Table of Contents

Executive Summary…………………………………………………………………………………………………………….ES-1
i. Spinal motion preservation devices market…………………………………………………………………..ES-1
a. Impact of COVID-19 …………………………………………………………………………………ES-3
b. Selected market drivers and limiters………………………………………………………….ES-5
c. Leading competitors…………………………………………………………………………………ES-5
ii. Methodology ……………………………………………………………………………………………………………ES-5

Exhibit ES-1: Spinal motion preservation devices, combined market forecast ($m), by region, 2019—24 ………………………………………………………………………………………..ES-2
Exhibit ES-2: Spinal motion preservation devices, combined market forecast ($m), by product category, 2019—24…………………………………………………………………………ES-4

1. Clinical Overview…………………………………………………………………………………………………………….. 1-1
1.1 Spinal anatomy……………………………………………………………………………………………………….. 1-3
1.2 Selected spinal disorders………………………………………………………………………………………….. 1-6
1.2.1 Disc herniation……………………………………………………………………………………. 1-6
1.2.2 Degenerative disc disease…………………………………………………………………….. 1-7
1.2.3 Abnormal curvature of the Spine ………………………………………………………… 1-10
1.2.4 Spondylolisthesis……………………………………………………………………………….. 1-11
1.2.5 Stenosis……………………………………………………………………………………………. 1-11
1.2.6 Spinal tumors……………………………………………………………………………………. 1-12
1.2.7 Traumatic spinal injuries…………………………………………………………………….. 1-12
1.3 Bibliography………………………………………………………………………………………………………….. 1-14

Exhibit 1-1: Prevalence of lower back pain, per 100,000, Japan and 5 Euro, 2015………………………. 1-1
Exhibit 1-2: Population-based projections for incidence of low back pain, United States…………….. 1-2
Exhibit 1-3: The human spine ………………………………………………………………………………………………. 1-5
Exhibit 1-4: Forecast for prevalent cases of osteoporosis in the US, Japan, and five major European markets, by country, 2019-24 ………………………………………………………………. 1-9

2. Artificial Cervical and Lumbar Discs…………………………………………………………………………………… 2-1
2.1 Fusion vs. nonfusion………………………………………………………………………………………………… 2-1
2.2 Total disc replacement…………………………………………………………………………………………….. 2-1
2.3 Artificial cervical discs………………………………………………………………………………………………. 2-2
2.3.1 Clinical evidence …………………………………………………………………………………. 2-2
2.3.2 Cost effectiveness……………………………………………………………………………….. 2-2
2.3.3 Products/clinical trial results ………………………………………………………………… 2-4
2.3.4 Emerging artificial cervical disc……………………………………………………………. 2-11
2.3.5 Market analysis…………………………………………………………………………………. 2-11
2.3.6 Competitive analysis………………………………………………………………………….. 2-16
2.4 Artificial lumbar discs…………………………………………………………………………………………….. 2-19
2.4.1 Clinical evidence ……………………………………………………………………………….. 2-19
2.4.2 Products/clinical trial results ………………………………………………………………. 2-20
2.4.3 Market analysis…………………………………………………………………………………. 2-24
2.4.4 Competitive analysis………………………………………………………………………….. 2-27
2.5 Artificial discs, combined market forecast………………………………………………………………… 2-30
2.6 Bibliography………………………………………………………………………………………………………….. 2-32

Exhibit 2-1: Cost of Mobi-C artificial cervical disc, UK ……………………………………………………………… 2-3
Exhibit 2-2: Mobi-C artificial cervical disc ……………………………………………………………………………… 2-5
Exhibit 2-3: Prestige LP cervical disc …………………………………………………………………………………….. 2-6
Exhibit 2-4: Selected cervical total disc replacements…………………………………………………………….. 2-9
Exhibit 2-5: Artificial cervical discs, global market forecast ($m), 2019—24…………………………….. 2-12
Exhibit 2-6: Artificial cervical discs market ($m), share by supplier, 2019 ……………………………….. 2-15
Exhibit 2-7: Zimmer Biomet net sales ($m), by product category and region, 2017—19 …………… 2-17
Exhibit 2-8: Medtronic net sales ($m), by product category and region, 2017—19 ………………….. 2-18
Exhibit 2-9: prodisc L artificial lumbar disc ………………………………………………………………………….. 2-22
Exhibit 2-10: Selected lumbar total disc replacements …………………………………………………………. 2-23
Exhibit 2-11: Artificial lumbar discs, global market forecast ($m), 2019—24 …………………………… 2-25
Exhibit 2-12: Artificial lumbar discs market ($m), share by supplier, 2019 ………………………………. 2-28
Exhibit 2-13: B. Braun net sales, by division and region, 2017—19…………………………………………. 2-29
Exhibit 2-14: Artificial discs, combined market forecast ($m), 2019—24 ………………………………… 2-31

3. Dynamic Stabilization Devices ………………………………………………………………………………………….. 3-1
3.1 Interspinous process decompression…………………………………………………………………………. 3-1
3.1.1 Interspinous process decompression products……………………………………….. 3-3
3.1.2 Pedicle screw dynamic stabilization systems ………………………………………… 3-12
3.2 Market forecast…………………………………………………………………………………………………….. 3-17
3.3 Competitive analysis, interspinous process decompression devices…………………………….. 3-24
3.4 Competitive analysis, pedicle screws……………………………………………………………………….. 3-27
3.5 Facet replacement products …………………………………………………………………………………… 3-31
3.6 Bibliography………………………………………………………………………………………………………….. 3-36

Exhibit 3-1: In-Space interspinous spacer………………………………………………………………………………. 3-4
Exhibit 3-2: LimiFlex Paraspinous Tension Band……………………………………………………………………… 3-4
Exhibit 3-3: Renegade interspinous spacer…………………………………………………………………………….. 3-5
Exhibit 3-4: DIAM system…………………………………………………………………………………………………….. 3-5
Exhibit 3-5: coflex interspinous spacer………………………………………………………………………………….. 3-6
Exhibit 3-6: Superion Indirect Decompression System…………………………………………………………….. 3-8
Exhibit 3-7: UniWallis Posterior Dynamic Stabilization System…………………………………………………. 3-9
Exhibit 3-8: Selected interspinous process decompression devices…………………………………………. 3-10
Exhibit 3-9: Zimmer Biomet’s Dynesys dynamic stabilization system ……………………………………… 3-14
Exhibit 3-10: Selected pedicle-screw based semi-rigid/dynamic stabilization systems………………. 3-16
Exhibit 3-11: Dynamic stabilization devices, combined market forecast ($m), 2019—24 …………… 3-18
Exhibit 3-12: Semi-rigid/dynamic stabilization pedicle screw systems, global market forecast ($m), 2019—24…………………………………………………………….. 3-20
Exhibit 3-13: Interspinous process decompression devices, global market forecast ($m), 2019—24 ……………………………………………………………………………………………………… 3-22
Exhibit 3-14: Interspinous process decompression devices market ($m), share by supplier, 2019 …………………………………………………………………………………………………………….. 3-25
Exhibit 3-15: Boston Scientific net sales ($m), by product category and geography, 2017—19 ……………………………………………………………………………………………………… 3-26
Exhibit 3-16: Dynamic stabilization/semi-rigid pedicle screw systems market ($m), share by supplier, 2019…………………………………………………………………………………… 3-28
Exhibit 3-17: Globus Medical net sales ($’000), by product category and region, 2017–19……….. 3-29
Exhibit 3-18: Zimmer Biomet net sales ($m), by product category and region, 2017–19…………… 3-30
Exhibit 3-19: Facet joint anatomy ………………………………………………………………………………………. 3-31
Exhibit 3-20: ACADIA Facet Replacement System …………………………………………………………………. 3-32
Exhibit 3-21: The TOPS System …………………………………………………………………………………………… 3-33
Exhibit 3-22: Selected facet replacement product(s) …………………………………………………………….. 3-34
Exhibit 3-23: Facet replacement under development……………………………………………………………. 3-35

4. Vertebroplasty and Kyphoplasty Devices …………………………………………………………………………… 4-1
4.1 Vertebroplasty………………………………………………………………………………………………………… 4-1
4.1.1 Clinical evidence and guidelines……………………………………………………………. 4-2
4.1.2 Polymethylmethacrylate alternatives…………………………………………………….. 4-4
4.1.3 Products…………………………………………………………………………………………….. 4-5
4.1.4 Market forecast ………………………………………………………………………………….. 4-8
4.1.5 Competitive analysis………………………………………………………………………….. 4-10
4.2 Kyphoplasty ………………………………………………………………………………………………………….. 4-14
4.2.1 Clinical evidence and guidelines………………………………………………………….. 4-15
4.2.2 Products…………………………………………………………………………………………… 4-15
4.2.3 Market forecast ………………………………………………………………………………… 4-17
4.2.4 Competitive analysis………………………………………………………………………….. 4-19
4.3 Vertebroplasty and Kyphoplasty, combined market analysis………………………………………. 4-22
4.4 Bibliography………………………………………………………………………………………………………….. 4-28

Exhibit 4-1: Stryker’s Cortoss bone augmentation material…………………………………………………….. 4-5
Exhibit 4-2: Medtronic’s Kyphon V Premium Vertebroplasty system ……………………………………….. 4-6
Exhibit 4-3: Selected vertebroplasty products………………………………………………………………………… 4-7
Exhibit 4-4: Vertebroplasty systems, global market forecast ($m), 2019—24…………………………….. 4-9
Exhibit 4-5: Vertebroplasty systems market, share by supplier ($m), 2019………………………………. 4-11
Exhibit 4-6: Stryker net sales ($m), by product category and geography, 2017–19…………………… 4-12
Exhibit 4-7: Medtronic net sales ($m), by product category and geography, 2017–19 ……………… 4-13
Exhibit 4-8: Globus Medical’s Affirm kyphoplasty system………………………………………………………. 4-14
Exhibit 4-9: Selected kyphoplasty systems and their features………………………………………………… 4-16
Exhibit 4-10: Balloon kyphoplasty systems, market forecast ($m), 2019—24…………………………… 4-18
Exhibit 4-11: Kyphoplasty systems market ($m), share by supplier, 2019………………………………… 4-20
Exhibit 4-12: Medtronic net sales ($m), by product category and geography, 2017–19 ……………. 4-21
Exhibit 4-13: Stryker net sales ($m), by product category and geography, 2017–19…………………. 4-22
Exhibit 4-14: Percutaneous vertebral augmentation systems, combined market forecast ($m), 2019—24 ………………………………………………………. 4-23
Exhibit 4-15: Cost of vertebroplasty and kyphoplasty kits ……………………………………………………… 4-25
Exhibit 4-16: Vertebroplasty and kyphoplasty US Medicare reimbursement, outpatient, physician office, and ambulatory surgery center, 2019……………………… 4-26
Exhibit 4-17: Vertebroplasty and kyphoplasty US Medicare reimbursement, outpatient, physician office, and ambulatory surgery center, 2020……………………… 4-26
Exhibit 4-18: Vertebral compression fracture, hospital inpatient, 2019 …………………………………… 4-27
Exhibit 4-19: Vertebral compression fracture, hospital inpatient, 2020 …………………………………… 4-27

APPENDIX: COMPANY LISTING……………………………………………………………………………………………………..A-1