The relationship between orthopedic spine surgeons and neurosurgeons has evolved over the past several decades. Thirty years ago, spine surgeons were trained to perform fusion procedures while neurosurgeons dealt with nerve decompression and oncology cases related to the spine. The two specialists would work together on patients who needed both types of procedures, but wouldn't perform the other.
"When I was in training, the neurosurgeon would come in for a cervical procedure and expose the neck before decompressing the nerve," says Nick Shamie, MD, co-director of the UCLA Comprehensive Spine Center and associate professor of orthopedic surgery at David Geffen School of Medicine at UCLA. "The spine surgeon would put in the implant, plate and fuse the spine before closing the neck. That's often how the collaboration was done, but we aren't seeing that as much anymore because the separate specialties are blending."
Neurosurgeons now receive proficient training in fusion and orthopedic spine surgeons are adept at decompressing the neural elements, but that doesn't mean the collaboration should end; in fact, many specialists still prefer to partner with their colleagues in spine care to broaden the expertise available for their patients.
"Spine surgeons and neurosurgeons come from different backgrounds and they compliment each other in understanding the pathology," says Alexander Vaccaro, MD, PhD, vice chairman of the department of orthopedics at Thomas Jefferson University Hospital and senior partner at Rothman Institute in Philadelphia. "They have different perspectives and it's a lot of fun to work together."
Here are five benefits and challenges for orthopedic and spine surgeon partnerships.
1. Everyone must want the partnership to work. In any type of partnership, it's essential for both sides to completely support the other. When spine surgeons and neurosurgeons work together, both sides must have the same goals and the support of the hospital to make the partnership work.
"You are getting married to someone in the other specialty and there are some known differences between the two; you have to agree to disagree sometimes and expand your horizons together," says Dr. Shamie. "In the past, partnerships between spine and neurosurgeons failed at UCLA because the two departments didn't see eye to eye and there wasn't an impetus by the hospital for us to work together. The surgeons have to be willing and eager to work together — that's what makes hospital administrators and department heads go through with it."
A more recent collaboration between spine surgeons and neurosurgeons over the past decade has survived because all parties involved were concerned with the same central issue: providing better patient care.
"We have the same vision of enhancing patient care, and that has helped us tremendously in maintaining this relationship," says Dr. Shamie.
2. Surgeons broaden their expertise. Even though orthopedic spine and neurosurgeons are now able to perform many of the same cases separately, they still come from different training backgrounds. Orthopedic spine surgeons traditionally had a deeper understanding of spinal deformity, shoulder biomechanics and hip pathology as they relate to back pain and spinal conditions; neurosurgeons traditionally were more practiced with nerve issues and spinal cord tumors.
"The neurosurgeons have talent that goes beyond the expertise of an orthopedic spine surgeon," says Dr. Vaccaro. "Having the neurosurgeon available enhances the entire surgical experience."
In more complex cases, patients will have multiple issues crossing the two specialties. For example, patients may have nerve problems — which traditionally were the purview of neurosurgeons — but also suffer from spinal deformity. In this case, bringing together multiple specialists to discuss treatment can boost global understanding of the case.
"Collaboration helps you work through a problem and survey different opinions," says Alok D. Sharan, MD, chief of the orthopedic spine service at Montefiore Medical Center in Bronx, N.Y. "We have a multidisciplinary spine conference once per month where specialists come together and discuss cases. It's really nice to hear different opinions on treatment for our patients."
3. Patient care is improved. When patients have access to more specialists in a coordinated effort, their care becomes instantly better. Spine surgeons and neurosurgeons partnering regularly on cases are able to provide patients with increased care options and expertise.
"The patients have the benefit of two different specialists consulting on their pathology," says Dr. Vaccaro. "When surgeons can work with someone they respect, the surgery runs more smoothly."
Dr. Vaccaro partners with a neurosurgeon on some of the more complex cases associated with opening the dura. There are also times when neurosurgeons require his assistance, such as when patients with scoliosis deformity require a specific type of detethering procedure. He also works alongside neurosurgeons for patients with spinal cord injuries so patients benefit from expertise in both areas. Orthopedic spine surgeons and neurosurgeons at Thomas Jefferson Hospital rotate as the primary specialist with spinal cord injury patients every week so both are able to work with each patient and share emergency room responsibilities.
"This partnership really helps patient care, and it saves patients the time and agony of going from the orthopedic surgeon's office across town to the neurosurgeon's office because both specialists aren't at the same hospital," says Dr. Shamie.
Dr. Sharan has a special interest in spinal oncology cases, where complex decompressions and fusions are required. He often works with neurosurgeons to decide upon the proper method to resect the tumor. "Having someone else to work with helps in planning the procedure and executing that plan in the operating room," he says. "I think it's important to understand treating spinal disorders requires a multidisciplinary effort to treat patients."
4. Make sure there is contract uniformity. It's important for both sides of a partnership to feel they are treated fairly and equally — which includes payment. When Dr. Shamie and his colleagues began the formal collaboration between orthopedic spine and neurosurgeons, they noticed neurosurgeons were paid more for performing the same procedures as orthopedic spine surgeons.
"That's the kind of difference that can have a big impact on your collaboration," says Dr. Shamie. "If the administration favors one specialty over another, the underdog has to speak up and the favored group has to back them up and say the arrangement isn't good for the hospital, even though they are benefiting from it."
Right now, there isn't much financial incentive for spine surgeons and neurosurgeons to work together on cases, but that could be changing in the near future.
"The way the system is currently set up, the specialists live in their separate silos and there aren't any incentives to work with others," says Dr. Sharan. "As we start to work t in an ACO model with coordinated patient care, those silos are breaking down and we'll see better value for the patient. I would argue that as the payment reform system moves toward higher value, it's moving toward spinal payments that require more cooperation between physicians."
5. Expand the partnership to include other specialists. While orthopedic spine and neurosurgeons compliment each other nicely in the operating room, a vast majority of patients with back pain don't make it that far; they benefit more from conservative care and interventional pain management techniques. Bringing these specialists into the partnership creates a comprehensive approach to care for a wider range of patients, and is also beneficial for patients after surgery.
"Specialists in pain management, physical medicine and neurology can raise patient safety concerns before surgery," says Dr. Shamie. For example, if a surgical patient has a pacemaker, it can't be turned off for the MRI and must be modified before the procedure. "That takes a very thorough discussion with the cardiologist and internal medicine specialist. Those are people we work with regularly."
When all specialists are involved, patients can be plugged into the appropriate course for care at the initiation of their treatment, like cancer patients are in large cancer centers. "If I had cancer, I might go to a large cancer center and get plugged into the kidney cancer team and there would be specialists who looked after me who focus just on kidney cancer," says Dr. Sharan. "The specialists are like the spokes on a wheel with the patient in the middle. We need to move toward that model for spine because patients will benefit from all types of treatment."
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"When I was in training, the neurosurgeon would come in for a cervical procedure and expose the neck before decompressing the nerve," says Nick Shamie, MD, co-director of the UCLA Comprehensive Spine Center and associate professor of orthopedic surgery at David Geffen School of Medicine at UCLA. "The spine surgeon would put in the implant, plate and fuse the spine before closing the neck. That's often how the collaboration was done, but we aren't seeing that as much anymore because the separate specialties are blending."
Neurosurgeons now receive proficient training in fusion and orthopedic spine surgeons are adept at decompressing the neural elements, but that doesn't mean the collaboration should end; in fact, many specialists still prefer to partner with their colleagues in spine care to broaden the expertise available for their patients.
"Spine surgeons and neurosurgeons come from different backgrounds and they compliment each other in understanding the pathology," says Alexander Vaccaro, MD, PhD, vice chairman of the department of orthopedics at Thomas Jefferson University Hospital and senior partner at Rothman Institute in Philadelphia. "They have different perspectives and it's a lot of fun to work together."
Here are five benefits and challenges for orthopedic and spine surgeon partnerships.
1. Everyone must want the partnership to work. In any type of partnership, it's essential for both sides to completely support the other. When spine surgeons and neurosurgeons work together, both sides must have the same goals and the support of the hospital to make the partnership work.
"You are getting married to someone in the other specialty and there are some known differences between the two; you have to agree to disagree sometimes and expand your horizons together," says Dr. Shamie. "In the past, partnerships between spine and neurosurgeons failed at UCLA because the two departments didn't see eye to eye and there wasn't an impetus by the hospital for us to work together. The surgeons have to be willing and eager to work together — that's what makes hospital administrators and department heads go through with it."
A more recent collaboration between spine surgeons and neurosurgeons over the past decade has survived because all parties involved were concerned with the same central issue: providing better patient care.
"We have the same vision of enhancing patient care, and that has helped us tremendously in maintaining this relationship," says Dr. Shamie.
2. Surgeons broaden their expertise. Even though orthopedic spine and neurosurgeons are now able to perform many of the same cases separately, they still come from different training backgrounds. Orthopedic spine surgeons traditionally had a deeper understanding of spinal deformity, shoulder biomechanics and hip pathology as they relate to back pain and spinal conditions; neurosurgeons traditionally were more practiced with nerve issues and spinal cord tumors.
"The neurosurgeons have talent that goes beyond the expertise of an orthopedic spine surgeon," says Dr. Vaccaro. "Having the neurosurgeon available enhances the entire surgical experience."
In more complex cases, patients will have multiple issues crossing the two specialties. For example, patients may have nerve problems — which traditionally were the purview of neurosurgeons — but also suffer from spinal deformity. In this case, bringing together multiple specialists to discuss treatment can boost global understanding of the case.
"Collaboration helps you work through a problem and survey different opinions," says Alok D. Sharan, MD, chief of the orthopedic spine service at Montefiore Medical Center in Bronx, N.Y. "We have a multidisciplinary spine conference once per month where specialists come together and discuss cases. It's really nice to hear different opinions on treatment for our patients."
3. Patient care is improved. When patients have access to more specialists in a coordinated effort, their care becomes instantly better. Spine surgeons and neurosurgeons partnering regularly on cases are able to provide patients with increased care options and expertise.
"The patients have the benefit of two different specialists consulting on their pathology," says Dr. Vaccaro. "When surgeons can work with someone they respect, the surgery runs more smoothly."
Dr. Vaccaro partners with a neurosurgeon on some of the more complex cases associated with opening the dura. There are also times when neurosurgeons require his assistance, such as when patients with scoliosis deformity require a specific type of detethering procedure. He also works alongside neurosurgeons for patients with spinal cord injuries so patients benefit from expertise in both areas. Orthopedic spine surgeons and neurosurgeons at Thomas Jefferson Hospital rotate as the primary specialist with spinal cord injury patients every week so both are able to work with each patient and share emergency room responsibilities.
"This partnership really helps patient care, and it saves patients the time and agony of going from the orthopedic surgeon's office across town to the neurosurgeon's office because both specialists aren't at the same hospital," says Dr. Shamie.
Dr. Sharan has a special interest in spinal oncology cases, where complex decompressions and fusions are required. He often works with neurosurgeons to decide upon the proper method to resect the tumor. "Having someone else to work with helps in planning the procedure and executing that plan in the operating room," he says. "I think it's important to understand treating spinal disorders requires a multidisciplinary effort to treat patients."
4. Make sure there is contract uniformity. It's important for both sides of a partnership to feel they are treated fairly and equally — which includes payment. When Dr. Shamie and his colleagues began the formal collaboration between orthopedic spine and neurosurgeons, they noticed neurosurgeons were paid more for performing the same procedures as orthopedic spine surgeons.
"That's the kind of difference that can have a big impact on your collaboration," says Dr. Shamie. "If the administration favors one specialty over another, the underdog has to speak up and the favored group has to back them up and say the arrangement isn't good for the hospital, even though they are benefiting from it."
Right now, there isn't much financial incentive for spine surgeons and neurosurgeons to work together on cases, but that could be changing in the near future.
"The way the system is currently set up, the specialists live in their separate silos and there aren't any incentives to work with others," says Dr. Sharan. "As we start to work t in an ACO model with coordinated patient care, those silos are breaking down and we'll see better value for the patient. I would argue that as the payment reform system moves toward higher value, it's moving toward spinal payments that require more cooperation between physicians."
5. Expand the partnership to include other specialists. While orthopedic spine and neurosurgeons compliment each other nicely in the operating room, a vast majority of patients with back pain don't make it that far; they benefit more from conservative care and interventional pain management techniques. Bringing these specialists into the partnership creates a comprehensive approach to care for a wider range of patients, and is also beneficial for patients after surgery.
"Specialists in pain management, physical medicine and neurology can raise patient safety concerns before surgery," says Dr. Shamie. For example, if a surgical patient has a pacemaker, it can't be turned off for the MRI and must be modified before the procedure. "That takes a very thorough discussion with the cardiologist and internal medicine specialist. Those are people we work with regularly."
When all specialists are involved, patients can be plugged into the appropriate course for care at the initiation of their treatment, like cancer patients are in large cancer centers. "If I had cancer, I might go to a large cancer center and get plugged into the kidney cancer team and there would be specialists who looked after me who focus just on kidney cancer," says Dr. Sharan. "The specialists are like the spokes on a wheel with the patient in the middle. We need to move toward that model for spine because patients will benefit from all types of treatment."
More Articles on Spine Surgery:
7 Spine Surgeons & Industry Experts on Forming a Positive Relationship With Local Hospitals
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