Designing evidence-based spine care
Dr. Kenneth Cohen, MD, FACP, Chief Medical Officer
New West Physicians
New West Physicians is one of the largest physician groups in Colorado and has grown to 18 offices located throughout the Denver metro area.
The Family Practice and Internal Medicine offices of New West Physicians are Patient Centered Medical Home (PCMH) certified Level 3, and all eligible providers are National Committee for Quality Assurance (NCQA) recognized for Heart/Stroke and Diabetes.
The highly-qualified group of board certified family practice and internal medicine physicians, hospitalists, cardiologist, gastroenterologist, psychiatrist, endocrinologist, neurologist, physician assistants and nurse practitioners are committed to providing excellent service to every patient … every time.
The current model of spine care is seriously flawed. It does not provide adequate clinical outcomes for a large portion of patients. Moreover, for most patients it is a “passive system” that does not actively engage them in their own rehabilitation to help assure long-term success.
Many of the services provided to patients with spine disorders do not have a high-quality evidence base to support the interventions being utilized including the following:
- Overreliance on MRI and subsequent invasive therapies including epidural steroid injections (ESI), facet injections, vertebroplasty and kyphoplasty.
- Overreliance on pharmacotherapy including opioids, muscle relaxants, tricyclic antidepressants and benzodiazepines.
- Overreliance on surgery, particularly lumbar fusion.
So what would a progressive model of spine care look like? We began building a new model in 1999 that has evolved over the past decades. It started with a philosophical underpinning grounded in evidence-based medicine.
First and foremost, it involved actively engaging patients in various rehabilitative modalities to move them away from the passive dependent model of care toward a model of active participation. The goals are to improve core strength and flexibility and reduce pain.
These programs begin with supervised physical therapy and then transition to maintenance therapy with a variety of modalities to choose from, including yoga, Pilates and strength training.
Other modalities with an evidence base to support their use include chiropractic care, mindfulness meditation, guided imagery and acupuncture.
Additionally, the program should include ergonomic adaptions at both work and home. For the subset of patients with chronic back pain, working with a pain psychologist is important as patients need to understand that they will not be completely free of pain.
It is pivotal to define the individual blocks preventing improvement, which may include depression, substance dependence, secondary gain, etc.
In this new model, there is a place for imaging, pharmacotherapy and procedures, but they are adjunctive and need to be chosen carefully to achieve benefit in the correct subset of patients.
With respect to pharmacotherapy, there is not a panacea. No therapy is markedly effective but some are modestly so.
Opioids have a very limited role, if any, in the management of chronic spine pain. There is no evidence to support improvement in outcomes and the problems with chronic opioid therapy are well-documented and often devastating.
The medications for which there are data to support use include nonsteroidal anti-inflammatories , duloxetine and possibly pregabalin and gapapentin, although recent studies have questioned whether there is any benefit to the use of pregabalin and should be explored further.
The data is conflicting, however short courses of glucocorticoids when used for flares of radicular pain are well-tolerated and may be of benefit.
Although there is no strong data to support the use of ESI, there is limited data supporting a benefit in the circumstance of acute severe radiculopathy due to disc herniation or extrusion of a disc fragment.
Well-done randomized trials have not shown a benefit in patients with spinal stenosis with or without radiculopathy.
However, we also will occasionally use ESI in the setting of degenerative disc disease with foraminal stenosis and radiculopathy to achieve short-term pain relief that will allow the initiation of a rehabilitation program.
Choosing which patients may benefit from spine surgery can be very difficult.
There is a sixfold variability in the per capita use of spine surgery across the country and the areas with the lowest utilization do not appear to have inferior outcomes when compared to the areas with the highest utilization.
As is seen with other specialties, the utilization of surgery is most closely correlated with the density of spine surgeons in a given region.
The evidence base supporting spine surgery is strongest for two conditions. These are acute lumbar disc herniation refractory to conservative therapy, and spinal stenosis refractory to conservative therapy, particularly in the setting of pseudo claudication due to spinal cord compression.
Many primary care providers do not feel they have the expertise to choose optimal surgical candidates. Given this conundrum, our spine program has enlisted the expertise of our physiatrists to help with decision making.
Because physiatrists are experts in the non-surgical management of spine disorders, they are uniquely qualified to not only guide the rehabilitation process, but also to help determine who may most likely benefit from surgery.
Therefore, in the absence of red flag signs and symptoms, when we are faced with patients who have not had an adequate response to rehabilitative modalities, our referrals go to physiatry and not spine surgery.
This not only affords patients additional expertise in non-invasive management, but also allows us to feel comfortable that physiatry will recommend a surgical evaluation when this is appropriate.
One could take the nihilistic position that truncating the use of drugs, procedures and surgery leaves little to use in treating this patient population. However, we are learning that too much care, particularly when it is the wrong care, is as dangerous as not enough care.
We have all seen the direct result of this in patients who have failed spine surgery and are worse off than they were preoperatively. Whereas the options for evidence-based therapies may be limited, this reality should not result in the use of non-evidence-based therapies.
Adoption of the above program will optimize the success in the long-term management of these patients while still allowing for the proper selection of the subset of patients who are likely to benefit from invasive management, including the use of ESI and surgery.
The views and opinions expressed herein are those of the authors and do not necessarily represent the views of OptumCare®. The views and opinions expressed may change without notice.