Advances in Care

The Visionary: Seeing the Future of Spine Surgery

Episode 3
The Visionary: Seeing the Future of Spine Surgery
The Visionary: Seeing the Future of Spine Surgery

Neurosurgeon Dr Roger Härtl discusses his work using navigation and augmented reality technologies to improve minimally invasive spine surgery.

Dr. Roger Härtl is no stranger to forging new ground in neurosurgery. In this episode, Dr. Härtl  and Host Catherine Price discuss how far navigation technology has come over the past 20 years and look ahead to how implementing augmented reality can make surgery even more precise for surgeons and less invasive for patients. Dr. Härtl also shares the impact of his work teaching and training neurosurgeons in Tanzania and discusses where he hopes technology will take the field of neurosurgery next. 


Catherine Price: When I first spoke to Dr. Roger Hartl, he said that at home he’s, quote, “not the most tech savvy person.” 


But while Dr. Hartl may not be tinkering with circuit boards in his garage, in the operating room he’s known for pushing forward some of THE most– and please excuse the surgery pun– cutting edge technologies used to assist doctors in performing spine surgery.

Dr. Hartl is the co-director of Och Spine at NewYork-Presbyterian and Director of Spinal Surgery at the Weill Cornell Medicine Brain and Spine Center in New York. And he is a leader in the use of computer assisted navigation and augmented reality in spinal surgery – making surgeries in this delicate area of the anatomy safer, less invasive, and more precise. 

My name is Catherine Price, and this is Advances in Care. 


On today’s episode Dr. Hartl leads us on a journey, 


from his early impressions of stereotactic navigation, to today’s advances in augmented reality, and finally, to the future, sharing his vision of where he hopes these technologies will take us.


Catherine Price: Do you remember the first time you actually did perform spinal surgery using navigation?

Dr. Roger Hartl: I started using navigation during my fellowship, which I did at the Barrow Neurological Institute in Phoenix, Arizona. And, uh, there was a group of, uh, spine surgeons there who were very forward thinking, and they used, uh, navigation for spine cases.

I remember it was Dr. Papadopoulos, who's, uh, retired now, but he used navigation technology to put in screws into the spine. They used it for the instrumentation part of spine surgery. I remember this kind of aha feeling in the operating room many


times. Especially in the beginning, it was just a lot of fun to see the technology work and to see how the technology could make an operation that was extremely complicated and complex and risky, much safer and much more targeted.

Catherine: So wait, why is this ability to be targeted so important when you’re doing spine surgery? Like, what, what difference does it make?

Dr. Hartl: So whenever you put implants into any part of the body, but especially the spine.  You wanna make sure that these implants are totally, a hundred percent spot on. And stereotactic navigation really allows us to do that now very efficiently and very precisely. So if you put in a screw, for example, in the cervical spine, and there's the spinal cord and the vertebral artery. Sometimes you look at the, um, regular anatomy and everything looks fine, but then you look at the pointer on the screen, you can see, oh my God, I'm right next to the vertebral artery. 

Dr. Hartl: I’m just two millimeters away from the spinal cord. 

Catherine: Oh, wow… 

Dr. Hartl: So as you can imagine, this can be extremely helpful 


information and it can really help you avoid accidents in the operating room.

Catherine: Gotcha. So can you walk me through what using navigation actually looks like in practice, when you're performing spine surgery?

Dr. Hartl: One of the challenges with spine surgery is that it involves typically localizing pathology in an environment that's very difficult to visualize.

Catherine: Mm-hmm. 

Dr. Hartl: Because it's covered by skin, by bone, by muscles. One of the reasons why I really saw the value of navigation was the, um, tremendous frustration that I experienced and many spine surgeons experience, in figuring out sometimes where exactly things are in the spine. We have to make a big incision. You have to look around, you feel, you palpate. But on the other hand, when you use navigation, what you do essentially is you have an instrument or a pointer. And the pointer is being displayed on a screen in relationship to the anatomy of the spine.

So you see the lumbar spine or the cervical spine, 


you see the individual bones, you see parts of the anatomy. You can sometimes see the spinal cord. And then when you take that pointer that's being navigated and you point it into the spine that's right in front of you, you can see on the screen, you can see exactly where that pointer is in relationship to the spine. And then we can find those areas and operate on, on these areas, on these pathologies, through a relatively small skin incision where in the old days we had to open everything up. 

Dr. Hartl: Now we can just kind of basically point at them with a little, uh, navigated pointer. 

Catherine: Wow, that's amazing. But when you first started using it, the, the technology was still pretty new, right?

Dr. Hartl: It was very controversial. It was really, um, debated very heavily in the surgical community. 

Catherine: Wait, why? 

Dr. Hartl: Because a lot of surgeons that had been trained with more traditional surgeries, thought that it would not be as safe. You would not be as much in control because you can't see as much. You don't really have the immediate


ability to get in there with your hands if something goes wrong, and looking at a video screen on the wall somewhere, rather than looking down at your hands, where you’re actually working in somebody's body, was a little bit terrifying. But then what happened was that as the technology was evolving and became more user friendly, and more and more surgeons started using it for spinal surgery, it became something that surgeons realized was actually making the surgery safer and more, more efficient and improved the workflow. 

Catherine: Uh huh… So okay, so you performed your first spinal surgery using navigation and then you saw firsthand what an impact it made. So, what happened next?

Dr. Hartl: When I came back from Phoenix, I started at Cornell, New-York Presbyterian as a spine faculty. So I started, uh, building the spine program at the department here. I requested a navigation system for spine…


Catherine: Mm-hmm. 

Dr. Hartl: And I was lucky that the hospital agreed. So, so we got a navigation system, and I think we're probably the first ones in New York to start using navigation for spinal surgery. But the first five years or so, it was just to put in screws. It was not for any other part of the spinal procedure. It was just to put in pedicle screws or screws into the cervical spine. 

Catherine: But at… but at some point, you realized navigation could help with more than just screw placement, right? 

Dr. Hartl: Yeah, I did. I remember one case where I was doing an operation that I was gonna do without navigation technology because it was a relatively, you know, straightforward surgery. And then I saw the patient before surgery and I met her husband and it turned out it was somebody who is very involved with Waze. I don't know if you use Waze when you're on the, uh, you know when you're, when you're traveling, right? 

Catherine: Oh you mean like Waze, the traffic app.

Dr. Hartl: Yeah.

Catherine: Okay.

Dr. Hartl: And we talked about… and and, I had just come back from Egypt. I was teaching a course in Cairo and I was invited to go to the pyramids


after a meeting. And I was late and I had a driver who got lost in Cairo. 

Catherine: Oh boy. 

Dr. Hartl: So I pulled up my Waze, I showed the Egyptian driver, I showed him Waze, and he said he's gotta go here and there. So we made it to the pyramids before that, uh, event started. 

Catherine: Okay, and so then you came back from Egypt you were telling this story about your experience with Waze to your patient’s husband…

Dr. Hartl: He told me, well, you're gonna operate on my wife, I’m sure you’re gonna use something like Waze when you do your surgery. And then I realized, well, he's right. You know, I should really do that. And, and that was a case I remember where I used navigation in a setting where usually I probably would not have used it, but I found it so helpful because it really facilitated the surgery, even though it was an operation that had nothing to do with putting screws or pedicle screws into the spine.

It was simply an operation where I needed to find certain spots in the spine quickly and efficiently and safely. And I used navigation because of that conversation that I had with this individual,


and it made the surgery so much easier. And then afterwards, I remember thinking, well, I mean, I should really use navigation more frequently.

Catherine: Wait, that's amazing. I just love the idea that the fact that you got lost on the way to the pyramids, or that you were trying to find a better traffic pattern, that in some way influenced you to try navigation in the operating room in a way that you hadn't thought to do before.

Dr. Hartl: Yeah. Yeah. 

Catherine: Did you have any personal reasons that you were interested in switching from traditional techniques to computer assisted navigation in the operating room?

Dr. Hartl: You know, as a spine surgeon, we wear a lot of lead because traditionally we would use fluoroscopy in the operating room. For localization when you open up the spine, you want to see where you are, of course, so you get x-rays. In order to really make it safe for the surgeon, but also for the staff in the operating room everybody wears heavy lead aprons. 

Catherine: Mm-hmm.

Dr. Hartl: And over the years, I noticed that every time I was wearing the heavy lead, I had back pain afterwards. And then, um, 


I went rock climbing at a gym here. That was just when they were opening up these rock climbing gyms. 

Catherine: Right. 

Dr. Hartl: And I made some odd movements and I developed a herniated disc.

Catherine Price: Oh no. I don't like the irony of this. 

Dr. Hartl: Yeah, yeah. So I, I, I had a, I had a disc herniation. I actually had foot weakness, almost like a foot drop. 

Catherine: Oh, wow. 

Dr. Hartl: But I knew that, uh, the, the reason I had the disc herniation was really the lead because I, every time I was wearing lead, I had back pain and then sciatica pain.

But, but I realized that if I really want to do this for the rest of my career, I gotta come up with a solution. The obvious solution was to really maximize the utility and the efficiency of navigation. 

Catherine: Uh huh. 

Dr. Hartl: And then I started, and then I realized that, well, navigation is great, but why limit it just for the placement of screws? So much of what we do in spine surgery is really something other than just putting in screws as, as a matter of fact, as spine surgeons we're trying to get away from uh, stabilizing and fusing the spine. We're trying to use biologics. 


We're trying to use minimally invasive techniques to avoid fusion surgery. So I realized, well, if I really try to take advantage of all the other things that we can do with minimally invasive spine surgery, and I add that with navigation technologies. I, I don't have to wear lead. My back is gonna be much happier.

Catherine: Uh huh… right.

Dr. Hartl: And maybe I can actually use that to an advantage. And that's, that's what we did, then, with fellows and students, some of my colleagues here, we worked on a way to utilize navigation, not only for placement of the screws, but really for the whole procedure. From the skin incision to the decompression part, for the screws also to put in cages if we have to, but then also for all the other parts of the operation.

And we called that total navigation, meaning we'd navigate everything. We don't rely on fluoroscopy and x-rays anymore…

Catherine: Huh.

Dr. Hartl: Nobody wears lead. The workflow is facilitated because you don't need the x-ray technician in the operating room the whole time. Of course, 


you have to get an x-ray or you have to get a low dose, a CT scan, at the very beginning of the procedure. You navigate off that intraoperative x-ray or intraoperative CT scan. And, uh, you can use that initial GPS spin to perform the whole operation safely and accurately and efficiently.

For example, I just had a patient who traveled for a very complicated spine surgery. She had a previous fusion done about 10 years ago. 

Catherine: Hmm.

Dr. Hartl: And she had a problem at the level above that would've been a huge operation in the old days… removing the old screws, putting in new screws, extending the fusion one level higher.

In her case, because of these things coming together the way that I just described it, you know, the team working together, the minimally invasive surgery, the navigation, we were able to do this operation in two and a half, three hours.

She stayed one night in the hospital. The next day she went home. 

Catherine: Wow. 

Dr. Hartl: So she did really well. And this is something that we do now.


Every week we have patients like this.

Catherine Price: That's amazing. 

Dr. Hartl: Yeah

Catherine: So, I wanted to ask you a bit about how the field has progressed since the early days of navigation.

Dr. Hartl: I think now we're at the point where tons of studies have been published that if you use navigation to put in screws into the spine, the screws are gonna be in a much safer and better position than if you don't use navigation. I think the safety and efficiency of navigation is being accepted by the wide community of spine surgeons.

We have integrated that in our, in our training. So our residents, our fellows, they all train in navigation. Now, the next, the next step forward then is the concept of total navigation. That's something that is now kind of the frontier in spinal surgery, where a lot of surgeons are still doubtful maybe.

Catherine: Hmm. 

Dr. Hartl: And that's, I think, where augmented reality comes into play. 

Catherine: So, so… how is using augmented reality in the operating room different from traditional stereotactic navigation?


Dr. Hartl: With augmented reality, the difference is that you essentially look through the spine and you can see structures within the spine without having to open the skin or the muscle.

Catherine: Wait, walk me through that. How does that possibly work?

Dr. Hartl: Well, you need to know, obviously, what's inside the spine. So you need some kind of scan, a CT scan or an MRI scan, that shows you the structures inside the spine. The best example is a spinal tumor in the lumbar spine. 

Catherine: Mm-hmm. 

Dr. Hartl: So you can see that on the MRI scan, it shines up, you can see at a certain level, let's say L four and L five on the MRI scan. Now that MRI scan, we have available when we actually do the surgery. We get another scan in the operating room with the patient positioned on the operating room table, and that scan is done with 3D navigation technology. 

And we merge that scan with the preoperative MRI scan that shows the tumor. 

Catherine: Okay

Dr. Hartl: So now we have, intraoperatively, we have a reference. We know exactly where the tumor is


in relationship to the spine in the patient who's actually on the operating room table, and then either you wear goggles, or I use a microscope, and that picture of that tumor is then superimposed on your field of view. So you're looking through the goggles, you're looking at the spine, and the computer projects the location and the size and the geometry of the tumor into your field of view. 

Catherine: Hmm. 

Dr. Hartl: So you can essentially look through the spine and you can see the tumor inside, even though you haven't made a skin incision. But you know exactly where that tumor is.

Catherine: So I'm also assuming there's a benefit to not having to look away from the patient's body?

Dr. Hartl: Yeah, that's a very good point, because with the old navigation system, you would always have to look at a, at a screen that's somewhere else. You would have to move the microscope away, look at the screen to know where you actually are, in relationship to the anatomy, and then bring the microscope back in.

So now you can project everything into the microscope so you don't have to look away from the patient and from the surgery. 


Catherine: Wow, that's amazing.

Dr. Hartl: Yeah. And then if you know where that tumor is, that of course that allows you to make a much more precise skin incision. 

Catherine: Mm-hmm.

Dr. Hartl: Instead of making a huge skin incision because you don't know where the tumor is exactly, you gotta look for it. Now you know exactly where the tumor is. So you make a small skin incision, you remove a little bit of bone… so you can kind of custom size and tailor your surgical approach to the exact location of the tumor, or, could be a disc herniation or a cyst, whatever it is that you are looking for surgically. That's what augmented reality allows you to do, makes the surgery much more precise and elegant and, uh, is certainly the way to go forward.

Catherine: Huh. So would it be possible to use this AR technology to, you know, like practice and rehearse surgeries too…

Dr. Hartl: Yeah, yeah. We, we've worked on taking apart certain surgical procedures that we do a lot and trying to figure out, well, how do we teach this really to young surgeons in a way that they can train it with


surgical simulation or with models before actually performing the operation on patients. So we took an operation that's now one of the more frequent spine surgeries that we do, which is called a Transforaminal Lumbar Interbody Fusion, a T-L-I-F, a TLIF procedure.

Catherine: Okay…

Dr. Hartl: In a model, we took that apart and we kind of broke it up into certain steps. 

Catherine: Huh. 

Dr. Hartl: Every operation that you do, you go from one landmark to the next. It's always the same. So then we realized in the model that we can actually mark those landmarks with augmented reality. We can highlight them with different colors. And then when the surgeon does the operation in the spine model, the surgeon can actually play in these landmarks with different colors the moment when that surgeon is looking for these landmarks.

Catherine: That's amazing. 

Dr. Hartl: And so we did that in spine models with 12 surgical residents and fellows, and we tried to compare with augmented reality and without augmented reality.


Is there a difference in the learning curve for this operation? And what about the stress that surgeons go through to perform this operation?

And we found that if you utilize augmented reality to show the surgeon the particular landmarks through the microscope in different colors at the right moment, it actually streamlines the procedure, it facilitates the learning curve, and it decreases the mental stress that these residents go through when they do the operation.

It was just, uh, great. It was amazing. Rather than looking up and down at the screen or getting fluoroscopy in, cuz I'm not sure, where's that pedicle? Where's the lamina? Where's the landmark? Am I at the right level? Am I on the right side? I could just look through the microscope and I see everything in different colors.

We can play it in and out as needed. 

Catherine: Huh. 

Dr. Hartl: So I think that's really where we're going with augmented reality, not only to localize the pathology, the tumor, but also to find a way to actually guide surgeons through an operation. 


Surgeons in training, but also experienced surgeons, because sometimes you are, you're doing a tough case, you don't know exactly where things are, so you can mark those things on the scan and that helps you then find the structure and… talking about mental stress. I mean, surgery is incredibly stressful. 

Catherine: Yeah.

Dr. Hartl: First of all, there's time pressure because you have to do this, obviously you don't have all day. You have, some patients are more fragile, some patients may have medical issues, so you wanna make sure you get them in and out quickly. And then if on top of that you're doing a case and you're not entirely sure, well, where's that pedicle? Where's that tumor?

Catherine: Hmm. 

Dr. Hart: Where's that disc herniation? And you're looking around and you can't find it. And then the anesthesiologist says, oh, the blood pressure is not great, or… and then meanwhile, the clock is ticking. And then it's incredibly stressful, obviously, for the patient, but also for the surgeon and for the whole team.

Catherine: Yeah. 

Dr. Hartl: So if you can do something to make surgery more precise and streamlined, 


and take some of that mental stress away, I think that that's incredibly important and helpful.

Catherine: You know, it's interesting. We often assume that these advances in medicine are for the patient's benefit, but we don't think, well actually, it's also for the benefit of the person performing the procedure. So, it makes total sense that if you're doing a procedure, that it'll be very helpful to have the next step highlighted for you in a very precise way.

Dr. Hartl: The advantages really penetrate everything else. 

Catherine: So speaking of advancements that have really driven the field forward, you were talking earlier about how up to this point a lot of spinal surgery has to do with fusing things and there's pins involved… I think you used the word screwdriver at one point, but you were also alluding to biologics and how you're working on new techniques so that you might not have to do as much kind of pinning things back together. Can you tell me a bit about biologics and how they could apply to spinal surgery?

Dr. Hartl: Sure. I think where biologics potentially could play a big role is at early stages of patients developing disc


degeneration, where we use biologics to regenerate diseased discs and therefore prevent those discs from herniating, prevent those discs from collapsing, or prevent those discs from developing instability that may require a big operation even in patients who need surgery because they have a herniated disc.

What can we do at the time of the surgery other than removing the disc fragrant that's causing the foot drop or the sciatica pain? Is there anything else that we can do at the time, even in the operating room, that potentially can accelerate the healing process and prevent further deterioration in these patients? We're also looking at ways of replacing discs using tissue engineered biological implants. 

Catherine: Huh… and you're working on a pilot study right now where you're using those implants to repair herniated discs, right? 

Dr. Hartl: Yeah, thank you for bringing that up. That is actually an ongoing study. 


You know, one of the most common reasons we operate and the biggest challenge is really herniated lumbar discs in the lumbar spine, but also in the cervical spine.

So a patient comes in, let's say they have severe sciatica pain and maybe they have foot weakness like the disc herniation I had.

Catherine: Right. I was gonna ask if you had a personal interest in this.

Dr. Hartl: I remember I looked at my MRI scan, and there was a huge disc herniation. And my concern was, well, I know the surgeon can take out the disc herniation, but what's gonna happen afterwards?

Because there's gonna be a huge hole… like 90% of the disc is still there between the bone... what prevents more disc material from herniating out? And there's, unfortunately, there's not much we can do as surgeons. There's a 10, 15% chance that you may have another disc herniation. And the only thing you can do is try to be careful after surgery.

Catherine: Oh wow.

Dr. Hartl: Engineers have developed devices over the years, little metal devices that you can put into the disc that prevent disc herniation,


but they're not very popular and they all come with side effects. 

Catherine: Mm-hmm.

Dr. Hartl: So almost 15 years ago, I met Larry Bonassar in Ithaca, who's a professor of biomedical engineering. He's really a pioneer when it comes to cartilage and disc work.

With his background in tissue engineering and my clinical expertise and research background in clinical spine surgery, we decided to collaborate. We were interested in developing a glue, a collagen glue. 

Catherine: Hmm. 

Dr. Hartl: It's, it's essentially, it would work as a glue that you inject, you remove the part of the disc that's causing nerve compression.

You're looking at a big hole and that hole you fill with the glue. And then that glue hardens and we use, uh, blue lights with riboflavin like the dentist. 

Catherine: Huh.

Dr. Hartl: And then that collagen glue you can combine with the patient's own cells. And that's part of the study that we're doing now in patients. We’re using just the cells, not for the purpose to seal the hole, 


but to see if it's safe to use the patient's own cells in that setting. Once we remove the disc herniation, we inject the bone marrow derived cells into that defect, and then we get MRI scans afterwards to see if that disc rehydrates.

Catherine: That's fascinating. So essentially you would get rid of the part that's causing the pain, but then you would be able to refill that hole. 

Dr. Hartl: Yes.

Catherine: With something that wouldn't just glue it and therefore make the reherniation less likely, but actually could help to regenerate some of the part that had been destroyed. 

Dr. Hartl: Exactly. We've seen very promising results, but these are all pilot studies. There's preliminary data. We're, we're still working on that, but eventually, eventually we would like to combine those cells with the collagen glue that has worked so well in the lab that we're trying to get through the FDA now.

Catherine Price: Okay. That's fascinating. I could ask you many questions about each of these things anymore, but I wanna move on cause I, I wanna make sure that we have time to talk about your humanitarian work and your work in Tanzania. Tell me the story of what you have done in Tanzania. 


What inspired it? 

Dr. Hartl: One of my most, um, valuable early experiences really in medical school was the time that I spent in a small central African country called Malawi that a lot of people have never heard of. I went there with a friend of mine when I was in medical school and we flew to Nairobi and we hitchhiked from Nairobi through Tanzania into Malawi. We actually had to hike for 10 miles through the bush, cross the border into Malawi until we got to the next road and then made it to the hospital. 

Catherine: I can see why you were so appreciative of Waze when it did come out. 

Dr. Hartl: Yeah. There was no Waze, so. We got there and then we spent six weeks or seven weeks in the hospital. There was, uh, Dr. Burnham, who, he was an infectious disease doctor from Hopkins who had spent many years in, in Malawi. Just watching him and his setup, a few other doctors there, obviously local doctors as well. 

Catherine: Mm-hmm. 

Dr. Hartl: And it was just very meaningful and, and really impressive to see


how they dedicated their life to this work and the suffering that they were able to address and, and to ameliorate and prevent in many cases.

We spent six weeks there and after that I went back to medical school. I finished my medical degree, I did research. I got into neurosurgery, but I never forgot about the experiences that I had in Malawi and how significant that was really, and how beautiful it was really, to see those missionary doctors.

It was only then years later when I went to Tanzania, I spent time in the hospital in Dar es Salaam, the University hospital. And I can tell you, as soon as I stepped into that hospital in Dar es Salaam…

Catherine: Mhm…

Dr. Hartl: You could see little kids with hydrocephalus. You could see infectious disease problems, all types of issues, many of which were really related to some kind of neurosurgical problem.

Catherine: Huh.

Dr. Hartl: There were a total of three neurosurgeons in Tanzania at the time. 

Catherine: Wow. 

Dr. Hartl: At the time, 40 million people, three neurosurgeons,


two of those neurosurgeons were in that hospital that I visited. I realized immediately, well they, they really need help. So from then on, I went back every year and Weill Cornell Medicine has a relationship with Tanzania.

Catherine: Hm.

Dr. Hartl: So I, I worked with the Weill Cornell team. Dan Fitzgerald, who's one of the medical doctors here, runs the Cornell Initiative also in Tanzania. So now we have a program in place where we send fellows back and forth. We teach and we train, we organize meetings every year. And uh, now we are at 15, one five, neurosurgeons in Tanzania.

Catherine: Wow. 

Dr. Hartl: Versus three, still not enough, but certainly much better than what we started out with.

Catherine: A fivefold increase is a large increase.

Dr. Hartl: Yeah. 

Catherine: Do any patient stories stand out to you from your work there that really have made a personal impact for you?

Dr. Hartl: Oh yeah. So many. I mean, one of the biggest things you have to keep in mind, you have come… you have to go there with realistic expectations. You know, there are certain things that,


as terrible as they are, that you just can't take care of. On the other hand though, also wonderful experiences where we were able to share some technology that has been helpful for them, to treat patients with spinal trauma, for example, we talked about pedicle screws and implants and I mentioned before that for spinal trauma, they're definitely very important. It's the only means that we really have frequently to, to really help patients who have unstable fractures. And with the help of some industry sponsors and with the help of surgeons who facilitate the training of, of the spine surgeons in Tanzania, we've been able to really increase the knowledge and increase, increase the training status of those surgeons to take care of spinal trauma safely and successfully in Tanzania. 

Catherine: Hmm. That's amazing. 

Dr. Hartl: Yeah. 

Catherine: I mean that sounds like an enormous undertaking. So what advice would you have for other physicians who are thinking about initiating a partnership like this?

Dr. Hartl: You know,


when I started to work in Tanzania, I, I didn't think about… oh, I'm gonna come here once or twice and we're gonna change the world and then everything is gonna be great, and then that's it. I always looked at it as a project that would last a lifetime potentially, where the goal was really to build relationships.

Sustainability was very, very important. And small changes, not radical changes. What do you have to do to achieve that? You have to build relationships. You have to communicate, you have to be open, you have to have open channels. 

Catherine: Mm-hmm. 

Dr. Hartl: And you gotta be resistant, uh, to frustration so you don't get frustrated.

A lot of what we do in surgery comes with a lot of frustration. So you gotta be immune to that. The same is true with technical innovation. When I started using navigation in spine surgery, I never looked at it as something that's gonna revolutionize spine surgery one day to the next. It was always a process, 


and I think that is very important for young surgeons to remember. Don't get frustrated, be persistent. Show resilience and communicate and be open-minded. And then always share your knowledge with others. That means collect your data, publish it, and share it with others, and don't get upset if other people criticize you.


Catherine: Well, thank you so much Dr. Hartl, for making the time to speak with us this afternoon. You have single-handedly improved my posture just over the course of our time together. I'm not even kidding. I am much better, you should see my shoulders right now. But thank you so much. It's been such a pleasure to speak with you.

Dr. Hartl: Catherine, thank you. Thank you very much. It's been an immense pleasure sharing my, uh, limited wisdom with you.

Catherine: Huge thanks to Dr. Roger Hartl for sitting down and sharing his– extremely NOT limited– wisdom with us today. I’m Catherine Price.


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