Affordable spine care.

Spine related disability secondary to disease or trauma but mostly because of – natural - degenerative changes, is a major societal burden world-wide. No country is spared, but the available financial resources for care and social support do vary dramatically: many people in the world have no other choice as to live with their back ailment. That is no fatality and shouldn't be so. Yet, those who are fortunate enough to have access to care are not out of trouble. In the rich countries, one has observed over the last three decades an exponential increase in spine care related costs. Surgical procedures have gained in numbers and complexity, but global outcome has not changed proportionally, at least regarding degenerative pathology that represents by far the biggest part of spinal pathology. The aging population remains often very active in advanced age and is confronted to the wearing out of joints and of the most complex one: the spine! While total joint replacement for the hip, knee, shoulder, is remarkably effective to restore a durable and almost normal and painless function, we are still far from achieving these excellent results for the spine. This, because of the complexity of the spine as an organ and the still limited knowledge of the pathophysiology of pain and aging.

Where do lie the costs in the advent and management of spine ailments?

Loss of income and productivity, financial support or compensation and dependence on external help induce the largest burden for the community in most cases.

Rehabilitation by conservative management is cheap, often effective and complication free. It is available almost anywhere and doesn't need much infrastructure. For common low back pain, there is grade A evidence proving benefits of physical activity and the adverse effect of prolonged bed rest and interruption of activity. Yet, this is not universally applied. Despite the lack of evidence of reliable effectiveness, surgery is often proposed before the completion of a cycle of conservative management. Obviously, conservative management cannot solve all problems, and this should also be recognized by all conservative care provider.

Despite getting better comprehension of the body and spine equilibrium, mechanism of collagen and cartilage aging, we are still far from understanding all mechanism of degeneration, and more relevant, the links between back pain and degeneration. The bio-psycho-social model dear to Wadell (1998), is often far more influent on the evolution of a given patient than his sagittal balance, Modic changes, disc degeneration characteristics or facet arthrosis. The correlation between back pain and the various degenerative phenotypes is weak. We have all seen normal-for-age back MRIs in patient with major pain and disability, and worrisome back X-rays, CT-scans and MRI from patients with … no significant complain. Fact is, there is still a long way to go before we fully understand the physiopathology of back pain and hence, become reliable in our prognosis of a favorable outcome of a planned surgical procedure.

Based on good clinical judgement, adapted to the individual patient, surgery is an integral part of the rehabilitation armamentarium. While immediate costs are high, without complications, rapid resumption of activities, functional restoration and independence will happen, resulting in a considerable reduction of indirect costs. If ever a complication occurs, direct costs will increase dramatically, because of lengthy hospital stay, eventual re-interventions, medications, prolonged rehabilitation, or lasting disability. All efforts should be taken to avoid them. The tools for allowing safer complex surgery involving implants, like navigation, per-operative 3D imaging, and robotic surgery are remarkable. Of course, all these fancy tools come with a huge cost, not only to acquire them, but also for their yearly maintenance. In countries where the fundamentals for health care are still scarce or even missing, this is simply out of reach.

But is this all necessary?

Implants are used in a lot of spinal conditions: deformity, trauma, infection, tumors, spondylolisthesis and degenerative pathology. The later involves the largest use of implant … with the lowest evidence for doing so! If surgery is considered for a degenerative case, the first question is whether implants are really needed for a successful outcome. The use of pedicular screws, significantly increases the incidence of complications, and need for reoperation, be it for infection, implant malposition or non-union. Of course, the risk of iatrogenic damage increases exponentially with the number of implants and the complexity of the procedure. In all spinal conditions where instrumentation is avoided, direct and indirect costs are considerably reduced.

What are the demonstrated indications for spinal fixation?

There is strong, A-grade evidence that severe spinal deformity in the growing patient is an absolute indication for instrumented fusion. The goals are well defined: stop progression, correct balance, and reduce deformity. The development of spinal implants initiated by Roy-Camille, Cotrel and Dubousset was a true game changer. Instrumentation allows a remarkable deformity correction in a few hours of surgery. Before that, scoliosis patients stayed for weeks if not months in hospital, lying in a plaster corset until fusion was obtained. Today, an adolescent operated for scoliosis will leave the hospital within three or four days, is immediately able to walk around without corset and will resume normal activities in a matter of months with a high rate of solid fusion. All this with a very low rate of complications. Unfortunately, a reliable, early medical treatment, addressing the still unknown cause of idiopathic scoliosis and preventing the need for bracing or surgery, is still not in sight.

Unstable fractures, with rupture of most stabilizing components, are clear indications for stabilization and reconstruction. Indications for major resection/reconstruction surgery in tumors are also quite clear, and fortunately very seldom. Active Infectious diseases or sequalae of these, like severe kyphosis in Pott's disease, may warrant surgical stabilization, with or without deformity correction. Though more common in less favored countries, these are not so frequent either.

The largest group by far of patients in need for spine surgery are those with a degenerative condition, ranging from the simple disc herniation to spinal stenosis, degenerative disc disease or degenerative deformity cases including scoliosis or spinal imbalance. Beside deformity correction, indications for instrumented fusion in degenerative cases are, to put it mildly, a matter of debate and certainly lack grade A evidence. Only very unstable spines do require fixation with some degree of certainty. In most cases the indication for instrumented fusion is a matter of surgeon's preference rather than an evidence-based decision. In a very common condition like degenerative spondylolisthesis, the odds of getting simple decompression versus decompression with instrumented fusion is mostly dependent by whom or where you are operated! Extensive register data from Sweden shows that in most cases, outcome is as good without fixation. These data have induced a significant, nation-wide reduction in fixations for this condition, with a tremendous reduction in direct and indirect costs. In the other side of the Atlantic Ocean, the trend is just opposite!

In most degenerative cases where instrumentation is needed -or optional-, landmarks are reliable. A simple per-operative lateral and in particular AP radiograph, allow to check the accuracy of screws position. Sophisticated imaging means and navigation have certainly a place in deformity or revision procedures or in difficult anatomic areas like the upper cervical and thoracic spine where implants, in particular screws, need to be placed in the vicinity of important but hidden structures like a vertebral artery, a nerve root, or the spinal cord.

Treat the patient, not the images

With the advent of accurate sagittal balance analysis, it becomes rather easy to define the ideal spinal shape of a given patient and hence, calculate the correction needed to restore a nice anatomical balance. But that is only part of the story. Beside the fact that realizing the calculated correction is not always that simple and sometimes even impossible, the planned procedure needs to fit the patient's status, expectations, and acceptance of the many unknowns. These includes a very high rate of surgical complications with the need of one or several revisions, uncertainty regarding pain relief and functional improvement and not to forget, all the general complications that can occur in these often, fragile patients. The European Spine Study Group, including quite outstanding surgeons, reported an overall complication rate of 71 major and 64 minor complications plus one death in a group of … 61 adult scoliosis patients. Nonetheless their outcome at 2 years was superior to that of a similar group treated conservatively (Carabulut, 2019) … The issue is to define who will benefit of degenerative deformity correction. In these difficult cases, sophisticated imaging means, and navigation have certainly a place. These patients should be addressed to surgical spine centers of excellence, recognized for their specific competence. Most spine patients can however be treated in standard settings.

The key for sustainable surgical spine care, anywhere in the world, for the rich and the poor, is first and foremost the appropriate indication for treatment, based on the available evidence and fitting the team capacities, surgical setting and, most importantly, the expectations of a well-informed patient.