Thanks, Matt. Thanks everybody for joining. Happy to be here and share a little bit of the story and the journey that we're on here at Saluda. Look, I'll start with just a quick background of the company and the market that we're in. Saluda is actually founded in Australia several years back. We still have a large footprint in Sydney. It is our R&D hub where there's over 150 employees still there. The company was originally founded by the Chief Technology Officer of Cochlear, the former Chief Technology Officer, with some sensing technology that was being used at Cochlear as a part of the way to sense the nerves in their cochlear implants.
That has really become the foundation of the technology that we have today. If I just start first with a little bit of an overview of the market in which we play. We are a company that delivers pain relief through spinal cord stimulation. Spinal cord stimulation itself is actually not a new technology. Spinal cord stimulation has been around for over 40 years. At the end of the day, spinal cord stimulation is really about using electricity as a therapeutic to block pain signals to the brain. That concept, as I said, that has been around for some time, still though, while a very large market, has some drawbacks that has kept it from full penetration of the existing market.
Chronic pain in itself, a very large unmet need, not just in the U.S., but globally. The annual cost of chronic pain in the U.S. exceeds the cost of heart disease, cancer, and diabetes combined. And almost one in four employees, or people in America, have chronic pain. That spinal cord stimulation market that I spoke of is actually well-established with a nearly $2.7 billion worldwide market. About $2.2 billion of the $2.7 billion is located in the U.S. The U.S. has been a real focus for us as we've launched our technology. Our technology fits inside existing reimbursement for spinal cord stimulation. That existing reimbursement has also been well-established over the years of this existing technology and the existing players.
The $2.7 billion worldwide revenue is made up really of four big players, that we are at Saluda beginning to compete with. However, if you totaled up the total addressable market of patients that would be eligible or possibly treated by spinal cord stimulation, it's closer to $23 billion in the U.S. alone, resulting in nearly only about a 6% penetration in that market. We think that really has to do with two primary problems, and that's the lack of the durability of the outcomes of the therapy today, and the burden that it takes to manage these patients over the long term. First, let me describe to you traditional fixed-dose spinal cord stimulation. This is the description of the technology that exists today.
Patients with chronic pain would end up seeing a pain specialist, and the technology really is two leads with electrodes, 12 or 10-12 electrodes spaced along the leads are implanted into the spinal column just next to the spinal cord. Connected to that is a small battery or an impulse generator that is then implanted just below the hip, just below the skin above the hip. What that does is it sends electrical stimulation into the spinal cord to help block the pain.
That concept goes back to a scientific theory called the gate theory that goes back into the 1960s, which proved that if you send electrical signals to activate the nerves of the spinal cord, you can essentially block those pain signals from reaching the brain and thus essentially block a person or a patient from receiving and feeling that pain. We're not treating the underlying pain source, but rather the pain signals and the symptoms of that problem. At the end of the day, once that implantation is done, a physician after prescribing and implanting the device will then hand this over to a sales rep from the company.
The company's sales rep is then really the one that will program the device, set the stimulation level, and all they really have is a subjective feedback loop from the patient. What that rep will do is essentially start to turn the stimulation up and ask them how they feel. They will begin to feel a tingling sensation. It's called paresthesia. What that tells you is that the nerves are being activated, but there's no real ability to measure the level or the amount of activation that is happening. The patient will tell them once they feel it. When they feel that they've got that sensation, the rep will essentially turn the stimulation power down about 20% to try to alleviate any uncomfortable stimulation.
Then they essentially send the patient home with a small remote control. That patient then has remote control with the ability to manually adjust the stimulation on their own over time. Because the spinal cord is a dynamic space, the leads that are implanted in there will often move closer to the spinal cord or farther away as a patient moves and lives their life and goes about their everyday life. If you lean forward, the leads move farther away from the spinal cord, and at which point there's not enough energy getting absorbed by the spinal cord, and they're not getting therapeutic benefit from the technology. If they lean back, the leads will move up close to the spinal cord, absorbing more of that energy and often becoming a bit uncomfortable or even painful stimulation.
As a patient goes about their life, they're on average probably adjusting the therapy over 30 x a day, moving it up, moving it down, trying to avoid the uncomfortable stimulation, trying to find something comfortable that relieves their pain. What this creates is a long cycle in which over time the therapy is not delivering what they want in terms of pain relief. They'll end up connecting back to the sales rep, and on average end up having an adjustment to the therapy called a reprogramming, where the sales rep will be adjusting the technology's programming parameters over and over again, on average 6x per year. That event is a non-revenue-generating event and ultimately a burden for the sales rep.
A burden for the patient over time for ineffective therapy. Now if I move to Saluda's technology. What Saluda has developed is the ability to sense and measure the nerve's response to stimulation. When that electrical pulse is delivered to the spinal cord, it gives off a small electrical signal. Saluda's technology has developed very advanced amplification and filtration so that it can find that electrical signal, measure it accurately, and determine the amount and level of the nerve fibers that are being activated. That activation of the nerve fibers is what blocks the pain signals to our brain, and so activation essentially is what creates pain relief. The second step of our technology is that the technology then can calculate a personalized dose.
Every patient has a unique physiology in which the amount of energy it takes when it stimulates the cord to create an activation level is different. We call that the slope of the activation curve. While some people may have a very sensitive spinal cord, others it may take much more energy to create activation. Even with that, we have determined with retrospective analysis of our clinical data that the relationship of the amount of energy it takes to first measure activation and the amount of energy to get to maximum pain relief has a consistent ratio over time, and it's 40% above the energy to first measure the activation. As a result, our system is able to measure the nerve's response and then calculate that optimal amount of neural activation that will create optimal pain relief.
The third key step is adaptation. Because the system then has a closed-loop algorithm, it is able to lock the patient into that optimal therapeutic dose and keep it there by adjusting the stimulation in real time. Up to 250 x per second the system is adjusting the energy to keep that activation level at that optimal dose calculated for that specific patient. At the end of the day, the implantation portion, the hardware, the procedure, and the workflow are all the same as traditional technologies. The same leads, the same IPG, but the magic is in our software and in the microchip that has the control, the closed-loop controller inside the impulse generator.
What this allows the patient to do is to go home with the same remote, but rather than pushing the remote, our data suggests that patients use their remote less than 1x a day. The reprogramming burden that exists in traditional fixed-dose therapy is almost eliminated. In our clinical trial it showed less than 1 reprogramming event per year. What we've shown commercially is that reprogramming burden has actually been getting lower and lower as time progresses. An ability to deliver a very accurate and personalized dose, but then to keep it in that same dose over the long term of the implant. These are the clinical results of the study that we ran to get our approval in the United States.
We did run a large IDE trial of over 130 patients in really what is an unparalleled clinical trial in the pain space. It was the only double-blinded randomized controlled trial followed out three years. The key in the double blinding is that neither the patient nor the physician knew whether the patient was in the therapy arm. The way we designed the trial to deliver that was that the therapeutic arm was our device implanted with the closed-loop feature turned on, and the control arm was simply our device with the closed-loop feature turned off. We were therefore able to isolate the real impact of the ability to control the dose in real time, and take the bias out of the study because there was no ability to coach a patient into what their pain response was.
What you see here are the results of those clinical trials. We had 83% of the patients that were responders, which is a patient with greater than 50% pain relief. We had nearly 60% of the patients were high responders, which is a patient with greater than 80% pain relief. None of the patients had an explant due to loss of efficacy. By contrast, in the marketplace today with traditional fixed-dose therapy, the published rates of explant near 30%-40% over a 10-year cycle. Over time, explantation becomes the solution for a patient that is not getting the therapy that they want. The other critical piece I mentioned that the reprogramming rates in our clinical trial, less than 1 reprogramming event per year for those in the closed-loop arm.
55% of the patients in closed-loop were able to reduce or eliminate their opioid usage, which becomes a very important aspect of good chronic pain therapy, is to get people off of the problematic nature of long-term opioid usage. This clinical data is the foundation for our commercial launch in the U.S.
It has been a big part of our sales process, how we have been able to go to market, and how we've been able to win in the early days against what our larger competitors with long-standing practices, our really superior clinical outcomes that are showing that we are beginning to solve those two big problems I mentioned at the beginning, the durability of clinical outcomes and the reduction of that therapy burden, both for the patient but also for the company and the sales rep. What that allows us to do is not only to be able to take share in this space, but to build a commercial engine that can be done much more profitably and much more efficiently than the competition because we have such a.
We are reducing the time spent on reprogramming by nearly 40%-60% from the competition. To give people a little bit more context on the progress of the business, we just did our IPO on the ASX at the end of calendar 2025. We've now reported our half-year results at the end of February of our fiscal 2026, which is a June year end. In our first half-year results, we did show good accelerating global revenue growth year-over-year of 17%, really on the back of us continuing to expand our U.S. commercial sales footprint.
We have been using our IPO proceeds for that very thing, and we are taking what was about 63 fully trained sales reps in the U.S. at June 2025, and we are targeting to have, on average, about 89 fully trained reps in the U.S. over the fiscal 2026 period, with a target to end the year with total sales reps in the U.S. of 154. We are on track to meet our 89 fully trained sales reps for the year on average, and we are actually ahead of plan to end the year with likely above the 154 target mark. Our U.S. business has been the real focus, the focus of the expansion of our commercial team, but our international business has been performing well as well.
We are commercial in several countries in Europe as well as in Australia. Those approvals came ahead of the U.S. launch. We did deliver $11 million in the first half of the year in our international business, which was a 27% year-over-year growth rate, which was spread across many of the different countries. Our other key financial metrics across gross margin, adjusted EBITDA and cash usage at our half-year results call, we did call out that we believe we will be ahead of the forecast that was in our prospectus at IPO. That forecast had us at 46% gross margin. We delivered 49% in the first half, and we believe we will be ahead of the 46% for the full year.
We did deliver a negative adjusted EBITDA of $57 million in the first half with a target of a - $115 million for the full year that we believe we will improve upon by the end of this fiscal year based on our performance in the first half. In January, we did increase our revenue guidance. At the time of the IPO and our prospectus, we had an $82 million dollar global revenue guidance. In January, we did increase and then reaffirm in February an increased $85 million dollar global revenue guidance, which would represent 21% year-over-year growth and a second half implied growth rate of 24%. We've seen some really positive momentum in the business. We're pleased with the progress we're making on the commercial expansion front.
We are cognizant of the path we are making towards a path to long-term profitability by being ahead of our plans on gross margin improvement and ahead of our plans in the cash usage forecast that we had done. We've seen really good momentum in both the hiring and in the retention of our sales team in the U.S., which has given us the confidence to be ahead of plan on that expansion. We have also announced and delivered that we did do a reduction in force of about 50 employees in December that allows, we think will.
They're all non-commercial, and we think we'll actually be able to deliver an incremental savings about $5 million-$8 million on an annualized basis, really trying to be focused on driving to an efficient P&L that can get us to break even with the cash that we've raised collectively together with our undrawn debt. A lot there, but gives you a sense of where we are, what we're doing and the progress we've made thus far. With that, Matt, I think I'll open it up to questions.
All right. Thanks, Jim. We've got about five minutes for questions. Again, to the audience, if you have one you'd like to submit, please do so using the option within Zoom. Jim, you've touched on it there, but talk to us on the importance of expanding the sales force and how that translates into sort of scaling and really going after the U.S. market.
Yeah, really good question. The way we framed it for a lot of people, the U.S. market does have some, y ou know, it's large geographically, but it's got some dispersed nature to the market. There's over 7,000 physicians that have done a spinal cord stimulation procedure before. If you map that market, we, by insurance claims data, sort of map where those physicians sit, what the market looks like. We estimate that there's about 180 territories in the U.S. if you right-size them for the size that's needed, not too big, not too small. As we said, we're really only gonna average about 89 fully trained reps this year. We began the year with about 63 fully trained reps.
We're really starting the year only about 1/3 penetrated in terms of the number of territories that are out there to attack this market. Because it is still, even though we don't have the long-term burden care, it is still a market where you have to be there for a trial of the device. You need to be there to support the implantation of the device, and you need to be there for the initial programming to get them into the right initial program. There is an aspect of presence and making sure you can call on the breadth of the market, but be there routinely to be able to get the portion of the share that you're trying to earn. The sales force expansion becomes really critical.
If you're not there and present routinely, it's gonna be really difficult not only to take share, but to keep share over the long term. This has been why we've been so focused on the expansion of the team. Not just in quantity, but in quality. I think we're doing that as well, and we've seen some really quality salespeople that we've been bringing into the organization, especially over the last six to nine months, as we've continued to up our game both in the quantity and the quality.
You touched on it there, but how do you think about the breakdown in the U.S. market? Is it a state-by-state, or is it a bit more complicated than that?
Yeah. It's, you know, it is, I'll say, a little bit metro area by metro area. We can map it in terms of where is the existing physician volume based on insurance claims. It also becomes things like, what I didn't cover in here is, there is about 1/3 of the market that are neurosurgeon implanters, and those neurosurgeon implanters generally prefer a different lead called a paddle lead. We did not come to market with a paddle lead, but we have submitted one to the FDA, and we expect to commercialize it sometime this calendar year. That will open up about a third of the market that we're not calling on today. It does become a bit of a metro area by metro area, how much is neurosurgeon-based, how much is pain physician-based?
You know, how dense or widely dispersed is the physician base that we're attacking? I'll say we have reps in most of the major metro areas where we are. There are some where we have not really been present. What we have definitely not done is fully penetrated. My example is always, if you've only got one rep in Los Angeles, you do not have an optimal territory. There's just too much business there for one rep to actually geographically cover that territory. That is the tactics of how we attack the market, is really sort of opportunity by opportunity at the metro level.
Maybe just one last one. You know, spinal cord stimulation has commonly been late in the continuum of care. When you think about your product, how do you see that being used sooner in the list of options that are available?
It's a really good question. You're right. You know, over half of the market that exists today is failed back surgery syndrome. These are often patients that have already had a you know, a traditional spinal surgery of disc replacement, fusions, things of the like, that have either failed or frankly may have corrected the deformity, but have left the patient with nerve damage and still have neuropathic pain. Spinal cord stimulation has been that sort of late stage solution for a patient with nerve pain, maybe post-surgery pain. Part of the reason that we think that it's not moved farther to left or up the continuum of care is those same two issues I talked about.
The long-term durability still has issues, and that therapy burden for both the patient and for the sales rep. Because we've gotten to a world where we're nearly removing the therapy burden and the closed-loop aspect, we believe, and we are seeing an ability to replicate our clinical outcomes in commercial reality. I think this creates an opportunity for physicians and patients to think about something that is a fully reversible technology, something that could be explanted, does not destroy tissue, to create pain relief ahead of other, more invasive interventions, and create a wider population of patient profile.
My last example is always even anatomically, if you put traditional fixed-loop leads into the cervical spine with all the dynamic movement of the head and neck, they'd have a lot of overstimulation and shocks even, as the leads bounced off the spinal cord. With a closed-loop technology, you've got an ability to adjust in real time, and it gives physicians an ability to think more widely about the patient population where this could work.
Well, that's all we've got time for, Jim, but thanks very much for your presentation today, and we look forward to hearing more from Saluda going forward.
Thanks, Matt, and thanks to all the attendees for giving us a little time to listen to our story.
Thank you. Next up, in about three or four minutes, we've got Vitruvian Partners as our next presentation. I hope you can join us for that one. Thank you.