I read the article titled “Are Lumbar Fusion Guidelines Followed? A survey of North American Spine Surgeons” with great interest, as these guidelines are extremely popular on an international basis. As a Past-President of the North American Spine Society, this article gives me a personal window into the effect of the guidelines on the clinical practice of spine surgeons in North America. I recall that as a member of the North America Spine Society (NASS) Board of Directors, and as President, I was constantly being asked to review the guidelines, give feedback, approve ideas, and ultimately approve the guidelines. In reading this article, I now get a sense of the effect that these guidelines have on the clinical practice of spinal surgeons.

As I read this article, the survey, and the results, I am delighted to see the results of the guidelines amongst those that follow the guidelines. However, I am perhaps even more interested in the results of those who do not report following the guidelines. When I see the data, I am extremely satisfied with the results. These guidelines were designed to put forth the current evidence to determine suggestions for best practices in the modern environment. To see that the discordance was similar in those who follow the guidelines as those who do not follow the guidelines, allows me to see that the guidelines follow clinical practice. In addition, these guidelines are not meant to be concrete rules, but rather evidence-based guidelines or suggestions for the management of certain pathologies. Each patient is different, and will have individualized aspects to their own clinical scenario, which requires that each surgeon evaluate their own patients as unique individuals. The variations in management of certain pathologies, falls along the lines of critical debates about patient management, which should exist and should continue. We should not fall into one predetermined protocol for the management of groups of patients as hard-fast rules, but rather use evidence-based guidelines to help guide decision-making for our individualized and different patients we treat on a daily basis. I believe many of the differences in management reflect actual various opinions that exist between surgeons today, and is a healthy concept that should not change. We must continue to think critically about our patients, and not conform completely to a strict set of rules.

I will finish by giving some inside information on these guidelines. There are a substantial number of NASS volunteers and staff, who put countless hours of exceedingly hard work into the creation of these guidelines. These guidelines are a top priority for the NASS organization, and I am both pleased and delighted to see that they are being used appropriately. I do believe that the NASS folks who helped to create these guidelines, would be very pleased with the results of this study.

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