Other Articles

Using DNA to Predict Scoliosis
Six million people (estimate from the National Scoliosis Foundation) have scoliosis in one form or another. The primary age for onset of idiopathic scoliosis is 10-15 years old. Finally, there is a test which can reliably predict scoliosis. Fewer X-rays. Lower cost. Better outcomes.

New Capital, New Science for Cartilage Repair
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Should I Become a Physician-Employee?
Large healthcare institutions are increasingly purchasing orthopedic practices. What does this mean for patient referrals? How beneficial can it be for orthopedists? The upside is more stability, among other things…and one of the downsides is loss of freedom.

Outrageous Whistleblower Lawsuit Challenged
Spine surgeons sued by whistleblowers in Boston are fighting back. Their lawyer is outraged and says the claimants are just shopping an old and settled case to another judge. Is this the proverbial lipstick on a pig? Find out.

Medical Education Under the Microscope – Is It Up to Today’s Challenges?
Where is the line drawn between what medical schools, residencies, and professors should provide to students and what doctors-in-training should reach for themselves? Here are the results of interviews with three senior surgeons, who opine on things such as attitudes, how people learn, and the possible effects on the field.

The Underlying Meaning of Zimmer’s Purchase of Abbott Spine
From the price paid to the timing, this transaction held an underlying meaning for the entire spinal implant industry. Zimmer, the $4.2 billion (revenue) diversified orthopedic company is now #5 in spine. More to come?

Resurging Lumbar and Cervical Total Disc Replacement Markets! New PearlDiver Estimates
Rumors of the TDA market’s demise were premature. Increasingly positive long term patient data is at the core of a resurging lumbar and cervical TDR market. Senior analyst Matt Menze tackles the TDA market and interviews one of the fathers of TDR, Dr. Scott Blumenthal from the Texas Back Institute. Where is this market actually heading? We think to the $2 billion range by 2015. All details here.

Six Days in June – Biomet and Zimmer Battle for Distributors in Kentucky
Documents filed recently in a Kentucky lawsuit pull the curtain back on an epic battle between Biomet and Zimmer. For six fevered days in June 2007, Biomet CEO Jeff Binder and founder Dane Miller went into the trenches to save one of their own. For all the details, read on.

Multicenter Clinical Trials: Do They Get the Respect They Deserve?
They’re not fast or sexy, but they are critical…large trials, that is. With multiple sites and principal investigators who donate their time, large trials are more complex—and normally yield more actionable data—than smaller, quicker studies. But large trials don’t always get the respect they deserve. And, says at least one physician-researcher, this could affect the future of the field.

Patent Wars: Medtronic Attacks NuVasive
MSD’s lawsuit came amid a period of declining spinal implant market share – from a peak of 60% in late 1998 (just prior to being acquired by Medtronic) to, we estimate, 36% currently – and a growing sense that MSD’s reign as the king of spine was coming to a close. What’s really behind Medtronic’s attack on its former senior exec? Read on.

Spine Gainsharing Through the Looking Glass
The feds have issued their first opinion allowing a spine gainsharing proposal. In Alice in Wonderland style, Through-the-Looking-Glass logic, they said the proposal was improper but would not impose sanctions. Who is the author of such a plan and what’s her secret? Read here.

PearlDiver Data Raises New Questions About Synovial Injections
Synovial injections for painful knees have been approved for use since 1997. If the goal is to improve the quality of life for the patient, is that being accomplished? The latest numbers from the PearlDiver Patient Records Database cast doubt.

Plantar Fascia: The Annual 3 Million Patient Market
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Orthopedic Incubators: Where Little Ideas Grow Up
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Just Say No to CMS Potential Coverage Decision List
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Staking a BIG Claim
Alphatec, the company whose IPO collapse served as an object lesson for all medical device companies, has nearly completed its turnaround. The key? New management and new technology. Exhibit A: OsseoFix™—with it Alphatec stakes a claim to the next big spinal implant market.

They say the best don’t have to advertise. Such is the case with Dr. Larry Khoo and his minimally invasive talents. Says Dr. Khoo, a neurosurgeon at the University of Los Angeles (UCLA) Medical Center, “My patients come in asking for minimally invasive spine surgery (MISS). They are savvy and well-read on the technique.”

The spine is tough. But he could have ended up working on another hard substance—shale rock. “I was born in Malaysia, where my father was a geologist with the oil companies. My brother followed in his footsteps as a petroleum engineer. I wanted to be an engineer like my brother so when I attended Stanford University, I followed in his course of study. As it turns out, I didn’t enjoy the work. When I began looking at internships and jobs at oil companies it was the mid 1980s, a time when this type of work was becoming less hands-on. I did not want to be trapped, like so many other young engineers at the time, in a cubicle solving abstract flow equations on data sets from some far-off oil well that I had never seen. One summer when I was searching for a job, I took over an acquaintance’s internship in a hospital while he was ill. I worked for a world-renowned heart surgeon at the Texas Heart Institute in Houston, the biggest medical center in the world; it was the size of Pasadena. This doctor had invented the artificial heart graft. I was thrilled to work with him at an animal transplant lab where I helped to design cardiac pumps. At the end of the summer he said, ‘You’re perfect for a career in surgery because you have the right kind of personality and a good pair of hands.’ Inspired personally by this surgeon’s example and encouragement, I returned to Stanford and immediately switched to premed.”

Having found a more hands-on profession than geology, Larry Khoo entered Yale School of Medicine in 1989. “From the outset I wanted to be a surgeon. I was drawn in by not only the intellectual stimulation, but by the ability to, shall we say, tinker in a meaningful way. At Yale, about half of each med school class takes an extra year to do research or just to solidify their career paths. I did take an extra year to do research and worked on the molecular biology of malignant brain tumors. While I originally intended to become a heart surgeon, I found that I didn’t want to spend a lot of time in a small dark room with catheter wires doing things like angioplasty—which was where the field of cardiac medicine was headed. In essence, I didn’t want to be locked into doing only the tertiary salvage procedures that were left for the cardiac surgeons as the interventional cardiologists expanded their territory. In retrospect I can see that engineering led me to neurosurgery because of the intricate mechanical and intellectual aspects of both fields. I was also influenced by a number of neurosurgery residents, who became my friends. I rotated on their service and when we all went to the gym they taught me neuroanatomy as we were working out. Furthering my interest in the field was the year of brain tumor research I did. I could see that there were still a lot of contributions to be made by neurosurgeons…meaning, of course, that I could have a stimulating career for years to come.”

As with many surgeons, however, Dr. Khoo found that there was a challenging emotional component to this line of work. “In 1994 I began a six-year neurosurgery residency at the University of Southern California (USC). While I enjoyed cranial surgery, I had a feeling that it wasn’t the perfect fit. By the time you’re doing brain surgery it’s often a lost battle in many ways. It was pretty tough to deal with being surrounded by constant death and loss. I initially thought I was a bad surgeon because the patients did so horribly, but then I saw that my bosses were having the same results. I then realized that it’s just the nature of the work in cranial neurosurgery.”

He then stumbled on a better fit for his temperament and design talents. Says Dr. Khoo, “Spine was a young field at the time. I could see that it was highly mechanical, and would thus fit well with my engineering background. Manipulating, moving, correcting…I was accustomed to these concepts and enthused by them all. And frankly, there’s the added bonus that your patients rarely die. I chose to spend my elective neurosurgery time in orthopedic spinal research, at which time I worked with Drs. Robert Watkins, Srinath Samudrala and Lytton Williams. For several months I conducted biomechanical basic science research on spine in their lab. I was fully occupied and focused as I studied analysis of motion and forces on the spine. I realized that I had found my niche.”

This work led him into new territory. “Upon graduating from residency in 2000 I did a fellowship in minimally invasive spine surgery with Dr. Richard Fessler at Rush Medical Center in Chicago. We concentrated heavily on MIS techniques, a pretty radical area for that time. There were only a small handful of guys in the entire country doing it and there was hardly any equipment to speak of. I spent a lot of time on R & D and we ended up helping to pioneer and establish many of the new procedures. During this time, we published some of the sentinel papers on MIS, decompression, and lumbar fusion. I returned to Los Angeles and found a professional home at UCLA, where I have been doing MIS spine surgery for five years. It now comprises over 60% of my practice. There is a bit of snobbery with spine, however, as many neurosurgeons view spine as the second cousin locked away in the attic. Fortunately, these negative attitudes are changing.”

Perhaps Dr. Khoo feels like the engine pushing the train. “While MISS is the big buzz in the spine world, the fact is that only about 20% of spine surgeons are doing it. Here at UCLA we are continuing to help perfect and expand these procedures, however, and are trying hard to advance interest in them. Working with our industry and research partners, we have developed and validated many new tools, portals, and instruments that have expanded the scope of minimally invasive spinal surgery. We have engaged in prospective comparisons, trying to help surgeons answer the question, ‘Is this really better and why should I change?’ We are attempting to get data to show that MI techniques are indeed better for not only the patient but also the surgeon. While our initial goal was to demonstrate equivalency to traditional techniques, we are now confident that MISS is better. Using several standardized medical metrics, we have shown in many cases that MISS techniques reduce hospital length of stay, blood loss, and complications. Then there is the decrease in required narcotics, as well as better pain and function scores at six weeks and three months. Despite this growing body of evidence some people still argue about its efficacy.”

Physicians usually follow the evidence, so what is different in the case of minimally invasive spine surgery? Explains Dr. Khoo, "There is a barrier to adoption because for surgeons to retrain on these techniques takes time. You have to interrupt your normal routine and do a completely new surgery that initially takes four or five hours instead of the two hours you’re accustomed to. The result is that most of the growth in MI spine surgery has been from younger surgeons. There are seven to ten fellowships focused on this subfield, as well as many courses around the country. We have an active training program here at UCLA, where to date we have trained six American surgeons and 15 to 18 foreign fellows in MISS. When we ask attendees why they are here the top reason is patient demand. The patients, an increasingly sophisticated group, are coming in and asking specifically for MISS. Within certain communities there is more pressure, of course. In LA people have an understanding of the technique and seek it out. I have never had to advertise it.”

But there is some selling involved…to the surgeons. “In my MI class I get questions such as, ‘What is the learning curve?’ I explain that they must give themselves enough time in their practices to evolve (10 to 20 cases). The techniques themselves have had years of evolution from labs and teaching centers to actual practice. If you’re patient and good at MIS, you will be competent in one or two years. I encourage them to try the simpler cases first. We used to open the spine wide and then put screws in. Now we are asking surgeons to make little holes using only fluoroscopic X-ray guidance in order to insert screws over the wires. I tell them that at first they are going to have decreased accuracy because they are not as comfortable, but that with time, their screws will actually be more accurate and ideally placed as seen on postoperative CAT scans. They are also naturally concerned about safety issues. Because we depend on things like videos and endoscopic techniques, we must use fluoroscopic X-rays—a legitimate health risk for surgeons. Whereas patients only have one dose, a busy surgeon will likely be exposed several times a day. My routine is to wear a lead apron, glasses, and lead-lined gloves. Also, it’s important not to stand in the beam, but just position the needle or tool and step away. We will ultimately have a type of navigation system that can help to replace fluoroscopy thereby reducing the negative side-effects of increased radiation exposure to all involved.”

So what’s next for MISS? Laughs Dr. Khoo, “Seven years ago anyone who was advocating minimally invasive spine surgery was practically booed off stage. What they thought was rubbish or a fad is now evolving and becoming the standard of care. Here at UCLA all chief residents, even if they’re not doing a spine fellowship, prefer using MI techniques. Whereas we began with small procedures like lumbar decompressions and then fusions, we are now making inroads into the cervical and thoracic world, as well as large trauma and scoliosis. MISS is a philosophy as opposed to a particular cage or screw. It’s all about small access and minimizing tissue exposure. As a result you can do anything this way. We are now entering the motion preservation world with things like moving rods, artificial discs and things that allow stability and strength without locking a patient’s motion segment down. Our basic science research is leading us into this exciting new area. Those new devices can all be placed through MI approaches. It’s really a natural marriage between the two areas of minimally invasive surgery and motion preservation.”
Continues Dr. Khoo, “Those of us involved with the Minimally Invasive Spine Surgery Society, a relatively new group, are trying to serve the greater spine surgery community. We are working out the kinks of the procedures in a slow, controlled fashion so the rest of the world can learn from our work and our mistakes. Someone always has to lead; now it’s a small cadre of us who are doing so. While we have room for 100 surgeons in the society, we are keeping it small for the moment because we want a dedicated core group. Part of our growth is that we are now linking to bigger societies and presenting our information in a scientifically rational manner.”

When not teaching MISS, Dr. Khoo may be found at the kitchen table teaching fractions. “Family is a huge part of my life. My wife and I have twin six-year-olds, a boy and a girl. I often sit with them to do homework, or review their piano lessons with them. Overall, I try to integrate the children into my daily life by bringing them to meetings and other events. My wife, a nurse practitioner in the cardiology field, helps us ensure that no matter what, Sunday is for family. We love doing sports together and often go hiking, skiing, and swimming together.”

Dr. Larry Khoo…minimally invasive, maximally effective.