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Variability in Spine Surgery Training
The route to becoming a spine surgeon, whether through orthopedic or neurosurgery residency, requires extensive and rigorous training.[1] Although several similarities do exist, the minimum requirements and the quantity and quality of cases that trainees are exposed to have been shown to vary between and within subspecialty groups.[2-4] This has led to a recent focus on whether this variation in training has clinical implications on patient outcomes[5-7] and whether minimizing these differences could help the delivery of spine care in today’s rapidly evolving health care system.[8]
This variation in training has been amplified by the COVID-19 pandemic,[9-11] which demonstrated a significant reduction in trainees’ case logs.[11] The suspension of elective surgery and deployment of trainees to assist in other subspecialties has only further emphasized the importance of fellowships in preparing future spine surgeons.[12] With increasing numbers of spine surgeries and applicants applying into the subspecialty over the past 10 years,[13,14] the demand for well-trained spine surgeons has become quite evident. This review will discuss the variations in training that exist in the current model,[15] as well as potential changes that could positively affect the way spine surgeons deliver care to their patients.
Orthopedic and Neurosurgery Residency Training
The Accreditation Council for Graduate Medical Education (ACGME) requires both orthopedic and neurosurgery residents to complete a minimum number of cases in both adult and pediatric spine for graduation.[16,17] Despite this similarity, the emphasis on spine surgery in orthopedics is significantly less for graduation. Currently, of the 15 case categories required for by the ACGME, only one is within the field of spine surgery. In addition, of the 20 orthopedic milestones evaluated by program directors, none are devoted specifically to spine surgery.[18]
Daniels et al further examined this variability in training by comparing case logs between orthopedic and neurosurgical residents.[2] The authors found that the average number of spine surgeries performed during orthopedic residency was 160 cases compared to 375 in neurosurgical training.[2] Variations also existed within each cohort, as the top 90% of orthopedic residents by volume had nearly a 13-fold higher exposure to spinal arthrodesis compared to the bottom 10% in the same cohort.[2]
Although both specialties are expected to have a similar understanding and technique in treating spinal disorders, there appears to be a significant variation in the types of cases that residents are exposed too.[2,3] Orthopedic residents tend to be exposed to a greater number of thoracolumbar deformity cases and fewer cervical and intradural pathology cases compared to their neurosurgical colleagues.[3] Dvorak et al surveyed senior orthopedic and neurosurgery residents to compare their self-perceived confidence in performing 25 different spine procedures.[3] The authors found that neurosurgical residents had significantly higher dedicated exposure to spine (37% compared to 16%) with higher levels of confidence in all 25 procedures.[3] This variation in training has only increased over the past 10 years,[19] emphasizing the importance of spine fellowships.
Spine Fellowship
Although not required, the spine fellowship has become increasingly popular for both orthopedic surgeons and neurosurgeons.[2,20] This extra year of training can be critical, as it provides an opportunity to correct for any deficiency in case exposure that was present during residency. With an estimated minimum of 250 spine cases required before starting practice, this is especially important for orthopedic residents.[12,21] Silvestre et al compared the spine case volume of fellows to graduating orthopedic residents and found nearly a 4-fold increase in total spine cases in 1 year of fellowship compared to residency training.[22] Regardless of subspecialty, Konczalik et al found that those who did a spine fellowship were significantly more likely to feel comfortable with complex deformity and trauma compared to those who did not complete a fellowship.[21]
Despite these many benefits, there continues to be some variation in training even within the spine fellowships. Malik et al analyzed case logs of orthopedic spine fellows between 2010 and 2015, noting an overall decline in pediatric cases performed during these years.[23] The greatest variation was in deformity cases, with the top 90th percentile in cases logged having at least 43 deformity procedures, compared to zero in the bottom 10th percentile cohort.[23] While these difference may just reflect geographic location and physician practice, it does open the door for a more standard requirement from the ACGME for fellowships and for the potential collaboration between spine departments.
Future Considerations
Although several gaps between neurosurgical and orthopedic residency training can be filled with fellowship training, during the global pandemic, many fellows faced decreased operative time and case volume.[9,12] In addition, having 2 routes to the same specialty with such variation in training and technique can lead to potential downstream effects on patient outcomes. As such, the role of either an integrated or more spine-focused training in residency could be considered for future surgeons.
Daniels et al proposed the development of a spine residency, with dedicated focus on operative and nonoperative treatment modalities of spinal disorders.[24] This would allow integration of both orthopedic and neurosurgical techniques to fully optimize physicians to start practice after residency. While this would be ideal, institutional politics and economic barriers have made this difficult to come to fruition.[24]
In a recent meta-analysis comparing orthopedic to neurosurgical surgeon outcomes, the only differences found were a lower transfusion rate and a longer operative time by neurosurgeons among several studies.[15] This difference may be due to technique, as neurosurgeons require meticulous hemostasis during intra-cranial surgery; however, there were no differences in overall complications or 30-day readmission rates between cohorts.[15] The authors did note that improvement in surgical outcome in certain studies were those from high volume providers or those who had department collaboration on complex cases.[15,25] This highlights the importance of greater collaboration between neurosurgical and orthopedic surgeons to provide more consistent patient outcomes, research findings, and education to trainees.
Conclusion
The current 2 routes to spine surgery are often vastly different in residency training, with limited cross-over in interaction. With resident working hours becoming limited, optimizing spine education has become critical for future trainees. Limiting variation in quantity and spectrum of cases observed, especially in residency, can provide a much greater confidence to graduating residents. While studies have not shown a difference between subtypes, a fellowship has been shown to significantly increase the confidence of a provider in performing several spine procedures. A future spine residency would be a large undertaking, but it would help fill the gaps of the current model.
References
1. Lad M, Gupta R, Para A, et al. An ACGME-based comparison of neurosurgical and orthopedic resident training in adult spine surgery via a case volume and hours-based analysis. J Neurosurg Spine. 2021;35:553–563.
2. Daniels AH, Ames CP, Smith JS, Hart RA. Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data. J Bone Joint Surg Am. 2014;96:e196.
3. Dvorak MF, Collins JB, Murnaghan L, et al. Confidence in spine training among senior neurosurgical and orthopedic residents. Spine (Phila Pa 1976). 2006;31:831–837.
4. Pham MH, Jakoi AM, Wali AR, Lenke LG. Trends in spine surgery training during neurological and orthopaedic surgery residency: a 10-year analysis of ACGME case log data. J Bone Joint Surg Am. 2019;101:e122.
5. Baek J, Malik AT, Khan I, et al. Orthopedic versus neurosurgery–understanding 90-day complications and costs in patients undergoing elective 1-level to 2-level posterior lumbar fusions by different specialties. World Neurosurg. 2019;131:e447–e453.
6. Esfahani DR, Shah H, Arnone GD, et al. Lumbar discectomy outcomes by specialty: a propensity-matched analysis of 7464 patients from the ACS-NSQIP database. World Neurosurg. 2018;118:e865–e870.
7. Kim BD, Edelstein AI, Hsu WK, et al. Spine surgeon specialty is not a risk factor for 30-day complication rates in single-level lumbar fusion. Spine. 2014;39:E919–E927.
8. Snyder DJ, Neifert SN, Gal JS, et al. Assessing variability in in-hospital complication rates between surgical services for patients undergoing posterior cervical decompression and fusion. Spine. 2019;44:163–168.
9. Kogan M, Klein SE, Hannon CP, Nolte MT. Orthopaedic education during the COVID-19 pandemic. J Am Acad Orthop Surg. 2020;28(11)e456-e464.
10. Swiatek PR, Weiner JA, Butler BA, et al. Assessing the early impact of the COVID-19 pandemic on spine surgery fellowship education. Clin Spine Surg. 2021;34:E186-E193.
11. Munro C, Burke J, Allum W, Mortensen N. Covid-19 leaves surgical training in crisis. BMJ. 2021;372:n659.
12. Dowdell JE, Louie PK, Virk S, et al. Spine fellowship training reorganizing during a pandemic: Perspectives from a tertiary orthopedic specialty center in the epicenter of outbreak. Spine J. 2020;20:1381-1385.
13. Lopez CD, Boddapati V, Lombardi JM, et al. Recent trends in Medicare utilization and reimbursement for lumbar spine fusion and discectomy procedures. Spine J. 2020;20:1586–1594.
14. Ruddell JH, Eltorai AEM, DePasse JM, et al. Trends in the orthopaedic surgery subspecialty fellowship match: assessment of 2010 to 2017 applicant and program data. J Bone Joint Surg Am. 2018;100:e139.
15. Lambrechts MJ, Canseco JA, Toci GR, et al. Spine surgical subspecialty and its effect on patient outcomes – a systematic review and meta-analysis. Spine. 2023;48(9):625-635.
16. Review Committee for Orthopaedic Surgery. Orthopaedic surgery minimum numbers. Accreditation Council for Graduate Medical Education. September 10, 2014. https://www.acgme.org/ globalassets/pfassets/programresources/260_ors_case_log_minimum_numbers.pdf. Accessed April 16, 2023.
17. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in neurological surgery. July 1, 2013. http:// www.acgme. org/acgmeweb/Portals/0/ PFAssets/ProgramRequirements/160_neurological_ surgery_07012013.pdf.
18. Accreditation Council for Graduate Medical Education. Orthopaedic surgery milestones. https://www.acgme. org/specialties/orthopaedic-surgery/ milestones/. Accessed April 1, 2023.
19. Pham MH, Jakoi AM, Wali AR, Lenke L. Trends in spine surgery training during neurological and orthopaedic surgery residency. J Bone J Surg Am. 2019;101:e122.
20. Chandra A, Brandel MG, Yue JK, et al. Trends in neurosurgical fellowship training in North America over two decades 1997 to 2016. Neurosurgery. 2019;66(Suppl 1):310-326.
21. Konczalik W, Elsayed S, Boszczyk B. Experience of a fellowship in spinal surgery: a quantitative analysis. Eur Spine J. 2014;23(Suppl 1):S40–S54.
22. Silvestre J, Wu HH, Thompson, TL, Kang JD. Utility of spine surgery fellowship training for orthopaedic surgeons in the United States. J Am Acad Orthop Surg. 2023;31:335-340.
23. Malik AT, Kim J, Ahmed U, Yu E, Khan SN. Understanding the trends and variability in procedures performed during orthopedic spine surgery fellowship training: an analysis of ACGME case log data. J Surg Educ. 2021;78(2):686-693.
24. Daniels AH, Ames CP, Garfin SR, et al. Spine surgery training: Is it time to consider categorical spine surgery residency? Spine J. 2015;15:1513-1518.
25. Bauer JM, Yanamadala V, Shah SA, et al. Two surgeon approach for complex spine surgery: rationale, outcome, expectations, and the case for payment reform. J Am Acad Orthop Sur. 2019;27:e408–e413.
Cameron Kia, MD
Gregory Lopez, MD