Daniel Lubelski1, Vincent J Alentado2, Seth K Williams3, Colin O'Rourke4, Nancy A Obuchowski4, Jeffrey C Wang5, Michael P Steinmetz4, Alfred J Melillo4, Edward C Benzel4, Michael T Modic4, Robert Quencer6, Thomas E Mroz4. 1. Center for Spine Health and the Department of Neurosurgery Cleveland Clinic, Cleveland, Ohio, USA; Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland, USA. Electronic address: dlubelski@jhmi.edu. 2. Center for Spine Health and the Department of Neurosurgery Cleveland Clinic, Cleveland, Ohio, USA; Department of Neurosurgery, Indiana University, Indianapolis, Indiana, USA. 3. Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin, USA. 4. Center for Spine Health and the Department of Neurosurgery Cleveland Clinic, Cleveland, Ohio, USA. 5. Department of Orthopedic Surgery, University of Southern California, Los Angeles, California, USA. 6. Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA.
Abstract
BACKGROUND: There are a multitude of treatments for low-grade lumbar spondylolisthesis. There are no clear guidelines for the optimal approach. OBJECTIVE: To identify the surgical treatment patterns for spondylolisthesis among United States spine surgeons. METHODS: 445 spine surgeons in the United States completed a survey of clinical/radiographic case scenarios on patients with lumbar spondylolisthesis with neurogenic claudication with (S+BP) or without (S-BP) associated mechanical back pain. Treatment options included decompression, laminectomy with posterolateral fusion, posterior lumbar interbody fusion, or none of the above. The primary outcome measure was the probability of 2 randomly chosen surgeons disagreeing on the treatment method. RESULTS: There was 64% disagreement (36% agreement) among surgeons for treatment of spondylolisthesis with mechanical back pain (S+BP) and 71% disagreement (29% agreement) for spondylolisthesis without mechanical back pain (S-BP). For S+BP, disagreement was 52% for those practicing 5 to 10 years versus 70% among those practicing more than 20 years. Orthopedic surgeons had greater disagreement than did neurosurgeons (76% vs. 56%) for S+BP. Greater clinical equipoise was seen for S-BP than for S+BP regardless of surgeon characteristics. For spondylolisthesis without mechanical back pain, neurosurgeons were significantly more likely to select decompression-only than were orthopedic surgeons, who more commonly selected fusion. CONCLUSIONS: Clinical equipoise exists for the treatment of spondylolisthesis. Differences are greater when the patient presents without associated back pain. Surgeon case volume, practice duration, and specialty training influence operative decisions for a given pathologic condition. Recognizing this practice variation will hopefully lead to better evidence and practice guidelines for the optimal and most cost-effective treatment paradigms.
BACKGROUND: There are a multitude of treatments for low-grade lumbar spondylolisthesis. There are no clear guidelines for the optimal approach. OBJECTIVE: To identify the surgical treatment patterns for spondylolisthesis among United States spine surgeons. METHODS: 445 spine surgeons in the United States completed a survey of clinical/radiographic case scenarios on patients with lumbar spondylolisthesis with neurogenic claudication with (S+BP) or without (S-BP) associated mechanical back pain. Treatment options included decompression, laminectomy with posterolateral fusion, posterior lumbar interbody fusion, or none of the above. The primary outcome measure was the probability of 2 randomly chosen surgeons disagreeing on the treatment method. RESULTS: There was 64% disagreement (36% agreement) among surgeons for treatment of spondylolisthesis with mechanical back pain (S+BP) and 71% disagreement (29% agreement) for spondylolisthesis without mechanical back pain (S-BP). For S+BP, disagreement was 52% for those practicing 5 to 10 years versus 70% among those practicing more than 20 years. Orthopedic surgeons had greater disagreement than did neurosurgeons (76% vs. 56%) for S+BP. Greater clinical equipoise was seen for S-BP than for S+BP regardless of surgeon characteristics. For spondylolisthesis without mechanical back pain, neurosurgeons were significantly more likely to select decompression-only than were orthopedic surgeons, who more commonly selected fusion. CONCLUSIONS: Clinical equipoise exists for the treatment of spondylolisthesis. Differences are greater when the patient presents without associated back pain. Surgeon case volume, practice duration, and specialty training influence operative decisions for a given pathologic condition. Recognizing this practice variation will hopefully lead to better evidence and practice guidelines for the optimal and most cost-effective treatment paradigms.
Authors: Daniel Lubelski; Andrew Hersh; Tej D Azad; Jeff Ehresman; Zachary Pennington; Kurt Lehner; Daniel M Sciubba Journal: Global Spine J Date: 2021-04
Authors: Charles G Fisher; Y Raja Rampersaud; R Andrew Glennie; Christopher S Bailey; Edward Abraham; Neil Manson; Steve Casha; Kenneth Thomas; Jerome Paquet; Greg McIntosh; Hamiton Hall Journal: Eur Spine J Date: 2021-07-29 Impact factor: 3.134