Subspecialists Contemplate Their Future – Workforce Outlook Explored for Pain Management and Spinal Surgery

In this issue, Oren Sagher, MD, offers his view on the neurosurgical workforce in the area of pain management, and Regis Haid, MD, addresses the future of spinal surgery.

Pain Management
Oren Sagher, MD
Surgical intervention for pain management traditionally has been considered an exclusively neurosurgical realm. In the last decade, however, non-neurosurgeons and even non-surgeons such as anesthesiologists and physiatrists increasingly have undertaken these procedures. There are myriad reasons for the increasing involvement of non-neurosurgeons in pain surgery, among them a relative economic disincentive for neurosurgeons to be involved in pain care that creates a need then met by other practitioners. In spite of such challenges to neurosurgery’s participation in pain management, there is ample opportunity in the next several years both for neurosurgeons to increase their involvement in this subspecialty and for pain sufferers to receive the highest quality of care.

In order to understand the demographics of pain surgery, it is useful to classify pain procedures as either ablative or modulatory. Ablative procedures, such as dorsal root entry zone lesions, cordotomies, and myelotomies have a well-established place in the treatment of certain intractable pain syndromes and still exclusively are performed by neurosurgeons. However, the demand for such procedures is fairly low and likely to remain constant in the coming years.

The real growth area in pain surgery is in modulatory procedures such as intraspinal drug delivery and electrical stimulation. Patients’ demand for neuromodulation is likely to continue to grow in the next decade because of the inherently nondestructive nature of these procedures, as well as the increasing sophistication of the devices being utilized. However, the minimally invasive nature of these procedures requires a more limited technical skill set, allowing a wider array of practitioners to get involved. Anesthesiologists, physiatrists and neurologists increasingly have shown an interest in learning the surgical techniques necessary for implementation of intraspinal drug delivery and neurostimulation. At the same time, neurosurgeons have shown increasing reluctance to take on neuromodulation for pain as part of their practices. Patients undergoing this therapy require significantly more ongoing care than other neurosurgical patients, and reimbursement for these procedures (as well as for postoperative care) is not commensurate with the effort required. This shift in demographics has resulted in a steady erosion of the neurosurgical presence in pain medicine: For example, currently only about 30 percent of pain implants are placed by neurosurgeons. Reversing this trend is neurosurgery’s challenge.

And yet, with every challenge comes opportunity. In the case of neurostimulation, there is significant opportunity for neurosurgeons. While procedures to place intrathecal drug delivery systems typically are brief, straightforward, and seemingly quite amenable to non-neurosurgical practitioners, the same cannot be said of electrical stimulation. There is mounting evidence now that well-established therapies such as spinal cord stimulation for the treatment of chronic radicculopathy are more effective when placed in an open procedure, through laminotomy, for example, than when placed percutaneously. Moreover, the increase in the number of procedures performed by non-surgeons already is resulting in a rising need for surgical revisions. Finally, the development of novel stimulation therapies and indications, such as motor cortex stimulation and deep brain stimulation in central neuropathic pain, likely will increase the role of neurosurgery in the management of pain.

In the coming decade, neurosurgeons-the only specialists who combine a fundamental understanding of neurophysiology with the skill set necessary to alter it through either modulatory or permanent means-are positioned to resume their prominence in pain management. What is needed for this to come to fruition is renewed focus on pain surgery and pain research within residency training programs.

Oren Sagher, MD, is chair of the AANS/CNS Section on Pain and associate professor in the Department of Neurosurgery at the University of Michigan in Ann Arbor.

Spinal Surgery
Regis Haid, MD
Spinal surgery continues to grow and evolve. Why? Quite simply, the aging of the U.S. population increases the sheer volume of patients in need of treatment for disorders of the spine and peripheral nerves, while technological advances expand the therapies that are available for operative and nonoperative treatment of these disorders. In addition, patients’ increased demand for these therapies fuels the need for expanded efficacy and efficiency in the management of the entire spectrum of disorders of the spine and peripheral nerves.

It is inescapable that advances in imaging, surgical technology, and most importantly, our understanding of spinal disorders, have increased our ability to treat both basic and complex spinal problems. Compare today’s environment with that of 20 or so years ago. When I was a junior resident, the standard operative intervention for spinal disease was laminectomy, with the occasional anterior cervical fusion. Halo brace application was the treatment of choice for most acute cervical injuries, while for cases of traumatic spinal instability, standard stainless steel wiring was the material of choice. Bone grafts typically were harvested by our orthopedic colleagues.

So, although there exists a legitimate concern that technology may influence treatment, as recent articles in the press have argued, it would be foolhardy to refute the fact that internal fixation techniques, biomaterials, and biologics such as bone morphogenetic protein, significantly have changed the landscape of spinal surgery. However, concomitant with these advances comes the responsibility to utilize them appropriately in the best interest of our patients. In the short term, this perhaps is our greatest challenge.

While functional neurosurgery is on the verge of some major breakthroughs, and cerebrovascular neurosurgery is focusing on the endo-techniques that complement microsurgical skills, for a variety of reasons spinal surgery currently is one of the strengths of neurosurgery. I do not have to cite the number of neurosurgeons who are members of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves; it is the largest subspecialty section. I do not have to affirm the number of U.S. healthcare dollars spent to treat “back pain”; it is more than for any other specific disorder. I do not have to reiterate that spinal surgery today accounts for the majority of reimbursement for neurosurgery, for those both in private and academic practice. I do proclaim that neurosurgery needs to emphasize continually its strength in the treatment of spinal disease.

Our view must be farsighted. Rather than focusing solely on the surgical aspects of the disease, we must take steps to direct all aspects of care, including the nonsurgical therapeutic and diagnostic treatments(for example, facet injections and selective nerve injections) as well as the surgical treatments.. If we focus only on the surgery, to the exclusion of primary spinal treatment, we may lose the ability to direct patients to neurosurgeons, who are the most qualified specialists in the treatment of spinal disorders. If you are skeptical, I remind you to think back before noninvasive vascular labs, when neurosurgery performed a very significant proportion of the carotid endarterectomies. The “gatekeepers” of vascular disease, that is, the vascular surgeons, now dominate treatment for vascular disease.

Are there enough neurosurgeons to treat our patients? For treatment of spinal disease—absolutely not.

The aforementioned factors-the burgeoning baby boomer demographics and the associated increased incidence of degenerative disease, advances in our abilities to image and treat spinal disease, the increased need to be involved in identifying the correct treatment for a specific pathology and correlating it with objective, measurable outcomes, and lastly, the need to be more involved with the total treatment of spinal disease, beginning with nonsurgical therapy-demonstrate the need for more neurosurgeons:

But the necessary skill set required to fulfill this need is not something that can be acquired in a six-month “mini-fellowship” in the middle of neurosurgical residency. Rather, a commitment to respect and teach state-of-the-art spinal diagnostic skills and surgical techniques is required. Such training must be accomplished at multiple levels: residency, postgraduate fellowship, and continuing medical education for the practicing neurosurgeon.

Without an increase in neurosurgeons who are proficient in the spinal skill set, neurosurgery will fail to capitalize on a major opportunity. The obstacles are obvious: decreasing reimbursement, increasing professional liability insurance premiums with the attendant pressure to practice defensive medicine, changes in resident work hours…and the list continues. If we want not only to survive, but also to prosper, changes must be made. Although there are innumerable aspects of the future we cannot control, we are able to make choices regarding workforce, training, and emphasis. These choices must be made.

Regis Haid, MD, is chair of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves and a neurosurgeon at Atlanta Brain and Spine Care in Georgia. ]]>