“Essentialism is not about how to get more things done; it’s about how to get the
right things done.” Greg McKeown
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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.
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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.
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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.
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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.
Jens R. Chapman, MD
Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
Jeffrey C. Wang, MD
USC Spine Center, Los Angeles, CA, USA
Karsten Wiechert, MD
Schön-Klinik München Harlaching, Academic Hospital, Paracelsus Medical University
Salzburg, Munich, Germany