Neurosurgical spine:clinical and research priorities

David Welsh

Cape Town

Neurosurgical spine:clinical, research and training

prioritiesDavid Welsh

Cape Town

Spine surgery in Neurosurgery

• ‘step child’ of brain surgery

• Rapid evolution over past 20 years:• Imaging

• Instrumentation• Fixation

• Mobility preservation

• biologics

• Neuro navigation

Spine surgery in Neurosurgery

• ‘step child’ of brain surgery

• Rapid evolution over past 20 years:

• Imaging

• Instrumentation

• $$$$ of spine surgery• ‘Third party’

• Incentives

• Direct marketing / internet era

• Patient expectations: consumer medicine

• Shift in center of training

Spine in neurosurgery: origins

• “Surgery of central nervous system:”

• Myelopathy, radiculopathy, spinal stenosis

• Decompression:

• “wide laminectomy”

• Requirements:

• Sound clinical and anatomical training

• Diagnosis

• Surgery

• Surgical skills

• Handling neural tissue

• Operating microscope

• Vertebral tumours, trauma, infection…..

Spine in neurosurgery: evolution

• Surgery of the whole spine:• Neural elements and surrounding structures…..

• Requirements:• Understanding of:

• Spinal alignment /deformity

• Balance

• Stability

• Bone biology

• Grafting

• Instrumentation choice, placement, imaging, complications, biomechanics…

Spine in neurosurgery: evolution

• Surgery of the whole spine:• Neural elements and surrounding structures…..

• Requirements:• Understanding of:

• Spinal alignment

• Balance

• Stability

• Bone biology

• Grafting

• Instrumentation choice, placement, imaging, complications, biomechanics…

Complex (modern) spine surgery training

• When?• Fellowship

• Post-fellowship

• Where?

• By Whom?

Fellowship training in spine surgery:

• Cranial surgery ‘bias’• HOD interests

• Pathology mix in public hospitals• Infection, trauma, oncology…..

• Emergency case load over elective surgery

• Lack of funds for spinal instrumentation

• Few spine surgeons in full-time hospital practice

• False dichotomy with orthopaedic spine

• Exponential growth in neuroscience information…• Endovascular, glioma surgery, functional..

Fellowship training in spine surgery:

• What are we training neurosurgeons to do?

Post-Fellowship challenges:

• Cranial ‘bias’ endpoint of training• Limited posts in academic units / public hospitals• Trainee debt

• Degenerative spine ‘bias’ in private practice• Post-Fellowship education

• Industry funded• Emphasise on implants• Informal, narrow, sporadic, poor follow up……

• Medico-legal litigation • Solo practice

Post-Fellowship training in spine surgery

• 1 year resident fellowship• SA

• Overseas

• 2 year super-specialty training• “Spine surgeon”

Post-Fellowship training in spine surgery

• 1 year resident fellowship• SA

• Overseas

• 2 year super-specialty training• “Spine surgeon”

Some suggestions:

• Modern spine surgery training must be incorporated into all NS training programs in SA:• Curriculum to be drawn up with minimum standards

• Theoretical topics to be covered

• Surgical skills required

• Re-visit allocation of marks and averaging across questions in exams

• Support spine sub-speciality in Departments

• Co-operation with orthopaedic spine departments

• Embrace spine trauma as a teaching and training tool• ASCI units

Traditional curriculum priorities:

• Spinal clinical anatomy and assessment:• Accurate diagnostics

• Nexus between spine pathology and other neurological disorders• Movement disorder

• Neuro-degenerative disorders

• Disorders of affect

• Disorders of spinal development

Traditional skills priorities

• Operative handling of neural tissues

• Peri-operative neural protection

• Anatomy of spinal neural decompression

• Use of operating microscope

• Minimally invasive spine sugery?

Non-traditional curriculum topics

• Spinal alignment and deformity

• Spinal balance:• Assessment and restoration

• Bone:• Primary tumours

• Metabolic diseases (osteoporosis)

• Fusion

• Instrumentation:• Basic metals and biomechanics

Research priorities

• Clinical v. basic sciences / lab

• Clinical:• Plenty of research material (trauma, infection….)

• Clinician driven

• Lower costs

• Collect data from the beginning

• SA /LMIC relevant (competeing with China, India, Brazil…)• Local pathology / local solutions

• Cost /benefit assessments

Research priorities: examples

• Neurological injury:• Trauma

• Cervical myelopathy• Common

• Uniquely neurosurgical pathology

• Significant morbidity

• Huge amount of clinical material in SA

• Urbanisation and the spine:• Evolution of spinal degeneration

Lastly……

• Avoid solo practice• Maintain links with local university unit

• Talk about your complications and failures

• NHI may allow for restructuring of neurosurgical practice