Comparative effectiveness research in spine surgery

Orthopedic surgery versus neurosurgery: Prevalence and surgical detail assessment of adult spinal fusion procedures

Background

A significant procedural overlap exists between orthopedic and neurosurgeons with both subspecialties performing adult spinal fusion procedures. However, the prevalence of varying adult spinal fusion procedures performed by orthopedic surgeons, relative to neurosurgeons, is unknown. This study sought to compare the prevalence of spinal fusion procedures among orthopedic and neurosurgeons.

Materials and Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for adult spinal fusion procedures from 2008 to 2016. Procedure prevalence, operative time, and hospital length of stay (LOS) were recorded and analyzed by surgical subspecialty. Spinal fusion cases investigated include all fusions, 2-3-level lumbar fusion, ≥4-level lumbar fusion, anterior cervical discectomy and fusion (ACDF), 3-6-level posterior cervical fusion, and ≥ 6-level posterior cervical fusion.

Results

67,775 spinal fusions were identified, of which 44,879 (66.2%) were performed by neurosurgeons and 22,896 (33.7%) were performed by orthopedic surgeons. Procedures that involved the lumbar spine were more likely to be performed by orthopedic surgeons while cervical fusions like ACDF were more likely to be performed by neurosurgeons. Orthopedic surgeons had significantly shorter operative times (124.0 vs. 134.0 min, P < 0.001) for 2-3-level lumbar fusions while having a similar patient LOS (4.3 vs. 4.2 days, P = 0.196). The remaining procedures saw no significant difference in operative time and patient LOS between orthopedic and neurosurgeons.

Conclusions

Neurosurgeons performed nearly double the amount of spinal fusion cases compared to orthopedic surgeons, with an even greater disparity seen in ACDFs, while orthopedic surgeons performed significantly more fusions of the lumbar spine. Orthopedic surgeons had shorter operative times for 2-3-level lumbar fusions.

Quality and Safety Improvement in Spine Surgery

STUDY DESIGN

Review article.

OBJECTIVES

A narrative review of the literature on the current advances and limitations in quality and safety improvement initiatives in spine surgery.

METHODS

A comprehensive literature search was performed using Ovid MEDLINE focusing on 3 preidentified concepts: (1) quality and safety improvement, (2) reporting of outcomes and adverse events, and (3) prediction model and practice guidelines. The search was conducted under appropriate subject headings and using relevant text words. Articles were screened, and manuscripts relevant to this discussion were included in the narrative review.

RESULTS

Quality and safety improvement remains a major research focus attracting investigators from the global spine community. Multiple databases and registries have been developed for the purpose of generating data and monitoring the progress of quality and safety improvement initiatives. The development of various prediction models and clinical practice guidelines has helped shape the care of spine patients in the modern era. With the reported success of exemplary programs initiated by the Northwestern and Seattle Spine Team, other quality and safety improvement initiatives are anticipated to follow. However, despite these advancements, the reporting metrics for outcomes and adverse events remain heterogeneous in the literature.

CONCLUSION

Constant surveillance and continuous improvement of the quality and safety of spine treatments is imperative in modern health care. Although great advancement has been made, issues with reporting outcomes and adverse events persist, and improvement in this regard is certainly needed.

Spinal Surgeon Variation in Single-Level Cervical Fusion Procedures: A Cost and Hospital Resource Utilization Analysis

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To compare perioperative costs and outcomes of patients undergoing single-level anterior cervical discectomy and fusions (ACDF) at both a service (orthopedic vs. neurosurgical) and individual surgeon level.

SUMMARY OF BACKGROUND DATA

Hospital systems are experiencing significant pressure to increase value of care by reducing costs while maintaining or improving patient-centered outcomes. Few studies have examined the cost-effectiveness cervical arthrodesis at a service level.

METHODS

A retrospective review of patients who underwent a primary 1-level ACDF by eight surgeons (four orthopedic and four neurosurgical) at a single academic institution between 2013 and 2015 was performed. Patients were identified by Diagnosis-Related Group and procedural codes. Patients with the ninth revision of the International Classification of Diseases coding for degenerative cervical pathology were included. Patients were excluded if they exhibited preoperative diagnoses or postoperative social work issues affecting their length of stay. Comparisons of preoperative demographics were performed using Student t tests and chi-squared analysis. Perioperative outcomes and costs for hospital services were compared using multivariate regression adjusted for preoperative characteristics.

RESULTS

A total of 137 patients diagnosed with cervical degeneration underwent single-level ACDF; 44 and 93 were performed by orthopedic surgeons and neurosurgeons, respectively. There was no difference in patient demographics. ACDF procedures performed by orthopedic surgeons demonstrated shorter operative times (89.1 ± 25.5 vs. 96.0 ± 25.5 min; P = 0.002) and higher laboratory costs (Δ+$6.53 ± $5.52 USD; P = 0.041). There were significant differences in operative time (P = 0.014) and labor costs (P = 0.034) between individual surgeons. There was no difference in total costs between specialties or individual surgeons.

CONCLUSION

Surgical subspecialty training does not significantly affect total costs of ACDF procedures. Costs can, however, vary between individual surgeons based on operative times. Variation between individual surgeons highlights potential areas for improvement of the cost effectiveness of spinal procedures.

LEVEL OF EVIDENCE

4.

Treatment of degenerative cervical spondylosis with radiculopathy. Clinical practice guidelines endorsed by The Polish Society of Spinal Surgery

INTRODUCTION

Degenerative cervical spondylosis (DCS) with radiculopathy is the most common indication for cervical spine surgery despite favorable natural history. Advances in spinal surgery in conjunction with difficulties in measuring the outcomes caused the paucity of uniform guidelines for the surgical management of DCS.

AIMS

The aim of this paper is to develop guidelines for surgical treatment of DCS. For this purpose the available up-to-date literature relevant on the topic was critically reviewed.

METHODS AND RESULTS

Six questions regarding most important clinical questions encountered in the daily practice were formulated. They were answered based upon the systematic literature review, thus creating a set of guidelines. The guidelines were categorized into four tiers based on the level of evidence (I-III and X). They were designed to assist in the selection of optimal and effective treatment leading to the most successful outcome.

CONCLUSIONS

The evidence based medicine (EBM) is increasingly popular among spinal surgeons. It allows making unbiased, optimal clinical decisions, eliminating the detrimental effect of numerous conflicts of interest. The key role of opinion leaders as well as professional societies is to provide guidelines for practice based on available clinical evidence. The present work contains a set of guidelines for surgical treatment of DCS officially endorsed by the Polish Spine Surgery Society.