“The last 25 years has seen a technological revolution”: What will the next 25 years bring to spine surgery?

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Paul Arnold

Paul Arnold, a spine surgeon based in Kansas for most of his career, now practising at the University of Illinois, USA, and current chair of the ethics and professionalism committee of the North American Spine Society (NASS), talks to Spinal News International about the ethics of medicine, the danger of the possibility that insurance companies dictate which surgeries can occur through machine learning algorithms, and what the future holds for spinal surgery.

What advice would you give to someone starting their own practice?

When I first started in Kansas, spinal surgery as we know it now was in
its infancy, so there was no one really doing what I did. I started the spinal practice from scratch at the University, and built it up to become very large, with a lot of clinical trials
and complex patients. If you are just starting out, my advice would be find a niche—there is plenty of room for more spine surgeons.

What would you say are three particular personality traits a spine surgeon should have?

Empathy, relentlessness, and honesty. Spine surgeons should know where their strengths and limitations lie; if you are honest with yourself, I think you will do well. Not every
spine surgeon should do every spine procedure; when people attempt operations they have not been trained to do, that is when most surgeons get into trouble.

You are a neurotrauma consultant for the National Football League. What are the unique challenges that this patient group represent?

The National Football League (NFL) recognised that they had a problem; a lot of famous or well-known football players were having severe dementia problems and a couple committed suicide. So, the NFL decided to be proactive. There is now a head and neck committee for the NFL, run by two neurosurgeons, and a whole programme designed for neurotrauma consultants, which has been running for six years. These consultants are on
the side-lines at every football game; there is a lot of training involved. It is a great privilege to be associated with the NFL. We provide coverage for both teams during a game, and spend all day at the stadium. I think everyone is taking this problem seriously; the NFL has committed a lot of money to the National Institute of Health (NIH) for research, and they are committed to making sure that players with injuries do not go back before they are ready.

Why do you think it is important to have a society like NASS championing spine surgeons?

I am very grateful to NASS for taking on a lot of the roles that they do on behalf of spinal practitioners; in terms of lobbying in Washington, DC, and advocating for both patients and physicians, I think NASS is really the voice of the spine care practitioner. I am constantly amazed at the breadth of society activity. I did not really appreciate a lot of it until I got onto the Board of Directors, and now I listen to groups talk to our legislators, other groups talking to Medicare about paying for a certain procedure, or groups advocating for certain patients. If we do not do this advocacy work, no one will. It is about advocating for patients and patient care. I think every physician here [at the NASS 2018 annual meeting] went into medicine or surgery to take care of patients; I think this is true at the gut level for every physician, and that is why we do what we do.

What are the key aims of the ethics and professionalism committee?

The committee acts to ensure surgeons are “playing by the ethical rules” of medicine or spine surgery—a lot of it is about transparency. It involves being open about your relationships with industry. Relationships with industry are not inherently bad; the engineers who design these devices may never see the patients treated with them, and you cannot design instruments and hardware for surgeons without surgeon input. Additionally, surgeons should be paid for their time and rewarded for their input. However,
when surgeons push an agenda, for example by advocating for a device or company they have a financial interest in, then this needs to be disclosed. NASS has the strictest guidelines for being a board member of any spine society I am involved with. When I joined the board, I had to divest a lot—NASS has really taken the high road in this arena. Transparency, as current NASS president Jeff Wang said [in his keynote address], is critical, and I think that NASS has gone the extra mile to make sure that the speakers and physicians are compliant with ethical rules.

What is the current status of your company?

I started a company with a mechanical engineering professor at the University of Kansas. Along with an outside group, we designed an interbody cage which acts as a piezoelectric
implant—it captures mechanical energy as the patient walks, and translates that into electrical energy, which aids bone growth. We have got some very promising pilot data, and have hired a CEO for the company. We initially received a US$65,000 NIH grant, and
recently the company was the recipient of the second phase NIH grant, totalling US$1.5 million—so obviously that is a big deal for the company! This has been a 10-year project, and one I am very proud of, so we are very excited. We have talked to some potential investors, and hope to take the project to the next level by making some design improvements on the cage, and perhaps enrolling a bigger animal study, before we can potentially take the technology to market.

What is the biggest change you have seen in spinal surgery over your career, and what is the future of spinal surgery?

I do not think there is any doubt that spinal surgery has become far safer, and now tries to solve more problems than when I first finished my fellowship 25 years ago. There were a lot fewer spine surgeons then, and now I think we are tackling bigger problems. Additionally, the last 25 years has seen a technological revolution. When I first started using pedicle screws, there was a big controversy over whether you could use them, including multiple law suits. Now, there are a multitude of available screws and rods and plates that simply did not exist when I was training. We can take on problems that were
completely hopeless before, and that is a huge change.

I think we need to be careful now that the technology does not outgrow humanity; but I am excited about the next 25 years. I think there is going to be new hardware and drugs and cells and robotics; I think it is possible that surgery will become a video game—or
closer to a video game than it is now. However automated surgery becomes, though, you will still rely on the judgement of the surgeon. To use the analogy of a self-driving car: you can programme it to get you from A to B, but should you go out in a rainstorm to drive it? Should you go out in the snow? Are the wind conditions safe? In the same way, the accuracy of the screw placement can be optimised by machines, but the judgement of
the physician as to whether or not to operate is going to be hard to machine learn. There is no shame in having a machine implement perfectly placed screws for a patient that needs to have an operation; I am all for that.

Maybe there is going to be an algorithm that will dictate what procedure is needed for which patient. For example, if a patient has a certain amount of stenosis, and there is a
degree of leg and back pain, coupled with certain comorbidities, then an algorithm may be programmed to recommend a particular operation. However, you will still need some humans somewhere along the line to decide whether that person will have that surgery… and hopefully that will be a physician and not an insurance company.

I think the danger is that these insurance companies will come up with the algorithms, and will establish an arbitrary cut-off. For instance, say an 85-year-old woman has lumbar
stenosis, and say she has heart disease and diabetes; the algorithm calculates that there is a 5% risk of complication. If this were 4.9%, the company might cover it, but at 5% the company will not pay as they deem the risk too high. We cannot allow that to happen.

My son is in medical school right now, and I advised him not to go into radiology or pathology because I think that will all become machine learned. I do not think robotics will completely take over medicine, but they are going to cause major disruptions in many medical fields. So watch this space!

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