Robert Gunzburg followed in the footsteps of his father and grandfather in becoming a doctor. Breaking with the family tradition of rheumatology, Gunzburg decided to specialise in spinal medicine. Having completed his undergraduate and graduate degrees in his native Belgium, he pursued international postgraduate postings, foreign exchanges and volunteer work—including in South Africa, Australia, France and Tunisia—to expose himself to the varied world of spinal medicine. For many years Gunzburg has been involved in the education of his peers, active in organising international conferences in spinal and orthopaedic medicine and as one of the cofounders of the annual Brussels International Spine Symposium. He has also served in editorial posts at several notable scientific journals. Gunzburg told Spinal News International about his path to spinal medicine and what he has learned from his journey so far.
Why did you decide to become a doctor and why, in particular, did you decide to specialise in spine surgery?
Both my father and grandfather were doctors, so the career was kind of the obvious choice. When I picked spine as in my hospital back in 1985 nobody else was really interested in the field! Strangely enough, there was no tradition of spine surgery at my university. So, I decided to go abroad and I never regretted it!
My grandfather—born in Riga, Latvia, in 1880—was a rheumatologist and one of the founders of physical medicine and rehabilitation between the two World Wars. Unfortunately he passed away whilst being deported in 1943. My father was also a rheumatologist and when I started medicine, my idea was to follow in the footsteps of my parentage. That was until in my sixth year at university when I spent a few weeks in a department of orthopaedics. I then sat Dad down and gave him the news: I would not take over his shop!
My father was instrumental in teaching me the ways to learn things in general, not only specifically in medicine. As a matter of fact he did not interfere much in my medical education or practice. When, later in life, he was pensioned and I started my private work, I asked him to come and assist me in the operating theatre. He did this for years, and finally learned from me what it all was about (only joking!).
Who have been your career mentors and what wisdom did they impart?
Robert Fraser was my mentor. He taught me when to operate, how to operate and especially when not to operate. He also further nurtured my interest in research. Jacques Wagner and in particular Max Aebi were my mentors for reviewing and editorial activities.
What do you think has been the biggest development in spinal surgery during your career?
The realisation that the pedicle is something we can put a screw into! The pedicle is important as it allows a firm grip on a single vertebra that allows mobilisation of the bone and a solid anchorage for instrumentation. The main indications are reduction of deformity and fixation of fractures. This was a revolution. Before, there were Harrington rods which were better than nothing for scoliosis, but did not allow reduction of deformity in all planes, and for fractures there was mainly cast immobilisation. Unfortunately the use of the pedicle as fixation was extended to a means of fixation in arthrodesis to combat low back pain, with very poor evidence of success. I have personally abandoned treating back pain surgically and have not fused for over 10 years.
Of the research you have been involved with, which piece are you proudest of and why?
I have two pieces to mention here. The first piece of research is my PhD thesis, in which I put the emphasis on the role of rotation in disc degeneration. The second piece of research involves the use of a sheep model in Adelaide, Australia, through which we found a non-invasive way to assess stability of fusion. This is ongoing research with the respected spine team at the Royal Adelaide Hospital and Chris Colloca, who is a chiropractor.
What are your current research interests?
At the moment my research is focused on exploring the biomechanics of nanosurfaces. Here there are confidentiality agreements I have to respect, but let me just say that it looks like the contact between bone and implant will be more intimate with nanotechnology than with any other coating available up to now.
You have worked and studied in many countries. What lessons did you take from these experiences?
In South Africa, in the days of apartheid, I learned to treat everyone on an equal footing. In Australia I learned that as long as I felt confident, I could do whatever I planned to do—I learned not to go beyond my competences.
The differences from country to country vary at different levels. First there is education. After spending two years in Cape Town and one year in Adelaide I must say that the level of tuition was higher there than in my own country. When I trained in surgery and orthopaedics, there was no exam, neither theoretical nor practical. After six years of practical work you received your specialist degree—simple. Since then, luckily, things have changed. However, in these Anglo-Saxon countries the required level of knowledge was higher, although I doubt that this led to better doctors, as there is much more to being a good doctor than simply knowing a lot. Then of course there are the differences related to the culture. Being in Belgium I face both the Latin world and the Germanic Anglo-Saxon world. The differences are huge. I alluded to that in my ISSLS Presidential address this year in San Francisco where I spoke about the evolution from paternalism over consent and informed consent right up to shared decision making. My point was that shared decision making is probably not the way to go. This will appear in Spine early next year for those who are interested and were not at the meeting.
You have been involved in several different organisations and societies in your career—why do you think that these societies are important?
They are important as pluridisciplinary platforms where clinicians and researchers with varied backgrounds can get together and create intellectual sparks. An example of how this approach leads to collaboration is in my current research—I am one of the surgeons, but there is also a radiologist, a chiropractor, a statistician, an engineer and a pathologist.
What have you learned from your experience working in editorial positions for scientific journals?
This is very interesting. First of all you are aware before anybody else where the trends lie! It has also taught me to see if a study is sound and deserves to be peer reviewed or not. Unfortunately there are too many papers being submitted. We still receive more retrospective than prospective studies, which is a pity as there are often too many confounding factors in retrospective studies. The best thing is always to put forward a question and shape a study from there onwards. What is changing the ball game however, is the ever increasing amount of data in spine registries. We will see more and more valuable information coming to us from such data banks.
You have been involved in the Brussels International Spine Symposium meeting for several years—how has the meeting developed since your involvement began?
The meeting has enjoyed steady growth since it started, and I dare say it is now on the agenda of many European spine professionals as a “yearly must”. As Marek Szpalski, my partner in many ventures, and I invite the speakers, and there are no free papers, we can always be assured of the quality of the contributions. It is a win-win situation.
What do you think will be the highlights of this year’s meeting?
At this year’s meeting we will be discussing new technologies in the field of spinal medicine, so I am curious to hear what the current trends are and what future trends might appear.
What are the three questions in spinal medicine that still need an answer?
- How can we fight low back pain by prevention and education or simple acceptance rather than resorting to surgery?
- How can we pursue research in the cause of adolescent scoliosis in order to hopefully prevent it?
- How can we best work towards promoting spinal medicine as its own discipline?
How do you think spinal medicine can become its own unique discipline?
Things take time. I was instrumental in creating a multidisciplinary joint committee on spine surgery at the UEMS (European Union of Medical Specialists). I chair this committee and we have started putting together a curriculum jointly with orthopaedic surgeons and neurosurgeons, but also radiologists and other specialties. This is the first step. My guess is that spine surgery as an entity will slowly become a field requiring official recognition in the future. It will not happen in my time however. The most important aspect here is to actively work towards a good understanding between the different basic approaches: orthopaedic and neuro. It is like married life: give and take and, most important of all, carry on talking and listening to one another!
What advice would you give to someone who was starting their career in spinal surgery?
I would suggest that anyone starting out now should aim to spend at least two years in a big spinal unit. I felt that my own training in Adelaide, although it was of the highest level, did not expose me enough to all types of spine surgery, in particular scoliosis and cervical surgery. I would have needed one more year. A spine surgeon should have a sound exposure to conservative management, trauma, deformity, cervical and thoracic pathology, and degenerative conditions. Basically, a spine surgeon should be confident from the back and from the front in all three sections of the spine; cervical, thoracic, lumbosacral.
Do you think that more young doctors are attracted by spinal surgery now than they were in 1985?
I have the impression that fewer orthopaedic doctors are interested in going purely into spine surgery. Perhaps the stress is higher than with routine hip or knee surgery, and this explains why in many parts of the world neurosurgeons are doing the bulk of spinal work.
What do you think will be the next big development in spinal medicine?
I think the next big development has already taken place, but is still gaining attention and traction. The first French Revolution took place in 1789. In the 1980s, the French “discovered” the pedicle—a second revolution. Now, there is a third French revolution as they put “balance” on the map. One paper out of five sent to the European Spine Journal now is in one way or another regarding this question of balance.
What has been your most memorable case?
My most memorable case is one I that guess every surgeon has faced: a lady with stenosis and mild degenerative scoliosis which I decompressed through a minimally invasive approach. Sciatica and claudication resolved, but there was then an increase in back pain leading me to try and correct the scoliosis with a lumbosacral fusion (L3–S1). The correction proved to be too short and failed at L2–L3, prompting me to go higher. This also failed above the fusion and I then performed a subtraction osteotomy and fused up to a high thoracic level. Unfortunately, this again failed! Nowadays we are more aware of sagittal balance than before and hopefully these cases will become less frequent. What this case taught me was to be as restrictive as possible in decompression surgery and to be rather generous with corrections of deformity, especially respecting balance as is being preached today.
I would like to take the opportunity to thank all my patients over the years who trusted me and put their fates in my hands. I am truly grateful.
Outside of medicine, what are some of your hobbies and interests?
Now we are talking! My hobby is cooking and I have a cooking club called ‘Peace of Cake’. We meet once a month at one of our homes and cook. As a matter of fact, quite a few spine people have already been entertained by Peace of Cake. Then of course there is always the number one focus—my spouse and kids, an area in which I am truly blessed.
Diplomas and degrees
1981 Graduate degree, University of Louvain, Belgium
1991 PhD, Free University of Brussels, Brussels, Belgium
1997 Undergraduate, Rijks Universitair Centrum Antwerpen and Vrije Universiteit Brussel, Brussels, Belgium
1984–1987 Hôpital Universitaire Brugmann, Brussels, Belgium
1984 Hôpital Universitaire Erasme, Brussels, Belgium
1982–1984 University of Cape-Town, Groote Schuur Hospital, Cape Town, South Africa
1981 Free University of Brussels, Brussels, Belgium
Foreign study exchanges
1988–1989 Adelaide Bone and Joint Research Foundation, Adelaide, Australia
1986 Hôtel-Dieu Hospital, Marseille, France
1982–1983 University of Cape-Town, Groote Schuur Hospital, South Africa
1980 Volunteer work, Ben Gardane, Tunisia
1979–1980 Cochin University Hospital, Paris, France
2004–present Private practice consultant spine surgeon, Clinique Edith Cavell, groupe CHIREC, Uccle, Belgium
1999–present Private practice, Eeuwfeestkliniek, Antwerp, Belgium
1987–2001 Senior consultant, Department of Orthopaedics, Brugmann University Hospital, Free University of Brussels, Belgium
1988–1989 Clinical fellowship in spinal surgery, Royal Adelaide Hospital, Adelaide, Australia
2014 President of ISSLS
2008 President of SSE
2014–present Editor-in-Chief of the European Spine Journal
1994–present Organiser of the annual Brussels International Spine Symposium
2000, 2007 Organiser and Chairman of the EUROSPINE meeting
1998 Organiser and Chairman of the ISSLS meeting