Dr. Stephen Hochschuler: Future trends in spine – telemedicine, robotics, AI & more

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Orthopedic spine surgeon Stephen Hochschuler, MD, is co-founder of Texas Back Institute in Plano and chairman of the Texas Back Institute Holdings Corporation. Dr. Hochschuler stopped operating two years ago but is still very much involved in the spine field.

A decorated spine surgeon and a former United States Air Force Major, Dr. Hochschuler is also a past-president and founding member of the Spine Arthroplasty Society, now known as the International Society for the Advancement of Spine Surgery. 

Dr. Hochschuler served on the medical board of several device companies and was founding chairman of Innovative Spinal Technologies.

Here, Dr. Hochschuler shares his insight on the development of minimally invasive surgery, new payment models and emerging trends in spine, as well as his plans for the future.

This article was edited for length and clarity.

Question: Minimally invasive surgery seems to have become quite a broad term. What was the first minimally invasive procedure that you performed and how has this trend evolved over the years?

Dr. Stephen Hochschuler: It would be injections. Going back to the '80s you always had epidurals, which was a combination of steroids and an anesthetic. There was something called chymopapain and it worked. In essence, a needle would be placed in the disc and this enzyme would be injected. It would take the pressure off the herniation pressing on the nerve. We did about 200 cases at the Texas Back Institute in the '80s but the problem at that time was that we did not have dual-planar fluoroscopy. So, people were putting in needles and they didn't know where the needle was. Consequently, they injected it into the nerve canal — and the nerves themselves — and it caused big problems. Today nobody injects anything until you've proven where the needle is and with biplanar, antero-posterior and a lateral fluoroscope you know immediately where the needle is. 

At about the same time Parviz Kambin, MD, in Philadelphia started doing endoscopy. Anthony Yeung, MD, myself and one of my partners Richard Guyer, MD, were at his meetings. Because we had chymopapain we decided we wouldn't use the endoscope — why do that when a needle would achieve the desired result? Well Dr. Tony Yeung stuck with endoscopy and has become a real pioneer. Now many others are learning this, and that's minimally invasive. Minimally invasive surgery is becoming bigger and bigger, and outpatient surgery coordinating with it.

Q: Outside of minimally invasive surgery, where do you see the next biggest trend in spine? 

SH: I think telemedicine is going to be bigger and bigger. I think it's the cheapest, fastest expender of healthcare that exists if properly set up. Robotics are going to have to get cheaper so that your quality care, global fees and episodes of care can be reasonably done and reasonably charged. Companies are working on robots that are less expensive, there are new materials now that are better and cheaper, but I think robotics is here to stay. Initially robots, because of FDA approval, all had to be physician controlled. I think with time it's going to be almost like what you see in car manufacturing; you have some amazing robots doing very complex tasks. It will take a while, but it will occur. 

What's becoming very fascinating now as you marry artificial intelligence to robotics, is the FDA is going to have to put a whole new silo in to deal with AI. It's a whole new skillset they're going to need. Either they're going to bring in people who readily understand it and not lengthen the time to approval or they're going to make it very difficult to achieve integration of AI with robots. 

Q: How do you see 3D printing developing in spine? Do you think it will take off as we look for more cost-effective approaches to spinal surgery?

SH: It depends on the quality and the cost of goods. Right now, the big hot thing is 3D printing but some of these are failing. In some cases the quality of implant isn't as good as non-3D printed implants on the market. 

Q: How do you see bundled payments and other value-based models developing in spine? Are there any other methods we can use to make spine surgery more cost-effective without sacrificing quality? 

SH: In my mind the only two people we should count in all of healthcare is the patient and the physician. So the payers, hospital companies, implant companies, attorneys, they're all leeches. What they do is they feed on the system and cause the cost of care to rise. My suggestion would be to look at hospitals as hotels; choose the best hospital with the cleanest record and the lowest price. 

Q: Is retirement in your mind down the line or do you plan to stay involved in the spine industry?

SH: I stopped operating two years ago. The bottom line is I'm always looking downstream. There's no way I'm retiring. Firstly, my wife would divorce me if I were home all the time and secondly; I'd go crazy. But by being involved in the non-surgical aspects of new companies, new ideas, biologics and telemedicine, it keeps my mind going. I think to stay healthy, it's not just about staying physical and dieting, you've got to keep your mind going. So as long as my mind can function, I'll die with my boots on.

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