The North American Spine Society’s new patient safety position statement could be read as the latest round in a long-running dispute between spine surgeons and nonsurgical physicians. But two physicians who helped shape it say the real story is simpler: Spine care is innovating faster than training can keep up, and there is no standardized way to verify that physicians are ready to perform the procedures now reaching patients.
On Sept. 28, the NASS released its Patient Safety Position Statement on Education, Training, and Competency for Spine Interventions. The statement addresses the wider range of spine interventions and sets competency-based principles tied to the complexity and risk of each procedure.
The statement says physicians should complete structured education and clinical training before performing spine interventions on their own. That training should include supervised procedural experience and objective assessment of competency. Minimum case requirements may be one part of that training. Educational courses can help, but they should complement structured clinical experience rather than replace it.
Brian Su, MD, chair of the NASS’ Task Force on Patient Safety for Spine Interventions and an orthopedic spine surgeon at Marin Health Spine Institute in Larkspur, Calif., and task force member Pierce Nunley, MD, director of Shreveport-based Spine Institute of Louisiana, spoke with Becker’s about the statement.
‘The headline should be the patient’
Dr. Nunley said the task force avoided turning the statement into a question of specialty.
“The headline should be the patient, what’s best for the patient,” he said. “If you have a disorder that can be treated by a specific procedure, the question is who should be performing it, and what training and setup they need to be doing it appropriately. Period, full stop.”
He added that the question is not whether certain physicians can perform a procedure. The question for any physician is whether they have “the appropriate training, knowledge, expertise to do this procedure in a way that’s best for our patients.” That includes knowing what to do if something goes wrong during or after the procedure, such as infections, dural tears or cerebrospinal fluid leaks.
“Innovation in spine care is a good thing, but it has blurred some of the traditional lines between specialties,” Dr. Su said. “The question is less about specialty designation and more about whether a physician has the appropriate training and competency to perform a particular procedure safely.”
The same standard applies within surgery. Dr. Su noted that the statement says not every surgeon should perform endoscopic spine surgery without the right training. Dr. Nunley pointed to complex deformity cases, such as a 360-degree, three-column osteotomy. He said those require a surgeon and a team that know how to handle them, and not every spine surgeon or hospital is equipped to do that.
To draw a line, the task force defined the difference between a procedural intervention and a surgical one. Dr. Su said a surgical intervention is one that treats structural spinal anatomy and meaningfully alters its biomechanics or involves direct visualization and decompression of a nerve root or the spinal cord.
“Every day you’re going to hear about a different spine surgery or procedure coming about,” Dr. Su said. “We really have to figure out: Are people well trained?”
A training gap unfamiliar to many patients
Dr. Su said the biggest surprise from his work on the task force was how much standardized training requirements vary among specialties. He said anesthesiology, physical medicine and rehabilitation, diagnostic radiology and interventional pain medicine fellowships include substantial relevant clinical experience, but do not have nationally standardized minimum case volumes across the spectrum of advanced spine interventions comparable to established surgical training pathways.
“I don’t think the average patient realizes how different the formal training requirements can be among specialties,” Dr. Su said. “Those differences don’t necessarily determine competency, but they highlight the need for clear, procedure-specific standards.”
He said case numbers are not the only measure of competency, and physicians can learn new procedures outside of a residency or fellowship. But that pathway needs to be well established.
Dr. Nunley said the concern grows when a pathology that once required open surgery becomes treatable with a less invasive technology that has not been validated. Physicians are then sent to a weekend course, often without long-term data. When data does exist, he said, it is frequently single arm or industry-driven.
“A weekend course for anything complex is simply not going to work,” he said.
Dr. Su added that a less invasive approach does not automatically mean a procedure is less complex or carries less risk. The relevant considerations are the anatomy involved, potential complications and the training needed to perform the procedure safely. Patients may see a smaller incision as less risky, he said, but “physicians performing these procedures need to recognize that minimally invasive approaches can actually be more technically demanding and that complications may be more challenging to manage.”
For emerging interventions for which evidence is still developing, the statement calls for prospective registries to better define patient selection, safety, outcomes, durability and the training needed to perform them safely.
What adequate training looks like
Dr. Nunley said there is no single answer as to what constitutes adequate training. Some physicians become proficient in a new minimally invasive technique in about 10 cases, others need 30, and some never get there. But the training should combine coursework, didactic work, training with an expert on live patients, and proctoring on the physician’s own early cases, with oversight and safeguards if something goes wrong.
He speaks from experience. Endoscopic surgery was not part of his training, so he built his own pathway, going slowly and reviewing each case. He said his concern is many physicians will not take that approach on their own.
Dr. Su said gaps remain in ACGME procedure-specific training requirements, and professional societies have a responsibility to help address them by developing clear competency standards. For procedures such as endoscopic spine surgery, that could mean defining minimum case numbers and required proctored cases for physicians without formal fellowship training, along with case and complications reporting.
Dr. Su, also an oral examiner for the American Board of Orthopaedic Surgery, said board certification illustrates how competency is evaluated across multiple dimensions, including indications, decision-making, outcomes, technical knowledge and complication management.
“Regardless of specialty, physicians performing the same procedure should be held to the same standard of knowledge and competency for that procedure,” he said.
He compared the situation to aviation.
“We wouldn’t say that a pilot who hasn’t crashed an airplane therefore doesn’t need to complete the established training and competency requirements for flying that aircraft,” Dr. Su said. “The absence of a bad outcome doesn’t validate the training pathway. The purpose of training and credentialing standards is to establish competency before something goes wrong.”
Dr. Nunley, who also is a commercially rated pilot, agreed.
Hundreds of hours of work
Both physicians stressed the size of the effort behind the NASS’ statement. Dr. Su said the task force went through dozens of meetings, emails and phone calls with physicians and leaders from seven surgical and 13 nonsurgical societies. Dr. Su said the project also drew strong engagement from NASS leadership. The presidential line, including current NASS President Bill Mitchell, MD, served on the task force and was engaged throughout the process, reflecting how seriously the society’s leadership viewed the issue. Dr. Nunley said he put 50 to 60 hours into it himself, and Dr. Su estimated his own time commitment at hundreds of hours.
“This has taken hundreds of hours, not tens,” Dr. Nunley said. “There were surveys at the outset, then multiple communications within the task force and with the leadership of multiple societies. This was a massive effort to reach this goal.”
Dr. Su said the task force initially organized its work by procedure, then worked backward toward broader principles. He called it the most engaged he has ever seen spine surgeons on a society committee because they clearly are passionate about this topic.
An opportunity to come together
Both physicians said they hope the statement starts conversations across specialties rather than deepens divisions.
Dr. Su pointed to cardiology as a model. As interventional cardiology grew alongside cardiac surgery, the specialties disagreed but ultimately set competency standards and built a continuum of care. He pointed to transcatheter aortic valve replacement as an example of multidisciplinary collaboration between specialties. Spine care has nothing like that yet.
“There has been significant disagreement among specialties that care for the same patients, but that’s why this conversation is so important,” Dr. Su said. “Ultimately, we all share the same goal of providing safe, high-quality spine care. NASS is well positioned to lead this effort because its membership includes both surgical and nonsurgical physicians.”
Dr. Nunley said societies need to have the difficult conversations they have avoided.
“You’re not going to grow in a marriage if you avoid all the hard topics,” he said. “The way you’re going to grow is when you get to the tough topics where you have disagreements, and you get together and you figure it out.”
He described the statement not as a source of tension but as “the opportunity to come together.” In his view, it sets guardrails for where the conversation should go next.
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