Clinical Expert Talks: Multitom Rax through the eyes of a spine surgeon

My name is Christophe Bilkenmeyer. I'm 59 years old. I'm a spine surgeon by training. I'm a general, an orthopedic, and a trauma surgeon, and I have dedicated the last 25 years of my life to treat spinal disease and mostly spinal deformity. I have a strong interest in scoliosis and in adult deformity and because that is so, I'm also very passionate about high quality imaging and the possibilities that we have nowadays with full body imaging. I think pertaining to adolescents, they typically come with an adult and so it's not only building a relationship with the patient but also with the parent. I try to work in two tiers. One is to best understand what the medical problem is or is there a medical problem? Do I need to recommend a certain treatment or is everything optional? That's a medical analysis based on history, age, different factors, imaging. Sometimes we need hand and wrist radiographs to determine like skeletal age, etcetera. And then the other aspect of it is what are the expectations, what are the fears, what are the desires and the hang ups possibly of the family and, and what can, what can they support? I would like to believe that it's because patient and parent get a sense that we really, really care and that we are adequately equipped and adequately skilled and we have an interest in taking care of them so that they have enough trust to not just be a number and not just be another surgical notch on, you know somebody's bulletin board. I think there is two major aspects that I would like to point out. One is that with the increased knowledge about sagittal alignment and satchel balance with adult deformity, we have also understood that these principles apply to scoliosis analysis and scoliosis surgery just as well. So the sagittal plane analysis has become increasingly important when we indicate for and when we perform surgical treatment for idiopathic adolescent scoliosis. And more recently the renewed attempt to use non fusion treatments to control scoliosis is probably the most exciting topic right now. So currently these treatments are only on label for juveniles who still have growth potential and we are still struggling with shortcomings of the implants and failures and increased revision rates. But fact of the matter is that there is promise that certain very flexible curves may be controlled more or less by means of a surgically implanted brace. So rather than wearing a brace, you would have a screw and rope construct built in which would control the scoliosis curve and which would direct the remaining growth in order to compensate for the mist growth or for the for the asymmetric growth which is associated with a scoliosis. So I think vertebral body tethering and flexible anterior scoliosis surgery is probably the most controversial and most vividly discussed topic in both ways. What has become a lot more complex is the imaging analysis of Scholastic curve to better understand the three dimensionality of what we have to assess the flexibility or rather rigidity of every curve and to understand the natural progression that would be associated with any particular curve. So that we can best decide whether someone requires surgery, what kind of surgery anterior, posterior and which should be the upper and the lower instrumented vertebra. And that again ties in with what we nowadays understand about sagittal spinal pelvic balance. Because even though most scoliosis fusions are successful and uncomplicated in the short term, there is a significant amount of long term problems with proximal junctional kyphosis and even sometimes distal adding on. Which means if you have a very immature skeleton and you correct and fuse the spine, but growth continues, you may actually have an add on curve at the bottom of what you have operated on. And so many of the risk factors which are associated with these undesired outcomes have to do with the correct analysis of the curve, which is why imaging is the key ingredients to all we do. I think most important is the education of the surgeons the next generation, because at the end of the day, the the factors which tie in with optimally indicating and operating on a scoliosis curve is to understand as many of the contributing factors as possible. Obviously fully understanding that we always will be short in understanding what is the true complexity of it, but to understand as many of the important factors as we can and to learn to learn to think in a in a three-dimensional way is a big step. And so the imaging may not actually be necessarily have to be there in the operating room, But when we look at the three-dimensional imaging and then look at the human who belongs to the image, we would probably be able to translate and to to form a surgical LAN, which would be more individual and more optimal for a desired outcome. Precise diagnostic imaging is key to me because I'm trying to be as precise as reasonably possible in indication and treatment of my patients and I can only be as good as the images I work with. And so for example, stitched images, they have a lot of risk of artefacts or stitching mistakes. And I know that because I've, I've worked with a number of different radiographic systems in different institutions. And more often than not, I ended up sitting down with a radiologist and say, you know, I believe there's a vertebra missing here. And it can happen. It can happen when the the automated stitching algorithm for whatever reason, is not perfect and there never are, and you don't catch it and you get an image. And sometimes you have T11 missing, or you have an offset of a vertebra by 1 centimeter with a little slight double image that you don't even notice if you just quickly superficially measure your angles. And so imagine that you have a daughter 15 years old, almost skeletally mature, but she has a 45° thoracic curve. If that is the case and if that's truly a 45° thoracic curve, I would have to actually recommend the corrective surgery. If the curve is only 38°, we may decide otherwise and we may choose an Ave. of treatment which is non operative so that the potential, the potential differences in medical decision making are sometimes enormous based on just a few degrees difference in what you measure. Now we already know that when you take an image and you measure it two or three times on different days, you would have like plus -3 to 4° which is the margin of error just to your measurement. But if you have a missing vertebra or if you have like a 2 centimetres offset in a stitching mistake, you would be off maybe by 10 by 10°. And it could mean that someone who needs a surgery will not be recommended to have one or the other way around. And so the a slot scanning image by means of the underlying technology rules out stitching compromise, has other has other potential influence factors for artifacts, but the stitching mistakes are basically not possible. While slot scanning technology certainly makes me makes me feel a lot more confident about what I'm analysing from the images I'm working with. And in that sense, yes, at the end of the day, even though we treat the patient and not the image, there is many situations where an image makes all the difference between surgery or not or about what kind of surgery somebody should have or should not have. And once we come to that point, we want the best possible image. And the avoidance of potential stitching errors is just one aspect. The other issue that you have with conventional radiography is cone beam distortion. Especially towards the ends of an image you may have considerable cone beam distortion or you could end up with an evaluate projection of a vertebral endplate which really should be like more aligned, which then again influences your measuring accuracy on the X-ray. So basically if you have a tall person and you take a stitched image, you will have like 3 segments of cone beam distortion which are fused in an sometimes imperfect way. Whereas if you take a have a slot scanning technology you can image the region of interests if need be, the whole body in a distortion free manner. At least in the vertical axis it would be physically distortion free and in the horizontal axis you can typically control for the fan beam distortion by means of an algorithm. So those are the two aspects why I think for those applications that we've been talking about, slot scanning technology is simply suerior and that's why I would always want to have a slot scanner available for those decisions. I think when you take pride in your work and if you're passionate about your work, it's not about images and paper, but you, you want to know how the images are acquired. Sometimes you want to know why the image doesn't look the way you expected it to be looking. And so that that's how you enter the conversation. And and then when we want to push the limits of what a device can offer, we need to work together. We need to actually tweak the machine, see what we can do and see what we can get out of it. For one, it's just a matter of purposefulness to get the most of what we have. And the second is also the the professional exchange. Because a written report is all fine, but if you don't agree what is the lower end vertebra, what's the typical torque of a vertebra, then the written report may be not useful to you. I think for spine surgeons, imaging is so important and maybe in terms of radio graphic equipment, our understanding is good enough so that we can participate in the conversation. So in, in the setting that we have, we have many specialities who need imaging, advanced imaging. It's not, it's not all about spine, even though I wish it was, you know, so, but it's about lower extremity, it's about arthroplasty, it's about sitting standing, it's about trauma. It's about 3D reconstructions in our setting. I see that the Multi Tom is a formidable compromise that satisfies most of what most people want. But yes, I would certainly try and stress that any radio graphic equipment which is installed nowadays needs to be capable of not only full spine but full body images. So it's not just about the physical equipment, it's also we need the software to run it and to get the most out of the equipment. Especially for adult deformity, it's immensely important to be able to to fully image a standing human because with adult deformity we typically compensate without pelvis and with our legs. And if you don't see that, you can very often not fully understand the spine if you don't see what's below the spine. So that's important, yeah. As low as reasonably possible, yes, I think the biggest, the biggest factor in dose reduction is the image you don't take. So that is key. And I think it takes a lot of experience and responsibility to decide when somebody does not take an image because we are so curious. We'd we'd like to image everybody all day long because we want to see those images and wanted to talk about them and discuss. So we have to also control our own curiosity and then say, well, OK, I guess we do not need another image today. Or we can do with only one plane or we can do with a limited view. But at the end of the day, when it is about juveniles, children or when it is a treatment modality that we know requires long term radio graphic follow up, for example with flexible, flexible scoliosis correction, the it's not, it's not like with the fusion then when you have a two years image and everything is fine, you can release them back into humanity. You need to follow them and they need imaging maybe every year. And so at that point those becomes much more important. And so when we when we have very young kids or when we have people that we know will be followed up radio graphically for many years of their of their coming life, that's when those reduction is, is very important. That that's when that's when also like slot scanning technologies, new detectors and, you know, other technology becomes more important.

Multitom Rax through the eyes of a spine surgeon ARTEMED KLINIKUM MÜNCHEN SÜD My name is Christof Birkenmaier. I'm 59 years old. Prof. Dr. Christof Birkenmaier Chief of Spine Surgery and the Scoliosis Speciality Clinic, Artemed Hospital Munich South I'm a spine surgeon by training. I'm a general -, an orthopedic- and a trauma surgeon. And I have dedicated the last 25 years of my life to treat spinal disease and mostly spinal deformity. he I have a strong interest in scoliosis and in adult deformity. Study ID 5aac707 And therefore, I'm very passionate about high-quality imaging and the possibilities that we have nowadays with full body imaging. How do you enhance the patient experience? HUMAN SKELETON I think pertaining to adolescents, they typically come with an adult. Therefore, it's not only building a relationship with the patient, but also with the parent. I try to work in two tiers. First tier is to best understand what the medical problem is. Is there a medical problem? Do I need to recommend a certain treatment or is everything optional? That's the medical analysis based on history, age, and many different factors. Study ID 5aac619 Sometimes in imaging we need wrist and hand radiographs to determine skeletal age etc. And then the other tier is the human aspect: what are the expectations, what are the fears, what are these desires and concerns of the family and how can they support. I would like to believe that the patient and parent get a sense that we really care and that we are adequately equipped and adequately skilled. And that we have an interest in taking care of them, that they have enough trust and do not think that they are just a number and not just be another surgical notch on somebody's bulletin board. What progress has been made in the surgical treatment of scoliosis patients over the last six decades? ARTEMED KLINIKUN MUNCHEN SUD I think there are two major aspects that I would like to point out. One is, that with the increased knowledge about sagittal alignment and sagittal balance with adult deformity, Sagittal alignment Sagittal balance we have also understood that these principles apply to scoliosis analysis and scoliosis surgery as well. Thus, the sagittal plain analysis has become increasingly important when we indicate and perform surgical treatment for idiopathic adolescent scoliosis. And more recently, the renewed attempt to use non-fusion treatments Non-fusion treatments to control scoliosis is probably the most exciting topic right now. Could you provide more information about these non-fusion treatments for the spine? Currently, these treatments are only officially approved for use in juveniles who still have the potential to growth . We are still struggling with shortcomings of the implants and failures and increased revision rates. But, fact of the matter is, that there is promise that certain very flexible curves may be controlled by means of a surgically implanted brace. Rather than wearing a brace, you would have a screw and rope construct built in which would control the scoliosis curve and would direct the remaining growth, in order to compensate for the misgrowth or asymmetric growth, which is associated with a scoliosis. What are the current trending topics in spine surgery? I think vertebral body tethering and flexible anterior scoliosis surgery Vertebral body tethering Flexible anterior scoliosis surgery are probably the most controversial and most vividly discussed topics. What has become a lot more complex is the imaging analysis of scoliotic curve, Study ID 5aaf546 to better understand the three-dimensionality. To assess the flexibility or rather rigidity of every curve and to understand the natural progression that would be associated with any particular curve, in order to best decide whether someone requires surgery. And for example, what kind of surgery? Anterior, posterior? And which should be the upper and the lower instrumented vertebra. And that again ties in with what we nowadays understand about sagittal spinal pelvic balance. Because even though most scoliosis fusions are successful and uncomplicated in the short-term, there is a significant amount of long term problems with proximal junctional kyphosis. And even sometimes distal adding-on, which means if you have a very immature skeleton and you correct and fuse the spine, but growth continues, you may actually have an add on curve at the bottom of what you have operated on. Many of the risk factors that are associated with these undesired outcomes have to do with the correct analysis of the curve, which is why imaging is the key ingredient to all we do. SIEMENS Healthineers How does Artemed maintain its knowledge of the newest trends and advancements in diagnostic imaging? I think most important is the education for surgeons of the next generation. Because at the end of the day, the factors which tie in with optimally indicating and operating on a scoliosis curve, are to understand as many of them as possible. Obviously, we always will be short in understanding what the true complexity of it is. But to understand as many of the important factors as we can and to learn to think in a three-dimensional way is a big step. Therefore, the imaging may not necessarily have to be there in the operating room. But when we look at the three-dimensional imaging and then look at the patient who belongs to the image, ARTEMED KLINIKU we would probably be able to translate and to form a surgical plan, which would be more individual and more optimal for a desired outcome. How crucial is accuracy and precision in the field of diagnostic imaging? Precise diagnostic imaging is key, because I'm trying to be as precise as reasonably possible, in indication and treatment of my patients. And I can only be as good as the images I work with. For example, stitched images have a lot of risk of artefacts or stitching mistakes. Study ID 5aad375 5aad373 And I know that, because I've worked with a number of different radiographic systems in different institutions. Study ID 5aad373 And more often, I had to sit down with the radiologist and say: "I believe there's a vertebra missing here." Saad373 And it can happen when the automated stitching algorithm is not perfect. They never are. And then you don't catch it. Sometimes, you would get an image with a T11 missing, or you would have an offset of a vertebra by one centimeter with a slight double image, that you don't even notice if you just quickly superficially measure your angles. For example, let's imagine that you have a daughter of 15 years old, almost skeletally mature, but she has a 45 degrees thoracic curve. If that is the case, and if that's truly a 45-degree thoracic curve, I would actually have recommended a corrective surgery. If the curve would be only 38 degrees, we would decide otherwise. And we would choose an avenue of treatment which is non-operative. The potential differences in medical decision-making are sometimes enormous, based on just a few degrees difference in what you measure. We already know that when you take an image, and you measure two or three times, on different days, you would have a difference plus minus three to four degrees, which is the margin of error, just of your measurement. But if you have a missing vertebra or if you have a two-centimeter offset in a stitching mistake, you would be off maybe by ten degrees. It could mean that someone who needs surgery, will not be recommended to have one, or the other way around. Therefore, a slotscanning image, by means of the underlying technology, rules out stitching compromises. EN SÜD It has other potential influence factors for artifacts. But the stitching mistakes are basically not possible. In your view, what are the key distinctions between conventional radiography and slotscanning? Slotscanning technology makes me certainly feel a lot more confident about what I'm analyzing from the images. In that sense, at the end of the day, we treat the patient and not the image. There are many situations where an image makes all the difference between having surgery, or not having surgery. Or about what kind of surgery somebody should have or should not have. And once we've come to that point, we want the best possible image. And the avoidance of potential stitching errors is just one aspect. The other issue that you have with conventional radiography, is cone-beam distortion. Especially towards the ends of an image, you may have considerable cone-beam distortion. Or you could end up with an oval projection of a vertebral in plane, which really should be more a line, which then influences your measuring accuracy on the x-ray. Basically, if you have a tall person, and you take a stitched image, you will have three segments of cone-beam distortion, which are fused in an imperfect way. Whereas, if you have a slotscanning technology, you can image the region of interest, if needed the whole body, in a distortion free manner. At least in the vertical axis, it would physically be distortion free. And in the horizontal axis, you can typically control for the fan beam distortion, by means of an algorithm. KL Those are the two aspects, why I think for those applications that we've been talking about, slotscanning technology is simply superior. And that's why I would always want a slotscanner available for those decisions. What motivates you to delve deeper into the technical aspects of imaging, beyond just the final images and reports? Well, I think when you take pride in your work and if you're passionate about your work, it's not about images and paper, but you want to know how the images are acquired. Sometimes you want to know why the image doesn't look the way you expected it to be looking. And so that's how you enter the conversation. And then when we want to push the limits of what a device can offer, we need to work together. We need to actually tweak the machine, see what we can do and see what we can get out of it. It's for one, it's just a matter of purposefulness, to get the most of what we have. And the second is also the professional exchange, because a written report is all fine. C. But if you don't agree, what is the lower end vertebra? What's the apical torque of a vertebra? Then the written report may be not useful to you. KUM Then the written Can you elaborate on the importance of imaging in spine surgery and how Multitom Rax fits into the needs of your hospital? I think for spine surgeons, imaging is so important. And maybe in terms of radiographic equipment, our understanding is good enough to participate in the conversation. In our setting, we have many specialties that need advanced imaging. It's not all about spine, even though I wish it was, but it's also about lower extremity, it's about arthroplasty, STOP STO it's about sitting and standing. It's about trauma. It's about 3D reconstructions. At our setting, I see that Multitom Rax is a formidable compromise that satisfies the majority of what most people want. CAUTION But I would certainly try and stress that any radiographic equipment, which is installed nowadays needs to be capable of not only full spine, but full body images. It's not just about the physical equipment, we need the software to run it and to get the most out of the equipment. Especially for adult deformity, it's immensely important to be able to fully image a standing human because with adult deformity, we typically compensate with our pelvis and with our legs and if you don't see that, you can very often not fully understand the spine if you don't see what's below the spine. So that's important. How important is dose reduction? How low should dose be? As low as reasonably possible. Yes, I think the biggest factor in dose reduction is the image you don't take. So that is key. And I think it takes a lot of experience and responsibility to decide when somebody does not need an image. Because we are so curious, we'd like to image everybody all day long, because we want to see those images and what it is, talk about them and discuss. We have to also control our own curiosity and then say, well, okay, I guess we do not need another image today or we can do with only one plane or we can do with a limited view, but at the end of the day when it is about juveniles, children or when it is a treatment modality that we know requires long-term radiographic follow up for example with flexible scoliosis correction. It's not like with the fusion then when you have a two years image and everything is fine, you can release them back into humanity, you need to follow them and they need imaging maybe every year. And so, at that point dose becomes much more important. And so when we have very young kids or when we have people that we know will be followed up radiographically for many years of their coming life, that's when dose reduction is very important that's when also like slot scanning technologies, new detectors. And you know, other technology becomes more important. Siemens Healthineers AG, 2024 The products/features (mentioned herein) are not commercially available in all countries. Their future availability cannot be guaranteed. The statements by Siemens Healthineers' customers described herein are based on results that were achieved in the customer's unique setting. Because there is no "typical" hospital or laboratory and many variables exist (e.g ., hospital size, samples mix, case mix, level of IT and/or automation adoption) there can be no guarantee that other customers will achieve the same results. Dr. Birkenmaier is employed by an institution that receives financial support from Siemens Healthineers for collaborations.