How to Select a Spine Surgeon

 by

Edward S. Pratt, M.D., M.B.A.

Director Memphis Spine Center

The science of spine surgery is one of the most rapidly developing areas of medicine today. New technology is coming of age providing patients with minimal access options which make spine surgery less painful, safer and more effective than ever. Acronyms such as ALIF, PLIF, TLIF, and XLIF are becoming commonplace. It is essential for a patient to understand what all this means in order to make good decisions. Successful surgeons must not only stay abreast of all the surgical advancements, but must become effective patient educators as well in order to effectively do their jobs. 

 Along with this rapid advancement has come an evolution in the identity of the spine surgeon. Gone is the old collegial relationship which existed in Memphis where Neurosurgeons performed discectomies or nerve decompressions and Orthopaedic Surgeons performed fusions, many times in the same patient during the same operation. It has been replaced by a new collegial relationship which does honor to the spine surgeons involved and benefits patient care in ways that were simply unimagined thirty years ago. Understanding how this has changed can help provide insight into how the science of spine surgery has changed, and how a patient is best able to select a spine surgeon.

 In 1980 the proper questions for a patient to ask were: Should I choose a Neurosurgeon  or an Orthopaedic Surgeon to do my surgery? Do I need both specialties involved?

 Since then, the science of spine surgery has become infinitely more complex. Many surgeons, responding to this complexity, devoted their entire practice energy to learning and mastering spine surgery. The old Neurosurgical or Orthopaedic Surgical Residency system did not adequately prepare surgeons for careers in this area. In many major University programs, fellowships were developed to train both Neurosurgeons and Orthopaedic surgeons in all the newest techniques. These individuals would complete the requirements of residency, study, private practice and examination required to become Board Certified, a process which traditionally took seven or eight years. They then followed this intensive process by an even more intense training in surgical spine techniques during a dedicated spine fellowship.

 When fellowship trained spine surgeons began to arrive in Memphis, they were actually better trained to perform all aspects of spine surgery by themselves than the Orthopaedic/Neurosurgical teams that preceded them. So, as these individuals gained in experience and began to take center stage, they replaced the neuro/ortho collegial relationship with a subtle competition between the large orthopedic groups and the large neurosurgical groups each with their own fellowship trained spine surgeons.  Interestingly however, on the international stage, these new fellowship trained spine surgeons began to realize that whether they started out as Neurosurgeons or as Orthopaedic Surgeons, they had more in common with each other than they did with their parent specialties. As these individuals labored to improve and advance the science of spine surgery, they began to leave behind the mantle of Neurosurgeon or Orthopaedic Surgeon and consider all such fellowship trained spine specialists as “brothers or sisters in arms”. Traditionally, Neurosurgeons receive Board Certification through the American Board of Neurological Surgeons (ABNS), while Orthopaedic Surgeons receive Board Certification through the American Board of Orthopaedic Surgeons (ABOS). A movement is now underway in which an entirely new Board Certified specialty of spine surgery may one day complete this transformation. Today however, no such Board Certification exists; nevertheless, the proper question for a patient to ask has changed. In 2005, that question is; is my surgeon fellowship trained? Does at least 75% of his or her practice consist of spine surgery? The choice of which surgeon to choose is still not easy, so here is my top 10 list to help in make a determination.

 Top 10 List of Questions you should ask in selecting a spine surgeon.

1)      Is the spine surgeon Board Certified?

2)      Is he or she Fellowship trained?

This identifies one of the new breed of spine surgeons, those who have completed the highest level of organized formal training in spine surgery.

3)      Does the spine surgeon devote 75% or greater of his or her practice to spine surgery?

Physicians who devote this much of their practice to the care of spinal disorders will be more up-to-date on newer technologies and techniques than physicians who see spine patients only occasionally.

4)      Is the spine surgeon trained in, and does he or she regularly perform, the newest techniques, technologies, and procedures, such as minimal access surgery?

Like most surgical subspecialties, spine surgery is moving toward minimal access techniques which many times offer significant advantages over traditional open surgery. Although this is not always possible, a discussion with your surgeon to determine if he or she is proficient in these techniques will let you know if he or she can even offer them to you.

5)      Does the surgeon spend enough time with you to answer all questions and provide enough information about your condition?

6)      Is he or she reachable? Open-minded? A good listener? A good teacher?

Collectively, these questions identify someone who enjoys teaching and has the personal skills to do it well. Finding someone who can inform and inspire trust can be as important as his or her surgical skill.

7)      Are second opinions welcome?

A physician that is dedicated to your education and peace of mind will not object to this.

8)      Is the surgeon willing to refer you to former patients who may be available to share their experiences with you?

This can be a window through which you can see your future. With the more recent patient information protection laws (HIPAA) now in force a physician must obtain written permission from his or her previous patients before he can disclose their information to you, or set up an interview.

9)      Does the spine surgeon come with good recommendations from a reliable source such as your primary care physician, a friend, or relative?

It is always wise to ask around. Every surgeon and his employees will consider themselves top notch. A third party recommendation can do wonders. If you have concerns, check it out.

10)   Does the spine surgeon take your insurance? If so, what part of my surgery will be covered and what part will I be responsible for?

As complex as medical reimbursement has become, it is only prudent to investigate this part of the relationship as well. Insurances change and reimbursement schedules vary, forcing many groups to opt in or out of a particular insurance on a yearly basis. Be sure to get up-to-date information here before you have a whopping bill on your hands that you insurance company won’t touch.

Cautions

There are also a few things you should be cautious of when selecting a spine surgeon. Be critical here as you will always be the one with the most to gain and the most to lose. Avoid any doctor who does the following:

1)      Discourages or does no allow second opinions.

Remember you are purchasing a service from your surgeon. If you have concerns regarding his or her approach, a second opinion is in order.

2)      Suggests or recommends “exploratory” surgery.

With modern imaging technology such as MRI this is rarely if ever indicated. In the majority of situations these technologies can demonstrate pathology as well or better than it can be seen at the time of surgery.

3)      Tries to directly influence your decision to have surgery.

It is the role of the surgeon to provide you with unbiased information from which you can comfortably make a decision, rather than to make it for you.

4)      Bypasses conservative treatment options.

Except in cases of cancer, infection, life threatening trauma, or progressive neurologic deficit, surgery should be the treatment of last resort. Medications, time, manual physical therapy, pool rehab, interventional steroid injections and other treatments should all be considered before moving on to surgical options.

5)      Is not forthcoming about treatments, techniques, costs, outcomes and expectations for recovery.

Sometimes this information cannot be spelled out in black and white with certainty. Nevertheless, the surgeon is your agent - one in whom you must have trust. Trust cannot develop if there is a sense that information is being withheld.

6)      Makes you feel uncomfortable about asking questions, or does not teach or encourage you to learn as much as possible about your condition.

You and your surgeon must form a team. Each must play their part. In order for you to make your best decision your surgeon must provide you with a free flow of information. In order to teach effectively a teacher must not only provide the information, but create and encourage an environment in which that information can be understood. Only in such an environment can trust flourish, the team reach its maximum potential, and your surgery be provided the best possible chance of success.

If you have any concerns about a particular physician, you can contact the state medical board to find out whether the practitioner has ever had disciplinary action taken against his or her license. The Federation of State Medical Boards lists each of its members at the following website: www.fsmb.org/members.htm.

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                                                    Last modified: 04/04/06