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This is Alan Condon with the Becker's ASC
podcast, and I am delighted to be joined
today by doctor John Paloza,
an orthopedic spine surgeon with Midwest Orthopedic and
Spine Specialists. And, doctor Paloza, a real pleasure
to have you on, make your debut appearance
on the Becker's podcast today.
I'd love to turn the floor over to
you to tell our listeners a little bit
more about your role and your background,
as well as your practice.
Well, thanks, Alan. I appreciate you having me
today. I've been in practice for over 30
years, done fellowships in sports medicine and spine
surgery. And then I've had, quite a bit
of practice,
mostly in private practice, but also training residents
and fellows and then also postgraduate
surgeons and all the various techniques.
Started out with a highly complex surgery, deformity
surgery, tumors, infections and stuff and then did
more and more degenerative disc disease and that
led
to pioneering
minimally invasive surgery. So, we have patents in
terms of different implants and
retractors
and ways to put it in techniques and
such.
So we've been I've been involved in the
minimally invasive since the late '90s till today.
Then in the early 2000s, we were involved
with the FDA on these studies for disc
replacement
devices and we've done a lot of FDA
trials infusion, disc replacement, minimally invasive surgery,
etcetera. So, we've got a quite a robust
experience with it.
So, what happened over the years is that
we got better with minimally invasive, we found
that we could do more things with it.
We could not only do, we'll say, a
microdiscectomy
or laminectomy, but actually put metal into the
spine to little tubes.
And then,
the technology advanced to have
intraoperative
CT navigation
and that made everything much more accurate so
that we could even get
to smaller and smaller incisions.
So basically, minimally invasive means that you don't
damage the normal tissues, you just address
the problem like the we call that the
pathology.
It's akin to,
I used to describe it,
open surgeries like a World War II bombing
run where you just drop bombs everywhere and
sometimes you hit the target and a lot
of times you don't versus precision guided bombing
that you see today,
decompression,
our burs,
the,
putting in metal were very, very precise.
And that's made everything quite a bit better.
So what we eventually did is we start,
applying minimally invasive to, all kinds of things
such as deformity. We use minimally invasive techniques
to fix curves in the spine. We can
actually do sometimes,
depending on the case, a tumor and remove
it. We can,
put in,
disc replacements
through just small incisions.
And what that has done has expanded our
ability to take care of spine problems
with very little
pain from the exposure.
So people get better faster and much more
predictably.
So then we were able
to take a lot of these kind of
cases outside of the
purview of a hospital
into a surgery center
environment.
So surgery centers, particularly if they're
geared
to say spine surgery,
everybody, the staff,
doctors, the equipment, everything is geared to just
do spine surgery and do it at a
very high level.
So that means we get
very predictable results
with very little trouble for the patient and
make it very convenient for them.
And one of the things that struck my
attention years ago is we had a friend
that I did a microdiscectomy
on and his wife drove him up to
our surgery center, came up, we had a
report to cashier where he got out of
the car, went into the center,
signed in,
went to the back, got his gown on,
an ID, talked to anesthesia, talked to me,
talked to our nurses,
went back to surgery, had the microdiscecting
minimally invasive techniques, took about 30 minutes,
woke up, walked around feeling great and then
left about an hour later.
And his wife described the whole experience for
them as like
going to meetings to the makeup counter and
getting your shirt cosmetics,
dropping her car out at the the concert
at the valet, getting her cosmetics, and then
leaving. It was that simple.
Not scary at all.
Not very painful, his leg pain went away
and he had a very good result. So
that's the kind of thing you can do
with the minimally invasive techniques with the high
end technology in a center
that is geared for
without all the baggage of a big hospital.
Yes, it's fascinating
to hear and I guess just your own
experience particularly within this realm, like you said,
I've
been in the field in a minimally invasive
in these. Fascinating to see how some of
that surgical technology has evolved over the last
couple decades
and what potentially lies ahead for the future
as well. Kind of just following up on
your story there. You know, it wasn't too
long ago where
patients who undergone spine surgery would usually be
2, 3, 4 days in a hospital.
Now, like you said, it's possible to do
a lot of these complex spine cases with
patients up, ambulated, out the door in an
outpatient setting in just a matter of a
couple of hours. I guess, with that said,
when what are the key
kind of surgical technologies that you see reshaping
the future of minimally invasive spine care, Doctor.
Palossa?
Well, generally we make
incremental improvements. It's not like we have a
eureka moment, but every now and then
the accumulation of
incremental improvements
comes to something big.
I think one of the big things
was to be able to do
surgery through small tubes and now even endoscopic
tubes.
Then the other thing was the ability to
navigate the spine in real time in the
operating room and that was the CT navigation.
To go further on that, now there are
robots.
The robots are dependent on the CT Navigation,
but the robot itself can fire in
can place the metal. And now, you know,
the ultimate goal is have the robot be
able to do the decompression part 2 controlled
by the surgeon
as an adjunct to the surgery, basically a
tool that the surgeon would use.
In addition to that, a whole lot of
improvements have been made in
the biologics
of how we get tissue to heal.
Also the metallurgy in our implants
that they can actually interact with say the
bone in a fusion to create,
to turn on the bone cells to make
bone.
So then we don't have to take a
bone graft
and because of the surface treatments or the
internal architecture of the implant,
the chance that we're going to, you know,
get a good solid fusion are now approaching,
you know, almost a 100%.
So that creates
really good certainty for a good result.
The other thing has been the improvements in
disc replacements.
The first disc replacement was, designed in Germany
in the eighties,
and so that eventually was brought to
different iterations of that design was brought to
America in the late 1990s, early 2000s
and then there's been improvements since then over
the years
to where the implants we're using now.
We also have done these level 1 studies,
randomized controlled trials
for the FDA.
So we have lots of data,
not just,
you know, a couple weeks data. We have
up
to 10 year data comparing disc replacements, fusions,
and even, you know, in our European colony,
colleagues, we have, like, 20 year outcome data.
So when people
talk to us us about what's likely to
happen,
we really do have a robust literature to
draw on.
The spine literature
is probably the best literature
in orthopedics and neurosurgery in terms of level
1 studies
to answer the different questions.
So it's an exciting place to be as
a doctor,
because we have all these tools, plus we
have outcome data, and if you use the
tools the way they were indicated, to get
a good outcome.
So as a doctor then,
you can take all that, improve your skills
and say minimally invasive surgery and then do
the surgery
in a,
a venue
that is actually
conducive to a very good patient experience.
So what we're trying to do is take
the fear out of spine surgery because of
the uncertainty
to where it's very certain that we'll get
a good result and not very painful
and very convenient too.
It's fascinating to hear just
all the technology that you mentioned there. Kinda
touched on the the evolution of endoscopic spine,
robotic spine surgery. Touched on biologics there.
The 10, 15, 20 year data that now
we have before disc replacements.
I'm curious to hear, doctor Fallows, when you
think about the future of the field, whether
from a technological standpoint or just the spine
field more broadly,
what what are you most excited about?
Well, I think we're in a transition from
most of the,
the tools were fusions for a long time,
and now it's kinda turning over to disc
replacement. And the thing that's important about disc
replacement for patients
is that it maintains the motion of your
spine, so you don't have the stiffness problem,
but biomechanically
it helps prevent
the level next to the surgery from becoming
diseased or adjacent level disease. So, infusions, everybody
worries about what happens to the next level
because forces are transferred. That's much less of
a problem,
although not totally eliminate, but much less of
a problem
with this replacement.
So, the chances of having another operation at
the next level is, you know, either
1 5th to 1 third that of a
fusion.
So, that's a big step. So, that we're
in that transition and I think the next
transition probably in
5, 10 years from now will be actually
regenerative medicine where we're actually
able to help heal the tissue
with cellular
techniques.
There's a study we're involved now that actually
uses
disc cells that are expanded
in culture
and then mixed with a carrier that is
injected into the disc.
That has been presented at meetings, so I
can talk about it, but it's part of
a FDA trial, it's just finished Phase 1.
So Phase 1 basically,
is small numbers of patients. This is going
on to Phase 2, Phase 3. This may
be, if everything goes well, available for patients
in 4, 5 years from now, but there's
another study using proteins that block the inflammatory
cytokines in the disc to help preserve the
disc too. So there's a lot of different,
strategies and studies going on that I think
in the future, we may be also able
to offer
a regenerative
option
as well as fusion or disc replacement or
just make more room for the nerves, which
is called the decompression,
all done through little tiny incisions.
Now
this applies to mainly degenerative disc disease, things
like tumors and scoliosis and other, they may
have a different solution set. But the main
thing is by keeping abreast of all these
things, we are able to understand
the spine and predict what's going to happen
with
the intervention at the moment and help predict
what's going to happen in the future too,
so that we can give the best solution
to the patient
for their individual
problem.
Yeah. Absolutely. It's so fascinating to hear. So
many studies that you've mentioned as well from
the regenerative medicine side in terms of what
disc cells might even stem cells might be
able to do in the future for spine
surgery or or nonsurgical, excuse me, in the
future as well. I wanted
to finish out our conversation today by just
getting a little bit of an insight into,
your own practice, doctor Palossa. I guess, when
you think about the next year, the next
2 years,
where are the key areas? How are you
thinking about growth?
Well,
complicated question.
The bigger problems in medicine is insurance and
reimbursement
and those things. And that, although we tend
not to think about that as doctors so
much, it's having an effect that, if you
can even do an operation
And and not from the technical part of
it, but if you're allowed to, how do
you afford all these wonderful things? Because somebody's
gotta pay for it.
So
the idea is to
make it
by putting in a venue, a less expensive
venue where you can negotiate
with, patients and vendors and insurance companies
to get the cost down
so that you can offer
pass those savings on to patients. So
there are a couple of things afoot
to do that. It's usually, you know, the
business guys are very good at that, how
to manage costs,
but that's the biggest
issue.
One thing we're doing is we're also getting
involved with
a more of a concierge or cash pay
business where
we can actually present to the patient exactly
what's wrong, how we would deal with it,
how to pay for it, put in a
less expensive venue so that those cost savings
are passed on to the patient that they
can
patient that they can actually afford it afford
it. So if they get denied by Medicare
or government or or insurance company that we
can do something
that we think works best
at an affordable price.
Yeah. I think that's one thing that I've
heard at a recent ASV event as well.
A few,
independent spine practice or orthopedic practices like yourself
are also go going down that pathway, that
concierge or cash pay business.
Certainly interesting way to kinda combat some of
these challenges and no doubt with the insurance,
sector as well.
Doctor Peroza, it's been a a real pleasure
to have you on the podcast first and
foremost. It's fascinating.
Can I get your perspective on the spine
technology that you're watching, that you're excited for
the future, also how you're looking at practice
growth as well?
Really, really enjoyed the conversation. I certainly learned
a a lot, and no doubt our listeners
did too. I really, really enjoyed it, and
I look forward to connect with you again
down the line.
That'd be great. It was a pleasure.
Thank you very much.