A fresh face in the surgical world, Dr. Kleck of University Colorado Anschutz Medical Campus is one of Medicrea’s beloved early adopters in the US. We sat down with him to review the state of spine surgery as it is now and where he thinks his profession is heading based on the emerging new technological advancements. Kleck also shares how patient-specific surgeries come with a peace of mind: both for himself and the patients.

 

Please introduce yourself and tell me where we are.

I’m CJ Kleck. I’m one of the professors at the University of Colorado. We’re on the Anschutz Medical Campus today in my office.

 

Can you tell us a bit about your background as a surgeon and how you got started?

I did my undergrad at Portland State University in Oregon. It was there that I first started exploring orthopedic surgery. I worked at the Portland Veterans Affairs Hospital and Oregon Health and Sciences University in the Orthopedic Biomechanics lab. After this I taught high school for a year in Higley, Arizona and eventually went to medical school at the University of Arizona in Tucson. I knew I wanted to do orthopedics due to my early experiences in undergrad.

I was accepted to residency in Tucson at the University of Arizona. During residency, I did my rotations on spine and saw a pedicle subtraction osteotomy (PSO). I was hooked. From then on, as a 2nd year resident, I knew I had to do spine. I chose the University of Colorado for fellowship because of the staff, and the possibility of doing spine deformity. I was interested in doing complex spine surgery and took a job at the University of Colorado. From there, I have continued to expand my practice doing deformity, revision surgery, and infections. I love the challenge these cases provide and am very happy to be building such a practice.

 

What has been the progression of the equipment you use for surgery over the years?

Prior to fellowship, I had never used an O-Arm or StealthStation Navigation. I planned osteotomies cutting actual X-ray films and manually manipulating them. With time, I would use PowerPoint to achieve the same goal on digital images. We didn’t have an axis table, so we literally “cracked” the PSO and closed it by stressing the pedicle screws. Rods had to be manually bent, and this was considered a true “art” form in spine surgery. We now can use computer navigation with CT scans taken during the surgery.

We pre-plan and can place cages, plan osteotomies and pre-order a rod contoured to the patient. We can use machines to get full length X-rays and not have to rely on stitching or long cassettes. The Axis table allows us to control the osteotomy closure. We are light-years beyond where we used to be.

Can you talk to me about the the state of spine surgery and where it’s headed?

I’m a newer surgeon so I came in kind of late into the world of spine surgery, but for me the reason I got into spine surgery was because of the expansiveness of it all. There’s a lot that’s out there and it’s an open field. Spine surgery went from Harrington rod and hook constructs to pedicle screws and it really continues to grow. A lot of the interesting growth has really come around pedicle screws and deformity and realizing how to correct it and trying to do better as far as the patients are concerned.

 

How have innovations in the medical field affected patient care, especially around the spine?

In spine, it just seems like it’s always been the same with the use of fusions, and that’s the way we treat almost everything. But over time, as you see things like disc replacement becoming more commonplace in the lumbar and cervical spine, people are starting to try and figure out ways to advance it so we’re not just doing the same standard fusion. Now we are trying to look at how we can specifically treat each individual patient instead of looking at population medicine. We are looking at degenerative diseases in different ways and people are innovating with new devices. You can see that in the last five to ten years, interspinous devices and non-fusion devices are becoming more commonly used.

 

What can you say about your use of products from Medicrea?

The Medicrea [PASS LP]system is the first time I really ever saw a non-tulip pedicle screw system. During my training for deformity, I saw Medicrea being used, I saw DePuy Synthes and other competitors being used, but for me is it was amazing to see the usefulness of a non-tulip screw and the corrections we could get from that. To me, it was kind of a no-brainer. I felt like the system worked really well and that’s all I’ve used as far as my deformity practice is concerned and even in my degen practice now.

 

What is your surgeon workflow like when using a preoperative analysis through Medicrea and their patient-specific rods?

A preoperative analysis used to be on PowerPoint. So we used to take an image from a patient, I would cut it where I thought that the the osteotomy should go, and then rotate it and I’d look at the values on PowerPoint. And even before that, I remember cutting actual film. So you would take a film and cut it where you want the osteotomy, and then you would change it using a protractor and say “Alright that’s about a 30 degree osteotomy.” But with the advent of the new systems that are out there, we can do a lot more of this through the computer system and with digital imaging.  

But the thing that UNiD does is allow us to use our computer imaging or what we planned preoperatively and implement in the surgery. Not only do I have the ability to pre-plan, but now I have the UNiD rod that I can put into the patient and I can actually see that I’ve achieved the planned correction. I can actually match it up and in some ways it actually helps me in the surgery to really critically look at what I’m doing. It allows me to take the preoperative plan and actually have a physical way of checking it intraoperatively.

 

Where is there room for additional innovations to make your life easier as a surgeon?

I think it’s going to come back to patient-specific everything. Patient-specific surgery and being able to individualize the treatments. We often try and fit everybody into a few diagnostic categories and then we give them a surgery to fit that diagnostic category, and that can be a problem. Given time, I hope we find ways to regenerate disks and I hope we find ways to somehow reinvigorate facet joints that are degenerative. I don’t know if that’s gonna happen, but given time those are the things that we hope for.

“We often try and fit everybody into a few diagnostic categories and then we give them a surgery to fit that diagnostic category, and that can be a problem.”

What about the software side. Is there any opportunity for an app to streamline your process or your patient care?

Yeah – I think that medicine is going to become more global. We even see that here because we have telemedicine and we’re seeing patients through the camera and doing consults that way. If someone can upload an X-ray and I can look at it, then they don’t have to travel hundreds of miles to come see me, and  we can do a phone consult. That would be a big deal. The same thing can be done for the surgical planning. Even now, we’re already starting to do that. I do a preoperative plan on a computer system here, the images are then sent to one of Medicrea’s offices, and within a few days I get a rod back that I can put into the patient. We’re going to start seeing that more and more across medicine in general.

I think that’s going to continue to expand. And that will create jobs and opportunities for people. And in the long run I think that’s how we’ll end up doing medicine. I’ll get an image from somebody and I’ll talk to them over the phone and we can do a lot of this stuff without having to necessarily have the in-office visit that is kind of the establishment of medicine and has been over time.

 

Can you speak to other savings with this approach to surgery in terms of blood loss, time, and money?

We used to take straight rods and contour them to create 60 degrees of angulation across a large area. To actually make this rod fit my patient, I have to use manual force. This takes time in the operating room and it takes effort for me to actually bend this rod. Then I do multiple bends and, if it doesn’t fit, I have to go back to the table and bend it again.

This could take 30-45 minutes at the end of the case and that’s the time when everybody is the most tired. You’ve already done the entire surgery, but if you don’t get a rod that fits you’re gonna lose the correction. The patient may have a broken rod and they may not heal. There’s a lot that can happen so it’s an important part of the procedure. And at the end of our procedure using UNiD, I don’t have to worry about that. All I have to do now is set the rod in and ensure I’ve done the proper correction. It takes me five minutes now to put the set-caps in and then we’re done.

 

Wow. That’s a big difference.

It’s a peace of mind. We’ve gotten to the point where these rods fit perfectly. These rods almost go in without any effort and we’re not doing any real contouring anymore. Even when we first started with UNiD, we would do some recontouring of the rods and I think that was a lack of trust in ourselves and in our preoperative planning. We just weren’t quite ready for it but now at this point in time, I can’t remember the last rod that we recontoured. We’re putting these rods in and seeing the X-rays and the results are coming out just the way we wanted them to. It’s perfect.

I think if you handed patients the rods and said “Look, you can take this rod that is perfectly contoured to what the spine surgeon wants and is planned out for your back, or you can take this rod that is beat up and worn.” It’s kind of like saying “Look at two cars. Do you want the used car, or do you want the new car for the same price?” Everyone’s going to take the nice new car that looks good. And I think that we’re going to find out that not only does it look better, but it also works better.

 

What do your patients think about this type of technology?

I think it’s peace of mind for them as well. We talk to them about new technology because for patients it’s kind of a black box. I don’t think many of them know what happens. They just know that they go into surgery and come out with a bunch of screws and rods.

But for us to be able to tell them ”Look, we planned this out” and we can show them on the software the plan for their operation. So we’ll show them and say “This is the plan that we have for you. This is actually how we’re planning to fix your spine.” Now they know what to expect. They know this is the outcome and they know why I’m doing what I’m doing. I think that might be some of the reason for these patients to get back quicker. The happiest patients we have are the ones that we do these bigger deformity corrections on and I think it’s because we change their lives in a major way.

If the patient knows that the surgeon is confident, then I think that instills confidence in them. We’re almost like a coach to them afterwards. We can say “Look, your back is straighter and you’re looking great and the surgery went perfectly. We planned it and then we implemented the plan and we’re very happy with it. The outcome looks exactly like we planned it would look.” From a patient standpoint, that takes away the worry and the doubt.