Dr. Eeric Truumees on the year ahead and his hopes for the North American Spine Society 

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Eeric Truumees, MD, was named president of the North American Spine Society earlier this month. Dr. Truumees practices at Texas Spine and Scoliosis and is a professor of orthopedic and neurological surgery at the University of Texas-Dell Medical School, both in Austin.

He spoke with Becker's Spine Review about his plans for the North American Spine Society and his outlook on the spine industry going forward.

Note: This conversation has been lightly edited for clarity and length.

Question: What do you hope to achieve as NASS president?

Dr. Eeric Truumees: COVID has changed some of our big goals and smaller, short- and medium-term goals. But I think it's also provided us some opportunities on top of the challenges. I think one of those is increasingly moving some of the vast archives of educational and other materials we have into user-friendly formats online and meeting our members where they are in terms of educational needs and professional development.

Q: What were some of the bigger challenges, and how did NASS adapt to that?

ET: I think there's some issues around how any medical society works, in terms of in-person meetings and the financial implications of that. Those are things that NASS on the staff side, including [NASS Executive Director] Eric Muehlbauer, have done a great job addressing. 

But I think another big challenge in our coming year has to do with financial challenges coming from CMS and payers. There's this big change in the [relative value unit] conversion factor for the orthopedic and neurosurgical spine specialists that make up a big part of our organization, as well as a number of the codes of the procedures we do being devalued.

Another big goal for us this year is the ability to address through advocacy and other means these other hits to the solvency of our practices, among other things.

Q: What areas of spine are NASS members keen on exploring in 2020-21?

ET: I think there's several areas that are really hot topics in spine research right now and can and probably will do a lot to change the field overall. One of those is the era of big data from new registries coming online to the increasing use of insurance and CMS databases. 

One of the problems in spine care is determining the optimal treatment pathway. What's the optimal period of nonoperative care?  What treatments are most effective, durable and cost-effective? For example, when someone has multilevel degenerative change and mild, moderate and severe stenosis at different levels, how many of these problems should be treated at once? With machine learning of large databases, will we be able to better delineate the benefits of limited surgery versus the risk of reoperation for adjacent segment problems?  As we have with some of the risk assessment tools now available online, we can use this information as part of the shared decision-making process with our patients.

I think looking at that data and increasingly using things like machine learning and artificial intelligence tools to crunch those numbers will give us a more detailed guidance for our patients when we're engaging them in shared decision-making. 

On the surgical side, there have been a number of enabling technologies that continue to excite a lot of interest. We've been using robotics and guidance systems over the last few years and those are getting better. 

We've seen a great deal of interest in virtual reality tools across a number of domains. Virtual reality may be a powerful way of increasing engagement with and enhancing the impact of online learning. Surgical simulators using a real patient's data may improve efficiency and safety at the time of surgery. When these tools become more available as enhanced visualization instruments in surgery, they may improve safety, decrease neck strain and continue the trend of larger procedures through incisions that are less damaging to surrounding normal tissue.

Q: How will you manage your clinical practice with your role as president?

ET: While most of my time is spent in clinical practice, I also have some administrative, research and educational responsibilities. Each of these will be impacted differently. Our multidisciplinary group includes nonoperative spine specialists (from Physical Medicine and Rehabilitation), as well as neurosurgical and orthopedic spinal surgery specialists. This gives me a great deal of backup when my NASS responsibilities take me away from the practice.
I suspect the time commitments associated with being NASS president will be a challenge, but luckily my partners share the academic and service goals that have always been a big part of my practice. So they understand and they're happy to pitch in what I'm a little less available for trauma call and last-minute consults and things like that.

Even there with COVID-19, the amount of travel that used to be a big part of the NASS presidency has gone down. So I guess it remains to be seen just how much of an impact it will have on the day to day.

Q: What spine research are you currently engaging in? Is there anything particularly innovative you see on the horizon?

ET: Most recently we've been very interested in how to address a fixation, that is, how much do you use and how do you use it in patients with multilevel cervical degenerative problems? A big issue for us with the aging of the population is how do you address bone quality issues and how they impact both operative and nonoperative spine problems. We've been looking specifically at some of the newer medications that are bone-building agents and how they impact spine outcomes.

Another big part of what we do is around the patient education in the shared decision-making concept and looking at what information is out there for people that is either in agreement or disagreement with what we're trying to tell them, and how people can sort through the mass of information to come up with a reasonable sense of what their options are so they can make a good choice. 

A lot of our research efforts have been these technical things and many of our advances have been terrific. I've been doing this for 20 some years now, and it's been amazing how far we've come in some areas.

Then there are other areas like spinal cord injury and even just plain old back pain where we haven't made the progress that I'd like to have seen. Our group has been involved with a number of other sites looking at a procedure called basivertebral nerve ablation as a treatment for chronic degenerative back pain. It was something I was kind of skeptical about at first. But over the last several years, we've seen very good results for these procedures and those results have held up over time. This is one of those new techniques that actually can expand the types of people we can help. And it's a percutaneous procedure; it's not a big surgery. So that's been an exciting thing, and I hope we see similar changes in other areas of spine care.

Q: How do you see stem cells developing in the field?

ET: Stem cells and regenerative medicine have been controversial recently. As an area with a tremendous amount of promise, there are two very different pathways seen today. One area, still mainly limited to animal research, involves growing out cells on a scaffold and then surgically implanting the tissue into the spine. Over time, these approaches could represent paradigm shifts in the management of spinal cord injury and intervertebral disc regeneration, among other areas.
On the other hand, there are the stem cell and regenerative medicine clinics that have popped up all over the country, often as part of long-standing and well-regarded spine practices. The centers usually aspirate cells from the iliac crest or utilize platelet-rich plasma. These substances are then injected into many parts of the body, from the discs to knees. While there are hundreds or thousands of internet testimonials about how wonderful these injections were for individual patients, the peer-reviewed evidence remains limited. While these approaches may also have a big impact on care, it's just too soon to say at this point.

Q: What area of regenerative medicine holds the most promise for the spine?

ET: We have used regenerative approaches in different areas of medicine for years. In spine, bone morphogenic proteins stimulate the body to grow bone and have been useful to improve fusion rates in cases with high risk of fusion failure.
Human parathyroid analog medications, like teriparatide and abaloparatide, have been shown to rebuild bone in osteoporotic patients. Not only will these more aggressive approaches to bone loss prevent spinal and other fractures in high-risk patients, they also allow patients with spine problems to undergo surgical reconstruction.

More articles on orthopedics:
A simple solution to the health insurance marketplace: Authorize interstate competition
Where orthopedic PE partnerships stand in 2020
Facet joint replacement, stem cells & AR: 9 surgeons discuss new technologies 

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