In the United States and most of the world, spine surgery is performed by both orthopaedic (OS) and neurological surgeons (NS). Patients and referring providers may have beliefs about how training background influences spine surgeon practice patterns and outcomes and may select a surgeon based on this factor. Few studies have evaluated how specialty (OS vs. NS) affects outcomes, so most beliefs held by physicians and patients are based on anecdotal evidence. To address this gap in the literature, Dr. Kim and his colleagues from Chicago used the National Surgical Quality Improvement Program database to compare 30 day complication rates between OS and NS patients undergoing single level lumbar fusion. Data from 2006-2011 were included, and about 3,000 patients were identified for analysis. Due to potential selection bias and confounding, propensity score matching was performed to create two matched groups including about 1,250 patients in each group. The unmatched groups were remarkably similar, with the only significant differences being that the NS group included more smokers and ASA class 3 and 4 patients. After matching, these differences were no longer present. In terms of surgical variables, the NS group included slightly more posterior lumbar interbody fusion patients, and the OS group slightly more anterior lumbar interbody fusion patients. The operative time was about 30 minutes longer for the NS group. The overall complication rate was approximately 7%, and there were no significant differences in overall, surgical or medical complications between the OS and NS patients in either the unmatched or matched analyses. Re-operation and mortality were also similar for the two cohorts.
This study supports the concept that complication rates are not influenced by spine surgeon specialty and should help patients and referring providers overcome biases about theoretical differences between orthopaedic and neurological spine surgeons. While previous literature has suggested that orthopaedic surgeons are more likely to perform fusions than neurosurgeons, it seems as though differences in spine surgery practice patterns between the two specialties are diminishing. 1 Unfortunately, the limited amount of data available in the NSQIP precludes any firm conclusions about the increasing similarity of orthopaedic and neurological spine surgeons. Patient reported measures are the gold standard outcomes in spine surgery, and these are not available in NSQIP. Additionally, the complications captured in NSQIP tend not to be surgeon dependent and are more related to patient factors (i.e. infection rate, medical complications, mortality, etc.) Surgeon influenced technical complications such as nerve injury, dural tear, hardware malposition, and pseudarthrosis are not recorded. The overall complication rate of 7% is also quite low and reflects the limited number of complications captured in the database and the short temporal window included. While this paper indicates that overall complication rates are similar for the two specialties, this outcome is probably not the most important one to patients who are selecting a surgeon. Future studies should consider differences in indications for surgery, type of surgery selected, and patient reported outcomes. These are probably more relevant to patients and referring providers and may show more differences between the two specialties. Most spine surgeons would likely agree that surgeon specialty is probably no longer the major driver of differences in practice patterns and outcomes in spine surgery. It seems as though we are moving towards an era in which spine surgeons are just spine surgeons rather than orthopaedists or neurosurgeons, but it may take a while for the rest of the medical world to realize this.
Please read Dr. Kim’s article on this topic in the July 1 issue. Does this article change how you view the effect of spine surgeon specialty on outcomes? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor
1. Bederman SS, Kreder HJ, Weller I, Finkelstein JA, Ford MH, Yee AJ. 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. Can J Surg 2009;52:283-90.