Speaker 0: This is Carly Beam with the Becker Spine and Orthopedics podcast. And today, I'm thrilled to be joined by doctor David Skaggs, co director of Cedars Sinai Spine. Doctor Skaggs, thank you so much for being here today.

Speaker 1: Hello. Thanks for having me. Love Beckers. Love keeping up with, what's new in spine.

Speaker 0: Thank you. I'm glad to hear it. And before we dive into our questions, can you introduce yourself and tell us a bit about your background?

Speaker 1: Sure. Absolutely. I'm now the co director of spine at Cedars Sinai along with doctor Alex Tuchman, who's the neurosurgical co director. We probably have about 30 spine surgeons here. We run seven or eight spine rooms a day and believe very deeply that a combination of neurosurgeons and orthopedic surgeons working together deliver the best spine care.

I was here for five years. Before that, I was at Children's Hospital Los Angeles for twenty five years, And it's, been very invigorating and eye opening to come to an adult spine center and honestly learn about some of what we're gonna talk about today, new technology and how we could make spine care better for children with new technology.

Speaker 0: Absolutely. And so I know you have a lot of expertise in pediatric pediatric spine area as well. Can you, go through some of the the biggest innovations that you've seen develop in, last few years?

Speaker 1: Yes. So one of the biggest is just happening right now. It is getting a synthetic CT from an MRI. And it's probably most important in children because children are most, susceptible to radiation. And what it is, it's one of the few things I've seen in medicine where AI actually makes a difference, you know, in practical terms.

And now what happens is when we get an MRI, a CT comes out. In addition, really just doing one quick sequence, you know, might take a few minutes longer, and you can get an amazing quality CT that's accurate to within one millimeter, you know, including three-dimensional reconstructions. So for pediatrics, what this does, you know, is save, children from unnecessary radiation. But if we think bigger picture in adult spine, what it could also do is save people from getting two studies. So instead of someone being sent for an MRI and it is separate time being sent for a CT, it could all be done at once.

Mhmm.

Speaker 0: So sounds like it's a real win win both for children and adults as well.

Speaker 1: Yeah. And if you don't mind, there's eve even more to this one. Yeah. One of the biggest advances, you know, in the past decade or so in spine surgery has been using navigation intraoperatively and robotics intraoperatively. And up until now, that has required a CT scan.

And now we can use this synthetic CT, the proprietary, name right now is called bone MRI. We can load that up into navigation, and or robotics. And all of a sudden, we don't radiate the patient, at any point for navigation or robotic usage, which is a a complete game changer.

Speaker 0: Yeah. And and I'm wondering, you know, when working with pediatric patients, you're obviously smaller patients that are also still growing. What kind of developments are you excited about in terms of just having tools or navigation technologies that are tailored to them?

Speaker 1: Yes. Great question. So, you know, I have to admit, I never even saw a robot until I came to Cedars. And next thing you know, I'm really just trying to meet my colleagues and go into the rooms and seeing, wow, they're doing incredible surgery through tiny incisions. And, one of my partners, doctor Corey Walker, who was trained at Barrow Institute with Juan Eirebi, taught me how to use a robot.

And in, young athletes, and I'll say, you know, kids in college and high school, they frequently have something called spondylolysis, which basically means it's a fracture most commonly of l five. And in the old days, to fix this, you had to open them up and put in screws and rods and hooks. And now with the use of a robot, we could literally make a two centimeter incision or even less and put a screw or screws perfectly across the fracture site. And I never, you know, back in my days at Children's Hospital, imagine I'd be doing outpatient pediatric spine surgery. But the use of robotics and navigation have really changed what we can do.

Speaker 0: And are there any lessons that you've learned in your time working with adult patients and your colleagues, you know, that you can carry over to working with pediatric patients?

Speaker 1: Yes. Absolutely. And, one of the things that adult surgeons have taught us is how to align the spine in a way that leads to long term back health and avoiding back pain. And, you know, not to be too technical here, but when we do spondylolisthesis surgery, probably the most important thing is we get l four to s one to at least a 35 degree, if not, you know, 40 or 45 degree angle. And as long as we have the lower lumbar lordosis L4 through S1 to be 35 degrees or over, there's a pretty good chance that we're setting the patient up for long term back health and to be, you know, free of significant back pain due to malalignment.

And this is new. This comes from the adult world. And if I wasn't, you know, sitting in a bunch of meetings, learning from my adult colleagues, I probably wouldn't be doing as good of a job on children as we are now.

Speaker 0: That's really cool to hear. And so so it sounds like less ray radiation, new developments and tools, and just new approaches is what's really the future of pediatric spine.

Speaker 1: Yeah. Yeah. I learned something interesting. I had a spine fellow last year named Vivian Chan, who's a neurosurgeon. And when using different implants, she says, I can't get my hands around this.

And I've now designed five lines of spinal instrumentation. I realized every time I design a tool, I put it in my hands. I go, yep. This feels good. So I have size eight hands and I realized, you know, I owe everyone in the world with small hands an apology.

Because without knowing I've been designing things for people with big hands. And my fellow doctor Chan had size five point five hands, so she couldn't quite get her hands around things designed for size eight hands. So I think that this is gonna become increasingly important as we have more women in spine surgery and we have more people with small hands in spine surgery. So I think the enlightened, companies are gonna start designing spine tools for people with small hands. So I I view that as, something I have to apologize and we all have to do better at.

Speaker 0: And doctor Scabs, there's one other thing I wanted to ask you is, you know, what can training programs for spine surgeons do to better equip them to be leaders in, you know, adapting these pediatric spine tools?

Speaker 1: So I think one of the most important parts about being a pediatric spine surgeon is getting enough experience. So the truth is there just aren't that many children in the world who need spine surgery, and there's not that many centers in the world that do enough of it to train someone. So it's highly specialized with small numbers. And if somebody really wants to be a pediatric spine surgeon, they either have to go to a pediatric orthopedic fellowship with a huge amount of spine experience, and there's probably only a handful of those, or do a true spine fellowship and then do additional time, at a busy pediatric spine center. And I think this raises a larger question of, you know, how are spine surgeons training?

And there's now so many new techniques that many people are feeling increasingly you can't learn it all in one year. And here, I think the neurosurgeons were a bit ahead of the orthopedic surgeons having enfolded fellowships. So So without increasing the length of a fellowship, neurosurgeons are able to do one year of a spine fellowship during their residency. And then if they wanna do something special or go into academics, or I'd say probably more common than not, they then do an additional post residency year fellowship. So a lot are doing essentially two years of spine fellowship.

And I think that, the next step for orthopedics is if people are going into spine, the PGY five years should probably be all spine and then do an additional, year of spine surgery. So I think increasingly, if people are gonna subspecialize in endoscopy, MIS, robotics, tumor, pediatric spine, you know, whatever it is, there's gonna have to be a little bit of additional training because there's really just too much to learn for one year to know all of spine and really be good at it all. Right.

Speaker 0: And just sounds like really you wanna be able to master the specific area and type of surgery of the spine that you wanna hone in on.

Speaker 1: Yes. Yep. And, you know, it's just like cardiac surgery branched on its own, plastics did, vascular did. You know, as we know more and more, we have to admit that we're not experts at everything. You know, the general practitioner is not doing heart surgery, spine surgery and vascular surgery.

Speaker 0: Got it. And doctor Skaggs, my last question, I wanna ask you, what are two or three of the biggest healthcare trends that you'll be following headed into 2026?

Speaker 1: Oh, you know, people get tired of hearing about cutbacks in the government, but I think that that's going to affect us a lot over the oncoming years. You know, there's been good studies in the past showing that if a doctor sees a patient on government insurance such as Medicaid, they actually lose money because their overhead is more than Medicaid pays. So we're starting already from a bad place of access. And if that government support is gonna be cut back even more, I think the patients on Medicaid are gonna have even more difficult time with access to medical care. So I think that's one of them.

And, you know, throw on top of it the academic centers are being cut back on research. You know, I think that it's gonna take a long time of going downhill before we have any possibility of unwinding this all. So that's a negative. The positive and it almost sounds trite to talk about AI, but I think that AI really is going to offer us, solutions that are better, faster, and less expensive than existing technology. You know, I think radiology may be leading the field in this.

You know, I could imagine many different options such as neuro monitoring during spine surgery. You're doing some great work at Columbia University with Michael Vitale. We're using AI. They could predict when a surgeon is about to lose neuro monitoring, you know, basically meaning the the patient is going paralyzed. You can predict it twenty minutes earlier if AI interprets compared to what we do today is having a neuro monitoring technician, a human being look at it.

So I think that AI is really gonna make things safer.

Speaker 0: Absolutely. Well, doctor Skaggs, thank you so much for joining us today. It's been a pleasure speaking with you, and I look forward to connecting again down the line.

Speaker 1: Thank you so much. It's great talking to you. Hope we've helped. Have a great day.

Speaker 0: Thank you.