Discussion

This study provides a snapshot of the delivery of spinal care at centers with neurosurgery residency programs in Canada, demonstrating a trend toward subspecialization of both personnel and infrastructure (Figure 1). We are also able to summarize the opinions of current program directors regarding the state of spinal subspecialization and its role in neurosurgical residency training, which demonstrates disparate responses, suggesting uncertainty within our field. These findings add a substantial contribution to a rich body of literature exploring both spine education and neurosurgical subspecialization in Canada over the past two decades. ^{Reference Elkaim, Niazi and Tso1,Reference Tso, Findlay, Lownie, Wallace, Toyota and Fleetwood2,Reference Toyota6,Reference Skulsampaopol, Ming and Cusimano12–Reference Dvorak, Collins and Murnaghan15}

Figure 1.

Comparison of spine-specific infrastructure at neurosurgery residency programs in Canada. Data from the current survey are compared with data from a survey released in 2003. ^{Reference Toyota13} Vertical axis represents the percent of all programs for which each feature was reported present.

When comparing the present findings with our 2003 survey, ^{Reference Toyota13} the proportion of faculty members capable of spine instrumentation (simple or comprehensive) has not changed significantly, with a reported 47.5% in the 2003 survey compared to the 50.5% observed in the present survey. However, the proportion of attending neurosurgeons capable of performing comprehensive spine instrumentation has increased, from 19.3% to 29.1%. Therefore, even when considering only neurosurgeons who perform spine instrumentation, a greater proportion are now capable of advanced techniques. This 29.1% figure, representing the proportion of neurosurgery teaching faculty capable of comprehensive spine instrumentation, coincides neatly with a 2006 study ^{Reference Dvorak, Collins and Murnaghan15} which found that 29% of graduating neurosurgery residents in Canada planned on entering a spine fellowship.

In 2017, the Royal College of Physicians and Surgeons of Canada (RCPSC) adopted a competence by design curriculum, which was implemented by neurosurgery residency programs in 2019. ¹⁶ In practice, it shifted resident evaluation to a primarily outcomes-based approach: As a requisite for program completion, each neurosurgery resident in Canada must complete all EPAs as determined by the Neurosurgery Specialty Committee. With respect to the “Core of Discipline” EPAs, which makes up the majority of competencies required for neurosurgery training programs, a summary follows: ¹⁷ Each resident must acquire 41 cranial-specific achievements (30.1% of total), 31 spine-specific achievements (22.8% of total), 8 peripheral nerve achievements (5.9% of total) and 56 other general neurosurgical achievements including those involving CSF disorders (41.2% of total). This suggests a misalignment between training and practice for academic neurosurgeons: While over 20% of the core competencies acquired during residency are spine-specific, half of practicing neurosurgeons at residency programs are not capable of even simple spine instrumentation. Reciprocally, while 30.1% of neurosurgical core competencies are cranial-specific, the spinal neurosurgeons at 35.7% of centers with residency programs do not treat or manage patients with cranial neurosurgical conditions.

This misalignment may result from a differential evolution of academic neurosurgical practice when compared to that of residency education. First, neurosurgeons’ clinical practices at academic centers have narrowed in scope. Our survey shows that all programs now report the presence of dedicated spinal neurosurgeons, and a greater proportion of centers now employ spinal neurosurgeons who restrict their practice to the care of spinal patients only as compared to 2003 (Figure 1). Subspecialization is supported by evolving infrastructure, with dedicated spine programs, call schedules and hospital wards becoming increasingly common. Secondly, the breadth of achievements required during residency training has grown. While achieving competency in simple spine instrumentation was already ubiquitous in neurosurgery residency programs in 2003, training in comprehensive spine instrumentation was only reported in two-thirds of programs. Now, nearly all programs train residents in both simple and comprehensive spine instrumentation (Figure 2). A discrepancy between residency training and academic practice is further supported by the observation that, according to the current standards set out by the RCPSC, all graduating neurosurgery residents are expected to be independently competent in the microsurgical clipping of cerebral aneurysms (EPA C34), the utilization of instrumentation to perform occipital-cervical fusion procedures (EPA C29) and the transnasal resection of pituitary tumors (EPA C40). ¹⁷ We suggest that vanishingly few practicing neurosurgeons at academic centers maintain competency in each of these skills, which are by definition considered basic and to be acquired without additional fellowship training. While clinical practice has evolved to facilitate subspecialization and narrowness of scope, neurosurgical education has not. ^{Reference Toyota6}

Figure 2.

Comparison of neurosurgery program director responses in Canada. Responses from the current survey are compared with summary responses from a survey released in 2003. ^{Reference Toyota13} Vertical axis represents the percent of all programs for which the program director responded “agree” or “strongly agree”.

In 2007, Drs Richard Fessler and Edward Benzel each wrote editorials commenting on the role of spine within neurosurgery, published simultaneously. ^{Reference Fessler18,Reference Benzel19} In his piece, Dr Fessler offered a reflection on the contemporaneous marginalization of spine surgery within neurosurgery and discussed the possibility of spine surgery evolving out of neurosurgery into its own subdiscipline. We had proposed this in our 2003 survey, to which the program directors responded with uniform disagreement. ^{Reference Toyota13} However, in the present study over one third of respondents agree that spine surgery should become its own subspecialty separate from cranial neurosurgery. This may signal a changing climate, more amenable to Dr Fessler’s suggestion.

Dr Benzel offered a more radical prediction, suggesting that continued subspecialization would result in the emergence of a compressed “core curriculum” neurosurgery residency, which would shorten in length to 3 or 4 years. This would be accompanied by the evolution of fellowship programs into subspecialty “residencies.”

Instead of developing a core curriculum to be delivered in a compressed manner with subsequent subspecialized training, as proposed by Dr Benzel, accredited neurosurgical residency training in the United States was in fact extended to 7 years in length, perhaps with a view to contain the ever-growing knowledge base and technical skills within a unified neurosurgery program. ²⁰ Similarly, in Canada, there has not been development of a compressed generalist program as proposed by both Benzel ^{Reference Benzel19} and others, ^{Reference Toyota6} though an increasing proportion of graduates seek out post-residency training. ^{Reference Elkaim, Niazi and Tso1,Reference Tso, Findlay, Lownie, Wallace, Toyota and Fleetwood2} We suggest that the development of a compressed core training program has been precluded, in part, by a lack of sufficiently standardized specialist programs. That is, before a paradigm shift to a shortened core curriculum can occur, it must be ensured that formalized, well-regulated subspecialist training programs are in place such that patients requiring specialized management are adequately cared for.

In February 2026, the RCPSC accepted the application from the Canadian Spine Society to establish an Area of Focused Competence (AFC) for Spine Surgery. ²¹ Essentially, this allows the RCPSC and the Spine Surgery Specialty Committee to set national standards for all existing and new postgraduate spine surgery fellowships with respect to competencies required of trainees, akin to residency programs (also overseen by the RCPSC). The standardization of competency-based postgraduate spine surgery training in Canada is likely to have downstream effects on neurosurgical residency training. Currently, there are areas of significant disagreement with respect to the scope of spine competencies in neurosurgical residency. For example, in response to the statement that EPAs should include comprehensive spine instrumentation, program director opinions are split: 6/14 (42.9%) agreed that this should be a competency required for all neurosurgery residents, and 8/14 (57.1%) disagreed. If the AFC for Spine Surgery precisely defines “fellowship-level competencies, this will necessarily provide guidance as to what is expected of individuals prior to entering the AFC for Spine Surgery, that is, graduates of neurosurgical (and orthopedic) residency programs.