What were your initial thoughts regarding this recognition?
I am tremendously honored, humbled and appreciative.
Who were your early mentors in neuro- surgery & spine surgery?
Two of my earliest mentors in neurosurgery were David Hunt, MD and Ed Benzel, MD. Also, my mentors in spine surgery included Alex Vaccaro, MD and Todd Albert, MD from whom I learned how to do spine surgery.
What prompted you to 1) switch from general surgery and into neurosurgery and 2) apply for an orthopedic spine fellowship?
I wasn’t sure where I was going with general surgery as I hadn’t identified a focus that I truly loved. I had rotated in neurosurgery and found it very interesting and immediately considered an opportunity to switch into neurosurgery. This was one of the best decisions I have made in my professional life. The second best decision was choosing to do a complex orthopedic spine fellowship at the Rothman Institute.
I was one of the very first neurosurgeons to do an orthopedic spine fellowship and the first neurosurgeon trained at the Rothman Institute. I chose to pursue a complex orthopedic spine fellowship as I felt that the operative experience, the didactic experience, and the overall clinical experience offered some of the best opportunities for a career in spine surgery.
What do you believe is/are your main contribution(s) to neurosurgery and spine surgery?
One of my main contributions over my twenty plus year career has been always obtaining a postoperative CT after I’ve placed instrumen- tation into a patient. I have found this to be very valuable for resident education and has helped me become a better surgeon. It can be humbling to see that you may not have done the surgery as well as you thought. First and foremost, you must be critical of yourself to improve.
Additionally, I have always followed my patients for a minimum of two years. Follow-up of shorter durations simply does not allow for improvement. For example, how do you know the patient fused? Did the patient’s quality of life improve over the long term? This too has been tremendously valuable in becoming a better surgeon and in training my residents.
Bottom line: short term imaging and long-term clinical follow-up.
What do you believe is the future of spine surgery?
An emphasis on judgement and indications. I believe they are the key to recognize that not every single patient requires metal. Further and further along in my career, I am finding that in many cases a simple decompression without instrumentation can offer your patient significant benefit. Of course, I also think that one needs to know how to do complex spine surgery as it is often necessary; but judgement in determining when you need to offer a small surgery versus a bigger operation is a key aspect of the future.
I have some concerns about the direction of minimally invasive spine surgery. I am seeing many patients for revision surgery after a failed minimally invasive spine surgery. While we have become very good at minimally invasive decompression and fusion, I do believe we must continue to work on improving minimally invasive fusion.
What is needed to improve outcomes in spine surgery?
A focus on indications. Don’t operate on people who don’t need surgery. Don’t do big surgery when a small surgery is adequate. Paying attention to long term clinical outcomes – what works and doesn’t work for your patients. Examining your results closely.
How do you see neurosurgeons and orthopedic spine surgeons interacting in the future?
To continue to develop better and closer relationships. Now a days all you need is a good surgeon who treats the patient and family with respect and knows what they are doing.
I see that you published on the Open Payments Database and found the accuracy of the database wanting. What are your thoughts regarding the relationships between spine surgeons and industry?
Public perception is a challenging issue. Many of the techniques that we employ today are the result of a fruitful collaboration between surgeons and industry. However, we must be careful not be to become too greedy.
As to the Open Payments Database, I understand the rationale, but I’m not sure it is achieving its intent. The accuracy needs to improve. However, to some extent, patients are interested in knowing they can trust the information offered by their surgeon.
How do we counteract the often negative image of spine surgery in the media?
First, I think it is important to be careful on patient selection and indications. Choose patients for surgery that have significant problems that you are confident you can help. A practice with a great majority of patients with great results will improve your reputation and nothing helps your reputation more than good results. Well indicated surgery with good results can offset the negativity.
Second, I often tell patients that when they search the internet, they will often find mostly negative stories. I explain there is an inherent bias in the media as the patients who are doing great are living their lives and do not often post their positive stories.
Third, the spine registries have an important role in A) helping identify which patients may benefit from a smaller surgery versus a larger surgery and in B) encouraging long term follow-up of patients. Registries have a marked value not only for the field of neurosurgery, but also for the individual practice.
What advice would you give a young neurosurgeon interested in spine surgery?
Spend some time with an experienced spine surgeon not only in the operating room, but also in the office. The one thing that I do today that I also did while in residency and fellowship is seeing patients in the office. Practically everything else that I do is markedly different than when I was a resident and fellow. What hasn’t changed is seeing patients, talking to patients. Nothing helps gain judgement, wisdom, and an understanding of indications than seeing patients. Everyone looking at a training situation should have an outpatient experience in addition to the technical training experience.
What are your thoughts on the incorporation of deformity training into neurosurgery? Should this be something that requires a fellowship?
I think if you are going to do major deformity surgery on a regular basis, then it behooves you to at least commit one year of training to defor- mity surgery. This is not something that you can learn overnight or at a weekend course. I was involved in the AANS Spine Deformity Course for residents and fellows. This is a great environment to explore defor- mity surgery and determine if a fellowship is the right thing for you.
What advice would you give to a young neurosurgeon who aspires to develop a successful research career?
It’s challenging now in today’s world. I do both clinical research and basic science research. It is harder to get funding for basic science research. If you are interested in basic research, then teaming up with a basic scientist is critical. For clinical research, teaming up with your friends around the country and doing multicenter trials is much easier then attempting to do the clinical research by yourself. Make friends and team up and we all learn and benefit.
What advice would you give someone who wants to become more involved in the section?
Get in touch with leadership and make your interests known. I have been fortunate to have served in many leadership positions over my career, including Chair of the Spine Section. Leadership wants to have young people involved but are often not sure who is interested. Make your interests known, look for opportunities for tasks and jobs. We are always looking for young, bright, energetic neurosurgeons to step up and report for duty.
How do you balance the competing priorities of clinical work, basic science research, clinical research, education, and family?
It is difficult. If you are interested in clinical practice, clinical research, and basic research; then that will eat into your personal life to some extent. The best you can do is to constantly work on achieving balance with your practice and your family.