New AO Spine Research Commission Chairperson Klaus Schnake lays out his vision for more diverse, active, and cost-effective research

As Assistant Professor Klaus Schnake, MD, dives into his three-year term as AO Spine Research Commission chairperson, he brings with him a wealth of clinical and research experience. Schnake, who began his three-year term on July 1, 2024, laid out a leadership vision that builds on the AO Spine legacy and calls for diversity, action, and cost-effective research.

Also joining the AO Spine Research Commission on July 1 were Alfredo Guiroy (regional research officer representing Latin America), Marcel Dvorak (KF Trauma & Infection representative), and Shekar Kurpad (KF Spinal Cord Injury representative). Charles Fisher will assume the role of past chairperson. 

Prof Schnake, tell us about your pathway into spine surgery in research. Who and what inspired you?

I started my medical education at the Charité – Universitätsmedizin Berlin and, when I was a resident, the Charité was one of the first hospitals in Germany to acquire a navigation system that could be used for computer-assisted spine surgery. I was appointed to take care of this navigation system and became kind of a “navigation resident”. Later, I wrote my thesis about surgical navigation in thoracic spine surgery and in doing so I learned more about spine surgery. Because of this and my growing interest in spine, I had a chance to undertake a fellowship in 2002 with Prof Walter Dick, who was head of the hospital’s orthopedic clinic until 2008, and Prof Bernhard Jeanneret, who was head of the spinal surgery department from 1996 to 2013. It was during this time that I “tasted blood” or really discovered my passion for spine surgery. Because I was so fascinated by these two surgeons’ work, how they performed surgeries, and the whole setup, I decided to really specialize in spine surgery.

When I returned to the Charité after my fellowship in Basel, I focused on spine and began working academically in terms of performing research. My friend and colleague Prof Frank Kandziora encouraged me and, because the Charité has an academic environment and is a university hospital, I was able to perform several preclinical and clinical studies. I was fascinated by the knowledge gaps existing in the field, such as whether dynamic stabilization of the spine would be a meaningful approach for patients with degenerative spine diseases. So, I performed a large animal study where we applied a disc injury to sheep, then performed dynamic stabilization, and over several months observed what happened to the discs: Would they recover or not? In this way, we gained more insight into the role of dynamic stabilization.

How did you become involved with the AO and how has your AO Spine involvement evolved?

My first contact with the AO was around the turn of millennium, when the Charité hosted a trauma course. This was followed by classical basic and advanced trauma courses. After five years, I became a member of AO Spine Germany, frequent joining courses, and was invited to give lectures; eventually I helped organize a course in Frankfurt. Since 2010, I have served in a number of AO Spine leadership positions: community development officer on the AO Spine Germany Country Council and for the AO Spine Europe and Southern Africa region, and in 2015, I was elected chairperson of the AO Spine Community Development Commission, representing community development on the AO Spine International Board.

Tell us about your involvement in the AO Spine Knowledge Forums (KFs).

Even before I became involved with the AO Spine KFs, my passion for this area had already begun: I was part of AO Spine Osteoporotic Fracture Working Group from 2008 to 2012. We developed the fundamental basis for the AO Spine Fracture Classification Systems. Shortly after the AO Spine KFs were founded, the KF Trauma incorporated this classification group and I became a member of the KF Trauma, which is now the KF Trauma and Infection. In 2015, I was accepted as a steering committee member and in 2020 became its chairperson. I was really fascinated by the outstanding quality and professionalism of the group, comprising of bright minds; this motivated me to catch up with these giants. 

What motivated you to seek the role of AO Spine Research Commission chairperson?
Previous chairpersons have made the AO Spine Research Commission one of the most important pillars of AO Spine’s success: AO Spine research includes clinical and preclinical research, as well as research training and that’s unique. The achievements of the KFs are amazing. AO Spine’s contributions are clear when we look at the classifications, treatment recommendations, the patient-reported outcome measures, the multicenter prospectives studies, and the more than 290 peer-reviewed publications. 

Leading the AO Spine Research Commission means that I have the chance to help one of the most respected research groups in the spinal field worldwide. I see my role as a promoter and facilitator of the AO Spine Research Commission—to help the commission achieve the best possible results. I want to make commission members’ and researchers’ lives easier and to give them an environment where they can really perform the best possible research.

What are your key AO Spine research priorities for the next three years?

I’ve defined three slogans to explain my priorities:

• Research is diverse. Over the next three years, I want to improve geographic and gender representation within the knowledge forums. For example, there’s still a lack of women researchers, so we must actively look for women researchers; as another example, we must actively seek researchers and clinical scientists from regions like Asia Pacific, the Middle East, Latin America, and Africa. Currently, in some of the knowledge forums, we have a bias for North America and Europe. And, because research itself is diverse, I would like to expand activities to so-called emerging technologies: minimally invasive approaches, endoscopy, robotics, augmented reality, artificial intelligence, for example. I hope to set up a new KF encompassing these emerging technologies.
• Knowledge results in action. Here, I would like to make research more visible both inside and outside of the AO and to share best practices between the KFs. Exchange between the KFs has traditionally been limited, yet we know that our KFs have different techniques and pathways—these are opportunities for us to exchange ideas and experiences to make each KF more efficient.
• Cost-effective research. This means I would like the KFs and the AO Spine Research Commission to focus on feasible, clinically relevant studies with the goal of improving patient care. Ultimately, the KFs should really focus on studies and research that will have a meaningful impact on how we treat patients, rather than on very specific problems which may not really help surgeons or patients in their daily lives.

Across AO Spine, there is a very strong focus on creating and translating new knowledge. Why is this important and how does the AO Spine Research Commission help make it happen? 

Translating knowledge is the key for effective and lifelong learning. We know that it typically takes 17 years on average for evidence-based knowledge to be adopted by physicians in their daily practices. That’s a shame because ours is a fast-developing world where we have many, many studies coming out and plenty of knowledge is being created. But researchers don’t necessarily know how to translate their findings into daily practice, into meaningful education. That’s why I think AO Spine’s work to translate knowledge coming from the AO Spine Research Commission and—through our community development system—distribute this knowledge to our members and the world is great and absolutely necessary. The AO Spine Research Commission members know what research both inside and outside of the AO is really new, meaningful, and likely to improve patient care and can transfer this knowledge to the educational bodies as well as community development, and then packaged appropriately to help both AO members and nonmembers.

As a surgeon scientist, what have been the most exciting spine research breakthroughs in your career?

My personal breakthrough was the development and validation of a specific classification and therapeutic score for osteoporotic thoracolumbar spine fractures, which I accomplished during my time as chair of the osteoporotic fracture working group of the German Society for Orthopaedics and Trauma Surgery (DGOU). The development of this classification and score, which was later endorsed by AO Spine, took more than 10 years together with both groups: DGOU and AO Spine. I’m convinced that we created something very meaningful that helps us to classify these types of fractures so that we all speak the same language and, hopefully, we will find with the score and all the work we’ve done the most appropriate way to treat these patients. This has been my personal research breakthrough.

In general, the most exciting spine research breakthrough I’ve seen in my career was the introduction of the pedicle-screw-based internal fixator to our daily clinical work, developed by Prof Walter Dick and in parallel by Patrick Kluge. The internal fixator was a milestone in spinal surgery and still used in our daily work today, 40 years later.

Looking to the future, what spine research areas do you see as the most promising?

For me, the technical developments are fascinating. There are several technologies that I think will definitely change the way we diagnose and treat patients: With artificial intelligence (AI), robotics, augmented reality (AR), and technologies like endoscopy, I think we will be able to revolutionize our treatment strategies. In the future, I’m sure we will design our treatments, indications, and treatment strategies based on big data and AI because will have the data to help us find a very personalized treatment pathway for each patient. We will get help from robots, navigation and maybe AR to be more precise and predictable with our surgical work and, ideally, reduce complications. 

Finally, I think there’s an ongoing trends toward more minimally invasive surgical procedures including endoscopy; so, the future will be minimally invasive and driven by AI and other modern technologies. All of these are tools that can help us more quickly get better as surgeons and, ultimately, provide patients with the best possible treatments. 

I’m convinced that the future of spine surgery is bright and the options to perform research are countless. Since AO Spine is the only truly international spine organization driven by really engaged members, I believe the AO will play a crucial role in further developing spine surgery. And, since research has become one of the most important AO Spine pillars—this is acknowledged by people both inside and outside the AO—I’m sure the AO will be at the forefront of all these activities.