Doctors with a backbone
During her studies, Professor Carmen Vleggeert-Lankamp developed a passion for spinal surgery. From exploring unknown fields and supervising PhD candidates to providing appropriate patient care and making the most of data: her fascination remains to this day.
The title of your inaugural lecture is 'Doctors with a backbone'. Why did you choose this?
'I believe it’s important that doctors really do care for their patients. Sometimes, people who come to a spinal surgeon aren’t just in pain because something in their body is wrong. There may be something going on in their lives, and many people project this onto their backs or necks. Then they ask us, as doctors, to fix it. Often, they come to a neurosurgeon as a last resort. In many cases, it’s easy to say: "Fine, let’s operate." Surgeons like to do surgery. But you have to think carefully: will this really help? Surgery also carries risks. For some patients, surgery is the best option; for others, it might just be about explaining things. That’s where the title comes from. As a doctor, you need a backbone and stick to what you believe is right for the patient. That’s the essence of being a good doctor.'
What research areas are you and your team working on?
'We have three major research areas. One is evaluating the care we provide. In our field, there’s a strong focus on supervisors, and their approach is often copied. It’s important to keep investigating what works better: operating with one instrument or another? And is there a patient group that benefits more from a different treatment? Comparing treatments remains essential.
'The second is predicting outcomes. If you can feed patient characteristics into a computer model that contains data from thousands of similar patients, you can predict: with this treatment, this is likely to happen. For example, an injection and medication treatment might give someone a 70% chance of improvement, while surgery offers 50%. Knowing this, helps you to have a better conversation with the patient. This is still in its early stages but will become increasingly important in the coming years.
'The third is researching why someone experiences pain. It’s outdated to say pain only occurs when something presses on a spinal nerve. There are many other mechanisms, such as immune system reactions. That’s why we now take tissue samples during surgery to examine how many inflammatory cells are present and whether that number relates to the patient’s pain.'
What is something that was really a memorable moment during your career?
'At one point, we conducted a large study on patients with a lower back herniated disc. We wanted to see what worked better: surgery or no surgery? Some patients had surgery; others received different treatment. Everyone had an MRI before the study and another a year later. We also knew whether they still had pain after a year. By comparing all the data, we saw that lingering pain had no link to whether there was still a herniated disc. That was remarkable. We then changed the neurosurgery guideline: if someone returns after a year with mild pain, you don’t need another MRI. It doesn’t provide extra information for decision-making.
'In fundamental research, we looked at macrophages, cleanup cells. There are different types, such as M1, which cause pain, and M2, which clean up well. We thought patients with severe degeneration and poor treatment response might have more M1 cells. Surgery might be more useful for patients with more M2 cells. We’re still investigating this in international collaborations.
'We also did groundbreaking research on patients with a fracture of the second cervical vertebra, a so-called dens fracture. For years, surgeons had a very low threshold for operating on these patients. A neck fracture sounds serious, but surgery is risky, especially for older people. We discovered that patients also do well with a neck brace. A large study showed that 98–99% of patients with a brace recover and remain stable. A new guideline is now in development. Today, we mainly operate on younger patients, where surgery is less risky and the fracture mechanism is different.'
You also supervise PhD candidates. What do you enjoy about that?
'It’s great to work with young people because they have a different perspective on the world, something anyone with children will recognise. But what I enjoy most is teaching them. During their research, you see their development: at first, they’re enthusiastic, then they start understanding the field better. There’s a phase where they feel stuck, and finally, they understand the field so well that they come up with new ideas themselves. It’s wonderful when they continue in neurosurgery. Unfortunately, there aren’t enough positions for everyone. Some choose a different path, or neurosurgery isn’t the right fit. What matters most to me is that they’re happy.'
What made you decide to specialise in spinal surgery during your training?
'I found spinal surgery fascinating during my studies, and still do. I’m often amazed by what I encounter or by a patient’s question that makes me think: that’s a great question, I don’t know the answer. That motivates me to do more research. The work is very diverse. Neurosurgery is also a small field in the Netherlands, we have 160 neurosurgeons. So if you want to exchange ideas, it quickly becomes international. Learning from each other is great. This type of surgery really suits me.'
Where would you like the field to be in 15–20 years?
'That we include every patient with a spine-related complaint in research. Based on that, we can build strong prediction models. If I can dream big, I’d love to see all electronic patient records in the Netherlands connected. Then we can predict better and involve patients more in what they can expect.'
The inaugural lecture, Doctors with a Backbone, will take place on 5 December and will be streamed live on Leiden University’s website.