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Mannion AF, Mariaux F, Werth PM, Pearson AM, Lurie JD, Fekete TF, Kohler M, Haschtmann D, Kleinstueck FS, Jeszenszky D, Loibl M, Otten P, Norberg M, Porchet F. Evaluation of "appropriate use criteria" for surgical decision-making in lumbar degenerative spondylolisthesis. A controlled, multicentre, prospective observational study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:1773-1785. [PMID: 38416192 DOI: 10.1007/s00586-024-08157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Selecting patients with lumbar degenerative spondylolisthesis (LDS) for surgery is difficult. Appropriate use criteria (AUC) have been developed to clarify the indications for LDS surgery but have not been evaluated in controlled studies. METHODS This prospective, controlled, multicentre study involved 908 patients (561 surgical and 347 non-surgical controls; 69.5 ± 9.7y; 69% female), treated as per normal clinical practice. Their appropriateness for surgery was afterwards determined using the AUC. They completed the Core Outcome Measures Index (COMI) at baseline and 12 months' follow-up. Multiple regression adjusting for confounders evaluated the influence of appropriateness designation and treatment received on the 12-month COMI and achievement of MCIC (≥ 2.2-point-reduction). RESULTS As per convention, appropriate (A) and uncertain (U) groups were combined for comparison with the inappropriate (I) group. For the adjusted 12-month COMI, the benefit of surgery relative to non-surgical care was not significantly greater for the A/U than the I group (p = 0.189). There was, however, a greater treatment effect of surgery for those with higher baseline COMI (p = 0.035). The groups' adjusted probabilities of achieving MCIC were: 83% (A/U, receiving surgery), 71% (I, receiving surgery), 50% (A/U, receiving non-surgical care), and 32% (I, receiving non-surgical care). CONCLUSIONS A/U patients receiving surgery had the highest chances of achieving MCIC, but the AUC were not able to identify which patients had a greater treatment effect of surgery relative to non-surgical care. The identification of other characteristics that predict a greater treatment effect of surgery, in addition to baseline COMI, is required to improve decision-making.
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Affiliation(s)
- Anne F Mannion
- Spine Centre Division, Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland.
| | - Francine Mariaux
- Spine Centre Division, Department of Teaching, Research and Development, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Paul M Werth
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | - Jon D Lurie
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | | | | | | | | | | | - Markus Loibl
- Spine Centre, Schulthess Klinik, Zurich, Switzerland
| | | | - Michael Norberg
- Centre Médical de Lavey-les-Bains, Lavey-les-Bains, Switzerland
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Reitman CA, Hills JM, Standaert CJ, Bono CM, Mick CA, Furey CG, Kauffman CP, Resnick DK, Wong DA, Prather H, Harrop JS, Baisden J, Wang JC, Spivak JM, Schofferman J, Riew KD, Lorenz MA, Heggeness MH, Anderson PA, Rao RD, Baker RM, Emery SE, Watters WC, Sullivan WJ, Mitchell W, Tontz W, Ghogawala Z. Cervical fusion for treatment of degenerative conditions: development of appropriate use criteria. Spine J 2021; 21:1460-1472. [PMID: 34087478 DOI: 10.1016/j.spinee.2021.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) are a means of determining appropriate recommendations when high quality evidence is lacking. PURPOSE Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine. STUDY DESIGN/SETTING Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations. OUTCOME MEASURES Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters. METHODS Inclusion criteria for scenarios included patients aged 18 to 80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed. RESULTS Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, p<.01). A multivariable ordinal regression adjusting for symptom type, diagnosis, and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance. CONCLUSIONS Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."
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Affiliation(s)
- Charles A Reitman
- Baylor College of Medicine, 7200 Cambridge Street Suite 10A 10th Floor, Houston, TX 77030-4202, USA.
| | - Jeffrey M Hills
- Washington University Orthopaedics, 660 S. Euclid Avenue Campus Box 8233, Saint Louis, MO 63110-1010, USA
| | | | - Christopher M Bono
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115-6110, USA
| | - Charles A Mick
- Pioneer Spine & Sports, 766 N. King Street, Northampton, MA 01060-1142, USA
| | - Christopher G Furey
- Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-1716, USA
| | | | - Daniel K Resnick
- Department Neurosurgery, University of Wisconsin Medical School, 600 Highland K4/834 Clinical Science Center, Madison, WI 53792-0001, USA
| | - David A Wong
- Denver Spine Surgeons, 7800 E. Orchard Road Ste. 100, Greenwood Village, CO 80111-2584, USA
| | - Heidi Prather
- C/O Melissa Armbrecht, Washington University in St. Louis-School of Medicine, 660 S. Euclid Campus Box 8233, Saint Louis, MO 63110, USA
| | - James S Harrop
- Thomas Jefferson University, 909 Walnut Street Floor 2, Philadelphia, PA 19107-5211, USA
| | - Jamie Baisden
- Department of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226-3522, USA
| | - Jeffrey C Wang
- USC Spine Center, 1520 San Pablo Street Ste. 2000, Los Angeles, CA 90033-5322, USA
| | | | - Jerome Schofferman
- SpineCare Medical Group, 455 Hickey Boulevard #310, Daly City, CA 94015-2204, USA
| | - K Daniel Riew
- 425 S Euclid Avenue Ste. 5505, Saint Louis, MO 63110-1005, USA
| | - Mark A Lorenz
- Hinsdale Orthopaedic Associates, 550 W. Ogden Avenue, Hinsdale, IL 60521-3186, USA
| | - Michael H Heggeness
- University of Kansas SOM-Wichita Orthopaedic Surgery Residency Office, 929 N. Saint Francis Street Room 4076, Via Christi Regional Medical Center, Wichita, KS 67214-3821, USA
| | - Paul A Anderson
- University of Wisconsin Orthopedics & Rehabilitation, 1685 Highland Avenue Floor 6, Madison, WI 53705-2281, USA
| | - Raj D Rao
- Department of Orthopedic Surgery, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226-3522, USA
| | - Ray M Baker
- Washington Interventional Spine Associates, 11800 NE 128th Street,Ste. 200 MS 65, Kirkland, WA 98034-7211, USA
| | - Sanford E Emery
- Department of Orthopaedics, West Virginia University, PO Box 9196, Morgantown, WV 26506-9196, USA
| | - William C Watters
- Bone and Joint Clinic of Houston, 6624 Fannin Street Ste. 2600, Houston, TX 77030-2338, USA
| | - William J Sullivan
- Denver VA Medical Center, 1055 N. Clermont 2B-124, Denver, CO, 80220, USA
| | - William Mitchell
- Coastal Spine, 4000 Church Road, Mount Laurel, NJ 08054-1110, USA
| | | | - Zoher Ghogawala
- Department of Neurosurgery, Lahey Hospital & Medical Center, 41 Mall Road Charles A, Tufts University School of Medicine, Burlington, MA 01805-0105, USA
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Mannion AF, Mariaux F, Pittet V, Steiger F, Aepli M, Fekete TF, Jeszenszky D, O'Riordan D, Porchet F. Association between the appropriateness of surgery, according to appropriate use criteria, and patient-rated outcomes after surgery for lumbar degenerative spondylolisthesis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:907-917. [PMID: 33575818 DOI: 10.1007/s00586-021-06725-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/13/2020] [Accepted: 01/06/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Treatment failures in spine surgery are often attributable to poor patient selection and the application of inappropriate treatment. We used published appropriate use criteria (AUC) to evaluate the appropriateness of surgery in a large group of patients operated for lumbar degenerative spondylolisthesis (LDS) and to evaluate its association with outcome. METHODS This was a retrospective analysis of prospectively collected outcome data from patients operated in our Spine Centre, 2005-2012. Appropriateness of surgery was judged based on the AUC. Patients had completed the multidimensional Core Outcome Measures Index (COMI) before surgery and at 3 months' and 1, 2 and 5 years' follow-up (FU). RESULTS In total, 448 patients (69.8 ± 9.6 years; 323 (72%) women) were eligible for inclusion and the AUC could be applied in 393 (88%) of these. Surgery was considered appropriate (A) in 234 (59%) of the patients, uncertain/equivocal (U) in 90 (23%) and inappropriate (I) in 69 (18%). A/U patients had significantly (p < 0.05) greater improvements in COMI than I patients at each FU time point. The minimal clinically important change (MCIC) score for COMI was reached by 82% A, 76% U and 54% I patients at 1-year FU (p < 0.001, I vs A and U); the odds of achieving MCIC were 3-4 times greater in A/U patients than in I patients. CONCLUSIONS The results suggest a relationship between appropriateness of surgery for LDS and the improvements in COMI score after surgery. The findings require confirmation in prospective studies that also include a control group of non-operated patients.
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Affiliation(s)
- Anne F Mannion
- Department of Teaching, Research and Development, Spine Center Division, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland.
| | - Francine Mariaux
- Department of Teaching, Research and Development, Spine Center Division, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Valérie Pittet
- Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Felix Steiger
- Department of Teaching, Research and Development, Spine Center Division, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Martin Aepli
- Department of Teaching, Research and Development, Spine Center Division, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Tamás F Fekete
- Department of Teaching, Research and Development, Spine Center Division, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Dezső Jeszenszky
- Department of Teaching, Research and Development, Spine Center Division, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - Dave O'Riordan
- Department of Teaching, Research and Development, Spine Center Division, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
| | - François Porchet
- Department of Teaching, Research and Development, Spine Center Division, Schulthess Klinik, Lengghalde 2, 8008, Zurich, Switzerland
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Development of appropriateness criteria for the surgical treatment of symptomatic lumbar degenerative spondylolisthesis (LDS). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1903-17. [PMID: 24760463 DOI: 10.1007/s00586-014-3284-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 12/22/2013] [Accepted: 03/22/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Spine surgery rates are increasing worldwide. Treatment failures are often attributed to poor patient selection and inappropriate treatment, but for many spinal disorders there is little consensus on the precise indications for surgery. With an aging population, more patients with lumbar degenerative spondylolisthesis (LDS) will present for surgery. The aim of this study was to develop criteria for the appropriateness of surgery in symptomatic LDS. METHODS A systematic review was carried out to summarize the current level of evidence for the treatment of LDS. Clinical scenarios were generated comprising combinations of signs and symptoms in LDS and other relevant variables. Based on the systematic review and their own clinical experience, twelve multidisciplinary international experts rated each scenario on a 9-point scale (1 highly inappropriate, 9 highly appropriate) with respect to performing decompression only, fusion, and instrumented fusion. Surgery for each theoretical scenario was classified as appropriate, inappropriate, or uncertain based on the median ratings and disagreement in the ratings. RESULTS 744 hypothetical scenarios were generated; overall, surgery (of some type) was rated appropriate in 27%, uncertain in 41% and inappropriate in 31%. Frank panel disagreement was low (7% scenarios). Face validity was shown by the logical relationship between each variable's subcategories and the appropriateness ratings, e.g., no/mild disability had a mean appropriateness rating of 2.3 ± 1.5, whereas the rating for moderate disability was 5.0 ± 1.6 and for severe disability, 6.6 ± 1.6. Similarly, the average rating for no/minimal neurological abnormality was 2.3 ± 1.5, increasing to 4.3 ± 2.4 for moderate and 5.9 ± 1.7 for severe abnormality. The three variables most likely (p < 0.0001) to be components of scenarios rated "appropriate" were: severe disability, no yellow flags, and severe neurological deficit. CONCLUSION This is the first study to report criteria for determining candidacy for surgery in LDS developed by a multidisciplinary international panel using a validated method (RAM). The panel ratings followed logical clinical rationale, indicating good face validity. The work refines clinical classification and the phenotype of degenerative spondylolisthesis. The predictive validity of the criteria should be evaluated prospectively to examine whether patients treated "appropriately" have better clinical outcomes.
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Congenital anterior midline cleft of the atlas and posterior atlanto-occipital fusion associated with symptomatic anterior atlantoaxial subluxation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 22 Suppl 1:35-9. [DOI: 10.1007/s00590-012-1011-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 05/02/2012] [Indexed: 10/28/2022]
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Schizas C, Kulik G. Decision-making in lumbar spinal stenosis: A survey on the influence of the morphology of the dural sac. ACTA ACUST UNITED AC 2012; 94:98-101. [PMID: 22219255 DOI: 10.1302/0301-620x.94b1.27420] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surgical decision-making in lumbar spinal stenosis involves assessment of clinical parameters and the severity of the radiological stenosis. We suspected that surgeons based surgical decisions more on dural sac cross-sectional area (DSCA) than on the morphology of the dural sac. We carried out a survey among members of three European spine societies. The axial T2-weighted MR images from ten patients with varying degrees of DSCA and morphological grades according to the recently described morphological classification of lumbar spinal stenosis, with DSCA values disclosed in half the assessed images, were used for evaluation. We provided a clinical scenario to accompany the images, which were shown to 142 responding physicians, mainly orthopaedic surgeons but also some neurosurgeons and others directly involved in treating patients with spinal disorders. As the primary outcome we used the number of respondents who would proceed to surgery for a given DSCA or morphological grade. Substantial agreement among the respondents was observed, with severe or extreme stenosis as defined by the morphological grade leading to surgery. This decision was not dependent on the number of years in practice, medical density or specialty. Disclosing the DSCA did not alter operative decision-making. In all, 40 respondents (29%) had prior knowledge of the morphological grading system, but their responses showed no difference from those who had not. This study suggests that the participants were less influenced by DSCA than by the morphological appearance of the dural sac. Classifying lumbar spinal stenosis according to morphology rather than surface measurements appears to be consistent with current clinical practice.
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Affiliation(s)
- C Schizas
- Centre Hospitalier Universitaire Vaudois, Hôpital Orthopédique, CHUV-University of Lausanne, Av P. Decker 4, Lausanne 1011, Switzerland.
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Chan WCW, Sze KL, Samartzis D, Leung VYL, Chan D. Structure and biology of the intervertebral disk in health and disease. Orthop Clin North Am 2011; 42:447-64, vii. [PMID: 21944583 DOI: 10.1016/j.ocl.2011.07.012] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The intervertebral disks along the spine provide motion and protection against mechanical loading. The 3 structural components, nucleus pulposus, annulus fibrosus, and cartilage endplate, function as a synergistic unit, though each has its own role. The cells within each of these components have distinct origins in development and morphology, producing specific extracellular matrix proteins that are organized into unique architectures fit for intervertebral disk function. This article focuses on various aspects of intervertebral disk biology and disruptions that could lead to diseases such as intervertebral disk degeneration.
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Affiliation(s)
- Wilson C W Chan
- Department of Biochemistry, The University of Hong Kong, LKS Faculty of Medicine, Pokfulam, Hong Kong SAR, China
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Abstract
Degenerative disk disease is a strong etiologic risk factor of chronic low back pain (LBP). A multidisciplinary approach to treatment is often warranted. Patient education, medication, and cognitive behavioral therapies are essential in the treatment of chronic LBP sufferers. Surgical intervention with a rehabilitation regime is sometimes advocated. Prognostic factors related to the outcome of different treatments include maladaptive pain coping and genetics. The identification of pain genes may assist in determining individuals susceptible to pain and in patient selection for appropriate therapy. Biologic therapies show promise, but clinical trials are needed before advocating their use in humans.
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Hansen KE, Wilson HA, Zapalowski C, Fink HA, Minisola S, Adler RA. Uncertainties in the prevention and treatment of glucocorticoid-induced osteoporosis. J Bone Miner Res 2011; 26:1989-96. [PMID: 21721042 DOI: 10.1002/jbmr.362] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 01/18/2011] [Accepted: 02/03/2011] [Indexed: 01/30/2023]
Abstract
Much knowledge has accrued since the 2001 American College of Rheumatology (ACR) guidelines were published to assist clinicians in the prevention and treatment of glucocorticoid-induced osteoporosis (GIO). Therefore, the ACR undertook a comprehensive effort to review the literature and update the GIO guidelines [Grossman JM, Gordon R, Ranganath VK, et al. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken). 2010;62:1515-1526]. Herein, we review the new guidelines for JBMR readers, highlighting the changes introduced by the 2010 publication. We discuss several patient scenarios for which the new treatment guidelines do not apply, or for which our committee interprets existing literature differently and suggests an alternative approach.
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Affiliation(s)
- Karen E Hansen
- University of Wisconsin Department of Medicine, Madison, WI, USA.
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