Gode indikasjoner (appropriateness criteria) for operasjon av degenerativ spondylolistese

Transkript

1 1 Gode indikasjoner (appropriateness criteria) for operasjon av degenerativ spondylolistese Konsensus fra en tverrfaglig internasjonal studie basert på gjennomgang av 744 fiktive pasientkasuistikker Jens Ivar Brox, Ryggseksjonen-Rikshospitalet, Ortopedisk avdeling, OUS

2 Surgery for Lumbar Degenerative Spondylolisthesis (LDS) An Appropriateness Study Porchet F, Pittet V, Becker HJ, Steiger F, Vader JP, Mannion AF, ZASS Group: Balagué F, Brox JI, Cedraschi C, Fairbank J, Fekete T, Fritzell P, Jeszenszky D, Lurie J, Pellisé F, Reitmann C, Sonntag V, Standaert C, Szpalski M

3 Disclosure There are no conflicts of interest. The authors have no financial or personal relationships that inappropriately influence their actions. 3

4 Degenerative spondylolisthesis without pars defect Isthmic spondylolisthesis with pars defect 4Ortopedisk avdeling

5 Appropriateness A procedure is appropriate if the medical benefit exceeds the medical risks by a sufficiently wide margin that the procedure is worth performing Benefit Risk 5

6 To fuse or not to fuse? that is the question 6

7 Appropriateness of Surgery for Lumbar Degenerative Spondylolisthesis (LDS) Procedures evaluated: Decompression only Decompression with fusion Instrumented fusion 7

8 RAND Appropriateness Method UCLA / Santa Monica International multidisciplinary expert panel (12 panellists) An extensive systematic literature review was provided Matrix of scenarios of all potential indications for surgery for LDS was created Initial evaluation done separately by each expert Inappropriate Equivocal Appropriate Panel meeting Appropriateness criteria 8

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10 Hva er instabilitet ved degenerativ spondylolistese? I denne studien er instabilitet ikke definert Klassifisering i instabilt/stabilt er derfor en teoretisk antakelse med mange svakheter Begrepet instabilitet blir ofte brukt i ortopedien og enda mer i paramedisinske fag uten at det er klart definert.

11 A stable spine in an unstable mind ( Fritt etter Spinoza) 11

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13 RAND Appropriateness Method UCLA / Santa Monica Panel meeting New evaluation of appropriateness criteria Inappropriate Equivocal Appropriate - Final consensus 13

14 Results: Appropriateness of Surgery in all 744 Scenarios Only 7% of scenarios had frank disagreement 14

15 Results: Appropriateness for a surgical procedure 15

16 Results: Surgeons vs Physiatrist/Rheumatologists 16

17 Results: Psychosocial yellow flags Appropriateness of surgery (especially instrumented fusion) was markedly reduced for all categories when psychosocial yellow flags were present. Surgery with flags Surgery without flags 17

18 Results: Example of appropriateness of using a surgical procedure (in the absence of yellow flags) Patients with lumbar degenerative spondylolisthesis (LDS) with back pain, with instability and: 1.Neurogenic claudication with stenosis (central/foraminal), + moderate/severe disability OR 2. Radicular pain with major neurological abnormality, + stenosis (central/foraminal), + moderate comorbidity, + moderate/severe disability 18

19 Patient 47-year old healthy woman, moderate back pain, sciatica of the left L5 root, weakness of toe extension and ankle dorsiflexion left side sensory disturbance left side L5 currently working as a nurse aid, 19

20 Patient X-rays - severe disc degeneration L4/L5 and L5/S1 - facet joint degeneration - degenerative spondylolisthesis grade I, L3/L4 MRI - root canal stenosis L4/L5 and L5/S1 20

21 Er det god indikasjon for kirurgi? 21

22 Future of Appropriateness Criteria? - Criteria to be validated: Hypothesis: If treatment in accordance with appropriateness criteria better results! - Retrospective Study - Prospective Study 22

23 Implikasjoner Etter å ha blitt enige om gode indikasjoner (appropriateness criteria) Kan pasienter i en fremtidig studie randomiseres til behandling etter vanlig praksis eller appropriateness criteria Vil bruk av slike kriterier bedre kvaliteten på behandlingen? Vil flere eller færre pasienter bli operert?

24 Thank you! 24