Procedure Selection for Endoscopic Lumbar Spinal Decompression Surgeries

Three primary endoscopic decompression techniques have emerged for treating symptomatic lumbar spinal stenosis: transforaminal, interlaminar, and unilateral biportal (UBE) techniques. Choosing the most appropriate method is a complex decision influenced by multiple factors, including the patient's condition and the surgeon's expertise. Lumbar spinal stenosis is a degenerative condition that causes narrowing of the spine, leading to pain, numbness, muscle weakness, and impaired walking due to neurogenic claudication. The chosen surgical technique can significantly affect the patient's recovery and overall quality of life.

Navigating Surgical Decisions in Endoscopic Lumbar Spinal Decompression

The Rasch Methodology

The Rasch model, a form of Item Response Theory (IRT), offers a sophisticated way to analyze these complex decision-making processes. It goes beyond simple right or wrong answers, providing a probabilistic analysis based on the interaction between decision difficulty and surgeon expertise. This nuanced approach is particularly useful in high-stakes fields like spine surgery, where traditional descriptive statistics may fall short.

Advantages of the Rasch Model

1. Quantifying Decision Difficulty and Surgeon Ability: The model assesses not just the correctness of decisions but their difficulty, aligning this with the surgeon's skill level.

2. Creating an Interval-Level Measurement Scale: It converts ordinal survey data into interval-level scales, allowing meaningful comparisons between individuals or groups.

3. Invariance and Comparison: The model's invariance ensures that measurements of ability are stable, enabling comparisons across different contexts and patient cases.

4. Identifying Misfitting Items: It can identify decisions that do not constructively contribute to understanding a surgeon's competence, helping refine assessment tools.

5. Continuous Improvement, Education, and Clinical Guideline Development: Insights from Rasch analysis can guide educational interventions, professional development, and systemic improvements, ultimately enhancing patient outcomes.

Surgeon Survey

An online survey was distributed to 296 potential respondents via email and messaging platforms, gathering views on factors influencing the selection of transforaminal, interlaminar, and UBE techniques for lumbar spinal stenosis. Surgeons rated their agreement with six statements on a Likert scale from 1 (Strongly Disagree) to 5 (Strongly Agree):

1. Comfort and Familiarity

2. Patient-Related Factors

3. Expected Surgical Outcomes

4. Technical and Instrumental Aspects

5. Postoperative Recovery and Rehabilitation

6. Preference for Endoscopic Procedure

Survey Results

The survey received a 49.1% response rate from 296 spine specialists, with the majority being neurosurgeons and orthopedic specialists. The Rasch analysis revealed that the transforaminal technique was considered the best for lumbar endoscopic stenosis decompression. However, items like clinical outcomes and postoperative rehabilitation showed a broader spread of logit locations, indicating more variability in surgeon opinions.

Key Findings:

• Comfort level with the procedure and patient-related factors were the easiest items for surgeons to agree on.

• Clinical outcomes and postoperative rehabilitation were the most challenging items.

• The UBE procedure was the most controversial and hardest for surgeons to agree on.

Discussion

Surgeons' decisions are influenced by their perceptions and clinical experiences. Despite high-grade clinical evidence and guidelines, surgeons often prioritize their understanding of optimal patient care, developed through hands-on experience and patient interactions. This patient-centric approach fosters trust and may sometimes supersede standardized guidelines.

The Rasch model's ability to transform ordinal data into equal-interval data using logits allows for a detailed analysis of the decision-making process. It helps identify the nuances in surgical decisions that traditional statistics might overlook, providing a clearer picture of surgeons' preferences and challenges.

Summary

Understanding the thought processes behind surgeons' decisions in endoscopic lumbar spine surgery can offer insights into how clinical evidence is applied in practice. The Rasch model provides a robust tool for this analysis, revealing the underlying dynamics of patient selection and helping to refine clinical guidelines. By highlighting the complexity and variability in surgical decisions, this approach can improve patient outcomes and support the continuous development of surgical techniques and protocols.

Authors:

Kai-Uwe Lewandrowski, MD, Rossano Kepler Alvim Fiorelli, MD, Mauricio G Pereira, MD, PhD, Ivo Abraham, PhD, RN, Heber Humberto Alfaro Pachicano, MD, John C Elfar, MD, Abduljabbar Alhammoud, MD, Stefan Landgraeber, MD, Joachim Oertel, MD, Stefan Hellinger, MD, Álvaro Dowling, MD, Paulo Sérgio Teixeira De Carvalho, MD, PhD, Max R.F. Ramos, MD, PhD, Helton Defino, MD, PhD, João Paulo Bergamaschi, MD, Nicola Montemurro, MD, PhD, Christopher Yeung, MD, Marcelo Brito, MD, Douglas P. Beall, MD, Gerd Ivanic, MD, Zhang Xifeng, MD, Zhen-Zhou Li, MD, Jin-Sung L. Kim, MD, PhD, Jorge F Ramirez, MD, and Morgan P Lorio, MD, FACS

Reference:

Polytomous Rasch Analyses of Surgeons' Decision-Making on Choice of Procedure in Endoscopic Lumbar Spinal Stenosis Decompression Surgeries Int J Spine Surg 2024 Vol. 18 Issue 2 Pages 164-177.DOI: 10.14444/8595.