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Pierce Nunley, director of the Spine Institute of Louisiana (Shreveport, USA) and associate professor at LSUHSC Department of Orthopaedic Surgery, talks to Spinal News International about his own experience with the titanium cervical BEE® cage (NGMedical), how the spinal implant optimises bone ingrowth and fusion while reducing subsidence, and how collaboration and an aligned vision are helping the company behind the device make waves in the US market.
As an early adopter of the BEE cage, what first drew you to the device and to NGMedical?
It really all started when Joshua Sandberg (CEO of NGMedical), who I have known for many years, came to me and said ‘I have a German company who I think you might be interested in working with’. I did a Fellowship in Basel, Switzerland, so I previously spent time in Germany and have a lot of friends outside of the USA. Working with smaller companies and directly with engineers is really important to me because it means you are part of the process. When I provide input or advice it is frequently adopted. However, when you are working with larger companies, the engineers might have 20 different people telling them what to do and then often decide to do whatever they want rather than the surgeon consultants. So, I really like being part of the creative process. I also really liked the background of Peter and his team, I liked the story, I liked their vision of creating simple reproducible instrumentation and the thought they put into the design process.
What are some of the main features and advantages of the BEE cage and what has been your own personal experience with it?
The BEE cage is produced using a really cool process called additive manufacturing. Basically, how it works is that you lay many micron layers down on top of each other and after several hours you have a printed implant. The great thing about this is that you can create just about anything you want, but it has to be biomechanically stable enough to pass the rigorous testing that is required for a product to be approved. So you can have a lot of great ideas but if you do not have the engineering behind it then you are dead in the water.
What I like about the BEE cage specifically is, first of all, the honeycomb design across the top which allows for load sharing. This helps to reduce subsidence issues because the forces are distributed over a large surface area. But, at the same time, it has holes that are large enough to allow bone to grow through them and into the cage. It also has a large lateral window to look into which is important because, when we are evaluating our patients postoperatively, if it is all metal you cannot see bone and you cannot see the density change over time. So, then you do not have a good metric without having to do a computed tomography (CT) scan which is a lot more radiation and expense. The other benefit is that it is anatomically designed. Many cages are just flat but the BEE cage fits the patient’s natural anatomy. It is not a difficult device to implant and the cases I have done have all gone extremely well and I have been impressed with the images postoperatively.
What sets this implant apart from other devices on the market?
This is a crowded space and there is a lot of competition. Personally, I have not seen another fusion device that has this kind of anatomic design. I particularly like the relative small amount of material of this device compared to others. There is a fine line between having enough material in order to withstand the cyclic loading and prevent implant failure and too much material to absolutely ensure that failure will never happen. I think NGMedical have moved that needle closer to the point of making this probably about as small an amount of material you can probably have in an implant and still have a safe, usable device. Ultimately this equates to more room for graft, more room for bone, more visibility and more ability to evaluate the patient’s fusion status postoperatively.
What has been your experience working with the NGMedical team?
I really like working with smaller companies and smaller teams which allow for greater collaboration and where we can see change happen and ultimately see everything come to fruition. The family nature of the business appeals to me as do the personalities involved. It is very much a one-for-all and all-for-one environment. The thought process of what we are trying to achieve is very compatible. The structure of the company also means they can be more agile. For example, one of the issues of bringing the cage to the US market is that 12-degree lordosis cages have become very popular here, but not so much in Europe, and in fact, even eight-degree lordosis cages are not used that much. So now the BEE cage comes in four, eight and now 12 degrees as we move into the US market and that is just one example of how such a company can expand its product line and, not just its availability, but its desirability for our market.
Pierce Nunley is director of the Spine Institute of Louisiana (Shreveport, USA), associate professor at LSUHSC Department of Orthopaedic Surgery and the chairman of the American Board of Spine Surgery. He has multiple patents and has developed several implants and surgical techniques. He has also published more than 130 peer reviewed papers, multiple book chapters and lectures regularly at national and international societies and meetings.