Hans Jörg Meisel has always been inspired by creating new and bringing people together. Today, Meisel himself is an inspiration to young surgeons and stimulates their minds with good questions and ideas.
Here, Meisel explains why he thinks every spine surgeon should do research, how back pain will eventually be solved, and how he engaged with AO Spine in a time that was bursting with new innovations, both good and bad.
Meisel's story resonates with the times we live in today. Read on and uncover a hefty surprise from his first career, weighing no less than half a ton!
I got into spine surgery in a time when a lot of new things were being developed. I was also excited by the combination of skills and technique, research, education, and business.
My career started in the 80's in Florence, Italy, where they were already operating very minimally invasive, up to scoliosis surgeries. To see all that as a young student was fascinating and really got me into spine surgery. Neurosurgery was the easiest way to achieve that.
"It was big stuff—it was the time when we moved from external to internal fixation."
My first superior in Berlin was Brazilian, very international, with a huge interest in education. It was big stuff—it was the time when we moved from external to internal fixation. Before that spondylolisthesis could not have been treated by fixation. We shared knowledge of major innovations and technologies that we had only just learned ourselves. Over 15 years, we trained 400 Latin American neurosurgeons in spine and general neurosurgery.
In the early 1990's, I gave my first training course in Curitiba, Brazil. AO International provided the instruments and the background. At first, the AO Spine Chairperson Max Aebi did not want me to use AO material, but we solved our conflict and became friends. I have been with the AO ever since.
After the wall came down, I was approached by the German Ministry of Research, who wanted us to find startups and develop the greater Berlin area into an innovation hub. For example, we developed the first transplantation for disc cells repair after disc surgery with the biopharmaceutical company Co.don. That was the kick-off into research and innovation for me, and the first step into the biotech business.
"I understood that biotechnology would be valuable for spine surgery."
I understood that biotechnology would be valuable for spine surgery and set up BioSpine to bring people from this field together. We did the first human disc cell transplantation with autologous chondrocyte in 2000. Max Aebi attended our first congress in 2002, and I was invited to help launch AO Spine Europe in 2003. We developed new formats for education and new biological approaches. I then did a lot of research and activities in biotechnology, and a bit later after I joined the AO Spine Knowledge Forum Degenerative.
That is one side of it. It was a time of major biologic innovations and the time of medical devices being developed for spine surgery, and suddenly, I was part of it.
The industry was developing fast. Sometimes you could not even recognize if a development came from surgeons or from the industry and for what aim. Up to the early 2000's, a lot of money was made in spine industry with an annual growth rate of up to 20%. I would say there was also a lot of unneeded innovation, a lot of money-making, and unhealthy financial interest associated with the creation of the MedTech branch with all the big companies.
Vertebroplasty is a good example. There was an idea to stabilize osteoporotic and other spine fractures by pushing cement into vertebral bodies. The industry supported that strongly and it became a big hype. Or look back at the lumbar spine prothesis from the Charité University Hospital in Berlin in the early eighties. This was not protected well and was taken on as a fantastic innovation in the early 2000 and distributed worldwide. In the end, it was too difficult to use even at the current technology level.
But I was also active in research of interventional neuroradiology for minimally invasive treatment of neurosurgical diseases like aneurysms and arteriovenous malformations of the brain. With Pierre Lasjaunias we did a lot of data banking and cases together, and successfully developed and published a data bank.
"We want to make everyone see how important it is to generate clean data, to understand it, and to publish it."
So, I learned early on how important it is to generate sufficient good quality data.
That is what we are doing in the AO Spine Knowledge Forum Degenerative. We want to make everyone see how important it is to generate clean data, to understand it, and to publish it.
They really should. Every surgeon knows the importance of performing good medicine. By collecting data, you get an overview on what you have done. Surgeons should publish their own data, know their own complication rates, and benchmark themselves. The surgeon community must work together, and AO can help with this—this is what the AO was founded for! In such collaborations, you should do your own research, clinical or in the lab with in-vitro and preclinical questions.
"Surgeons should publish their own data, know their own complication rates, and benchmark themselves."
So yes, I think it is extremely important. I see many people at universities not being active in research when they really should be. In my institution, we had no money for research, but we got funding from outside and set up a research group. People should do that more; it is immensely rewarding to encourage young people into research.
We have learned this also with AO Spine studies. For example, for the AOGO we put out a call and asked if people would collaborate with us in developing a guideline for the use of osteobiologics. Currently people do not know what they are using or how the materials should be used.
There was a huge interest! In two days, we received 150 applications. We brought the people together, set up working groups, gave them topics, and now we are collecting the results and driving AOGO towards a recommendation of using biologics in ACDF. It is a great experience; you see the interest and with good questions you stimulate people to collaborate.
First, you need good ideas and good questions. You need to know what you want to study. Then, you must collect clean data and you must collect your own. In Germany, this is not mandatory, and people do not collect their own data as they should. If you ask a surgeon about their complication rate, most people working in public institutions will not know. They are not collecting the data because nobody is paying for it.
Luckily, this is changing with registries. For example, in Sweden it has been obligatory for a long time, and they have good results to show—these databanks are a gold mine to publish.
We are trying to inspire people to combine their data, join research groups with good questions and ideas, and to publish together to create evidence. In spine surgery clinical trials, the level of evidence is still extremely low.
"We are trying to inspire people to combine their data, join research groups with good questions and ideas, and to publish together to create evidence."
We have analyzed this from the very beginning of our Knowledge Forum Degenerative. We found that there is an enormous amount of data and number of publications available. You find good results; you find fantastic fusion results. But if you evaluate the evidence, you see a lot of it is useless, time and money spent for nothing, because the evidence is lacking.
Having said that, the situation is improving. Ten years ago, the Cochrane report asked why spine surgery is not delivering better data or better research. It was still a field in development, there was no collaboration, and it was not easy to implement common rules or guidelines. Everyone was working it in the way they could. But this will not bring good evidence or results in the long run. A lot of time and effort were needed to start improving the field and to make it more serious.
I want to see better evidence in research. In spinal diseases and back pain, we must move into earlier phases. This means we must step into the natural history of degeneration and be in earlier with our treatments.
We should also educate people in general about the first signs of spine diseases and move towards earlier phases this way. In the early pre-degenerative phases, we at least have a chance to repair tissue and not just treat the very late degenerations, huge spondylolisthesis, or similar.
"We should also educate people in general about the first signs of spine diseases and move towards earlier phases this way."
Focus must be put on new technologies, big data, and artificial intelligence to better predict outcomes and degeneration and to clearly understand which technologies to use where. This of course affects all medical fields, not just spine.
Eventually, breakthrough innovation will come in biologics, this is clear. So much is happening now! With our transplantation at the time, it was difficult to convince the conservative communities, but the environment has changed. We have more knowledge and active groups in the field, and one day there will be a breakthrough that can heal a disc prolapse. We will be able to heal early phases with knowledge created in molecular and genetic medicine, things like that. These are the first steps for advances in back pain.
"Eventually, breakthrough innovation will come in biologics, this is clear."
It will take a while, but Big Pharma has already understood there is value in these new therapies. With collaborations between good research and pharma groups, sooner or later we will have the results. This will be good for the facet joints, disc, and cartilage repair.
I follow closely for example developments in the knee, where the amount of data is growing and there is more evidence. The disc is also of cartilage, and these are all developments where clinicians need guidelines how to use new materials. We can only support that. A surgeon is not normally trained in biotechnology.
We can also help surgeons understand why they should be interested and investigate general developments in medicine, not only from the perspective of a spine surgeon. Participating for example in projects as a peer, reviewing abstracts or applications is something you should do once in a while. It gives a good view into other fields. Banks and industry have foundations for research, and we can help them find the best projects in life science.
When we were developing AO Spine Europe in 2003–2006, one of the nicest things was to finally meet the people you had been collaborating with. A huge community was created in that work, and we still benefit from it today.
All meaningful activities are somehow born from such personal collaborations. It is the most valuable thing for doctors, researchers, or the entire Spine network out there, that they do something together.
International research is fantastic because the network is such a big part of it, and in the end, it is very personal. You have to sit down together, have a beer together, have dinner together, ski together to have this kind of exchange. Without this, nothing would be possible. That is really the number one thing, bringing people together, connecting people, expanding the network, and enabling young people to approach these circles. Sounds simple, but it is enormously important to stimulate people and grow their enthusiasm.
"All meaningful activities are somehow born from such personal collaborations. (…) Trust comes from being with a person and being able to connect physically."
The pandemic forced us to develop easy-to-use collaboration tools where we can see and hear each other. Before, it was all done by email, but without seeing each other's expressions, the exchange is less valuable. Meeting people is most exciting, and to me, developing personal relationships is enormously important.
Trust comes from being with a person and being able to connect physically.
I am extremely happy about the good response we have received from the AO Spine community, bringing people together, and engaging them in research collaborations. They have accepted the challenge, taken the time, and I can see they enjoy it. This makes me happy.