The Spine Journal Resources
Commentary from Chris Bono, MD; Editor in Chief, The Spine Journal
COVID-19 is making us rethink how we do things; Reflecting back on some published TSJ
articles that might be relevant, or at least thought-provoking, during these crazy times.
- Reliability of smartphone-based teleradiology for evaluating thoracolumbar spine fractures: How far things have come! Look at this 2017 article about sending video clips of CTs via text for TL fractures. Now, most can access images (and notes, labs, etc, on their smartphone via EMR apps)—all make remote work easier during lock down.
- Effectiveness of telehealth-based interventions in the management of non-specific low back pain: a systematic review with meta-analysis: Another 2017 article—examining telehealth for LBP—described as “potential alternative”. Now it is a common, everyday occurrence. MGH calls them “virtual visits”—book them just like a regular office visit—quickly becoming a go-to for those who can’t/don’t want to come into the hospital. Dario et found “moderate-quality evidence”—bet there won’t be much question of its use now.
- —An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy
—Increasing reoperation rates and inferior outcome with prolonged symptom duration in lumbar disc herniation surgery — a prospective cohort study
—The effect of waiting time on pain intensity after elective surgical lumbar discectomy
Who knew this body of literature would be useful during the COVID crisis? Does timing matter for disc herniations—take a look at these 3 TSJ articles—the NASS Guideline reviewed the world’s literature at that time, cites the SPORT post-hoc analysis (among others) finding better outcomes with discectomy w/ <6 months symptom duration; Canadian group (Quon et al) found worse outcomes with waits >12 weeks---important data from a system that favors triaging; this past year, Støttrup et al (2019) found delayed surgery leads to worse outcomes AND more complications (adhesions?—dural tears).
- —Early versus late surgery of thoracic spine fractures in multiple injured patients: is early stabilization always recommendable?
—A review of surgical intervention in the setting of traumatic central cord syndrome
TL fractures—getting into the weeds of triaging—can be relevant with reduced # of trauma rooms available—Konieczny et al (2015) found there may be such a thing as “too early” for some patients—found somewhat higher mortality rate w/ surgery <72h compared to >72h—preop Hb<10 associated w/ 67% mortality rate; Steven et al (2010) found that pts w/ central cord who had surgery during initial admission or w/in 24h had fewer complications, lower mortality (trend, not significant)—no difference in complication rate op vs nonop—though debate on this topic still goes on, in resource strained system, important data to consider.
- —Surgeon equipoise as an inclusion criterion for the evaluation of nonoperative versus operative treatment of thoracolumbar spinal injuries
—Development of a machine learning algorithm for prediction of failure of nonoperative management in spinal epidural abscess
Stadhouder et al (2008), in collaboration with TLICS champion Alex Vaccaro, found substantial percentage of patients with TL fractures had disagreement on treatment (op vs nonop)—thus equipoise. While analysis was done to help a future RCT on the topic, it highlights something important—if there is equipoise, meaning that either op or nonop can lead to equivalent outcomes---if someone doesn’t really “need” surgery during the crisis, maybe nonop treatment is best, helps conserve resources—for TL burst fractures, Wood et al (JBJS, 2015), certainly supports this; same idea, Shah et al’s recent paper (2019) using machine learning to predict failure of nonop Tx for epidural abscess—could help streamline those in high risk for failure to early surgery, leave others w/ better chance with nonop care.
- The usefulness of a mobile device-based system for patient-reported outcomes in a spine outpatient clinic: Kim et al (2016) published an early report on using mobile devices (smartphones, iPads) to collect PROMS—done widely in the US at this time. With fewer patients coming into the clinics/offices for routine follow-ups, we will rely more on these online methods for patients to report how they’re doing at home—maybe this can help maintain our spine registries/databases/studies during these struggling times.
- Virtual reality-based simulators for spine surgery: a systematic review: Collateral damage during COVID crisis—resident education—we’re all having to get creative—live webinar lectures has helped—but what about surgical experience? Our residents are limited to emergent/urgent cases, and left to be scrubbed by the skeleton crew allowed to be in the hospital—what about elective surgical experience—study by Pfandler et al (2017) describes how virtual reality (VR) can be used to simulate procedures—maybe a great way, along with any other computer-based simulator, to continue full breadth of surgical technical education while we try to contain the virus.
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