Spinal Surgery News talks to Mr Syed Aftab, consultant spinal orthopaedic surgeon at the Royal London (Barts Health NHS Trust). He is the first robotic spinal surgeon in the UK and is actively involved in teaching other doctors, nurses and allied health professionals
Q: As a specialist in spinal surgery, could you tell us more about your experience and training background in this field?
A: I am a fellowship trained spinal orthopaedic surgeon and undertook my spinal surgery fellowships at the Royal National Orthopaedic Hospital (Stanmore) and the Royal London Hospital. I completed my orthopaedic training in the Stanmore rotation. Before that, I undertook basic surgical training in the North West Deanery. I studied medicine at Pembroke College Cambridge and clinical medicine at Edinburgh.
Since being appointed in 2016, my work has been a combination of complex spinal trauma, spinal deformity and also a lot of degenerative spinal pathologies. In particular, I undertook the first robotic assisted spinal surgery in the UK (as it happened on a trauma case) and I have also pioneered the IMAS (Interpedicular micro access surgery) technique in the UK.
Q: What drove you to choose surgery as a career – and spinal surgery in particular?
A: Orthopaedics for me was really the only thing I felt very strongly about, to the point where if I did not get the orthopaedic training number I wanted I was prepared to leave medicine entirely. This isn’t something that I knew from the beginning, but the first time Professor Hamish Simpson at the Royal Infirmary of Edinburgh handed me a spanner to tighten the nuts on an Ilizarov frame while I was a medical student, I was sold and in love with orthopaedics.
The person who got me into spines was Mr Jan Lehovsky at the Royal National Orthopaedic Hospital. I was his registrar as a second year trainee. Watching him operate was like watching a musician perform all the instruments in an orchestra simultaneously by himself and be the conductor of a perfect symphony every time. Despite me being generally a fool, we got on and overall it was an inspirational six months.
Q: What’s the best part of your job?
A: When a patient does well
Q: … and the worst?
A: When a patient doesn’t do well.
Q: What has been the highlight of your career so far?
A: Being medical advisor on Holby City.
Q: Tell us more about the robotic assisted spine surgery you perform at the Royal London?
A: It is just as described, robotic assistance rather than a truly autonomous robot. Robotic surgery and assistance are very topical at the moment and nobody really knows if they really are efficacious. However, as with everything else, you never know until you have tried it and as long as it is done safely and within the correct framework, this is the only way to achieve progress. I initially was tasked with arranging for navigation to be brought into the Royal London, but with navigation alone we would just be playing catch up with the rest of the world. What I wanted was something that would really put us at the forefront. I thought about this and, ultimately, with endorsement from the Trust and support from industry we trialed the first and only robot in the UK at the time. It was in fact sent from Germany just for us to use. We undertook 12 thoracic spine pedicle screws in a fracture stabilisation case. The case went smoothly and the patient went home in 48 hours after a potentially life-threatening fracture. There had to be something in it.
One of the main things in spinal instrumentation is safe placement of pedicle screws, it’s not just about finding the right path between perilous structures (spinal cord on one side, major blood vessels on the other) but maintaining that trajectory while inserting a sharp pointed metal instrument into the area. The robot we use at present helps us maintain a safe trajectory (hence it is an assistant).
We recently acquired one such robot (the same one we trialed) and used it in another trauma case where we inserted 12 screws into the thoracolumbar spine in a case of a fractured spine for a patient with ankylosing spondylitis. Again, two days later the patient was raring to go home. Whether it is to do with the soft tissue retraction or something else we do not know, but so far our experience has been very good (however n=2!). We are collecting all parameters and plan to put it together to establish the first British experience of robotics in spinal surgery.
Q: If you weren’t a spine surgeon what would you be?
A: Truck Driver. Nothing beats the open road.
Q: What would you tell your 21-year-old self?
A: Have faith, you’ll be alright.
Q: If you were Health Minister for the day what changes would you implement?
A: Pay nurses more money. They are the backbone of our NHS and get paid an insultingly small amount. In fact, if you work in London, are on a single income household and have a family, it is not possible to survive on a nurse’s average salary.
Q: Away from the clinic and operating theatre – what do you do to relax?
A: Travel, read and run. But that was before I had my children. Now I travel to children’s birthday parties, read Gruffalo at bed time and run around the living room pretending to be chased by my three-year-old daughter.
Q: How do you think the future looks in the field of spine surgery?
A: Tough question. Just like anything else spinal surgery is susceptible to trends and fashion. About every 10 years something changes. There was an era of interspinous spacers, lumbar disc replacements and dynamic stabilisation. Now its all about minimally invasive surgery (actually, that’s totally old news now), augmented reality and technological navigation of some description, along with automation and robotics.
Whether or not this wave will survive or peter out like the innovations before is difficult to predict. Technology of this nature is controversial, with many arguing that if you are so heavily tech dependant you are no longer a surgeon or should not be performing surgery. Equally, that is what was said about calculators when they were first being used in universities. I learnt recently that children are now allowed mobile phones in classrooms. So the technological wave is inevitable. It is up to us to decide whether or not we will be dragged kicking and screaming, or whether we want to be ahead of the curve, leading the way. The answer is therefore not to be one or the other, but to find a way that utilises the best of raw skill and technological finesse.
However, what will no doubt survive are the non-surgical aspects of spinal surgery (I know). I think we will become more and more selective about who and what pathology we operate on. This is already the case, but I think we will be even more fine tuned. Then we will become even more careful and refined in what surgery we perform and how it is performed. This is where the tech comes in. I think we are still at an age when we are making large leaps in spinal surgery rather than marginal gains. Once those leaps have completed, hopefully we will be able to reach a relatively steady state, like hip and knee arthroplasty or hernia surgery has. Spinal surgery is nowhere near the maturity these specialties have reached.
I am sure my lower limb orthopaedics and general surgery colleagues will vilify me for saying this (they probably also believe there is a long way to go within their areas of work) but spines are a long way from plateauing – that is what makes it the most interesting subspecialty in orthopaedics, neurosurgery and perhaps all of medicine. Go on, punch me – I can take it!
Mr Syed Aftab is a Consultant Spinal Orthopaedic Surgeon at the Royal London (Barts Health NHS Trust). He studied medicine at Pembroke College, Cambridge University and Edinburgh University. He underwent higher surgical training in Orthopaedics and Spinal Surgery on the London NE Thames rotation at the Royal National Orthopaedic Hospital, Stanmore. He also gained a Master of Science at University College London in Trauma and Orthopaedics during his training. Syed completed advanced fellowships in Spinal Surgery at the Royal London Hospital. Furthermore, he continues to broaden his experience with visitations to international centres of excellence for spinal surgery (Antwerp, Belgium; Bordeaux, France; Neustadt, Germany; and Orlando, USA). Syed has been pioneering the iMAS technique in the UK, using micro access techniques developed by Dr Robert Masson at Neurospine Institute, Orlando, USA (a Federally accredited Centre of Excellence). Syed believes that the best outcomes for patients can only be achieved when decisions are carefully considered and works within the framework of a multidisciplinary team. He is the Clinical Effectiveness Lead for Orthopaedics at the Royal London and is actively involved in teaching other doctors, nurses and allied health professionals. He organises the ‘Spine Term’ for the Royal London Hospital and Sir Percival Pott Orthopaedic Rotations. Syed has published widely in a number of peer-reviewed medical journals and is actively involved in research into spinal surgery. He has presented at national and international conferences.