Association of decision-making in spinal surgery with specialty and emotional involvement—the Indications in Spinal Surgery (INDIANA) survey
- 79 Downloads
Although recent trials provided level I evidence for the most common degenerative lumbar spinal disorders, treatment still varies widely. Thus, the Indications in Spinal Surgery (INDIANA) survey explores whether decision-making is influenced by specialty or personal emotional involvement of the treating specialist.
Nationwide, neurosurgeons and orthopedic surgeons specialized in spine surgery were asked to answer an Internet-based questionnaire with typical clinical patient cases of lumbar disc herniation (DH), lumbar spinal stenosis (SS), and lumbar degenerative spondylolisthesis (SL). The surgeons were assigned to counsel a patient or a close relative, thus creating emotional involvement. This was achieved by randomly allocating the surgeons to a patient group (PG) and relative group (RG). We then compared neurosurgeons to orthopedic surgeons and the PG to the RG regarding treatment decision-making.
One hundred twenty-two spine surgeons completed the questionnaire (response rate 78.7%). Regarding DH and SS, more conservative treatment among orthopedic surgeons was shown (DH: odds ratio [OR] 4.1, 95% confidence interval [CI] 1.7–9.7, p = 0.001; SS: OR 3.9, CI 1.8–8.2, p < 0.001). However, emotional involvement (PG vs. RG) did not affect these results for any of the three cases (DH: p = 0.213; SS: p = 0.097; SL: p = 0.924).
The high response rate indicates how important the issues raised by this study actually are for dedicated spine surgeons. Moreover, there are considerable variations in decision-making for the most common degenerative lumbar spinal disorders, although there is high-quality data from large multicenter trials available. Emotional involvement, though, did not influence treatment recommendations.
KeywordsDecision-making Degenerative spinal disorders Emotional involvement Lumbar disk herniation Lumbar degenerative spondylolisthesis Lumbar spinal stenosis
American Medical Association
body mass index
british medical research council
lumbar disk herniation
Indications in Spinal Surgery
magnetic resonance imaging
randomized controlled trial
lumbar degenerative spondylolisthesis
Spine Patient Outcomes Research Trial
lumbar spinal stenosis
visual analogue scale
NS gratefully acknowledges the support of the Graduate School’s Faculty Graduate Center of Medicine of our university.
Compliance with ethical standards
Conflict of interest
SK is consultant for Brainlab AG (Munich, Germany) and Nexstim Plc (Helsinki, Finland). The authors declare that they have no conflict of interest regarding the methods used or results presented in this survey.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all participants who took part in this survey.
- 1.American Medical Association Council on Ethical and Judicial Affairs Chapter 1: Opinions on Patient-Physician Relationships. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page. Accessed 14 Sept 2016
- 2.Arnold PM, Brodke DS, Rampersaud YR, Harrop JS, Dailey AT, Shaffrey CI, Grauer JN, Dvorak MF, Bono CM, Wilsey JT, Lee JY, Nassr A, Vaccaro AR, Spine Trauma Study G (2009) Differences between neurosurgeons and orthopedic surgeons in classifying cervical dislocation injuries and making assessment and treatment decisions: a multicenter reliability study. Am J Orthop 38:E156–E161PubMedGoogle Scholar
- 8.Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, Coumans JV, Harrington JF, Amin-Hanjani S, Schwartz JS, Sonntag VK, Barker FG 2nd, Benzel EC (2016) Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. N Engl J Med 374:1424–1434. https://doi.org/10.1056/NEJMoa1508788 CrossRefPubMedGoogle Scholar
- 9.Grauer JN, Vaccaro AR, Beiner JM, Kwon BK, Hilibrand AS, Harrop JS, Anderson G, Hurlbert J, Fehlings MG, Ludwig SC, Hedlund R, Arnold PM, Bono CM, Brodke DS, Dvorak MF, Fischer CG, Sledge JB, Shaffrey CI, Schwartz DG, Sears WR, Dickman C, Sharan A, Albert TJ, Rechtine GR 2nd (2004) Similarities and differences in the treatment of spine trauma between surgical specialties and location of practice. Spine 29:685–696CrossRefPubMedGoogle Scholar
- 13.Jacobs WC, Arts MP, van Tulder MW, Rubinstein SM, van Middelkoop M, Ostelo RW, Verhagen AP, Koes BW, Peul WC (2012) Surgical techniques for sciatica due to herniated disc, a systematic review. Eur Spine J 21:2232–2251. https://doi.org/10.1007/s00586-012-2422-9 CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Lequin MB, Verbaan D, Jacobs WC, Brand R, Bouma GJ, Vandertop WP, Peul WC, Leiden-The Hague Spine Intervention Prognostic Study G, Wcp, Bwk, Rtwmt, WbvdH, Rb (2013) Surgery versus prolonged conservative treatment for sciatica: 5-year results of a randomised controlled trial. BMJ Open 3. https://doi.org/10.1136/bmjopen-2012-002534
- 19.Lubelski D, Williams SK, O'Rourke C, Obuchowski NA, Wang JC, Steinmetz MP, Melillo AJ, Benzel EC, Modic MT, Quencer R, Mroz TE (2016) Differences in the surgical treatment of lower back pain among spine surgeons in the United States. Spine 41:978–986. https://doi.org/10.1097/BRS.0000000000001396 CrossRefPubMedGoogle Scholar
- 20.Lurie JD, Tosteson TD, Tosteson AN, Zhao W, Morgan TS, Abdu WA, Herkowitz H, Weinstein JN (2014) Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine 39:3–16. https://doi.org/10.1097/BRS.0000000000000088 CrossRefPubMedPubMedCentralGoogle Scholar
- 21.Lurie JD, Tosteson TD, Tosteson A, Abdu WA, Zhao W, Morgan TS, Weinstein JN (2015) Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine 40:63–76. https://doi.org/10.1097/BRS.0000000000000731 CrossRefPubMedPubMedCentralGoogle Scholar
- 23.Mroz TE, Lubelski D, Williams SK, O'Rourke C, Obuchowski NA, Wang JC, Steinmetz MP, Melillo AJ, Benzel EC, Modic MT, Quencer RM (2014) Differences in the surgical treatment of recurrent lumbar disc herniation among spine surgeons in the United States. Spine J 14:2334–2343. https://doi.org/10.1016/j.spinee.2014.01.037 CrossRefPubMedGoogle Scholar
- 24.Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, Thomeer RT, Koes BW, Leiden-The Hague Spine Intervention Prognostic Study G (2007) Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 356:2245–2256. https://doi.org/10.1056/NEJMoa064039 CrossRefPubMedGoogle Scholar
- 25.Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW, Leiden-The Hague Spine Intervention Prognostic Study G (2008) Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 336:1355–1358. https://doi.org/10.1136/bmj.a143 CrossRefPubMedPubMedCentralGoogle Scholar
- 27.Ruetten S, Komp M, Merk H, Godolias G (2008) Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study. Spine (Phila Pa 1976) 33:931–939. https://doi.org/10.1097/BRS.0b013e31816c8af7 CrossRefGoogle Scholar
- 31.Tosteson AN, Tosteson TD, Lurie JD, Abdu W, Herkowitz H, Andersson G, Albert T, Bridwell K, Zhao W, Grove MR, Weinstein MC, Weinstein JN (2011) Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation. Spine (Phila Pa 1976) 36:2061–2068. https://doi.org/10.1097/BRS.0b013e318235457b CrossRefGoogle Scholar
- 33.Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA (2006) Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 296:2441–2450. https://doi.org/10.1001/jama.296.20.2441 CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Blood EA, Birkmeyer NJ, Hilibrand AS, Herkowitz H, Cammisa FP, Albert TJ, Emery SE, Lenke LG, Abdu WA, Longley M, Errico TJ, SS H (2007) Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 356:2257–2270. https://doi.org/10.1056/NEJMoa070302 CrossRefPubMedPubMedCentralGoogle Scholar
- 35.Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, Herkowitz H, Hilibrand A, Albert T, Fischgrund J (2008) Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine 33:2789–2800. https://doi.org/10.1097/BRS.0b013e31818ed8f4 CrossRefPubMedPubMedCentralGoogle Scholar
- 36.Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H, Investigators S (2008) Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 358:794–810. https://doi.org/10.1056/NEJMoa0707136 CrossRefPubMedPubMedCentralGoogle Scholar
- 37.Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, SS H (2009) Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. Four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am 91:1295–1304. https://doi.org/10.2106/JBJS.H.00913 CrossRefPubMedPubMedCentralGoogle Scholar
- 38.Weinstein JN, Tosteson TD, Lurie JD, Tosteson A, Blood E, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H (2010) Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine 35:1329–1338. https://doi.org/10.1097/BRS.0b013e3181e0f04d CrossRefPubMedPubMedCentralGoogle Scholar