A short history of spinal training and outlook on spine speciality development in the UK 1948–2013

With the production of the second UK supplement under the auspices of the British Association of Spinal Surgeons (BASS), it appears appropriate to reflect on the history and evolution of spine training over the last 50 years, leading up to the challenges that we will be facing as of 2013 due to the specialist services refinement driven by the Department of Health. The authors of this editorial span three generations of spinal surgeons. Robert Mulholland is one of the first orthopaedic surgeons who recognised and promoted the development of spinal surgery as an emerging speciality field and founded The Harlow Wood Spinal Research Unit in 1974, which when Harlow Wood Hospital closed became the Spinal Research and Surgical unit at the Queens Medical Centre in Nottingham. Bronek Boszczyk is the current Head of Service of the same unit which now sees neurosurgeons and orthopaedic surgeons fused into a true comprehensive department; Jonathan Clamp is the first Fellow to have completed the new 2-year fellowship program which seamlessly joins traditional “Neuro” and “Ortho” techniques to forge fully qualified spinal surgeons.

It is important to understand how training developed in the UK. The creation of the NHS in 1948 essentially created a salaried service in the hospital system. Consultants had security of tenure; junior staff progressively occupied the posts of house surgeon, senior house officer, registrar and senior registrar. All non-consultant appointments were short-term contracts and obtained in open competition. The young doctor, who aspired to become a surgical consultant, would know he had to pass the Fellowship—an examination in two parts—before he would embark on a surgical speciality. Courses were run by the colleges and some highly motivated trainers; they were expensive and the doctor had to pay for them himself. Frank Holdsworth (an orthopaedic surgeon in Sheffield) was unique in offering a 2-year registrar appointment which was designed to expose the doctor to all aspects of surgery, to specifically prepare the doctor to take the Fellowship. Such a post was highly sought after and attracted the best junior staff. From the NHS point of view these were service posts, there being no specific funding for training. After obtaining the Fellowship, then the aspiring surgeon would seek to secure a post in a highly regarded unit gaining clinical experience. In Orthopaedics, the registrar would probably do a further two years in this grade especially gaining experience in trauma. During this time he would be expected to improve his CV with some research and papers, and then compete to obtain a senior registrar appointment. This was a recognised training post, insofar as once one was a senior registrar, one in time would become a consultant. The registrar/senior registrar divide however meant that registrars had no certainty of progressing to a senior registrar appointment and becoming a consultant. JIP James, Professor of Orthopaedics in Edinburgh, advocated a unified training post—and came to Oswestry in 1971 and spoke strongly in support of a 4- or 5-year training post—abolishing the senior registrar/ registrar divide, and providing at last security for registrars. It was a copy of the training posts in the USA.

In the early seventies, it was envisaged that the orthopaedic consultant would do trauma, cold orthopaedics (which now involved joint replacement but no polio and very little tuberculosis) and posterior spinal surgery—laminectomies and posterior un-instrumented fusions. The new orthopaedic consultant would have done a rotation of at the most 6 months in his training doing spinal work and most would feel competent to treat a disc protrusion surgically. It must be appreciated that spinal surgery at this time was a small field.

However, in the late 1970s, Orthopaedics underwent a massive change with the development of internal fixation of fractures and the rapid expansion of joint replacement. This affected spinal surgery. Spinal fractures could be reduced and fixed and it was appreciated that the spine could be operated upon anteriorly. Brian O’Connor had the foresight to recognise the rapidly changing nature of spinal surgery and set up a specific Spinal Unit at Oswestry in the early 1970s and invited Jack O’Brien to become the Director. O’Brien had trained with Hodgson in Hong Kong. Hodgson had pioneered the anterior approach to the spine in treating tuberculosis. O’Brien brought this concept to Oswestry and introduced the concept of spinal training, creating specific fellowships in spinal surgery. Many such appointees were from abroad because UK senior registrars were aware that the number of consultant appointments specifically to do spinal surgery were few and at that stage were usually in centres dealing with spinal deformity in adolescents and children. The number of orthopaedic consultant posts—overall about 1,500—would not allow orthopaedic consultants in District General Hospitals, or even University Hospitals, to practice spinal surgery exclusively.

When O’Brien left Oswestry he was succeeded by Steve Eisenstein, in 1985 who again unusually was a fully trained spinal surgeon. He had been one of O’Brien’s Fellows in 1976 and had returned to Johannesburg University Hospital in South Africa as a principal orthopaedic surgeon and found himself doing a great deal of spinal work there. Eisenstein was subsequently joined by David Jaffrey, who also was already a fully trained spinal surgeon, and had been to Hong Kong. The Oswestry Unit was formed at a time when spinal surgery was rapidly expanding and met this challenge with a very active training program, increasingly training UK trainees. One of the UK Fellows was John Webb, whom Peter Jackson had interested in spine surgery when he was at Harlow Wood as a registrar, so that he went to Oswestry and the US and so returned to Harlow Wood as a well trained and experienced spinal surgeon in the early 1980s.

In 1974, Robert Mulholland had set up a Spinal Research Unit at Harlow Wood Orthopaedic Hospital funded in part by the Coal Board. Spinal surgery then was the surgery of the disc and the management of back pain, mainly non-surgical. Fellows were appointed at the registrar level, wrote some papers, learnt the surgery of the disc, and various minimal intervention techniques, and then with an improved CV competed to become senior registrars. Of the 16 Fellows over the years, 14 became orthopaedic consultants with an interest in the spine. Mike Sullivan in London and John Getty in Sheffield were heavily involved in spinal training, again with the view that the surgeon so trained would have an interest in spines, rather than be exclusively a spinal surgeon.

Then in the mid-1980s Harlow Wood was closed and Nottingham was given their own spinal unit with John Webb as the Director. The Spinal Research Unit became part of what was a Spinal Surgical Unit—The Centre for Spinal Studies and Surgery as it is known to this day—training spinal surgeons who would be exclusively spinal surgeons; the era of the orthopaedic surgeon with an interest in spines was past. John Webb initially had one Fellow, and then two, both funded by the hospital. By the early 1990s the British Orthopaedic Association (BOA) was funding two Fellowships, one at Nottingham and one at Leeds where Professor Robert Dickson had developed a spinal unit to train spine surgeons.

However, in those 10 years three changes in the organisation of specialities occurred. The Calman report in 1995 established a unified appointment, the “numbered registrar”; restricting the number of registrars in training. Secondly, an exit examination was now developed, the FRCS (Orth). It was usually taken after 4 years of training, leaving a further 2 years to develop a special interest. At the end of training, the Certificate of Completion of Surgical Training (CCST) was awarded. In 1999 possession of this certificate was required to obtain a consultant appointment. Thirdly there was a vast expansion in the number of consultant posts and reduction in registrar posts. It was recognised by the colleges how critical training was as the time in training was now likely to be perhaps just 4–5 years after being given a number. Speciality Advisory Committees (SAC) for each surgical speciality were subsequently created conducting regular inspections of centres with numbered registrars.

At this stage it was still envisaged, that whilst consultants might be appointed with an interest in spinal surgery, they would not practice it exclusively. However, the speciality as a whole started to fragment into numerous sub-specialities. The rapid advances in spine surgery made it increasingly clear that longer specific training would be essential in spine surgery.

External events again intervened. The UK in 2003, in order to conform with European requirements as Member of the European Community, altered the numbered registrar to a specialist registrar and converted the CCST to CCT—the Certificate of Completion of Training which now was on par with other European qualifications of completion of training. The training program developed after the Calman re-organisation was enshrined in legislation with the formation of PMETB (Postgraduate Medical Education Training Board). The consequence was that exposure to spinal surgery was at the most 6 months during this training period, and indeed in some rotations, candidates appeared for the examination not having done a spinal attachment. Hence it was clear that the aspiring spinal surgeon had to gain much more experience to practice spinal surgery as a sub-speciality on level with other sub-specialists. Funding for training posts however had been handed to Post-Graduate Deans. They were not empowered to fund post certification training, so that individual units had to attract funding for Spinal Fellowships on the basis of service need. It was in the hands of individual leaders in the field of spinal surgery to establish these speciality training posts.

From April 2013 the national commissioning of specialised services will be a core responsibility of the NHS Commissioning Board (http://www.commissioningboard.nhs.uk/). Complex spinal surgery and spinal cord injury have been identified as specialist services in the 2012 report by the Clinical Advisory Group to the Department of Health (http://www.dh.gov.uk/health/2012/09/cagreport/). Amongst the reasons for developing this is the lack of pre-existing nationally defined service standards or specifications produced by recognised bodies. The international efforts of the Spine Society of Europe (SSE) and the EuroSpine Foundation (ESF) have not yet sufficiently permeated to a national level to have an immediate impact in the UK. With this new directive, centres offering these specialised services will now be defined across the UK. Complex spinal surgery will only be performed in specialist spinal surgery centres or as an outreach as part of a provider network (hub and spoke model). The scope of procedures that falls under the specialised definition includes:

• All spinal deformity surgery (adults and children)

• All spinal reconstruction surgery (adults and children)

• Palliative or curative spinal oncology surgery (adults and children)

• Revision surgery for which the primary surgery is specialist, for example, revision surgery with instrumentation for over 2 levels

• All primary thoracic and primary anterior lumbar surgery

• Posterior cervical decompression surgery using instrumentation

• Cervical corpectomy

With this development, the UK has taken steps towards implementing the equivalent of a spinal surgery speciality. The designated specialist centres in the UK will now need to provide a fully fledged spinal surgery service competently offering the above range of surgical interventions. The considerable volumes treated by UK centres of these pathologies demonstrate that this is achievable [1–3]. It is anticipated that specialist centres will additionally need to provide a dedicated spinal on-call service and collect data via national or international registries, and have 24 h access to CT and MRI imaging services. Consideration is currently being given to the development of nationally recognised speciality spinal fellowship training posts (including recognition of “overseas” posts) for a duration of 12–24 months.

At the same time an international recognition within the UEMS (European Union of Medical Specialists) as a separate speciality appears unlikely and spine surgery is still limited to Multidisciplinary Joint Committee status on a European level (http://www.uems.net/index.php?id=30) and does not feature as a specialist division. Developments by the SSE and ESF directed at developing a network of recognised EU fellowship sites is still underway with very few centres offering genuine hands-on surgical training posts that cover the entire range of spinal pathologies. While exact figures do not exist, the majority of specialised fellowship posts available to EU graduates appear to be on offer in the UK.

UK training centres remain dedicated to retaining the link with the supranational societies [4, 5]. Given the rapid development of specialist services in the UK driven by the Department of Health, there is much to be gained by coordinating the efforts of the SSE and ESF with those of the British Association of Spinal Surgeons (BASS). The tremendous political challenges that this involves should not be underestimated. With Eurospine being hosted in Liverpool in 2013 and being led by a British President, there is an unparalleled chance to “come together” [6] to unify the approach to spine surgery training and the development of the speciality as a whole on a national and international basis.