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Aired: April 20, 2020

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Drs Khalsa and Malhotra

In this interview, Drs. Amrit Khalsa and Neil Malhotra review types of minimally invasive and traditional spine surgeries offered at the Penn Spine Center, identify when to refer your patient, and discuss they decide which types of procedures to perform when necessary. This interview is a part of the Penn Medicine Spine Center Podcast Series.


Podcast Interview Transcript

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Melanie Cole (Host): Degenerative disease of the spine is a common and increasingly prevalent condition that’s often implicated as the primary reason for chronic back pain and a leading cause of disability in the Western world. In this panel today, we have Dr. Amrit Khalsa. He’s the Co-Director of the Spine Surgery Fellowship at the Hospital of the University of Pennsylvania. And Dr. Neil Malhotra. He’s the Vice Chairman for Operations in the Department of Neurosurgery and an Associate Professor of Orthopedic Surgery and Neurosurgery at the Hospital of the University of Pennsylvania.

Gentlemen, thank you so much for joining us today. Dr. Khalsa, what is the course of spinal degeneration and who does it affect?

Amrit Khalsa, MD (Guest): Great question Melanie. So, spinal degeneration it’s often an arthritic related condition that we as early as your 30s and 40s, we will continue to see it oftentimes progress but whether that progression directly correlates with symptoms or not is kind of the name of the game of how we kind of manage and treat patients.

Host: So, Dr. Malhotra ,if we are expanding on this and talking about the Penn Medicine Spine Center; what types of conditions are you most often treating there?

Neil Malhotra, MD (Guest):  Well since it’s a degenerative disorder that Dr. Khalsa commented on that we will most commonly see although we take care of the entire spectrum of spinal disorders across orthopedics and neurological surgery and intermittently consulting colleagues from outside of the services when necessary.

The most typical conditions we face are those related to this progressive degeneration that affects all adults, increasing year by year as patients become increasingly symptomatic, we typically are seeing patients with arm symptoms related to neck pathology, leg symptoms related to low back pathology. And intermittently isolated low back or neck pain and thoracic spine pain.

Host: Dr. Khalsa, why don’t you take this one and tell us what you’re doing there as far as some of the new technology and surgeries.

Dr. Khalsa:  Sure. Absolutely. Over the last decade or so, one of the big innovations in spine surgery in general is the adaptation of minimally invasive approaches. Whether it be in the lumbar, thoracic or cervical spine; we implement and utilize some of the more modern technology in an effort to really optimize the patient’s experience in the operating room and after the operating room and really their overall recovery.

Host:  Dr. Malhotra, expand on that a little bit. Speak about some of the benefits to the patient for minimally invasive procedures versus traditional more invasive procedures and what’s new and different now?

Dr. Malhotra: We are at a special time sort of within spine surgery and spinal care in that we are able to create 3-D reconstructions of the patient’s own spine to guide our surgical intervention and this allows us to perform interventions with less direct anatomical data. So, in some cases, where we had to once expose an enormous amount of the patient’s spine now we can expose very small elements of it and treat just the targeted component we are trying to treat.

In addition to that, we’re very excited about the endoscopic tools that we now have to accomplish those tasks. We are now sort of advancing those tools, working in partnership with technology companies to build the right instruments so that we can sort of advance a patient’s care. When minimally invasive surgery is used our broad view is that it has to give a patient an equally successful outcome to an open more traditional surgery, but the goal is to do so with less side effects or symptoms. So, instead of a six week or three month recovery; hopefully we are looking for a multiple week recovery, less than four weeks.

Host: So, Dr. Khalsa tell us a little bit about what this is like for the surgeon, how it makes what used to be quite a long, complex spinal surgery into something now that does not take you quite nearly as long but may have a different learning curve.

Dr. Khalsa:  Sure absolutely. When these techniques initially came about, we were using a lot of fluoroscopic intraoperative x-ray imaging that really it got the job done in a minimally invasive technique when appropriate, but it exposed the patient, exposed the surgeon and it exposed the operating room staff to a fair amount of radiation.

So, with that in mind with some of these technologies that we now have whether it be an intraoperative navigational tool or intraoperative robotic technology, we are able to wean ourselves from the dependence on intraoperative x-ray fluoroscopy and we have been shown to reduce the radiation burden both on the surgeon, on the operating room staff and actually on the patient as well.

What we are doing needs to be the same if not better than what we were doing with traditional open approaches and we are able to achieve that while still increasing our accuracy of implant placement and a lot of really other benefits to patients again, in the operating room and postoperatively as well through the recovery.

Dr. Malhotra:  I would just want to add to Dr. Khalsa’s excellent points that here at Penn Medicine, the patient is always sort of at the center and sometimes that means we are using a new technology, sometimes we recognize that the new technology doesn’t provide benefit or provides risk perhaps. Everything we do here is centered around how do we give the patient the best outcome whether it’s at one month, six months, one year, five years and how do we do that in a way that the patient gets back to normal life as quick as they can.

Host: Dr. Malhotra, as a neurosurgeon that also is involved in orthopedics; tell us about the multidisciplinary approach at the Penn Medicine Spine Center and how you all work together in a comprehensive way.

Dr. Malhotra:  To speak specifically about what we’re doing here, it’s the collaborative model, it’s that we work so closely together to determine the best treatment for our individual patients. We have multiple conferences in which multiple specialties meet to discuss an individual patient. So, particularly if we think about the patients with spinal cancers; a room for example I was at a meeting this morning at 7 a.m. with 25 clinicians of multiple specialties that might be talking about one individual patient.

They are getting the benefit of 25 second opinions to get the best intervention for that patient. The team effort I think allows us to find the right path for each individual patient and the population of patients.

Host:  As we wrap up, Dr. Khalsa I’d like you to give us a good summary of the Penn Medicine Spine Center, the conditions that you treat and what other referring providers can expect from your team.

Dr. Khalsa:  Yeah, absolutely. Here at the Penn Medicine Spine Center, we really comprehensively manage all spinal conditions whether it be cervical disc herniation, cervical arthritis, scoliosis, spinal deformity, as Dr. Malhotra pointed out spinal cancers, in the lumbar spine commonly disc herniations, disc slippages or spondylolisthesis, spinal stenosis. So, we really run the entire gamut of spinal pathologies that we manage both operatively and nonoperatively.

Dr. Malhotra:  And I would just add to that, I would add to the approaches that we take. We use interventions from sort of the most minimally invasive endoscopic treatments on to much more extensive decompression, reconstructions. So the entire spectrum of care is covered here and there’s not a lot of places in the country that the entire spectrum of spinal care is addressed and, in the way, that we do.

Host:  Excellent information and what a great topic. Gentlemen, thank you so much for joining us today and sharing your incredible expertise and telling us about the Penn Medicine Spine Center. This concludes this episode From the Experts at Penn Medicine.

To refer your patient to Dr. Khalsa or Dr. Malhotra at the Penn Medicine Spine Center please visit our website at or you can call 877-937-PENN for more information and to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Penn Medicine podcasts. I’m Melanie Cole.




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