Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, we're highlighting from referral to recovery, how AHN is redefining spine surgery.

Joining me is Dr. Kyle Holmberg. He's an orthopedic spine surgeon at the Allegheny Health Network. Dr. Holmberg, thank you so much for joining us today. So, as we think about matching those right interventions to the right patient, can you tell us how AHN's approach really emphasizes that individualized treatment planning from conservative care to advanced surgical interventions based on all of the history that you get with imaging, symptoms, functional impact, what the patient tells you? How does that work?

Dr. Kyle Holmberg: Sure. Well, first of all, thanks so much for having me. It's a pleasure to be here today. I think here at Allegheny Health Network, what maybe makes us unique is that our goal is really precision spine care, trying to match the right treatment to the right patient at the right time. And that may mean something like physical therapy, sometimes injections, oftentimes observation, or it may mean a surgical intervention such as a minimally invasive procedure, motion-preserving technique, or even a complex reconstruction. But the focus is not necessarily operating more. It's on delivering the most appropriate treatment that helps patients recover efficiently and safely as possible.

Melanie Cole, MS: Well, it certainly does. And that's when we look today at shared decision-making and patient-centered outcomes. So, when we're thinking about surgery and in your field, you know, it's been historic that people think, "Oh, he's an orthopedic surgeon. He wants to cut right away." But now, we know differently. And you mentioned conservative management and physical therapy and meeting the patient where they are. So, how do you determine which patients need surgery truly versus those who might benefit from continued conservative management?

Dr. Kyle Holmberg: I'd say the main thing is that we try to treat patients, not MRIs. Not every patient with a positive MRI finding necessarily needs surgery. Their imaging findings definitely have to correlate with their symptoms and their physical exam findings. And also, you know, what they tell us is the main problem or the reason that brings them into the office. Many, many patients will improve with non-operative care, especially if it's appropriately directed and supervised. And the goal is sort of an individualized treatment rather than a one-size-fits-all approach.

So, I think our job as orthopedic spine surgeons is to try to identify the true pain generator and develop the least invasive treatment strategy necessary to help improve their function and hopefully improve their quality of life.

Melanie Cole, MS: Well, that really is what it's about and pain is certainly somewhat subjective. And so, when you talk to patients, how do you determine that pain level, what they can live with?

Dr. Kyle Holmberg: I've had that experience where you see folks that while their MRI findings may be relatively benign, they're still struggling. And so, oftentimes, that means we need to take a comprehensive look at not just maybe what brought them into the office, but what does their day-to-day look like? What do they do for a living? Are they lifting heavy equipment at work, or do they have a desk job? Is it somebody who has two young kids at home and their main complaint is, "When I get down on the floor and play with my kids, I can't get back up again." As everyone's lifestyle, general health and fitness are all individualized. And so, we have to, like you mentioned, meet patients where they are.

Oftentimes that involves kind of an individualized treatment strategy and a multidisciplinary approach, whether it's with our physical therapists, our home health services, our occupational therapists, aquatherapy, physical medicine and rehabilitation doctors. And so, we're very quick to engage other resources and not just think about what surgery does this patient need, but what resources do they need to provide kind of a comprehensive care model.

Melanie Cole, MS: Well, that's true. It is moving really toward that multidisciplinary approach. It's so important. Now, as we look at the spine conditions and surgical interventions, what types of conditions are now being treated less invasively? And how have you seen some of the newer techniques change the outcomes?

Dr. Kyle Holmberg: One thing that we're doing at Allegheny Health Network is there is a big emphasis on endoscopic spine surgery. And so, endoscopic spine is truly, in terms of minimally invasive surgery, from a spine standpoint, it's sort of the cutting edge. And while it's been around for a long time, there have been lots of folks doing endoscopic spine surgery around the country. There's been a big interest in it and not only in our patients, but in our providers as well. But we can take what was typically done through an open approach and really minimize the incision, the surgical dissection, really preserve muscle and soft tissue in order to solve the problem, which in most cases is primarily a radiculopathy or a pinched nerve from a disc herniation, or foraminal stenosis or something along those lines, which can be oftentimes managed and treated from an endoscopic approach.

So, that's truly the far end of the spectrum in terms of minimally invasive surgery from a spine standpoint. And so, patients are often able to be treated for their debilitating, functionally limiting radicular pain or leg pain. And then, after surgery, there's less restrictions, less time off work, quicker recovery in terms of getting back to normal activities and exercise and things like that. So, I think patients have been very happy with that approach.

Melanie Cole, MS: Well, thank you for that. So Dr. Holmberg, as AHN evaluates and treats the full spectrum of spinal disorders, including degenerative disease, deformity, scoliosis, that sort of thing, and revision surgery when prior interventions fail, when should primary care providers refer more complex or patients that may be considered failed back patients earlier for that specialty evaluation? What are some of the flags for referral and some of those really important triggers?

Dr. Kyle Holmberg: Really, in any neurologic condition or any spine patient, early referral is particularly important for things like progressive neurologic deficits, things like lower extremity weakness, foot drops, numbness or tingling that's new or progressive, suspected myelopathy, whether that's cervical or thoracic myelopathy, secondary to spinal cord compression. And that can manifest as things like gait and balance abnormalities, urinary incontinence or dysfunction, hand dysfunction. So, those signs can be subtle. Spinal tumors, unstable fractures, or previous revision surgery with failed conservative management or worsening or functionally deficits.

All those things would be a very reasonable early referral and we'd be happy to help sort those patients out. And that's really one of the great things about our practice is we have a lot of resources and a lot of surgeons who are capable of managing those types of things here.

Melanie Cole, MS: Pretty exciting time in your field, Dr. Holmberg. And when we hear about minimally invasive motion-preserving techniques for a more complex pathology, and we think of faster recovery, return to function, and why that matters. Tell us about some of the exciting minimally invasive approaches that you've got now for that shorter recovery when we're thinking of robotic-assisted, you mentioned endoscopic spine surgery. What are some of those motion-preserving solutions and some of the newer technology you're excited about?

Dr. Kyle Holmberg: You're absolutely right. It is an exciting time in spine surgery. There's been a lot of emphasis in trying to make surgical techniques more efficient through smaller incisions. And like you mentioned, motion-preserving techniques.

Some things that come to mind are disc replacement surgery. And so, both cervical and lumbar disc replacement surgeries can be a motion-preserving technique for debilitating or functionally limiting nerve pain. In some cases, chronic back pain under the right circumstances can be managed with a lumbar disc replacement, but primarily neurologic symptoms. And then, there's also a variety of techniques we can use from a tubular decompression standpoint. So, using a small tube to make a window in the bone for a hemilaminotomy or a decompression through a tube, which results in less tissue dissection and smaller incisions.

But from a motion-preserving standpoint, you know, there's lots of techniques that have been around for a long time. Cervical disc arthroplasty, lumbar arthroplasty, and then also cervical laminoplasty procedures for cervical spinal stenosis, is a nice way to decompress the spinal canal while preserving motion without having to do a fusion procedure.

Melanie Cole, MS: Dr. Holmberg, as you're telling us about these different procedures and modalities that are available now, everybody always asks you about the benefits for the patient, how it changes their experience, their expectations, recovery quicker. But I'd like you to also speak about how it's changed for you, the surgeon, these things, whether it's an ergonomic benefit for you sitting there doing a spinal surgery and not being as uncomfortable when you're using these robotics or intraoperative imaging, which has helped you to see better and find the focal point. Tell us a little bit about the benefits for the patient, but also for you.

Dr. Kyle Holmberg: You're absolutely right, the goal is patient outcomes and how is this going to affect the patient. But when I think about things that are going to make my day a little bit easier in the operating room, robotics are something that have been sort of a game-changer in the operating room. They take a procedure, and they add the ability to provide very, very precise surgical planning, as well as very reproducible results very consistently. And so, what the robotics aspect of things have achieved from a spine surgery standpoint, right now, the main use of robotics in spine surgery is for the insertion of something called pedicle screws. Pedicle screws are screws that are placed into a channel of bone called the pedicle, that can help stabilize the spinal column. And that can be done for a variety of reasons. From a trauma standpoint, if there's an unstable fracture that needs stabilized, oftentimes pedicle screws and rods are used to stabilize those structures. From a degenerative standpoint, oftentimes if we have to do a thorough decompression or a wide decompression in order to treat nerve symptoms or neurologic compression, that can functionally make the spine inherently unstable, and so a fusion can oftentimes be required. And so, what the robotic assistance has kind of provided is that we are now able to place very precise and very accurate pedicle screws very reproducibly over and over again.

But I would say that even one step further, an added benefit is that we can very precisely plan the operation to where the screws and rods need to be to best support the overall alignment goals of the operation as well. Because thinking long-term for spine patients, anytime that a fusion is indicated, we have to think about how it may or may not change the lumbar spine alignment or the spinal pelvic alignment, and what the long-term impact that may be on the patient from an alignment standpoint in order to minimize further adjacent segment disease or further breakdown of the spine, that may eventually mitigate future surgeries for revisions and things like that.

So, I would say from a planning standpoint and an ergonomic standpoint, robotics have certainly played a role in helping our surgeons perform better in the operating room.

Melanie Cole, MS: It's really amazing some of those technological advances and what's going on in your field today. So as I understand it, AHN also offers advanced therapies like neuromodulation, nerve-targeted treatments for complex pain cases. Tell us about some of those.

Dr. Kyle Holmberg: As we mentioned previously, this spine care, it's a team sport, it's a multidisciplinary approach, and one arm of our, team would be our rehabilitation doctors, our physical medicine and rehabilitation physicians, and our pain management colleagues. And so, in some cases, when patients have had either multiple spine surgeries and they have "failed back syndrome," or they have a complex pain history, perhaps they're on narcotics preoperatively, we are very quick to engage our pain physicians and our physical medicine and rehabilitation doctors to support our patients in going through that process.

And in some cases, neuromodulation, which is better known as like spinal cord stimulation can be appropriate. And so, getting the right patient to the right physician to help make those decisions and undergo a thorough workup before jumping to a procedure that requires putting a permanent implant in somebody, I think, is very important. And so, we have a nice pathway for that in our complex pain patients as well.

Melanie Cole, MS: This has been a great discussion, Dr. Holmberg. And as we get ready to wrap up, I'd like you to expand, because you gave some referral triggers and criteria before for complex pain. I'd like you to sort of reiterate some of those to streamline the access to that specialty spine care. Whether someone has just got neck pain or persistent back pain that hasn't really worked with those conservative measures, lay some clear referral triggers for those physicians, patients, and how easy it is for referring physicians to get patients in quickly, what you would like the key takeaways to be here, and all of the great work that you're doing at the Allegheny Health Network.

Dr. Kyle Holmberg: I guess the short answer is, if you're wondering whether a patient should be referred, we're happy to evaluate them and determine the most appropriate next step for them. We have a number of spine surgeons, we have a number of PM&R physicians, a number of pain doctors, and we all communicate very well with each other. And so oftentimes, if one of my PM&R colleagues has a patient in the office and they have a concern, you know, they'll send them over to me for just a surgical evaluation. "Hey, does this patient need an operation or can we continue with conservative care here?"

And that's a very simple process. You can certainly place a referral through Epic. You can call our office, and I'd be happy to provide my office number here as well. But the short answer to that question is if you're wondering if they need an evaluation, we're happy to do it. Things that we mentioned before, progressive neurologic deficits, foot drops or cervical radiculopathy, lumbar radiculopathy that's refractory to things like physical therapy and anti-inflammatory medicines.

Those patients often may go on to need something like a steroid injection or a corticosteroid injection that can be helpful in helping their symptoms. Progressive, neurologic symptoms or history of anything like concern for a tumor or an unstable fracture. Certainly, those are great referrals that we'd be happy to take care of. And honestly, provider to provider communication for any urgent concern. So if you have the ability to just send a message on Epic and say, "Hey, can you take a look at this? I was wondering if they needed to be evaluated." You know, we can get them in the office relatively expeditiously. That way, that seems to be a pretty reliable pathway for that. But that would be my short answer is anybody that you think needs an evaluation, we're happy to evaluate.

And additionally, I'd like to just emphasize that our mission at Allegheny Health Network is to provide comprehensive spine care across the entire spine spectrum, from conservative management and minimally invasive surgery to the most complex reconstructive trauma and oncologic cases. We really value our relationships with our referring physicians and strive to deliver timely access to care and clear communication, trying to provide evidence-based care that puts the patients first.

Melanie Cole, MS: Thank you so much, Dr. Holmberg, for joining us today and sharing your incredible expertise for other providers. And to learn more or to refer your patient, please call 844-MD-REFER, or you can visit findcare.ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.