Differences in the Surgical Treatment of Lower Back Pain Among Spine Surgeons in the United States

Study Design. Electronic survey. Objective. To identify the surgical treatment patterns for low back pain (LBP), among U.S. spine surgeons. Specifically determine (1) differences in surgical treatment responses based on various demographic variables; (2) probability of disagreement based on surgeon subgroups. Summary of Background Data. Multiple surgical and nonsurgical treatments exist for LBP. Without strong evidence or clear guidelines for the indications and optimal treatments, there is substantial variability in surgical treatments used. Methods. A total of 445 U.S. spine surgeons completed a survey of clinical and radiographic case scenarios on patients with mechanical LBP, no leg pain, and concordant discograms. Surgical treatment options included no surgery, anterior lumbar interbody fusion (ALIF), posterolateral fusion with pedicle screws, transforaminal/posterior lumbar interbody fusion (TLIF/PLIF), etc. Statistical significance was set at 0.01 to account for multiple comparisons. Results. There was substantial clinical equipoise (∼75% disagreement) among surgeons on the approach to treat patients with LBP. Disagreement was highest in the southwest and lowest in the Midwest (82% vs. 69%, respectively); there was significantly lower disagreement among those in academic practices versus those in private/hybrid practices (56% vs.79%, respectively). Those in academic practices had approximately four times greater odds of choosing no surgery as compared to those in hybrid and private practices, who were more likely to choose ALIF or PLIF/TLIF. Those with fellowship training had approximately two times greater odds of selecting no surgery and four times greater odds of selecting ALIF as compared to those without fellowship training who were more likely to select TLIF/PLIF. Conclusion. Significant differences exist among U.S. spine surgeons in the treatment of LBP. These differences stem from geographical location of the practice, specialty, practice type, and fellowship training. Recognizing the substantial variability underlies the importance of additional studies aimed at identifying the proper indications and most cost-effective treatments for LBP. Level of Evidence: 3

[1]  Alan H. Daniels,et al.  Variability in spine surgery procedures performed during orthopaedic and neurological surgery residency training: an analysis of ACGME case log data. , 2014, The Journal of bone and joint surgery. American volume.

[2]  N. Obuchowski,et al.  Differences in the surgical treatment of recurrent lumbar disc herniation among spine surgeons in the United States. , 2014, The spine journal : official journal of the North American Spine Society.

[3]  Alan H. Daniels,et al.  The Current State of United States Spine Surgery Training: A Survey of Residency and Spine Fellowship Program Directors , 2014, Spine deformity.

[4]  G. Murtaza,et al.  Variations in Practice Patterns among Neurosurgeons and Orthopaedic Surgeons in the Management of Spinal Disorders , 2011, Asian spine journal.

[5]  Jeffrey C. Wang,et al.  Geographic and Demographic Variability of Cost and Surgical Treatment of Idiopathic Scoliosis , 2010, Spine.

[6]  Joel A Finkelstein,et al.  The who, what and when of surgery for the degenerative lumbar spine: a population-based study of surgeon factors, surgical procedures, recent trends and reoperation rates. , 2009, Canadian journal of surgery. Journal canadien de chirurgie.

[7]  Z. Isaac,et al.  Discography in practice: a clinical and historical review , 2007, Current reviews in musculoskeletal medicine.

[8]  R. Pietrobon,et al.  Geographic variation in lumbar fusion for degenerative disorders: 1990 to 2000. , 2007, The spine journal : official journal of the North American Spine Society.

[9]  James N Weinstein,et al.  United States’ Trends and Regional Variations in Lumbar Spine Surgery: 1992–2003 , 2006, Spine.

[10]  M. Fehlings,et al.  Agreement Between Orthopedic Surgeons and Neurosurgeons Regarding a New Algorithm for the Treatment of Thoracolumbar Injuries: A Multicenter Reliability Study , 2006, Journal of spinal disorders & techniques.

[11]  R. Deyo,et al.  Trends and variations in the use of spine surgery. , 2006, Clinical orthopaedics and related research.

[12]  Robert A Hart,et al.  Variation in Surgical Decision Making For Degenerative Spinal Disorders. Part II: Cervical Spine , 2005, Spine.

[13]  A. Hilibrand,et al.  Variation in Surgical Decision Making for Degenerative Spinal Disorders. Part I: Lumbar Spine , 2005, Spine.

[14]  R A Deyo,et al.  An Assessment of Surgery for Spinal Stenosis: Time Trends, Geographic Variations, Complications, and Reoperations , 1996, Journal of the American Geriatrics Society.

[15]  D. Nilasena,et al.  Surgical Trends in the Treatment of Diseases of the Lumbar Spine in Utah's Medicare Population, 1984 to 1990 , 1995, Medical care.

[16]  R. Deyo,et al.  An International Comparison of Back Surgery Rates , 1994, Spine.

[17]  Y. Rampersaud,et al.  Differences between neurosurgeons and orthopedic surgeons in classifying cervical dislocation injuries and making assessment and treatment decisions: a multicenter reliability study. , 2009, American journal of orthopedics.