The Electrician vs. The Carpenter Revisited

Who is Better Trained to do Your Spine Surgery?

“A dance goes better when both partners know the steps.” -Anonymous

One of the most common internet queries for patients is: who is better qualified to perform spine surgery? An orthopedic surgeon or a neurosurgeon? Five years ago, I addressed this topic in a blog, and I am honored to be asked to update this discussion.

In the spirit of collaboration, I invited an orthopedic spine surgeon with whom I regularly operate with to be a cowriter of this new piece that was originally titled “The Electrician vs. the Carpenter.”¹

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The basis of the metaphor is simply that in the past orthopedists were considered “carpenters” who did not get involved with the nerves or spinal cord. They only treated bone and joint disorders in the spine as well as sports injuries, skeletal deformities and scoliosis. On the other hand, neurosurgeons were considered to be “electricians,” more focused on the nerves and neurological structures. Of course, we all know that any competent and well-trained spinal surgeon is focused equally on the bones and the nerves.

Over the past 30 years, differences between the specialties have diminished as neurosurgeons have learned more about bone physiology and creating bone fusions, while orthopedic surgeons have learned more about treating nerves, including nerve decompression.

As a result of this evolution of knowledge, patients have benefitted.

Differences in Training

A 10-year analysis of trends in training during residency published in 2019 demonstrates clear differences in resident training of each specialty.² This study shows that neurosurgical residents performed roughly three-and-a-half times more of spine procedures than orthopedic surgery residents on average. This discrepancy appears to be increasing over time, but does not account for the additional post graduate training that an orthopedic surgeon would obtain pursuing spine fellowship training. This data supports that a neurosurgery resident is qualified to perform spine surgery at the completion of their residency, whereas an orthopedic resident will need an additional year of fellowship training required by most hospitals for credentialing.

General Differences in Outcomes

Many routine cervical, thoracic and lumbar surgeries are performed well by surgeons from both specialties. Research supports this statement. A study published in July 2015 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.³

They 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.”

Another study published 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.”⁴

Differences in Outcomes by Procedure

Literature review of outcomes of specific neurosurgical vs. orthopedic surgeons are mixed and overall show little differences.

In a study of outcomes of single level anterior cervical discectomy and fusion (ACDF) between orthopedic and neurosurgeons found no difference in overall complications, surgical site infections or medical complications.⁵ This finding is also supported by another study that reviewed nearly 18,000 ACDF procedures and found no difference in complication rates.⁶

A study that looked at one and two level posterior lumbar fusions by different specialties in 10,509 patients found that orthopedic surgeons had a slightly lower infection rate (OR 0.81), and neurosurgeons had a slightly lower dural tear rate (OR 1.9) with no other significant complication rates.⁷ Interestingly, the costs appeared similar, but the reimbursement was higher for neurosurgeons by $170 per case.

A 2017 study retrospectively looked at 197,682 patients who underwent either lumbar laminectomy, lumbar fusion or ACDF over a four-year period.⁸ They found neurosurgeons had a marginally higher odds of any complication for lumbar fusions. They also found that neurosurgeons had slightly higher rates of revision surgery for lumbar laminectomy with fusion as well as with ACDFs, but concluded that these differences were small and unlikely to be clinically meaningful.

A study of 90-day complication rates for surgical intervention of spinal metastasis found that in 887 patients there was no statistically significant difference in complications between orthopedic and neurosurgeons.⁹

Solid Evidence Demonstrates Synergy

Research shows that when an orthopedic surgeon and a neurosurgeon who are both properly trained perform a spinal surgical procedure as a team, patient safety rates improve dramatically.

“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.” ¹⁰

A 2014 study that 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, MD, 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.

In a 2013, researchers evaluated the two-surgeon theory for pedicle subtraction osteotomies that restore the normal curvature of the spine.¹¹ This is a 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.

In their conclusion researchers wrote, “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.” In 2017, research showed similar benefits of dual attending surgery in scoliosis surgery.¹²

In the most up-to-date comparison between dual surgeon vs. single surgeon comparisons, authors reported that dual-attending care for adult spinal deformity was more favorable compared to single surgeon care.¹³ They found a trend toward less blood loss, fewer intraoperative transfusions and fewer 90-day readmissions in the dual attending group compared to the single surgeon.

We have seen the similar synergistic results in our practice. There is little doubt that a neurosurgeon and an orthopedic surgeon performing as a team generally are faster and more efficient. This is associated with less blood loss and lower infection rates. Intuitively, two sets of highly trained hands and eyes is better than one.

It has been our experience that by sharing their different experiences and perspectives, a two-surgeon team can often design a plan of care that is safer and more comprehensive. This team approach provides a better chance for a successful outcome as compared to one surgeon alone providing care for a patient.

Conclusion

So, what is 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 lumbar discectomy or a single level ACDF. In our experience, for more complicated surgery such as a multilevel revision surgery in an obese patient or difficult reconstruction two surgeons collaborating and working together is the best option.