Spine surgery is one of the most intriguing, clinically complex and technically challenging surgical fields. The tag of being a Spine Surgeon has a highly fulfilling appeal and most surgeons are respected as being a cut above the rest dealing with the challenging complexities.
Being a good spine surgeon combines astute clinical history and examination skills, attention to the diagnostic details and sound operating hands. For the properly selected patient, spine surgery provides the opportunity to dramatically improve a person's quality of life by applying innovative surgical techniques.
Spine surgery is performed on patients of all age groups and activity levels, as well as dealing with a broad spectrum of disease processes such as trauma, tumour, infection, degenerative and deformity. Hence the challenges posed by the clinical variability makes each working day different from any other.
Consultant life can be a lonely place, but in spinal surgery the MDT input for planning and decision making is a valuable asset in sharing the workload burden. Complex spine surgery is in many centres performed by two Consultant surgeons, giving the additional support required for these challenging cases. The surgeons in a Spinal unit are usually part of a very supportive and cohesive unit. Team-working skills and inter-personnel communication skills are constantly put to test as a Spine surgeon.
It is a highly evolving speciality with abundant scope for pursuing academics and research. Constant updates in the field of bio-metallurgy, minimal access surgery, robotics, perioperative care, patient outcomes are the ethos of “intelligent” surgery where the traditional techniques combined with high-end technology will be pushing the frontiers of spine surgery.
Spine surgeons are also among the highest earners and the greater financial viability is also an attractive option. Majority of spinal centres are located in larger urban areas where greater access to social and lifestyle amenities are an added appeal.
Spinal Surgery Disadvantages
The aspects of spine surgery that budding Surgeons worry about most are the physical and intellectual demands of the job coupled with the long/odd working hours that can adversely impact the work-life balance.
Spinal surgery is the one of the hardest surgical field to learn; and to perfect. This requires not only great skill and greater intellect but is a speciality that takes many years of training to master confidence.
The tag of being "high risk" compared to other specialties in orthopaedics attracts its own quagmire of medicolegal litigation.
In summary life as a Spine surgeon is a highly challenging, but the accomplishment of significantly improving the quality of life for our patients is an over-riding motivation.
There are several regular conferences and courses organised on a monthly basis, please visit the courses and conferences listing website in our Training and Education sections - visit the menu at the top if the page.
You can train to be a spinal surgeon as either an orthopaedic or neurosurgical trainee. Being a trainee can be incredibly enjoyable, but it is important to recognise what you get out of each firm as a trainee will be a direct reflection of what you put in.
As an orthopaedic trainee, my registrar training was six years long. I committed to a career in spinal surgery at the start of my third year, this enabled me to experience different specialties, develop insight and make an informed decision- it may be however that you decide a lot earlier, or even a little later- there is no correct time, however the sooner you recognise what it is you want to do, the sooner you can tailor the remainder of your path.
As a trainee on a spine firm you will be expected to attend outpatient clinics seeing new, follow up and post-op patients. This will exercise your clinical and diagnostic skills and ability to formulate management plans. Typically there is an elective clinic each week, but can vary depending on the number of consultants you work for. Additionally you will be expected to review inpatients on a regular basis and be on top of their progress. As a trainee, I always found if I did these things well I would benefit more from the operating theatre. When you are more confident in diagnosis patients, reading scans and listing for surgery you tend to have developed an understanding of operative rationale and as such are able to ask intelligent questions and subconsciously display a greater enthusiasm when operating. Typically the consultant you work for will have one full day operating list a week. It is important to make sure you are a few weeks ahead of what is coming up- keeping a checklist, ensuring patients who are coming up for surgery have pre been assessed, have a group and save, appropriate kit available, up to date scans and MDT outcomes will demonstrate good housekeeping but more importantly there will be fewer cancellations and more operating opportunities!
There is often a fair amount of admin work as a trainee in general. This can be in the way of preparing presentations for MDT discussion or actioning the outcomes, or it may be responding to queries that the secretary passes on. Managing time and keeping on top of this side to your practice will prevent it from eating into your other training opportunities. Typically you will have an admin session set aside, however if you are able to get it done as you go along you can use this ring fenced time to further your portfolio, in the way of delivering teaching sessions, involvement in a research project or audit.
Performing these duties as a trainee is very realistic and engaging with the firm certainly helps you achieve your targets. Before you start and during your initial meeting with your educational/clinical supervisor, make sure you set realistic goals that you can meet. Touch base with your supervisor regularly. By being enthusiastic about these meetings and engaging with ISCP processes you can really tap into their experienced advice and develop close mentorship, which is what a lot of modern trainees so desperately crave!
Kiran Divani, Jan 2021
Spinal Surgery is not, at the moment, an isolated single arm training programme or field in the UK. To become a Spinal Surgeon, the incumbents must derive from either a Neurosurgery or Trauma and Orthopaedics specialist training programme.
How does the journey begin?
After undergraduate qualification, the Foundation programme commences. Particularly latterly, the Foundation training programme is designed to offer breadth of experience to juniors in a variety of specialities amongst primary, urgent and secondary hospital care. For the potential Spinal surgeon, whilst this may not offer the specific experience that they would choose it does deliver on offering time with aspects of care, pathology and management in different facets that will create a hopefully rounded Core trainee.
There are many examples of the evolution of the Foundation programme including jobs that are tailored to specific interests for each applicant. There are numerous academic, research and management themed Foundation programmes that could bolster not only the CV of the trainee but also offer a very solid and attractive experience profile in these facets of healthcare that may well become key in their future career.
The interim journey…
Competitive application into Core training takes place after FY2 or after the increasingly popular “F3” year. For surgically inclined doctors this provides the bedrock of experience and knowledge for the early part of Specialist training. Rotations may be 3,4 or 6 months and generally (if full-time) will last 2 years. Less than full time (LTFT) training is increasingly popular and recognised by the Royal College or Surgeons and this would mean taking more time than the original 2 year period to allow the gathering of experience, knowledge and competency in Surgery. There are numerous “themed” Core Surgical training programmes focused on a single speciality although providing breadth of experience in others. Generally, there will be surgical placements in General surgery, Vascular, Urology, Breast, Neurosurgery Trauma and Orthopaedics amongst others. It is generally common at this stage to undertake the MRCS examination allowing the trainee to apply for their National training number (NTN) or ST3 post if not in a “run through” programme.
The Registrar Journey
At this stage once an ST3 position has been secured in either Trauma and Orthopaedics or Neurosurgery programme training will be more specialised and more technically based with the acquisition of operative skills crucial. In Trauma and Orthopaedics experience amongst the subspecialties will be provided in Trauma, Hand, Upper limb, Hip, Knee, Foot and Ankle, Paediatric and of course Spinal Surgery. This experience amongst the other subspecialties is crucial in terms of the knowledge base and technical skills required of the trainee both from an operative “logbook” point of view and knowledge base as the FRCS exam looms ever closer. Of course this is crucial in terms of context when evaluating a Spinal patient in terms of identifying pathology and formulation of management plans. Its is important to remember that the level of Spinal surgery experience gathered in your Speciality programme will depend on the deanery in which you work and the number of “Spinal firms” available. Keeping in contact with the Spinal seniors in your area or deanery and the Training Programme Director with regards to your training requirements and needs is crucial.
Life after FRCS…
Once the FRCS is navigated successfully, the focus will be on senior training. Certainly in Trauma and Orthopaedic training the amount of time spent in Spinal surgery in your speciality training may not offer the experience required to transition from trainee to Consultant at the end of your time. Post FRCs fellowship training is generally sought and may be over a few years prior to application to a Consultancy. There are JCST and Royal College of Surgeons approved Fellowships available nationally including the Spinal Trainee Interface Group.
Al Durst and Alex Goubran (Inaugural JCST Spinal Trainee Interface Group Fellows), Jan 2021
First things are first, the day has to start with a nice cup of coffee. Then off we go.
On arrival to the hospital, the daily schedule differs slightly according to the designated duties. It usually starts with meeting other team members to go through admissions of the night before. We go through their admission notes, radiological investigations and laboratory results. This is a great opportunity for teaching. Every individual in the team, regardless of their seniority level, learns something from these daily briefings. We then go on a ward round to review patients and plan what the next step in their management would be. As a team, we formulate a management plan and put it into action.
Daily duties vary between outpatient clinics, operating theatres, admin work or teaching duties.
Clinics usually start at 9:00 am. As a spine surgeon, variability is the most attractive part of my role. I see patients of different ages, and with different spinal pathologies. Each of them requires different approach, so we need to have multiple thinking hats in each clinic. Scope of work varies between trauma, degenerative problems as well as spinal deformities (paediatric and adults). Each consultation results in either a schedule for surgery, prescription of medicines or referral for further investigation/trial of treatment. On these days, I also review patients whom I have operated on previously to gauge their progression.
I operate of various conditions, including fractures, spinal stenosis, prolapsed discs, spinal degeneration-related conditions and spine tumours. Each condition has different patient preparation and surgical approaches. The day starts by reviewing the patients’ scans and other investigations, followed by a briefing in the operating theatre with the theatre team to go through the list and the plan for the day. At the end of the day, I review all patients that I have operated on that day to give them a brief of their operation and their expected post-operative recovery schedule.
During oncall duties, emergencies might necessitate me to go back to the hospital, even at odd times of the night. One of the latest emergencies I was involved in was an accident casualty who needed immediate surgery at 2 am in the night!
Overall, I have to admit that spine surgery is fun, exciting and very satisfying. If I go back to medical school, I would take the same choice again.
Ahmed Abdelaal, Jan 2021
Alex Goubran - Inaugural JCST appointed Spinal Trainee Interface Group Fellows
My training began with the Foundation programme in the London area. At this stage a choice of firms and placements were available. My ambition as a potential Trauma and Orthopaedic surgeon was to gain experience in acute care, surgery and care of the surgical patient in the intensive setting as well as experience in Trauma and Orthopaedic surgery. Over my two years I undertook placements in both general surgery and medicine as well as Intensive care, Accident and Emergency, Vascular surgery and Orthopaedic surgery. I felt this gave me a fantastic basis and foundation for my continued education and training.
I undertook an Orthopaedic themed Core surgical training programme over two years gaining experience in General surgery and 12 months in Trauma and Orthopaedic surgery. During this time I began to bolster and strengthen my CV, passed my MRCS examinations and undertook time performing audit, research and management projects.
I undertook a LAT post prior to obtaining my NTN at ST3 level. It was in this period that I was part of the Spinal surgical firm and knew within 2 weeks that Spinal surgery was to be my future speciality. I ensured that I discussed my progression, development and plans with the Spinal surgical Consultants and mentors. This was crucial and gave me direction, focus and planning for my future career. Once I obtained my ST3 number I ensured that I made myself known to all the Spinal Surgical Consultants in the region and my desire to become a Spinal surgery Consultant in the future. I also ensured that my Training Programme director was aware of my career ambitions. It is important to remember that as an Orthopaedic trainee, the Spinal surgery orientated trainee will be in the vast minority as things stand and the path to become a Spinal surgeon may not be well trodden.
I ensured that my experience in the other facets of Orthopaedic surgery were structured well and I gained all the competency and experience required, not just for the forthcoming FRCS exam but for my own experience moving forward as a clinician and surgeon. Courses run by the specialist organisation such as BASS, AO spine and the BOA ensured that continued to gather further experience and knowledge in Spinal surgery.
I believe it was crucial to immerse myself in Spinal surgery as much as possible throughout my training programme so I ensured that I kept abreast of developments in the speciality and training. I ensured that I attended Spinal meetings and conferences, not only to gain experience and knowledge and to meet Spinal surgeons to ask for their counsel, advice and guidance. This directly lead to my interest and subsequent success in obtaining my Spinal Trainee Interface Group fellowship.
Al Durst - Inaugural JCST appointed Spinal Trainee Interface Group Fellows
I first contemplated spines as a career during my Core Surgical Training in Norwich, at which stage I had already committed to an orthopaedic career. Before this placement I had little to no spine experience except the perception that all orthopods hated back pain and “?Cauda equina” referrals. Exposure to a centre with a spinal on call and an MSCC service changed my perspective, as did clinical research into paediatric deformity. After attending BASS and BSS to present our work, I became enamored with the subspecialty and scope of a career I knew little about before. By the time I received my ST3 national training number, I was strongly considering a Spinal career however needed definitive experience.
After completing the majority of my core competencies and indicative numbers through ST6 I received my first spinal placement as a registrar, again at Norwich (cumulatively 12 months, split over 3 placements; involving swaps). Despite having a focused interest in spines, like many orthopaedic trainees, my spinal logbook was small in comparison to my trauma and appendicular operative experience. In a unit with a senior fellow gaining this operative experience was difficult, however managing the oncall, clinic and ward patients was an extremely valuable exercise. I also knew from the day-to-day work that I wanted to continue with my pursuit of a spinal career. It was at this stage that I started attending courses and investigating fellowships, including the rumored STIG.
At the start of my ST8 year, the pilot STIG fellowship was advertised. I was fortunate enough to be successful in my application and have found this fellowship to be a good consolidation of clinical acumen, knowledge and experience. As per Alex Goubran’s recommendation, I would advise any budding spinal surgeons to maintain focus on gaining their T&O experience and working towards their FRCS before concentrating on spines. We both found attending Britspine, BSS and BASS, as well as local and regional MDTs and meetings, piqued our interest regardless of our training placements. They were also good opportunities to meet others in the same boat; Alex and I actually met at BSS.
For medical students considering a career in Spinal surgery, see our ‘So you want to be a Spinal surgeon?’ guide, which will be available and published shortly.