David Antezana, MD, is a board-certified neurosurgeon at The Oregon Clinic in Portland and co-medical director of the Spine Center at Providence Brain and Spine Institute, also in Portland.
Dr. Antezana discusses the initiative he is most proud of in spine, his professional goals for the future and more.
Question: Is there a single initiative your organization has undertaken recently that you are particularly proud of?
Dr. David Antezana: The Complex Spine Roadmap. During the last few years, I have been intimately involved and the main driver of the Complex Spine Roadmap we have developed. It is an outstanding collaboration between Portland, Ore.-based The Oregon Clinic and the Providence Brain and Spine Institute. Initially, I got it off the ground with funding from the independent practice association.
The Roadmap has three arms: preoperative, intraoperative and postoperative. It essentially functions as a risk stratification tool to minimize complications and improve outcomes. It is far-reaching in the areas it covers. At its core is a multidisciplinary conference to discuss our more challenging patients. There we adjust or add to surgical plans. At times, we change them altogether. Everyone has an input.
While there are other such approaches to surgery in the spine world, there is a dearth of them published in the literature. All of them from academic centers. The Roadmap is very similar to other initiatives at Northwestern (Chicago), Seattle Spine and UPenn (Philadelphia) but we have strived to include more disciplines in our conference and encompass outcome measures. It is also adjustable to allow evaluation of less complex surgeries in more medically complex patients. To date, more than 80 patients have taken part. We hope to roll it out throughout Providence Portland Medical Center and Providence Saint Vincent’s Medical Center this fall. Private practice offers challenges different from academics. We have sought to recognize this in our work and look forward to the Complex Spine Roadmap helping patients in our community.
Q: What are the challenges that drive you as a neurosurgeon? What do you most enjoy?
DA: I enjoy all of it. From a personal point of view, patients with spine problems can suffer immensely depending on the pathology. When we can help a patient and alleviate their suffering or restore function and the use of limbs they have lost, there is an immense satisfaction. Many an evening I have driven home exhausted, wishing I had been home earlier for my family but I know that my work had an important purpose.
From a professional point of view, the variety that spine offers for those of us who choose to indulge ourselves in the breath of it, is immense and challenging. From a straightforward microdiscectomy or laminectomy to a deformity correction or tumor resection with reconstruction, the procedures require an unparalleled understanding of anatomy and function. One might only need to do a simple posterior approach through the paraspinal musculature. Perhaps a lateral or complex anterior approach may be called for. Whatever it may be, there is a need to understand the anatomy we must deal with on the way to the spine. I am fond of saying: 'I am like an anatomy tourist who must be well-informed in order to travel safely.' And we definitely get around.
The challenges posed by spine surgery are legion. The surgical ones seem to be the easiest to tackle from an emotional standpoint. After all, that is what we do, what we’ve been trained to do. These are the ones that primarily drive me. At the end of the day, we are physicians like any other. It's all about the patient.
The harder challenge to tackle is navigating my way through the administrative issues. This is not how we were trained. Yet these wide ranging issues from economic to epidemiological to market assessment and more — I won’t even get started on the internet and computers — are of paramount importance if we are to understand how our practices fit within a larger context.
Q: What are your professional goals this year and for the next few years?
DA: Continued evolution of spine at PBSI and TOC with inclusion of technological advancements, robotics and a fellowship.
Robotic technology is here to stay. While these "robots" are more a union with image-guided surgery than strictly robots like the da Vinci, they will become immensely useful. I suspect they will permit minimally invasive procedures to be more easily performed turning many of our two to three day hospital stays into same-day or overnight stays.
The improvement of expandable spinal implant technology is changing how I approach many challenging cases. As one example, a patient that might have required a pedicle subtraction osteotomy to correct sagittal imbalance may now have a lateral interbody fusion with an expandable lordotic cage. Such an approach has inherently fewer complications and less blood loss. The downside: The cages are expensive and osteotomies don’t require a cage. However, high blood loss and complications can not only worsen outcomes, they exact a financial toll on our healthcare system. We would want to demonstrate this in showing hospitals and health plans the decrease in complication rates. This is not applicable to all kyphotic deformities, but enough that it can't be ignored.
There are 10 neurosurgeons in our group actively involved in spine covering two hospitals. That generates a lot of volume. Currently, we are recruiting an additional deformity/complex spine surgeon. Once that person arrives, we plan to start a fellowship. We already have experience with vascular and skull base fellows. A spine fellow would find plenty to do with us to improve and sharpen skills acquired in residency.
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