National variation in referral and surgical management of incident cervical disc herniation.

introductionCervical disc herniation (CDH) in working-age adults may cause substantial functional impairment. But knowledge is sparse on their transition from primary care to specialist evaluation, and whether regional differences in referral pathways influence management and outcome.

aimTo examine regional variation in CDH referral pathways, surgical rates, and work capacity outcomes in Denmark's five healthcare regions.

methodsUsing national registry data, we identified 4,322 individuals aged 18-65 with incident CDH in 2017, defined as the first presentation to specialist health care with no CDH record in the preceding year. Patients were stratified by region and by department type at the first contact (medical, surgical, or emergency) in the specialized health care sector. Work capacity one year prior to diagnosis was categorized as low (< 20%), intermediate (20-80%), or high (≥ 80%) of a standard 37-h work week and followed for two years after the initial contact in the specialized health care sector.

resultsRegional rates of specialized health care contacts for incident CDH were comparable, at 12-13 per 10,000 residents in Denmark aged 18-65 years. Nationally, 1,296 per 10,000 patients seen in specialized health care underwent surgery. However, surgical rates varied markedly between regions, from 793 per 10,000 patients in the Capital Region to 2,320 per 10,000 patients in the North Denmark Region. Nationally, 60.5% of patients were referred to medical departments, 30.7% to surgical departments, and 8.8% to emergency departments, but the pathways differed substantially across the regions of Denmark. The highest surgical rate was observed among those referred through emergency departments, where 95 of 379 referred patients underwent surgery (2,507 per 10,000 patients). In contrast, medical departments evaluated 2,615 patients, of whom 182 received surgery (696 per 10,000 patients), while surgical departments evaluated 1,328 patients, with 283 undergoing surgery (2,132 per 10,000 patients). A total of 87% of patients with high and 83% with intermediate baseline work capacity regained pre-diagnosis work capacity within six months, whereas only 5% of those with low capacity achieved a work capacity of 20% or above within two years.

conclusionAlthough national referral rates for incident CDH with specialized healthcare sector contact are comparable, substantial regional disparities were observed in entry pathways and surgical intervention rates. These findings underscore the need to identify the optimal specialized clinical pathway for CDH patients who are refractory to initial conservative treatment in primary care.