Many spine training programs embrace new technologies and teach minimally invasive techniques, but there are some complex cases that surgeons recommend all spine physicians master as well.
Next question: Is there anything you did at the start of your career that you wouldn't recommend early-career spine surgeons do now?
Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CST Wednesday, Sept. 11.
Editor's note: Responses were lightly edited for clarity and length.
Question: What is one complex spine procedure early-career surgeons should master?
Shawn Adams, MD, Norton Leatherman Spine and Norton Neuroscience Institute (Louisville, Ky.): A next level skill to master for early-career spine surgeons is the grade II posterior column osteotomy (PCO) or "Ponte" osteotomy. In the lumbar spine when planned and executed appropriately these can be a very beneficial correction tool. In the setting of what is sometimes viewed as a simpler surgery for short segment degenerative issues, a grade II osteotomy can prevent the iatrogenic flatback. The anatomical knowledge and individual skills required to perform this well are related or transferable to many other applications. The facetectomy portion is integral to many techniques, whether open or minimally invasive, for various transforaminal interbody fusions (TLIFs). Additionally, the skills of safely working around, localizing, and potentially decompressing the nerve roots is critical. It can be applied asymmetrically for coronal correction. It is a technique that can be applied at multiple levels for correction that decreases the risks of more significant morbidity and blood loss with a pedicle subtraction osteotomy (PSO).
When paired together with interbody arthrodesis, it can significantly increase the lordosis obtained with the interbody at the same level. I believe the utility of this PCO is greater than that of higher grade PCOs as demonstrated in the declining number of PSOs being reported. It is more frequent that we encounter people with thoracolumbar issues in need of instrumented fusions that, when evaluated by the aware surgeon considering their global sagittal alignment, would benefit from some restoration of appropriate lordosis through utilization of this technique and its applications rather than the morbidity associated with three column osteotomy. However, it foundational to the higher grade osteotomies and there are still going to be major and/or fixed deformities requiring those.
Paul Bagi, MD. Kayal Orthopaedic Center (Paramus, N.J.): While not one single procedure, I believe early-career surgeons should master revision spine surgery because it requires a broad range of essential skills. Revision spine surgery often involves addressing complications from prior surgeries, making it inherently more challenging. Mastery of revision surgery demands a thorough understanding of spinal anatomy and pathology, meticulous surgical planning, and the ability to adapt to unexpected intraoperative findings.
Revision surgery also requires a high level of precision and technique to ensure safe and effective outcomes, including achieving adequate decompression, restoring proper alignment, and placing stable instrumentation all while minimizing complications. By becoming proficient in revision spine surgery, early-career surgeons will build a strong foundation of surgical skills and clinical judgment, gaining the confidence to tackle complex cases and provide the best care for their patients.
Rachel Bratescu, MD. George Washington University (Washington, D.C.): A single but extremely versatile complex spine procedure that early career surgeons should master is a T10-pelvis. This requires skill in efficiency, exposure, pedicle screw placement, rod contouring and potentially a variety of interbody techniques depending on surgeon preference. This particular case can be a workhorse for revision lumbar degenerative pathology and primary adult deformity cases as well, making it an excellent procedure for early career surgeons to master.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: The posterolateral thoracic corpectomy with instrumentation is critical to master early on. In many practices, a thoracic surgeon may not be available to get access to a lateral trans thoracic approach. While technically and physically demanding, this surgery is very powerful in terms of trauma, infection, and neoplasm. It is a difficult venture, especially late at night, when many of these seem to have to take place, but once a surgeon gets comfortable doing them, they can really save patient function if done in a timely manner.
Michael Oh, MD. UCI Health (Orange, Calif.): It is not necessarily complex, but it does have a steep learning curve and is not incorporated into most residency programs that prepare spine surgeons. It is also not taught in most spine fellowships. I am, of course, talking about endoscopic spine surgery.
This skill should be adopted early in your career. As an established spine surgeon who already has several minimally invasive techniques and procedures, it is difficult to incorporate a new technique that has a difficult learning curve. In addition to longer surgeries, different reimbursements, acquisition of new equipment, adopting endoscopic techniques exposes our patients to complications associated with that learning curve. This risk is something I can justify if I am early in my career and gaining expertise. But if I already do a very good job with mini-open or tubular approaches, it becomes much harder to justify.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Neurosurgeons are ultimately relied upon for their community omnipresence and lifesaving contributions for young and old patients. The neurotrauma surgical service provides urgent and nonurgent surgical interventions, consultation and referral for traumatic head and spinal injuries. Mastering these facets of surgical care is essential to the health of our communities and populace. This is achieved through nationally recognized and dedicated Trauma Centers, which possess the entire compendium of care continuum and post-surgical treatments.