Charles Grudem, MD
What first brought you to NASS, and what do you remember about the early years?
In response to the first Emeritus NASS Member question of “What brought me to NASS, and what do I remember about the early years?”
The first and simplest part of my response is that I was personally invited to join NASS shortly after it was created by one of its founding fathers—a very early president of NASS and also ISIS (the International Society of Spine Surgeons). That literally world-renowned spine surgery and medical spine care innovator was, and still is, the finest medical doctor I have ever met in my own fifty-plus years as an MD: the extraordinarily skilled, caring, and openly compassionate neurosurgeon Dr. Charles Dean Ray at the Institute for Low Back Care (I.L.B.C.) in Minneapolis, Minnesota.
At the time he invited me to join NASS and then become a Fellow of that professional society, I had known Dr. Charles Dean Ray for about four years—as both a treating and consulting surgeon for me and then for a fairly large number of patients I referred to him for his truly excellent, state-of-the-art spine surgery care.
Part of what brought me to become involved with spine care and NASS was the large number of similarities and challenges between how badly fragmented patient care was in both my original specialty, Emergency Medicine, and spine patient care—now “Spine Medicine.” Both of these fields had multiple types of physicians providing care from several specialty training backgrounds, with no real standards of good care and little, if any, coordination of care between doctors over time.
Another similarity was how profoundly some of the conditions being encountered impacted patients’ lives—including the need for expensive medical care and the very real risks of serious permanent and total disability, paralysis, or even death.
During the first half of that period, I actively participated in creating more strongly patient-focused care for complex medical problems that abruptly, unexpectedly, and often seriously disrupted lives and work abilities, as I repeatedly encountered during medical school, volunteer externships at a local trauma center, part-time employment as a critical care ambulance attendant, and later in my postgraduate training at one of the very first residency programs in the country in Emergency Medicine.
This included the earliest teaching of EMTs, nurses, and other doctors in my first full-time job as a credentialed emergency physician, where I focused on promoting and disseminating the most critically important—and then totally new—life-saving public and professional training in CPR, ACLS, and critical care ambulance services as vital components in the development of new medical subspecialties, including Emergency Medicine and the first line of freestanding “Industrial Medicine” clinics, like the one I created in the service area of my first Emergency Medicine hospital contract.
As we emergency physicians and our Emergency Department nursing staff became more fully trained and capable of handling cardiac and respiratory system emergencies, it became obvious that all of us who saw so many spine pain and spine injury cases needed to become more alert, capable, and attentive to reducing that glaring deficit in our knowledge—and to create or implement a vastly more organized, intelligent, and science-based approach to the potentially disabling “elephant in the room”: the numerous people every day complaining of serious spine pain.
Sadly, this time frame also brought more people complaining about serious pain and requesting potentially dangerous narcotic pain medicine at a time when we were seeing an actual and serious increase in prescription and illegal drug abuse, often without objective medical evidence of a clear physical source for that level of pain or a known, consistent pain generator.
In those early to early-middle years of my career, the need for the science-based North American Spine Society had become obvious—a huge, unmet need for better and more objective knowledge of pain-generating problems involving spine function, spine pathology, and the how and why of different spinal injuries creating so much interference with people’s ability to function in their normal state and daily activities or job demands.
As one of the emergency physicians who had, by then, addressed as best we could the organization and distribution of training and physical resource needs for our community’s most pressing life-saving care, my focus for the next obvious community need shifted to not just treating but also preventing the large number of serious and often disabling spine injuries and spine care needs in our community and beyond.
The most personal of the series of experiences and events that brought me to NASS (and its co-founder and early president) also serves as my first and overall lifetime “favorite NASS memory,” in answer to the Emeritus Fellow Time Capsule survey.
This personal story started with a confusing and very individual exposure to the same need for answers to the same questions that far too many—seemingly most—people had back then. Namely:
- “What the heck was that weird event?” (in the recent past)
- “Why do I hurt like this now?”
- “After following my doctor’s advice and self-care, why has nothing helped me do my necessary home and work activities?”
- “Why did the surgery by that very confident neurosurgeon not solve my pain and work disruption problem last year, as nearly promised?”
As an emergency physician group president with a fairly new and rapidly growing industrial medicine clinic near the first of a hoped-for second hospital 24/7 site, I began having worsening low back pain without any recent obvious injury or other medical problem to explain the symptoms. Concerned that it might threaten our clinic’s survival, I sought the advice of the only neurosurgeon I had ever referred an emergency department patient to.
Despite having two lower discs showing “bulges” on a myelogram, he assured me that even as a robust and muscular 31-year-old, degeneration was likely the problem and only the one disc with the bigger bulge needed surgery—and that my pain and functional losses would almost certainly be gone with a simple one-level fusion, if we did the surgery soon.
With no other available consultation and outside my own expertise, we proceeded as he planned. Following the tapering of pain meds and a short course of physical therapy, I improved in overall function—only to worsen again with no new injury event.
Puzzled by the same “what the heck?” questions above, I was understandably anxious about the long drive and my future health. My despair was real and much like what many patients later expressed to me in decades of watching—and helping share in—the amazing growth of knowledge about the vastly better science of spine medicine and spine surgery, along with expert and safe pain management that now makes sense in almost every case.
That real despair and fear of the unknown began its first steps toward hope when I met an interesting physician who had heard about my IMS clinic and came in to talk with me about his brand-new outpatient CT scanning facility.
In what was likely a sales call by a real doctor introducing very new and exciting imaging technology, he not only educated me, gained an immediate customer (me), and introduced me to the name of a spine-focused clinic run by what he said were excellent neurosurgeons—real pioneers in new ways of diagnosing and treating people with serious back pain.
CT scan techniques guided by detailed clinical history and careful physical exams were just the start. A new form of traction using gravity to reduce pain and make surgery less likely, combined with literature analysis and real, first-hand research and testing of ideas on themselves and others, made major improvements to their and the world’s understanding of complex spine functions, disorders, and injuries.
I could not restrain my obvious enthusiasm for the opportunity to help my patients—and myself—start to benefit from working with and learning from Dr. Heithoff and his highly regarded, world-class experts who were enthusiastic about using practical and available new science as it was being discovered and defined locally.
Can you share your favorite NASS memory?
As a fellow and active participant in, and student of, NASS throughout most of my career in direct patient care, there were many wonderful or favorite memories in addition to those described above, which led me to one of the most important and intellectually rewarding relationships I have ever had. That all started with regard to patient spine injury care—not just for me but for the patients I referred to Dr. Charles Dean Ray over the decades.
As the key physician to help me return to very busy, active patient care with foci on several aspects of life stressors and helping them be more productive and have less pain and suffering, my overall favorite NASS memory would have to be related to the amazing discovery that I learned about and was successfully treated for my first serious life disruption from a medical problem and first early career interruption because of the science focus and successful, timely surgical application of then very new spine diagnosis by Dr. Ray.
He applied the very latest and incredibly insightful diagnostic concepts within months after such information was published and made sense for me. The learning experience and enthusiasm about the best spine injury care available spread to several other areas of medical assessment and care planning, as well as prevention for my corporate clients—helping thousands of people in my lifetime. That all wrapped around my favorite surgical role model, as explained in detail below.
Dr. Ray and I first met a year or two after I unexpectedly sustained an initially very subtle and temporarily painless lumbar spine injury by moving a very heavy unconscious patient with what I thought then, in my briefly distracted mindset, was ideal body mechanics. When I felt an odd “give way” sensation but no pain at that moment, I noted that event and odd sensation in my incident report to the EMS medical director (myself) and in that patient’s hospital record.
That brief and admittedly compulsive record-keeping eventually proved to be essential to my career, my family’s financial survival, and the availability of basically any future or ongoing medical care for what was not identified until a few years later in any orthopedic or neurosurgical journal as an internal disc derangement syndrome. The initial radiology images and clinical course after that indicated that this injury event and the “IDD syndrome” took place at both of the two lowest lumbar motion segments, L4-5 and L5-S1—not just the L5-S1 level, which had the more obvious disc abnormality and got the only attention and focus of the sole neurosurgeon I knew that early in my career.
That neurosurgeon was from our contacts at a hospital which, despite all its other positives, did not have a lot of brain or spinal surgery cases. That unexpected and unusual injury event occurred while I was serving as the medical director of Emergency Medical Services at one St. Paul hospital and head of a full-time emergency medicine physician group at another hospital in the inner-ring west Minneapolis suburb of Golden Valley, MN.
I had already pressed upon my E.D. physicians and EMS personnel the sometimes critical importance of taking and recording accurate and detailed activities and situational descriptions of not just what their symptoms were, but all practical details of what potential or obvious injury events preceded the onset of the patient’s distressing symptoms.
Dr. Ray and I were literally blessed to have been part of—and both benefactors of—what one colleague recently called “the Golden Age of Medical Care Development.” That period went from the late 1970s and 1980s up through the last decades of my active medical practice, during which I actively participated in the creation of patient-focused early development of new medical subspecialties, including Emergency Medicine and “Industrial Medicine.”
My busy career was cut short prematurely a decade or so ago by the accumulated effects of multiple spine injuries and various complications, the roles and treatments of which were only then being initially and concurrently identified and defined in the best scientific literature by people like Dr. Ray and other early NASS spine care pioneers. The first injury was in 1980—five years before NASS was founded—but after Dr. Ray and his colleagues at ILBC had been trying to improve surgical and pre- and non-operative care for the spine pain patients referred to them from a variety of other doctors in the Minneapolis area and beyond.
Dr. Ray did treat me when the other initially internally deranged disc adjacent to the first one—and seen before that first surgery—finally worsened from that first injury, likely with a transitional level syndrome of increased physical stresses after successful fusion. I did not need more spine surgeries until other and very obviously significant next injury events. Until then, I successfully returned to full-time work and a normal, happy, and rewarding life.
The treatments by Dr. Ray and the lifetime of state-of-the-art education and scientific enlightenment from NASS laid the foundation and precedent for my enthusiastic and career-full efforts to help improve medical care through honest, well-founded medical disability evaluations, solid medical-legal support, and patient-focused care of the highest possible integrity.
That fulfilled my career with appreciation from patients, their families, and honorable employers of both me and my patients, as well as the other professional people I was happy and honored to work with—and usually help. Retired now, I feel fulfilled by my calling and the hard and enthusiastic life of work I did as the physician I swore an oath to be 51 years ago.
What was spine care like when you entered the field and how did it evolve throughout your career?
Also in the early years leading up to the founding of NASS, we noted that in both Emergency Departments and Industrial/Occupational Medicine clinics, the most common cause of serious, non-lethal life and work disruption was (and still is) significant acute and also chronic pain involving the spine.
In this period of five to 10 years before NASS, there were only a few places in the country with dedicated, whole-person, and multidisciplinary centers for effective and efficient spine care. Everywhere else, there was almost no useful or organized approach, and there was an enormous amount of oversimplification and literal ignorance as to what were—and are—the actual sources and causes of a specific patient's serious complaints, at least not in any easily understood or scientifically provable fashion by today’s standards.
Likewise, although there clearly was apparent need for at least some forms of useful evaluation or treatment, prescriptions for useful and specific types of treatment that would be promptly effective could not usually be provided, coordinated, or even explained within the time, training, and resource constraints of essentially any primary care clinic or Emergency Department (or “E.R.”) in that time frame—even if the doctor had some interest in doing so.
In the absence of prior knowledge, communication channels, and awareness of the patient’s workplace—and their employer’s ability and established interest in “limited duty” for workers who needed and could work with some accommodations—“off work” for an unknown period of time was almost universal. After their first contact back then, it was also unclear whom or who else the spine pain patient should necessarily or optimally see next.
Other than simply sending someone “to rehab” or to one of a couple of different surgeons who might eventually be needed for their surgical skills, very few doctors and clinics had carefully targeted assessments and treatments for the conditions we can now define after the examinations, reliable testing, and knowledge we have now at spine medicine and pain management clinics with doctors who can do or arrange for targeted therapeutic interventional treatments short of surgery.
Such interventional pain management often confirms tissue-specific diagnoses based on high-quality, careful history and examinations and high-tech imaging not in existence then. In the years prior to NASS and after that, Dr. Ray and I were literally blessed to have been part of—and both benefactors of—what one colleague recently called “the Golden Age of Medical Care Development,” when numerous new technologies and new techniques were developed.
Coinciding with these initial new tools was a focus on the patient’s needs—to know why they had their specific problems and also for truly informed consent. That period went from the 1970s and 1980s up through the last decades of my active medical practice, which ended eleven years ago.
Part of that “Golden Age” also related to doctors most often being able to make treatment decisions with their patients and with relatively little challenge from non-medical insurance company employees. There was even a provision in the CPT office visit billing codes to upgrade for greater amount of time when spent with patients needing or receiving more detailed counseling regarding their planned treatment and/or disability status decisions.