The additional value of intraoperative parathyroid hormone assessment is marginal in patients with nonfamilial primary hyperparathyroidism: a prospective cohort study

BackgroundThe success of minimally invasive parathyroidectomy is attributed to evolving preoperative imaging techniques and intraoperative parathyroid hormone (IOPTH) measurement. The additional value of IOPTH measurement in patients undergoing surgery for primary hyperparathyroidism (pHPT) was evaluated.MethodsBetween 1999 and 2010 there were 119 patients who underwent surgery for pHPT at our institutions. In all patients, preoperative imaging was performed and IOPTH samples were collected prospectively but the results were not disclosed during surgery.ResultsPostoperative calcium level normalized in 114 patients (96%). The 5 surgical failures represented the maximum yield of IOPTH sampling. Three of these patients would have been identified intraoperatively by an inadequate IOPTH decrease, whereas IOPTH decreased inaccurately in the other 2 patients. In addition, in 1 of these 3 patients no abnormal gland was found during minimally invasive parathyroidectomy and subsequent conventional neck exploration. Therefore, only 2 reoperations would have been prevented (1.7%).ConclusionsIOPTH would have changed the outcome in 2 patients, increasing the biochemical cure rate from 96% to 98%. We believe that although it can be helpful in certain cases, it may not be necessary routinely in patients treated for pHPT.     

Utility of Intraoperative Parathyroid Hormone Monitoring in Patients with Multiple Endocrine Neoplasia Type 1-Associated Primary Hyperparathyroidism Undergoing Initial Parathyroidectomy

Background

Intraoperative parathyroid hormone monitoring (IOPTH) is a widely used adjunct for primary hyperparathyroidism (pHPT). However, the benefit of IOPTH in familial pHPT, such as in multiple endocrine neoplasia type I (MEN1), remains unclear.

Methods

We performed a retrospective analysis of 52 patients with MEN1-associated pHPT undergoing initial parathyroidectomy with IOPTH monitoring at our institution. Parathyroid hormone (PTH) levels were measured before skin incision and 10 min after resection of the last parathyroid gland. Variables analyzed included percent drop of PTH from baseline and the final PTH level compared to the normal reference range (RR).

Results

A total of 52 patients underwent initial subtotal parathyroidectomy with IOPTH. An IOPTH decrease cutoff of ≥75 % from baseline had the highest biochemical cure rate (87 %). In the remaining 13 % who met this cutoff, all had persistent pHPT, with ≥90 % drop of PTH from baseline. The remaining patients, who did not meet the ≥75 % cutoff, were cured. Follow-up was available for three of four patients with final IOPTH levels above the RR: one had persistent pHPT, two had hypoparathyroidism (50 %). When a postresection PTH level was within the RR, 88 % of patients were cured. While considered cured from pHPT, 7 % of patients in this group developed permanent hypoparathyroidism. When the final PTH level dropped below the RR, 28 % developed permanent hypoparathyroidism.

Conclusions

A cutoff in IOPTH decrease of ≥75 % from baseline has the highest biochemically cure rate in patients with pHPT associated with MEN1. However, a 75 % cutoff in IOPTH decrease does not exclude persistent pHPT. The absolute IOPTH value does not accurately predict postoperative hypoparathyroidism.     

Hemolysis falsely decreases intraoperative parathyroid hormone levels

Background

Intraoperative parathyroid hormone (IOPTH) measurement is used to confirm biochemical cure during parathyroidectomy. Falsely decreased IOPTH measurements could result in false-negative or false-positive results and lead to failed parathyroidectomy or unnecessary additional exploration.

Study design

The records of all patients who underwent parathyroidectomy with IOPTH between May and August 2007 were retrospectively reviewed, and the frequency of hemolysis of IOPTH samples was determined. Separately, 10 split-samples were hemolyzed using the freeze-thaw technique.

Results

Forty-seven patients underwent parathyroidectomy, and 226 IOPTH samples were sent. Seventeen (7.5%) specimens from 9 (18.8%) patients were hemolyzed. In 8 split-samples, the range of decrease caused by hemolysis was 24.5% to 53.8% compared with nonhemolyzed controls.

Conclusions

Hemolysis of IOPTH samples occurs commonly and falsely decreases IOPTH levels. Unrecognized hemolysis in pre-excision specimens could result in false-negative IOPTH results and lead to unnecessary continued exploration. Unrecognized hemolysis in postexcision specimens could lead to false-positive IOPTH results and lead to failed parathyroidectomy and the need for reoperation. Thus, hemolysis may be an easily preventable cause of erroneous IOPTH measurements.     

Minimally invasive parathyroidectomy in patients with previous endocrine surgery

Objective:

Previous endocrine neck surgery (PENS) in patients with sporadic primary hyperparathyroidism (PHP) is considered a contraindication for minimally invasive parathyroidectomy (MIP). The purpose of our study was to determine the effectiveness of MIP in such patients.

Methods:

From January 2004 to December 2009, 270 patients with PHP were treated in our department; 30 had had PENS in the past. Eighteen were selected to have MIP, while the other 12 had traditional neck explorations. Selection criteria for MIP were unilateral single- or double-gland disease localized preoperatively with at least 2 concordant imaging techniques and patient informed consent. Imaging studies included high-resolution neck ultrasound and sestamibi scan in most patients, and CT scan, selective venous sampling, and MRI in 7 patients. Unilateral explorations via a lateral approach with the patients under local (UALA in 13 patients), general (MIP in 4 patients), or local followed by general anesthesia (1 patient) were performed.

Results:

Sixteen of the 17 patients became normocalcemic after the operation. There was no conversion to traditional exploration. A single adenoma was found in 16 patients and hyperplasia in one. One patient underwent a successful parathyroidectomy 8 months later via mesothoracoscopy, because the parathyroid gland was localized correctly but was beyond access via neck. There were no postoperative complications. Mean duration of the procedure and length of stay were similar to MIP in patients without PENS. Mean follow-up of 33 months (range, 4 to 70) did not reveal any recurrence.

Conclusion:

These results illustrate that MIP is a valuable option in select patients with sporadic PHP and PENS. Localization with 2 or more concordant imaging techniques could avoid intraoperative sestamibi or qPTH testing with low morbidity (0%), high biochemical cure rate (100% in this series), rapid recovery, and finally substantially lower the cost of the procedure.     

The value and role of low dose methylene blue in the surgical management of hyperparathyroidism

Introduction

Methylene blue (MB) has been used in the identification of abnormal parathyroid glands in surgery for hyperparathyroidism. Its efficacy and safety profile have been questioned recently and this study sought to demonstrate such aspects in a unit where its use is routine.

Methods

Prospective data collected over six years in a single surgeon’s practice were interrogated to identify factors affecting MB staining, side effects suffered and unusual cases where the dye was invaluable in locating the diseased gland.

Results

A total of 98 patients underwent MB infusion. Of these, 77 cases (78.6%) stained positively with MB and 21 (21.4%) did not. Six patients suffered side effects but there were no cases of neurotoxicity. No positive predictive factors of dye uptake were found. MB was particularly useful in cases of intrathyroidal and ectopic glands as well as improving efficiency in both targeted and open parathyroidectomy.

Conclusions

This series shows that when used correctly, MB is efficacious in locating diseased parathyroid glands, with similar sensitivity rates to preoperative ultrasonography and radionucleotide imaging. Adverse effects were much lower than published previously, which may be attributed to the low dose of MB used (3.5mg/kg).     

Laparoscopically Assisted Spinal Surgery

Background:

Spinal surgery is one of the newest frontiers of videolaparoscopic surgery, but requires the cooperative efforts of both the spinal surgeon and the laparoscopic general surgeon.

Data Base:

We report our experience with 76 cases of laparoscopic spinal surgery, using both a transperitoneal and a retroperitoneal approach. Technical details and complications are described in detail.

Conclusions:

Fifty-one patients had a transperitoneal approach with an average operating time of 117 minutes. Uncomplicated cases stayed 4.4 days. Five patients required conversion. All but one patient had L5-S1 level surgery. Twenty-five patients had a retroperitoneal approach with 150 minutes operating time and a 5.7 day stay. Conversions were minimized with a two-balloon technique. The retroperitoneal approach allows for multiple level surgery with virtually unlimited fusion devices. Laparoscopically assisted spine surgery affords all the benefits of minimally invasive surgery, without limitations for the spinal surgeon.     

The impact of surgeon-based ultrasonography for parathyroid disease on a British endocrine surgical practice

INTRODUCTION

Surgeon-based ultrasonography (SUS) for parathyroid disease has not been widely adopted by British endocrine surgeons despite reports worldwide of accuracy in parathyroid localisation equivalent or superior to radiology-based ultrasonography (RUS). The aim of this study was to determine whether SUS might benefit parathyroid surgical practice in a British endocrine unit.

METHODS

Following an audit to establish the accuracy of RUS and technetium sestamibi (MIBI) in 54 patients, the accuracy of parathyroid localisation by SUS and RUS was compared prospectively with operative findings in 65 patients undergoing surgery for primary hyperparathyroidism (pHPT).

RESULTS

The sensitivity of RUS (40%) was below and MIBI (57%) was within the range of published results in the audit phase. The sensitivity (64%), negative predictive value (86%) and accuracy (86%) of SUS were significantly greater than RUS (37%, 77% and 78% respectively). SUS significantly increased the concordance of parathyroid localisation with MIBI (58% versus 32% with RUS).

CONCLUSIONS

SUS improves parathyroid localisation in a British endocrine surgical practice. It is a useful adjunct to parathyroid practice, particularly in centres without a dedicated parathyroid radiologist, and enables more patients with pHPT to benefit from minimally invasive surgery.     

Patterns of disease in patients at a tertiary referral centre requiring reoperative parathyroidectomy

Introduction

Reoperative parathyroidectomy is required when there is persistent or recurrent hyperparathyroidism following the initial surgery (at least 5% of parathyroidectomies nationally). By convention, ‘persistent disease’ is defined as the situation where the patient has not been cured by the first operation. The term ‘recurrent hyperparathyroidism’ is used when the patient was confirmed to be biochemically cured for six months from the first operation but has hyperparathyroidism after this date. Reoperative surgery is associated with higher rates of postoperative complications as well as a greater rate of failure to cure. The aim of our study was to review our departmental experience of reoperative parathyroidectomy, with a view to identify patterns of disease persistence and recurrence.

Methods

Using a departmental database, patients were identified who had undergone reoperative parathyroidectomy between 2006 and 2014. All the pre, intra and postoperative information was documented including the operative note so as to record the location of the abnormal parathyroid gland found at reoperation.

Results

Almost two-thirds (63%) of patients had negative, equivocal or discordant conventional imaging so secondary investigative tools were required frequently. The majority of abnormal glands were found in eutopic locations. The most common locations for ectopic glands were intrathyroidal, mediastinal and intrathymic. A third (33%) of the patients had multigland disease and over a quarter (28%) had coexisting thyroid disease.

Conclusions

Persistent hyperparathyroidism represents a challenging patient subgroup for which access to all radiological modalities and intraoperative parathyroid hormone monitoring are required. Patient selection for reintervention is a key determinant in the reoperation cure rate.     

Bilateral Neck Exploration Decreases Operative Time Compared to Minimally Invasive Parathyroidectomy in Patients with Discordant Imaging

Background

Unilateral parathyroidectomy for primary hyperparathyroidism (PHPT) has a high success rate in patients with concordant imaging by sestamibi and ultrasound. However, the optimal procedure when imaging is discordant remains controversial; therefore we compared unilateral exploration with intraoperative parathyroid hormone (IOPTH) monitoring to bilateral neck exploration without IOPTH monitoring in patients with discordant localization studies.

Methods

We conducted a retrospective study of 324 consecutive patients with PHPT treated at our institution from October 2005 to September 2009. We collected information regarding imaging, localization site, procedure performed, operative time, and calcium/PTH measurements.

Results

Of the 324 patients in the study, 79 (24 %) had discordant imaging by sestamibi and ultrasound. Of these, 62 patients (78 %) underwent bilateral neck exploration without IOPTH monitoring, and 14 patients (18 %) had unilateral exploration with IOPTH monitoring. IOPTH monitoring during unilateral exploration correctly predicted removal of single adenomas in 10/14 patients (71 %) and altered operative management in 4/14 cases (29 %), resulting in conversion to bilateral neck exploration. Operative time for unilateral exploration with IOPTH [median time: 96 min (range: 51–153 min)] was significantly increased relative to bilateral exploration [median time: 52 min (range: 28–149 min)]; p = 0.0027. We identified single-gland disease in 53/76 patients (70 %), double adenomas in 13/76 patients (17 %), and multiglandular hyperplasia in 10/76 patients (13 %). There was no difference in cure rate between these two surgical approaches (p = 1.0)

Conclusions

In contrast with prior studies, we found that operative time for unilateral exploration with IOPTH was significantly increased compared to bilateral neck exploration. In patients with discordant imaging, IOPTH is a useful adjunct in limiting exploration to a single side despite a high false negative rate.     

Laparoscopic repair of colonic anastomotic leak in an elderly patient

Background:

Laparoscopy to repair iatrogenic colonoscopic perforation of the colon has proven to be a safe, effective, and reproducible means to treat these potentially devastating emergencies. The use of the laparoscope provides exceptional diagnostic yield, and under the hand of a trained surgeon, produces excellent therapeutic results while minimizing recovery time for the patient.

Methods:

We report the case of an 86-year-old man who underwent emergent laparoscopic repair of a postoperative anastomotic leak following sigmoid colectomy.

Results:

The patient underwent laparoscopic oversewing of a colonic anastomotic leak, omental patch, and diverting loop ileostomy. The patient recovered fully from his emergency procedure without any further complications.

Conclusion:

Laparoscopic surgery can be extended to a wider variety of colorectal emergencies in a carefully selected group of patients, including the elderly.     

A Multimodal Imaging Protocol, <Superscript>123</Superscript>I/<Superscript>99</Superscript>Tc-Sestamibi,SPECT, and SPECT/CT,in Primary Hyperparathyroidism Adds Limited Benefit for Preoperative Localization

Introduction

Focused parathyroidectomy in primary hyperparathyroidism (1°HPT) is possible with accurate preoperative localization and intraoperative PTH monitoring (IOPTH). The added benefit of multimodal imaging techniques for operative success is unknown.

Method

Patients with 1°HPT, who underwent parathyroidectomy in 2012–2014 at a single institution, were retrospectively reviewed. Only the patients who underwent the standardized multimodal imaging workup consisting of ¹²³I/⁹⁹Tc-sestamibi subtraction scintigraphy, SPECT, and SPECT/CT were assessed.

Results

Of 360 patients who were identified, a curative operation was performed in 96 %, using pre-operative imaging and IOPTH. Imaging analysis showed that ¹²³I/⁹⁹Tc-sestamibi had a sensitivity of 86 % (95 % CI 82–90 %), positive predictive value (PPV) 93 %, and accuracy 81 %, based on correct lateralization. SPECT had a sensitivity of 77 % (95 % CI 72–82 %), PPV 92 % and accuracy 72 %. SPECT/CT had a sensitivity of 75 % (95 % CI 70–80 %), PPV of 94 %, and accuracy 71 %. There were 3 of 45 (7 %) patients with negative sestamibi imaging that had an accurate SPECT and SPECT/CT. Of 312 patients (87 %) with positive uptake on sestamibi (93 % true positive, 7 % false positive), concordant findings were present in 86 % SPECT and 84 % SPECT/CT. In cases where imaging modalities were discordant, but at least one method was true-positive, ¹²³I/⁹⁹Tc-sestamibi was significantly better than both SPECT and SPECT/CT (p < 0.001). The inclusion of SPECT and SPECT/CT in 1°HPT imaging protocol increases patient cost up to 2.4-fold.

Conclusion

¹²³I/⁹⁹Tc-sestamibi subtraction imaging is highly sensitive for preoperative localization in 1°HPT. SPECT and SPECT/CT are commonly concordant with ¹²³I/⁹⁹Tc-sestamibi and rarely increase the sensitivity. Routine inclusion of multimodality imaging technique adds minimal clinical benefit but increases cost to patient in high-volume setting.

     

Technical factors,surgeon case volume and positive margin rates after breast conservation surgery for early-stage breast cancer

Background

For patients with breast cancer, a negative surgical margin at first breast-conserving surgery (BCS) minimizes the need for reoperation and likely reduces postoperative anxiety. We assessed technical factors, surgeon and hospital case volume and margin status after BCS in early-stage breast cancer.

Methods

We performed a retrospective cohort study using a regional cancer centre database of patients who underwent BCS for breast cancer from 2000 to 2002. We considered the influence of patient, tumour and technical factors (e.g., size of specimen and preoperative diagnosis of cancer available) and surgeon and hospital case volume on margin status at first and final operation. We performed univariate and multivariate regression analyses.

Results

We reviewed 489 cases. There were no differences in patient or tumour characteristics among the low-, medium- and high-volume surgeon groups. High-volume surgeons were significantly more likely than other surgeons to operate with a confirmed preoperative diagnosis and to resect a larger volume of tissue. In our univariate analysis and at first operation, the rates of positive margins were 16.4%, 32.9% and 29.1% for high-, medium- and low-volume surgeons, respectively (p = 0.002). In the multivariate analysis, tumour factors (palpability, size, histology), presence of a confirmed preoperative diagnosis and size of resection specimen significantly predicted negative margins. However, when we controlled for these and other factors, high surgeon volume was not a predictor of negative margins at first surgery (odds ratio 1.8, 95% confidence interval 0.9–3.8, p = 0.09). Increased hospital volume was not associated with a lower rate of positive margins at first surgery.

Conclusion

Various tumour and technical factors were associated with negative margins at first BCS, whereas surgeon and hospital volume status were not. Technical steps that are under the control of the operating surgeon are likely effective targets for quality initiatives in breast cancer surgery.     

Assessment of pre-operative delays in the management of elective abdominal aortic aneurysms

INTRODUCTION

Successful endovascular aneurysm repair (EVAR) requires detailed pre-operative imaging to allow device planning. This process may delay surgery and some aneurysms may rupture prior to intervention. The aim of this study was to quantify these delays.

PATIENTS AND METHODS

Data were collected prospectively on all patients presenting with non-ruptured abdominal aortic aneurysms (AAAs) between January 2003 and October 2005. The delay between referral, the first out-patient visit, CT-scan, follow-up appointment and surgery were quantified in all patients and compared between two groups undergoing open repair and EVAR.

RESULTS

A total of 146 patients underwent AAA repair during the study (48 EVAR versus 98 open repair). There was no significant differences in the wait for CT scans between the groups (median 42 days for EVAR versus 47 days for open repairs [P = 0.48]) or the median interval between decision to operate and surgery (56 days versus 42 days [P = 0.075]). However, the median delay between referral and surgery was significantly longer in those patients undergoing EVAR at 129 days versus 77 days for open repair (P = 0.02).

CONCLUSIONS

Patients presenting electively with AAAs experienced significant delay from referral to surgery. This delay was significantly greater in those patients undergoing endovascular repair. Inevitably, some patients will rupture whilst waiting and strategies aimed at reducing delay should be pursued.     

Persistent hyperparathyroidism as a risk factor for long-term graft failure: the need to discuss indication for parathyroidectomy

Background

Although a successful kidney transplant (KTx) improves most of the mineral and bone disorders (MBD) produced by chronic kidney disease (CKD), hyperparathyroidism may persist (pHPT). Current guidelines recommend parathyroidectomy if serum parathormone is persistently elevated 1 year after KTx, because pHPT has been recently associated with poor graft outcomes. However, whether patients with pHPT and adequate renal function are at risk for long-term graft failure is unknown.

Reoperations for primary hyperparathyroidism—improvement of outcome over two decades

Purpose

Reoperations (R-PTX) for primary hyperparathyroidism (pHPT) are challenging, since they are associated with increased failure and morbidity rates. The aim was to evaluate the results of reoperations over two decades, the latter considering the implementation of Tc^99msestamibi-SPECT (Mibi/SPECT), intraoperative parathormone (IOPTH) measurement, and intraoperative neuromonitoring (IONM).

Patients and methods

Data of 1,363 patients who underwent surgery for pHPT were retrospectively analyzed regarding reoperations. Causes of persistent (p) pHPT or recurrent (r) pHPT, preoperative imaging studies, surgical findings, and outcome were analyzed. Data of patients who underwent surgery between 1987 and 1997 (group 1; G1) and between 1998 and 2008 (group 2; G2) with the use of Mibi/SPECT, IOPTH, and IONM were evaluated.

Results

One hundred twenty-five patients with benign ppHPT (n?=?108) or rpHPT (n?=?17) underwent reoperations (R-PTX). Group 1 included 54, group 2 71 patients. Main cause of ppHPT (G1?=?65 % vs. G2?=?53 %) and rpHPT (G1?=?80 % vs. G2?=?60 %) was the failed detection of a solitary adenoma (p?=?0.2). Group 1 patients had significantly less unilateral/focused neck re-explorations (G1?=?23 % vs. G2?=?57 %, p?=?0.0001), and more sternotomies (G1?=?35 vs. G2?=?14 %, p?=?0.01). After a median follow-up of 4 (range 0.9–23.4) years, reversal of hypercalcemia was achieved in 91 % (G1) and in 98.6 % in group 2 (p?=?0.08, OR 7.14 [0.809–63.1]). The rates of permanent recurrent laryngeal nerve palsy (G1?=?G2?=?9 %, p?=?1) and of postoperative permanent hypoparathyroidism (G1?=?9 % vs. G2?=?6 %, p?=?0.5) were not significantly different. Other complications such as wound infection, postoperative bleeding, and pneumonia were significantly lower in group 2 (p?<?0.001).

Conclusion

Nowadays, cure rates of R-PTX are nearly the same as in primary operations for pHPT. These results can be achieved in high-volume centers by routine use of well-established preoperative Mibi/SPECT and US in combination with IOPTH. However, morbidity is still considerably high.     

Improving the Provision of Carotid Endarterectomy in Line with UK Government Targets Requires More than Just Motivated Surgeons

INTRODUCTION

Carotid endarterectomy confers maximum benefit in symptomatic patients provided it is performed within < 2 weeks of presentation, but few centres achieve this target. The objective of this study was to determine if a surgeon with an interest in carotid endarterectomy could make simple modifications to practice so that carotid endarterectomy was performed within 2 weeks of referral in the majority of patients.

PATIENTS AND METHODS

Audit of 44 symptomatic patients undergoing carotid endarterectomy by one surgeon in 2007 after implementing simple changes in practice (e.g. ad hoc cancellation of non-urgent cases, ad hoc utilisation of cancelled theatre sessions). Outcomes were compared with 36 symptomatic patients undergoing carotid endarterectomy in 2006.

RESULTS

There was only a modest reduction in delay to surgery. In 2006, 11% underwent carotid endarterectomy within 2 weeks of referral increasing to 20% in 2007. By 2007, 48% underwent surgery within 4 weeks compared with 33% in 2006.

CONCLUSIONS

Notwithstanding the additional impact of delays from symptom onset to referral, achieving a 2-week target will require more than motivated surgeons making simple changes to practice. It seems inevitable that vascular units will have to identify 1–2 ‘ring fenced’ theatre sessions per week (but some could go unused) and surgeons will have to accept that they may not always operate on the patients they work-up.     

Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring

Background

Reoperative parathyroidectomy (R-PTX) in primary hyperparathyroidism (1HPT) has increased failure rates and morbidity. This study evaluated R-PTX during the era of minimal-access PTX with intraoperative parathyroid hormone (IOPTH) monitoring.

Methods

Two thousand sixty-five patients with 1HPT who underwent PTX were assessed for R-PTX. Preoperative studies, operative findings, and outcomes were evaluated.

Results

Two hundred twenty-eight patients underwent 236 R-PTX procedures. Imaging performed included sestamibi (89%), ultrasound (US; 56%), computed axial tomography/magnetic resonance imaging (5%), and selective venous sampling (1%). Sestamibi was more sensitive than US (84% vs 68%). Curative surgery was performed in 89% of patients. IOPTH was 99% sensitive. There was no relationship between cure and the following parameters: preoperative calcium or PTH levels, persistent or recurrent disease, or use of IOPTH. Solitary gland disease and a single previous operation were associated with increased likelihood of cure (P = .06). Hypoparathyroidism was decreased using IOPTH monitoring (2% vs 9%). One patient had recurrent laryngeal nerve palsy.

Conclusions

R-PTX can be performed effectively with minimal complications. IOPTH is an accurate predictor of cure and may decrease the frequency of permanent hypoparathyroidism.     

The who,what and when of surgery for the degenerative lumbar spine: a population-based study of surgeon factors,surgical procedures,recent trends and reoperation rates

Background

Degenerative disease of the lumbar spine (DLS) is a common condition for which surgery can be beneficial in selected patients. With recent surgical trends toward more focused subspecialty training, it is unclear how characteristics of the surgical consultant may impact on treatment and reoperations. Our objective was to understand the relations between surgeon factors (who), surgical procedures (what) and recent trends (when) and their influence on reoperations for DLS surgery.

Methods

We performed a longitudinal population-based study using administrative databases including all patients aged 50 years and older who underwent surgery for DLS. We collected data on surgeon characteristics (specialty, volume), index procedures (decompressions, fusions) and reoperations.

Results

We identified 6128 patients who underwent surgery for DLS (4200 who had decompressions, 1928 who had fusions). We observed an increasing proportion of fusions over decompressions while the per capita surgeon supply declined. Orthopedic specialty and higher surgical volume were associated with a higher proportion of fusions (p < 0.001). The overall reoperation rate was 10.6%. Reoperations were more frequent in patients who had decompressions than those who had fusions at 2 years (5.4% v. 3.8%, odds ratio 1.4, p < 0.013), but not over the long-term. Long-term survival analysis demonstrated that a lower surgical volume was related to a higher reoperation rate (hazard ratio 1.28, p = 0.038).

Conclusion

Lumbar spinal fusion rates for DLS have been increasing in Ontario. There is wide variation in surgical procedures between specialty and volume: namely high-volume and orthopedic surgeons have higer fusion rates than other surgeons. We observed better long-term survival among patients of high-volume surgeons. Referring physicians should be aware that the choice of surgical consultant may influence patients’ treatments and outcomes. With increasing rates of spinal surgery, the efficacy and cost benefit of current surgical options require ongoing study.