Advertisement

European Spine Journal

, Volume 18, Supplement 3, pp 331–337 | Cite as

The case for restraint in spinal surgery: does quality management have a role to play?

  • Richard A. DeyoEmail author
  • Sohail K. Mirza
Original Article

Abstract

Most quality improvement efforts in surgery have focused on the technical quality of care provided, rather than whether the care was indicated, or could have been provided with a safer procedure. Because risk is inherent in any procedure, reducing the number of unnecessary operations is an important issue in patient safety. In the case of lumbar spine surgery, several lines of evidence suggest that, in at least some locations, there may be excessively high surgery rates. This evidence comes from international comparisons of surgical rates; study of small area variations within countries; increasing surgical rates in the absence of new indications; comparisons of surgical outcomes between geographic areas with high or low surgical rates; expert opinion; the preferences of well-informed patients; and increasing rates of repeat surgery. From a population perspective, reducing unnecessary surgery may have a greater impact on complication rates than improving the technical quality of surgery that is performed. Evidence suggests this may be true for coronary bypass surgery in the US and hysterectomy rates in Canada. Though similar studies have not been done for spine surgery, wide geographic variations in surgical rates suggest that this could be the case for spine surgery as well. We suggest that monitoring geographic variations in surgery rates may become an important aspect of quality improvement, and that rates of repeat surgery may bear special attention. Patient registries can help in this regard, if they are very complete and rigorously maintained. They can provide data on surgical rates; offer post-marketing surveillance for new surgical devices and techniques; and help to identify patient subgroups that may benefit most from certain procedures.

Keywords

Spine surgery Quality management 

Notes

Conflict of interest statement

None of the authors has any potential conflict of interest.

References

  1. 1.
    Roos NP, Black CD, Roos LL, Tate RB, Carriere KC (1995) A population-based approach to monitoring adverse outcomes of medical care. Med Care 33:127–138PubMedCrossRefGoogle Scholar
  2. 2.
    Brennan TA, Leape LL, Laird NM et al (1991) Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 324:370–376Google Scholar
  3. 3.
    Deyo RA, Nachemson A, Mirza SK (2004) Spinal-fusion surgery: the case for restraint. N Engl J Med 350(7):722–726. doi: 10.1056/NEJMsb031771 PubMedCrossRefGoogle Scholar
  4. 4.
    Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G (1994) An international comparison of back surgery rates. Spine 19(11):1201–1206. doi: 10.1097/00007632-199406000-00001 PubMedCrossRefGoogle Scholar
  5. 5.
    Deyo RA, Mirza SK (2006) Trends and variations in the use of spine surgery. Clin Orthop Relat Res 443:139–146. doi: 10.1097/01.blo.0000198726.62514.75 PubMedCrossRefGoogle Scholar
  6. 6.
    Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES (2006) United States trends and regional variations in lumbar spine surgery: 1992–2003. Spine 31(23):2707–2714PubMedGoogle Scholar
  7. 7.
    Gray DT, Deyo RA, Kreuter W, Mirza SK, Heagerty PJ, Comstock BA, Chan L (2006) Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine 31:1957–1963. doi: 10.1097/01.brs.0000229148.63418.c1 PubMedCrossRefGoogle Scholar
  8. 8.
    Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BIUS (2005) Trends in lumbar fusion surgery for degenerative conditions. Spine 30(12):1441–1445. doi: 10.1097/01.brs.0000166503.37969.8a PubMedCrossRefGoogle Scholar
  9. 9.
    Lurie JD, Weinstein JN (2001) Shared decision-making and the orthopaedic workforce. Clin Orthop Relat Res 385:68–75. doi: 10.1097/00003086-200104000-00012 Google Scholar
  10. 10.
    Bono CM, Lee CK (2004) Critical analysis of trends in fusion for degenerative disc disease over the past 20 years: influence of technique on fusion rate and clinical outcome. Spine 29(4):455–463. doi: 10.1097/01.BRS.0000090825.94611.28 PubMedCrossRefGoogle Scholar
  11. 11.
    Keller RB, Atlas SJ, Soule DN, Singer DE, Deyo RA (1999) Relationship between rates and outcomes of operative treatment of lumbar disc herniation and spinal stenosis. J Bone Joint Surg Am 81(6):752–762PubMedGoogle Scholar
  12. 12.
    Abelson R, Petersen M (2003) An operation to ease back pain bolsters the bottom line, too. The New York Times, December 31Google Scholar
  13. 13.
    Groopman J (2002) A knife in the back. New Yorker (April):8Google Scholar
  14. 14.
    Shufflebarger HL (2001) Surgeons, societies, and companies: ethics and legalities. Spine 26:1947–1949. doi: 10.1097/00007632-200109150-00002 PubMedCrossRefGoogle Scholar
  15. 15.
    Deyo RA, Cherkin DC, Weinstein J, Howe J, Ciol M, Mulley AG Jr (2000) Involving patients in clinical decisions: impact of an interactive video program on use of back surgery. Med Care 38(9):959–969. doi: 10.1097/00005650-200009000-00009 PubMedCrossRefGoogle Scholar
  16. 16.
    Phelan EA, Deyo RA, Cherkin DC et al (2001) Helping patients decide about back surgery: a randomized trial of an interactive video program. Spine 26(2):206–211. doi: 10.1097/00007632-200101150-00016 PubMedCrossRefGoogle Scholar
  17. 17.
    Waddell G, Kummel EG, Lotto WN, Graham JD, Hall H, McCulloch JA (1979) Failed lumbar disc surgery and repeat surgery following industrial injuries. J Bone Joint Surg Am 61(2):201–207PubMedGoogle Scholar
  18. 18.
    Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA (2007) Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine 32(3):382–387. doi: 10.1097/01.brs.0000254104.55716.46 PubMedCrossRefGoogle Scholar
  19. 19.
    Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA (2007) Are lumbar spine reoperation rates falling with greater use of fusion surgery and new surgical technology? Spine 32(19):2119–2126. doi: 10.1097/BRS.0b013e318145a56a PubMedCrossRefGoogle Scholar
  20. 20.
    Lurie JD, Birkmeyer NJ, Weinstein JN (2003) Rates of advanced spinal imaging and spine surgery. Spine 28(6):616–620. doi: 10.1097/00007632-200303150-00018 PubMedCrossRefGoogle Scholar
  21. 21.
    Jarvik JG, Hollingworth W, Martin B et al (2003) Rapid magnetic resonance imaging vs radiographs for patients with low back pain: a randomized controlled trial. JAMA 289(21):2810–2818. doi: 10.1001/jama.289.21.2810 PubMedCrossRefGoogle Scholar
  22. 22.
    Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ (1993) Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population. Spine 18:1463–1470. doi: 10.1097/00007632-199311000-00002 PubMedCrossRefGoogle Scholar
  23. 23.
    Fritzell P, Hagg O, Nordwall A (2003) Complications in lumbar fusion surgery for chronic low back pain: comparison of three surgical techniques used in a prospective randomized study. A report from the Swedish Lumbar Spine Study Group. Eur Spine J 12:178–189PubMedGoogle Scholar
  24. 24.
    Carreon LY, Puno RM, Dimar JR 2nd, Glassman SD, Johnson JR (2003) Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am 85A:2089–2092Google Scholar
  25. 25.
    Fritzell P, Hagg O, Wessberg P et al (2001) Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicenter randomized controlled trial from the Swedish Lumbar Spine Study Group. Spine 26:2521–2532. doi: 10.1097/00007632-200112010-00002 PubMedCrossRefGoogle Scholar
  26. 26.
    Fritzell P, Hagg O, Wessberg P, Nordwall A (2002) Swedish lumbar spine study group. Chronic low back pain and fusion: a comparison of three surgical techniques. Spine 27:1131–1141. doi: 10.1097/00007632-200206010-00002 PubMedCrossRefGoogle Scholar
  27. 27.
    Gibson JNA, Waddell G (2005) Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine 30:2312–2320. doi: 10.1097/01.brs.0000182315.88558.9c PubMedCrossRefGoogle Scholar
  28. 28.
    Moller H, Hedlund R (2000) Instrumented and noninstrumented posterolateral fusion in adult spondylolisthesis—a prospective randomized study: part 2. Spine 25:1716–1721. doi: 10.1097/00007632-200007010-00017 PubMedCrossRefGoogle Scholar
  29. 29.
    Thomsen K, Christensen FB, Eiskjaer SP, Hansen ES, Fruensgaard S, Bunger CE (1997) The effect of pedicle screw instrumentation on functional outcome and fusion rates in posterolateral lumbar spinal fusion: a prospective, randomized clinical study. Spine 22:2813–2822. doi: 10.1097/00007632-199712150-00004 PubMedCrossRefGoogle Scholar
  30. 30.
    Carragee EJ, Lincoln T, Parmar VS, Alamin T (2006) A gold standard evaluation of the “discogenic pain: diagnosis as determined by provocative discography. Spine 31:2115–2123. doi: 10.1097/01.brs.0000231436.30262.dd PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  1. 1.Department of Family MedicineOregon Health and Science UniversityPortlandUSA
  2. 2.Department of Orthopaedic SurgeryDartmouth Medical SchoolHanoverUSA

Personalised recommendations