Surgeon, not hospital expertise affects spine surgery outcome

By Sarah Guy

The risk for complications after spine surgery are significantly lower among patients treated by very high-volume surgeons compared with those treated by very low-volume ones, report US researchers.

By contrast, and contrary to previous suggestions, greater hospital volume of the procedure has no effect on postoperative complication rate nor in-hospital mortality rates, they add.

"The finding suggests that for patients undergoing surgery for lumbar spinal stenosis, the individual surgeon's experience, skill, and clinical knowledge may be key determinants of outcomes, whereas hospital resources may be of secondary importance," they write, in Neurosurgery.

Specifically, after adjustment for potential confounders, patients treated by very-low volume surgeons (less than 15 procedures over 4 years) had a significant 1.38-times higher complication rate (including pulmonary, urinary and renal, and infectious complications) than patients treated by a very-high volume surgeon (more than 81 per 4 years).

However, the team highlights that there were no significant differences in complication rates between patients who underwent spine surgery by a low-, medium-, or high-volume surgeon compared with a very high-volume surgeon.

This suggests that there may be a certain threshold of annual volume of surgery for spinal stenosis that is required to maintain surgical skill, say Ali Bydon (Johns Hopkins University, Baltimore, Maryland) and colleagues.

Indeed, simply reducing the number of operations undertaken by surgeons who rarely perform this surgery "may be sufficient to improve outcomes," they add.

The study cohort included 48,971 US lumbar spinal stenosis patients treated from 2005 through 2008. The authors compared surgeon and hospital volume effect on in-hospital mortality, postoperative complications, and nonroutine discharge.

None of the outcomes were significantly associated with hospital volume, while increasing surgeon volume was only significantly associated with a significantly lower adjusted odds for development of at least one complication (odds ratio=0.72).

In light of their findings, the research team warns that centralization of spine surgery into centers of excellence as prior authors have suggested may not be necessary, and that procedural centralization should be done with caution.

"Although volume may be an important variable, it may be an imperfect proxy for quality," conclude Bydon et al.

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