Twin Cities Spine Center A Specialty Practice Devoted to Patient Care, Education and Research

Twin Cities Spine Center A Specialty Practice Devoted to Patient Care, Education and Research

Twin Cities Edition

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coverstory

In a quiet corner of the Abbott Northwestern campus, framed photographs adorn the office of Twin Cities Spine Center (TCSC) staff surgeon Dr. Francis Denis. One frame holds a photograph of a lovely Brazilian woman on horseback. A panoramic view captures a grinning Midwesterner standing next to a Sherpa on the summit of Mount Kilimanjaro. Another image features a beaming Italian man standing amidst Roman ruins. Behind these smiles are individual stories of personal triumph over physical adversity, triumphs made possible by the work of TCSC.

TCSC evolved out of the pioneering practice of Dr. John H. Moe — widely regarded as the founder of spine and scoliosis research and treatment. In the 1940s, he helped to establish the first dedicated inpatient hospital spine unit. Dr. Moe’s Minnesota

Spine Center and Twin Cities Scoliosis Spine Center practices were combined in 1998 to create TCSC.

Today, this independent specialty practice is one of the largest spine centers in the world, with 10 surgeons devoted exclusively to spinal conditions, over 90 professional and support staff and a full research department. TCSC surgeons see approximately 6,000 new patients a year, and handle an estimated 2,800-3,000 spine surgeries annually.

“We offer spinal management resources including outpatient evaluation, treatment, and 24-hour on-call consultations,” explains staff surgeon and President Dr. Timothy A. Garvey. “Our practice specializes in treatment of degenerative conditions, with particular expertise in scoliosis, kyphosis and spondylolisthesis. Although

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Twin Cities Spine CenterA Specialty Practice Devoted to Patient Care, Education and ResearchBy Marian Deegan

Many typical spinal implants can be placed through minimally invasive surgical approaches. Dr. Manuel Pinto (right) and Dr. James Schwender (left) perform a minimally invasive eXtreme lateral interbody fusion through a 1! inch incision.

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we have a reputation for handling complex high-risk cases, our surgeons also enjoy treating more routine issues.”

Central to the TCSC commitment to education is their fellowship program, which has trained 140 spine surgeons over 38 years. “Our goal,” says staff sur-geon and Fellowship Director Dr. Ensor Transfeldt, “ is to train well-rounded surgeons who know how to perform excellent surgery and, particularly, know how to evaluate patients, make good decisions about who needs surgery and recommend appropriate treatment plans.” The TCSC program has at-tracted fellows from 19 countries and visiting physicians from 33 countries including China, Turkey, India, Iran, Israel, Argentina, Brazil, Botswana and Australia. Although most patients come from the surrounding five-state area, the practice also receives national and inter-national referrals through relationships cultivated with visiting physicians.

Dr. Denis, who came to the Twin Cities from France to study with Dr. Moe, remembers a young Brazilian patient he treated. “We have worked with colleagues in Brazil since the ’70s,” he explains. “This little girl was brought to us by her parents. The girl’s mother was a surgeon, and insist-ed on being present through her daughter’s surgery. It was over seven hours — a big surgery.” He smiles. “This little girl grew up to become a steeplechase champion in Brazil. I have her photograph in my office.”

Participants in TCSC’s international visitors program reflect changing global dynamics. “As China has strengthened its global presence, we’ve seen a significant increase in the number of visit-ing Chinese surgeons,” relates Dr. Denis. “For decades, China was closed to the outside world. Today, the Chinese government provides funding to send surgeons to study with us. The tradi-tional acupuncture methods for anesthesia and Eastern approach to medical problems are rapidly being supplemented with Western methods. Chinese surgeons arrive with laptops to demonstrate the work they are doing. Interestingly, some of the best teaching hospitals in China are the military hospitals. Our international program gives us the ability to learn about new developments around the world, to have wonderful ideas brought to us and to take new procedures with us when we travel.”

The TCSC philosophy of practice embodies Dr. Moe’s dedica-tion to patient quality care, education and research. “We aren’t the practice for surgeons who focus exclusively on operating,”

explains Dr. Garvey. “We believe strongly that research and education add value to our care. With the support of our research department, and the assistance of Dr. Robert Winter, our physi-cians published 10 papers this year in leading spine and medical journals. We conduct weekly continuing education conferences. Every Thursday, a faculty member presents a lecture for fellows and staff on a select topic. Practice partners are involved with national organizations including the Scoliosis Research Society, the Cervical Spine Research Society, the Society of Minimally Invasive Spine Surgery, the North American Spine Society, the AAOS and ABOS. We are also involved in local community organization work.”

The international scope, subspecialty focus, technical re-sources and surgical expertise of a major spine program provide a rich range of treatment resources. TCSC offers subspecialty experience with instrumentation for the low back, mid back and neck, as well as the complex technology required to reposition the spine in scoliosis, kyphosis and other deformity conditions.

Dr. Daryll Dykes (staff surgeon) discusses a case with Dr. Nicholas Wills (Fellow).

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This depth of focus benefits patients with simple as well as more complex spine issues.

“There is always a risk when you are working around nerves,” explains Dr. Garvey. “We have access to interoperative X-ray and real-time neuro monitoring with a neurologist to measure spinal cord and nerve root function. Many institutions do not have the patient volume to support such high-quality technology.”

When a Twin Cities attorney fractured his spine in a riding accident, TCSC surgeons drew on the full array of available technology to repair the injury. Five years later, the patient

sent a panoramic photo of himself on a mountain summit. On the photograph he’d written: “I wanted you to know that your spine surgery made it up to the top of Mount Kilimanjaro.”

TCSC surgery styles reflect the trend toward less-invasive procedures. Staff surgeon Dr. James Schwender is a na-tional leader in minimally invasive spine techniques and serves as Vice President first elect of the Society for Minimally Invasive Spine Surgery. Dr. Manuel Pinto also takes a leadership role with newer, less-invasive procedures. “There are several techniques,” says Dr. Denis. “We choose what is best for the individual pa-tient. Success depends on a combination of technology and the surgeon’s art. We do not rely on the X-ray CR drill alone; we also rely on a sense of feel. I think we are humble enough to know when it’s the right decision to refer to one of our partners. Dr. Joseph Perra and Dr. John Lonstein have a lot of experience with children’s spine issues as well as spine problems in people with dwarfism. If I had a child with these issues, I’d send that child to Joe, or consult with John.”

Clinical research has been integral to TCSC since its inception. “Dr. Moe had the foresight to keep the data from the early days of his practice,” notes Dr. Garvey. “He focused on clinical research of scoliosis patients at a time when little published data was available.”

Today, patient evaluations benefit from years of data collected by TCSC to better guide treatment options. Access to the Foundation for the Advancement of Spinal Knowledge biomechanical lab helps the physicians, fellows and visitors conduct biomechanical research to evaluate surgi-cal products used in spine surgery. These

studies identify products that create the safest, most effective corrections.

“One of the most exciting developments on the horizon is improved disc replacement for the lower back and neck,” notes Dr. Garvey. “We’ve participated in studies with a variety of com-panies, and see some very promising products coming out of FDA trials, particularly for neck treatment.”

Staff surgeon Dr. Kevin Mullaney has utilized cervical disc replacement to treat patients with work-related neck injuries. “Patients were able to maintain cervical range of motion and return

Dr. Amir Mehbod examines a patient during a recheck appointment following lumbar spine surgery.

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to work in a very timely manner,” Dr. Mullaney notes.TCSC has also participated in research for children with

scoliosis to improve the predictability of developmental risks. “Testing genetically analyzes saliva samples from young scoliosis patients,” explains Dr. Garvey. “The children are studied over a 20-year period to track and evaluate developmental issues through young adulthood. This data allows surgeons to more accurately assess potential risks. Genetic analysis stratifies children with a low risk of developing a severe spinal curve. This enables us to reassure parents early on, avoiding years of angst and uncertainty. Tests can also indicate higher genetic risks, even if a child has only a 25º curve on presentation. This gives us more information when we are considering surgery to prevent the curve from increasing.”

Active research underlies TCSC’s conservative approach to surgery. Only 25% of new patients go on to surgery within two years. “There are several circumstances in which we just cannot justify surgical intervention,” says Dr. Garvey. “I have an elderly patient in the hospital now who is too physi-cally ill to be a good surgical candidate. Sometimes the risks of surgery are so great that even though there is potential benefit, you can’t do it.”

Patients with unrealistic expectations are also not good surgical candidates. “They may be experiencing pain,” Dr. Garvey explains, “but unless I can identify a compressed nerve, a bad joint or an

unstable spine, I’m not able to fix it. I can’t operate on pain. I have to verify a specific problem.” The presence of psychosocial issues also demands careful evaluation. “Patients with nonorganic pain are high risk,” says Dr. Garvey. “We may elect to work with the family doctor and a psychologist or psychiatrist to address psychosocial issues before surgery is considered.”

“For any patient, it is best to address issues with conservative therapy first,” says Dr. Denis. “It would be ideal to have a family practitioner call us to explore issues like epidural steroid injections, or to request an MRI review. Personally, I would love that, but I know that demanding schedules and large practices make direct communication difficult for referring physicians. If I could change the way things are done, I would try to increase opportunities for direct consultation. We do offer a provider consult line for physi-cians during clinic hours.”

“We want our patients to have a great experience from the minute they come into the clinic, through the hospital and after they leave,” says Dr. Garvey. “We survey patient satisfaction with our clinic and hospital care. We study and grade ourselves every month. We sit down, look at each other’s cases, and talk about them. All of these efforts reflect our commitment to ongoing quality of care.

“If you ask me why I chose this specialty,” Dr. Garvey reflects, “I’d tell you that it’s because spine puts everything together. I treat men, women, children and geriatrics. There is a diagnostic chal-

Research Fellows Dr. Xiujun Zheng and Dr. Rahul Chaudhari, working in the Foundation for the Advancement of Spinal Knowledge biomechanics lab run by Chunhui Wu, Ph.D.

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lenge. You have to talk to people; you have to have a relationship with your patients. We have the assistance of excellent high-tech imaging. And then, this is a subspecialty where you can actually fix things. You make people better, and that is very gratifying.”

“There are so many patient stories,” muses Dr. Denis. “One of my patients was a young man from Rome. He had Elephant Man disease, a terrible case of neurofibromatosis. Three surgeries in Italy had left him paraplegic. When his family brought him to see me, I told him that I didn’t know if I could help him. His chances of recovery were very low. He had been paralyzed for a month; he had no sensation, no motor function at all. Following surgery, he still could not move anything. I didn’t think it was going to happen. This young man returned to Rome. Three months later, I received a video from him. He was walking between parallel bars.”

Dr. Denis smiles. “Eventually, he walked completely normally. My wife and I went to Italy, and visited him during our trip. He walked with us through Rome, showing us sights, and took us to dinner at a little restaurant with his family. It was very ceremonial, very beautiful. His father showed me the X-rays, and the family presented me with a gift of black truffles. I was very touched.

“Not so long ago,” Dr. Denis chuckles, “I had briefly considered

that I might pre-retire and improve my golf game. But I find that I would miss my practice tremendously. It’s not just that I am happy being a surgeon; I really enjoy the rapport with my patients. It is wonderfully rewarding to have the feeling that you understand them and are able to make a recommendation that reassures them. At the time of surgery, it is great to see my patient in the preopera-tive unit and have them smile and be comfortable. It is gratifying to have the impression that you have made a difference in someone’s life. I think my golf game is going to have to wait.” ■

Left to right: Manuel R. Pinto, M.D.; James D. Schwender, M.D.; Ensor E. Transfeldt, M.D.; Daryll C. Dykes, M.D., Ph.D.; Francis Denis, M.D.; Kevin J. Mullaney, M.D.; Joseph H. Perra, M.D.; John E. Lonstein, M.D.; Timothy A. Garvey, M.D.; Amir A. Mehbod, M.D.

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REPRINTED FROM TWIN CITIES M.D. NEWS

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