Variation in Surgical Decision Making For Degenerative Spinal Disorders. Part II: Cervical Spine

Zareth N. Irwin, MD; Alan Hilibrand, MD; Michael Gustavel, MD; Robert McLain, MD; William Shaffer, MD; Mark Myers, MD; John Glaser, MD; Robert A. Hart, MD


Spine. 2005;30(19):2208-2213. 

In This Article

Abstract and Introduction

Study Design: Survey-based descriptive study.
Objective: To study relationships between surgeon-specific factors and surgical approach to degenerative diseases of the cervical spine.
Summary of Background Data: Geographic variations in the rates of cervical spine surgery are significant within the United States. Although surgeon density correlates with the rates of spinal surgery, other reasons for variation such as surgeon-specific factors are poorly understood.
Methods: A total of 22 orthopedic surgeons and 8 neurosurgeons of varied ages and geographic regions answered questions regarding the need for surgery, surgical approach, and use of fusion and instrumentation for 5 simulated cases. Cases included: (1) single-level disc herniation with osteophyte and radiculopathy, (2) single-level pseudarthrosis with axial neck pain, (3) multilevel stenosis with radiculopathy and neutral lordosis, (4) multilevel stenosis with myelopathy and neutral lordosis, and (5) multilevel stenosis with myelopathy and marked kyphosis. The effects of surgeon age and training background on surgical decision making were analyzed using an independent samples t test and Fisher exact test, respectively.
Results: The greatest agreement occurred for the single-level disc herniation, with all surgeons choosing an anterior discectomy, and 28 of the 29 respondents recommending fusion. Younger surgeons recommended instrumentation more often for all cases, reaching significance for the case of multilevel stenosis with myelopathy and neutral lordosis (Fisher exact test P = 0.02). Differences in recommendation for fusion, instrumentation, and the use of a posterior approach between orthopedic and neurosurgeons were limited.
Conclusions: Variations in surgical procedures for cervical degenerative disease may depend on the clinical condition. Although this study found strong agreement in treatment approach to single-level disc herniation, significant variation was seen for the other degenerative conditions of the cervical spine. While differences in recommendation for fusion were not clearly associated with surgeon age, there was a trend toward the higher use of instrumentation by younger surgeons. Previously documented geographic variation may result in part from a lack of consensus regarding appropriate treatment techniques for certain degenerative conditions of the cervical spine, as well as surgeon-specific factors.

More than 10-fold geographic variations have been shown in the per capita rates of cervical spine surgery in the United States.[1,2] Although geographic variations in medical practice patterns and population features may produce geographic differences in the rates of spine surgery, it is unlikely that these factors account for all observed variation.[1] Factors inherent to individual surgeons' backgrounds, such as age and type of spine surgery training (orthopedic vs. neurosurgical), may also affect their approach to specific clinical problems and contribute to this variation.

Because multiple treatment options with reported success exist for the treatment of many degenerative conditions of the cervical spine,[3,4,5,6,7,8,9,10] there may be uncertainty regarding the optimal treatment method for a specific clinical condition. Such uncertainty forces surgeons to rely on personal clinical experience and training when choosing a treatment approach for a particular patient, and may thus also contribute to observed variation.

Examining differences in surgical decision making may help improve the consistency and success of surgical interventions. The Purpose of this study was to examine the extent of variation among spine surgeons in treatment decisions for 5 clinical scenarios involving degenerative conditions of the cervical spine. We also sought to assess the importance of training background and surgeon age as predictors of surgical approach to each of the individual cases.


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