2013 UCSF SPINE SYMPOSIUM - - PowerPoint PPT Presentation

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2013 UCSF SPINE SYMPOSIUM RICHARD DEYO, MD MPH

¥ OHSU Professor and the Kaiser-

Permanente Endowed Professor of Evidence-Based Medicine in the Department of Family Medicine at Oregon Health and Science University

¥ Deputy Editor of Spine and a member

• f the Editorial Board of the Back

Review Group of the Cochrane Collaboration

¥ interest in measuring patient function,

involving patients in clinical decisions, and managing low back pain

MICHAEL GROFF, MD

¥ Chief of spine service and

co-director of the Spine Center at Beth Israel Deaconess Medical Center

¥ specializing in spinal

• ncology and degenerative

disease

FRANK PHILLIPS, MD

¥ Professor, Director, Section

• f Minimally Invasive Spine

Surgery, Rush University Medical Center

¥ founder, board member and

past president of the Society

• f Minimally Invasive Spine

Surgery

VINCENT TRAYNELIS, MD

¥ Vice chair Dept of

Neurosurgery Rush

¥ Past President of the

Congress of Neurological Surgeons

¥ Chair of editorial board of

JNS

DISCLOSURES

¥ Medtronic - consultant ¥ Lilly - research support

OVERVIEW

identify the spectrum of painful spinal disorders highlight the importance of understanding the natural history

• f common spinal conditions

identify the challenges to understanding the natural history of spinal disorders

ETIOLOGY OF PAIN OF SPINAL ORIGIN

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disc facet nerve root

SYMPTOMATOLOGY

¥ BACK PAIN ¥ LEG PAIN ¥ COMBINATION

RADIOGRAPHY

¥ single level disease ¥ disc herniation ¥ spondylolisthesis ¥ degenerative disc ¥ stenosis ¥ multilevel disease ¥ spinal stenosis ¥ multi-level degenerative disease ¥ facet arthropathy ¥ deformity ¥ combination ¥ systemic disease ¥ osteoporosis ¥ osteomalacia ¥ vasculopath - smoker

DDD

¥ 45 Y MALE ¥ BASIC SCIENTIST ¥ 1.5 YR BACK PAIN ¥ POSITIVE L5/S1 DISCOGRAM

DDD ++

¥ 22 Y MALE ¥ SKI RACER ¥ BACK PAIN FOR 3 YRS ¥ POSITIVE L5/S1 DISCOGRAM

DISC HERNIATION

LEG PAIN

¥ Radiculopathy: ¥ Compression of lumbar

nerve roots

¥Central ¥Peripheral ¥ Neurogenic claudication ¥ Vascular claudication ¥ Peripheral nerve compression

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What is the outcome if we treat without surgery? What is the outcome if we treat with surgery? What is the outcome with a complication?

RAPIDLY PROGRESSIVE SCOLIOSIS

IATROGENIC BACK PAIN

SYMPTOM NOT A DIAGNOSIS

OUTCOMES ASSESSMENT: HISTORICAL PERSPECTIVE

The End-Result Idea ÒThe common sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, ÔIf not, why not?Õ with a view to preventing similar failures in the future.Ó

• E.A. Codman

Ernest Amory Codman 1869-1940

MEASURES OF VALUE

change in health status (utility) duration of change

QALY = ICER = !Treatment A - !Treatment B Cost Treatment A - Cost Treatment B

NATURAL HISTORY

SINGLE LEVEL DISEASE SINGLE LEVEL DISEASE

RCT 1 yr 63% OBS 95% no diff ~14

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NATURAL HISTORY OF SCIATICA

Atlas, S. J., Deyo, R. A., Keller, R. B., Chapin, A. M., Patrick, D. L., Long, J. M., & Singer, D. E. (1996). The Maine Lumbar Spine Study, Part II: 1-year outcomes of surgical and nonsurgical management of sciatica. Spine, 21(15), 1777-1786. Atlas, S. J., Keller, R. B., Wu, Y. A., Deyo, R. A., & Singer, D. E. (2005). Long-term outcomes of surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine, 30(8), 927-935.

DO SPINAL DISORDERS LIE ON A CONTINUUM? /J+&$#)+!'+-'*.)!/'0)*/"*/

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Kirkaldy-Willis, W. H., Wedge, J. H., Yong-Hing, K., & Reilly, J. (1978). Pathology and pathogenesis of lumbar spondylosis and stenosis. Spine, 3(4), 319-328. Masui, T., Yukawa, Y., Nakamura, S., Kajino, G., Matsubara, Y., Kato, F., & Ishiguro, N. (2005). Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. Journal of spinal disorders & techniques, 18(2), 121.

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SYMPTOM: BACK PAIN

¥ 45 Y MALE ¥ BASIC SCIENTIST ¥ 1.5 YR BACK PAIN ¥ POSITIVE L5/S1 DISCOGRAM

FUSION FOR BACK PAIN?

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Cheh, G., Bridwell, K. H., Lenke, L. G., Buchowski, J. M., Daubs, M. D., Kim, Y., & Baldus, C. (2007). Adjacent segment disease followinglumbar/ thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up. Spine, 32(20), 2253-2257.

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Different survival function of the adjacent segment according to age. The 120 month survival function was 98% for < 61 year-old age group and 88% for equal or above the 61 year-old age group (p = 0.000).

Ahn, D. K., Park, H. S., Choi, D. J., Kim, K. S., & Yang, S. J. (2010). Survival and prognostic analysis of adjacent segments after spinal fusion. Clinics in orthopedic surgery, 2(3), 140-147.

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RAPIDLY PROGRESSIVE SCOLIOSIS

IATROGENIC NATURAL HISTORY OF MULTILEVEL DISEASE

Treating a deformity, creating a deformity, preventing a deformity

CHALLENGE OF CLINICAL OUTCOMES: SPINE

¥ multiple levels ¥ multiple etiologies ¥ multiple regions ¥ multiple co-morbidities

CHALLENGES

¥ Point of Care Capture ¥ Survey Completion ¥ Longitudinal Collection X

RCT VS. REGISTRY

¥ Clinical trials focus on efÞcacy ¥ inclusion criteria ¥ homogeneous population ¥ control for differences by randomization ¥ do not track patient factors ¥ expensive ¥ Registries look at effectiveness ¥ data from a generalized practice-setting ¥ heterogeneous population ¥ control for differences during analysis

SUMMARY

¥ Natural history of spinal disorders are difÞcult to study due to

the combination of symptoms, etiologies, treatments, follow up

¥ Adopt a perception of spinal disease as a continuum vs static

entity: treat now for the future delivers greatest value

¥ Sagittal balance is paramount

Thank You