1:36 Variation in surgical decision making among spine surgeons for dengenerative conditions of the lumbar spine

Abstract

Purpose of study: Significant geographic variation in rates of spine surgery has been previously demonstrated. Factors contributing to this variation may include not only the density of spinal surgeons, but also differences in practice patterns between surgeons. Evaluation of potential contributing factors, such as surgeon age, training background and practice location, have not been evaluated. This study tested surgeons' approaches to simulated case histories of five patients representing common diagnostic categories of degenerative disease of the lumbar spine. We hoped to evaluate both the extent of variation in treatment plans as well as the effect of specific demographic variables on surgical approach.Methods used: Five simulated case presentations, including history, physical examination and imaging studies, were presented to 30 US surgeons of varying ages and geographic regions, with training backgrounds from both neurological and orthopedic surgery. Surgeons responded regarding the need for surgery, surgical approach, indication for fusion and use of instrumentation. Cases included a one-level herniated disc with osteophyte formation (Case 1), a lytic spondylolisthesis (Case 2), a degenerative spondylolisthesis (Case 3), degenerative scoliosis with stenosis (Case 4) and stenosis with prior laminotomies (Case 5). Surgeon age, training background and practice location were tested as predictors of observed variation using an analysis of variance.of findings: The most consistency was found in the approach to Case 1, for whom 100% of respondents indicated a fusion procedure and 93.3% indicated simultaneous posterior instrumentation. Fusion was indicated much less frequently for Cases 1 and 5 (18.5% and 15.4%, respectively). The greatest variation in surgical plan was found for the patients with degenerative spondylolisthesis and degenerative scoliosis (Cases 3 and 4). Fifteen of 29 respondents (51.7%) indicated fusion for Case 3, whereas 12 of 25 (48.0%) indicated fusion for Case 4. Several predictive variables reached or tended toward statistical significance. Surgeon age was significantly predictive of the use of instrumentation for Cases 1 and 5 (p = .048 and .014, respectively). There was a similar trend toward increased indication for fusion and use of instrumentation among younger surgeons for the remaining cases. There was also a trend toward increased use of fusion and instrumentation among orthopedists compared with neurosurgeons for all cases, which reached significance for Case 4 (p = .015).Relationship between findings and existing knowledge: Variation in approach to surgical treatment may depend on the clinical problem presented. Among the surgeons in this study, we found impressive consistency in approach to the patient with lytic spondylolisthesis, which may indicate better agreement regarding appropriate treatment of this clinical problem. Significant variation in indication for fusion and instrumentation was found to result from surgical training background and surgeon age.Overall significance of findings: Although concern has been expressed regarding the significant variability in the per capita rate of surgery for degenerative spinal conditions, these variations may occur partly because a lack of consensus on appropriate treatment techniques for certain problems, as well as such surgeon-specific factors as age and training background.Disclosures: No disclosures.Conflict of interest: No conflicts.