gms | German Medical Science

Objective: Although the SPORT trial provided level I evidence for the most common degenerative spinal pathologies, treatment still varies widely. Thus, the INDIANA trial explores whether decision-making in spine surgery is influenced by the personal emotional affection of the surgeon.

Method: We designed exemplary cases for an internet-based questionnaire, consisting of patients with disc prolapse (case 1), spinal stenosis (case 2), and spondylolisthesis (case 3). Orthopedic surgeons and neurosurgeons were asked nationwide to answer the questionnaire. For each case, the optimal treatment had to be named, and it was asked whether the decision was based on experience, gut feeling, or scientific evidence. The cases were the same for all surgeons, but the surgeons were assigned to a patient group (PG) or relative group (RG). In the PG, the questionnaire outlined that the cases were derived from anonymous patients, whereas it was explained that a relative is seeking medical advice in the RG.

Results: 68 spine surgeons filled out our questionnaire (36 PG, 32 RG). In case 1, which is the case without clear therapeutic recommendation by current evidence, 66.7% of PG surgeons and 56.3% of RG surgeons chose pure decompression, and the others chose conservative treatment (p=0.38). However, only 12.5% of PG surgeons and 28.1% of RG surgeons stated that their decision was based on evidence (p=0.07). For cases 2 and 3 there is clear level I evidence towards surgical treatment: In case 2, 55.6% of PG surgeons and 37.5% of RG surgeons voted for pure decompression (therefore following current evidence), whereas 3.7% (PG) and 6.3% (RG) advocated for stabilization while the rest chose conservative treatment (p=0.14). In 19.4% of PG, the surgeon's decision was based on evidence, whereas this was the case in 25.0% of RG cases (p=0.58). For case 3, 97.2% of PG surgeons chose surgical stabilization (therefore following current evidence), and a similar result was observed in the RG (96.9%; p=0.93). 19.4% of PG surgeons and 21.9% of RG surgeons stated that their decision was based on evidence (p=0.80).

Conclusions: For cases in which there is no “wrong or right” concerning surgery or conservative treatment (e.g., case 1), there was a trend towards more conservative treatment within the RG. This was also observed in case 2 for which we have level I evidence in favor of surgery. Although only spine surgeons were enrolled in this study, the rate of colleagues who are aware of current literature underlying our daily practice is rather small.