Roger Härtl, MD, is the director of spine surgery at Weill Cornell Brain and Spine Center in New York. His clinical practice focuses on minimally invasive spine surgery and he has published on novel techniques throughout his career, including lateral approaches and navigation.
Q: What are the most important findings from your work with minimally invasive spine surgery and 3D navigation?
Dr. Roger Härtl: Over the years, we have elaborated on the minimally invasive procedures and incorporated the 3D stereotactic navigation to perform precise spine procedures on a daily basis with minimal radiation. We have replaced fluoroscopy in the operating room for 75 percent of our cases and now use navigation. That's remarkable. We are using navigation for spinal fusions but also introduced the concept of "Total navigation" using navigation for all parts of the operation, not only screw insertion, which gives us a huge advantage.
Q: You've incorporated the navigation technology into your medical mission work in Africa. What was that experience like?
RH: I do work in Tanzania in Africa. We have a relationship with two hospitals there where we perform less invasive surgery. We took the 2D navigation system there a few times to see how quickly the surgeons picked it up. They immediately understood the concept of navigation and although we couldn't keep the system there, it was a great experience to get that technology up and running in their ORs.
Q: You've focused on training for young surgeons abroad as well as in the U.S. How would you characterize the spread of MIS?
RH: A lot of the surgeons I train haven't used the microscope or microsurgical instruments before. We want to create a strategy and model to teach those surgeons how to use the microsurgical equipment and drills in the spine. At Weill Cornell together with a company from Germany Realspine, we created an almost identical human spine model where surgeons can perform the whole microscopic approach on the pathology in a real surgical experience. There is blood loss and the bone feels like real bone. This experience replaces a cadaver workshop, which most companies rely on for training their surgeons. But we have replaced that with artificial models and you could do that with many procedures.
The advantage of using artificial bone is you can conduct the lab anywhere — a lecture room, hospital hallway — because we don't use human tissues. It's a huge advantage and step forward in terms of teaching surgeons. We are working to incorporate our navigation system into the lab as well with models for future courses to see which courses would be most beneficial.
Q: Your research spans several areas from tissue engineering to disc arthroplasty, three-dimensional printing and tissue-engineered biological disc replacements. Where are you focused now?
RH: We are working closely with patients who have herniated discs to fix the related annular tears. We can repair and seal the disc with a tissue engineered glue made from a highly concentrated collagen material to prevent further degeneration and back pain. We've done that with animal labs and we're hoping in the next three to five years to conduct clinical trials.
We also do a lot of clinical research for XLIF, translumbar surgery and minimally invasive spinal fusions. In December, we conducted our 10th annual course on minimally invasive spinal surgery and navigation. My goal is to stress the importance of microsurgical techniques for spine surgery, teaching and training so surgeons worldwide will minimize the surgery they do, have fewer complications and keep costs down.
Q: How has your practice changed over the past several years as MIS spine surgery evolved?
RH: Increasingly I realize that surgery is only a small part of what I do when taking care of patients with spinal problems. As the director of our newly established Weill Cornell Medicine Center of Comprehensive Spine Care here in Manhattan I realize that me and my colleagues can't function as a surgeons alone; we have to work with practitioners who cover different aspects of spine care. Together we work closely to find the least invasive and most successful treatment for patients.
If you work with a team, you can avoid surgery because you have options for treating a particular patient. If the patient needs to see a neurologist or have injections, it's easier to ensure they get the right type of care when you're partners with the non-operative providers. This may also include alternative or complementary interventions such as acupuncture, biofeedback or cognitive behavioral therapy and mindfulness.
Together we can also improve our ability to diagnose degenerative processes more accurately; if I know as a surgeon where the pain is coming from I can devise a less invasive, more targeted operation without causing unnecessary iatrogenic injury to the spine.
Most practitioners work on their own and don't take advantage of their colleagues. The interdisciplinary care team is the most important aspect of success in the future of spine care. It will ultimately help us increase quality and decrease cost.