Technological innovations have made it possible for nonsurgeon clinicians, such as physiatrists and pain management anesthesiologists, to perform less invasive spinal fusions in outpatient settings, but spine societies are warning against the potential dangers of such specialists performing these procedures without the same anatomical training surgeons have.
Arthrodesis of the sacroiliac joints, facet joints and stabilization of a lumbar segment with interspinous process clamps are performed in various settings, including ASCs and, in some cases, physician offices, according to a joint statement from various professional societies, including the American Academy of Orthopaedic Surgeons, International Society for the Advancement of Spine Surgery and American Association of Neurological Surgeons.
The statement, made public Jan. 12, raises concerns about the rising number of nonsurgeon clinicians performing fusion procedures that alter the biomechanics of the spine.
"The absence of formal training raises patient safety and quality of care considerations, given that these nonsurgeon clinicians are not required to undergo training in spinal biomechanics or in the broad spectrum of spinal fusion and instrumentation techniques. These physicians lack the necessary understanding of the potential ramifications of such interventions and cannot render the appropriate management of common surgical complications," according to the statement.
The societies outlined six reasons spinal arthrodesis should be performed only by neurosurgeons and spine surgeons:
1. Neurosurgeons and spine surgeons are the only physicians who have undergone extensive training in the biology, biomechanics, surgical anatomy and techniques of instrumentation and stabilization of the spine. That foundation provides them with expertise in diagnosis, decision-making, creating treatment plans and altering biomechanics in the treatment of spinal disorders.
2. Surgeons can directly address common potential complications that arise from instrumentation or arthrodesis of the spine.
3. A unique range and depth of surgical skills are acquired throughout neurosurgeon and spine surgeons' careers, including residency, fellowship and post-training continuing education and practice.
4. Nonsurgeon spine practitioners, such as pain management specialists or physiatrists, are core members of the spine care team, particularly for their roles in the diagnosis and treatment of nerve root compression, using nonoperative interventions such as medial branch blocks, radiofrequency ablations, epidural steroid injections, etc. However, these nonoperative measures do not result in arthrodesis, which invariably alters spinal biomechanics.
5. Nonsurgeon spine practitioners do not have the expertise to deal with complications that may arise from percutaneous instrumentation or stabilization of the spine. The consequences of such instrumentation fall outside the scope of a pain management or physiatrist physician's training.
6. Confounding issues affect the decision to stabilize the spine. Spino-pelvic parameters — specifically sagittal balance, pelvic incidence and lumbar lordosis — must be incorporated into the calculus of the stabilization. Consideration of overall spinal balance is critical because stabilizing the lumbar spine could lead to adjacent segment degeneration, which may require further surgery. Given patient safety and quality of care considerations and education and training experience, managing surgical or other stabilizing interventions for spinal degeneration falls exclusively within the purview of the neurosurgeon and spine surgeon.
Click here to read the full statement.