Steven Garfin is the distinguished professor and chair of the Department of Orthopaedic Surgery at the University of California San Diego (UCSD) and is the incoming president of the International Society for the Advancement for Spine Surgery (ISASS). He talked to Spinal News International about the history of his impressive career.
Why did you choose medicine as a career and in particular, why did you choose to specialise in orthopaedic spinal surgery?
At the end of my second year of university, I applied for two jobs: one was in a cardiovascular surgery lab and one was in the pharmacology school. Dr Eugene Bernstein, a cardiovascular surgeon, responded to me five minutes before the pharmacology lab professor, so I took the job he offered me. If the calls had been reversed, I probably would have been a pharmacist!
I loved the research. I admired Dr Bernstein and what he did and his lifestyle in academic medicine. Therefore, I explored medicine as a career and eventually (after completing medical school at the University of Minnesota), I obtained a surgical internship at a new school in San Diego as Dr Bernstein was now working there. During my internship and then while working as a general medical officer in the military, I found orthopaedic problems (including back pain) the most interesting. This led me to an orthopaedic surgery residency, followed by a fellowship in spinal surgery.
Who has inspired you in your career and why?
A number of individuals have inspired and encouraged me, the overriding ones being my wife and my parents. In medicine, people who have inspired me include Dr Bernstein and his wife, who became role models for my wife and me in terms of academics and an academic career. He was creative, innovative, and one of the best surgeons I have ever seen. He also had a good and interesting life in and outside of academics.
Dr Wayne Akeson, who was my chair at the University of California San Diego, was a leader nationally and internationally in orthopaedic surgery/research. He led by example. He had a unique skill in being able to take anyone through any case, as much verbally as with his hands. Dr Richard Rothman took me, and many of his other spinal surgery fellows, under his wing and created opportunities for us that we could never have achieved on our own. He has excellent surgical judgment and skills. I am still close friends with Drs Akeson and Rothman. Unfortunately, Dr. Bernstein is no longer with us, but his wife remains a close friend.
What have been the most important developments in spinal surgery since you started your career?
The important developments include the Pennsylvania plan algorithm, which was developed by Drs Rothman and Sam Wiesel, to guide treatment and decisions for degenerative lumbar conditions. Though the algorithm itself may not be the one used today, it was the foundation for how to think about spinal treatment based on available science, literature, and experience. Another important development is Dr Charles Edwards’s work moving beyond Harrington rods. Although hooks and rods were already in existence, Dr Edwards changed the designs and added a sleeve to create (and emphasise the importance of) three-point fixation when treating thoracolumbar fractures. Over time this concept has been lost, but is as relevant today in spine as it is when applying casts to long bone fractures, screws and plates for long bone fixation, as well as for the reduction of spinal fractures
You have been involved in designing new techniques for the management of spinal deformities, which ones are you most proud of and why?
I am proud to have helped develop modular pedicle screw systems. They allow the insertion of screws in a deformed spine while still being able to connect the heads to the rods and then reducing deformity and realigning the spine, as opposed to just holding them in place as with older rigid screw and plate systems. Of note, at the time of the introduction of pedicle screws as well as anterior spinal surgery techniques, most orthopaedic surgeons were reluctant to move in these areas, as hooks and rods seemed OK. My venturing into these unchartered areas for a relatively “conservatively trained” spinal surgeon was a leap of hope and helped start my career, but also helped advance spinal surgery as I was able to cajole my friends to try these tools, most of whom were Rothman fellowship trained and equally “conservative”. We had the academic podia where we could demonstrate the procedures and more importantly the results.
Other techniques I am proud of being involved with developing or improving include anterior/posterior fusion spinal rigid fixation, the Halo, biologics for fusion, and kyphoplasty—my pride in the latter relates not just to the treatment of osteoporotic fractures with kyphoplasty, but as the organiser and moderator for most of the programmes for the American Academy of Orthopaedic Surgeons and the North American Spine Society, I was able to reintroduce osteoporosis as a pathologic challenge to orthopaedic and spinal surgery.
Specifically, you have been involved with the development of minimally invasive sacroiliac joint fusion (iFuse, SI-Bone). What is this technique and how does it compare with open fusion techniques?
The titanium iFuse implants are delivered to and across the sacroiliac joint using a cannulated delivery system and soft tissue protection instruments. The relatively straightforward technique is performed under fluoroscopic control and comprised of four basic steps for each implant: guide pin placement, drilling, broaching, and implant placement. This is performed through a 2–3cm lateral incision rather than the traditional open approaches (anterior, posterior, or lateral). The minimally invasive surgery approach is less invasive than traditional fusion surgery with no extensive soft tissue stripping. Early clinical results for the iFuse Implant System have been positive and impressive. A presentation at the 11th annual meeting of ISASS reported 90% of responding patients at 12 months indicated they would have the procedure again. The clinical success with this technique appears higher than with open techniques.
What are the three big questions in orthopaedic surgery that you want to see the answers to?
- The causes of low back pain
- Finding new diagnostic tools (imaging, functional tests, biologic markers, etc.) to determine a pain source/generator that can be targeted (oral or injected medications, altered biology, etc.) to treat pain when there is less than an ideal surgical solution
- Developing specific strategies for fusion/motion preservation treatments in spinal disorders that are more reliable than we currently have, coupled with fewer complications and less surgical insult.
What have been your most memorable cases and why?
I have had several memorable cases, including a 22-year-old male whale trainer from Sea World. He was crushed between two whales and the impact essentially ripped him partially apart through his middle. He presented with femur fractures, perineal tear and pelvic separation with a traumatic isthmic L5 spondylolisthesis, sagittal sacral and L5 fractures with some separation. His first operation was an emergency laparotomy and colostomy. We then placed his femur in traction and performed posterior L2-S1 screw/rod (first generation modular) instrumentation, realigning his sagittal split of his sacral and L5 body fractures and pulling L5 back over the sacrum and fusing him. We then “rodded” his femur. After all that he remained neurologically intact. He eventually healed all areas (though he developed a flat back later in life). He became an orthopaedic device distributer, is married and has children, and someone I see on a fairly regular basis (he does not sell spinal instrumentation).
Another memorable case was a 19-year-old freshman [first-year university student] who was a star swimmer for Notre Dame University (Indiana, USA). She had severe paraparesis as the result of a team bus crash. She underwent surgery in a local hospital with posterior instrumentation and fusion, without cord decompression or spinal realignment. She had some minor functional recovery, but could not ambulate, though she could transfer with help, and did not have normal bowel or bladder function. Over a six-month course her recovery stabilised, at a minimal level, but the rods started to cut out of the bone. After researching spinal surgeons, her father and Notre Dame sent her to me in San Diego, about the time the rods punctured through her skin. We performed staged procedures, first removing her posterior instrumentation and then performing an anterior thoracotomy, corpectomy, cord decompression, and strut fusion, followed by posterior instrumentation and fusion (this was with hooks and rods as thoracic pedicle screws were not yet used in this country). She had a remarkable recovery and regained almost all function, though she still had a neurogenic bladder, but now only catheterises twice a day as she regained spontaneous urination and relatively normal bowel function. A few years later she invited me to her wedding. During the father-daughter dance she left her father and came to me to dance and she whispered in my year “you are the only reason I am dancing at my wedding”.
You are renowned for your patient care, being recognised by America’s Top Doctors as one of the country’s best orthopaedic surgeons. In your view, what are the basic tenets of good patient care?
There are several tenants to good patient care, including listening to patients’ complaints and examining patients, giving adequate time to each patient, and responding, as appropriate, to their hidden concerns (ie, many patients with back pain feel they have cancer and ordering X-rays and MRIs may alleviate those fears). Also, appropriately using available clinical/basic science studies when developing treatment plans, and/or to assess new treatment plans/devices.
As the incoming president of the International Society for the Advancement of Spine Surgery (ISASS), what will be your goals when you become president?
During my one-year term as president, I would like to focus on the following goals:
- Continue ISASS’s growth, stature and reputation, and evolve to the point that we are perceived as the “go to” society for spinal surgeons, internationally as well as in the USA. This involves positioning us not only as an educational resource for surgeons, but also as the best place to turn to learn about new technologies and innovative solutions to spinal disorders.
- Accelerate our expansion internationally. Spinal surgeons gathering from countries around the world have much to learn from, and teach, each other.
- I would like to see ISASS evolve as a society intent on creating and nurturing a community that highlights the incredible value that appropriate spinal surgeries can bring to improve patients’ lives. We need to continue to focus on the advances in the field that bring real clinical benefits to patients.
Outside of medicine, what are your hobby and interests?
Hobbies and interests outside of medicine? You have got to be kidding! Fortunately for me I work in an academic institution, in academic spinal surgery. I have a huge clinical practice. However, if I get bored with that I can fall back to teaching and research and/or the dreaded administrative work which never ends. As chairman of a highly rated Department of Orthopaedic Surgery with an exceptionally active clinical (clinic and surgery) practice, these four areas never give me a lot of free time. I do, however, travel a lot, though almost always for meetings, but it does allow me to get to wonderful places to see friends and take advantage, to some degree, of the opportunities of travel. We do live in San Diego which has many more nice days than not, just to be outside. It allows me to jog on a regular basis outdoors, on the edge of the water (bay or ocean) and kayak from our house in the summer. Having said that, we have a new, and first, grandson who may change (and in fact already is) everything and hopefully will expand, or in reality give me, interests “outside of medicine”.
2011–present Distinguished professor and chairman, Department of Orthopaedic Surgery, University of California, San Diego, USA
1996–2011 Professor and Chairman, Department of Orthopaedic Surgery, University of California, San Diego, USA
1989–1996 Professor, Department of Orthopaedic Surgery, University of California, San Diego, USA
September 1982 Board certification, American Board of Orthopaedic Surgery
1980–81 Fellowship (disorders of the spine), Pennsylvania Hospital, Philadelphia, USA
1975–79 Residency (orthopaedic surgery), University of California, San Diego, California, USA
1973–75 Military Service, US Public Health Service
1972–73 Internship (surgery), University of California, San Diego, USA
2009 Distinguished Service Award presented by the Western Orthopaedic Association
2005–2011 San Diego Physicians of Exceptional Excellence—Top Doctors in San Diego, San Diego Magazine
2003 North American Spine Society, David Selby Award for Contributing Greatly to the Art and Science of Spinal Disorder Management through service to NASS
2002–present America’s Top Doctors, The Best in American Medicine, America’s Top Doctors and Hospitals, Castle Connolly Guide
2000 North American Spine Society, Wiltse Award for Leadership in the Field of Spine
Research papers awards
NASS (2), ISSLS (2), CSRS (2), ORS (1)
- American Academy of Orthopaedic Surgeons
- American Orthopedic Association
- California Orthopaedic Association
- Cervical Spine Research Society
- Creta Club (International Spine Discussion Group)
- International Society for the Study of the Lumbar Spine
- International Society for the Advancement of Spine Surgery
- North American Spine Society
- Orthopaedic Research Society
- Western Orthopaedic Association