This is Carly Beam with the Becker Spine
and Orthopedics podcast. I'm thrilled to be joined
today by doctor Dan Chen at Geisinger. Doctor
Chen, thank you so much for being here
today. Thanks for having me. And so before
we dive into our questions, could you introduce
yourself and tell us a bit more about
your background?
Of course. So like you said, you know,
my name is Dan Chen. I'm a double
board certified orthopedic spine surgeon at Geisinger Health.
We're based primarily at, Northeast Pennsylvania and Central
Pennsylvania.
I serve in a couple different positions outside
of just my political role. I'm an I'm
an assistant professor and senator at the the
Geisinger Commonwealth School of Medicine.
I also do, a lot of core faculty
key core faculty teaching for the orthopedic residency
programs,
both in the Northeast and, Central Pennsylvania
in Danville.
My,
my clinical focus is mostly on minimally invasive
techniques,
outpatient surgery,
and then comp, complex spinal reconstructions.
You know, for in most of my clinic
kinda deals with a lot of these, like,
degenerative and
deforming pathologies of the spine,
as well as, you know, a sprinkling of
trauma and infections and some spine oncology here
and there.
In terms of my educational background, I, did
my undergraduate studies in, neuroscience,
at Dartmouth College and Harvard Harvard University.
I went to medical school at the Michigan
State University,
College of Human Medicine, and I completed my,
orthopedic surgery residency
at the University of Toronto.
I stayed in Toronto to complete,
a combined
orthopedic and neurosurgical fellowship,
in complex spine and, trauma surgery, thereafter.
Great. So sounds like you've done a little
bit of everything throughout your entire career.
Yeah. A little bit of everything. Traveled, you
know, to a lot of different places, you
know, meet a lot of different people, different
background. I think, you know, it's been a
it's been it's been quite the ride.
You know, but I think it's been, you
know, it's it's eye opening. Correct. Definitely.
And, you know, when you're looking into the
2025,
what are some of the biggest headwinds you're
anticipating?
Yeah. So I I I kinda think of,
you know, there's kinda two different
categories that I see in terms of kind
of the the upcoming challenges.
And I I kinda broke it down into,
you know, the there's, like, this the the
individual and the the surgeon challenges, like, the
one that I have to deal with myself
and then also the one that are, you
know, more systemic or hospital based, issues. So,
you know, with the first,
with the first challenge, it's just individually,
as a surgeon.
You know, I've I've kind of one of
the biggest challenges that I see is to
figure out how to continue to push the
envelope,
in terms of developing these new, minimally invasive
techniques and to fine tune my own surgical
repertoire,
to better help my patients.
Over the past couple years, I've I've been
a pretty heavy proponent of the, MIS,
TLIF technique.
It's become a very powerful technique in my
hands with, pretty strong outcomes.
But I think there are times when, there
are alternative fusion option that may actually better
serve,
a specific patient's,
pathology.
And so,
one of the biggest challenges for me in
the last year or two is to develop
some of these other alternatives and fine tune
those, skills,
one of which has been,
to develop a more minimally invasive,
pronelateral
spine surgery. So,
you know, I think prone lateral surgery has
been growing in the last couple years with,
you know, growing in popularity for, you know,
a whole bunch of different reasons. I think
there's, you know, many benefits of of prone
lateral surgery because it allows,
simultaneous
access to both, the posterior and anterior columns
of the spine.
So it allows you to do all your
your decompression work, your screw and rod placement,
as well as access,
the disc space in the front all in
one go instead of having to,
reposition the patient, like, more like so for
an a lift or for, like, traditional lateral
surgery.
So I think that certainly helps with, operative
efficiency.
And then the the second the,
the second kind of front that I look
at from from my
own, you know, my own personal development is,
you know, developing a,
orthopedic
endoscopic
spine practice.
We've we've been working with our local, same
day surgical center
to try and build up this program. I
think,
you know, certainly there's regulatory and and the
financial, difficulties with that.
But I think endoscopy, you know, endoscopy has
come a long way since since its first,
development many years ago.
And, certainly, there are benefits that I can
see, you know, if we can bring this
program to our our system. You know, certainly,
that's that's another, area that you know, it's
another treatment option that patients patients can have
versus our traditional open, techniques.
Could you dive into how you're tackling
some of the regulatory and financial challenges both
with endoscopic
and,
anything
standing the way of proned lateral spine surgery?
Yeah. So I think I think what pronelateral
surgery,
so so the
the,
I think one of the biggest challenges is
to,
bring in the right vendors
to have,
the right retractors and the right implants. A
lot of
the pro lateral work that I'm doing right
now is, in many ways, is kind of
MacGyver from
more traditional lateral or or posterior,
lumbar surgeries that I'm kind of putting together
to make to make it work.
But there are companies out there that are
very focused purely on pro lateral surgeries, and
and so they have these, like, you know,
these very specific implants or very specific retractors
that make this make the technique a lot
easier.
But, of course, one of the biggest problem
with adopting that is to bring, you know
especially in a in a cost health care
system that's as big as Geisinger.
You know, there is a lot of, moving
parts and, you know, there are, you know,
major contracts that have to be changed in
order to bring these smaller companies in. There's,
you know, then then, of course, there's the
financial aspects too. You know, how much is
this gonna cost?
You know, what is actually is the reimbursement?
What's the return on something like that?
So, certainly, you know, right now, it's I
think it's still a bit of a MacGyver
technique, but it does work.
It just may not work as well as
I would like it to.
So, certainly, that's that's, my area of,
you know, for for for development later on
in the year.
Kind of this I would say it's about
the same thing with,
the, you know, the endoscopic side of things.
You know, endoscopy is upcoming.
I think there are still major issues with,
you know, figuring out the the, the CPT
codes
and the exact reimbursements. You know, some some
of these insurance companies are still is still
calling it experimental.
Certainly, that that's gonna cause a lot of
issues for for reimbursement.
And so, you know, when the when the
health care administration, when they look at when
they look at it, you know, whether or
not they're gonna approve of bringing such a
program
into the system
and they start looking at the returns on
that, it it it sometimes it can be
very hard to justify
why we should spend,
you know, $6.06 figures
to bring in these trades and these these,
these instruments
and these towers
when the return
the financial return doesn't really make any sense.
Mhmm. So that's that's that's certainly a fight.
That's an ongoing fight, I'm sure, at many
many places.
So we'll so we'll see. We'll see how
that goes.
Yeah. And then turning to you mentioned,
some systemic
headwinds as well in health care.
How are you thinking about
that in in your work?
Certainly.
And I'm sure this is gonna sound like
a broken record at this point.
But, you know, I think, you know, this
is I think this is an interesting time.
Right? We we live Right. In a in
a period
where the, you know, the
the the the regulatory environment is constantly changing
and evolving.
And, you know, physician reimburse at least the
relative physician reimbursements continue to draw.
You know, now we have kind of these,
you know, questions about what's gonna happen to
a lot of the, you know, the the
patients that have, like, government insurance.
You know, are they gonna get kicked off
of it? Are they gonna you know, how
many people are are are going to, you
know, have insurance? Right? And and so that's
I think for some for a system as
big as Geisinger, it certainly is going to
be a I I foresee it as being
a problem. You know, Geisinger overall is is
a rural,
health care system,
and we have a pretty large government payer
mix. You know? And I think that's the
truth. And then so, you know, if all
these patients are,
you know, are are they gonna lose their
insurance,
yeah, I think it's gonna cause a lot
of issues,
in terms of staying financially viable.
And so
I think, ultimately, what is that gonna translate
to? Well, typically,
you know, when that when something like that
happens, it often means, you know,
major staffing cuts.
It means, cut cutbacks on on the services
that we can provide.
And, typically, from a physician standpoint, it often
means that we're expected to do more and
more,
but with less and less.
So, certainly, that can be a strain on,
you know, the whole system. And, hopefully, we
have some plans in store, in place to
to counteract that. You know? I I think
I think there's, you know, I'm I'm all
for running like a like a lean efficient
practice. I think that's great if if it's
possible.
But I think it's we had we had
to be really careful to, you know, not
let, like, the the quality of our patient
care and outcomes, like, suffer because of that,
you know, with a limited resource, we it's
always this kind of careful balance between
being efficient
but also having the good outcomes.
Like a tight rope, it sounds like.
It is. Absolutely. Ex especially for for a
system like Geisinger.
You know, I I I think I think,
you know, with with the number of government
government insurance patients that we have in our
in in our, you know, in our overall
patient population here, you know, I think that's
gonna be a major headwind,
you know, in the next six months, year,
two years. So Yeah. And, you know, you
think it has.
How are you
talking about these
developments
with your residents that you work with? How
are you preparing them
to face these challenges then when they go
on either in private practice or with a
health system like Geisinger?
You know, that I think that is an
excellent question. Thank you. When when I when
I was going through residency in fellowship, I
I really had no
no training on any of this stuff, like,
about, you know, the health care, like, you
know, health care policies and the reimbursements and
all that. Like, all the, like, the the
practical matters, I didn't get any of that
stuff. And I think most people don't.
But I think nowadays,
you know, not only do do these residents
have to learn all the all the medical
and surgical education and the techniques and all
that stuff, but I think it's really important
that they start to understand
just like the the different,
you know, the different types of practices that
they can join, the the pros and cons
of each one, whether, you know, it's a
a major academic hospital, whether it's an employed
model, whether it's private practice,
you know. And and not to say one
is better than the other, but but they
all have their own pros and cons.
And I think it's really just about it's
about informing them of, like, these you know,
just try to give them as much of
the information as possible and kind of let
let let them make their own decisions on
on what they wanna do with their life
and their career.
Mhmm. But just try to keep them as
informed as possible.
Absolutely. And then, obviously, you know, we're discussing
a a lot of the challenges, but I
also want to pick your brain on some
what are the most exciting areas
of spine technology
for you? I know you touched someone endoscopic
endoscopic
and proned lateral,
but, like, what other areas
in spine surgery make you optimistic
about the next coming years?
Yeah. So I I think I think, you
know, from from a technology and and,
implant implant standpoint, I think spine surgery is,
at at least in the last maybe five,
ten years, I I feel like it's a
kind of undergoing or renaissance of, you you
know, all these, like, small and large companies.
You know? They're all coming up with these
new new toys and new,
new devices. You know? They're all trying to
experiment. They're all trying to innovate.
And it kinda reminds me of,
you know, maybe about fifty,
sixty years ago when when when hip and
knee or when the hip and knee arthroplasty
field was kinda like the same thing where,
you know, everybody's coming up with their own
designs for for, you know, the ball and
stem,
you know,
you know, and then they're all just trying
to to to find what's the best thing.
And I feel like slime is kind of
in that
kind of entering that phase now, which is
really exciting.
For me, you know, I I I see
I kinda see three areas of major growth,
for spine that I'm I would say I'm
the most excited about.
First one we kinda talked about already is,
you know, endoscopy. Endoscopy, you know, it's been
around like, the the idea of endoscopic spine
surgery, it's it's been around for, like,
I don't know, like, forty, fifty years or
so.
But, really, I think only in the last,
like, maybe five to ten
years has, like,
the technology
really grown. You know, we nowadays, we have
much better visualization.
We have, you know, all these new techniques.
We have these new, expandable
implants that that can go down the tube
to help you produce you know, not only
do a decompression or a discectomy, but also
do, like, a, like, a endo lift or,
like, endo endo endoscopic fusion.
And then on top of that, you couple
that with with all the navigation technologies nowadays.
I mean, I think I think endoscopy
is is I'm hope I think it's gonna
it's here to stay.
I think it's gonna continue to develop.
You know, right now, most people, when people
think endoscopy, they think, you know, laminectomies, decompression,
discectomies.
But I think later on, as as the
technology continues to grow, I think it's gonna
become the new
minimally invasive lumbar fusion surgery.
You know, the the the new MIS T
lift or the new MIS lift.
I think at some point, once the once
the technology gets there, it's gonna be I
think it's gonna grow a lot, especially with,
you know, if if the
you know, from an insurance and reimbursement standpoint,
all that stuff gets figured out,
I think there's gonna be much wider adoption
of these techniques.
So that's really exciting for me. The second
area is cage design. So so, I'm I'm
I'm really for one reason or another, I'm
really into, talking about cages and, like like,
different,
technology involving, you know, interbody cages. And there's
and nowadays,
I feel like there's been, like, this explosion
of,
variability in in cage design. You know, every
company has so many different types of cages,
you know, different footprints, different materials, different,
expansion mechanisms.
And I think I think the fact that
there are so many
different
options available right now means that nobody really
knows what what the right answer is.
And so, you know, everybody kind of you
know, it's like a renaissance. Everybody's everybody's experimenting.
Everybody's trying to see what's the best.
Yeah. I was gonna I was gonna just,
interject here real quick. So and, you know,
without, like, naming names, if you can give
just kind of, like, an when it comes
to spying pages, can you kind of just
give, like, a a real quick,
sixty second
overview of the most
exciting
change or improvement you've seen in these designs?
Again, without necessarily naming company names, but just
kind of overall what's, like, a general trend
in design that's
you noticed?
I think one of the biggest so as
a as a MIS surgeon, I what I've
noticed is that, you know, the the traditional
expandable
cage,
it goes in and it expands only in
the cranial caudal direction. So so, basically, it
gets taller, and that's it. But nowadays, there
there are more and more companies developing these,
like, what we call bivector cages where it
goes in. You know, it essentially goes in
as small as possible,
and it and it's able to expand not
only in the cranial caudal direction, but also
the the medial lateral direction. So the thing
the thing starts to open up, like, its
footprint
starts to, like, double to the point where
it's almost the size of an ALIF.
And so, you know, there there are many,
many benefits to that. So
one is you get a lot of theoretically,
you get lower subsidence rates. You have a
much bigger graph window. You know, if you
have a bigger footprint, it means that you
have you're usually able to put more force
on your reduction. So when you expand,
you might be able to produce more lower
doses or a better,
correction,
for the patient.
Oh, that's fascinating. That's fascinating.
And then can you dive in, into the
last, area of spine technology that you were
gonna discuss?
Yeah. So the last one, I think, is
arthroplasty.
It's specifically lumbar arthroplasty. I think,
you know, I think cervical and lumbar arthroplasty
ideas have been around for for quite a
while, kinda like kinda like, endoscopy.
I think at this point, cervical arthroplasty is
very well accepted, you know, because we already
do ACVFs all the time. It's quite simple
to just you know, instead of putting in
a cage, you put in a, you know,
an artificial disc. That that part, I think,
is
more
or less, I would say, well accepted.
I think the thing that's not as well
accepted nowadays is is Luvart disc arthroplasty. And,
I think, you know, there there are some
major centers around the country that are doing
them routinely,
But I would say for the average spine
surgeon,
I don't think it's a common thing to
see. And I think the evidence is not
not quite there yet in terms of, you
know I think the biomechanics is not quite
the same as as a
as a cervical arthroplasty.
But I think for for me, you know,
what what's really exciting about this motion sparing
technology
is is that nowadays, there are these companies
that are coming out where,
you know, not only are you trying to
change the disc in the front, you're also
addressing the pathology in the back. So, you
know, the way I the way I think
about,
lumbar arthroplasty, it's kinda like, you know, if
you if you have a tricycle, right, so
you got a big wheel in the front,
you got two little wheels in the back.
Well, if if those wheels are starting to
wear out,
usually, it's not just the front wheel that
wears out. It's it's the front and the
ones the little guys in the back. So
when you do a disc arthroplasty, all you're
doing is that you're addressing the pathology in
the front without without addressing the stuff in
the back. So nowadays, there are companies that
have,
facet replacement or facet arthroplasty where you're addressing
the pathology in the back.
You have other companies that are actually, you
know, purely through through a pure posterior approach
and sometimes even minimally invasive approach.
You can address
both the front pathology
and the back pathology. So, you know, it's
like it's like changing out all three wheels
of the tricycle instead of just replacing the
big wheel on the front.
A great way to put it.
And my last question is just worse are
there any other big opportunities
that you're
seeing that you're excited for in terms of
growth?
You know, I think outside of,
I think outside of the implant implant space,
I think, you know, artificial intelligence is certainly,
you know, it's it's been kinda like this
hot topic, and, you know, everybody's kinda publishing
on, you know, the benefits and the pros
and cons of AI AI. You know, I
think I think the overall consensus is still
up in the air about how great AI
is. But I think,
you know, with more and more of these
studies coming out looking at how AI can
be can help us predict
patient outcomes,
I think at some point down the line,
once we have enough data, once we have
a a strong enough
system or predictive system,
I think
one day, we may be we may be
able to use that.
You know, we can input patient demographics
or radiographic
out you know, radiographic,
numbers
and have AI essentially recommend to us, like,
hey. Based on these things,
we think that,
you know, if you do, you know, a,
b, and c,
this patient is gonna have the best outcome.
You know, if we can get to that
point, I think that would be that would
be amazing.
Absolutely. That we can then standardize we really
standardize,
spine care because I think, you know, unlike
unlike hip and knee arthroplasty nowadays, you know,
spine care is just
there is, like, so much variability
in in in what a spine surgeon would
recommend. You know? My my my mentors have
always told me, you know, if you have
if you ask 10 spine surgeons for a
for an answer, you're gonna get 11 ants
you're gonna get 11 answers.
And and I think that says a lot.
You know? Like,
because nobody really has,
like, the I don't I don't think there's
much of a consensus right now in spine
surgery,
which means does does that mean that everybody
is does that mean everybody's right? I don't
think so. Right? It can't that can't be
right. So I think I think at some
point down the line, you know, with AI,
with with better outcomes with better outcome measures
and and and,
research,
I think at some point, it's gonna become
a lot more standardized, like, kinda like the
hip and knee world,
you know, whether or not somebody should get
a hip replacement or knee replacement. I think
it's gonna start to eventually head that direction.
Definitely. And hopefully, it'll get there sooner than
later.
Maybe. Maybe. I don't know. I mean,
I would say, you know, it took it
took hip and knees,
like, forty, fifty years
Yeah. To kinda get there. I think I
would say maybe in my
in my career, I I I think it's
gonna come, but I I suspect it'll be
kinda near the tail end, maybe. Yeah.
So we'll see. We'll see. But it is
exciting.
Definitely. Definitely.
Well, thank you, doctor Chen for joining us
today. This has been a great conversation,
and I look forward to connecting with you
again down the line. Awesome. Awesome. Thank you
so much. I really appreciate it.