Irwin Zareth N, Hilibrand Alan, Gustavel Michael, McLain Robert, Shaffer William, Myers Mark, Glaser John, Hart Robert A
Oregon Health and Science University, Portland, OR, USA.
Spine (Phila Pa 1976). 2005 Oct 1;30(19):2214-9. doi: 10.1097/01.brs.0000181056.76595.f7.
Survey-based descriptive study.
To study relationships between surgeon-specific factors and surgical approach to degenerative diseases of the cervical spine.
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.
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.
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.
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.
基于调查的描述性研究。
研究外科医生特定因素与颈椎退行性疾病手术方式之间的关系。
在美国，颈椎手术率存在显著的地区差异。尽管外科医生密度与脊柱手术率相关，但对于诸如外科医生特定因素等其他差异原因，人们了解甚少。
共有22名不同年龄和地区的骨科医生以及8名神经外科医生回答了关于5个模拟病例的手术必要性、手术方式以及融合和内固定使用情况的问题。病例包括：（1）伴有骨赘和神经根病的单节段椎间盘突出症；（2）伴有颈部轴向疼痛的单节段假关节；（3）伴有神经根病和中立位前凸的多节段狭窄；（4）伴有脊髓病和中立位前凸的多节段狭窄；（5）伴有脊髓病和明显后凸的多节段狭窄。分别使用独立样本t检验和Fisher精确检验分析外科医生年龄和培训背景对手术决策的影响。
对于单节段椎间盘突出症，一致性最高，所有外科医生都选择前路椎间盘切除术，29名受访者中有28人推荐融合术。年轻外科医生在所有病例中更常推荐使用内固定，在伴有脊髓病和中立位前凸的多节段狭窄病例中达到显著水平（Fisher精确检验P = 0.02）。骨科医生和神经外科医生在融合、内固定推荐以及后路手术使用方面的差异有限。
颈椎退行性疾病手术方式的差异可能取决于临床情况。尽管本研究发现对于单节段椎间盘突出症的治疗方法有很强的一致性，但对于颈椎的其他退行性疾病情况，仍存在显著差异。虽然融合推荐的差异与外科医生年龄没有明显关联，但年轻外科医生使用内固定的趋势更高。先前记录的地区差异可能部分是由于对于某些颈椎退行性疾病的适当治疗技术缺乏共识，以及外科医生特定因素。
