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Ali H. Mesiwala, M.D., is fellowship trained in complex spine surgery and a leader in the field of sacroiliac (SI) joint surgery. In 2021, Dr. Mesiwala became a partner at the renowned DISC Sports & Spine Center in Newport Beach, California.
He performs about 400 total disc replacements a year, many of which are done in the outpatient setting where he employs the latest minimally invasive surgical techniques.
He’s also a bit of a tinkerer. Before developing into a top neurosurgeon, Dr. Mesiwala graduated from Johns Hopkins University with degrees in biomedical and electrical engineering. He’s collaborated with companies such as Abbott, SI-Bone, Life Spine, NuVasive, Providence Medical Technologies and Neo Medical to develop novel technologies for spine and cranial surgeries.
Here he discusses how he developed a love for medical device design, the barriers to performing spine procedures in ambulatory surgery centers (ASCs) and why motion preservation technology is a game-changing evolution in spinal care.
What sparked your interest in the industry side of surgical care? How has your engineering background helped you as a surgeon?
Dr. Mesiwala: I grew up in Silicon Valley with an engineer father and had access to the Stanford campus from an early age. Tinkering was always fun for me, and I was able to work with medical students when I was in high school, so it was a fairly natural progression for me to combine engineering and medicine. I had many experiences and mentors along the way who reinforced my desire to pursue both disciplines.
Before medical school, I studied biomedical engineering and worked with medical device companies. Designing implants for sacroiliac fixation and spinal fusion was one of the projects that I found most interesting and exciting.
Having backgrounds in engineering and medicine allows me to tackle complex cases and problem-solve in a unique way. I’m able to look at surgical approaches from a novel perspective to achieve the best possible outcomes.
I can also identify unmet clinical needs or problems that haven’t been solved — or that could be solved more effectively — and then design devices that improve patient care.
Minimally invasive surgical techniques help make outpatient spine procedures possible. What’s preventing surgeons from performing more cases in ASCs?
Dr. Mesiwala: The biggest challenge is the reluctance of insurance companies to cover procedures performed in that setting. If Medicare converted inpatient and outpatient codes to universal codes, commercial payors would be motivated to do the same.
Additionally, commercial payors are not interested in covering historically inpatient procedures like pedicle screw fusions in ASCs. The conflict between technological advances and insurance restrictions slows the migration of cases to outpatient facilities.
Still, economic pressures and the overall desire for affordable surgical care will likely increase the number of procedures that are performed in ASCs as long as patients are healthy and have no major medical issues. The ability to control the clinical environment in the ASC setting results in predictable care, which improves outcomes, efficiencies and patient safety.
What spine procedures are suitable for the ASC setting?
Dr. Mesiwala: The most common procedures performed are laminectomies, discectomies and chronic pain management interventions. One- and two-level cervical and lumbar disc replacements are frequently done in ASCs. Complex procedures such as percutaneous anterior lumbar interbody fusions and lateral fusions can be performed in ASCs with minimally invasive techniques, which minimize blood loss and lessen recovery times.
The ASC at DISC is quite sophisticated. We have a great relationship with payors. This allows us to tackle challenging cases, such as spinal tumor resections, deformity reconstructions, cranial operations and shunting procedures. Safety is paramount, and we always evaluate whether a procedure is suitable for the ASC setting.
There aren’t many limitations to what can be done in an outpatient setting. Favorable reimbursements, capable spine surgeons, appropriate patient selection and the latest technologies make most procedures possible.
How do enabling technologies transform minimally invasive spine surgery and lead to more personalized patient care?
Dr. Mesiwala: They’re independent, but overlapping, concepts. Patient-specific implants aren’t common in spine due to cost and insurance reimbursement issues. However, robotic surgery and navigation systems enhance patient care without the need for personalized implants. The platforms account for the anatomy of individual patients and allow surgeons to make real-time adjustments during surgery.
Let’s say a surgeon places pedicle screws in perfect positions and now must bend a rod to connect the screws to match the curvature of the spine. Surgical navigation systems can measure the location of each screw and inform the surgeon on how to accurately bend the rod. iPad-based systems are also available that scan the surgical field and provide an augmented reality overlay of the screws, allowing the surgeon to see how to position the rod perfectly. This leads to personalized care and has the potential to improve outcomes.
And yet, robotic assistance and navigation are not widely used in spine. What will increase the adoption of these technologies?
Dr. Mesiwala: The current iterations of spine navigation systems are still very cumbersome, making it difficult to convince surgeons to use the technology — especially if it interferes with their workflow. Surgeons might not see the value in using navigation if it increases surgery time by an hour or two and they can achieve excellent results without it.
Economics is also a factor that cannot be ignored. Surgeons get paid based on the number of cases they perform and the amount of time they spend on each case. A navigation system that slows down procedures without providing clear clinical benefits can significantly impact their income.
The direct and indirect costs of adding new technology is not something that most spine companies consider, but they are challenges that need to be addressed.
It’s important to advance surgery with new technology. It’s equally important to make platforms easier, faster and more efficient for surgeons to use. As spine navigation systems become more refined and consistent, they’ll be used more frequently.
How do you see spine surgery evolving over the next five years?
Dr. Mesiwala: Artificial disc replacement is the future of minimally invasive surgical care. One of the fundamental principles of spine surgery is to reestablish or preserve normal anatomy and function. The field of motion preservation, or specifically disc replacement within spinal surgery, is a relatively recent area of interest for industry. Although the emphasis has been on cervical arthroplasty, lumbar arthroplasty is gaining in popularity.
The appeal of motion preservation lies in the ability to reestablish normal mobility of the spine. In most cases, it prevents adjacent level disease that results from fusing spine segments that should have normal mobility.
Commercial payers increasingly cover artificial disc replacement, and patients increasingly request it. This is leading to a transition away from spine fusion surgery and toward motion preservation.
How has industry responded to the increased interest in motion preservation technology?
Dr. Mesiwala: The designs of artificial discs have improved over the last two decades — the biomechanics are closer to the spine’s normal motion. The surgical techniques to implant these devices have also been refined. The goal is to remove the entire diseased disc and replace it with a prosthetic in the least invasive way possible.
Newer implants provide a combination of disc replacement and facet joint replacement technologies for use in the cervical and lumbar spine. Surgeons now have more options available to tackle a variety of challenging anatomy and deformities. It’s possible to correct a complex deformity — such as thoracolumbar scoliosis — with a motion-preserving surgery that reestablishes the spine’s normal mobility.
For spine to keep pace with surgical innovations, regulations for approving medical devices and implants need to change. Industry and surgeons must work toward a common goal of advancing technology and improving outcomes in an economically responsible way. Doing so will reduce the cost of advanced surgical care and make it accessible to more patients.
Ali H. Mesiwala, M.D., is fellowship trained in complex spine surgery and a leader in the field of sacroiliac (SI) joint surgery. In 2021, Dr. Mesiwala became a partner at the renowned DISC Sports & Spine Center in Newport Beach, California.
He performs about 400 total disc replacements a year, many of which are done in the...
Ali H. Mesiwala, M.D., is fellowship trained in complex spine surgery and a leader in the field of sacroiliac (SI) joint surgery. In 2021, Dr. Mesiwala became a partner at the renowned DISC Sports & Spine Center in Newport Beach, California.
He performs about 400 total disc replacements a year, many of which are done in the outpatient setting where he employs the latest minimally invasive surgical techniques.
He’s also a bit of a tinkerer. Before developing into a top neurosurgeon, Dr. Mesiwala graduated from Johns Hopkins University with degrees in biomedical and electrical engineering. He’s collaborated with companies such as Abbott, SI-Bone, Life Spine, NuVasive, Providence Medical Technologies and Neo Medical to develop novel technologies for spine and cranial surgeries.
Here he discusses how he developed a love for medical device design, the barriers to performing spine procedures in ambulatory surgery centers (ASCs) and why motion preservation technology is a game-changing evolution in spinal care.
What sparked your interest in the industry side of surgical care? How has your engineering background helped you as a surgeon?
Dr. Mesiwala: I grew up in Silicon Valley with an engineer father and had access to the Stanford campus from an early age. Tinkering was always fun for me, and I was able to work with medical students when I was in high school, so it was a fairly natural progression for me to combine engineering and medicine. I had many experiences and mentors along the way who reinforced my desire to pursue both disciplines.
Before medical school, I studied biomedical engineering and worked with medical device companies. Designing implants for sacroiliac fixation and spinal fusion was one of the projects that I found most interesting and exciting.
Having backgrounds in engineering and medicine allows me to tackle complex cases and problem-solve in a unique way. I’m able to look at surgical approaches from a novel perspective to achieve the best possible outcomes.
I can also identify unmet clinical needs or problems that haven’t been solved — or that could be solved more effectively — and then design devices that improve patient care.
Minimally invasive surgical techniques help make outpatient spine procedures possible. What’s preventing surgeons from performing more cases in ASCs?
Dr. Mesiwala: The biggest challenge is the reluctance of insurance companies to cover procedures performed in that setting. If Medicare converted inpatient and outpatient codes to universal codes, commercial payors would be motivated to do the same.
Additionally, commercial payors are not interested in covering historically inpatient procedures like pedicle screw fusions in ASCs. The conflict between technological advances and insurance restrictions slows the migration of cases to outpatient facilities.
Still, economic pressures and the overall desire for affordable surgical care will likely increase the number of procedures that are performed in ASCs as long as patients are healthy and have no major medical issues. The ability to control the clinical environment in the ASC setting results in predictable care, which improves outcomes, efficiencies and patient safety.
What spine procedures are suitable for the ASC setting?
Dr. Mesiwala: The most common procedures performed are laminectomies, discectomies and chronic pain management interventions. One- and two-level cervical and lumbar disc replacements are frequently done in ASCs. Complex procedures such as percutaneous anterior lumbar interbody fusions and lateral fusions can be performed in ASCs with minimally invasive techniques, which minimize blood loss and lessen recovery times.
The ASC at DISC is quite sophisticated. We have a great relationship with payors. This allows us to tackle challenging cases, such as spinal tumor resections, deformity reconstructions, cranial operations and shunting procedures. Safety is paramount, and we always evaluate whether a procedure is suitable for the ASC setting.
There aren’t many limitations to what can be done in an outpatient setting. Favorable reimbursements, capable spine surgeons, appropriate patient selection and the latest technologies make most procedures possible.
How do enabling technologies transform minimally invasive spine surgery and lead to more personalized patient care?
Dr. Mesiwala: They’re independent, but overlapping, concepts. Patient-specific implants aren’t common in spine due to cost and insurance reimbursement issues. However, robotic surgery and navigation systems enhance patient care without the need for personalized implants. The platforms account for the anatomy of individual patients and allow surgeons to make real-time adjustments during surgery.
Let’s say a surgeon places pedicle screws in perfect positions and now must bend a rod to connect the screws to match the curvature of the spine. Surgical navigation systems can measure the location of each screw and inform the surgeon on how to accurately bend the rod. iPad-based systems are also available that scan the surgical field and provide an augmented reality overlay of the screws, allowing the surgeon to see how to position the rod perfectly. This leads to personalized care and has the potential to improve outcomes.
And yet, robotic assistance and navigation are not widely used in spine. What will increase the adoption of these technologies?
Dr. Mesiwala: The current iterations of spine navigation systems are still very cumbersome, making it difficult to convince surgeons to use the technology — especially if it interferes with their workflow. Surgeons might not see the value in using navigation if it increases surgery time by an hour or two and they can achieve excellent results without it.
Economics is also a factor that cannot be ignored. Surgeons get paid based on the number of cases they perform and the amount of time they spend on each case. A navigation system that slows down procedures without providing clear clinical benefits can significantly impact their income.
The direct and indirect costs of adding new technology is not something that most spine companies consider, but they are challenges that need to be addressed.
It’s important to advance surgery with new technology. It’s equally important to make platforms easier, faster and more efficient for surgeons to use. As spine navigation systems become more refined and consistent, they’ll be used more frequently.
How do you see spine surgery evolving over the next five years?
Dr. Mesiwala: Artificial disc replacement is the future of minimally invasive surgical care. One of the fundamental principles of spine surgery is to reestablish or preserve normal anatomy and function. The field of motion preservation, or specifically disc replacement within spinal surgery, is a relatively recent area of interest for industry. Although the emphasis has been on cervical arthroplasty, lumbar arthroplasty is gaining in popularity.
The appeal of motion preservation lies in the ability to reestablish normal mobility of the spine. In most cases, it prevents adjacent level disease that results from fusing spine segments that should have normal mobility.
Commercial payers increasingly cover artificial disc replacement, and patients increasingly request it. This is leading to a transition away from spine fusion surgery and toward motion preservation.
How has industry responded to the increased interest in motion preservation technology?
Dr. Mesiwala: The designs of artificial discs have improved over the last two decades — the biomechanics are closer to the spine’s normal motion. The surgical techniques to implant these devices have also been refined. The goal is to remove the entire diseased disc and replace it with a prosthetic in the least invasive way possible.
Newer implants provide a combination of disc replacement and facet joint replacement technologies for use in the cervical and lumbar spine. Surgeons now have more options available to tackle a variety of challenging anatomy and deformities. It’s possible to correct a complex deformity — such as thoracolumbar scoliosis — with a motion-preserving surgery that reestablishes the spine’s normal mobility.
For spine to keep pace with surgical innovations, regulations for approving medical devices and implants need to change. Industry and surgeons must work toward a common goal of advancing technology and improving outcomes in an economically responsible way. Doing so will reduce the cost of advanced surgical care and make it accessible to more patients.
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Dan Cook is a senior editor with more than 18 years of experience in medical publishing and an extensive background in covering orthopedics and outpatient surgery. He joined ORTHOWORLD to develop content focused on important industry trends, top thought leaders and innovative technologies.
