Vertebral Columns International Society for the Advancement of Spine Surgery
ISASS20
Summer 2019
February 26-28, 2020 San Juan, Puerto Rico
San Juan, Puerto Rico, Home of ISASS2020. Credit: Lorie Shaull. Cover by Calle Fortleza.
In This Issue EDITORIAL Medicare and Specialty Surgery............................................................. 3 NEW TECHNOLOGIES Precision Medicine In Spine Surgery: How Machine Learning and Artificial Intelligence May Change the Practice of Spine Surgery..........4 MIS Maximizing Lordosis with MIS TLIF Part 2: Cage Selection and Placement...............................................................................................6
Editor in Chief Kern Singh Editorial Board Peter Derman, MD, MBA Brandon Hirsch, MD Sravisht Iyer, MD Safdar Khan, MD Yu-Po Lee, MD Grant Shifflett,MD Sheeraz Qureshi, MD Publisher Jonny Dover
PRACTICE Digital Media in Spine Surgery Practice Marketing...............................8 PEDIATRIC SPINE Back Pain in Children and Adolescents.................................................11 PAIN Complex Regional Pain Syndrome....................................................... 14
Vertebral Columns is published quarterly by the International Society for the Advancement of Spine Surgery. © 2019 ISASS. All rights reserved. Opinions of authors and editors do not necessarily reflect positions taken by the Society. This publication is available digitally at http://vertebralcolumns.com. ISSN 2414-6277.
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EDITORIAL
Medicare and Specialty Surgery Kern Singh, MD “Medicare For All,” a term coined by Senator Bernie Sanders, has come to the forefront of political focus in recent years. Regarding the current state of health care insurance, American citizens have a range of options from private insurance to government subsidized Medicare. Although approximately 130 million Americans are covered under a private health care plan, the push for universal health care has never been stronger. Medicare is a federally funded program eligible for citizens aged 65+ and/or with disabilities. Currently covering more than 60 million individuals, Medicare is comprised of four main parts that allow different aspects of healthcare coverage. While Medicare spending was estimated at $590 billion in 2017, government spending on healthcare could reach $1.2 trillion by 2027 due to the rapid increase in the senior population. Projected universal healthcare costs range from $1.4 trillion to $2.5 trillion annually into the future. This would require budget cuts on essential hospital and staff services resulting a reduced quality of care Wait times for surgery and clinical care play an important role especially in the treatment of those requiring immediate care. Currently, a major advantage of private insurance is the ability to see a specialty provider without obtaining a referral. Under Medi-
care for All, an additional specialty service will require a referral from a primary care provider. An influx of citizens having to complete this extra step would cause longer wait times, especially in the wake of the projected physician shortage. The current system of universal healthcare implemented in Great Britain sees four million people awaiting hospitalization or surgical services annually. The Canadian government utilizes a similar system that prioritizes patient necessity when determining who has access to certain services. This limits the amount of elective surgeries performed each year thus making the weight time for surgery longer. While the wait times for government funded Veterans Affairs (VA) services has decreased in the recent years, this has been a result of extensive efforts – which would not be immediately feasible if a universal system was implemented. Additional decline in care quality would be seen in the availability of technology. Replacing the free-market for technological advancements in healthcare for a universal system would slow the current wave of innovation, reducing the need for research funding. Universal Health Care could lead to a 16% decline in hospital revenue, amounting to approximately $150 billion in losses. This could lead to less direct access to diagnostic services. Assuming a cut in spending from a universal healthcare system, United States hospitals could see a reduction in the amount of available magnetic resonance imaging
(MRI) devices. Currently, 38.1 MRI devices exist per million citizens compared to the Canadian and Britain MRI count at 7.2 and 8.9 respectively. This reduced access to accurate imaging could increase the number of misdiagnoses and inappropriate procedures. Converting healthcare into a bureaucratic institution would have repercussions. Universal healthcare would eliminate the free-market competition among primary and specialty physicians alike, thus eradicating competition and the impetus to provide top quality care. Patient neglect could work its way into the system causing issues seen in VA services. Over a twenty year span, unprocessed records and neglect from VA staff were associate with 310,000 veteran deaths due to not abiding to set procedures and policies. Training quality would be affected through less funding for residency programs, causing fewer competent physicians in practice. Large private practices would have to adjust to less financial reimbursement from the government causing restricted access to essential medical services. If implemented, Medicare for All would negatively alter the current system of healthcare. This system would yield substandard care quality regarding access to a provider, hospital funding, and diagnostic accuracy. While just a prediction, a universal healthcare system would show negative results in obtaining quick and sufficient patient treatment. Vertebral Columns • Summer 2019
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NEW TECHNOLOGIES
Precision Medicine In Spine Surgery: How Machine Learning and Artificial Intelligence May Change the Practice of Spine Surgery Sravisht Iyer, MD How do you get two spine surgeons to disagree? Quite simple: show them an MRI and ask for a treatment plan. “Why did you fuse that?” “Definitely not safe to go lateral there.” “I don’t believe in stand-alone.” “You can get by with indirect decompression.” “You operated on that?!” Healthy disagreement, after all, is at the foundation of every spine conference. In many ways, the difficulty in choosing an optimal treatment plan represents an embarrassment of riches; the growth in implant technology, minimally invasive techniques and intraoperative assistance (navigation, robotics, etc.) has resulted in a tremendous increase in the permutations available to treat every problem. And yet… If a patients’ first opinion is a T10-pelvis fusion and their second opinion is a micro decompression, can you really blame them for being confused about the best next step? The patient, of course, is seeking the underlying truth: a “best” answer for their life and circumstances. And undeniably, there exists a “best” answer for every patient. 4
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The difficulty lies in arriving at that answer. This variability in decision making has been well reported in the literature.1–3 It can have a tremendous impact on the cost of care4 and potentially compromise outcomes or require a revision. In an era of value-driven care, it represents an attractive target for improvement; arriving at a uniform treatment plan will allow us to deliver consistent, reproducible outcomes to our patients. While this goal might have seemed quixotic in the past, advances in artificial intelligence coupled with an increased appreciation of Precision Medicine suggest that it may be attainable in the not-too-distant future. In the 2015 State of the Union Address, President Obama announced the launch of the Precision Medicine Initiative. This initiative encouraged providers to develop treatment plans based on each patients’ unique lifestyle and environmental profile. The promise of this new approach has been immediately apparent in the field of pharmacogenomics and cancer chemotherapy; in this setting, molecular and genetic testing are now routinely used to select medications tailored to each tumor’s genetic profile. The implications of this “new” approach to medicine,
however, is less obvious in surgical subspecialties. However, the growth of large health registries, patient databases, the electronic medical record and improvements in machine learning are paving the way for “Precision Spine Surgery.” Machine learning techniques are increasingly being utilized to predict patient disposition and the risk of complications.5,6 The use of machine learning techniques allows researchers to create predictive risk models that considers a huge number of clinical inputs; beyond what would be reasonable for any single clinician to review. Similar techniques are also being used to help predict the likelihood of surgical success, allowing patients to make a truly informed decision regarding surgery. These techniques, however, offer far more promise than risk stratification. Adult spinal deformity offers a prominent use-case. In the past few decades, our understanding of spinal balance has grown from a simple concept (SVA), to something much more nuanced; surgeons now consider pelvic incidence, lumbar lordosis, compensatory mechanisms, PILL and patient age among a bevy of other important radiographic parameters. While these factors are already complex (it is why we need a refresher on adult deformity
parameters at every conference), they still do not consider a number of important factors: muscle quality, patient activity levels, gait, presence of other musculoskeletal discrepancies, etc. Fortunately, machine learning algorithms will soon be able to account for these and other relevant variables to suggest optimal surgical alignment targets.7
These techniques, however, offer far more promise than just risk stratification. There are similarly exciting opportunities for degenerative pathology. The rapid improvement in image recognition recently led to the FDA approval of the first AI device to detect diabetic retinopathy.8 In spine surgery applications, similar techniques have been applied to accurately and reliably segment the spine and identify relevant anatomic structures.9 As these techniques evolve, we will soon have the ability to pair imaging data with registry and EHR data. Doing so would allow us to create deep clinical phenotypes, allowing us to classify patients not simply by diagnosis (degenerative spondylolisthesis, scoliosis, etc.) but by a huge number of clinical, imaging and demographic variables shown to impact outcomes. Sorting patients into these phenotypic categories would, in turn, allow for much more informed risk prediction and treatment selection. Those questions in conferences would no longer be simply academic but defensible by data: “Why Not Fuse?” The model predicted an 88% chance of success for decompression alone.
References 1. Deyo RA, Mirza SK. Trends and Variations in the Use of Spine Surgery. Clin Orthop Relat Res 2006;443:139–46. 2. Lubelski D, Williams SK, O’Rourke C, et al. Differences in the Surgical Treatment of Lower Back Pain Among Spine Surgeons in the United States. Spine (Phila Pa 1976) 2016;41:978–86. 3. Irwin ZN, Hilibrand A, Gustavel M, et al. Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine. Spine (Phila Pa 1976) 2005;30:2208–13. 4. Alvin MD, Lubelski D, Alam R, et al. Spine Surgeon Treatment Variability: The Impact on Costs. Glob spine J 2018;8:498–506. 5. Ogink PT, Karhade A V., Thio QCBS, et al. Development of a machine learning algorithm predicting discharge placement after surgery for spondylolisthesis. Eur Spine J. Epub ahead of print March 27, 2019. DOI: 10.1007/s00586019-05936-z. 6. Merali ZG, Witiw CD, Badhiwala JH, et al. Using a machine learning approach to predict outcome after surgery for degenerative cervical myelopathy. PLoS One 2019;14:e0215133. 7. Lafage R, Pesenti S, Lafage V, et al. Self-learning computers for surgical planning and prediction of postoperative alignment. Eur Spine J 2018;27:123–8. 8. Ting DSW, Cheung CY-L, Lim G, et al. Development and Validation of a Deep Learning System for Diabetic Retinopathy and Related Eye Diseases Using Retinal Images From Multiethnic Populations With Diabetes. JAMA 2017;318:2211. 9. Ji X, Zheng G, Liu L, et al. Fully Automatic Localization and Segmentation of Intervertebral Disc from 3D Multi-modality MR Images by Regression Forest and CNN. 92–101.
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MIS
Maximizing Lordosis with Minimally Invasive TLIF, Part 2: Cage Selection and Placement Peter Derman, MD, MBA This is the second installment in a two-part series focused on techniques for maximizing lordosis with minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). The first part, published in the Spring 2019 edition of Vertebral Columns, discussed pre-operative patient optimization, intra-operative positioning, facetectomy, and disc preparation. This second portion will explore the nuances of cage selection and placement. The disc preparation is done, and it’s time to insert a cage. Interbody device selection can directly impact the ability to achieve lordosis with MIS TLIF. Numerous cage options are available, but regardless of the type of device used, the appropriate size must be selected. Oversizing may complicate insertion, increasing the risk of endplate violation, subsidence, pseudoarthrosis, and inadequate lordosis. Choosing a cage that is not sufficiently tall may result in inadequate restoration of disc height, cage migration, and difficulty producing lordosis. Selection of a cage of the appropriate height is largely a matter of “feel” intra-operatively. Careful use of expandable cages, which can be inserted in a collapsed position and then expanded once within the disc space, may help 6
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address this issue, especially in the setting of a fish-mouthed disc space. Early studies of expandable TLIF cages demonstrate promising results regarding restoration of lordosis and disc height,1,2 but the body of data is currently limited. These devices should be used to fill rather than aggressively distract the disc space to minimize the risk of endplate violation and subsequent subsidence3 given the relatively small footprint of TLIF cages (Figure 1). The amount of lordosis built into a cage is another key variable in the equation. Cages with parallel superior and inferior surfaces increase the risk of global and segmental hypo-lordosis as well as the incidence of endplate violations and subsidence, especially with posterior compression in an attempt to achieve lordosis (Figure 2). Hong et al. published a retrospective comparison of radiographic parameters in patients who underwent TLIF with cages ranging from 4° to 15°
of lordosis and found significantly greater restoration of segmental and overall lordosis as well as disc height with 15° lordotic cages at an average of approximately 20 months of follow up.4 Cage footprint must also be considered. Straight (also known as oblique) TLIF cages are popular, largely due to their relative simplicity of insertion. Banana-shaped (also called kidney-shaped) cages were developed more recently. They feature an articulating insertion arm and allow for more anterior implant placement. There is evidence, including the results of an RCT, that banana-shaped cages produce significantly more lordosis than straight cages.5–8 However, the comparison group in each of these studies has been straight cages with parallel superior and inferior surfaces rather than straight cages with lordotic profiles. It remains to be seen how straight cages with built-in lordosis perform compare to banana-shaped
Figure 1. Expandable Cage. Expandable cages can be inserted in the collapsed state into the relatively small cranio-caudal bounds of the TLIF window (A) and then expanded to fill the intervertebral space (B). Avoid over-aggressive distraction via the cage to prevent endplate violation and subsidence.
Expandable Interbody Devices in Minimally Invasive Transforaminal Lumbar Interbody Fusion: Comparison of Radiographic and Functional Outcomes. In: Las Vegas, NV; 2018. 3. Massie LW, Zakaria HM, Schultz LR, Basheer A, Buraimoh MA, Chang V. Assessment of radiographic and clinical outcomes of an articulating expandable interbody cage in minimally invasive transforaminal lumbar interbody fusion for spondylolisthesis. Neurosurg Focus. 2018;44(1):E8. doi:10.3171/2017.10. FOCUS17562
Figure 2. Impact of Cage Lordosis. Use of TLIF cages with parallel superior and inferior endplates predispose to segmental hypolordosis (A). Posterior compression intended to increase lordosis despite use of a parallel cage can produce endplate violations and subsidence (B). Use of a cage with built-in lordosis and good endplate contact can help reduce the incidence of these undesirable outcomes (C). In each diagram above, vertebral bodies are viewed in the sagittal plane, oriented with anterior to the left. cages so definitive conclusions on this subject cannot currently be drawn. Regardless of interbody cage selection, sufficiently anterior placement of the implant is critical to achieving and maintaining lordosis. Such cage positioning provides an anterior fulcrum across which increased lordosis can be achieved.9,10 Furthermore, resting at least a portion of the cage on the robust apophyseal bone anteriorly rather than on the weaker endplate bone centrally has been associated with decreased rates of subsidence.6,11 Gentle use of paddle distractors can help mobilize the disc space to facilitate disc preparation and cage insertion. Surgeons performing a unilateral approach might consider placing contralateral instrumentation prior to disc preparation – locking the contralateral set screws with a paddle in place allows for temporary maintenance of distraction. Screw-based distraction devices also exist and are another option. After cage insertion, distraction should be relaxed to allow the posterior column to shorten, accentuating segmental lordosis, before final
tightening the implants. Additional lordosis can be achieved by compressing posteriorly, but care should be taken to avoid excessively closing the foramena, which can generate iatrogenic stenosis. Combining these considerations for maximizing lordosis with those of Part 1 of this series yields the following array of strategies: optimizing bone mineral density; positioning the patient in lordosis; thorough disc preparation to mobilize the level and maximize fusion; avoiding endplate violations to reduce the chance of subsidence and loss of lordosis; considering bilateral approaches in severely collapsed discs; selecting a cage with a lordotic profile; and placing the cage anteriorly within the disc space. Thoughtful and deliberate attention to these factors will allow surgeons and their patients to reap the benefits of MIS TLIF. References 1. Hawasli AH, Khalifeh JM, Chatrath A, Yarbrough CK, Ray WZ. Minimally invasive transforaminal lumbar interbody fusion with expandable versus static interbody devices: radiographic assessment of sagittal segmental and pelvic parameters. Neurosurg Focus. 2017;43(2):E10. doi:10.3171/2017.5.FOCUS17197
4. Hong T-H, Cho K-J, Kim Y-T, Park J-W, Seo B-H, Kim N-C. Does Lordotic Angle of Cage Determine Lumbar Lordosis in Lumbar Interbody Fusion? Spine. 2017;42(13):E775-E780. doi:10.1097/ BRS.0000000000001957 5. Shau DN, Parker SL, Mendenhall SK, et al. Transforaminal lumbar interbody graft placement using an articulating delivery arm facilitates increased segmental lordosis with superior anterior and midline graft placement. J Spinal Disord Tech. 2015;28(4):140-146. doi:10.1097/BSD.0b013e318275658e 6. Choi W-S, Kim J-S, Hur J-W, Seong J-H. Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Banana-Shaped and Straight Cages: Radiological and Clinical Results from a Prospective Randomized Clinical Trial. Neurosurgery. 2018;82(3):289-298. doi:10.1093/neuros/nyx212 7. Lindley TE, Viljoen SV, Dahdaleh NS. Effect of steerable cage placement during minimally invasive transforaminal lumbar interbody fusion on lumbar lordosis. J Clin Neurosci. 2014;21(3):441-444. doi:10.1016/j. jocn.2013.06.006 8. Rice JW, Sedney CL, Daffner SD, Arner JW, Emery SE, France JC. Improvement of Segmental Lordosis in Transforaminal Lumbar Interbody Fusion: A Comparison of Two Techniques. Global Spine J. 2016;6(3):229233. doi:10.1055/s-0035-1559583 9. Recnik G, Košak R, Vengust R. Influencing segmental balance in isthmic spondylolisthesis using transforaminal lumbar interbody fusion. J Spinal Disord Tech. 2013;26(5):246-251. doi:10.1097/BSD.0b013e3182416f5c 10. Kwon BK, Berta S, Daffner SD, et al. Radiographic analysis of transforaminal lumbar interbody fusion for the treatment of adult isthmic spondylolisthesis. J Spinal Disord Tech. 2003;16(5):469-476. 11. Fukuta S, Miyamoto K, Hosoe H, Shimizu K. Kidney-type intervertebral spacers should be located anteriorly in cantilever transforaminal lumbar interbody fusion: analyses of risk factors for spacer subsidence for a minimum of 2 years. J Spinal Disord Tech. 2011;24(3):189195. doi:10.1097/BSD.0b013e3181e9f249
2. Khechen B, Haws B, Patel D, et al. Static vs.
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PRACTICE
Digital Media in Spine Surgery Practice Marketing Brandon P Hirsch, MD In the digital age of medicine, creating a positive online reputation has become an essential part of a surgeon’s practice management strategy. The rapid expansion of access to high-speed internet during the last 30 years have fundamentally changed how patients make healthcare decisions. A 2010 Pew research study found that 59% of survey respondents look to the internet for health information, ranking behind only email and search engines as the most common reasons for individuals to go online.1 Social media use has also exploded during the last decade with 65% of adults reporting use of these platforms in 2015, compared to just 7% in 2005.2 Any spine surgeon looking to grow or maintain their patient base should have a marketing plan with significant emphasis on their online presence. In creating a plan for digital media, it is important to first consider what goals are to be achieved. In its most basic form, an online presence serves to make patients and potential referral sources aware that your practice exists in their market and provides information about your background and the services you provide. While this approach would be appropriate for individuals at the very beginning of their practice, it underutilizes powerful opportunities to grow and shape a spine surgery practice. Surgeons who want to maximize the potential of digital media can use it to grow a patient base in a specific geographical area or age 8
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demographic as well as expand a part of their practice related to a specific disease process or surgical technique. Understanding your practice’s marketing objectives is important as it helps determine which online tools to prioritize and how best to utilize them. A website is the home base for a surgeon’s digital media efforts. At a minimum, websites contain a brief biography including training background, information about where the practice is located, which services you provide/problems you treat, and how to make an appointment. Information on diagnoses and specific procedures (written at a patient-appropriate level), postoperative recovery, patient testimonials, and video content all significantly improve patient engagement. Even more important than the content of the site is the ability of patients to find it. This ability is primarily driven by a process called search engine optimization (SEO) whereby website features determine where the site will rank in a search result list. This dramatically influences the likelihood that the patient will visit a site as the majority of individuals do not proceed beyond the first or second page of search results. SEO is affected by features intrinsic to the site such as “tags” (keywords, page titles), mobile device compatibility, and content quality/age. SEO is also affected by factors outside the site related to incoming links from other webpages, press releases, and social media activity. Unfortunately, there are many more factors that impact
SEO for a website and the search engine algorithms that dictate their importance are constantly changing. Surgeons without significant knowledge of SEO should consider seeking out professionals to help them with this process if they have chosen to build their website on their own. Social media and social networking platforms now dominate the internet landscape and are used by twothirds of adults. This includes significant adoption by seniors during the last 10 to 15 years. In fact, the most recent Pew study with data through 2015 shows that 35% of the age 65+ community now use social media compared to just 2% in 2005.2 Social media is differentiated from passive websites or other digital ads by two-way interaction between creators and consumers of content. Health problems (and particularly spine problems) are both personal and technically complex. Most patients are motivated to seek information about a new diagnosis or symptom that they do not understand. Primary care providers’ relative lack of knowledge about spine conditions combined with long waits for and short visit with spine surgeons can make it difficult for patients to have their questions answered via traditional means. As a result, online interactive communities an attractive place for patients to seek health information. Using social media, a patient can search a symptom or diagnosis and be instantly connected to a community of other patients seeking the same information. The interactive
nature of these platforms allows patients to anonymously ask questions and share experiences regarding their health conditions. This creates a targeted community of individuals for a surgeon to interact with via social media where they are perceived as an authoritative source. Literature on the influence of social media on the spine patient population is still in its infancy, but early analyses suggest that it does relate in some way to surgeon’s online reputation. In a recent study of 215 spine surgeons in Florida, those with a presence on at least one social media platform had a higher number of ratings on Healthgrades. com, Vitals.com and Google.3 In a similar analysis of 299 spine surgeons in Texas, the number of comments on Healthgrades.com was higher for surgeons with a social media presence.4 Surgeons’ actual average rating on these sites did not correlate with their use of social media in either analysis. While many options exist, some of the most popular social media platforms are Facebook, YouTube, and Twitter. All are similar in that they allow content to be delivered to the audience in an interactive manner and in near-real time. All have mobile apps that are the primary ways that individuals use the platform. Each product delivers content in slightly different ways and with different drawbacks. Facebook is the most popular social networking site frequented by 71% of adult internet users and by 56% of internet users over age 65.5 Facebook combines the ability to have a home page via which content can be displayed for other users, not dissimilar from the way a traditional website functions. This page can include basic information about
office address and phone number, hours, brief biography, etc. Video, audio, and static image content are delivered via “posts”. Users are then able to comment and or “like” posts generating interactivity based on content. Its widespread adoption and flexibility in content delivery are main advantages of Facebook. In addition, Facebook allows for very detailed analysis of user demographics as well as the ability to create highly targeted advertisements based on users location, age, gender, interests, and online behavior. These features make it an essential part of any surgeons’ online presence. Downsides include challenges in maintaining patient/physician boundaries due to its “friend request” function and the potential for users to misconstrue messages from providers as medical advice. YouTube is considered the second largest search engine behind Google and is the primary vehicle for video content on the internet. Despite its widespread use in other field, physicians have been slow to utilize this platform. Video content is superior for transmission of the highly technical information inherent to spine care as well as generally preferred by consumers when compared to text based content. YouTube is centered around “channels” which transmit content and can be subscribed to by users. Similar to Facebook, users can like and comment on videos. YouTube offers advertising in the form of both short video clips that precede their videos and static page links, both of which are relatively inexpensive. Like other platforms this advertising can be targeted to users in a certain demographic based upon age, geographic region, content being viewed, and a host of
other variables. Downsides to use of YouTube for marketing in spine surgery primarily relates to the cost, time commitments and expertise required to create high quality original video content. Twitter is a considered a microblogging platform and is focused on character-limited messages. Users have a “handle” that identifies them and can be followed by other users. Messages (a.k.a “Tweets”) can be either posted for all followers to see or directed to an individual handle, either publicly or privately (direct messages). Posts frequently contain links to outside content either on a website or another social media platform. Inclusion of hashtags (#’s) allow users to track content from different handles that relate to the same topic. Similar to other platforms, Twitter offers advanced analysis of user demographics, interests, daily activity patterns, preferred content type, and engagement level (among many other data points). Advertising on Twitter can take the form of promoted individual tweets or more comprehensive ad campaigns. Both types of ads can be highly targeted based on variables such as age, gender, location, device type, interests, number of followers and more. Thus far, surgeons have been slow to adopt Twitter. This is likely related to a combination of factors including the limitation in length of messages, perception that patient base does not use the platform, and relative technical difficulty in using the platform. Maintaining a professional appearance online is just as critical as it is in person in your day to day practice. It is advisable to keep any personal social media accounts completely separate from any Vertebral Columns • Summer 2019
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professional accounts. Providing individualized medical advice to patients via these web-based mediums is strongly discouraged. Like unhappy customers in any industry, dissatisfied patients are often inclined to leave negative comments on social media. Although unpleasant, special attention should be paid to such comments. Privacy settings on all platforms allow comment features to be disabled although this does decrease the utility of these mediums. Having a digital presence online is essential for spine surgeons in today’s healthcare environment. Surgeons have been quite slow to adopt social media as a com-
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ponent of their marketing plan when compared to other sectors. Having a high-quality website as well as a social media presence are very powerful means of reaching a desired patient population and can be done in an inexpensive, highly targeted manner. Surgeons should be vigilant to avoid inadvertently providing individual medical advice to patients. They should also be careful to maintain professionalism in all online activity and should keep their personal and professional identities on these platforms separate. When utilized properly, digital marketing can be a highly effective way to reach potential patients and referral sources.
References 1. Fox S. The Social Life of Health Information, 2011 | Pew Research Center. Pew Research Center. Available at https://www.pewinternet. org/2011/05/12/the-social-life-of-health-information-2011/. 2011, Accessed June 27, 2019. 2. Perrin A. Social Media Usage: 2005-2015 | Pew Research Center. Pew Research Center. Available at https://www.pewinternet.org/2015/10/08/ social-networking-usage-2005-2015/. 2015, Accessed June 27, 2019. 3. Donnally CJ, Li DJ, Maguire JA, et al. How social media, training, and demographics influence online reviews across three leading review websites for spine surgeons. Spine J 2018;18:2081–90. 4. Donnally CJ, McCormick JR, Li DJ, et al. How do physician demographics, training, social media usage, online presence, and wait times influence online physician review scores for spine surgeons? J Neurosurg Spine 2019;30:279–88. 5. Duggan M, Ellison NB, Lampe C, Lenhart A MM. Social Media Site Usage 2014 | Pew Research Center. Available at https://www. pewinternet.org/2015/01/09/social-media-update-2014/. 2015, Accessed June 27, 2019.
PEDIATRIC SPINE
Back Pain in Children and Adolescents Yu-Po Lee, MD Low back pain (LBP) in children and adolescents is a common event. The prevalence of LBP rises with age, and the incidence is nearly equal to adults by age 18 years old.1 The effect of LBP on this population can be considerable and may significantly impact their ability to attend school and play sports. Low back pain in this age group may also be a harbinger for developing LBP as an adult. Several potential risk factors for developing LBP in school-aged children have been studied.2 There is a U-shaped association between physical activity and the incidence of LBP in school-aged children. Both low and high levels of physical activity are associated with a higher risk. Female sex, growth acceleration, adverse psychosocial factors, increasing age, previous back injury, constantly carrying heavy items, and family history of LBP are all potential risk factors for schoolaged children to develop LBP. But most cases of LBP in children and adolescents are non-specific and self-limited. Spondylolysis and spondylolisthesis are common causes of back pain in children over the age of ten. Spondylolysis is a defect in the pars interarticularis and most commonly affects the fourth and fifth lumbar vertebrae (Figure 1). Most cases in children are due to a fatigue or stress fracture of the pars. Spondylolisthesis occurs in the presence of bilateral pars defects and is
defined by the forward translation of one vertebra on the next caudal segment. Spondylolysis is more common in boys and athletes participating in sports which involve repetitive extension, flexion and rotation. Traditionally, the diagnosis of spondylolysis relied on plain radiography with oblique views. CT is the most accurate method of diagnosing a spondylolysis. Treatment includes rest, non-steroidal anti-inflammatory medications, bracing, and physical therapy. Surgery is reserved for patients who do not respond to conservative management. Lumbosacral fusion is the most common operation performed in these cases, but a direct repair of the pars defect may also be considered in appropriate patients. Lumbar disc herniation is not common in adolescents or children (Figure 2). Most patients with a disc injury report some form of trauma or sports-related injury. Management of an adolescent lumbar disc herniation should begin with a period of relative rest, including the cessation of sporting activities, followed by physiotherapy. Surgical intervention is reasonable in a child with a prolapsed lumbar disc after a limited trial of conservative treatment and/or image-guided steroid injection. Scheuermann’s deformity is a common cause of a progressive structural thoracic or thoracolumbar hyperkyphosis with back pain in the adolescent. It occurs in 1% to 8% of this age group and affects boys and girls equally.3 It usually starts
Figure 1. Lateral view of 17 yo male with bilateral L5 pars fractures. just before the onset of puberty and is commonly attributed to poor posture, which is a cause of delay in diagnosis and treatment. It presents as a dull, non-radiating pain around the apex of the deformity with local tenderness. Radiographs
Figure 2. Sagittal view of 16 yo male who suffered a L1-2 disc herniation while playing water polo. Vertebral Columns • Summer 2019
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show that the kyphosis exceeds 45° (normal range 20° to 45°) and is accompanied by wedging of at least 5° in three adjacent vertebrae. Non-surgical management consists of anti-inflammatory medication and physical therapy. The indications for bracing have been debated, and its efficacy is uncertain. Surgery is generally reserved for those skeletally mature patients who have a kyphosis > 70° with pain or concerns about its appearance. Idiopathic scoliosis affects 1% to 3% of children and adolescents. The Adams forward bending test will elicit the curve of structural scoliosis on examination, and a Cobb angle of at least 10° on a standing coronal radiograph will confirm the diagnosis. Patients with an adolescent idiopathic scoliosis (AIS) usually present with asymmetry of the shoulders, a flank crease, prominence of the ribs and, on occasion, back pain. Idiopathic scoliosis generally is not painful, therefore, pain should be further worked up for another cause of the pain, such as an infection, tumor, or spondylolysis. Management of the deformity itself is determined on an individual basis and depends on the skeletal maturity of the patient and the degree of curvature. Infectious causes of back pain in adolescents include discitis, vertebral osteomyelitis, tuberculous osteomyelitis, epidural abscess and sacroiliac joint infections. Intervertebral discs are more vascular in children and have direct vascular channels that close by 20 years of age, with ossification of the endplates. The difference in blood supply accounts for the rarity of true vertebral osteomyelitis in children and the predominance of discitis, the most common cause of which 12
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is haematogenous infection. The main clinical signs of a discitis are general irritability and a refusal to walk or to stand due to abdominal pain, hamstring spasm or back pain. Work-up includes WBC, C-reactive protein, ESR, and blood cultures; yet, it is important to keep in mind that these labs may be normal even in the presence of a discitis. Radiological investigations may be normal in the early stage and lag behind the clinical findings. The earliest changes are seen on MRI. Treatment is with the use of IV or oral antibiotics. Surgical debridement is considered in patients with an established abscess or who have an evolving neurological deficit. Neoplastic disease of the spine in childhood is rare. Benign tumors seen commonly in the posterior column include osteoid osteomas, osteoblastomas and aneurysmal bone cysts.4 Eosinophilic granuloma (histiocytosis X) usually occurs in the anterior column.4 Osteoid osteoma often presents with back pain. A scoliosis develops because the asymmetric involvement of the vertebra gives rise to muscle spasm. Patients typically have back pain at night, which is relieved by NSAIDs and aspirin. A CT typically shows a nidus surrounded by sclerosis, and treatment usually starts with a trial of NSAIDs. Thermal ablation therapy (radiofrequency ablation or cryoablation) has been shown to be an effective minimally invasive alternative to excision. It is larger than an osteoma and usually > 2 cm in diameter. NSAIDs are usually ineffective. These lesions are locally expansive and destructive. Surgical treatment options range from intralesional curettage to complete surgical excision. Aneurysmal bone cysts typically
involve the posterior elements. Radiographs show a radiolucent lesion that may have a bubbly, cystic appearance with a thin rim of the surrounding bone. Eosinophilic granuloma (histiocytosis X) is a general term for a subgroup of syndromes related to abnormally functioning monocytes, macrophages and dendritic cells (also known as antigen-presenting cells). Back pain is localized to the area of granuloma formation (i.e. the vertebral body). Radiographs reveal lytic lesions which can cause collapse of the vertebral body, giving the appearance of vertebra plana. Some patients undergo spontaneous resolution; consequently, the need for surgery or adjuvant therapy remains controversial and is usually reserved for those patients who have neurological manifestations or polyostotic involvement. Malignant lesions of the spine include leukemia, metastases and primary malignant tumors such as Ewing’s sarcoma and osteogenic sarcoma. Leukemia is the most common cancer in children and may present with back pain. The symptoms are non-specific, and the diagnosis may not at first be considered. It is unusual to find spinal injury in cases of child abuse. If non-accidental injury is suspected, the principles of diagnosis and treatment of child abuse should be followed, including the acquisition of radiographs of the entire spine as part of a skeletal survey. Fractures and subluxations of the vertebral bodies have moderate specificity for child abuse, but become highly specific if a history of trauma is absent or inconsistent with the injuries.
References 1. King S, Chambers CT, Huguet A, et al. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain. 2011 Dec;152(12):2729-38. 2. MacDonald J, Stuart E, Rodenberg R. Musculoskeletal Low Back Pain in Schoolaged Children: A Review. JAMA Pediatr. 2017 Mar 1;171(3):280-287. 3. Shah SA, Saller J. Evaluation and Diagnosis of Back Pain in Children and Adolescents. J Am Acad Orthop Surg. 2016 Jan;24(1):37-45. 4. Altaf F, Heran MK, Wilson LF. Back pain in children and adolescents. Bone Joint J. 2014 Jun;96-B(6):717-23.
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PAIN
Complex Regional Pain Syndrome Avani Vaishnav, MBBS, and Sheeraz Qureshi, MD, MBA Complex regional pain syndrome (CRPS), a chronic pain disorder that most commonly affects the extremities and usually develops following a traumatic injury, can be triggered after a spinal injury or spine surgery. The pain in CRPS is typically persistent, out of proportion to the severity of any associated tissue injury, accompanied by autonomic and inflammatory changes and not defined by dermatomal distribution or innervation zones of affected nerve(s).1–3 CRPS is a rare entity with the reported prevalence ranging from 5.44 to 26.25 per 100,000 person years. It can be divided into two subtypes – CRPS I (previously known is ‘reflex sympathetic dystrophy’) is defined by the absence of a major nerve injury and CRPS II (previously known as ‘causalgia’) is defined by the presence of a major nerve injury. Epidemiologic trends have demonstrated higher prevalence in females and following upper extremity trauma.3,4 Although the exact pathophysiology of CRPS is yet to be elucidated, it has been attributed to a complex interplay of various factors including sensitization of the central and peripheral nervous system, autonomic dysregulation, inflammatory pathways and autoimmune responses.6–8 A number of studies have reported the development of CRPS following spine surgery, with a majority of cases occurring 14
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following lumbar spinal procedures. Suggested mechanisms for the development of CRPS following spinal surgery include nerve root injury due to intra-operative manipulation and sympathetic reaction as a result of mobilization of the ventral sympathetic trunk during anterior surgical approaches to the spine.9 Due to the lack of a clearly defined etiology or pathophysiology, CRPS is often a diagnosis of exclusion and is diagnosed solely on the basis of clinical signs and symptoms. The most widely used diagnostic criteria, commonly referred to as the ‘Budapest Criteria,’10 have been accepted and codified for clinical and research purposes by the International Association for the Study of Pain’s (IASP) Committee for Classification of Chronic Pain. For the diagnosis of CRPS, these criteria depend on the presence of disproportionate pain, sensory, vasomotor, sudomotor and/or trophic or motor signs and symptoms, and the exclusion of other differential diagnoses. Further, the severity of the disease can be assessed using the CRPS Severity Scale (CSS),11,12 which has been shown to correlate with pain levels, functional limitation and response to treatment.8 The intricate and multifactorial pathophysiology makes this condition difficult to treat,1 with studies evaluating the role of various treatment modalities including physical and occupational therapy,13 nerve and ganglion blocks,7 spinal cord stimulators (SCS)14
and pharmacotherapy (NSAIDs, anticonvulsants such as gabapentin, bisphosphonates etc.).1,2,8 SCS works by neuromodulation, wherein the application of an electrical stimulus to the dorsal column is thought to mask the sensation of pain by replacing the pain sensation with paresthesia, and thus reducing perceived pain.8,15 The electrical stimulus is applied via electrodes placed percutaneously into the epidural space, or through a surgical paddle lead that is implanted via a laminotmoy. An outcome-specific systematic review on the use of SCS for the management of CRPS reported high-level evidence for improvements in perceived pain relief, pain score, quality of life and patient-satisfaction. However, data on functional improvements, sleep hygiene, psychological impact, and analgesia-sparing effect were sparse or of low-quality.14 While some studies have also demonstrated favorable results with mirror therapy,13 interdisciplinary pain management programs1 and certain pharmacologic agents,16 the overall evidence for a majority of these interventions is extremely limited due to the lack of well-designed and adequately powered randomized trials. A number of studies have also evaluated the role of vitamin C for the prevention of CRPS, but the lack of conclusive evidence supporting its utility has limited its use for this purpose.8,17 In conclusion, CRPS is a complex, multifaceted disorder that is not yet fully understood. This opacity re-
garding the underlying mechanisms make the diagnosis and management of this disorder a challenge for both physicians and patients. Further research on the etiology and pathophysiology and larger well-designed trials to evaluate and compare the efficacy or various available treatment options will be essential to drive advancements in the understanding of this disease, and subsequently in the care of these patients. References 1. Mccormick ZL, Gagnon CM, Caldwell M, Patel J, Kornfeld S. Short-Term Functional , Emotional , and Pain Outcomes of Patients with Complex Regional Pain Syndrome Treated in a Comprehensive Interdisciplinary Pain Management Program. Pain Med. 2015;16(12):23572367. 2. Morgan B, Wooden S. Diagnosis and Treatment of Common Pain Syndromes and Disorders. Nurs Clin North Am. 2018;53(3):349-360. doi:10.1016/j.cnur.2018.04.004 3. Petersen PB, Mikkelsen KL, Lauritzen JB, Krogsgaard MR. Risk Factors for Post-treatment Complex Regional Pain Syndrome (CRPS): An Analysis of 647 Cases of CRPS from the Danish Patient Compensation Association. Pain Pract. 2018;18(3):341-349. doi:10.1111/papr.12610 4. Sandroni P, Benrud-Larson LM, McClelland RL, Low PA. Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Pain. 2003.
Clinical and prognostic implications. Eur Neurol. 2012;68(1):52-58. doi:10.1159/000337907 10. Harden RN, Bruehl S, Perez RSGM, et al. Validation of proposed diagnostic criteria (the “Budapest Criteria”) for Complex Regional Pain Syndrome. Pain. 2010;150(2):268-274. doi:10.1016/j.pain.2010.04.030 11. Harden RN, Bruehl S, Perez RSGM, et al. Development of a severity score for CRPS. Pain. 2010;151(3):870-876. doi:10.1016/j. pain.2010.09.031 12. Harden RN, Maihofner C, Abousaad E, et al. A prospective, multisite, international validation of the Complex Regional Pain Syndrome Severity Score. Pain. 2017;158(8):1430-1436. doi:10.1097/j.pain.0000000000000927 13. Smart Keith M, Wand Benedict M, O’Connell Neil E. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Database Syst Rev. 2013;(11). doi:10.1002/14651858.CD010853 14. Visnjevac O, Costandi S, Patel BA, et al. A Comprehensive Outcome-Specific Review of the Use of Spinal Cord Stimulation for Complex Regional Pain Syndrome. Pain Pract. 2017;17(4):533-545. doi:10.1111/papr.12513 15. P. V, C. S, A. B. A review of spinal cord stimulation systems for chronic pain. J Pain Res. 2016;9:481-492. doi:10.2147/JPR.S108884 16. Henderson J. Updated guidelines on complex regional pain syndrome in adults ✰. J Plast Reconstr Aesthetic Surg. 2019;72(1):1-3. doi:10.1016/j.bjps.2018.08.017 17. Koh T-T, Daly A, Howard W, Tan C, Hardidge A. Complex regional pain syndrome. JBJS Rev. 2014;2(7):e5. doi:http://dx.doi. org/10.2106/JBJS.RVW.M.00085
5. de Mos M, de Bruijn AGJ, Huygen FJPM, Dieleman JP, Stricker BHC, Sturkenboom MCJM. The incidence of complex regional pain syndrome: a population-based study. Pain. 2007;129(1-2):12-20. doi:10.1016/j. pain.2006.09.008 6. David Clark J, Tawfik VL, Tajerian M, Kingery WS. Autoinflammatory and autoimmune contributions to complex regional pain syndrome. Mol Pain. 2018;14. doi:10.1177/1744806918799127 7. Zhu X, Kohan LR, Morris JD, Hamill-Ruth RJ. Sympathetic blocks for complex regional pain syndrome: a survey of pain physicians. Reg Anesth Pain Med. 2019:rapm-2019-100418. doi:10.1136/rapm-2019-100418 8. Shim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome: a narrative review for the practicing clinician. Br J Anaesth. 2019;(March):1-10. doi:10.1016/j. bja.2019.03.030 9. Wolter T, Knöller SM, Rommel O. Complex regional pain syndrome following spine surgery:
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