Frank Schwab (chief of the Spinal Deformity Service, Division of Spine Surgery, New York University, New York, USA) helped to develop the Scoliosis Research Society (SRS) Adult Spinal Deformity Classification system and is a board member of the International Spine Study Group (ISSG). He talks to Spinal News International about his work with the Spine Deformity Study Group (SDSG), the ISSG, and why he believes the multicentre approach to be the most important development in spinal surgery.
Why did you decide to become a doctor and why in particular, did you decide to specialise in spinal surgery?
I was always drawn to the sciences and my first love was biology. Through my studies, the desire to find an applied and clinical field drove my interest in orthopaedics. During my residency, Jean-Pierre Farcy (New York University School of Medicine, New York, USA) was doing some amazing things in spinal surgery at Columbia Presbyterian Medical Center and I fell in love with the specialty when I was doing my residency in orthopaedic surgery there. The range of interesting pathologies, impact on patient care and room for innovation in spinal surgery is enormous.
Who have been your mentors during your career and what influence did they have on you?
Dr Farcy was an early mentor and he instilled in me a dedication and passion in the technical and anatomic considerations. Jean Dubousset (Academie Nationale de Medecine, Paris, France) was more influential in the theoretical and conceptual side of developing my knowledge of spinal surgery.
In your career, what has been the most important development in spinal surgery?
I think that the multicentre approach to outcomes based analysis has been the most important development. I have the good fortune to participate in numerous groups and what I learn from these groups continues to be enormously valuable. If your mind is open to ongoing dialogue with the observations and analyses of others, then spinal surgery becomes incredibly dynamic and the translation to improved clinical care is substantial.
What do you think are the three key questions in the field of spinal surgery that still require an answer?
- -What is the best treatment approach for each specific patient—from decision regarding surgery to approach, technique, implants and levels?
- -Can early intervention change natural history in a clearly favourable manner, and what are the procedures and patient profiles that permit improved outcome with early intervention?
- -Can biologic and non-fusion approaches outperform fusion as a mainstay in the treatment of spinal pathology?
Of the research you have been involved in, which piece of research are you most proud of and why?
I am most proud of the multicentre work through the SDSG and more recently, ISSG—in particular my collaboration with Virginie Lafage (New York University, Langone Medical Center, Department of Orthopaedic Surgery, New York, USA). The impact on patient care has already been substantial and will certainly increase. It is wonderful to see how many other colleagues have come to recognise the value of these study groups and are now contributing to them in meaningful ways. The impact on our field will dramatically increase over the coming decade
What has been achieved through the research of these groups?
The multicentre research groups have offered a much clearer correlation between radiographic findings and patient reported function, pain and satisfaction with care. This has directly lead to the development of the SRS-Schwab Adult Spinal Deformity Classification system. The project that started at our centre, but then it became part of the SDSG and then ultimately part of the SRS adult spinal deformity committee. The system is the result of (team) effort that has spanned nearly 10 years and is based on extensive outcomes data.
Other areas where the multicentre research groups have contritubed relates to the clear demonstration of value to patients related to complex spinal reconstruction surgery. The goals of realignment have been defined and models predicting outcome established.
What are the current research interests of these groups?
Unfortunately, the SDSG has been dissolved due to complex factors of funding and industry shifts. However, the ISSG has really taken off and is now the leading outcomes research group related to adult spinal deformity. The focus of the group has been on prospective outcomes research, although a number of targeted retrospective efforts have been pursued. Our work spans from outcomes of surgical and non-operative approaches for various deformity and patient parameters to complex osteotomies and site variations in treatment approach and patient-reported satisfaction. More recently, efforts have been initiated in the area of minimally invasive surgery, cervical deformity and health economics. The ISSG has grown to over 15 sites across the USA and is partnered with the European Spine Study Group in Europe.
What are your own research interests?
My own research interests are firmly aligned with the ISSG, where I have the privilege to sit on the board and help shape the direction of our various scientific and clinical efforts. In addition, my lab in New York has initiated work on soft tissue analysis in the setting of spinal deformity to determine the role muscle quality and volume have on patient function and standing alignment. Furthermore, we are examining sensor technology and the role it may play in obtaining objective dynamic information on patients suffering from spinal deformity.
Outside of your own work, what has been the most interesting paper that you have seen in the last 12 months?
There has been substantial interest in the economic aspects of what we do as surgeons and the efforts by several teams in this area will have a big impact. There are several ongoing studies and reports in this field that I find fascinating. Ultimately, payors and governments will want an open dialogue and data to determine what treatments should be paid for and for which patients. In the spinal deformity field, the large upfront costs have stirred concern but data are being published demonstrating the cost-effectiveness of surgery over the long term. I find the field of health economics extremely interesting and am certain it will become more heated over time, particularly as societal and ethical elements weigh in on decisions that are made.
As a member of various spinal societies, how have you benefitted from being a member of a spinal society?
My favourite society remains the SRS. I have immensely enjoyed the scientific and academic level of this society. Additionally, on a personal level there is a wonderful exchange with great thinkers, scientists and surgeons. Also, the SRS offers members an ability to shape the direction of our field and interact with other stakeholders on the big issues.
Given that so much educational material is online these days, what do you think the benefits of attending a medical conference are?
It is very hard to replicate the information gained from the debates, conversations in the corridors and the exchange of thoughts, challenges and tips of the trade over a coffee, a great glass of wine or dinner that occur at conferences with online discussions. Conferences will always be an important part of our field.
What has been your most memorable case and why?
We often say as surgeons that our last complication is the case that marks us the most. This might be true in the short term but our successes and patient encounters shape us overall. One of my very memorable cases was a patient who had failed multiple previous surgeries and was left with substantial disability and deformity. It was the first patient I pursued a grade four osteotomy, expanding a classic pedicle subtraction osteotomy (PSO) into a larger resection that I had never seen or heard of. The osteotomy permitted enhanced 3D correction of the deformity and left the patient with markedly improved function. That case triggered an extended multicentre effort to define osteotomy techniques and variations with an emphasis on outcomes.
What advice would you give to newly- qualified spinal surgeons?
I would think it is most important to remain passionate and follow your heart. The profession is full of challenges from the clinical side to the administrative and economic. In the end though, it is tremendously rewarding and it seems essential to maintain a sense of wonder and passion so that the outside forces do not wear you out. I would also recommend establishing a programme to track patient outcomes and develop self-audits on performance to improve over time. We owe that to ourselves and certainly to our patients.
Outside of medicine, what are your hobbies and interests?
My family is certainly the counterbalance to the many professional obligations. I exercise regularly and travel a good amount where I add on time for pleasure and discovery. A great personal pleasure aside from that is wine—which I mostly share with other colleagues in our field! Wine combines an appreciation in geography and culture with passion of a vintner and a unique expression of soil and climate
2007 -Chief of the Spinal Deformity Service, Division of Spine Surgery, New York University, New York, USA
2006 -Clinical professor, New York University School of Medicine, New York, USA
2004 -Director, Spine Center, Maimonides Medical Center, Brooklyn, USA
1996 -Attending Surgeon, Maimonides Medical Center, Brooklyn, USA
1996 -Attending surgeon, The Hospital for Joint Diseases, Orthopaedic Institute, New York, USA
1992–1996 -Resident in Orthopaedic Surgery, The New York Orthopaedic Hospital, Columbia-Presbyterian Medical Center, New York, USA
1991–1992 -Internship in General Surgery, Columbia Presbyterian Medical Center, New York, USA
1990 -MD, Medicine Columbia University, New York, USA
Awards and honours
2013 -SRS Russell A Hibbs clinical award, best clinical presentation at SRS annual meeting.
2013 -Frauenthal honouree, NYU Langone Medical Center, USA
2009 -SRS Russell A Hibbs clinical award, best clinical presentation at SRS annual meeting.
1994 -New York Academy of Medicine, Pediatric Orthopaedic Society of New York, resident paper competition winner
1990 -Andrew Puperre award for excellence in orthopaedic research, biomechanics of the bovine growth plate
1990 -NATO-NSF postdoctoral research fellowship. Laboratoire de Recherches Orthopédiques. Faculté de Médecine, Lariboisière-St. Louis. Paris, France
1989 -NIH medical student research scholarship, Columbia Presbyterian Medical Center, Orthopaedic Research Laboratory. USA