Cervical Spine Surgery: Disagreement of Experts
Disagreement Over Cervical Spine Surgery
Agreement among the surgeons was poor with regard to the specific levels requiring surgery.
A new study demonstrates that there is substantial disagreement over the indications for cervical surgery among experienced spine surgeons. “The surgeons agreed upon the indications for operative treatment of …patients with cervical spondylotic [degenerative] disease only two thirds of the time,” according to Alan S. Hilibrand, MD, and colleagues. (See Hilibrand et al., 1999.) They also found disagreement among the same surgeons as to how they would approach specific cases. “Agreement among the surgeons was poor with regard to the specific levels requiring surgery, even between surgeons with similar training and practice focus,” they noted. Hilibrand et al. compared the consistency of the surgical decisions of five prominent cervical surgeons (four orthopaedic surgeons and one neurosurgeon) in an academic practice setting. The researchers presented each surgeon with information about 18 patients with cervical spondylosis who had failed nonoperative management and were considering surgery. In each case, the surgeons analyzed the clinical history, physical examination, MRI, and CT-myelogram. The surgeons were asked to answer the following questions for each case: (1) Is surgery indicated? (2) What is the best approach (anterior, posterior, or combined)? (3) Which levels require decompression? and (4) What should be the technique of reconstruction? The surgeons agreed the patients should have surgery in two thirds of the cases (12 of 18). In these 12 surgical cases, the five surgeons agreed upon the operative approach about 75% of the time. The surgeons showed substantial disagreement about specific levels requiring decompression in these 12 procedures, however. All agreed about the specific levels requiring decompression in only two out of the 12 cases. There was greater agreement about specific surgical techniques. In cases involving multilevel disease, for instance, all surgeons recommended corpectomy/strut grafting.
“These findings suggest that patients and insurers are likely to hear different surgeons recommending different surgical plans, even when the surgeons have similar training,” Hilibrand et al. note. There could be several reasons for the observed variability. Cervical degeneration takes on myriad patterns, and surgeons must intervene in complex degenerative processes. “There may not be only one path to an optimal result,” comments nerurosurgeon John D. Loeser, MD. “Some patients are more risk aversive than others. Some docs think that preventing a problem at an adjacent level may be worth the extra risk of more surgery.” Diagnostic technology for cervical complaints is in many respects primitive, especially when it comes to distinguishing symptomatic from asymptomatic abnormalities. There is also a lack of high-quality controlled trials comparing specific surgical techniques with other operative and nonoperative treatments. In addition, there does not seem to be a consensus among surgeons as to what constitutes “state-of-the-art” practice in cervical surgery.
Reference:
Hilibrand A et al.,Variability in the surgical management of cervical spondylosis, presented at the annual meeting, North American Spine Society, Chicago, 1999; as yet unpublished. m
Taken from "The Back Letter", Volume 14, Number 12, 1999