Competency-Based Training and Certification for Minimally Invasive Spine Interventions and Surgery

Introduction

The American Society of Pain and Neuroscience (ASPN) is a multidisciplinary society spanning anesthesiology, physical medicine and rehabilitation, neurosurgery, orthopedic surgery, neurology, radiology, emergency medicine, internal medicine, preventive medicine, functional and longevity medicine, public health, and interventional pain medicine.

ASPN is uniquely qualified to help define education, training, and competency standards for the rapidly evolving field of minimally invasive spine intervention. Its multidisciplinary membership spans pain medicine, physical medicine and rehabilitation, neurosurgery, orthopedic surgery, radiology, neurology, and related specialties, providing expertise across diagnosis, imaging, biomechanics, patient selection, intervention, complication management, and longitudinal care. This breadth is reinforced by multidisciplinary, peer-reviewed guidance addressing procedural credentialing, minimally invasive lumbar spinal stenosis treatment, interventional low back pain care, basivertebral nerve ablation, sacroiliac disorders and minimally invasive fusion, and standardized neuromodulation training.^1–6 By contrast, standards developed within more traditional, predominantly surgical organizations or committees with limited multidisciplinary representation may unintentionally reflect the training paradigms, procedural experience, and clinical endpoints of a narrower constituency. Such imbalance risks interpreting newer percutaneous and minimally invasive therapies through frameworks designed for conventional surgery rather than through their own evidence, outcomes, risk profiles, and training requirements. To avoid specialty-driven “turf” guidance, standards should be patient-centered, multidisciplinary, evidence-based, and procedure-specific, with balanced representation from the physicians who actually evaluate, perform, manage, and study these evolving therapies.

Now more than ever, the interventional approach to the spine is rapidly evolving, recognizing the historical challenges of interventions and the high cost of failed surgery, both in patient suffering and quality of life and in a very poor health care utilization profile that has jeopardized patient access. Innovation in new minimally invasive approaches, targets, and emerging technologies, along with accompanying research, is outpacing formal training programs. Societal recommendations are therefore needed to help construct a framework for education, training, and peer review for their deployment.

The Challenge

Spine care is undergoing rapid technological change. Percutaneous fixation and fusion, minimally invasive decompression, endoscopic techniques, vertebral augmentation and stabilization, basivertebral nerve ablation, image-guided denervation, sacroiliac interventions, interspinous procedures, advanced neuromodulation, and other emerging technologies are evolving more rapidly than traditional residency and fellowship curricula can be revised. As a result, formal training pathways across multiple specialties may not fully address the complete set of competencies required for many recently introduced procedures.

This creates a shared challenge rather than a specialty-specific deficiency. Physicians enter advanced procedural practice with different foundational strengths and different educational gaps. Surgeons may possess substantial training in anatomy, biomechanics, operative exposure, decompression, fixation, and management of surgical complications. Interventional pain physicians and other image-guided specialists may possess extensive training in fluoroscopic navigation, percutaneous access, needle and cannula techniques, neuromodulation, diagnostic blocks, radiofrequency procedures, longitudinal pain management, and the evaluation of patients for less invasive alternatives. Neither background should be presumed to establish competence in every emerging procedure, nor should either automatically preclude a physician from developing competence through rigorous supplemental education and objective assessment.

Terminology

Much of this debate is conducted in words that are treated as risk categories, a practice that misinterprets the terminology. The AMA CPT framework publishes no single cross-specialty glossary making “minimally invasive,” “percutaneous,” “endoscopic,” “intervention,” “procedure,” and “surgery” mutually exclusive. These terms identify access route, visualization method, therapeutic action, and code-family context, not degree of hazard and not who is qualified to perform the service.

Four consequences follow directly:

1. Percutaneous is not automatically minimally invasive surgery. A fluoroscopically guided transforaminal epidural steroid injection is percutaneous, yet it is an interventional pain procedure, not spine surgery.
2. Endoscopic and percutaneous are not interchangeable terms. Endoscopic describes the method of visualization; percutaneous describes the access route. A procedure may be one, both, or neither.
3. A procedure can be surgical regardless of incision size. “Surgery” reflects the nature of the operative treatment; the other three terms describe only how it is performed.
4. “Minimally invasive” is not a coding category and carries no independent regulatory or credentialing meaning.

Competency requirements cannot be indexed to a label. These words describe technique. They do not measure hazard, and they do not identify who is qualified. The AMA CPT Editorial Panel has itself addressed the need for consistent terminology for spine endoscopic and percutaneous procedures, reinforcing that these are meaningful technique descriptors, not interchangeable labels. A credential must therefore rest on what a given procedure places at risk and what the operator can demonstrably do, assessed procedure by procedure.

Percutaneous and endoscopic techniques, sacroiliac and interspinous fixation, facet fusion, vertebral augmentation with permanent implants, basivertebral nerve ablation, percutaneous image-guided decompression, endoscopic or image-guided rhizotomy, and next-generation neuromodulation therapies have created a unique category of care, one that did not exist in recognizable form when current training pathways were designed. Current residencies and fellowships across all specialties, surgical or nonsurgical, cannot solely certify competence in these specific procedures against a national standard. That is a shared deficiency, and it cannot be closed by deciding in advance which formal residency a physician completed, while still appreciating the foundational knowledge commonly acquired from the pedigrees of anesthesiology, physiatry, radiology, orthopedics, and neurosurgery.

ASPN Position

Patient safety and treatment efficacy should be determined by demonstrated competence. Competence must be clearly defined, rigorously taught, objectively assessed, and periodically reassessed for every physician performing an advanced spine procedure, regardless of the specialty in which that physician originally trained.

No physician, whether trained primarily in interventional, surgical, or other spine-related disciplines, should perform an advanced spine intervention without demonstrated knowledge of relevant anatomy, biomechanics, pathology, imaging, patient selection, technical execution, complication recognition and management, and longitudinal care. These competencies may be acquired through appropriately structured intramural or extramural education, but they must be validated through objective assessment, supervised experience, outcomes review, and ongoing maintenance of competency.

Historical Precedent

Medicine has repeatedly adapted as procedures moved from open surgery toward catheter-based and percutaneous techniques. Charles Dotter pioneered percutaneous transluminal angioplasty, and Andreas Grüntzig later advanced balloon angioplasty, helping establish catheter-based revascularization as a distinct discipline.⁷

A particularly relevant model is neuroendovascular surgery, which evolved across neurosurgery, neurology, and radiology. Rather than relying on a single residency pathway, these specialties developed structured advanced training standards through the Society of Neurological Surgeons (SNS) and its Committee on Advanced Subspecialty Training (CAST), which oversees accreditation standards for advanced neurological surgery fellowship programs.⁸ Current CAST neuroendovascular requirements recognize entry pathways from neurosurgery, neurology, and radiology, with specialty-specific prerequisites followed by defined advanced training requirements and competency expectations.⁹

This model provides a useful precedent for minimally invasive spine care: entry pathways may differ, but physicians performing the same advanced procedure should ultimately be held to the same procedure-specific competency standard.

In contrast to the structured neuroendovascular model, some areas of spine care still lack clear, reciprocal standards for physicians expanding beyond the scope of their foundational training. Interventional pain physicians and interventional radiologists undergo formal residency, fellowship, and additional procedure-specific training before performing complex image-guided injections, ablations, and related interventions. The same principle should apply when physicians from any specialty incorporate procedures not adequately addressed during their original training.

Accordingly, credentialing should identify the knowledge and skills already established by a physician’s foundational specialty, define the additional education and supervised experience required for the new procedure, and apply the same terminal competency standard to all practitioners. Entry requirements and remedial curricula may differ according to prior specialty training, but the final procedure-specific competency standard should be identical for every physician.

Interventional pain medicine has undergone a maturation comparable to that of neuroendovascular medicine, evolving far beyond diagnostic nerve blocks into complex spinal and neuromodulation procedures. Safely advancing the field requires treating these spine interventions with the same institutional rigor seen in interventional cardiology and neuroendovascular care. Cross-specialty expansion, whether an interventionalist advancing into endoscopic procedures or a surgeon incorporating complex percutaneous modalities and spinal injections, cannot rely on casual adoption or workshops for novice physicians. It demands rigorous, multi-society credentialing frameworks in which procedural competency, rather than specialty pedigree alone, dictates scope of practice.

Despite these concerns, the curriculum, teaching, mentoring, and certification should be specific to the specialty of practice. In this regard, ASPN seeks to provide solutions to improve the health care of those with spinal disease and those with chronic pain. We have committed to this by developing standardization requirements.

Standardization Requirements

ASPN proposes that a national Minimally Invasive Spine credential, developed by multispecialty consensus, be built on:

• Seven assessable competency domains: anatomy and biomechanics; diagnostic and imaging competence; patient selection and clinical judgment; technical execution and procedural proficiency; complication recognition and management; longitudinal and perioperative care; and radiation safety.
• Requirements that scale with risk, not approach. A percutaneous corridor does not make a procedure minor. Requirements should be indexed to the structures at hazard, permanent biomechanical alteration, implant placement, reversibility, and complication severity: procedure by procedure, not by incision size and not by specialty.
• Differentiated prerequisites, identical terminal standards. Physicians enter with different strengths and different gaps; every gap is addressable by curriculum. What must be identical is the destination.
• Assessment, not just volume. Verifiable case logs as primary operator; cadaveric and simulation certification before first independent human application; objective structured clinical examinations (OSCEs) administered by evaluators independent of the training site, when applicable; milestone progression; written examinations, when applicable; and a push for registry reporting.
• Maintenance: minimum ongoing volume and required education when platforms or evidence change.
• Real complication management capability. Prospectively established arrangements specifying emergent communication, after-hours availability, transfer logistics, and subsequent care, documented at credentialing, including in office-based settings. An ad hoc referral relationship is not adequate; this applies equally to any interventionalist or surgeon.
• Comparable competency standards should apply bidirectionally when physicians incorporate procedures not adequately addressed during their foundational training.

What ASPN Has Built, and to What We Commit

ASPN has published a peer-reviewed, proposed standardized fellowship curriculum for advanced minimally invasive spine interventions, authored by both spine surgeons and interventional pain physicians. It is operationalized through the ASPN Minimally Invasive Spine and Neuromodulation (MISN) Certification, a twelve-month pathway of sequenced didactics, a proctored written examination, mentored procedural certification with site visits, structured case preparation and debriefing, and an observed structured clinical examination in a cadaver laboratory. Certification is procedure specific. It is assessed, not attended.

ASPN commits to:

1. Publishing the complete competency curriculum.
2. Defining and publishing procedure-specific case minimums and milestones, revised on evidence rather than preference.
3. Building an outcomes and complication registry and making certification contingent on participation.
4. Keeping curriculum design independent of commercial influence.
5. Joining or helping convene a multi-society body, on the CAST model, to accredit programs and certify practitioners across specialty lines.
6. Establishing a fair and balanced pathway for physicians already in practice, so that competence, rather than timing, determines certification.

ASPN is committed to assembling the appropriate stakeholders, centered on the patient, to improve patient outcomes by innovating responsibly. We welcome a multidisciplinary effort to create educational offerings, evidence, and accountability.

Signatories

ASPN Leadership

ASPN Executive Board

Sean Li, MD · Kasra Amirdelfan, MD · David Lee, MD · Nomen Azeem, MD · Melissa Murphy, MD · Erika Petersen, MD · Jason E. Pope, MD

Endorsing Societies

Society of Women Innovators in Pain Management (WIPM)

Sierra Spine Society

References

1. Naidu RK, Chaturvedi R, Engle AM, et al. Interventional spine and pain procedure credentialing: guidelines from the American Society of Pain & Neuroscience. J Pain Res. 2021;14:2777-2791. doi:10.2147/JPR.S309705
2. Deer TR, Grider JS, Pope JE, et al. Best practices for minimally invasive lumbar spinal stenosis treatment 2.0 (MIST): consensus guidance from the American Society of Pain and Neuroscience (ASPN). J Pain Res. 2022;15:1325-1354. doi:10.2147/JPR.S355285
3. Sayed D, Grider J, Strand N, et al. The American Society of Pain and Neuroscience (ASPN) evidence-based clinical guideline of interventional treatments for low back pain. J Pain Res. 2022;15:3729-3832. doi:10.2147/JPR.S386879
4. Sayed D, Naidu RK, Patel KV, et al. Best practice guidelines on the diagnosis and treatment of vertebrogenic pain with basivertebral nerve ablation from the American Society of Pain and Neuroscience. J Pain Res. 2022;15:2801-2819. doi:10.2147/JPR.S378544
5. Sayed D, Deer TR, Tieppo Francio V, et al. American Society of Pain and Neuroscience best practice (ASPN) guideline for the treatment of sacroiliac disorders. J Pain Res. 2024;17:1601-1638. doi:10.2147/JPR.S464393
6. Pritzlaff SG, Goree JH, Hagedorn JM, et al. Pain Education and Knowledge (PEAK) consensus guidelines for neuromodulation: a proposal for standardization in fellowship and training programs. J Pain Res. 2023;16:3101-3117. doi:10.2147/JPR.S424589
7. Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruction: description of a new technic and a preliminary report of its application. Circulation. 1964;30:654-670. doi:10.1161/01.CIR.30.5.654
8. Day AL, Siddiqui AH, Meyers PM, et al. Training standards in neuroendovascular surgery: program accreditation and practitioner certification. Stroke. 2017;48(8):2318-2325. doi:10.1161/STROKEAHA.117.016560
9. Committee on Advanced Subspecialty Training. Program Requirements for Fellowship Training in Neuroendovascular Surgery. Society of Neurological Surgeons; 2025. Updated September 23, 2025.