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Table 1 Characteristics of the included studies

From: Second opinions for spinal surgery: a scoping review

Study, year
Country
Design
Type
Sample size and setting Eligibility Intervention Downs & Black score Outcomes
Citation: Gamache, 2012
Country: US
Design: Prospective observational study
Type of second opinion: Patient-initiated
155 patients;
Neurosurgery outpatient practice
No information Consecutive patients seeking a surgical opinion for a spine problem. 4 (poor) • Format of the service
• Agreement (need for surgery)
Citation:
Lenza, 2017
Country:
Brazil
Design: Prospective observational study
Type of second opinion: Doctor-initiated
Referred for second opinion: 544
Completed stage 1: 485
Completed the full protocol: 425
Tertiary outpatient service in Brazil within a large private hospital
Inclusion
All patients aged 18+ referred to the outpatient centre recommended for surgery
Exclusion
Spinal fractures, major scoliosis, congenital spinal deformity, spinal tumours, spondyloarthropathies, or infection”
Each patient attended two appointments with a physiatrist and an orthopaedic surgeon who did not perform spine surgery. When consensus was not reached or consensus in favour of surgery was reached, patients were seen by a spinal review board (9 senior spine surgeons and 6 neurosurgeons). The board made the final recommendation. Participants who were recommended conservative management were offered treatment at the physiotherapy outpatient service. 18
(fair)
• Format of the service
• Agreement (diagnosis)
• Agreement (need for surgery)
• Agreement (type of surgery)
• Patient-reported outcomes
Citation: Marnitz, 2019
Country: Germany
Design: Retrospective observational study
Type of second opinion:
Patient-initiated
243
Setting unclear
No information No information 10 (poor) • Surgery rates
Citation: Namiranian, 2018
Country: US
Design: Retrospective observational study
Type of second opinion: Doctor-initiated
11 (reviewed by the spine board)
291 (pre and post spine board implementation period but not reviewed by board
Veteran Affairs Maryland Health Care System
Inclusion
Patients considered for elective lumbar spine surgery and considered at high risk of poor outcome
Exclusion
• Red flags (eg progressive lower extremity weakness, bladder disorders, fever, malignancy, intractable pain, or significant lumbar spine trauma)
A multidisciplinary spine board including orthopaedic spine surgeons, neurosurgeons, pain psychologists, physical therapists, radiologists, pain pharmacists, primary care clinicians, pain management clinicians, anaesthetists, and veteran advocacy was created. After a board discussion, a formal recommendation for the treatment plan was made. 14 (poor) • Format of the service
• Agreement (need for surgery)
Citation: Vialle, 2015
Country: Brazil
Design: Prospective observational study
Patient-initiated
94
Orthopaedic surgery practice
Patients aged 18–82 years who required a second opinion due to disagreement with the pre-established protocol for surgical indication Opinions from two surgeons were compared and classified as:
• Complete agreement: both surgical options were similar
• Partial disagreement: minor difference in surgical indication (eg extension of procedure or number of implants). A third opinion was not needed.
• Complete disagreement: there was a significant difference in surgical indication, diagnosis, need for surgery or type of procedure. Required a third opinion by another spine surgeon.
10 (poor) • Format of the service
• Agreement (need for surgery)
Citation: Yanamadala, 2017
Country: US
Design: Retrospective observational study
Type of second opinion: Doctor-initiated
100
Medical Centre
Inclusion
Patients scheduled to undergo spine surgery involving up to three levels of fusion or unusual spinal pathology that required a multidisciplinary approach for diagnosis of treatment planning.
Exclusion
Not mentioned
A spine multidisciplinary conference with at least one member of the following areas: physical medicine and rehabilitation, anaesthesia pain service, neurosurgery, orthopaedic spine surgery, nursing, physical therapy, and social work.
Consensus was reached on the recommendation to be given on each case. The recommendation included a decision to offer surgery or not.
11 (poor) • Format of the service
• Agreement (diagnosis)
• Agreement (need for surgery)
Citation: Epstein, 2011
Country: US
Design: Prospective observational study
Type of second opinion: Patient-initiated
274
Neurosurgery outpatient practice
No information Patients who had been referred for surgery by another spine surgeon and wanted a second opinion were assessed by a neurosurgeon who classified the surgical recommendations as “necessary” or “unnecessary”. There were two criteria for classifying surgeries as “unnecessary”:
•No focal neurological deficits
•No significant abnormal surgical pathology on imaging
3 (poor) • Format of the service
• Agreement (need for surgery)
Citation: Epstein, 2013
Country: US
Design: Prospective observational study
Type of second opinion: Patient-initiated
183
Neurosurgery outpatient practice
No information Patients receiving a second opinion and for whom surgery had been recommended by another surgeon had their initial surgery recommendation classified as:
• Unnecessary: surgeries recommended for pain alone, without neurological deficits, or significant radiographic abnormalities.
• Wrong: Overly extensive surgeries (eg too many levels anterior, posterior, or circumferential) or performed from the wrong access route (eg anterior vs posterior vs circumferential)
• Right: The neurosurgeon providing the second opinion agreed with the surgical recommendation from the previous surgeon (necessity, extent, and approach)
7 (poor) • Format of the service
• Agreement (need for surgery)
Citation: Lien, 2020
Country: US
Design: Cross-sectional study
Type of second opinion: patient-initiated
Online survey with 30 hospitals N/A N/A 8 (poor) • Format of the service
• Costs
Citation: Viola, 2013
Country: Brazil
Design: Prospective observational study
Type of second opinion: Doctor-initiated
419
Tertiary outpatient service in Brazil within a large private hospital
Patients recommended surgery were referred by their health insurer for a second opinion at the tertiary outpatient service Each patient attended two appointments with a physiatrist and an orthopaedic surgeon who did not perform spine surgery. When there was no consensus or consensus that surgery was required, patients were seen by a spinal review board (9 senior spine surgeons and 6 neurosurgeons). The board made the final recommendation. Participants who were recommended conservative management were offered treatment at the physiotherapy outpatient service. 12 (poor) • Costs
Citation: Fox, 2013
Country: US
Design: Prospective observational study
Type of second opinion: Insurance-initiated
No information
54 physiatrists from 33 practices providing consultations in Spine Centres of Excellence approved by the health insurer
Inclusion
Any patient requiring a surgical consultation
Exclusion
Patients that had evidence of trauma, tumour, infection, progressive bilateral neurological findings, cauda equina syndrome, follow-up to an inpatient or emergency department evaluation by a spine surgeon
A health insurer formed a multidisciplinary advisory group to define criteria required for physiatrists to be eligible to obtain the designation of a Spine Centre of Excellence. Every patient was required to be seen by a physiatrist prior to evaluation by a spine surgeon (except if patient had any of the exclusion criteria).
Surgeons were not reimbursed unless services were approved by the health insurer. After the consultation with the physiatrist, the patient could choose what care to receive (eg continue care with physiatrist, see a surgeon) without any other limitations.
10 (poor) • Format of the service
• Surgery rates
• Costs
• Healthcare use
Citation: Goodman, 2016
Country: US
Design: Prospective observational study
Type of second opinion: Insurance-initiated
501
Physiatrist practices authorised to provide services to a health insurer
Inclusion
People aged 18–65 with a membership with the health insurer with an episode of back pain
Exclusion
Serious clinical presentations or other reasons (eg surgical follow-up)
In order for a surgical consultation to be authorised by the health plan, patients were required to see a physiatrist (any) within the previous 6 months of the surgical appointment. 9 (poor) • Format of the service
• Surgery rates
• Costs
• Healthcare use
  1. PROMs, patient-reported outcome measures; N/A, not applicable