Appropriateness of lumbar spine referrals to a neurosurgical service

Appropriateness of specialized care referrals for LBP: a cross-sectional analysis

Background

Low back pain (LBP) accounts for a significant proportion of primary care visits. Despite the development of evidence-based guidelines, studies point to the inefficient use of healthcare resources, resulting in over 60.0% of patients with LBP being referred to spine surgeons without any surgical indication. Centralized waiting lists (CWLs) have been implemented to improve access to specialized care by managing asymmetry between supply and demands. To date, no study has provided data on patients' clinical profiles and referral patterns to medical specialists for LBP in the context of a publicly funded healthcare system operating a prioritization model. The objective of this study was to evaluate the appropriateness of specialized care referrals for LBP after the implementation of a CWL.

Methods

A retrospective cross-sectional analysis of 500 randomly selected electronic health records of patients who attended the outpatient neurosurgery clinic of the administrative Mauricie-et-Centre-du-Québec region was performed. Inclusion criteria were neurosurgery consultation referrals for adults ≥18 years suffering from a primary complaint of LBP, and performed between September 1st, 2018, and September 1st, 2021. Data relevant for drawing a comprehensive portrait of patients referred to the neurosurgery service and for judging referrals appropriateness were manually extracted.

Results

Of the 500 cases analyzed, only 112 (22.4%) were surgical candidates, while 221 (44.2%) were discharge from the neurosurgery service upon initial assessment. Key information was inconsistently documented in medical files, thus preventing the establishment of a comprehensive portrait of patients referred to the neurosurgery service for LBP. Nevertheless, over 80.0% of referrals made during the study period were deemed inappropriate. Inappropriate referrals were characterized by higher proportion of patients symptomatically improved, presenting a back-dominant chief complaint, exhibiting no objective neurological symptoms, and diagnosed with non-specific LBP.

Conclusion

This study reveals a significant proportion of inappropriate referrals to specialized care for LBP. Further research is needed to better understand the factors that prompt referrals to medical specialists for LBP, and the criteria considered by neurosurgeons when selecting the appropriate management strategy. Recent studies suggest that triaging approaches led by musculoskeletal experts may improve referral appropriateness to specialized care.

Current Applications of Machine Learning in Spine: From Clinical View

STUDY DESIGN

Narrative review.

OBJECTIVES

This review aims to present current applications of machine learning (ML) in spine domain to clinicians.

METHODS

We conducted a comprehensive PubMed search of peer-reviewed articles that were published between 2006 and 2020 using terms (spine, spinal, lumbar, cervical, thoracic, machine learning) to examine ML in spine. Then exclude research of other domain, case report, review or meta-analysis, and which without available abstract or full text.

RESULTS

Total 1738 articles were retrieved from database, and 292 studies were finally included. Key findings of current applications were compiled and summarized in this review. Main clinical applications of those techniques including image processing, diagnosis, decision supporting, operative assistance, rehabilitation, surgery outcomes, complications, hospitalization and cost.

CONCLUSIONS

ML had achieved excellent performance and hold immense potential in spine. ML could help clinical staff to improve medical level, enhance work efficiency, and reduce adverse events. However more randomized controlled trials and improvement of interpretability are essential to clinicians accepting models' assistance in real work.

Inappropriate use of clinical practices in Canada: a systematic review

Background:

Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada.

Methods:

We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level.

Results:

We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%–56.6%). Underuse (median 43.9%, IQR 23.8%–66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%–30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%–85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%–35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%–71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%–97.3%, n = 9).

Interpretation:

We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Nerve root sedimentation sign on MRI: A triage screen for leg dominant symptoms?

PURPOSE

Surgical indications for lumbar spinal stenosis are controversial, but most agree that leg dominant pain is a better predictor of success after decompression surgery. The objective of this study is to analyze the ability of the Nerve Root Sedimentation Sign (SedSign) on MRI to differentiate leg dominant symptoms from non-specific low back pain.

METHODS

This was a retrospective review of 367 consecutive patients presenting with back and/or leg pain. Baseline clinical characteristics included Oswestry disability index (ODI), visual analog pain scores, EuroQol Group 5-Dimension Self-Report (EQ5D) and Saskatchewan Spine Pathway Classification (SSPc). Inter- and intra-rater reliability for SedSign was 73% and 91%, respectively (3 examiners).

RESULTS

SedSign was positive in 111 (30.2%) and negative in 256 (69.8%) patients. On univariate analysis, a positive SedSign was correlated with age, male sex, several ODI components, EQ5D mobility, cross-sectional area (CSA) of stenosis, antero-posterior diameter of stenosis, and SSPc pattern 4 (intermittent leg dominant pain). On multivariate analysis, SedSign was associated with age, male sex, CSA stenosis and ODI walking distance. Patients with a positive SedSign were more likely to be offered surgery after referral (OR 2.65). The sensitivity and specificity for detecting all types of leg dominant pain were 37.4 and 82.8, respectively (ppv 77.5%, npv 43.8%).

CONCLUSIONS

Patients with a positive SedSign were more likely to be offered surgery, in particular non-instrumented decompression. The SedSign has high specificity for leg dominant pain, but the sensitivity is poor. As such, its use in triaging appropriate surgical referrals is limited.

Predicting Spinal Surgery Candidacy From Imaging Data Using Machine Learning

BACKGROUND

The referral process for consultation with a spine surgeon remains inefficient, given a substantial proportion of referrals to spine surgeons are nonoperative.

OBJECTIVE

To develop a machine-learning-based algorithm which accurately identifies patients as candidates for consultation with a spine surgeon, using only magnetic resonance imaging (MRI).

METHODS

We trained a deep U-Net machine learning model to delineate spinal canals on axial slices of 100 normal lumbar MRI scans which were previously delineated by expert radiologists and neurosurgeons. We then tested the model against lumbar MRI scans for 140 patients who had undergone lumbar spine MRI at our institution (60 of whom ultimately underwent surgery, and 80 of whom did not). The model generated automated segmentations of the lumbar spinal canals and calculated a maximum degree of spinal stenosis for each patient, which served as our biomarker for surgical pathology warranting expert consultation.

RESULTS

The machine learning model correctly predicted surgical candidacy (ie, whether patients ultimately underwent lumbar spinal decompression) with high accuracy (area under the curve = 0.88), using only imaging data from lumbar MRI scans.

CONCLUSION

Automated interpretation of lumbar MRI scans was sufficient to correctly determine surgical candidacy in nearly 90% of cases. Given that a significant proportion of referrals placed for spine surgery evaluation fail to meet criteria for surgical intervention, our model could serve as a valuable tool for patient triage and thereby address some of the inefficiencies within the outpatient surgical referral process.

Achieving Value in Spine Surgery: 10 Major Cost Contributors

STUDY DESIGN

Narrative Review.

OBJECTIVES

The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused-often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement.

METHODS

We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal-if any-clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive.

RESULTS

We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing.

CONCLUSIONS

In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.

Association between the appropriateness of surgery, according to appropriate use criteria, and patient-rated outcomes after surgery for lumbar degenerative spondylolisthesis

INTRODUCTION

Treatment failures in spine surgery are often attributable to poor patient selection and the application of inappropriate treatment. We used published appropriate use criteria (AUC) to evaluate the appropriateness of surgery in a large group of patients operated for lumbar degenerative spondylolisthesis (LDS) and to evaluate its association with outcome.

METHODS

This was a retrospective analysis of prospectively collected outcome data from patients operated in our Spine Centre, 2005-2012. Appropriateness of surgery was judged based on the AUC. Patients had completed the multidimensional Core Outcome Measures Index (COMI) before surgery and at 3 months' and 1, 2 and 5 years' follow-up (FU).

RESULTS

In total, 448 patients (69.8 ± 9.6 years; 323 (72%) women) were eligible for inclusion and the AUC could be applied in 393 (88%) of these. Surgery was considered appropriate (A) in 234 (59%) of the patients, uncertain/equivocal (U) in 90 (23%) and inappropriate (I) in 69 (18%). A/U patients had significantly (p < 0.05) greater improvements in COMI than I patients at each FU time point. The minimal clinically important change (MCIC) score for COMI was reached by 82% A, 76% U and 54% I patients at 1-year FU (p < 0.001, I vs A and U); the odds of achieving MCIC were 3-4 times greater in A/U patients than in I patients.

CONCLUSIONS

The results suggest a relationship between appropriateness of surgery for LDS and the improvements in COMI score after surgery. The findings require confirmation in prospective studies that also include a control group of non-operated patients.

The Use of a Self-Administered Questionnaire to Reduce Consultation Wait Times for Potential Elective Lumbar Spinal Surgical Candidates: A Prospective, Pragmatic, Blinded, Randomized Controlled Quality Improvement Study

BACKGROUND

In a public health-care system, patients often experience lengthy wait times to see a spine surgeon for consultation, and most patients are found not to be surgical candidates, thereby prolonging the wait time for those who are. The aim of this study was to evaluate whether a self-administered 3-item questionnaire (3IQ) could reprioritize consultation appointments and reduce wait times for lumbar spinal surgical candidates.

METHODS

This prospective, pragmatic, blinded, randomized controlled quality improvement study was conducted at a single Canadian academic health-care center. This study enrolled 227 consecutive eligible participants with an elective lumbar condition who were referred for consultation with a spine surgeon. All participants were mailed the 3IQ after their referral was received. Patients were randomized into the intervention group, in which leg-dominant pain reported on the 3IQ resulted in an upgrade in priority to be seen, or into the control group, in which no change to wait-list priority occurred. The main outcome measured was time to consultation for participants who were deemed surgical candidates following consultation.

RESULTS

There were no significant differences between groups with regard to demographics, overall group wait times, proportion of surgical candidates, or disability. A total of 33 patients were deemed surgical candidates after consultation. The median wait from referral to consultation was shorter for the 16 surgical candidates in the intervention group (2.5 months; interquartile range [IQR]: 2.0 to 4.8 months) compared with the 17 surgical candidates in the control group (4.5 months; IQR: 3.4 to 6.9 months; p = 0.090). The odds of seeing a surgical candidate within the acceptable time frame of 3 months were 5.4 times greater (95% confidence interval: 1.2 to 24.5 times; p = 0.024) in the intervention group.

CONCLUSIONS

The use of a simple, self-administered questionnaire to reprioritize referrals resulted in shorter consultation wait times for patients who required a surgical procedure and significantly increased the number of surgical candidates seen within the acceptable time frame. It may be valuable to consider adding the 3IQ to clinical care practices to better triage these patients on waiting lists.

Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings

BACKGROUND

The Inter-professional Spine Assessment and Education Clinics (ISAEC) were developed to improve primary care assessment, education and management of patients with persistent or recurrent low back pain-related symptoms. This study aims to determine the effect of ISAEC on access for surgical assessment, referral appropriateness and efficiency for patients meeting a priori referral criteria in rural, urban and metropolitan settings.

METHODS

We conducted a retrospective review of prospective data from networked ISAEC clinics in Thunder Bay, Hamilton and Toronto, Ontario. For patients meeting surgical referral criteria, wait times for surgical assessment, surgical referral-related magnetic resonance imaging (MRI) scans and appropriateness of referral were recorded.

RESULTS

Overall 422 patients, representing 10% of all ISAEC patients in the study period, were referred for surgical assessment. The average wait times for surgical assessment were 5.4, 4.3 and 2.2 weeks at the metropolitan, urban and rural centres, respectively. Referral MRI usage for the group decreased by 31%. Of the patients referred for formal surgical assessment, 80% had leg-dominant pain and 96% were deemed appropriate surgical referrals.

CONCLUSION

Contrary to geographic concentration of health care resources in metropolitan settings, the greatest decrease in wait times was achieved in the rural setting. A networked, shared-cared model of care for patients with low back pain-related symptoms significantly improved access for surgical assessment despite varying geographic practice settings and barriers. The greatest reductions were noted in the rural setting. In addition, significant improvements in referral appropriateness and efficiency were achieved compared with historical reports across all sites.

Self-referrals versus physician referrals: What new patient visit yields an actual surgical case?

OBJECTIVE Spine surgeons in the United States continue to be overwhelmed by an aging population, and patients are waiting weeks to months for appointments. With a finite number of clinic visits per surgeon, analysis of referral sources needs to be explored. In this study, the authors evaluated patient referrals and their yield for surgical volume at a tertiary care center. METHODS This is a retrospective study of new patient visits by the spine surgery group at the Cleveland Clinic Center for Spine Health from 2011 to 2016. Data on all new or consultation visits for 5 identified spinal surgeons at the Center for Spine Health were collected. Patients with an identifiable referral source and who were at least 18 years of age at initial visit were included in this study. Univariate analysis was used to identify demographic differences among referral groups, and then multivariate analysis was used to evaluate those referral groups as significant predictors of surgical yield. RESULTS After adjusting for demographic differences across all referrals, multivariate analysis identified physician referrals as more likely (OR 1.48, 95% CI 1.04-2.10, p = 0.0293) to yield a surgical case than self-referrals. General practitioner referrals (OR 0.5616, 95% CI 0.3809-0.8278, p = 0.0036) were identified as less likely to yield surgical cases than referrals from interventionalists (OR 1.5296, p = 0.058) or neurologists (OR 1.7498, 95% CI 1.0057-3.0446, p = 0.0477). Additionally, 2 demographic factors, including distance from home and age, were identified as predictors of surgery. Local patients (OR 1.21, 95% CI 1.13-1.29, p = 0.018) and those 65 years of age or older (OR 0.80, 95% CI 0.72-0.87, p = 0.0023) were both more likely to need surgery after establishing care with a spine surgeon. CONCLUSIONS In conclusion, referrals from general practitioners and self-referrals are important areas where focused triaging may be necessary. Further research into midlevel providers and nonsurgical spine provider's role in these referrals for spine pathology is needed. Patients from outside of the state or younger than 65 years could benefit from pre-visit screening as well to optimize a surgeon's clinic time use and streamline patient care.

Managing spine surgery referrals: The consultation of neurosurgery and its nuances

INTRODUCTION

Spinal disorders, particularly low back pain, are among the most common reasons for general practitioner (GP) consultation and can sometimes be a source of professional friction. Despite their frequency and published guidelines, many patients are still mistakenly referred by their GP to specialists for spinal surgery consultation which can create colleague relationship problems, suboptimal or unnessary delayed care, as well as the financial implications for patients.

PURPOSE

To assess the management of GP lumbar spine referrals made to 4 neurosurgeons from 3 neurosurgical teams specialized in spinal surgery.

METHODS

All patient's medical records relating to 672 primary consultants over a period of two months (January and February 2015) at three institutions were retrospectively reviewed. Medical referral letters, clinical evidence and imaging data were analyzed and the patients were classified according the accuracy of surgical assessment. The final decisions of the surgeons were also considered.

RESULTS

Of the 672 patients analyzed, 198 (29.5%) were considered unsuitable for surgical assessment: no spinal pathology=10.6%, no surgical conditions=35.4%, suboptimal medical treatment=31.3%, suboptimal radiology=18.2% and asymptomatic patients=4.5%.

CONCLUSION

Unnecessary referrals to our consultation centers highlight the gap between the reason for the consultation and the indications for spinal surgery. Compliance with the guidelines, the creation of effective multidisciplinary teams, as well as the "hands on" involvement of surgeons in primary and continuing education of physicians are the best basis for a reduction in inappropriate referrals and effective patient care management.

Dural sac cross-sectional area and morphological grade show significant associations with patient-rated outcome of surgery for lumbar central spinal stenosis

PURPOSE

Lumbar central spinal stenosis (LSS) is one of the most common reasons for spine surgery in the elderly patient. Magnetic resonance imaging (MRI) represents the gold standard for the assessment of LSS and can be used to obtain quantitative measures of the dural sac cross-sectional area (DCSA) or qualitative measures (morphological grades A-D) of the rootlet/cerebrospinal fluid ratio. This study investigated the intercorrelation between these two MRI evaluation methods and explored their respective relationships with the patient baseline clinical status and outcome 12 months after surgery.

METHODS

This was a retrospective analysis of prospectively collected data from 157 patients (88 male, 69 female; age 72 ± 7 years) who were undergoing first-time surgery for LSS. Patients with foraminal or isolated lateral stenosis were excluded. The Core Outcome Measures Index (COMI) was completed before and 12 months after surgery. Preoperative T2 axial MRIs were blinded and independently evaluated for DCSA and morphological grade. Spearman rank correlation coefficients described the relationship between the two MRI measures of stenosis severity and between each of these and the COMI baseline and change-scores (pre to 12 months' postop). Multiple logistic regression analysis (controlling for baseline COMI, age, gender, number of operated levels, health insurance status) was used to analyse the influence of stenosis severity on the achievement of the minimum clinically important change (MCIC) score for COMI and on global treatment outcome (GTO).

RESULTS

There was a correlation of ρ = -0.69 (p < 0.001) between DCSA and morphological grade. There was no significant correlation between COMI baseline scores and either DCSA or morphological grades (p > 0.85). However, logistic regression revealed significant (p < 0.05) associations between stenosis ratings and 12-month outcome, whereby patients with more severe stenosis (as measured using either of the methods) benefited more from the surgery. Patients with a DCSA <75 mm² or morphological grade D had a 4-13-fold greater odds of achieving the MCIC for COMI or a "good" GTO, compared with patients in the least severe categories of stenosis.

CONCLUSIONS

Postoperative outcome was clearly related to the degree of preoperative radiological LSS. The two MRI methods appeared to deliver similar information, as given by the relatively strong correlation between them and their comparable performance in relation to baseline and 12-month outcomes. However, the qualitative morphological grading can be performed in an instant, without measurement tools, and does not deliver less clinically useful information than the more complex and time-consuming measures; as such, it may represent the preferred method in the clinical routine for assessing the extent of radiological stenosis and the likelihood of a positive outcome after decompression.

Second opinion for degenerative spinal conditions: an option or a necessity? A prospective observational study

BACKGROUND

Second opinions may improve quality of patient care. The primary objective of this study was to determine the concordance between first and second diagnoses and opinions regarding need for spinal surgery among patients with back or neck pain that have been recommended spinal surgery.

METHODS

We performed a prospective observational study of patients who had been recommended for spinal surgery and received a second opinion between May 2011 and May 2012 at the Hospital Israelita Albert Einstein on the advice of their health insurance company. A physiatrist and orthopaedic surgeon independently performed the second assessment. If both agreed surgery was indicated, or consensus could not be reached, participants attended a spine review panel for a final recommendation. Descriptive analyses compared diagnoses and management plans of the first and second opinions.

RESULTS

Of 544 referred patients, 16 (2.9%) did not meet inclusion criteria, 43 (7.9%) refused participation and 485 were included. Diagnoses differed from the first opinion for 290 (59.8%). Diagnoses of cervical and lumbar radiculopathy were concordant in 36/99 (36.4%) and 116/234 (49.6%) respectively. The second opinion was for conservative treatment for 168 (34.6%) participants, 27 (5.6%) were not considered to have a spine condition, and 290 (59.8%) were referred to the review board. 60 participants did not attend the board review and therefore did not receive a final recommendation. Board review was conservative treatment for an additional 67 participants, 20 were not considered to have a spine condition and 143 participants were recommended surgery. Overall, 33.6% received a final opinion of surgery (143/425) although only 66 (15.5%) received the same surgical recommendation, 235 (55.3%) were advised to have conservative treatment, and 47 (11.1%) were not considered to have a spinal diagnosis.

CONCLUSIONS

We found a large discordance between first and second opinions regarding diagnosis and need for spinal surgery. This suggests that obtaining a second opinion could reduce potentially unnecessary surgery.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN07143259 . Registered 21 November 2011.

Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction

BACKGROUND

Surgery for lumbar spine pain is indicated for specific etiologies. Given the majority of individuals referred to spine surgeons are not surgical candidates, care delivery is inefficient, with consultations being of limited value for most. Using specially trained physiotherapists in triage is a human resource strategy that may optimize surgeons' time and the patient experience.

METHODS

An advanced-practice physiotherapist (APP) and a surgeon assessed consecutive patients with lumbar spine pain presenting at an academic health centre's spine surgery clinic. The second assessor was blinded to the outcome of the first. We used the κ statistic to evaluate surgeon-APP level of chance-corrected agreement concerning patients' need for a surgical consultation. To assess satisfaction with the APP, patients completed a modified version of the validated Visit-specific Questionnaire.

RESULTS

The sample included 102 participants (54 women) with a mean age of 54.3 ± 14.3 years and a mean Oswestry Disability Index score of 35.4 ± 16.6. The assessors' overall agreement was 86%. The κ coefficient for the need for a surgical consultation was 0.69 (95% confidence interval 0.54-0.84). The APP identified that 77% of patients did not require a surgical consultation. Twenty-one patients underwent surgery. Satisfaction scores for the APP were very high (mean score 92 out of 100).

CONCLUSION

In triaging patients with lumbar spine pain, the APP and surgeon had a high level of agreement. An APP performing triage at a surgical centre can effectively reduce wait lists by 70%, reserving surgical consultations for those patients in whom they are indicated.

Patients' Attitudes Toward Nonphysician Screening of Low Back and Low Back Related Leg Pain Complaints Referred for Surgical Assessment

STUDY DESIGN

A questionnaire survey.

OBJECTIVE

The aim of this study was to explore patient attitudes toward screening to assess suitability for low back surgery by nonphysician health care providers.

SUMMARY OF BACKGROUND DATA

Canadian spine surgeons have shown support for nonphysician screening to assess and triage patients with low back pain and low back related leg pain. However, patients' attitudes toward this proposed model are largely unknown.

METHODS

We administered a 19-item cross-sectional survey to adults with low back and/or low back related leg pain who were referred for elective surgical assessment at one of five spine surgeons' clinics in Hamilton, Ontario, Canada. The survey inquired about demographics, expectations regarding wait time for surgical consultation, as well as willingness to pay, travel, and be screened by nonphysician health care providers.

RESULTS

Eighty low back patients completed our survey, for a response rate of 86.0% (80 of 93). Most respondents (72.5%; 58 of 80) expected to be seen by a surgeon within 3 months of referral, and 88.8% (71 of 80) indicated willingness to undergo screening with a nonphysician health care provider to establish whether they were potentially a surgical candidate. Half of respondents (40 of 80) were willing to travel >50 km for assessment by a nonphysician health care provider, and 46.2% were willing to pay out-of-pocket (25.6% were unsure). However, most respondents (70.0%; 56 of 80) would still want to see a surgeon if they were ruled out as a surgical candidate, and written comments from respondents revealed concern regarding agreement between surgeons' and nonphysicians' determination of surgical candidates.

CONCLUSION

Patients referred for surgical consultation for low back or low back related leg pain are largely willing to accept screening by nonphysician health care providers. Future research should explore the concordance of screening results between surgeon and nonphysician health care providers.

LEVEL OF EVIDENCE

3.

The Use of Lumbar Spine Magnetic Resonance Imaging in Eastern China: Appropriateness and Related Factors

Back pain is common and costly. While a general scene of back pain related practice in China remains unknown, there are signs of excessive use of lumbar spine magnetic resonance (MR). We retrospectively studied 3107 lumbar spine MRIs in Eastern China to investigate the appropriateness of lumbar spine MR use. Simple back pain is the most common chief complaint for ordering a lumbar MR study. Only 41.3% of lumbar spine MR studies identified some findings that may have potential clinical significance. Normal lumbar spine is the most common diagnosis (32.7%), followed by lumbar disc bulging and lumbar disc herniation. Walk difficulties, back injury and referred leg pain as chief complaints were associated with greater chance of detecting potentially clinically positive lumbar MR image findings, as compare with simple back pain. There was no difference in positive rates among orthopedic surgeon and specialists of other disciplines. Lumbar spine MR imaging was generally overused in Eastern China by various specialists, particularly at health assessment centers. For appropriate use of lumbar spine MR, orthopedic surgeons are no better than physicians of other disciplines. Professional training and clinical guidelines are needed to facilitate evidence-based back pain practice in China.

Triage of spine surgery referrals through a multidisciplinary care pathway: a value-based comparison with conventional referral processes

STUDY DESIGN

Retrospective medical record review.

OBJECTIVE

To (1) determine if outpatient referrals for low back pain (LBP) and leg pain triaged through a multidisciplinary spine care pathway (group A) were more likely to be candidates for surgery than conventional physician referrals (group B); (2) compare relevant clinical differences in the 2 groups (e.g., diagnosis, pain scores, level of disability); and (3) compare wait times for magnetic resonance imaging and surgical assessment.

SUMMARY OF BACKGROUND DATA

The Saskatchewan Spine Pathway was introduced on the basis of evidence that a co-ordinated, multidisciplinary, and stratified approach to the assessment and management of LBP may improve quality. During early implementation, some physicians began to refer patients to Saskatchewan Spine Pathway clinics, whereas others continued to refer patients directly to the surgeon through the conventional process.

METHODS

We retrospectively analyzed consecutive new outpatient referrals for LBP and leg pain, June 1, 2011 through May 30, 2012 for 2 surgeons.

RESULTS

We identified 215 referrals, including 66 (30.7%) in group A and 149 (69.3%) in group B. There was no difference in overall health (mean EuroQol Group 5-Dimension Self-Report Questionnaire visual analogue scale) or lower back-related disability score (Oswestry Disability Index). Group A patients were significantly more likely to be candidates for surgery (59.1% vs. 37.6% for group B; P = 0.0034, χ test), had significantly poorer scores for EuroQol Group 5-Dimension Self-Report Questionnaire mobility, a higher proportion of leg dominant pain, and a lower proportion of back dominant pain. Group A patients also had significantly shorter wait times for magnetic resonance imaging and surgical assessment.

CONCLUSION

A co-ordinated multidisciplinary pathway with a stratified approach to LBP assessment and care provided a greater proportion of surgery candidates than the conventional referral process. The implementation of such processes may allow surgeons to restrict their practices to patients who are more likely to benefit from their services, thereby reducing wait times and potentially reducing costs.

LEVEL OF EVIDENCE

3.

Development of appropriateness criteria for the surgical treatment of symptomatic lumbar degenerative spondylolisthesis (LDS)

PURPOSE

Spine surgery rates are increasing worldwide. Treatment failures are often attributed to poor patient selection and inappropriate treatment, but for many spinal disorders there is little consensus on the precise indications for surgery. With an aging population, more patients with lumbar degenerative spondylolisthesis (LDS) will present for surgery. The aim of this study was to develop criteria for the appropriateness of surgery in symptomatic LDS.

METHODS

A systematic review was carried out to summarize the current level of evidence for the treatment of LDS. Clinical scenarios were generated comprising combinations of signs and symptoms in LDS and other relevant variables. Based on the systematic review and their own clinical experience, twelve multidisciplinary international experts rated each scenario on a 9-point scale (1 highly inappropriate, 9 highly appropriate) with respect to performing decompression only, fusion, and instrumented fusion. Surgery for each theoretical scenario was classified as appropriate, inappropriate, or uncertain based on the median ratings and disagreement in the ratings.

RESULTS

744 hypothetical scenarios were generated; overall, surgery (of some type) was rated appropriate in 27%, uncertain in 41% and inappropriate in 31%. Frank panel disagreement was low (7% scenarios). Face validity was shown by the logical relationship between each variable's subcategories and the appropriateness ratings, e.g., no/mild disability had a mean appropriateness rating of 2.3 ± 1.5, whereas the rating for moderate disability was 5.0 ± 1.6 and for severe disability, 6.6 ± 1.6. Similarly, the average rating for no/minimal neurological abnormality was 2.3 ± 1.5, increasing to 4.3 ± 2.4 for moderate and 5.9 ± 1.7 for severe abnormality. The three variables most likely (p < 0.0001) to be components of scenarios rated "appropriate" were: severe disability, no yellow flags, and severe neurological deficit.

CONCLUSION

This is the first study to report criteria for determining candidacy for surgery in LDS developed by a multidisciplinary international panel using a validated method (RAM). The panel ratings followed logical clinical rationale, indicating good face validity. The work refines clinical classification and the phenotype of degenerative spondylolisthesis. The predictive validity of the criteria should be evaluated prospectively to examine whether patients treated "appropriately" have better clinical outcomes.

Spine surgeons' requirements for imaging at the time of referral: a survey of Canadian spine surgeons

BACKGROUND

Routine imaging of patients with spine-related complaints referred for surgical assessment may represent an inefficient use of technological resources. Our objective was to explore Canadian spine surgeons' requirements with respect to imaging studies accompanying spine-related referrals.

METHODS

We administered an 8-item survey to all 100 actively practising surgeon members of the Canadian Spine Society that inquired about demographic variables and imaging requirements for patients referred with spine-related complaints.

RESULTS

Fifty-five spine surgeons completed our survey, for a response rate of 55%. Most respondents (43; 78%) required imaging studies to accompany all spine-related referrals. The type of imaging required was highly variable, with respondents endorsing 7 different combinations. Half (47%) required magnetic resonance imaging and 38% required plain radiographs either alone or in combination with other forms of imaging. Half of the respondents refused to see 20% or more of all patients referred for spine-related complaints.

CONCLUSION

Most Canadian spine surgeons require imaging studies to accompany spine-related referrals; however, the type and combination of studies is highly variable, and many patients who are referred are never seen (for a consultation). Standardization and optimization of imaging practices for patients with spine-related complaints referred for surgical assessment may be an important area for cost savings.

Spine surgery referrals redirected through a multidisciplinary care pathway: effects of nonsurgeon triage including MRI utilization

Object

The Saskatchewan Spine Pathway (SSP) was introduced to improve quality and access to care for patients with low-back and leg pain in the province. There is very limited data regarding the efficacy of nonsurgeon triage of surgical referrals. The objective of this early implementation study was to determine how the SSP affects utilization of MRI and spine surgery.

Methods

The authors performed a retrospective analysis of 87 consecutive patients with low-back and leg pain who were initially referred to a spine surgeon but were instead redirected to the SSP clinic between May 1, 2011, and November 30, 2011. The SSP clinic triaged patients into 2 groups: Group A (nonsurgical management) and Group B (referred back to the spine surgeon). The SSP classification was modified from the classification proposed by Hall et al. Pain and disability were scored by pain-related visual analog scale, modified Oswestry Disability Index, and EuroQol-5D.

Results

Sixty-two patients (Group A, 71.3%) were discharged after patient education, self-care advice, and/or referral for additional mechanical therapies. Although only 25 patients (Group B, 28.7%) were directed back to the surgeon, the final percentage (12.6%) offered surgery was similar to that of historic controls (15%). Total MRI utilization was significantly lower in Group A (25.8%) than Group B (92.0%) (p < 0.0001). Nonsurgeon triage captured all red flags detected by the surgeon. Patients in Group B were much more likely to have a leg-dominant pain (p = 0.0088) and had significantly higher Oswestry Disability Index (p = 0.0121) and EuroQol-5D mobility (p = 0.0484) scores.

Conclusions

The SSP significantly reduced MRI utilization and referrals seen by the surgeon for nonoperative care. Although this early implementation study suggests potential for cost savings, a more rigorous analysis of outcomes, costs, and patient satisfaction is required.

Appropriateness of lumbar spine magnetic resonance imaging in Spain

OBJECTIVES

To determine the minimum percentage of lumbar spine magnetic resonance imaging (LSMRI) which are inappropriately prescribed in routine practice.

METHODS

LSMRI performed prospectively on 602 patients in 12 Radiology Services across 6 regions in Spain, were classified as "appropriate", "uncertain" or "inappropriate" based on the indication criteria established by the National Institute for Clinical Excellence, the American College of Physicians and Radiology, and current evidence-based clinical guidelines. Studies on patients reporting at least one "red flag" were classified as "appropriate". A logistic regression model was developed to identify factors associated with a higher likelihood of inappropriate LSMRI, including gender, reporting of referred pain, health care setting (private/public), and specialty of prescribing physician. Before performing the LSMRI, the radiologists also assessed the appropriateness of the prescription.

RESULTS

Eighty-eight percent of LSMRI were appropriate, 1.3% uncertain and 10.6% inappropriate. The agreement of radiologists' assessment with this classification was substantial (k=0.62). The odds that LSMRI prescriptions were inappropriate were higher for patients without referred pain [OR (CI 95%): 13.75 (6.72; 28.16)], seen in private practice [2.25 (1.20; 4.22)], by orthopedic surgeons, neurosurgeons or primary care physicians [2.50 (1.15; 5.56)].

CONCLUSION

Efficiency of LSMRI could be improved in routine practice, without worsening clinical outcomes.