Blood Brain Barrier..Neurosurgeon versus orthopaedic .. No Contest!

Variation in Surgical Opinion Regarding Management of Selected Cervical Spine Injuries: A Preliminary Study

Glaser, John A. MD; Jaworski, Beth A. MA; Cuddy, Brian G. MD; Albert, Todd J. MD; Hollowell, James P. MD; McLain, Robert F. MD; Bozzette, Samuel A. MD, PhD

Spine   Volume 23(9), 1 May 1998, pp 975-982

Not really news but quite a fun archive article that raises questions about how decide on best management. Really, the summary is that there is very little consensus on management of common serios spine disorders.

Study Design. The opinions of orthopedic surgeons and neurosurgeons were compared regarding appropriate management of selected cervical injuries and the timing of stabilization.

Objective. To determine whether there is consistency of opinion regarding the management of cervical trauma.

Summary of Background Data. Numerous forms of management for cervical trauma exist, but there are few consistent recommendations. No previous study has been done to determine uniformity of preferences of the surgeons who manage these injuries.

This minimally displaced type 2 odontoid is an example of the typ of case used as an example.

Methods. Thirty-one orthopedic surgeons and neuro-surgeons were given a brief clinical situation and pertinent radiographic studies of five selected cervical injuries. Management options included halo and nonhalo orthoses, traction, and various forms of anterior and/or posterior procedures. The surgeons rated, in whole numbers from 1 to 10, their opinions on the appropriateness of each technique. Each surgeon was given a case of a "generic" cervical injury, in which stabilization was required and for which preoperative alignment was adequate in traction. They gave opinions on the timing of stabilization, with a choice of four time frames. Four neurologic situations were rated, ranging from intact to complete cord injury.

Results. Of 46 possible responses to the five test cases regarding appropriateness, 18 ranged from 1 to 10, the largest possible variation. Only 2 had a range of 5 or less, implying better consensus among tested surgeons. Mean values ranged from 1.9 to 9.5. Agreementamong respondents regarding appropriateness was slight with a range of [kappa] statistics from 0.09 to 0.14. Of 16 possible responses regarding timing, 14 were within a range of 8 or higher. Within 24 to 72 hours was the generally preferred time frame, with all possible responses showing a range of 3 or 4. Results of a multiple analysis of variance showed no significant differences among respondents.

Conclusion. There is a large variety of opinion regarding appropriateness of specific operative and nonoperative management procedures and surgical timing among the surgeons polled who manage cervical trauma. This implies that there is no widely accepted standard management procedure for many of these injuries.

The [kappa] statistic for agreements among response categories (1, 2, 3; 4, 5, 6, 7; and 8, 9, 10) for the management procedures in the five cases ranged from 0.089 to 0.136, with a grand mean [kappa] of 0.10. For reference, the [kappa] shows the amount of agreement in excess of that expected by chance. That is, chance agreement yields a [kappa] of near zero, whereas slight agreement yields less than 0.2 and fair, moderate, substantial, and nearly perfect agreement produce values of 0.21-0.4, 0.41-0.6, 0.61-0.8, and higher than 0.8, respectively.