Are Guidelines Important? Results of a Prospective Quality Improvement Lumbar Fusion Project

Emes, Alexandra; Chitale, Ameet; Wu, Chengyuan; Saiegh, Fadi Al; Stricsek, Geoffrey; Gonzalez, Glenn A.; Jallo, Jack; Heller, Joshua; Hines, Kevin; Philipp, Lucas; Thalheimer, Sara; Prasad, Srinivas; Montenegro, Thiago S.; Fatema, Umma; Sharan, Ashwini

doi:10.1093/neuros/nyab062

Cited by 8 publications

(7 citation statements)

References 31 publications

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“…[11][12][13][14] Surgical decision-making concerning revision of lumbar fusion is controversial, with recent studies suggesting that revisions supported by evidence-based criteria were associated with better functional outcomes. 14,15 The most common indications for revisions are postlaminectomy syndrome, adjacent segment degeneration (ASD), and pseudarthrosis. 11 Pseudarthrosis was found to be the most common cause of revision lumbar surgery, responsible for 31% of revision cases.…”

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confidence: 99%

Independent Predictors of Revision Lumbar Fusion Outcomes and the Impact of Spine Surgeon Variability: Does It Matter Whether the Primary Surgeon Revises?

Montenegro¹,

Singh²,

Elia³

et al. 2021

Neurosurg.

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BACKGROUND There is a paucity of information regarding treatment strategies and variables affecting outcomes of revision lumbar fusions. OBJECTIVE To evaluate the influence of primary vs different surgeon on functional outcomes of revisions. METHODS All elective lumbar fusion revisions, March 2018 to August 2019, were retrospectively categorized as performed by the same or different surgeon who performed the primary surgery. Oswestry Disability Index (ODI) and clinical variables were collected. Multiple logistic regression identified multivariable-adjusted odds ratio (OR) of independent variables analyzed. RESULTS Of the 130 cases, 117 (90%) had complete data. There was a slight difference in age in the same (median: 59; interquartile range [IQR], 54-66) and different surgeon (median: 67; IQR, 56-72) groups (P = .02); all other demographic variables were not significantly different (P > .05). Revision surgery with a different surgeon had an ODI improvement (median: 8; IQR, 2-14) greater than revisions performed by the same surgeon (median: 1.5; IQR, −3 to 10) (P < .01). Revisions who achieved minimum clinically important difference (MCID) performed by different surgeon (59.7%) were also significantly greater than the ones performed by the same surgeon (40%) (P = .042). Multivariate analysis demonstrated that a different surgeon revising (OR, 2.37; [CI]: 1.007-5.575, P = .04) was an independent predictor of MCID achievement, each additional 2 years beyond the last surgery conferred a 2.38 ([CI]: 1.36-4.14, P < .01) times greater odds of MCID achievement, and the anterior lumbar interbody fusion approach decreased the chance of achieving MCID (OR, 0.19; [CI]: 0.04-0.861, P = .03). CONCLUSION All revision lumbar spinal fusion approaches may not achieve the same outcomes. This analysis suggests that revision surgeries may have better outcomes when performed by a different surgeon.

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confidence: 99%

Independent Predictors of Revision Lumbar Fusion Outcomes and the Impact of Spine Surgeon Variability: Does It Matter Whether the Primary Surgeon Revises?

Montenegro¹,

Singh²,

Elia³

et al. 2021

Neurosurg.

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“…Prior analysis found significant predictors and/or meaningful confounders of 6-month MCID in ODI to include NASS concordance, preoperative ODI, ASA, and revision surgery; which were included in multivariable analysis. 29 Multivariable logistic regression analysis reaffirmed the significant predictive value of the variables previously described. The most optimal regression model (Table 2) included only statistically significant variables predicting MCID in ODI-NASS Concordance (P = 0.0441), preoperative ODI (P < 0.0001), ASA Class (P = 0.0063), classification as a revision surgery (P = 0.0004)-and the principal variable of interest: Attending surgeon (Wald χ 2 = 43.68, P < 0.0001; R 2 = 73.7%).…”

Section: Resultsmentioning

confidence: 55%

“…As seen in previous literature, patient specific factors such as preoperative ODI, ASA class, and classification of revision surgery demonstrated statistical correlations with PRO in the form of MCID at 6 months postoperatively. 29,34 Of note, patient factors traditionally predictive of increased morbidity such as age, 35 BMI, 36 and smoking status 37 did not improve outcome modeling as they did not significantly contribute to differences in PRO in this cohort. This is likely When examining surgeon experience, this study confirmed that MCID in ODI improvements postoperatively were statistically correlated with the surgeon's years in practice.…”

Section: Discussionmentioning

confidence: 78%

“…This criteria has been since evaluated in a prospective study and shown to improve outcomes. 29 To date, there has not been any studies evaluating the effect of this criteria of lumbar fusion on surgeon-specific patient outcomes. This study seeks to evaluate surgeon-specific variable effects on PRO such as ODI and the effect of NASS concordance on outcomes in the setting of variable surgeon characteristics.…”

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confidence: 99%

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Increased Surgeon-specific Experience and Volume is Correlated With Improved Clinical Outcomes in Lumbar Fusion Patients

Hines¹,

Philipp²,

Thalheimer³

et al. 2022

Clinical Spine Surgery: A Spine Publication

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Study Design: The present study design was that of a single center, retrospective cohort study to evaluate the influence of surgeon-specific factors on patient functional outcomes at 6 months following lumbar fusion. Retrospective review of a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis identified the present study population. Objective: This study seeks to evaluate surgeon-specific variable effects on patient-reported outcomes such as Oswestry Disability Index (ODI) and the effect of North American Spine Society (NASS) concordance on outcomes in the setting of variable surgeon characteristics. Summary of Background Data: Lumbar fusion is one of the fastest growing procedures performed in the United States. Although the impact of surgeon-specific factors on patient-reported outcomes has been contested, studies examining these effects are limited. Methods: This is a single center, retrospective cohort study analyzing a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis by 1 of 5 neurosurgery fellowship trained spine surgeons. The primary outcome was improvement of ODI at 6 months postoperative follow-up compared with preoperative ODI. Results: A total of 307 patients were identified for analysis. Overall, 62% of the study population achieved minimum clinically important difference (MCID) in ODI score at 6 months. Years in practice and volume of lumbar fusions were statistically significant independent predictors of MCID ODI on multivariable logistic regression (P=0.0340 and P=0.0343, respectively). Concordance with evidence-based criteria conferred a 3.16 (95% CI: 1.03, 9.65) times greater odds of achieving MCID. Conclusion: This study demonstrates that traditional surgeon-specific variables predicting surgical morbidity such as experience and procedural volume are also predictors of achieving MCID 6 months postoperatively from lumbar fusion. Independent of surgeon factors, however, adhering to evidence-based guidelines can lead to improved outcomes.

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“…[1][2][3] Despite the increasing utilization of instrumented fusion for the treatment of lum-bar pathology, there is still a lack of medical literature detailing concrete fusion indications and studies validating guidelines as predictors of outcomes. [4][5][6] This is largely secondary to heterogeneity in clinical decision-making amongst spine surgeons and surgical indications in lumbar spine pathology management.…”

Section: Introductionmentioning

confidence: 99%

Are Lumbar Fusion Guidelines Followed? A Survey of North American Spine Surgeons

et al. 2021

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Objective: To evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America. Methods: An anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics. Results: A total of 105 responses were entered with complete data available on 70. Sixty percent of the respondents (n = 42) were considered compliant with NASS guidelines. NASS-discordant responses did not differ between surgeons who stated that they include the NASS guidelines in their decision-making algorithm (5.10 ± 1.96) and those that did not (4.68 ± 2.09) (p = 0.395). The greatest number of NASS-discordant answers in the United States. was in the South (5.75 ± 2.09), with the lowest number in the Northeast (3.84 ± 1.70) (p < 0.01). For 5 survey items, rates of NASS-discordant answers were ≥ 40%, with the greatest number of NASS-discordant responses observed in relation to indications for fusion in spinal deformity (80%). Spine surgeons utilizing a NASS-concordant approach had a significant lower number of NASS-discordant answers for synovial cysts (p = 0.03), axial low back pain (p < 0.01), adjacent level disease (p < 0.01), recurrent stenosis (p < 0.01), recurrent disc herniation (p = 0.01), and foraminal stenosis (p < 0.01). Conclusion:This study serves an important role in clarifying the rates of uptake of clinical practice guidelines in spine surgery as well as to identify barriers to their implementation.

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Are Guidelines Important? Results of a Prospective Quality Improvement Lumbar Fusion Project

Cited by 8 publications

References 31 publications

Independent Predictors of Revision Lumbar Fusion Outcomes and the Impact of Spine Surgeon Variability: Does It Matter Whether the Primary Surgeon Revises?

Independent Predictors of Revision Lumbar Fusion Outcomes and the Impact of Spine Surgeon Variability: Does It Matter Whether the Primary Surgeon Revises?

Increased Surgeon-specific Experience and Volume is Correlated With Improved Clinical Outcomes in Lumbar Fusion Patients

Are Lumbar Fusion Guidelines Followed? A Survey of North American Spine Surgeons

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