This is Carly Beam with the Becker Spine
and Orthopedics podcast. And today, I'm thrilled to
be joined by doctor David Skaggs, co director
of Cedars Sinai Spine.
Doctor Skaggs, thank you so much for being
here today.
Hello. Thanks for having me. Love Beckers. Love
keeping up with, what's new in spine.
Thank you. I'm glad to hear it. And
before we dive into our questions, can you
introduce yourself and tell us a bit about
your background?
Sure. Absolutely. I'm now the co director of
spine at Cedars Sinai along with doctor Alex
Tuchman, who's the neurosurgical co director. We probably
have about 30 spine surgeons here. We run
seven or eight spine rooms a day
and believe very deeply that a combination of
neurosurgeons and orthopedic surgeons working together deliver the
best spine care.
I was here for five years. Before that,
I was at Children's Hospital Los Angeles for
twenty five years,
And it's, been very invigorating and eye opening
to come to an adult spine center
and honestly learn about some of what we're
gonna talk about today, new technology and how
we could make spine care better for children
with new technology.
Absolutely. And so I know you have a
lot of expertise in pediatric
pediatric spine
area as well. Can you, go through some
of the the biggest innovations that you've seen
develop in,
last few years?
Yes.
So one of the biggest is just happening
right now.
It is getting a synthetic
CT
from an MRI.
And it's probably most important in children because
children are most,
susceptible
to radiation.
And what it is, it's one of the
few things I've seen in medicine where AI
actually makes a difference, you know, in practical
terms.
And now what happens is when we get
an MRI,
a CT
comes out. In addition,
really just doing one quick sequence, you know,
might take a few minutes longer, and you
can get an amazing quality CT that's accurate
to within one millimeter,
you know, including three-dimensional
reconstructions.
So for pediatrics, what this does, you know,
is save,
children from unnecessary
radiation.
But if we think bigger picture in adult
spine, what it could also do is save
people from getting two studies.
So instead of someone being sent for an
MRI and it is separate time being sent
for a CT,
it could all be done at once.
Mhmm. So sounds like it's a real win
win both for children
and adults as well. Yeah. And if you
don't mind, there's eve even more to this
one. Yeah. One of the biggest advances,
you know, in the past decade or so
in spine surgery has been using navigation
intraoperatively
and robotics
intraoperatively.
And up until now, that has required
a CT scan.
And now we can use this synthetic CT,
the proprietary,
name right now is called bone MRI.
We can load that up into navigation,
and or robotics.
And all of a sudden, we don't radiate
the patient,
at any point for navigation
or robotic usage,
which is a a complete game changer.
Yeah. And and I'm wondering, you know, when
working with pediatric patients, you're obviously
smaller patients that are also
still growing. What kind of
developments are you excited about in terms of
just having tools or navigation technologies that are
tailored to them?
Yes. Great question. So, you know, I have
to admit, I never even saw a robot
until I came to Cedars.
And next thing you know, I'm really just
trying to meet my colleagues and go into
the rooms and seeing, wow, they're doing
incredible surgery through tiny incisions.
And, one of my partners, doctor Corey Walker,
who was trained at Barrow Institute with Juan
Eirebi,
taught me how to use a robot.
And in,
young athletes, and I'll say, you know, kids
in college and high school, they frequently have
something called spondylolysis,
which basically means it's a fracture most commonly
of l five.
And in the old days, to fix this,
you had to open them up and put
in screws and rods and hooks. And now
with the use of a robot, we could
literally make a two centimeter incision or even
less
and put a screw or screws
perfectly across the fracture site. And I never,
you know, back in my days at Children's
Hospital, imagine I'd be doing outpatient
pediatric spine surgery.
But the use of robotics and navigation have
really changed what we can do.
And are there any lessons that you've learned
in your time working with adult patients and
your colleagues, you know, that you can carry
over to working with pediatric patients?
Yes. Absolutely. And,
one of the things that adult surgeons
have taught us
is how to align the spine
in a way that leads to long term
back health and avoiding back pain.
And, you know, not to be too technical
here, but when we do spondylolisthesis
surgery, probably the most important thing is we
get l four to s one to at
least a 35 degree, if not, you know,
40 or 45 degree angle. And as long
as we have the lower lumbar lordosis L4
through S1
to be 35 degrees or over, there's a
pretty good chance that we're setting the patient
up for long term back health and to
be, you know, free of significant back pain
due to malalignment.
And this is new. This comes from the
adult world. And if I wasn't, you know,
sitting in a bunch of meetings, learning from
my adult colleagues, I probably wouldn't be doing
as good of a job on children as
we are now.
That's really cool to hear. And so so
it sounds like less ray radiation,
new developments and tools, and just new approaches
is what's really
the future of pediatric spine.
Yeah. Yeah. I learned something interesting. I had
a spine fellow last year named Vivian Chan,
who's a neurosurgeon.
And when using different implants, she says, I
can't get my hands around this.
And I've now designed five lines of spinal
instrumentation. I realized every time I design
a tool, I put it in my hands.
I go, yep. This feels good. So I
have size eight hands and I realized, you
know, I owe everyone in the world with
small hands an apology.
Because without knowing I've been designing things for
people with big hands. And my fellow doctor
Chan had size five point five hands, so
she couldn't quite get her hands around things
designed for size eight hands.
So
I think that this is gonna become increasingly
important
as we have more women in spine surgery
and we have more people with small hands
in spine surgery. So I think the enlightened,
companies are gonna start designing
spine
tools for people with small hands.
So I I view that as, something I
have to apologize and we all have to
do better at. And doctor Scabs, there's one
other thing I wanted to ask you is,
you know, what can training programs for spine
surgeons do to better equip them to be
leaders
in, you know, adapting these pediatric spine tools?
So I think
one of the most
important parts about being a
pediatric spine surgeon is getting enough experience.
So the truth is there just aren't that
many children in the world who need spine
surgery, and there's not that many centers in
the world that do enough of it to
train someone.
So it's highly specialized with small numbers.
And if somebody really wants to be a
pediatric spine surgeon,
they either have to go to a pediatric
orthopedic fellowship with a huge amount of spine
experience,
and there's probably only a handful of those,
or do a true spine fellowship
and then do additional time,
at a busy pediatric spine center.
And I think this raises a larger question
of, you know, how are spine surgeons training?
And there's now so many new techniques that
many people are feeling increasingly you can't learn
it all in one year.
And here, I think the neurosurgeons were a
bit ahead of the orthopedic surgeons having enfolded
fellowships.
So So without increasing the length of a
fellowship,
neurosurgeons are able to do one year of
a spine fellowship during their residency.
And then if they wanna do something special
or go into academics, or I'd say probably
more common than not, they then do an
additional
post residency year fellowship.
So a lot are doing essentially two years
of spine fellowship.
And I think that, the next step for
orthopedics is if people are going into spine,
the PGY five years should probably be all
spine and then do an additional,
year of spine surgery. So I think increasingly,
if people are gonna subspecialize
in
endoscopy,
MIS, robotics, tumor, pediatric spine, you know, whatever
it is,
there's gonna have to be a little bit
of additional training because there's really just too
much to learn for one year to know
all of spine and really be good at
it all.
Right. And just sounds like really you wanna
be able to master the specific area and
type of surgery of the spine that you
wanna hone in on.
Yes. Yep. And, you know, it's just
like cardiac surgery
branched on its own, plastics did, vascular did.
You know, as we know more and more,
we have to admit that we're not experts
at everything. You know, the general practitioner
is not doing heart surgery, spine surgery and
vascular surgery.
Got it. And doctor Skaggs, my last question,
I wanna ask you, what are two or
three of the biggest healthcare trends that you'll
be following headed into 2026?
Oh, you know, people get tired of hearing
about
cutbacks in the government, but I think that
that's going to
affect us a lot over the oncoming years.
You know, there's been good studies in the
past showing that if
a doctor sees a patient on government insurance
such as Medicaid, they actually lose money
because their overhead is more than Medicaid pays.
So we're starting already from a bad place
of access.
And if
that government support is gonna be cut back
even more, I think the patients on Medicaid
are gonna have even more difficult time with
access to medical care. So I think that's
one of them. And, you know, throw on
top of it the academic centers are being
cut back on research.
You know, I think that it's gonna take
a long time of going downhill before we
have any possibility of unwinding this all. So
that's a negative.
The positive and it almost sounds trite to
talk about AI,
but I think that AI really is going
to offer us,
solutions
that are better,
faster, and less expensive than existing technology.
You know, I think radiology
may be leading the field in this. You
know, I could imagine many different options such
as neuro monitoring during spine surgery. You're doing
some great work at Columbia University with Michael
Vitale.
We're using
AI.
They could
predict
when
a surgeon is about to lose neuro monitoring,
you know, basically meaning the the patient is
going paralyzed.
You can predict it twenty minutes earlier if
AI interprets
compared to what we do today is having
a neuro monitoring technician, a human being look
at it. So I think that AI is
really gonna make things safer.
Absolutely.
Well, doctor Skaggs, thank you so much for
joining us today. It's been a pleasure speaking
with you, and I look forward to connecting
again down the line.
Thank you so much. It's great talking to
you. Hope we've helped. Have a great day.
Thank you.