Thanks Praveen. Thanks everybody for waking up, coming early. Unlike the previous sessions, I'm not going to pimp anybody except the Alabama fan. You're going to get a couple of questions. But in 35 minutes, I may run one minute over or something, but I thought it would be important for you guys to have a good idea, really out of fun, just to know about ancient history, but more importantly to know what's happened in the last couple of decades so that when you go to work every day and train and ask your attendings about cases, you have an idea of how we got to where we are. My disclosures, I currently get a royalty, I'm about to get a royalty from a plate that I helped design. I helped create the website Spine Universe. I work for the Department of Justice going after bad guys, and I'm a consultant for a couple of other companies. When you look back at any type of recorded documents or archaeological finds, one of the most important findings is the papyrus found from ancient Egypt that was discovered by a real shady relics dealer named Edwin Smith, and was later translated by a guy named Breasted in 1930. But in that, deciphered from that document were 48 medical types of cases, and four of them were related to brain and spine injuries, and the Egyptians clearly understood the relationship between spine injuries and the effects on body function. In this papyrus, the translation is such that it had a fatalistic attitude towards complete injuries, and one of the quotations from it is, one having a dislocation in the vertebra of the neck while he's unconscious of his two legs and two arms, an ailment not to be treated. However, they felt that if thou examinest a man having a sprain in a vertebra and he contracts both his legs in pain, incomplete, that should say I will treat. They were treated by priests, and they basically just laid them prostrate. The real learning process began with the Alexandrian school back in 300 BC, and that involved Hippocrates, and they had cadaveric dissection, they had didactic teachings. Hippocrates felt that if somebody was complete, that it was basically a situation where you did not treat, but if you had an incomplete injury, they designed, he helped design a treatment called succussion where you would do a sudden violent pressure on the patient's back trying to reduce a fracture, and if that didn't work, you would take a goat splatter filled with water, put it between the back and the rack, and then do this type of sudden, forceful type of reduction. Hippocrates understood the relationship between the injury and paralysis and urinary problems. The next major figure in the whole history of spine treatment is Galen of Pergamon, lived in A.D. 129 to 200. He was a physician to the gladiators, so you can imagine the injuries that he saw, and he understood the correlation between the level of an injury and function. He was the first guy to use the term scoliosis, lordosis, kyphosis, and he actually advocated for surgery for fragments of bone to be removed from the spine. There's very little evidence as to how that went or how many he did, but he was the very first advocate for it. And if you had an infection, that was thought to be good. If you saw pus, they actually had a term called laudable pus, thinking that was a good thing. Things changed in the mid-7th century with Paul of Aegina. He trained in the Alexandrian school. He wrote seven books on the Galen traditions and Greek medical thought. He actually did trepanation to remove bone fragments from a compressed spinal cord, and he was really into instruments. There's a lot of evidence that's been revealed about different types of instruments that he designed, including one that he called a red-hot poker or red-hot iron. One can only imagine what that was like in an era of absolutely zero anesthesia. After him, there was really no new ideas for almost 1,000 years, and there was a resurgence in Italy in the Italian school of Salerno led by a guy named Roger of Salerno. He wrote the first Italian textbook on the practice of surgery that included some descriptions of spine treatment. One of the original copies of that book from the 1100s was owned by Harvey Cushing. The next major figure was a guy pictured here, Abasin of Baghdad. He wrote a treatise called Canon Medicina. Basically, there was no new advances, but he illustrated in great detail how to basically put someone into traction to distract spine injuries. The next major figure in the medieval period was Theodoric of Bologna. He wrote a famous book, translated it just means Surgery of Theodore. He described how to examine the spine-injured patient. He felt that pus was not a good thing. It probably hindered healing. He was one of the very first people to recommend some type of anesthetic-type treatment using a combination of usually wine and other products such as these, such as opium, hemlock, flax, laptham, mulberry, etc., which was applied to the nostrils. He was one of the first to advocate in great detail realigning a fracture dislocation by reduction and traction and even splinting using a type of brace. For the cervical spine, this is a quote from his. You can imagine doing this in an era of having a little wine put on your nostrils where he describes how to reduce a fracture. He wrote, put a sling under the jaw, hold each end of the sling firmly while lifting upward, putting one foot on the shoulders, pressing downward with the feet, and pulling hard on the sling with the hands. The vertebrae may be forced to align rightly. Probably not the technique you're using in the ICU. Then there was a real stagnation for many, many years, literally 1,500 years where there was no further writings about it, no further advances in the treatment of spine injuries, which of course went on indefinitely. One of the Scottish surgeons, John Bell, was quoted as saying that cutting into a vertebra is a dream. Charles Bell, his brother, denounced laminectomy and the terrible pain that it inflicted on a patient. You can imagine a trepanation type procedure or any type of laminectomy with no anesthesia. The problem was with no anesthesia, no technology, the surgeries were very hurried, there were mistakes made, poor judgment, poor surgical techniques, infection, and so spine surgery was really considered inhumane. And what really sounded the death knell was a case presented by Henry Klein in 1814. He had a 28-year-old man that fell out of a second-story window, had a fracture dislocation, was paralyzed. Klein presented a case where he made an incision, removed a fractured spinous process and portions of the lamina, noted that the cord was transected, and the patient died four days later. And it caused a huge uproar in Europe, and that basically killed things for quite a while. Percival Pott, you've probably heard of Pott's disease. Percival Pott was someone who kind of kick-started the treatment of spine problems and began the acceleration phase, which we'll talk about in the next few minutes. The main problem with the spine, if it wasn't a traumatic injury or a gladiator having a lion crush their spine, it was tuberculosis. And he described a breeding pair of vertebral abscesses, which was the most common infection, and reported some success. And then helping the acceleration phase were other related types of discoveries. Louis Pasteur, with his descriptions of bacteriology and bacteria. Crawford Long, the hospital where I operate in Atlanta is named after him. Most people give credit to a different surgeon, Morton, who apparently did the first anesthetic type of surgery in the ether dome at Harvard. But it was actually Crawford Long in Jefferson, Georgia, who had been doing it for years, and actually reported first. Joseph Lister, with his concepts of antiseptic surgery. And ever since William Rankin took an x-ray of his wife's hand, then almost immediately radiographs of the lumbar spine, cervical spine, began to be used for treatment of patients. And the first real successful laminectomy since the time of Agena, it goes back to Kentucky, I think it was Danville, Kentucky, where Albin Smith had a patient who had an injury, had an incomplete paralysis for about, I think about two years. He did a laminectomy, and the patient improved. And for reasons that are not clear, Albin Gilpin Smith then changed his name to Goldsmith, became a urologist, and worked the rest of his career at the College of Physicians and Surgeons in New York. So it was sort of a one-shot deal, but he made his contribution. Now another major, you all have probably seen on the set, we call it the elephant toenail clipper, the big Horsley spine cutter. Well, Sir Victor Horsley also advanced the field, and did one of the first successful laminectomies for spinal cord tumors, and later presented a series of them. He developed instruments, he used antiseptic bone wax, he used deep anesthesia, and just so you have a sort of a cultural reference, that was a time when Major League Baseball consisted of teams named like the Wolverines and the Browns, where they had a 15-game World Series that traveled around the United States. And at that time, Gottlieb Daimler had presented the first four-wheeled vehicle in Germany. Entering into the 20th century as we move along, you know, traumatic injury and POTS disease and associated deformity really were the main things that surgeons or physicians in general treated. And surgical debridement remained the mainstay of POTS disease until surgical stabilization techniques began to emerge. And one of the great starts and contributions were made in New York City by a guy named Fred Albee. And he had a concept, I'm certainly not a gardener, but apparently you can graft fruit trees by splitting the stems and putting pieces of another tree in there. And he had the same kind of concept by using cancellous tibial bone or cortical cancellous bone, splitting the spinous processes and putting bone into that area and spanning an area of deformity. He was very cognizant of the importance of the periosteum and doing decortication to get things to heal. I guess from his, and I've read some of his original papers, he actually had used animal bone into humans. And so he was one of the first people that had the concept that you probably ought to use somebody's own bone or somebody in his family as opposed to a dog or a goat. He understood mechanical factors and he personally was responsible for taking care of many, many soldiers injured in World War I and worked right on the front lines. And for cultural reference to that time, that's when the Model T was introduced and Babe Ruth, then at the Red Sox, helped defeat the Philadelphia Phillies with Woodrow Wilson looking on. And so just to summarize, he understood what was already described at the time as Wolf's Law. And what I think really is the simplest way to think about bone biology is something called Murphy's Law, which is the amount of growth in bone depends on the need for it. And he understood that and really made a huge contribution to the field. But then decades passed before the understanding of degenerative conditions came to light. Really up to this time it was just infection and trauma. And one of the great advances, most of you have heard about Mixter and Barr and their contributions to disc surgery, but the first disc operation that reported in the literature was actually Walter Dandy. And it was five years before Mixter and Barr presented their landmark paper. Preoperatively, he had made the diagnosis through an oil-based myelogram of a tumor. And when you read his original monograph, he starts off talking as the pathology is a tumor and by the end of the paper, he's describing it as a cartilaginous fragment simulating tumor. It's this sort of confusion in his monograph why he is not always quoted as the first guy to do disc surgery. And though some of you may have already done this accidentally in surgery, he did basically a complete transgirl approach to the disc. He opened up the posterior aspect of it, went in, parted the nerves, opened up the ventral surface of the sac, took the fragment out, sewed everything up, and the patient did well. But in his original paper, he made the link that this sort of pseudo-tumor or cartilaginous tumor was likely related to repeated injuries or trauma to the lumbar spine. And that really began the process of thinking about degenerative problems. And to me and to many, the real father of degenerative conditions of the spine is Ralph Cloward. I had the honor of seeing him several times. And some people in the room, like I don't know if Eric Woodard is here or Pat, he used to religiously attend the spine section up until the time of his death. And he was the father of posterior lumbar interbody fusion. And in my practice in Atlanta, I saw two patients that had been operated on in the 1950s that had an uninstrumented pliff where the entire disc space was filled with beautiful, well-heeled, mature bone. He was a master technician. He made major contributions to the anterior approach to the spine. Prior to Ralph Cloward, everything was done through four different described approaches by Scoville, which basically ranged from phrammonotomy all the way to full laminectomy. So he was thought of as a heretic. He was criticized at meetings. No one was able to reproduce his results with pliff. And that's why in one of the excellent lectures yesterday, somebody pointed out it wasn't until the 1970s when Lynn described pliff techniques that the resurgence began. But he was known as a master technician. And he had a quote. He had presented some cases to the, it was called like the Hawaiian Regional Surgical Meeting. And people were yelling at him and whatnot. And he said, you can always tell a pioneer, he's the one with arrows in his back. For cultural reference, at the time that he presented his ACDF paper, the Chevy Impala was the hottest car in America. And the Yankees with Mickey Mantle, Yogi Berra, Whitey Ford, Casey Stengel. If you can't tell, I'm a Yankees fan. Were the winners of the World Series for the 18th time. And we'll go back to more Yankee history in just a few minutes. So in the following decades, things started advancing at a really, at a very rapid pace. And so even to this day, still controversial, it's back then when discography began. There were people like Sanford Larson, who Eric Woodard trained with, that began describing extracavitary approaches, transoral, transsternal approaches, costotransversectomy, transperitoneal approaches, transthoracic. Biomechanical concepts began to be better understood. People were starting to think about the actual metallurgy involved in fixating the spine. There was a better understanding of bone healing. And this was all setting the stage for better instrumentation. And up to this point, around the 1950s, still the surgical treatment was quite limited, particularly for scoliosis that had very bad results. Until this man. And you, I don't know if any of you, you probably in your training will still encounter a patient that will come in that had a Harrington rod placement probably as late as the late 1980s. And beyond that, they basically disappeared. But he was really the first guy back in the 50s that came out with a system that was very useful for scoliosis. When I was a resident, this is all we had. We had one hammer and everything looked like a nail. If you had a compression fracture or a deformity or a slipped spine or anything, Harrington rods were what we had to use. And he understood the concepts of scoliosis. And basically his system was either a compression or distraction system based on rods and hooks. And the basic concept was to lengthen the short side of the deformity or the concave side of the deformity. And probably his greatest contribution was linking or measuring the rate of time to failure of that instrumentation to the rate or time of healing of a successful fusion. But the problem was this system was limited to posterior only. The hooks would frequently become dislodged. And it usually required a very long construct to treat the affected area. So the next big advance was Dwyer from Sydney, Australia. He introduced a system that could be used anteriorly. And it provided compression on the convex side of the curve, allowing for shorter constructs across the deformity. And it was a screw and cable system with multi-segment fixation distributed, which distributed the load more evenly across the curve. The problem was that it was very limited in axial loading. It allowed for progressive kyphosis to occur. It resisted tensile forces but not shear forces. But it was a great advance at that time. And that was around the time that the Mustang was introduced at the 1964 World's Fair. And my parents have a picture of me standing in front of that car at the World's Fair in New York. Just a little extra tidbit. The race of the technological advancement continued on and quickly accelerated. Zilke, Klaus Zilke, replaced the cable system of the Dwyer system with flexible rods, which allowed for better control of sagittal balance. Eduardo Luque, who used to travel a lot, he came to America frequently. I was involved in several meetings with him. He was a guy who could make things happen with very little materials. I remember going to meetings in Mexico and other places where we talked about pedicle screws and titanium rods and everything. He basically did things with wire and rods. He was really a very creative guy and advanced the techniques of sublaminar wiring and L-shaped rods. You would put rods down with a bend at the bottom, so when you fixated them to the lamina, there would be some resistance to settling. His contributions, he's passed away now, but he was a remarkable man. The next huge leap in spinal surgery and spinal instrumentation involved two guys, Cottrell and Duboiset. Their system was really the first system that came to this country. There was a period where companies would sponsor courses for thoracic and lumbar fixation before any of these products were FDA approved. I went to one of those courses back in the, I think it was 1990, and it was absolutely staggering. The CD system, the Cottrell-Duboiset system, when it was spread out, it was about 12 trays, an unbelievable array of hooks and screws and cross links. It was overwhelming to try and learn that system, but it provided maximal rigidity. You had much greater power to control the coronal and sagittal balance in a patient, and it was a major advance. It was these guys that then just basically lit the fire that took off in America. But it wasn't until the late 1980s that neurosurgeons began to use spinal instrumentation. Increasingly, neurosurgeons began treating fractures with wiring techniques. Anybody here heard of the Rogers interspinous technique? Probably not. That was what we used. We would take little plates of Iliac crest, and your instrument was the bone. You would wire it down either with that or a Bowman triple wire technique using what's called Wisconsin wire, and that was state of the art in the 80s. The early leaders were Caspar and Paul Cooper, Volker Sontag, Reg Haid, that really helped lead organized neurosurgery. Fewer halo vests were used, and more internal fixation was starting to be used. When I was a resident, I was at UCLA. Every single resident had in his pocket a halo wrench. We put every kind of trauma in a halo. You were putting on a halo, if you were at a major medical center as a resident, you were putting on one or two halos a day. I can't even remember the last time I put a halo on a person. How many residents here have put a halo on somebody in the last two months? A couple. There's still a role for it, but far, far less than what it used to be. But as neurosurgeons started delving into this, and the first entree of neurosurgeons was really getting more into cervical instrumentation, all of a sudden territorial battles started arising with our orthopedic colleagues, particularly over thoracolumbar instrumentation. The AANS, the longest standing spokesperson for neurosurgery, took the reins and appointed David Kelly to form a task force in 1987. This is probably the most seminal event in spine surgery in America, was this task force. Because in 1987, they realized that they needed to expand the scope of spine surgery in the field of neurosurgery and have neurosurgeons become surgeons of the entire spine, from the base of the occiput to the bottom of the sacrum. And so this committee worked with the ABNS, the RRC. There were formal statements released that confirmed that neurosurgeons had received training equivalent, if not much better, than orthopedic fellowship training, who were the guys that were out there doing most of the instrumentation. And the ABNS and the RRC amended their definitions of neurosurgery to emphasize spinal surgery infusion techniques, much like what happened recently where the ABNS and the RRC redefined what is neurocritical care to make sure that all of us are still included in that. So it was a very interesting time. People in this room, you may grow up to be general neurosurgeons, you may be a couple of people that express an interest in spine, you may be a functional neurosurgeon, but the organization for neurosurgeons still remains the spine section. For those of us who don't do any peripheral nerve, we have to remember that it's the AANS, CNS joint section on disorders of the spine and peripheral nerves, so there's always a portion of the meeting dedicated to that. But the very first meeting took place in Greenleaf, Florida, in 1985. Think of the practical courses that take place at the meetings now, AANS, CNS, NAS, etc. The first practical course was back in 1987, and Volker Sontag wrote a paper where he described that the highlight of the course was learning how to twist two strands of 24-gauge wire three times per centimeter and use that for wiring techniques in the cervical spine, and that it was a great advance over using 18-gauge wire. That was the practical course. There were practical courses on how to put a halo on. It's actually mind-boggling to think what happened in really a very short time. But the turf battles raged on, and when I went into fellowship in 1994, there were fights in hospitals where orthopedic surgeons were trying to prevent neurosurgeons from doing fusions, and really up to that point, things like ACDS were done by the neurosurgeon decompressing the spinal cord and then the orthopedic surgeon stepping in and putting in the bone graft. In places like even Duke University, that continued right up until the 1990s. But the one thing that brought everybody together and really stimulated the relationship that has blossomed to this day was litigation that broke out over pedicle screws, and the company that was attacked first was Acromed in Cleveland. Despite all the fighting over who gets to do what in hospitals and orthopedic surgeons trying to keep neurosurgeons out of the thoracolumbar market, all of a sudden everybody was united in this fight to be able to use pedicle screws. And Benzel at that time quoted a 19th century proverb, adversity can indeed odd bedfellows make. And ultimately, through the strength of some other corporations, Acromed folded and settled and wrote a check for $200 million in this class action lawsuit. But at that time, Sophomore Danik and others fought it, and ultimately the winners were the patients. We were able to use off-label until it became FDA-labeled. We were able to use pedicle screws for thoracic and lumbar disorders. Then, for the first time ever, when I was a fellow in 1994, I went to an AO course. Most of you have heard the term AO, an arm of synthese. They paid for my airfare back when you could do that, and I flew to Bermuda. I went to a course. I was the only neurosurgeon there. There was about 100 orthopedic surgeons. I checked into the hotel, sat down, went to the lecture hall, and everyone's lecture was digging at neurosurgeons. During the practical part, some of the teachers would come up to me and say, Oh, you're the neurosurgeon? You don't need to know how to do this. These guys will do this for you. I actually went back to my room, packed up my bag, went to the airport, and flew home. That's how things were back then. But then all of a sudden, things started changing. We started inviting orthopedic people to our meetings, and they would invite neurosurgeons to their meetings. So a lot of cross-fertilization started to occur in NAS, and the Scoliosis Research Society, and the CSRS, and the WNS, and the CNS, not to overwhelm you with organizational acronyms. In 1999, the Journal of Neurosurgery Spine was started. I can tell you, we used to talk about the White Journal and the Red Journal, and there was almost nothing in it that was pertinent to spine surgery. In a single issue, there would be 10 articles on the anatomy of the thalamus, and yet 80% of neurosurgeons in America were out doing spine surgery every day, five days a week, and there was very little recognition of that activity until this started. Those of us that were interested in spine, we knew not to send our articles to neurosurgery or JNS. We would send it to Spine or Journal of Spinal Disorders, et cetera. But the relationship with orthopedics continued to blossom. Then what progressed after that, and we're talking about right up into the late 1980s, early 90s, is truly astonishing. I don't know how I'm doing on time, I'm going to go more rapidly, but I just wanted you to have a concept of how slow everything was for hundreds and hundreds of years, and there was a dichotomy between orthopedics and neurosurgery, and all of a sudden it just took off at an amazing pace in the late 1980s. The story really begins with a horse. Anybody know the story of the horse? George Bagby was an orthopedic surgeon. There's a condition with racehorses called Wobbler Syndrome. It's basically a degenerative disc problem. Horses get myelopathy, they can't run well. He had the idea of fusing a horse's disc space with what was called at that time a Bagby basket or a Bagby cage. This is where the term cage first started. By fusing through an anterior approach, the necks of horses with Wobbler Syndrome, they were able to improve or stabilize the neurological function of horses. People like Kuslich and Charlie Ray and others took that and ran with it. What was fascinating for me at the time of my training was in the early 90s, we didn't have pedicle screws, we had Harrington rods. There were a couple of things that were on the market, like these funny little distraction devices we used to put in people's lumbar spines and make them kyphotic. There was the DUN device, which used to pop out of the anterior spine and rupture the aorta. There were unbelievable things that were on the market and immediately taken off. But then all of a sudden this major revolution started with the BAK cages, the Ray cages. When I was in the state of Georgia, there were neurosurgeons that had no concept of bone healing, sagittal balance, spondylolisthesis, never done a fusion in their entire lives. All of a sudden there were these little cylindrical devices that you could put in somebody's spine and fuse them with little to no training and get a nice handsome fee for it, and it exploded. In our state alone, the number of fusions within just two years just catapulted. With that, there have been major advances in arthroplasty, minimally invasive techniques, computer-assisted image guidance. The biology of bone healing has been revolutionized, not just by BMP, but other types of things. The problem now is we didn't police ourselves well. Spine surgery reimburses well for the current time being. That will change. But when the companies got involved, there was just massive production and innumerable products that were brought to market. If you look at the fusion rates in the United States based on Medicare data, after the introduction of cages, it just exploded. Everybody was racing to courses to learn how to do this, even if you didn't even know how to handle the complications, which is what, in my fellowship, we used to just basically take care of the cage gone bad frequently. It actually was a very exciting time. But the staggering growth took place at a rate that went well beyond any medical evidence for doing some of these procedures, and it was abused. I think that in your lifetime, one of the greatest challenges you will have in your career is maintaining proper ethics. In your training, if you're operating on a patient with an attending and you're doing a four-level fusion for back pain, ask them why. Ask them what the evidence is behind that. Particularly in communities where quality assurance rounds are not well-documented or even enforced, there are countless surgeons that are out there fusing the spine for minimal pathological-type findings. It's unethical, and sometimes it's even criminal. This was really reflected in an article by Jim Robertson back in 1993. He wrote an article called The Rape of the Spine. I use that term a lot with our residents. He expressed a concern about the growing number of lumbar fusions for low back pain, ill-defined clinical and radiographic criteria, which even with all of our guidelines, we still don't have good evidence. He emphasized that nurse surgeons have a serious responsibility to put the patient first and to assist on participating in clinical studies to establish indications and efficacy. He even called for a registry of complications. I can tell you right now, many of you have already been trained and do things like X-lift and D-lift and Axi-lift, types of procedures that are becoming very popular. In my experience, the complications from those procedures are vastly underreported. If you look at the current issue of general neurosurgery, spine, there's a horrifying case example. But patients out there, they don't know. They're not sophisticated. They are overwhelmed by the myriad of opportunities that are out there. Forget chiropractic care, which still accounts for about 70 cents on every dollar spent in spine care in the United States. But patients are coming to us now wanting to know about, when can I have stem cell treatment for my degenerated disc? Doctor, do you use the laser? I usually pull one out and say yes. Every time I give a lecture, I use a laser. Minimally invasive techniques, like in the upper right here. Anybody know what that thing is sitting in the anterior middle column of the spine? Axi-lift. Right. I was at a meeting years ago when somebody was giving a presentation on the marvelous, and if you don't know, the axi-lift, which is the commercial term. It's basically an inner body fusion done with the patient in the prone position, where you go all the way down to the tip of the coccyx and go ventral to the sacrum and drive this thing up through the L5-S1 disc space. This guy gave a wonderful presentation on how incredibly minimally invasive it is and how great it is. Sitting next to me was one of his colleagues from his institution who said, funny how he didn't mention the two people with colostomies. Imagine coming in for back pain and leaving the hospital with a colostomy from a colon injury. So there's a lot of dishonesty out there. This guy, I don't know who reads the New York Times, and if you ask me why I read it every day, it's because I tell them I like reading the other team's playbook. But this guy right here, Ditsworth, he's a colleague. He's your colleague. He's in New York. He pays for a quarter-page ad in the New York Times every Sunday in the A section of the New York Times about how he cures people with no incisions, no nothing, no pain, magical. It's B.S. In Atlanta, I see innumerable people that have gone down to the Laser Spine Institute of Tampa. In my opinion, the police should walk up and put cuffs on them and arrest them because they are hurting people. I see people that have had a little tiny incision and the facet joint was removed, and now they have a spondylolisthesis. I see people that had severe stenosis with leg pain, and they had $50,000 worth of laser treatment of their disc and radiofrequency ablation of the facet joint. They need a laminectomy and a fusion, and there's no way to police these people. And the Laser Spine Institute is now everywhere. You'll see an ad in your town soon. So patients are really bewildered, and it is your responsibility to talk to them and tell them, this is what's real and supported by evidence. In Cooperstown, New York, I'm a huge baseball fan. In fact, when I was at Columbia, I intentionally did a rotation up there. There's an affiliated hospital, Mary Imogene Bassett Hospital, and I went up there solely to be able to go to the Hall of Fame every day for 30 days, and they stopped charging me after the third day. It was in January. I was the only guy there. But I went through everything. But really, we owe a great debt to what I kind of think of as the first class of Hall of Fame surgeons, and included in that class, I would include Eric Woodard. I don't know if Eric's here. Hey, Eric. But these are the guys that helped us ride the wave. And the wave began in the late 80s, early 90s. Thankfully, Eric took a job somewhere else, and I actually got his desk at Crawford Log and sat in his office and began my own career. But these are the guys that really paved the way and made. Some of them are gone now. Obviously, Scoville, Dr. Cloward, I think Sanford Larson passed away years ago. But these guys made an enormous contribution. And sitting on your faculty today are others like Dom and Pat and Mike Wang and others that I kind of consider the next incoming class to the Hall of Fame because these are the people that have really contributed an enormous amount. So I'll close just by one thing. The greatest challenge to me in spine surgery is ethics. And it is the most easily raped part of the body. If you have a brain tumor, you need a craniotomy or a biopsy and radiation or something. It's pretty simple. If you have back pain, there's this huge gray area. Stick to what is supported by the medical evidence. Call out your attending physicians if they're doing something that you don't think makes sense because it goes on every day, and we're getting hammered for it now. The outliers that are out there doing four-level A-lifts or D-lifts or X-lifts, whatever you want to call it, for back pain. I can't tell you how many laminectomies I've done on people that have had X-lifts done at three or four levels, and they have stenosis. They need a laminectomy. And you are personally responsible for asking the questions that can help us all do things in a better way. Thanks. Applause.

spine surgery

instrumentation

advancements

challenges

pedicle screws

fusion surgeries

ethical issues

evidence-based practices