Does the Specialty of the Surgeon Performing Elective Anterior/Lateral Lumbar Interbody Fusion for Degenerative Spine Disease Correlate with Early Perioperative Outcomes?

Establishing case volume benchmarks for ACGME-accredited orthopedic surgery of the spine fellowship training

BACKGROUND CONTEXT

There has been increasing scrutiny on the standardization of surgical training in the US.

PURPOSE

This study provides case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopedic spine surgery fellowship training.

STUDY DESIGN/SETTING

This was a retrospective cross-sectional study of fellows at ACGME-accredited orthopedic spine surgery fellowships (2017-2022).

PATIENT SAMPLE

N/A.

OUTCOME MEASURES

Reported case volume during fellowship training.

METHODS

Case volume percentiles were calculated across ACGME-defined case categories and temporal changes assessed via linear regression. Variability between the highest and lowest deciles by case volume was calculated as fold-differences (90th percentile/10th percentile). Sensitivity analyses were performed to identify potential targets for case minimum requirements.

RESULTS

A total of 163 spine surgery fellows were included in this study. Total mean reported spine surgery case volume increased from 313.2±122 in 2017 to 382.0±164 in 2022 (p=.19). Most cases were classified as adult (range, 97.2%-98.0%) over pediatric cases (range, 2.0%-2.8%). An average of 322.0 cases were reported and most were classified as laminectomy (32%), posterior arthrodesis (29%), and anterior arthrodesis (20%). Overall variability in total case volume was 2.4 and the greatest variability existed for posterior instrumentation (38.1), application of cage (34.6), anterior instrumentation (20.8), and fractures and dislocations (17.3). If case minimum requirements for total reported cases was assumed at 200 cases, then all spine fellows included in this study would achieve this requirement. However, if case minimum requirements were assumed at 250 total cases, then approximately thirty percent of fellows (n=49) would not achieve this requirement for graduation.

CONCLUSIONS

Increasingly, national societies and accrediting bodies for surgical education recognize the need for standardized training. This study provides benchmarks to inform potential case minimum requirements and help reduce variability during spine fellowship training. Future studies are needed to establish case minimum requirements for spine surgery fellowship training across comprehensive and granular case categories that cover the full gamut of orthopedic spine surgery.

Surgeon Experience Matters: An Exact Matched Analysis of TLIF Outcomes Demonstrates No Difference in Surgical Outcomes Between Experienced Neurosurgeons and Orthopedic Surgeons

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare surgical and medical complications profile between neurosurgeons and orthopedic surgeons after transforaminal lumbar interbody fusion (TLIF) procedures.

BACKGROUND

Studies comparing the impact of spine surgeon specialty (neurosurgery vs. orthopedic spine) on TLIF outcomes have been inconclusive and failed to control for operative learning curves and surgical maturity. Orthopedic spine surgeons perform fewer spine procedures in residency, although these differences may be attenuated by mandatory fellowship before starting practice. Any observed differences are likely attenuated with increasing surgeon experience.

MATERIALS AND METHODS

Using an all-payer claims database, PearlDiver Mariner, 120 million patient records were analyzed between 2010 and 2022, to identify individuals with lumbar stenosis or spondylolisthesis who underwent index one- to three-level TLIF procedures. International Classification of Diseases-Ninth Edition (ICD-9), International Classification of Diseases-10th Edition (ICD-10) and Current Procedural Terminology (CPT) codes were used to query the database. Only Neurosurgeons and Orthopedic spine surgeons who had performed at least 250 procedures were included in the study. Patients undergoing surgery for tumor, trauma, or infection were excluded. 1:1 exact matching was performed using demographic factors, medical comorbidities, and surgical factors which were significantly associated with all-cause surgical or medical complications in a linear regression model.

RESULTS

1:1 exact matching created two equal groups of 18,195 patients without baseline differences who underwent TLIF procedures by neurosurgeons or orthopedic surgeons. There was no difference in all-cause surgical complications between neurosurgeons and orthopedic spine surgeons (relative risk=1.008, 95% CI: 0.850-1.195, P =0.965). All-cause medical complication rate was higher in the neurosurgery cohort (relative risk=1.144, 95% CI: 1.042-1.258, P =0.005).

CONCLUSION

The results of this study suggest that after accounting for surgical maturity, neurosurgeons and orthopedic spine surgeons have similar surgical outcomes. However, neurosurgeons have higher all-cause medical complication rates compared with orthopedic spine surgeons. Further research is warranted to validate this relationship in other spine procedures and for other outcomes.

Influence of Surgeon Specialty on 30-day Outcomes Following Single-Level Cervical Disc Arthroplasty: A Propensity-Matched Analysis

STUDY DESIGN

Retrospective, propensity-matched analysis.

OBJECTIVES

Cervical disc arthroplasty (CDA) is being increasingly utilized for cervical disc generation. Surgeon specialty has been shown to influence the risk for postoperative complications in spine surgery, but this has not yet been explored for CDA. Thus, the purpose of this study is to determine whether there is any difference in 30-day complications between patients undergoing single-level CDA by neurosurgeons vs by orthopaedic surgeons.

METHODS

A retrospective, 1:1 propensity score matched analysis was performed using the NSQIP database from 2015 to 2020. Patient demographics, operative characteristics, and postoperative complications were recorded. Independent multivariate logistic regression models were constructed using the propensity-matched dataset to assess surgical specialty influence on any complication, any site complication, any operative infection, and any medical complications.

RESULTS

3179 single-level CDAs (28.8% orthopaedic surgery patients, 71.2% neurosurgery patients) were identified that met the inclusion criteria. Well-matched cohorts of 916 patients each were generated. After controlling for all possible confounders, orthopedic surgery specialty was not associated with a higher odds for any complication (OR: .87, 95% CI: .35 - 2.20, P = .7696), any site complication (OR: .32, 95% CI: .08 - 1.32, P = .1359), any operative infection (OR: .31, 95% CI: .07 - 1.34), P = .1172), nor any medical complication (OR: 2.11, 95% CI: .62 - 7.20, P = .2311) vs neurosurgery.

CONCLUSION

This is the first propensity-matched analysis to show that spine surgeon specialty does not influence the risk for any complication, any site complication, any operative infection, nor any medical complication following single-level CDA within the first 30 days after surgery.

Specialty Impact on Patient Outcomes: Paving a Way for an Integrated Approach to Spinal Disorders

Spinal surgical procedures are steadily increasing globally due to broad indications of certain techniques encompassing a wide spectrum of conditions, including degenerative spine disorders, congenital anomalies, spinal metastases, and traumatic spinal fractures. The two specialties, neurosurgery (NS) and orthopedic surgery (OS), both possess the clinical adeptness to perform these procedures. With the advancing focus on comparative effectiveness research, it is vital to compare patient outcomes in spine surgeries performed by orthopedic surgeons and neurosurgeons, given their distinct approaches and training backgrounds to guide hospital programs and physicians to consider surgeon specialty when making informed decisions. Our review of the available literature revealed no significant difference in postoperative outcomes in terms of blood loss, neurological deficit, dural injury, intraoperative complications, and postoperative wound dehiscence in procedures performed by neurosurgeons and orthopedic surgeons. An increase in blood transfusion rates among patients operated by orthopedic surgeons and a longer operative time of procedures performed by neurosurgeons was a consistent finding among several studies. Other findings include a prolonged hospital stay, higher hospital readmission rates, and lower cost of procedures in patients operated on by orthopedic surgeons. A few studies revealed lower sepsis rates unplanned intubation rates and higher incidence of urinary tract infections (UTIs) and pneumonia postoperatively among patient cohorts operated by neurosurgeons. Certain limitations were identified in the studies including the use of large databases with incomplete information related to patient and surgeon demographics. Hence, it is imperative to account for these confounding variables in future studies to alleviate any biases. Nevertheless, it is essential to embrace a multidisciplinary approach integrating the surgical expertise of the two specialties and develop standardized management guidelines and techniques for spinal disorders to mitigate complications and enhance patient outcomes.

Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty

BACKGROUND CONTEXT

Surgery to correct adult spinal deformity (ASD) is performed by both neurological surgeons and orthopedic surgeons. Despite well-documented high costs and complication rates following ASD surgery, there is a dearth of research investigating trends in treatment according to surgeon subspeciality.

PURPOSE

The purpose of this investigation was to perform an analysis of surgical trends, costs and complications of ASD operations by physician specialty using a large, nationwide sample.

STUDY DESIGN/SETTING

Retrospective cohort study using an administrative claims database.

PATIENT SAMPLE

A total of 12,929 patients were identified with ASD that underwent deformity surgery performed by neurological or orthopedic surgeons.

OUTCOME MEASURES

The primary outcome was surgical case volume by surgeon specialty. Secondary outcomes included costs, medical complications, surgical complications, and reoperation rates (30-day, 1-year, 5-year, and total).

METHODS

The PearlDiver Mariner database was queried to identify patients who underwent ASD correction from 2010 to 2019. The cohort was stratified to identify patients who were treated by either orthopedic or neurological surgeons. Surgical volume, baseline characteristics, and surgical techniques were examined between cohorts. Multivariable logistic regression was employed to assess the cost, rate of reoperation and complication according to each subspecialty while controlling for number of levels fused, rate of pelvic fixation, age, gender, region and Charlson Comorbidity Index (CCI). Alpha was set to 0.05 and a Bonferroni correction for multiple comparisons was utilized to set the significance threshold at p ≤.000521.

RESULTS

A total of 12,929 ASD patients underwent deformity surgery performed by neurological or orthopedic surgeons. Orthopedic surgeons performed most deformity procedures accounting for 64.57% (8,866/12,929) of all ASD operations, while the proportion treated by neurological surgeons increased 44.2% over the decade (2010: 24.39% vs 2019: 35.16%; p<.0005). Neurological surgeons more frequently operated on older patients (60.52 vs 55.18 years, p<.0005) with more medical comorbidities (CCI scores: 2.01 vs 1.47, p<.0005). Neurological surgeons also performed higher rates of arthrodesis between one and six levels (OR: 1.86, p<.0005), three column osteotomies (OR: 1.35, p<.0005) and navigated or robotic procedures (OR: 3.30, p<.0005). Procedures performed by orthopedic surgeons had significantly lower average costs as compared to neurological surgeons (orthopedic surgeons: $17,971.66 vs neurological surgeons: $22,322.64, p=.253). Adjusted logistic regression controlling for number of levels fused, pelvic fixation, age, sex, region, and comorbidities revealed that patients within neurosurgical care had similar odds of complications to orthopaedic surgery.

CONCLUSIONS

This investigation of over 12,000 ASD patients demonstrates orthopedic surgeons continue to perform the majority of ASD correction surgery, although neurological surgeons are performing an increasingly larger percentage over time with a 44% increase in the proportion of surgeries performed in the decade. In this cohort, neurological surgeons more frequently operated on older and more comorbid patients, utilizing shorter-segment fixation with greater use of navigation and robotic assistance.