2013 UCSF SPINE SYMPOSIUM RICHARD DEYO, MD MPH MICHAEL GROFF, MD

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1 2013 UCSF SPINE SYMPOSIUM RICHARD DEYO, MD MPH MICHAEL GROFF, MD 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 Chief of spine service and co-director of the Spine Center at Beth Israel Deaconess Medical Center specializing in spinal oncology and degenerative disease

2 FRANK PHILLIPS, MD VINCENT TRAYNELIS, 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 Vice chair Dept of Neurosurgery Rush Past President of the Congress of Neurological Surgeons Chair of editorial board of JNS DISCLOSURES OVERVIEW identify the spectrum of painful spinal disorders Medtronic - consultant Lilly - research support highlight the importance of understanding the natural history of common spinal conditions identify the challenges to understanding the natural history of spinal disorders

3 ETIOLOGY OF PAIN OF SPINAL ORIGIN nerve root disc facet SYMPTOMATOLOGY BACK PAIN LEG PAIN COMBINATION

4 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 DDD Y MALE BASIC SCIENTIST 1.5 YR BACK PAIN POSITIVE L5/S1 DISCOGRAM 22 Y MALE SKI RACER BACK PAIN FOR 3 YRS POSITIVE L5/S1 DISCOGRAM

5 DISC HERNIATION LEG PAIN Radiculopathy: Compression of lumbar nerve roots Central Peripheral Neurogenic claudication Vascular claudication Peripheral nerve compression

6 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

7 IATROGENIC BACK PAIN SYMPTOM NOT A DIAGNOSIS OUTCOMES ASSESSMENT: HISTORICAL PERSPECTIVE The End-Result Idea Ernest Amory Codman 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

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

9 RCT OBS 1 yr 63% 95% no diff ~14 NATURAL HISTORY OF SCIATICA 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), 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),

10 DO SPINAL DISORDERS LIE ON A CONTINUUM? 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), SYMPTOM: BACK PAIN 45 Y MALE BASIC SCIENTIST 1.5 YR BACK PAIN POSITIVE L5/S1 DISCOGRAM

11 FUSION FOR BACK PAIN? 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),

12 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),

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15 RAPIDLY PROGRESSIVE SCOLIOSIS

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

17 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