I'm Bob Watkins, I'm from Memphis, Tennessee. Born and raised there, my mother worked for American Airlines for 30 years, raised me and went to SMU undergraduate school and came back to Memphis for medical school at the University of Tennessee. Every surgeon that looks back on their career centers around the men who trained you and the men that you emulated, and the men that you wanted to be like. The University of Tennessee was the third largest medical center in the Country and the Campbell Clinic influenced me, Dr. Alvin Ingram and David Sisk and others at the Campbell clinic teach you a method of dealing with human beings and their problems and their difficulties and it's not any specific thing, but I still examine patients today exactly the way Dr. Ingram taught me.
He treated cerebral palsy kids, said you gotta be sitting lower than the kid, you can't dominate over them. You know, certain techniques, just making people feel at ease, I trained that way, I do the same things now. I try to never be standing over my patient because if they're gonna make decisions about their care, you're gonna provide them the information to do that, you can't be a dominant figure in the room. You gotta be there to serve them. Left for California, intern at LA County hospital, which was fantastic working over a hundred hours a week and Doctor J. Paul Harvey was the leader, he was the chairman of the department and probably the most influential surgeon in my life.
And he just demanded a level of excellence from young men under him that few people were prepared for when they got there. It was perfect for me, I loved it. He gave you a certain level of training that stays with you forever. Dr. Harvey's thing was to work up the whole patient, be the whole patient's physician. Not just fix that broken leg. He was adamant about that. And we'll give you the whole story, how these things evolve, because it's-it's real. Jacquelyn Perry, the first female member of AOA an honors society for Orthopedists, was Rancho Los Amigos Hospital for years. Famous, famous surgeon, doctor and-and she gave up her service that major hospital in Hong Kong to John O'Brian who also was my mentor in England, and they were surgically operating on tuberculosis of the spine.
John O'Brian was one of the people learning under her, and Mr. O'Brian worked on developing these techniques for going through the chest and the belly and the throat and the pelvis and other things to get to the spine because that's where the tuberculosis is in the front of the spine. And so I trained under him in England, and went to Switzerland to work with, uh, professor Fitzmogrel [PH] Fitzmogrel was a brilliant-is a brilliant spine surgeon. Mogrel invented the external fixture of the spine, where it's like a fixture of the leg, it's sticking out in the back and has a thing on the back and you adjust the dials and it's goin' in to somebody's spine.
And I reviewed his first cases there, internal fixture with chest being developed at that time in Europe, for various things, were just starting to evolve and that was 1980. I came back to Los Angeles full time at USC at the county hospital, I put in the first sectional fixture of the spine I know of at, uh, in America. It led, uh, internal fixation techniques that by the mid to late 80's became the standard of care all around the world. There's a lot of turmoil when that first came out, understanding a new technology like that actually testified before congress on one of the sub committees over use of that type of instrumentation.
And there's always a lag factor, knowing how to use a technology like that. Segmental fixation means that you're going to fix the spine of each level, whether it's with a wire hooked to a rod, or it's a screw hooked to a rod, that means there's gonna be screws at four, five, three, four, two, three, whatever level you're gonna try to do a fusion. It's segmental so there's a wire at each level. But the idea that segmental fixation is better than just having four hooks on a rod that's 12 segments long, which is where internal fixation started that led to putting a screw in the spine at each level and fixing that to the rod.
When people have surgery on their back, they're laying on their stomach so you have frames that protect their spine and protect them while the surgery is going on. That lets the abdomen swing free, well that's important because if you put pressure on the abdomen it bleeds more. But then you look at what position is the spine in? Well, if your hips are extended- some of the early fixations of the spine didn’t understand exactly what position the spine should be on, on the operating table. We did one paper that was published that showed that some people normally, whether they have back pain or not, stand in 60 degrees of lordosis.
So there's a 60 degree curve in their lower back, like belly out butt out, that’s lordotic curve. And when they sit down it goes to zero. So, some people when they sit naturally, their spines in zero or 20, 30 degrees of lower dose. Well, when you do a segmental fixation, that patient's in the position you put them in forever. And so, how do you compensate for someone that stands at 60 degrees and sits with zero degrees. Well, learning those things about spine and function and that type of thing is important and our paper showed that. So everybody went to not a hip flexion frame, but hip extension frame.
There are things you can do during surgery to try to enhance that proper curve in your back. So, that was an evolution of thinking and by the time that the controversy was centered around pedicel screw fixation, it was the standard of care worldwide. If you want to fuse a spine, put a screw at each level. Fusion rate, boom, skyrocketed. You could get it to fuse if you fix it ridgally, and other modifications on that generally did not have as high a fusion rate. Do what you can to enhance that fusion. You don’t want to have a failed fusion if you can avoid it, so you do everything you can to fuse that level that you're setting out to fuse.
DR. ROBERT WATKINS III V4 2997 [00:06:03]
ROBERT: So, then, Mr. O'Brian's contributions, putting something in the disc space itself, to help fuse that. So it's not just a matter of going in the back and putting some bone in the back and putting some bone in the joints, 80 percent of the biomechanical activity takes place in the disc space. So, if you put something in the disc space, it can grow from vertebrae to vertebrae, allow bone to do that, your fusion rate goes up again. And also it's mechanically sounder. You've got these screws, you've got some fixation in the back, but if you've got something in the disc space, every time the patient stands or walks or coughs or anything, there's pressure stimulating that growth there.
DR. ROBERT WATKINS III V4 2997 [00:06:40]
ROBERT: And that's where things have gone. It's a combination of fixation, the angle you fix them in, and things we've talked about. And then the other thing is what type of stimulatory type substances, generally some type of Alspone [PH] or, artificial bone substitute that you can put in there to allow that fusion to take place. And the evolution has been different types of devices in the disc space, we used a lot of bone in those days, still do at times. Mechanical devices that help fix the disc space, but something has to allow the bone to grow. Bone has to grow from one vertebrae to the other. So these allograft, methods of allograft substitution products and other types of things that you can put in there to stimulate that growth, has been the subsequent evolution of research.
I go to Kerlan-Jobe [PH] The Karolyn Job Orthopedic Clinic in 1981. Suddenly I go from fixing scoliosis and tumors and infections and everything, to my back only hurts when I throw the ball 90 miles an hour, it doesn't hurt if I throw it 70. Taking care of professional athletes, and I've always been a total fan. My nickname in medical school was the fan.
So, subsequently we've developed different ways of taking care of high performance athletes, adolescent athletes or senior golfer athletes. We developed an area of expertise in managing those back problems in athletes from a very early age to very elderly age. And allowing people to perform what they wanna do and that's been, part of our mantra's been, you give us the goal that you have in mind. You wanna play this sport, you wanna do this, then our job is to do everything we can to ensure your ability to safely do that.
If you look at a high performance athlete, male, female, in all different areas, if you look at their body mechanics, muscle strength, everything, mental capacity, aerobic capacity, I mean it's in the 99 percentile. The conditioning and performance they have to do in order to qualify for their sport. I mean, there's a lot of people that want that spot and we assume responsibility for the whole person, I'm his physician, and those things are sacred. So, that comes first. You've gotta realize, if you've got a patient whose part of a team sport, I mean, he's gotta go back to the team.
Cause they're the guys that know how to give him the tools to succeed at what he wants to do. It's not you. So you've gotta work hand in hand with the therapist and the trainers. There are times we take a guy for a month, six weeks in Los Angeles to work with our therapists, our trainers. We do surgery. We do something and he works with our people but then we have to work hard on that transition from us to them. Where they go back to their own trainers, their own therapists. I've had such a great relationship with the trainers in the different leagues, they've just been a fantastic group of men and women that have been wonderful for me to work with.
I sit down and talk to them for hours at times because they and the coaches have that return to sport thing down. Our rehab program is a five level endurance core balance and coordination exercise program. Level five before you can return to professional sport, level three before you can be a recreation golf and tennis guy. NFL guy before he goes to the weight room needs to do a level three workout. I mean we've worked out a lot of these techniques, rehabilitation both operative and non-operative care, it's the same program. Another part to that is that it's my responsibility to, you know, what future risks there are to them returning to play, not returning to play.
You know, the decision to operate on someone so they can do a professional sport's a big decision. There are consequences for all these treatment methods. Part of the thing that you have to do is asses the morbidity. What's the problem? Not only what mechanically is the problem, what structures the problem, but what impact is that having on the patient? We’ve done studies for a long time of the psychological impact of constant severe pain, I mean it's tough. So we try to put yourself in the position of the patient, understanding what they're going through, helps you determine how aggressive you should be in your treatment methods and so it's a critical part.
And then as the physician, the surgeon has to understand what impact is this disease, this injury having on this patient? And what are the patient's goals and objectives of recovering from this? So If I could just get a good night's sleep. If I can stand more than the three minutes, I can stand now without sitting down. If I can stand 30 minutes I can go walking with my wife and walk the dog. You know, every surgeon has to understand those things because that determines your treatment. How aggressive you're going to get on the treatment depends on how big a problem the patient has. We have to merge those things together.
You hear exactly the same thing I've said about the professional athletes, it's exactly the same. Some guy wants to return to the top of that profession, another person wants to walk the dog. These are important things for the surgeon. You've gotta understand these things and tailor your treatment to match what the patient's expectations are, what the patient wants to do, what are their goals and objectives. That has to be your goals and objectives. [LAUGH] That's it.
The beauty of the spine is it's a multiple series of joints, there's a disc space, two joints, connected by ligaments and it has to move and bend and go in different directions. It's like a multi segmental thing. And therefore there are more things that can go wrong. And the forces that are exerted on the spine are fantastic forces. I mean, you sit here, if you bend forward 40 degrees you multiply the drop line of the weight of your body times the distance back to the joint in your spine, weight times distance is force, that's a huge torque there. Whereas if you stand up instead of 100 pounds times 12 inches, it's 100 pounds times one inch. That's an exponential decrease in tremendous forces exerted on the spine. In every disc there's a multi woven basket type ligament that connects the vertebrae together, but it's richly innervated with its own joints.
It's like a bad sprained ankle, it kills you step on it, to walk, to move, but it's in there you don't see it. You get a disc space infection, it's excruciating. You open your mouth, much less cough or anything, it just kills you. So it's richly innervated pressure sensitive nerves there. That's not even counting the ones that make your arms and legs work and control your bowel and bladder function. They're running through this, it's like a house, the disc is in the bottom, the nerves are running through the house, they're going out through a window called a foramen, it's moving all the time with these forces exerted on it. So not only can you hurt the structure, the bones and ligaments and tendons of your spine, it hurts badly.
You also pinch the nerves going down your legs that are exquisitely tender. You can get weakness, numbness, those are all running through that. So that's a very complex structure and how do we control that motion and activity there, that's where the muscle strengthening comes in. All the muscles in your trunk, your glutes everything, insert into the spine through the fascia. So that's controlling the motion in the spine. So if the problem is abnormal motion in joints, instead of doing this it's doing that, then you build up the strength and support muscles and train them to make it work right mechanically when you're bending, moving and doing things.
That’s what all the rehab is about. That's what the core strengthening is about. We're training muscles to make your spine work properly mechanically. Too much motion in the spine when you're trying to do the rehab, irritates things. So, working out these techniques of restoring normal mechanical function of the spine, makes this highly sensitive richly innervated multi segmental series of joints, work right mechanically and not hurt. For an athlete or anybody, they're back's killin' 'em. They're just standing there, there's no brace, there's no cane, there's no sling. They're just standing there and the natural inclination is for the people that depend on them, like a teammate or a spouse or something, in their mind they're saying, come on let's go.
I need help here. Studies have shown that if you crush your hand, well it's a different psychological impact because your hands out here, it's crushed and that's my hand. This hurts every time you take a deep breath, hurts every time you do anything, and nobody can even see other than the wince on your face. And having an appreciation of what people go through that have a bad spine problem. I mean, you know, I've just heard some horrendous stories and seen huge impacts. So, you have to have an appreciation for that as a physician, because the patient certainly does. And having an internal fixation on those products, has moved things faster.
And people are moving faster and able to get up better. The process means that if you're gonna have an outpatient surgery department, then you've gotta cover the nursing, the home care, who do you call, how do you get home. But the process has to account for everything in that regard. You can't just send somebody down the street. Our prescription is for the patient to walk as much as you can from the minute of the surgery. We want progressive ambulation four times a day, so the evolution is toward better patient care. And most sub specialties as soon as you're out of the hospital the better, those are things we're all striving for.
If you've got a fragmented disc sticking out and you're having sciatica and leg pain, taking the fragment out's the best solution. It’s not a spinal fusion. I've seen lots of people that I've assessed their entire history, physical and all the things together and I can tell them the only surgery you should have for this is spinal fusion. Microscopic decompression's not gonna help. So that's part of the surgeon's decision making process, and part of his rapport with the patient. Part of this assessment is to go through the patient. You gotta walk before you run, so, some guy wants to go back to running six miles a day, that's a worthwhile goal, but let's have you walk 100 yards first.
So it's kind of that process. Walking is good for spines. I think it wakes up the core muscles because everybody's pelvis rotates like this, these muscles connect to your spine and by relieving obstructions sometimes if somebody can’t stand in one spot for three minutes, then you start restoring that mechanical functioning to the spine with walking. Part of our rehab program is aerobic exercise because if you're out of shape and not fit, you lose your balance and coordination. We've gotta get you in good aerobic condition, and walking's where it starts. Orthopedics is about function, that's what I was taught from the very beginning. It's about function, how does it work. It's not an artistic thing, it's not a qualitative thing.
It's not what it looks like, so that fits right into how you assess an individual patient's ability to return to work safely. If you don't know the difference between a pitcher and a second baseman, you need to reevaluate what you're doin' takin' care of these guys. You gotta identify exactly what the problem is, so there are times we do a surgery hoping that a patient can stand 40 minutes. Well that doesn't cover their whole life, but you define what is my surgery designed to correct. Well, for spinal stenosis, by and large the decompressive surgeries are designed, in my experience, to correct your standing time. If you're laying down you can't sleep because you're sleeping in the same position you are standing, and you can't sleep, well we can relieve that compression that you have there. Then we triple your sleeping time and we triple your standing time.
We assess future products a lot for various mechanisms. We look at anything we think is in the ballpark. We go over the product at times, but I think that you know, I hate to be too individualistic about this, but I don't see any big panacea. Ten years from now, theoretically, injecting something into disc space and making it healthy again, everybody would love to have that. It's currently a not possible, but I think for me, there's so much of a struggle just maintaining what we have.
Getting across the concept if an adolescent has a stress fracture in the back, they've gotta do our stabilization program, and when you talk about progress, there are gonna be some setbacks along the way. We come up with a great fusion product, but it costs us some secondary effects that it takes some time to figure out what those are. So, there's two steps forward, one step back in medicine. You’ll get a cancer treatment that someone goin' through, St. Jude's, wonderful place like that, and they don’t get it 100 percent. There are going to be steps forwards and steps back. And that's part of what science is.
So these advances come in starts and stops; you can generally say less invasive, cause less problems, better approaches, more microscopic and endoscopic approaches to the spine. That's a broad topic, but a worthwhile one and we've been on that path. You can't talk about improvements and innovations in surgeries. It’s not always a better screw, a better bolt. You've gotta feed in there the human part, better rehabilitation programs and better recognition for rehabilitation programs that can be used instead of surgery. That's why the physical therapist, the trainers just play a vital role in the surgical results, so for us we don't wanna leave the human part behind. It's just a big picture, a composite picture of a number of different things for progress I think.