Which Type of Spine Surgeon Should You Refer To: Ortho or Neuro?

When a patient needs spine surgery, it can be hard to know whether to refer to a neurological spine surgeon or an orthopedic spine surgeon. We touched base with a surgeon in each area – Elliot Min, MD, (neurosurgeon) and Mark Freeborn, MD, (orthopedic spine surgeon) – for a Q&A to understand the differences in their expertise, and to get their take on when to refer to one versus the other.

What are the differences in how the two types of surgeons are trained?  

The differences are pretty subtle. Medicine has migrated increasingly toward niche subspecialties and that’s certainly true for spine surgery.

In orthopedics, there is now a very specialized training program for spine surgery and it involves completing all of your training for orthopedic surgery first and then doing an additional year of subspecialty training just in advanced spine surgery. That means an orthopedic spine surgeon has completed a residency where they've become a general orthopedic surgeon, and part of that is spine training, and then they've spent an extra year just focused on spine. These are folks that typically practice only spine surgery, all day every day. They take care of complex spine conditions and do a wide variety of surgeries – things like tumor surgery, fracture surgery and surgery for disc herniations, both open and minimally invasive.

Neurosurgery has gone down the same path. A general neurosurgeon who graduated from a residency program has very capable training in all different aspects of neurosurgery. That training includes basic and, sometimes, advanced spine surgery. Many neurosurgeons also choose to pursue spine fellowships as well for additional training.

So an orthopedic spine surgeon and a neurological spine surgeon have about 90% of the same skillset. For nine out of 10 spine surgical needs, as long as you go to a surgeon who specializes in spine, there really isn't a lot of difference in their capabilities. But there are still some instances when you’d be better off referring to one than the other.

When exactly should you refer to a neuro spine surgeon versus an ortho spine surgeon, or vice versa?

Neuro spine surgeons have advanced training in taking care of the actual spinal cord. If there’s an intradural tumor, that’s the type problem that you would want to see a neuro spine surgeon for. This requires micro surgery to remove a tumor that is stuck to nerves or within the spinal cord. That’s not something orthopedic surgeons are trained on.

And there are some cases where an ortho spine surgeon would have unique strengths. People with a significant structural problem might require complex reconstructive surgery that would be more bread-and-butter for an orthopedic surgeon, who has advanced training in spine and scoliosis reconstruction.

Q: Do you have an example of a case that would make you say: This should involve someone in the other subspecialty?

Dr. Freeborn: Absolutely. There’s a diagnosis called a schwannoma that can involve an encroachment of a tumor both out on the peripheral nerves and also into the actual spinal canal. Here at the Eastside Neuroscience Institute, that’s a surgery we do with a combined approach. So you would have an orthopedic spine surgeon like me do the reconstructive part of the procedure, and I would partner with Dr. Min or one of his colleagues. They would actually open up the covering in the spinal cord and tease the tumor off of it and out off of the peripheral nerves. Those aren’t uncommon and we find ourselves frequently operating with our partners, because they have the ultra-specialized training and experience that we talked about earlier.

Q: What are two rules of thumb that a provider should use to guide their decision on which type of surgeon to refer to?

Rule one is: Go to a spine surgeon. Whether they’re ortho or neuro, refer your patients to somebody who focuses their practice on spine surgery, because it’s proven that outcomes are better when surgery is performed by somebody who does that type of procedure day in and day out.

For rule two, find a provider who’s collaborative and practices in a multidisciplinary environment. In our building, we have neurosurgeons that specialize in spine, neurosurgeons that specialize in brain, orthopedic spine surgeons, physiatrists, neurologists, rehab medicine physicians, physical therapists, occupational therapists and speech therapists. We all work together to provide a multidisciplinary, one-stop shop for spinal care.

When one of us sees a patient that isn’t the best fit for our skillset, it’s part of our culture to very quickly to say, “You know what? One of my colleagues does this type of procedure better than I do, so this patient should actually go see them.” And we can walk down the hall and hand that doctor a sticky note or go through a case with them. There are a number of occasions every month where one of us sees a patient in clinic and says “You know what? Hang on one second.” We walk down the hallway, grab one of our partners, go through the pictures with them and actually bring that doctor into the room to meet that patient so that patient knows they’re going to have a seamless transition of their care.

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