Neurosurgical Updates 2016 Brain & Spine Symposium: Presented by: Mary L. Dombovy, MD, MHSA Paul K. Maurer, MD Anthony L. Petraglia, MD Patrick J. Reid, MD Matthew L. Dashnaw, MD, Pharm D M. Gordon Whitbeck, Jr., MD

Trends & Outcomes To Fuse or Not to Fuse Paul K. Maurer, MD Presented by Paul K. Maurer, MD Chief of Neurosurgery, Unity Hospital Rochester Regional Health

Not a Readily Quantifiable Issue Spinal degenerative disease is a very heterogeneous group of cases (age,weight,levels involved,ROS) entry group is variable with variable Nat Hx... FOCAL vs non-focal disease (difficult to quantify) How do we measure outcome (vs CABG data)... Are 13 different pain/function outcome scales (SF36, ODI etc etc) How accurate is a pain scale???? evidence based studies are inherently difficult variable entries, var NatHx and uncertain outcome criteria “garbage in....garbage out”

Role of Spine Surgery Data to date suggests there is clearly a role for spinal surgery BUT… Amongst this vast array of variable patients... Who will benefit from surgery (FOCAL vs non-focal) WHAT TYPE of surgery (fusion vs non fusion etc)

Fusion Rates by Surgeon 163 44 178 93 441

Spine Patient Outcomes (SPORT): Weinstein J et al...JAMA 2006 randomized cohort (HNP) to surgery or nonsurg at 6 wks of sxs (232surg...240nonsurg) “goal was to detect 10 point or > difference in SF36 and ODI bodily pain / function scales”..2yrs and 4yrs all had clear radiculopathy...all failed 6 weeks of prior conservative care (67% PT...42%ESI...32%chiro) 97% had MRI, 3% CT (?myeloCT)

SPORT HNP “…given the limited evidence regarding most non-oper. treatments, creating a specific non operative paradigm is not clinically feasible” Atlas et al “...there is limited evidence regarding most non-surgical treatments for lumbar HNP, stenosis and spondylolisthesis” Cochrane et al (Eur Spine J 2006): “...pooled analysis showed no significant difference in injection groups (corticosteroid vs saline) at 6 months”

Van Tulder et al (EurJSpine 2006) “. insuff Van Tulder et al (EurJSpine 2006) “..insuff. evidence to declare spinal injections effective or ineffective.” Outcomes (unlike CABG data): are 13 different pain/funtionality outcome scales (PPQ, QOL, DRI, SF36, Oswestry Dis Index etc etc)...SPORT used SF36 and ODI Resnick D et al (JNSurg 2005): “...outcome assessments are significantly limited in their accuracy and reliability”

SPORT Results Conclusion: “...patients treated surgically for HNP showed significantly greater improvement in pain, function, satisfaction and self rated progress over both 2 year and 4 year follow up compared to pts treated non-operatively” What to do first 6-8 weeks? How much is mech LBP vs radiculopathy? What type of surgery and what are surgeons results?

Spine April 2010: Fourney et.al. Review of 361 articles 1990-2010 Conclusion: “…showed less favorable results for MAS diskectomy…no defined difference between MAS and open lumbar fusion.” …”no evident difference in complication rates” INDUSTRY PUSH!

37 y/o with significant, daily, “unrelenting” LBP coupled with RLE sxs to calf with numbness in foot. Present and progressive x 12 months

52 y/o MD (PCP) with Hx 8 ws “really terrible” UE pain Sensory loss C8 ulnar, weak triceps at 3/5 No UMN release, no fasics MRI only DJD correl with age

Rare event that in 2010 has virtually NO true cost comparison data from institution to institution, from surgeon to surgeon etc etc What % does the surgeon fuse and why The curative fantasy…hip vs spine “one stop shopping” vs “one shop endless economic loss” ???

Bottom Line Surgery of the spine CAN be effective in PROPERLY selected pts... Hx... Focality... (who eval the pt?) Results are very dependent on pt selection Procedure should be least possible to “get the job done” Results (and costs) will vary from surgeon to surgeon Spine may not lend itself to crisp “protocol guidelines”