Q&A Mr Dan Plev
Q&A - 18TH MAY 2017
Consultant neurosurgeon at The London Clinic on spinal surgery, maintaining flexibility and the importance of a patient-centred approach
As a neurosurgeon, what do you specialise in?
Our initial training is based on the central nervous system, mainly in relation to the brain and the spine. These are our main remit, along with the peripheral nervous system, which is a network of motor and sensory nerves which branch out from the spinal cord and go to the rest of the body.
What are the main types of spinal surgery you perform?
There are two main types. Neurological surgery is focused on the nerves. This can involve freeing nerves that have been trapped or repairing nerves that have been damaged, either within the spinal cord, as they emerge from the spine, or on their way to other parts of the body. The second type of surgery is where we repair physical damage to the spinal vertebrae or discs.
What is the spinal cord and what does it do?
The spinal cord is a thick bundle of nerves that sits inside the spinal column. It acts as the body’s central processing centre, relaying information between the brain and the body. It is indispensable to the regulation of a large range of the body’s functions.
Can you tell us a bit about the spine itself?
Think of the spine as a column made up of boxes with cushions in between them, supported by muscles and ligaments. The boxes are the vertebrae and the cushions are the discs. This column sits on a level platform provided by your pelvis. For anatomical reasons, we think of the spine as several different sections: the cervical, which is the neck region; the thoracic, where the ribcage attaches to most of the vertebra; and the lumbar, which is the lower back. But during diagnosis and treatment, it is very important to approach the spine as a functional whole.
Why is that?
Due to the number of digital devices we use and how long we spend looking at them, many people have developed a slightly head-forward posture. This means the muscles in the back designed to support your head are constantly working that bit harder. This can lead to pain in the neck and at the base of the skull, but because many of those muscles attach to the area between the shoulder blades, the pain can also be felt between the shoulder blades. These people end up going to their doctor saying they have thoracic pain and are worried because this can be a symptom of some more serious underlying issues, but in reality these cases can be addressed simply by correcting the posture through exercise. You have to look at the spine as a whole and not simply say “this is thoracic pain or cervical pain” and treat that in isolation.
How does this philosophy manifest itself in practice?
The first thing I do is spend time talking to the patient. I take a detailed medical history but I also talk to them about what is going on at the present time. Often patients will themselves put you on the road to the correct diagnosis through important information they do not realise they have. They will then have some functional diagnostic tests and be sent for a scan. The idea is to find out exactly what structures are generating the pain.
What kinds of tests might they undergo?
One is a nerve conduction test where we measure the speed at which an electrical pulse passes along a nerve. This can tell us a lot about the state it is in. Then there are MRI scans, which we use to closely examine the affected area. So, for example, the nerve conduction test may show us healthy nerves, while the MRI scan may show that certain muscles around the painful area have grown weak through inactivity. Because the muscles are not working properly, it causes a structural imbalance which is the possible cause of the pain. Working with a physiotherapist to strengthen these muscles can cure the pain without the need for medication or surgery. You would be surprised at how common this is.
What about when it is not simply muscular?
Then the treatment depends upon a series of questions. Is it an infectious disease, or is it a problem with the veins in the area compromising the blood flow to the spinal cord? Is something fractured or crumbling away, like a disc, a vertebra or a joint? Is it something happening within the spinal cord like a tumour, or is it a degenerative disease such as MS? This is what our initial checks are designed to discover, so we will know if surgery is needed or not.
What are some of the indications that surgery will be needed?
If there is a physical problem such as a fracture or damage to a disc, then surgery is likely to be appropriate, but things get a bit more complex if it is neurological. If the patient is suffering an element of referred pain, where, for example, neck pain radiates down their arm, we will start looking along that nerve path to identify the particular nerve affected. This is not always easy, as scans will show changes due to wear and tear, so the challenge then becomes nailing down the specific nerve causing the problem and understanding exactly how it is affected.
If the patient has weakness or numbness that is not improving, we will consider a surgical intervention. If there is something affecting bladder or bowel function, then you definitely need some kind of decompressive surgery.
But the question must always be, does the patient really need an operation? There can sometimes be a rush to reach for the scalpel, even on the part of the patient. Less than 10 per cent of spinal problems actually need surgical intervention, the rest can be successfully dealt with by exercise or with medical treatment. If you try to address what led to their condition, particularly in the degenerative conditions, you can achieve a great deal of progress without surgery.
What have been the major changes in your field?
The most obvious advance is in the materials we now have available. This has changed our ideas about what can be achieved. But for me the most important change emerged from Germany about 25 years ago, when surgeons began to think much more in terms of how they could retain motion and flexibility in the areas around a spinal repair. Before this change—which was partly driven by material advances—everything we put in place was aimed at providing strength and support as opposed to maintaining flexibility. The more flexibility you maintain, the better the long term experience the patient has.
In your field, what would the silver bullet be?
I think it would be the increase of multi-modal treatments where different specialities work together for the benefit of the patient. For example, when someone suffering from osteoporosis presents with a fractured vertebra, in many cases the damage will be repaired and the patient sent on their way. But no one has addressed the cause. For me, it is about working with all specialties to offer the patient a more holistic treatment path. So, in this hypothetical case, a rheumatologist or endocrinologist may get involved once the surgery has been successfully completed, to address the osteoporosis. Working together like this is hugely beneficial for the patient. Clinicians can sometimes get too hung up on a patient being ‘theirs’. They are not ‘your’ patient, they are suffering from a condition or injury in which you have some expertise. Whatever makes the patient better is good for them. It is not a case of concentrating on the pathology, but going into the underlying conditions and working out ways to deal with them overall.
What do you like most about what you do?
The patients. I love working with them, because they all come with a story. My mother always told me that if you spent enough time with a patient, they will diagnose themselves. And over the years I have found this to be true. They cannot diagnose the condition, but talking to them will often give you a very good lead as to where the problem lies.
Neurosurgery and spinal surgery is a very exciting field right now. We are continually improving the tools we have and devising new prosthetics which can replicate what is going on in different areas of the spine. Also, as the population ages it is gratifying to know that your work will help an increasing amount of people.
But it all goes back to the fact that you are dealing with a person, you are not treating an MRI image or a list of test results. Those are your tools, but the patient is the most important thing. Everything starts and ends with them.
For more information, visit The London Clinic