Second opinion in spine surgery: A scoping review.

BACKGROUND: As a growing number of patients seek consultations for increasingly complex and costly spinal surgery, it is of both clinical and economic value to investigate the role for second opinions (SOs). Here, we summarized and focused on the shortcomings of 14 studies regarding the role and value of SOs before proceeding with spine surgery.
METHODS: Utilizing PubMed, Google Scholar, and Scopus, we identified 14 studies that met the inclusion criteria that included: English, primary articles, and studies published in the past 20 years.
RESULTS: We identified the following findings regarding SO for spine surgery: (1) about 40.6% of spine consultations are SO cases; (2) 61.3% of those received a discordant SO; (3) 75% of discordant SOs recommended conservative management; and (4) SO discordance applied to a variety of procedures.
CONCLUSION: The 14 studies reviewed regarding SOs in spine surgery showed that half of the SOs differed from those given in the initial consultation and that SOs in spine surgery can have a substantial impact on patient care. Absent are prospective studies investigating the impact of following a first versus second opinion. These studies are needed to inform the potential benefit of universal implementation of SOs before major spine operations to potentially reduce the frequency and type/extent of surgery. Copyright:

INTRODUCTION

Second opinions (SOs) in spine surgery are particularly important as there are tremendous variations regarding indications and types of spinal operations offered/performed.[7,8,11] Here, we reviewed 14 studies looking at the frequency and impact of SO on the incidence, type, and extent of spine surgery being offered to patients.

MATERIALS AND METHODS

Literature review

PubMed, Google Scholar, and Scopus databases were the search engines utilized to identify 14 peer-reviewed articles on SO before spine surgery; these studies were assessed by two reviewers [Figure 1].[2,4,13-15]

Figure 1:

Study inclusion criteria. Process of exclusion and inclusion of studies for the scoping review. Search terms included: “spine surgery” AND “SO,” and “SO programs.” Primary articles/ titles included “spine,” “orthopedic,” “opinion,” text included (“SO,” “surgery,” “operation”) and (“neuro”/“ortho” “spine”). SO: Second opinion.

Evaluation of potential bias

Study descriptors, methodological considerations, and potential sources of bias were noted [Table 1].

Table 1:

Study design and methods.

In half of the studies, the SO provider also authored the published work, and in the majority of studies there was the potential for selection bias (i.e., the SO was sought by patients as opposed to systematic recruitment).

Data collection

The following data were extracted: SO recommendation for no or different surgery, SO surgery practices across spine specialties, discordance rates between first and SO treatment and diagnosis, discordance rates for specific operations, likelihood for surgical recommendation during a first versus SOs, and patient-reported outcomes [Tables 2-6].

Table 2:

Discordant SO recommendations.

Table 6:

Reported outcomes after obtaining second opinions.

RESULTS

Two reviewers reached a consensus on 14 articles that were included in this analysis regarding the utility of SO in spinal surgery [Figure 1 and Table 1].[1-6,9-12,14-17]

Discordant SO recommendations

Two categories of discordant SO recommendations were reported in five of the studies: (1) surgery was recommended by the first and not the SO, or (2) the type of surgery recommended by the SO was different from the type recommended by the first surgeon [Table 2]. Using pooled data from these studies, the majority (75% [n = 719]) of discordant cases involved a SO recommendation for nonoperative treatment, whereas a different surgery was recommended in 25% [Table 2]. Notably, in the two studies that examined surgical recommendations for both first and SOs from a single provider, the rates of surgical recommendation were comparable but slightly higher in SOs (pooled first opinion surgical recommendation: 35.5% and SO surgical recommendation: 47%).[4,6]

Frequency of SOs in spine surgery practice

Using pooled data across studies, 40.6% (n = 1020) of spine surgery consultations were for a second opinion [Table 3]. One study only reported discordant SO cases,[3] and another study reported patients who had a previous spinal surgery elsewhere, excluding patients seeking a SO for a first operation.[1] In a one study, where frequency of SO consultation on individual procedure types across a number of specialties was reported, spine surgery had the second most SO requests out of any operation, comprising 23.7% of SO cases[17] [Table 3]. Thus, SOs are common in spine surgery practices and frequently discordant from first opinions.

Table 3:

Frequency of SOs.

Discordance rates

Discordance rates between first and SOs in spine surgery suggest that SOs provide patients with additional information regarding medical risks and financial costs.

One study reported 59.8% diagnosis discordance in spine surgery for SO[9] [Table 4]. Additional studies did not report specifically on spine surgery, but reported on SOs in surgical specialties that typically perform spine surgery. Using pooled data from spine/neurological/orthopedic surgery, diagnosis discordance was 24.8% (n = 1879) and treatment discordance was 49.2% (n = 3031).

Table 4:

Discordance rates between first and SOs across specialties and within spine.

In another study, concordance was either “confirmed” or “clarified,” possibly deflating discordance values relative to the other studies.[10] Two additional studies used overlapping data. In Epstein, 2011, out of the discordant cases previously identified in Epstein and Hood 2011 (n = 47), seven were geriatric cases (age > 65).[2,3,5] A second study re-mined data from Epstein 2013, and found that of the patients seen for SO, 3.8% had a neurodegenerative disease, and the discordance rate in this population was 100%, whereby the SO recommended no surgery.[2]

The estimated rate of SO cases diagnosed as nonspinal was 11.8% (n = 404), including myofascial pain syndrome, multiple sclerosis, lupus, and fibromyalgia.[3,9]

In all studies, discordance was observed in all surgical categories reported [Table 5, Columns 1 and 2].

Table 5:

Discordance rates in specific spine operations.

Patient reported outcomes after SO

Two studies included patient self-reports of perceived health (74.3% reported improvement and 76.5% rated health as good/very good) [Table 6]. A third study showed that 80.7% of SO patients undergoing surgery experienced significant pain reduction versus 64% of patients treated conservatively.

DISCUSSION

Approximately half of new visits to spine surgeons (40.6%) are SO consultations. Among those SOs, discordance with first opinion is (59.8%). Many patients seek a SO because they are afraid of having surgery, and the majority of discordant SOs recommend no surgery (75%). SOs, therefore, may inform decisions related to surgical costs and undesirable risks/complications of surgeries.

Factors contributing to discordance rates

Factors contributing to discordance rates would appear to include: variable training between physicians/spine surgeons, the different times elapsed between spine surgical opinions, and the potential changes occurring in the patients’ clinical status between opinions.

In addition, providers of the SO should be separate from those providing the service to avoid any conflict of interest.

CONCLUSION

This report highlights the discordance rates found regarding spinal surgical recommendations between first and SOs. Prospective studies are needed to objectively investigate the impact of following a first versus a SO since, SOs may reduce the physical and financial costs of spine surgery.