Shaping the modern spine surgeon: core competencies for a digital era

Historically, excellence in spine surgery was defined by the mastery of fundamentals-detailed anatomical and pathological knowledge, safe exposure and meticulous dissection, the capacity for 3D visualisation, ability to adequately decompress neural structures and achieve mechanical stability.

However, the understanding of surgical competence is evolving. Comprehensive knowledge and technical precision remain the foundation, but cognitive adaptability, interdisciplinary collaboration and the nascent field of digital literacy are emerging requirements for modern practice. Digital literacy is defined as the ability to use, evaluate, communicate, and create information using digital technologies. It encompasses both the technical skills to operate technology as well as the critical thinking skills to use it appropriately.

Artificial intelligence (AI) is the application of computer systems to produce output very rapidly, previously requiring human intelligence. It does so by applying machine learning techniques to large collections of data. A large language model (LLM), for example ChatGTP^©, uses deep learning architecture to understand and generate its output. It is trained on massive volumes of data to understand and generate human-like text.

There is a plethora of variable quality information available from a multitude of sources including traditional literature, the internet, social media and AI. Social media will increasingly impact upon the future surgeon’s decision-making.

Technological transformation of spine surgery has rapidly progressed. Robotics, navigation, endoscopy, augmented reality (AR), and AI are established and becoming standard of care. For example, navigation systems are now standard in complex spinal procedures, and 3D planning has supplanted two-dimensional imaging. These innovations have redefined the surgeon’s operative environment, demanding new competencies that blend psychomotor skills with digital and analytical fluency.

The next generation of spine surgeons must master multiple interdependent domains: technical proficiency, analytical capacity, teamwork and social media.

• Technical proficiency. Now extends beyond manual dexterity to include operation of robotic and endoscopic systems, trusting navigation, interpretation of digital feedback, and real-time management of multimodal data. The surgeon’s hands and computational algorithms function as co-pilots within the same theatre. Technology advancements enhance a surgeon’s skill set that in turn changes operative techniques. However, responsible utilization of technology is vital as costs of new techniques are usually higher (1). The increased costs imposed by new techniques may include set-up, consumables and operative time.
• Analytical capability. Currently, the commonest source of information regarding the results from techniques is garnered through peer-reviewed journals, which have tested the veracity of the publication. However, the future sources and volumes of information are numerous, but may not be subject to the rigors of peer review. The modern surgeon must engage and critically analyse information and data. AI algorithms can predict perioperative risks, optimize implant selection, and estimate postoperative outcomes. Without an understanding of how AI data is generated, and the biases embedded within it, surgeons risk becoming passive recipients rather than informed decision-makers. Training programs must cultivate an understanding of statistical principles, model validation, and ethical implications of AI-guided care (2).
• Collaboration is now indispensable. Complex spinal disorders intersect with neurology, endocrinology, pain, perioperative and rehabilitation medicine. Surgeons must function within multidisciplinary teams. As a team member, they must balance authority with insightful communication.
• Social media. Patients, colleagues and third parties will increasingly rely upon the ubiquitous internet using search engines (e.g. Google^© and YouTube^©) and AI (e.g. ChatGPT ^©) for information, opinions, and advice regarding their management. This information will impact on the consultation with the surgeon and the subsequent management discussions. The modern surgeon must anticipate and be able to appropriately incorporate this input into their management decisions and discussions.

The modern surgeon will need to acquire new skills in addition to the current requirements to practice in the future. The skill set for effective consultation and surgery requires adequate practice and is built predominantly by experience. The efficacy of training programs is anchored in procedural volume. Globally, access to advanced surgical technologies and techniques is and will remain, unevenly distributed (3). Multiple challenges exist to the successful acquisition and incorporation of new skills (4).

• Digital literacy. Digital literacy needs to be incorporated as a core competency in surgical training. Trainees and surgeons must understand how AI algorithms influence recommendations for patient selection, operative strategy, and outcomes reporting. Comprehending the capabilities and limitations of AI empowers surgeons to use these tools optimally.
• Simulation and virtual reality (VR). In situations where there is a paucity of operative experience, simulation allows trainees and surgeons to gain repeated experience with new and complex procedures safely. Virtual models of spinal anatomy, pathology and intraoperative events enhance learning, and allow contingency training for adverse episodes. Crucially, VR can democratize access: a trainee or surgeon in a resource-limited region can now experience the same digital operative experience as one in a major academic centre.
• Learning Curve. Gaining access to training and equipment, overcoming the initial trepidation, and minimising the learning curve of new techniques and skills are barriers to their adoption (5). Support, education, and mentorship are required to overcome this.
• Human factors and adverse outcomes. Adverse outcomes in surgery may not be the result of technical failure alone and often stem from communication lapses, surgeon and staff fatigue, cognitive overload, or a combination of factors. The effect of these human factors may be magnified when performing a new procedure. Integrating human factors training cultivates situational awareness, teamwork, and psychological safety enhancing patient-centred care.
• Accountability and ethics. Emerging technology can confuse and complicate accountability. For example, who is responsible when an AI recommendation contributes to harm? And how should surgeons communicate procedural risk derived from algorithms? And what are the ethical implications of increasing reliance on AI in making treatment decisions? Training must foster ethical reasoning and patient-centred judgment alongside technical proficiency.

Mentorship remains a vital bridge between generations (6). Senior surgeons contribute prior experience, complication reduction and avoidance, tactile wisdom; younger colleagues bring digital fluency, enthusiasm, novel and innovative thinking (7). Newer techniques rely increasingly on visual rather than haptic input of the older treatments, and there are generational skill differences between surgeons. Mentorship allows the pairing of experience with innovation and ensures that while technologies evolve, guidance and wisdom for safe surgery remain.

Future procedures will be mainly minimally invasive resulting in less exposure to traditional open techniques (8) that may be needed especially in revision or failed surgical cases. Additionally, assistive technology with robotics and navigation sometimes fails resulting in case cancellation if alternative open techniques are not practiced (9). Ultimately, the future of spine surgery will not be defined by automation but by augmentation-enhancing, not replacing, human capability (10). The enduring measure of surgical excellence will remain the responsible relief of our patients’ pain and disability.

Novel techniques (11) allow less invasive or more effective treatments of conditions. These new techniques and equipment require learning and experience, and they displace older techniques. Some of the older techniques are indeed outmoded and can be safely discarded. However, other older techniques are not redundant and must not be discarded. They may be required in cases when the new treatments are ineffective, unavailable, or to rescue a situation after failure of the new technology. It may be difficult to determine which techniques can safely be relegated to the history books, and which need to be maintained. The challenge for the profession is to maintain these valuable older skills and facilitate adequate experience in the next generation of surgeons.

The future of spine surgery is defined by augmentation rather than automation. Digital tools will expand precision, situational awareness, and analytical capability. Yet the core measure of surgical excellence remains unchanged: providing safe, evidence-driven care that relieves pain, restores function, and improves quality of life. Technology should strengthen—not replace—the surgeon’s judgment, adaptability, and commitment to patients.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Spine Surgery. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-2025-03/coif). R.J.M. serves as the Editor-in-Chief of Journal of Spine Surgery. G.M.M. serves as an unpaid editorial board member of Journal of Spine Surgery. R.J.M. reports royalties from Stryker Spine and Medacta Int., support from Medacta Int., patents of WAGAR, ROC_GUARD and PERCUTANEOUS SYSTEMS, stocks in Johnson & Johnson Int., Medtronic Int. and Stryker Int. He participates in the SUCCESS Trial and BMP2 Trials, and is a member of NSURG Research Group and Spine Society of Australia, and a consultant for training in Matrix Medical. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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