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19 SPINE SURGEONS How Minimally Invasive Spine Surgeons can Stay Independent: Key Opportunities from Dr. Brian Gantwerker By Laura Dyrda B rian Gantwerker, MD, founder of e Craniospinal Center of Los Angeles, discusses key opportunities for private practice spine surgeons in the future. Question: How do you see indepen- dent practice evolving among spine surgeons? Dr. Brian Gantwerker: I really see synergies between private practices and concierge med- ical groups. I think it's a natural fit and there will be an independent network of high quality, low volume physicians available for patients. e quality private practice can give patients attention to detail and follow through in a way that other physicians can't. Also, because they don't want to lose patients to the systems that have high volumes but low patient satisfaction, patients will have a better experience. Going forward, I think there will be fewer private practice physicians out there as a whole; there are a lot of physicians joining large groups or selling to a hospital. For those of us who are brave enough, there is a nice oppor- tunity out there for concierge physicians to provide good quality services. If you have your own set of patients, it can be hard to be on call and pro- vide direct-to-patient marketing. Insurance pressures may drive some patients out of your practice because patients will get plans from large companies that don't do direct-to-physician contracting. e physicians will then stop taking insurance and do direct fee-for-service models the old-fashioned way. ere is the added benefit of having their stream of patients who have access to the physician any time instead of having to go through the system. You can distinguish yourself in the market because most surgical specialists will be forced to join larger practices or relocate. Q: What are the biggest challenges and opportunities for independent practice spine surgeons? BG: ere is a pressure for surgeons to do things outside of practice medicine. Some physicians are working on internet startups or med- ical device startups, designing devices, consulting or providing med- icolegal work. ere is a pressure to do things outside of medicine. If things become as big as they are expected, it could be a nice adjunct to their practice and become a second career if the physician decides to cut back on their practice and do more paramedical activities. I'm involved in a surgery simulation company, VR projects, that's another opportunity on the back end. Q: Where do you see the spine field headed over the next decade? BG: I think you'll see about 50 percent or more of spine surgeries in the ASC setting. You will see the pressure from insurance companies and patients to do more outpatient procedures. at being said, the complexity of the inpatient side will also increase. More patients will have deformity corrections or big multilevel procedures and academic medical centers will drive up costs further. ere will be a crunch on bigger hospitals and academic hospitals. It is an uncertain future with the acuity being lumped into academic centers along with high-risk patients. ey will have artificially in- creased complication rates compared to others with fewer higher acu- ity cases. Surgeons will be performing endoscopic spine surgery, min- imally invasive decompressions, artificial disc replacements and more. I foresee specialty physicians will be performing these procedures and releasing patients to 72-hour stay facilities to drive the cost down. n Dr. Brian Ganwerker 5 Key Notes on Posterior Spinal Fusion for Degenerative Spondylolisthesis: Is TLIF Necessary? By Laura Dyrda A new study published in Spine ex- amines whether transforaminal lumbar interbody fusion makes an impact for patients undergoing sur- gery for one-level lumbar degenerative spondylolisthesis with the posterior ap- proach. The study authors conducted an open-label randomized controlled trial at a single center comparing the isolated instrumented posterior fusion and associated instrumented posteri- or fusion and transforaminal lumbar interbody fusion approach. There were 60 patients included in the study, with 30 patients in each group. The study authors found: 1. Both groups reported significant improvement in pain and disability. 2. There wasn't a difference in the im- provement reported in each group. 3. The posterolateral fusion rate was better for the TLIF patients according to the radiographic assessment. How- ever, there wasn't superiority in seg- mental lordosis improvement. 4. At baseline among the PLF patients there was a case of deformity cascade with spino-pelvic mismatch, accord- ing to the study abstract. 5. The study authors concluded, "Pos- terior decompression and instrument- ed fusion is an efficient technique that proved its significant clinical benefit in the surgical treatment of DS." The re- sults showed TLIF isn't mandatory for the degenerative spondylolisthesis indication. n