By: 8 January 2019
Surgeon Focus –  Professor Alex Green

Spinal Surgery News talks to Alex Green, a Neurosurgeon and an Associate Professor at the University of Oxford. He specialises in Functional Neurosurgery – Deep Brain Stimulation and Spinal Cord Stimulation, as well as Dorsal Root Ganglion (DRG) stimulation. His research focuses on the autonomic effects of neuromodulation. He has been implanting DRG stimulators for pain since 2013 and was one of the early implanters in the UK

In routine UK medical practice, treatment of certain chronic pain conditions through conventional medicine fails to achieve adequate relief and long-term recovery in many patients. In their search for relief, many of Professor Green’s patients often endure inadequate treatments and struggle with prescription painkillers over the course of multiple years.

The introduction of the latest advances in health-tech devices has been an exciting trend to observe and also one in which Professor Green plays an active role; both in education and implementation across Europe and the US.

New spinal neurosurgical techniques, coupled with new therapies, are helping to move the field forwards. Studies demonstrate that some of these new and emerging techniques work in improving therapy outcomes and quality of life for patients.


SSN: As a specialist in neurosurgery, could you tell us more about your experience and training background in this field?

AG: I qualified in medicine in 1997 from University College London. My neurosurgical training started at the Royal London and St Bartholomew’s Hospitals in 2001. Most of my training occurred in Oxford where I learnt functional neurosurgery under the auspices of Professor Tipu Aziz.


SSN: What drove you to choose surgery as a career – and neurosurgery in particular?

AG: I was always interested in neurosciences, having done an intercalated BSc degree in the subject. When I started medicine, I had not decided whether to do medicine or surgery, but after working in neurosurgery I never really looked back. Neurosurgery combined my interest with neuroscience and the ability to deliver therapies in this field that would make a difference.


SSN: What’s the best part of your job?

AG: Taking a patient who is debilitated by their condition (pain or Parkinson’s disease) and doing a procedure that makes them much better. I also like the research aspect.


SSN: … and the worst?

AG: Bureaucracy – there is plenty of it in the NHS!


SSN: What has been the highlight of your career so far?

AG: Introducing new techniques such as DBS for pain and DRG stimulation for pain, and seeing them make a difference.


SSN: Tell us more about your work as a pioneer of dorsal root ganglion (DRG) stimulation therapy?

AG: I was first approached in 2012 to bring this technique to Oxford. Myself and a colleague (James FitzGerald) then started teaching on DRG courses and we helped to introduce the technique to the US (although it had originated there). This involved running courses in both the US and Europe. We now run DRG Masterclasses along with both US and European colleagues, and sit on a steering group for education in DRG stimulation.


SSN: What is it and how does it affect the patient’s experience and outcome?

AG: We percutaneously, under X-ray guidance, insert an epidural needle into the spinal canal and then feed a DRG electrode over the DRG of interest. In the UK, we have been implanting Abbott’s DRG stimulation therapy on the Proclaim™ DRG Neurostimulator System using Bluetooth wireless technology, iOS software and an Apple iPod touch mobile digital device as the system’s controller. A loop is placed in the wire and the wire is connected to a subcutaneous implantable pulse generator (like a pacemaker). The patient can then change the settings from the outside and it helps to switch off the pain signals from the affected area. In general, we see pain relief of around 70-80 per cent and significant improvements in quality of life.


SSN: What does it mean with regard the recent changes in the UK guidelines for Complex Regional Pain Syndrome (CRPS) in adults?

AG: Patients with CRPS are eligible for DRG stimulation and DRG stimulation has been proven to work in CRPS in a large US randomised controlled trial – the ACCURATE study. This means that we can offer DRG stimulation for CRPS.


SSN: How could this change the future of neurosurgery and pain management?

AG: DRG stimulation has allowed us to treat pain indications that we were unable to successfully treat with standard spinal cord stimulation. Some conditions (such as Failed Back Surgery Syndrome) may still be better treated with SCS, but DRG is often better for focal pain and has allowed us to treat conditions such as post-herniorrhaphy pain, that we couldn’t treat with SCS.


SSN: If you weren’t a neurosurgeon what would you be?

AG: I always wanted to be a fighter pilot, but I failed the medical!


SSN: What would you tell your 21-year-old self?

AG: That hard work and perseverance usually pay off, and to focus. You can only do one thing (or may be two) well.


SSN: If you were Health Minister for the day what changes would you implement?

AG: I would cut out bureaucracy from the NHS and remove targets as they skew healthcare provision in line with Goodhart’s law (that when waiting times became a target, they stopped being a good measure). I would also not fund treatments that are not proven to work but provide money for trials instead.


SSN: Away from the clinic and operating theatre – what do you do to relax?

AG: I would say 98 per cent of my time is taken up controlling my three young boys and the other 2 per cent flying a flexwing microlight.


SSN: How do you think the future looks in the field of neurosurgery?

AG: It is very exciting, especially with the advent of more advanced technology for brain restoration and more sophisticated surgery.