A Cape Town study has found that spinal operations – with the largest open medical scheme in SA – was dominated by surgery for degenerative pathology in older adults, and performed largely by neurosurgeons.
However, in the public sector, the procedure is performed mostly by orthopaedic surgeons, highlighting the stark contrast in the profile of the surgery between the two sectors, and the need for private-public collaboration.
Furthermore, said the researchers, the findings support the need for spine fellowships for all specialists intending to practise spinal surgery.
Spinal pathology may have significant implications for functional ability, work productivity and quality of life, highlighting the need for effective treatment, wrote the authors in the SA Medical Journal, and while many spinal disorders improve with conservative management, surgery may provide an equivalent or superior outcome in some cases.
Relatively few studies have investigated the overall profile of surgery in a particular context, with the existing literature focused largely on specific spinal pathologies or procedures.
This study described the characteristics of admissions to an orthopaedic spine unit based at a major tertiary hospital in the Western Cape, and found that only 52% of admissions underwent spinal surgery, of which 40% were for trauma and 36% for infection. This suggested spinal surgery in the public sector is dominated by trauma and infection, notably spinal tuberculosis.
Furthermore, it is generally accepted that spinal surgery in the public sector is managed largely by orthopaedic service, but in contrast, most surgeries in the private sector were performed by neurosurgeons, with less than a third performed by orthopaedic spinal surgeons.
Spinal surgery has been described as the core business of neurosurgeons who move into private practice after specialisation, therefore the surgeon profile in the private sector would also be expected to differ from that of the public sector.
However, there has been little formal investigation of spinal surgery in the private sector, and these perceptions remain unsubstantiated. A holistic understanding of the profile of this surgery within the SA setting may be beneficial for applications like resource allocation, identifying areas for improvement and informing the training needs of future specialists.
The aim of this study was to provide insight into spinal surgery in the SA private healthcare sector by describing spinal surgery characteristics within a large open medical scheme, including both patient and surgeon profiles.
A total of 54 998 adult scheme members underwent inpatient spinal procedures during the study period. However, 200 cases were excluded, as the procedure codes indicated medical management only, 4 686 cases were excluded as the ICD-10 and/or procedure codes indicated a revision or follow-up surgery, and 536 codes were excluded based on insufficient evidence of spine surgery from the ICD-10 or procedure codes. The remaining 49 576 were considered index spine surgeries and included in the analysis.
Most spinal pathology occurred in the lumbar region (n=29 716, 60%), followed by the cervical region (n=14 483, n=29%), and degenerative-type pathologies were predominant. The top five ICD-10 codes accounted for 59% of all spine surgeries, and all referred either to a ‘disc disorder’ or to stenosis as the nature of the problem. The median age of those undergoing surgery for degenerative pathology was 54 (interquartile range 44-64).
Only 4% of spine surgeries were related to trauma. Spinal surgeries for deformity, infection and inflammation were the rarest overall, accounting for <1% of all surgeries, respectively.
Neurosurgeon v. orthopaedic surgeon
Surgeon specialisation was unknown for 318 surgeries, and a further 236 surgeries had neither a neurosurgeon nor an orthopaedic surgeon associated with the surgery.
The remaining 49 022 (98.9%) surgeries were associated with a neurosurgeon or orthopaedic surgeon, and were included in a subanalysis to investigate relationships between surgeon specialisation and surgery characteristics.
Spinal surgery is thought to be a less popular sub-specialisation among orthopaedic surgeons in SA, perhaps partly because of the high medical insurance involved. Uptake of spinal surgery among neurosurgeons, therefore, meets a need that might not otherwise have been addressed solely by orthopaedic surgeons sub-specialising in spinal surgery.
The authors said there was an apparent mismatch between registrar training and practice post specialisation.
Most spinal surgeries were performed by neurosurgeons, who may have had limited spinal training during specialisation. And while orthopaedic surgeons may have had higher exposure to spine surgery during their training, this exposure would have been dominated by trauma and infection rather than the degenerative pathology seen in private practice.
It is acknowledged that these are generalisations. The role of orthopaedic surgeons or neurosurgeons in spinal surgery varies by country and by institution and, likewise, the average level of trainee exposure to spinal surgery during specialisation.
Another finding was associations between surgeon specialisation and certain surgery characteristics: neurosurgeons may have had higher exposure to cervical spine pathology and disc disorders as part of the surgical management of neurological deficit, whereas trauma and deformity surgery fall within the domain of orthopaedics at tertiary level.
Neurosurgeons may also have received greater training in minimally invasive techniques, whereas orthopaedic surgeons may perform more invasive surgeries, sometimes requiring blood transfusions.
The current study had several limitations, being conducted on retrospective data collected for administrative purposes, and the findings are dependent on the accuracy with which this information was captured. Non-specific code descriptions made it difficult to categorise surgeries in some cases: e.g. spine region was unspecified in 9% of cases and it was difficult to determine surgery pathology in 7% of cases.
Finally, it is acknowledged that a more nuanced comparison of neurosurgeons and orthopaedic surgeons, including the complexity of the surgeries and use of specific techniques or equipment, would have been interesting, but fell beyond the scope of what could be readily accomplished with the available data.
Similarly, it was not possible to evaluate whether surgeries were necessary, or the outcomes thereof. These present topics for future study.
Study details
Private healthcare sector spine surgery: Patient and surgeon profiles from a large open medical scheme in South Africa
T N Mann, A J Vlok, R N Dunn, S Miseer, J H Davis.
Published in the SA Medical Journal in July 2023
Background
It is generally understood that the profile of spine surgery varies by setting, based on factors such as the age profile of the population, the economic context and access to healthcare. Relatively little is known about the profile of spine surgery in South Africa (SA), although a previous report from the public healthcare sector suggested a high burden of trauma and infection-related surgery. To our knowledge, there has been no formal investigation in the private sector. A holistic understanding of spine surgery within our setting may be beneficial for applications such as resource allocation and informing the training needs of future specialists.
Objectives
To provide insight into spinal surgery in the SA private healthcare sector by describing spine surgery characteristics within a large open medical scheme, including both patient and surgeon profiles.
Methods
This retrospective review included adult inpatient spine surgeries funded by the largest open medical scheme in SA between 2008 and 2017. An anonymised dataset extracted from the scheme records included patient demographics, ICD-10 codes, procedure codes and surgeon specialisation. Descriptive patient and surgery data were presented. Furthermore, the association between patient and surgery factors and surgeon specialisation was investigated using univariate and multivariate analyses.
Results
A total of 49 576 index spine surgeries were included. The largest proportion of surgeries involved members aged 40 – 59 years old (n=23 543, 48%), approximately half involved female members (n=25 293, 51%) and most were performed by neurosurgeons (n=35 439, 72%). At least 37 755 (76%) surgeries were for degenerative pathology, 2 100 (4%) for trauma and 242 (0.5%) for infection. Adjusted risk ratios (aRR) significantly associated with orthopaedic surgeon specialisation included cervical spine region (aRR = 0.49; 95% confidence interval (CI) 0.39 – 0.61), trauma (aRR = 1.50; 95% CI 1.20 – 1.88), deformity (aRR = 1.77; 95% CI 1.33 – 2.35) and blood transfusion (aRR = 1.46; 95% CI 1.12 – 1.91).
Conclusion
Spine surgery in SA’s largest open medical scheme was dominated by surgery for degenerative pathology in older adults, and performed largely by neurosurgeons – a stark contrast to a previous report from the public sector, highlighting a mismatch between exposure during public sector registrar training and private practice post specialisation. The findings support the need for private-public collaboration as well as the importance of spine fellowships for all specialists intending to practise spine surgery.
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