Perspective on Training Future Spine Surgeons

Peer Reviewed

A new residency pathway focused specifically on training future spine surgeons should be developed to meet the changing needs of modern spine surgery practice and address inconsistencies in spine surgery training, according to a recent report by a group of orthopedic and neurological surgeons.
Team of surgeons in the operating room.There could be independent departments of spine surgery, with operative and nonoperative divisions. Photo Source:

“…the world is changing around us, and the old model of training is no longer the most efficient and effective strategy for training tomorrow’s spine surgeons,” the report’s lead author, Alan Daniels, MD, and his coauthors write in The Spine Journal.1

Complement Existing System

The authors argue that spine surgery would benefit from its own residency training program to complement—rather than replace—the existing system for training spinal surgeons. They maintain that a focused “spine surgery residency would foster a spine-centric education, with the ultimate goal of a spine-specific practice [and] an expected effect of improving patient outcomes.”

While acknowledging that both orthopaedic and neurological surgeons “bring unique perspectives to the art and science of spine surgery,” Dr. Daniels and his coauthors argue that the existing training models employing the two distinct pathways “may not be the optimal environment for educating tomorrow’s spine surgeons” because “wide variations in training may be detrimental to surgeon quality and patient care.”

Pathway Deficiencies

The authors present several deficiencies of the current dual pathway models. For example, they argue that the existing separate training models were not designed to meet the needs of modern spine practice. In addition, these two specialties offer residents different levels of exposure to case loads and case variety, which can result in discrepancies in the levels of experience and skills residents gain. Noting that the minimum case requirements of the Accreditation Council for Graduate Medical Education (ACGME) for spine surgery differs for orthopaedic surgery and neurosurgery, the authors write, “The minimums are strikingly different between the two specialties and are at levels that are likely far below the minimum needed to achieve proficiency.”

Recent criticisms of spine surgeons in the media and scientific literature and relatively high failure rates on step II of the American Board of Orthopedic Surgery provide further impetus for the proposed new training model.

Examine Options

Dr. Daniels and his coauthors recommended that spine surgeons should look at the experience of other surgical specialties, such as vascular surgery, that has branched off and formed their own residency training programs. Pointing to 5-, 6- and 7-year training programs that allow vascular surgeons to opt for board certification in general surgery and vascular surgery or just the latter, the authors suggest that a similar approach could be used for spinal surgeons.


  • A shortened primary orthopaedic or neurological surgery residency followed by a prolonged spine surgery fellowship.
  • A traditional orthopaedic or neurological residency followed by the spine surgery residency.

Spine surgeons who trained through the traditional approach could practice general orthopaedics or neurological surgery as well as spinal surgery, and those who took the shortened approach would be dedicated spinal surgeons.

“A spine surgery residency program would be designed to provide pertinent rotations to optimally train spine surgeons,” the authors suggest. “This may vary from institution to institution based on local resources, although ACGME requirements would have to be developed.”

Institutions that are appropriate candidates for developing a spine surgery residency would offer exposure to the full range of spine procedures, from basic spine surgery to minimally invasive surgery as well surgery for deformities, tumors, and traumatic spine conditions, suggest Dr. Daniels and his coauthors. They recommend that programs would be developed based on collaboration between orthopaedic and neurological surgery spine divisions “to promote a well-rounded educational experience.” Ultimately, they write, there could be independent departments of spine surgery, with operative and nonoperative divisions, the latter focusing on nonsurgical spine care.

Potential Challenges

The authors predict that such an initiative would meet with challenges, such as resistance to disruptions of the status quo, high costs of developing training programs, and concerns that such a move may increase subspecialization within orthopaedics and neurological surgery, which could decrease the availability of surgeons within these specialties for on call emergency care.

Despite these challenges, the authors call for the development of a committee to explore “the issue of spine surgeon training reform,” with representatives from orthopedic and neurological surgery as well as multiple spine-related specialty societies, “to improve spine surgeon training and thus spine patient care.

Updated on: 10/26/19
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