Spine Surgery Training: Time for Introspection

Low back pain is the most common musculoskeletal disorder affecting millions of people in both the developed and developing countries with a significant influence on physical and mental health.[1] A Lancet publication in 2017 has identified spinal disorders as one of the top three non-communicable disorders across the world.[2] There is an increasing trend for the treatment of spinal disorders by surgical intervention which has resulted in a sharp increase in spinal surgeries in the last three decades.[3] In the United States, the number of spine surgeries increased by 220%[4] in one decade and there is a similar trend reported in many countries across the world. The results of spine surgery is not very uniform and a higher rate of complications and patient dissatisfaction in comparison to other orthopaedic surgeries like joint replacement surgeries has been reported.[5] Complications ensuing spine surgeries are also more devastating and incapacitating to the patient with a possibility of even permanent neurological deficit. There is also an increasing penetration of technology and new devices in spine surgery which requires constant updating and acquirement of new skills. All these facts point to the need for a robust training program that will ensure adequate number of surgeons who have been well trained in spine surgery to meet the needs of the society. Spine surgery is performed by both the specialties of orthopedics and neurosurgery. While initially there was a restriction of orthopaedic surgeons confining themselves to the bony problems of vertebral column and the neurosurgeons concentrating on the intradural neural diseases, the boundaries have become fluid as most diseases involve both the bony and neural components of the spine. This makes it imperative that training in spine surgery is more challenging and must be very robust so that surgeons are adequately trained to the increasing needs of spine surgery demands. Traditionally, specialization in spine surgery in India involved practical and rigorous training under an experienced surgeon for an undefined period without a structured training or standardized curriculum. Only a few had the opportunity for multicenter training or overseas fellowships. This resulted in the younger surgeons to be restricted in their training and to follow their institutional practices without an opportunity for a comprehensive training. Formal spine surgical training started with the launch of FNB Super speciality training programs of the National Board of Examinations in 2001 and the fellowships provided by the Association of Spine Surgeons of India (ASSI), the premier national organization of the spine surgeons in 2011. Both the fellowships are standardized with well-established syllabus and with well conducted entrance and exit exams ensuring merit in both selections and qualification. Together they offer 45 fellowship opportunities every year. In addition, there are a number of short term fellowships offered by State Chapters, professional organizations like the AOSpine, 1 year fellowships by state universities, fellowships attached to individual institutions with faculty members who attract mentees. However, they all stand to the disadvantage of lacking a standardized training curriculum and often being confined to training in a particular procedure or a small segment of spine surgery. The high demand for training in spine surgery has also been capitalized by many implant companies which target young surgeons with short term fellowships, often lasting less than 2 weeks, hands-on workshops and week-end cadaveric courses for training in specific aspects of spine surgery such as deformity correction, endoscopy and minimally invasive surgeries. There is also a number of certification courses by national and international spine societies where online e-learning is encouraged with no scope for practical training but ending up with an attractive certificate of training. These certificates are fraught with a danger of inappropriate recognition by the society and patients. The entire training scenario calls for an urgent introspection on the quantity of trainees without dilution of quality of surgical training. In particular, regulations in terms of duration and training curriculum, inculcation of both orthopaedic and neurosurgical skills, the duration of fellowship training, evaluation of competency at the end of the fellowship and the respective roles of universities, the National Board of Examinations, National Societies and even the industry needs deliberations and strong decisions. The Government and the National Board have frequently expressed their intent and commitment to increase the post graduate training opportunities. At present there is a great disparity between the number of under graduate medical seats and the post graduate seats available. The current ratio is 0.5 and the plan is to improve it to 0.8 which means that the training seats will be multiplied many times. While this may be welcome move from the public health point of view, there are serious concerns about the availability of teachers and training institutes. Increasing training positions without ensuring adequate infrastructure and human resources will only lead to inadequate training of surgeons and be counterproductive to the aims of providing better health for the society. The lack of formal training opportunities also lead many young surgeons to look at ultra-short term training and observerships. While these help to keep a young spine surgeon updated and develop a few psychomotor skills, they have the disadvantage of shifting the training from the outpatient department, ward rounds and operating theatres to lunch workshops, week end courses and industry developed training labs. While these may be important for a spine surgeon to hone his technical skills, it may give a false sense of confidence for the untrained surgeon to perform these procedures in real patients. In an international survey among 430 spine surgeons performing endoscopic surgeries, only 14% (41/292) of surgeons had completed a formal fellowship. Though their main source of knowledge acquisition were learning in small meetings (57.3%) or attending workshops (63.1%), or from national and international conferences (59.8%), 33.5% surgeons rated their skill level equivalent to a master and experienced surgeon.[6] More importantly, it may misplace the focus of the young surgeon on the technique rather than the rationality and decision making in spine surgery. The management of a patient requires expertise in clinical examination, arriving at a differential diagnosis, skills and interpreting investigations and formulating a treatment plan. In this process, surgery will be an important but only a small part of the entire process. The decision of whom and when to operate and also whom and when not to operate is also very important, which can be acquired only from many years of mentorship acquired working with the patients. So, at best, out of hospital training programs can form only an insignificant component of the entire training program. In a country with 1.4 billion population, the available number of trained spine surgeons is very low. There is also the problem of skewed distribution with most of the spine surgeons being concentrated in the urban cities and very few in the rural population leading to a disparity of services. There is also a need for gender inclusivity with more female spine surgeons and the challenge of making trainees equally competent in both orthopaedic and neurosurgical aspects of spine surgery. With every crisis comes a great opportunity and this is where national societies like the Association of Spine Surgeons of India have a great role to play. Currently the training fellowships offered by the ASSI and the Neurosurgical society of India are very much skewed towards either one of the specialties and efforts must be made where the two societies will join hands to provide an effective and balanced training. The societies must also play a great role in identifying more centers and mentors who can train more surgeons into this challenging field. The association must also take up a very active role of advocacy and liaise with Universities and national bodies in setting the basic requirements and the syllabus for the trainees. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.