Science News: Physical Medicine and Rehabilitation and Interdisciplinary Spine Clinic Referrals Are Associated With Increased Conversion to Spine Surgery

Summary: Currently, in the US, many patients receive immediate referral to a spine surgeon upon concern for any spine pathology prior to undergoing conservative management. However, research has demonstrated that referrals to spine surgeons for common problems such as low back pain are often not indicated. This leads to inefficient care, delayed conservative treatments, and longer wait times for available surgical consultations.
This study highlights an opportunity to improve efficiency in care for patients and clinicians through proper triaging for spine surgery.

Objective: To examine whether clinicians from physical medicine and rehabilitation
(PM&R) and nonsurgical interdisciplinary spine clinics effectively triaged
patients for spine surgeon evaluations.

Design: Retrospective study (May 2022–April 2023) of consecutive new
patients referred to a spine surgery clinic. Charts were evaluated to determine
if surgery was indicated at the initial spine surgeon evaluation. The proportion
of patients who had an indication to have surgery was calculated based on the source of referral.
An odds ratio (OR) of patients indicated for surgery was calculated to compare
different specialty groupings.
Setting: All new consecutive patients evaluated between May 2022 and April
2023 on the panels of two fellowship-trained orthopedic spine surgeons at a
single outpatient clinic in the Pacific Northwest United States were included.
 All patients were evaluated for symptoms of lumbar degenerative disease including stenosis, radiculopathy, neurogenic claudication and/or instability.
Patients whose symptoms were associated with infections, trauma, and tumors
were excluded.
Once a patient has been evaluated by one of the integrated interdisciplinary spine
group providers and had maximized conservative management, patients were then referred to the spine surgical team. If there were questions regarding the indications for a spine surgeon evaluation, they were presented in one of weekly multidisciplinary meetings and reviewed by a group of spine surgeons, physiatrists, as well as pain providers.

Results: Of 503 patients, 247 (49.1%) had indications for and underwent spine
surgery within 6 months of initial evaluation. PM&R referrals were more likely to
result in surgery compared to primary care physician referrals. Patients referred from interdisciplinary spine clinics were also more likely to undergo surgery compared to those referred by a primary care physician. Of the patients who were referred by generalists, 42.7% were indicated for and underwent surgery; similar to the 42.8% who were indicated for surgery following a referral from a PCP. Of those who were referred by the interdisciplinary spine clinic, 63.7% were indicated for surgery; and 68.2% of patients who were evaluated and referred by PM&R were indicated for surgery.

Conclusion: Referrals from PM&R and interdisciplinary spine clinics were significantly
associated with greater odds of having an indication for surgery at the
time of initial evaluation by a spine surgeon. These findings highlight how
interdisciplinary efforts may reduce nonoperative consultations seen by surgical
spine clinicians. This study also demonstrated that many patients referred directly to orthopedic surgeons by PCPs or generalists are not appropriate surgical candidates.

Comments: These findings highlight changes in referral pathways and training as key areas to improve efficiency in care for patients with spinal pathologies. Many of these referrals would be more appropriately sent to PM&R or interdisciplinary spine clinicians, who possess the expertise to treat these patients conservatively and as needed triage them which would increase care efficiency.

This study’s findings suggest that changing the referral framework for patients with spine pathologies, where PM&R or interdisciplinary spine clinicians serve as intermediaries to triage patients, may improve efficiency in care.

The study results suggest changing the referral and treatment algorithm for patients with spine pathology to optimize their care.