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background. Furthermore, the null hypothesis also states that surgeon ‘expertise’ and

surgeon specialty background are not related to trends and patient outcomes in surgical

care of the degenerative lumbar spine.

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LEGEND: CATEGORY

1-Diagnosis & Management Skills-Spine Specific 2-History & Physical Examination Skills 3-Investigations

4-Problem-Based Management Skills 5-Treatment of Infections

6-Continuity of Care

7-Management of Chronic Inflammatory Conditions

8-Management of Chronic Pain

9-Medical/Legal Aspects of Practice 10-Rehabilitation/Physiotherapy

11-Personal & Professional Skills

12-Involvement in Research & Teaching 13-Peri-operative Management

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(p < 0.001), the age and percent female differences weresmall considering the study sample size (1.1 yr older, 7.2%more men). There was also no change in the ratio of pro -cedures (i.e., decompresson v. adjunctive fusion) performedby neurosurgeons compared with orthopedic surgeons overthe study period.

The number of decompressive and fusion procedures bysurgical specialty and surgical volume is shown in Table 4.The odds of performing fusions over decompressions was2.9 for higher-volume compared with lower-volume sur-geons (95% confidence interval [CI] 2.5–3.2) and 12.5 fororthopedic surgeons compared with neurosurgeons (95%CI 10.6–14.6). We found heterogeneity in the odds ratios(ORs) for surgery by specialty between the low- and high-volume groups (p < 0.001, Breslow–Day test) such that theOR for fusions in low-volume surgeons was 6.3 (95% CI4.7–8.3) compared with an OR in high-volume surgeons of17.7 (95% CI 14.6–21.6).

From 1995 to 2005, there were 649 reoperations(10.6%; Table 5). The reoperation rate was higher fordecompressions than fusions at 2 years (OR 1.4, 95% CI1.1–1.8). Overall, the reoperation rate was lower foryounger patients (mean difference 2.0 yr, 95% CI 1.3–2.8) and those without significant comorbidities (OR 0.7,95% CI 0.6–0.9). We found no significant differences inlong-term survival for index procedures or surgeon spe-cialty (Fig. 2 and Fig. 3). Cox proportional hazardsregression demonstrated that patients with lower-volumesurgeons had a significantly higher reoperation rate afteradjusting for age, comorbidity and surgeon specialty (haz-ard ratio 1.28, p = 0.038; Fig. 4).

DISCUSSION

From 1995 to 2001 in Ontario, we observed a trendtoward more spinal fusions and fewer isolated decompres-sions with a simultaneous decrease in overall supply of

RESEARCH

Can J Surg, Vol. 52, No. 4, August 2009 287

Table 5. Reoperations among patients in Ontario who underwent surgery for degenerative disease of the lumbar spine between Apr. 1, 1995, and Dec. 31, 2001, by demographics and surgeon factors

Reoperation; no. (%)*

Characteristics 6 weeks 1 year 2 years Overall

No. of patients 36 (0.6) 142 (2.3) 297 (4.9) 649 (10.6) Age, mean (range) yr 66

(50–81) 67

(50–87) 67

(50–87) 66

(50–87) Female sex 20 (0.6) 77 (2.3) 165 (4.9) 354 (10.5) Male sex 16 (0.6) 65 (2.4) 132 (4.8) 295 (10.7) Charlson = 0 24 (0.5) 108 (2.4) 227 (5.1) 506 (11.3) Charlson ! 1 12 (0.7) 34 (2.0) 70 (4.2) 143 (8.6)

Index operation Decompression 23 (0.6) 108 (2.6) 223 (5.3) 449 (10.7) Fusion 13 (0.7) 34 (1.8) 74 (3.8) 200 (10.4)

Surgeon volume Low volume 9 (0.4) 56 (2.4) 120 (5.2) 255 (11.1) High volume 27 (0.7) 86 (2.2) 177 (4.6) 394 (10.3)

Surgeon specialty Neurosurgery 12 (0.5) 73 (2.7) 134 (5.0) 279 (10.4) Orthopedic surgery 24 (0.7) 69 (2.0) 163 (4.7) 370 (10.8)

*Unless otherwise indicated.

0 2 4 6 8 10

Time, yr

1

0.95

0.9

0.85

0.8

Prob

abili

ty o

f sur

viva

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Fusion

Decompression

Fig. 2. Kaplan–Meier probability of reoperation-free survival, byindex procedure.

0 2 4 6 8 10 Time, yr

1

0.95

0.9

0.85

0.8

Prob

abili

ty o

f sur

viva

l Orthopedic surgery

Neurosurgery

Fig. 3. Kaplan–Meier probability of reoperation-free survival, bysurgeon specialty.

0 2 4 6 8 10

Time, yr

1

0.95

0.9

0.85

0.8

Prob

abili

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Fig. 4. Kaplan–Meier probability of reoperation-free survival, bysurgeon volume.

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(p < 0.001), the age and percent female differences weresmall considering the study sample size (1.1 yr older, 7.2%more men). There was also no change in the ratio of pro -cedures (i.e., decompresson v. adjunctive fusion) performedby neurosurgeons compared with orthopedic surgeons overthe study period.

The number of decompressive and fusion procedures bysurgical specialty and surgical volume is shown in Table 4.The odds of performing fusions over decompressions was2.9 for higher-volume compared with lower-volume sur-geons (95% confidence interval [CI] 2.5–3.2) and 12.5 fororthopedic surgeons compared with neurosurgeons (95%CI 10.6–14.6). We found heterogeneity in the odds ratios(ORs) for surgery by specialty between the low- and high-volume groups (p < 0.001, Breslow–Day test) such that theOR for fusions in low-volume surgeons was 6.3 (95% CI4.7–8.3) compared with an OR in high-volume surgeons of17.7 (95% CI 14.6–21.6).

From 1995 to 2005, there were 649 reoperations(10.6%; Table 5). The reoperation rate was higher fordecompressions than fusions at 2 years (OR 1.4, 95% CI1.1–1.8). Overall, the reoperation rate was lower foryounger patients (mean difference 2.0 yr, 95% CI 1.3–2.8) and those without significant comorbidities (OR 0.7,95% CI 0.6–0.9). We found no significant differences inlong-term survival for index procedures or surgeon spe-cialty (Fig. 2 and Fig. 3). Cox proportional hazardsregression demonstrated that patients with lower-volumesurgeons had a significantly higher reoperation rate afteradjusting for age, comorbidity and surgeon specialty (haz-ard ratio 1.28, p = 0.038; Fig. 4).

DISCUSSION

From 1995 to 2001 in Ontario, we observed a trendtoward more spinal fusions and fewer isolated decompres-sions with a simultaneous decrease in overall supply of

RESEARCH

Can J Surg, Vol. 52, No. 4, August 2009 287

Table 5. Reoperations among patients in Ontario who underwent surgery for degenerative disease of the lumbar spine between Apr. 1, 1995, and Dec. 31, 2001, by demographics and surgeon factors

Reoperation; no. (%)*

Characteristics 6 weeks 1 year 2 years Overall

No. of patients 36 (0.6) 142 (2.3) 297 (4.9) 649 (10.6) Age, mean (range) yr 66

(50–81) 67

(50–87) 67

(50–87) 66

(50–87) Female sex 20 (0.6) 77 (2.3) 165 (4.9) 354 (10.5) Male sex 16 (0.6) 65 (2.4) 132 (4.8) 295 (10.7) Charlson = 0 24 (0.5) 108 (2.4) 227 (5.1) 506 (11.3) Charlson ! 1 12 (0.7) 34 (2.0) 70 (4.2) 143 (8.6)

Index operation Decompression 23 (0.6) 108 (2.6) 223 (5.3) 449 (10.7) Fusion 13 (0.7) 34 (1.8) 74 (3.8) 200 (10.4)

Surgeon volume Low volume 9 (0.4) 56 (2.4) 120 (5.2) 255 (11.1) High volume 27 (0.7) 86 (2.2) 177 (4.6) 394 (10.3)

Surgeon specialty Neurosurgery 12 (0.5) 73 (2.7) 134 (5.0) 279 (10.4) Orthopedic surgery 24 (0.7) 69 (2.0) 163 (4.7) 370 (10.8)

*Unless otherwise indicated.

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0.8

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abili

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Fig. 2. Kaplan–Meier probability of reoperation-free survival, byindex procedure.

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Fig. 3. Kaplan–Meier probability of reoperation-free survival, bysurgeon specialty.

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Fig. 4. Kaplan–Meier probability of reoperation-free survival, bysurgeon volume.

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