Nancy A. Melville

May 04, 2017

LOS ANGELES — The review of patients scheduled for lumbar spine surgery by a multidisciplinary team of specialists significantly alters decision making and in a large percentage of cases avoids unnecessary and costly surgeries, a new study shows.

"When nonsurgeons are empowered to make decisions, nearly 60% of patients who were recommended surgery were found to have nonsurgical options," first author, Vijay Yanamadala, MD, said in presenting the study here at the American Association of Neurological Surgeons (AANS) 2017 Annual Meeting.

With lumbar spine surgery increasing eight-fold over the past 30 years and a troubling number of randomized controlled trials showing overall outcomes to be no better than those seen with nonoperative care, centers are increasingly subjecting such cases to review by a broad range of specialists instead of just following the recommendation of a single surgeon, the researchers note.

At Virginia Mason Medical Center in Seattle, Washington, where Dr Yanamadala is a complex spine surgery fellow under Rajiv Sethi, MD, the multidisciplinary specialists can include anesthesiologists, pain specialists, rehabilitation specialists, neurosurgeons, orthopedic spine surgeons, physical and occupational therapists, and nursing staff.

"At Virginia Mason, for the past year and a half, we have reviewed every single proposed lumbar fusion surgery in a multidisciplinary conference," Dr Sethi told Medscape Medical News.

"A patient cannot undergo a lumbar fusion surgery at our center without the review, where an in-person multidisciplinary discussion has to take place and all providers are given a voice to say yes or no and ultimately given equal voting power to determine whether patients will undergo surgery."

To investigate the effect of the multidisciplinary review policy on surgical decisions, the authors evaluated 100 patients who had been recommended for spinal fusion by outside spine surgeons or had a complex history of prior spinal surgery.

They found that as many as 58% of cases that were originally recommended for surgery by the outside spine surgeon were instead recommended for nonsurgical approaches by the multidisciplinary review.

In addition, 16 (28%) patients had their surgical treatment plan revised. Of the surgeries that were performed, there were no 30- or 90-day complications and no 90-day readmissions.

Among leading factors for the decisions not to opt for surgery included misdiagnosis, contraindications (including morbid obesity and active smoking), and possible benefits from nonoperative intervention.

The study  was also published in January in the journal Spine.

"Such [review policies] lead to superior care, better patient satisfaction, and better outcomes, and I think this is going to be the future of care," Dr Yanamadala told Medscape Medical News.

"This is already done with tumor boards in oncology and we are now demonstrating its efficacy in the treatment of patients with degenerative spinal disorders as well."

Dr Yanamadala noted that at the crux of the issue is the potential complexity and clinical challenge of pain and spine diagnoses.

"Ultimately, I think surgeons are trying to do the right thing, and this isn't about better training or incentives," Dr Yanamadala said. "It's about the problem of isolated decision-making leading to suboptimal decisions and outcomes."

"One person may not be able to always pinpoint the correct diagnosis or come up with the correct treatment plan."

He cited a previous study  showing that a wide range of symptoms can appear to be associated with the lumbar spine.

"There are at least 20 or 30 diagnoses that can mimic a lumbar spine problem however will not be fixed with surgery," he said.

"As surgeons, we have to be very cognizant the wide range of differential diagnoses."

Compounding the challenge of pain typically being multifactorial is that the diagnostic tools available to clinicians, despite rapid advances, continue to be far from perfect, with another study  showing that up to 64% of magnetic resonance images fail to correlate with clinical findings.

"Many patients have very bad radiographic stenosis of the lumbar spine and the findings may not correlate with their symptoms.

"A multidisciplinary care paradigm can powerfully reduce complications and improve appropriate patient selection for operative and nonoperative care," Dr Yanamadala said.

While the review of challenging cases is commonplace in medicine, the model of multidisciplinary review of every lumbar spine surgery is intriguing — if not challenging, said Jason M. Schwalb, MD, surgical director of the Movement Disorder & Comprehensive Epilepsy Centers at Henry Ford Medical Group, in West Bloomfield, Michigan.

"I am very interested in their multidisciplinary model, but we are not utilizing that model that at our center," he told Medscape Medical News.

"We have a monthly conference that reviews difficult cases for which the staff submit cases for which they want to hear others' opinions, including orthopedics and pain medicine, but it is not every case."

"I am curious how long this takes given the huge volume of cases we see in our center."

Asked about this issue, Dr Sethi responded that their approach "takes dedicated infrastructure and staff to review all lumbar fusions in a multidisciplinary format.

"At Virginia Mason, all proposed simple lumbar fusions (one to three levels) are reviewed at a weekly conference on Tuesday mornings. Complex spine cases are reviewed at a separate conference on Friday mornings. Each case takes approximately 5 to 7 minutes," he explained.

"This effort requires additional resources for physicians from multiple specialties, nurses, physician assistants, spine fellows, and research staff to maintain and record the conference data."

The authors and Dr Schwalb have disclosed no relevant financial relationships.

American Association of Neurological Surgeons (AANS) 2017 Annual Meeting. Abstract 813. Presented April 25, 2017.

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