After performing three lumbar and one cervical spine surgeries on Sept. 12, John Rhee, MD, left Emory University School of Medicine in Atlanta to speak to Becker's Spine Review about the university's new spine publication.
Dr. Rhee is professor of orthopedic surgery and neurosurgery at Emory and editor of the textbook, titled "Emory University Spine — Illustrated Tips and Tricks in Spine Surgery." The book, available on Amazon, provides illustrated descriptions of methods used by the university's physicians to perform spine surgeries.
Here, Dr. Rhee discusses the idea behind the book, Emory's spine fellowship program and emerging trends in the field.
Question: How did the idea to develop a spine textbook come about?
Dr. John Rhee: The publisher Wolters Kluwer has a series of tips and tricks for a variety of different orthopedic subspecialties. We approached them with an opportunity to do it for spine. Given our track record in education and training spine fellows over the years, we really wanted to come up with a book that is almost like doing a mini fellowship with us in a sense. People can see how we do things in a step-by-step fashion. It covers everything from anterior cervical to lumbopelvic and from big deformity correction surgery to minimally invasive surgery — it really covers the gamut of everything.
Q: What was your contribution as editor of the book?
JR: I was the editor and I also wrote several chapters, all of which were in conjunction with several of our spine fellows, when we were working on the book three years ago. It was a lot of work because the book is very heavy on illustrations and figures. The fellows would write step-by-step how we do [the surgeries] based on how things are done at Emory. Then we would look through old books or the internet to find a picture that encapsulates what we're trying to explain, or we would sketch it out. Our medical illustrator would make it look nice, but I would have to keep going back to tweak it to get exactly what I wanted. Almost every figure in the book was either drawn or modified by me, in conjunction with the artist.
I've edited several books before. The usual way we do it is come up with an outline for the chapters or topics we want covered and we ask our friends in academia who are experts in that particular topic to write it. Those are written from the perspective of a variety of different viewpoints, but this one really shows how we do things at Emory. I think it showcases our fellowship and the thought processes that go into how we do surgery. Hopefully there will be a second edition and we will expand it and add surgical videos.
Q: What is it about Emory's spine fellowship that makes it so unique?
JR: I think we have an incredible breadth and depth of spine surgery that we train our fellows in. They get the full spectrum of the relatively straightforward to the extremely complex, and they learn how to evaluate these patients. It's not just a factory where you come and do surgery — obviously that's a big part of it — but you also learn how to think and problem solve. In spine surgery that's probably half the battle — figuring out what the problem is — and the other half is fixing it. As opposed to other fields, it's often not obvious what the problem is. Or it may seem obvious, but what you think is the actual cause of pain or neurologic dysfunction may not be it. It takes a lot of detective work to figure things out and then design an appropriate operation to solve that problem.
Q: What do you see as the next big innovative trend in spine?
JR: There's always going to be innovation in the spine field, and it's necessary. But at the core, the most important thing for success is diagnostic information, figuring out what the patient's problem actually is and designing an operation around that. There are a lot of things related to big data and analytics that may be able to give us better insight as to what types of patients are going to do well with surgery and what types are not. With experience you get kind of a sixth sense for that, but I think in the near future there should be some hardcore data that you can tap into a computer and find out with this type of patient and these parameters, what's the likelihood of a successful outcome or major complication. I think that will help us to tailor operations better to patients and council them appropriately.
Q: It seems that robotics could greatly benefit less experienced spine surgeons but may not have the same impact for more tried and tested surgeons. Have you incorporated robotics programs at Emory? How do you see the trend progressing?
JR: We haven't gotten a robot yet, but we use navigation for certain cases. I think robotics is something that may potentially have some benefit in the future for certain cases. It's certainly a field of interest for us.
With too much technology, sometimes the surgeons aren't learning what they need to learn about anatomy and how to actually do surgery. I don't think the robot is doing surgery on its own but there's something that is important about really understanding and knowing the anatomy, so I don't think there will ever be a substitute for that. There can be a variety of different widgets that allow us to accomplish what we'd like to, maybe in better and less invasive ways, but at the core it's going to be the surgeon that needs to understand not only the disease, but also the details of the anatomy.
Q: Minimally invasive surgery has been a huge trend in spine. What percentage of minimally invasive versus open procedures do you perform and how do you see the trend developing in the field?
JR: I do the vast majority of spine surgeries open or mini-open. I'm going to guess that probably 20 percent of fusions are done in a minimally invasive way. I think that number will grow but I don't think it will ever fully replace open surgery. It's just like when artificial disc came out; it kind of came to a point where a certain percentage of cases were appropriate and do well, but it's never going to completely replace fusion.