DESPITE groundbreaking advances in medical knowledge, technology and treatment concerning spine trauma and injuries, spine surgery remains a delicate and complex procedure.
However, spine surgery patients and their families will likely find assurance from knowing that in Malaysia, spine surgeons with the Health Ministry are required to undergo years of rigorous training before they are permitted to carry out surgery independently.
According to Dr Wong, most spine surgeons in Malaysia come from either an orthopedics (musculoskeletal) or neurosurgery background.
Spine surgery is considered a sub-specialist category – meaning doctors have to undergo additional training.
Speaking from his experience as an orthopedic surgeon, Dr Wong noted that since 2005, orthopedic specialists who intend to perform spine surgery must complete a four-year specialist training programme with the Health Ministry in order to carry out complicated procedures such as those involving implants and artificial joints.
Without this programme, orthopedic surgeons can only perform very basic spine surgery procedures.
“The Ministry of Health is very strict. In that sense, we are improving the standard of care. We don’t allow anybody to do it. To the public, this is also reassuring,” Dr Wong said.
This means on average, an individual will have to work and train for at least 17 years before he or she will be qualified to perform spine surgery independently in Malaysia under the Health Ministry.
Breaking it down, it takes at least five years of medical school before medical students graduate to become general practitioners. They will need another three years of work experience under their belt before they will be accepted into a specialist programme (orthopedic or neurosurgery), which, in turn, will take another four years.
Once the specialist training is completed, it will take about one or two more years before they can enter a spine specialist programme which will require an additional four years of training.
Policies and checklists
Patients can also draw confidence from the fact that most hospitals have strict policies in place to minimise human error during spine surgery.
It is a fact that the risk of something wrong occurring is very real such as performing the correct procedure but on the wrong place, especially when it’s a very specific area on the spine which needs to be treated.
“All this kind of possible human error may have nothing to do with how well you are trained or how good your equipment is,” pointed out Dr Wong, adding that this is where thorough checklists can be very effective in reducing the risk of human error.
Checklists are used – from the moment a patient is admitted to the pre-operation briefing to the actual operation, the post-operation follow-up and monitoring. This is to ensure the whole medical team involved in the patient’s care is aware and updated on the patient’s condition and treatment.
According to Wong, research has shown that checklists have been so effective at minimising human error that the World Health Organisation (WHO) reinstated the use of checklists in a lot of the medical workflow.
Wong also pointed out that thanks to medical and technological advances, there are other avenues open for treating spine conditions.
Generally, there are five main categories of spine conditions that spine surgeons deal with which may or may not require surgery to treat.
The first category is spine trauma or inflicted injury to the spine which is often related to a country’s socio-economic status.
In Malaysia, incidences of spine trauma is quite common because of the high number of people working under dangerous conditions such as in logging and construction sectors, and relatively low public awareness as well as lax implementation of safety procedures.
The country’s high ratio of road accidents is also a significant contributor to the number of spine injury cases.
The second major group are categorised as degenerative conditions.
Wong noted the rise in degenerative spine cases could be traced to changes in the quality of life in these modern times which encourage less exercise that strengthens bones, but at the same time, causes more problems with joints and bones because of factors such as poor posture for extended periods and such like.
Degenerative conditions may be due to injury such as carrying excessively heavy loads which wear down spine cartilage.
Cartilage degeneration may also be caused by a ge and genetics.
Wong highlighted that in some countries, genetic research was being carried out to modify some of the genes which had been identified as agents for degeneration but it was not being used yet in Malaysia.
The third category belongs to conditions caused by infections which includes spine tuberculosis, a condition which often needs operation.
The fourth category is spine deformities. The most common is scoliosis (curvature of the spine) usually in young girls and happens around puberty when they experience growth spurts. Sometimes, spine operations are required to correct the condition, depending on how severe it is.
The fifth group is categorised as metabolic which is to do with vitamins and functions of spine. Osteoporosis falls into this category. While osteoporosis can be treated with medication, some instances will require surgery.
Despite the explosion in medical knowledge and technologies over the past 20 years which has greatly improved the quality and effectiveness of spine surgery, Wong emphasised that patients should be realistic of their limitations, especially in cases of nerve injury.
“Nerves are slow, reparative tissue. When you talk about nerve recovery, it can be complete or incomplete. Because the spinal cord is so complicated and you injure one area, it is virtually impossible to reconstruct it. Everything is at a microscopic level.
“We have tried many medications to improve it but still, I don’t think we are able to confidently make an injured nerve recover. If it is a partial injury, yes, some do recover but if it is a complete injury, chances are very rare.”
Prevention still best
When it comes to nerve injury, the best that spine surgeons can do is to make conditions as conducive as possible to help the spine recover.
This delicate nature and structure of the spine means that prevention of damage to the spine is still the best. In certain cases such as those involving degenerative conditions, the main objective of the spine surgeon will be to prevent further damage to the spine.
Wong urged people to take care of their spines and if they suspect they may have a spine condition to seek treatment as early as possible to give themselves the best chances for recovery.
He added that in terms of lifestyle, two of the most basic things which people can do to take care of their spine are to adopt good posture and exercise regularly. This improves circulation and blood flow to the cartilage areas and help to keep joints healthy.