Technological advances in healthcare mean we should last longer than our forebears did, but will our aching backs endure? When Scott Blumenthal was beginning his career as a spine surgeon nearly 20 years ago, magnetic resonance imaging technology was just coming on the horizon. His biggest worry, he says, was getting a clean diagnostic image that could tell him what was tormenting the patient.
But he also has had to battle the negative perception of back surgeries. "Everybody had an aunt or uncle or friend who had unsuccessful spine surgery," recalls Blumenthal, president of the Texas Back Institute based in Plano.
With 21 physicians and eight locations in Texas and one in Phoenix, the institute boasts that it is the largest freestanding spinal pain practice in the U.S. Each year, approximately 12,000 new patients seek help at the organization, which is affiliated with 195-bed Presbyterian Hospital of Plano, Blumenthal says.
Only about 10% of those patients eventually have surgery, the bulk of them at Presbyterian. Currently, he says, most patients who undergo surgery are receiving discectomies in which herniated or ruptured discs are surgically removed to relieve pressure on the nerve.
"I think that's such a prevalent problem that can be treated simply; it will remain fairly mainstream for the time being," Blumenthal says. Technology will improve the technique even further by finding minimally invasive ways to limit collateral damage from the surgery itself, he says.
But at least one analyst who is highly optimistic about the future of spine surgery believes discectomies will be on the decline as technological innovation changes the game. Robin Young, managing director of research for HealthPoint, a New York-based orthopedic research, private equity and advisory firm, says spine industry revenue will triple from 2002 to 2012, climbing from $2 billion annually in sales to more than $7 billion-a 12.8% annual growth rate. Technology and demographics are the main drivers for the growth, he says.
The sea change is already occurring. Seventy years ago, an alarming 30% of the patients who underwent spine surgery died on the operating table and only 7% of the procedures were successful, according to Young. Today the death rates attributed to back surgery are essentially zero and spine surgery boasts a success rate-pain relief and restoration of function-better than 80%, Young says.
What makes the spine industry particularly attractive to Young is the broad swath of people afflicted with back pain. As many as 90% of us are expected to suffer from back pain at some point in our lives and at any given point, 25 million Americans are experiencing some kind of pain, yet only 600,000 patients receive treatment annually-less than 3% of the potential market, Young says. Still, that meager market penetration represents the second most common reason people see a doctor. "Back pain is as big as the entire cardiovascular market," Young says.
Back pain also is a predominantly middle-age issue, occurring most frequently between the ages of 40 and 60, according to HealthPoint research. The incidence actually declines after age 60 as a percentage of the population. Blumenthal says this is not because back pain stops in the elderly. To the contrary, the back takes so much stress from life's woes compared to the knees and hips that back pain just appears earlier in life than other arthritic types of pain, he says.
Young believes the reluctant majority of back pain sufferers who resist surgical solutions are likely to have a major attitude change thanks to new treatments and technologies that are poised to enter the market, some as early as a year away. Last month, he hosted HealthPoint's first annual Spine Industry Summit in which 30 spine medical device companies, both private and publicly traded, presented their latest innovations. Blumenthal discussed his clinical experience with disc arthroplasty, or artificial discs. More than 175 people including institutional investors and venture capitalists attended the conference.
In Young's estimation, new and notable technologies presented at the conference included a potato starch that offers a cheap and safe method for controlling bleeding during surgery and a surgical robot that gives the surgeon superhuman powers to work tirelessly and more accurately. A video demonstration during the presentation showed a surgeon using a robotic arm to cut the shell off an egg without breaking the membrane. Such minimally invasive surgical techniques promise to promote faster healing for patients.
The most captivating news of the summit surrounded disc arthroplasty, which is expected to revolutionize spine surgery as greatly as the advent of implants changed hip and knee surgery. Young says major orthopedic companies have spent more than $1 billion in the past 12 months to stake a claim in the technology. He predicts disc arthroplasty will be ready for market within the next 12 to 18 months.
Disc arthroplasty employs an artificial disc to replace degenerated ones, with the hope of relieving back pain while maintaining flexibility. Within five years, Young expects the Food and Drug Administration will have approved as many as nine disc arthroplasty products, typically made from titanium and polymers, and by 2012, it's expected to be the standard of care with spinal surgeons performing about 150,000 disc arthroplasty procedures that year.
The standard of care right now is to perform a fusion, where the surgeon fuses the discs together. A generation ago, failing hips and knees were treated in much the same way with the surgeon fusing joints, "which created a lot of disability," Blumenthal says. "Now 30 years later, hip and knee replacements are commonplace. I think the same will happen with the spine."
In 2002, spine fusions represented the second most common spinal procedure after discectomies, according to HealthPoint research. In 1990, spine surgeons performed 112,000 spinal fusions; patients averaged 8.9 days in the hospital for a lumbar fusion in the lower back. By 2002, HealthPoint estimates the number of spinal fusions performed in the U.S. almost tripled to 320,000.
But spine surgery is an untapped wellspring at many facilities, according to HealthPoint. In 1990, one-third of U.S. hospitals-2,053- performed at least one spinal fusion, while 211 hospitals accounted for 40% of all spine surgeries in the country. That penetration compares with the 65% of all 6,144 U.S. hospitals that performed at least one hip implant that year.
Meanwhile the cost of a spine fusion using implants such as hooks, plates, rods or screws, doubled to $40,000 to $45,000 per procedure in 2002 from $20,000 to $22,000 per procedure in 1990, HealthPoint says.
The market for disc repair is about where hip and knee surgeries were some 30 years ago, Blumenthal says. He guesses that disc replacement will cannibalize as much as 50% of the spinal fusion market. Young expects the volume of fusions will grow to 588,000 procedures annually by 2012. Since the surgery is still awaiting FDA approval a price hasn't been set, but Blumenthal expects it will compare with the cost of a fusion. "That's a big market," Blumenthal says.
Early results 'encouraging'
The Texas Back Institute was involved in three of four clinical trials of various disc implants that have yet to win approval from the FDA, and Blumenthal says he was "very encouraged by that technology." He expects the first such device to be in front of the FDA will be the SB Charite implant, marketed by DePuy, a Johnson & Johnson company. The implant already is marketed in more than 30 countries outside the U.S. Two-year patient follow-up trials will be completed in December, and DePuy anticipates submitting an application for FDA approval in 2004, says Marc Monseau, a J&J spokesman.
From 2000 to 2001, 300 patients at the institute underwent surgery testing DePuy's implant, Blumenthal says. Word of the artificial disc has "spread like wildfire" on the Internet among consumers, and patients are asking for the artificial disc, he says.
As the institute's affiliated hospital, Presbyterian reaps the dividends of spine surgery. Hospital President Phil Wentworth says spine surgery is "a major product line here" as well as orthopedics in general.
Financially, Presbyterian is in good shape, earning $28.2 million on $321.3 million in gross patient revenue-a whopping 17% operating margin-for the nine months ended Sept. 30, says Scott Siemer, the hospital's decision-support manager. During that same period, Presbyterian surgeons performed a little more than 1,100 inpatient spine surgeries, representing about 8% of the total inpatient population, Siemer says. That is roughly equal to other orthopedic surgeries such as hip and knee replacements.
On a revenue basis, spine surgery accounts for even more business: $43 million, or 18%, of $234 million in gross inpatient revenue, Siemer says. Spinal surgery is second only to maternity services, which brought in $50 million in revenue the first nine months of this year. With spine surgery, costs rise dramatically because of the implantable devices that are commonly used in such surgeries, Siemer says.
Working with the institute, Presbyterian has been able to significantly compress its length of stay, getting spine surgery patients out the door in less than three days. The institute's physicians are not scalpel-happy either, using surgery as a last resort. "They are a very conservative group," Wentworth says. "They do a lot of palliative care before they do surgery."
Presbyterian Hospital hasn't targeted spine surgery as a growth area, but it clearly is growing in the Plano market in the suburban Dallas area, where a young population prone to a lot of sport injuries is expected to keep orthopedic surgeons busy, Wentworth says.
Blumenthal says he got into spine surgery because he has always found the back interesting and the surgery challenging. "I could see advances yet to be had. I wanted to be part of the wave," he says. Apparently, his hunch is being realized.
"This is one of the fastest-growing sectors in healthcare right now," Blumenthal says.