'The "team sport" mentality is pervasive': 2 surgeons on growing Northwell Health's spine program

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A "shared passion and purpose" among surgeons is important to Northwell Health's spine program, Alexander Butler, MD, and Frank Schwab, MD, said.

Dr. Butler in October joined New York City-based Lenox Hill Hospital and Lenox Health Greenwich Village and plans to focus on technological innovation in spine surgery. He arrived as Dr. Schwab marked one year as chair of orthopedics at Lenox Hill Hospital and system chief of spine surgery at Northwell Health. Dr. Schwab is also chair of orthopedics at Lenox Hill Hospital and vice president of orthopedics for Northwell Health's Western region.

Dr. Butler and Dr. Schwab told Becker's about their outlook for minimally invasive spine surgery and plans to develop Northwell Health's spine program.

Note: Responses were edited for clarity.

Question: What trends in minimally invasive surgery are you following closest?

Dr. Alexander Butler and Dr. Frank Schwab: The outpatient revolution. As several pioneering groups across the country have demonstrated, a large number of spine procedures may be performed successfully outside of the inpatient setting. Expertly utilized minimally invasive techniques and enabling technology allow the local trauma of surgery to be as innocuous as possible. Additionally, a comprehensive pain management program, which includes perioperative analgesia and appropriate anesthetic technique, is also imperative for minimizing the systemic surgical footprint and allowing for a satisfied patient's smooth transition home. Many patients have a growing desire to avoid hospital stays, and the potential value that this service may provide for the system is clear.

Q: What spine technology will fall with hype and which will remain strong in the next decade?

AB and FS: From a minimally invasive surgery perspective, any new technology that allows for enhanced access and visualization will continue to generate value in spine surgery. Innovation is currently being driven forward by expanding abilities to perform and reliably confirm adequate decompression, discectomy, end plate preparation for interbody fusion and pedicle screw placement with less tissue trauma, less radiation and less time. Endoscopy, robotics and augmented reality all offer these advantages; their expanding applications and respective capital value implications will determine which will stand the test of time and achieve universal adoption. In the open deformity arena, light-based radiation-free navigation platforms hold great promise in permitting repeated and rapid registration of intraoperative 3D navigation to pre-op scans. This can be done segment by segment, all while obviating the need for intraoperative radiation.

Q: What technologies will see more investment from Northwell during the next two to three years?

AB and FS: Our priorities, in large part, reflect the specifics of what's been discussed above. Across the entire perioperative encounter, maximal image quality with minimal radiation exposure for all involved is a top priority. Accessibility of full-length, low-dose standing XR for all of our patients will help make informed decisions regarding global alignment in both the deformity and degenerative arenas. Reliable and high-quality 2D and 3D imaging devices are a must. The incorporation of varying types of mixed reality is being actively considered — augmented and virtual reality assist with pre-operative planning, as well as with a high level of intraoperative accuracy and efficient procedural ergonomics and workflow.

Additionally, there is some exciting work being done in creating options to incorporate preoperative imaging and planning into intraoperative navigation platforms without additional radiation to the patient or clinical team.

Finally, we've become very interested in technology to track postoperative outcomes in both the short and long term. We plan to augment the breadth of data captured through the routine use of wearable tech to evaluate how our patients are moving and functioning as they respond to various interventions.

Q: What's the top payer challenge for spine surgeons at Northwell, and how are you addressing them?

AB and FS: Northwell's size and scope create some unique advantages with regards to payer relationships. That being said, the process of negotiating fair reimbursement for the use of new technology can be challenging. As mentioned previously, ongoing efforts to consolidate our systemwide research infrastructure will allow us to demonstrate these benefits to all stakeholders on a large scale. Preapproval for surgical intervention remains a persistent difficulty across our field. Even in cases where patients are significantly disabled by pain and impaired functional status, having a recommended and necessary surgery approved can delay or even preclude appropriate care.

Q: How is culture built within the spine and orthopedic program at Northwell Health, and how does it impact the health system as a whole?

AB and FS: As with any great organization, the culture of Northwell Spine reflects shared passion and purpose. Whether immediately post-training or later in career, physicians who join us want to be part of what Northwell is building within the spine and orthopedic service lines. Clinical excellence is, of course, a must, but we also look for potential to actively contribute to our shared vision of uncompromisingly superior outcomes and world-class patient experience. All of our team members are encouraged and empowered to continually examine and improve our internal operations, technology, communication and patient-facing services. Our culture is built from applying our shared passion and purpose to constantly improve and the optimism for what that will inevitably create.

While these guiding principles are essential, how they manifest day to day is what makes this such a unique organization. The "team sport" mentality is pervasive. Within our spine service line, collaboration between the orthopedic and neurosurgical services is really unparalleled. We frequently cooperate on shared cases and gather weekly to discuss joint clinical pathways to improve the patient experience. Providers from both departments also participate in weekly conferences focused on indications, radiology and outcomes. Northwell Spine is in the process of starting a joint ortho-neuro fellowship, which will offer a fantastic, well-rounded experience for trainees of both backgrounds as they transition into practice.

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