This is Carly Beam with the Becker Spine
and Orthopedics podcast.
I'm thrilled to be joined today by doctor
Alex Vaccaro, president of Rothman Orthopedics.
Doctor Vaccaro, thank you so much for being
here today. Oh, sure, Carly. It's a pleasure
and an honor.
Absolutely.
And before we get started, can you just
share a little bit more about your background?
Sure. I grew up I was born in
New York. I grew up in Northern New
Jersey.
I went to school in Boston,
and and then I went to med school
at Georgetown.
I I did an internship
in Cedars Sinai in Los Angeles, and I
did a residency at Thomas Jefferson University in
orthopedics. And then I did a fellowship at
University of California, San Diego in spine surgery.
And now I'm a professor of neurosurgery and
professor of orthopedics
at Thomas Jefferson University. I'm the chairman of
the department of orthopedic surgery, and I'm the
president of the Rothman Institute. So that's my
background.
Thank you. And to kick things off, can
you tell me about some interesting research projects
that is going on at Rothman this year?
Well, I'll tell you what I'm interested in.
I I I've always been a big fan
of spinal cord injury research. So we as
a university
have participated in all the medicinal pharmaceutical trials.
But what's really fascinating
is the department of neurosurgery,
and neurology
have developed a lab
where it's called the Rafael Center,
and I'm involved with that, helping that. And
what we were doing is
as a group, and it's under the,
auspices of of my neurology partner, Michelle Saruri.
We're developing
exoskeletons
and sensors
to sort of recreate motion,
until we figure out a cure which we
don't see on the horizon for spinal cord
injury. So using chips that can be placed
in the brain
to
utilize Bluetooth to control
stimulators and implantables that are placed in a
patient or to mobilize an exoskeleton.
So this is done at the Rafael Center,
and
I have a
patient that is,
his name is
mister Reynolds,
who unfortunately
was involved in a motor vehicle collision
where he became a paraplegic,
and he's been a very gracious donor
to this project.
We've written several papers on it using
implantables,
contact surface electrodes,
and the goal is to sort of use
your mind to control your extremities in the
future. So that's what I'm personally
interested in. We have a very large research
group in the Department of Orthopedic Surgery.
We publish about 30 to 50 peer reviewed
papers a year where we do a lot
of clinical studies because it's a high volume
spine institution. We we get along really well
with different disciplines such as rehab,
general surgery, neurosurgery, orthopedics work together,
and we look at our patient population in
spinal trauma, spinal cord injury, and degenerative disease,
and deformity, and infection, and tumor.
And, we just every week get together, and
we we ask questions. We developed a very
robust database.
So
doing research and writing papers is great.
We train four fellows
a year, and one fellow has a two
year position.
And he's in the basic science lab. And
that lab is headed by Chris Kepler.
And we do animal studies looking at, like,
different
things such as,
the effect of nicotine
and GLP ones on bony fusions, on outcomes,
and so forth.
And then our basic science lab, we're we're
the highest NIH
recipient in terms of dollar amount at Thomas
Jefferson Art Department of Orthopedics,
and we do a lot of,
disc regeneration
work
there in disc regeneration. So it's it's it's
great. It's
we have a lot of fun. And I
and I'm I'm so thankful I'm at the
university because if I was just doing surgery,
that would be gratifying helping people. But the
extra dimension of teaching and research really
makes what we do at Thomas Jefferson very
satisfying.
So it sounds like you touch a lot
of different areas in your research, and I
imagine all of that will touch more lives
just exponentially in the future.
Oh, I I think so. So I always
say,
when you decide
when you're younger to go into research, I
said, just don't jump all over the place.
Have a theme. So the theme at Thomas
Jefferson when I was younger in the nineteen
eighties and early nineteen nineties was spinal trauma.
And we took that theme
and through the AO
and through different study groups, we developed classification
systems, management protocols.
We worked on the biomechanics of various instrumentation,
and we became very aggressive in certain traumatic
injuries. And we became less aggressive than others
when we found out through our
registry studies that surgery really didn't make a
difference or it didn't really move the needle.
So that's where we sort of made made
the move. And I think in spinal injury
and spinal trauma,
we've sort of made great strides in anesthesia
care and operating on patients in their mid
eighties after trauma when in the past, we
would never do that. We moved away from
halos, and we moved more to
implants to stabilize his internal,
support structure so we can get people out
of out of the hospital the next day.
I mean, if you have an odontoid fracture
in an 80 year old and we operate
on you, we could literally send you home
without a collar the next day.
That's impressive.
Yeah. And before,
and I can tell you when I first
got here, they were in the hospital forever.
They got a halo, and then they developed
a nonunion. And then they got a Brooks
Fusion, which is a wire and bone graft,
and they went back in a halo. And
now you do c two c one toaster
fixation,
and you can get the patient out the
next day.
Oh. And the goal is the goal is
to mobilize.
The goal is
to provide motion and mobility to a patient.
So it's exciting.
So then I had a couple quick follow-up
questions
circling back on what you're talking about in
terms of exo exoskeletons
and then these brain chips.
One, I want to know, you know, obviously,
there are other companies and groups out there
looking at the potential of brain chips in
spinal cord injury patients. I was wondering what
your outlook
is for that technology. And then kind of
hand in hand with that, we were thinking
about the ask the exoskeleton
technology and the in the brain implants.
Which of those two do you think will
take off sooner?
Okay. So they're here now.
And I'll I'll use there's four companies that
I know of, but Neuralink is the most
advanced.
So just
using the mind
to send a signal through Bluetooth
to a computer,
and that computer then
tells an exoskeleton
what type of motion to do, or it
can be you can have a direct
implantable
electrode
into an extremity
that can power that extremity.
It could be wiring from the brain or
it could be through Bluetooth and so forth.
So that's here now, and it's being experimented
on at the present time.
And I know that Barrows is sort of
leading
in that. So
we have developed a whole series of exoskeletons
through
the Rafael Center under the gentleman I mentioned
previously, the neurologist,
who's heading that program.
And they're very advanced,
very advanced. And I'm excited to be able
to participate,
in that in those studies. I mean, it's
it's exciting.
But that's here now, and it makes so
much sense
developing
devices in the extremities to help move the
foot, help move the hand.
They've developed sensors
that tell someone with a severe neuropathy or
someone with who's insensate
to move their extremity so they don't get
get it to cubit eye. And these braces
can also move to the cubit eye. So
if it senses a certain amount of pressure,
it automatically moves the extremity with a brace.
So
that is phenomenal. And and and people have
phantom limb discomfort after an amputation.
And with these type of sensors, it gives
a patient a sensation that they do have
an extremity. So instead of feeling pain, they
feel another sensation.
So it it's a phenomenal technology, and that's
that's here now,
going through development
at our university.
And it's just it's just mind boggling. But,
you know, because as you know, all the
medicinal or slash pharmaceutical
interventions,
none of them have proven to be
efficacious in clinical studies. And all the
beginning studies,
they've been found to be safe than these
medications. But when it when you look at
a a larger study with multiple patients and
control groups, we really haven't moved the needle.
So people say to me, well, what do
you do when you have a spinal cord
injury? I say there's three things I do.
Number one, I stabilize the spine because a
bruised spinal cord doesn't like to move around
and be unstable.
Number two, I get the blood pressure up
so I can profuse the spinal cord. And
number three, I take the pressure off surgically.
And we've done studies to show all three
make sense.
Everything else we do, if you look at
hypothermia, if you look at
all
steroids and
ganglucides and
esethrin and all the, you know, no go,
you know, medications,
It really hasn't moved the needle yet, so
we'll see.
But but the exoskeletons make sense to me.
That that is here today,
and,
they come to my today, we had a
meeting in my office where they brought a
bunch of,
prototypes over. And and we we put them
on ourselves,
and we stimulate through the robot to make
our extremities move. It's really it's fun to
do. It's fun to do. That's fascinating. Absolutely.
Yeah.
And then I want to, pivot a little
bit. Can you talk about some most valuable
tech resources that Rothman has invested in over
the last five years?
Okay. So the number one so it's interesting.
You could look at Rothman as a business,
and you could look at Rothman
when it comes to treatment of patients. So
I think the most important and it's and
it's just blossoming now
is AI companies. And I won't mention the
AI company we use because I'm sure there's
competitors, and I I don't wanna promote one.
But the one thing that
every
RCM,
revenue cycle management,
we we get
hung up on when we do a procedure
and we go to build a procedure
with so many check boxes for prior authorization,
then you have to get an explanation of
benefits, then you have to send it to
the insurance company, and the insurance company says,
okay. You didn't do this, this, or that,
and they send it back to you. And
then you have to scrub it to make
sure that the bill is appropriate and then
goes to insurance company, and then they pay
you. And they may pay you according to
the contract you have. But how do you
know? They may or may not. Sometimes you
just check off a box as you get
paid. And using artificial intelligence
that can look at a bill and can
say,
this has been documented appropriately through the medical
records because it scanned your preoperative note. It
scanned the operative report. It makes sure that
the codes are appropriate.
It understands what the insurance company wants to
see.
And then if the insurance company sends it
back, it develops an instantaneous
appeal
to send it back again, and then it
tells you where you paid according to your
contract.
That is the most important technological investment that
we have. And that's not just not for
private practice. I'm I'm I'm in a academic
group that's private practice, but this is for
any private equity,
hospital system,
university system,
you just to make sure that everyone's in
compliance with the contracts you have.
Mhmm. It's it's and and again and again,
you could take this technology and you could
use it for anything.
I would exploit it for patient safety, you
know, just using that concept of checklist.
Like, I I say to the residents all
the time, go slow to go fast,
be quick, but don't hurry,
get things done. And these are quotes from
famous people. I I didn't make these quotes
up. These are from people who are in
the business. But and I'm and and and
I love the checklist concept
that pilots use. I said, you walk into
an Operating Room. You have these six things
you wanna get done.
You do a briefing before you begin the
operating
the operation.
You do the operation.
You read
the checklist off before you begin the closure.
Did I do everything I planned to do?
Did I do the biopsy like I wanted
to do? Did I check this level? Did
I check it off? And then when the
case is complete, run the checklist again when
you're signing the case out to the resident
or the fellow.
And but now exploiting technology to help us
do that
is phenomenal. Today,
I did five spine surgeries,
and one of my cases was a deformity
case.
I went anteriorly at multiple levels,
performed osteotomies,
placed interbody spacers,
and then I went posteriorly
fused down to the pelvis, and I used
a robot.
And the robot, what it does for me,
who's been operating forever,
is that it just dramatically
reduces the stress
psychologically.
And we did a study here
at Thomas Jefferson in the joint arthroplasty division
where
the surgeons put undergarment sensors on.
And then they did, like, revision surgery
normally,
and the sensors looked at perspiration,
heart rate,
respiration rate, all that. And then they used
the robot,
and they showed that the robot it may
take longer. By the way, it doesn't mean
it's gonna go faster. It may take longer.
But the stress, as long as the robot
is accurate and it's working.
So, again, we we have so many checks
and balances
in an operating room. When I use a
robot,
you just have to have so many different
strategies to make sure the robot's accurate. It's
taking you where you need to go,
when you drill, when you burr, anything like
that. You you you have to figure out
ways of double checking everything
before you use the precision of a robot.
But if it's working well, like it did
today,
you're a happy man.
It's you're happy. Happens. You're you're able to
do five
spine surgeries pretty
comfortably,
not as much stress as usual, I'd imagine.
Yeah. And the most important thing, Carly, is
that
I
the rep for the
robot told me that he had a case
the day before, but the surgeon canceled the
case because
the o arm wasn't working. And that's one
thing that
I'm disappointed with.
These are enabling technologies.
They shouldn't be supplanting our ability to do
surgery without the enabling technology. So,
it's so important when you train the young
surgeons
that they understand the anatomy. They could do
any operation.
For me, getting a spine operation done without
enabling technology, I'm a lot faster because I've
been doing it forever. And enabling technology
decreases the stress level, potentially increases the precision,
potentially, but not always.
But
it takes away the stress,
and it takes away the radiation exposure to
the operative staff and surgeon.
But when that technology is not available or
if that technology fails,
you should just transition seamlessly into doing the
operation.
I I hope we never get to the
point where
the computer's not working, and therefore, we can't
do the surgery. That's what we can't do.
We can't get to that point. We become
so dependent yeah. You become so dependent
on enabling technology,
then you're lost. Because then you don't really
under I mean, everything's about anatomy. But once
you master anatomy, and I and I I
love it when we have to teach the
residents and the fellows anatomy. I love dissecting
out the vertebral artery both from the front
and the back, and I love dissecting out
the aorta. I love I love doing that
because
I love to feel it. I love to
dissect out the pelvic anatomy because you don't
really I mean, how often do you see
it? You don't see it. I've I've never
seen it. I've never dissected anything, but I
can imagine it's very
thorough and intricate.
Oh my good. Well, remember, you were in
earth science back in
sixth grade. You dissected out the earthworm. Right?
That was a frog?
Did a sheep heart when I was in
middle school.
Okay. That's disgusting.
No. But that's cool. I I remember I
loved it. I remember the earthworm dissecting all
the organs, and I remember trying to dissect
out the frog's brain
and not in any way
blemishing the brain and doing it perfectly. It's
but that's when you say to yourself, oh,
I'd like to be a surgeon.
So, you know, so we do that now
in cadaver labs, you know, which I love.
I love cadaver labs dissecting the and, of
course, you die you dissect cell things you
would never want to see in the Operating
Room. Like, you don't wanna see the vertebral
artery.
But you wanna but you wanna know how
to get to it if you need to
get to it. Like, if there's an injury,
you wanna be able to expose it, stop
the bleeding, and repair it. So that's why
I just love the concept of always a
good surgeon is great at anatomy.
Definitely.
And then last question I have for you
today, doctor Vaccaro.
I was wondering
what's an area of
AI use in spine surgery that you'd like
to see
utilized
more?
Okay. So I I this is what I
would love. And it's kinda here and kinda
not here yet. I would like to have
a patient come in
and get an imaging study. And right off
the bat,
AI labels all the vertebral bodies,
labels all the measurements.
Now you may be a a measurement believer
or a non measurement believer,
but put it all together.
Tell me what the normative value should be
for a patient of that age.
Tells me what the bone mineral density is.
So if I decide to use an implant,
I know what's the potential
for subsidence.
And then suggest to me, if I plan
to do surgery,
what the surgical
approach and procedure
should be.
And on top of that, that's that's just
on the objective
quantitative aspect.
I also want AI to say, in the
whole vast universe of patients of that age
and that pathology
and that neurologic presentation,
this is what has been proven to be
the best in terms of outcome.
Do not operate
or
operate but do a minimal procedure or operate
and do a larger procedure.
And that can happen within seconds with AI
as it amasses data and accumulates data and
analyzes it. It's like a propensity
analysis. It just comes up with predictive modeling
that tells me
what the outcome is. Now, again, you're the
doctor, so you have to sort of digest
everything it gives you
and say thank you very much for that.
Now I'm gonna use this and I'm gonna
use that. I might disagree with that. And
because it's the art of medicine, and and
I'm gonna use this as the educational process
with patient. When that happens, Carly,
life is gonna get really interesting. Now remember,
we are the physicians, so we're not gonna
let a computer, I e a I, tell
us who and who not to operate on.
But it can inform us
on what has happened in the past that
if that patient has this operation, what are
the more likely outcomes?
That sounds like a really good assistant and
tool more than anything else.
100%.
Awesome. Well, thank you so much for joining
us on the podcast today, doctor Vaccaro. It's
been a pleasure speaking with you, and I
look forward to connecting down the line. Thank
you, Carlin. You have a nice day.