Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty.


Background context

Surgery to correct adult spinal deformity (ASD) is performed by both neurological surgeons and orthopedic surgeons. Despite well-documented high costs and complication rates following ASD surgery, there is a dearth of research investigating trends in treatment according to surgeon subspeciality.


The purpose of this investigation was to perform an analysis of surgical trends, costs and complications of ASD operations by physician specialty using a large, nationwide sample.

Study design/setting

Retrospective cohort study using an administrative claims database.

Patient sample

A total of 12,929 patients were identified with ASD that underwent deformity surgery performed by neurological or orthopedic surgeons.

Outcome measures

The primary outcome was surgical case volume by surgeon specialty. Secondary outcomes included costs, medical complications, surgical complications, and reoperation rates (30-day, 1-year, 5-year, and total).


The PearlDiver Mariner database was queried to identify patients who underwent ASD correction from 2010 to 2019. The cohort was stratified to identify patients who were treated by either orthopedic or neurological surgeons. Surgical volume, baseline characteristics, and surgical techniques were examined between cohorts. Multivariable logistic regression was employed to assess the cost, rate of reoperation and complication according to each subspecialty while controlling for number of levels fused, rate of pelvic fixation, age, gender, region and Charlson Comorbidity Index (CCI). Alpha was set to 0.05 and a Bonferroni correction for multiple comparisons was utilized to set the significance threshold at p ≤.000521.


A total of 12,929 ASD patients underwent deformity surgery performed by neurological or orthopedic surgeons. Orthopedic surgeons performed most deformity procedures accounting for 64.57% (8,866/12,929) of all ASD operations, while the proportion treated by neurological surgeons increased 44.2% over the decade (2010: 24.39% vs. 2019: 35.16%; p<.0005). Neurological surgeons more frequently operated on older patients (60.52 vs. 55.18 years, p<.0005) with more medical comorbidities (CCI scores: 2.01 vs. 1.47, p<.0005). Neurological surgeons also performed higher rates of arthrodesis between one and six levels (OR: 1.86, p<.0005), three column osteotomies (OR: 1.35, p<.0005) and navigated or robotic procedures (OR: 3.30, p<.0005). Procedures performed by orthopedic surgeons had significantly lower average costs as compared to neurological surgeons (Orthopedic Surgeons: $17,971.66 vs. Neurological Surgeons: $22,322.64, p=.253). Adjusted logistic regression controlling for number of levels fused, pelvic fixation, age, sex, region, and comorbidities revealed that patients within neurosurgical care had similar odds of complications to orthopaedic surgery.


This investigation of over 12,000 ASD patients demonstrates orthopedic surgeons continue to perform the majority of ASD correction surgery, although neurological surgeons are performing an increasingly larger percentage over time with a 44% increase in the proportion of surgeries performed in the decade. In this cohort, neurological surgeons more frequently operated on older and more comorbid patients, utilizing shorter-segment fixation with greater use of navigation and robotic assistance.





Published Version (Please cite this version)


Publication Info

McDonald, Christopher L, Rodrigo A Saad Berreta, Daniel Alsoof, Alex Homer, Janine Molino, Christopher P Ames, Christopher I Shaffrey, D Kojo Hamilton, et al. (2023). Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty. The spine journal : official journal of the North American Spine Society. p. S1529-9430(23)00213-9. 10.1016/j.spinee.2023.05.012 Retrieved from

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Christopher Ignatius Shaffrey

Professor of Orthopaedic Surgery

I have more than 25 years of experience treating patients of all ages with spinal disorders. I have had an interest in the management of spinal disorders since starting my medical education. I performed residencies in both orthopaedic surgery and neurosurgery to gain a comprehensive understanding of the entire range of spinal disorders. My goal has been to find innovative ways to manage the range of spinal conditions, straightforward to complex. I have a focus on managing patients with complex spinal disorders. My patient evaluation and management philosophy is to provide engaged, compassionate care that focuses on providing the simplest and least aggressive treatment option for a particular condition. In many cases, non-operative treatment options exist to improve a patient’s symptoms. I have been actively engaged in clinical research to find the best ways to manage spinal disorders in order to achieve better results with fewer complications.

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