ATEC - NASDAQ

Good afternoon, everyone. And welcome to the webcast of ATEC’s Third Quarter Financial Results. We would like to remind everyone that participants on the call will make forward-looking statements. These statements are based on current expectations and are subject to uncertainties that could cause actual results to differ materially. These uncertainties are detailed in documents filed regularly with SEC. During this call, you may hear the company refer to non-GAAP or adjusted measures. Reconciliations of non-GAAP measures to US GAAP can be found in the supplemental financial tables included in today’s press release, which identify and quantify all excluded items and provide management’s view of why this information is useful to investors. Leading today’s call will be ATEC’s Chairman and CEO, Pat Miles; and CFO, Todd Koning. And now, I will turn the call over to Pat Miles.

Thank you, Kathleen. So really a great Q3. So super excited about what's going on here. We've outgrown everyone in the spine business again by at least 2x. I'm expecting more. And our focus is on perpetuating profitable growth. And so just a couple of stats from a Q3 highlight perspective, $151 million in total revenue, which is 27% growth. 30% surgical revenue growth, excited about that, means a lot of volume. So 20% surgical volume. 9% growth in revenue per procedure, 19% in new surgeon users, so that's back up and good. Increase -- we did over 200 surgeon training engagements. EOS Insight is launched and we have a record number of orders year-to-date. The profitability is good at $7.4 million in adjusted EBITDA, greater than 50% sequential reduction in cash burn. So we're on track to generate cash in Q4 ‘24. And we increased our term loan capacity by $50 million. So that's helpful. Our value creation and cash generation is really the focus of what we're doing. So as a spine focused company, creating value clearly is our intention. And so we're accomplishing this through multiple means. And the first one is, and I think that nobody questions our capacity to do this because we've done it for five straight years, which is really lead in revenue generation. And so by leading in revenue generation and increasing profitability, clearly, it will reflect in cash flow. And so what I want to do is provide you why we are so confident in this walk. And so as it relates to revenue, as I said, it's been five years of growth at multiples of anybody in the spine industry. Three years of organic growth greater than $100 million. Our procedural strategy is absolutely the right one and it's driving industry high ASPs, 20% surgical volume, 19% new surgeon growth. So that's being well accepted. Our sales force continues to expand rapidly. We have record EOS orders year-to-date. And what that does is lay the foundation for future growth. So can't be more excited about that. 25% growth guidance in ‘24 with 27% growth in Q3 and 26% year-to-date. So I would tell you that no one feels better about the perpetuating revenue growth leadership that we have taken on over the last five years. I think the focus on increasing profitability is hugely important. Third consecutive quarter of flat operating expenses, second consecutive quarter of adjusted EBITDA positive greater than expectation, 10% adjusted EBITDA margin implied for Q4 '24. When you start to think about what leverage you can pull to impact profitability, improving efficiency of asset and inventory is a big one. This is a people and a sets and instrument business. And so we are -- when you look at kind of the approach we're taking on the people side, we're taking a very focal effort in people investment. So if you're a sales guy or you're a product development guy, we like your chances in terms of joining the family. We're keeping a very focused effort with regard to hiring. As of late, we've strategically narrowed our organizational structure. We have to be lean and mean and who and what we're doing is making sure that we streamline the organization. We are closer now to the end user as we have ever been, and we are aiming to keep it that way. All these things ultimately reflect in cash flow. So we have an infrastructure in place with all of our facilities to ultimately scale this business and that was the intention from the beginning. We are positioned with sets and inventory to fuel expansive growth. We have a lot of sets and inventory to grow into. Our adjusted EBITDA in Q4 ‘24 will continue to contribute and our sustained inflection of positive cash flow beginning in Q2 ‘25 will continue. So we love it and we love the flexibility that the $50 million expansion our existing term loan has provided us and we have great partners in Braidwell and Pharmakon that we can't be more thrilled about. So I would say that we are aligned and focused on achieving our long term financial commitments. We said back in '23, we do a $1 billion in '27 in revenue, we'd have an adjusted EBITDA of $180 million, our margin would be 18% and we’d have free cash flow of $65 million. Nothing has changed with regard to our goal to fulfill our LRP. We are on our way. Let me turn it over to Todd to provide you some financial detail.

Thank you, Pat. And good afternoon, everyone. We appreciate you joining us today. I'll begin with revenue. Third quarter total revenue was $151 million, up 27% compared to the prior year and up 4% sequentially. The $151 million in revenue was comprised of $135 million in surgical revenue and $15 million of EOS revenue. Third quarter surgical revenue of $135 million increased $32 million, 30% growth over the prior year. Procedural volume growth was 20%, a reflection of strong surgeon adoption and utilization. We saw strong contributions across the portfolio, particularly in our lateral and expandable implant technologies, which contributed to the 9% growth in average revenue per procedure. Third quarter results grew $5 million sequentially as we benefited from the increased product availability and new territory additions. EOS revenue in the third quarter was $15 million, up 7% compared to last year. Notably, our year-to-date EOS order volume has been the strongest we've ever seen, which is encouraging for Q4 and 2025. Next, I'll turn to results for the remainder of the P&L. Third quarter non-GAAP gross margin was 69%, down 60 basis points compared to the prior year due to the impact of product mix. Third quarter non-GAAP R&D was $13 million and approximately 9% of sales compared to $13 million and 11% of sales in the prior year. We continue to invest in innovation and future growth of the business while top line growth drove 250 basis points of leverage. Non-GAAP SG&A was $100 million and approximately 67% of sales in Q3 compared to $80 million and 68% of sales in the prior year period, an improvement of 150 basis points. Now included in this period's SG&A is a [step] [Technical Difficulty] in depreciation related to the purchase of instrument sets. As a percent of sales, depreciation increased about 180 basis points year-over-year. So excluding that impact, SG&A improved 330 basis points, driven primarily by infrastructure leverage. Total non-GAAP operating expense amounted to $114 million and approximately 75% of sales in the third quarter compared to $94 million and 79% of sales in the prior year period, demonstrating 390 basis points of operating leverage year-over-year. And in the third quarter, we achieved our second consecutive quarter of positive adjusted EBITDA, which was $7.4 million, a 5% margin. That compares to a loss of $400,000 and 0% of sales in the prior year, a 530 basis point improvement. Drop through of the year-over-year growth in revenue dollars to adjusted EBITDA was 24%. Adjusted EBITDA improvement was driven by 330 basis points of SG&A leverage and 250 basis points of R&D leverage and slightly offset by 60 basis points of gross margin impact. The chart on the next slide depicts the deliberate substantial profitability execution that we have demonstrated since the beginning of 2022. Adjusted EBITDA has increased from a loss of $13 million and 18% of sales to a contribution of $7 million and 5% of sales here in the Q3 of 2024, a 2,300 basis points improvement. The drivers of that progress have contributed as we expected with the improvement driven by variable selling rate followed by SG&A infrastructure leverage and R&D leverage. In fact, our non-GAAP operating expenses have been flat sequentially for the last three quarters, resulting in adjusted EBITDA growth and guidance that implies Q4 adjusted EBITDA of $17 million or 10% of sales. The considerable margin expansion that the business has produced gives us great confidence in our ability to deliver on our financial commitments and translate revenue growth into cash generation. Turning to the balance sheet. We ended the third quarter with $81 million in cash [Indiscernible] carrying value was $538 million. As we begin to move past the phase of intense growth investment, we reduced free cash use in the third quarter by over 50% sequentially to $21 million. That was net of approximately $30 million in cash that was directed toward inventory and instruments to support distribution expansion and new product launches. The chart at the bottom of this slide depicts the linear progression towards cash generation as we exit 2024 with the improving cash use trend from Q1 leading to an inflection in cash generation in the fourth quarter. The improvement from the third quarter to the fourth quarter is primarily driven by reduced instrument and inventory spend and an increase in adjusted EBITDA, partially offset by working capital. We continue to expect cash used to range between $125 million and $135 million for the full year of 2024. In conjunction with the financial results released today, we announced an increase in our term loan of $50 million, bringing the total term loan to $200 million. Through this transaction, we have added another strong lending partner in Pharmakon. The key terms of the loan are the same as the original facility bearing an interest rate of SOFR plus 5.75% and interest only payments until its maturity in 2028. With this incremental capital, our pro form a cash at close is $128 million. Upon close of the transaction, we used proceeds to pay down our revolver balance. Exiting the year, we expect to have access to cash and liquidity of $145 million, which we believe provides us with ample liquidity going into 2025 where we expect to be cash flow breakeven. I'd also like to share our thoughts for the $316 million convertible notes that mature in August 2026. While we won't rule out doing a convert if the equity is at the right price, we expect the material improvement in EBITDA over the next few years to allow us to refinance without dilution. As we progress towards our 2027 long range plan financial targets when we expect a $1 billion in revenue with 18% adjusted EBITDA margins and cash flowing, the company will have a different level of access to financing alternatives. Turning to our increased outlook for the full year 2024. The strong surgeon adoption and large volume of surgeon training are great indicators of durable revenue growth and are a testament to the ATEC clinical distinction. We expect that the [indiscernible] total revenue growth of 25% to approximately $605 million. That includes surgical revenue growth of 28% to approximately $540 million and EOS revenue of approximately $65 million. That implies surgical volume grows at a high teens rate and revenue per surgeon growth at a high single digit rate for the full year. Sales growth is powering leverage, and with the third quarter adjusted EBITDA outperformance, we are raising full year adjusted EBITDA guidance to approximately $27 million, which equates to 640 basis points of margin expansion. That implies a 30% drop through of the year-over-year growth in revenue dollars, a material acceleration compared to 22% drop through in 2023. We continue to expect cash used to range between $125 million and $135 million for the full year 2024. Our expectations for cash flow breakeven in 2025 remain unchanged. We expect the cadence next year to include seasonal cash used in the first quarter, followed by positive free cash flow in quarters two through four. I'll close today with reinforcing how well we are positioned for growth in 2025 and why that translates to cash flow breakeven. When you look at this year, our adjusted EBITDA is expected to be $27 million. We will have invested $140 million in CapEx and inventory and $17 million in interest and other working capital. In 2025, our expectation is that we will have [$70 million] of adjusted EBITDA consistent with our long range plan assumption. Because we come into the year with an asset base from the 2024 investment that will support 2025 revenue growth, the required investment effect in inventory in 2025 is $50 million. We will also expect to see a step up in interest and other working capital to $25 million. That all adds up to a cash flow breakeven year. We recognize that execution on cash generation is crucial to rebuilding shareholder value. As such, we are focused on growing revenue and expanding profitability to generate cash, which has informed how we are attracting investments and the realignment of internal resources. Those efforts are complete and strengthen our position as we progress towards cash generation. Our organization has a lot of work to do and a lot to be excited about. As we seek to rebuild shareholder value know that this leadership team is confidently aligned. We know what needs to be prioritized and the work is underway. With that, I'll turn the call back over to Pat.

Thanks, Todd. Our best is yet to come. We are actually focused on value creating long term objectives and our objectives are bettering this environment, so creating clinical distinction. That means distinguishing ATEC through procedures and informatics. I think we're well on our way on that front. Also compelling surgeon adoption, earning surgeon users by improving surgery. There's a lot to do in the spine business and we're thrilled about engaging to do it. And then expand and elevate our sales force, strengthening sales teams and enhancing our operations. And clearly, we know something that others don't. So I love this picture. It's from the most recent North American Spine Society meeting. At this time, about -- not even about, exactly five years ago, [Dr. Clemente] presented PTP, our prone transpsoas approach to an empty room. This year, his PTP demonstration was standing room [indiscernible]. So we are thousands of surgeries into the experience and continue to apply our learnings. We know we are still early in the -- are in the early phase of our lateral reconstructive spine surgery journey with a heck of a lot of opportunity forward. So by looking at this picture and appreciating our historical performance, it would be a great mistake to not realize our following and lateral probe surgery. So as always, plenty of work to do. But I think that this is indicative of who we are and power further distancing ATEC in lateral. The way we further distance ourselves is really investing in the approach. So that means to continue to integrate informatics into improving precision, like the case in Valence. We will also further minimize the potential for neural complications with the expanded applications and feature set of SafeOp, as well as increasing predictability and alignment with EOS. So we're attracting new users with our informatic platform and expanding applications and utility across the board, that means more users and more reasons to utilize. If you could see in the right hand side, the opportunity to increase complexity with things like corpectomy, multilevel deformity, there's a lot going on with regard to lateral. I think there's every reason to be profoundly confident in our perpetuating growth profile. It is the growth segment and it is the most coveted piece of thoracolumbar spine in the business. And so when you think about our growing business in lateral, much like NASS, SRS was also standing [remotely]. SRS is the most influential society in the treatment of spine deformity. There was probable enthusiasm for our prospective deformity influence with AI informed EOS Insight. I would tell you, it was the bell of the ball. So ATEC has the only AI informed automated tool that is an adjunct to clinical decision making. We talk about variable mitigation incessantly and this tool is absolutely foundational to that. The decision making is informed by EOS Insight and also gets reflected in our implants. And so it's not lost on us that these decision making tools ultimately get driven through implant utility and can't be more excited about that. So with the launch of EOS Insight, it literally turns the most coveted image in spine surgery into information. The early sites are very enthusiastic about the experience and screams of another unique technology that provides valuable information that drives improved surgery. Everything from the pre op auto alignment tool that happens in virtual real time, to the opportunity to create a 3D surgical planning effort to patient specific implants, to the interoperative ability to reconcile what the plan is, to the objective data reflected in the post op sequence. And so we love this tool, we cannot be more excited about where we are today, it's the reflection of future growth. Like [Dr. Lockey] said, EOS Insight streamlines our workflow and enhances our ability to track outcomes. Everything is automated. The reason that outcomes have not been consistently captured in spine surgery is because it wasn't automated. All these things are automated. And as he says, it ultimately improves patient care. So totally excited about what's going on there. We continue to compel surgeon adoption reflected in a 19% growth in surgeon users with over 200 surgeons trained. Clearly, people want to come into the company. One of the things that we're doing is we're improving on focusing on yield. So the more surgeons come in, the more users we can create and the better yield that can have, the more business will impact by doing so. So we are committed -- continue to drive clinical predictability through improved training. So when you look at a proxy for continued growth, this is one of them. And training and education has been a hallmark of what we believe in terms of preparing surgeons for application of our clinical distinction, which again, will continue to power our growth leadership. Moving on to the sales force. It's another source of significant confidence. We're completely confident in the growth leadership based upon not only the people who are there today but the people who are forthcoming. And so when you start to look at the demographics of our sales, you start to say, lateral as a percentage of business, for our top 10 agencies is 30%. I will tell you, you want that mix, it's a protectable mix based upon the suite of technology that we have. That compares to 13% of our US lateral share. So clearly, there is a head start with the people who are performing best. We have a 25% growth rate in established territories. Again, that suggests a lot of momentum with people who have been with us for a little while. And then in certain markets, what we call benchmark territories, we have a 25% market share, that compares to a 5% in most places. It does nothing but reek of a forward growth profile that, again, we have been completely consistent on for five years. And so our confidence is perpetuated by robust growth in established territories and the whole leading of -- with lateral, ramping in new major or in major new US territories, bringing new people on, we're starting to contribute, putting 2024 set and inventory investments to work. We've got a ton of inventory in 2024. It's being put to work in the way that we intended. Improving efficiency of set and inventory utility. We know this business, as I said, is people and it sets an inventory. You got to be efficient with your sets and inventory and we're doing that and aligning sales and sets it with operational requirements. We recently had an agent meeting. I don't think we've ever been more aligned with regard to our sprint forward. And so, completely excited about our alignment. And then strong talent funnel to further US footprint expansion and elevation. So there's a lot of good people out there and a lot of people that we want to attract to this business and we can't be more excited about the prospective growth profile and business profile of ATEC. So the undeniable truth is that spine needs ATEC. When you start to look at the revision rates associated with our field, people that increment in this business don't make any difference in this business. We're going at this in an aggressive way. And it needs to be going after at an aggressive way because spine surgery needs to be improved and we're doing that. We're going to go from a 5% market share holder to a low double digits in the coming years and just cannot be more bullish as it relates to what we're creating. And so with that, I will turn it over and take questions.

[Operator Instructions] And your first question comes from the line of Brooks O'Neil from Lake Street Capital Markets.

Thank you very much, and congratulations on a terrific quarter guys. I have one question for you and that is, appreciate your enthusiasm, appreciate your track record, but investors still seem to believe you're going to outspend your resources. How can you convince us that that is not going to happen?

Let me start and then I'll let, Todd, jump in. And so the one thing that I will tell you is we are committed to building a monstrosity. And to build a monstrosity, you have to be self funding. And when we start to demonstrate consecutive quarters of flat operating expenses, when we start to talk about adjusted EBITDA above expectations, when we start to talk about breakeven next year. And I got to tell you, we're taking kind of the internal, not kind of, we're taking the internal moves necessary to make sure that we're streamlining the organization. If people and sets and inventory are the spend profile of these companies, we're narrowing the spend profile associated with people. We've done that internally. We've made challenging moves. We're getting closer to the business. But also as it relates to the efficient utility of the assets, we've made a ton of progress in that realm. And so when I start to think about leverage, those are the areas that I think about and I see this stuff happen in real time and it provides me significant content.

And Brooks, I would add to that. I think, clearly, this is a business of growth. That growth is generating incremental profitability through adjusted EBITDA. And as we think about the actions we've recently taken to ultimately narrow the organization, we also have done a significant deep dive in the operation to really root out discretionary spending and to really ultimately reduce our overall spend in that area as well. And so I think we're being very thoughtful and very diligent about where we're placing our resources and overall reducing that resource consumption today. As you think about next year and I think that is -- gives you confidence in our ability to continue to expand our profit margins. So I think that was one of the reasons I laid out the adjusted EBITDA path that we've seen over the last probably two, two and half years. It's been a deliberate walk of expanding EBITDA margins over that time period. And that has happened as a result of the way that we've built the company. And that gives us confidence that we can ultimately continue to expand those profit margins into 2025 and beyond. Then the second component, so I think that's the profitability piece. The second component of where our investments go is in the sets and inventory. And I think as we laid out on the call, we made a significant investment in sets and inventory in 2024. And there are a level of inventory and sets that exist today that will contribute to 2025's growth. And therefore, the required amount of investment in sets and inventory in 2025 is, as we've described it, in the order of magnitude of $50 million. And so when you think about cash flow, you think about $75 million of adjusted EBITDA, spending about $50 million on sets and inventory and then a step up of about $25 million of investment in additional working capital and interest, that really gets you to breakeven. And I think that ultimately is where our confidence comes from. And then going into next year with a further enhanced balance sheet that also just gives you more and more confidence that we can run the play that we've outlined.

Your next question comes from the line of Mathew Blackman of Stifel.

Maybe Todd, if I could start with you, just a couple of housekeeping questions. And we're asking this to everybody this quarter, so not saving it specifically for you. But anything notable in terms of hurricane exposure? And you've also been hearing some anecdotes of institutions delaying elective procedures due to the IV solution shortages. So just I appreciate any impact from both would be transient, but are you or what are you hearing from the field, if anything? And is there anything baked into the implied 4Q guidance as a headwind? And then I've got one follow-up.

As it relates to hurricanes, really no impact in the third quarter. And while we did see a little bit in the first half of the month, we're seeing that recover now. So really our guidance assumes that we're going to catch up all of that, and we feel very good about that as a base case. And so I think that's from a hurricane standpoint. And really no impact we're seeing on the IV side. And maybe Pat, you can give your perspective on elective surgeries and spine surgery and how that's probably less elective than maybe people think.

Yes, no impact.

I also think the deductible for now also works in everybody's favor here…

Amazingly.

And then my follow-up, maybe hoping you could put a little bit finer point on where sort of new rep, new distributor productivity is today. You gave us a lot of great stuff in the slides. But is there a way to frame or relative to what inning we're in, in terms of how they're ramping? And I guess the other question is, it sounds like -- I just want to make sure that the new folks are sort of at full fighting weight in terms of their ability to access sets, but also the broadest range of implants?

Let me give a little bit of the subjectivity and Todd, as objectivity he can add. It's fascinating. We actually have inventory available to them. These are always ramps. And what happens is you walk away from one group who has been there that wasn't very good that wasn't going to scale the business as you intend and you enter a new group. And then so you walk away from all that business and then you jump into new business. And it's not like it all comes on on day one. And so what we're seeing is we're putting together the sales force that we intend. And I still believe it to be a very effective sales force, effective in pockets. And we have geographies that are mature that are reflective of the growth profile of the company and then we have others that are just getting going. And so what keeps me very, very bullish is the same store sales continue to ramp at the way that we intend and it hasn't even taken into account the new areas that ultimately are starting to ramp. And the ramp is mushy, right? It's like you lose the revenue on the previous distributor or the previous little group if we had a group there and then you start to grow the bill, you get access to the hospital. And one of the things I've always said and I know that people hate to hear this but -- so this is such a 12 to 18 to 24 month business, which is you make these investments in people and the reality is they don't get reflected for 18 to 24 months. And so the reality is we're seeing continued perpetuation of same store and we're starting to see the engagement of many of the new guys.

And Mat, I would add to that. We've been adding coverage continuously for the last six years, however, long we've been doing this. And so we're seeing the investments we've made over the last 12 to 18 months begin to contribute. I think one good example of that is just the $5 million sequential step up Q2 to Q3. Clearly, some of that was product contribution but also some of that was the reflection of those investments beginning to ramp in an easier way. And so I think that's a good proof point for the effectiveness of the investment in those territories.

And just to add something to that. I just think it is relevant is, somebody will come on and they will have a non-compete, either they will sit out or will do something whereby they operate in a different territory. So it's everything from somebody coming on, having a non-compete, serving a non-compete, entering into a different geography that first 12 months and then coming off a non-compete. And we only see a little bit of a boost after that. And so it's one of these things where there's so many puts and takes to these things, like it's tough to provide you the exact because, again, there's a lot of different ins and outs as we continue to evolve the business.

But I guess the point is is that we're ramping up that productivity curve and we still have a ways to go…

We still have a ways to go. Yes, we're a nominal player in this business. There's 95% to go. It's -- we're a 5% market shareholder. But clearly, we're growing aggressively. And I got to tell you, we're the bell of the ball. You look at what we're doing procedurally with the lateral, what's going on with regard to EOS. And it's not a secret to the industry that there's a lot going on here with regard to evolving care and people want to be associated with it.

Your next question comes from the line of Matt Miksic from Barclays.

Nice to see you kind of turning the corner here in terms of cash use and continued growth. One question that I wanted to ask, Pat, is one that I get sometimes often. I think it's sort of part of the Alphatec story as folks look at what's happening with robots, look at where your robot is in the pipeline and ask the question, why isn't competing with a robot today more of a challenge. Maybe if you could talk about your growth drivers today and how the robot and imaging kind of dovetails with that as you get into the 12, 18, 24 month period? And then I have one follow-up.

I love this question, just because it's -- our intention is to have a profound influence on spine care. And if you were to prioritize the challenges and the variables that influence spine care, placing screws would not be at the top. And at this point, the robot helps place screws, which again, I think is fantastic. And fantastic enough for us to spend $50 million on a tool that ultimately will do that and help do that. And so what I think is hugely valuable is an information piece that says, hey, the highest likelihood for a patient to get better from this type of intervention is this pathology and be able to pre-correlatives that drive decision making and behavior by surgeons. And so I think that that's at the top of the list and that was the rationale behind the EOS. And what happens is it becomes the foundation of the ecosystem that ultimately drives better decision making. Within the context of the intervention is the opportunity to improve the variables within the intervention. And that's where a robot comes in and that's where navigation comes in. And so all of our work has been how do we architect a procedure that's reflective of a step-by-step execution where we can provide interoperative information to drive predictable outcomes, that is our strategy. And so when you start to assemble those technologies and you create an ecosystem, I got to tell you, you better love the foundation of that ecosystem. And the foundation of that ecosystem is the most coveted image in all of spine care, which is EOS. And so translating that image throughout the experience, through the surgical plan into the operative experience is the magic. And so our enthusiasm is all about monumental evolution in spine care, because it needs it in the hands of the masses. And that's where it's like again, we love robotics, we love navigation. We're in the process of integrating it. We're doing cases today literally with our robotic tool. But the reality of it is it's the assembly of tools that ultimately is the answer to these, it's not just a single tool. So that would be my diatribe, and probably I didn't answer the question you intended.

And I have one follow-up. Maybe on the way that you're guiding, the way you're thinking about the EBITDA and cash deployment comments that you've made in terms of titrating or the level of deployment and capital and some of the inefficiencies that you had earlier in the year. I guess, how you feel about that and how you feel about where in the bell curve you're sort of guiding us? And what maybe you're doing a little differently in the way you're communicating and planning for Q4, Q1 and going forward?

When you look at how we described our inventory challenges in the second quarter call, we really had a mix challenge more or less. And so the way that works its way out is and if you remember, it was really one of timing where we had stuff we needed at that point, or we did have stuff in the end and we had stuff we didn't necessarily need. And so ultimately, when you grow into a level of revenue that ultimately is supported by the inventory that we have today. So my point being is the inventory that we had in the second quarter and we have today that is less sufficient than it needs to be, that ultimately supports a revenue growth number next year, meaning you don't have to buy a certain amount of sets and inventory to support some portion of next year's growth. And so I think you look at what our expected growth rate is internally for next year. You understand what asset base you have, what asset base or what revenue base that that asset base will support. And you ultimately do the math and you come to the conclusion that about $50 million of investment in sets and inventory is what you need. And so I think our level of resolution and confidence in that is reasonably high given where we are in the planning cycle, knowing what investments we've made and subsequently what assets we have today and where we expect the revenue to come over the next 18 months. And so that's I think the level of confidence that we go into next year with on the asset front. And more specifically to Q4 and maybe the question is, you came in at $21 million of cash use, which was favorable to what you expected in the third quarter. Your cash flow expectation is 125 to 135. Ultimately, we saw some improvement in DSOs in the Q3, which helped us. And as we think about landing the plane in Q4 as it relates to cash flow, ultimately, we're giving ourselves a little bit of room for DSOs to creep back up to maybe in that 50 range, which is still pretty good. And also, we have some incremental cash expense associated with some of the actions we've taken from an operating expense standpoint here in the third quarter or in the fourth quarter. And so that will also play itself out in the fourth quarter. So when you take all of those things into context, our view was, let's stick with the $125 million to $135 million cash used on the full year and all the things that we're doing should give us confidence that we can hit that in a good way.

Your next question comes from the line of Matthew O'Brien from Piper Sandler.

It's a long one, but it is one question, I think we're supposed to be sticking with. So maybe this question is for Todd. Todd, as I look at your CapEx spending the last couple of years and again, it's a long question, so bear with me. But you spent about $80 million in '23 on CapEx. You're going to grow the top line this year about $100 million and $20 million-ish. So call it a 1.6 like productivity of that capital, and I know it takes time to get up the curve and all that stuff. But you're adding $130 million this year and you're able to get some level of productivity that's similar to what you see here in '24. Why wouldn't your top line in '25 be something that's greater than $130 million of incremental revenue just based on all the investments that you've made this year? Because as I look at The Street, only modeling things up about $120 million year-over-year it seems like just based on all these investments, it should be much higher than that.

So Matt, if you look at where we've invested over the course of '22 and '23, and I think we shared this in our long range plan. Historically, that rate has been $0.75 on the dollar of growth. And so if you look at the investment in inventory and sets and inventory -- inventory and sets combined, it takes about $0.75 to drive a dollar of growth. Clearly, here in 2024, our investment level is about $140 million. And so we ultimately bought ahead to support the potential for a higher revenue ramp. And so we wanted to be prepared for that. Clearly, we're growing at significant rates today. And so when you look at the investment over the course of 2024 and what we expect to invest in 2025 that 140 plus 50, that actually is ultimately, if you assume a 7.25, I think that's where The Street's at. If you look at that, that's about $0.80 on the gross dollar. So I think to your point, our asset base does support a level of revenue growth that is higher than what's implied. Ultimately, we'll look at where we are and we'll talk about guidance in 2025. But I think your observation that we have invested and we have the asset base to continue to grow at meaningful rates and we've grown about, call it, over $100 million a year for the last three years or so. Clearly, we've got the assets that will allow us to continue to grow at that significant rate.

Your next question comes from the line of Josh Jennings of TD Cowen.

This is Eric on for Josh. Really strong momentum in the surgeon training front with 200 plus. Just curious about what the conversion rate is on those surgeon trainings. Should we be assuming that the vast majority of those surgeons are going to be added to the ATEC base once they're at your training center and have exposure to your technology? And then secondly, is there anything that you think can be done to possibly improve that conversion rate?

Every one of them is going to be a customer, I'm kidding. It's a great question and I got to tell you, it's one that we ask every day. And I think that when you look at the greater than 200, it's reflective of the perpetuation of the interest in what we're doing. And I think people are at different places in their kind of evolution of surgery and evolution, I think, especially the lateral. Lateral really is kind of the place that people clearly find that that, hey, how do I learn lateral and can I learn it from the guy who created it, Luiz Pimenta. And so what they want to do is they want to come in here, and we have such a unbelievable group of surgeons. So the peer-to-peer experience here is unbelievable. And so we see a high level of engagement as surgeons come. Everybody has a different algorithm in terms of what makes them comfortable to engage in the technique. And so some guys will come in here, they won't do anything. Then we'll do a peer-to-peer at a facility. They'll go to that facility,t hey'll either watch a surgeon or they'll watch it online. We have some online tools. But every surgeon has a different algorithm of things that they require to ultimately be comfortable on applying the technique to a patient. And so oftentimes it's different for each surgeon. So not to evade the question, but I'm not going to disclose the specific rate. But on the other side, it's one of those things where everyone is different and what we're doing is tailoring each of the different experiences. Part of the effort there is aligning interest. And I think it's making sure that are the right people being invited to come in and are they people that are serious about engaging in the technique. Do we have the sales structure in place in that geography, do we have access to the hospital, do we have the things aligned such that we can ultimately count on someone applying the technique if the comfort level is there. And so those are the ways that you ultimately continue to elevate the yield associated with people coming in. But it's something that I've dealt with over the last 20 some odd years in this business or 25 years in the business. And I wish that there is a predictable algorithm associated with exactly who's going to use and who's not. There just isn't.

Your next question comes from the line of Caitlin Cronin of Cannacord.

I just want to turn to EOS, you noted some record orders. Are these new EOS users or are they upgrades to the newer EOS system in order for those legacy users to use the Insight software specifically? And also just why keep EOS guys the same given the strength in order volumes? Is there a lead time for these volumes that isn't really translating to the Q4?

Todd, just told me he'll take two and I'll take one. I mean, take both. I'm just kidding. Can I tell you, there's great enthusiasm with regard to EOS Insight. And I think that people understand the translation of the technology. And if you saw the order book for Q3, it's outstanding and it's a who's who. And the thing that makes me most excited is that here's this little ATEC five years ago that that couldn't buy themselves into a meeting, and now it's like who's who in spine surgery is buying EOS. And so it's all that speaks to is our getting access to those institutions and now proliferating those institutions with our implants. And I can't wait for the day that we are a ubiquitous player in this field, as well as what we're doing is we're taking the data from these tools and ultimately improving care. And so the vision is just that. And so to me, it's highly comforting to see the volume of enthusiasm of engagement associated with a tool. And a little bit like in [indiscernible] EOS is a much more significant influence to spine care than, say, SafeOp is. And I love SafeOp. I think SafeOp is the gateway to lateral surgery. Because without automated neurophysiology, especially automated SSCPs and now automated MEPs, that is a gateway to lateral surgery and beyond. But when you start to think about the influence that SafeOp has had on lateral surgery, I will tell you the influence that EOS can have on deformity is profoundly bigger. And so that I think is what creates all of the enthusiasm. But this is a step by step by step exercise. And so we're gonna be perpetually conservative with regard to placing the units, and these are new places that we're placing units they're not upgrades. And we continue to upgrade units, which is inspiring. But if you look at the recognition of revenue, I think, Todd could go into exactly why we -- why it's such a step by step phenomenon.

Ye, it is. And I think, Caitlin, the point is that we've been about $15 million of revenue in EOS for the last probably six or seven quarters or so. And so this Q4 actually, the implied Q4 EOS revenue in our guidance is an $18 million number. And so it is a step up going from Q3 to Q4. And so I think our comfort with that number is backed up by the level of interest we're seeing in the order book.

Your next question comes from the line of David Saxon of Needham.

I'll just ask one quick one on Valence. I know that's in kind of a friends and family stage launch at this point. So maybe just talk about kind of early feedback you've been getting and how we should think about the cadence from going from a friends and family into a broader launch in 2025?

This is one of my favorite ones. It's like, I love when you don't have to back a bus up to a OR to bring in a tool that ultimately guides your screws. And we don't have to do that with Valence. It's a meaningfully small footprint in the operating room. And as I said, we're doing cases today. We want to continue to refine the thing in a way that there is real elegance to its integration into the operative work flow, and I would tell you that that's where we're spending most of our time. And so if I look over the kind of the time frame, our excitement is let's continue to refine the thing through middle of next year and then let's discern if we're ready to launch it then, that's our expectation and that's our excitement. And so -- but I would tell you, from a footprint perspective, from a technological perspective, from a software and capability perspective, having guys that have the type of experience who are putting this together, Brad Clayton, Kevin [Fred] [indiscernible], these guys are years into this business. There's a whole slew of software people in house here and in house in Colorado that have meaningful experience in this field. And so what gives me confidence is I see the improvement that we're making every day on the thing and I see the opportunity that it presents, because it is a not a huge cost of goods, comparatively speaking, not a big footprint -- comparatively speaking. And so it just provides us flexibility in terms of how we get these things into the hospitals. And so I know not a specific response to your question, but kind of where we are today.

Your next question comes from the line of Sean Lee of H.C. Wainwright.

My question is kind of a top level one. Looking back from beginning of last year, we can see that you have been able to consistently outperform your previous guidance. And now the latest revenues are more than 10% higher than what you expected you were able to achieve at the beginning of the year. So I was wondering whether this has been driven by a specific tailwind and whether this -- the upward surprises is coming from the trend that we can expect to continue going to next year?

Well, Sean, I think when you look at the guidance we put out, at the beginning of the year and that was $595 million. Ultimately, that was where we're looking at today in terms of our guidance and the improvement and the increase in it, it's really all come from surgical revenue. So our EOS guidance has been consistent throughout the year. So you ask yourself why has the surgical revenue done better than what we anticipated early on? And it's really come through our volume assumptions. And so ultimately, I think this is a reflection of the interest, the adoption of our technology and our procedures by surgeons and aided and advanced through the addition of sales coverage and sales reps. And so it's not just one thing and I hate to be super simple about it. But ultimately, this has been a greater volume experience than we guided to at the outset of the year. And so I think that gives you confidence that we're on to something.

Your next question comes from the line of Drew Ranieri from Morgan Stanley.

Just I'll sneak in two, this should be pretty quick. But Pat, maybe on EOS, I think in your part of the slide deck, you're talking about it laying the foundation for future implant growth. And maybe just put a little bit more context there, especially against what that means for the record EOS orders that you're seeing with Insights. Are you embedding volume based commitments with kind of like every new order from EOS, whether it's an upgrade or replacement? So maybe just talk to us a little bit about that. And then, Todd, just on the gross margin for the quarter. It came in a little bit weaker than we were expecting. And I know you highlighted product mix but we saw lateral kind of continue to take more share. So just talk to us a little bit more about why it was a little bit softer versus maybe our expectations and what you're kind of thinking about for the fourth quarter?

I'll start, Drew, and thanks for the question. And I'm just worried about not doing a great job in terms of describing the integration of our implants into that experience. And so the beauty of automating these measures is that we get a ton of radiographs and a ton of opportunities to create plans, and those plans are informed by our implants. And the beauty of that is we see it all the way through the surgical intervention, all the way through the post op assessment. Our ability to start to see the reflection of that spine care on the adjacent level and start to understand what the change has been in the spine alignment is profoundly valuable, because ultimately, it's the indicator of a future issue. And so the great part is the surgical planning element ultimately is informed with our implant. Our implant's to the tune of, hey, here's the type of rod, patient specific rod you need, we will bend that rod, that rod will go with our implant. And so when you have the early engagement with the surgeon on what his findings are radiographically as he sees the patient and identifies the intervention that he's going to apply, our ability to plan it and integrate our implants and understand how our implants fulfill the requisite obligation is really outstanding. And so it really ties the implants to the plan and then we have an integrated tool interoperatively to reconcile against that plan, all that is proprietary. And so when we start to think about selling these units and garnering access to hospitals, our opportunity to garner access based upon the utility of this preoperative plan that's fundamentally driven by the AI that drives the alignment measures is outstanding. And so tying our implants is a very presumptive exercise in this effort. And so I think just to give you a perspective of the type of volume, the automation is so important to ultimately garnering information and creating predictive -- like a predictive measure. I think we're over a 100,000 images in the 10 sites that we had in our alpha evaluation. And so when you start to think about the volume of information that we get through the integration of these tools that ultimately inform predictable spine surgery, it's awesome. And so anyway, that's what creates all the enthusiasm. I'm sure I'm droning. But it's like that's why you really can get a tool that is unlike anybody else has.

And Drew, just on the product mix. Our EOS margins were a bit lower, driving a little bit of headwind there, that's just really kind of geographic mix more than anything with the international markets being at a lower margin because many of those are distributor sales. So that just provides a little bit of a margin drag in the quarter. And also as we kind of got healthy in our biologic portfolio, we saw a good strong biologic revenue performance in the quarter that had a lower margin profile as well. So both of those things contributed to the little bit of a headwind that we saw in the quarter. And think about the second -- think about the fourth quarter non-GAAP gross margin in that 69.5% range and we expect to end the year at about 70% gross margin.

And EOS [Multiple Speakers] internationally.

That concludes our Q&A session. I will now turn the conference back over to Pat Miles for closing remarks.

I just want to thank everybody for their attention. And I hope you share your enthusiasm about what we're building. So thanks very much.