2013 UCSF SPINE SYMPOSIUM - PowerPoint PPT Presentation

2013 UCSF SPINE SYMPOSIUM !"#$%"&'()*#+%,'+-'.")!-$&'*.)!/' %/&"#/0'0)*+%0/%* *1234'56781'90 "::;:<23<'.7=>4::=7';3'%4:;?4384 RICHARD DEYO, MD MPH MICHAEL GROFF, MD ¥ OHSU Professor and the Kaiser- Permanente Endowed Professor of ¥ Chief of spine service and Evidence-Based Medicine in the co-director of the Spine Department of Family Medicine at Oregon Health and Science University Center at Beth Israel Deaconess Medical Center ¥ Deputy Editor of Spine and a member of the Editorial Board of the Back Review Group of the Cochrane ¥ specializing in spinal Collaboration oncology and degenerative ¥ interest in measuring patient function, disease involving patients in clinical decisions, and managing low back pain

FRANK PHILLIPS, MD VINCENT TRAYNELIS, MD ¥ Professor, Director, Section ¥ Vice chair Dept of of Minimally Invasive Spine Neurosurgery Rush Surgery, Rush University ¥ Past President of the Medical Center Congress of Neurological ¥ founder, board member and Surgeons past president of the Society ¥ Chair of editorial board of of Minimally Invasive Spine JNS Surgery DISCLOSURES OVERVIEW identify the spectrum of painful spinal disorders highlight the importance of understanding the natural history ¥ Medtronic - consultant of common spinal conditions ¥ Lilly - research support identify the challenges to understanding the natural history of spinal disorders

ETIOLOGY OF PAIN OF nerve root SPINAL ORIGIN !"#"$%& #'#()*"+,-,+./%+0.*%,# facet ¥ 04@43472AB4 ¥ )3C2DD2<=7E ¥ )3>48A=3 disc ¥ !4=FG2:A8 ¥ #726D2A8 ¥ 04>=7D;<E ¥ !467=@43;8 ¥ H=3@43;<2G SYMPTOMATOLOGY ¥ BACK PAIN ¥ LEG PAIN ¥ COMBINATION

RADIOGRAPHY ¥ single level disease ¥ multi-level degenerative disease ¥ facet arthropathy ¥ disc herniation ¥ deformity ¥ spondylolisthesis ¥ degenerative disc ¥ combination ¥ stenosis ¥ systemic disease ¥ multilevel disease ¥ osteoporosis ¥ spinal stenosis ¥ osteomalacia ¥ vasculopath - smoker DDD DDD ++ ¥ 45 Y MALE ¥ 22 Y MALE ¥ BASIC SCIENTIST ¥ SKI RACER ¥ 1.5 YR BACK PAIN ¥ BACK PAIN FOR 3 YRS ¥ POSITIVE L5/S1 DISCOGRAM ¥ POSITIVE L5/S1 DISCOGRAM

LEG PAIN DISC HERNIATION ¥ Radiculopathy: ¥ Compression of lumbar nerve roots ¥ Central ¥ Peripheral ¥ Neurogenic claudication ¥ Vascular claudication ¥ Peripheral nerve compression "0$&#'0/I/!/%"#)J/'*H+&)+*)*

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 Ernest Amory Codman - E.A. Codman 1869-1940 � �

MEASURES OF VALUE change in health status (utility) QALY = duration of change ! Treatment A - ! Treatment B ICER = Cost Treatment A - Cost Treatment B NATURAL HISTORY SINGLE LEVEL DISEASE SINGLE LEVEL DISEASE

RCT OBS 1 yr no diff ~14 95% 63% )1234567.892:1:.#;<;=926>?9.@296AB9<A.C;2.&1BD62.)=4<67.)A9<;:4:.-;12(E962.$9:17A:. NATURAL HISTORY OF SCIATICA ;C.AF9.)=4<9.*6>9<A.'1A5;B9:.$9:9625F.@2467G K4;3:<4;3L'M2D4:'4<'2GN *F;34N'OPQRSTUROVWXROOYL'M634'RPL'VZRZN 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. 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.

/J+&$#)+!'+-'*.)!/'0)*/"*/ DO SPINAL DISORDERS LIE ¥ (473;2<4?'0;:8 ¥ %=<2<=7E':6]G6^2A=3 ¥ 000'['G=::'=>'G=7?=:;: ¥ +G;:<14:;: ON A CONTINUUM? ¥ -284<'27<17=F2<1E ¥ *2@;_2G';D]2G2384 ¥ *F;32G'*<43=:;:U'843<72G'23?' >=72D432G' ¥ "?\2843<'*4@D43<'0;:42:4 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. 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. SYMPTOM: BACK PAIN H+9./!*"#)+!'X'./&J)H'%/#%+J/%*)+!' ¥ 45 Y MALE ¥ BASIC SCIENTIST ¥ 1.5 YR BACK PAIN ¥ POSITIVE L5/S1 DISCOGRAM

"'F7=:F48AB4'723?=D;:4?':<6?E'=3'<14'G=3@X<47D'4`48<'=>'G6D]27'>6:;=3'=3'2?\2843<' FUSION FOR BACK PAIN? ?;:8'?4@43472A=3N /67'*F;34'MN'VZZW'"6@aRYQYTURRbPXYc RRR'F2A43<:L'2@4?'RYXPPL'd;<1';:<1D;8':F=3?EG=G;:<14:;:'d474'723?=D;:4?'<='4^478;:4' Q/eL'3'f'OST'=7'F=:<47=G2<472G'>6:;=3'Q.&-L'3'f'bbTL'd;<1'Q3'f'ObT'=7'd;<1=6<'F4?;8G4':874d' ;3:<76D43<2A=3'Q3'f'SZT %2?;=@72F1;8'232GE:;:':1=d4?'3=7D2G'?;:8:';3'RZZg'=>'F2A43<:';3'<14'/e'@7=6FL' 8=DF274?'<='cVg';3'<14'.&-'@7=6F'QF'f'ZNZVcT "?\2843<':4@D43<'?;:42:4'>=GG=d;3@G6D]27h<1=728=G6D]27'>6:;=3'd;<1'F4?;8G4':874d' "?\2843<':4@D43<'?4@43472A=3';3'<14'G6D]27':F;34N ;3:<76D43<2A=3U'2'D;3;D6D'PXE427'>=GG=dX6FN M'5=34'M=;3<'*67@'"DN'VZZS'M6GaYcX"QbTURSWbXPZON *F;34'Q.1;G2'.2'RWbcTN'VZZb'*4F'RPaOVQVZTUVVPOXbN I1;:4GG;'4<'2GN RYY'F2A43<:'d;<1'D;3;D6D'PXE427'>=GG=dX6F'd1='12?'G6D]27h<1=728=G6D]27'>6:;=3'd;<1'F4?;8G4' #d='163?74?'23?'ik443'F2A43<:'d1='12?'63?47@=34'F=:<47;=7'G6D]27'27<17=?4:;:'d474' :874d';3:<76D43<2A=3'>=7'?4@43472AB4'?;:=7?47:'d474';38G6?4? ;38G6?4? %2?;=@72F1;8'"*0'=886774?';3'SVNcg'QYZ'=>'RYYT'=>'F2A43<: QVbNSgT'=>'<14'VRP'F2A43<:'12?'4B;?4384'=>'?4@43472A=3'2<'<14'2?\2843<'G4B4G:'23?'4G48<4?'<=' 12B4'23'2??;A=32G'?48=DF74::;=3'Qik443'F2A43<:T'=7'27<17=?4:;:'Q>=7<EX>=67'F2A43<:T "@4'2<':67@47E'=B47'PZ'E427:'23?'G43@<1'=>'>6:;=3'd474':;@3;i823<'7;:j'>28<=7:'>=7'<14'?4B4G=FD43<' =>'"*0';3'<14'G6D]27':F;34N' #14'72<4'=>':EDF<=D2A8'?4@43472A=3'2<'23'2?\2843<':4@D43<'d27723A3@'4;<147' ?48=DF74::;=3'=7'27<17=?4:;:'d2:'F74?;8<4?'<=']4'RcNPg'2<'iB4'E427:'23?'OcNRg'2<'<43'E427: -6:;=3'<='&RX&O'F7=^;D2GGE';38742:4?'<14'7;:j'=>'"*0'd143'8=DF274?'d;<1'&S'23?'&PN 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.

)12?4?67.6<H.*2;3<;:>5.%<67I:4:.;C.%HJ659<A.)93B9<A:.6K92.)=4<67.-1:4;<. HG;3'+7<1=F'*67@N'VZRZ'*4FaVQOTURSZXRSb'' 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

NATURAL HISTORY OF IATROGENIC MULTILEVEL DISEASE Treating a deformity, creating a deformity, preventing a deformity CHALLENGE OF CLINICAL CHALLENGES OUTCOMES: SPINE ¥ Longitudinal Collection X ¥ multiple levels ¥ Point of Care Capture ¥ multiple etiologies ¥ Survey Completion ¥ multiple regions ¥ multiple co-morbidities

RCT VS. REGISTRY SUMMARY ¥ Clinical trials focus on efÞcacy ¥ inclusion criteria ¥ homogeneous population ¥ Natural history of spinal disorders are difÞcult to study due to ¥ control for differences by randomization the combination of symptoms, etiologies, treatments, follow up ¥ do not track patient factors ¥ expensive ¥ Adopt a perception of spinal disease as a continuum vs static entity: treat now for the future delivers greatest value ¥ Registries look at effectiveness ¥ data from a generalized practice-setting ¥ Sagittal balance is paramount ¥ heterogeneous population ¥ control for differences during analysis Thank You