A clinical professor of neurosurgery, Ronald Bartels talks to Spinal News International about his career. From his days at medical school to his appointment as chair of the Department of Neurosurgery at Radboud University Medical Center, he discusses how he thinks the field of neurosurgery has changed over the years, and how it might develop in the near future.
Why did you decide to pursue a career in medicine?
I knew at young age that I would become a physician, but the reason why remains obscure to me. A romantic version is that I decided to become a medical doctor at the age of eight years, when I was walking after the hearse in which the coffin with my deceased grandfather, who died because of lung cancer, was placed.
What drew you to neurosurgery and later spinal surgery in particular?
The nervous system has always intrigued me. This is due to the embryology, anatomy and clinical syndromes associated with its pathology. Topological diagnosis is only possible in the nervous system. My interest in the nervous system was stimulated by excellent teachers in embryology, anatomy and neurology. Since I knew very early on in medical school that I should be surgically active, the choice for neurosurgery was obvious. Actually, I never considered another specialty as a career despite the very low chance of obtaining a residency in neurosurgery. During my residence and in my early years as a staff member, I was exposed as a primary surgeon to nearly all kinds of neurosurgical procedures. Spinal surgery attracted me more than other neurosurgical activities for several reasons. The approaches to the spine are very diverse and specific for each region within the spine. The combination of wide anatomical knowledge and the basics of general surgery are challenging. Biomechanics were not usual in neurosurgical training at that time. It is intriguing since it combines physics, anatomical knowledge, restoration of spinal imbalance and expectations regarding clinical results. The neural elements within the spine are very delicate, necessitating accurate and sensitive surgical handling. Intraoperative neuromonitoring might be useful in selected cases. Finally, the treatment of patients with signs and symptoms due to spinal diseases warrants consideration of the complete spine, including biomechanical alterations and their influence on the disease. Decompression of the neural tissue might not be the sole solution to a spinal problem.
Have you had important mentors throughout your career? What have they taught you?
I had several mentors who influenced me. I will name the ones who were most important to me. Dr van der Spek was an old fashioned neurosurgeon, who confirmed my idea that a patient may account for your attention 24 hours a day. Every detail of the patient should be known and considered in your judgement. A surgical treatment should not be offered without thorough consideration. Professor Grotenhuis stimulated further study of neuroanatomy. He was very innovative and prompted the careful introduction of new techniques. Professor Harms showed me also innovative techniques at that time like transforaminal lumbar interbody fusion and C1C2 fixation. Finally, Dr Donk acted not as a mentor but merely as a “a partner in crime”. He was an orthopaedic surgeon and experienced in spinal surgery. We collaborated extensively, and introduced new techniques that we carefully evaluated.
What is the main focus of your current research?
I try to focus on demonstrating the clinical relevance of known techniques. The main problem with all reports in journals and meetings is that statistically significant results are emphasised without mentioning any clinical relevance. An example are the reports about cervical arthroplasty. Whereas many authors report statistically significant results in favour of arthroplasty, the clinical relevance is absent. This information is relevant to correctly inform the patient. It is also important from the viewpoint of costs, especially when your alternative is much cheaper. Recently, I recognised why this message is not really accepted in the USA. The alternative is anterior cervical discectomy and fusion (ACDF) with a plate. The costs for both methods are similar. I can imagine why American surgeons are in favour of an arthroplasty, a simpler technique with no chance of pseudoarthrosis and, therefore, preventing regular follow-ups with X-rays and eventually re-surgeries. A situation that raised many questions regarding clinical relevance arose recently with the studies about restoration of global sagittal balance in all patients. Another focus is recovery after spinal cord injury and autonomous robotic surgery.
What is the most interesting piece of research you have read recently?
I think that the following article should be read by every research minded spine surgeon: Ronald L Wasserstein & Nicole A Lazar (2016) The ASA’s statement on p-values: Context, process, and purpose, The American Statistician 70(2):129–133, DOI: 10.1080/00031305.2016.1154108. It clearly states the restrictions of the p-value. Furthermore, many interesting viewpoints in JAMA regarding this subject have been published. I recommend studying these to anyone who is really interested in implementing the results of studies into their clinical practice.
How have your research activities influenced your clinical practice, and vice versa?
Clinical practice has often been the source of a hypothesis and design of a study. The results of a study always influence my practice, either by continuing it or changing it. After publishing the results of a randomised controlled trial comparing simple decompression versus anterior subcutaneous transposition—the usual technique—of the ulnar nerve we only performed simple decompression. After we reported our result regarding the interspinous process device we stopped implanting it. The publication of the meta-analysis of cervical disc prostheses was the reason for ending our trial comparing disc prosthesis, ACDF with a cage and anterior cervical discectomy. It was also the reason for stopping implanting it and it contributed to the decision that this kind of surgery was not reimbursed anymore in The Netherlands.
How has the field of spinal neurosurgery changed since you started your career?
Since the late nineties I have seen many implants being introduced. Some of them still are being used, others have been abandoned. The focus changed from the radiological result to the result reported by the patient. Fortunately, patients demand correct information in order to make a decision for a treatment together with the physician. The role of the patient has changed dramatically. When I started I was not expected to inform the patient. They accepted any decision. Nowadays, this is not accepted anymore. The availability of the internet has facilitated this development enormously.
In your opinion, what are the most exciting developments in spinal neurosurgery that we can expect in the next five to 10 years?
The ageing of the population will ask for our attention more and more. We will be confronted with more spinal cases, whereas the prevalence will remain nearly stable. Extra effort is needed, necessitating the education of more spinal surgeons. In order to monitor the quality of our care, we need to introduce national registries. This is the only way to investigate if the treatments are really clinical relevant. Additionally, the current re-emphasis on the value and the interpretation of RCTs is meaningful. Pragmatic designs are considered as meaningful. These developments might be promising for larger, less expensive studies with results that are meaningful for clinical practice. Finally, the development of autonomous robotics will start, or has already been started. The main advantage of an autonomous robotic system will be that a learning curve will eventually be absent, the quality will gradually be improved, and can be distributed worldwide with the same level of quality for the same costs. A functioning robotic system will not be available in 10 years but major developments in this direction will be achieved.
What do you think are the main challenges in the field at the moment?
A major challenge is the selection of the patients that will benefit from a surgical procedure on the spine. I think that, at this moment, too many are operated on. We focus on what are we capable of, without taking the characteristics of the complete patient into consideration. As we do not have a good insight into predictive factors, we do not discuss it with the patients. They are interested in relieving complaints at this moment, but would they chose the same treatment when the effect on the long term was known, given their specific characteristics?
What are the potential solutions?
Installation of national or worldwide registries would help to investigate predictive factors. It also would contribute to the outcomes as registered by the patient in the long term. People should also be informed about physical burden and pain accompany ageing. It is normal, but not everything can be fixed. This needs a mentality shift in the general population, and within spine surgeons.
You have been an active member of CSRS-Europe for some time. What did you achieve as president of the society 2016–2018?
Since I entered the board I was convinced that the length of the term for a board member should be restricted. In the beginning, not all board members were enthusiastic. During my presidency, I stated this again, and now we have a scheme for retiring in order to invite new, younger board members. I am aware that I have also been a board member for too long, so as soon as possible I will retire from the board. For good functioning of the board, a good mix of young blood and experience is needed. We also started with a more transparent rating system for the annual meetings. This is still developing. Now, I have made a proposal that is based on a rating similar to the GRADE statement, and secondly on a personal rating in order to evaluate the importance for the annual meeting of CSRS-Europe.
What advice would you give to someone wishing to start their career in spinal surgery?
My advice to anyone interested in spinal surgery would be to focus. Spinal surgery should be your main activity. Within the spine focus on a region and/or a group of pathologic conditions. It improves your surgical skills, your knowledge, and your scientific activities. Furthermore, try to be unbiased. Financial disclosures contradict unbiasedness. You can only make the right decisions if you are not bound to any company. Your scientific results will be more easily accepted.
What are your interests and hobbies outside spine?
I like jogging, especially in the early morning when all the animals are awake. Apart from the health benefits, I need it for being relaxed during my daily professional activities. Another interest is reading. I like literature as well as comics. I have a collection of nearly 1,000 comics. I am also active in fine metal working. I am building a steam locomotive for my garden railroad, another hobby of mine.