Technological advancement now allows spine surgeons to perform simple and some more complex procedures with less invasive techniques, and spine surgeons going through training are increasingly interested in adopting them.
Long term studies now show that several of these techniques are safe for patients while limiting complications, hospital stays and overall costs.
"Minimally invasive spine techniques are certainly gaining more popularity in the academic and non-academic programs and more faculty and residents are exposed to these techniques," says Ali A. Baaj, MD, Director of the Spinal Neurosurgery Program and Assistant Professor of Surgery at the University of Arizona in Tucson. "The residents and fellows are in part driving the demand for these technologies because they are eager to learn about them."
However, learning the open techniques for these procedures is still imperative for young spine surgeons. As a result, residencies and fellowships aiming to instruct the next generation of spine surgeons are developing new and innovative ways to ensure their trainees have a full grasp on open procedures while also feel comfortable performing minimally invasive techniques and prepared to adopt new advancements in this rapidly changing field.
Keeping up with new technology
While young spine surgeons are eager to learn, their tenacity demands that faculty stay abreast of the latest in the field and become well-versed in multiple approaches.
"Residents return from meetings where minimally invasive techniques are discussed and are eager to learn more about them," says Dr. Baaj. "They want to be involved in these new techniques. There is an interest among the surgeons and trainees about learning the strength and limitations of these techniques. We as trainers are striving to meet these challenges because we feel that MIS is actually playing a bigger role — and rightly so — in some of these disease pathologies and we want our trainees to have exposure to them."
Many institutions now are looking for surgeons with experience and flexibility with minimally invasive techniques to hire as faculty. Others are sending their current faculty for training in these new techniques, which have a steep learning curve.
"It requires patience and commitment to wanting to learn these techniques to actually adopt them into your practice," says Dr. Baaj. "Some surgeries may even take longer initially and utilize more operative time. Then when we teach these techniques to residents and fellows, there is typically a need for more direct faculty involvement in minimally invasive cases than there is for more traditional open cases before the trainees are comfortable taking the lead on them."
Teaching MIS approach
The MIS techniques are often a more hands-on approach for the trainers because these procedures are so delicate and rely on minimal exposure. In many cases, Dr. Baaj says they are more challenging than performing the open procedure. As a result, the breadth of proficiencies expected in training has expanded.
"What I expect my residents to know now is different from how many residents in the past have trained," says Dr. Baaj. "They are expected to know how to place percutaneous screws, perform MIS TLIF and lateral fusions, as well as MIS decompressions. These are the techniques they must be comfortable with in their general spine training and whether they want to use these techniques in their practices is up to them. But these techniques represent a significant portion of their spine training and what they must be proficient in."
Working extensive minimally invasive technique training into an already packed residency and fellowship schedule is challenging.
"We definitely have to remember to emphasize that our trainees don't lose track of the open techniques that are so crucial to treat many pathologies — especially those who are excited about MIS," says Dr. Baaj. "We still want our trainees to excel at open techniques and not forgo them for newer, seemingly slicker procedures."
Surgeons must still receive adequate training in open techniques and then familiarize themselves with the minimally invasive surgery.
"Many of the minimally invasive procedures we do are an evolution of existing techniques," Dr. Baaj says. "Therefore, the anatomic and surgical concepts are still the same. We continue to teach key concepts of stenosis, deformity and instability and the trainees have to understand the anatomy and biomechanics of these conditions before they even choose the treatment options."
Diversity in training
Faculty members are more careful now than ever to expose surgeons to minimally invasive techniques early in their training, and teach them on multiple systems so they can decide which ones work best.
"The challenge is to continue expanding the skill set of our faculty to ensure our residents have a balanced view of the spine technology available and which cases should be treated with the MIS approach as opposed to traditional approaches," says Dr. Baaj. "Therefore, as trainers we have to adapt and ensure that we are not biased in our training and can demonstrate different techniques to our residents regardless of our own personal biases. We want them to have a very diverse and comprehensive training."
The residents in Dr. Baaj's program assist in surgery with different faculty members so they become familiar with each faculty member's technique and preferred instrumentation style. Dr. Baaj makes sure his trainees observe him performing open as well as MIS techniques and demonstrate the pros and cons of each technique.
Future of training
Dr. Baaj sees the primary skills for training surgeons eventually revolving around working with small exposure, MIS tubes and retractors, and relying on fluoroscopy and other image guided navigation platforms instead of direct visualization.
"Given the rapidly emerging technology as well as the limited clinical time and regulations, one of the highlights of our program are the quarterly cadaveric workshops for trainees to employ techniques in the cadaver lab before using them on patients," says Dr. Baaj. "With the decreased amount of clinical exposure, the challenge is for us to provide opportunities outside of the clinical curriculum to complement their training. I think we are going to see an increase in those types of educational activities."
In the future, Dr. Baaj sees spine training evolve to a more structured and coordinated neurosurgery-orthopedic effort at the residency and fellowship level. As the techniques continue to evolve, faculty will stay abreast of the changes with refresher workshops and new technology training while maintaining a strong foundation from their training in open surgical technique.
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