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Lorio MP, Watters WC, Grunch BH, Metzger AK, Lewandrowski KU, Block JE, Andersson GBJ. Utilization of Bone-Anchored Annular Defect Closure to Prevent Reherniation Following Lumbar Discectomy: Overcoming Barriers to Clinical Adoption and Market Access. Int J Spine Surg 2024:8592. [PMID: 38569929 DOI: 10.14444/8592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
While achieving premarket approval from the US Food and Drug Administration represents a significant milestone in the development and commercialization of a Class III medical device, the aftermath endeavor of gaining market access can be daunting. This article provides a case study of the Barricaid annular closure device (Barricaid), a reherniation reduction device, which has been demonstrated to decrease the risk of suffering a recurrent lumbar intervertebral disc herniation. Following Food and Drug Administration approval, clinical adoption has been slow due to barriers to market access, including the perception of low-quality clinical evidence, questionable significance of the medical necessity of the procedure, and imaging evidence of increased likelihood of vertebral endplate changes. The aim of this article is to provide appropriate examination, rationale, and rebuttal of these concerns. Weighing the compendium of evidence, we offer a definition of a separate and unique current procedural terminology code to delineate this procedure. Adoption of this code will help to streamline the processing of claims and support the conduct of research, the evaluation of health care utilization, and the development of appropriate medical guidelines.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O'Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Corrigendum to "Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain" [The Spine Journal 20/7 (2020) p 998-1024]. Spine J 2021; 21:726-727. [PMID: 33640275 DOI: 10.1016/j.spinee.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- D Scott Kreiner
- Barrow Neurological Institute, 4530 E. Muirwood Dr. Ste. 110, Phoenix, AZ 85048-7693, USA.
| | - Paul Matz
- Advantage Orthopedics and Neurosurgery, Casper, WY, USA
| | | | - Charles H Cho
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Zoher Ghogawala
- Lahey Hospital and Medical Center, Burlington, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | | | - William C Watters
- Institute of Academic Medicine Houston Methodist Hospital, Houston, TX, USA
| | - Thiru M Annaswamy
- VA North Texas Health Care System, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Randall P Brewer
- River Cities Interventional Pain Specialists, Shreveport, LA, USA
| | | | - David S Cheng
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Park
- University Of Michigan, Ann Arbor, MI, USA
| | | | | | - Ravi Prasad
- University of California, Davis, Sacramento, CA, USA
| | | | - Kris E Radcliff
- Rothman Institute, Thomas Jefferson University, Egg Harbor Township, NJ, USA
| | | | | | | | | | | | | | | | | | | | - Ryan A Tauzell
- Choice Physical Therapy & Wellness, Christiansburg, VA, USA
| | | | - Yakov Vorobeychik
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amy M Yahiro
- North American Spine Society, Burr Ridge, IL, USA
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Kreiner DS, Matz P, Bono CM, Cho CH, Easa JE, Ghiselli G, Ghogawala Z, Reitman CA, Resnick DK, Watters WC, Annaswamy TM, Baisden J, Bartynski WS, Bess S, Brewer RP, Cassidy RC, Cheng DS, Christie SD, Chutkan NB, Cohen BA, Dagenais S, Enix DE, Dougherty P, Golish SR, Gulur P, Hwang SW, Kilincer C, King JA, Lipson AC, Lisi AJ, Meagher RJ, O'Toole JE, Park P, Pekmezci M, Perry DR, Prasad R, Provenzano DA, Radcliff KE, Rahmathulla G, Reinsel TE, Rich RL, Robbins DS, Rosolowski KA, Sembrano JN, Sharma AK, Stout AA, Taleghani CK, Tauzell RA, Trammell T, Vorobeychik Y, Yahiro AM. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J 2020; 20:998-1024. [PMID: 32333996 DOI: 10.1016/j.spinee.2020.04.006] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016. PURPOSE The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN This is a guideline summary review. METHODS This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors. RESULTS Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.
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Affiliation(s)
- D Scott Kreiner
- Barrow Neurological Institute, 4530 E. Muirwood Dr. Ste. 110, Phoenix, AZ 85048-7693, USA.
| | - Paul Matz
- Advantage Orthopedics and Neurosurgery, Casper, WY, USA
| | | | - Charles H Cho
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Zoher Ghogawala
- Lahey Hospital and Medical Center, Burlington, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | | | | | - William C Watters
- Institute of Academic Medicine Houston Methodist Hospital, Houston, TX, USA
| | - Thiru M Annaswamy
- VA North Texas Health Care System, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Randall P Brewer
- River Cities Interventional Pain Specialists, Shreveport, LA, USA
| | | | - David S Cheng
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Paul Park
- University Of Michigan, Ann Arbor, MI, USA
| | | | | | - Ravi Prasad
- University of California, Davis, Sacramento, CA, USA
| | | | - Kris E Radcliff
- Rothman Institute, Thomas Jefferson University, Egg Harbor Township, NJ, USA
| | | | | | | | | | | | | | | | | | | | - Ryan A Tauzell
- Choice Physical Therapy & Wellness, Christiansburg, VA, USA
| | | | - Yakov Vorobeychik
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Amy M Yahiro
- North American Spine Society, Burr Ridge, IL, USA
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Ammerman J, Watters WC, Inzana JA, Carragee G, Groff MW. Closing the Treatment Gap for Lumbar Disc Herniation Patients with Large Annular Defects: A Systematic Review of Techniques and Outcomes in this High-risk Population. Cureus 2019; 11:e4613. [PMID: 31312540 PMCID: PMC6615588 DOI: 10.7759/cureus.4613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Lumbar disc herniation (LDH) is one of the most common spinal pathologies and can be associated with debilitating pain and neurological dysfunction. Discectomy is the primary surgical intervention for LDH and is typically successful. Yet, some patients experience recurrent LDH (RLDH) after discectomy, which is associated with worse clinical outcomes and greater socioeconomic burden. Large defects in the annulus fibrosis are a significant risk factor for RLDH and present a critical treatment challenge. It is essential to identify reliable and cost-effective treatments for this at-risk population. A systematic review of the PubMed and Embase databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies describing the treatment of LDH patients with large annular defects. The incidence of large annular defects, measurement technique, RLDH rate, and reoperation rate were compiled and stratified by surgical technique. The risk of bias was scored for each study and for the identification of RLDH and reoperation. Study heterogeneity and pooled estimates were calculated from the included articles. Fifteen unique studies describing 2,768 subjects were included. The pooled incidence of patients with a large annular defect was 44%. The pooled incidence of RLDH and reoperation following conventional limited discectomy in this population was 10.6% and 6.0%, respectively. A more aggressive technique, subtotal discectomy, tended to have lower rates of RLDH (5.8%) and reoperation (3.8%). However, patients treated with subtotal discectomy reported greater back and leg pain associated with disc degeneration. The quality of evidence was low for subtotal discectomy as an alternative to limited discectomy. Each report had a high risk of bias and treatments were never randomized. A recent randomized controlled trial with 550 subjects examined an annular closure device (ACD) and observed significant reductions in RLDH and reoperation rates (>50% reduction). Based on the available evidence, current discectomy techniques are inadequate for patients with large annular defects, leaving a treatment gap for this high-risk population. Currently, the strongest evidence indicates that augmenting limited discectomy with an ACD can reduce RLDH and revision rates in patients with large annular defects, with a low risk of device complications.
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Affiliation(s)
| | - William C Watters
- Clinical Orthopedic Surgery, Institute of Academic Medicine, Houston Methodist Hospital, Houston, USA
| | | | - Gene Carragee
- Orthopaedic Surgery, Stanford University Medical Center, Stanford, USA
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Watters WC. North American Spine Society presidential address. Spine J 2015; 15:383-7. [PMID: 25572705 DOI: 10.1016/j.spinee.2014.12.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- William C Watters
- Bone and Joint Clinic, Suite 2600, 6624 Fannin St, Houston, TX 77030-2312, USA.
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7
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Dhall SS, Choudhri TF, Eck JC, Groff MW, Ghogawala Z, Watters WC, Dailey AT, Resnick DK, Sharan A, Mummaneni PV, Wang JC, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 5: correlation between radiographic outcome and function. J Neurosurg Spine 2014; 21:31-6. [PMID: 24980582 DOI: 10.3171/2014.4.spine14268] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In an effort to diminish pain or progressive instability, due to either the pathological process or as a result of surgical decompression, one of the primary goals of a fusion procedure is to achieve a solid arthrodesis. Assuming that pain and disability result from lost mechanical integrity of the spine, the objective of a fusion across an unstable segment is to eliminate pathological motion and improve clinical outcome. However, conclusive evidence of this correlation, between successful fusion and clinical outcome, remains elusive, and thus the necessity of documenting successful arthrodesis through radiographic analysis remains debatable. Although a definitive cause and effect relationship has not been demonstrated, there is moderate evidence that demonstrates a positive association between radiographic presence of fusion and improved clinical outcome. Due to this growing body of literature, it is recommended that strategies intended to enhance the potential for radiographic fusion are considered when performing a lumbar arthrodesis for degenerative spine disease.
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Affiliation(s)
- Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, California
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Ghogawala Z, Resnick DK, Watters WC, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Sharan A, Groff MW, Wang JC, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: assessment of functional outcome following lumbar fusion. J Neurosurg Spine 2014; 21:7-13. [PMID: 24980579 DOI: 10.3171/2014.4.spine14258] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Assessment of functional patient-reported outcome following lumbar spinal fusion continues to be essential for comparing the effectiveness of different treatments for patients presenting with degenerative disease of the lumbar spine. When assessing functional outcome in patients being treated with lumbar spinal fusion, a reliable, valid, and responsive outcomes instrument such as the Oswestry Disability Index should be used. The SF-36 and the SF-12 have emerged as dominant measures of general health-related quality of life. Research has established the minimum clinically important difference for major functional outcomes measures, and this should be considered when assessing clinical outcome. The results of recent studies suggest that a patient's pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome.
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Affiliation(s)
- Zoher Ghogawala
- Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
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Ghogawala Z, Whitmore RG, Watters WC, Sharan A, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Groff MW, Wang JC, Resnick DK, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 3: assessment of economic outcome. J Neurosurg Spine 2014; 21:14-22. [PMID: 24980580 DOI: 10.3171/2014.4.spine14259] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A comprehensive economic analysis generally involves the calculation of indirect and direct health costs from a societal perspective as opposed to simply reporting costs from a hospital or payer perspective. Hospital charges for a surgical procedure must be converted to cost data when performing a cost-effectiveness analysis. Once cost data has been calculated, quality-adjusted life year data from a surgical treatment are calculated by using a preference-based health-related quality-of-life instrument such as the EQ-5D. A recent cost-utility analysis from a single study has demonstrated the long-term (over an 8-year time period) benefits of circumferential fusions over stand-alone posterolateral fusions. In addition, economic analysis from a single study has found that lumbar fusion for selected patients with low-back pain can be recommended from an economic perspective. Recent economic analysis, from a single study, finds that femoral ring allograft might be more cost-effective compared with a specific titanium cage when performing an anterior lumbar interbody fusion plus posterolateral fusion.
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Affiliation(s)
- Zoher Ghogawala
- Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
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Kaiser MG, Eck JC, Groff MW, Watters WC, Dailey AT, Resnick DK, Choudhri TF, Sharan A, Wang JC, Mummaneni PV, Dhall SS, Ghogawala Z. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 1: introduction and methodology. J Neurosurg Spine 2014; 21:2-6. [PMID: 24980578 DOI: 10.3171/2014.4.spine14257] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fusion procedures are an accepted and successful management strategy to alleviate pain and/or neurological symptoms associated with degenerative disease of the lumbar spine. In 2005, the first version of the "Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine" was published in the Journal of Neurosurgery: Spine. In an effort to incorporate evidence obtained since the original publication of these guidelines, an expert panel of neurosurgical and orthopedic spine specialists was convened in 2009. Topics reviewed were essentially identical to the original publication. Selected manuscripts from the first iteration of these guidelines as well as relevant publications between 2005 through 2011 were reviewed. Several modifications to the methodology of guideline development were adopted for the current update. In contrast to the 2005 guidelines, a 5-tiered level of evidence strategy was employed, primarily allowing a distinction between lower levels of evidence. The qualitative descriptors (standards/guidelines/options) used in the 2005 recommendations were abandoned and replaced with grades to reflect the strength of medical evidence supporting the recommendation. Recommendations that conflicted with the original publication, if present, were highlighted at the beginning of each chapter. As with the original guideline publication, the intent of this update is to provide a foundation from which an appropriate treatment strategy can be formulated.
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Affiliation(s)
- Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
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Sharan A, Groff MW, Dailey AT, Ghogawala Z, Resnick DK, Watters WC, Mummaneni PV, Choudhri TF, Eck JC, Wang JC, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 15: electrophysiological monitoring and lumbar fusion. J Neurosurg Spine 2014; 21:102-5. [PMID: 24980592 DOI: 10.3171/2014.4.spine14324] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intraoperative monitoring (IOM) is commonly used during lumbar fusion surgery for the prevention of nerve root injury. Justification for its use stems from the belief that IOM can prevent nerve root injury during the placement of pedicle screws. A thorough literature review was conducted to determine if the use of IOM could prevent nerve root injury during the placement of instrumentation in lumbar or lumbosacral fusion. There is no evidence to date that IOM can prevent injury to the nerve roots. There is limited evidence that a threshold below 5 mA from direct stimulation of the screw can indicate a medial pedicle breach by the screw. Unfortunately, once a nerve root injury has taken place, changing the direction of the screw does not alter the outcome. The recommendations formulated in the original guideline effort are neither supported nor refuted with the evidence obtained with the current studies.
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Affiliation(s)
- Alok Sharan
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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12
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Kaiser MG, Groff MW, Watters WC, Ghogawala Z, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Sharan A, Wang JC, Dhall SS, Resnick DK. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 16: bone graft extenders and substitutes as an adjunct for lumbar fusion. J Neurosurg Spine 2014; 21:106-32. [PMID: 24980593 DOI: 10.3171/2014.4.spine14325] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In an attempt to enhance the potential to achieve a solid arthrodesis and avoid the morbidity of harvesting autologous iliac crest bone (AICB) for a lumbar fusion, numerous alternatives have been investigated. The use of these fusion adjuncts has become routine despite a lack of convincing evidence demonstrating a benefit to justify added costs or potential harm. Potential alternatives to AICB include locally harvested autograft, calcium-phosphate salts, demineralized bone matrix (DBM), and the family of bone morphogenetic proteins (BMPs). In particular, no option has created greater controversy than the BMPs. A significant increase in the number of publications, particularly with respect to the BMPs, has taken place since the release of the original guidelines. Both DBM and the calciumphosphate salts have demonstrated efficacy as a graft extender or as a substitute for AICB when combined with local autograft. The use of recombinant human BMP-2 (rhBMP-2) as a substitute for AICB, when performing an interbody lumbar fusion, is considered an option since similar outcomes have been observed; however, the potential for heterotopic bone formation is a concern. The use of rhBMP-2, when combined with calcium phosphates, as a substitute for AICB, or as an extender, when used with local autograft or AICB, is also considered an option as similar fusion rates and clinical outcomes have been observed. Surgeons electing to use BMPs should be aware of a growing body of literature demonstrating unique complications associated with the use of BMPs.
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Affiliation(s)
- Michael G Kaiser
- Department of Neurosurgery, Columbia University, New York, New York
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13
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Resnick DK, Watters WC, Sharan A, Mummaneni PV, Dailey AT, Wang JC, Choudhri TF, Eck J, Ghogawala Z, Groff MW, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: lumbar fusion for stenosis with spondylolisthesis. J Neurosurg Spine 2014; 21:54-61. [PMID: 24980586 DOI: 10.3171/2014.4.spine14274] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients presenting with stenosis associated with a spondylolisthesis will often describe signs and symptoms consistent with neurogenic claudication, radiculopathy, and/or low-back pain. The primary objective of surgery, when deemed appropriate, is to decompress the neural elements. As a result of the decompression, the inherent instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. Since publication of the original guidelines there have been a significant number of studies published that continue to support the utility of lumbar fusion for patients presenting with stenosis and spondylolisthesis. Several recently published trials, including the Spine Patient Outcomes Research Trial, are among the largest prospective randomized investigations of this issue. Despite limitations of study design or execution, these trials have consistently demonstrated superior outcomes when patients undergo surgery, with the majority undergoing some type of lumbar fusion procedure. There is insufficient evidence, however, to recommend a standard approach to achieve a solid arthrodesis. When formulating the most appropriate surgical strategy, it is recommended that an individualized approach be adopted, one that takes into consideration the patient's unique anatomical constraints and desires, as well as surgeon's experience.
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Affiliation(s)
- Daniel K Resnick
- Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
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14
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Wang JC, Dailey AT, Mummaneni PV, Ghogawala Z, Resnick DK, Watters WC, Groff MW, Choudhri TF, Eck JC, Sharan A, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8: lumbar fusion for disc herniation and radiculopathy. J Neurosurg Spine 2014; 21:48-53. [PMID: 24980585 DOI: 10.3171/2014.4.spine14271] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Patients suffering from a lumbar herniated disc will typically present with signs and symptoms consistent with radiculopathy. They may also have low-back pain, however, and the source of this pain is less certain, as it may be from the degenerative process that led to the herniation. The surgical alternative of choice remains a lumbar discectomy, but fusions have been performed for both primary and recurrent disc herniations. In the original guidelines, the inclusion of a fusion for routine discectomies was not recommended. This recommendation continues to be supported by more recent evidence. Based on low-level evidence, the incorporation of a lumbar fusion may be considered an option when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor. For recurrent disc herniations, there is low-level evidence to support the inclusion of lumbar fusion for patients with evidence of instability or chronic low-back pain.
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Affiliation(s)
- Jeffrey C Wang
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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15
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Dailey AT, Ghogawala Z, Choudhri TF, Watters WC, Resnick DK, Sharan A, Eck JC, Mummaneni PV, Wang JC, Groff MW, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 14: brace therapy as an adjunct to or substitute for lumbar fusion. J Neurosurg Spine 2014; 21:91-101. [PMID: 24980591 DOI: 10.3171/2014.4.spine14282] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The utilization of orthotic devices for lumbar degenerative disease has been justified from both a prognostic and therapeutic perspective. As a prognostic tool, bracing is applied prior to surgery to determine if immobilization of the spine leads to symptomatic relief and thus justify the performance of a fusion. Since bracing does not eliminate motion, the validity of this assumption is questionable. Only one low-level study has investigated the predictive value of bracing prior to surgery. No correlation between response to bracing and fusion outcome was observed; therefore a trial of preoperative bracing is not recommended. Based on low-level evidence, the use of bracing is not recommended for the prevention of low-back pain in a general working population, since the incidence of low-back pain and impact on productivity were not reduced. However, in laborers with a history of back pain, a positive impact on lost workdays was observed when bracing was applied. Bracing is recommended as an option for treatment of subacute low-back pain, as several higher-level studies have demonstrated an improvement in pain scores and function. The use of bracing following instrumented posterolateral fusion, however, is not recommended, since equivalent outcomes have been demonstrated with or without the application of a brace.
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Affiliation(s)
- Andrew T Dailey
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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16
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Eck JC, Sharan A, Ghogawala Z, Resnick DK, Watters WC, Mummaneni PV, Dailey AT, Choudhri TF, Groff MW, Wang JC, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: Lumbar fusion for intractable low-back pain without stenosis or spondylolisthesis. J Neurosurg Spine 2014; 21:42-7. [DOI: 10.3171/2014.4.spine14270] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Establishing an appropriate treatment strategy for patients presenting with low-back pain, in the absence of stenosis or spondylolisthesis, remains a controversial subject. Inherent to this situation is often an inability to adequately identify the source of low-back pain to justify various treatment recommendations, such as lumbar fusion. The current evidence does not identify a single best treatment alternative for these patients. Based on a number of prospective, randomized trials, comparable outcomes, for patients presenting with 1- or 2-level degenerative disc disease, have been demonstrated following either lumbar fusion or a comprehensive rehabilitation program with a cognitive element. Limited access to such comprehensive rehabilitative programs may prove problematic when pursuing this alternative. For patients whose pain is refractory to conservative care, lumbar fusion is recommended. Limitations of these studies preclude the ability to present the most robust recommendation in support of lumbar fusion. A number of lesser-quality studies, primarily case series, also support the use of lumbar fusion in this patient population.
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Affiliation(s)
- Jason C. Eck
- 1Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Alok Sharan
- 2Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Zoher Ghogawala
- 3Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
| | - Daniel K. Resnick
- 4Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | | | - Praveen V. Mummaneni
- 6Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew T. Dailey
- 7Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Tanvir F. Choudhri
- 8Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Michael W. Groff
- 9Department of Spinal Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey C. Wang
- 10Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Sanjay S. Dhall
- 6Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael G. Kaiser
- 11Department of Neurosurgery, Columbia University, New York, New York
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Mummaneni PV, Dhall SS, Eck JC, Groff MW, Ghogawala Z, Watters WC, Dailey AT, Resnick DK, Choudhri TF, Sharan A, Wang JC, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 11: Interbody techniques for lumbar fusion. J Neurosurg Spine 2014; 21:67-74. [DOI: 10.3171/2014.4.spine14276] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Interbody fusion techniques have been promoted as an adjunct to lumbar fusion procedures in an effort to enhance fusion rates and potentially improve clinical outcome. The medical evidence continues to suggest that interbody techniques are associated with higher fusion rates compared with posterolateral lumbar fusion (PLF) in patients with degenerative spondylolisthesis who demonstrate preoperative instability. There is no conclusive evidence demonstrating improved clinical or radiographic outcomes based on the different interbody fusion techniques. The addition of a PLF when posterior or anterior interbody lumbar fusion is performed remains an option, although due to increased cost and complications, it is not recommended. No substantial clinical benefit has been demonstrated when a PLF is included with an interbody fusion. For lumbar degenerative disc disease without instability, there is moderate evidence that the standalone anterior lumbar interbody fusion (ALIF) has better clinical outcomes than the ALIF plus instrumented, open PLF. With regard to type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft; however, this was not associated with a difference in clinical outcome.
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Affiliation(s)
- Praveen V. Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Sanjay S. Dhall
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Jason C. Eck
- 2Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Michael W. Groff
- 3Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zoher Ghogawala
- 4Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
| | | | - Andrew T. Dailey
- 6Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Daniel K. Resnick
- 7Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | - Tanvir F. Choudhri
- 8Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alok Sharan
- 9Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jeffrey C. Wang
- 10Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Michael G. Kaiser
- 11Department of Neurosurgery, Columbia University, New York, New York
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Groff MW, Dailey AT, Ghogawala Z, Resnick DK, Watters WC, Mummaneni PV, Choudhri TF, Eck JC, Sharan A, Wang JC, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 12: Pedicle screw fixation as an adjunct to posterolateral fusion. J Neurosurg Spine 2014; 21:75-8. [DOI: 10.3171/2014.4.spine14277] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The utilization of pedicle screw fixation as an adjunct to posterolateral lumbar fusion (PLF) has become routine, but demonstration of a definitive benefit remains problematic. The medical evidence indicates that the addition of pedicle screw fixation to PLF increases fusion rates when assessed with dynamic radiographs. More recent evidence, since publication of the 2005 Lumbar Fusion Guidelines, suggests a stronger association between radiographic fusion and clinical outcome, although, even now, no clear correlation has been demonstrated. Although several reports suggest that clinical outcomes are improved with the addition of pedicle screw fixation, there are conflicting findings from similarly classified evidence. Furthermore, the largest contemporary, randomized, controlled study on this topic failed to demonstrate a significant clinical benefit with the use of pedicle screw fixation in patients undergoing PLF for chronic low-back pain. This absence of proof should not, however, be interpreted as proof of absence. Several limitations continue to compromise these investigations. For example, in the majority of studies the sample size is insufficient to detect small increments in clinical outcome that may be observed with pedicle screw fixation. Therefore, no definitive statement regarding the efficacy of pedicle screw fixation as a means to improve functional outcomes in patients undergoing PLF for chronic low-back pain can be made. There appears to be consistent evidence suggesting that pedicle screw fixation increases the costs and complication rate of PLF. High-risk patients, including (but not limited to) patients who smoke, patients who are undergoing revision surgery, or patients who suffer from medical conditions that may compromise fusion potential, may appreciate a greater benefit with supplemental pedicle screw fixation. It is recommended, therefore, that the use of pedicle screw fixation as a supplement to PLF be reserved for those patients in whom there is an increased risk of nonunion when treated with only PLF.
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Affiliation(s)
- Michael W. Groff
- 1Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew T. Dailey
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Zoher Ghogawala
- 3Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
| | - Daniel K. Resnick
- 4Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | | | - Praveen V. Mummaneni
- 6Department of Neurological Surgery, University of California, San Francisco, California
| | - Tanvir F. Choudhri
- 7Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NewYork, New York
| | - Jason C. Eck
- 8Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Alok Sharan
- 9Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jeffrey C. Wang
- 10Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Sanjay S. Dhall
- 6Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael G. Kaiser
- 11Department of Neurosurgery, Columbia University, New York, New York
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Kaiser MG, Eck JC, Groff MW, Ghogawala Z, Watters WC, Dailey AT, Resnick DK, Choudhri TF, Sharan A, Wang JC, Dhall SS, Mummaneni PV. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 17: Bone growth stimulators as an adjunct for lumbar fusion. J Neurosurg Spine 2014; 21:133-9. [DOI: 10.3171/2014.4.spine14326] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The relationship between the formation of a solid arthrodesis and electrical and electromagnetic energy is well established; most of the information on the topic, however, pertains to the healing of long bone fractures. The use of both invasive and noninvasive means to supply this energy and supplement spinal fusions has been investigated. Three forms of electrical stimulation are routinely used: direct current stimulation (DCS), pulsed electromagnetic field stimulation (PEMFS), and capacitive coupled electrical stimulation (CCES). Only DCS requires the placement of electrodes within the fusion substrate and is inserted at the time of surgery. Since publication of the original guidelines, few studies have investigated the use of bone growth stimulators. Based on the current review, no conflict with the previous recommendations was generated. The use of DCS is recommended as an option for patients younger than 60 years of age, since a positive effect on fusion has been observed. The same, however, cannot be stated for patients over 60, because DCS did not appear to have an impact on fusion rates in this population. No study was reviewed that investigated the use of CCES or the routine use of PEMFS. A single low-level study demonstrated a positive impact of PEMFS on patients undergoing revision surgery for pseudarthrosis, but this single study is insufficient to recommend for or against the use of PEMFS in this patient population.
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Affiliation(s)
- Michael G. Kaiser
- 1Department of Neurosurgery, Columbia University, New York, New York
| | - Jason C. Eck
- 2Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Michael W. Groff
- 3Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zoher Ghogawala
- 4Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
| | | | - Andrew T. Dailey
- 6Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Daniel K. Resnick
- 7Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | - Tanvir F. Choudhri
- 8Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alok Sharan
- 9Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jeffrey C. Wang
- 10Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Sanjay S. Dhall
- 11Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V. Mummaneni
- 11Department of Neurological Surgery, University of California, San Francisco, California
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Choudhri TF, Mummaneni PV, Dhall SS, Eck JC, Groff MW, Ghogawala Z, Watters WC, Dailey AT, Resnick DK, Sharan A, Wang JC, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 4: Radiographic assessment of fusion status. J Neurosurg Spine 2014; 21:23-30. [DOI: 10.3171/2014.4.spine14267] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The ability to identify a successful arthrodesis is an essential element in the management of patients undergoing lumbar fusion procedures. The hypothetical gold standard of intraoperative exploration to identify, under direct observation, a solid arthrodesis is an impractical alternative. Therefore, radiographic assessment remains the most viable instrument to evaluate for a successful arthrodesis. Static radiographs, particularly in the presence of instrumentation, are not recommended. In the absence of spinal instrumentation, lack of motion on flexion-extension radiographs is highly suggestive of a successful fusion; however, motion observed at the treated levels does not necessarily predict pseudarthrosis. The degree of motion on dynamic views that would distinguish between a successful arthrodesis and pseudarthrosis has not been clearly defined. Computed tomography with fine-cut axial images and multiplanar views is recommended and appears to be the most sensitive for assessing fusion following instrumented posterolateral and anterior lumbar interbody fusions. For suspected symptomatic pseudarthrosis, a combination of techniques including static and dynamic radiographs as well as CT images is recommended as an option. Lack of facet fusion is considered to be more suggestive of a pseudarthrosis compared with absence of bridging posterolateral bone. Studies exploring additional noninvasive modalities of fusion assessment have demonstrated either poor potential, such as with 99mTc bone scans, or provide insufficient information to formulate a definitive recommendation.
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Affiliation(s)
- Tanvir F. Choudhri
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Praveen V. Mummaneni
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Sanjay S. Dhall
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Jason C. Eck
- 3Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Michael W. Groff
- 4Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zoher Ghogawala
- 5Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
| | | | - Andrew T. Dailey
- 7Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Daniel K. Resnick
- 8Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | - Alok Sharan
- 9Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Jeffrey C. Wang
- 10Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Michael G. Kaiser
- 11Department of Neurosurgery, Columbia University, New York, New York
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Resnick DK, Watters WC, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Sharan A, Groff MW, Wang JC, Ghogawala Z, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 10: Lumbar fusion for stenosis without spondylolisthesis. J Neurosurg Spine 2014; 21:62-6. [DOI: 10.3171/2014.4.spine14275] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lumbar stenosis is one of the more common radiographic manifestations of the aging process, leading to narrowing of the spinal canal and foramen. When stenosis is clinically relevant, patients often describe activity-related low-back or lower-extremity pain, known as neurogenic claudication. For those patients who do not improve with conservative care, surgery is considered an appropriate treatment alternative. The primary objective of surgery is to reconstitute the spinal canal. The role of fusion, in the absence of a degenerative deformity, is uncertain. The previous guideline recommended against the inclusion of lumbar fusion in the absence of spinal instability or a likelihood of iatrogenic instability. Since the publication of the original guidelines, numerous studies have demonstrated the role of surgical decompression in this patient population; however, few have investigated the utility of fusion in patients without underlying instability. The majority of studies contain a heterogeneous cohort of subjects, often combining patients with and without spondylolisthesis who received various surgical interventions, limiting fusions to those patients with instability. It is difficult if not impossible, therefore, to formulate valid conclusions regarding the utility of fusion for patients with uncomplicated stenosis. Lower-level evidence exists, however, that does not demonstrate an added benefit of fusion for these patients; therefore, in the absence of deformity or instability, the inclusion of a fusion is not recommended.
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Affiliation(s)
- Daniel K. Resnick
- 1Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | | | - Praveen V. Mummaneni
- 3Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew T. Dailey
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Tanvir F. Choudhri
- 5Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jason C. Eck
- 6Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Alok Sharan
- 7Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Michael W. Groff
- 8Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey C. Wang
- 9Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Zoher Ghogawala
- 10Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts; and
| | - Sanjay S. Dhall
- 3Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael G. Kaiser
- 11Department of Neurosurgery, Columbia University, New York, New York
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Watters WC, Resnick DK, Eck JC, Ghogawala Z, Mummaneni PV, Dailey AT, Choudhri TF, Sharan A, Groff MW, Wang JC, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: Injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine 2014; 21:79-90. [DOI: 10.3171/2014.4.spine14281] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The medical literature continues to fail to support the use of lumbar epidural injections for long-term relief of chronic back pain without radiculopathy. There is limited support for the use of lumbar epidural injections for shortterm relief in selected patients with chronic back pain. Lumbar intraarticular facet injections are not recommended for the treatment of chronic lower-back pain. The literature does suggest the use of lumbar medial nerve blocks for short-term relief of facet-mediated chronic lower-back pain without radiculopathy. Lumbar medial nerve ablation is suggested for 3–6 months of relief for chronic lower-back pain without radiculopathy. Diagnostic medial nerve blocks by the double-injection technique with an 80% improvement threshold are an option to predict a favorable response to medial nerve ablation for facet-mediated chronic lower-back pain without radiculopathy, but there is no evidence to support the use of diagnostic medial nerve blocks to predict the outcomes in these same patients with lumbar fusion. There is insufficient evidence to support or refute the use of trigger point injections for chronic lowerback pain without radiculopathy.
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Affiliation(s)
| | - Daniel K. Resnick
- 2Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | - Jason C. Eck
- 3Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Zoher Ghogawala
- 4Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
| | - Praveen V. Mummaneni
- 5Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew T. Dailey
- 6Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Tanvir F. Choudhri
- 7Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alok Sharan
- 8Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Michael W. Groff
- 9Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey C. Wang
- 10Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | - Sanjay S. Dhall
- 5Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael G. Kaiser
- 11Department of Neurosurgery, Columbia University, New York, New York
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Eck JC, Sharan A, Resnick DK, Watters WC, Ghogawala Z, Dailey AT, Mummaneni PV, Groff MW, Wang JC, Choudhri TF, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 6: Discography for patient selection. J Neurosurg Spine 2014; 21:37-41. [DOI: 10.3171/2014.4.spine14269] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Identifying the etiology of pain for patients suffering from chronic low-back pain remains problematic. Noninvasive imaging modalities, used in isolation, have not consistently provided sufficient evidence to support performance of a lumbar fusion. Provocative testing has been used as an adjunct in this assessment, either alone or in combination with other modalities, to enhance the diagnostic capabilities when evaluating patients with low-back pain. There have been a limited number of studies investigating this topic since the publication of the original guidelines. Based primarily on retrospective studies, discography, as a stand-alone test, is not recommended to formulate treatment strategies for patients with low-back pain. A single randomized cohort study demonstrated an improved potential of discoblock over discography as a predictor of success following lumbar fusion. It is therefore recommended that discoblock be considered as a diagnostic option. There is a possibility, based on a matched cohort study, that an association exists between progression of degenerative disc disease and the performance of a provocative discogram. It is therefore recommended that patients be counseled regarding this potential development prior to undergoing discography.
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Affiliation(s)
- Jason C. Eck
- 1Center for Sports Medicine and Orthopaedics, Chattanooga, Tennessee
| | - Alok Sharan
- 2Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Daniel K. Resnick
- 3Department of Neurosurgery, University of Wisconsin, Madison, Wisconsin
| | | | - Zoher Ghogawala
- 5Alan and Jacqueline Stuart Spine Research Center, Department of Neurosurgery, Lahey Clinic, Burlington, and Tufts University School of Medicine, Boston, Massachusetts
| | - Andrew T. Dailey
- 6Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Praveen V. Mummaneni
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael W. Groff
- 8Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey C. Wang
- 9Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Tanvir F. Choudhri
- 10Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York; and
| | - Sanjay S. Dhall
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael G. Kaiser
- 11Department of Neurosurgery, Columbia University, New York, New York
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Watters WC, Sanders JO, Murray J, Patel N. The American Academy of Orthopaedic Surgeons Appropriate Use Criteria on the treatment of distal radius fractures. J Bone Joint Surg Am 2014; 96:160-1. [PMID: 24430416 DOI: 10.2106/jbjs.m.01314] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Chambers HG, Shea KG, Anderson AF, Jojo Brunelle TJ, Carey JL, Ganley TJ, Paterno M, Weiss JM, Sanders JO, Watters WC, Goldberg MJ, Keith MW, Turkelson CM, Wies JL, Raymond L, Boyer KM, Hitchcock K, Sluka P, Boone C, Patel N. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis and treatment of osteochondritis dissecans. J Bone Joint Surg Am 2012; 94:1322-4. [PMID: 22810404 DOI: 10.2106/jbjs.9414ebo] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Jacobs JJ, Mont MA, Bozic KJ, Della Valle CJ, Goodman SB, Lewis CG, Yates ACJ, Boggio LN, Watters WC, Turkelson CM, Wies JL, Sluka P, Hitchcock K. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Bone Joint Surg Am 2012; 94:746-7. [PMID: 22517391 PMCID: PMC3326685 DOI: 10.2106/jbjs.9408.ebo746] [Citation(s) in RCA: 134] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Pedowitz RA, Yamaguchi K, Ahmad CS, Burks RT, Flatow EL, Green A, Wies JL, St Andre J, Boyer K, Iannotti JP, Miller BS, Tashjian R, Watters WC, Weber K, Turkelson CM, Raymond L, Sluka P, McGowan R. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: optimizing the management of rotator cuff problems. J Bone Joint Surg Am 2012; 94:163-7. [PMID: 22258004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Esses SI, McGuire R, Jenkins J, Finkelstein J, Woodard E, Watters WC, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Sluka P, Boyer KM, Hitchcock K, Raymond L. American Academy of Orthopaedic Surgeons clinical practice guideline on: the treatment of osteoporotic spinal compression fractures. J Bone Joint Surg Am 2011; 93:1934-6. [PMID: 22012531 DOI: 10.2106/jbjs.9320ebo] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Della Valle C, Parvizi J, Bauer TW, DiCesare PE, Evans RP, Segreti J, Spangehl M, Watters WC, Keith M, Turkelson CM, Wies JL, Sluka P, Hitchcock K. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am 2011; 93:1355-7. [PMID: 21792503 DOI: 10.2106/jbjs.9314ebo] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Lichtman DM, Bindra RR, Boyer MI, Putnam MD, Ring D, Slutsky DJ, Taras JS, Watters WC, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Haralson RH, Boyer KM, Hitchcock K, Raymond L. American Academy of Orthopaedic Surgeons clinical practice guideline on: the treatment of distal radius fractures. J Bone Joint Surg Am 2011; 93:775-8. [PMID: 21508285 DOI: 10.2106/jbjs.938ebo] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Izquierdo R, Voloshin I, Edwards S, Freehill MQ, Stanwood W, Wiater JM, Watters WC, Goldberg MJ, Keith M, Turkelson CM, Wies JL, Anderson S, Boyer K, Raymond L, Sluka P, Hitchcock K. American academy of orthopaedic surgeons clinical practice guideline on: the treatment of glenohumeral joint osteoarthritis. J Bone Joint Surg Am 2011; 93:203-5. [PMID: 21248219 DOI: 10.2106/00004623-201101190-00012] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Chiodo CP, Glazebrook M, Bluman EM, Cohen BE, Femino JE, Giza E, Watters WC, Goldberg MJ, Keith M, Haralson RH, Turkelson CM, Wies JL, Hitchcock K, Raymond L, Anderson S, Boyer K, Sluka P. American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of Achilles tendon rupture. J Bone Joint Surg Am 2010; 92:2466-8. [PMID: 20962199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Kocher MS, Sink EL, Blasier RD, Luhmann SJ, Mehlman CT, Scher DM, Matheney T, Sanders JO, Watters WC, Goldberg MJ, Keith MW, Haralson RH, Turkelson CM, Wies JL, Sluka P, McGowan R. American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of pediatric diaphyseal femur fracture. J Bone Joint Surg Am 2010; 92:1790-2. [PMID: 20660244 DOI: 10.2106/jbjs.j.00137] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Watters WC, Gilbert TJ, Kreiner DS. Diagnosing lumbar spinal stenosis. JAMA 2010; 303:1479; author reply 1480-1. [PMID: 20407054 DOI: 10.1001/jama.2010.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Richmond J, Hunter D, Irrgang J, Jones MH, Snyder-Mackler L, Van Durme D, Rubin C, Matzkin EG, Marx RG, Levy BA, Watters WC, Goldberg MJ, Keith M, Haralson RH, Turkelson CM, Wies JL, Anderson S, Boyer K, Sluka P, St Andre J, McGowan R. American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of osteoarthritis (OA) of the knee. J Bone Joint Surg Am 2010; 92:990-3. [PMID: 20360527 DOI: 10.2106/jbjs.i.00982] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Bono CM, Heggeness M, Mick C, Resnick D, Watters WC. North American Spine Society: Newly released vertebroplasty randomized controlled trials: a tale of two trials. Spine J 2010; 10:238-40. [PMID: 19822459 DOI: 10.1016/j.spinee.2009.09.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 09/24/2009] [Indexed: 02/03/2023]
Abstract
This commentary is a product of the North American Spine Society (NASS). It was approved by the NASS Board of Directors and accepted for publication outside The Spine Journal's peer review process.
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Affiliation(s)
- Christopher M Bono
- Department of Orthopedic Surgery, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115-6110, USA.
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Keith MW, Masear V, Chung KC, Amadio PC, Andary M, Barth RW, Maupin K, Graham B, Watters WC, Turkelson CM, Haralson RH, Wies JL, McGowan R. American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of carpal tunnel syndrome. J Bone Joint Surg Am 2010; 92:218-9. [PMID: 20048116 PMCID: PMC6882524 DOI: 10.2106/jbjs.i.00642] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Bono CM, Watters WC, Heggeness MH, Resnick DK, Shaffer WO, Baisden J, Ben-Galim P, Easa JE, Fernand R, Lamer T, Matz PG, Mendel RC, Patel RK, Reitman CA, Toton JF. An evidence-based clinical guideline for the use of antithrombotic therapies in spine surgery. Spine J 2009; 9:1046-51. [PMID: 19931184 DOI: 10.1016/j.spinee.2009.09.005] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Revised: 09/17/2009] [Accepted: 09/17/2009] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The objective of the North American Spine Society (NASS) Evidence-Based Clinical Guideline on antithrombotic therapies in spine surgery was to provide evidence-based recommendations to address key clinical questions surrounding the use of antithrombotic therapies in spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of February 2008. The goal of the guideline recommendations was to assist in delivering optimum, efficacious treatment with the goal of preventing thromboembolic events. PURPOSE To provide an evidence-based, educational tool to assist spine surgeons in minimizing the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). STUDY DESIGN Systematic review and evidence-based clinical guideline. METHODS This report is from the Antithrombotic Therapies Work Group of the NASS Evidence-Based Guideline Development Committee. The work group was composed of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member of the group was involved in formatting a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answers to each clinical question were arrived at via Web casts among members of the work group using standardized grades of recommendation. When Level I to IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. RESULTS Fourteen clinical questions were formulated, addressing issues of incidence of DVT and PE in spine surgery and recommendations regarding utilization of mechanical prophylaxis and chemoprophylaxis in spine surgery. The answers to these 14 clinical questions are summarized in this article. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence. CONCLUSIONS A clinical guideline addressing the use of antithrombotic therapies in spine surgery has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to assist spine surgeons in minimizing the risk of DVT and PE. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.
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Keith MW, Masear V, Chung KC, Maupin K, Andary M, Amadio PC, Watters WC, Goldberg MJ, Haralson RH, Turkelson CM, Wies JL, McGowan R. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am 2009; 91:2478-9. [PMID: 19797585 PMCID: PMC7000128 DOI: 10.2106/jbjs.i.00643] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Richmond J, Hunter D, Irrgang J, Jones MH, Levy B, Marx R, Snyder-Mackler L, Watters WC, Haralson RH, Turkelson CM, Wies JL, Boyer KM, Anderson S, St Andre J, Sluka P, McGowan R. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg 2009; 17:591-600. [PMID: 19726743 PMCID: PMC3170838 DOI: 10.5435/00124635-200909000-00006] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The clinical practice guideline was explicitly developed to include only treatments less invasive than knee replacement (ie, arthroplasty). Patients with symptomatic osteoarthritis of the knee are to be encouraged to participate in self-management educational programs and to engage in self-care, as well as to lose weight and engage in exercise and quadriceps strengthening. The guideline recommends taping for short-term relief of pain as well as analgesics and intra-articular corticosteroids, but not glucosamine and/or chondroitin. Patients need not undergo needle lavage or arthroscopy with débridement or lavage. Patients may consider partial meniscectomy or loose body removal or realignment osteotomy, as conditions warrant. Use of a free-floating interpositional device should not be considered for symptomatic unicompartmental osteoarthritis of the knee. Lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis of the knee. The work group was unable either to recommend or not recommend the use of braces with either valgus- or varus-directing forces for patients with medial unicompartmental osteoarthritis; the use of acupuncture or of hyaluronic acid; or osteotomy of the tibial tubercle for isolated symptomatic patellofemoral osteoarthritis.
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Affiliation(s)
- John Richmond
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
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Watters WC, Bono CM, Gilbert TJ, Kreiner DS, Mazanec DJ, Shaffer WO, Baisden J, Easa JE, Fernand R, Ghiselli G, Heggeness MH, Mendel RC, O'Neill C, Reitman CA, Resnick DK, Summers JT, Timmons RB, Toton JF. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J 2009; 9:609-14. [PMID: 19447684 DOI: 10.1016/j.spinee.2009.03.016] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Revised: 02/24/2009] [Accepted: 03/20/2009] [Indexed: 02/06/2023]
Abstract
BACKGROUND CONTEXT The objective of the North American Spine Society (NASS) evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spondylolisthesis is to provide evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of degenerative lumbar spondylolisthesis. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of January 2007. The goal of the guideline recommendations is to assist the practitioner in delivering optimum, efficacious treatment of and functional recovery from this common disorder. PURPOSE To provide an evidence-based, educational tool to assist spine care providers in improving the quality and efficiency of care delivered to patients with degenerative lumbar spondylolisthesis. STUDY DESIGN Systematic review and evidence-based clinical guideline. METHODS This report is from the Degenerative Lumbar Spondylolisthesis Work Group of the NASS Evidence-Based Clinical Guideline Development Committee. The work group was comprised of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member participated in the development of a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology) and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via face-to-face meetings among members of the work group using standardized grades of recommendation. When Level I-IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. RESULTS Nineteen clinical questions were formulated, addressing issues of prognosis, diagnosis, and treatment of degenerative lumbar spondylolisthesis. The answers to these 19 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence. CONCLUSIONS A clinical guideline for degenerative lumbar spondylolisthesis has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid practitioners involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.
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Johanson NA, Lachiewicz PF, Lieberman JR, Lotke PA, Parvizi J, Pellegrini V, Stringer TA, Tornetta P, Haralson RH, Watters WC. American academy of orthopaedic surgeons clinical practice guideline on. Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Bone Joint Surg Am 2009; 91:1756-7. [PMID: 19571100 DOI: 10.2106/jbjs.i.00511] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Akuthota V, Argoff C, Watters WC. Interpreting Reviews and Guidelines: The Case of Lumbar Epidural Steroid Injections. PM R 2009; 1:576-9. [DOI: 10.1016/j.pmrj.2009.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Accepted: 05/07/2009] [Indexed: 11/28/2022]
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Keith MW, Masear V, Chung K, Maupin K, Andary M, Amadio PC, Barth RW, Watters WC, Goldberg MJ, Haralson RH, Turkelson CM, Wies JL. Diagnosis of carpal tunnel syndrome. J Am Acad Orthop Surg 2009; 17:389-96. [PMID: 19474448 PMCID: PMC5175465 DOI: 10.5435/00124635-200906000-00007] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
This clinical practice guideline was created to improve patient care by outlining the appropriate information-gathering and decision-making processes involved in managing the diagnosis of carpal tunnel syndrome. The methods used to develop this clinical practice guideline were designed to combat bias, enhance transparency, and promote reproducibility. The guideline's recommendations are as follows: The physician should obtain an accurate patient history. The physician should perform a physical examination of the patient that may include personal characteristics as well as performing a sensory examination, manual muscle testing of the upper extremity, and provocative and/or discriminatory tests for alternative diagnoses. The physician may obtain electrodiagnostic tests to differentiate among diagnoses. This may be done in the presence of thenar atrophy and/or persistent numbness. The physician should obtain electrodiagnostic tests when clinical and/or provocative tests are positive and surgical management is being considered. If the physician orders electrodiagnostic tests, the testing protocol should follow the American Academy of Neurology/American Association of Neuromuscular and Electrodiagnostic Medicine/American Academy of Physical Medicine and Rehabilitation guidelines for diagnosis of carpal tunnel syndrome. In addition, the physician should not routinely evaluate patients suspected of having carpal tunnel syndrome with new technology, such as magnetic resonance imaging, computed tomography, and pressure-specified sensorimotor devices in the wrist and hand. This decision was based on an additional nonsystematic literature review following the face-to-face meeting of the work group.
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Watters WC, McGirt MJ. An evidence-based review of the literature on the consequences of conservative versus aggressive discectomy for the treatment of primary disc herniation with radiculopathy. Spine J 2009; 9:240-57. [PMID: 18809356 DOI: 10.1016/j.spinee.2008.08.005] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Accepted: 08/05/2008] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT It remains unknown whether aggressive disc removal with curettage versus conservative removal of a disc fragment with little disc invasion provides a better outcome for the treatment of lumbar disc herniation with radiculopathy. PURPOSE Determine the level of evidence within the clinical literature that supports the performance of a conservative versus aggressive technique for discectomy. STUDY DESIGN/SETTING Systematic evidence-based review of clinical literature. PATIENT SAMPLE Patients with primary lumbar disc herniation with radiculopathy. OUTCOME MEASURES Operative time, return to work status, recurrent disc herniation, self-reported, and functional measures assessed less than 2 years (short term) and greater than 2 years (long term) after surgery. METHODS Systematic Medline search was performed to identify all published studies relating to outcome after aggressive or conservative discectomy. Levels of evidence (I-V) were assessed for each study and grades of recommendation were generated (Good, Fair, Poor, Insufficient evidence) based on the NASS Clinical Guidelines' Levels of Evidence and Grades of Recommendation. RESULTS There is fair evidence that conservative discectomy will result in shorter operative times and a quicker return to work despite similar lengths of hospital stay, similar pain levels at discharge, similar 6-month functional status, and a similar 2-year incidence of persistent/recurrent back and leg pain. There is poor quality evidence that conservative discectomy will result in a lower incidence of recurrent back pain beyond 2 years postoperatively. There is fair quality evidence that conservative discectomy will result in a higher incidence of recurrent disc herniation. CONCLUSIONS There are no Level I studies to support conservative versus aggressive discectomy for the treatment of primary disc herniation. However, systematic review of the literature suggests that conservative discectomy may result in shorter operative time, quicker return to work, and a decreased incidence of long-term recurrent low back pain but with an increased incidence of recurrent disc herniation. Prospective randomized trails are needed to firmly assess this possible benefit.
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Affiliation(s)
- William C Watters
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
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Watters WC, Baisden J, Bono CM, Heggeness MH, Resnick DK, Shaffer WO, Toton JF. Antibiotic prophylaxis in spine surgery: an evidence-based clinical guideline for the use of prophylactic antibiotics in spine surgery. Spine J 2009; 9:142-6. [PMID: 18619911 DOI: 10.1016/j.spinee.2008.05.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 03/12/2008] [Accepted: 05/19/2008] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline on Antibiotic Prophylaxis in Spine Surgery is to provide evidence-based recommendations on key clinical questions concerning the use of prophylactic antibiotics in spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of December 2006. The goal of the guideline recommendations is to assist in delivering optimum, efficacious treatment to prevent surgical site infection. PURPOSE To provide an evidence-based, educational tool to assist spine surgeons in preventing surgical site infections. STUDY DESIGN Evidence-based Clinical Guideline. METHODS This report is from the Antibiotic Prophylaxis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group comprised multidisciplinary surgical spine care specialists, who were trained in the principles of evidence-based analysis. Each member of the group formatted a series of clinical questions to be addressed by the group. The final questions agreed upon by the group are the subjects of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via Webcast meetings among members of the work group using standardized grades of recommendation. When Level I to Level IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified in the guideline. RESULTS Eleven clinical questions addressed the efficacy and appropriateness of antibiotic prophylaxis protocols, repeat dosing, discontinuation, wound drains, and special considerations related to the potential impact of comorbidities on antibiotic prophylaxis. The responses to these 11 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supported literature which was stratified by levels of evidence. CONCLUSIONS A clinical guideline addressing the use of antibiotic prophylaxis in spine surgery has been created using the techniques of evidence-based medicine and the best available evidence. This educational tool will assist spine surgeons in preventing surgical site infections. The entire guideline document, including the evidentiary tables, suggestions for future research, and references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.
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Watters WC, Baisden J, Gilbert TJ, Kreiner S, Resnick DK, Bono CM, Ghiselli G, Heggeness MH, Mazanec DJ, O'Neill C, Reitman CA, Shaffer WO, Summers JT, Toton JF. Degenerative lumbar spinal stenosis: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis. Spine J 2008; 8:305-10. [PMID: 18082461 DOI: 10.1016/j.spinee.2007.10.033] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 10/04/2007] [Accepted: 10/13/2007] [Indexed: 02/09/2023]
Abstract
BACKGROUND CONTEXT The objective of the North American Spine Society (NASS) evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (DLSS) is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of DLSS. The guideline is intended to reflect contemporary treatment concepts for symptomatic DLSS as reflected in the highest quality clinical literature available on this subject as of April 2006. The goals of the guideline recommendations are to assist in delivering optimum, efficacious treatment, and functional recovery from this spinal disorder. PURPOSE To provide an evidence-based tool that assists practitioners in improving the quality and efficiency of care delivered to patients with DLSS. STUDY DESIGN/SETTING Evidence-based clinical guideline. METHODS This report is from the Spinal Stenosis Work Group of the NASS Clinical Guidelines Committee. The work group comprised medical, diagnostic, interventional, and surgical spinal care specialists, all of whom were trained in the principles of evidence-based analysis. In the development of this guideline, the work group arrived at a consensus definition of a working diagnosis of lumbar spinal stenosis by use of a modification of the nominal group technique. Each member of the group formatted a series of clinical questions to be addressed by the group and the final list of questions agreed on by the group is the subject of this report. A literature search addressing each question and using a specific literature search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases. The relevant literature to answer each clinical question was then independently rated by at least two reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Any discrepancies in evidence levels among the initial raters were resolved by at least two additional members' review of the reference and independent rating. Final grades of recommendation for the answer to each clinical question were arrived at in face-to-face meetings among members of the work group using the NASS-adopted standardized grades of recommendation. When Levels I to IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. RESULTS Eighteen clinical questions were asked, addressing issues of prognosis, diagnosis, and treatment of DLSS. The answers to these 18 clinical questions are summarized in this document along with their respective levels of evidence and grades of recommendation in support of these answers. CONCLUSIONS A clinical guideline for DLSS has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid both practitioners and patients involved with the care of this disease. The entire guideline document including the evidentiary tables, suggestions for future research, and all references is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.
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Affiliation(s)
- William C Watters
- Bone and Joint Clinic of Houston, 6624 Fannin, 26th Floor, Houston, TX 77030, USA.
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Abstract
STUDY DESIGN A review of issues linking advocacy, patient safety, and quality. OBJECTIVE To heighten awareness of patient safety issues that require ongoing advocacy efforts by physicians treating spinal disorders. SUMMARY OF BACKGROUND DATA The 1999 Institute of Medicine report "To Err is Human. Building a Safer Health System" was a landmark publication that vaulted patient safety into the limelight of public awareness and media attention. The American Academy of Orthopedic Surgeons had addressed the wrong site surgery issue with its Sign Your Site Program even before the Institute of Medicine report. Several professional medical societies involved in spine care have made advocating for patient safety a priority. METHODS A summary of areas of advocacy efforts involving patient safety and quality. These include the Sign Your Site Program from the American Academy of Orthopedic Surgeons, Sign, Mark and X-ray from the North American Spine Society, Joint Commission on the Accreditation of Healthcare Organizations Universal Protocol, and technology assessment. Advocacy on the Federal, state, and local levels concerning patient safety is reviewed. RESULTS Awareness of patient safety issues has increased. Several patient safety protocols (Sign Your Site, Sign, Mark and X-ray, and the Universal Protocol) are in place. There is increased monitoring of medical errors on the state and local, especially hospital, levels. CONCLUSIONS Patient safety is an absolute provision of health care. Physicians need to set a personal example for compliance with existing patient safety systems such as the Universal Protocol and be active advocates for patient safety.
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Affiliation(s)
- David A Wong
- Advanced Center for Spinal Microsurgery, Presbyterian St. Luke's Medical Center, Denver, CO, USA.
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Resnick DK, Watters WC. Lumbar disc arthroplasty: a critical review. Clin Neurosurg 2007; 54:83-87. [PMID: 18504901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Lumbar disc arthroplasty may be the most innovative and exciting development in the history of spinal surgery. Manufacturers and proponents cite the ability of these devices to relieve pain while preserving motion at the disc space. The preservation of motion is hypothesized to lower the risk of adjacent segment disease and, thereby, improve long-term outcomes. However, the devices are expensive and their use is associated with the potential for significant complications above and beyond those seen with lumbar fusion. At the present time, there is no evidence to suggest that the use of disc arthroplasty results in better short- or long-term functional outcomes than fusion in properly selected patients. Furthermore, there is little if any evidence to support the hypothesis that adjacent segment degeneration is an important clinical entity. Although the absence of proof is not the same as the proof of absence, greater efficacy must be demonstrated to offset the increased costs and complications associated with these devices. Therefore, these devices require further long-term study in a controlled environment before widespread application.
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Affiliation(s)
- Daniel K Resnick
- Department of Neurosurery, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
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