Abstract
PurposeManagement 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.MethodsUsing 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).ResultsAppropriateness 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.ConclusionsUsing 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.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.
Highlights
Spinal decompression and spinal fusion are frequently performed surgical procedures in patients with back and/or leg pain due to degenerative lumbar spine disease
Unsatisfactory results after spinal surgery are often referred to as “failed back surgery syndrome” (FBSS), but this term has been criticised because it unilaterally puts the blame on the operation as the cause of the problem, while the aetiology is much more complex and often multifactorial [6,7,8,9]
Inappropriate indications were seen for neurostimulation (15%) and re-operation (37%)
Summary
Spinal decompression (including removal of herniated discs) and spinal fusion are frequently performed surgical procedures in patients with back and/or leg pain due to degenerative lumbar spine disease. In the UK, the frequency of this type of surgery increased from 25 to 49 per 100,000 in the population over the period 1999–2013 [1]. In the USA, the surgery rate is considerably higher (135 per 100,000 in 2013), but does not show a further increase [2]. There is a considerable proportion of patients who experience recurrent or remaining pain following initial spine surgery, ranging from 3 to 34% at follow-up between 6 and 24 months after surgery, and 5 to 36% upon long-term evaluation (> 2 years) [3, 4]. A recent populationbased cohort study in England reported that over the period 2007–2012 on average 20.8% of lumbar surgery patients experienced persistent post-operative pain [5]. Unsatisfactory results after spinal surgery are often referred to as “failed back surgery syndrome” (FBSS), but this term has been criticised because it unilaterally puts the blame on the operation as the cause of the problem, while the aetiology is much more complex and often multifactorial [6,7,8,9]
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