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And getting to the nitty gritty. Now we get the main event. Uh Mr Tim German Klim, a uh a look back on back pain. Yes, thank you very much. I'm I'm very grateful as I'm sure we are all our to the organizers is this has been a fantastic opportunity to catch up with a lot of people who have meant a lot to me over the years. So, thank you very much. I thought I'd take the opportunity um to take a look back at the evolution of my ideas on back pain. And in particular, what role in neurosurgery in Bristol has played in my current position slide, please. In this book, the Sleepwalkers, Arthur Costless suggests that like most scientific advances, those of Copernicus Kepler and others were largely accidental. They were the result of their personal circumstances and their environment and they're unique contribution to science was more by accident than design. And I think the same principles apply to all of us. We sort of meander through life, responding to and interacting with events, ideas, people and opportunities which take us in unpredictable directions. Next slide, please, whether we can accurately recall these events or not is a slightly different matter. Next slide. In my case, I have acquired some rather maverick ideas about back pain. Now, this isn't somewhere I ever intended to be and it can be rather uncomfortable on occasion. So how did I arrive where I am? Next slide, please? I first encountered neurosurgery at French. And to me, the two terms are almost synonymous in my first week as a clinical medical student in September 1984 and I have weekly tutorials with you. Griffiths are returned as a medical houseman in 1987. And following house jobs, I demonstrated anatomy for a year. And then I just had to go to Australia to realize my lifetime ambition and learn to surf. I needed a job to come back to and I was able to arrange a neurosurgical job for a year's on the sho department for a year's time. When I returned from uh next slide, please. When I returned from Australia, having been persuade, I had been persuaded the ent was the perfect career choice for me. But first I had to complete six months as a neurosurgical sho slide, please. In those days, we still had a firm structure and I worked for Mr Griffiths. We did a single ward round every morning and as always in medicine, there were humorous events and tragic events. But um on one ward round, I remember Martin mcgee College was one of Australian Essar's asked the patient had undergone surgery for an acoustic neuroma if he could please show us his teeth too, which he said in your cupboard, another patient had undergone surgery for a growth almost accreting adenoma. I can't remember the s are was, but he said, don't worry, everything will get back to normal size within a few months. And the guy said what everything anyway, I had to report back to Mr Griffiths every day and one day I went into his office and it was full of the latest batch of medical students. Mr Griffith was telling them on their second day of clinical medicine, how to take a history and perform an examination on the phone, something which it took COVID for the rest of the world to catch up with. And I wonder it came up in conversation that I've been surfing um for in Australia for a year and he said, what a great thing to do. You should be a neurosurgeon and I was taking it back and I thought to myself, well, I'm not sure I want to work all hours forever. Um Anyway, with that comment, he was the first person in authority in surgery, whoever had been positive about my slightly wayward career progress, which up until that point had felt like a bit of a millstone and in both deed and word, he demonstrated that challenging medical dogma was okay and even important he and others in the department at that time, planted a seed in my mind that perhaps I should try and be a neurosurgeon. So I went off to do six months of ent and realized it wasn't quite for me. And I decided that actually where I did fit in most and when my interest labor's neurosurgery. So whilst doing two years of so our next slide please while doing two years of general surgery in ex cetera, I started talking to Rick about the possibility of doing a higher degree. And Rick had become interested in the potential of near infrared spectroscopy to monitor cerebral metabolism. There were already publications on how useful this technology was for monitoring people with reduced consciousness and money was being made from sales of machines and expensive disposables. I was awarded three years of funding by the Stroke Association. When a prototype machine from Johnson and Johnson finally arrived, there was no way of attaching the sensor to a person's scalp. I spent a lot of time with Nick Cain who became guinea pig in chief. For many subsequent experiments, I used the crate bandage to attach the sensor to his scalp and was it was immediately obvious that a very small change in pressure applied to the sensor created a fairly major change in the signals recorded by the monitor. In other words, it seemed overwhelmingly likely that these machines were measuring signal changes within the scalp rather than the brain. This meant my grant application and project proposals were based on an unfounded assumption that the technology was proven. We had to rethink the whole project and ended up subjecting members of the neurosurgical department to various physiological insults. The most notorious of which was being rendered hypoxic by re breathing with carbon dioxide taken out of the circuit. And rumor had it that the neurosurgeons were flatlining. Next slide, please. I would um regularly meet up with Rick. I would explain that I've read papers and expressed incredulity how imprecise or potentially dishonest. Many publications were abstract, often close, often made claims of draw conclusions that were not justified by the content of the paper and papers would regularly quote references in support of a particular argument. But on reading the particular reference, it was not uncommon for me to find that it did not actually support the claim which was being made. Rick was constantly telling me I had to be cynical and one couldn't be too cynical. So as usual, I did as I was instructed and I became very cynical, even got to the stage where I started to ask myself why Rick was telling me to be cynical. Anyway, after my research period, I started as a clinical register and I start with Steve Gill. And as you know, he was, he perpetuated the idea that you have, you have to question everything. And of course, he's got very many accolades, one thing I remember, um which was very unorthodox and I don't know if this is unreliable memoirs or not. Is I seem to remember that at least went through a period of thinking that surgery was expedited by starting the operation in the anesthetic room and the patient will be wheeled into the operating theater with a bleeding wound. I've progressed through the rotation which included being subject to all sorts of other heresies from all sorts of places and in particular, I have fond memories of Doctor Brown's enthusiasm for his particular unorthodox ideas in microbiology. But during that time, I decided that I really wanted to live in Devon where I'd grown up. And that meant trying to get a job in Plymouth. But I felt like I needed some extra training and spinal surgery. Next slide, please. Um And again, I ended up being the first neurosurgeon to complete the National Orthopedic Spinal Fellowship in Nottingham. And this changed the trajectory of my career in many ways. Clinics in Nottingham were full of patient's who had lots of injections followed by fusions or possibly disc replacements. But most of them seem to end up back in the clinic, still complaining of back pain and generally very unhappy. And I decided that that was an area of practice. I was going to steer clear of next slide, please. I was very fortunate to be appointed as a consultant in Plymouth, but being the only surgeon orthopedic or neurosurgical with a major spinal interest, I did have some drawbacks. It became impossible for me to avoid the issue of back pain. It seemed a strange paradox to me that one of the most effective operations for relieving pain I had ever observed was a microdiscectomy. And yet other interventions of spine related pain appeared to be much more of a lottery. And then one day I had an heretical thought. Um next slide, please. Could it be the outcomes were poor because we were treating people without a diagnosis. Now, it doesn't sound heretical but it is because it implies that for example, national guidelines on the management of non specific low back pain, back pain without a diagnosis is fundamentally wrong. So next slide please. My current position is I believe you cannot effectively treat someone without a diagnosis. In my opinion, 40 to 50% of the people I see have their pain is unexplained by any structural abnormality, an unexplained back pain in my view is no different to any other unexplained symptom. The diagnosis for these people is likely to lie in a much more difficult and abstract domain by which I mean mood related conditions such as anxiety, depression and stress. Next slide please. I've reexamined pretty much everything I've ever been told or read about the causes, investigation and management of back pain. In my view, the current management of back pain is based on ideas propagated by text books which are based on supposition and dogma rather than evidence and which largely predates the MRI era. For example, I believe that dural compression can cause back pain and is treatable with decompression. I don't really know what people mean by mechanical back pain. I don't describe any significance to the leg or back dominant pain. I don't believe there's any evidence that any spinal injections have any significant benefit and there are others. But you get the general idea. Next slide, please. So the fundamental principles inculcated into me during my time in neurosurgery in Bristol are very much alive and kicking. And I'm now involved in this publication which aims to promote critical thinking and challenges to medical dogma. So if any of you would like to share your unorthodox ideas and submit an article, please consider contacting me. Thank you very much. Thanks Tim.