In just three decades, the practice of spine surgery has gone through, first, an explosion of procedural and technical innovation and more recently, the tough review of surgeon industry relationships. Very few surgeons have been so instrumental in all phases of spine surgery development and, indeed, taking the leadership role in designing the future of spine care as Charlie Branch.
But that was an almost unimaginable future when 13-year-old Charles Branch sat in his Canadian living room and saw television images of local French-Canadian violence…images that would affect the trajectory of his life.
Dr. Branch, the Chair of Neurosurgery at Wake Forest University and the former President of the North American Spine Society (NASS), explains, “My dad was a neurosurgeon, and we lived in Montreal in the late ‘60s, a time when the Quebecois were inciting violence in their efforts to secede. My parents were originally from the U.S., so, concerned about the political environment, they decided to return home. We moved to San Antonio, Texas, where I began the transition from a French/English community to an English/Spanish community.”
Enthused by his father’s inquisitive mind, it wasn’t a big leap for Charles Branch to end up poring over medical textbooks. “I was stimulated by my dad’s thoughts on various spine problems and how they might be solved. I first walked through the doors of the University of Texas Southwestern Medical School in 1977. It was a vibrant learning environment, and the teachers and senior residents really enjoyed being doctors. After completing the MD program, I began my neurosurgery residency at Wake Forest University Baptist Medical Center, then known as Bowman Gray. On many occasions I thought, ‘Wow, this is an interesting case. How great it will be when I can join my dad in practice and we can share these things.’”
Although enrolled in a clinically oriented training program, Dr. Branch would don a researcher’s hat as well.
Bowman Gray was recognized as a classical neuro-spine environment, but when it involved the neck the program was iconoclastic…they treated cervical fractures with wire and acrylic. I had to defend this to my colleagues from other institutions who thought we were loopy. But the results spoke for themselves—the patients did great and the acrylic didn’t get infected.
“In the lumbar region where decompression alone was the norm, my dad was continually questioning this traditional approach. So, in my fourth year I did a rotation in San Antonio and pulled all of my dad’s records to see how his failed backs were doing with the PLIF (posterior lumbar interbody fusion). I found that they actually did very well, better than another decompression with solid fusions on the Xrays.”
Not willing to ignore the data staring him in the face, Dr. Branch added “advocate” to his list of accomplishments. “In San Antonio I learned the Steffee screw and plate system, something that they weren’t doing in North Carolina at the time. Still being questioned by detractors, I said, ‘But what about patients who didn’t improve after decompression, couldn’t some of them benefit from a fusion?’”
I returned to North Carolina, showed the evidence to my chair, David Kelly, and he ultimately convinced organized neurosurgery to add spinal fusions to the residency training. This dovetailed with the zeitgeist because it was the late ‘80s, a time when neurosurgeons were feeling threatened because so many fusions were underway and we weren’t the ones doing them.
Continuing in maverick mode, Dr. Branch headed to the University of California, San Francisco (USSF). “During fellowship I learned a number of anterior cervical approaches, as well as several treatments for the thoracic discs. I also had the opportunity to work with some world famous brain tumor neurosurgeons. Afterwards, I returned to Wake Forest and started an academic career.”
And what of his plans to work with Dad? “Several of my surgeon mentors convinced me that going into business with my dad was a great way to ruin our relationship. I returned to North Carolina and began to use some of the novel brain tumor surgery technology I had learned at UCSF. I also indulged my love of spine, and spent a significant amount of time doing fusions; by the late ‘90s my major focus was spine. I became ‘the PLIF guy.’”
Those tasked with bringing new products to life soon heard of Dr. Branch and his talents. “In 1997 I began working with Medtronic on developing minimally invasive (MI) approaches to lumbar interbody fusion. I’m proud of this work; at the same time, it was a different ‘political’ environment then, of course. My advice to young surgeons these days with regard to industry is, ‘Be creative and be careful.’ Industry can facilitate this creativity, but don’t get sucked into something that sounds too good to be true. The worst thing that can happen to a young surgeon is to make a poor decision from a relationship perspective that will taint his or her career from the outset.”
Detailing his industry work, Dr. Branch says, “In 1998 Sofamor Danek as it was called then, was struggling to get its threaded interbody cage approved by the FDA and their interbody group asked me to help them make modifications. I was concerned that the round threaded cages were too large and that the posterior approaches added the risk of nerve injury. Yet, neurosurgeons were embracing this PLIF technique because it was technically simpler than Cloward’s PLIF technique. I advised them to make a posterior impacted device using the stepwise, standardized method of the threaded cage. Ming Liu, an engineer, worked with me to develop a system which gave neurosurgeons a set of tools to use after decompression. One tool allowed them to chisel out the disc space and another let them clean out the soft tissue and put in a cortical bone wedge—without stretching the nerves. That is how the Medtronic Sofamor Danek Tangent and Capstone product lines developed.”
And because he helped those products along, Dr. Branch was vilified by some parties. He notes, “The most significant challenge was assuming the NASS presidency during a time when the regulatory environment of industry relationships was changing.”
Here I am, a surgeon who has worked closely with Medtronic on product development…well, I was just the epitome of evil according to some.
“We at NASS decided to lead the ethics/industry relationship issue; it was challenging to find a middle ground, though, because on the one hand there were people advocating for immediate, strict measures, and others saying, ‘No, that is too much too soon.’”
So how did he manage the high wire act? “After some tough, but collegial negotiating, we have arrived at the following positions. First, physician leaders must be very transparent and somewhat separated from industry, despite the fact that the two parties are dependent on one another. Second, the regulatory environment has been putting the brakes on new technology development which we believe will negatively impact healthcare. The government and payors have responded, ‘Prove that what you’re doing or developing is worth it’ and we are addressing this with registry development. Third, we saw the need for a change in mindset such that we can no longer take someone’s published literature and say, ‘This operation is better than that one, ’ but not be obligated to show that our personal outcomes with that technology are as good as the published data.”
Dr. Branch, who completed his tenure as President of NASS in 2009, says, “The ‘thing’ for the foreseeable future is establishing the value of our work and defending our current practices. It is appropriate that we hold ourselves accountable for reviewing outcomes and determining what we do well. Traditionally, we have done a lot of ‘My TLIF trumps your PLIF’ studies, but what we haven’t done yet is a ‘Dr. A does a better job than Dr. B’ comparison. I believe that is the next wave.”
And, says Dr. Branch, the future will be based on the size and will of the gorillas. “Healthcare reform involves distinct groups with different interests. The federal government is the biggest gorilla in the room, with the law and funding on its side. The insurance companies are a good sized gorilla themselves. And the professional societies have clout, but also have the substantial challenge of working together (no group wants to let the other group be the leader).”
If we join forces as a field and can establish group-wide value metrics that we can use to defend the profession against government/payer encroachment then things will improve substantially.
A glimpse of his views on the clinical side of things finds that Dr. Branch is a little old fashioned…with a dash of radical. “There are times when you open up a patient and things aren’t what you had hoped for. Maybe the bone quality is poor, for example. In those cases you must be creative and confident that you can fix that person ‘on the fly, ’ and that your solution will be safe and effective. While things such as nerve monitoring and InFuse can be helpful, being able to call on one’s experience is invaluable. Younger surgeons don’t have that yet, and as we focus more on MI surgery, knowing what you can do with the spine and what you can’t is critical. “
I tell residents that they must learn how to operate open. Why? Because they need to see the relationships between things and know the anatomy so that when they are doing MIS they can know what is under the surface.
The best chance he has of influencing doctors may be on the home front. “My wife and I have five children, three of whom are on the path to become physicians. Our two youngest are still undergraduates and are more artistic like their mother, who is a painter. We live on a large farm and nature preserve and spend a lot of time outdoors. While my medical and administrative work demands much of my life, I am also very involved with mission work. The faith-based group that I work closely with has distributed a good deal of Biblical literature to the former communist countries, areas where the people were starving for this information because they had been so controlled by the government. It is very rewarding to be able to help them.”
Dr. Charles Branch…encouraging unity and transparency in the field.
