Christopher Bono’s interest in surgery was piqued after watching live operations on television as a teenager. After training and working in New York, USA, Bono became involved in orthopaedic surgery and spinal research. During his career he has worked closely with the American Association of Orthopaedic Surgeons (AAOS), the International Society for the Study of the Lumbar Spine, the American Association of Neurological Surgeons (AANS) and the International Society for the Advancement of Spine Surgery (ISASS), and is currently serving as the 2015–16 president of the North American Spine Society (NASS). He talks to Spinal News International about scientific societies, spinal research, and the current state of spinal medicine.
Why did you decide to become a doctor and why, in particular, did you decide to specialise in spinal surgery?
I decided to become a doctor when I was about 15 years old with the sole intention of being a surgeon. Being extremely naive, I really did not know what kinds of surgeons did what operations. What impressed me the most at this early age was a broadcast on the Public Broadcasting Service (PBS—in New York City, this was “Channel 13”). Before reality TV, PBS was pretty much the only place where you could see a live operation. While watching a surgeon perform a total knee replacement, I was not only enthralled, but I foolishly reflected to myself, “I can do that, and I have all the tools in my garage.” I would later learn it was not entirely that easy! It was not until medical school and residency that I decided that I would focus on spinal surgery.
Who have been your career mentors and what wisdom did they impart?
I was fortunate to have several mentors early in my career. First was Tom Haher. At the time, he was a spinal surgeon at St Vincent’s Hospital in New York City with an academic appointment at my medical school in Brooklyn, Downstate Medical College (also known at the time as SUNY Health Science Center at Brooklyn, USA). He introduced me to the spine, spinal research, and the idea that there was a great deal to still be understood in this area.
Next was Paul Tornetta, who was a brand new orthopaedic trauma attending at Downstate when I was thinking of applying to orthopaedic residency. Honestly, I was not the greatest candidate on paper. My grades were average at best. As orthopaedics was, and still is, a highly competitive match, I decided not to apply.
It was at the prompting of my good friend and medical student in my year, Mark Grossman, to come with him one day to talk to “Paul” about doing some orthopaedic research to help him get into residency. Mark nearly dragged me down there. I reluctantly and sheepishly asked if I could talk to Paul, who agreed to speak to me. His advice was clear: “Do some research with me, work hard, and you will get in.” I am not sure I entirely believed him, but I was willing to take the advice and the chance. It worked. Later in residency, Casey Lee, one of my attendings in Newark, USA (and a NASS past president), inspired me to do some of my best spinal research. He has been a mentor and guiding force ever since.
What do you think has been the biggest development in spinal surgery during your career?
It really has to be evidence-based medicine. I stumbled upon this field via some serendipitous circumstances, having done a rudimentary meta-analysis of lumbar fusion outcomes as a senior resident. I did not quite realise that the skills I had inadvertently learnt would be the foundation for future work in evidence-based medicine guideline development. As a resident, I cannot really remember ever hearing about these guidelines. You followed textbooks, a few individual papers, and mostly what your attendings taught you. In the following decade and a half, evidence-based medicine has become the driving force for not only “boots on the ground” care but also insurance reimbursement.
Outside of your own work, what has been the most interesting paper that you have seen in the last year?
There was a paper published in JBJS in June 2015 by Takemoto et al reporting on a randomised controlled trial comparing 24 hours of antibiotic prophylaxis to that extended for the full duration of wound drain indwelling. While it was a “negative” trial, demonstrating that antibiotic duration did not make a difference, it highlighted some other very important and significant risk factors for postoperative infection following spinal surgery, which were diabetes and smoking. This has very much changed my discussion with patients before surgery in regards to infection risk.
You have been involved with spinal medicine research for a number of years. Which piece are you most proud of, and why?
I am most proud of a study that examined the relationship between a patient’s level of pain and their willingness to accept a greater risk of complications. While this seems intuitive, it was a relationship not examined previously. Furthermore, it has changed the way in which I consent patients, asking them to think of what they would say (yes or no) on a day that their pain was not quite as bad.
What has been your most memorable project?
On a personal level, my most memorable project was a resident study that examined the effects of sacral fracture malreduction on safe iliosacral screw placement. The study idea was from one of my residency attendings, Mark Reilly. Back in those days, you could run with a project pretty much on your own as a resident. I enlisted the help of a college student who was getting facile with a computer-assisted design program. While it doesn’t seem like a big deal today, in the late 1990’s, we seemed to be ahead of our time by scanning pelvises, creating simulated fractures and displacements in a computer 3D model, and measuring cross-sectional area across the region of interest. The study won the Edward Bovill award at the Orthopaedic Trauma Association the year it was presented.
What are your current main research interests?
My current research is focused on examining the outcomes of common operations, such as lumbar discectomy for lumbar disc herniations, as well as validating a number of imaging studies for the evaluation of this and other common spinal disorders.
You are currently president of NASS. What has been the most rewarding part of this position?
Thus far, the most rewarding part of being president of NASS is the opportunity it brings. In my travels to other countries, there is opportunity for collaboration with international societies for education and beyond. Back home in the USA, the position brings the opportunity to bring the greater number of societies involved with spinal care closer together.
What plans do you have for NASS this year?
My plans are to support three of the main projects initiated in the past: the NASS Registry, the North American Spine Foundation, and NASS Coverage Recommendations. These three projects have immediate and direct impact on not only the society, but on spinal care as a whole. In addition, it is my plan to collaborate with other societies as much as possible in order to unify the voice of spinal care providers.
You have been involved with a number of other spinal societies as well. Why do you think that such societies are important?
Each society represents a particular group of practitioners. While NASS would love to be the one and only society for all of spinal care, other groups will continue to develop more unique and specific interests.
My involvement in the AAOS, for instance, represents orthopaedic surgeons. There is of course a great deal of overlap between what the AAOS and NASS does for spinal care, but the AAOS is not necessarily interested in many of the nonoperative areas such as radiology, physical medicine and rehabilitation, and anaesthesia pain care of spinal disorders.
Though I am an orthopaedic surgeon, I have attended, spoken at, and collaborated with the AANS and Spine Section. Again, this is a group more focused on surgery than anything nonoperative. Then there is a group like ISASS, the International Society for the Advancement of Spine Surgery. I have served on committees for ISASS and served as programme chair for one of the annual meetings. Why be involved with this society, I have been asked, which seems to be in competition with NASS? I don’t see it as competition. I see it as a group of international surgeons who feel strongly about advancing spinal technologies. This sort of group has a role that may be distinct from NASS, which has to balance the role of new surgical technologies with other more traditional surgical and nonsurgical forms of care.
In our March issue (SNI38), you told us that insurance coverage decisions were the number one issue affecting field of spinal surgery. Is this still the case? How has this area developed in the last few months?
Yes, insurance coverage decisions continue to be a key issue facing spinal care providers. The NASS leadership and Coverage Committee continue to meet with major insurance companies in order to make them aware of what our organisation has to provide. It seems that we continue to make inroads with these insurance providers. Behind the scenes, the NASS Coverage Committee continues to develop more coverage recommendations, and updates previously published ones. It is an ongoing process.
What are the three questions in spinal medicine that still need an answer?
Is there an objective diagnostic study to determine a clear and treatable pain generator in a patient with chronic, axial low back pain?
Can a comprehensive risk assessment tool become a reliable and trustworthy method of predicting outcomes and complications of treatment for spinal conditions?
Will there be a feasible and practical method of spinal cord regeneration that can be used to treat those who have sustained spinal cord injuries?
What do you think will be the next big development in spinal medicine?
The next big development, by design or by need, will be investigation of multidisciplinary treatment algorithms for specific spinal disorders.
What advice would you give to someone who was starting their career in spinal medicine?
My advice would be the following: Identify an area of research that interests you. Next, determine if you have the resources to answer that question, or if you can practically acquire those resources. Learn as much about previous research done in this area with volume literature searches and wide reading. Become the expert on what has been done thus far; this will allow you to develop a unique and effective research plan.
Outside of medicine, what are some of your hobbies and interests?
My main hobby outside of medicine is fitness. I enjoy working out in the gym and keeping aerobically fit with running. I also enjoy doing small projects around the house.
1992 BA in Chemistry, CUNY Brooklyn, College, Brooklyn, USA
1996 MD, SUNY Health Science Center, Brooklyn College, Brooklyn, USA
1996–1997 Internship in General Surgery, New Jersey Medical School, Newark, USA
1997–2001 Residency in Orthopaedic Surgery, New Jersey Medical School
2001–2002 Fellowship in Spinal Surgery, UCSD Medical Center, San Diego, USA
2002–2006 Attending Orthopaedic Surgeon, Boston Medical Center, Boston, USA
Attending Orthopaedic Surgeon, Quincy Medical Center, Quincy, USA
2006– Chief, Orthopaedic Spine Service, Brigham and Women’s Hospital, Boston, USA
Consulting Staff, Dana-Farber Cancer Institute, Boston, USA
2014– Co-Director, Comprehensive Spine Center, Brigham and Women’s Hospital
2015– Director, MGH-BWH Combined Orthopaedic Spine Surgery Fellowship
2002-2006 Assistant Professor, Orthopaedic Surgery, Boston University School of Medicine, Boston, USA
2010 Associate Professor, Orthopaedic Surgery, Harvard Medical School, Boston, USA
Current society positions
NASS – 2015–16 President
CSRS – Special Projects Committee
ISSLS – Fellowship Committee
AAOS – Evidence Based Quality and Value Committee
Editorial review positions
2005– Editorial Board Member, Journal of Orthopaedic Trauma
2006-2008 Associate Editor (Founding Member), Current Reviews in Musculoskeletal Medicine
2006– Editorial Board Member, Journal of Spinal Disorders and Techniques
2007–2008 Editorial Board Member, European Spine Journal
2008–2014 Deputy Editor, The Spine Journal
2008–2013 Section Editor, SpineLine
2009– Deputy Editor, Journal of the American Academy of Orthopaedic Surgeons