bit in the way. They're not terribly in the way. Image, please.

[00:09:56]I'm happy with that. So, then what I'm going to do is I'm going to go ahead and um put the extension guide wire on.

[00:10:02]And it's all right. It's always going to be backwards when you hand it somebody.

[00:10:05]It goes on, threads clockwise.

[00:10:08]And then I'm going to have Jim put his hand right here so that I don't back out the thing I tried so hard to place. Walk out the inner dilators, keeping the black sleeve in.

[00:10:19]Good.

[00:10:20]Nice. And take a picture, make sure I didn't move too far.

[00:10:25]Let's Let's go ahead and take this and break it down with that.

[00:10:28]Put right here. Oh, you want to take the facets down? Yeah, I'm just going to show you what it looks like to take the facets down. I don't think it's going to be a problem here cuz of just the access was pretty straightforward. But, image, please.

[00:10:40]You're going to walk down the facet joint. Image, I can feel it now. And all I'm going to do is just turn back and forth. And that further decorticates that facet joint and opens up the space I'm going to be entering into.

[00:10:52]Again, thank you, Jim, for doing that.

[00:10:56]And then we're going to go to this. We talked about this earlier. It's going to be also further decorticating the spinous process. You can picture almost like um softening up the bone, making it kind of irritated a little bit so that we're as anterior as we can be. This goes over the guide wire.

[00:11:13]And it also again functions as a sizing device. I'm going to take this. Image, please.

[00:11:18]And I'm going to walk this across midline, raising my hands a little bit so that I stay a little bit posterior.

[00:11:26]Image there. I want By raising my hands up, it drives from posterior to anterior. I'm through midline there, so I feel pretty good about that. Let's go ahead and take the guidewire out and have me Todd. And let's go to our lateral again, please. Before I go too far, Todd, please.

[00:11:43]Before I go too far, I like to check and make sure I'm going anterior enough and I'm happy with my placement.

[00:11:53]Yeah, and that looks really nice.

[00:11:55]It's a little hard to see the back. I don't know if if you can see it, but you can see the the inferior spinous process. For those of you who are learning again, when you're looking at your lateral image like this, it's basically you can see your vertebral bodies, and then you're going to watch out what drops down and posterior to there is going to be the spinous process. So, I can tell I'm pretty anterior, which I'm pretty happy with.

[00:12:16]So, we can go back to the other view. I can take out the spinal needle, which was just there to help me with my placement. And then I'm going to work on getting this across. And this is where it becomes a little bit tactile.

[00:12:27]You want to be able to do a couple things. I want to see where I am on the screen and with my mind's eye I figure out about how much room I have between the spinous processes, but at the same time I'm also using my hand to twist clockwise to see how far it goes before it starts getting tight. And it's starting to get tight, not terribly tight, but even just at this point image there.

[00:12:51]I'm I'm I'm past the eight and I'm headed for a 10, and I think that's about where we're going to stop. So, it it's just slipping cuz I have stuff in my hands, not not tight yet. Image there.

[00:13:00]And we're going to go just a little further, and that's going to be the size of our implant, so it's going to be a 10, guys. So, you can see that the spinous processes are surrounded by the the tap, the sizing device, the decorticator, if you will. And what you can see is the second hole is just almost exactly underneath it. So, I'm going to turn it just a couple more turns just to make it so that I can easily get through it.

[00:13:24]And then I'm going to let them go ahead and add the uh implant. So, while they're doing You guys already These guys are super fast. Chad, Chad, this is Neil. Yeah, Neil. Uh uh your Is your progress across to the contralateral side being blocked by facet hypertrophy?

[00:13:40]Uh not yet. Um I I don't feel like it is on this patient, but there are a lot of patients, Neil, where it is. And so, there is also a device to decorticate the contralateral facet if you need to, um that's in the It's not in this kit, but it's in the other kit. And so, um in this situation, I don't think I'll have much of a problem, but and there's a few little things you can do with your implant if you feel like the nose is kind of heading into it. So, we'll we'll know in just a second if it's going to.

[00:14:08]Um but we for the most part with this device, we haven't had much of a problem with hitting the other side um as long as they're not just really degenerative um like if you think about like a three stages of degeneration, the people that are like already in the the the third phase where they're basically re-stabilizing themselves with big osteophytes, their facets are huge, you have Sometimes you do have to take some of those down, but in this case, I think we'll be okay. I'm just going to back this out, keep my dilator in, take this out with just turning it counterclockwise, and I'm going to go right in with the implant.

[00:14:46]The implant is going to work its way across the joint. Image, please.

[00:14:50]Yeah.

[00:14:51]So, you can see I'm about the 50-yard line. I'm going to start to apply some pressure to go across.

[00:15:01]Picture, please.

[00:15:03]It's moving pretty good. We're going to keep working it.

[00:15:06]Sometimes the reps get underneath the other side and give you a little bit of support like Jordan is doing.

[00:15:11]Image, please.

[00:15:13]What I want to do is I want to get just the other side where the wings will open up. If you can You can probably can't quite see here, but there's a black line here, a cephalad and caudad line. You'll turn it this way so you can see it. That line, the wing reference line. So, when the when it's in this plane, if it was loaded correctly, which I'm sure it was, then um then your wings should be in the cephalad caudad. So, I'm going to go a little bit further.

[00:15:39]Should be getting pretty close to cross there. Image, please.

[00:15:43]Yeah, we're almost there.

[00:15:51]Picture, please.

[00:15:53]I think we're close enough there to open the wings. To open the wings, you just push in back here.

[00:16:00]Image, please.

[00:16:02]And they're trying to open. They're getting caught just a little bit. Let me see if I can give it a little encouragement with this.

[00:16:08]The mallet sometimes gives me just a little bit more encouragement here.

[00:16:12]Image, please.

[00:16:14]And now your wings are opened up.

[00:16:16]And then you just keep your hands up and turn the second knob, the knob two. And this is going to bring the threaded body on the left together with the wings on the right. And you'll see us catch into the bone pretty quickly here. Image, please.

[00:16:31]Looking good. It's settling nicely. It's starting to get tight.

[00:16:35]We're getting our four points of fixation, at least three. Image there.

[00:16:39]And you can see it's settling in nice.

[00:16:41]And now it's starting to get tight.

[00:16:43]Picture.

[00:16:45]Let me have Todd, please. We'll look at our lateral and see if we like our position.

[00:16:53]Mhm.

[00:16:54]Yep.

[00:16:59]Do you just have an open up an implant for me so I can just show that?

[00:17:02]Just hold that.

[00:17:04]Okay, so let's see. So, you can see the wings you can kind of extrapolate where the superior wing probably is because you can see the inferior wing is is lined up nicely. But if you can't, Anthony, just give me just a little bit of a oblique tilt here.

[00:17:19]Just a touch more.

[00:17:20]That's perfect. And you can see just a touch more. You should be able to see both your wings. There you go. And we can see that we're really anterior because we can see how far back it is the spinous process and we can see that we're standing up nicely. What some people will do is they get to this point in the procedure and what happens is they don't like the angle they're in and so they're like, "Oh, I'll just turn it one way or the other." And if you do that, you've got your points of fixation around the spinous process, so it's not a good idea to do that. So, if you want to make a change with your wings, all you got to do is loosen up two. It will pull the wings and threaded body apart from each other a little bit and then you can make your final adjustment. So, let's go back to AP, please. I'm going to finish in the AP and then we're going to talk a little bit about the device itself.

[00:18:12]Okay. So, I'm going to just go until I feel like we're we feel two fingers tight and I feel like that's money right there. So, I like my implant there. So, let let me hone in on this just a second. So, why do these procedures get done? Um we've done a lot of different spacers through time, but in this case, what we're looking for is something that's going to actually fuse. So, each of the threaded bodies, this is the threaded body where my finger is. This is going to be coated with hydroxyapatite.

[00:18:38]Hydroxyapatite is something that bone loves. Those orthopedists in the crowd, you know, Sean or Nothers know what I'm talking about. And then there's a window in here where you put bone graft. So, the bone graft goes in here. Um there was a study done in the Northeast by one of the colleagues up there um and read by some independent radiologist that demonstrated they did um about 69 levels with 43 patients and what they noted is that there was a 93% fusion rate, fused or probably fused was the way the radiologist read it. And that was at about 6 months post-op. The nice thing about that study is a real-world study.

[00:19:17]A guy named Jasper did that for him. And it was a study that showed patients that were bad candidates for fusion. They were smokers, they had autoimmune problems, they had diabetes, they they were not handpicked by any stretch of the imagination. And the bone graft was not even implanted in all those before the the patient cuz it was a retro active a retrospective [clears throat] study. So, that showed really good fusion rates. There's been another study published in Pain that showed 89% fusion rate. So, what's happening is these are these are fusing at a high rate. So, what do these patients look like? Really and truly, I can teach anybody here in the audience how to do this procedure in just a few minutes. But, what's hard is as you go back to your office and you go, "Okay, I know I'm seeing these patients." To use one of our colleagues' lines, you may not have seen it, but it's seen you. These patients are watching in and out of your office. What do they look like? Well, I kind of gave you a little bit of a a early test a bite about it earlier. It's a patient that comes in and they they tell you that they are having trouble with walking very far. They tell you they can't stand very long at the table to to or to the sink to wash dishes or to cook. They can't take care of their own daily functioning activities. And that's really important. So, because of that, they have to do other things. They have to go out to eat all the time, they have to miss their grandkids' games, whatever, whatever. This is a procedure that is done mostly on people that have that degenerative spine. People that are in their you know, the average age of one of the safety studies that was done by this company was 71 years old. So, these are not the youngest people necessarily, but they're neurogenic claudicators. And and what we need to be thinking of as pain doctors is what is the solution to the degenerative spine?

[00:20:56]There's going to be degenerative spine patients walking out of your office all the time. And one of them is going to be this MinuteMan thing we just did.

[00:21:03]Another is going to be the Patriot SI fusion we show you in while on on a posterior implant. And so, I'm always thinking about in this class of people, what am I going to do for them? Back in the day, it was just load them up with a bunch of narcotics, put them in physical therapy, but they they're not good surgery candidates cuz they're either too old, too too sick, too many comorbidities, too large. Um there's a lot of reasons why people would pass on doing surgery on these people, but this these degenerative spine patients with the neurogenic claudication picture, they walk in telling you they can't walk more than a few feet and have to sit down. That's the key little question there. If you have a patient that comes in and says, "Man, I can walk about 50 ft and just stand there for a minute and then walk that far again." What they're telling you is they have vascular genic claudication. But if they have neurogenic claudication, they're going to have to sit to get resolution of their symptoms. So, neurogenic claudicators, they're going to come in and you're going to examine them. When you extend them back, their pain's going to increase. Again, not like the facet picture where it's extension, rotation, side bending, but they're going to when they extend back, their pain's going to increase. When they flex forward, their pain's going to improve. Pretty consistently. In other words, they're able to decompress their own spine when they're weight bearing. And that's a critical aspect of the patient we're looking for. Then you go to your imaging. And under imaging, you're going to get an MRI and see what is going on at the level you're seeing that you know they have instability, you know they have spinal stenosis. You just go to the MRI and see where what level it's at.

[00:22:25]And you look on the MRI, you look at the ligamentum flavum, you look at all the other structures, facet effusions, facet hypertrophy, trying to figure out is there motion, micro motion, is there a grade one spondy. So, grade one spondy's, degenerative disc disease are some of the indications too. But what you're looking for is a patient that then you get their flexion extension x-ray. If you hear nothing else today about this, get flexion extension x-rays on everybody because what we're doing is a stabilization device. And stabilization devices, fusion devices are used on unstable segments. In fact, when you use your coding, your coding needs to involve unstable segments of instability. So, when you find that patient that you expect to have instability, you get your flexion extension x-rays. You can look at how things change with regard to each of the segments when they're in flexion extension. And you can also, if you have a question whether you have a spinous process that's still behind left behind or if they've been operated if they cut it off or if you don't know how strong the process is or if you're doing a questionable pars level, you get a CT scan. A CT scan will show you the approach that you're going to use for these procedures. So, all the imaging helps you. Going back to the flexion extension x-ray, think about these patients as patients that have some sort of instability. They have either they have the transitional slipping of a grade one spondy. You can do up to a grade one spondy with this. Or maybe they have what we call angular changes, angular instability, where on the extension x-ray you see them open up the end plates anteriorly making a Pac-Man mouth, if you know who that is, or an alligator mouth, if you know who that is. So, those are going to balance out when you put the MinuteMan device in posteriorly, what happens is the end plates balance out and it increases the foraminal area by twice and it increases the height between the posterior end plates by three times. So, that allows for those degenerative spines we talked about where the bony structures have gotten to where they're so tight that the nerve can't control the bony structure no longer protecting the nerve. So, what we want to do is take some of the pressure off the nerve roots by opening up the spinal canal about 20 25% by increasing the foramen area by double and decreasing the radicular pain the patients experiencing. So, those are the kind of patients you're looking for.

[00:24:40]Patient selection is the most critical part of any procedure. Again, the procedure itself is not hard to do, but the patient selection part is important.

[00:24:47]And so, getting through this with your with your local reps, like in this case it'd be Jim. In my area we have Jordan Stickler here with us. And if your local reps are very good at helping you get through the process of patient selection, authorization, and getting patients on the schedule. So, uh those are things I really want to hone in on.

[00:25:05]Again, we are doing a fusion procedure, so it's it's a fusion code. It's a decortication of the area you're going to go ahead and a fuse. You've got to think like you're being a surgeon in these procedures. You're going to do your flex extension x-rays. You're going to pre-plan. You're going to follow these patients postoperatively at 1 week for their incision check, at 1 month to see how they're doing, start them in physical therapy, at 3 months to make sure they're doing well, 6 months get a follow-up x-ray, and 12 months get a follow-up x-ray or CT scan. So, you want to prove that you're getting the fusion that you're setting out to achieve. Um that is the stuff I wanted to tell you in a nutshell.

[00:25:44]Um either one of you guys think of anything I've not hit on?

[00:25:47]Okay. Now, I'll ask the audience for questions.

[00:25:50]>> Yes.

[00:25:51]Thanks, Neil.

[00:25:51]>> [clears throat] >> Oh.

[00:25:59]Are they coming up to the front? They'll come Oh, they're going We'll We'll go to them. This is Dr. Yusuf Mosuru uh from Jacksonville. Uh I practice in Jacksonville, Florida.

[00:26:09]Um the the Minuteman is from, you know, you you approach it from the lateral aspect. There are other products that you approach it interlaminarly.

[00:26:21]Yes.

[00:26:21]>> Like like the Key Key lift, the Aurora Yep. procedures. What do you think about the um you know, the advantages of one over the other? Yes. Especially the laminar procedures that you can actually do medial facetectomy. You can remove more of the uh you know, of the ligamentum flavum.

[00:26:42]Yep. You know, in there. What do you think about that?

[00:26:45]>> Yeah, no, those are great points that I didn't bring up. So, when I was in my big ortho group that I started out with, I remember we had a big board meeting one night to talk about how the doctors the the spine surgeons were going to start doing lateral approach fusions.

[00:26:57]And I remember thinking, why are we all coming together taking our time tonight to hear about this? It didn't hit me until I got later in my career the importance of coming in lateral. I'm glad you pointed that out doctor. So, the key is this. When you use the posterior approaches that you have alluded to Aurora, StableLink, others where you're going to immediately cut through the the back muscles, what you're going to do is you're going to cut through the supraspinous ligament.

[00:27:19]The supraspinous ligament is a structure that is designed to help stabilize the spine. And we just alluded to the fact that a lot of these patients have grade one spondylolisthesis or angular instability. And so, taking that ligament out immediately is not the the most uh intelligent thing to do in my opinion.

[00:27:35]But then, you we all know what the multifidus muscle is now thanks to our friends at Reactivate. And so, what happens when you cut through the multifidus muscle is you can devascularize and denervate that. And you start to see the fatty atrophy that we see on our axial T2 images now where we're looking at um patients that might be a candidate for a Reactivate procedure because they have atrophy. And so, when you start to see atrophy and you talk about the disconnect from the nerve to the muscle function, and you have to reactivate that muscle work again, it tells us how important the multifidus muscle is with core uh core flexi- or core strengthening and with core um flexibility. So, the reasons I would state is saving the supraspinous ligament and not violating the multifidus muscle. You're coming underneath the supraspinous ligament with this lateral approach and you're not violating the multifidus muscles um to any significant degree. And in fact, you're just going through muscle and fat as you work your way to the midline process where we come between the spinous processes and uh deposit the device. Excellent point.

[00:28:40]Glad you brought up. We'll take another question from the audience.

[00:28:43]Uh one question I have for since this is a lateral fusion device, have there been any studies looking at um um adjacent segment disease for um this procedure? Yes, great question. So, this procedure started long before Doug and I about 2011, they started doing this in Europe. So, there's been over 16,000 implants now throughout the Europe and the in the United States. One of the things that they have not seen is adjacent segment problems. And the belief is that the adjacent segment problems come on because of high facet screws. When you put a When you do a facet screw, it it essentially locks down that facet joint, which causes even more immobility and more movement at the level above. So, the belief is that we don't see the adjacent segment problems because this is a posterior implant and there's no uh facet screw involved.

[00:29:33]Next question.

[00:29:35]Uh for the approach like the posterior medial uh I'm sorry, posterior lateral approach, would you change the orientation on right versus left based on the degree of hypertrophy of Good question. Yeah. So, I I don't know about y'all, but I like to keep things as as routine in the OR as I can. I do lots and lots of cases every time I go in. So, if I don't have to flip the OR, that keeps me from getting flipped off by my radiology tech, right? Yeah, exactly. I got a thumbs up. I like that one better than the other finger. So, the point is um on this side I can work almost all my cases, but like I said early on, say it's a guy and they have a really high iliac crest on the left side and I can I can kind of do a crisscross technique where I cross the legs and pull the hip down, but if I still can't get satisfactory hip height drop, then I will either come into the other side and do everything upside down backwards, or I'll do a procedure where I go over the iliac crest and I dive down kind of steep and then readjust and come in really flat. And so, there's ways to do um people with high hip crests as well.

[00:30:33]What you probably noticed a little bit on this, doctor, is is I started out with a little bit of an angle and as you put the implant in, it just kind of It itself and gets almost exactly horizontal. And so, um that would be my answer to that question.

[00:30:46]Any other questions from the audience?

[00:30:50]Chad, I think we're in good shape.

[00:30:52]>> Thank you, Neil. Appreciate it. Thanks for the questions, guys.