Mr. Maratheftis, tell us a few words about your career in Medicine and neurosurgery in particular.
– First of all, I would like to thank you, it is an honor to give an interview for your newspaper. As for my CV, you can read it on the website www.maratheftis.gr, along with a series of useful information about modern neurosurgery. Long story short, I was born in Piraeus in 1970, graduated from the Medical School of the Aristotle University of Thessaloniki and completed the specialty at the Neurosurgery Clinic of the University of Athens at Evangelismos Hospital. During my specialty I worked closely with Professor Mr. Damiano Saka, who inspired me and encouraged me to complete my specialization in Functional Neurosurgery.
Long story short, I was born in Piraeus in 1970, graduated from the Medical School of the Aristotle University of Thessaloniki and completed the specialty at the Neurosurgery Clinic of the University of Athens at Evangelismos Hospital. During my specialty I worked closely with Professor Mr. Damiano Saka, who inspired me and encouraged me to complete my specialization in Functional Neurosurgery.
Then I worked for about two years at Cardiff University Hospital, UK where I was the direct collaborator of the famous British neurosurgeon Brian Simpson. There I specialized in the Neurosurgical Treatment of Chronic Pain (spasticity, chronic pain syndromes, surgical treatment of drug-resistant depression, implantation of spinal cord stimulators). I then became a Clinical Fellow in the Spine Department of the same hospital, with an area of responsibility throughout Wales. I worked there for another year and then returned to Greece. I worked there for another year and then returned to Greece. For a year now I have taken over the Pediatric Neurosurgery Department of the Euroclinic for Children and I am a collaborator of the Euroclinic of Athens. I also did research in the field of microdialysis of the brain, a field with potential in research into the treatment of ischemia and cerebral edema that cause diseases such as traumatic brain injuries and strokes.
Chronic pain in the spine afflicts many people in whom often no cause of pain is found despite the necessary clinical and imaging examination. Are there more specialized diagnoses and treatments?
Unfortunately, in many patients suffering from chronic back pain, ie pain for more than 3 months, routine imaging tests, such as X-rays, CT scans and MRI scans, which most patients undergo, may not show any real cause. Many times there is a small slipped disc that can cause the problem, but performing a surgery is not justified, while conservative measures do not alleviate the problem. In these cases the patient may undergo a special examination called a “discography”. Under local anesthesia and with radioscopic guidance, we administer a small amount of special fluid into the suspected disc. If the patient’s symptoms are reproduced in this way, then we consider the test positive and proceed to invasive treatment. In other cases, there is pain in the movement of the waist or neck, without the MRI showing anything special. However, if there is a sufficient degree of osteoarthritis of the intervertebral joints, we can suggest to the patient an infiltration of the joint follicle with a long-term local anesthetic and steroids. This test can prove the origin of the pain and significantly relieve the pain. Radiofrequency coagulation can then be performed on the affected joint for more permanent relief. Even nerve root infiltration in all degrees of the spine (cervical, thoracic, lumbar) can relieve symptoms, aid in definitive diagnosis and prevent useless surgery. Combining it with a test called “rhizography” helps to correctly identify the cause of the pain. All these mild interventions are performed under local anesthesia and require a short stay in the hospital, with immediate mobilization of the patient. They have been shown to offer significant help and reduce the long-term use of analgesics by patients.
What possibilities does modern neurosurgery offer that can alleviate patients’ pain in cases where drug treatment has either failed or is not indicated?
– Unfortunately, many patients have to go through that. If we talk about the so-called neuropathic pain (pain due to the nerves themselves), the correct diagnosis of the cause is paramount. Unfortunately, many patients have undergone failed back / failed neck pain syndrome and are in pain, while imaging tests do not show a cause that can be treated surgically, such as a spondylolisthisis for example.
They may also suffer from the so-called complex regional pain syndrome. In these cases, 2 out of 3 patients can benefit from the implantation of a spinal cord stimulator, an operation that sets up a system of mild electrical stimulation and effectively “misleads” the pain pathways, significantly relieving patients. So they do not need to take amounts of drugs that often affect their daily activities due to sedation or other side effects they cause. This treatment has been shown to be beneficial both in improving patients’ quality of life and in reducing their treatment costs and in reducing their lost working hours. With the reduction of pain, the life of these patients changes completely and they can then mobilize, do physiotherapy, exercise, lose unnecessary weight and enjoy their life.
Do you think the various problems of the spine are psychosomatic and to what extent?
– Usually pain is a complex phenomenon. There is no fully objective scale for measuring it (as we would measure sodium in the blood, for example) and, unlike other senses such as smell, the longer the stimulus lasts, the more noticeable it is. The so-called pain threshold decreases as long as the painful stimulus remains. This creates a vicious cycle of emotional burden-pain-further burden that can cause depression, thus further mitigating the healing effort.
It is also known that people who are dissatisfied with their profession present higher rates of back pain and a worse response to treatment. Smoking, weight gain, withdrawal from social activities are additional factors that worsen the overall picture. Therefore, doctors need to treat these problems in a global way and not just focus on the possible anatomical background of a slipped disc. A recent study identified a similar role to placebo, not in terms of the administration of drugs but of the positive influence of the physician himself on patients. The way the patient is approached is very important and I think you are absolutely right to correlate these factors.
As a surgeon, I imagine that your first choice is, of course, the surgery. Apart from that, are there other conservative means to improve the diseases of the spine?
– In the past, surgeons used to say that the best surgeon is the one who knows when not to operate. We want to treat our patients invasively. However, the success of an operation, in addition to the correct technique, depends on whether the indications for its execution have been observed. Every year, especially in the field of spine surgery, the indications are modified, the implant materials are modernized, and whoever is not constantly updated and does not modify his indications accordingly, ceases to be effective.
There is a clear tendency for less invasive procedures, not only in the case of the infiltrations and thermocoagulations I mentioned earlier, but also the minimally invasive surgery, using a microscope or an endoscope. These enlarge the surgical indications and allow, for example, a spinal fusion to be performed to older people with mobilization within 24 hours, with minimal blood loss and reduced hospitalization time.
However, alternative therapies have been and will always be present. Acupuncture, for example, has been proven effective in relieving symptoms, unlike other methods such as chiropractic, which have not been shown to help. You know, as far as back pain is concerned, 90% of patients will overcome their problem even without any treatment. This gives room for useless therapies to survive after being applied to patients who would improve anyway.
In addition to acupuncture, biofeedback, TENS, physical therapy (when it is appropriate), modification of daily life habits, can have spectacular results and help patients overcome their problem with non-invasive methods.
What is the success rate of the various surgical reconstructions and which spinal disease is best treated surgically?
– When a surgery has the appropriate indications, i.e. it is performed on patients who need it, then the success rates are very high. For example, a young patient with cervical or lumbar disc herniation who presents radicular symptoms and does not improve with conservative treatment will then undergo microdiscectomy, be discharged from the hospital in 24 hours, and fully recover from their symptoms (95%) However, if they undergo an operation such as PLIF and spinal fusion for the same reason, then they will suffer without any reason and may continue to be in pain for a long time. On the contrary, if they have spondylolisthesis, then a spinal fusion is needed. In this case, the success rates are about 75-80% for the lumbar spine and about 90-95% for the cervical spine.
In addition to the surgical technique, the patient’s will to follow the doctor’s instructions also plays an important role. In the case of spinal fusion, they should drastically reduce smoking if they do smoke, otherwise the success rates are reduced because the microcirculation that helps stabilize the operation and the development of a bony bridge is disturbed in smokers.
Advances in biomechanics, the evolution of materials used in implants, the crystallization of indications keep increasing the success rates of these surgeries. For example, in the case of the cervical spine, the introduction of the use of artificial disks to replace a damaged disc, especially in young people, now allows almost complete functional recovery and has spectacular results when used with the right indications. In contrast, in the lumbar spine, where weight loads are greater, the use of artificial discs has not yet reached the level of perfection that justifies their widespread use.
What do you think about chiropractic and homeopathy and all the other alternative therapies?
– My personal opinion is not so important. In the international literature, all methods are constantly evaluated and the results are published. Chiropractic is shown not to be statistically significant for use on the spine, so it should be avoided because in some cases it can be dangerous. Also laser “discectomy”, or IDET (Intradiscal Electrothermal Therapy) are methods that have been tried and failed. Other alternative methods based on biofeedback, lifestyle modification and other relaxation and self-healing techniques may work, but medical monitoring should not be discontinued, as these methods have not been reported to address the patient’s neurological problem ( nerve palsy) resulting in permanent neurological damage. I remind you that even the best neurosurgeon can decompress a nerve, but nobody can repair a nerve. So, if permanent damage occurs, it is too late for any treatment to take place.
After surgery, what other therapeutic approaches do you use to maintain any surgical outcome?
The purpose of the surgery is to protect the nerve structures, to restore and stabilize the anatomical structures and to ensure the functionality of the organs. Neuromodulation, as is the case with spinal cord stimulators, helps reprogram a neural circuit for the benefit of the patient. After the operation, especially in the spine, the strengthening of the muscular system takes place in order to properly support the renewed structure, followed by the training of the patient in order for them to gradually return to their original activities, or even to being more active than before. Finally, the loss of extra weight takes place, if needed. You may also need to use mild medication (anti-inflammatory or neuropathic pain medication) for a while. If the patients are no longer in pain, it is easier to recommend that they exercise, go to the swimming pool, walk more, get out of the house and socialize with more people, etc., because they have been deprived of it and it will prove to be beneficial. So, physical therapy, physical activity, muscle strengthening, weight loss if needed, and smoking cessation are some of the most basic components of proper recovery. In the case of the implantation of a system such as a spinal cord stimulator or a continuous infusion pump (as in spasticity), the patients and their environment must be trained in the proper use, utilization and protection of themselves and the implanted device.
What is the future of neurosurgery?
– In recent years, neurosurgery has improved rapidly and has progressed rapidly. The future is expected to be even more impressive. Further progress in neuroimaging will enable us to understand the cause of neurological diseases that are now considered “idiopathic”, i.e. of unknown etiology. If you do not see something, you can not cure it.
Neurodegenerative diseases, such as Parkinson’s disease, dementia, Alzheimer’s disease, movement disorders, psychiatric disorders, will be treated with surgery more and more often. Malignant brain tumors will be treated with gene therapies, individualized therapies with implantation of genetically modified cells and viruses that will infect the tumors. Strokes and cerebral palsy will be treated by implanting microchips in the cerebral cortex, which will reprogram functions.
Drug-resistant epilepsy will be treated with implantation of intracerebral pacemakers that will prevent the onset of epileptic seizures. Neuroprosthetics are already available, in the form of sensory rehabilitation implants (there are cochlear implants for hearing and implants for vision).
With neuromodulation and functional neurosurgery, it is already possible to therapeutically reshape those neural circuits of the brain and spinal cord that have lost their normal self-regulation and cause diseases such as movement disorders.
In the spine there will be implants for all areas, with “smart” materials that will replace the defective intervertebral discs, the slippage of the vertebrae and will replace the bones with new ones. Genetic engineering will heal nerve tissue, spinal cord and injured nerves.
In the near future we will be more and more able to understand what lies behind the manifestation of neurological diseases, to intervene and to reprogram the underlying circuits. New concepts are being developed such as neuroethics, which is expected to have the same implications as genetics does to this day, dealing with dilemmas about what one can achieve by correcting nerve deficits. This may remind us of plastic surgery, but the target is the nerve tissue. Dilemmas and challenges that are already here for us.