spine

[jeesapeesa]

MSI here. I tried doing a search for spine surgery and it spit out some results on ortho vs neuro spine. I'm very interested in orthopedic spine (deformities,etc) and I would someday love to do a fellowship; I would just like to ask:

-hours? daily routine (if any)?
-quality of life (for the doc)?
-future outlook for the subspecialty?

If anybody can give some input or post a link to previous posts it would be great. Good day.

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[PediBoneDoc]

well jeesapeesa, there some historical differences between neuro and ortho spine. historically, ortho did the fusions and neuro did the decompressions. in some hospitals and residencies that is still the case. typically, neuro sees more stenosis and nerve compression problems and ortho sees more back pain. those lines have significantly blurred in past 10 years or so. the one thing that has not changes, a majority of deformity work is done by orthopaedic surgeons. deformity can be split into pediatric and adult. therefore you again may do deformities being pediatric trained or adult trained. there was a previous thread (ortho vs neuro spine http://forums.studentdoctor.net/showthread.php?t=373826)

so, to answer some of you questions
-hours? daily routine (if any)?
>>normal hours for most. it depends on the trauma situation at the hospital or hospitals you cover. we take spine trauma call 1 week at a time. (level 1 trauma center, high volume trauma, but very few nighttime surgeries)

-quality of life (for the doc)?
>>life style depends on the practice and not so much the subspecialty. if you are the only person or 1 of a couple, you will be busy and maybe even overworked. if you are 1 of a few, the life is better. most neurosurgeons when the complete residency will do some spine because it pays the bills and (they tell me) it helps the do what they love but doesn't pay well, brain surgery. in orthopaedics, most do a fellowship unless they had a high volume in residency; this is because of malpractice issues. when you add spine to your malpractice it significantly increases (sometimes doubles). now depending on interests, you can go through the pediatrics route if you are interested primarily in deformity (a majority of deformity is in children. scoliosis, kyphosis, congenital scloli); or you can go through straight spine route, where your experience varies based on the fellowsip.

-future outlook for the subspecialty?
>>as for most things, reimbursement will most likely go down. they are already restricting implant choices in hospitals because of cost. (1 pedicle screw cost between $600-1200 depending on company and type of screw) the specialty is a growing specialty, they question is when will the reimbursements decrease enough for it to be malpractice cost prohibitive. there are many things in the horizon that may be wonderful inventions or disasters (fusionless surgery and total disc replacements)

i hope this helps. if you are in medical school now, look at the residents and attendings and see who's personality fits more with you personality.

hope that helps

pedi out

 

[Tired]

Now that we have an attending floating around, I finally can start asking the questions I could never float in person:

Every sub-i I did this year had a couple of big spine cases. And in every one I was bored senseless. Granted, none of the attendings were going to let a med student play around with some kid's spine, and most of the cases were double-attending jobs, futher marginalizing my already non-existent role. It's not suprising that standing over a field for 7+ hours with nary a retractor to hold would put me to sleep.

I was wondering, are these cases any fun to do when you're actually doing something? Do you actually enjoy placing dozens of pedicle screws for hours on end? Honestly, the whole process, while complex with small margins for error, seemed a little dull. But then again, I thought carpal tunnel releases were kind of boring too until a very nice hand surgeon let me do one start to finish.

It's late, so long lead-in to a simple question: Do actually like spine, or do you do the cases because you have to?

 

[PediBoneDoc]

Now that we have an attending floating around, I finally can start asking the questions I could never float in person:

Every sub-i I did this year had a couple of big spine cases. And in every one I was bored senseless. Granted, none of the attendings were going to let a med student play around with some kid's spine, and most of the cases were double-attending jobs, futher marginalizing my already non-existent role. It's not suprising that standing over a field for 7+ hours with nary a retractor to hold would put me to sleep.

I was wondering, are these cases any fun to do when you're actually doing something? Do you actually enjoy placing dozens of pedicle screws for hours on end? Honestly, the whole process, while complex with small margins for error, seemed a little dull. But then again, I thought carpal tunnel releases were kind of boring too until a very nice hand surgeon let me do one start to finish.

It's late, so long lead-in to a simple question: Do actually like spine, or do you do the cases because you have to?

well young dr. tired, i don't know if i should answer this questions because last tie you referred to me you hurt my feelings .... not (lol ... that still cracks me up, thank you borat for bringing back the not joke).

you know, i enjoy pretty much everything i do right now. i am a pedipod, so the variation in the procedures i do is wonderful. everyday, there is something different. if i only did single level fusions, discectomies, and laminectomies, i think i would get bored.

as you progress through your career, you perspective will significantly change. as a med student, everything is new and exciting but you don't ge to do much; as a resident, you do more and some things become more exciting than others not so much. in surgery, there are "Big" cases and there are little cases. you have to figure out if you are a big case surgeon or a little case surgeon. if you enjoy challenges and can endure the long cases, then that is what you do; you you like to know exactly whant to expect day in and say out, then that is what you do.

spine is a upperlevel resident rotation. the concepts are difficult to grasp and the 3-d anatomy and risk are daunting. so as a med stud, those cases are never fun. even as a lower level residentm never fun. as a resident in a double attending case, that is adult swim and all kids need to get out of the pool (do rock paper scissors to see who scubs that one).

so this is a very long winded way of saying, i love what i do. scoli season is coming up and i have many 8 - 12 hour surgeries schedule and a couple adult swim cases. i am looking forward to them now, but it is kind of like when i am getting ready for a marathon, i look forward to it and then when i am about 16 miles into it i think to myself "why the hell do i do this?" in the end, i am always glad that i did it and look forward to the next one.

 

[naegleria brain]

at my school, ortho and neuro spines work together. that means even ortho-spine guys are removing tumors and neuro spine guys are putting in the heavy metal.

it appears the mentality of neuro spine goes inside the thecal sac and ortho does reconstructive is falling apart. the neuro-spine fellow did an arthroplasty with the ortho-spine attending.

but if this isnt the trend nationwide, neurospines probably have nerves, schwannomas, tumors, etc. pinned whereas orthos would get the sweet scoli's. orthos dont go in the thecal sac, neuros do. but i have yet to see a neuro spine guy say "that's ortho". i HAVE seen ortho guys say "thats neuro". but this wasnt at my school where they were integrated. i strongly feel they soon will become one and the same

in terms of hours/lifestyle, the attendings work very very hard. insurance reaches 200 grand a year, so theyre anal about everything. they are married and have kids nevertheless

in terms of salary, they are the highest paid, and my guess theyll continue to be for a while longer when all the baby boomers start getting back trouble

ortho is 5 years. you'll need a spine fellowship, making it 6-7. neuro is 6-7 yr residency, with no fellowship needed for spine (you'll get plenty training along the way)

so, until you get there, would you rather do hip replacements, or clips and coils?

 

[PediBoneDoc]

at my school, ortho and neuro spines work together. that means even ortho-spine guys are removing tumors and neuro spine guys are putting in the heavy metal.

it appears the mentality of neuro spine goes inside the thecal sac and ortho does reconstructive is falling apart. the neuro-spine fellow did an arthroplasty with the ortho-spine attending.

but if this isnt the trend nationwide, neurospines probably have nerves, schwannomas, tumors, etc. pinned whereas orthos would get the sweet scoli's. orthos dont go in the thecal sac, neuros do. but i have yet to see a neuro spine guy say "that's ortho". i HAVE seen ortho guys say "thats neuro". but this wasnt at my school where they were integrated. i strongly feel they soon will become one and the same

in terms of hours/lifestyle, the attendings work very very hard. insurance reaches 200 grand a year, so theyre anal about everything. they are married and have kids nevertheless

in terms of salary, they are the highest paid, and my guess theyll continue to be for a while longer when all the baby boomers start getting back trouble

ortho is 5 years. you'll need a spine fellowship, making it 6-7. neuro is 6-7 yr residency, with no fellowship needed for spine (you'll get plenty training along the way)

so, until you get there, would you rather do hip replacements, or clips and coils?

i would have to agree with naegleria brain it is more difficult to separate out spine trained surgeons both ortho and neuro.

i can say that in general most neuro surgeons do at least some spine where as many orthopaedic surgeons do not unless they have a great residency training or a fellowship.

i will also say that one clear separation between neuro and ortho is who does deformity. deformity is mainly done by orthopaedic surgeons. at all of the deformity meetings i have been to, i have only met 2 neurosurgeons attending the courses.

another separation is the base of the skull, fusions to the base of the skull, chiari malformations, odontoid resections, these are generally done by the neurosugeons.

the last thing i will say is that the division of who does what depends on the culture of your hospital or area. whoever was dominant in the spine arena will maintain dominance based on history. i think this has to do a lot with egos. we work very well with our neurosurgeons. in some academic centers, there is fighting between departments and turf wars; some have a very cordial relationship. in my experience, we have separate strengths based on our basis of training; we can learn a lot from one another. working together only makes you a better surgeon. everyday is a school day

 

[Tired]

well young dr. tired, i don't know if i should answer this questions because last tie you referred to me you hurt my feelings .... not (lol ... that still cracks me up, thank you borat for bringing back the not joke).

Yes, I had forgotten the "not" joke until I saw the film. Hadn't used that one in 10-15 years.

I knew you wouldn't be upset, I mean hell, we're not those touchy Medicine guys . . .

I like the "young Dr. Tired". In a month when I graduate I'm making that my SDN sig.

Thanks for the perspective.

 

[PediBoneDoc]

Yes, I had forgotten the "not" joke until I saw the film. Hadn't used that one in 10-15 years.

I knew you wouldn't be upset, I mean hell, we're not those touchy Medicine guys . . .

I like the "young Dr. Tired". In a month when I graduate I'm making that my SDN sig.

Thanks for the perspective.

well i had to get you back some kinda way. that was what one of my old attendings use to say when she wanted to put us in our little place. it is a great way of establishing dominance . just jokes

 

[Tired]

well i had to get you back some kinda way. that was what one of my old attendings use to say when she wanted to put us in our little place. it is a great way of establishing dominance . just jokes

Now that I think about it, I had a Shiner's doc a few years back who used to refer to her residents as "the young doctors". At first I thought it was kind of funny, but then I realized how good it was for the patients. That way the attending could establish that they were overseeing the case, but also made it clear that the resident was still a surgeon. After all, outside this little cloistered world are a whole bunch of patients who only vaguely understand the difference between the multitude of docs who walk in their room every day.

 

[PediBoneDoc]

Now that I think about it, I had a Shiner's doc a few years back who used to refer to her residents as "the young doctors". At first I thought it was kind of funny, but then I realized how good it was for the patients. That way the attending could establish that they were overseeing the case, but also made it clear that the resident was still a surgeon. After all, outside this little cloistered world are a whole bunch of patients who only vaguely understand the difference between the multitude of docs who walk in their room every day.

this is a little off the topic ... but, oh well

you are right. when said around patients, it does establish a hierarchy. it lets the patients know who has ultimate say. it is a way of giving patients some comfort. many patients do not like going to a university hospital or one with a lot of residents because they don't want to be "practiced on". many patients ask, "you (pointing) are doing the surgery right?" and as one of my mentors said, "yes i will be leading the team that does your child's surgery, but i can not do it alone." so in that instance, i think it is a nice way of establishing your place with the patient.

now, on the other hand, when used in speaking directly to a resident or medical student, i think it is very condescending. "now, young dr. tired you need to take a look at the article by suchandsuch from whosawhatsa journal. it obviously says yada yada yada." (looking down my nose).

for me it's just jokes

 

[jeesapeesa]

Thank you all for the replies thus far, they've been quite helpful.

- Have any of you ever seen a botch job, and how bad was it? (spine surgery, paralysis, etc)

- What is the longest case you've ever participated in?

 

[Tired]

Thank you all for the replies thus far, they've been quite helpful.

- Have any of you ever seen a botch job, and how bad was it? (spine surgery, paralysis, etc)

- What is the longest case you've ever participated in?

1) Yes, but I don't have the appropriate experience to describe exactly what happened, so I'll pass on this part.

2) Hardware revision, fusion, further hardware placement in a medically-complicated 5yo. Two day case, total time = 18hrs (11 + 7). Don't ask me what all they ended up doing or why it was so long, because after about 4hrs I just zoned out completely.

 

[PediBoneDoc]

Thank you all for the replies thus far, they've been quite helpful.

- Have any of you ever seen a botch job, and how bad was it? (spine surgery, paralysis, etc)

- What is the longest case you've ever participated in?

botch jobs, use this term loosely. most orthopaedic surgeons (ans neuro surgeons) are smart people. so if you see something questionable, there may be a "story behind it." but, yes i have seen things that brought that brought out the question "what was he thinking?" but, remember we all make mistakes, you don't have god's hands you have human hands, errors are made. some error are errors of judgment, and others just unfortunate circumstances.

longest case, anytime you see anterior and posterior surgery scheduled, it is always a long day. if you see "front back front", eat your wheatiest longest case i have ever done start 730 am finish 12am (single day surgery) front back front surgery. those days there are breaks. so it isn't as bad as it sounds, but it is still long.

 

[jeesapeesa]

I meant due to unforseen circumstances, of course. Someone mentioned that the margin of error must be at the minimum (spinal cord) so I wonder how often errors are made and how bad it can get.

 

[PediBoneDoc]

I meant due to unforseen circumstances, of course. Someone mentioned that the margin of error must be at the minimum (spinal cord) so I wonder how often errors are made and how bad it can get.

the margin for error in spine is actually better than you think. you can "get away with" than you think (i use that term loosely because you should never try to get away with something). the problem is that if you make a mistake around the cord, it can be permanent. paralysis is a bad complication. just write the check now, at fault or not.

i have several kids in my practice who have had unfortunate events. one was paralyzed by a LP. so it happens.

i am going to say something that on these forums will be unpopular, but it is true. people concentrate on the 80 hour work week and attendings not caring etc. i think yeah yeah yeah. they also complain about attending being malignant and why do they have to yell and throw and curse. why can't they give us more freedom. well, for me, i am pretty happy in the OR, am loose. i let the residents struggle (because that is important for their problem solving). i let med students sew and put in screws. the only time i am serious is around the cord. it is the only time that i am strict about how things are done; it is the only time i will ask the nurses to stop talking about their up coming weekend; i ask the music to be turned down; and i become an dingus. i may even yell at the resident if he should make an error. why? because if that child is paralyzed, it is my fault. i am ultimately responsible. i will have to live with that consequence. so residents know with me, over the spine, everything is a 2 handed instrument, we always pay attention to the field and proceed with caution. this is not child’s play folks

Son we live in a world that has walls, and those walls have to be guarded by men with guns. Whose gonna do it? You? You, Lt. Weinburg? I have a greater responsibility than you could possibly fathom. You weep for Santiago, and you curse the marines. You have that luxury. You have the luxury of not knowing what I know. That Santiago's death, while tragic, probably saved lives. And my existence, while grotesque and incomprehensible to you, saves lives. You don't want the truth because deep down in places you don't talk about at parties, you want hat wall, you need me on that wall. We use words like honor, code, loyalty. We use these words as the backbone of a life spent defending something. You use them as a punchline. I have neither the time nor the inclination to explain myself to a man who rises and sleeps under the blanket of the very freedom that I provide, and then questions the manner in which I provide it. I would rather you just said thank you, and went on your way, Otherwise, I suggest you pick up a weapon, and stand a post. Either way, I don't give a damn what you think you are entitled to.

 

[jeesapeesa]

Any comments on where the top fellowship programs in spine may be found?

 

[Bull's eye]

the margin for error in spine is actually better than you think. you can "get away with" than you think (i use that term loosely because you should never try to get away with something). the problem is that if you make a mistake around the cord, it can be permanent. paralysis is a bad complication. just write the check now, at fault or not.

i have several kids in my practice who have had unfortunate events. one was paralyzed by a LP. so it happens.

i am going to say something that on these forums will be unpopular, but it is true. people concentrate on the 80 hour work week and attendings not caring etc. i think yeah yeah yeah. they also complain about attending being malignant and why do they have to yell and throw and curse. why can't they give us more freedom. well, for me, i am pretty happy in the OR, am loose. i let the residents struggle (because that is important for their problem solving). i let med students sew and put in screws. the only time i am serious is around the cord. it is the only time that i am strict about how things are done; it is the only time i will ask the nurses to stop talking about their up coming weekend; i ask the music to be turned down; and i become an dingus. i may even yell at the resident if he should make an error. why? because if that child is paralyzed, it is my fault. i am ultimately responsible. i will have to live with that consequence. so residents know with me, over the spine, everything is a 2 handed instrument, we always pay attention to the field and proceed with caution. this is not child's play folks

Yeah Dr. P I thought you were going to strangle me during our posterior fusion the other day(Not because anything that you said just the tension was high in the room). She was so unstable and trying to get those lateral mass screws in was about the most nervous I have been in my residency. Thanks for being cool with me.

 

[PediBoneDoc]

Yeah Dr. P I thought you were going to strangle me during our posterior fusion the other day(Not because anything that you said just the tension was high in the room). She was so unstable and trying to get those lateral mass screws in was about the most nervous I have been in my residency. Thanks for being cool with me.

Bull's eye i wasn't going to strangle you, i was just going eat you 1st and 2nd born just jokes. things can get tense, and not having instruments in you hands can make you even more tense. you know the whole pucker factor increases.

anyway, the top spine fellowships, it is tough to say. the names that are thrown around are thomas jefferson in philadelphia, emory, washington university, rush, case western reserve. all the programs have some sort of weakness. the one thing you need to consider when applying for fellowships is what practice you would lke to have. if you are going into academics, a high power fellowship is important (for connections and networking). if you are going into a private practice, you need to decide what type of spine you will practice (deformity, degen, minimally invasive, osteotomies, c-spine, trauma). you will also want to augment what training you already have. say for our residents, they get a lot of spine trauma; so they don't need that training.

jeesapeesa i would worry about matching into your chosen specialty at this point (neuro or ortho), you may get to the end and realize that spine is not for you. i can tell you that the profit margin for spine will be decreasing over the next 5-10 years. insurance carriers are already cracking down.