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

Abstract

BackgroundSecond 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.MethodsWe 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.ResultsOf 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.ConclusionsWe 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 registrationCurrent Controlled Trials ISRCTN07143259. Registered 21 November 2011.

Results of a patient-oriented second opinion program in Germany shows a high discrepancy between initial therapy recommendation and second opinion

“…These changes in diagnosis or therapy and therefore agreement varied noticeably per independent specialist. Two-thirds non confirmed initial therapy recommendations and above 50% non confirmed initial diagnoses were also found by Lenza et al in their recent study from 2017 including patients referred for spinal surgery [18]. Another study showed that the second opinion can be influenced if the specialist has knowledge of the initial therapy recommendation [19].…”

Outcomes of second opinions in general internal medicine

“…When compared to second opinions in other medical specialties, diagnostic value of second opinions in internal medicine is low. Studies in other medical specialties have shown that a new diagnosis is established in approximately 30-60% of patients, ranging from 30% in surgical oncology to 60% in orthopedic surgery [10,12,13,18,20,23,24]. This difference might be explained by the fact that, in this study and in previous studies [7,8], up to 85% of patients referred for a second opinion in internal medicine, had poorly defined conditions without a diagnosis at the time of referral.…”

“…Over the years, many studies in various medical specialties and multiple countries have shown that second opinions lead to the establishment of a new diagnosis in 2-60% [ 7 – 30 ] and a change in treatment in 20-60% of patients [ 8 – 19 , 21 , 22 , 24 – 27 , 31 ]. In addition, studies have shown that patients are generally satisfied with the process, even if it has not led to a new diagnosis or treatment [ 7 , 9 , 12 , 32 ].…”

Zukunft der operativen Therapie degenerativer Wirbelsäulenerkrankungen: Kontra – Wandel hin zu weniger Operationen aufgrund fehlender Evidenz

“…In 33,6 % der Fälle wurde die Operationsindikation bestätigt, wobei jedoch nur in 15 % die gleiche OP-Technik empfohlen wurde. 55 % wurde eine konservative Behandlung nahegelegt und in 11 % der Patienten konnte das Board keine spinale Pathologie feststellen [26]. Diese dramatischen Differenzen mögen nicht auf alle Regionen übertragbar sein, dennoch zeigen sie die Notwendigkeit für eine evidenzbasierte Überprüfung der Operationsindikationen.…”