Abstract
It is always an eye opener to view specialized spine care from a global perspective. During last years Global Spine Congress in Paris, AOSpine organized a highly successful precourse on Spinal Interventions. While the practical content focused around the techniques of spinal interventions and radiofrequency ablations, some of the lectures highlighted indications and results of those procedures. One of the things that stuck with me most was a discussion I had with a colleague from another region of this world. When asked how spinal injections and interdisciplinary spine care were handled in his part of the world, he replied: “I really cannot send my patients to these colleagues because I never get them back”.
This was a very honest and very condensed answer to a much bigger and significant underlying problem. Spine surgery is a specialty that has grown and evolved from several different specialties, predominantly orthopedic surgery and neurosurgery. Global consensus is that all aspects of specialized surgical training and different philosophies belong to the field of spine surgery and make it unique, compared to other subspecialties. However, in non-operative and interventional spine care, this process has not been seen.
Neurologists, specialists on physical medicine and rehabilitation, pain specialists, anesthesists, psychologists, radiologists, physical therapists and others are involved in treating back pain patients. All have their professional societies and all have their pathways and recommendations. Joint guidelines of multispecialty origin tend to be “diluted” in a way that their acceptance into everyday institutional protocols are far from universally accepted. And often no common consensus can be found on the best way forward for a number of reasons.
The lack of understanding a different diagnostic or therapeutic concept is widespread and is often based in highly focused and specialized training. Residency and fellowship programs worldwide do not focus on meaningful exchanges with other nonoperative specialties when it comes to treating spine patients. And much less an exchange between nonoperative and specialized departments for spine surgery. Additionally, the global approach to professional education of physiotherapists is very inhomogeneous and establishing a joint approach to spine care is far from a common standard.
A consequence of this knowledge gap can be a lack of trust and mutual understanding. One does not recommend patients to a colleague if he/she does not have faith in their abilities. This is natural and human nature. In treating spine patients, this lack of trust can significantly limit the ability to pick the most effective and beneficial treatment.
Addressing knowledge gaps can obviously be done faster and easier than gaps in interdisciplinary trust.
The simple lack of knowledge of other specialties pathways can be overcome by the classical means of education. Global Spine Journal and others do play an important role in this. Diploma programs from professional multispecialty societies can also address the shortcomings of national certification programs, often designed decades ago by individual societies. Often they were designed in the spirit of professional lobbyism and medical protectionism.
Without the legal implications of national certification bodies, programs like the Global Diploma Training Program by AOSpine can provide an honest overview as well as in-depth knowledge, beyond limitations of a singular spine specialty.
Informally, collaboration with surgical or nonoperative colleagues is usually based on personal relationships. Understanding each others thinking and specific needs is helpful and comes with time spent together. Many surgeons have “their favorite” radiologist, physiotherapist, neurologist or anesthesist in their daily practice because there is trust and understanding. This usually does not translate into a formal educational exchange which clearly is a gap.
The ideal scenario where nonoperative and surgical spine care teams work together, under one (actual/financial/administrative/collaborative) roof is still scarce, at least on a global scale. Local competition by hospitals or surgeons is common and widespread.
Nevertheless it will certainly be the way forward in the future as patients, health insurance companies as well as certifying bodies will increasingly demand a comprehensive and interdisciplinary approach to spine care as such. Our specialty has proven in the past that the integration of different surgical backgrounds has proven useful and future oriented. The same will be true by integrating non-operative and surgical pathways and philosophies. The task will not be small but surely worthwhile.