Abstract

Background:Neck or back problems are experienced at some time by many Americans and many patients receive recommendations for spinal surgery. Patients naturally seek another opinion to confirm the need for surgery, or for the particular procedure recommended.

Methods:Over approximately a 14-month period, the author prospectively collected data regarding 240 consecutive patients seeking a surgical opinion regarding a spine problem. Imaging studies were reviewed and patients were asked to comment on the consultation experience.

Results:Of the 240 patients, 155 (65%) came for a second, third, or fourth surgical opinion following an earlier opinion from a surgeon who recommended an operation. Of these patients, the author recommended no surgery for 69 (44.5%) patients. The remaining 85 (35%) were referred by primary care doctors or neurologists for initial surgical (first) opinions because of magnetic resonance imaging (MRI) or computed tomography (CT) reports indicating the presence of surgical lesions. The author recommended no surgery for 37 (43%) of these 85 patients.

Conclusions:Patients request and deserve the attention of a physician who will listen to their history and perform a careful neurological examination. The results of the neurological examination and the imaging studies must then be carefully integrated and correlated with the patient's complaints. The results should be explained to the patient so that he or she will understand the surgical or non surgical nature of his or her problem.

Keywords: Imaging studies, not satisfied, spinal surgery, very helpful

INTRODUCTION

Neck or back problems are experienced at some time by approximately 80% of Americans. Many patients receive recommendations for some type of surgical therapy. Patients naturally seek another opinion to confirm the need for surgery or for the particular procedure recommended. Additional opinions may generate confusion or perhaps may provide a better explanation and understanding of the patient's problem.

MATERIALS AND METHODS

Over approximately a 14-month period, the author pro-spectively correlated data regarding 240 consecutive patients seeking a surgical opinion regarding a spine problem. Of these, 155 patients had prior surgical opinions recommending spinal surgery, while 85 were patients newly referred by primary care physicians or neurologists. Imaging studies were reviewed by hospital staff (board certified) neuroradiologists. For initial surgical opinions (all opinions), patients were asked to comment on the consultation experience, for example, neurological exam, explanation of the surgical problem, time spent with the patient, time allowed to ask questions, use of models and the value of the consultation. The routine time spent with a new patient for a surgical consultation involved generally 60-80 min. Occasionally longer times were spent if necessary.

RESULTS

Duration of therapy and narcotic dependence of patients seeking surgical opinions

Of the 240 patients, 106 were females and 134 were males. The median age for patients in each group was 49 years. Forty-six patients (19%) presented after having spent from 4 months to 4 years involved with various forms of therapy which resulted in no improvement in their spine problem. Almost half of those (20 of the 46) became habituated to narcotic pain medication by the time they presented for their neurosurgical opinion.

Frequency of second, third, and fourth surgical opinions

Of the 240 patients, 155 (65%) visited for a second, third, or fourth surgical opinion following an earlier opinion with a surgeon [ Table 1 ]. Of the 155 patients seeking surgical opinions after already having seen a surgeon, 24 came for a third or fourth opinion because of either a complicated surgical problem for which multiple different treatment options were available or because they were hoping to obtain an opinion recommending no surgery (50%) (as they did not wish to have surgery). Of those patients seeking a second, third, or fourth opinion, no surgery was recommended in 69 (44.5%). This was typically the result of additional imaging utilized to supplement original low-quality studies. When better resolution studies were obtained, unless a clear-cut surgical problem was documented, surgery was not recommended.

Table 1

Patient group breakdown

Frequency of initial surgical opinions requested by primary care physicians or neurologists

The remaining 85 (35%) patients sought neurosurgical consultations following the recommendation of a primary care physician or a neurologist [ Table 1 . These patients were referred because of a magnetic resonance imaging (MRI) or computed tomography (CT) report indicating surgical lesions. No surgery was recommended for 37 (43%) out of these 85 patients.

Number of patients seeking additional opinions after seeing the author

Of the 240 patients, 14 indicated they were intending to seek yet another opinion (5%). Of interest, eight returned after their additional consultation.

Patients’ opinions regarding the quality of consultations

Satisfaction versus dissatisfaction

Consultations were described as “very helpful” by 141 (59%) of the 240 patients. Six patients (2.5%), however, indicated they were not satisfied with the consultation because they wished to have surgery when no surgery was recommended. Twenty-eight patients (approximately 11.5%), on the other hand, expressed dissatisfaction because surgery was recommended, and they did not wish to have surgery (primarily because of various forms of anxiety disorders) [ Table 2 ].

Table 2

Satisfaction/dissatisfaction with the consultation (240 patients)

Complete and clear explanations

One hundred and six patients (44%) out of the 240 commented that the neurosurgical examination was much more complete than that obtained from a prior physician (i.e. primary care, neurologist, prior spinal surgeon) [ Table 2 ].

Explanation for the diagnosis and treatment

Of the 240 patients, the explanation for the diagnosis [184 (77%)] and the explanation for the treatment [185 (77%)] offered by the author were clear, understandable, and more complete than those obtained in a prior consultation (i.e. primary care, neurologist, spinal surgeon). Furthermore, 152 (63%) patients appreciated the time spent face to face; 77 (32%) commented that the prior physician had only spent 15-20 min in their prior consultation (i.e. primary care, neurologist, or spinal surgeons).

Educational value of models

One hundred and twenty-three patients (51%) of the 240 expressed appreciation for the author having utilized spine models to explain the imaging results and treatment plans. One hundred and fifty (approximately 63%) patients also commented how valuable the time available was for asking questions. This had not been the case for a prior consultation or consultations.

DISCUSSION

Argument for more timely spinal surgical consultations

If patients do not improve after a reasonable amount of conservative therapy, consultation with a spine specialist should be obtained in a timely fashion. In this study, an unexpected observation was that one-fifth (19%) of patients arrived for a neurosurgical consultation only after many months (or even years) of therapy which had failed to resolve their spinal problem. Furthermore, almost half of those patients had become habituated to narcotic medication.

Shopping for multiple spine surgery opinions

Some patients shop fore more and more opinions simply because they are unable to face the truth about their problem, or because they have various anxieties which prevent them from reaching a definitive treatment plan. Approximately two-thirds (65%) of the 240 patients were seeking a second, third, or fourth surgical opinion (155 patients). The majority (131) were seeking second opinion. Patients seeking a third or fourth opinion presented either because of a complicated surgical problem for which multiple different treatment options were available or because they (50%) were hoping to obtain a recommendation for no surgery (as they did not wish to have surgery).

Review and often reordering of spinal imaging studies

The issue of imaging technology quality is currently being addressed by the center for devices and radiological health (FDA) where clinical trials are currently underway.[ 3 ] Clearly, the accuracy of imaging is tied directly to the diagnosis and treatment of spinal disorders. In this study, the author reviewed spinal imaging studies with a neuroradiologist. When findings were equivocal, a new high-resolution scan was requested, particularly in the instance of scans which were many months old or where symptoms had changed. This accounted for a large number of patients in the group referred by medical specialists (43.5%) or for those who had already been evaluated by a surgeon (44.5%) (for whom no surgery was recommended). This finding was a surprise to the author, who, prior to reviewing these results, would have predicted recommending surgery in 75-80% of patients presenting for a spinal consultation.

Divulging or not divulging prior spine surgical opinions

In the current study, patients were allowed to divulge or not divulge the opinion of the first surgeon. All opinions were based on the patients′ complaints, neurological examination findings, and imaging studies.

In a large study involving over 2000 orthopedic patients in the Netherlands, where second opinions are not common, questionnaires completed by the patients indicated that 30% sought a second opinion because they wished for more information about their condition or its treatment.[ 4 ] Another study evaluated second opinions “Through Patients’ Eyes”; 30% of patients who voluntarily sought second opinions discovered that the second opinion doctor disagreed with the first, which naturally raised some confusion.[ 2 ] In some cases, patients believed they should not divulge the results of the first opinion to the second opinion physician because that might influence the opinion of the second surgeon.[ 1 ]

Another spinal opinion: Is it helpful?

The majority of patients found “another opinion” for spinal surgery “very helpful,” whether referred by a primary care doctor, neurologist, or after obtaining an opinion from another surgeon.

The value of time spent with patients

The time the author spent on consultations with new spinal patients was probably a little bit longer than the time spent by the average spine surgeon. The extra time was likely translated by the patients into the following positive factors: a “more complete examination,” a “clearer understanding” of their problem, a greater “opportunity to ask questions,” and a more consistent “use of models.” As reimbursements are down for most physician services, including spine surgeons, it is apparent that many physicians are trying to “move” more patients in and out of the office. This results in spending less and less time on consultations, and thus leads to reduced patient satisfaction. Some patients commented that a prior surgeon, after a brief encounter, had recommended a surgical procedure. After spending little time explaining the procedure, patients described the surgeon as offering that the patient “take it or leave it” (e.g. the suggested surgery). Such terse, dismissive comments do not likely breed a satisfactory experience for any patient.

Patients request and deserve a physician's attention

Patients request and deserve the attention of a physician who will listen to their history and perform a careful examination. Additionally, the accompanying imaging needs to be carefully evaluated, and supplemented where necessary. The results of the neurological examination and imaging studies must subsequently be correlated with the patient's symptoms and signs, and this correlation should then be explained to the patient so that he or she will understand the surgical or non-surgical nature of his or her problem. Additionally, the patient should certainly have the opportunity to ask questions, without feeling intimidated. Should the patient indicate interest in yet another opinion, the physician should not become defensive, but rather encourage the patient to explore his/her options.

The aim of a spine consultation: A satisfied patient

In the end, the satisfied patient is typically the patient who does not feel that he or she is being rushed. Unfortunately, in this era of increasing costs and decreasing reimbursements, it is very difficult to provide patients with more of the desired time. Nevertheless, without a certain amount of time devoted to the patient, the surgeon will find a progressively shrinking population of patients for whom he or she is able to offer his/her skills.

I commend Dr. Gamache for his insightful study involving 240 patients seeking spinal consultations over a 14-month period. Of the 240 patients, 155 (65%) came for second, third, or fourth surgical opinion where a prior surgeon had recommended an operation. Dr. Gamache found no indications for surgery in 69 (44.5%) cases. Out of the remaining 85 (35%) patients who sought “first surgical opinions,” having been referred by primary care doctors/neurologists (based upon MRI or CT reports “indicating” the potential presence of surgical lesions), Dr. Gamache recommended no surgery in 37 (43%) patients. In addition, Dr. Gamache explored patients’ attitudes and responses to the quality of the consultation, for example, time spent with the patient, completeness of the examination, and response to their questions.

In a preceding study, Epstein had highlighted the significant incidence of “unnecessary” spine surgery being recommended to patients, including geriatric patients with multiple major comorbid factors, for pain alone, without focal neurological deficits, or significant radiographic findings.[ 1 ] Studying a consecutive series of 274 spinal consultations performed over 1 year, 47 (17.2%) patients had been told by other surgeons they needed operations which were deemed “unnecessary” by the author. The 21 “unnecessary” cervical operations included 1-4 level anterior diskectomy/fusion (18 patients), laminectomies/fusions (2 patients), and a posterior cervical diskectomy (1 patient), while the 26 “unnecessary” lumbar operations involved 1-5 level posterior lumbar interbody fusions. Notably, 29 patients exhibited one or more major overlapping comorbidity(s). Unfortunately, as the number of first versus second, third, and fourth opinions was not quantitated in Epstein's study, the percentage of “unnecessary” operations was grossly underestimated as the denominator utilized was 47/274, and included all opinions.

Unanticipated high frequency of recommendations against spinal surgery

The high frequency of recommendations against spinal surgery documented in this study came as a surprise to the author. Prior to reviewing these data, the author would have predicted that he had recommended spinal surgery to 75-80% of his patients presenting for spinal consultations. In fact, however, he recommended against spinal surgery in nearly half of the patients from both categories. These findings indicate that an enormous number of patients who did not need surgery are being referred for surgical opinions (in Dr. Gamache's opinion). This major finding underscores how critical it is for more surgeons to exercise similar “good judgment” and “appropriate restraint” when selecting patients for spinal operations. It also brings to light our increasing responsibility to spinal patients when providing initial or subsequent opinions, to advise them whether a spinal operation is indicated.

Satisfaction versus a lack of satisfaction with the author's spine consultation

In Gamache's study, patients coming in for the author's consultation expressed satisfaction in 59% of cases, but a lack of satisfaction in 14% of cases (2.5% were not satisfied because they wanted surgery, while 11.5% were not satisfied because they needed surgery they did not want). These data raise many issues regarding the New York City patient population seeking first through fourth spinal consultations, while also signaling how a multitude of spinal surgeons concentrated in a metropolitan area may generate so many spinal procedures.

Patients deserve optimal care, requiring the complex integration of their medical, neurological, neuroradiological, neurosurgical, and psychosocial information. In order to “do no harm,” we must assuredly “do some good.”

I commend Dr. Gamache for his insightful study involving 240 patients seeking spinal consultations over a 14-month period. Of the 240 patients, 155 (65%) came for second, third, or fourth surgical opinion where a prior surgeon had recommended an operation. Dr. Gamache found no indications for surgery in 69 (44.5%) cases. Out of the remaining 85 (35%) patients who sought “first surgical opinions,” having been referred by primary care doctors/neurologists (based upon MRI or CT reports “indicating” the potential presence of surgical lesions), Dr. Gamache recommended no surgery in 37 (43%) patients. In addition, Dr. Gamache explored patients’ attitudes and responses to the quality of the consultation, for example, time spent with the patient, completeness of the examination, and response to their questions.

In a preceding study, Epstein had highlighted the significant incidence of “unnecessary” spine surgery being recommended to patients, including geriatric patients with multiple major comorbid factors, for pain alone, without focal neurological deficits, or significant radiographic findings.[ 1 ] Studying a consecutive series of 274 spinal consultations performed over 1 year, 47 (17.2%) patients had been told by other surgeons they needed operations which were deemed “unnecessary” by the author. The 21 “unnecessary” cervical operations included 1-4 level anterior diskectomy/fusion (18 patients), laminectomies/fusions (2 patients), and a posterior cervical diskectomy (1 patient), while the 26 “unnecessary” lumbar operations involved 1-5 level posterior lumbar interbody fusions. Notably, 29 patients exhibited one or more major overlapping comorbidity(s). Unfortunately, as the number of first versus second, third, and fourth opinions was not quantitated in Epstein's study, the percentage of “unnecessary” operations was grossly underestimated as the denominator utilized was 47/274, and included all opinions.

Unanticipated high frequency of recommendations against spinal surgery

Unanticipated high frequency of recommendations against spinal surgery

Unanticipated high frequency of recommendations against spinal surgery

The high frequency of recommendations against spinal surgery documented in this study came as a surprise to the author. Prior to reviewing these data, the author would have predicted that he had recommended spinal surgery to 75-80% of his patients presenting for spinal consultations. In fact, however, he recommended against spinal surgery in nearly half of the patients from both categories. These findings indicate that an enormous number of patients who did not need surgery are being referred for surgical opinions (in Dr. Gamache's opinion). This major finding underscores how critical it is for more surgeons to exercise similar “good judgment” and “appropriate restraint” when selecting patients for spinal operations. It also brings to light our increasing responsibility to spinal patients when providing initial or subsequent opinions, to advise them whether a spinal operation is indicated.

Unanticipated high frequency of recommendations against spinal surgery

Unanticipated high frequency of recommendations against spinal surgery

Satisfaction versus a lack of satisfaction with the author's spine consultation

Satisfaction versus a lack of satisfaction with the author's spine consultation

Satisfaction versus a lack of satisfaction with the author's spine consultation

In Gamache's study, patients coming in for the author's consultation expressed satisfaction in 59% of cases, but a lack of satisfaction in 14% of cases (2.5% were not satisfied because they wanted surgery, while 11.5% were not satisfied because they needed surgery they did not want). These data raise many issues regarding the New York City patient population seeking first through fourth spinal consultations, while also signaling how a multitude of spinal surgeons concentrated in a metropolitan area may generate so many spinal procedures.

Satisfaction versus a lack of satisfaction with the author's spine consultation

Satisfaction versus a lack of satisfaction with the author's spine consultation

Patients deserve optimal care, requiring the complex integration of their medical, neurological, neuroradiological, neurosurgical, and psychosocial information. In order to “do no harm,” we must assuredly “do some good.”

Satisfaction versus a lack of satisfaction with the author's spine consultation

References

1. Last accessed on 2012 Feb 6. ScienceDaily [Internet] Available from: http://www.sciencedaily.com/releases/2011/01/110127101315.htm .

2. Klitzman R. Second opinions, through a patient's eyes. The New York Times. 2008. p.

3. Last accessed on 2012 Jul 17. Available from: http://www.washingtonpost.com/politics/improving-the-reliability-of-medicalimaging-technology/2012/07/15/gJQAZZzJnW_story.html .

4. Van Dalen I, Groothoff J, Stewart R, Spreeuwenberg P, Groenewegen P, van Horn J. Motives for seeking a second opinion in orthopedic surgery. J Health Serv Res Policy. 2001. 4: 195-201

5. Epstein NE, Hood DC. “Unnecessary” Spinal Surgery: A prospective one-year study of one surgeon's experience. Surg Neurol Int. 2011. 2: 83-