Good-quality training is essential in becoming a specialist doctor. Most Spinal trainees are encouraged to do a specialist spinal fellowship thereby improving their operative skills, case selection, decision making and research. It is interesting to note that a particular spinal diagnosis can be treated differently from one region to another. This can be confusing to a young trainee, but it is important that they are exposed to many different surgical philosophies and treatment algorithms, provided these show validated improvements in patient outcome. Having access and contributing to a National Spine Registry will allow us to judge the results objectively.
To date no such validation exists in assessing spinal training. I would hope that in the future both Neuro and Ortho can agree on a spine curriculum (like Plastic Surgery and Orthopaedics have in Hand Surgery) and eventually a certificate of competency/specialist exit exam in spinal surgery. I believe that our spinal societies have an important role to play in this development.
The Presidents travelling fellowship allows senior Orthopaedic and Neurosurgical trainee/junior consultants to travel to different spinal centres to observe spinal practice, engage in discussion, observe spinal techniques, ask questions and most importantly have open discussion amongst themselves about what they have seen. Last year these 5 young surgeons were exposed to over 50 Consultant spinal surgeons in 2 weeks giving them not only a huge breath of experience but also the opportunity to network and establish contacts with whom to share opinions about difficult and challenging spinal cases they may in future be involved in.
This fellowship also gives each centre an opportunity to validate their surgical practise. It is hoped that in the future established consultants will also travel to other centres to observe and give opinion therefore contributing towards validation in a very practical sense. In time I would hope every spinal centre is able to host the president’s fellowship.
This year BASS and BSS have extended an invitation to the Indian Spine Society to nominate a fellow to accompany this year's travelling fellowship. Our aim is to extend this invitation to different countries each year to improve learning.
With our members support I am optimistic that the travelling fellowship will continue to evolve and be a focus of learning to all.
Spinal fellow’s Report 2013
H.A. Anwar, S.A.C. Morris, V. Ellwell, N. Furtado, J. Panchmatia
An initiative of the British Association of Spinal Surgeons (BASS) with the British Scoliosis Society (BSS) led to the development of a travelling spinal fellowship in the United Kingdom in 2013. A competitive application system was open to all senior spinal trainees and judged by a panel with representatives from both spinal societies. Five senior spinal trainees were appointed to the fellowship on the basis of this process (three orthopaedic and two neurosurgical) and the results were announced at the BASS annual academic meeting in 2013.
The programme included five major spinal units in the UK over a 2-week period with access to spinal outpatient clinics, operating theatres, regional spinal meetings and local symposia. An award of £1,000 per person was available to each fellow and travel arrangements were made as a group. At some centres, the attending consultants hosted the fellows at their homes.
The fellows were in touch by e-mail to arrange the travel arrangements, which allowed them to get to know each other before the fellowship (Fig. 1).
Fig. 1.
The Fellows—Stephen Morris, Navin Furtado, Vivian Elwell, Jaykar Panchmatia, Hanny Anwar
Week 1
- Frenchay Hospital, Bristol (2 days):
- Mr John Hutchinson (Orthopaedic Spinal Surgeon)
- Mr Ian Nelson (Orthopaedic Spinal Surgeon)
- Mr Ian Harding (Orthopaedic Spinal Surgeon)
- Mr Michael Katsimihas (Orthopaedic Spinal Surgeon).
- Mr Richard Edwards (Neurosurgical Spinal Surgeon)
- Mr Crispin Wigfield (Neurosurgical Spinal Surgeon)
- Mr Ian Pople (Neurosurgical Spinal Surgeon)
- Mr Maurice Paterson (Orthopaedic Spinal Surgeon, Royal United Hospital, Bath)
We commenced our travels at Frenchay Hospital, Bristol, and were treated to an excellent educational programme, delivered by both the orthopaedic and neurosurgical spinal surgeons. Operative cases included a long posterior stabilisation for multilevel lumbar osteomyelitis, percutaneous fracture stabilisation, trans-foraminal lumbar interbody fusion, selective dorsal rhizotomy, and spinal cord untethering. Small group discussions gave us the opportunity to examine the theory and evidence behind many spinal conditions and procedures, including sagittal balance, cervical disc replacement, odontoidectomy and reconstruction, and key spinal research papers.
After 2 days of intensive discussions and demonstrations, we were invited to an evening dinner with the South West Spine Club and 30 spinal consultants from around the region travelled to join us. We took the opportunity to present some of our personal research before a lively debate on current spinal technologies ensued. Later that evening, we travelled down to Exeter with the Exeter spinal surgeons and stayed with them overnight.
- Royal Devon and Exeter Hospital, Exeter (1 day):
- Mr Daniel Chan (Orthopaedic Spinal Surgeon)
- Mr Mike Hutton (Orthopaedic Spinal Surgeon)
- Mr Andrew Clarke (Orthopaedic Spinal Surgeon)
Following excellent hospitality from the consultants’ families, we arrived at the RD + E hospital, Exeter. We were treated to an anterior lumbar spinal surgery spectacular with four anterior lumbar interbody fusions and one lumbar disc replacement in two concurrent theatre lists. This gave the opportunity to discuss indications for these procedures and tips for anterior approaches, as well as discussing use of SPECT CT imaging and the potential complications in adult deformity surgery.
- The John Radcliffe Hospital, Oxford (2 days):
- Professor Jeremy Fairbank (Orthopaedic Spinal Surgeon)
- Mr Colin Nnadi (Orthopaedic Spinal Surgeon)
- Mr James Wilson-MacDonald (Orthopaedic Spinal Surgeon)
- Mr Jeremy Reynolds (Orthopaedic Spinal Surgeon)
The final 2 days of the first week were spent at the Nuffield Orthopaedic Centre and the John Radcliffe Hospital. The departmental multidisciplinary team meeting was observed before discussing the management of spinal bone tumours. We also attended a research meeting and paediatric spinal clinic. Operative cases involved posterior stabilisation of a cervical metastasis and posterior scoliosis fusion for neuromuscular scoliosis.
Of particular interest were the purpose built facilities and the advantages of having a high density of academics working alongside a clinical unit. This allows a high standard of basic science and clinical research to be performed with the expertise and resources to support the work. There was also further evidence that spinal surgery in the UK is increasingly becoming an independent specialty, requiring spinal out-of-hours cover.
After lunch, the fellows had the opportunity to debrief for that week and look into travel and accommodation arrangements for the following week.
Week 2
- Addenbrooke’s University Hospital, Cambridge (2 days):
- Mr John Crawford (Orthopaedic Spinal Surgeon)
- Mr Doug Hayes (Orthopaedic Spinal Surgeon)
- Mr Rodney Laing (Neurosurgical Spinal Surgeon)
- Mr Ricky Trivedi (Neurosurgical Spinal Surgeon)
Week 2 began on early on Monday morning at Addenbrooke’s with a tour of the spinal services and theatres. Two operating theatres were operating that day, an orthopaedic spinal theatre and a neurosurgical spinal theatre. The fellows were split into two groups and alternated between theatres where there were excellent opportunities for clinical discussions with consultants.
Of particular note were the efforts that had been made to streamline the pathway for deformity patients through to surgery and the multidisciplinary approach in complex patients. This involved paediatricians, respiratory physicians, anaesthetists, radiologists and surgeons to ensure that the appropriate assessments were undertaken in a timely manner and the patients were discussed at an MDT with all the necessary information and specialists to make decisions. It was also an example of a close relationship between neurosurgical and orthopaedic spinal surgeons in one unit, and the benefits that both sets of surgeons could gain by a close working relationship. Cambridge is also an example of a unit that has moved towards two consultant operating for spinal deformity cases.
We were joined that evening by the East Anglia Spine Club (Cambridge, Norwich and Ipswich) for dinner. The following morning a meeting of the East Anglia Spine Club was arranged. This consisted of several symposia detailing the challenges facing spinal surgeons in the UK both clinically and with the changing face of the NHS, particularly regarding clinical commissioning. Interesting and difficult cases were discussed and there was some debate regarding the surgical treatment of back pain. Following the meeting we travelled to Norwich.
- The Norfolk and Norwich University Hospital NHS Trust (1 day):
- Mr Robert Crawford (Orthopaedic Spinal Surgeon)
- Mr Am Rai (Orthopaedic Spinal Surgeon)
- Mr Lennel Lutchman (Orthopaedic Spinal Surgeon)
On a sunny afternoon in Norwich we were greeted at Mr. Rai’s house for drinks and cricket, followed by dinner in Norwich. The following morning the fellows were divided to two parallel operating lists and participated in the cases. Demonstrations of cervico-thoracic osteotomy, reduction and fixation of Grade 3 lytic spondylolisthesis and anterior cervical surgery were performed with tips and tricks from the surgeons.
Norwich was a closely knit spinal unit and the three spinal consultants there worked very closely together. There was a further example of two consultants operating for a complex spinal deformity case and the facilities were impressive. We debated the benefits of cervical disc replacement and after a busy day in theatre, the fellows travelled to London.
- The National Hospital for Neurology and Neurosurgery, Queen Square (2 days):
- Mr Adrian Casey (Neurosurgical Spinal Surgeon)
- Mr James Allibone (Neurosurgical Spinal Surgeon)
On Thursday we were greeted at Queen Square and, again, two operating theatres were simultaneously running. We gained an insight to intradural tumour resection, minimally invasive surgery on thoracic disc prolapse and open mouth surgery on the craniocervical junction augmented with computer-aided navigation demonstrated continued innovation in these homegrown procedures.
The spinal service at Queen Square operates within a highly specialised hospital dedicated to excellence in the treatment of neurosurgical conditions. The neurosurgical intensive care and high dependency unit were adjacent to the operating theatres.
Our second day included a complex spine clinic, which invited spinal surgeons (orthopaedic and neurosurgical) from across the region to discuss specially invited complex spinal cases. There were lectures on current and ongoing research by a selection of eminent spinal surgeons including a further discussion on the treatment of back pain. There was also a symposium of difficult cases and the opportunity to discuss practice with senior spinal surgeons from across the region.
The day culminated with dinner in central London, final presentations and debriefing on the 2-week fellowship.
Highlights and reflections
As the travelling fellows lived and travelled together for the duration of the fellowship, close friendships were formed, even between neurosurgeons and orthopaedic surgeons! This has allowed the fellows to develop personal and professional networks that will be valuable for the future. The involvement of regional spinal network groups in the discussions was a excellent source of education and benefitted all involved.
The fellows gained an intense snapshot at the provision of spinal services across southern England, the differences in patient pathways, and the progression towards centralisation of spinal services as an independent specialty. With this came the chance to get to know spinal surgeons from different parts of the country, which might have been difficult to achieve otherwise.
This overview of the practice at multiple centres will enable the fellows to build on what all of these centres have already achieved, in their own practice in the future and hopefully bring together best practice from different parts of the United Kingdom (Fig. 2).
Fig. 2.
Dinner with the East Anglia Spine Group
The future
The second BASS/BSS travelling fellowship will take place in 2014. It will undoubtedly present a similarly enlightening experience advancing personal and professional development. It is available to senior orthopaedic and neurosurgical trainees, and offers a fantastic opportunity to see how the two disciplines can work together to maximise professional and patient satisfaction. It is planned that the fellows will visit a number of different units throughout the country over the next few years and there is also the potential for consultants to travel with the fellows to maximise learning opportunities.
Conflict of interest
None.