Spine surgeon Michael Gallizzi, MD, has had his eye on endoscopic spine surgery for years.
Dr. Gallizzi, of The Steadman Clinic in Vail, Colo., spoke with Becker's about his endeavors with endoscopic surgery, collaboration with Arthrex and potential payer challenges ahead.
Note: This conversation was lightly edited for clarity and length.
Question: How would you describe the current state of endoscopic spine surgery and what are your predictions for the next couple of years?
Dr. Michael Gallizzi: It is evident from a significant amount of media coverage and the increasing interest, particularly among younger surgeons, that their interest in endoscopic spine surgery will drive its adoption. I believe that its prevalence will continue to grow in the United States. Internationally, especially in South Korea and among our European counterparts, it has already gained significant traction. However, the United States lags behind in its adoption. One contributing factor is the absence of a major player in the market willing to provide training and education.
Q: Could Arthrex be one of those major players?
MG: Absolutely. The most significant takeaway from my residency, as I began to specialize in spine, was the lack of substantial work being done in terms of device development and procedures for soft tissue and motion preservation. In 2013, I pitched the idea of getting into spine to Arthrex, as I believed that this company had the potential to make a real difference in this field. We then created what is now the Spine Scorpion to assist in the facial closure of minimally invasive spine surgeries. Rather than solely focusing on metal screws, they prioritized soft tissue and motion preservation. It's crucial that we start considering the treatment of spinal diseases in a manner similar to how we approach sports injuries.
Q: When you're looking back at these 10 years up to now and this launch, what were some of the biggest challenges?
MG: We encountered several significant hurdles. Ensuring that we had a comprehensive offering from the outset was a primary challenge. We aimed to avoid merely creating a "me too" product and instead sought to incorporate extensive feedback from surgeons into the design.
Q: What does Arthrex's endoscopic line entail?
MG: It will primarily focus on four key domains. First, there's medial branch transection, which provides a way to permanently innervate the facet joints. Rather than using radiofrequency ablation, endoscopic medial branch transection allows the identification and cutting of the medial branch using a punch or scissors. This method offers more thorough relief from extension-based axial back pain.
The next aspect is the discectomy, whether through a transforaminal or intralaminar approaches, to remove disc herniations with minimal bony work compared to even a tubular approach. This can be done without violating adjacent structures, thanks to their visualization system, which has been used in sports medicine for years. The system provides 4K super clear images of the spine, revealing details that were previously difficult to see up close.
The third area focuses on decompression space, which involves different drills and bone resection devices in the pipeline to facilitate the endoscopic approach. When necessary, patients can undergo motion-restricting procedures or fusion safely and successfully.
One of the primary issues we've encountered over the last decade is that most major companies require surgeons to either pay for their own training or find ways to get trained. However, my experience in the spine industry is that when surgeons are learning a new procedure, companies should provide educational events and support. There's often a lack of guidance on what to prepare for and no clear pathway for easy skill acquisition in these areas.
Touching on what we're doing at Steadman, Dr. Sonny Gill and I have started a Spine Fellowship at the Steadman Clinic. We are currently interviewing candidates for the class of 2025, with the program encompassing minimally invasive, complex cervical, endoscopic and robotic cases. This initiative at the Steadman Clinic represents our effort to provide more people with hands-on experience and advance this technology.
Q: When you're thinking about forming this program, what advice would you give to other spine surgeons who might want to do something similar?
MG: The most significant aspect is that surgeons need to actively perform these cases and undergo training while relying on the expertise of others. I recently hosted a visiting surgeon from Texas who came to learn some of these techniques. During my journey in learning endoscopic spine surgery, I had to allocate time away from my practice to visit other surgeons. When you're building a program, it's essential to seek diversity in techniques, providing individuals with as many tools as possible. I'm not suggesting that the endoscopic approach is suitable for all cases, but it is a valuable tool. When used appropriately and in well-indicated cases, patients can benefit significantly from it
Q: It sounds like with these increased efforts in endoscopic education, we're probably going to eventually start seeing more spine surgeons using this. What's the situation between like payers when it comes to endoscopic spine surgery? Do you anticipate that being any kind of barrier to people wanting to get this procedure done?
MG: Payers currently pose a significant barrier. Some states strongly oppose the adoption of this technology on the payer side, even though it's an approved Medicare procedure. The only way to address this issue is through data, demonstrating either equivalency or, ideally, superiority in certain aspects. This could include getting patients back to work faster and reducing opioid use after the procedure.
I believe that other aspects, such as the complication profile, will likely remain similar due to the nature of spine surgery. However, by minimizing damage to soft tissue in endoscopic cases, there's the potential for reduced dependence on opioids. In fact, I collaborate with some endoscopic peers who don't prescribe any opioids after surgery. Achieving this in the field of spine surgery could be a significant development because traditionally, spine surgery has been associated with the management of significant postoperative pain.
Q: Artificial discs have had a real uphill battle in terms of getting payer coverage. Do you anticipate any kind of struggle like that with endoscopic spine?
MG: I believe that part of the issue with disc replacement in the neck and lumbar spine arises from the fact that it involves an implant rather than a technique or technology. Because it's an implant, payers are often reluctant to cover something that's expensive. Conversely, adopting these tools and performing procedures in this manner usually falls under the category of equipment, typically the responsibility of hospitals. Thus, hospitals endorsing the use of this endoscopic equipment for their surgeons would necessitate a capital investment. However, the advantage of having Arthrex driving this initiative is that they are already present in a majority of outpatient facilities today, which significantly reduces the facility's financial commitment.
Q: Besides working on the fellowship program at Steadman, is there anything else exciting going on at the practice?
MG: In the last 19 months, the Steadman Spine Program has seen significant expansion. We now have a surgical team consisting of myself, Dr. Sonny Gill, specializing in a wide range of complex cervical and minimally invasive procedures, and Dr. Stuart Kinsella, who also is a robotic spine user like me. As a result, we have developed a robust spine service line, incorporating all the latest technology. Our faculty is not only using this technology but also actively teaching others how to use it effectively. We are dedicated to upholding the principles set forth by Dr. Steadman, with the primary objective of getting people back to their athletic lives as swiftly as possible while minimizing tissue damage, and we apply these principles within the realm of spine surgery.
Q: Is there anything else that you wanted to discuss?
MG: It is essential that a major player like Arthrex has entered the endoscopic spine space because they have the capacity to provide effective surgeon training. When surgeons complete their training programs, they are well-equipped to apply the technology in their subsequent cases.