Surgeons and patients both win when surgical specialties cooperate. The alternative—intensifying competition for patients and procedures—plunges surgeons and specialty associations into increasingly acrimonious turf battles that invite attack from the outside.
That’s the simple and complex story neurosurgeon Edward C. Benzel, MD, FACS, will weave during this year’s Charles G. Drake History of Surgery Lecture at 1:00 pm Central Time on Monday, October 25. The Evolution of Modern Day Spine Surgery: Conflict, Compromise and Collaboration will explore the turf battle that pitted orthopaedic surgeons against spine surgeons in the 1980s, culminating with both groups on the receiving end of potentially devastating legal and public relations campaigns over the use of pedicle screws in spinal repairs.
The annual Drake Lecture explores the historical development of surgery to help surgeons better understand current developments and surgical practices.
“In the 1950s, ’60s and ’70s, neurosurgeons were decompression surgeons, taking pressure off the spinal cord, and orthopaedic surgeons used hooks, screws, rods, and other hardware to stabilize the spine,” explained Dr. Benzel, co-director, Cleveland Clinic Foundation Spine Research Laboratory, Cleveland, OH. “By the 1980s, there was growing conflict because neurosurgeons were training themselves to place screws and rods. That generated heat between the American Academy of Orthopaedic Surgeons, the American Association of Neurosurgeons, the Congress of Neurological Surgeons, and other specialty groups as both groups tried to defend and expand their respective turf.”
The battle intensified when the Accreditation Council for Graduate Medical Education began the process of approving spine fellowships in 1989. Neurosurgeons, fearing orthopaedic surgeons could claim complete care of the spine, formed a task force that concluded spine surgery should be integral to neurosurgical training.
The world of spine surgery changed in the early 1990s.
Medical liability attorneys realized that pedicle screws had been approved by the U.S. Food and Drug Administration (FDA) as Class III medical devices with no indication for spinal fixation. The group launched multiple liability claims against spine surgeons, actions against orthopaedic and neurosurgical societies, and a public relations campaign that prompted a 1993 television news segment on 20/20 that was highly critical of pedicle screws, surgeons who used them off-label, and professional societies that supported their use.
“Adversity can make strange bedfellows,” Dr. Benzel said. “Instead of competing, orthopaedic surgeons and neurosurgeons were suddenly on the same side. They collaborated to collect data on patients who had been operated on using pedicle screws to demonstrate both safety and efficacy. The FDA ultimately reclassified pedicle screws as Class II devices, which allowed us all to continue using them. That battle forged bonds between orthopaedic surgeons and neurosurgeons, and the rest is history.”
But not the end of the story.
When Dr. Benzel joined Cleveland Clinic in 1990, he set about building a spine program, along with many like-minded colleagues, that drew on the strengths of both orthopaedic surgeons and neurosurgeons, as well as medical specialists for nonsurgical management.
“We developed, for all intents and purposes, a ‘spine department’ that sat between orthopaedic surgery and neurosurgery, with its own administrator and bank account,” he said. “We initiated a spine surgery fellowship that combined orthopaedic surgery and neurosurgery and a medical spine fellowship focusing on nonoperative management.”
The new program flourished, and other programs sought to create multidisciplinary departments or centers. The traditional departments were augmented by independent multidisciplinary centers.
The Center for Spine Health at the Cleveland Clinic incorporated the best of surgical and nonsurgical approaches into a well-orchestrated approach to spine care. Pain psychology is the latest addition, Dr. Benzel said, adding psychiatrists, psychologists, and chronic pain specialists to the spine team.
“We have developed a hugely successful, multidisciplinary program to provide one-stop shopping that has improved outcomes and satisfaction by putting patients first,” he said. “This multidisciplinary, patient-focused approach is the wave of the future. Benjamin Franklin had it right when he said, ‘We must all hang together or most assuredly, we will all hang separately.’”
The Advisory Council for Neurological Surgery established the Charles G. Drake History of Surgery Lecture in 1992 to honor this leader in neurological surgery.
This and other Clinical Congress 2021 sessions are available to registered attendees for on-demand viewing for a full year following Congress on the virtual meeting platform. Also, be sure to tune into Clinical Congress Daily Highlights for an interview with Dr. Benzel conducted by Peter Kernahan, MD, PhD, FACS, for more details about the lecture.