Geographic Variation in the Surgical Treatment of Degenerative Cervical Disc Disease

HEALTH SERVICES RESEARCH (Spine 2012;37:57–66)

Title
Geographic Variation in the Surgical Treatment of Degenerative Cervical Disc Disease 
- American Board of Orthopedic Surgery Quality Improvement Initiative; Part II Candidates-

Authors
Kevin J. McGuire
John Harrast
Harry Herkowitz
James N. Weinstein
Study Design.
Retrospective case series.

Objective.
To examine and document the hange in rates and the geographic variation in procedure type and utilization of plating by orthopedic surgeons for anterior cervical discectomy–fusion.

Summary of Background.
Age/sex-adjusted rates of cervical spine surgery have not increased.
But, cervical spinal fusion rate has, accounting for 41% of all fusion procedures in 2004.

Methods.
1. Records were selected from American Board of Orthopedic Surgeons part II examination from 1999 to 2008.
2. Current Procedural Terminology (CPT) and International Classifi cation of Diseases, 9th Revision,
Clinical Modifi cation (ICDM-9-CM) codes were used to determine utilization of structural allograft, autograft/ interbody devices, and anterior cervical plating over time and within geographic region.
3. Main outcome measures were physician workforce, and rates and variation of procedure types.

Results.
1. From 1999 to 2008, the number of self-declared orthopedic spine surgeon candidates increased 24%.
2. Over this period, the annual number of discectomies with fusions for degenerative cervical disc disease increased by 67%, whereas the number of such operations per surgeon operating on at least 1 such case increased 48% (P= 0.018).
3. Interbody device (0%–31%; P< 0.0001), anterior cervical plating (39%–79%; P <0.0001), and allograft (14%–59%; P < 0.0001) use increased, whereas autograft use decreased (86%–10%; P 0.0001).

4. Region (surgical treatment of degenerative cervical disc disease from 1999 to 2008)
-Northeast: 16%  (Anterior Plating 14%, Autograft 20%, Allograft 15%, Interbody Cage 11%)
-Midwest: 22%    (Anterior Plating 22%, Autograft 18%, Allograft 27%, Interbody Cage 19%)
-Northwest: 6%   (Anterior Plating 06%, Autograft 05%, Allograft 08%, Interbody Cage 05%)
-South: 21%        (Anterior Plating 21%, Autograft 21%, Allograft 22%, Interbody Cage 20%)
-Southeast: 16%  (Anterior Plating 17%, Autograft 15%, Allograft 16%, Interbody Cage 19%)
-Southwest: 19% (Anterior Plating 19%, Autograft 21%, Allograft 12%, Interbody Cage 27%)

5. Surgical complications were more often associated with autograft compared with allograft.

Conclusion & Key points.
From 1999 to 2008, the number of OS spine surgeons have increased with performing more fusion and utilizing more structural allografts, interbody devices and or anterior cervical plates.
Regional variations also remain in the types of constructs utilized.

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