Updates From the Orthopedic Spine World

Every year, physicians involved in treating spine patients come together at the Spine Society's Annual Meeting. Experts in the field bring information and updates on studies done in a wide variety of topics. In this report, six areas of interest were reviewed, summarized, and presented. A brief recap of these six areas is offered below:

1) Assessing Psychologic Factors in Spine Patients

In this report, physicians are reminded not to rely on their own memory by asking favorite questions when interviewing patients to assess the patient's psychologic state. There are better, more accurate tools available to do this. One of those tools is a psychologic questionnaire called the Distress Risk Assessment Method (DRAM).

According to a recent study, experienced surgeons aren't any better than less experienced physicians in assessing patients' psychologic stress. This type of evaluation is important because past research has shown there is a significant impact of a patient's psychologic health on their response to treatment for spine-related back pain.

To come to this conclusion, eight spine doctors (equal numbers of surgeons and physiatrists) interviewed 50 patients each (for a total of 200 patients in the study). The doctor-patient interview was meant to do a psychologic assessment and determine who needed psychologic help. Each of the 200 patients also filled out the DRAM questionnaire. The results of these two measures were compared. Categories used to classify patients' psychologic risk included normal (N), at-risk(AR),distressed depressive (DD), and distressed somatic (DS).

It turned out that nonoperative spine specialists (those who offer conservative, nonsurgical care) were much better at recognizing when patients had significant levels of psychologic stress to be at risk for a poor treatment result. Surgeons relying on their own instincts were less likely to detect patients who were at-risk or distressed.

It was suggested that physicians use the DRAM for better results in this area of assessment. The DRAM has been validated by research studies. This means it is both reliable and effective in measuring psychologic distress in spine patients.

2) Comparing Cervical Spine Fusion to Cervical Total Disc Replacement

Total disc replacement is still a fairly new innovation in the treatment of degenerative disc disease of the cervical spine (neck). Studies are ongoing to compare the results of spinal fusion with disc replacement. Disc replacement has the major advantage of preserving neck motion. But does it improve overall function better than a spinal fusion?

That was the focus of a small study (51 total patients) comparing anterior cervical fusion with the Kineflex-C total disc system. Everyone in the study had a one level cervical disc problem caused by degenerative disc disease. The main measures used to compare the results were return-to-work status and narcotic use for pain. The number of days patients were off work was tracked along with frequency and dosage of narcotic medication used over time.

Patients in the cervical disc replacement group were back on the job three times faster than the fusion group. This was true even for manual laborers (not just those on light duty). Not only that, but this same disc replacement group were off the narcotic pain relievers much sooner than the fusion group.

Using these two measures of function offered some added valuable insight into the rehab and recovery of cervical spine patients opting for surgery. Instead of just using the standard Visual analogue scale (VAS) to measure pain and the Neck Disability Index to assess function before and after surgery, work and drug status offer additional helpful information.

3) Benefit of Lumbar Fusion By Age

Six months after lumbar spinal fusion, older adults (65 years old and older) have better results than younger adults. These findings apply to patients who had a single-level fusion. X-rays and CT scans showed better fusion rates for the Medicare-age group. They also reported more improved function compared to the younger group. These improvements were still present two years after the surgery.

The older adults did have more complications and problems after surgery. But overall, the study confirmed that lumbar spinal fusion is an acceptable and helpful procedure in Medicare recipients. The impetus for the study came from the Centers for Medicare and Medicaid. This government organization is reviewing outcomes of different procedures for this age group and requiring evidence that the treatment is both effective and cost-effective.

4) Exercise May Be Better Than Fusion For Spondylolisthesis

Spondylolisthesis is a spinal disorder that often causes pain, dysfunction, and disability. Surgery may be needed to fuse the spine and keep the condition from getting worse. In this condition, a supporting column of the vertebra called the pars interarticularis has a break or fracture in it.

Two sets of spinal bones form a bony ring around the spinal cord. Two pedicle bones attach to the back of each vertebral body. Two lamina bones complete the ring. The place where the lamina and pedicle bones meet is the pars interarticularis, or pars for short. There are two such meeting points on the back of each vertebra, one on the left and one on the right. The pars is thought to be the weakest part of the bony ring.

Spondylolisthesis alters the alignment of the spine. The affected vertebra slips forward over the one below it. As the bone slips forward, the nearby tissues and nerves may become irritated and painful. Exercises are often prescribed to strengthen the core trunk muscles and maintain proper posture to keep the vertebra from slipping forward even more. An alternative approach is surgery to fuse the spine and keep the bone from slipping any further.

Which one works best? What's the impact of adjacent segmental disease (ASD)? Adjacent segmental disease refers to the break down of the next vertebral bone above or below the area of spondylolisthesis. Two groups of patients with spondylolisthesis were included in this study. One group had a one-level lumbar spinal fusion. The second group were given standard exercises for spondylolisthesis.

The presence and severity of ASD were measured using two types of digital X-rays. The results showed that the fusion group lost disc height and the quality of the adjacent disc material declined compared to patients in the exercise group. Patients in both groups were followed for 10 years. No one in the exercise group developed ASD.

5) Bracing No Longer Needed After Neck Fusion

It's fairly routine to give a patient a cervical neck brace after neck fusion. But according to the results of a study done in multiple U.S. centers, bracing isn't always needed. Fusion rates and return-to-work status were the same with or without the bracing.

These findings apply to patients who had a single-level anterior cervical disc fusion (ACDF). Surgeons involved in the study say these results makes sense because the fusion was done with a metal plate along the front of the spine that was combined with bone graft at the same site. Bracing used to restrict motion isn't needed because the plate and graft material have the same effect of preventing motion.

Surgeons performing an ACDF should not give patients cervical bracing unless there is a specific need for it. They should rethink the policy of prescribing a cervical brace for everyone after this type of surgery.

6) National Registry of Surgery Results Helps Identify Patterns of Results

Instead of conducting 100s of small studies tracking the results of surgical procedures, it makes good sense to create a national registry (central database) that everyone can contribute to. If data on all patients having a particular surgical procedure could be downloaded into a registry, then the results of individual studies could be combined together for better analysis.

Procedures such as cervical and lumbar total disc replacement for degenerative disc disease or balloon kyphoplasty for vertebral compression fractures are common among older adults. Spinal surgeries of this type can be invasive and expensive. We need studies that show if these treatment methods are really safe and effective.

The Swiss government has required the use of a national spine surgery registry to track the results of spine treatment. It tracks cost and effectiveness of these procedures as well as revision rates. After two years of collecting data, the researchers were able to say that total disc replacement does reduce pain and improve quality of life. More patients were able to stop taking narcotic pain medications sooner compared with patients who had a spinal fusion.

Similar benefits were reported for patients having balloon kyphoplasty. Balloon kyphoplasty is a treatment that involves the placement of a balloon into a collapsed vertebra. A special bone cement is injected into the space created by the inflated balloon. The cement hardens and helps restore the bone's natural height and shape.

Results for balloon kyphoplasty reported over the past two years since the registry was started have not shown any changes. But even this kind of information is helpful. It reflects the combined efforts of many surgeons, educators, and the health care industry to track treatment results and report them. This informs health care profesionals how effective treatments are and provides evidence-based best care for patients.

SUMMARY: The brief summaries offered here of six key areas in the advancement of orthopedic research only represent a small portion of the work that's being done around the world. The North American Spine Society offers a conference every year with updates like this for both the physicians who can attend and for those who look for updates in summaries such as this.

Susan M. Rapp. DRAM Assessment Recommended for Spine Patients. In Orthopedics Today. November 2008. Vol.28. No.11. Pp. 1, 48-51.



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