Volker M Tronnier1, Sam Eldabe2, Jörg Franke3, Frank Huygen4, Philippe Rigoard5,6, Javier de Andres Ares7, Richard Assaker8, Alejandro Gomez-Rice9, Marco La Grua10, Maarten Moens11, Lieven Moke12,13, Christophe Perruchoud14, Nasir A Quraishi15, Dominique A Rothenfluh16, Pedram Tabatabaei17, Koen Van Boxem18, Carmen Vleggeert-Lankamp19, Björn Zoëga20, Herman J Stoevelaar21. 1. Department of Neurosurgery, University Hospital Schleswig-Holstein, Lübeck, Germany. 2. Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK. 3. Department of Orthopedics, Klinikum Magdeburg, Magdeburg, Germany. 4. Department of Anesthesiology and Pain Management, Erasmus University Medical Center, Rotterdam, The Netherlands. 5. Neurosurgical Department, University Hospital Poitiers, Poitiers, France. 6. CNRS, UPR 3346, Futuroscope, Poitiers, France. 7. Pain Unit, Department of Anaesthetics, University Hospital La Paz, Madrid, Spain. 8. Department of Neurosurgery, University Hospital Lille, Lille, France. 9. Spine Unit, University Hospital Getafe, Madrid, Spain. 10. Multidisciplinary Spine Center, Santa Maria Maddalena Hospital, Occhiobello, Italy. 11. Department of Neurosurgery, University Hospital Brussels, Brussels, Belgium. 12. Department of Development and Regeneration KU Leuven, Institute for Orthopaedic Research and Training (IORT) KU Leuven, Leuven, Belgium. 13. Division of Orthopaedics, University Hospitals Leuven, Leuven, Belgium. 14. Clinique de la Douleur, Hôpital de la Tour, Geneva, Switzerland. 15. Centre for Spine Studies & Surgery, Queen's Medical Centre, Nottingham, UK. 16. Division of Spinal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. 17. University of Umeå, Umeå, Sweden. 18. Department of Anaesthesiology, Intensive Care and Pain Management, Hospital Oost-Limburg, Genk, Belgium. 19. Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands. 20. Stockholm Spine Center, Stockholm, Sweden. 21. Centre for Decision Analysis and Support, Ismar Healthcare, Oudewater, The Netherlands. herman.stoevelaar@ismar.com.
Abstract
PURPOSE: Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS. METHODS: Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1-3 and 7-9). RESULTS: Appropriateness outcomes showed clear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability. CONCLUSIONS: Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. These slides can be retrieved under Electronic Supplementary Material.
PURPOSE: Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS. METHODS: Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1-3 and 7-9). RESULTS: Appropriateness outcomes showed clear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability. CONCLUSIONS: Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. These slides can be retrieved under Electronic Supplementary Material.
Entities:
Keywords:
Consensus; Failed back surgery syndrome; Neurostimulation; RAND/UCLA Appropriateness Method; Spinal surgery
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