NWH's Spring Conversation, A New Standard of Care: The Future of Spine Surgery at NWH

Hi everyone, I'll just ask you to take your seats and we'll get started. We might, uh, we'll hope to have our additional guests join us in the back, so I'll invite you to sit up front. You don't need to sit so far away. We do, we do think a few more people will come. It will make it easier for them, they can sit in the back when they get here. Whatever your preferences, thank you so much. Welcome everyone, we're so happy to see you. My name is Katie Connolly, I'm the Vice President for Development and Community Engagement at Newton-Wolsey Hospital, and it's just a pleasure to be in a room with all of you. Tonight is special in so many ways. After so long, we're thrilled to just have you join us and come together again as a community around this hospital that has been so important for us in the last couple of years. Reminds me of how powerful it is to gather, to be together as friends, and to be brought together around what we believe in and what we care about. I'm grateful that you can be here. Even more, I'm grateful for all that you have done over the last 2 years to ensure that Newton-Wellesley could continue continue as the community resource we so needed as we endured the pandemic. But tonight, tonight we're going to have fun. You have such a great night ahead of you. We'll start with this wonderful program and then we'll have some time for questions and then we'll join together and have a reception just next door. So that's what's ahead. I'm delighted to welcome you, but now it's really a pleasure to hand it over to Newton-Wellesley's hospital president, Dr. Errol Norwitz.

Katie, thank you. And greetings, everyone. I'm really excited to welcome you here today. And I'm very excited to hear about the presentation about our spine program. It's wonderful to see so many familiar faces. I recognize many people from Zoom meetings, but it's very different being in person again. And if I haven't had a chance to meet you in person, please do come up during the reception. I'd like to get to know each and every one of you. So back in the fall, I had the privilege of speaking virtually at our last conversation to share a little bit about— I don't know if you remember the virtual telehealth program that we have ongoing. And also to talk a little bit about my personal history. And although I've lived in and worked in 5 different countries on 3 continents, I tell people and remind them I've had a lot of exposure to different healthcare systems, my wife and I have raised our 3 kids right here in Newton. We've lived around the corner. And for more than 2 decades, we've used Newton-Wellsy, we've relied on Newton-Wellsy as the institution in which we've got our healthcare. So I have a very deep understanding and appreciation for the quality of the care that the hospital provides and its special place in our community. In the fall, as I mentioned, we had Dr. Jeff Phillips talk about virtual visits and the future of primary care. And tonight we're going to hear about the future of spine surgery and the emerging vision of orthopedics both at Newton-Wellesley and at Mass General Brigham. As you'll see, there's a, there's a common theme here, which is the extraordinary ways in which we see the future taking shape right here in our community. As we enter a new era, we do have a clear vision, and I believe that Newton-Wellesley is perfectly situated for where healthcare is heading. As a community-based hospital, Newton-Wellsley fits perfectly into Mass General Brigham's vision of connecting patients with high-quality care right here in their community. We are ideally positioned not only to participate in this mission, but also to lead. Our patients have relied on us for their care for generations, and as we further integrate into Mass General Brigham and strengthen our relationship with Mass General Hospital and Brigham and Women's Hospital. We will be increasingly relied upon to play a larger role in delivering exceptional care close to home. At the same time, we at Newton-Wellsley have our unique identity and our unique culture, and we will retain this special identity and culture even as we integrate within the system. We've developed a 3-year strategic plan you may have heard about, and it was done with collaboration from staff throughout the breadth and depth of the organisation. And while it clearly aligns with the system-wide goals, it also accentuates what makes us uniquely Newton-Wellesley. It's designed around 5 core competencies, what what I call the 5 Cs, and it's bookended on the one hand by our culture, our people, and on the other hand by the communities that we serve, our communities. As we embark on the mission of integrating care throughout our system and providing exceptional care closer to home and at lower cost— that's a key element as well— we have a solid foundation in, in place. Your ongoing Your engagement, your ongoing belief in us as a system and as a hospital strengthens that foundation immeasurably. And I want to thank you for your enduring support, your engagement here today. Thank you for coming to make this such an incredible place of healing. So tonight you're going to hear from two of our faculty members, two of our exceptional providers, Dr. Tim Foster and Dr. Jess Adlin, both leaders in their field. And exemplify our commitment to clinical excellence and world-class care for our patients. They together will give you a glimpse of the presence and future of orthopedic surgery, truly one of our centers of excellence. So thank you again for coming and joining us today. Please enjoy the presentation and a glimpse of our outstanding, forward-thinking, and patient-centered healthcare that distinguishes us as Newton-Wellesley Hospital. So thank you very much for your attention, and I will turn it over, I think, at this point to Tim Foster.

All right.

Thank you.

I want to tell you a story about orthopedic surgery over the past few years at Newton-Wellesley. And that story starts with the pandemic that we've all been through that hasn't been seen in this country, in this world for the past 100 years. And through that, we learned a new vocabulary. We learned about N95s, we learned about distancing, We learned about contact tracing, words that we hoped we would never have to hear or learn about, but we learned about them. We also saw in the headlines in the news that there were cancellations at hospitals, that we were so busy, the clinicians were so busy caring for patients, the beds were so filled with COVID patients that we couldn't do anything else. We could not do elective surgery because there were so many cancellations throughout the country. And so it was at Newton-Wellesley, so it was at Mass General Brigham. And the statistics continue to rise and rise. The death toll rose, the number of patients who had COVID rose. And tonight I'm gonna remind you that for every one of those patients who's a statistic, there's a patient, there's a human being behind that. There's somebody who has a father and a mother, somebody who has a child and a daughter. And I wanted to introduce to you John and Caitlin tonight. John lost his wife due to the COVID crisis. And I'll tell you how I met John a little bit later on in the presentation. But John had hip arthritis after he lost his wife, and his son was very worried. His son did not live close by. His son lives in Wellesley. His son was worried that because of the severe osteoarthritis that his father was really diminishing in stature. His father was no longer ambulatory, could no longer take care of himself. His wife was no longer the caregiver. And so he needed a hip replacement in order to keep him out of long-term care. Unfortunately, hospitals were not doing hip replacements at that time. I met John Sr. and I met John the son, the father of Caitlin, because Caitlin is a lacrosse player in Wellesley. And unfortunately, Caitlin had an on-field injury in which she had an anterior cruciate ligament tear. She was seen at our Newton-Wellesley Hospital emergency room, our pediatric emergency room. And at that time, our emergency room was just filled with COVID patients, overwhelmed with COVID patients. Our ER typically sees 150, 175 patients a day. There were days that it was up to our 275, 300 patients filled with COVID And this is a text that I got from John, and it says, Dr. Foster, this is John R. I got your number from Jessica. Jessica gives my number to everybody here. Her son was a previous patient, so everybody who knows Jessica just has my, has my cell phone. So my 15-year-old daughter Caitlin was injured playing lacrosse today. The trainer at the game is concerned about multiple ligament injuries, including an ACL tear. We are in your emergency room with many sick patients. There's a 3 to 4 hour wait. "I'm not sure what we should do, if we should stay. What would you recommend? My cell phone number is— I'm sorry to bother you on a Sunday morning, but I'm worried about Caitlin." And my response to him was very straightforward. "No worries, John. I'm sorry to hear about your daughter, but please bring Caitlin to 978 Worcester Street, Route 9. We have an orthopedic urgent walk-in clinic that is open and staffed on the weekends. She'll be evaluated by an orthopedic physician assistant who works with me in MGB, Mass General Brigham Sports. We'll get x-rays and probably an MRI scan. I'll look at the images and speak to the PA, and essentially I'll talk to you later after we see the images. And so they went to our orthopedic walk-in clinic at 978, and this is what it looks like. This is what her knee looked like. She had a large effusion of her knee, which is in fact a telltale sign that she had an anterior cruciate ligament tear, She was seen within 30 minutes at our urgent walk-in clinic instead of 3 to 4 hours in the emergency room. The next day she had an MRI scan which indeed showed an anterior cruciate ligament tear. Caitlin went on to have arthroscopic surgery and an arthroscopic ACL reconstruction, and I'm glad to say I saw Caitlin for the last time today actually, and she's back on the field playing lacrosse after going through extensive rehabilitation. But I started to talk to her father, John Jr., about his father who was looking at assisted living and worried that who was going to be able to take care of him. And I told him about Newton-Wellesley and how many joint replacements we do at Newton-Wellesley. In fact, we do over 1,400 hip and knee replacements a year and many revision surgeries as well, and that we had started to investigate outpatient hip replacement and outpatient knee replacement surgery. And in fact, our MGH Newton-Wellesley surgeons had been pioneers in this type of field. And during the pandemic, we actually performed over 500 outpatient total hip and total knee replacements, and 94% of those patients who we planned on doing as outpatient went home. And that is best in class. It would be hard to get to 100%, but 94% of them went home and they thrived at home and they did not come back to the emergency room. But the planning for that started way before the pandemic. The planning for that started in 2016 when we knew the market was shifting toward outpatient surgery and we became very interested in this. So we went to, of all places, we went to Columbus, Ohio, And we took board of trustee members, we took surgeons, we took anesthesiologists, we took nurses with us, we took administrators who knew about finance to learn more about everything we could about outpatient total joint replacement. We spent 3 days in Columbus, Ohio. I'll never have those 3 days back again. We spent 3 days in Columbus, Ohio, and with the collaboration with surgeons, the operating room nurses, the recovery room nurses, physical therapy, home health, because it's just not a matter of sending patients home after hip replacement. Let me tell you, there's a lot of planning that goes into sending somebody home after having a joint replacement the same day. But with all this and with the help of hospital leadership, we were nominated to win a Pillar of Excellence Award for MGB. And by gosh, we did win the award. But simultaneously, I wanted to tell you about the walk-in clinic that Caitlin went to. There was only one other freestanding urgent care orthopedic clinic in the United States when we started to think about that. And that clinic was at Duke. And a friend and colleague, Nettie Amendola, and I had talked about opening an outpatient orthopedic-only freestanding clinic. And by gosh, he beat me to it at Duke. And not only did he beat me to it, but he said, "It's so darn successful, I think we're gonna open two more because the influx of patients." is so great. So we play Duke, and when I say we, Boston College plays Duke. I'm a BC team physician. We play Duke in football, we typically win. We play them in basketball, we don't typically win. But I see Dad a couple times a year, and I actually went down to Duke so I could take a look at their outpatient urgent care clinic. And this is 3 years before we opened the one at Newton-Wellesley Hospital. So on February 16th, 2021, we opened the urgent, the walk-in urgent care clinic at Newton-Wellesley Hospital. And our pro forma, and we had to prove this to Errol, our pro forma said that if we saw 1,000 patients a year, so, you know, 3 patients a day, we would break even. We quadrupled it. We saw 4,000 patients within the first year of operations. Wildly successful. It has not been externally marketed. We've marketed only to our primary care physicians. When we start to externally market this, I can't imagine what's going to happen because we're bursting at the seams at the moment. Because who wants to go to the emergency room when you can be seen within an hour? When I say being seen within an hour, being out the door within an hour rather than being in an emergency room. And you can just walk in. You can call and make an appointment, but you can also just walk in and we'll be happy to see you. So this was also nominated for— this year was nominated for an award. And I'm sad to say We didn't get it because the joint replacement program got it instead, instead of this. So I was terribly disappointed about our walk-in clinic, but I was happy with the, the joint replacement. So to, to finish up, I just wanted to ask you what these companies have in common. And I think you would all agree when you think about it, many of these companies on the Forbes top 10 list for consumer experience and consumer satisfaction. So we continue to ask one bold question in orthopedics. This is what drives orthopedic surgery at Newton-Wellesley. What if we treated patients like consumers? And there are many patients who say, I don't want to be treated like a consumer, I want to be a patient. But what if we did treat patients like consumers, like they were consuming healthcare, that they were paying for the healthcare that they were receiving? What if we provided convenience, access, coordinated, integrated care? How novel. What if we provided that? What if we put the patient at the center and said, we're going to have care integration, we're going to have access, we're going to provide physical comfort and family support and convenience and shared decision and quality and safety. That's what we've tried to do. Excellent expert care in the community, patient access, value-based care. Value-based care meaning quality over cost. Are you getting what you— what your insurance company or what you are paying for? Quality over cost equals value. The best teaching, education, and research brought to you by Mass General Brigham, and innovation in healthcare delivery brought to us by Newton-Wellesley Hospital. And you overlay quality and safety on that, and what you have left is the Department of Orthopedic Surgery. So this is what we've done over the past couple years. You can only imagine what we're going to do with the spine center and what you're going to hear from Dr. Adlan. Dr. Adlan is a summa cum laude graduate of Lemoyne College in upstate New York, where she was a varsity soccer player. Not, not an easy task to be a varsity soccer player in a Division II school and to graduate summa cum laude. Went on to the University of Buffalo to earn her medical degree, University of Massachusetts for her residency training, and then she did a very prestigious spine fellowship at Brown. So I call her vice chairman, chief of the division of orthopedic spine surgery, and now she's the chief of the entire service line, including physiatry, neurosurgery, orthopedic surgery, everything that makes up the spine center. So she's wearing many, many hats. We're going to take those hats off, but it's my honor and privilege to introduce Dr. Aylan.

Good evening, everyone. I'm really excited to be here seeing everyone in person. It's been a long time since we've all been in a room together unmasked and seeing smiling faces and, and chatting. And so I hope that this will be a nice conversation for all of us. And thank you to Dr. Foster and Dr. Norwitz, um, for the introduction and those excellent presentations. And I think that Basically what I'm going to talk about with the spine service line and spine surgery and our future at Newton-Wellesley is really based on the platform that Dr. Foster just described. So we've really accelerated our spine care over the last few years, in particular with COVID and kind of how we're looking at spine surgery and how we deliver spine care in the community. I've been at Newton-Wellesley for about 10 years now, and I can tell you that things have drastically changed since, since I started here. I think when I started, we only had 4 or 5 spine surgeons, and we didn't really have any imaging technology in the operating room. We didn't have the collaborative kind of robust center that we have now. It was started back then, and we've just continued to build it with our colleagues in the other departments of the Spine Center. So I just want to give a little overview of that and hopefully have some good questions questions and discussion afterwards. So this is really a new standard of care. And, you know, I think when I think about spine surgery, I think about kind of the whole community, the whole person, the whole collaborative approach with my colleagues and with other folks that take care of, of you as patients. So, you know, if you think about the current landscape, I'm sure many of you here— and I actually see some familiar faces in the audience have had back pain and you have an injury or you have, you know, some chronic issue and you look at these doors and you say, what do I do? Where do I go? Who do I turn to? I'm going to call my friends. I'm going to call my primary care doctor. I'm going to go to the chiropractor that I saw his ad on TV. Maybe I'll go to the Spine Center. And really the bottom line is, is that back pain is super common. I know there's some primary care doctors here in the audience and I think probably— what's the statistic— over 80% of visits over a lifetime can be, you know, due to chronic back pain or acute back pain. So it's a super common problem, yet patients don't know where to go. And it's really amorphous as far as how we're treating this problem. So you could go into any door. So what we've really thought about with the Newton-Wellesley Spine Center is looking at how to offer one-stop shopping for patients who have neck and back problems. And we really want to provide easy access and individualized multidisciplinary, disciplinary care. And, you know, I really love the, the mission statement for Newton-Wellesley. We treat every patient as if they were a beloved family member, because I actually think that myself and all of my colleagues actually do that. And I think that really speaks to the culture of Newton-Wellesley and kind of how we approach our patients. So if you call the Spine Center, it's located on Wells Avenue in Newton, you will be, you will have access to all of these different options for treatment of your back problem. Physical therapy, we have a beautiful physical therapy facility there. Pain management, we have anesthesia, anesthesiologists who do pain management and injections. We have physiatry and rehab medicine. Dr. Borgstein deserves a shout out. She's in our audience today and she is our top-notch leader of the our physiatry department and very well known in the MGB system and nationally. We have behavioral health services with our pain psychologists and also several of our spine surgeons in our division see patients there. So you can have access to all of these services and we can really help to have you, you know, help you to figure out who and where is the best place for you to start and how you navigate through that, through that problem. And so we developed the Spine Navigator program a couple of years ago. This has been really a game changer for us. So we hired a physician assistant who is very experienced in spine, and she basically will see patients who need easy access within 24 to 48 hours. So if you call the Spine Center or you refer a patient to the Spine Center and a patient has not been treated or hasn't had workup for their problem, they'll come into the Spine Center and see Sarah, and then she will really help to direct the treatment plan for that patient. And sometimes, you know, the patient's kind of And we'll go back and forth. And, you know, we'll try to figure out a plan until they're feeling better. So I just want to kind of talk about who my patients are as a surgeon. So I think there's a lot of misconceptions out there about who is having spine surgery, who are candidates for spine surgery. Will spine surgeons see patients who don't necessarily need surgery? And the answer is all of the above. So, you know, I think that I actually have a— fantastic practice and the ability to see patients from a teenager all the way up to patients in their 90s. I have a pretty active patient population, and active means, you know, some Boston College football players all the way to, you know, an older patient who really just enjoys gardening and playing with her grandchild. And we really want to restore that function for patients. So you're not too young, you're not too old. If you come and see a spine surgeon for a consult, it doesn't necessarily mean you need or have to have spine surgery. So those are really important things just so we can make sure we're educating you on what your options are. So we do really, I think, offer the best in regional spine care working under the MGB system and developing this program. And the exciting part is that it's really just starting. We've done so much over the last 5 to 10 years and particularly in the past couple of years. But we really have a lot of work to do and we're continuing to expand and provide this care. So I'm going to take a little poll of the audience. If someone told you that you may be a candidate for or needed spine surgery, who would feel like this? Yes, I think that is the general consensus is that everyone's like, no, I don't want to see a surgeon. I don't— I'm never having spine surgery. My friend and my brother and this person and that person had a horrible experience. And my doctor says, don't let anyone touch your back. And, you know, it goes on and on and on. So, so, yes, I mean, I'm sure that those stories exist, but I'm here to tell you that if you are having, you know, if you have a problem and you are getting listened to and you have a good multidisciplinary team taking care of you and surgery is not necessarily the first go-to answer that we can relieve pain, we can restore function. And I really want to kind of highlight that for everyone in my talk about what we're doing in the operating room to help people get back to their active lives. So spine surgery is not all bad, or else I probably wouldn't do this job. So if you always do what you always did, you will always get what you always got. And so I think that myself and my colleagues, we really try to think, we try to think in a forward fashion as far as what can we do better? How can we help people better? How can we, you know, treat a spine problem in a more wholesome way? And this pertains to nonsurgical treatment and also the surgical treatments that we do. And so Albert Einstein says that, and I think it's really captivating. And just for the history buffs in the audience, just a little bit of a historical perspective. So Hippocrates, as many of you know, is the father of medicine in ancient Greece, and he wrote the Hippocratic Oath and really looked at the spine as the cause of disease. So he was really interested in, in kind of seeing the spine as our center and, you know, how back pain and spinal problems can really affect your entire life, your physical well-being, your mental well-being. So, you know, this has been a longstanding chronic pervasive problem in our, in our society, and we've really come a long way way for sure. So if you look at this picture on the right, this is a patient with scoliosis, you know, from long ago, and she's basically sitting in this traction device. And people used to be put in these traction devices for hours and hours a day, and then we moved to body casting for hours and hours a day. And now we— I mean, just, just the evolution has been, has been pretty remarkable as far as what we've done in surgery. So just a little bit about spinal fusion. So the evolution. So in the early 1900s, there were a lot of deformities caused by tuberculosis. And this is where fusion surgery really gained popularity because people were having these unstable spinal problems from their TB. And we needed to figure out how to make them stable. So initially, it was those body casts that I spoke about. And then surgically, we were putting big chunks of bone graft in there that we took from people's hips and other places and wiring them into the vertebrae to try to make that keep that segment stable. And then in the second picture, there's these big metal devices that we would put in, and there's one thing called a Harrington rod for scoliosis. It's just basically a big metal rod that we used to slap on the back of the spine, and, you know, it was a pretty big extensive procedure, and people had a lot of problems long-term because of that hardware. And now we have, you know, what we call segmental fixation. Essentially, you know, we have screws and cages and different things that we can use to stabilize the spine. And now we can do that with tiny incisions in a much more minimally invasive way. So, you know, spinal fusion is one of those, one of those things that's quite scary when, when we talk about it. But it's, it can be really effective and the recovery is, is not as bad as one may think. So this is just a little picture of a traditional open technique. And I just want to start with the caveat that my practice— so I do a lot of minimally invasive surgery, but I also do a lot of big surgery. I do some deformity surgery, some tumor surgery, and some people really do need a more extensive procedure with a big open incision. But if I can avoid this, I will do it, do it at all costs. So, you know, instead of having sort of this big, massive incision on your back with a lot of soft tissue and muscle, disruption and things like that, you know, we're able to do things through smaller incisions. So that's just a picture of what the traditional technique looks like, which can really increase post-op pain and extend patients' recovery. So the evolution. So on the left side, this is basically that big open procedure. That's a picture from the operating room with the— all the screws and rods in the spine. And what we really want to do is try to evolve to tiny stab incisions and using our imaging capabilities and our knowledge of 3D spine anatomy to be able to do something like that through much smaller and less invasive approaches. So how can we do it better? You know, we've, we've really developed a lot of new things in the, in the industry over the last 10 years. And at Newton-Wellesley, we've really tried to be forward-thinking and adopt a lot of those techniques to be cutting edge in the, in the region. And so when you think about spine surgery, there are really many options for less invasive procedures. So a lot of patients are candidates for just what we call a decompression. So taking pressure off the nerves to relieve back pain and leg pain. And that can be if you have a herniated disc or if you have some arthritis. That we go in and open up the space for the nerves. And actually, I'll just tell you a story. Today, I operated on a patient and I did what we call just a hemilaminectomy and a decompression of one of his nerve roots. And I went to see him in the recovery room, and it was literally like less than an hour after we got out of the operating room. And I went to see him and the nurse said, oh, he's gone. And I said, oh, Okay, so I'll go over. So usually patients go from the recovery room over to the day surgery side. And so I said, okay, I'll go over to the day surgery side. She's like, no, no, no, he's gone. Like he went to his car, he went home. And I'm like, wow, that's great. So, you know, even sometimes I'm surprised at how quickly patients are getting up and walking and going home. And, you know, I would say now, and, you know, again, this is probably due to COVID, it has really accelerated this, but I would say at Newton-Wellesley, probably between 40 and 50% of our spine surgeries are all going home the same day and are outpatient. And these are fusions, decompressions, all different types of cervical and lumbar procedures. So, you know, it's really remarkable how, how quickly we've kind of moved to that. And patients do better when they're home. I mean, who wants to stay in a hospital bed? People want to be in their own bed. And we've really decreased— we've worked with our pain management team to decrease opioid use. And a lot of patients are just going home with Motrin and Tylenol and Really, we're doing a lot of pre-op education for patients to be able to recover quicker. So there's spinal fusion techniques. You can do all sorts of different techniques, which I'll describe in a moment. And then motion preservation. So this is another big one because, you know, to fuse the spine seems non— not really normal or physiologic. Like, our spine wants to move, so why would we fuse it together? And some people you know, truly have instability. So we want to fuse it because we don't want it to move. But there are some conditions where we really want to preserve motion, especially in younger patients who may have, you know, a disc herniation in their neck. And we don't want them to have problems, you know, long term if we can avoid it. So we want to preserve that normal motion. So we, we do cervical disc replacements for those patients. And again, we try to do less invasive techniques. So just a little picture with a cervical disc replacement. So this is surgery from the front of the neck, and we basically go in and we take out the disc. We shave down bone spurs. We can relieve pressure on nerves and spinal cord, take out herniated discs, and we can put in these little devices that actually move like a normal spine. So if you see a flexion-extension X-ray, someone moving their neck while they're getting an X-ray, you can see that little device moving normally. And so that takes pressure off those other discs in the neck to allow, you know, you know, less stress and hopefully less degenerative problems or other issues in those other discs. And the best thing about this procedure is that it's done as an outpatient. So patients go home the same day and there's really no restrictions postoperatively, like none. Like I say, you know, don't go like going to CrossFit tomorrow. But other than that, do whatever you want. You can move your neck. You can, you can do whatever. And I've had patients going back to like full military duty and, and athletic activities like in 4 to 6 weeks. So it's pretty, pretty remarkable. So this is something called a lateral spinal fusion. And basically what we do in this is we make a very small incision and it's actually right here on the side of your of your flank, and we're able to put this little retractor and this camera, or this lighted retractor down here to get to your spine from the side. And this is just a picture of a patient of mine. I don't know if I have a— oh yeah, I do. So this disc right here is super collapsed, and there's a big bone spur right there. This is looking at the spine from the front, and this is post-op. We put that cage in from the side, and then we put minimally invasive screws in from the back. And again, this is the disc that's collapsed, and there's a lot of nerve compression that this patient had. And we were able to jack open that disc with this little spacer from the side. And the incisions were, you know, less than an inch all around. So pretty remarkable. And that guy, you know, went home the next morning at like 8:00 AM after his surgery. So an anterior spinal fusion is going in from the front. And we often use our vascular surgery colleagues to help us get to the front of the spine from your abdomen or your belly. Oops. And we can basically put in this nice spacer here after we take out the disc and secure it into place with screws. So there are a lot of different ways to approach the spine. And then a posterior minimally invasive fusion, this is from the back. Again, this is that picture that I showed you before with the big open incision. And these small incisions, we use these small retractors and tubes to get cage into the disc. So this is what you get with a traditional open incision, and these are your incisions on your back with a minimally invasive. So we preserve all the muscles and ligaments that are in the middle of your spine. And I, you know, there's a lot of studies about this, and I really believe that patients have less post-operative pain and they mobilize much quicker when you can preserve those soft tissues, and they can still keep up with their core strengthening and things like that pretty, pretty quickly post-op. So this is kind of the exciting part of the talk. So at Newton-Wellesley, we've really looked at and talked about how can we get better imaging and better techniques to help our patients. So we have an excellent service line of 12 spine surgeons, including orthopedic spine surgeons and neurosurgeons on our service line right now. And by the way, you know, the other question I get is, what's the difference between orthopedic spine surgery and neurosurgery. And from a spine surgery perspective, it's really the same. We do the same training for spine. The main difference is that a neurosurgeon can do something with your brain and I can fix your broken hip if you break your hip. So, but from a spine training perspective, over the last several years, it's really come together and we really do a lot of the same things. So, you know, we have amazing surgeons from Mass General, from Newton-Wellesley, and from from elsewhere who, who come in to Newton-Wellesley to do surgery. And we really want to look at this enabling and transformative technology that can help us help our skills and help patients. So endoscopic techniques, we talked about the motion preservation, and then there's all this computer-navigated surgery, robotics, virtual reality that we're, that we're doing now. This is just a picture of an endoscopic spine surgery. So it's a little tube with a camera. There's a little light on the end, and we can actually take out disc herniations with this little camera. And tiny incision, patients recover very quickly and go home pretty quickly after the procedure. So this is just a picture, and, and I know a lot of folks don't really know what happens in the operating room when the patients go to sleep, but there's a lot of work that goes into prepping the room and planning the surgery and, you know, kind of organizing everything during the surgery and A lot of times our older technologies added cost, time, complexity, things get crowded and chaotic in the operating room with all these different things that we need in there to do our job. We really looked at different technologies to figure out how we could do this better. We actually recently acquired this technology called the Pulse Platform, and it's an integrated platform that enables us to do all the things we want to do and use all the different technologies that we want and need in one, you know, sleek system. So it's been really a game changer for us to enhance our minimally invasive program and again, just push that having patients get quicker or get better quicker and get out of the hospital quicker and mobilizing quicker. And so I'm proud to say that Newton-Wellesley was actually the first facility on the East Coast to acquire this cutting-edge Pulse technology for spine surgery. And we currently are the only hospital in the entire Northeast region that offers this. So it's actually pretty exciting, and I'm, I'm happy to be able to, to provide this for our patients. So like I said, this is not a one-solution system. So we are able to address all of the clinical challenges that we see in spine surgery. We can use it in 100% of spine cases. So whether we're operating on the neck, the thoracic spine, the lower back, minimally invasive, open surgery, fusion, not fusion. We can use this for everything and it really improves our, our efficiency. And the one thing that is amazing about the technology is that there's a component of it called the LessRay. And we actually get a lot of radiation exposure in the operating room and the patient not so much because the patient's there one time, hopefully. But over my career and the nurses in the room and my surgical techs and the residents, and the, you know, the PAs and everybody. So we get a lot of radiation exposure over the lifetime of our career. We wear lead aprons, but still it's concerning if you look at the data on how much we actually get exposed to. And this system actually allows for 60 to 80% less radiation per picture. And also we are able to use computer navigation, so that eliminates radiation altogether while we're putting in our hardware. So So again, just when you talk about safety for the patient, but also safety for our staff at Newton-Wellesley, it's been really important. So we are able to use and integrate this in all of our spine surgery. Like I said, we can use it for the front surgery, for the side surgery, for the back surgery. It's really an integrated platform. And so I'm going to go through some of the components just because I think it's fun and interesting to, to kind of teach you all about, about what it actually does and what we do. So this is just a picture in surgery of— this is me, this is my physician assistant, and I don't know if you can see how small that incision is that I'm putting that screw into, but it's tiny. And I'm using this, this little computer-navigated thing that is basically giving me a real-time view of this patient's spine on a 3D CT scan. And I actually can see my screw going into the, to the bone that I want it to go into while I'm doing it. So it's pretty remarkable and incredibly accurate and safe because, you know, we are excellent technical surgeons, but we're human. And, you know, we have for a long time put in screws freehand because we know the anatomy and we understand it. But this really is sort of a check to say this is definitely going exactly where I want it. It's the right length, it's the right size. And you can see where, you know, in the operating room, here's our scrub techs here, but it's really just this tower and then this little imaging C device here. So there's really minimal kind of clutter around, which I like. I like organized, non-cluttered spaces. So this is just a picture of the computer-navigated accuracy here. So you can see where, you know, these colored things kind of show us where in the bone the screws are going. And then this is actually the picture— this was the case I did just the other day. And after we put the screws in, I could take this pretty picture with the— they put a different color for every screw just so I can see it on the side view. But that's what it looked like. So I can check my screws after I put them in. And so one of the other features of this is that we can do nerve monitoring during surgery. And this is something that we've done for a long time. But again, it was a separate computer, a separate platform. It's like a separate piece of equipment that comes in. And now this is part of the Pulse. So while I'm putting that screw in, I can actually, I have like a wire hooked up to the screwdriver and I can tell whether or not I'm near a nerve, I'm irritating a nerve based on these numbers that come up. So if I see a 15 and that circle's green, that makes me happy. The nerves are happy. We're good. If I see a 4.5, it means I might be getting a little close to the nerve and I probably want to reposition it or do something else or not irritate that nerve. So it really does increase our safety in the operating room and decreases our risk of neurological complications with surgery. So the other, one of the other things that this system does is it actually helps us bend our rods. And if you have a scoliosis procedure and you have a pretty extensive, you know, multilevel fusion, we basically connect the screws that are in your spine with a rod. And again, you know, usually I'm in there trying to use this rod bender and it can be pretty heavy and bulky. And, you know, sometimes I have to call Dr. Foster in to help me. And, you know, it can be, it can be pretty taxing. And, you know, sometimes you can't get it perfect. And this is so quick and so easy. You basically put this thing on all the screws, you pump, pipe them into the computer, you put it through the machine. And the rod comes out perfectly bent the way you want it, and you put it in and you lock it all in and you're done. So less time under anesthesia for patients, easier for me, and less frustration in the operating room and really a perfect result for the alignment that we want. So it's pretty remarkable. And then the last really important thing which we've looked at in the spine surgery world as far as research and evolution over time is how important alignment is. So you may not have a scoliosis, but as we age, our discs or those cushions that are sitting in between the vertebrae here start to dry out. They collapse. You get bone spurs, you get arthritis. And what happens is that— and then if you have hip arthritis on top of that, what happens is patients tend to have what we call a flatter spine. They can start compensating by, you know, rotating their pelvis a little bit. They can bend their knees and their hips. You know, they can hunch forward. And if you think about it, all of those types of, you know, things that we do to compensate or patients who compensate make you fatigue very quickly. Like, people can't walk a mile in that position. So it's not just about, you know, taking pressure off the nerves, but we want to get you back to a normal alignment so you can be more functional with your day-to-day activities and walk farther and do all of those things. So on the left side, this is a nice harmony, harmonized balance of the spine and the pelvis and the knees and the hips. This is, you know, partial compensation, meaning the patient is kind of tilting their pelvis. And this is a decompensated spine where you can see the hips are flexed, the knees are flexed, and the spine, the person's kind of leaning forward. And those are patients who are really debilitated. And we can actually use the Pulse Platform to do our corrections in the operating room. So sometimes we have to, you know, cut some bone and remove some bone. Sometimes we, you know, have to put screws in long construct, sometimes short construct. But what we can do is we can put all of that stuff in. And what we were doing before is just having patients wake up from anesthesia. You know, we did our surgery, we think it looks pretty good. The next day they stand up and they get X-rays and we kind of do our measurements and we see how we did. And so we were kind of getting this delayed response as far as like seeing how, how well our work was. And now we can do it in the operating room on the table with the Pulse platform. So we do all of our corrections and we get everybody back in a harmonized balance and we can get the, the measurements right on the table. So we know that we got the result we wanted before the patient leaves the operating room, which is really great. So as far as less invasive surgery goes and just spine surgery in general, you know, I really think about this as a team approach, and I really think about it as a whole person approach. And I think about the patient as part of that team. And this really, to me, will deliver success with spine surgery. So it's not just the fancy technology we use. It's not just, you know, how great my hands are. It's not— it's not any of that. It's how, how we actually function as a whole before surgery, in surgery, after surgery, and then preventing in the future. So when you come to the Spine Center, and again, we have our amazing colleagues over there who help us with these things, you may go to prehab. So you'll see one of our physical therapists to get as strong and as good as you can before you have surgery if you need it. We look at nutrition, bone health, weight management, diabetes management, smoking cessation. And actually, the other thing that I'll give a plug for at Newton-Wellesley is what we call our SPAN clinic. So this is something that has been open now for, what, 2 years maybe? And it's basically our anesthesia and medical colleagues have put together this amazing pre, uh, pre-surgical evaluation clinic where patients who have multiple medical issues or things that we need to work on or have evaluated, a cardiology consult, whatever they need, they can go to that SPAN clinic and, and again have that one-stop shop to get them optimized and ready for their surgery so they can have the safest and best outcome and result. So we have those services as well. And then in surgery, with all of the stuff we offer, less, less soft tissue disruption, less radiation, extreme accuracy with our hardware placement, and really efficiency to minimize the time that patients are under anesthesia, which I think is really important. And a lot of patients worry about that, especially as we get older. After surgery, patients are going home the same day. There is early mobility. I tell patients you need to walk right away. I want you walking as much as you want and can before you see me for your post-op visit. They take little to no pain medication. There's no brace needed. There's a much faster recovery. I mean, for future prevention, we also help them through that phase. So we hook them up with some of our physical therapists on how to maintain a core strengthening exercise program, how to maintain your bone health. Focusing on body mechanics, ergonomics, and posture, and then just a general healthy lifestyle with weight management and fitness. So our goal, you know, this is kind of the antiquated hospital where everyone used to stay for 5 days after the spine surgery. We're really looking to move things towards a more outpatient setting and then get people back to their active lifestyle and reactivating what they were doing before that they enjoyed. So the future is bright. You know, the Pulse platform as well as the cervical disc replacement, the endoscopic surgery, these are really extensible platforms for the future of our care. And right now we're doing all of these things that I just spoke about. We look to robotics and virtual reality in the very near future as options to put onto this platform. And then beyond that, we're really going to continue to combine platforms. There's a ton of technology and research going on right now in spine, and we're going to expand motion preservation innovation. There's a lot of biologics research as far as stem cells and, you know, bone grafts and things like that that we can use. And one of the things that I think we really focus on at Newton-Wellesley is quality and safety. And we have a lot of projects going on now with quality and safety and how we can really provide spine care in a safe manner and have people do well. So thank you to our community. It is really an honor and a privilege to do this work, and I love having the opportunity to help patients reactivate their lives and improve their function and their mobility. So we are committed to innovation and advancements in spine care to provide the best possible experience and recovery for our patients. So it's really this triad of the patient as the center, your spine care team, and the enabling technology and the innovations that we can use choose to provide that care. Thank you very much.

Oh, okay, perfect. Yeah.

Just a question.

Do you see the Wells Avenue facility turning into some sort of a day surgery facility for pilot patients? That's a great Great question because it's just another idea that your main hospital seems to be overwhelmed.

Yeah, so we are actually looking at options for that and we do have our—

Yep. Your main hospital from the standpoint of MRI, I remember making an appointment there, it was about maybe, just an exaggeration, 6 months out? Not really, but It was in the range of 2 a month, 6 weeks, whatever, before you could get an MRI done. So it would seem as though it would be advantageous to have that facility elsewhere too. Yes, yes, and that— those are great points, and I think we are in the process of working on those things and talking about them and finding other places to be serving Thank you for starting off our Q&A.

We have some time for questions, but first I just want to say thank you again to Dr. Adlan and to Dr. Foster and to Dr. Norwitz for bringing us all back to the sort of magic of Newton-Wellesley and what is happening every day at our hospital. So really, I was delighted. I laughed a lot more than I thought. Who knew you two would be so entertaining in your presentation? Now I know who to come to with all of that. Although that word cloud, Dr.

Foster, I never want to see again.

The COVID word cloud can go away. So I am really excited to let you know we are recording this. There were a lot of members of our community who wanted to be with us but are still a little bit more nervous about coming out. So as, if you're comfortable, as you ask your question, I have colleagues who will share a microphone just so we can capture it. And with that, I do have some that some of our friends who weren't with us sent in ahead of time. But from the audience, who has a question for these clinicians here?

Excellent.

Mr. Sullivan will start us off, and Kristen has you.

I'd love to hear a description.

I'd love to hear a description of how virtual reality is used in surgery?

What role does it play?

Yeah, that's a great question.

Yeah.

So some of the virtual reality platforms that we've looked at, so it's actually the surgeon wearing goggles, like virtual reality goggles, and putting in— so it's similar to the navigation in that we get that pre-op CT scanner technology, and then we wear the goggles and put the screw in so we can see the navigation right in our eyes, basically. So it's pretty cool. Yeah. I can't even imagine it.

I had that same question, Steve. I'm so glad that you asked it. Yes, please. We have another question here in the middle.

Thank you.

Jessica, I've had a lot of back surgeries. 6, actually. Should have come to you earlier. But one of the things that you mentioned was stem cell, and my surgeon told me that in the old days you had to cut your— they used to take bone out of your hip and put it into your back, and it was very painful. And one thing that was interesting to me is that I, I don't know what's in my back now, but it's stem cell. Which they gave me a device which created an electric current that goes— that used to go across the base of my spine for 9 months. And it helped to, I guess, make that stem cell.

Yep.

Yeah.

So I was curious, is that sort of— is that what you do? Is that a new technique?

So that's actually an old technique, and we still use that. So we don't necessarily take a chunk of the bone from your hip or your pelvis, but sometimes we will aspirate what we call bone marrow. So that has stem cells in it, and we will mix that with some bone graft or, you know, other materials to, to help your bones fuse together. So we put all that hardware, that metal in there to kind of hold things together while the bone— but we really want the bone around that to fuse together. So we need to rely on the patient's biology and some and obviously some other, you know, bone-forming techniques to make that happen. So the bone stimulator is one thing that we do use sometimes. We don't really use it that much though, because I think our techniques with our hardware and our bone graft is so much better now. But we do take that stem cell from the bone marrow at times to mix together. But even aside from that, there are a lot of— there's a lot of research going on with stem cells for spinal cord injury and other things. And it's, you know, none of it's really being used clinically yet, but it's remarkable some of the exciting research that's happening around that idea now.

Thank you.

You're welcome.

If I go to the Spine Center and see a navigator, but I don't need spine surgery, can you talk about the other services that are offered at the Spine Center and who provides those services?

Yes. So if you come to the Spine Center and you have back pain and maybe even some sciatica, Basically what we do is we will probably send you to a physical therapist. That'd be the first thing. And then usually our physical medicine rehab doctors will probably want to take a look at you to, to talk about how can they direct your functional rehab, maybe do some medications or some pain management, maybe some trigger point injections, some epidural cortisone injections. So those are the other services that we have there. And actually, our PM&R docs not only see spine problems, but they see, you know, sports problems, hand problems. There are different— they have a lot of different— we have hand therapists at the spine at Wells Ave. So there are a lot of different orthopedic things that can be taken care of there. And then our anesthesia pain management folks do other types of, you know, if you have chronic pain, and you need to see Dr. Smith or Dr. Whitkower, our behavioral health providers, for, you know, appointments with them. They do group therapy and SMART training, which is like a stress management resiliency training that is really helpful for patients to cope with their chronic pain. And we talk about, you know, how do medications fit in, how does behavioral health fit in, how's meditation and, and exercise and all of those types of things fit into your well-being and, and and helping with your chronic pain. So yeah, we have it all.

Anyone else have a question?

Yeah, we have a couple.

Start here in the middle.

Hi.

It's exciting to hear about all the innovation that's happening and to see what the leading edge looks like. But as a as a customer or consumer of these services, there's another piece of the equation that we all experience that's outside your control, and that's the negotiation with your— with the insurers. So as you're working down the leading edge of clinical care, say something about your experience in working with the world of insurers and bringing them along so that they're able to kind of keep up with what you're doing and provide the appropriate insurance to cover those things?

Do you guys want me to start with that?

So, what?

Oh yeah, yeah. So, this is, that is a great question. And I do think that we are really in the leading edge with those types of thoughts as well because we're looking at value-based care. How can we look at cost? How can we look at the resources we're using? Um, you know, we have— we work with Avantgarde actually, which is a company through, you know, that, that was born at Harvard Business School. And, um, we actually work closely with them to look at all of our cost savings and our— what we're using in the operating room, what our post-acute care looks like. So we can go back to insurance companies now once we have all this data, which we've been collecting now for 5 years, I think, that we've been working with Avantcard and say, this is how we're providing value with these technologies, and this is how we're working in a service line fashion with this multidisciplinary care, and, you know, what we're doing to, to look at the overall episode of care and what our resources are being used and what the long-term cost savings can be with some of the stuff. So yeah, is that—

it is. I, I'm, I'm looking around.

It's working.

Yep.

I'm looking around to make sure the CFO isn't here. But, you know, our focus first and foremost is on patient care. And we provide the best quality care of the patient to give them the best outcome. And we deal with the finances on the back end. What's important though is, you know, this whole movement towards no secret billing. So people should know ahead of time what the costs are that they will incur. And from our perspective, we need to understand what costs we're going to incur. But first and foremost, it's what's the right approach to take care of this patient and what is the best for this patient. Everybody's on their own journey when it comes to back pain, at least. So I'm not an orthopedic surgeon or spine surgeon, I'm an OB-GYN. So just a caveat before I start to speak about one. But, but, you know, people come to develop back pain, they don't necessarily know what the cause is. It could be a simple muscular problem, it could be a neurologic problem, it could be an orthopedic problem. And the idea of this center is to bring all those disciplines together. So you have one place you can go to if you're experiencing back pain, and they will help figure out what the problem is, do all the imaging that needs to be done, and then help you move on your individual personal journey to resolution and to health. And so, and that may involve physical therapy and maybe some behavioral health interventions. It may involve an injection or series of injections. It may end up with surgery. But the idea is to come to the single center and we'll provide the best navigation for you to figure out what the cause is and how to resolve it. And yes, we know the finances are top of mind, Um, but, but first and foremost, it's about what's right for the, for the individual, the consumer.

Yeah, because I— if you think about it, it's really costly for patients to go to— so we see patients who have already been through their journey for a year, say, and then they find us. And if you look at the amount of healthcare resources that they've used in the past year and haven't gotten anywhere because their, their care has been so fragmented, because they go to one place and they go another place and recently, you know, because that's where they're kind of bounced around. You know, it really is better value and better care to have everything under one roof. And for the patient, you know, you get better quicker, and, you know, it's just a much more cohesive approach.

And to go one step— to go one step further, and I have to make sure that no other surgeons in the room— I'm able to look the cost per surgeon for a specific procedure all across the orthopedic surgery, including spine surgery. So I can then compare surgeons and say, why can Dr. Adlon have excellent outcomes but her cost is half of Dr. Smith? And that's very powerful information to be able to do that. It's very powerful to bring people along to do what Dr. Adlon is doing, which is probably best practice. And then we can go to the insurance companies and say, we can provide care. For less.

I think that I'm gonna, I'm gonna wrap this part up because we're not a huge group, so we can continue conversation together just next door and just outside. So more questions to, uh, to be asked and answered for sure, and we can do it in smaller conversation. I'll just underscore what Dr. Norwitz said. We are a patient-first hospital, and we are able to do that because of all of you. If we couldn't rely on support from people like you, we wouldn't be the hospital that we are. So we are extremely grateful for your confidence in us, your investment in us, and your community with us. So please join me in thanking these great doctors, and then out we'll go.

Thank you.