Summer 2009
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Message from Stephanie West, Manager DePuy FUTURE LEADERS Program
Hello and welcome to another installment of the Future Leaders in Spine Surgery Newsletter! As always I hope you find this newsletter to be a valuable source of information.In this issue you will find an interesting clinical case presentation from Dr. Amer Samdani. Also, I had the opportunity to talk to Dr. David Shapiro from the Chicago area. We discussed his current clinical practice and how it’s changed as new technology becomes available.
New to this issue is a section with a focus on neurosurgery specifically, the importance of neuro-monitoring for traumatic brain injury authored by Dr. Geoffrey Manley and Dr. Guy Rosenthal from the University of California, San Francisco.
In regards to our educational activities this year, we recently held 3 FUTURE LEADERS educational programs. The “look back” section features highlights & photos from these meetings.
And finally a reminder to those of you who have submitted an abstract for the 2008-2009 DePuy Spine Clinical Research Paper Challenge, the deadline for full paper submissions is fast approaching! June 30, 2009 is the deadline.
I hope you enjoy this issue. To be a contributing author or to request content please feel free to contact me at any time. Swest03@its.jnj.com or 508 828-3680.
Best regards,
Stephanie
SECTION I: Case discussion: Minimally Invasive Surgery for Adolescent Spinal Deformity
Amer F. Samdani, MDShriner’s Hospital for Children, Philadelphia
Dr. Samdani is a pediatric spine surgeon at the Shriner’s Hospital for Children in Philadelphia, PA. He is treating many of his patients using a minimally invasive surgical approach. The following is a case study featuring the use of minimally invasive surgery to treat a severe spinal deformity.
History and Examination
WC is a 12-year-old girl who presented to our institution with a Lenke 1AN 72 degree curve. She had originally presented with a 35 degree curve at age 9. MRI revealed no intraspinal anomalies.
She progressed despite being braced in a TLSO for 16 hours/day. On physical examination her right shoulder was elevated, and on Adams forward bending test the inclinometer read 17 degrees. Neurological examination was within normal limits.
Radiographic Studies
Full length standing PA/lateral and bending films were obtained (Figure 1a-c). These demonstrated a right convex 72 degree curve from T5-L1, which bend down to 29 degrees.
Operative Treatment
The patient was brought to the operating room for a posterior spine fusion (PSF) utilizing a muscle sparing approach (Figure 2). After standard prep and drape, the fluoroscopy machine was used to plan a midline incision from T2-L2. The skin was opened sharply and undermined laterally maintaining fascial integrity. Under fluoroscopic guidance the Jamshidi needles were placed into the pedicle to a depth of 20 mm. This was done sequentially from L2-T2 bilaterally, skipping T4 on the right (Figure 3). Subsequently, guide wires were advanced with removal of the Jamshidi needles. At this point, the fluoroscopy machine was positioned for a lateral projection and a muscle protective sleeve passed over the guide wires. A cannulated awl was used to start the pedicle hole, followed by the appropriate size tap. At this point, each facet was visualized with a hand held retractor and the facets drilled with a high speed burr. Care was taken to ensure adequate decortication and the grafting material was placed. This consisted of a mixture of corticancellous chips, aspirated blood from the pedicle, and HEALOS
Bone Graft Replacement. Subsequently, the appropriate size pedicle screw was inserted and the guide wire removed. 
Curve correction and derotation was performed by the 'rod second' technique as described by Vallespir et al.1 In this technique, vertebral coplanar alignment is attained by first placing two rods through the tubes on the convexity. Controlled, forceful separation of the rods results in coronal and axial correction. Once, the correction was attained an appropriately sized cobalt chrome rod bent into the appropriate sagittal contour was introduced on the concavity. The rod was inserted through L2 and sequentially up. Tactile and visual feedback guides the passing of the rod through the tubes. Once all tubes were engaged, set screws were placed and the rod reduced using reduction instruments. The concave rod was turned into the appropriate sagittal plane, and the set screws tightened. In a similar manner the rod on the convexity of the curve was placed. Prior to placement of the convex rod, an en bloc derotation maneuver was performed. Intraoperative x-rays confirmed good correction and the wound was closed in a standard manner. Intraoperative blood loss was 250 cc. The patient was discharged home on postoperative day 5. Her two month standing PA/lateral x-rays demonstrate her correction (Figure 4a,b).
For the complete case report including references click on the following link SECTION I Amer Samdani's case report.pdf
SECTION II: ASK THE EXPERT - The Evolution of Fusion Technologies
Interview conducted by Stephanie West, DePuy Spine Manager, Medical Education
David E. Shapiro, MDIllinois Bone & Joint Institute
Dr. David Shapiro is a board-certified orthopaedic surgeon currently in private practice at the Illinois Bone & Joint Institute in Glenview, IL.
Interview conducted by Stephanie West, DePuy Spine, Manager, Medical Education
In this interview, Dr. Shapiro discusses how the evolution of fusion technologies has had an impact on his practice.
SW: How has the evolution of spinal fusion technologies and techniques affected your practice over the past 10 years?
DS: My indications for fusions have remained fairly constant over the past 10 years. The most common are spondylolisthesis, spinal stenosis with radiographic evidence of instability, recurrent disc herniation, stenosis and/or severe breakdown at a level adjacent to a previous fusion, and primary low back pain refractory to a year of conservative therapy.SW: How have these technologies benefited your patients?
I make extensive use of biologic products as graft replacements. Generally, I mill the bone removed during the laminectomy portion of the surgery, add it to cadaver cancellous chips, combine it with platelet rich plasma prepared by the SYMPHONYsystem, and add HEALOS
Whenever possible, I use interbody devices at each fusion level. I used to perform more ALIF's but as TLIF technology has improved, that has become my interbody fusion of choice. Recently, I started to perform more direct lateral fusions in patients where a TLIF is either inadvisable or too difficult, such as previously operated levels with extensive scarring or very small spinal canals. I have also begun to use the direct lateral approach in scoliosis surgery.
Finally, over the past year, I have switched almost entirely to 6.35 mm EXPEDIUM
DS: Comparing the outcomes for both primary surgery and revision/secondary surgery patients who received PEEK vs. titanium rod implants - my PEEK patients (105) have markedly decreased postoperative pain in the short term which I attribute to the improved load sharing of the PEEK constructs. They were driving within 1-2 weeks, and were out of their braces within 4-6 weeks. Most were taking no pain medication other than TylenolSW: What are some of the key things you tell your patients when educating them about new spinal implant technologies such as PEEK rods?
8 of my patients have had previous fusions with titanium rod implants and were then converted to PEEK implants after developing adjacent level breakdown with stenosis. Without exception, all found the experience with PEEK instrumentation superior, for all of the reasons outlined above.
DS: I explain to my patients the material characteristics and potential benefits of load sharing or flexible rod fusion constructs and what they can expect regarding post-op pain and return to life, etc. I tell them that PEEK rods may help reduce post-operative pain due to 5 the reduced load that the rod places on the screw. The implants rarely have to come out due to residual pain. Not only that, I have achieved excellent fusion rates with them.SW: How do you think the use of PEEK rods will change your practice moving forward?
DS: I suspect I will eventually move from 6.35 mm to 5.5 mm rod constructs. I like the idea of using the PEEK system in a percutaneous surgical approach. I recently used the VIPER
SECTION III: A Look Ahead – Upcoming Education / Events
For a complete look at the 2009 educational calendar please click on the following link:http://onlinespinecenter.com/ee/EducationEvents/CalendarofEvents/tabid/177/Default.aspx
*For more information regarding DePuy Spine Medical Education events please contact the DePuy Spine Medical Education department at 1-800-741-8075 or visit our website at www.onlinespinecenter.com/ee
SECTION III.I: A look "back": 2009 FUTURE LEADERS Educational events
2009 DePuy Spine Fellows Spinal Deformity Summit: 1st annual meetingFebruary 6-7, 2009 Las Vegas, NV
Chairmen: Munish Gupta, MD & Nathan Lebwohl, MD
This past February the DePuy Spine Medical Education department hosted the 1st annual Spinal Deformity Summit at the Science Care facility in Las Vegas, NV.
This program was offered to current spine fellows preparing to complete their fellowship this summer. Most of the attendees of this program had participated in the past FUTURE LEADERS educational programs starting with the 2008 Pre-fellowship Bioskills workshop.
This goal of this program was to offer spine fellows the chance to learn surgical techniques in the area of adolescent idiopathic scoliosis and adult scoliosis. This course is an introductory training program designed to expose fellows to new treatment options for their patients with spinal deformities. Time was also set aside to cover topics related to socio-economic considerations including, contract negotiations with potential employers and billing and coding.
March 5-7, 2009 Miami, FL
Chairmen: Professor Alan Crockard, Robert Heary, MD, Brian Hoh, MD, Stephen Lewis, MD & Michael Wang, MD
The 5th annual Neurosurgery Residents Education Summit was held on March 5-7, 2009 in Miami, FL. This year, 72 chief and senior neurosurgery residents attended the 2-day summit taught by 36 faculty including 5 chairmen.
In prior years the Summit was limited to solely spinal surgery education. For the first time in 2009 the Summit included didactic and laboratory sessions covering both spinal and neurovascular surgical techniques. As in past years, topics related to practice management were also presented and well received.
To read the full article please click on the following link: SECTION III.I - NeuroRes Summit09FINAL.pdf
2009 DePuy Spine Pre-fellowship Bioskills Workshop: 6th annual meeting
May 15-16 & May 17-18, 2009 Denver, CO
Chairmen: Carl Lauryssen, MD & Nathan Lebwohl
The 6th annual DePuy Spine Pre-fellowship Bioskills Workshop was held in 2 sessions back-to-back the weekend of May 15-18, 2009.
This program is designed to assist residents preparing to enter into a spine fellowship program with the transition. The faculty consists of fellowship directors from key institutions around the country. Many of the participants had the opportunity to work directly with their fellowship instructor prior to starting their fellowship.
The course was attended in total by 50 incoming fellows and 25 faculty instructors. The course curriculum focused on the anatomy of the spine as well surgical techniques for anterior and posterior spine instrumentation.
Upcoming FUTURE LEADERS Educational Programming:
2009 Advanced Concepts in Spine Arthroplasty and Minimally Invasive Surgery
August 29-30, 2009 Chicago, IL
Chairmen: Richard Guyer, MD, Nathan Lebwohl, MD & Michael Wang, MD
2009 Skills in Neurosurgery
October 2-3, 2009 Phoenix, AZ
Chairmen: Randall Porter, MD & Nicholas Theodore, MD
For more information about these programs please contact Stephanie West in the DePuy Spine Medical Education department.
SECTION IV: Neurosurgery Focus
Guy Rosenthal, MD and Geoffrey T. Manley, MD, PhD
Department of Neurosurgery, University of California, San Francisco
Geoffrey T. Manley, MD, PhD is the Chief of Neurosurgery at San Francisco General Hospital and Professor of Neurosurgery at the University of California San Francisco (UCSF). He is a trauma neurosurgeon with clinical interests in brain injury, spinal cord injury and neurocritical critical care. His translational research interests span from the laboratory to the bedside.
Guy Rosenthal, MD is a clinical instructor and neurosurgical fellow at the University of California San Francisco (UCSF).
The following is a case report authored by Dr. Rosenthal and Dr. Manley discussing the importance and the advances in neuromonitoring in patients who have suffered a severe traumatic brain injury.
Overview
Traumatic brain injury (TBI) remains a leading cause of death in young people. Monitoring and treating raised intracranial pressure following TBI is currently the main goal of therapeutic strategies in these patients. However, preventing secondary brain injury also requires ensuring adequate cerebral perfusion and oxygenation to the injured brain. In recent years our bedside cerebral monitoring capabilities in the Neurointensive Care Unit have progressed considerably. The recently revised Guidelines for the Management of Traumatic Brain Injury published by the Brain Trauma Foundation contain new recommendations that reflect these developments in Advanced Neuromonitoring. Previous editions of the Guidelines recommended maintaining CPP greater than 60 mm Hg in all adult severe TBI patients. Recent evidence suggests that patients with impaired autoregulation may have better outcomes when cerebral perfusion pressure (CPP) is maintained at lower levels (50-60 mmHg) compared with patients in whom autoregulation is intact, where higher CPP values (60-70 mmHg) are associated with improved outcome3. The newly-revised Brain Trauma Foundation Guidelines for the Treatment of Severe Traumatic Brain Injury incorporate the concept of differential CPP goals based on autoregulatory status1. The ability to assess cerebral autoregulation in severe TBI patients at bedside by a simple clinical test is thus becoming an important goal that can influence clinical care. The revised Guidelines indicate that Advanced Neuromonitoring can serve as an important adjunct in optimizing care in individual patients following severe TBI, suggesting monitoring of cerebral blood flow, oxygenation or metabolism to facilitate CPP management1. They also point out that Advanced Neuromonitoring can be useful when hyperventilation is employed as a therapeutic measure to treat elevated ICP2.
At San Francisco General Hospital we incorporate Advanced Neuromonitoring as part of our routine monitoring protocol of severe TBI patients. In addition to ICP monitoring, patients are typically monitored with a Licox brain tissue oxygen tension (PbtO2) monitor, a jugular venous bulb monitor, and a HEMEDEX
Cerebral Blood Flow (CBF) monitor. Part of our monitoring protocol involves performing bedside mean arterial pressure (MAP) challenges in severe TBI patients to assess cerebral autoregulation. When cerebral autoregulation is intact relatively large changes in mean arterial pressure do not lead to significant changes in cerebral blood flow. However, in some patients with brain injury cerebral autoregulation is disturbed. These patients are “pressure passive”, meaning that increases in MAP may lead to increased CBF, and conversely, a drop in MAP may lead to decreased CBF. Knowing whether an individual patient has intact cerebral autoregulation or is “pressure passive” can influence therapy. The new Guidelines for the Management of Severe TBI recommend a CPP goal of 50-70 mmHg and indicate that patients who have intact cerebral autoregulation will tolerate higher CPP values (up to 70 mmHg), while patients in whom autoregulation is impaired a lower CPP goal is appropriate (50-60 mmHg). In order to determine which patients have intact cerebral autoregulation and which patients do not, we initiate a controlled rise in MAP with a phenylephrine drip ("pressure challenge"). Our goal is to slowly raise MAP by 10-15 mmHg over a period of 10-20 minutes while monitoring CBF, ICP, and brain oxygenation. We closely monitor any changes in cerebral blood flow, ICP, and PbtO2 as MAP increases during the challenge. Patients with intact autoregulation will typically have only minimal changes in CBF, ICP, and PbtO2 during the MAP challenge. In contrast, those patients with impaired cerebral autoregulation respond with increased CBF and ICP as MAP rises. To read an illustrative case describing how the authors used the information derived from a pressure challenge in clinical care.
For Clinical Case Click Here
Section V: Must Read Clinical Articles
To obtain a free copy of these articles simply click on the link below.Costs and state-specific rates of thoracic and lumbar vertebroplasty, 2001-2005 Gray, et al. SPINE 33:17, 1905-1912 2008
http://delivery.sheridan.com/downloads/mobile/LWW_143929_CP.exe
Sterility of c-arm fluoroscopy during spinal surgery Biswas, et al SPINE 33:17 1913-1917 2008
http://delivery.sheridan.com/downloads/mobile/LWW_143932_CP.exe
How accurately do novice surgeons place thoracic pedicle screws with the free-hand technique? Bergeson, et al SPINE 33:15 E501-E507 2008
http://delivery.sheridan.com/downloads/mobile/LWW_143931_CP.exe
SECTION VI: DePuy Spine in the Journals
As part of our commitment to further the clinical evidence in the spine community, we are proud to offer the following clinical research articles that further support the use of our products. To obtain a free copy of these articles simply click on the link below.Minimally Invasive Posterior Fixation Wang, et al. NEUROSURGERY 63:A197-A203, 2008
http://delivery.sheridan.com/downloads/mobile/LWW_152051_CP.exe
Mini-open removal of extradural foraminal tumors of the lumbar spine Lu, D. et al. J Neurosurg Spine 10:46-50, 2009.>
http://delivery.sheridan.com/downloads/mobile/JNS_151787_CP.exe
Biomechanical evaluation and comparison of polyetheretherketone rod system to traditional titanium rod fixation Ponnappan, et al. The Spine Journal 9: 263-267, 2009.
http://delivery.sheridan.com/downloads/mobile/ELS_151849_CP.exe
Section VII: DePuy Spine News
HEALOS Fx
In April DePuy Spine, Inc. announced the launch of HEALOS Fx Injectable Bone Graft Replacement, the company’s first bone graft solution designed specifically for minimally invasive spine surgery (MIS).
HEALOS Fx Injectable Bone Graft Replacement is DePuy Spine’s next generation HEALOS product. A moldable and injectable material based on the proven HEALOS technology, HEALOS Fx meets the clinical demand for a versatile, easy to use bone graft replacement and is specifically designed for use in minimally invasive procedures. HEALOS Fx is osteoconductive and becomes osteogenic with the addition of autologous bone marrow aspirate (BMA). The cohesive consistency of the BMA saturated graft material provides a continuous scaffold for bone formation and the osteoprogenitor cells necessary for initiating new bone growth. In under a minute, the HEALOS Fx Graft Mixing and Delivery System allows for seamless mixing and cannula extrusion of the ready-to-use fibrous material with BMA. The HEALOS platform technologies are designed using proprietary nanotechnology which enables osteoprogenitor cell attachment and maturation. HEALOS Bone Graft Replacement has been implanted in over 65,000 patients nationwide and is supported by peer-reviewed publications demonstrating clinical fusion results comparable to autograft.HEALOS Fx is compatible with DePuy Spine’s minimally invasive VIPER™2 Pedicle Screw Fixation System and can also be used with the LifeNet Health
VERTIGRAFT portfolio of interbody spacers.Education Update
THE DEPUY INSTITUTEThe DePuy companies continue to make great strides with the construction of the new state-of-the-art DePuy Institute. Scheduled to open this year, the institute will provide opportunities for health professionals to learn about new techniques, technologies and best practices.
The 70,000-squarefoot DePuy Institute, the largest center of its kind in the Northeast, will act as the global training, education and research hub for pathologies, conditions and treatments across a continuum of spine, orthopaedic, sports medicine/soft tissue repair and neurosciences.
The DePuy Institute will offer presentations, displays and hands-on learning activities and will host programs that connect health professionals including surgeons, physicians, researchers, and hospital administrators to share best practices that advance patient care and increase value. The institute will also have interactive video conferencing capability that will connect people from all over the world and an advanced rapid prototyping center that can create prototypes during a surgeon’s visit.
Q&A with Diana Bacci-WalshWorldwide Vice President of Professional Education, DePuy, Inc.
With a brand new facility, state-of-the-art educational tools and technology and a world-class faculty, the DePuy Institute is poised to become a global resource for the health care community. Diana Bacci-Walsh expands on the pivotal role the new institute will play in spine and beyond.
Q: What is the primary goal of the DePuy Institute?
A: We are committed to providing members of the health care community with world-class educational and training resources and with new opportunities to share knowledge about best practices and optimal patient outcomes. By bringing together major resources from all DePuy companies across the continuum of care, we are in a great position to provide true value and innovation to the spinal community and their peers in other disciplines.Q: How will spinal care fit into the DePuy Institute?
A: New spine technologies are emerging in aging spine, interbody fusion, and deformity and the spine community needs the tools and techniques to optimize patient outcomes. Hands-on training, education and research are the cornerstone of success inside and outside the operating room. In addition, visitors from the spine community will have opportunities for collaboration with peers inside and outside their specialty. We also want visitors to get a glimpse inside our company so that we can show them our approach to product development and our serious commitment to education and patient care. The company behind the products and solutions is as important as the products and solutions themselves.
Q: What about the DePuy Institute excites you the most?
A: There are many things, but I think we are most excited about the world-class faculty that will teach at the DePuy Institute and the health professionals who will visit us for courses, lectures and other unique learning opportunities. It’s always about the people.
Section VIII: Practice Nuances
To Earn a Bonus the Business Office Must Work as Hard as You AreSteve Gillies, KarenZupko & Associates, Inc.
Reimbursements are declining and medical debt is rising. Many patients are losing their jobs, and consequently their insurance. Providing top quality of care and having a more-than-full schedule isn't enough anymore. In order to deal with today's economic realities, you need a top-notch staff and systems to ensure that your work is being paid for. You need your business office to work just as hard as you do.
Many practices think reimbursement begins and ends in the Billing and Collection departments. This mistaken attitude wastes staff time fixing errors that could have been corrected at the reception desk. Instead, use an integrated approach to reimbursement management with all areas of your office work together. This starts in reception. A proactive front desk can strengthen billing and collections in several ways.
To read the entire article please click on the following link SECTION VII Practice Nuances.pdf
DePuy Spine does not endorse or recommend practice management firms. Physicians should research practice management consulting options before choosing one to work with.
SECTION X: Spine Case Challenge #6
Case provided by Dr. Faissal Albanna, Des Peres Hospital, St. Louis, MO.
To take part in the spine case challenge please read the case and answer the multiple choice questions below. Participants who answer the questions correctly will be eligible to receive an educational item. Please submit answers to Stephanie West via email.
Deadline for responses July 31, 2009
Case overview
Patient BM is a 30 year old banker. Cannot sit and has had low back pain for several months. He is in good physical condition and is a non–smoker but he cannot meet the activities of daily living. BM presents with back pain, right buttock pain and right lower extremity radiating pain.
Decreased range of motion lumbar sacral spine, flexion and extension associated with pain. Positive straight leg raising test right lower extremity 30 degrees and left lower extremity 60 degrees. Full range of motion on lateral bending and lateral rotation. No response to physical therapy or non-steroidal anti-inflammatories. No response to three epidural steroid injection treatments.
Refuses to undergo any further conservative modalities. MRI of Lumbar-Sacral Spine shows disc degeneration and annular tears L4-L5, moderate disc herniation L4-L5, no lateralization. Mild degree of central stenosis L4-L5 with mild to moderate lateral recesses L4-L5.
Questions:
1. Patient treatment options?
a. observation and monitor care, with no additional treatment2. Assuming surgical options selected and agreed upon by patient, surgical intervention is?
b. pain management
c. minimally invasive microdiscectomy
d. lumbar fusion with or without decompression
a. posterior lumbar interbody fusion with instrumentation3. If a Posterior Lumbar Interbody Fusion or Transforaminal Interbody Fusion was selected, would your approach include?
b. anterior lumbar interbody fusion with or without posterior instrumentation
c. lumbar decompression
d. both a and c
a. lumbar decompression (ie. laminectomy) with lateral fusion, with pedicle screw fixation4. If Anterior Lumbar Interbody Fusion selected, would you combine this with the following?
b. instrumentation using Steffee plate with or without lateral fusion
c. instrumentation using rods with or without lateral fusion
d. non-instrumented lateral fusion
a. stand alone, no further procedures5. Should an open procedure be decided on this patient, Posterior Lumbar Interbody Fusion or Transforaminal Lumbar Interbody Fusion, which of the following additional steps would you include?
b. posterior instrumentation using minimally invasive approach
c. posterior instrumentation, open approach
d. none of the above
a. lateral fusion with pedicle screws and Steffee plates
b. lateral fusion with pedicle screws and PEEK rods
c. lateral fusion with pedicle screws and titanium rods
d. none of the above
Answers to the Spine Case Challenge #5
The patient is an 89-year-old male with a longstanding history of mild, chronic, low back pain. There is no history of radiculopathy, weakness, bowel or bladder dysfunction. His only other medical problem is coronary artery disease.
1. The most likely diagnosis is:
a) lymphoma of L4
b) metastatic prostate adenocarcinoma
***c) Paget's disease L4 (correct answer)
d) hemangioma L4
2.Classic radiographic findings of Paget's disease affecting the spine include:
a) vertebral enlargement
b) picture window appearance of vertebral body
c) ivory vertebra
***d) all of the above (correct answer)
3. Differential diagnosis of ivory vertebra includes:
a) hemangioma
b) osteosarcoma
c) metastatic Carcinoma of the prostate
d) lymphoma
***e) all of the above (correct answer)
4. Neurologic deficit in Paget's disease may be due to:
a) arterial steal syndrome
b) spinal stenosis
c) platybasia
***d) all of the above (correct answer)
References: Hadjipavlou A.G. et all Paget's disease of the spine and its management, Eur Spine J. 10:370-84 (2001)
Download File - http://delivery.sheridan.com/downloads/mobile/LWW_140628_CP.exe
Winners of Spine Case Challenge #5
Congratulations to:• Howard Levene, MD, PhD, Miami, FL
• Kamran Majid, MD, York, PA
• Avraam Ploumis, MD Thessaloniki, Greece
• Rakan Shahaltough, MD, Amman Jordan
• Modar Samara, MD, Amman Jordan
Submit a case! Would you like one of your cases to be featured in next quarter’s issue of the Future Leaders E-Communication? Please submit your case to Stephanie West with the DePuy Spine Medical Education Department. Stephanie can be reached at 508 828-3680.
Is there something clinically relevant or practice related that you would like to us to add to the next edition of this communication? Submit your ideas to Stephanie .
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