This is Carly Beam with the Becker Spine
and Orthopedics podcast, and I'm thrilled to be
joined today by doctor Rachel Protesco with George
Washington University Hospital.
Rachel, thank you so much for being here
today.
Thank you. Thanks so much for having me.
I'm thrilled.
Absolutely. And before we dive into our discussion,
could you introduce yourself and tell us a
bit about your background?
Yeah. So my name is Rachel Bortescu.
I'm an orthopedic spine surgeon in the department
of orthopedic surgery at George Washington University where
I'm faculty
in Washington, DC.
And, doctor Botescu, what are your top three
goals,
in your work this year?
Yeah. I would say great question to kick
off the new year. Number one, my number
one goal I would say is incorporating endoscopy
in my practice.
Mhmm. So if you're not familiar or those
who are not familiar, spinal endoscopy is a
technique
that a lot of people are more familiar
with in the context of other joints.
Right? So the shoulder, the knee, and the
hip, for example.
It's the idea of doing the work that
you need to do as a surgeon through
one portal while viewing and seeing what you're
doing in another portal.
What's really exciting is that this technique can
also be translated to spine surgery.
This was a technique I trained in, during
one of my fellowships in my orthopedic spine
fellowship at NYU.
I was trained in by portal endoscopy.
What makes
this unique is that it is essentially
doing ultra minimally invasive spine surgery.
This is incredibly important when we are looking
to offer patients
less invasive forms of surgery that can
get them out of surgery with less pain
in the acute postoperative period and get them
back to the things that they love to
do.
Whether that's working, whether that's spending time with
your family, or any other recreational activities that
patients wanna get back into, whether that's sports
or just staying active throughout your life. So
this is a really amazing technique in particular
for spinal surgeries such as decompressions and microdiscectomies,
but it's also being
utilized,
as well in some fusion surgeries.
I'm currently in the process of having this
approved at our hospital. I'm hopeful in the
next few months that that will be the
case and then I can start employing this
technique with my patients.
That's awesome to hear. And, you know, so
sound it sounds like things are looking pretty
good. Can you dive into sort of your,
I guess, sales pitch to the hospital to,
you know, have them thinking about this?
Yeah. I think
when we consider what goes into patients having
spine surgery, there's a lot of things. There's,
not only from a hospital standpoint,
think considering things like length of stay, length
of surgery,
anesthesia,
efficiency of surgery, OR time, staffing, and things
of that nature.
Really doing these surgeries in less invasive manners
allows us to be more efficient to help
more patients and also consider doing things on
more of an outpatient basis or ambulatory surgery.
So it's really advantageous
from a hospital standpoint,
and also from a patient standpoint.
And I I think that's one of the
the greatest advantages of doing surgery this way.
Sounds like an absolute win win. And what
were some of your other goals, besides,
this? If you wanna say two more?
Sure. So So I I think the next
one that I'm really excited about, which is
also founded in
in my training as a spine surgeon, having
done both orthopedic and neurosurgical spine fellowships,
is creating a comprehensive
spine center at GW.
And what that means is merging both the
orthopedic and neurosurgery
spine departments.
I am fortunate that I have a great
relationship with the neurosurgeons here, and this is
really the future of spine surgery, especially at
many large academic centers in The United States
and around the world that employ this model.
And what that really means is that you
have orthopedic
and neurosurgeons
who are spine surgeons collaborating and working together
instead of being two separate departments.
You're working under the same department,
the Department of Spine Surgery, and a comprehensive
spine center isn't just about the surgeons. It's
also about everything else that we can offer
patients, whether that is pain management,
injections,
physical therapy.
These are other departments and other providers that
I work very closely with who take care
of my patients, and there's often multiple steps
that happen
before a patient even goes to surgery in
addition to patients
for whom surgery is not in their best
interest.
So it really makes sense to have all
of these offerings under the same roof and
in the same place.
At the same time, this promotes better patient
care,
better access, streamlining
of
appointments
of staffing,
and having everything in one place,
both figuratively, but also
in many cases under the same roof like
sharing clinic space. When you can walk down
the hallway and speak to one of your
colleagues about a mutual patient or come up
with a plan
or even see that same patient both in
the same
day or have their intervention done, whether that's
an injection, an ablation, etcetera, and then go
check-in and see how they're doing. It's just
better involvement in your patient's care and and
can also contribute to better patient outcomes. So
that makes a a lot of sense. Mhmm.
Obviously, these things can take some time,
but I'm hopeful that that by the end
of this year, that that's another thing that
will be on our horizon and both
from a neurosurgery and an orthopedic standpoint here
at GW,
we both agree that that this is the
future,
and and we look forward to offering this
to our patients.
Yeah. Absolutely. No. I mean, I've heard from
a lot of other spine surgeons and orthopedic
surgeons about
the importance
of having more, interdisciplinary
multidisciplinary
collaborations.
Exactly. Yeah.
And so what are some other exciting things
going on with, the spine program out here?
Obviously, you mentioned this comprehensive spine center you're
working on, endoscopy
spine surgery.
But what else is going on?
Yeah. I would say that probably the most
important thing is is creating the comprehensive spine
center.
We're also working on collaboration,
by educating other providers in our referral base.
So that's not just things that are very
spine adjacent like
pain management,
and spine surgeons in general, but this also
includes our primary
care physicians. This includes other disciplines like endocrinology
and rheumatology, people that we work with,
very closely as well or have common patients
with.
And right now, they're
in most cases for spine surgery, there's a
process by which patients are seen.
In many cases, you require six weeks of
physical therapy in order to get an MRI.
In other cases, we're looking to get patients
treated for things like osteoporosis.
We're looking to get,
before spinal fusions, for example.
And just looking to have patients worked up
by by other means for other medical conditions
to get optimized for surgery.
And so
really facilitating that communication,
educating other providers about how this process works
and how we can better take care of
our patients,
I would say is another thing that's on
my list of goals for the upcoming year,
but it is an exciting thing that's happening
at GW so that we can all work
on collaborating and taking better care of patients.
Yeah. And I'd love to also pick your
brain a bit on, the faculty
work you've been doing. What are some of
the most important,
lessons,
themes that you're instilling in,
residents, fellows, students, etcetera?
I think one of the most important
things is mentorship,
And that's something that you and I may
even have spoken about previously.
It's such an important thing
as a resident. Not that that was terribly
long ago for me, but as a resident,
when you think back to the people who
influenced your choice in the field you go
into and into your sub specialty.
And you you think about it like not
every orthopedic resident that comes to work with
me is gonna be a spine surgeon, but
there are people who want to be. So
whether I'm serving as a mentor,
for somebody who is interested in in the
field of spine surgery,
from someone from a research standpoint or academics,
a medical student who's trying to decide what
subspecialty they might want to go into, whether
that's orthopedics or not. This is one of
the reasons that I really enjoy being in
in academic side of things because I do
get to to mentor and teach and really
guide people and figure out,
from both a medical student and a resident
standpoint,
what makes them happy and what might provide
them with a fulfilling career.
Absolutely.
And, you know, what are some of the
biggest headwinds you're bracing yourself for in 2026?
Yeah. I I would imagine that there are
a number of other spine surgeons who have
some of the same feelings,
on these issues, but one of the main
concerns for for me for the upcoming year
is really the continued challenges
that we have and whether or not insurance
companies are going to continue increasing things like
denials and peer to peers.
The the authorization
process, this is goes for imaging, but also
surgeries in general has just been incredibly time
consuming. It's challenging, and we really noticed a
drastic increase
in the peer to peers required not just
to get things like MRIs done,
but also for denials related to surgeries. And
a lot of these patients are really well
indicated,
and really suffering,
leading into their spine surgeries. And it's something
that we we fight for, and almost every
spine surgeon that I know is fighting for
on a daily basis.
So that's one of the challenges that we
kind of brace ourselves as the years progressed
for in the upcoming year, but we will
continue to fight it for our patients.
Yeah. Can you just kind of dive into
just kind of your strategy when it comes
to dealing with,
insurers, these peer to peers?
I think that one of the most important
things, number one, is
just the foundation of this indicating your patients
well for surgery,
doing the right surgery for the right patient
at the right time,
as well as documenting. I mean, your documentation
supports your clinical decision making. You can look
back at your note or your your office
visits, and you can say, this is why
you know, this is what this patient's symptoms
were. This is, from an imaging standpoint, what
I believe the pathology is, and this is
why these are the things that they've tried
and why I believe things
that they've tried and why I believe they're
indicated for this specific surgery, and you can
demonstrate that that's your logical mode of thinking.
I think that's one of the most important
things,
as well as it being a medical legal
document. So I think
having really tight and strong indications as well
as documenting,
in the medical record appropriately
and providing very objective evidence for for what
has been done and why you are recommending
this are probably the most important things going
in because then you have a leg to
stand on.
Yeah. So, like, really having that paper trail
to back you up. Exactly. Yeah. Yeah. And
then, doctor Protesco, the last question I had
for you is, how else are you thinking
about growth in your practice? I know you
touched on wanting to, you know, expand their
endoscopy
work. But, you know, what are some other
areas of growth that you're envisioning?
Yeah. I think on on the along the
lines of incorporating less invasive options for patients,
which we touched on already,
another thing that is very exciting as far
as spine surgery goes is the incorporation of
advanced technology.
So these are things like not only robotics,
in in navigation, which I use very frequently,
but,
additional things in the pipeline like augmented reality.
I I mean, the the goal is to
be able to
do a less invasive spine surgery
through a microscope
where you can see an overlay of the
pathology without actually looking
at it. Right? There are companies here that
are working on these technologies and so these
are these are things that other companies I'm
talking to, things we're exploring,
and we're always looking for ways. The bottom
line is not just that these things are
cool and exciting, but we are looking for
ways to make surgery
safer and incorporate them into our workflow and
our practice
so that we can take care of patients
better and for them to have better outcomes.
That's the goal. Yeah. And then I just
had a quick follow-up. I mean, obviously, without,
like, naming names, but are there any any
particular,
types of spine technologies that you think will
really soar, really develop in the next twelve
months?
I think in in terms of what I
know is available and what I know is
out there,
there
are navigation systems
that are
vendor agnostic, meaning you can use any implants
that that you would like from any company
in addition to having
the accuracy
that is incredible. Right? So what that means
is
submillimeter
accuracy when you're placing a screw in the
pedicle of the spine when you're doing a
spinal fusion, for example, that's very close to
the nerves or the spinal canal. I mean,
these are things that are real and that
are out there and that are gaining in
popularity.
So I I wouldn't be surprised, especially
at the rate that this type of technology
is developing and being utilized,
that it doesn't come to a head and
become even more popular in the next year.
Yeah. So it sounds like that versatility is
probably just especially important, I imagine, for,
spine surgeons.
Yeah. Well, doctor Portescu, thank you again for
joining us on today's podcast. I hope you
enjoy the rest of your evening, and I
look forward to connecting again in the future.
Yeah. Likewise. Thank you so much for having
me. It's been great.