Why would a specialty ever want to be described by what they do not do? This is exactly what happened for many years and to some extent still continues when describing an aspect of spine care not delivered by a spine surgeon. Let me give you an example. When I began to co-direct a mid-year spine meeting for the North American Spine Society (NASS), the largest spine society in the world, about 10 years ago our sessions were divided into three distinct areas named joint, surgical, and non-operative. Since we had four surgical co-directors and two physiatrist co-directors, I politely asked them why our sessions are called non-operative spine. After a brief discussion, we all agreed that moving forward our sessions will be described by what we do and not by what we do not do. Therefore, the term medical spine was used going forward.
Ever since the first disc surgery article was published in 1934, by Mixter and Barr, one a neurosurgeon and the other an orthopedic surgeon respectively, you might say the surgeons had a head start on treating spine problems. After all, our specialty of Physical Medicine and Rehabilitation not only did not become a board-certified specialty until shortly after World War II but we did not even have a driving force and a strong voice in spine care until the early 1990s. This is when a small group of physiatrists, interested in musculoskeletal disorders, formed a separate counsel within our academy, to advance education, research, and clinical care in this area. The Physiatric Association of Spine, Sports and Occupational Rehabilitation (PASSOR) was formed and accelerated and advanced the field of medical spine care. Eventually, PASSOR set up guidelines for fellowship training in the areas of spine and sports medicine. Fellowship programs that met these guidelines would be designated as PASSOR “recognized” fellowships.
Even today it is estimated, we are still training 100 spine surgeons in fellowship programs to every medical spine specialist trained in a physiatry spine fellowship. It is generally accepted that the spine surgery fellowships offered by the specialties of Orthopedics and Neurosurgery do not offer extensive medical spine care training. Not surprisingly, this has led to an opposite ratio of what is needed from the spine practitioners based on the fact that most spine problems can be successfully treated medically. It should also be noted that no subspecialty board certification is currently offered in spine care as the three specialties currently offer fellowship training that being Orthopedics, Neurosurgery and Physiatry would have to agree on a fellowship curriculum as well as the content and of a board certification examination. Even though this has been accomplished, with even more specialties involved, in sports medicine we are unlikely to see this happen in spine care. Unfortunately, this has led not only to less standardization of fellowship training, but also to the overtraining of surgical vs medical spine specialists. To some extent, NASS has developed some guidelines for surgical spine fellowships and recently has taken on the medical fellowships as well.
The whole field of spine care has failed the patient in providing the best and most effective treatments. There are a wide variety of fields that have a role in evaluating and treating patients with spine problems. These include, but are not limited to, Orthopedic Spine Surgeons, Neurosurgical Spine Surgeons, Physiatrists, Physical Therapists, Chiropractors, and Anesthesiologists trained in pain management fellowships. None of these specialties have adequate training in some of the most effective treatments that research has demonstrated work for treating spine problems.