In orthopaedics, the connection between a hospital/surgeon performing a surgical procedure many times and improved outcomes has been demonstrated compellingly with total joint replacement. In the October 18, 2017 edition of JBJS, Schoenfeld et al. show that this same volume-outcome relationship holds true in the surgical treatment of spinal metastases.
The study analyzed 3,135 patients treated by 1,488 surgeons at 162 hospitals throughout Florida. Using sophisticated statistics, the authors defined high-volume surgeons as those who had performed ≥49 procedures per year and high-volume hospitals as those at which ≥167 procedures per year had been performed.
Among the entire cohort, the 90-day complication rate was 26% and the readmission rate was 43%. (Rates that high are not unexpected with such risky spinal surgeries.) Here are the findings according to surgeon volume:
- 21% complication rate for patients treated by high-volume surgeons
- 30% complication rate for patients treated by low-volume surgeons
- 37% readmission rate for patients treated by high-volume surgeons
- 47% readmission rate for patients treated by low-volume surgeons
In other words, the relative odds of complications and readmissions following operations performed by low-volume surgeons were approximately 40% higher than those following operations done by high-volume surgeons. A similar percentage difference was found between the odds at low- and high-volume hospitals. In a secondary analysis, the authors found that African Americans and Hispanics were significantly less likely than white patients to receive care from a high-volume surgeon or at a high-volume hospital.
Schoenfeld et al. state that the ideal care for patients facing surgery for spinal metastases comes from a team of experienced surgeons, medical oncologists, radiation oncologists, nurses, and support staff. They conclude that their findings “speak to the need for regionalization of subspecialty spinal oncology care as a means to optimize treatment for this cohort of patients.”
A significant portion of metastatic disease comes with no clear identification of a primary tumor; this is unfortunately the case with many spinal metastases. In the October 4, 2017 issue of The Journal, Ma et al. evaluate the survival and patient-reported quality-of-life (QOL) outcomes for patients with spinal metastases from cancer of unknown primary origin.
Their prospective longitudinal study confirms that a more aggressive strategy that combines surgery and radiation therapy results in better QOL (as measured with the four-domain FACT-G instrument) than radiation alone. There was no significant difference in survival time between the two groups. In a subgroup analysis of patients receiving surgery, those who underwent circumferential decompression had significantly better functional and physical well-being and higher total QOL scores than those who underwent decompressive laminectomy.
These findings emphasize the critical role of shared decision making in such difficult situations. A dire diagnosis with poor statistical chances of long-term survival does not mean that patients should not be informed of treatment options and have the opportunity to opt for an aggressive surgical approach, especially if that decision is likely to result in improved QOL. Let us endeavor to compassionately provide patients with the facts, as we understand them, and let them select from among the medical and surgical options that are at their disposal. More often than not, in this sad scenario, it seems aggressive is better in terms of quality of life.