Lonjon G, Grelat M, Dhenin A, Dauzac C, Lonjon N, Kepler C K, Vaccaro A R
Service de chirurgie orthopédique, hôpital Raymond-Poincaré, 104, avenue Raymond-Poincaré, 92380 Garches, France.
Service de neurochirurgie, CHU Dijon, 21079 Dijon, France.
Orthop Traumatol Surg Res. 2015 Feb;101(1):5-10. doi: 10.1016/j.otsr.2014.10.018. Epub 2015 Jan 9.
In France, attempts to define common ground during spine surgery meetings have revealed significant variability in clinical practices across different schools of surgery and the two specialities involved in spine surgery, namely, neurosurgery and orthopaedic surgery.
To objectively characterise this variability by performing a survey based on a fictitious spine trauma case. Our working hypothesis was that significant variability existed in trauma practices and that this variability was related to a lack of strong scientific evidence in spine trauma care.
We performed a cross-sectional survey based on a clinical vignette describing a 31-year-old male with an L1 burst fracture and neurologic symptoms (numbness). Surgeons received the vignette and a 14-item questionnaire on the management of this patient. For each question, surgeons had to choose among five possible answers. Differences in answers across surgeons were assessed using the Index of Qualitative Variability (IQV), in which 0 indicates no variability and 1 maximal variability. Surgeons also received a questionnaire about their demographics and surgical experience.
Of 405 invited spine surgeons, 200 responded to the survey. Five questions had an IQV greater than 0.9, seven an IQV between 0.5 and 0.9, and two an IQV lower than 0.5. Variability was greatest about the need for MRI (IQV=0.93), degree of urgency (IQV=0.93), need for fusion (IQV=0.92), need for post-operative bracing (IQV=0.91), and routine removal of instrumentation (IQV=0.94). Variability was lowest for questions about the need for surgery (IQV=0.42) and use of the posterior approach (IQV=0.36). Answers were influenced by surgeon specialty, age, experience level, and type of centre.
Clinical practice regarding spine trauma varies widely in France. Little published evidence is available on which to base recommendations that would diminish this variability.
在法国，脊柱外科会议上试图确定共同基础的尝试表明，不同外科流派以及脊柱外科所涉及的两个专业（即神经外科和骨科）的临床实践存在显著差异。
通过基于一个虚拟脊柱创伤病例进行调查，客观描述这种差异。我们的工作假设是创伤治疗实践中存在显著差异，且这种差异与脊柱创伤护理缺乏强有力的科学证据有关。
我们基于一个临床病例 vignette 进行横断面调查，该病例描述了一名 31 岁男性，患有 L1 爆裂骨折并伴有神经症状（麻木）。外科医生收到该病例 vignette 和一份关于该患者治疗的 14 项问卷。对于每个问题，外科医生必须从五个可能的答案中选择。使用定性变异指数（IQV）评估外科医生答案的差异，其中 0 表示无差异，1 表示最大差异。外科医生还收到一份关于他们的人口统计学和手术经验的问卷。
在 405 名受邀的脊柱外科医生中，200 人回复了调查。五个问题的 IQV 大于 0.9，七个问题的 IQV 在 0.5 至 0.9 之间，两个问题的 IQV 低于 0.5。关于是否需要 MRI（IQV = 0.93）、紧急程度（IQV = 0.93）、是否需要融合（IQV = 0.92）、是否需要术后支具（IQV = 0.91）以及器械的常规取出（IQV = 0.94）的差异最大。关于是否需要手术（IQV = 0.42）和是否使用后路手术（IQV = 0.36）的问题差异最小。答案受外科医生专业、年龄、经验水平和中心类型的影响。
在法国，关于脊柱创伤的临床实践差异很大。几乎没有已发表的证据可作为减少这种差异的建议依据。
