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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 of 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 oncology and degenerative disease

FRANK PHILLIPS, MD

• Professor, Director, Section of Minimally Invasive Spine Surgery, Rush University Medical Center

• founder, board member and past president of the Society of 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 of 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 PAINSYMPTOM NOT A DIAGNOSIS

OUTCOMES ASSESSMENT: HISTORICAL PERSPECTIVE

The End-Result Idea

“The 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, ‘If not, why not?’

with a view to preventing

similar failures in the

future.”

-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 DISEASESSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIINNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNNGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE LLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVVEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEELLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLL DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIISSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAASSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE

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?

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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.

H+9./!*"#)+!'X'./&J)H'%/#%+J/%*)+!' SYMPTOM: BACK PAIN

• 45 Y MALE

• BASIC SCIENTIST

• 1.5 YR BACK PAIN

• POSITIVE L5/S1 DISCOGRAM

FUSION FOR BACK PAIN?"'F7=:F48AB4'723?=D;:4?':<6?E'=3'<14'G=3@X<47D'4`48<'=>'G6D]27'>6:;=3'=3'2?\2843<'

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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

IATROGENICNATURAL 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 efficacy• 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 difficult 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