Spinal Fusions by Orthopaedic Surgeons Linked to Greater In-Hospital Complications in National Database

Peer Reviewed

Patients undergoing posterior cervical decompression and fusion (PCDF) who are operated on by orthopaedic surgeons are more likely to experience in-hospital complications than those operated on by neurological surgeons, according to data from a nationwide database. This discrepancy was not found among patients who underwent PCDF at a single institution where interdisciplinary collaboration via two-surgeon spinal surgery is common. The findings were published in the February 1 issue of Spine.

“The study is not intended be divisive,” lead author Daniel J. Snyder, BS, told SpineUniverse. “The point that we are trying to make is that we noticed differences in in-hospital complications between PCDF performed by orthopaedic surgeons and neurosurgeons in a national database, that also have been documented in the literature previously. However, we did not find these differences when we looked at our institutional database,” said Mr. Snyder who is a medical student at the Icahn School of Medicine at Mount Sinai, New York, NY.
cervical spine highlighted in green, posterior lateral views.Posterior cervical discectomy and fusion (PCDF) is performed by both orthopaedic surgeons and neurosurgeons. Photo Source: 123RF.com.

Large Institutional and National Samples Evaluated

The researchers evaluated 10 years of data from 1,221 PCDF cases performed at a single institution (Mount Sinai Hospital, 2006-2016) and 9 years of prospective data on 11,116 cases performed between 2007 and 2015 in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Participant User Files.

In both data sets, PCDF was more commonly performed by neurosurgeons than orthopaedic surgeons (56% vs 44% at Mount Sinai and 78% vs 22% in the NSQIP). Patients who were operated on by neurosurgeons were slightly older than those treated by orthopaedic surgeons, and this difference was statistically significant in the NSQIP dataset (61.11 vs 60.16 years; P=0.002). Other significant demographic differences included a slightly higher proportion of male patients in the NSQIP dataset (59.7% vs 57.26%; P=0.03), and a higher mean ASA status (American Society of Anesthesiology Physical Status Classification) of patients treated at the single institution.

In-Hospital Complication Rates Vary by Specialty

At the single institution, univariate analysis showed a significantly higher rate of bleeding requiring transfusion and pulmonary embolism among patients who underwent PCDF performed by orthopaedic surgeons versus neurosurgeons (Table 1). In contrast, patients who underwent PCDF by neurosurgeons showed significantly higher rates of airway complications and pneumonia. However, when in-hospital complications were considered as a whole, both univariate and multivariate analysis showed no significant differences between the patients treated by neurosurgeons or orthopaedic surgeons in the single institution cohort.

In the NSQIP, PCDF cases performed by orthopaedic surgeons showed a significantly higher rate of bleeding requiring transfusion and septic shock, while cases performed by neurosurgeons showed higher rates of deep vein thrombosis (Table 2). In multivariate analysis that adjusted for age, sex, and ASA status, patients in this cohort who underwent PCDF by orthopaedic surgeons had a 1.66 higher likelihood of an in-hospital complication compared with patients operated on by neurosurgeons (P<0.0001).
Table 1. Univariate Analysis of PCDF Outcomes and Complications at a Single InstitutionTable 1. Univariate Analysis of PCDF Outcomes and Complications at a Single Institution.Table 2. Univariate Analysis of PCDF Outcomes and Complications in the NSQIP DatasetTable 2. Univariate Analysis of PCDF Outcomes and Complications in the NSQIP Dataset

Interdisciplinary Collaboration May Lower Complication Rate

“Reasons for a lack of discrepancy in outcomes at our institution may also be due to the fact that orthopaedic spine fellows spend time every week operating with neurological spine attendings,” Mr. Snyder said. “At our institution, we regularly have interdisciplinary 2-surgeon spinal surgery,”

Other potential factors underlying the discrepancies found in the nationwide database include differences in levels fused, which could not be corrected for in the analysis, as well as differences in training between the two specialties and volume discrepancies. Fellowship training could make up for these latter discrepancies, Mr. Snyder noted.

“If you look at other specialties (lung, breast, and vascular surgery), differences in training pathway has been correlated with differences in outcome,” Mr. Snyder explained. “It is important to note that there is an increasing trend towards combined training programs in the United States, such as those at Emory and The Cleveland Clinic.”

However, he noted that “in a retrospective study like this, it is hard to speculate on what may be driving differences in individual complication rates. We want to emphasize that association is not causation and that there are likely a myriad of variables driving differences between the two groups. A prospective study would better highlight the differences, but hopefully increased collaboration can help spur initiatives that decrease these discrepancies as well.”

He hopes the finding will push for more research on the effects of dual-attending surgery on complication rates, and also to “encourage a dialogue and collaboration between the two specialties so that we can ultimately improve the complication rate for PCDF patients.”

Mr. Snyder has no relevant disclosures.

Updated on: 02/12/19
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Daniel J. Snyder, BS
Icahn School of Medicine at Mount Sinai
New York, NY

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