One of the world’s foremost specialists in the treatment of the cervical spine, Daniel Riew talks to Spinal News International about his illustrious career. Riew, who has served as the President of the Cervical Spine Research Society (CSRS), and as chairman of the International Board of AO Spine, reflects on the increasing drive towards subspecialisation in spine care, his current research interests, and the emerging trends he sees impacting the field over the next decade.
Why did you decide to become a doctor, and what was it that led you to specialise in spine care?
When I started college, I thought I wanted to be a lawyer. But I soon found that law was a bit too subjective for my personality. I was drawn to the scientific part of medicine. As far as spine, I liked the complexity of the field. To properly diagnose a spine patient, one has to take a very careful history, perform a thorough physical exam and review all of the imaging studies. The diagnosis is often not obvious or simple. I guess that being a former internal medicine doctor, I was particularly drawn to a field that requires more diagnostic skills.
Have you had important mentors throughout your career? What have they taught you?
I have been very fortunate to have outstanding mentors throughout my career. I did my fellowship with Henry Bohlman, who was a great mentor. He taught us how to do thorough decompressions, detailed exams and the importance of spending time with a patient. He would spend an entire day seeing just eight to 10 patients. Every patient felt that he was giving his all for them and they all felt special. Sandy Emery, now chair of orthopaedics at the University of West Virginia, is the unsung hero of my fellowship year. He was an amazing surgeon and teacher and always calm under pressure and never said or did an unkind thing. Richard Gelberman was a tremendous academic mentor during my first 20 years in practice. Without his mentorship and even gentle but firm pressure, I would not have been academically productive and would not be where I am today. John McCulloch taught me microsurgery and the importance of osteology. He was a master anatomist and great mentor. He once said to me that if I, as his mentee, did not surpass him academically and as a surgeon, he would have failed me. I try to follow in his footsteps by passing on what I have learned to the fresidents that I teach. Sadly, he passed away and I will always miss him.
How has the field changed since you started your career, and what do you feel has been the most important development?
When I started, spine care did not have sub-specialties. Now there are surgeons who have sub-specialised in fields such as deformity, minimally invasive surgery, tumour and the cervical spine. Specialisation in spine is going to continue and even accelerate, as it has done in all medical specialties for the last 100 years.
What do you think are the main challenges facing spine care at the moment? What are the potential solutions?
There is too much unnecessary time devoted to learning skills that are not necessary to become a spine surgeon. Neurosurgeons spend seven years in residency. But perhaps only 50% of their training is in spine. Orthopaedic surgeons spend even less time during their five years of residency training in spine. The difference shows when they do their fellowship, as the average neurosurgery fellow is two years older and has had two more years of training in spine than the average orthopaedic surgeon. But even the three or more years of training in spine that the typical neurosurgery resident gets is not adequate. It would be much better if all spine surgeons spent five years training just in spine, with a fellowship year devoted to subspecialty training.
The COVID-19 pandemic is one of the biggest challenges facing modern healthcare. What impact do you see this having on the field of spine care?
In the short-term, until a vaccine or highly effective treatment has been identified, we are going to see significant changes in the indications for surgery, favouring young, healthy patients without co-morbidities, such as obesity, diabetes, cardiac, immunologic and respiratory diseases, or those who have already had the infection and are now immune. In the long-run, I think the only change will be related to telehealth. We will be able to see patients remotely, saving patients the time and expense of travelling to see us in person.
You have been a leading advocate for cervical artificial disc replacement. Does this technique have the potential to become more commonplace over the next decade?
I believe that it does. More and more patients are asking for it and we are getting a better handle on which patients are good candidates for the procedure.
What are your current research interests, and what are your future priorities for research?
We have a large number of projects that are going on at any given time. I am currently particularly interested in all aspects of research related to artificial disc replacements and anterior cervical fusions.
What is the most interesting piece of research you have read recently?
There is so much research going on out there that it would be hard to point to any one paper. What really excites me is when I see so many energetic and bright researchers in the next generation doing amazing and ground-breaking research. It tells me that the future of spine research is in outstanding hands and we will constantly be learning new things thanks to their efforts.
In your opinion, what are the most exciting new developments in cervical spine care that we can expect in the next five to 10 years?
My guess is that biologics and robotic surgery will be the next wave. I believe that we will learn how to harness the power of growth factors while avoiding the dangers and downsides. As far as robotics, I would guess that many cervical operations could be done more efficiently and safely with advanced robotics and navigation.
You have previously served as president of the CSRS, what do you feel you accomplished in the role?
My top goal as president was to get as many young key opinion leaders, especially in neurosurgery, involved in committees and as committee chairs. With the support of the entire board, we increased the size of the board by about 30% and increased the numbers involved in committees by about 50%. This allowed us to get many more neurosurgeons involved in the leadership. But, this is not something I did on my own. The CSRS is a democratic organisation and no leader can accomplish any goal without the support of the entire board.
What is your proudest career achievement to date and why?
I am most proud of seeing how accomplished our former fellows at Washington University, as well as the more recent ones at Columbia have become. I was privileged to be a part of the fellowship that Keith Bridwell started at Washington University in St. Louis. He and Larry Lenke were able to recruit some of the best and brightest fellows in the country. I was the junior member of the group and learned as much from the fellows as I taught them. Now I see that those fellows have grown up to become leaders in the field, as well as in just about every spine society. John Rhee will be the first of the Bridwell/Wash U fellows to become a president of a major spine society when he ascends to the presidency CSRS next year. But, I am confident that there are many others who will become presidents of the Scoliosis Research Society (SRS), CSRS and other societies.The proudest moment for any teacher is to see a student’s achievements surpass their own.
What advice would you give to someone hoping to start a career in spinal surgery?
These are exciting times with so many advancements in spinal surgery. I do not think there is a better time to be a spinal surgeon than now.
What would you have been if you had not been a medical doctor?
A trial lawyer.
Outside of medicine, what are your hobbies and interests?
My favourite activity is hiking with my family. I have a great pair of hiking sticks by Gossamer Gear that I use when trekking. With the COVID-19 induced shutdown, there is not much else to do in our free time, so every weekend as a family we hike in the nearby mountains.