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This is Carly Beam with Becker Spine and
Orthopedics podcast.
I'm thrilled to be joined today by doctor
Todd Landman of Cedars Sinai.
Doctor Landman, thank you so much for being
here today.
Thank you, Carly. It's a pleasure. I'm happy
to meet with you and speak to you
about all the latest and greatest in
spine technologies,
especially in motion preservation surgery.
Absolutely. And before we get into our conversation
about the latest and greatest, can you share
a bit more about your background?
Yes. I,
well, I trained in medicals how far do
you wanna go back? I mean, I can
go back to my childhood and everything. But
we'll probably just go medical school at Northwestern
in Chicago
and then UCLA training for, neurosurgery.
So even though it's an orthopedic
podcast,
technically,
but neurosurgery and orthopedics both,
do spine surgery. So neurosurgery is seven years
at UCLA.
And then after that, I've been, at Cedars
Sinai Medical Center, an associate professor at UCLA.
So I still do teach there. However,
I am part of the Institute of,
Spine Institute of Excellence and the Institute of
Spinal Disorders
at Cedars Sinai Medical Center and have been
for over thirty years.
So I've been working with
the group there and the teams there and,
working on, artificial disc replacement primarily as my
focus in motion preservation
of the spine.
Thank you. And, you know, when it comes
to total disc replacement, what's exciting you in
that sphere right now?
Yes. Well,
several things.
Every
especially in the cervical spine, we're seeing more
devices being approved and being investigated,
and there's new technologies.
And so there's some really interesting things that
are happening that are exciting.
One is that
there are some new devices that will be
coming out
that are able to preserve
sort of angulation
or or alignments of the spine better.
So there's some newer
devices,
particularly
one,
that,
should be FDA approved maybe late this year,
early next year,
that provides
curve of the neck so that your neck
should curve backwards.
And this this artificial disc still allows mobility,
but helps maintain the alignment
properly.
So that's more exciting because a lot of
the disc that we have now
really let your neck set itself where it
wants to go.
And because of the latest technologies,
phones, laptops,
so forth, we tend to flex forward mostly.
And so you can have
kyphosis or that
flex forward or what I call a chicken
neck looking
deformity where the, you know, people's head falls
forward. And most artificial discs will allow you
to roll forward, so it takes a lot
of rehabilitation and strengthening of the muscles to
really
keep the head in alignment. So there's new
technology coming out that may help that and
make that process much easier for the patients.
The other thing that's,
happening
is,
viscoelastic
discs, which are soft core
discs,
have gained some traction
outside The US. There's one that's FDA approved
in The US
for the cervical spine.
However, they just pulled it off the market.
And what we've seen is
and what I think people need to really
remember
is any implant that moves, whether it's a
total hip or total knee or shoulder
replacement,
artificial disc in the neck or the low
back, any implant that has motion will have
wear.
And so
how fast does that implant wear?
So we do know that the more common
implants that have
hard,
ultrahigh molecular weight polyethylene cores, cores, for example,
with titanium
tend to last,
like, forever. Seventy years, probably. They've been cycled
on
in what what we call life year repetitive
motions on these machines that replicate life years
for over seventy years, and they're still very
functional.
And,
but the viscoelastic
course, sort of the soft core disc. Right?
Because our our human disc will be more
compressible.
It allows motion up and down. Well, our
the hardcore discs don't do that.
When you look at the data carefully, though,
there's no real difference in the outcomes between
the sets of patients. Those the soft core
just sound intuitively better, but they do not
show any better outcome.
What they are happening to show, however,
is the core is wearing out early,
which means then you're back
to revise it. And nobody wants spine surgery
again if they can avoid it. And so
the the soft core discs that are not
available in The US are also having some
issues, and I've removed a lot that's my
patients who have gone to Europe particularly
for those discs.
I've taken out
many here.
And the one that was approved here, there's
some issue with the core,
as well, and the company's taken that off
the market for now.
So that's sort of coming up. The last
thing to mention really
is
I'm I I I I'm trying to help
patients connect,
with the most experienced and qualified disc replacement
surgeries in The United States
because they're
patients don't know where to go to find
the patients that preserve motion.
So
we created,
the top doctors in artificial disc replacement or
arthroplasty directory.
It's,
basically, adrspine.com.
And that lists doctors that
I have personally reviewed that have
experience
doing artificial discs with good outcomes.
And so we provide that directory so the
patients can go there and kinda look for
patients that are doctors that are near their
areas. So they don't have to travel so
far. I mean, I love it when they
all fly out here to see me. That's
great. But but if they, you know, if
they wanna stay, you know, closer to home,
if it's a more simple
type of procedure,
then
they can find doctors near them.
And how much has this, ADR
list grown in recent years?
We launched it last year, so it's pretty
new.
We have about 10 doctors on it now,
I believe. We're adding more
as time goes on. I have one of
my spine fellows now I'll be adding on
the East Coast. He's been sending me his
post op films because he wants to get
on the site, and I'm kinda picky about
who can be on there because I wanna
know that they have experience.
And so I told him, I said, you
made the cut. So
his name's Cameron Murphy. I'll be adding him
on soon.
And,
so there'll be more, but I'm I'm just
wanna be careful
and add add doctors that I know that
are and, we run into some issues where
some doctors are in big groups, and then
the group
corporate structure doesn't want them to be listed
on another site and things like that. But
we're trying to work around that. So it's
pretty new, but it it's out there. In
in that website, also, we show all of
the different discs that are FDA approved, how
they work. So patients have a resource
to learn more about, gee, what is the
disc this doctor recommends, and what is what's
different about the other discs, right? You have
nine discs FDA approved
in The United States. Well, they all work
a little differently.
And it's not a one size fits all.
And so I don't like it when
I talk to artificial disc replacement surgeons, like,
well, I always use this one disc. Well,
that may or may not be a good
thing
because each patient has different anatomy
and different angles,
and their motion is different. And certain implants
will work better in them than in others.
And that's sort of taking it up another
notch
or or a higher level. So I'm trying
to find doctors who are a little more
savvy, who can provide that expert care that
the patients need.
Got it. And I want to circle back
on what you were saying earlier about the
ViscoSoft type of
artificial discs.
Do you look
what do you think these devices need so
they don't have this wear and tear issue?
Well, the the one so each of the
the the ones that are out there,
that are OUS or outside The US
and the one that was here in The
US,
they all have polycarbonate
urethane cores, which is the softer's more springier
core.
That core seems to be relatively resilient,
but it's it's
the method that which it's encapsulated
around it
is variable.
And
the mechanical structure of the fibers that are
woven around that core
are different.
Some of them have
a different type of of elastic
polymer. Some of them have a weave
of a ultra high molecular weight polyethylene, like
fishing line, like a weave around it. And
those fibers
may possibly be tearing,
because they do not resist,
not to get too much into biomechanics here,
but what's called a shear.
Ultra high molecular weight polyethylene
has great tensile
strength, like a fishing line. Like, it'll pull
a fish out of the water. But if
you wanna push it on a sheer like
a crossways, it'll just cut right in half.
So we think that there may be shearing
causing some failures,
and then the core can expulse,
out of the implant, and then you're you're
just sitting the metal part sits on the
metal part.
We've seen a a lot of wear debris
occurring because they it's softer, so it there's
debris. There's a microparticulate
debris that occurs
that also
leaks out around the implant and can affect
the bone, then the bone gets some resorption
and can cause holes in it.
So,
right now,
at this time in place, I am in
a little bit more in favor of
the hardcore discs. I know that they're gonna
last.
And and, you know, I have four of
them implanted in me too. So
and they've been in since 02/2008. So, and
they look great on X-ray as of last
year. So I know that they last,
and I know that
they function well. And I don't really have
any back or neck pain anymore. So,
I sort of push more towards that.
I do love some of the biomechanical
features of the viscoelastic
core. I mean, it really replicates
exactly the physiologic motion of a human disc.
However, we have to work harder
on figuring out how to make that device
more
viable in longevity.
It needs to last and not break down.
Because patients really
you know, nobody wants to have a revision
or an exploitation
of their device.
I wanna pivot a little bit here. Can
you talk about some of the top challenges
that you're facing in your practice right now
and how you're getting ahead of them?
Well, the main the main challenge,
is insurance.
Right? Because
what a lot of people don't understand,
the patients are like, well, why isn't my
insurance approving a two level lumbar artificial disc
when that's been FDA approved
for several years?
And
insurance companies
like to look at the studies that have
been done.
And
the original studies in the low back, for
example, the lumbar disc replacement, were we did
both one and two level,
but we got the one level
approval from the FDA in 02/2005.
That's a long time ago. That's twenty years
ago.
And these insurance companies, there's still a few
insurance companies that still won't approve them at
all. They still call them experimental,
which is
it's criminal.
Whereas they'll approve
fusions of five discs, all five of your
discs in your low back. They'll insurance will
approve that in a in a second,
and they won't approve of one artificial disc.
And the data is unequivocally clear showing superiority,
we have two level approval.
I'd say most insurances won't even approve that.
And if I wanna put three artificial discs
in, none of them will approve it,
which is insane because the FDA says, and
when you look at their website carefully,
when they approve a device, they're saying that,
say, the device is safe and effective. And
it says right there, it says if the
physician
chooses to use this device
in what's termed an off label manner, and
I'll explain that in a minute, it's up
to the doctor and the patient
because that's that's our decision.
What what off label and on label mean
is on label is when we did the
clinical trial, we did one or two level.
That so if I said you need a
one or two level disc replacement, that's on
label because that's how the FDA clinical trial
approval was done.
Then
if I say, well, I wanna do a
three level, that's off label, but that's not
illegal.
It's not it's fine. It's
and, honestly,
lumbar fine spinal fusions that are done all
the time are all off label. The only
on label indication for a fusion
is a grade two
lytic spondylolisthesis
in it, which is a huge subluxation or
slippage of your vertebrae. That's the only on
label FDA approval. And this so insurance companies
seem to ignore that, approve those types of
fusions,
which are incredibly debilitating, in my opinion, to
the patients. They they
they it helps their pain,
and their pains are better, but they're incredibly
limited on their mobility.
And patients don't want
to lose motion.
You know, back in the day and I
do a do a lecture on this.
Back in the nineteen fifties, if you had
an arthritic hip,
they fused it.
They didn't have a total hip till 1958
when Robert Charnley invents the total hip replacement.
And I put up slides of all the
famous hip replacement surgeons at the time who
all said that's a fad. That device is
not gonna work. That hip replacement thing is
kind of a joke. My patients are very
happy with the hip fusion.
And if you see some really elderly people
walking around with a straight leg, you'll know
why. They they used to fuse your knee
and your hip.
And
today, if your doctor said he's gonna fuse
your hip or knee, you would be running
out the door. But people
get their spines fused all day
when the option of motion is there. I
mean, why wouldn't you get an artificial disc
if you're
unless you're
really not a good candidate, which in my
opinion is that that
is becoming a smaller window. But
who would want to not preserve mobility and
have their pain relieved both
and and maintain the motion that they wanna
have so they can have an active functional
life as they age.
So, yeah, that's that's basically
what our challenges are.
Got it. And then my last question for
you, doctor Landman, how are you thinking about
growth at your practice?
The thing I'm really working on now
and, again, this is off label, but still,
it's not it's not
illegal. It's just fine. But I have a
lot of patients coming in to see me
who have
had fusions,
and they're in terrible pain.
Some of them
part of the fusion didn't heal. Some of
them, all the fusion heal, but the way
they they fused him
or her, their their neck is out of
alignment. Their low back is out of alignment,
and they need to be rebalanced
in alignment. Because ours, when you stand, it's
a it's it's a balance. Right? Your head,
your ears should be over your shoulders, over
your hips.
But sometimes, the fusions are done, and they're
parking your head position too far forward or
your back
far forward. You see people walking kinda bent,
and they're confused.
And they have pain all the time because
the muscles of your spine
are always trying to rebalance you. It's subconscious.
Your your muscles start they're under tension. That's
why people have these muscle spasms, and they're
in chronic pain. So what we've been doing
and I've been working on very hard is
restorative motion surgery, where I go in, I
remove
the fusion, and place an artificial disc and
restore
motion.
And I'll be talking about that at the
ISAS meeting here in Miami coming up next
month and presenting my data
of over,
50 plus patients
and the outcomes. And it's quite encouraging. The
reduction in pain scores is dramatic. The the
the motion,
restoration, and I measured all of this, and
I'll be talking about that. But restorative motion
surgery,
remove
removing fusions,
removing failed fusions,
and converting those to artificial discs. Not everybody's
a candidate, but a lot of people are.
And when I do that, the results are
just fantastic because people have full restorative motion
of their spine again.
So it's exciting. I'm very excited about that.
Really encouraging to hear.
And, doctor Lamond, thank you so much for
joining us today. It's been a pleasure speaking
with you, and I look forward to connecting
with you again down the line. Thank you,
Carly. I appreciate it. It was great to
talk to you.