This is Carly Beam with the Becker Spine
and Orthopedics podcast.
I'm thrilled to be joined today by Doctor.
Andrew Fanu at Inova.
Andrew, thank you so much for being here
today.
Before we dive into questions,
sure. My name is Andrew Fanous. I am
a neurosurgeon
at Inova Health System in Northern Virginia.
I am based in Alexandria, Virginia. I am
a board certified neurosurgeon, and I'm also fellowship
trained
in complex and minimally invasive spine surgery.
Thank you, doctor Fannous. And first question, can
you tell me what are some of the
most exciting technologies
that you're seeing in spine surgery today,
and how are you incorporating them into your
practice?
Yeah. I mean, we are very lucky that,
spine surgery tends to be a very high,
tech,
subspecialty of neurosurgery and orthopedic surgery.
I would say that the most exciting technologies
today that are really shaping how we as
surgeons are planning and
executing and monitoring our surgeries,
are,
spine robotics,
augmented reality and mixed reality,
AI driven surgical planning and imaging tools.
There are also three d printed and patient
specific implants,
motion preservation
devices,
and, of course, endoscopic spine surgery.
I would say these are the top,
technologies,
that are currently very exciting for us as
spine surgeons.
Great. And I'd love to hear how you're
incorporating any or all of these technologies into
your work.
Yeah. I mean, there are, a lot of
different ways that we have been incorporating
those technologies.
So if you take them sort of one
by one and you take a look at
spine robotics, for example,
as we all know, they're increasing,
accuracy of instrumentation.
They are reducing
exposure to radiation.
They shorten operator of times.
So we are really employing them currently,
mainly for instrumentation,
in larger spine cases.
Of course,
you know, future trends, you know, beyond navigation
and instrumentation and so on,
I think that spine robotics are gonna become
more autonomous,
and they will offer sort of multilevel trajectory
planning.
And hopefully eventually they will also be able
to help us when we're performing the compressions
in spine surgery.
When it comes
comes to, augmented reality, for example, and mixed
reality,
currently, we are incorporating them in our practice
by using them for visualization,
of patient anatomy
directly into our field of view, as surgeons.
And,
we're hoping,
and I've actually been,
to some
meetings lately where I've seen kind of, more,
evolution of augmented reality and mixed reality systems,
where they are integrating multi functionality
kind of, abilities and capabilities only one platform.
And using those multi functionality
platforms, you hey. You can have the surgeon
use
the AR and MR technologies, not just to
perform surgery,
but also to visualize,
preoperative imaging,
looking at office notes,
you know, recording videos, taking intrapper pictures, and
so on.
So you can actually employ those powerful tools
for not just to perform surgery, but to
do more than just the the surgery.
When it comes to AI driven,
surgical planning
and imaging,
of course, it's very important
because currently, it uses predictive analytics and optimizing,
you know, alignments and implant sizes,
surgical trajectories,
and therefore, it enhances personalization
of surgeries,
which is something that's very desirable nowadays.
But moving forward, we're also hoping that,
we can employ AI,
for risk stratification
and patient selection.
And by doing this, we can actually avoid
post awkward complications.
In my practice, I've also been,
employing three d printed and patient specific implants.
They're extremely important because,
these are accustomed,
implants, usually interbodies and interbody cages
that are matching matching the patient's anatomy.
And by doing this, they actually improve osteo
integration
and by extension, fusion.
And when you improve fusion rates, then reduce
failures and revision risks.
Of course, there are some challenges currently with
those kind of technologies. For example,
you know, turnover is currently,
a challenge. It takes about a couple of
weeks. So if you have a patient coming
through the emergency department that needs a surgery
right away, you cannot really use,
patient specific implants at this time. But we're
hoping that,
in the future, we can have a rapid
point of care
printing, especially for trauma and deformity patients.
Motion preservation is another very interesting and very
exciting technology that we have been employing in
our practice as well.
So these are, you know,
technologies that decrease the risk of adjacent level
disease and, you know, addition segment disease by
preserving motion,
rather than fusion, which is what we, you
know, what most spine surgeons currently do.
And of course, by, you know, preventing fusion
and preventing addition segment disease, you're also by
extension
reducing,
reoperation rates down the road.
Limitations currently for this technology is that reimbursement
is still very much lagging.
So we're seeing less adoption of both, cervical
and lumbar spine motion preservation techniques in The
US
and less so in The US than in
places like Europe, for example, where there's better
reimbursement.
And finally, I would say that endoscopic spine
surgery is something that me personally, I'm very,
excited about.
It allows for minimally invasive procedures. It reduces
recovery time.
It,
minimizes muscle damage and
it lowers the risk of complications.
Of course,
the usage of inter subexpine surgery, especially in
the s, has still been limited
mainly because there are very steep learning curve
for surgeons.
And also because it offers, you know, to
a certain degree limited access to some areas
of the spine.
So it's not really suitable for all kinds
of conditions.
But I do believe that there is,
you know, big, room for improvement when it
comes to endoscopic spine surgery. I think there
is,
there will be more adoption in The United
States.
And I'm hoping that in the next few
years or so, we'll see more adoption to
the point where we're using it to the
same degree that it's being used in, you
know, places like East Asia, for example,
where it's mainstream for spine surgery.
Thank you. And I appreciate the your breakdown
of all these different
areas of spine technologies. I was I was
wondering specifically with endoscopic
spine surgery, what kind of evolutions
do you hope to see in the next
two or three years?
I would really love to see, more integration
of endoscopic spine surgery with,
things like robotics and robotic assistance that are
even stereotypic navigation.
For us, that will provide us with greater
precision.
When we currently use endoscopic spine surgery, we
are forced to use fluoroscopy,
which is very cumbersome. And, of course it's
fair, very high risk of radiation.
But if we can somehow develop in the
next couple of years,
some integration between
between endoscopy and robotics, I think that would
be, a huge thing.
Got it. And you mentioned earlier about, motion
preservation
and challenges with the reimbursement. Can you dive
more into how your,
reimbursement. Can you dive more into how you're
addressing those and how your what your strategy
is for
trying to get those payers to work with
you?
Yeah. I mean, honestly, what we do is
we end up doing what's right for the
patient. So especially for younger patients,
that we know fusion down the road is
going to be detrimental for them.
Regardless of what reimbursement is, we still push
hard for, motion preservation techniques like disc replacements.
And it is challenging, and we end up
doing a lot of, you know, peer to
peer,
meetings with the payers.
But, you know, we end up doing what
is right for the for the
continue to advocate for our patients.
Thank you. Thank you. And and then when
it comes to your work in augmented reality,
and can you discuss just kind of by
the numbers, how much
if there are any cost savings,
time efficiency
savings? If you could dive into that more,
that'd be great.
Yeah. There is definitely,
cost savings associated with augmented reality,
systems because it is very helpful,
in performing minimally invasive surgery. So as opposed
to, big open surgeries,
that will require a lot of,
interoperative resources and, of course, hospital resources postoperatively.
You can perform
smaller,
surgeries with smaller incisions,
using augmented reality and mixed reality systems.
So the recovery will be shorter.
The resources
interoperably will be less.
The patient will be discharged faster,
from the hospital.
So of course, in general, that that does
translate into
improved, you know, outcomes, but also,
better uses of, resources.
Thank you. And, obviously, you've been several developments
in federal health care policy from the GOP
spending bill to, CMS and their proposed
2026
physician fee schedule.
I was wondering how you anticipate
these changes or, in fact, the growth of
the spine technologies that we've been talking about.
Yeah. That's a great question, and it's really
what is on everyone's
mind right now.
If you take them kind of one by
one, if you, if we take first the
GOP is the one big, beautiful bill,
which is really spending bill with Medicaid cuts.
You see that there will be tighter Medicaid
budgets and
stricter eligibility for surgeries.
So it will slash Medicaid provider taxes. It
will tighten eligibility,
and it's going to add work requirements.
And this could reduce volume of spine surgery
referrals from Medicaid,
especially when it comes to rural areas and
low income areas.
In addition,
I would say that rural and community hospitals
may face,
operational strains,
even though there will be increased funding for
rural hospitals, this may not offset the overall
cuts.
And as a result, you know, spine tech,
vendors may see kind of lower uptake in
these areas,
of, you know, rural areas and community hospital
areas, and they may need to shift their
focus to better funded hospital systems,
on sometimes even to private pay markets.
When it comes to the CMS and the
twenty twenty six physician fee schedule that is
proposed,
it's also a mixed bag because there will
be higher base conversion factors.
CMS is proposing about a 3.7%
boost to physician payments for 2026.
However, when it comes to,
procedure based,
specialties like spine surgery,
there will be about a 2.5%
cut.
They're calling it the efficiency cut,
and that adjustment is probably going to end
up,
kind of offsetting,
the
proposed
boost in physician payments.
The
CMS 2020
physician fee schedule also proposing,
you know, mandatory ambulatory specialty models or ASMs.
It's a new model,
and it's mainly targeting spine and heart failure
management.
And it rewards usage of digital tools,
care coordination,
and outcome tracking.
So, you know, as a result, the spine
surgeons,
their effective reimbursement may stagnate or may even
decline.
And that's going to make,
investments in high cost technologies less financially appealing.
But on the other hand, there will be
new opportunities created,
by the,
ambulatory
specialty model,
through remote monitoring, telehealth,
patient engagement platforms, and so on.
I think the takeaways for,
the spine sector is
that there will be a shift to value
driven propositions.
Surgeons will need to engage,
early into alternative payment models,
and
there will be a focus on
data data and,
sort of evidence based medicine.
The
CMS would increasingly
reward data driven outcome tracking.
So the surgeons will need to be, very
careful about that.
And I think the market winners will be
the ones who are offering measurable value.
And,
you know, since CMS is,
is going to focus on value based shift.
And I imagine that some of the AI
tools, AR tools, and some of the technologies
that we've been we've been discussing will hopefully
help and
help surgeons
get that data that they need to show
their value.
Absolutely. That's a great point. So,
really, AI,
enhanced surgical assistance,
is gonna play a larger role in, predicting,
the most effective surgical approaches and the tools
for each patient.
And, of course, when you employ eye to
analyze thousands of databases from previous surgeries,
I can also recommend optimal approaches for achieving
the best possible outcome.
And it can also perform predictive analytics down
the road.
So you you can use softwares,
to predict complications,
healing times, you know, patient specific risks based
on the unique anatomy and pathology and history
of the patient.
That would ensure that the surgeons are, you
know, being more informed before making decisions,
and that will result in more individualized treatment
plans.
And this would,
further reduce complications and improve surgical precision down
the road, which is really what CMS is
looking for ultimately.
Yeah. And then and then Doctor. Fanucchi,
talk about, just minimally invasive surgery. How will
that evolve in the next two to three
years? I know we discussed a little bit
about endoscopic spine, but how about other minimally
invasive techniques?
Yeah, I think there is a lot of,
exciting
developments that will happen in the next two
to three years when it comes to minimally
invasive spine surgery.
I think, we will see smarter robotics,
and the surgeons will rely more,
on robotics for, you know, both routine and
complex cases.
And that will reduce human error and will
increase consistency.
I think there will be,
more patient centered approaches with advancement in imaging
and augmented reality,
biologics, and so on.
Spine surgery will be more individualized down the
road, and it's going to target the patient's
exact anatomy and pathology,
which will, result hopefully in faster recovery for
the patients.
There will be enhanced precision as well using
AI and augmented reality,
to push the boundaries of precision and personalization
in spine surgery.
And probably one of the most exciting parts
of,
minimally invasive spine surgery in the next couple
of years
is going to be the shift towards outpatient
surgery.
So as we're employing more and more, less
invasive techniques,
we'll see,
even more complex spine surgeries,
being performed in outpatient settings.
And, you know, if you combine all of
those exciting,
areas together, ultimately, we'll see that those changes
will improve,
patient outcomes, decrease recovery times,
decrease the risk of complications,
making spine surgery less invasive,
more accessible,
and, highly efficient.
Absolutely.
Well, doctor Fanous, thank you so much for
joining us today. It's been a pleasure to
speak with you, and I look forward to
connecting with you down the line.
My pleasure.