title: Variation in surgical decision making for degenerative spinal disorders. Part II: cervical spine.
abstract: METHODS
  Survey-based descriptive study.
  
  
  OBJECTIVE
  To study relationships between surgeon-specific factors and surgical approach to degenerative diseases of the cervical spine.
  
  
  BACKGROUND
  Geographic variations in the rates of cervical spine surgery are significant within the United States. Although surgeon density correlates with the rates of spinal surgery, other reasons for variation such as surgeon-specific factors are poorly understood.
  
  
  METHODS
  A total of 22 orthopedic surgeons and 8 neurosurgeons of varied ages and geographic regions answered questions regarding the need for surgery, surgical approach, and use of fusion and instrumentation for 5 simulated cases. Cases included: (1) single-level disc herniation with osteophyte and radiculopathy, (2) single-level pseudarthrosis with axial neck pain, (3) multilevel stenosis with radiculopathy and neutral lordosis, (4) multilevel stenosis with myelopathy and neutral lordosis, and (5) multilevel stenosis with myelopathy and marked kyphosis. The effects of surgeon age and training background on surgical decision making were analyzed using an independent samples t test and Fisher exact test, respectively.
  
  
  RESULTS
  The greatest agreement occurred for the single-level disc herniation, with all surgeons choosing an anterior discectomy, and 28 of the 29 respondents recommending fusion. Younger surgeons recommended instrumentation more often for all cases, reaching significance for the case of multilevel stenosis with myelopathy and neutral lordosis (Fisher exact test P = 0.02). Differences in recommendation for fusion, instrumentation, and the use of a posterior approach between orthopedic and neurosurgeons were limited.
  
  
  CONCLUSIONS
  Variations in surgical procedures for cervical degenerative disease may depend on the clinical condition. Although this study found strong agreement in treatment approach to single-level disc herniation, significant variation was seen for the other degenerative conditions of the cervical spine. While differences in recommendation for fusion were not clearly associated with surgeon age, there was a trend toward the higher use of instrumentation by younger surgeons. Previously documented geographic variation may result in part from a lack of consensus regarding appropriate treatment techniques for certain degenerative conditions of the cervical spine, as well as surgeon-specific factors.
authors.affiliation: Oregon Health and Science University, Portland, OR, USA.
authors.forename: Zareth N
authors.initials: ZN
authors.lastname: Irwin
authors.forename: Alan
authors.initials: A
authors.lastname: Hilibrand
authors.forename: Michael
authors.initials: M
authors.lastname: Gustavel
authors.forename: Robert
authors.initials: R
authors.lastname: McLain
authors.forename: William
authors.initials: W
authors.lastname: Shaffer
authors.forename: Mark
authors.initials: M
authors.lastname: Myers
authors.forename: John
authors.initials: J
authors.lastname: Glaser
authors.forename: Robert A
authors.initials: RA
authors.lastname: Hart
mesh_terms: D000328:Adult; D000367:Age Factors; D002574:Cervical Vertebrae; D003657:Decision Making; D017586:Diskectomy; D006801:Humans; D016268:Internal Fixators; D007405:Intervertebral Disc Displacement / Q000150:complications / Q000601:surgery; D007738:Kyphosis / Q000150:complications; D008141:Lordosis / Q000150:complications; D008875:Middle Aged; D019547:Neck Pain / Q000209:etiology; D009493:Neurosurgery; D019637:Orthopedic Procedures; D009985:Orthopedics; D010820:Physicians; D011364:Professional Practice; D011542:Pseudarthrosis / Q000150:complications / Q000601:surgery; D011843:Radiculopathy / Q000209:etiology; D013118:Spinal Cord Diseases / Q000150:complications; D013122:Spinal Diseases / Q000601:surgery*; D013123:Spinal Fusion; D013130:Spinal Stenosis / Q000150:complications / Q000601:surgery