January 20, 2016
3 min read

One for spine and all for one Clarifying the discipline of spinal surgery

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The practice, scope, birth and elimination of medical subspecialties is a continuously evolving process. Various specialties, with their own accrediting boards, arose out of what once was general surgery, not the least of which is orthopedic surgery.

In other instances, subspecialties are born out of two different specialties. A prime example is the subspecialty of hand surgery, which is populated by both plastic surgeons (general surgery derivation) and orthopedic hand surgeons (orthopedic surgery derivation). In this case, rather than create a new board, the fellowship training and certification through a Certificate of Added Qualification (CAQ) was the process by which training and accreditation was standardized. The key issue with spine surgery at this point in time is whether it should be its own specialty or remain a subspecialty populated by those initially trained in either neurological surgery or orthopedic surgery.

Scott D. Boden

In this issue’s Cover Story, you will see a case to make spine surgery its own subspecialty with a dedicated full residency training program that is separate from orthopedic surgery or neurological surgery. If we were designing the discipline from scratch, we might use the argument that spine-focused neurological surgeons have far more in common with orthopedic spine surgeons than they do with general neurological surgeons, which supports the notion of separating spine out of neurosurgery. In fact, several large spine groups have orthopedic and neurological surgery spine surgeons practicing side-by-side. However, many of the principles of biomechanics, biomaterials, spinal fixation and bone grafting biology are an integral part of orthopedic surgery training, so separating spine surgery from orthopedic surgery may not make as much sense. In addition, unlike in such countries as Japan, where orthopedic spine surgeons perform intradural procedures, that is not the case in the United States, where the bulk of intradural work is handled by neurological surgeons.

Separation presents challenges

The reality is that as at least 60% of general neurological surgeons’ practices include at least basic spine surgery, it would be politically and financially challenging to separate spine from neurological surgery. If you accept that assumption, then the most logical next step would not be creation of a new specialty, but rather formalizing the subspecialty of spine surgery along the lines of hand surgery, which is populated by graduates of either plastic surgery or orthopedic surgery residencies, typically upon completion of a hand surgery fellowship training program. There are already several combined orthopedic and neurological spine surgery fellowship training programs.

Creation of a standardized curriculum that includes a common set of diagnostic skills, non-surgical treatment expertise, surgical indications and technical capabilities would be a first step, if this could be created and endorsed by the spine surgeon leadership within both neurological surgery and orthopedic surgery. A standardized advanced spinal fellowship curriculum might permit shortening of the general neurological surgery and orthopedic surgery residency training programs to create time for future spine surgeons to participate in a spine surgery fellowship that follows the standardized curriculum. Whether a CAQ is required, beneficial or desirable beyond a standardized training experience for the subspecialty of advanced spinal surgery is a separate debate and also it is a question that need not be answered until after the standardized training is created, accepted and validated by all parties as a useful exercise.

Focus on the patient

In the end, such decisions should be patient-centered and not physician “turf”-centered. As a patient, I might prefer to focus on whether my surgeon was adequately trained as a spinal surgeon and completely move away from the older stereotypes of neurosurgeon and orthopedic surgeon and their historic roles in spine surgery. Afterall, if any of us in the field needed advanced spine surgery, I am sure we know members of both specialties that we would and would not trust to perform the procedure. Therefore, I think a standardized curriculum for advanced spinal surgery fellowships would allow the public to place trust in their surgeon if he or she has completed such a fellowship.

Spine-focused neurosurgery fellowships

Of course, the elephant in the room is whether or not spine-focused neurological surgery fellowships will continue to exist. They were originally created to fill the gap for spinal instrumentation placement that was not uniformly taught in neurosurgery residency programs, but that gap has diminished during the last decade. Will the general neurological surgery residency include only basic spine surgery and shorten its 7-year timeframe or continue to exist and train all neurosurgeons in all aspects of advanced spine surgery so we continue to consider every neurosurgeon a spine surgeon? That is a question for organized neurological surgery to address before we can work toward a collaborative and lasting clarification of the discipline of spinal surgery.

Disclosure: Boden reports no relevant financial disclosures.