National Variation in Referral and Surgical Management of Incident Cervical Disc Herniation

doi:10.21203/rs.3.rs-7660573/v1

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National Variation in Referral and Surgical Management of Incident Cervical Disc Herniation

https://doi.org/10.21203/rs.3.rs-7660573/v1

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published 01 Dec, 2025

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Introduction: Cervical disc herniation (CDH) in working-age adults may cause substantial functional impairment. However, little is known about how patients transition from primary care to specialist evaluation, and whether regional differences in referral pathways influence management and outcome.

Aim: To examine regional variation in referral pathways, surgical rates, and work capacity outcomes in Denmark’s five healthcare regions.

Methods: Using national registry data, we identified 4,322 citizens aged 18–65 diagnosed with incident CDH in 2017. Patients were stratified by region and the type of department first referred to e.g. medical, surgical, or emergency. Work capacity one year prior to diagnosis was categorized as low (<20%), intermediate (20–80%), or high (≥80%) of a standard 37-hour work week and followed for two years after initial specialized health care sector admission the.

Results: Admission rates were consistent across regions, ranging from 12 to 13 per 10,000 citizens. Nationally, the surgical rate was 1,296 per 10,000 admitted patients. However, surgical rates varied markedly between regions, from 793 per 10,000 in the Capitol Region to 2,320 per 10,000 in the Region of Northern Denmark. Nationally, 60.5 percent of patients were admitted through medical departments, 30.7 percent through surgical departments, and 8.8 percent through 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 admitted patients underwent surgery (2,507 per 10,000 admitted patients). In contrast, medical departments admitted 2,615 patients, of whom 182 received surgery (696 per 10,000 admitted patients), while surgical departments admitted 1,328 patients, with 283 undergoing surgery (2,132 per 10,000 admitted patients). A total of 87 percent of patients with high and 83 percent 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.

Conclusion: Despite similar national admission rates for CDH, substantial regional disparities were observed in referral practices and surgical intervention rates. The findings suggest a need for more research into the optimal specialized clinical pathway for CDH patients who are refractory to initial conservative treatment in the primary health sector.

Cervical disc herniation (CDH) represents a major cause for reduced physical ability and reduced quality of life among citizens of the labor-participating age (1–3). In the absence of severe neurological compromise e.g. red flags, initial management typically occurs in the primary health care sector with a focus on conservative treatment and symptom relief (4–6).

The Danish National Clinical Guidelines (NKR) recommend that CDH patients with red flags (e.g. neurological compromise) and those unresponsive to initial conservative treatment should be referred for specialist spine evaluation in the specialized health care sector (7). However, previous studies of similar back pain conditions – in particular incident lumbar disc herniation – have reported major variations in the involvement of different health care specialties, across the geographical regions of Denmark, suggesting inconsistencies in clinical decision making and referral practices (4, 8–13).

While national databases such as the Danish Spine Database (DaRD) and DaneSpine provide valuable patient-level data on spinal conditions, they do not capture the early transition from the primary health care setting to evaluation and treatment in the specialized health care sector (14, 15). Consequently, the role of referral patterns from primary to secondary care remains poorly understood. Whether this transition is consistent across regions and department types, and whether it influences patient outcomes, is largely unknown.

As previously established for lumbar disc herniation (LDH) in Denmark (6), this study examines regional and departmental differences in the referral and management of incident CDH among adults aged 18–65 years, Specifically, we investigate differences in the type of department patients are initially referred to (medical, surgical, or emergency), surgical treatment rates, and work capacity outcomes in regaining any lost work capacity. Prior studies have shown that local clinical traditions, access to specialized care, and interpretation of referral guidelines may vary across regions and influence both treatment decisions and patient trajectories (4, 6, 8). For example, Munting et al. emphasized that lack of interdisciplinary assessment can lead to both overtreatment and undertreatment depending on organizational context (4), and our previous study on LDH demonstrated substantial variation in both referral patterns and management across Denmark (6). By restricting the cohort to incident cases—defined as individuals with a first-time CDH diagnosis in the specialized healthcare sector and no prior diagnosis of CDH within the preceding year—we reduce bias from prior healthcare use. This design allows for a more valid comparison of how differences in healthcare organization at the point of referral and subsequent management influence outcomes within a nationally uniform healthcare system.

This nationwide, registry-based cohort study was performed on Danish registry data. The year 2017 was chosen to allow at least two years of follow-up while avoiding the distortions in health care utilization observed during and the years following the COVID-19 pandemic. Thus, 2017 represents the most recent year with stable nationwide registry data.

Information on age, gender, and region of residence was obtained from the Danish Civil Registration System (CRS). Information on diagnosis (ICD-10 code), initial department at admission, and surgical procedures was accessed through the Danish National Patient Registry (DNPR). All the databases provide complete coverage of public and private healthcare contacts and sociodemographic characteristics across Denmark’s five regions (16–18). The Danish National Registries contain information of all citizens in Denmark’s five geographical regions, which in 2017 varied in size from 0.57 to 1.6 million citizens (16).

The type of department to which patients were initially referred was based on registrations in the DNPR, classifying them into medical, surgical, or emergency departments, and the patients were subsequently grouped accordingly, allowing for an analysis of referral patterns and treatment outcomes. Surgical procedures were identified using the Danish Healthcare Classification System (SKS), with relevant codes listed in Supplementary Table A.

Work capacity was assessed using the Danish Register for Evaluation of Marginalization (DREAM), a comprehensive national registry that tracks proportion of registered employment and public transfer payments on a weekly basis for all citizens (19, 20). Participants were categorized based on their employment level one year prior to admission into three groups: Low (< 20%), Intermediate (20–80%), and High (≥ 80%) of a standard 37-hour work week, based on the proportion of registered employment, in DREAM (19, 20). Individuals who were unemployed or receiving disability benefits or early retirement pensions were classified as having low work capacity (see limitations for further considerations).

Population definitions

The study included all Danish citizens aged 18–65 who were diagnosed with incident cervical disc herniation (CDH) (ICD-10: DM50X.X) in 2017. Incident cases were defined as individuals with no prior registration of CDH in the specialized health care sector within the preceding year. The interval from first presentation in primary care to specialist evaluation may span weeks to several months, depending on urgency and regional capacity. However, nationwide registry data do not capture contacts in primary care, and it is therefore not possible to determine the exact duration or variation of this transition for individual patients.

Approximately 5% of the cohort had received a prior diagnosis of cervical pain (CP) within the preceding year before progressing to a CDH diagnosis. In this study, CP was defined as panniculitis (DM540), cervical radiculopathy (DM541), or unspecified cervical pain (DM542). These patients subsequently received a CDH diagnosis within one year. See Supplementary Material A for a full description of subcategory diagnoses.

Patients with prior CDH diagnoses, previous spinal surgery, or incomplete follow-up were excluded.

Each individual was only counted once. Multiple admissions or diagnoses within the same individual were not considered separate cases. The patient identification process is illustrated in a flowchart found in Fig. 1.

In Denmark, patients cannot directly self-refer to surgical units; referrals must be made by a medical doctor, typically through the primary healthcare system. However, some patients may access surgical treatment at private hospitals due to delays in the public healthcare system or through private health insurance. By Danish law, all healthcare providers, both public and private, are required to report treatment data to the DNPR (18). This ensures inclusion of patients regardless of referral route or insurance status.

Inclusion criteria for the study were: (1) individuals aged 18 to 65 years to focus on the working-age population and (2) a diagnosis of CDH recorded in the DNPR (ICD-10 code DM50X.X).

Exclusion criteria: (1) any prior registration of CDH in the specialized healthcare sector within the year preceding the CDH diagnosis and (2) incomplete essential data on age, diagnosis, referral pathways and follow-up.

Exposure and Outcome Variables:

The exposure variable was defined as the type of healthcare department to which patients with CDH were initially referred—categorized into medical, surgical, or emergency departments. Departments were classified as medical, surgical, or emergency based on their registration in the Danish National Patient Registry (DNPR).

The outcome variables were defined as work capacity prognosis and surgical intervention status. The work capacity prognosis was measured as the time taken to regain the same level of employment as one year prior to admission, assessed over a 2-year follow-up period at 6-month intervals. The surgical rate was defined as the proportion of patients who underwent at least one surgical intervention within each identified cohort and was presented per 10,000 admitted patients. The surgical rate was defined as the number of patients who underwent at least one surgical intervention—identified using SKS codes (see Supplementary A)—per 10,000 admitted patients in each cohort. Each patient was only counted once, regardless of multiple procedures. Patients were only counted once at their first procedure, regardless of whether they underwent multiple procedures. Supplementary B details the demographic characteristics and work capacity outcomes among (i) patients with low baseline capacity who improved, and (ii) those who remained below the 20% threshold after two years. Supplementary C compares the regional distribution and work outcomes between surgically and non-surgically treated patients.

Statistical analysis

Descriptive statistics including frequencies and percentages were used to summarize referral patterns, work capacity outcomes, and surgical rates by region and department type. Results are presented in tables and figures.

All data management of register data was programmed and designed by the study group for this study population using STATA(21).

Using the Danish National Patient Registry (DNPR), we identified 4,322 patients aged 18–65 years who were diagnosed with incident cervical disc herniation (CDH) in 2017 and referred to specialized spine care (Table 1). Across the five Danish healthcare regions, the overall admission rate for CDH ranged narrowly between 12 and 13 per 10,000 citizens aged 18–65 years. In Denmark, medical departments accounted for most initial admissions (2,615 patients; 60.5%), followed by surgical departments (1,328; 30.7%) and emergency departments (379; 8.8%) (Table 1, Fig. 2).

Despite this similarity in overall admission rates, marked regional differences were observed in the type of department initially receiving the patient. In the Capitol Region, admissions were predominantly to medical departments (59% of admitted patients) with fewer through surgical departments (17%). A similar pattern was seen in Zealand (88%) and Southern Denmark (76%), where most patients were also admitted to medical departments and only a minority through surgical or emergency departments. In contrast, surgical departments dominated in the Region of Northern Denmark (74% of admitted patients), while Central Jutland displayed a more even distribution between surgical (52%) and medical (46%) departments. Full details are provided in Table 1 and Fig. 2.

Although surgical departments generally had higher surgical rates, marked geographical variation was observed. Regional surgical rates ranged from 793 per 10,000 admitted in the Capitol Region, which also had the highest overall number of admissions, to 2,320 per 10,000 admitted in the Region of Northern Denmark, which had the fewest overall admissions. Full details are provided in Table 1 and Fig. 2.

Regarding work capacity, 67% (2,883 patients) had high work capacity (≥ 80%) prior to diagnosis, 7% (317 patients) had intermediate work capacity (20–79%), and 26% (1,122 patients) had low work capacity (< 20%) (Table 2). Among those with high or intermediate baseline work capacity, 87% and 83% regained their previous level within six months, and around 95% had returned after two years (Table 2, Fig. 3). In contrast, patients with low baseline work capacity had poor prognosis, with 95% not reaching ≥ 20% within two years (Table 2, Fig. 3). Within this group, the highest six-month return rates were observed following admission to surgical (9%) and emergency departments (8%), whereas patients admitted through medical departments had the lowest likelihood of returning to a higher work capacity (3%) (Supplementary B).

This national register-based study included 4,322 Danish citizens aged 18–65 years who were referred to the secondary healthcare sector with incident CDH during 2017. While the study design mirrors previous work in lumbar disc herniation (LDH) (6), the population examined here is substantially smaller. Interestingly, the national admission rate for CDH remained consistent across regions (12–13 per 10,000 adults), whereas LDH showed much greater variation between regions (6). One possible explanation is that CDH may present more uniformly in clinical settings — e.g., with clearer neurological symptoms—leading to more standardized referral thresholds.

Despite similar admission rates within each Region of Denmark, there were notable regional variations in the type of department initially receiving patients. Medical departments received the majority of referrals in the Region of Zealand (n = 569, 88% of the admitted in the region), the Capital Region (n = 813, 59%), and Southern Denmark (n = 888, 76%). By contrast, surgical departments dominated in Northern Denmark (n = 328, 74% of the admitted), while Central Jutland displayed an even pattern with admissions divided between surgical (n = 456, 52%) and medical departments (n = 404, 46%) (Table 1, Fig. 2). These differences in admission pathways were reflected in surgical rates. The lowest surgical rate was observed in the Capitol Region (793 per 10,000 admitted), whereas the highest was seen in Northern Denmark (2,320 per 10,000 admitted) (Table 1, Fig. 2). Such contrasts should be interpreted with caution, as smaller patient populations can amplify rate differences even when absolute numbers are modest. As observed in similar nationwide analyses of lumbar disc herniation (LDH) (6), these observations grounded in registry-based counts likely reflect local clinical traditions, organizational structures, and access to specialized care (4, 6, 7, 10–12), rather than differences in disease severity or patient preferences. The combination of a high number of referrals to medical departments and low surgical intervention rates in selected regions may indicate limitations to surgical evaluation in specific patient groups who might otherwise have benefited thereof. Nevertheless, the findings highlight considerable variation in the management of CDH across the Danish healthcare system, despite the presence of uniform national guidelines. This aligns with prior concerns raised in both international (4, 10–12) and Danish studies (5, 6) about inconsistent thresholds for surgical intervention in spine care.

Emergency departments accounted for almost a quarter of admissions in the Capitol Region (24%), compared with less than 4% elsewhere (Table 1). This suggests that emergency referrals are not used uniformly across Denmark, raising questions about how consistently patients with urgent or red flag symptoms are identified and routed. Munting et al. (4), emphasized that lack of interdisciplinary assessment may foster both overtreatment and undertreatment depending on organizational context, and prior studies have likewise suggested that frequent reliance on acute referral pathways can increase the risk of premature surgical decisions when not guided by structured, multidisciplinary assessment (11, 20, 22). The reliance on emergency departments without specialty evaluation may therefore be particularly relevant in the Capitol Region, where emergency referrals were frequent.

Despite regional variation in referrals and surgical treatment rates, the course of CDH were generally benign as 87% of patients with high and 83% with intermediate work capacity within six months had returned to their prior work capacity levels. In contrast, only 5% of those with low baseline work capacity reached a level of 20% or above within two years (Table 2, Fig. 3). This difference should be interpreted with caution, since patients with low baseline capacity were required to surpass their pre-diagnosis level, whereas those with high or intermediate capacity needed only to return. These findings are consistent with Wibault et al. (22), who noted that pre-existing functional limitations reduce the likelihood of return-to-work post-intervention.

Compared to lumbar disc herniation (LDH), where more than 30,000 patients were identified in a previous national study (6), the present CDH cohort of 4,322 patients is considerably smaller. Nevertheless, the national surgical rate per 10,000 admitted patients was almost twice as high for CDH (560 surgeries; 1,296 per 10,000 admitted) as reported for LDH (637 per 10,000) (6). This discrepancy likely reflects two complementary mechanisms. First, cervical disc herniation often raises greater concern due to its proximity to the spinal cord and associated risk of central neurological compromise, lowering the threshold for surgical referral. Second, CDH tends to be more clinically homogeneous, with clearer symptom–imaging concordance and more uniform surgical indications; by contrast, LDH comprises a broader, more heterogeneous case-mix in which non-specific symptoms are more often managed conservatively unless clearly progressive (6–8, 23).

Beyond clinical differences, the variation in patient volume has organizational implications. While uniform referral and surgical assessment of all patients with LDH would be logistically unfeasible, a similar approach for CDH may be more realistic. The relatively modest number of annual CDH cases could potentially allow for centralized or standardized surgical evaluation, thereby reducing regional variation in treatment strategies. While it remains uncertain whether such an approach would improve outcomes, the observed discrepancies in admission and management across regions and departments suggest that current practice is not fully aligned nationwide.

Strengths and limitations

A key strength of this study is the use of a large, unselected cohort from a nationwide registry, enhancing external validity and generalizability to other countries with similar tax-financed health systems.

An inherent limitation lies in the assumption that a prior diagnosis of cervical pain (CP; ICD-10: DM540-DM542) may represent an early-stage cervical disc herniation (CDH), rather than an unrelated or parallel condition. While this approach reflects typical clinical pathways, it also carries a risk of misclassification—particularly in cases with inconsistent coding or unclear diagnostic transitions. The broader case definition increases representativeness but reduces clinical specificity, as the DM50X.X code does not distinguish between radiculopathy, myelopathy, or axial pain, and some patients may therefore have varying indications for imaging or surgery. Although most patients in secondary care probably undergo MRI prior to treatment decisions, this is not a formal prerequisite for assigning a CDH diagnosis in the DNPR, leaving some diagnostic heterogeneity.

Work capacity classification relied on benefit registrations, which may not fully reflect prognosis or functional ability. However, any resulting misclassification is likely limited in Denmark, where unemployment (2.9%) and disability rates (< 7.5% in 2024) are relatively low (24, 25).

The referral decisions made by general physicians may also be influenced by subjective assessments of symptom severity and the intended purpose of the referral, which can lead to a non-uniform distribution of patients across departments. As a result, selection bias is likely, and outcomes such as return to work should not be directly compared across department types, as most patients hopefully are not randomly referred to the different department types. Instead, the results should be viewed as providing insight into referral patterns and the general capacity of patients with incident CDH to maintain or regain work capacity.

Finally, the study's one-year pre-diagnostic incidence period may exclude cases of prior surgery or chronic complications affecting initial work capacity. The study couldn't account for other causes of reduced work capacity such as education level or unrelated sick leave.

Despite similar national CDH admission rates, substantial regional disparities exist in surgical intervention and referral practices. This raises concerns about both potential undertreatment and overtreatment of CDH patients across Denmark. The findings suggest a need for further research into the optimal specialized clinical pathway for CDH patients who are refractory to initial conservative treatment in the primary health sector.

Competing Interests: None to declare

Ethical approval: This study was registered and approved as case nr. 2023-000206 at the scientifical ethics committee at the Region of Northern Jutland.

Consent of Participation: This study was conducted using data from national registries, which operate under strict regulations for data protection and privacy. According to national laws and ethical guidelines, informed consent from individual participants is not required for registry-based studies.

Data Availability Statement: Not available due to GDPR compliance and storage on secure, restricted-access servers of the Danish Statistics Registries with access through the University of Southern Denmark services.

Funding declaration: This study was funded by a research grant from The Danish Rheumatism Association, grant number: R209-A7533, and a research grant from The Lundbeck Foundation’s neurosurgical scholarship, grant number: R377-2021-407

Author Contribution

Mikkel Kjeldgaard M.D. was the main author and provided data management, and writing and creating manuscript, tables and figures. Carsten Reidies Bjarkam was the main supervisor for the project while all other have provided essential supervision and reviews to the full manuscript including tables and figures.

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Tables 1 and 2 are available in the Supplementary Files section.

No competing interests reported.

Table1.xlsx
Table 1: * Regional admissions per 10,000 of the regional general population aged 18-65 years ** Regional surgery rate per 10,000 admitted in the department aged 18-65 years Observation denoted "≤3" if observations (n) is ≤3 due to anonymization
Table2.xlsx
Table 2: Descriptive characteristics of the study population by high, intermediate, and low work capacity one year prior to admission. ED: Emergency department; MD: Medical department; SD: Surgical department. Subjects with missing information were excluded. Observations ≤3 denoted ”≤” accordingly . Total (%) indicates each group’s proportion of the national/regional population for admission rates, and the cumulative regain of work capacity for prognosis measures.
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You are reading this latest preprint version

National Variation in Referral and Surgical Management of Incident Cervical Disc Herniation

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Abstract

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Introduction

Methods

Population definitions

Exposure and Outcome Variables:

Statistical analysis

Results

Discussion

Conclusion

Declarations

Author Contribution

References

Tables

Additional Declarations

Supplementary Files

Status:

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