Abstract
“Essentialism is not about how to get more things done; it’s about how to get the right things done.” Greg McKeown 1
As the CoVID 19 pandemic heads into its one year anniversary (date depending upon where one wishes to set the “start date”) our lives everywhere remain fundamentally impacted by its ongoing spread. In reflection of the recalcitrantly surging waves of this disseminating viral disease our lives have become reduced to bare minimum personal interactions in a home setting. Given the ubiquitous travel and contact restrictions our fundamental human sentiments to directly connect with one another in cases of loss or serious illness of loved ones and to congregate in groups to exchange fellowship and ideas directly have become subsumed into remote transactions in a digital sphere.
Our generally prevailing atmosphere of prolonged restrictions paired with uncertainty has brought on the opportunities to embrace the philosophies of essentialism: in our private lives we (should) spend much more time with what really matters – family and close friends and care of self and others. Unfortunately in our work lives as Spine surgeons we continue to be challenged by public health boards and various selection committees to select the most “deserving” cases for surgery that are perceived to least impact general public resources. Pure “essentialism in spine care,” a subject to be further explored at a later time….
During the ongoing pandemic the care demands on our spine specialty seem to have morphed as well. Spine trauma of non-geriatric patients as a result of recreational, mobility and work activities seem to have receded while patient numbers presenting with de novo spine infections and delayed presentations of spinal oncologic disease seem to be on the rise. Only time will tell if the increased life stresses and its effects on public mental health brought on by prolonged anti-contagion measures and unemployment will further manifest themselves in greater numbers of patients seeking care for back and neck pain. The impact of having been subjected to forced “Essentialism in Spine Surgery” will undoubtedly provide a rich fodder for research in years to come.
As we are collectively floundering through this pandemic experience we do have a chance to practice another aspect of true essentialism – to pause and celebrate great achievements of past and present. In this vein the passing of Professor Friedrich “Fritz” Paul Magerl on November 14, 2020 gives rise to such a moment of reflection and appreciation. 2 The phrases “essential” and “essentialist” both apply to this unassuming foundational giant of AO and the Spine world at large. From the originating works of the AO Trauma pioneers he grasped the need for optimized fixation in Spine surgery before anyone else did and provided us with lasting implant concepts. This extends from the most original application of the AO interfragmentary compression screw fixation idea that he refined for the stabilization of suitable dens fractures to the use of screws to firmly attach cervical spine constructs to the skull. Another common fixation strategy—the safe application of lateral mass screws in the subaxial spine—is still commonly referred to as the “Magerl” screw and the elegant transarticular atlanto-axial screw fixation idea all were similarly pioneered and published by him and his team. Remarkably, all of these implant designs were carried out with tools and implants from the AO Trauma inventory and were reinvented for Spine use. For the thoracolumbar spine his lasting contributions consisted of the “Fixateur externe” a percutaneous pedicle-based fixation system for the stabilization and reduction of thoracolumbar fractures and certain deformities like isthmic spondylolisthesis. While some of his past fellows not so fondly remembered the difficulties of adapting hospital beds to external fixation systems protruding from patients’ backsides in fact this technology presaged the use of “MIS” (as in Minimally Invasive Surgery) by several decades. This pedicle-based implant technology would later morph into the “Fixateur interne” for internal fixation of thoracolumbar short segment fracture care, again by borrowing basic devices found in the AO Trauma instrumentarium. Not only did this implant philosophy revolutionize modern spine fracture care, it de facto brought current day pedicle-based fixation into the mainstream of spine practice. And yes – the breakthrough “Universal Spine system” commissioned by the AO also had his fingerprints on it - as did virtually any spine technology endorsed by AOSpine through his directorship of the “TK (Technische Kommission – Technical committee),” which he founded and lead for many years. His basic philosophy was always that of a true “essentialist”: to achieve the optimal result with the least invasive and most effective means of surgical technique, instrumentation and implant.
On a metaphysical basis the AO Spine community is perhaps most widely regarded for its comprehensive fracture classification systems which was in its spine incarnation conceived by Fritz Magerl and colleagues (aka “The Magerl classification”). While critics may hold its multiple subclassifications against it, in its purest most basic form – A, B and C with associated primary numbers of 1 through 3, this system remains unparalleled in its simplicity and impact. Tellingly, it has survived to the present day in an updated form true to the original spirit as a foundation for a comprehensive classification of the entirety of spine injuries. 3
Beyond the many accomplishments in device developments and creating a meaningful supporting development structure as well as spearheading a globally used classification system the perhaps most lasting legacy of great pioneers are their disciples and – in turn- their offspring. A small and incomplete sample of game changing spine surgeons who served as his clinical fellows in the 1980’s and 90’s may give an impression of the magnitude of this future impact: Mike Coscia, Mitch Harris, Mike Janssen, Bennie Jeanneret, Claudio Lamartina and Rick Sasso all have carried the spirit of Fritz Magerl into different regions of the world and are living and breathing examples of his spirit of what are “Essentials in Spine surgery”: to question the established and to always move forward with intent to improve patient outcomes by the simplest but most effective means possible. 4 A vivid first-hand description of the lessons learned from this departed master can be found in a Letter to the Editors from one of his former fellows, Dr Michael Janssen enclosed in the attachments. 5
In these moments of seemingly suspended reality it may help us all to draw inspiration from this essentialist Spine master by remembering the words credited to the unimitable Albert Einstein: “The true sign of intelligence is not knowledge but imagination.” Hopefully these words, which one can easily imagine having been said by the late Fritz Magerl, paired with the example of his life work, will embolden us to see beyond the current quagmire toward a better tomorrow.