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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