Once an aspiring architect, Frank Kandziora has never looked back from the medical profession since being assigned a medical assistant during his military service in Germany. As the outgoing president of EUROSPINE, he reflects on the successes of the past year, as well as the biggest challenges facing spine surgeons today.
When did you first know you wanted to go into medicine, and what specifically drew you to spine surgery?
When I graduated from high school, I wanted to become an architect. At that time, it was mandatory for every young male in Germany to enter the army. By chance, I was assigned to the medical service and became a medical doctor’s assistant. I was fascinated by his work and his way of helping people, so I decided to become a doctor myself.
My first contact with spine surgery was shortly after I graduated from university. I had the opportunity to participate in a transoral odontoid resection, carried out by my first mentor, Professor Kerschbaumer. In those days, this was a very special surgery and the operating room was overcrowded with visitors. I was tremendously impressed by this high-level surgery, and I decided that I wanted to be able to do that “super-challenging-spine-thing” on my own.
Have you had important mentors throughout your career? What have they taught you?
There have been two very important persons in my career: Professor Fridun Kerschbaumer, the orthopaedic surgeon from the Goethe University in Frankfurt who supervised my doctoral thesis, was a brilliant surgeon who had an unrivalled and elegant technique. I tried to learn as much as possible from him. Professor Norbert Haas, the trauma surgeon from the Humboldt University in Berlin who supervised my PhD thesis, was the most important trauma surgeon in Germany for more than a decade. He not only taught me surgery, but also showed me how health systems and medical politics work. I owe a lot to both of them.
What is your proudest career achievement to date and why?
As Head of the Spine Department at the BGU hospital in Frankfurt, I am tremendously proud to lead the “best spine team in the world”.
Can you describe a particularly memorable case?
There are many memorable cases every year. But so far, this year’s most remarkable case was a young female teacher in her mid-twenties, who was suffering from a Klippel-Feil Syndrome and Arnold-Chiari II-malformation, previously operated on elsewhere, resulting in an increased cerebellar tonsil herniation, a more severe myelopathy and an implant dislocation. When I first saw her, she was unable to walk, hardly able to sit and not able to write her name. Months after performing a revision surgery, this lady recovered extremely well—she is now walking and dancing again (tango is her hobby) and is fully back to work. It is always fascinating to see the potential for spinal cord recovery, especially in young patients.
How has the field changed since you started your career?
On the one hand, spine surgery in general has become much safer, because it has become much more common, but on the other hand it also has also become much more complex. Twenty years ago, spine surgery was only performed in a few highly-specialised hospitals. Nowadays, we have a lot of well-educated spine surgeons doing a wonderful job and making spine surgery safe and efficient. However, the increasing case load has also resulted in a substantial number of devastating failures and more complex revision surgeries. Taking special care of these cases is now one of our major challenges.
Outside of your own research, what is been the most interesting paper that you have seen in the last 12 months?
In my opinion, the best paper in 2017 was presented by Anne Mannion from Zurich, Switzerland at EUROSPINE 2017, demonstrating that outcomes after spine surgery are still poorer overall than outcomes for large-joint replacement. Her paper shows that a lot of work is still required to optimise indications and patient selection criteria for spine surgery. It was awarded the EUROSPINE Full Paper Award and published in the European Spine Journal.
In your opinion, what are the most exciting new developments in spine surgery that we can expect in the next five to ten years?
In the last two decades, many potential “eruptive innovations” in the implant manufacturing field have proven to be ineffective. As a result, the regulations for new implants, especially in Europe, have already become or will fortunately become much stricter. Hence, I am convinced that the speed of innovation in this area will decrease dramatically during the next decade. Therefore, the most exciting clinical developments will hopefully result from a more evidence-based spine surgery approach and an improvement of the surrounding conditions, raising the quality and safety of spine surgery.
What is the biggest challenge in spine surgery at the moment?
The biggest challenge in spine surgery in developed countries is the demographic change with a growing ageing population. With increasing age, the number of, for example, degenerative spinal disorders and osteoporotic fractures resulting in disability will continuously grow. This necessitates an adjustment of our resources to ensure that this increasing number of patients can still be treated adequately. I am convinced that there is already a need for a general society-based discussion about what we should do and how much we can afford to do.
For your habilitation, you studied the influence of cage design, carrier systems and growth factors on interbody fusion. What was your most interesting finding from this research?
The most interesting, but also slightly disappointing, finding in this research was that it is now possible to create a “perfect laboratory implant” by combining growth factors with carrier systems and optimised cages which guarantees(!) fast and secure spinal fusion. Unfortunately, bringing such innovative technology into the clinic, and especially to the individual patient, is tremendously complicated due to financial, logistic, technical and legal obstacles.
Could you explain your current research interests?
My current research interests focus on spine trauma and minimally invasive spine surgery. The most recent study we ran, published in the European Spine Journal, was a randomised controlled trial comparing posterior with posterior-anterior stabilisation of thoracolumbar burst fractures. It is also a great honour and a pleasure for me to be part of the large research network, AOSpine Knowledge Forum in Spine Trauma, which, for example, has most recently described and validated new classification systems for all spinal injuries, known as “AOSpine Classifications”.
As a specialist in trauma surgery, what are the biggest challenges facing the field right now, and have these changed over your career?
The biggest challenge in the field of spine trauma surgery is once again our ageing population. While 10 years ago the number of patients over the age of 80 treated surgically for highly unstable spine fractures in my department was less than 2% of all spine fractures, today this rate has increased to nearly 10%. Severe spinal fractures in old, multi-morbid, often poly-traumatised and typically osteoporotic patients, is by far the biggest challenge we are currently facing in spinal trauma surgery.
You are the current President of EUROSPINE. What have been the highlights of this position, and what do you like most about this organisation?
EUROSPINE is a healthy organisation that is continuously growing and evolving to advance spine surgery in Europe. With more than 8,000 members and associate members, it is by far the largest spine society in Europe and perhaps even the largest truly international spine society in the world. What I like most are the people that form this organisation. They are the “crème-de-la-crème” of European spine specialists and it is a great honour and a pleasure to be one of them.
So far, my personal highlight this year was the memorandum of understanding (MoU), that we signed with EANS, as well as with EFORT. This MoU helps us to align spinal education throughout Europe, together with our neurosurgical and orthopaedic colleagues. As a result, regardless of whether you attend a EUROSPINE, an EANS course or a course presented by the German, Turkish or the Spanish spine societies, under the equivalence programme you would qualify to receive the EUROSPINE Diploma, or EUROSPINE Advanced Diploma. This is a tremendous step forward in achieving a homogeneous, Europe-wide training programme for spine specialists.
Having been a long-term Board Member of the German Spine Society, you are now their President Elect—what are your ambitions for this role?
The German Spine Society has made a tremendous development since its founding in 2005. It is currently the largest national spine society in Europe, with a well-recognised education and quality-assurance programme. My main role will be to continue this excellent development and boost the international role of the German Spine Society.
As a surgeon in Germany, how does the German healthcare system help and hinder your research and/or practice?
The German healthcare system is one of the best in the world. In general, it allows me to provide excellent spine care to everyone in the country, because everybody is insured. On the other hand, the numbers of spine surgeries have increased, resulting in political pressure reflected by media campaigns complaining about too many and potentially unnecessary procedures. This has dramatically affected the surgeon-patient relationship, which is the basis for all we undertake. I think it is important to rebuild trust by improving the evidence in spine surgery and demonstrating that there are clear reasons for the increasing numbers in surgical procedures, which are predominantly the ageing population and improved treatment options.
As a member of the editorial board for several journals, what do you think makes a good original research article?
A good original research article is characterised by an intelligent idea, an interesting research question, up-to-date methodological techniques, an adequately-powered research population and honestly-presented results. If this results in a “game-changing” conclusion, please submit your work to EUROSPINE to receive one of the awards we offer.
There is still gender disparity among the top researchers in spine. How well do you think institutions are doing to encourage more women to pursue a career in spine, and could this be improved?
Although the gender gap in university medicine has decreased over the last two decades, at least at the universities where I was teaching, unfortunately not enough women end up in spine research or spine surgery. While other specialties such as anaesthesiology, gynaecology, or ophthalmology and even “exhausting” general surgery are made up of more than 50% female surgeons, women are still an exception in “spine”. We have already taken measures to improve this situation, such as optimising and adapting working hours and conditions, allowing pregnant surgeons to perform operations, etc., but still only 18% of my colleagues are female. I am not really sure how to further improve the situation, but I am open to any suggestions and very happy to accept female applications for positions in my department.
What advice would you give to someone wishing to start their career in spine surgery?
I think it is absolutely mandatory to love what you do. Spine surgery is a sometimes physically exhausting, often challenging and always interesting mission with long working hours and hopefully only a few setbacks. Therefore, you need love and passion to be successful. But if you really love it, it will be highly rewarding because your work will become your hobby, making you happy every time you work. If you are happy, you will be able to make others happy too. So, if you love “spine”, then go for it, because it is your chance to make yourself and many others happy.
What are your interests and hobbies outside spine?
Like many others, I have a soft spot for gourmet food and excellent red wine. However, my favourite hobbies are studying archaeology and reading historical books.