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This is Carly Beam with the Becker Spine

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and Orthopedics podcast. And today, I'm thrilled to

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be joined by doctor David Skaggs, co director

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of Cedars Sinai Spine.

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Doctor Skaggs, thank you so much for being

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here today.

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Hello. Thanks for having me. Love Beckers. Love

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keeping up with, what's new in spine.

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Thank you. I'm glad to hear it. And

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before we dive into our questions, can you

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introduce yourself and tell us a bit about

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your background?

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Sure. Absolutely. I'm now the co director of

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spine at Cedars Sinai along with doctor Alex

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Tuchman, who's the neurosurgical co director. We probably

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have about 30 spine surgeons here. We run

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seven or eight spine rooms a day

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and believe very deeply that a combination of

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neurosurgeons and orthopedic surgeons working together deliver the

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best spine care.

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I was here for five years. Before that,

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I was at Children's Hospital Los Angeles for

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twenty five years,

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And it's, been very invigorating and eye opening

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to come to an adult spine center

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and honestly learn about some of what we're

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gonna talk about today, new technology and how

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we could make spine care better for children

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with new technology.

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Absolutely. And so I know you have a

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lot of expertise in pediatric

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pediatric spine

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area as well. Can you, go through some

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of the the biggest innovations that you've seen

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develop in,

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last few years?

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Yes.

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So one of the biggest is just happening

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right now.

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It is getting a synthetic

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CT

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from an MRI.

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And it's probably most important in children because

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children are most,

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susceptible

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to radiation.

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And what it is, it's one of the

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few things I've seen in medicine where AI

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actually makes a difference, you know, in practical

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terms.

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And now what happens is when we get

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an MRI,

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a CT

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comes out. In addition,

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really just doing one quick sequence, you know,

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might take a few minutes longer, and you

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can get an amazing quality CT that's accurate

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to within one millimeter,

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you know, including three-dimensional

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reconstructions.

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So for pediatrics, what this does, you know,

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is save,

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children from unnecessary

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radiation.

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But if we think bigger picture in adult

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spine, what it could also do is save

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people from getting two studies.

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So instead of someone being sent for an

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MRI and it is separate time being sent

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for a CT,

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it could all be done at once.

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Mhmm. So sounds like it's a real win

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win both for children

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and adults as well. Yeah. And if you

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don't mind, there's eve even more to this

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one. Yeah. One of the biggest advances,

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you know, in the past decade or so

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in spine surgery has been using navigation

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intraoperatively

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and robotics

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intraoperatively.

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And up until now, that has required

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a CT scan.

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And now we can use this synthetic CT,

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the proprietary,

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name right now is called bone MRI.

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We can load that up into navigation,

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and or robotics.

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And all of a sudden, we don't radiate

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the patient,

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at any point for navigation

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or robotic usage,

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which is a a complete game changer.

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Yeah. And and I'm wondering, you know, when

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working with pediatric patients, you're obviously

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smaller patients that are also

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still growing. What kind of

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developments are you excited about in terms of

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just having tools or navigation technologies that are

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tailored to them?

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Yes. Great question. So, you know, I have

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to admit, I never even saw a robot

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until I came to Cedars.

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And next thing you know, I'm really just

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trying to meet my colleagues and go into

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the rooms and seeing, wow, they're doing

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incredible surgery through tiny incisions.

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And, one of my partners, doctor Corey Walker,

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who was trained at Barrow Institute with Juan

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Eirebi,

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taught me how to use a robot.

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And in,

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young athletes, and I'll say, you know, kids

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in college and high school, they frequently have

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something called spondylolysis,

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which basically means it's a fracture most commonly

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of l five.

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And in the old days, to fix this,

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you had to open them up and put

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in screws and rods and hooks. And now

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with the use of a robot, we could

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literally make a two centimeter incision or even

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less

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and put a screw or screws

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perfectly across the fracture site. And I never,

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you know, back in my days at Children's

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Hospital, imagine I'd be doing outpatient

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pediatric spine surgery.

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But the use of robotics and navigation have

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really changed what we can do.

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And are there any lessons that you've learned

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in your time working with adult patients and

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your colleagues, you know, that you can carry

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over to working with pediatric patients?

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Yes. Absolutely. And,

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one of the things that adult surgeons

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have taught us

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is how to align the spine

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in a way that leads to long term

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back health and avoiding back pain.

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And, you know, not to be too technical

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here, but when we do spondylolisthesis

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surgery, probably the most important thing is we

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get l four to s one to at

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least a 35 degree, if not, you know,

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40 or 45 degree angle. And as long

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as we have the lower lumbar lordosis L4

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through S1

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to be 35 degrees or over, there's a

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pretty good chance that we're setting the patient

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up for long term back health and to

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be, you know, free of significant back pain

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due to malalignment.

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And this is new. This comes from the

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adult world. And if I wasn't, you know,

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sitting in a bunch of meetings, learning from

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my adult colleagues, I probably wouldn't be doing

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as good of a job on children as

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we are now.

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That's really cool to hear. And so so

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it sounds like less ray radiation,

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new developments and tools, and just new approaches

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is what's really

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the future of pediatric spine.

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Yeah. Yeah. I learned something interesting. I had

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a spine fellow last year named Vivian Chan,

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who's a neurosurgeon.

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And when using different implants, she says, I

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can't get my hands around this.

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And I've now designed five lines of spinal

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instrumentation. I realized every time I design

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a tool, I put it in my hands.

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I go, yep. This feels good. So I

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have size eight hands and I realized, you

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know, I owe everyone in the world with

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small hands an apology.

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Because without knowing I've been designing things for

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people with big hands. And my fellow doctor

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Chan had size five point five hands, so

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she couldn't quite get her hands around things

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designed for size eight hands.

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So

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I think that this is gonna become increasingly

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important

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as we have more women in spine surgery

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and we have more people with small hands

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in spine surgery. So I think the enlightened,

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companies are gonna start designing

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spine

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tools for people with small hands.

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So I I view that as, something I

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have to apologize and we all have to

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do better at. And doctor Scabs, there's one

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other thing I wanted to ask you is,

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you know, what can training programs for spine

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surgeons do to better equip them to be

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leaders

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in, you know, adapting these pediatric spine tools?

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So I think

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one of the most

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important parts about being a

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pediatric spine surgeon is getting enough experience.

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So the truth is there just aren't that

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many children in the world who need spine

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surgery, and there's not that many centers in

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the world that do enough of it to

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train someone.

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So it's highly specialized with small numbers.

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And if somebody really wants to be a

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pediatric spine surgeon,

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they either have to go to a pediatric

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orthopedic fellowship with a huge amount of spine

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experience,

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and there's probably only a handful of those,

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or do a true spine fellowship

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and then do additional time,

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at a busy pediatric spine center.

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And I think this raises a larger question

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of, you know, how are spine surgeons training?

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And there's now so many new techniques that

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many people are feeling increasingly you can't learn

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it all in one year.

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And here, I think the neurosurgeons were a

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bit ahead of the orthopedic surgeons having enfolded

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fellowships.

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So So without increasing the length of a

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fellowship,

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neurosurgeons are able to do one year of

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a spine fellowship during their residency.

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And then if they wanna do something special

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or go into academics, or I'd say probably

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more common than not, they then do an

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additional

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post residency year fellowship.

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So a lot are doing essentially two years

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of spine fellowship.

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And I think that, the next step for

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orthopedics is if people are going into spine,

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the PGY five years should probably be all

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spine and then do an additional,

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year of spine surgery. So I think increasingly,

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if people are gonna subspecialize

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in

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endoscopy,

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MIS, robotics, tumor, pediatric spine, you know, whatever

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it is,

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there's gonna have to be a little bit

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of additional training because there's really just too

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much to learn for one year to know

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all of spine and really be good at

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it all.

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Right. And just sounds like really you wanna

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be able to master the specific area and

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type of surgery of the spine that you

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wanna hone in on.

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Yes. Yep. And, you know, it's just

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like cardiac surgery

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branched on its own, plastics did, vascular did.

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You know, as we know more and more,

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we have to admit that we're not experts

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at everything. You know, the general practitioner

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is not doing heart surgery, spine surgery and

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vascular surgery.

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Got it. And doctor Skaggs, my last question,

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I wanna ask you, what are two or

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three of the biggest healthcare trends that you'll

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be following headed into 2026?

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Oh, you know, people get tired of hearing

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about

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cutbacks in the government, but I think that

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that's going to

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affect us a lot over the oncoming years.

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You know, there's been good studies in the

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past showing that if

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a doctor sees a patient on government insurance

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such as Medicaid, they actually lose money

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because their overhead is more than Medicaid pays.

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So we're starting already from a bad place

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of access.

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And if

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that government support is gonna be cut back

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even more, I think the patients on Medicaid

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are gonna have even more difficult time with

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access to medical care. So I think that's

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one of them. And, you know, throw on

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top of it the academic centers are being

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cut back on research.

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You know, I think that it's gonna take

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a long time of going downhill before we

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have any possibility of unwinding this all. So

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that's a negative.

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The positive and it almost sounds trite to

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talk about AI,

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but I think that AI really is going

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to offer us,

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solutions

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that are better,

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faster, and less expensive than existing technology.

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You know, I think radiology

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may be leading the field in this. You

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know, I could imagine many different options such

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as neuro monitoring during spine surgery. You're doing

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some great work at Columbia University with Michael

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Vitale.

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We're using

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AI.

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They could

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predict

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when

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a surgeon is about to lose neuro monitoring,

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you know, basically meaning the the patient is

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going paralyzed.

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You can predict it twenty minutes earlier if

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AI interprets

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compared to what we do today is having

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a neuro monitoring technician, a human being look

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at it. So I think that AI is

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really gonna make things safer.

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Absolutely.

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Well, doctor Skaggs, thank you so much for

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joining us today. It's been a pleasure speaking

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with you, and I look forward to connecting

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again down the line.

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Thank you so much. It's great talking to

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you. Hope we've helped. Have a great day.

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Thank you.