Michael Fehlings (University of Toronto, Canada) was encouraged to enter the medical profession by his grandfather, eventually specialising in neurosurgery. He cites the intellectual and technical challenges of neuroscience and precise surgery combined with the ability to help individuals as his role’s most appealing aspects. A prolific researcher of spinal neurology and spinal cord injury, he has also been involved in several societies and medical journals during his career, believing that sharing local knowledge and experiences can lead to an improved and more useful global perspective on the big questions facing medical science.
Why did you decide to become a doctor and why, in particular, did you decide to specialise in neurosurgery?
I was inspired to become a doctor by my grandfather who felt that medicine is perhaps the noblest profession and one that was well suited to my skills and personality. It has indeed been an excellent fit for me in that it combines intellectual pursuits and challenges while at the same time focussing on trying to help individuals and to make an impact on the health of society. I decided to specialise in neurosurgery because I felt that it combined the pursuit of the challenges of neuroscience with the technical attributes of doing a precise surgery. It was really this combination that had tremendous appeal to me.
Who have been your career mentors and what wisdom did they impart?
I have had many career mentors, the two most significant ones being Charles Tator and Alan Hudson. Charles Tator was my PhD supervisor and the individual who taught me about neuroscience and spinal cord injury. He really inspired me to focus on the area of spinal neurosurgery and spinal cord injury. Alan Hudson was my professor of neurosurgery and was enormously influential in terms of my career development as a spinal neurosurgeon. Alan inspired me to focus in the area of spinal surgery and undertake postgraduate training in this emerging subspecialty. Another individual who had significant impact on my formative years was Paul Walker, who at that time, was the surgeon-in-chief after I had attained my first appointment as an assistant professor at the University of Toronto. Paul facilitated my formation of a combined multi-disciplinary spinal programme, and was very influential on my development.
What do you think has been the biggest development in spinal surgery during your career?
The development of internal fixation approaches to reconstruct the spine from the occiput down to the sacrum has dramatically influenced our ability to decompress and reconstruct virtually any condition in the spine. In particular, the development of lateral mass fixation, occipital cervical fixation, anterior cervical locking plates and pedicle screw fixation have been enormous advances. In addition, there have been significant technical advances in microneurosurgery as well as in our ability to approach virtually any area of the spine successfully.
Outside of your own work, what has been the most interesting paper that you have seen in the last 12 months?
I think the most fascinating work that I have seen has been the research pioneered by Reggie Edgerton at UCLA and Susan Harkema in Louisville, USA, related to the use of epidural stimulation to activate the central pattern generators of the lumbar spinal cord in individuals with complete spinal cord injury. Activation of these centres appears to promote significant endogenous plasticity and to enhance recovery of function. If this work is supported by larger clinical trials, this could represent a major breakthrough in the area of traumatic spinal cord injury.
Of the research you have been involved with, which piece are you proudest of and why?
I feel that one of my major contributions has been in the area of spinal cord injury and, specifically, the definition of post-traumatic ischaemia as a key secondary injury event. The critical translation of this into the clinical arena arose out of the STASCIS (Surgical Timing in Acute Spinal Cord Injury Study) clinical trial which determined that early surgical decompression of traumatic spinal cord injury resulted in a major improvement in neurological function. The STASCIS trial and the work around this has redefined how acute traumatic spinal cord injuries are managed. The concept that has emerged from this work is one of “Time is Spine” wherein early intervention for traumatic spinal cord injury is critical.
What are your current research interests?
My current research interests reflect my passion to understand the pathobiology of central nervous system injury and methods to improve the outcomes. I continue to have major research interests in traumatic spinal cord injury and am focusing on neuroprotective approaches, bioengineered strategies and stem cell-based regenerative neuroscience. This work has also been extended to cervical spondylotic myelopathy. It has involved the conduct of clinical trials to validate the significant role of surgical decompression to influence the outcomes of patients with cervical spondylotic myelopathy. Parallel to this, we have developed unique animal models to mirror human cervical myelopathy in the laboratory setting and we are currently studying the pathobiology of cervical spondylotic myelopathy in animal models. In addition, I have a significant clinical and research interest in the area of spinal oncology and have a focus, in particular, on optimal methods to treat metastatic epidural spinal cord compression.
What does the future of regenerative medicine for spinal cord injury look like?
Regenerative approaches for spinal cord injury would certainly be combinatorial in nature. The role of surgical decompression and reconstruction of the unstable spine is critical in optimising the milieu for recovery. Neuroprotective strategies to facilitate optimal recovery and preservation of neural structures are important. Rehabilitation approaches to influence plasticity are critical to any treatment paradigm. Undoubtedly, both bioengineered strategies to influence the milieu of the injured spinal cord and to serve as scaffolds to facilitate repair would be complementary to stem cell-based strategies to replace lost cells and to regenerate neural circuits.
What are the three questions in spinal medicine that still need an answer?
This is a challenging question to answer as we have many issues that need addressing. But if I was pinned down, the following are the three critical issues, in my opinion. First, finding an optimal approach to repair the injured central nervous system. This is absolutely critical as neurological deficits are the rate-limiting determinant of quality of life and of outcomes of an individual with a spinal condition. The second critical issue is to define the pathobiology and optimal treatments for neuropathic pain. Neuropathic pain is a key issue which arises after peripheral nerve injury and injury to the brain and spinal cord. We lack effective solutions for this disabling condition and unlocking the key to neuropathic pain will have dramatic impact on the outcomes of patients. The third key issue, in my view, is to convince a society and peers that surgical treatments for spinal conditions are highly effective and also cost effective for society and should be supported.
What do you think will be the next big development in spinal medicine?
I feel the next big development will relate to regenerative neuroscience technologies. This will involve both unique bioengineered strategies to influence soft tissue regeneration in the spinal cord and the adjacent paraspinal structures including the intervertebral discs. In addition, I feel that induced pluripotent stem cells offer considerable promise as a technique to regenerate damaged neural structures and paraspinal elements.
I have seen remarkable advances in the treatment of spinal cord injury and spinal conditions over the last 25 years. These advances have greatly influenced our ability to effectively treat a variety of spinal conditions. I am optimistic that the trajectory over the next 10–20 years will be very positive and that spinal surgeons have a major role in society to help patients recover from the impact of disabling spinal conditions.
You have been active in many medical societies during your career. What have you learned from these experiences?
My involvement in medical societies including the American Association of Neurological Surgeons, Cervical Spine Research Society, AOSpine and others has taught me the critical need for a global perspective in terms of collaborative opportunities and the importance of reaching out beyond one’s own local environment. These medical societies have also taught me the importance of learning from others and of fellowship opportunities.
What has been your most memorable case?
Early on in my career, I treated a young individual with a bilateral facet dislocation at C6–7 and complete traumatic quadriplegia. I treated this individual with an early procedure involving a reduction of the locked facets and a surgical procedure to decompress the spinal cord and to reconstruct the spinal column. Remarkably, this individual made a major neurologic recovery and essentially walked out of hospital a week after his admission. This case has stood by me over the years as validation of the concept that “Time is Spine” and that early surgical decompression of traumatic spinal cord injury is of critical importance.
What advice would you give to someone who was starting their career in spinal surgery?
I would advise individuals that spinal surgery is an exciting, dynamic field one that is based on solid evidence but also one that needs many questions to be addressed. I would advise individuals undertaking a career in spinal surgery to consider the best interests of their patients first and also to be inspired to develop new therapeutic approaches to influence the outcomes of spinal conditions.
Outside of medicine, what are some of your hobbies and interests?
I enjoy cycling, wine, travel, the arts, being in nature and, above all else, my friends and family.
2014 -Vice chair research, Department of Surgery, University of Toronto, Toronto, Canada
2011 -Halbert chair in neural repair and regeneration, University Health Network, Toronto, Canada
2008 -Co-director, University of Toronto Spine Program, University of Toronto, Toronto, Canada
2001–2014 Medical director, Krembil Neuroscience Center, University Health Network, Toronto, Canada
2000 -Professor, Department of Surgery, University of Toronto, Toronto, Canada
1997 -Senior scientist, Toronto Western Research Institute, Toronto, Canada
1994 Head, spinal program, Toronto Western Hospital, Toronto, Canada
Selected other experience
2012 -President, Cervical Spine Research Society
2010 -Director, International Research Development, Rick Hansen Institute
2008–2010 Chairman, Journal of Neurosurgery: Spine
2007 -Chairman, AOSI Outcome & Clinical Research Committee, AOSpine International
2007 -Chair, Medal Award in Surgery Committee, Royal College of Physicians & Surgeons of Canada
2006–2010 Chair, Joint Section of Neurotrauma and Critical Care, American Association of Neurological Surgeons
1988 Deputy editor-in-chief, Spine
University of Toronto MD (1983) Medicine
University of Toronto PhD (1989) Neuroscience
University of Toronto -FRCSC (1990) Neurosurgery
NYU Medical Center -PDF (1992) Spinal Cord Injury