Inspired by Alexander Fleming, Marek Szpalski wanted to become a medical researcher. After becoming disillusioned with a life in the laboratory, he embarked on a career in orthopaedic surgery, specialising in spinal surgery. Upon achieving his medical degree in Belgium, Szpalski went on to work in health systems as diverse as those in the USA and across Africa. During his career, he has been involved in the organisation of many international conferences, held editorial positions at numerous scientific journals and lectured around the world. Szpalski spoke to Spinal News International about his journey into the world of spinal medicine, and how he thinks it will develop.
Why did you decide to become a doctor and why, in particular, did you decide to specialise in spinal surgery?
When I was 12 or 13, I read a book about Alexander Fleming and the discovery of penicillin. This made me want to become a doctor, so that I could research and discover new treatments, too. During my studies, however, I hesitated, and dropped the idea of just working in the lab. Maybe I was not going to be the next Fleming after all!
Towards the end of medical school, I discovered my interest in surgery. Until the beginning of my residency I hesitated between orthopaedics and urology, but eventually decided on orthopaedics.
Who have been your career mentors, and what wisdom did they impart?
My first and main mentor was Michel Dupont; my boss during my residency. Like most orthopaedic surgeons in the mid-70s, he was practising general orthopaedics, but he had a specific interest in hip and spinal surgery. He was a brilliant surgeon—when you watched him operate everything looked simple and straightforward. He used to say that surgery was the opposite of the principle of entropy; in surgery you should always go from disorder to order, from complicated to simple. When things look complex and messy during a procedure, we need to breathe, and take small, simplifying steps to restore order.
During the late 80s and early 90s, I did research in Nashville at the Department of Orthopaedics of Vanderbilt University. I worked on trunk motion with Tony Keller, who was heading the department’s biomechanics lab. Tony introduced me to basic science research. He sadly passed away a few years ago, and is missed as a fantastic engineer and a great human being. You gave him a problem that seemed impossible, and he would never say that it could not be done. I worked with him after he left Vanderbilt, and up until his death.
What do you think has been the biggest development in spinal surgery during your career?
I am lucky to have witnessed fantastic developments in spine surgery over the past 30 years. We have seen a huge number of technical innovations; some good ideas are still with us, while some have failed and disappeared into the deep abyss of redundant technologies.
My boss and I used the Roy-Camille pedicular screws and plates, but their holes never seemed to be placed at the same interval as the patient pedicles! With some effort, however, it gave good fixation. I think that the modern pedicular screw that followed is one of the biggest developments that I have seen, because it was the first means of achieving a truly solid fixation.
Biologics, too, are a great innovation, in spite of their associated limitations. We can now really act precisely on the biology of bone growth and, so, fusion.
For me, however, one of the greatest developments has not been technical. It has been the emergence of evidence-based medicine, which is truly a patient-minded development.
Outside of your own work, what has been the most interesting research you have read over the past few years?
I found the paper by Albert et al. (Br J Sports Med 2008; 42), and the ensuing controversy about infection and Modic changes and disc degeneration, fascinating. Reading both sides’ heated opinions is very interesting.
Of the research you have been involved with, which piece are you most proud of and why?
I am most proud of a large epidemiological study on sociocultural factors and low back pain and its treatments in Belgium. The two papers we published from this study (Skovron 1994 and Szpalski 1995, Spine) are still regularly cited.
We interviewed over 5,000 Belgian patients to determine the sociocultural factors that can influence low back pain. Belgium is marvellous setting for this type of research because we have two very different cultures—the Flemish and the French—and an identical, single-payer healthcare system. Because of this, we were able to show that there is an influence of culture on the threshold of the expression of pain.
When we did a further analysis with the epidemiology department of New York University, we were able to show that, among patients who experience daily lower back pain, there is no difference in the expression of that pain along social and cultural lines. Rather, the only difference is patients’ work satisfaction. People who are not satisfied with work are four times more likely to complain of pain.
What are your current research interests?
I am currently involved in studies involving nanostructures, for example nanotubes used in implant surface coating. It is fascinating to see how those purely physical nanostructures can induce biological effects in the surrounding tissues. I am also working on bioactive bone substitutes.
You have worked and studied across the world. What lessons did you take from your various foreign postings?
I have been fortunate enough to work in opposite extremes of the healthcare technology spectrum; Africa and the US. Working in Africa for three years enables you to put certain things into context. I did not encounter much functional back pain there. When someone came to see you with back pain, the first thing to do was to rule out a severe pathology—black disc was not really a problem!
You have been involved in the BISS meeting for 22 years—how has the meeting developed since your involvement began?
When Robert Gunzburg and I began the conference it was an intimate affair—the first year had around 80 participants! We certainly did not expect it to become an annual event for two decades. Last year we had over 500 participants.
Each year we choose a specific subject, and ask our speakers to give an overview of the current state of the art. We cover from its basic aspects to diagnosis, to medical and surgical handling and finally to its economic and ethical aspects. I think that our success has been down to the format, the faculty of world-renowned opinion leaders, and the ample time we reserve for discussion.
You are one of the founders of Spineweek, which is in Singapore this year. How did this meeting come about, and how has it progressed over the years?
Jiri Dvorak, Dieter Grob, Robert Gunzburg and I had the idea of Spineweek in 1999. We wanted to create a kind of “Olympics of the spine”; a meeting every four years, bringing together societies from all over the world.
When we had our first meeting—in Porto in 2004—we expected maybe 800 people to attend. In the end we had over 2,000. Our next meeting was in Geneva in 2008, and then in Amsterdam in 2012.
After three successful events we saw a growing number of participants from Asia, so it seemed like a natural development to hold Spineweek in Singapore this year. We have the participation of a number of Asian specialist scientific societies—like the Korean Spine Society and the Association of Spine Surgeons of India—as well as societies like NASS and ISASS, and some newcomers like AfricaSpine and the Pan Arabic Spine Society. The European Spine Journal will be running academic writing seminars this year, and even F-Marc—the FIFA Medical Association and Research Centre—will be running a seminar on football and low back pain.
This will be the first time that different scientific spine societies from all around the world will meet together. We hope that this will enable great exchanges of ideas; a kind of “spinal fusion” cuisine!
What are the three questions in spinal medicine that still need an answer?
- Where does pain come from?
- Spine degeneration is a natural process; we will all have wrinkles, we will all have a degenerated spine. So, why do some people experience pain and others not?
- How can we better educate surgeons to follow evidence-based-medicine principles?
What do you think will be the next big development in spinal medicine?
Reversing the aging degenerative process. The use of stem cells seems promising, but we are probably many years from efficient clinical use.
What advice would you give to someone who was starting their career in spinal surgery?
I would say that you have to love the subject. It takes a lot of time to master it, and you will have to learn throughout your life. You also must be willing to make sacrifices in your personal life, too. You must also look carefully before adopting any new technology—especially abundant in spine—however exciting it may look.
What has been your most memorable case?
For me, the most memorable cases are not always the most complex ones. I think it is even more interesting to have done something simple and precise to change somebody’s life.
I saw a 79-year-old woman suffering for several years with back pain. She came to see me with a severe pain in her leg, which left her unable to walk her dog or play with her grandchildren. She had severe degenerative changes—a stenosis and a lumbar degenerative scoliosis—which had remained unchanged for years.
Some of the surgeons she spoke with recommended a long decompression with an L1-S1 fixation. She was a bit scared! As always the devil is in the details. In this case the devil was a calcified arthro-synovial cyst; not very obvious on magnetic resonance imaging scans, but evident on a computed tomography scan. Everyone up to then, (me included) had focused on the severe degenerative changes and overlooked it. This structure was impinging on the L5 root, and was a probable cause for her radiculagia. I told her that I could probably improve her leg pain with a fairly short and simple surgery, but that it would not have much impact on her back pain.
She told me, “Look, doctor, I have been coping with my back pain for over 30 years. I just want to walk my dog!” So, I did a simple unilateral L5S1 lateral decompression, and her leg pain disappeared.
I believe we must listen carefully and respond to patients’ precise complaints. Try not to deal with what they do not ask you to treat! Primum non nocere: first, do no harm.
Outside of medicine, what are some of your hobbies and interests?
I raced cars for fifteen years. I went to the same racing school and tracks as Jacques and Gilles Villeneuve and Emerson Fittipaldi. Unfortunately this was not enough to actually be Fittipaldi! It was great fun, but I stopped because it became too time consuming, and my wife started to find it less and less amusing! I have always liked cameras, too, so now I collect them.
1982 Master in Surgery, Free University of Brussels
1977 Doctor of Medicine, magna cum laude, Free University of Brussels
1984–1986 Head of Department of Orthopaedic Surgery, Hôpital Paul Igamba, Port-Gentil, Gabon, Teaching Hospital for University of Libreville, Gabon and University of Tours, France
1987–2003 Senior consultant, Department of Orthopaedic Surgery, Iris South Teaching Hospitals–Centre Hospitalier Molière Longchamp, Teaching Hospitals of the Free University of Brussels.
2003–present Chairman of the Department of Orthopaedic and Trauma Surgery, Iris South Teaching Hospitals, Teaching Hospitals of the Free University of Brussels.
Teaching and research positions
1998–present Professor of Orthopedic Seminars and Exercises, School of Medicine, Free University of Brussels
2001–present Adjunct associate professor of Orthopaedics, School of Medicine, New York University, New York City, USA.
2011–present Guest professor, Central South University, Changsha, China
2004-present Deputy editor, European Spine Journal
1994–present Organiser and co-chairman of the annual Brussels International Spine Symposium
1998 Organiser and co-chairman of the International Society for the Study of the Lumbar Spine Annual Meeting
2000 Organiser and co-chairman of the EUROSPINE meeting
2004–present Organiser of the Spineweek meeting
International Society for the Study of the Lumbar Spine (ISSLS) – past-president
International Society for the Advancement of Spine Surgery (ISASS) – member of the Board of Directors
Eurospine The Spine Society of Europe – past member of the Executive Board
North American Spine Society (NASS) – member of the International Education Committee and of the Research Project Management Committee