Evidence based spinal surgery or the “journal of anecdotal medicine?” Using qualitative interviews with spinal surgeons to understand how the drivers of orthopaedic decision making can influence the creation and adoption of surgical trial evidence

Background: There is uncertainty regarding the best available treatment for stable thoracolumbar fractures without spinal cord injury. We explore what influences surgical decision making for the treatment of stable thoracolumbar fractures in the UK and discuss the implications of variation in spinal surgical work on the creation and adoption of future evidence.

Methods: Qualitative semi-structured interviews with 19 spinal surgeons from 13 UK hospitals. Data were collected as part of a mixed methods randomised pilot study (PRESTO). A conceptual framework of drivers of variation in orthopaedic surgical work informed how we analysed and reported our findings.

Results: We identified various patient, surgeon, organisational and cultural factors to influence surgical decision making and variation in the treatment of stable thoracolumbar fractures. We then use our findings to present the ‘cycle of uncertainty,’ to illustrate how a lack of evidence is a justification for a Randomised Controlled Trial (RCT) and the reason why a trial is not deemed feasible.

Conclusion: Surgical decision-making is complex, particularly in the absence of robust evidence. The reliance on informal sources to inform decision making and the limited role of evidence, have implications for the likelihood that RCT evidence will be created and/or adopted. To break this cycle of uncertainty we suggest focussing earlier in the research cycle to develop context-specific strategies that are designed to avoid equipoise from deeming future surgical trials unfeasible and high quality evidence being created. This could include separate pieces of implementation research and/or targeted qualitative research conducted prior to RCTs to encourage evidence based surgical decision-making.