Luiz Pimenta is the immediate past president of the International Society for the Advancement of Spinal Surgery (ISASS) and is clinical director at the Department of Minimally Invasive Spinal Surgery, Instituto de Patologia da Coluna, São Paulo, Brazil. He talks to Spinal News International about the development of minimally invasive surgery and his achievements as president of ISASS.
Why did you decide to become a doctor and why in particular, did you decide to specialise in spinal surgery?
Throughout my childhood, I watched my forefathers—who were very important doctors in Brazil—work as physicians, which awakened in me the desire to participate in healthcare. I became interested in minimally invasive spinal surgery during the early part of my neurosurgical practice; I realised that many of the techniques in spinal surgery involved significant exposure to the spine, and I thought there were opportunities to decrease the morbidity associated with these techniques by making them less invasive.
My first significant experience in minimally invasive spine was when I undertook a thoracoscopy course, led by Daniel Rosenthal, in Germany. The course sparked a significant interest in looking at the spine in unconventional ways. Therefore after returning to Brazil, I started applying these new techniques with the aim of providing better results for my patients. However, the initial techniques and technology were very unsatisfying as they did not provide me with the level of predictability required to elevate the care I was providing my patients. At that point, I started what has since become my life’s professional passion of device/procedural development—from that day, improving spinal surgery has been my core professional challenge.
Who have been your career mentors and what influence did they have on your career?
I have been privileged to work and share knowledge with some exceptional people during my career. My father was one of Brazil’s early neurosurgeons and inspired me to follow his lead in surgery. He was chief of the department of neurosurgery at the hospital where I did my training and introduced to me to many of the skills that I rely upon today. More importantly, however, my father inspired a curiosity in me that has fuelled my interest in both research and procedural development.
As well as my father, other surgeons have significantly influenced my thinking. In particular, Dr Daniel Rosenthal—his thorcascopic training opened my mind to the possibilities of less musculature disruption by laterally approaching the spine. This has obviously had a profound effect on my thinking and career. Additionally, I have been significantly influenced by many other surgeons in how they approach and solve problems in an effort to provide better treatment options. So many names come to mind I would probably inadvertently leave someone out and it is suffice to say that I have been influenced by many and hope to continue to learn from them on a daily basis.
During your career, what have been the most important developments in spinal surgery?
Spinal surgery has come a long way during my career. Looking back over this period, I think there have been so many developments in spinal surgery that have failed to fulfil their expected promise (for example, lumbar total disc replacement). Furthermore, I think many of the early techniques in minimally invasive surgery never became widespread because of their lack of reproducibility. However, despite these early challenges, minimally invasive spinal surgery has now turned into one of the most promising aspects of spinal surgery. I am very proud to be part of this revolution in spinal surgery, and I believe that we are still in the infancy of how to lessen morbidity and accomplish our surgical goals in addressing all types of spinal pathology.
In addition to minimally invasive surgery, I am proud of the work in cervical arthroplasty. I believe both of these areas are key developments in improving spinal care. Only time will tell what has been the most important developments, but these two have survived long enough to suggest a high likelihood of them being deemed “important developments”.
You have focused on minimally invasive spinal surgery. What are the benefits and disadvantages of minimally invasive surgery compared with traditional surgery?
The benefits of minimally invasive surgery, which have been well documented, include preservation of normal anatomical structures, less blood loss, minimisation of collateral muscle and bone damage that culminates in a faster return to daily activities. Also, these benefits of minimally invasive surgery have resulted in increased cost effectiveness of these operations due to the lower intraoperative time, shorter hospital stay, less likelihood for infection and reduced incidence of recurrence.
The challenge of minimally invasive surgery most often relates to proper patient selection. When minimally invasive surgery fails, you can normally call into question the selection of the patients for the procedure. For minimally invasive surgery to be considered a good treatment option, it needs to be shown to produce at least the same clinical results—in appropriately selected patients—as traditional surgery.
Do you think there will be a point at which all spinal surgery is done through a minimally invasive approach or are there some conditions for which traditional surgery will always be required?
I believe that minimally invasive surgery is evolving at such a rate that much of spinal surgery in the future will be done in a less invasive manner. However unless foundational surgical goals can be accomplished through less invasive approaches, we should do what provides the patient the highest likelihood for successful outcome.
What do we know about artificial disc replacement for the cervical spine?
I have been intimately involved in the development of artificial disc prosthesis. I spent significant time studying the biomechanics of the cervical spine, as well as the anatomy of the most frequent pathologies. Cervical arthroplasty has made it possible to treat various diseases of the cervical disc with very satisfactory results. Long-term follow up has been significant but still goes unrecognised by many of the insurance carriers in the USA, which does not make sense to me! We have published our nine-year cervical arthroplasty experience with evidence that demonstrates very good long-term results. This experience has demonstrated superior clinical and radiolographical outcomes compared to anterior cervical discectomy and fusion (ACDF) over the same period. Cervical athroplasty does not have the longevity of ACDF but for well selected patients, it has demonstrated outstanding results.
Of the research you have been involved in, which piece of research are you proudest of and why?
I am most proud of the work that has been done in lateral access surgery. Over the last 10 years, we have taken minimally invasive surgery from an unpredictable decompression modality to an extremely predictable reconstructive surgery option. That has only been accomplished with the assembly of curious people interested in verifying and furthering the predictability of an approach that initiated in Brazil. Significant work has gone into the lateral access surgery effort and as you would expect, I am extremely proud to have popularized a minimally invasive pathway for various spinal conditions, providing pain relief for many patients worldwide. It has been an effort that includes many contributors who I consider to be friends.
What are your current research interests?
My interests are those related to the welfare of patients. Previously, there was limited information regarding the requirement for sagittal alignment in degenerative conditions. The focus has traditionally been on surgical correction in the coronal plane. But this has been without focus on global alignment, so the long-term clinical results of coronal plane (only) deformity correction has been unsatisfactory. My interest in improving the welfare of my patients is to drive better long-term clinical results by providing increased predictability of global alignment—predictably, through minimally invasive techniques!
What are the three questions in spinal surgery that still need an answer?
The onset of scoliosis in childhood and adolescence is a non-predictive event and deserves more effort to find its inherent issues. Regarding motion preservation, we still need more data to confirm its superiority in preventing adjacent level disease and its role in spinal biomechanics. Another important question is whether it is possible to completely recover the damaged nerve tissues in a spinal trauma, either by stem cell therapies, neurorraphies or through other technologies that may emerge in future.
You are the immediate past president of the ISASS. What are the current goals of the society?
ISASS is a global, scientific and educational society that discusses independently the issues involved multiple aspects of basic and clinical science related to the function of the spine. The society is organised to assess existing clinical strategies and innovative ideas that further clinical practice and enhance patient care; focusing on the advancement of major evolutionary steps in spinal surgery.
What were the key highlights of 2014 annual meeting (30 April—2 May, Miami, USA)?
The key highlights were those involved with all aspects of motion preservation, stabilisation, innovative technologies, minimally invasive spine procedures, biologics and other fundamental topics that drive restorative patient care for spine for surgeons, scientists, inventors and others.
What has been your most memorable case?
I remember an older woman coming into my office in a wheelchair, screaming in pain. She was unable to walk and only ambulated short distances in the previous two years, but was now restricted to bed. She had a 75 degrees degenerative scoliosis, with lateral spondylolisthesis, stenosis and other degenerative conditions. I offered her a less invasive alternative to minimise her suffering. We performed a three level standalone extreme lateral interbody fusion (XLIF; NuVasive) with significant success. One week after surgery, she entered my office walking with almost no pain, and she has maintained this improvement at her follow-up appointments. These are the cases that make our jobs most memorable.
What advice would you give to someone who was starting their career in spinal surgery?
Spinal surgery is not different from other careers in medicine. It requires an all-life sacrifice with training and learning. Never stop learning and being curious as to how to make things better. You must be aware of your steps, avoiding being consumed by work. Take care of your family and take a break to have fun with them. Listen to patients and colleagues, applying evidence-based medicine in your practice routine, always looking for better results. Update your knowledge reading papers and attending scientific meetings. But do it all with love, respect and care.
Outside of medicine, what are your hobbies and interests?
I really enjoy running long distances. The time allots me the necessary peace of mind for thinking about new alternatives for old problems. Wine is something that fascinates me; I love learning about its history and better understanding its flavours. My family are my safe “port” and whenever I feel lost, I surround myself with them.
Clinical director, Instituto de Patologia da Coluna (IPC), São Paulo, Brazil
Associated professor, University of California San Diego, USA
President, Society of Lateral Access Surgery
2013–2014 president, International Society for the Advancement of Spine Surgery
1998 Fellowship, Spine Endoscopy, Frankfurt, Germany (with Daniel Rosenthal)
1997 Spine endoscopy, training in Gainesville, USA
1980 PhD, neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
1971–77 Residency, Neurosurgery, Universidade Federal de São Paulo, São Paulo, Brazil
1971 Graduation, Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
World Spine column Society (WScS)
The Society of Lateral Access Surgery (SO LAS)
Sociedade Brasileira de Coluna (SBC)
Sociedade Brasileira de Neurocirurgia (SBN)
North America Spine Society (NASS)
Scoliosis Research Society (SRS)