The Invisible Made Standard: How Surgeons Built a Universal Map of the Spine
The Invisible Made Standard Procedural Redesign, Surgical Precision, and the Blueprint That Belongs to Everyone
I. The Screen and the Patient
Now the doctor looks at the screen before the patient.
That was what Dr. César Ramírez, the highest board-certified specialized surgeon in Europe, told me during our interview. It stayed with me. This genuine truth represents a path I am working on through personal communication, pure and authentic connections with incredible people. I agree with Dr. César — we have built powerful tools, and in doing so, we have sometimes begun to look past the person those tools are meant to serve.
Innovation has advanced medicine, but often at the cost of emotional presence. We have better tools, and worse connections. Who are we treating?
This is the question I keep coming back to. And it is the question that led me to the work of Dr. Omar Ramos — a spine surgeon in Minneapolis whose research does not abandon the screen, but uses it to see the patient more clearly than ever before.
II. The Surgeon as Scientist: Who is Dr. Omar Ramos?
Dr. Omar Ramos is not just a spine surgeon. He is what I call a procedural redesigner — a clinician who applies an engineering mindset to surgery, not to create new machines, but to make existing procedures more effective, humanistic, and precise. He was named 20 Under 40 by the North American Spine Society, an elite recognition in his field.
Patients describe him as a "guiding light" who gives them their "life back." They say he truly listens to all concerns. After watching him, he transmits a patient feeling — he gives calmness, genuine interest, and joy. He is a charismatic doctor. He wakes up early to exercise so that by evening he can be fully present — going on family walks and enjoying time with his daughters. He is, in the best sense, a surgeon who transmits and lives the essence of humanity.
This genuine interest in the patient as a whole person reminds me of the books of Dr. Oliver Sacks. I am currently reading The Man Who Mistook His Wife for a Hat, and it relates to his understanding of the patient as a whole story, not as a clinical case. I feel that his charismatic personality shares something with Dr. Omar Ramos — both seek precise care, both lead with empathy, and both see the human being before the condition.
What makes Dr. Ramos special to me is that his research embodies exactly the type of innovation I want to practice: scalable, not exclusive. It maximizes the potential of available technology. It does not require a million-dollar robot. Innovations that mark a before and after for the better of the patient. It requires creativity, curiosity, and communication.
This is the vision — and Dr. Ramos, in collaboration with other doctors, surgeons, and clinicians, is executing it. Together they have identified real problems in spine surgery that demand creative solutions, and through research, they are discovering better ways to see the patient, understand their anatomy, and operate with greater precision and less harm. An interest I am beginning to pursue.
III. Defining Normal: The Gold Standard of the Lumbar Spine
The Problem with "Eyeballing"
Imagine trying to fix a complex machine without ever knowing what a perfectly functioning one looks like. For a long time, spine surgeons diagnosed lumbar neuroforaminal stenosis — a condition where the tunnels that carry nerves out of the spine become too narrow, compressing the nerve root and causing severe pain — based on what they saw. They would look at a scan and decide: mild, moderate, severe. But that decision was open to interpretation. One surgeon's moderate was another's severe. There was no standard. There was no number. It was, essentially, an educated guess.
Dr. Ramos identified this as an engineering failure: a system without a reference point.
What They Did
To solve this, in collaboration with many clinicians, Dr. Ramos analyzed CT scans of 969 healthy young adults between the ages of 18 and 35 — people with no history of spinal disease. They performed 48,450 precise measurements of the lumbar spine, covering every level from L1 to S1. By studying healthy spines, they could define what "normal" actually looks like before the wear of injury or age sets in.
They measured three key things at each spinal level. The first was the Segmental Angulation (SA) — the angle between two vertebrae, which is critical to the natural inward curve of the lower back called lordosis. The second was the Disk Space Height (DSH) — how much space exists between the vertebral bones, measured at the front, middle, and back of each disk. The third, and most important, was the Neuroforaminal Dimensions (NFD) — the actual size of the nerve tunnel, measured in width, height, and total area.
The Surprising Discovery
Here is where the research amazed me and contradicted my prediction. You might assume that if the disk is taller, the nerve tunnel would naturally be larger too. Dr. Ramos's data proved this assumption wrong. They found only a weak-to-moderate correlation between disk height and tunnel size. The size of the nerve tunnel is actually determined more by the vertebral morphometry — the unique shape of the bone itself, particularly features like the vertebral notch and the pedicle length.
What this means for a surgeon is profound: you cannot look at the "cushion" between the bones and guess the size of the "doorway" for the nerve. You have to look at the bone.
And the same result occurred with the Segmental Angulation.
The Ethnic and Sex Differences
One of the most important contributions of this study is that it revealed "normal" is not the same for everyone. It was interesting to find that the research concluded on significant differences across sex and ethnicity. Males consistently demonstrated larger values across all measurements compared to females. And among ethnic groups, the Asian cohort had the largest nerve tunnel widths, while the African American cohort had the smallest widths and areas — though interestingly, the largest segmental angulation.
Just as critically, the study found that a patient's height and weight have only a weak association with these internal dimensions. You cannot look at someone's size on the outside and predict what their spine looks like on the inside. This is what equity in medicine looks like: recognizing that every patient is unique in its anatomy and the procedure should proceed accordingly.
What It Means for Surgery
By establishing these normative values — a mathematical "gold standard" for healthy anatomy by sex, ethnicity, and spinal level — Dr. Ramos has given surgeons something they never had before: a baseline to compare against. Now, when a surgeon looks at a patient's scan, they are not just guessing. They can compare the patient's neuroforaminal area at, say, L4-L5 against the average for someone of the same sex and ethnicity. The gap between those numbers tells the story of how severe the condition truly is.
This is surgery guided by precision rather than force. Not invasive exploration, but data-driven certainty.
I recognize this principle because I live it. This year, in collaboration with the Tecnológico de Monterrey and CODE Jalisco, I am part of Mexico's first national sports science research project — designing advanced testing protocols for elite Olympic and national-level athletes preparing for Los Angeles 2028, including World champions and Olympic gold medalists from sports such as track, cycling and fencing to name a few. Using Vicon motion capture, force plates, and EMG systems, I measure muscle-activation timing, force, power, and energy output during sprints to help coaches make precise injury-recovery decisions and build individualized training protocols. What the force plate gives a coach is what the CT scan gives a surgeon: not an impression, but a number. Not a guess, but a baseline. Before this research, coaches relied on visual assessments. Now they know exactly which muscles to train, for what phase of the race, and why. Seeing the athlete more clearly — that is the innovation of the gold standard, and it is the same insight that drives Dr. Ramos's work.
IV. The Surgeon's GPS: Mapping the Body's Surface
The Problem of the Wrong Map
Before a surgeon makes a single cut, they need to know exactly where they are on the anatomy. In spine surgery, especially when approaching the spine from the front of the body, surgeons use surface landmarks — bony points they can feel through the skin — to determine which vertebra lies beneath. For operations on the neck and upper back, these landmarks are the Sternal Notch (the "V-shaped" dip at the base of the throat) and the Sternal Angle (the horizontal ridge on the breastbone where the second ribs attach).
The problem is that traditional textbook descriptions of where these landmarks sit were based on cadaver studies — bodies that had undergone postmortem changes, from small and non-diverse samples. If a surgeon uses an inaccurate landmark, the incision can land in the wrong place. Then comes force: a larger opening, more tissue retraction, more trauma, longer recovery. Exactly what I want to eliminate from surgery.
Why the Front of the Chest Matters for Spine Surgery
It may seem strange to use a chest landmark to guide spinal surgery, but many critical spine operations are performed through an anterior approach — entering from the front to avoid cutting through the thick muscles of the back. The most common of these is ACDF, Anterior Cervical Discectomy and Fusion, where the surgeon removes a damaged disk and fuses the bones together through the front of the neck. For surgeries like this, the sternal notch marks the "floor" of the neck's accessible corridor. Knowing exactly which vertebra sits behind it determines the entire approach. This was interesting to me — why would you operate on the spine through an incision in the torso? But it actually remains very effective and less damaging to the patient for post-operative recovery.
Click on the image to observe the procedure
What They Did
In collaboration with a large team of clinicians, Dr. Ramos analyzed CT scans of 1,035 patients from a diverse cohort — 495 Hispanic, 321 Caucasian, 130 African American, and 68 Asian patients. They mapped precisely where the Sternal Notch and Sternal Angle aligned with the thoracic vertebrae behind them.
The Bimodal Discovery
The study's core finding was what they called bimodal distribution — meaning the data had two distinct peaks, not one. The Sternal Notch most frequently corresponded to the T2 or T3 vertebral bodies. The Sternal Angle most frequently corresponded to the T4 or T5 vertebral bodies. "Normal," it turns out, can look like two different things.
For a surgeon, this is critical. You cannot assume the notch is at T2 and proceed. You must be prepared for T3. This is precision: not the absence of variability, but the honest acknowledgment of it.
The Cephalad Shift: How Weight Changes the Map
The most clinically significant finding of this study involved weight. While height, sex, and ethnicity had no significant influence on where these landmarks sat, weight and BMI did. As a patient's weight increases, these landmarks shift in a cephalad direction — that is, toward the head, upward. A landmark that sits at T5 in a lean patient may sit at T4 or T3 in a heavier one.
This means that a surgeon's internal GPS must adjust for every individual body. The terrain is not fixed. It shifts. And now, thanks to this research, surgeons have the data to adjust their approach before making the first incision which makes planning safer and easier.
What This Means: Scalable Innovation
This research is the definition of what I believe innovation should be. Dr. Ramos and other doctors did not build a new robot. He used existing CT technology — available in virtually every hospital in the world — to make a fundamental surgical tool, the surface landmark, exponentially more accurate. He maximized the potential of available technology.
The innovation is not expensive. It is not exclusive. It is a number — shareable, translatable, usable across borders.
V. Procedural Redesign and the World It Can Reach
Both of these research studies, at their core, are acts of procedural redesign. They are not new machines. They are new ways of thinking about procedures that already exist, made more precise, more equitable, and more human.
The first study gives surgeons a map of what a healthy spine looks like for every type of person — so they can navigate back to that health with precision. The second study gives surgeons a GPS calibrated to the individual body in front of them — so they can enter that body with the smallest possible footprint.
These innovations create a more favorable outcome for the patient. I arrived at the understanding of procedural redesign through Dr. Diego González and his Uniportal VATS and RATS procedures for the lungs. Where creating new technologies is marvelous, it is highly restricted and limited in its spread and global health impact. It takes a large amount of resources to get there. A procedural redesign is also not an easy path, but I visualize it as a more creative, enlarging, collaborative, and human innovation. Where we use the technology we have available to improve the patient's outcomes — improvements that can be shared with the world and implemented. These sorts of creations are emotional, they are unique, and they represent a vision. Often I see excessive technology being used for the appeal of using it — if a device is sitting there and costs millions, then why not use it? Well, it is not the technology; it is the use we give such technology. It must be used ethically and always with the focus of the patient in mind: what will be best for them? With procedural redesign we connect the best of both worlds — the excellence of craft, innovation, precision, and love.
VI. What I Want to Adopt From Dr. Omar Ramos
Dr. Omar Ramos has shown me something I want to carry into every room I ever operate in. Using the screen is not the same as forgetting the patient. When used with the right intention — when the screen is a tool for precision, not a substitute for presence — it becomes the most human thing a surgeon can do.
His research does not just improve surgery. It improves surgery for everyone. The research transmits: the patient in front of you is not a universal template. They have their own biology, their own architecture, their own map. And before you operate, you owe it to them to know it.
That is the kind of surgeon I want to become. Not one who creates costly machines or seeks world-renowned technologies. One who redesigns procedures with what already exists. One whose innovation is scalable, not exclusive. One who, before the first cut, knows exactly where they are — and why.
Precision and decision. Fewer incisions, less pain, faster recovery. And above all: the patient, seen.
I will pursue the deep path of surgery — watching it live, reading it, studying it, feeling it the way a child feels his destiny: with wonder, with awe. I want to continue watching surgeries, reading about surgeons, reading meditations and philosophy — to understand the complexity of medicine, to execute solutions for it, to see its beauty and comprehend it as a poem. I will continue developing my research at the Tecnológico de Monterrey, seeing the patient more clearly, understanding their pathology, understanding why we do what we do — to help them become who they need to become, to get them to the goal, to the medal, to the Olympics. All innovation is precise. It is personal. It is for them. I will continue writing, exploring, reading — making ideas, creating ideas, imagining with curiosity what surgery truly is. That is what this work is doing to me. That is how this is changing me. I will grow.
Key Terms
Lumbar Neuroforaminal Stenosis (LNFS) — The narrowing of the bone tunnels (neuroforamina) where nerve roots exit the lower spine. When these tunnels become too small, they compress the nerve, causing pain, numbness, or weakness in the legs.
Neuroforaminal Dimensions (NFD) — The measurements of the nerve tunnel — its width, height, and total area. These are the key measurements Dr. Ramos used to define what is "normal" at each spinal level.
Segmental Angulation (SA) — The angle between two adjacent vertebrae. This angulation is essential to the natural curve (lordosis) of the lower back.
Vertebral Morphometry — The specific shape and structure of an individual vertebra, including features like the vertebral notch. Dr. Ramos's research showed this is the primary determinant of nerve tunnel size — more so than disk height.
Cephalad — A directional term in anatomy meaning "toward the head." In the landmark study, heavier patients showed a cephalad shift in their surface landmarks.
Bimodal Distribution — A statistical pattern where data clusters around two peaks rather than one. The sternal notch and sternal angle both showed bimodal distributions, meaning "normal" corresponded to two possible vertebral levels.
ACDF (Anterior Cervical Discectomy and Fusion) — A common spine surgery performed through the front of the neck. The surgeon removes a damaged disk and fuses the adjacent vertebrae together. The surface landmark research directly improves the precision of access for this procedure.
Just add these two lines at the end of the article, wherever he wants to place them — bottom of the page or after the Key Terms section:
References
Ramos, O. et al. (2023). Normative Measurements of L1–S1 Segmental Angulation, Disk Space Height, and Neuroforaminal Dimensions Using Computed Tomography. PubMed. https://pubmed.ncbi.nlm.nih.gov/37866208/
Ramos, O. et al. (2023). Surface Anatomical Landmarks for Spine Surgery: A CT-Based Study of the Sternal Notch and Sternal Angle in 1,035 Patients. PubMed. https://pubmed.ncbi.nlm.nih.gov/38032205/
