Neurosurgeon or Orthopedic Surgeon? Does it Matter?

If I need to be evaluated for a spinal problem, or, if I need spinal surgery, should I see a neurosurgeon or an orthopedic surgeon?

A few simple facts will help educate the interested patient.

It is important for patients to realize that both neurosurgeons and orthopedic surgeons perform spine surgery. Today, there is an emerging field of "spine surgery" that incorporates both specialties. In the future, there may be a well-defined medical specialty of "spine specialists" defined by its own board certification. This is not currently the case. Currently, neurosurgeons seek board certification from the American Board of Neurological Surgery and orthopedic surgeons seek certification from the American Board of Orthopedic Surgery. There is no certification process at the present time that is recognized by the "father" board, the American Board of Medical Specialties. It is very important that patients make sure that their doctor is certified by the appropriate board. This ensures that the doctor has met the highest standards set by his or her peers and passed both oral and written examinations.

Neurosurgeon Training
All neurosurgeons trained in the United States (and many places abroad) gain experience in the diagnosis and nonsurgical and surgical treatment of spinal disorders during a six or seven year residency training program (after medical school). When physicians graduate from an accredited neurosurgery training program, they usually have assisted in many hundreds of spinal procedures. If they wish to gain even more advanced training, they may elect to do a post-graduate fellowship in spine surgery. This intensive, focused training is typically one or two years after residency training. Though most patients think of neurosurgeons as "brain surgeons", it may be interesting to know that the majority of operations performed by neurosurgeons across the country are spine surgeries. In large group practices and certainly in academic (university-based) neurosurgery departments, there are some neurosurgeons that specialize in brain surgery and do very little spine surgery. In these settings, they will have a colleague who specializes in spine surgery.

Orthopaedic Surgeon Training
All orthopedic surgeons are also exposed to spine surgery during their four or five year training program. Some orthopedic residencies are at institutions where there are one or more orthopedic surgeons who specialize in spine surgery. At these institutions, orthopedic residents in-training may be exposed to a volume of spine surgeries comparable to many neurosurgery programs. In some orthopedic training programs, the emphasis is on trauma or joint surgery or on sports medicine. As in neurosurgery, some orthopedic surgeons who wish to specialize in spine surgery and gain further training may pursue a post-graduate (after residency) fellowship in spine surgery.

Both Can Specialize in Spine Surgery
Though things were different many years ago, today there are a large number of both orthopedic surgeons and neurosurgeons who specialize in spine surgery. More and more, we are referring to each other as "spine surgeons" as the distinction between us is becoming nonexistent. Both neurosurgeons and orthopedic surgeons specializing in spine surgery are skilled in taking care of disc herniations, disc degenerations, spinal stenosis, fractures of the spine, slippage of the spine (spondylolisthesis), scoliosis, bone tumors of the spine, etc. For younger patients, there is a subset of spine specialists that is devoted to the pediatric patient (usually defined by patients below age 15 or so).

Differences
There are a few areas where there still is a difference. Only neurosurgeons are trained during their six or seven year residency to perform procedures inside the lining of the spinal canal called the dura. Thus, spinal cord tumors, arachnoid cysts, syringomyelia, Chiari malformation, spinal cord arteriovenous malformation, diplomyelia or diastematomyelia, tethered spinal cord, spina bifida or myelomeningocele, lipomyelomeningocele, tumors at the junction of the base of the skull and upper cervical spine, nerve root tumors, and a few other diagnoses still fall under the domain of the neurosurgeon. Similarly, both pediatric and adult scoliosis and other spinal deformities are still primarily treated surgically by orthopedic spine specialists.

Sharing the Same Interests
Perhaps the most exciting news to report is that there is a terrific, productive collegiality developing between orthopedic surgeons and neurosurgeons who wish to devote their careers to the advancement of spine care. We no longer look at each other as competitors; rather, we look at each other as colleague with the same interests. Many international scientific organizations now open their doors to physicians from both specialties such as the North American Spine Society, the Scoliosis Research Society, the Cervical Spine Research Society, and others. This friendship and professional association of orthopedic surgeons and neurosurgeons will be of great benefit to patients.

Patients Have Choices
Currently, a patient does not have to settle on a neurosurgeon who does "mostly brain surgery and a little bit of spine surgery" or an orthopedic surgeon who does mostly "joint surgery and a little bit of spine surgery." A patient today can seek consultation with either a neurosurgeon or an orthopedic surgeon appropriately trained in residency and, possibly, in a post-graduate fellowship in spine surgery who has devoted his or her practice to spinal disorders. In other words, they take care of spine problems day to day, week to week, month to month, and year to year. The old walls separating these two specialties have been broken down by the shared goal of advancing the field of spine care. Don't be afraid to ask your surgeon about his or her training, practice focus, experience with whatever operation has been recommended, and whether you the patient have been presented all of the options that exist (regardless of whether your surgeon performs all of them or not). Don't be afraid to speak up. It's your body, your spine. Physicians place great value on educating patients to the best of their ability so that satisfactory decisions can be made and acceptable treatment initiated.