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Shukla GG, Matur AV, Childress K, Tao X, Garcia-Vargas J, Mehta J, Garner RM, Gibson J, Cass D, Vorster P, Wu A, Street S, Duah HO, Motley B, Cheng J, Adogwa O. Surgeon Experience Matters: An Exact Matched Analysis of TLIF Outcomes Demonstrates No Difference in Surgical Outcomes Between Experienced Neurosurgeons and Orthopedic Surgeons. Spine (Phila Pa 1976) 2024; 49:772-779. [PMID: 37432901 DOI: 10.1097/brs.0000000000004758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/13/2023] [Indexed: 07/13/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To compare surgical and medical complications profile between neurosurgeons and orthopedic surgeons after transforaminal lumbar interbody fusion (TLIF) procedures. BACKGROUND Studies comparing the impact of spine surgeon specialty (neurosurgery vs. orthopedic spine) on TLIF outcomes have been inconclusive and failed to control for operative learning curves and surgical maturity. Orthopedic spine surgeons perform fewer spine procedures in residency, although these differences may be attenuated by mandatory fellowship before starting practice. Any observed differences are likely attenuated with increasing surgeon experience. MATERIALS AND METHODS Using an all-payer claims database, PearlDiver Mariner, 120 million patient records were analyzed between 2010 and 2022, to identify individuals with lumbar stenosis or spondylolisthesis who underwent index one- to three-level TLIF procedures. International Classification of Diseases-Ninth Edition (ICD-9), International Classification of Diseases-10th Edition (ICD-10) and Current Procedural Terminology (CPT) codes were used to query the database. Only Neurosurgeons and Orthopedic spine surgeons who had performed at least 250 procedures were included in the study. Patients undergoing surgery for tumor, trauma, or infection were excluded. 1:1 exact matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with all-cause surgical or medical complications in a linear regression model. RESULTS 1:1 exact matching created two equal groups of 18,195 patients without baseline differences who underwent TLIF procedures by neurosurgeons or orthopedic surgeons. There was no difference in all-cause surgical complications between neurosurgeons and orthopedic spine surgeons (relative risk=1.008, 95% CI: 0.850-1.195, P =0.965). All-cause medical complication rate was higher in the neurosurgery cohort (relative risk=1.144, 95% CI: 1.042-1.258, P =0.005). CONCLUSION The results of this study suggest that after accounting for surgical maturity, neurosurgeons and orthopedic spine surgeons have similar surgical outcomes. However, neurosurgeons have higher all-cause medical complication rates compared with orthopedic spine surgeons. Further research is warranted to validate this relationship in other spine procedures and for other outcomes.
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Affiliation(s)
- Geet G Shukla
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Abhijith V Matur
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kelly Childress
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Xu Tao
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Julia Garcia-Vargas
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jay Mehta
- Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, OH
| | - Rebecca M Garner
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Justin Gibson
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daryn Cass
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Phillip Vorster
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrew Wu
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Seth Street
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Henry O Duah
- Institute for Nursing Research & Scholarship, University of Cincinnati College of Nursing, Cincinnati, OH
| | - Benjamin Motley
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH
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Kuruba V, Cherukuri AMK, Arul S, Alzarooni A, Biju S, Hassan T, Gupta R, Alasaadi S, Sikto JT, Muppuri AC, Siddiqui HF. Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders. Cureus 2023; 15:e45962. [PMID: 37900519 PMCID: PMC10600402 DOI: 10.7759/cureus.45962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.
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Affiliation(s)
- Venkataramana Kuruba
- Department of Orthopedic Surgery, All India Institute of Medical Sciences, Vijayawada, IND
| | | | - Subiksha Arul
- Department of Medicine, JONELTA Foundation School of Medicine, University of Perpetual Help System DALTA, Manila, PHL
| | | | - Sheryl Biju
- Department of Medicine, Christian Medical College, Vellore, IND
| | - Taimur Hassan
- Department of Medicine, Texas A&M College of Medicine, College Station, USA
| | - Riya Gupta
- Department of Medicine, Shri Atal Bihari Vajpayee Medical College and Research Institute, Bangalore, IND
| | - Saya Alasaadi
- Department of Medicine, University College of Dublin, Dublin, IRL
| | - Jarin Tasnim Sikto
- Department of Medicine, Jahurul Islam Medical College and Hospital, Bhagalpur, BGD
| | - Arnav C Muppuri
- Department of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Humza F Siddiqui
- Department of Internal Medicine, Jinnah Postgraduate Medical Center, Karachi, PAK
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McDonald CL, Berreta RAS, Alsoof D, Homer A, Molino J, Ames CP, Shaffrey CI, Hamilton DK, Diebo BG, Kuris EO, Hart RA, Daniels AH. Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty. Spine J 2023; 23:1365-1374. [PMID: 37236366 DOI: 10.1016/j.spinee.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/16/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND CONTEXT Surgery to correct adult spinal deformity (ASD) is performed by both neurological surgeons and orthopedic surgeons. Despite well-documented high costs and complication rates following ASD surgery, there is a dearth of research investigating trends in treatment according to surgeon subspeciality. PURPOSE The purpose of this investigation was to perform an analysis of surgical trends, costs and complications of ASD operations by physician specialty using a large, nationwide sample. STUDY DESIGN/SETTING Retrospective cohort study using an administrative claims database. PATIENT SAMPLE A total of 12,929 patients were identified with ASD that underwent deformity surgery performed by neurological or orthopedic surgeons. OUTCOME MEASURES The primary outcome was surgical case volume by surgeon specialty. Secondary outcomes included costs, medical complications, surgical complications, and reoperation rates (30-day, 1-year, 5-year, and total). METHODS The PearlDiver Mariner database was queried to identify patients who underwent ASD correction from 2010 to 2019. The cohort was stratified to identify patients who were treated by either orthopedic or neurological surgeons. Surgical volume, baseline characteristics, and surgical techniques were examined between cohorts. Multivariable logistic regression was employed to assess the cost, rate of reoperation and complication according to each subspecialty while controlling for number of levels fused, rate of pelvic fixation, age, gender, region and Charlson Comorbidity Index (CCI). Alpha was set to 0.05 and a Bonferroni correction for multiple comparisons was utilized to set the significance threshold at p ≤.000521. RESULTS A total of 12,929 ASD patients underwent deformity surgery performed by neurological or orthopedic surgeons. Orthopedic surgeons performed most deformity procedures accounting for 64.57% (8,866/12,929) of all ASD operations, while the proportion treated by neurological surgeons increased 44.2% over the decade (2010: 24.39% vs 2019: 35.16%; p<.0005). Neurological surgeons more frequently operated on older patients (60.52 vs 55.18 years, p<.0005) with more medical comorbidities (CCI scores: 2.01 vs 1.47, p<.0005). Neurological surgeons also performed higher rates of arthrodesis between one and six levels (OR: 1.86, p<.0005), three column osteotomies (OR: 1.35, p<.0005) and navigated or robotic procedures (OR: 3.30, p<.0005). Procedures performed by orthopedic surgeons had significantly lower average costs as compared to neurological surgeons (orthopedic surgeons: $17,971.66 vs neurological surgeons: $22,322.64, p=.253). Adjusted logistic regression controlling for number of levels fused, pelvic fixation, age, sex, region, and comorbidities revealed that patients within neurosurgical care had similar odds of complications to orthopaedic surgery. CONCLUSIONS This investigation of over 12,000 ASD patients demonstrates orthopedic surgeons continue to perform the majority of ASD correction surgery, although neurological surgeons are performing an increasingly larger percentage over time with a 44% increase in the proportion of surgeries performed in the decade. In this cohort, neurological surgeons more frequently operated on older and more comorbid patients, utilizing shorter-segment fixation with greater use of navigation and robotic assistance.
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Affiliation(s)
- Christopher L McDonald
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Rodrigo A Saad Berreta
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Daniel Alsoof
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Alex Homer
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Janine Molino
- Department of Orthopedics, Biostatistics Division, Brown University Warren Alpert Medical School, Grads Dorm Building 3rd Floor, Rhode Island Hospital 593 Eddy St, 02903, Providence, RI, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, Eighth Floor, 400 Parnassus Ave, CA 94143, San Francisco, California
| | - Christopher I Shaffrey
- Department of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, 200 Lothrop Street, A402 UPMC Presbyterian, PA 15213, Pittsburgh, Pennsylvania
| | - Bassel G Diebo
- Swedish Neuroscience Institute, 550 17th Avenue, James Tower, Suite 500, 98122, Seattle, WA
| | - Eren O Kuris
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA
| | - Robert A Hart
- Swedish Neuroscience Institute, 550 17th Avenue, James Tower, Suite 500, 98122, Seattle, WA
| | - Alan H Daniels
- Department of Orthopedics, Brown University Warren Alpert Medical School, 1 Kettle Point Avenue, East Providence, Providence, 02914, RI, USA.
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Hines K, Philipp L, Thalheimer S, Montenegro TS, Gonzalez GA, Hughes LP, Leibold A, Mahtabfar A, Franco D, Heller JE, Jallo J, Prasad S, Sharan AD, Harrop JS. Increased Surgeon-specific Experience and Volume is Correlated With Improved Clinical Outcomes in Lumbar Fusion Patients. Clin Spine Surg 2023; 36:E86-E93. [PMID: 36006405 DOI: 10.1097/bsd.0000000000001377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN The present study design was that of a single center, retrospective cohort study to evaluate the influence of surgeon-specific factors on patient functional outcomes at 6 months following lumbar fusion. Retrospective review of a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis identified the present study population. OBJECTIVE This study seeks to evaluate surgeon-specific variable effects on patient-reported outcomes such as Oswestry Disability Index (ODI) and the effect of North American Spine Society (NASS) concordance on outcomes in the setting of variable surgeon characteristics. SUMMARY OF BACKGROUND DATA Lumbar fusion is one of the fastest growing procedures performed in the United States. Although the impact of surgeon-specific factors on patient-reported outcomes has been contested, studies examining these effects are limited. METHODS This is a single center, retrospective cohort study analyzing a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis by 1 of 5 neurosurgery fellowship trained spine surgeons. The primary outcome was improvement of ODI at 6 months postoperative follow-up compared with preoperative ODI. RESULTS A total of 307 patients were identified for analysis. Overall, 62% of the study population achieved minimum clinically important difference (MCID) in ODI score at 6 months. Years in practice and volume of lumbar fusions were statistically significant independent predictors of MCID ODI on multivariable logistic regression ( P =0.0340 and P =0.0343, respectively). Concordance with evidence-based criteria conferred a 3.16 (95% CI: 1.03, 9.65) times greater odds of achieving MCID. CONCLUSION This study demonstrates that traditional surgeon-specific variables predicting surgical morbidity such as experience and procedural volume are also predictors of achieving MCID 6 months postoperatively from lumbar fusion. Independent of surgeon factors, however, adhering to evidence-based guidelines can lead to improved outcomes.
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Affiliation(s)
- Kevin Hines
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA
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Eli I, Whitmore RG, Ghogawala Z. Spine Instrumented Surgery on a Budget-Tools for Lowering Cost Without Changing Outcome. Global Spine J 2021; 11:45S-55S. [PMID: 33890807 PMCID: PMC8076804 DOI: 10.1177/21925682211004895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
STUDY DESIGN Review article. OBJECTIVES There have been substantial increases in the utilization of complex spinal surgery in the last 20 years. Spinal instrumented surgery is associated with high costs as well as significant variation in approach and care. The objective of this manuscript is to identify and review drivers of instrumented spine surgery cost and explain how surgeons can reduce costs without compromising outcome. METHODS A literature search was conducted using PubMed. The literature review returned 217 citations. 27 publications were found to meet the inclusion criteria. The relevant literature on drivers of spine instrumented surgery cost is reviewed. RESULTS The drivers of cost in instrumented spine surgery are varied and include implant costs, complications, readmissions, facility-based costs, surgeon-driven preferences, and patient comorbidities. Each major cost driver represents an opportunity for potential reductions in cost. With high resource utilization and often uncertain outcomes, spinal surgery has been heavily scrutinized by payers and hospital systems, with efforts to reduce costs and standardize surgical approach and care pathways. CONCLUSIONS Education about cost and commitment to standardization would be useful strategies to reduce cost without compromising patient-reported outcomes after instrumented spinal fusion.
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Affiliation(s)
- Ilyas Eli
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, MA, USA,Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, UT, USA
| | - Robert G. Whitmore
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, MA, USA
| | - Zoher Ghogawala
- Department of Neurosurgery, Lahey Clinic Medical Center, Burlington, MA, USA,Zoher Ghogawala, Department of Neurosurgery, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805, Burlington, MA 01805, USA.
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