By: 16 December 2020
Surgeon in focus – Mr Rai, London Norwich Spine Clinic

Mr Rai is a spinal consultant at St John’s & St Elizabeth Hospital, St Johns Wood, London and Spire Norwich Hospital, Norwich and is also a NHS consultant (appointed in 2001). Mr Rai treats patients from across the UK and abroad at his practice. He treats a wide range of problems, such as disc herniations in the neck and lower back, spinal deformities such as scoliosis and kyphosis in adults and children, plus trauma, infections and tumours. His approach emphasises non-invasive procedures and he refers to surgery only when other conservative treatment options have been explored.


Q: As a specialist in spinal surgery, could you tell us more about your experience and training background in this field?

A: I have been a consultant spinal surgeon for just under 20 years and have been involved in over 10,000 major spinal operations. I was elected by my peers as president of the British Association of Spinal Surgeons in 2016 and I have trained many spinal surgeons who work across the UK. I also regularly lecture at spinal meetings both on the national and international circuit. In 2012, I was involved in setting up the British spine registry (BSR) to give surgeons / providers of care and patients the opportunity to capture valuable clinical and patient outcome data and thereby be able to objectively assess the results of surgical intervention. The database within the BSR (with over 80,000 patients) is one of the largest in the country and allows my patients and London Norwich Spine to objectively look at our results to increase clinical understanding of operations and drive improvements in patient safety.


Q: You recently presented your data at this year’s EUROSPINE conference, looking at the risk factors of prolapsed disc post-surgery. Could you tell us more about the study and its results?

A: The study looked at primary single-level lumbar discectomy, collected over a 10-year period. The aim was to investigate the risk factors for two-year same-side, same-level recurrent disc herniation (sRDH).  We prospectively collected patient demographics, clinical factors and patient-reported outcome measures, including the Oswestry Disability Index (ODI). Postoperatively, we reviewed all patient MRI scans across the geographic region. A multivariable logistic regression analysis of demographic and clinical variables was used to identify risk factors for sRDH.

Out of 680 eligible cases, complete data capture was available for 653 (96.0%) for inclusion in the study. sRDH occurred in 63 cases (9.6%) at a median of 207 days post-surgery. Forty-five (6.9%) sRDH cases were reoperated. Current smoking and higher preoperative ODI were associated with an increased risk of sRDH.

Our results revealed that the female sex, smoking, and having a higher pre-operation disability were all factors for reherniation. This is important as the rate of reherniation after lumbar discectomy varies widely and the role of risk factors had not previously been fully established.

Out of 680 eligible cases, complete data capture was available for 653 (96.0%) for inclusion in the study. sRDH occurred in 63 cases (9.6%) at a median of 207 days (IQR 67–410) post-surgery. Forty-five (6.9%) sRDH cases were reoperated.

Our results revealed that the female sex, smoking, and having a higher pre-operation disability were all factors for reherniation. This is important as the rate of reherniation after lumbar discectomy varies widely and the role of risk factors had not previously been fully established.

Q: What could this mean for the patient experiences, management strategies and outcomes?

These findings are important for healthcare practitioners involved in the treatment of intervertebral disc herniation in consenting patients and for developing future management strategies.

Q: What’s the next step in your research?

The next step is testing the results of the study on a larger cohort of lumbar decompressive surgery patients, including patients with discectomy or decompression with or without fusion. In addition, to assess if preoperative disability has a dose-response relationship with postoperative disc herniation. These results will be reported at the East Anglia Spine meeting (December 2020) and British Association Spinal Surgeons meeting (spring 2021).


Q: As we head in 2021, it is clear that the healthcare industry has been greatly impacted by this year’s events, what has been the greatest impact within the orthopaedic and spinal industry?

A: The Covid crisis has created many challenges, the most significant being service delivery, with established clinical pathways having to be reimagined. Due to the restrictions in place, all spinal units had to ration valuable theatre time so they were only able to treat emergency and urgent cases. This, however, has led to huge waiting lists across all the surgical specialities, and I suspect that this delay in treating spinal patients may have caused permanent disability in some patients. All surgeons are encouraged to review their waiting lists to identify such patients. As the pandemic eases, we need to find efficient ways of managing this backlog of patients with surgical techniques that are validated by outcome data (BSR).


Q: How has life changed for you at work since the onset of the Covid-19 pandemic? 

Initially no one knew how this pandemic was going to affect our lives. The initial data from orthopaedics units in China treating Covid patients was very alarming as many practitioners were infected by aerosol generating procedures. As more data became available, we were able to assess and quantify risk allowing us to operate in a safer manner. We also learnt how to use PPE within the operating suite, which has its own difficulties.


Q: How do you think the future looks within the field of spinal surgery and what are your predictions for 2021?  

Spinal surgery is growing as a speciality. We are seeing more patients with spinal problems who demand and expect better quality of life. This is largely related to an ageing population. Improvements in spinal surgical techniques / minimal invasive procedures / better pain and anaesthetic techniques will improve patient care. Image guidance / computer technology and robotics will improve surgical results in the future. The operating suite in the future will be very different, like driverless cars on our roads.