From essential surgical techniques to business-oriented skills and how to navigate one's practice into the value-based care era, seven spine surgeons outline the attributes required to succeed in today's healthcare environment.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. Becker's invites all spine surgeon and specialist responses.
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Editor's note: Responses were lightly edited for clarity and length.
Question: What is the most important skill a spine surgeon needs in his or her armamentarium today?
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Above all, the highest level skill for a spine surgeon is discernment.The ability to look at a patient case and confidently tell the patient that surgery is not their first option is key. Second would be the ability to treat a patient, not a scan. It is incredibly important to take a detailed history and do a neurological exam. This must jive in the context of the patient's radiological picture. Many times, a patient may not need a five-level fusion for just left leg pain. It seems so basic, yet in some circumstances, the patient has been lost in favor of what makes the films look pretty.
Ehsan Jazini, MD. Virginia Spine Institute (Reston): Adaptability. Adaptability to a rapidly advancing field in enabling technologies (robotics, augmented reality, artificial intelligence, etc.) combined with predictive analytics to help improve patient outcomes, precision and patient recovery. The rapidly emerging field of biologics and regenerative medicine is another arm of treatment where the surgeon's adaptability and expertise will be critical in their success.
Michael Smith, MD. Rothman Orthopaedic Institute (Philadelphia): We have seen tremendous advances in technology in spine surgery over the last two decades, including in implants, imaging, minimal access techniques, and, more recently, navigation and robotics. Intraoperative navigation has long been a mainstay of cranial neurosurgery and therefore potentially more intuitive for spine surgeons coming from a neurosurgery training pathway. It is heartening to see our current fellows from both neurosurgery and orthopedic residencies receive in-depth exposure to navigation.
Navigation inside the rigid, fixed cranial vault is relatively straightforward from a technical perspective compared to navigating the mobile, multisegmental spine. Fortunately, techniques and technologies have progressed to overcome these heightened technical challenges and we now have a variety of computer-augmented options for spinal navigation.
Spinal navigation can be based on preoperative imaging, intraoperative image acquisition, optical registration and integration with fluoroscopic imaging. Navigation may be free hand or combined with robotic arm guidance. All of these techniques have advantages and disadvantages. I have always had some concern about surgeons jumping into navigation with robot arms before developing thorough familiarity with navigation using handheld instruments. The robotic arm disconnects the surgeon from the act of surgery to a significantly greater degree and therefore poses additional risks if errors are not identified. Registration problems or insufficient accuracy are generally quite apparent with handheld navigated instruments. Conversely, the stability of a robot arm can be of benefit in certain circumstances.
Navigation does offer the opportunity for improved patient safety and the potential for achieving safe fixation in challenging anatomy. It also offers important health benefits to the surgeon by essentially eliminating exposure to C-arm radiation as well as the comfort and endurance advantages of not wearing lead.
It is my opinion that spinal navigation is sufficiently mature and should be considered a routine part of the spine surgeon's armamentarium because of its workflow, patient safety and surgeon health benefits. I believe that currently practicing spine surgeons should have or attain familiarity and mastery of navigation and that spinal navigation (with or without robot arm assistance) should be routine for those currently going through training.
Conversely, in my opinion, spinal endoscopy techniques appear to be proceeding along a development and learning curve where they may become more mainstream in the foreseeable future. In my opinion spinal endoscopy techniques have not yet matured to the point where the reasonable majority of practicing spinal surgeons and those going through current fellowship training should feel obligated to have mastered the techniques. There are specific and demanding technical nuances to these techniques and the risks to the patient along every surgeons' learning curve. Therefore I believe at this point it should be an individual surgeon's choice to pursue sufficient additional focused training before adding such techniques to their armamentarium.
Mohammed Faraz Khan, MD. New Jersey Brain and Spine (Oradell, N.J.): A good spine surgeon needs to be able to ask: "If this was my spine, my MRI, my pain, would I propose this exact surgery for myself?" An answer to this question will lead you down the right path every time. It is a mental skill that needs to be cultivated early in a spine career. It is also one that leads to excellent patient satisfaction with compounding rewards over the years.
Philip Schneider, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): We are entering into a value-based system focused on quality and value to control cost. For spine surgeons, the most valuable skill is not necessarily a surgical skill. Physicians are educators. We must know how to educate patients and understand when not to operate. A great surgeon will teach patients how to improve their health, whether surgically or non-surgically.
Wesley Bronson, MD. Mount Sinai Health System (New York City): As a resident and fellow, my mentors always taught me that the single most important thing to learn was anatomy. With a thorough understanding, any new procedure or technique can be performed. Someone who has never performed a minimally invasive [transforaminal lumbar interbody fusion] can easily learn the skill if they understand how to perform an open TLIF. While not a particular skill per se, every surgeon therefore needs to have a deep understanding of spinal anatomy.
This may seem overly simple — of course spine surgeons need to understand spinal anatomy. But with an increasing use of enabling technologies and a trend toward less invasive surgery, residents and fellows will perform fewer open operations and gain less experience visualizing the open anatomy. Despite this trend, those in training must never overlook the basics of the procedures and the basics of spinal architecture. A thorough understanding is required to not just perform surgery safely, but enable them to learn new techniques and skills easily throughout their career.
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): The most important skill for a spine surgeon today is the same it always has been — the ability to carefully listen to your patients and understand what truly bothers them. It seems simple, but it is amazing how often I see clinicians miss important parts of medical history because they were in a hurry to either deal with their EMR or move on to another patient. Correct diagnosis is crucial for developing an optimal treatment plan. If the patient feels that they have truly been heard and understood, it builds trust and makes them much more compliant with the physician's recommendations. This, in turn, leads to better clinical outcomes and higher patient satisfaction. While technical skills of performing spine surgery can be complicated, they are far easier to learn than the ability properly diagnose a patient and develop the optimal treatment plan to make them better.