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Variations in Spinal Cervical Fusion Reflect Lack of Evidence

As More Orthopedic Surgeons Perform Upper Spine Surgery, Questions Remain as to the Best Techniques

If you're having surgery for degenerative disc disease of the cervical (upper) spine, the technique your surgeon uses may depend on what part of the country you live in, suggests a study in the January issue of  Spine.  The journal is published by  Lippincott Williams & Wilkins, a part of  Wolters Kluwer Health.

Persistent regional variations highlight the need for solid scientific research on the techniques and outcomes of cervical spine surgery, according to the new report by Dr Kevin J. McGuire of Beth Israel Deaconess, Boston, and colleagues.

As Number of Procedures Increases, Regional Variations Persist
The researchers analyzed data from a quality improvement project of the American Board of Orthopedic Surgeons, in which Board-certified surgeons provided information on all surgeries performed over a six-month period.  Data from 1999 to 2008 were analyzed to track trends in the rates and types of surgery for degenerative cervical disc disease.

The study focused on a procedure called cervical spinal fusion, or anterior cervical discectomy and fusion (ACDF).  In this procedure, the diseased disc between two vertebrae is removed and the vertebrae are fused together using bone grafts, hardware, or other techniques.  Alternatively, an artificial disc may be implanted between vertebrae, without fusing the vertebrae.

During the decade studied the number of cervical fusions performed by Board-certified orthopedic surgeons increased by two-thirds, while the number of surgeons performing these procedures increased by nearly half.  The number of surgeons who described themselves as spine surgeons increased by about one-fourth, while the number who said they were general orthopedic surgeons decreased by one-fourth.

As in previous studies, the techniques used to perform ACDF varied between different U.S. regions.  For example, surgeons in the South and Southeast were more likely to use artificial disc implants than Midwest surgeons.  The use of metal plates was lower for surgeons in the Northeast but higher in the Southeast.  Midwest surgeons were more likely to use bone substitutes (allograft) than the patient's own bone (autograft).  Complications were more common when autograft was used.

Variations Highlight Need for More Research Data
Overall rates of spine surgery in the United States have increased substantially in recent years.  While spinal fusion is more commonly performed in the lower (lumbar) spine, about 40 percent of fusion procedures are done in the cervical spine.  Previous studies have reported "enigmatic regional variations" in the rates of cervical spine surgery—significant differences in rates and techniques, with no apparent basis in research evidence.

The new study suggests that these variations persist while the number of cervical fusion surgeries increases.  Since there has been little change in the population rates of cervical disc disease, "[O]ne must question the increase in surgical rates among orthopedic candidates, and continued regional variations in the types of procedures," Dr McGuire and colleagues write.

These trends underscore the need for more evidence on the effectiveness of cervical spinal fusion surgery—especially since studies suggest that about half of patients will improve without surgical treatment.  There is also a lack of comparative data on which surgical technique provides the "best" results.

The study has some important limitations—including the fact that it provides no information on procedures performed by neurosurgeons.  However, the results suggest that decisions about whether and how to perform cervical spinal fusion are being made based on factors other than scientific evidence.  Dr McGuire and coauthors conclude, "The challenge of new technologies and the lack of evidence about comparative effectiveness...limit our ability to provide an informed choice to patients facing preference-based decisions."

About  Spine
Recognized internationally as the leading journal in its field,  Spine ( www.spinejournal.com) is an international, peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of spine. It is the leading subspecialty journal for the treatment of spinal disorders. Only original papers are considered for publication with the understanding that they are contributed solely to  Spine. 

About Lippincott Williams & Wilkins
Lippincott Williams & Wilkins (LWW) is a leading international publisher for healthcare professionals and students with nearly 300 periodicals and 1,500 books in more than 100 disciplines publishing under the  LWW brand, as well as content-based sites and online corporate and customer services.

LWW is part of  Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of  Wolters Kluwer, a market-leading global information services company with 2010 annual revenues of €3.6 billion ($4.7 billion).