TY - JOUR
T1 - Management of degenerative spondylolisthesis
T2 - development of appropriate use criteria
AU - Reitman, Charles A.
AU - Cho, Charles H.
AU - Bono, Christopher M.
AU - Ghogawala, Zoher
AU - Glaser, John
AU - Kauffman, Christopher
AU - Mazanec, Daniel
AU - O'Brien, David
AU - O'Toole, John
AU - Prather, Heidi
AU - Resnick, Daniel
AU - Schofferman, Jerome
AU - Smith, Matthew J.
AU - Sullivan, William
AU - Tauzell, Ryan
AU - Truumees, Eeric
AU - Wang, Jeffrey
AU - Watters, William
AU - Wetzel, F. Todd
AU - Whitcomb, Gregory
N1 - Funding Information:
Author disclosures: CAR: Trips/Travel: North American Spine Society (Travel expenses); Scientific Advisory Board: Clinical Orthopedics and Related Research (B, Deputy Editor, paid directly to institution/employer). CHC: Board of Directors: North American Spine Society (Evidence Compilation and Analysis Chair); Other Office: American Society of Neuroradiology (Finance Management Committee Co-chair). CMB: Royalties: Wolters Kluwer (B); Consulting: Harvard Clinical Research Institute (amount not disclosed), United Health Care (B); Board of Directors: North American Spine Society (1st Vice President); Other Office: JAAOS (B). ZG: Board of Directors: American Association of Neurological Surgeons, NeuroPoint Alliance (None), Congress of Neurological Surgeons (Vice President), Collaborative Spine Research Foundation (None), North American Spine Society (Clinical Research Development Chair); Research Support - Staff and/or Materials: Stuart Foundation (F, paid directly to institution/employer); Grants: NIH (A), PCORi (H, Paid directly to institution/employer). JG: Grants: SI Bone (D, Paid directly to institution/employer). CK: Stock Ownership: NOC2 (<1%); Consulting: Hospital Corporation of America (HCA) - TriStar Spine Physician Advisory Panel (amount not disclosed); Trips/Travel: SI Bone (amount not disclosed). DM: Consulting: First Consult (A); Trips/Travel: North American Spine Society (Travel expenses). DO: Nothing to disclose. JO: Royalties: Globus Medical (A), Pioneer Surgical (B); Consulting: Globus Medical (B), Pioneer Surgical (A). HP: Speaking and/or teaching arrangements: PM&R (Senior Editor for PM&R Journal, paid directly to institution/employer); Trips/Travel: North American Spine Society (Travel expenses, paid directly to institution/employer); Board of Directors: North American Spine Society (President). DR: Board of Directors: North American Spine Society (Secretary), CNS (Past President). JS: Nothing to disclose. MJS: Consulting: Inflexxion (A, paid directly to institution/employer). WS: Trips/Travel: North American Spine Society (Travel expenses). RT: Nothing to disclose. ET: Royalties: Stryker Spine (C); Stock Ownership: Doctor's Research Group (<1%); Private Investments: IP Evolutions (None); Board of Directors: North American Spine Society (Administration & Development Council Director); Other Office: AAOS Communications Cabinet (Travel expenses); Research Support - Investigator Salary: Relievant (B, Paid directly to institution/employer); Research Support - Staff and/or Materials: Globus (B, Paid directly to institution/employer); Relationships Outside the One-Year Requirement: Stryker Biotech (None). JW: Royalties: Stryker (A), Osprey (B), Aesculap (B), Biomet (G), Amedica (D), SeaSpine (D), Synthes (C); Stock Ownership: FzioMed (<1%), Alphatec (<1%); Private Investments: Promethean Spine (<1%), Paradigm spine (<1%), Benvenue (<1%), NexGen (<1%), Pioneer (<1%), Amedica (<1%), VertiFlex (<1%), ElectroCore (<1%), Surgitech (<1%), Axiomed (<1%), VG Innovations (<1%), CoreSpine (<1%), Expanding Orthopaedics (<1%), Syndicom (<1%), Osprey (<1%), Amedica (<1%), Bone Biologics (<1%), Curative Biosciences (<1%), PearlDiver (<1%); Board of Directors: North American Spine Society (Treasurer), Cervical Spine Research Society (Travel expenses), AOSpine/AO Foundation (E), Collaborative Spine Research Foundation (None); Fellowship Support: AO Foundation (E, Paid directly to institution/employer). WW: Royalties: Stryker Corporation (B); Board of Directors: North American Spine Society (Past President), World Spine Care (None), American College of Spine Surgeons (None); Other: The Spine Journal (Assistant Editor), Spine Arthroplasty Journal (Assistant Editor), Spine (None), Kirby Glenn Surgical Center (Financial, 1/22nd minority interest ownership). FTW: Stock Ownership: Relievant Medical (<1%); Board of Directors: McKenzie Institute International (B), North American Spine Society (2nd Vice President). GW: Speaking and/or Teaching Arrangements: North American Spine Society (A); Trips/Travel: North American Spine Society (Travel expenses). Funding Disclosure: No external funding was received for this project.
Publisher Copyright:
© 2021 Elsevier Inc.
PY - 2021/8
Y1 - 2021/8
N2 - BACKGROUND CONTEXT: Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE: The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN: A Modified Delphi process was used. METHODS: The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 – 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS: There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS: Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).
AB - BACKGROUND CONTEXT: Outcomes of treatment in care of patients with spinal disorders are directly related to patient selection and treatment indications. However, for many disorders, there is absence of consensus for precise indications. With the increasing emphasis on quality and value in spine care, it is essential that treatment recommendations and decisions are optimized. PURPOSE: The purpose of the North American Spine Society Appropriate Use Criteria was to determine the appropriate (ie reasonable) multidisciplinary treatment recommendations for patients with degenerative spondylolisthesis across a spectrum of more common clinical scenarios. STUDY DESIGN: A Modified Delphi process was used. METHODS: The methodology was based on the Appropriate Use Criteria development process established by the Research AND Development Corporation. The topic of degenerative spondylolisthesis was selected by the committee, key modifiers determined, and consensus reached on standard definitions. A literature search and evidence analysis were completed by one work group simultaneously as scenarios were written, reviewed, and finalized by another work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1 – 3), uncertain (4-6), or appropriate (7-9). Consensus was not mandatory. RESULTS: There were 131 discrete scenarios. These addressed questions on bone grafting, imaging, mechanical instability, radiculopathy with or without neurological deficits, obesity, and yellow flags consisting of psychosocial and medical comorbidities. For most of these, appropriateness was established for physical therapy, injections, and various forms of surgical intervention. The diagnosis of spondylolisthesis should be determined by an upright x-ray. Scenarios pertaining to bone grafting suggested that patients should quit smoking prior to surgery, and that use of BMP should be reserved for patients who had risk factors for non-union. Across all clinical scenarios, physical therapy (PT) had an adjusted mean of 7.66, epidural steroid injections 5.76, and surgery 4.52. Physical therapy was appropriate in most scenarios, and most appropriate in patients with back pain and no neurological deficits. Epidural steroid injections were most appropriate in patients with radiculopathy. Surgery was generally more appropriate for patients with neurological deficits, higher disability scores, and dynamic spondylolisthesis. Mechanical back pain and presence of yellow flags tended to be less appropriate, and obesity in general had relatively little influence on decision making. Decompression alone was more strongly considered in the presence of static versus dynamic spondylolisthesis. On average, posterior fusion with or without interbody fusion was similarly appropriate, and generally more appropriate than stand-alone interbody fusion which was in turn more appropriate than interspinous spacers. CONCLUSIONS: Multidisciplinary appropriate treatment criteria were generated based on the Research AND Development methodology. While there were consistent and significant differences between surgeons and non-surgeons, these differences were generally very small. This document provides comprehensive evidence-based recommendations for evaluation and treatment of degenerative spondylolisthesis. The document in its entirety will be found on the North American Spine Society website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).
KW - Appropriate use criteria
KW - Disability
KW - Epidural steroid injection
KW - Lumbar degenerative spondylolisthesis
KW - Mechanical back pain
KW - Neurological deficit
KW - Physical therapy
KW - Radiculopathy
KW - Yellow flags
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U2 - 10.1016/j.spinee.2021.03.005
DO - 10.1016/j.spinee.2021.03.005
M3 - Article
C2 - 33689838
AN - SCOPUS:85103730502
SN - 1529-9430
VL - 21
SP - 1256
EP - 1267
JO - Spine Journal
JF - Spine Journal
IS - 8
ER -