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Dartmouth Institute Gets it Right: On one issue, at least

Guest post from Daniel K. Resnick, MD (left)
Past President, Congress of Neurological Surgeons
Professor, Vice Chairman and Program Director
Department of Neurosurgery University of Wisconsin
Madison, WI
Anthony L. Asher, MD (right)
Co-Medical Director, Carolinas Healthcare System Neuroscience Institute
Director, National Neurosurgery Quality and Outcomes Database
Vice President, AANS/CNS NeuroPoint Alliance
Charlotte, NC

Resnick.AsherOur friends at Dartmouth continue to push their (copyrighted) agenda of shared decision making for surgery for lumbar stenosis. Dragging out weather beaten and previously criticized data, they continue to beat the drum of a perceived inappropriate rate of lumbar stenosis surgery. Despite acknowledging the complete lack of evidence to support any non-operative management strategy for patients with significant symptoms of neurogenic claudication, they continue to advocate for unproven and ineffective treatments as opposed to the most effective treatment available, surgical decompression as demonstrated by their own group in the SPORT publications.


  • The “Option Grid” (page 22) is a highly biased document offering opinions only obliquely supported by the cited references.
  • In the “long term results” section, the authors state that 48 of every 100 patients treated without surgery or injections feel better after four years, while 59 of 100 patients treated with surgery feel better after four years. A naïve reader would undoubtedly conclude that the benefits of surgery are marginal at best and probably not worth the risks and hassles of the procedure.

Real Facts:

  • The SPORT publication reporting the four-year results of surgical versus non-operative management of patients with lumbar stenosis indicates that 61 percent of surgically treated patients versus 32 percent on non-operatively treated patients achieves clinically significant improvements in functional outcome (Weinstein et al, Spine Volume 35(14), 15 June 2010, pp 1329-1338).
  • Also noted in the same SPORT publication is that at 4 years, 53 percent of those patients treated with surgery described a “major improvement” in quality of life as opposed to 23 percent in the non-operative group.
  • The chance of a “major improvement” is more than twice as likely in the surgical group – not a marginal improvement at all!
  • ALL measures were significantly improved in the surgical group at EVERY time point measured out through 4 years.

SpineThe original author’s conclusion states: “Patients with symptomatic spinal stenosis treated surgically compared to those treated nonoperatively maintain substantially greater improvement in pain and function through 4 years.” How does one reconcile the original data with the conclusions published in the October 29, 2014 report?

Getting it wrong on the benefits of surgery, though, is not enough. The report further impugns the role of fusion in lumbar stenosis. Their conclusions rely exclusively on administrative data, which has repeatedly been shown to be insufficient for making any conclusions regarding appropriateness of patient management. They cite no patient reported outcomes or actual medical outcomes data to support their assertion that the procedures are being done inappropriately.

What did they get right? The authors make a plea for increased registry reporting, and we agree. Only with the inclusion of accurate diagnostic metrics, procedural information, and reliable patient reported outcomes measures will we be able to make informed decisions regarding the appropriateness of any given procedure for any given patient. For true comparative effectiveness information, it will be necessary to compare both competing and complimentary treatment strategies. Organized neurosurgery has long supported the development of platforms such as the National Neurosurgery Quality and Outcomes Database (N2QOD) capable of providing true outcomes information.

The N2QOD was designed in partnership with numerous national healthcare stakeholders to provide robust information regarding the outcomes of patients undergoing all common forms of spine surgery. Importantly, the N2QOD involves prospective, longitudinal collection of patient reported clinical outcomes (PROs). As PROs are thought by many quality scientists to be more reflective of true underlying health status than traditional clinical estimates, this spine care registry allows for accurate assessments of treatment effect sustainability, while also promoting patient-centered care.

The N2QOD has rapidly become the largest cooperative national spine care registry, with over 18,000 patients presently enrolled in its cervical and lumbar programs. Recent database analyses suggest that most patients undergoing spine surgery present with significant baseline pain and disability. At 12 months following all forms of lumbar surgery, approximately 80 percent of patients report sustained improvement in pain, disability and quality of life. The majority of patients return to work and full activity by 12 months after surgery and express satisfaction with their outcome. Spine surgery in general is associated with low levels of surgical morbidity. Analyses of the combined contribution of patient characteristics collected by the N2QOD such as age and medical co-morbidities to specific outcomes will soon be used to facilitate truly informed therapeutic decision making and more effective resource utilization.

The potential yield of targeted, prospective data resources such as neurosurgery’s national registries stands in stark contrast to administrative datasets which poorly represent clinical and patient-specific realities.

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