Steven D Glassman is the president-elect of the Scoliosis Research Society (SRS), which is holding its annual meeting in September (18–21) in Lyon, France. He talked to Spinal News International about his goals for the SRS, why he thinks the evolution of neuromonitoring has dramatically changed spinal surgery, and his current research interests
Why did you decide to become a doctor and why, in particular, did you decide to specialise in spinal surgery?
I have been fortunate to have many great role models who have influenced my career choices. The most important was my father, who was a devoted clinical researcher. He instilled in me a dedication to teaching and learning. I was inspired to choose spinal surgery by my exposure to spinal deformity surgery in residency. I was particularly impressed with the rapid evolution in both technical capabilities and theoretical understanding for deformity correction.
Who have been your mentors during your career and what influence did they have?
My mentor in residency, Dr Jean-Pierre Farcy, passed on to me a passion for understanding spinal deformity as a three-dimensional problem. Beyond that, my career has been constantly influenced by many of my peers, particularly my surgical partner of 22 years, Dr John Dimar. His perspective on clinical problems often helps me clarify my own thought process, and his work ethic consistently inspires me to devote my best effort to every academic pursuit.
During your career, what has been the most important development in spinal surgery?
While there have been many important advances over the past 20 years, such as the development of pedicle screw instrumentation, conceptualisation of spinal deformity in three-dimensions, and the advent of patient-based outcome measures, I think perhaps the most important has been the evolution in neuromonitoring. This has dramatically changed our ability to manage complex problems more safely.
Of the research you have been involved in, which piece of research are you most proud of and why?
Certainly from a spinal deformity standpoint, our work in defining sagittal balance as the dominant predictor of symptoms in spinal deformity patients has had a substantial impact on both the evaluation and management of these complex problems. Outside of deformity, I am proud of our work in defining the role of patient-based outcome measures in spinal surgery. In particular, I believe that the definition of substantial clinical benefit as an alternative to minimal clinically important difference will help to better identify high value interventions.
What are your current research interests?
At present, my primary interest is in the healthcare economics of spinal deformity surgery. I believe that the time is rapidly approaching when spinal deformity surgery will be regarded as a value equation. Appropriate spinal surgery has proven economically favourable in several well-performed studies, but if you do not have the data then you cannot make the case.
In your view, outside of your own work, what has been the most interesting piece of research published in the past year?
A really important study is the work of Noelle Larson and Steve Richards looking at the 20-year follow-up of the lumbar curve after selective thoracic fusion in adolescent idiopathic scoliosis. This long-term study helps validate the concept of trying to avoid lumbar fusion in these young patients.
What are the three most important questions in spinal surgery that still need answering?
-A critical unmet need for spinal surgery in general is the need to establish clear diagnostic delineation for the wide range of pathologic entities currently described as degenerative disc disease. Spinal care providers have been collecting outcomes data more consistently, but translating that data to evidence-based guidance will require a clear understanding of the specific problem being treated. -For paediatric spinal deformity surgery, an important question is whether greater implant density, and thus greater cost, correlates with better clinical outcome. -As far as adult spinal deformity, it would be important to better understand the aetiology and treatment of proximal junctional kyphosis.
As the president-elect of the Scoliosis Research Society (SRS), what are your goals for the society?
The SRS has made great strides over the past several years toward a more evidence-based approach to the treatment of spinal deformity. My first goal is to continue that process. Specifically, the SRS will promote participation in a prospective registry effort for spinal deformity patients. The SRS will also work on an initiative establishing a culture of safety for spinal surgery. Beyond that, the SRS will continue to expand its commitment to spinal deformity treatment in under-served regions across the globe.
What are the key themes of the SRS annual meeting in September?
The SRS meeting in September will be in Lyon, France, under the direction of our current president, Dr Kamal Ibriham. The primary theme will be a global perspective on spinal deformity treatment in children and adults.
As well as its annual meeting, the SRS also organises the International Meeting on Advanced Spine Techniques (IMAST), what are the themes of this meeting?
In comparison to the SRS annual meeting and the world wide courses, which are deformity specific, IMAST (10–13 July, Vancouver, Canada) serves a broader audience. It includes a variety of symposia, debates and instructional course lectures, examining key topics in spinal deformity, degenerative disease, tumour and trauma. IMAST also continues its historic role as an important venue for the evaluation of new technologies.
In your view, what are the benefits of joining a society such as the Scoliosis Research Society?
The SRS is comprised of surgeons from around the world with tremendous dedication to the care of patients with spinal deformities. Its membership is earned through participation, self-selecting a motivated and inspired membership. The personal interaction among this group is the most outstanding benefit of SRS membership. Most members are actively involved in the society, contributing their time and effort to our shared goals.
What key piece of advice would you give to someone who was just starting their career in spinal surgery?
While it is hard to pick a single piece of advice, I believe that an important basic concept is that happy patients are the driver of a successful practice. They are your greatest source of personal satisfaction and your greatest source of referrals.
What has been your most memorable case and why?
Many cases are memorable, but one that I found particularly instructive was a 17-year-old young man with an L1 burst fracture. At presentation, he had only very minimal lower extremity function and we performed an anterior decompression and stabilisation. There was little recovery at hospital discharge, but the young man walked into my office at three months post operation. The case was memorable not only for the successful recovery of a significant neurologic deficit, but because the patient expressed complete surprise that any other outcome might have been a possibility. This always reminds me of the frequent disconnect between our explanations and the patient’s understanding of their problems or their treatment.
Outside of medicine, what are your hobbies and interests?
Spending time with my family, travel, and golf.
2012–2013 SRS president elect
2011–2011 SRS vice president
2009-present -Professor, Department of Orthopaedic Surgery, University of Louisville School of Medicine, Louisville, USA
2001–present Consultant reviewer for Spine
Scoliosis Research Society (president elect)
American Academy of Orthopaedic Surgery
American Medical Association
North American Spine Society
2010 -NASS Best Paper Presentations (Correlation between cervical spine sagittal alignment and clinical outcomes after ACDF)
2009 -IMAST Whitecloud Award for Best Clinical Paper (The cost effectiveness of lumbar fusion at five years after surgery)
2009 SRS Russell A Hibbs Best Clinical Paper Award (Risk-benefit assessment of surgery for adult scoliosis: an analysis based on patient age)
2006 SRS Russell A Hibbs Outcomes Paper Award (A large-scale, level 1, clinical and radiographic analysis of an optimised rhBMP-2 formulation as an autograft)
-Glassman SD et al. Does thoracic hypokyphosis matter in Lenke type 1 adolescent idiopathic dcoliosis? Spine Deformity 2013; 1: 40–45
-Glassman SD et al. The cost effectiveness of single-level instrumented posterolateral lumbar fusion at five years after surgery. Spine 2012; 37:769–74
-Glassman SD et al. Diagnostic classification for lumbar spine registry development. Spine J 2011; 11:1108–16
-Glassman SD et al. Complications with rhBMP-2 in posterolateral spine fusion: a consecutive series of one thousand thirty-seven cases. Spine 2011; 36:1849–54
-Glassman SD et al. The costs and benefits of nonoperative management for adult scoliosis. Spine 2010; 35:578–82
-Glassman SD et al. Outcome of lumbar arthrodesis in patients 65 years and older. J Bone Joint Surg Am 2009; 91:783–90
-Glassman SD et al. Lumbar fusion outcomes stratified by specific diagnostic indication. Spine J. 2009; 9:13–21. The Spine Journal outstanding paper runner up