Training pathways for nonoperative spine physicians differ substantially from those of spine surgeons and vary considerably among medical specialties. For the purposes of this position statement, the term “nonoperative spine specialist” refers to physicians whose formal residency and/or fellowship training includes the evaluation and treatment of spinal, musculoskeletal, neurologic, or pain disorders, including training in image-guided interventions when applicable. This term does not include physicians whose formal residency and fellowship training is unrelated to these areas and who acquire spine procedural skills primarily through isolated courses or industry-sponsored training. The training pathways of nonoperative spine specialists are summarized below:

At the time of this statement, none of the nationally recognized education and training pathways for nonoperative spine specialties have minimum required case volumes across the spectrum of advanced spine interventions comparable to those specified within accredited surgical spine training pathways.

Specifically, outside of established surgical training requirements, there are no standardized procedure-specific minimum case requirements across the spectrum of current and emerging spine interventions, including neural decompression, spinal fusion, sacroiliac joint fusion, basivertebral nerve ablation, vertebral augmentation, and endoscopic spine interventions. Additional education in newer technologies is frequently obtained through society-sponsored or industry-sponsored procedure-specific courses. The North American Neuromodulation Society (NANS) recognized the need for standardized education in spinal cord stimulation and developed a competency-based curriculum incorporating milestones to guide physician training from early learner to practitioner.9 Likewise, the American Society of Pain and Neuroscience (ASPN) has taken important steps toward developing a structured educational pathway for physicians interested in advanced spine procedures by expanding didactic education and competency-based curricula.

The absence of nationally standardized educational requirements and minimum procedural experience for many current and emerging spine interventions underscores the need for competency-based recommendations that can guide physician education, hospital/ambulatory surgery center credentialing, and ultimately promote patient safety.

Procedures involving direct decompression of spinal nerve root(s) and/or the spinal cord, whether performed through traditional open techniques, minimally invasive approaches, or endoscopic techniques, require comprehensive knowledge of spinal anatomy, surgical decision-making, and the independent management of neurologic injury, dural tears, postoperative instability, infection, and revision surgery. Direct decompression of nerve root(s) and/or the spinal cord should be performed only by surgeons with formal surgical spine training. Surgeons performing endoscopic spine surgery should complete dedicated education and supervised training specific to endoscopic techniques before independently performing these procedures.

The Task Force recognizes that endoscopic spinal medial/lateral branch neurectomy for axial joint denervation is fundamentally different from endoscopic decompression of the nerve root(s) and/or spinal cord. Accordingly, competency requirements for these procedures should be considered separately.

Nonoperative spine specialists performing endoscopic medial or lateral branch neurectomy should complete additional procedure-specific training that includes defined competency standards and minimum supervised case requirements or complete a formal interventional spine fellowship that incorporates training in these techniques, before performing these procedures independently. All physicians performing endoscopic medial or lateral branch neurectomy should have the education, training, and supervised procedural experience necessary to recognize and independently manage the full spectrum of potential complications or have an established relationship with a surgeon partner or surgical team capable of providing definitive management when necessary. Such arrangements should be established and in place prior to offering these procedures to patients.

Interventions intended to achieve spinal fusion or permanent stabilization, including lumbar facet fusion, interspinous fusion, and other interventions that permanently alter spinal biomechanics, require competency beyond the technical performance of the intervention. This includes an understanding of spinal biomechanics, fusion biology, appropriate patient selection, implant and instrumentation selection, complication management, and strategies to avoid and manage revision surgery. Based on current education and training pathways, fusion of any motion segment of the spine should be performed only by physicians who have completed formal surgical spine training.

Importantly, spinal fusion is fundamentally a biological process, regardless of whether instrumentation is used. Successful arthrodesis depends not only on implant placement but also on a thorough understanding of fusion bed preparation, graft selection, optimization of the local biological environment, and the technical principles required to achieve reliable osseous union.

Finally, clinicians should critically evaluate the scientific evidence and base treatment decisions on the highest-quality data. Particular attention should be given to published evidence regarding long-term fusion rates and patient-reported clinical outcomes for stand-alone fusion techniques, particularly those utilizing interspinous devices when performed without interbody fusion.

Historically, vertebral augmentation procedures primarily involved injection of polymethylmethacrylate (PMMA) cement or bone graft substitutes without implantation of structural devices. More recently, vertebral augmentation techniques utilizing structural implants, including metallic vertebral body or intrapedicular devices, have become increasingly available. Because such implants may alter vertebral anatomy, interfere with future instrumentation, or limit reconstructive surgical options such as pedicle screw fixation or vertebrectomy, vertebral augmentation involving structural implants or hardware beyond injected cement or bone graft substitutes should be performed only by physicians with formal surgical spine training.

Basivertebral nerve ablation, spinal bone tumor ablation, image-guided intervertebral disc access for diagnostic or therapeutic indications, percutaneous spinal cord, dorsal root ganglion, and peripheral nerve stimulation, and other image-guided percutaneous spine interventions encompass a broad range of complexity and potential complications.

Current practice supports that these interventions do not require formal surgical spine training but do require appropriate procedure-specific competency. Competency should be established through procedure-specific education and training, supervised clinical experience, objective competency assessment, and documented procedural experience, with minimum case requirements appropriate to the complexity and risk of each intervention.

Placement of spinal cord stimulation paddle leads, as distinguished from wire leads, within the epidural space should be restricted to physicians with formal surgical spine training, regardless of whether placement is performed through an open or percutaneous approach. Paddle lead placement requires epidural dissection and competency in the recognition and management of spinal cord injury, dural injury, epidural hematoma, and other procedure-specific complications.

Surgeons performing these or other interventions outside the scope of their residency and fellowship training should obtain appropriate procedure-specific education and supervised experience and demonstrate competency before performing these interventions independently.

There has been a rapid expansion of emerging spine interventions, many of which are less invasive and therefore may be particularly attractive to patients. As the adoption and utilization of these interventions increase, their use may outpace the development of evidence regarding safety, efficacy, durability, and long-term outcomes. For some interventions, important questions may remain regarding complications, reinterventions, and the potential implications for subsequent surgical treatment.

Prospective clinical registries can play an important role as new spine interventions are introduced and more broadly adopted. While established national registries exist for surgical spine care, comparable registry infrastructure is not currently available for many emerging procedural spine interventions.

NASS encourages professional societies and industry partners to support the development of and participation in prospective registries for emerging spine interventions, with independent oversight and standardized collection and reporting of patient selection, patient-reported outcomes, complications, reinterventions, and long-term durability. Such registries can provide transparent, real-world evidence to help ensure that expanding utilization is accompanied by ongoing evaluation of safety and clinical effectiveness.

Until the safety, efficacy, complications, and long-term consequences of these interventions are better characterized, NASS believes there is insufficient evidence to determine the training and procedural experience necessary to perform them safely and effectively. Where appropriate, outcomes should be stratified by physician training background, credentialing pathway, and site of service to identify factors that may influence patient safety and clinical outcomes.

Physicians performing advanced spine interventions should maintain formal agreements with an appropriate physician, surgeon, physician group, or facility when management of a reasonably foreseeable procedure-specific complication falls outside their training or scope of independent practice.

Such arrangements should be established prior to performing the intervention and documented at the time of credentialing and privileging. In settings without a formal credentialing or privileging body, including physician offices, these agreements should nonetheless be formally documented and maintained. These arrangements should address emergent communication, availability, coverage, and logistics for transfer of care, and should be reviewed at regular intervals. Informal or ad hoc referral relationships should not be considered a sufficient complication management plan.

The Task Force believes that minimum case requirements should be established for spine interventions requiring procedural or surgical competency, whether training occurs during residency, fellowship, or through structured post-fellowship education and training. These requirements should be met before physicians perform such interventions independently.

Attendance at educational courses alone, in the absence of structured clinical training and a defined minimum number of supervised clinical experiences with the intervention, should not be considered sufficient evidence of competency for independent performance.

Accordingly, NASS believes that hospitals, ambulatory surgery centers, and credentialing committees should establish privileging criteria based upon complexity of the procedure, the physician's formal education, supervised procedural experience, objective competency assessment, documented case experience, and demonstrated ability to independently recognize and manage procedure-specific complications or identify a collaborating surgeon/surgical team who is willing and able to aid in managing procedure-specific complications.

Professional societies have a responsibility to provide leadership in physician self-regulation and to establish standards that prioritize patient safety and high-quality care. These standards should be developed through rigorous evaluation of the scientific evidence and expert consensus, rather than being defined solely by industry, hospitals, payors, or regulatory agencies.

Multidisciplinary collaboration remains essential to achieving these goals. NASS remains dedicated to working with any society committed to continued dialogue and cooperation to advance evidence-based standards, improve patient outcomes, and ensure that innovation is accompanied by appropriate education and accountability.

Brian W. Su, MD, Chair Karin R. Swartz, MD Pierce D. Nunley, MD Christopher P. Kauffman, MD Edward J. Dohring, MD Alan S. Hilibrand, MD Kevin E. Macadaeg, MD Heidi M. Hullinger, MD D.J. Kennedy, MD Zoher Ghogawala, MD, FACS William Mitchell, MD

For more information and/or questions, please contact Karen James, Senior Mgr. of Health Policy.

Endorsed by the: Cervical Research Spine Society https://www.spine.org/Practice/Scientific-Policy-Comments/Education-Training-Competency-Spine-Interventions