Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons

Daniel Lubelski, Vincent J. Alentado, Seth K. Williams, Colin O'Rourke, Nancy A. Obuchowski, Jeffrey C. Wang, Michael P. Steinmetz, Alfred J. Melillo, Edward C. Benzel, Michael T. Modic, Robert Quencer, Thomas E. Mroz

Research output: Contribution to journalArticle

2 Citations (Scopus)

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.

Original languageEnglish (US)
JournalWorld Neurosurgery
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Spondylolisthesis
Spine
Back Pain
Decompression
Therapeutics
Laminectomy
Surgeons
Practice Guidelines
Health Care Costs
Outcome Assessment (Health Care)
Guidelines

Keywords

  • Clinical equipoise
  • National trends
  • Spondylolisthesis
  • Surgeon disagreement
  • Survey

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Lubelski, D., Alentado, V. J., Williams, S. K., O'Rourke, C., Obuchowski, N. A., Wang, J. C., ... Mroz, T. E. (Accepted/In press). Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons. World Neurosurgery. https://doi.org/10.1016/j.wneu.2017.12.108

Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons. / Lubelski, Daniel; Alentado, Vincent J.; Williams, Seth K.; O'Rourke, Colin; Obuchowski, Nancy A.; Wang, Jeffrey C.; Steinmetz, Michael P.; Melillo, Alfred J.; Benzel, Edward C.; Modic, Michael T.; Quencer, Robert; Mroz, Thomas E.

In: World Neurosurgery, 01.01.2018.

Research output: Contribution to journalArticle

Lubelski, D, Alentado, VJ, Williams, SK, O'Rourke, C, Obuchowski, NA, Wang, JC, Steinmetz, MP, Melillo, AJ, Benzel, EC, Modic, MT, Quencer, R & Mroz, TE 2018, 'Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons', World Neurosurgery. https://doi.org/10.1016/j.wneu.2017.12.108
Lubelski D, Alentado VJ, Williams SK, O'Rourke C, Obuchowski NA, Wang JC et al. Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons. World Neurosurgery. 2018 Jan 1. https://doi.org/10.1016/j.wneu.2017.12.108
Lubelski, Daniel ; Alentado, Vincent J. ; Williams, Seth K. ; O'Rourke, Colin ; Obuchowski, Nancy A. ; Wang, Jeffrey C. ; Steinmetz, Michael P. ; Melillo, Alfred J. ; Benzel, Edward C. ; Modic, Michael T. ; Quencer, Robert ; Mroz, Thomas E. / Variability in Surgical Treatment of Spondylolisthesis Among Spine Surgeons. In: World Neurosurgery. 2018.
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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.",
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AU - Steinmetz, Michael P.

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