Lindena Gabriele, Bienek Karen, Marnitz Ulf, von Pickardt Björn
CLARA Klinische und Versorgungsforschung, Clara-Zetkin-Str. 34, 14532, Kleinmachnow, Deutschland.
Reha Tagesklinik im Forum Pankow GmbH & Co. KG, Berlin, Deutschland.
Schmerz. 2023 Jun;37(3):175-184. doi: 10.1007/s00482-022-00656-8. Epub 2022 Jul 4.
Second opinion (SO) on spine surgery was recently implemented as a statutory right in Germany. Prior to this, one health insurer did offer SO to its policy holders including advice on additional conservative treatment options.
Which treatment recommendations did 522 patients receive in an interdisciplinary multimodal assessment (IMA) as part of a SO by 4 teams comprising physician, physio- and psychotherapist and what were the long-term consequences?
Second opinions under a selective contract between insurer and back pain centers were evaluated based on patient-related anamnesis and interdisciplinary multimodal clinical findings including treatment recommendations and patient reports after about 2 years.
Initially, spine surgery recommendation was confirmed in 15/522 (2.9%) patients (C-SS) versus 507 recommendations against. C‑SS patients were older, male, and had current high pain intensity more frequently, their well-being and quality of life were more often considerably impaired and from the perspective of the team morphological findings were stronger. Younger and female patients with higher pain grade and less previous surgery, but more visits to medical specialties received more often a recommendation of an interdisciplinary treatment option (ITO) versus standard care (SC). After 2 years, all 15 C-SS patients and 146 randomly selected patients were contacted. Of these 161 patients, 29 (18%) had undergone spine surgery. The long-term outcome was best in ITO patients without surgery, followed by the C‑SS after surgery and SC patients without surgery.
Most patients undergoing spine surgery make their decision based on the information that they are provided without requesting a SO. As in comparative studies, most patients with a confirmed surgical indication underwent surgery, while some did not. Some patients underwent surgery inspite of recommendations against-after considering conservative therapy recommendations by the IMA. In retrospect, sound advice and an intensive conservative therapy offer seem necessary and reasonable.
脊柱手术的二次诊断意见（SO）最近在德国被确立为一项法定权利。在此之前，一家健康保险公司就已向其投保人提供二次诊断意见，包括关于其他保守治疗方案的建议。
作为由医生、物理治疗师和心理治疗师组成的4个团队进行的二次诊断意见的一部分，522名患者在多学科综合评估（IMA）中接受了哪些治疗建议，其长期后果如何？
基于与患者相关的既往史以及多学科综合临床检查结果，包括治疗建议和大约2年后的患者报告，对保险公司与背痛治疗中心之间的一份选择性合同下的二次诊断意见进行评估。
最初，15/522（2.9%）的患者的脊柱手术建议得到确认（C-SS），而有507条建议反对手术。C-SS组患者年龄更大，男性居多，当前疼痛强度更高的情况更常见，他们的幸福感和生活质量更常受到严重损害，从团队角度来看，形态学检查结果更明显。年龄较小、女性、疼痛等级较高、既往手术较少但看专科医生次数较多的患者，相较于标准治疗（SC），更常收到多学科治疗方案（ITO）的建议。2年后，联系了所有15名C-SS患者和146名随机选择的患者。在这161名患者中，29名（18%）接受了脊柱手术。长期结果在未接受手术的ITO组患者中最佳，其次是接受手术的C-SS组患者和未接受手术的SC组患者。
大多数接受脊柱手术的患者是根据所提供的信息做出决定的，而没有寻求二次诊断意见。与比较研究一样，大多数有明确手术指征的患者接受了手术，而有些患者则没有。一些患者在考虑了IMA的保守治疗建议后，尽管有反对手术的建议，仍接受了手术。回顾来看，合理的建议和强化的保守治疗方案似乎是必要且合理的。
