Authors: K. Daniel Riew
Zoher Ghogawala, MD
Alexander R. Vaccaro
Christopher I. Shaffrey
Lawrence G. Lenke
Todd J. Albert
"You see things; and you say, 'Why?' But I dream things that never were; and I say, 'Why not?'"
- George Bernard Shaw
It is the dream of many Neurological and Orthopedic Spine surgeons to make Spine surgery its own specialty. While this may seem far-fetched at the present time, history suggest that this is likely to become reality within the next several decades.
During their formative years, both Neurological and Orthopedic Surgery were divisions of General Surgery and in some universities, they remained as divisions until very recently. General Surgery fought hard to keep both as divisions but several factors led to their emancipation as independent departments. First, and foremost, it was recognized that trainees needed to spend more time learning to perform operations in their designated specialty. With the explosive growth in the number of procedures, time spent learning General Surgery meant less time learning specialty procedures. Both patients and trainees were better served by making the majority of the training specialty specific. Second, because of the differences in reimbursement for General Surgical versus specialty procedures, Neurosurgeons and Orthopedic surgeons subsidized the rest of the department. As a result, the American Academies of both disciplines advocated for establishing their own departments. Eventually, the inability to attract top talent to Chair divisions of Neurosurgery and Orthopedics under a General Surgery Department led to the establishment of separate departments.
The same sensible arguments for secession are even more relevant concerning complex spinal procedures. The explosive growth in spinal procedures makes it difficult for trainees to gain proficiency even after 7 years of Neurosurgery or 5 years of Orthopedic training, which is why many opt for fellowship training. Even after fellowship, there can be significant variation in proficiency and approach between the disciplines. For this reason, many top spine fellowships include both Neurosurgery and Orthopedic training. It is well-recognized by most academic spinal surgeons from both specialties that much of the training in both Neurological Surgery and Orthopedic Surgery might not be necessary for those destined to become spine surgeons. Because diagnosis and treatment remain exceedingly nuanced, we would serve both trainees and their future patients much better if spine trainees spent the vast majority of their training with spine cases. Many Neurosurgery residencies recognize this and include an "in-folded" spinal fellowship.
What logically will occur with collaboration occurring between both specialties practicing spinal surgery? First, spine surgeons are beginning to consider themselves not as Neurological or Orthopedic Spine Surgeons but simply as Spine Surgeons. This will foster a formal commitment to working together for the common good and for the sake of our patients and trainees. Nearly every academic spine society and conference now includes both specialties. We will be more successful in obtaining federal funding to support spinal research to advance patient care by combining the expertise of both Neurological and Orthopedic surgeons as unified spinal surgeons. Second, academic institutions should follow the examples of top institutions such as The Cleveland Clinic and Duke who have created a unified Division of Spine Surgery. Trainees in both specialties will be exposed to attendings in both specialties. Optimal spinal education occurs through a collaborative effort from both fields. Third, the two specialties should establish a disciplined and high-quality American Board of Spinal Surgery to ensure a core competency for all trainees. Fourth, we should work in collaboration with the Residency Review Committees as well as the American Boards of both Orthopaedic and Neurological Surgery to develop a program that optimizes training in spine and limits disruption to our parent specialties. A proposed program for spine trainees might consist of either 4 years in Neurosurgery followed by 2 years in Spine or 3 years in Orthopedics followed by 3 years in Spine. It would be difficult to argue that this would not result in better-trained surgeons, which in turn would lead to better outcomes for our patients. Who amongst us would rather entrust one of our family members to a newly-minted product of our current system over the proposed one?
Finally, the above proposal is certainly not one that is likely to happen without a concerted effort on the part of a united Spine specialty. Academies and Departments of Neurosurgery and Orthopedics may still place self-interest ahead of patient outcomes, much as General Surgery stood in the way of Neurosurgery and Orthopedics becoming their own departments. But history has shown us that in the end, the march to ever-greater sub-specialization is inexorable and inevitable. The Hippocratic dictum exhorts us to first do no harm; we have to do what is right and ethical for our trainees and best for spine patients. For this reason, we believe that Spinal Surgery should become an independent surgical specialty.