Spine surgeons’ requirements for imaging at the time of referral: a survey of Canadian spine surgeons

Abstract

Background: Routine imaging of patients with spine-related complaints referred for surgical assessment may represent an inefficient use of technological resources. Our objective was to explore Canadian spine surgeons' requirements with respect to imaging studies accompanying spine-related referrals. Methods:We administered an 8-item survey to all 100 actively practising surgeon members of the Canadian Spine Society that inquired about demographic variables and imaging requirements for patients referred with spine-related complaints.Results: Fifty-five spine surgeons completed our survey, for a response rate of 55%. Most respondents (43; 78%) required imaging studies to accompany all spine-related referrals. The type of imaging required was highly variable, with respondents endorsing 7 different combinations. Half (47%) required magnetic resonance imaging and 38% required plain radiographs either alone or in combination with other forms of imaging. Half of the respondents refused to see 20% or more of all patients referred for spine-related complaints. Conclusion:Most Canadian spine surgeons require imaging studies to accompany spine-related referrals; however, the type and combination of studies is highly variable, and many patients who are referred are never seen (for a consultation). Standardization and optimization of imaging practices for patients with spine-related complaints referred for surgical assessment may be an important area for cost savings.Contexte : Le recours systématique aux épreuves d'imagerie chez les patients qui se plaignent de maux de dos et qui sont référés pour consultation en chirurgie pourrait constituer une utilisation inefficace des ressources technologiques. Notre objectif était d'analyser les épreuves d'imagerie demandées par les chirurgiens canadiens spécia -listes de la colonne vertébrale, suite aux demandes de consultation qui leur sont adressées pour des patients qui ont des problèmes de colonne vertébrale.Méthodes : Nous avons administré un sondage en 8 questions aux 100 chirurgiens en pratique active qui forment la Canadian Spine Society; le questionnaire portait sur des variables démographiques et sur les demandes d'épreuves d'imagerie pour les patients qui leur sont référés pour des maux de dos.

Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon–physiotherapist level of agreement and patient satisfaction

“…2 A recent survey showed that at least 20% of patients referred to a Canadian surgeon for spinerelated concerns are never seen after having undergone the requisite and costly diagnostic imaging. 3 Of the patients seen, the surgical yield is typically low, with less than 20% requiring a surgical solution. 4,5 In regions where wait times are long, timely clinical triage and prioritization have potential to redirect patients who are inappropriately referred to surgeons and improve access for surgical candidates, making effective use of limited and costly resources.…”

Improving spine surgical access, appropriateness and efficiency in metropolitan, urban and rural settings

“…It is common practice for spine surgeons in Canada to require an MRI upon referral. 11,12 Faced with a large number of nonsurgical referrals, this requirement may be an attempt to exclude patients with nonsurgical pathology. 7 It is also quite common for primary care providers to order MRIs for patients with chronic back pain, possibly owing to worsening, persistent or recurrent symptoms.…”

“…8,9 In Canada, the traditional referral process from a primary care provider to a spine surgeon has many regional barriers and inefficiencies. 10,11 The majority of surgeons report wait times from primary care referral to consultation for nonurgent spinal conditions in excess of 6 months despite a substantial proportion closing their practices to new referrals or screening them. 10 Approximately 75%-85% of patients referred to a spine surgeon in Canada are not surgical candidates.…”

“…[12][13][14] As a result, the majority of Canadian surgeons require advanced imaging (77% require magnetic resonance imaging [MRI] of the spine) prior to referral in an attempt to screen out nonsurgical patients). 11 To improve access, referral and imaging appropriateness and delivery of care for both surgical and nonsurgical patients, several spine models of care have recently been established in Ontario, Saskatchewan, Quebec and Manitoba. 5,13,15 These models have used nurse practitioners, chiropractors and physical therapists as adjunctive members of the medical team to assess and educate patients referred by their primary care providers and in some scenarios as a screening tool for surgical referral (i.e., serving a triage function).…”

Differences among primary care patients with different mechanical patterns of low back pain: a cross-sectional investigation

“…For example, in addition to directional exercise and activity modification as suggested by Hall et al , a clinical diagnosis of spinal osteoarthritis for P2 and P4 patients can also allow for more targeted medical management, such as more aggressive use of non-steroidal anti-inflammatory drugs, or more appropriate surgical referrals for patients with P4 without the need for advanced imaging 3064 65 This study has uniquely assessed the Hall system in a broader LBP population that, as noted above, is more representative of the primary care spectrum of chronic LBP. The study by Hall and colleagues evaluated a mixed group of patients assessed in an outpatient rehabilitation setting, suggesting that only patients with insurance coverage or the ability to self-pay were included, and thereby potentially introducing selection bias into the study.…”