Recent innovations have enabled nonsurgeon specialists such as physiatrists and pain management anesthesiologists to perform spinal fusions in outpatient settings, but spine societies have raised concerns about some potential dangers to patient care.
Three spine surgeons expand on why they believe neurosurgeons and orthopedic spine surgeons should be the only specialists to perform spinal fusion.
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Editor's note: The following responses were lightly edited for style and clarity.
Question: What is your position on nonsurgeons (such as pain management specialists and physiatrists) performing spinal fusion procedures? When, if at all, do you consider it appropriate for these specialists to perform such cases?
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: There was a joint position statement recently, put out by the AAOS, AANS, CNS and others, that is fairly clear on this. Neurosurgeons and orthopedic spine surgeons have undergone the training necessary to evaluate and perform spinal fusions. There is more that goes into evaluating a patient for fusion other than the presence of disease. There are other considerations — symptoms, presence of deformity, age, level of functionality and risk/benefit analysis. As I tell most patients, surgery is the first step. There is no place for scope creep when it comes to performance of spinal fusions. Simply put, if one cannot fix the complication, one should really carefully consider if you should be doing the surgery in the first place. This is a necessary red line.
William Taylor, MD. University of California San Diego: It's not just the performance of the procedure I find alarming, it's the inability to care for the patient afterward and manage both complications and patient expectations. I find when surgeons operate and take care of a patient, they are expected to and will manage all aspects of the care. My experience is that is not the case often with many physiatrists and/or pain management procedure-oriented professionals. Their interaction remains short term, procedure oriented and not the long-term care, which includes failures, complications, successes and ongoing treatment.
Richard Kube, MD. Prairie Spine (Peoria, Ill.): I do not support either of those specialties performing spinal fusions. While they hold a background in diagnostics and various management techniques for pain, fusions are major procedures. Procedures like fusions for back pain have mixed results when performed by fellowship-trained spine surgeons. Orthopedists and neurosurgeons both complete five-plus-year residencies prior to fellowship during which there is regular exposure to spine diagnosis and treatment. Principles of biomechanics, stability, bone fixation, fusion bed preparation — to name a few — are critical to success in fusion. These are not core competencies for pain specialists and physiatrists. When one considers that board-certified orthopedic surgeons cannot get spine privileges at hospitals without a spine surgery fellowship (bear in mind spine surgery is an integral component of the orthopedic board exams), I cannot think of a situation in which an interventional pain specialist or physiatrist should be performing an irreversible procedure that will permanently affect a patient's spinal mechanics.