Electricians vs Carpenters

Who’s Better Trained to do Your Spine Surgery?
By Mark R. McLaughlin, MD, FACS, FAANS

Now and then a patient will ask this question: Should I have my spinal surgery done by an orthopedic surgeon or a neurosurgeon?  Which one is better?

The Education of a Spine Surgeon
Many people believe orthopedic surgeons and neurosurgeons have vastly different expertise and should stick with the different surgical procedures for which they’re qualified.

This belief started many years ago, when orthopedic spine surgery was performed very differently than neurological spine surgery.

As my colleague John Tydings, M.D. puts it, back then, neurosurgeons were thought of as “electricians” who specialized in diagnosis and treatment of the nerves, spine and spinal cord, as well as brain and blood vessels within the skull.

Orthopedists were considered “carpenters” who didn’t get involved with the nerves or spinal cord, instead treating bone and joint disorders in the spine as well as sports injuries, skeletal deformities and scoliosis.

Over the past 20 years, these differences have diminished as neurosurgeons learned more about bone physiology, bone growth and creating bone fusions, and orthopedic surgeons learned more about treating nerves, including nerve decompression.

As a result of this evolution of knowledge, neurosurgeons now have expertise in orthopedic reconstruction of the spine, laminectomy and orthopedic lumbar procedures including placement of screws, braces, and other orthopedic spine hardware.

A New Sub-Specialty is Born
This expansion of learning has led to the subspecialty of spinal surgery. An orthopedic surgeon who receives additional training—a spine fellowship—is considered a spinal surgeon. In contrast, a neurosurgeon is trained to perform spine surgery during their residency.  And some neurosurgeons choose to do an additional fellowship in spine surgery.  After four years of medical school and a five or six-year residency in neurosurgery or orthopedic surgery, a doctor pursues this type of spinal disorder focused fellowship by spending one or two years gaining specific, additional expertise in spinal surgery.  There are also some neurosurgeons who no longer perform brain surgery and have chosen to focus solely on spinal surgery.

There are, however, some surgical procedures that orthopedic surgeons with spine fellowship training generally have more experience performing than neurosurgeons. These include pediatric and adult scoliosis, an outward curving of the spine called kyphosis, and other spinal deformities and procedures performed on the pelvis.

For surgical procedures in the area where the head and neck meet—the craniocervical junction—or inside the lining of the spinal canal (the dura) and for tumors on the nerves of the spinal cord, neurosurgeons typically have more expertise than orthopedic surgeons.

Many routine cervical, thoracic, and lumbar surgeries are performed well by surgeons in both specialties, so when a patient asks which type of surgeon they should choose, I tell them their surgery can be done beautifully by either type of doctor as long as that doctor is a neurosurgeon or a fellowship-trained orthopedic spinal surgeon.

Research supports my conclusion. A study published in the July 2015 issue of the medical journal Spine examined whether outcomes are different from spinal fusion procedures done by orthopedic surgeons and neurosurgeons. Procedures were evaluated for 30-day rate of return to the operating room, mortality and other perioperative (before, during, and after surgery) outcomes.

The research studied 9,719 patients and came to the conclusion that: “there was no difference in the majority of perioperative outcomes between orthopedic surgeons and neurosurgeons including death, rate of return to the operating room, and other complications associated with significant morbidity. Spine surgeons, regardless of specialty, seem to achieve equivalent outcomes.”¹

A different study published in Spine in 2014 had similar findings: “Analysis of a large, multi-institutional sample of prospectively collected clinical data suggests that surgeon specialty has limited influence on short-term outcomes after elective spine surgery.”²

Synergy in Having Co-Surgeons
Research shows that when an orthopedic surgeon and a neurosurgeon who are properly trained perform a spinal surgical procedure as a team, patient safety rates improve dramatically.

A 2014 study published in Spine Deformity found that “a team approach consisting of a dual-attending surgeon approach in the operating room…will significantly reduce perioperative complication rates and enhance patient safety in patients undergoing complex spinal reconstructions for adult spinal deformity.”³

The research, which evaluated 164 patients, found that after surgery performed by a neurosurgeon and an orthopedic surgeon working together, patients were three times less likely to develop major complications such as wound infection, deep vein thrombosis, pulmonary embolism, and urinary tract infections. Patients were also less likely to have to return to the operating room within 90 days after surgery.

“We can shorten the operation when we have two surgeons in the operating room as equal partners: a neurosurgeon and an orthopedic surgeon with specialized spine training,” said the lead author of the study, Rajiv K. Sethi, M.D., director of spinal deformity and complex reconstruction at Virginia Mason Medical Center and clinical assistant professor of health services at the University of Washington School of Public Health.

Another research study published in Spine Deformity in 2013 evaluated the two-surgeon theory for pedicle subtraction osteotomies that restore the normal curvature of the spine. This is a very challenging procedure for any spine surgeon. It has a high complication rate and it places a substantial physical burden on the patient.

The cases of 78 patients were studied for estimated blood loss, length of surgery, length of hospital stay, rate of return to the operating room within 30 days, and medical and neurological complications.

The researchers concluded that: “the use of two surgeons at an experienced spine deformity center decreases the operative time and estimated blood loss, and may be a key factor in witnessed decreased major complication prevalence. This approach also may decrease the rate of premature case termination and return to operating room in 30 days.”⁴

We’ve seen the same results in our practice. We work very closely with Dr. Tydings, an experienced orthopedic surgeon, and we’ve found that when two board-certified, fellowship-trained surgeons—a neurosurgeon and an orthopedic surgeon—perform surgical procedures as a team, procedures are done better, faster, and with less blood loss.  As I have practiced for over 15 years now I have learned that even if a procedure does not warrant having joint neuro ortho collaboration case seem to go better and more efficiently when two board certified surgeons are scrubbed on the case.  It intuitive that two sets of highly trained hands and eyes is better than one.

By sharing their different perspectives, a two-surgeon team can often design a plan of care that is more complete than if one surgeon provided care for a patient.

“Since the neurosurgeons from Princeton Brain & Spine and I are trained in spinal surgery, it’s a true collaboration,” Dr. Tydings says, “and through that collaboration, two surgeons from different specialties offer their opinions and  point of view. This helps surgical procedures go faster and better, but more importantly, it gives patients better and more predictable outcomes from surgery and improves their lives.”

Conclusion
So what’s the answer to the question: which surgeon is better to have operate on your spine: a neurosurgeon or an orthopedic surgeon?  Simple: BOTH!  Of course this is not always necessary for routine spine procedures like a discectomy or a simple laminectomy on the neck or low back.  But if it’s something complicated like a repeat surgery, or a multi-level spinal fusion or reconstruction it wouldn’t hurt to ask if the practice you are being cared for has both neurosurgeons and a fellowship trained orthopedic spine surgeons to collaborate on your surgery.

References
1.    McCutcheon B, Ciacci J, Marcus L, et al. Thirty-day perioperative outcomes in spinal fusion by specialty within the NSQIP database. Spine. 2015; vol. 40, issue 14: 1057-1148

http://journals.lww.com/spinejournal/Abstract/2015/07150/Thirty_Day_Perioperative_Outcomes_in_Spinal_Fusion.16.aspx

2.    Seicean, Alan N, Seicean S, Neuhauser D, et al. Surgeon specialty and outcomes after elective spine surgery. Spine. 2014; 1,39(19):1605-13
www.ncbi.nlm.nih.gov/pubmed/24983930

3.    Sethi R, Pong R, Leveque, J, et al. The seattle spine team approach to adult deformity surgery: a systems-based approach to perioperative care and subsequent reduction in perioperative complication rates. Spine Deformity. 2013; vol 2, issue 2, 95–103.

http://www.spine-deformity.org/article/S2212-134X(13)00198-6/abstract

4.    Ames C, Barry J, Keshavarzi S, et al. Perioperative outcomes and complications of pedicle subtraction osteotomy in cases with single versus two attending surgeons. Spine Deformity. 2013. Vol 1, Issue 1, 51–58.

http://www.spine-deformity.org/article/S2212-134X(12)00034-2/abstract

It's fun when you get to reference an article you were involved in writing. The content of this article was updated and published by AANS on their website. 

McLaughlin, MR, Tydings, John D, Fitzpatrick, Maggie E.   The Electrician vs The Carpenter Revisited.
AANS Neurosurgeon March 9, 2021 0
https://www.aansneurosurgeon.org/feature/the-electrician-vs-the-carpenter-revisited/