An ACGME-based comparison of neurosurgical and orthopedic resident training in adult spine surgery via a case volume and hours-based analysis

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.

Neurosurgery compared to orthopedic spine consultation: A single level I trauma center experience

Introduction

Both Orthopedic Surgery (OS) and Neurosurgery (NS) perform spine surgery in the setting of trauma. However, it is unknown whether outcomes differ between these specialties. This study compares management and outcomes for vertebral fractures between NS and OS, hypothesizing similar operation rate, length of stay (LOS), and readmission.

Research question

Do outcomes differ between NS and OS in the management of vertebral fractures following trauma?

Methods

A retrospective single-center study was conducted on adult patients with cervical, thoracic, lumbar, and sacral fractures treated at a single trauma center, where no standardized pathway exists across NS and OS. Patients were compared for injury profile, diagnostic imaging, and operative techniques as well as LOS, mortality, and complications.

Results

A total of 630 vertebral fracture patients (OS:350 (55.6%); NS:280 (44.4%)) were included. NS utilized magnetic resonance imaging (MRI) more commonly (36.4% vs. 22.6%, p < 0.001). NS patients more often underwent operation (13.2% vs. 7.4%, p = 0.016) despite similar fracture number and severity (p > 0.05). Post-operative complications, LOS, and readmission rates were similar between cohorts (p > 0.05).

Discussion and conclusion

Despite similar injury profiles, NS had higher rates of MRI usage and operative interventions in the context of traumatic spine fractures. Despite differences in management, major clinical outcomes were similar between NS and OS. However, we do call for further standardization of evaluation and treatment of patients based on established algorithms from such as the AOSpine Thoracolumbar Spine Injury Classification System (ATLICS).

Differences in productivity and collaboration patterns on spine-related research between neurosurgeons and orthopedic spine surgeons: Bibliometric analysis

BACKGROUND

Spinal surgeries are commonly performed by neurosurgeons and orthopedic spine surgeons, with many spine-related articles published by them. However, there has been limited research that directly compares their research achievements. This article conducted a comparative analysis of spine-related research achievements between neurosurgeons and orthopedic spine surgeons. This study examines differences in productivity and impact on spine-related research between them using these measures, particularly with a novel clustering algorithm.

METHODS

We gathered 2148 articles written by neurosurgeons and orthopedic spine surgeons from the Web of Science core collections, covering the period from 2013 to 2022. To analyze author collaborations, we employed the follower-leader clustering algorithm (FLCA) and conducted cluster analysis. A 3-part analysis was carried out: cluster analysis of author collaborations; mean citation analysis; and a category, journal, authorship, L-index (CJAL) score based on article category, journal impact factors, authorships, and L-indices. We then utilized R to create visual displays of our findings, including circle bar charts, heatmaps with dendrograms, 4-quadrant radar plots, and forest plots. The mean citations and CJAL scores were compared between neurosurgeons and orthopedic spine surgeons.

RESULTS

When considering first and corresponding authors, orthopedics authors wrote a greater proportion of the articles in the article collections, accounting for 75% (1600 out of 2148). The CJAL score based on the top 10 units each also favored orthopedic spine surgeons, with 71% (3626 out of 6139) of the total score attributed to them. Using the FLCA, we observed that orthopedic spine surgeons tended to have more collaborations across countries. Additionally, while citation per article favored orthopedic spine surgeons with standard mean difference (= -0.66) and 95%CI: -0.76, -0.56, the mean CJAL score in difference (= 0.34) favored neurosurgeons with 95%CI: 0.24 0.44.

CONCLUSION

Orthopedic spine surgeons have a higher number of publications, citations, and CJAL scores in spine research than those in neurosurgeons. Orthopedic spine surgeons tend to have more collaborations and coauthored papers in the field. The study highlights the differences in research productivity and collaboration patterns between the 2 authors in spine research and sheds light on potential contributing factors. The study recommends the use of FLCA for future bibliographical studies.

Management of incidental durotomies in an integrated Orthopaedic and Neurosurgical Spinal Unit

Introduction

Incidental durotomy (ID) is an intraoperative event associated to prolonged bed rest and hospital stay, antibiotic use, higher patient dissatisfaction, and leg pain among other complications of its postoperative course. Several repair techniques and postsurgical care have been proposed for its management. This study was designed to develop an agreed protocol in cases of ID among Orthopaedic Surgeons (OS) and Neurosurgeons (NS) integrated into a Spinal Surgery Unit.

Research question

Incidental durotomies management protocol.

Materials and methods

From 997 eligible cases operated in Hospital del Mar (Barcelona, Spain) from April 2018 to March 2022, demographic, clinical, surgical and postoperative data was collected for statistical analysis from the morbidity and mortality database, with 79 identified IDs. Redo procedures were significantly associated to OS, and cervical and anterior/lateral approaches to NS, both groups were not comparable.

Results

ID occurred in 7.9% of cases, more frequently after the lockdown (p=0.03), in females (p=0.04), during posterior approaches (p=0.003), and less frequently in the cervical spine (p=0.009). IDs were linked to postoperative infections (p< 0.001) and nerve root damage (p< 0.001). Patients without ID evolved more satisfactorily during the postoperative period (p=0.002), and those with CSF leak (20/79) spent on bed rest more than twice the time as those without (p<0.001). Multivariable logistic regression showed strong association between posterior approaches and ID, between complicated postoperative courses and ID.

Discussion and conclusions

ID is linked to an adverse postoperative recovery, and it should be primarily repaired under microscope, with early mobilization of patients after surgery.

Longitudinal Assessment of Modern Spine Surgery Training: 10-Year Follow-up of a Nationwide Survey of Residency and Spine Fellowship Program Directors

Spine surgeons complete training through residency in orthopaedic surgery (ORTH) or neurosurgery (NSGY). A survey was conducted in 2013 to evaluate spine surgery training. Over the past decade, advances in surgical techniques and the changing dynamics in fellowship training may have affected training and program director (PD) perceptions may have shifted.

Methods

This study is a cross-sectional survey distributed to all PDs of ORTH and NSGY residencies and spine fellowships in the United States. Participants were queried regarding characteristics of their program, ideal characteristics of residency training, and opinions regarding the current training environment. χ2 tests were used to compare answers over the years.

Results

In total, 241 PDs completed the survey. From 2013 to 2023, NSGY increased the proportion of residents with >300 spine cases (86%-100%) while ORTH remained with >90% of residents with < 225 cases (p < 0.05). A greater number of NSGY PDs encouraged spine fellowship even for community spine surgery practice (0% in 2013 vs. 14% in 2023, p < 0.05), which continued to be significantly different from ORTH PDs (∼88% agreed, p > 0.05). 100% of NSGY PDs remained confident in their residents performing spine surgery, whereas ORTH confidence significantly decreased from 43% in 2013 to 25% in 2023 (p < 0.05). For spinal deformity, orthopaedic PDs (92%), NSGY PDs (96%), and fellowship directors (95%), all agreed that a spine fellowship should be pursued (p = 0.99). In both 2013 and 2023, approximately 44% were satisfied with the spine training model in the United States. In 2013, 24% of all PDs believed we should have a dedicated spine residency, which increased to 39% in 2023 (fellowship: 57%, ORTH: 38%, NSGY: 21%) (p < 0.05).

Conclusion

Spine surgery training continues to evolve, yet ORTH and neurological surgery training remains significantly different in case volumes and educational strengths. In both 2013 and 2023, less than 50% of PDs were satisfied with the current spine surgery training model, and a growing minority believe that spine surgery should have its own residency training pathway.

Level of Evidence

IV.

Impact of Specialty on Cases Performed During Spine Surgery Training in the United States

OBJECTIVE

Two general pathways exist for spine surgery training in the United States: orthopedic surgery and neurological surgery. Previous studies have not quantified the impact of fellowship training when comparing case volumes between these 2 training pathways. This study compares reported spine surgery case volume upon graduation from orthopedic surgery and neurological surgery training.

METHODS

This was a retrospective cohort study of recent graduates from orthopedic surgery and neurological Surgery training programs in the United States (2018-2021). The Accreditation Council for Graduate Medical Education provided case logs for residents in neurological surgery and orthopedic surgery as well as fellows in orthopedic spine surgery. Case volumes were compared for adult and pediatric spine surgery cases using parametric tests.

RESULTS

Case logs from 3146 orthopedic surgery residents, 107 orthopedic spine surgery fellows, and 766 neurological surgery residents were included in this study. Across each cohort, neurological surgery trainees reported more total adult spine surgery cases than orthopedic surgery trainees (514 ± 206 vs. 383 ± 171, P < 0.001). Orthopedic surgery trainees reported more total pediatric spine surgery cases (21 ± 14 vs. 17 ± 12, P = 0.006).

CONCLUSIONS

Neurological surgery training affords a greater volume of adult spine surgery cases, but orthopedic surgery affords more pediatric spine surgery cases. Identification of relative strengths and weaknesses can help facilitate multidisciplinary training experiences in spine surgery.

Effect of surgical experience and spine subspecialty on the reliability of the AO Spine Upper Cervical Injury Classification System

OBJECTIVE

The objective of this paper was to determine the interobserver reliability and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeon experience (< 5 years, 5-10 years, 10-20 years, and > 20 years) and surgical subspecialty (orthopedic spine surgery, neurosurgery, and "other" surgery).

METHODS

A total of 11,601 assessments of upper cervical spine injuries were evaluated based on the AO Spine Upper Cervical Injury Classification System. Reliability and reproducibility scores were obtained twice, with a 3-week time interval. Descriptive statistics were utilized to examine the percentage of accurately classified injuries, and Pearson's chi-square or Fisher's exact test was used to screen for potentially relevant differences between study participants. Kappa coefficients (κ) determined the interobserver reliability and intraobserver reproducibility.

RESULTS

The intraobserver reproducibility was substantial for surgeon experience level (< 5 years: 0.74 vs 5-10 years: 0.69 vs 10-20 years: 0.69 vs > 20 years: 0.70) and surgical subspecialty (orthopedic spine: 0.71 vs neurosurgery: 0.69 vs other: 0.68). Furthermore, the interobserver reliability was substantial for all surgical experience groups on assessment 1 (< 5 years: 0.67 vs 5-10 years: 0.62 vs 10-20 years: 0.61 vs > 20 years: 0.62), and only surgeons with > 20 years of experience did not have substantial reliability on assessment 2 (< 5 years: 0.62 vs 5-10 years: 0.61 vs 10-20 years: 0.61 vs > 20 years: 0.59). Orthopedic spine surgeons and neurosurgeons had substantial intraobserver reproducibility on both assessment 1 (0.64 vs 0.63) and assessment 2 (0.62 vs 0.63), while other surgeons had moderate reliability on assessment 1 (0.43) and fair reliability on assessment 2 (0.36).

CONCLUSIONS

The international reliability and reproducibility scores for the AO Spine Upper Cervical Injury Classification System demonstrated substantial intraobserver reproducibility and interobserver reliability regardless of surgical experience and spine subspecialty. These results support the global application of this classification system.