In the play “As You Like It” the melancholy Jacques describes the “seven ages of man”. A tribute to the much greater health experienced in the developed world is that the octogenarian is not in the sixth or seventh age now, but in the fifth: “the Justice in fair round belly with good capon lined with eyes severe and beard of formal cut full of wise saws and modern instances”. In the context of our profession, the experienced surgeon has gained wisdom through experience, and is now ready to impart it to younger colleagues, writes Robert Mulholland.
In surgical disciplines, there are various physical reasons why a surgeon should discontinue operating much past their 70th year. These include vision and manual dexterity, and the ability to withstand stress and long operating sessions. It is also important for surgery as a whole that older surgeons make way for younger surgeons in their intellectual and physical prime. I was happy to stop operating at 65 because I found the anxiety and stress of operating was becoming burdensome, and as the senior surgeon I was expected to work on the difficult cases which were technically demanding and lasted many hours. One aspect of seniority and past experience is that one is more aware of risks and complications, having previously experienced them, and this awareness plays a role in the stress of the procedure.
However, it would be a loss to the profession if stopping one aspect of surgery meant that the surgeon would no longer contribute to their speciality. In my view, this would be especially unfortunate in our speciality of spinal surgery, where the operation is but part of the expertise the surgeon brings. We have experience that we can pass on to younger colleagues, giving a perspective that might otherwise be lacking.
One such perspective is on diagnosis. It is an interesting feature of most journal articles that they deal with treatment and outcome, yet seldom diagnosis. Experience in diagnosis is built on the experience of individual cases. One of the reasons that anecdotal cases are valued is because they act as proxy for experience—they stick in the mind—and are called upon when the clinician faces a similar problem. Diagnostic skills improve because one has seen cases like that in the past, and long experience is central to the acquisition of diagnostic skill. This is one area in which older surgeons can greatly assist our younger colleagues.
Examination should be carefully targeted to confirm a diagnosis. As a student I was always taught to conduct a thorough physical examination. I developed the view that in the field of spinal surgery this was inappropriate. The examination must be very carefully targeted. A general routine examination is inevitably cursory, and so unless it is very carefully targeted, physical signs will be missed.
Following examination, never diagnose the untreatable, or if you do, constantly reassess your diagnosis. The introduction of the term “non-specific back pain” is in my view a disaster as both patient and doctor are deceived. It is not a diagnosis; it is a statement that a diagnosis has not been made. Once labelled it is often the case that further review of the diagnosis is not carried out, patients may be sent to a pain clinic for six-monthly injections and they steadily accumulate a large variety of pills, but a diagnosis is not reviewed. It is certainly my view that this diagnosis should never be made in the absence of a magnetic resonance imaging (MRI) scan. MRI scans are cheap, non-invasive, and should be regarded as part of the clinical assessment in today’s world.
An essential feature of gaining diagnostic and clinical practice experience is the follow-up of patients. It is to my mind a very retrograde step that in recent years, follow-up of patients has become severely constrained in the British NHS. I believe that orthopaedic and spinal surgeons are at risk of not being aware of outcome, and therefore not able to fully inform patients or guide their own practice.
Older surgeons also have experience with the struggle to alter entrenched beliefs, which is always difficult. One in our speciality in particular has been the function and role of fusion in treating back pain. The success of fusion in treating back pain was unpredictable and much of this unpredictability was related to the psychological aspects of the disorder. We became very aware of these in the 1970s and 1980s, but despite filtering out patients with such problems, results did not greatly improve. Fusion could be very successful, but was unpredictable. The concept was that back pain was due to abnormal movement and thus failure was deemed to be due to persistent movement, and hence failure was treated by redoing the fusion, with usually lamentable results, and inevitably psychological damage.
However, with the advent of pedicle fixation, which was so rigid, we could not truly say that persistent movement was the cause of pain. As a result, we felt that the cause was failure of fusion. But how had the fusion failed? It had in my view failed because the fusion was not load bearing. My concept that mechanical low back pain was a failure of the disc to transmit load normally, despite being supported by peer reviewed biomechanical studies, has only been accepted in the last few years. This has of course led to an explosion of surgical devices that allow movement, but alter loading patterns. Sadly, many of these devices are not properly designed or researched. I am now firmly of the view that the aim of surgery for mechanical back pain is to create a normal loading pattern over the disordered segment. An interbody fusion is the best, a successful disc replacement is possibly better, but sadly the latter has the grave disadvantage that failure carries a very heavy penalty, including risk to life.
It is difficult to alter entrenched attitudes, for example the concept that rigid fixation aids union. Surgeons still instrument a posterolateral fusion in lytic spondylolisthesis, despite Volvo Award-winning papers which show it is both unnecessary and carries risks. Posterolateral fusion was never primary bone union and rigid fixation only acts to protect it from the loading that is necessary for fusion to occur—a fact acknowledged by our fracture surgeons, but not appreciated by our spinal surgeons.
As an experienced surgeon, I am well aware that all branches of orthopaedics have a problem with their relationship to industry. In spinal surgery this is particularly a potential problem, as much educational support is given by industry, and innovative ideas from surgeons can only become reality by close collaboration with industry. However the possibility of a surgeon making a vast fortune from the success of an implant that they designed, if it is successful, must create a great temptation to assess results with tinted spectacles. It is important that we maintain proper standards for new products and techniques, regardless of any relationship with industry.
We have lived through a most exciting time in spinal surgery with remarkable new advances, especially in the field of instrumentation. The octogenarian has seen enthusiasms come and go and hence is in a position to caution. Herein is a danger that their experience may make them unduly cautious. They are there to advise and caution, not dictate, because as dictators they will crush innovation.
I was stimulated to write these musings initially as I wished to persuade my younger colleagues, and indeed myself, that the octogenarian could still contribute to their speciality and should not feel that he should devote himself to boules or golf, or sink into “senile and inept repose” (Hillarie Belloc). I think we can contribute and advise because we have seen so much. However, we must not try to dominate, as the caution of age will dampen innovation.