The North American Spine Society (NASS) held its 29th Annual Meeting at San Francisco’s Moscone Center, Nov. 11–15, 2014. Program chairs Charles A. Reitman, MD and Michael Reed, DPT, OCS, and the Program committee assembled an excellent program mixing reports on surgical and nonsurgical spine care with the latest research, along with symposia and debates.
NASS President William C. Watters III, MD, of Houston, delivered a powerful personal address on the two sides to the physician-provider relationship. Noting that most caregivers will find themselves on the patient side eventually, Dr. Watters explored the issue using his own care after sustaining an arrhythmia and sudden cardiac death. He was the first patient in the Texas Heart Institute’s hypothermia registry and experienced an excellent outcome.
Dr. Watters highlighted the importance of evidence-driven, ethical decision making. That includes knowing “what works best.” In spine care, and arguably in the broad area of orthopaedics, patient outcomes may hinge on factors beyond the provider’s control, such as the patient’s desire to return to work.
The presidential guest speaker, John Craig Venter, PhD, founder and CEO of the J. Craig Venter Institute, was a key figure in the race to decode the human genome and in the creation of the first artificial life forms. Dr. Venter is also founder and CEO of Synthetic Genomics, a company that seeks to commercialize genomic solutions to various problems. His talk offered an overview of some of the future directions health care might take as the ability to understand the genetic influence on disease and, increasingly, to modify those influences expands. For example, one project seeks to re-engineer the pig genome to allow porcine organs to be used safely in human transplantation.
At the end of the meeting, Heidi Prather, DO, director of the Orthopaedic Spine Center at Washington University in St. Louis, became the first female president of NASS. Her goals for the year include partnering with industry to collaborate on true innovation in spine care.
Several significant papers were presented during the meeting, including The Spine Journal’s Outstanding Paper Awards. In surgical science, Lindsay Tetreault, representing AO Spine, presented a clinical prediction model for outcomes of surgery in cervical spondylotic myelopathy. Previously, a similar study had been undertaken among various North American sites. The ability for the parameters to predict outcomes was then confirmed using a cohort of patients from international facilities on four continents. In all settings, baseline modified Japanese Orthopaedic Association score, smoking status, and impaired gait were important predictors of outcomes.
Murat Pekmezci, MD, an associate professor at the University of California, San Francisco, studied the use of cervical spine clearance protocols at trauma centers in California. He reported that 63 percent of level I, II, and III trauma centers had written protocols. Most of these centers (83 percent of level I and 61 percent of level II centers) used NEXUS (National Emergency X-Radiography Utilization Study) criteria. Dr. Pekmezci recommended standardization and utilization of these protocols.
In basic science, Samantha A. Rodrigues, BE, of the University of Auckland, New Zealand, presented a structural study of the annulus-endplate anchorage system and mechanisms of failure. Using ovine motion segments, loading experiments to induce failure followed by close microscopic analysis of that failure found that the anchorage system was more vulnerable in axial loading due to acute fiber bending.
Several studies—many combining data from previous studies—focused on outcomes after cervical disk arthroplasty (CDA). Generally, good results were reported with both one- and two-level procedures, as were favorable cost utility metrics and, perhaps, lower rates of revision and adjacent-level surgeries. For example, Reginald J. Davis, MD, FACS; Hyun W. Bae, MD; and colleagues reported on the 5-year outcomes of two-level CDA. They reported that patients with CDA had lower additional surgery rates as well as improved neck disability index and visual analog pain scores when compared with patients who had two-level anterior cervical fusion procedures.
Adult spinal deformity
Several of the best studies examined the surgical and nonsurgical management of adult spinal deformity (ASD). Among these were three podium presentations from the International Spine Study Group. The first, a cohort analysis comparing surgery with continued nonsurgical treatment for ASD patients, found that surgical patients demonstrated significant improvements in health-related quality of life at minimum of 2 years. At best, those patients who continued nonsurgical treatments remained the same.
The second study reported that residual deformity, postsurgical complications, baseline depression, and baseline body mass index were among factors predicting worse outcomes after surgery. Finally, the third study found that lower levels of baseline disability and smaller deformities were predictive of better results with nonsurgical management.
In a study from Baron S. Lonner, MD; Yuan Ren, PhD, MSc; and colleagues, 95 percent of a 38-patient cohort of adolescents and young adults who underwent scoliosis surgery were able to return to presurgical levels of athletic participation.
Over the last few years, increased attention has been paid to the timing of surgery in patients with traumatic spinal cord injury. A Canadian cohort of 946 patients, reported by Carly S. Rivers, PhD, MSc, BS, found that, in patients with American Spinal Iinjury Association class B, C, and D injuries, surgery within 24 hours was associated with more favorable outcomes. Other trauma papers emphasized the importance of blood pressure maintenance before the patient reaches the operating room.
An Austrian group assessed the impact of vancomycin powder application to spine wounds. They reported a dose-dependent inhibition of cell migration, proliferation, and viability. The authors cautioned against high doses of intrawound vancomycin.
The impact of diphosphonates on successful incorporation of a lumbar fusion in osteoporotic patients was also examined. Zhehao Dai, PhD, from Xiangya Hospital in Changsha, China, reported similar fusion rates in a cohort of 79 patients randomized to receive either zoledronic acid or saline. There were no vertebral compression fractures (VCF) during the 12-month follow-up period in the diphosphonate group, but six VCF occurred in the saline control group.
At least two papers focused on outcomes of laminectomy compared with interspinous process device placement in patients with lumbar stenosis. Both concluded that laminectomy yielded superior outcomes.
NASS’s advocacy efforts, under the able leadership of John G. Finkenberg, MD, brought “Meet the Press” host Chuck Todd to San Francisco for a question-and-answer session and reception focusing on the impact of the midterm elections on the Affordable Care Act. NASS shares virtually all major advocacy issues with other orthopaedic organizations such as the AAOS. During advocacy updates, speakers highlighted the NASS mission of patient care, which continues to be challenged by changes in the health delivery system.
Preservation of access to quality specialty care will require direct physician and patient involvement. Increasingly, this involvement will require all orthopaedic surgeons to learn the language of healthcare delivery, which is distinct from the language of medicine. Economic modeling, cost-utility, and similar measures have recently entered the medical lexicon, much as patient-centered outcomes measures did a decade ago. Increasingly, physicians are also learning about complex systems of care integration.
NASS recently updated its Guideline on Lumbar Degenerative Spondylolisthesis and Stenosis, originally released in 2008. As part of a multisociety task force, David F. Fardon, MD, and colleagues reported on updated degenerative lumbar spine nomenclature. The first version was widely accepted and, in an increasingly multidisciplinary care model, speaking a common language is critical.
A new spine registry
Key to preservation of access to specialty care is the accumulation of data supporting the quality and utility of that care, so the introduction of a pilot phase for a new spine registry is important. Because NASS seeks to support spine care from a multidisciplinary perspective, its registry can not simply follow the outcomes of selected surgical interventions. Instead, it captures demographic and patient-reported outcomes data using a diagnosis focus. Patients treated with injections, physical therapy, or other modalities can be included. As various orthopaedic specialties face similar challenges, increasing coordination with and learning from the AAOS and other specialty groups that have gone through the same processes saves societies from each re-inventing the wheel.
The significance of registry data was underscored by one of the best papers presented, a Swedish Spine Study Group report on surgical outcomes, based on data from a large registry study. The data were presented as a means of benchmarking individual outcomes. Interestingly, the patients who underwent lumbar spinal fusion for spondylolisthesis had similar, favorable outcomes to those who had fusion for degenerative disk disease.
A report from Case Western University in Cleveland used data on more than 2,000 patients from the Ohio Bureau of Worker’s Compensation to assess the risk of failed spine surgery. They reported that the failure rate for spine surgery performed for degenerative disk disease patients, at more than 11 percent, was statistically significantly higher than the rate for surgery performed for spondylolisthesis (8 percent).
Papers examining follow-up issues were also presented. Scott L. Parker, MD, and his coworkers from Vanderbilt found that younger patient age was a predictor of loss to long-term follow-up. He suggested that future work include methods to better engage with younger patients, such as email reminders.
Another interesting study, presented by Richard L. Skolasky Jr, ScD, concerned the impact of patient activation on reported outcomes in spine care. Here, patient activation was described as the “motivation, knowledge, skills, and confidence to act” as patients navigate a healthcare system that requires them to “communicate preferences and concerns and be active managers of care.” In a separate study, the same group found that a brief intervention was able to significantly increase active patient participation.
North American Spine Foundation
Finally, the North American Spine Foundation (NASF) was introduced. NASS, as most specialty societies, has a bit of an inward-facing focus. It seeks donations, research funding, and volunteers from spine care providers and the spine industry. The NASF seeks to engage a broader swath of the public, industry, and foundations that are not currently involved in spine care. Based on data from the Bill and Melinda Gates Foundation, spinal afflictions are the number one cause of disability worldwide, frequently leading to poverty in the families affected.
“By inspiring and funding research that reveals innovative ways to prevent spine-related disability, through efforts to educate and build global awareness, and with a collective voice on policy issues, the North American Spine Foundation will benefit us all,” said Executive Director Michael L. Reed, DPT, OCS.
Eeric Truumees, MD, is the AAOS Now editor-in-chief designee, a spine surgeon at Seton Spine and Scoliosis, Austin, Texas, and director of the NASS administration & development council.
- NASS Annual Meeting
- NASS Best Paper: Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity
- NASS Outstanting Paper Awards
- NASS Best Paper: Sensitivity of MRI in the Diagnosis of L4-L5 Degenerative Spondylolisthesis
- NASS Value Abstract Award: Improving Surgical Spine Outcomes through a Targeted Postoperative Rehabilitation Approach