Evaluating Variability in Decision-Making Among Spine Surgeons Treating Adult Spine Deformity

Background context: Significant variability in the management of Adult Spinal Deformity (ASD) has been observed among spine surgeons worldwide. The variability among Canadian spine surgeons, a country with universal public healthcare, remains unknown.

Purpose: The study aims to evaluate areas of variability in the peri-operative optimization and surgical management of ASD among Canadian spine surgeons.

Study design/setting: In this cross-sectional study, 25 Canadian spine surgeons, predominantly orthopedic surgeons (20) and neurosurgeons (5) with varying experience, participated in an online survey focused on Adult Spinal Deformity (ASD).

Sample: The study involved 25 Canadian spine surgeons with varying level of experience, representing both orthopedic and neurosurgical specialities.

Outcome: Measure: The study aimed to evaluate the variability in surgical decision-making and peri-operative optimization strategies among Canadian spine surgeons when faced with simulated scenarios of ASD pathologies.

Methods: The online survey presented four vignettes with simulated scenarios of the most common ASD pathologies, including High Grade Spondylolisthesis (HGS), Neglected Adolescent Idiopathic Scoliosis (NAIS), Degenerative Scoliosis (DS), and Flat Back Syndrome (FBS). Questions in the vignettes explored ASD surgical decision-making, while additional questions focused on peri-operative optimization. Descriptive statistics were used to analyze multiple-choice responses, and open-text responses were categorized into themes.

Results: Variability was observed in the duration conservative treatment across the four ASD cases. Surgeons exhibited variability in the use of preoperative osteoporosis treatment. There was varied use of a dedicated anesthesiology team. Surgical goals varied in HGS and NAIS. The primary surgical method was variable in DS and HGS, the type of osteotomy varied in DS and FBS, and level of fixation varied in HGS and NAIS. Consensus was observed in the use of intraoperative monitoring across of all four ASD pathologies, the implementation of a team-based approach, and the selection of the primary surgical goal in DS and FBS.

Conclusion: Our cross-sectional study revealed variability among Canadian spine surgeons in the management of ASD, potentially influenced by the uncertain ASD progression, the need for evidence-based non-surgical guidelines, and insufficient evidence on optimal surgical approaches. These findings will help guide future research to ultimately reduce variability and improve ASD patient management and outcomes.