Joey Wahler (Host): It addresses many conditions. So, we're discussing orthopedic spine surgery. Our guest is Dr. Nicolas Minassale, an orthopedic surgeon. This is the Beebe Healthcare podcast. Thanks so much for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Nicholas Minissale, DO: Hi there. Thank you for having me.

Host: Great to have you aboard. We appreciate the time. So first, in a nutshell, what you say initially drew you to osteopathic medicine and ultimately a career in spine surgery now?

Nicholas Minissale, DO: When I was in high school, I basically wasn't sure what I wanted to do. At that time, my mother worked in healthcare. I grew up in New Jersey. And so, she kind of helped me decide one way or the other. She said, "Why don't you just come shadow someone and see if it's something you're interested in?"

So, I shadowed an orthopedic surgeon in New Jersey and just followed a day in the office with him, and I was hooked. And mind you, I was 16 years old. I saw he could use his hands and X-rays and just make diagnoses, fix people, make them feel better, and I was hooked. So, that's what kind of started the journey overall.

Spine surgery came much later when I was in residency already as an orthopedic surgery trainee, I was in the training portion for spine and was completely drawn to the surgeries themselves, the outcomes, and how well people can do. And it just became a snowball again from there of really heading full on into spine surgery.

Host: It seems so often that initial motivation in healthcare for people like yourself comes from something having to do with family affair as in your case. And it must have been great to your mid-teens that you what wanted to do, right?

Nicholas Minissale, DO: Absolutely. I think, people knew, I let everybody know it was one of those things where I wasn't quiet about what I wanted do, and I'm really thankful and privileged to have been able to make it far and never really have changed course. And to be honest, I really never had second thoughts. So, super lucky to have pursued and completed and followed through with my dream from being a young teenager.

Host: Yeah, I'm sure something that many people aspire to, but not everyone is able to pull off. So, how does your doctor in osteopathic medicine or DO training as it's known, how does that influence the way you approach spine care in your practice today, would you say?

Nicholas Minissale, DO: I think it's multifaceted. I think the biggest difference, and a lot of people still aren't really aware of this, is the medical school itself is different. So, we get additional training in hands-on osteopathic manipulative medicine. So, from the very first semester or the very first day, you start treating patients by diagnosing with your hands and trying your best to heal with your hands. That particular part of healing with my hands, the manipulative medicine portion is not part of my practice anymore, but it laid the foundation to be able to use my hands and feel for tension, muscle changes, you know, restrictions in range of motion and things like that from a very early part of my medical career.

And then, that helps springboard into my practice and my training further to, again, look for changes in posture, symmetry, muscle, ranges of motion and things that I do a pretty exam—I like to think I do at least—much more than, you know, the average spine surgeon, I think. And that stemmed from my early training. And so, I think that's a big part of it.

The misnomer is thereafter orthopedic surgery residency, my board exams, my in-training exams, and ultimately my board certification and my fellowship were all with the same exact boards and bodies of medical training that MD counterparts have. So thankfully, the outcome I think is ultimately very similar with maybe some additional training, like I said, in the osteopathic manipulative portion.

Host: And speaking of that training, you've completed extensive orthopedic and spine training across several high-volume centers. So, how do those experiences shape your approach, especially to the more complex spine problems when you're doing it through repetition on regular basis? That alone has be worth quite a bit, right?

Nicholas Minissale, DO: Absolutely. You know, the transformative, and none of us could do what we do without it. So, I'm always thankful for my mentors, both at Jefferson Health in New Jersey and at my fellowship, which was at Swedish Neuroscience Center in Seattle. I've gotten to meet and train with some of the world's best.

But ultimately, those things, larger centers, higher volume centers, tertiary referral centers, what they have are teams. So, none of this is done alone. You need a completely well-diversified and well-rounded team with a lot of effort from a lot of different places. So as a surgeon, whether it's the pre-op PACU nurses, the intra-op team, the scrub techs, everybody to the PACU and floor nursing ICUs, the biggest thing I took from all of that, aside from actually the hands-on training, is the team is one of the most important things.

And here at Beebe and at First State Orthopedics, we are building to be able to provide more complex care, and Beebe is very much invested in doing that. But at the same time, we have to know our limits. And so, there are times where I have to refer patients to larger volume centers, and I think that's one of the really important nuances that I've learned is this not just me. And so, we're not at a high-volume tertiary referral center. My hope is to continue to improve the spine care in the region. And again, Beebe's very much intended on doing the same, but part of this process is knowing what we can and cannot handle at our center right now. So, that's the biggest thing I've taken from those.

Host: And when you mention team, the team you're a part of on a daily basis is obviously just like pretty any other team, athletically or otherwise, everyone to play a role. So, what spine conditions would say you see most often? And why are back and neck issues so for patients really of all ages, right?

Nicholas Minissale, DO: Yes, it's very common. One of the most common things I see is either acute, meaning within the last several weeks to months, or chronic low back pain. It's one of the highest causes of disability in America. So, it's just very prevalent. And secondarily, I see a lot of neck pain. And then, within those realms, we see what people term as sciatica or nerve pain.

I always tell my patients sciatica is a very broad term for nerve pain. But ultimately, I treat these things because they are prevalent. And why are they prevalent? I think, you know, it's combination of many things: lifestyle, activity, habits. Some these are genetic, in sense that there is a genetic component to arthritic problems in general. And so, you know, we live in a fast-paced world, and there are times where we're not maintaining a good, solid, strong core, myself included. You know, there's multifactorial problems that all lead to this being a very prevalent issue. But there are absolutely many non-surgical ways to help it. So, that's a big part of my practice.

Host: So, wait a minute now. saying even a spine surgeon like yourself doesn't always have the greatest posture, right?

Nicholas Minissale, DO: Agreed. Agreed. It's something that is always—I often say we're not gaining, we're losing, whether that be muscle, posture, bone density, mass. You know, if we're not actively working on all of these things, then it can lead to some of these problems. And then, of course, there's true injuries that, you know, you could be the strongest person in the world, you can absolutely throw your back out and have trouble, and that's what I'm here to help with.

Host: My mom always say when I was kid, "Sit up straight." And I think she concerned about it both visually and health-wise. Now, you offer both traditional and minimally invasive spine procedures. As you well know, we hear so much now about minimally invasive in all areas of medicine. So, how has minimally invasive surgery changed patient recovery and outcomes in your world, would you say?

Nicholas Minissale, DO: Absolutely. I think it's really important. And going back to my training, minimally invasive has a lot of meanings. It doesn't just mean a small incision. It means the smallest, most effective surgery or non-surgical option that's going to help a patient. So, in my practice, I absolutely do the smaller, minimally invasive procedures, simple things like midline-sparing laminectomy or laminotomies, meaning I'm not ripping out bone that should stay there.

You there's small things like that. And then, there's larger procedures that do have smaller incisions. So, it's really not small incision, small surgery, it's the most effective surgery with the least tissue disruption and the least complications we can possibly provide. And think that's a nuance that's really important. So, I do provide both. I think maintaining normal anatomy as much as possible is a big part of how I picture minimally invasive.

So, the incision may be this big, but we're also maintaining the most normal anatomy and avoiding fusions when possible and things like that. So, that's all a big part of it rather than, "Hey, look how little my incision is." I think that's a really important nuance, and that's how I practice.

Host: Yeah, it's definitely a great point. So, when someone does come in with back neck pain, how do basically evaluate whether surgery, more conservative care, or some other approach is the right fit them?

Nicholas Minissale, DO: Absolutely. I think almost always we can approach it with a conservative effort. So, patients come at all different stages of workup, imaging, and length of time of their problem. Sometimes I'm their third opinion, sometimes they've had pain and trouble for a week and I'm the first person they see, and I'm happy to take care of all of those patients.

But in my hands, most often, greater than 90% of the time, if not higher, there's some conservative that had not been tried yet. And so, that can look something like we trial physical therapy. I can often give home exercises if a patient has the wherewithal and the drive to do more things at home.

You know, again, taking the patient's particular problem into account and personalizing their treatment plan is really important. And so, one-size-fits-all. There are times where I will re-attempt physical therapy with maybe my protocol if they hadn't specifically done certain things. Injections are a big part of spine care. And, as a spine surgeon, I personally don't provide those, but I absolutely can refer you to several practitioners in the area, and I always check in after to see how it went.

So, I think the biggest thing that I would like people to understand is that just because I'm a spine surgeon doesn't mean that's all I do, and that you shouldn't be afraid to come me I'm going to do everything in my power to get you better, whether that's surgical or not.

Host: I'm sure it's great for those joining us to hear. And switching gears a little you're also active in research and several professional spine organizations. So, how is staying involved in that influence your day-to-day clinical decision-making, would you say?

Nicholas Minissale, DO: It's really important. You know, medicine as a whole is constantly evolving, changing. There's always new research to be read. I also help peer review some journals like the Global Spine Journal. And reading these things keeps you abreast of all these topics. Again, patients are very in the know about modern advances, and they're going to ask.

And so if you have not read or at least attempted to learn about these things, going to be left behind, and that means you're ultimately not the best care for patients. So, it's really important to me. I will say difficult in private practice and as a human being who enjoys time with his family, but it's important to stay up on. And I think all practitioners should and do attempt to follow the most recent literature.

Host: How about the advancement or innovation spine surgery that you're most excited about right now?

Nicholas Minissale, DO: I think, like we said, there's always something on the horizon. There's always something new. I think in my training, the biggest things, the two biggest facets that have changed recently are motion preservation. So whenever possible, again, avoiding a fusion and providing either a disc replacement or just simply not fusing. I use some techniques that are motion-preserving. And it's really important to keep that in mind. Now again, not everyone's a candidate for that, so we can't just push it on everyone, just like minimally invasive. Not everyone's a candidate for that. So, super important, the motion-sparing techniques. I perform most of those that I can think of and happy to always discuss that with patients.

The second biggest thing is using navigation techniques and robotics, which, again, Beebe has made huge strides. We are one of the only facilities in Delaware who has a very specific imaging platform for intraop, and we use robotics and navigation regularly in our procedures. And that's a humongous change that's happened over the last 10 years or so. Most trainees now have significant exposure to it. And I think if I had not been trained on it, I would certainly want to be. So, that's a huge part of when I can use it, I do. It's an adjunct and an additional technology that's very helpful.

If I don't have it, I don't need it. I've often seen it likened to a backup camera. Can you drive your car and get it into a parking spot without a backup camera? Absolutely. Has it revolutionized safety and precision and reduced incidents and problems when used appropriately? Also absolutely. So, that's what two really important facets of spine care that are innovative, and I've been trained in both, and I'm happy to use both.

Host: A couple more for you. What is your best practical advice for those wanting maintain good long-term spine health other than, of course, trying to sit up straight like that, right?

Nicholas Minissale, DO: Absolutely. I talk to patients all the time about this too. I think, at any age, maintaining a healthy, active lifestyle, which is a very broad answer for a reason, is really important. So again, maintaining your bone health, muscle health, your core, and your spine are all super important at any age. And then, additionally, as we age, bone health in the form of certain medications such as bisphosphonates or other things, there's many options now, when it comes healthand fighting against osteoporosis.

So if you can keep a healthy, active lifestyle, good muscle, and healthy bone, you're going to great. I think that's super important. So, posture's important. But all the other things I mentioned before really keep a healthy spine.

Host: And in summary, Doctor, you're obviously passionate about what you do, that's clear, and very detail-oriented. What's the main thing that keeps you motivated in your work serving patients in Sussex County?

Nicholas Minissale, DO: Seeing outcomes of patients feeling better is what really drives most of us as doctors. Being able to say I fixed someone without surgery fantastic. Again, if can do it, I will do it. But when a patient comes back in after a surgery when they had that preconceived notion that spine surgery doesn't help anyone, and they had nerves, appropriate nerves leading into surgery, and they come back and thank me and their life has changed dramatically, You can't really describe that. It's what you every day. You know, there's always ups and downs, but being able to help people and, in my field as a surgeon, helping them with surgery is just priceless. So, seeing patients who have completely changed their day-to-day pain, their overall functionality is what drives me every day.

Host: That is the payoff right there. Well, we trust you are now more familiar with orthopedic spine health and surgery. Doctor, keep up all your great work and passion. And a pleasure. Thanks so much again.

Nicholas Minissale, DO: Thank you very much for having me.

Host: Absolutely. And for more information, please do visit beebehealthcare.org. If you found this podcast helpful, please do share it on social media. I'm Joey Wahler. And thanks again for being part of the Beebe Healthcare podcast.