Thomas J Errico, president of the SAS (which was formerly the Spine Arthroplasty Society and is now in the process of undergoing formal renaming to the International Society for the Advancement of Spine Surgery), tells Spinal News International how a large part of his fascination for work comes from the challenges associated with sometimes completely changing the “shape” of a person and having that effect last them a lifetime.
How did you become interested in medicine? Why spine surgery?
I became interested in medicine at age 12 when my older brother graduated and moved home temporarily before starting his internship. He brought in tow all his medical school textbooks and I was fascinated looking at the anatomy books and just in awe of the massive amount of material he had to learn. I found the topics and the challenge irresistible.
What is it that interests you about spinal deformities?
I had the opportunity to train early in my career with three of the past presidents of the Scoliosis Research Society. Dr Gordon Engler, Dr Theodore Waugh, and my fellowship director Dr John Kostuik. My awe of them as individuals and the work they did attracted me to the field. The challenge of completely changing the “shape” of an individual and having that effect last them a lifetime is a large part of the attraction to me. I add inches in height to patients of all ages and alleviate existing disability and hopefully prevent development of future disabilities. Also, the fact that the state-of-the-art in deformity surgery is constantly evolving and hopefully getting better–to be a part of that is a privilege.
Who were the people who inspired you in your career, and what advice of theirs do you remember today?
Certainly John Kostuik who I did my fellowship with in Toronto back in 1983–84 was the most influential in my career. However, the former chairman of Neurosurgery at NYU School of Medicine, Joseph Ransahoff, (himself a “legend” of neurosurgery) was very helpful to me. Considering I was an orthopaedic surgeon trying to do spine surgery at the same institution, it is remarkable how supportive he was to me at a very early crucial time in my career. The rest are too numerous to mention.
Could you identify some exciting developments in spine surgery today?
We are in a critical time in spine surgery! Without doubt, we help the vast majority of people we operate on. The exciting challenge is to do a better job tomorrow than we did today. Can we get the same results with less surgery? When is minimally invasive surgery appropriate? We have a saying in the Spine Division at NYU, partially adopted from one of our adult reconstructive surgeons. It says: “The patient who undergoes minimally invasive surgery expects maximally effective results, and if disappointed, is minimally understanding!”
What are the major challenges facing, particularly, paediatric orthopaedic surgery today?
The most important challenge in paediatric spine surgery today is to skillfully apply the new techniques that are evolving without creating neurologic deficits. We are tackling increasingly more and more difficult problems with ever more sophisticated techniques. The challenge is to do so without creating harm! We need new strategies that make complicated spine surgery more safe.
Could you describe some memorable cases you have treated?
As a surgeon with a career that has spanned over 25 years, I have had the privilege of interceding on behalf of so many patients that it is hard to single out one or two cases. I will mention three different types of cases. I was the youngest of five children. All five of us were delivered by a female general practitioner, Dr Greco, who became a lifelong friend of my mother. Because I was a “caboose” baby, born seven years after my closest sibling, Dr Greco knew I was the last. She refused to charge my mother and father the then “standard” fee of $50, because she had delivered our entire family. After a long and productive career, she retired to Europe to live in Switzerland, although she still frequently visited the States. When I first started my practice she came to me as a patient for a spinal consultation for spinal stenosis. Fortunately, she responded easily to conservative care. She, however, was surprised when I refused payment reminding her of her own courtesy at the time of my birth. That interaction was a rare occurance. A physician treating the physician who delivered him–that is truly a“full circle”.
My older brother, as I said, is 12 years older than I am and still practicing obstetrics and gynaecology in New Jersey. About 10 years ago I operated on a 14-year-old boy for scoliosis. When he came back in for his first post-op visit, the boy’s mother asked if I had any relatives who were physicians. I mentioned my older brother and she was embarassed to say she had not thought of it before but that my brother had delivered her son 14 years earlier. So another career event!
Sometimes a case in your early career stands out. I was on call at Bellevue hospital when I got called about a 13-year-old daughter of a physician who had a spinal fracture from a diving accident and was paralysed from the waist down. Her injury was technically incomplete because of a minimal amount of distal sparing. Her X-rays showed a 90% occluded spinal canal at L1 from a burst fracture. Using the techniques I had just learned the previous year in Toronto with Dr Kostuik, I performed an anterior decompression, strut grafting and anterior instrumentation with what was then known as the Kostuik-Harrington Device. She had a complete neurologic recovery and went on to become a nurse in adult life.
What is the most interesting paper you have come across recently?
I cannot pick just one paper but as a group of papers I am impressed with are the long-term five-year results and longer on lumbar disc replacement, recently presented in New Orleans at the SAS10 meeting. These represent the long-term data obtained both from Europe and the original US IDE studies and point to maintenance of the improvement seen initially and at two years in well-selected patients with degenerative disc disease. These papers represent hope that techniques (motion sparing technology) between decompression alone and fusion may be a viable option for patients.
Which technique or technology had a profound influence on your career?
I became a spine surgeon at the beginning of the blossoming of “modern spinal instrumentation”. When I started my training there was the Posterior Harrington Rod instrumentation for scoliosis and the Dwyer and Zielke devices anteriorly. Over the course of my career, the choices have blossomed into instrumentation techniques from occiput to pelvis, front to back, and including fusion as well as non-fusion devices. Truly an amazing progression in a relatively short period of time!
What do you hope to achieve as the president of the SAS?
The SAS is at a critical juncture. I hope to complete the evolution of the SAS into the International Society for the Advancement of Spine Surgery (ISSAS). The past presidents and present board are committed to the development of a five-year strategic plan that will grow us worldwide as an academic forum for spine surgeons who wish to learn the latest techniques in spinal surgery for the betterment of their patients.
With the focus on USA Healthcare Reform, could you tell us how “comparative effectiveness” research is going to affect spine surgeons?
In my presidential address at the SAS10 conference in New Orleans, USA, I said: “In spine surgery specifically, there are many things that remain poorly studied or lack consensus. Comparative effectiveness research could help us resolve some of these uncertainties. Spine surgery is already far ahead of most other medical specialties in this game, because most of our best research has been comparative all along – we do not really ever waste time and money studying placebos or waitlists in our clinical trials. Looking at arthroplasty for example, the early FDA trials were all comparative effectiveness research, because the comparison group – fusion – is an active real-world treatment that we routinely use. And now the ongoing trials of Kineflex and Activ-L are even more purely comparative, because they compare one disc against another. These studies may shed light more generally for all discs on the relevance of various disc design features. For another example, comparative effectiveness research could show us what are the best ways to prevent infections in our patients, by comparing different preventive measures in large multicentre studies or national patient registries. Simply stated, studying different procedures under identical conditions allows us to compare them and make future choices. A focus of the SAS will be to try to further the widespread use of spinal registries so that we can assess the real world results of modern spine surgery techniques.”
I would advocate a “house-cleaning” type of research. We cannot afford new technologies in medicine, unless we get rid of some of the previous old technologies that have been “grandfathered in” and would never meet the scrutiny of modern regulatory pathways. By the same token, we have to evaluate new technologies, and scrutinise them through the prism of “cost effectiveness” compared to older technologies that did work. It will only be by critical analysis of the new and the old that future guidelines for care can be developed.
What are your interests outside of medicine?
I enjoy deep-sea fishing, collecting fine wine, cooking, gardening and music.
Fact File
Education
1978 MD Medicine, New Jersey Medical School
Postdoctoral Training
1983–1984 Fellowship Training: John P Kostuik, MD, FRCS, University of Toronto
Academic Appointments
1986 Associate professor of Orthopaedic Surgery, NYU School of Medicine
1986 Associate professor of Neurosurgery, NYU School of Medicine
Hospital Appointments
1984 Attending physician, Tisch Hospital NYU Medical Center
1984 Attending physician, Bellevue Hospital NYU Medical Center
1984 Attending physician, Manhattan Veterans Administration Hospital
1996 Attending physician, Orthopedic Institute, NYU Hospital for Joint Diseases
Awards and Honors
2001–2009 “Top Doctors” award. New York Magazine/Castle Connolly Medical Ltd
Major Committee Assignments
1992–1999 Surgery Committee, chairman, North American Spine Society
1995–1998 Committee of Algorhythms of Care – Lumbar Spine, AAOS
1995–1998 Executive Committee, Proposal for a Multicentre Study of Surgical Treatment For Acute Spinal Cord Injury: Joint Section on Neuro Trauma and Critical Care, A Joint Section of the American Association of Neurological Surgeons and Congress of Neurological Surgeons Submitted to NIH
1995–1997 Programme Committee for National Meeting, North American Spine Society (NASS)
1999–2002 Treasurer, NASS
2002–2003 Second vice president, NASS
2003–2004 President, NASS
2005–2008 NASS Leadership Committee
2006–2008 NASS Public Relations Task Force Committee
2006–2009 NASS Spine Masters Institute Board Committee
2006 Board of Directors, National Association of Spine Specialists
2006 Past president, National Association of Spine Specialists
2006 Board of Directors, Spine Arthroplasty Society
2007–2008 Treasurer, Spine Arthroplasty Society
2008–2009 President elect, International Society for the Advancement of Spine Surgery (SAS)
2009–2010 President, International Society for the Advancement of Spine Surgery (SAS)
