This advertorial is sponsored by NuVasive.
The field of spine surgery has seen some major developments over the past few years, with new technological advances paving the way for more accurate and reproducible procedures which, in turn, has ultimately helped improve outcomes for patients. Spinal News International speaks to two renowned spine surgeons, Stewart Tucker (Great Ormond Street Hospital, London, UK) and Jacques Müller-Broich (Helios Klinikum Bonn/Rhein-Sieg, Bonn, Germany), about some of the key features of the recently CE-certified and US Food and Drug Administration (FDA)-cleared Pulse platform (NuVasive), their own experience with the technology and how it has changed their approach to spinal surgery.
Benefitting surgeons as well as patients
Pulse is an integrated technology platform which is designed to increase safety, efficiency, and procedural reproducibility in spinal surgery. It integrates radiation reduction1, imaging enhancement, rod bending, navigation, intraoperative neuromonitoring, and spinal alignment tools into a single condensed footprint in the operating room.
“Safety is the key issue for me” says Tucker, who specialises in treating paediatric patients. “Being able to insert metalwork safely while reducing the risk of spinal cord injury, is vital for these children.” He also states that the impact of a spinal cord injury on both ambulatory patients and also those who are wheelchair-dependent is “devastating” and if such an occurrence “can be minimised or avoided altogether that has massive advantages for the patients. It is also very important for the surgeon as well because it is high-risk surgery and this significantly reduces stress,” he adds.
Müller-Broich reveals how Pulse has changed his whole workflow. “We now not only have the haptic feedback, but also the imaging on the monitor showing us the position of the screw. So, we are able to be reproducibly more accurate than we were with the freehand technique. This has shortened the operation time.”1 A reduction in operation time not only benefits the surgeon, but also the patient. “If you imagine that now you save 30 minutes to an hour when putting in screws, for example in children during scoliosis surgery, that equates to a reduction of blood loss of around 300ml to 500ml,2 which might not seem that much over time when you think about a six-hour surgery, but for a small child who only has a very limited amount of blood volume that is a big change”.
Then and now
Historically, cases involving correcting spinal deformity, “would take considerable time” notes Tucker, who adds that putting pedicle screws into a deformed spine can be “extremely difficult,” particularly when working around the spinal cord without 3D-imaging. However, navigation with the Pulse platform allows surgeons, in his experience, to “do more in terms of instrumenting more complex deformities safely,” and can lead to “a better result and better correction” in the long-term.
Müller-Broich also sees substantial benefits with the new system. “I have been brought up using freehand technique, but it is an old technique and time consuming. Navigation with the Pulse platform has changed that,” he says. The efficacy of navigation technology has come on leaps and bounds in recent years, believes Müller-Broich. “In the beginning it [navigation technology] was very difficult because the accuracy of the navigation was not good enough but now we are much more accurate. That is what we need for spinal navigation because if we touch the nerves or the spinal cord there can be significant problems.”
The surgeons also open up about some of the cases where they have utilised the Pulse platform. For Tucker, his most recent was a patient with adolescent idiopathic scoliosis. “It was a right thoracic curve in which we were able to insert, with Pulse, a high volume of metalwork and that enabled the optimal correction to be achieved,” notes Tucker. “We are noticing that by having the highest density of metalwork accurately and safely inserted through Pulse, gives us a strong ability to correct the spine.”2
Müller-Broich highlights another case involving Pulse, this time in a 32-year-old patient with a severe case of Scheuermann’s kyphosis (images below). The lady in question wished to start a family but did not think she could cope with the pain. “So, we started talking about surgery,” says Müller-Broich. “Before Pulse we were able to plan, but not to measure, intraoperatively. So, in this case we used it [Pulse] to measure the angles. We were then able to use the Bendini spinal rod bending system, which is also a very powerful tool, to measure the screws after using navigation and as a correctional tool. In the end, we were able to achieve [spinal alignment] correction from 82 degrees to 39 degrees which is just perfect,” and shows that Pulse “really is a game-changer.”
Reducing X-ray dosage with Lessray
“Pulse has so many different features apart from the spinal navigation. For example, Lessray is also a very powerful tool that helps to reduce X-ray dosage for the patient,”1 says Müller-Broich. Lessray is an image enhancement technology designed to take low-quality, low-dose images and improve them to look like conventional full-dose images.1 Tucker adds that in his institution they use the Cios Spin (Siemens) to perform intraoperative scanning and then link that with Pulse. While Pulse is an open imaging platform, it offers enhanced integration with the Cios Spin 3D mobile C-arm. “Lessray allows us to obtain imaging of the entire construct so we can see the correction that we have achieved on the table,” he says, adding that one of the advantages with Lessray is that “you are able to achieve intraoperative imaging, for example to check levels and also positioning of metalwork, without subjecting the patient to the higher dose radiation that you would need if you did a spin [to get another intraoperative image] at that stage.” In addition, at the end of the operation “you are able to achieve a full-length image of the spine to assess the correction in both coronal and sagittal planes. So, that gives essential information which is not traditionally available with using standard imaging intensifier procedures,” says Tucker. This feature is called image stitching and is beneficial to surgeons as it minimises workflow interruption by quickly stitching together fluoroscopic images of the spine.
Looking to the future
“I think Pulse has broadened the scope of patients that we are able to offer instrumentation to safely,” says Tucker. “At Great Ormond Street we have a very high percentage of very seriously affected children with complex deformities,” he notes, adding that the technology now allows for more expansive operations “which will enable a greater correction and hopefully a better quality of life for them in the long term.” However, he also believes that surgeons should not ignore the old techniques as it is “essential to have the feel of inserting a pedicle screw and knowing it is in the correct place.”
“Deformity surgery is still a demanding task but it takes some of the pressure off,” adds Müller-Broich. “Pulse takes a lot of stress out of the surgery because we are reproducibly placing our screws correctly. Also, you are not having to tell the technician what to do all the time so you are not trying to play the whole orchestra in the operating room, you are instead just concentrating on the really complex steps and that is a really big advantage in my opinion.” He highlights that now even student surgeons can put in screws with this system. “We can probably in the future do surgeries which we never thought of before because technology like Pulse is really pushing the limits,” Müller-Broich concludes.
Stewart Tucker is consultant spinal surgeon at Great Ormond Street Hospital (London, UK). He also practices at the Wellington Hospital, King Edward VII Hospital and The Schoen Clinic.
Jacques Müller–Broich is a senior spine surgeon at Helios Klinikum Bonn/Rhein-Sieg (Bonn, Germany). He was previously head of the certified spine centre at the University Hospital Frankfurt in Germany.
Cios Spin is not yet available in all countries. Cios Spin is courtesy of Siemens Healthineers. Pulse is not yet available in all countries. Pulse navigation is not presently indicated for use in cervical procedures in the EU. For important product safety information please visit nuvasive.com/eIFU.
1. Wang TY, Farber SH, Perkins SS, et al. Internally randomized control trial of radiation exposure using ultra-low radiation imaging versus traditional C-arm fluoroscopy for patients undergoing single-level minimally invasive Transforaminal lumbar Interbody fusion. Spine 2017;42(4);217-23.
2. Eastlack R, Mundis G, Uribe J, et al. An evaluation of the accuracy, efficiency, and safety of Pulse Navigation percutaneous pedicle screw placement: a randomized, cadaveric study. NuVasive white paper. [December 10, 2021]. 9513871 B