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Development of appropriateness criteria for the surgical treatment of symptomatic lumbar degenerative spondylolisthesis (LDS)

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Abstract

Purpose

Spine surgery rates are increasing worldwide. Treatment failures are often attributed to poor patient selection and inappropriate treatment, but for many spinal disorders there is little consensus on the precise indications for surgery. With an aging population, more patients with lumbar degenerative spondylolisthesis (LDS) will present for surgery. The aim of this study was to develop criteria for the appropriateness of surgery in symptomatic LDS.

Methods

A systematic review was carried out to summarize the current level of evidence for the treatment of LDS. Clinical scenarios were generated comprising combinations of signs and symptoms in LDS and other relevant variables. Based on the systematic review and their own clinical experience, twelve multidisciplinary international experts rated each scenario on a 9-point scale (1 highly inappropriate, 9 highly appropriate) with respect to performing decompression only, fusion, and instrumented fusion. Surgery for each theoretical scenario was classified as appropriate, inappropriate, or uncertain based on the median ratings and disagreement in the ratings.

Results

744 hypothetical scenarios were generated; overall, surgery (of some type) was rated appropriate in 27 %, uncertain in 41 % and inappropriate in 31 %. Frank panel disagreement was low (7 % scenarios). Face validity was shown by the logical relationship between each variable’s subcategories and the appropriateness ratings, e.g., no/mild disability had a mean appropriateness rating of 2.3 ± 1.5, whereas the rating for moderate disability was 5.0 ± 1.6 and for severe disability, 6.6 ± 1.6. Similarly, the average rating for no/minimal neurological abnormality was 2.3 ± 1.5, increasing to 4.3 ± 2.4 for moderate and 5.9 ± 1.7 for severe abnormality. The three variables most likely (p < 0.0001) to be components of scenarios rated “appropriate” were: severe disability, no yellow flags, and severe neurological deficit.

Conclusion

This is the first study to report criteria for determining candidacy for surgery in LDS developed by a multidisciplinary international panel using a validated method (RAM). The panel ratings followed logical clinical rationale, indicating good face validity. The work refines clinical classification and the phenotype of degenerative spondylolisthesis. The predictive validity of the criteria should be evaluated prospectively to examine whether patients treated “appropriately” have better clinical outcomes.

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References

  1. Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah SM, O’Neil J, Wai EK (2007) The surgical management of degenerative lumbar spondylolisthesis: a systematic review. Spine (Phila Pa 1976) 32:1791–1798

    Article  Google Scholar 

  2. Weinstein JN, Lurie JD, Tosteson TD, Zhao W, Blood EA, Tosteson AN, Birkmeyer N, Herkowitz H, Longley M, Lenke L, Emery S, Hu SS (2009) Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. Four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am 91:1295–1304

    Article  PubMed Central  PubMed  Google Scholar 

  3. Pearson AM, Lurie JD, Blood EA, Frymoyer JW, Braeutigam H, An H, Girardi FP, Weinstein JN (2008) Spine patient outcomes research trial: radiographic predictors of clinical outcomes after operative or nonoperative treatment of degenerative spondylolisthesis. Spine (Phila Pa 1976) 33:2759–2766

    Article  Google Scholar 

  4. Watters WC 3rd, Bono CM, Gilbert TJ, Kreiner DS, Mazanec DJ, Shaffer WO, Baisden J, Easa JE, Fernand R, Ghiselli G, Heggeness MH, Mendel RC, O’Neill C, Reitman CA, Resnick DK, Summers JT, Timmons RB, Toton JF (2009) An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J 9:609–614. doi:10.1016/j.spinee.2009.03.016

    Article  PubMed  Google Scholar 

  5. Epstein NE, Epstein JA, Carras R, Lavine LS (1983) Degenerative spondylolisthesis with an intact neural arch: a review of 60 cases with an analysis of clinical findings and the development of surgical management. Neurosurgery 13:555–561

    Article  CAS  PubMed  Google Scholar 

  6. Katz JN, Lipson SJ, Lew RA, Grobler LJ, Weinstein JN, Brick GW, Fossel AH, Liang MH (1997) Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes. Spine (Phila Pa 1976) 22:1123–1131

    Article  CAS  Google Scholar 

  7. Kornblum MB, Fischgrund JS, Herkowitz HN, Abraham DA, Berkower DL, Ditkoff JS (2004) Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective long-term study comparing fusion and pseudarthrosis. Spine (Phila Pa 1976) 29:726–733 discussion 733–724

    Article  Google Scholar 

  8. Ghogawala Z, Benzel EC, Amin-Hanjani S, Barker FG 2nd, Harrington JF, Magge SN, Strugar J, Coumans JV, Borges LF (2004) Prospective outcomes evaluation after decompression with or without instrumented fusion for lumbar stenosis and degenerative Grade I spondylolisthesis. J Neurosurg Spine 1:267–272

    Article  PubMed  Google Scholar 

  9. Okuda S, Oda T, Miyauchi A, Haku T, Yamamoto T, Iwasaki M (2007) Surgical outcomes of posterior lumbar interbody fusion in elderly patients. Surgical technique. J Bone Joint Surg Am 89(Suppl 2 Pt.2):310–320

    PubMed  Google Scholar 

  10. Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgomery DM, Kurz LT (1997) 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (Phila Pa 1976) 22:2807–2812

    Article  CAS  Google Scholar 

  11. Abdu WA, Lurie JD, Spratt KF, Tosteson AN, Zhao W, Tosteson TD, Herkowitz H, Longely M, Boden SD, Emery S, Weinstein JN (2009) Degenerative spondylolisthesis: does fusion method influence outcome? Four-year results of the spine patient outcomes research trial. Spine (Phila Pa 1976) 34:2351–2360

    Article  Google Scholar 

  12. Schaeren S, Broger I, Jeanneret B (2008) Minimum four-year follow-up of spinal stenosis with degenerative spondylolisthesis treated with decompression and dynamic stabilization. Spine (Phila Pa 1976) 33:E636–E642

    Article  Google Scholar 

  13. Kelleher MO, Timlin M, Persaud O, Rampersaud YR (2010) Success and failure of minimally invasive decompression for focal lumbar spinal stenosis in patients with and without deformity. Spine (Phila Pa 1976) 35:E981–E987

    Article  Google Scholar 

  14. Toyoda H, Nakamura H, Konishi S, Dohzono S, Kato M, Matsuda H (2010) Clinical outcome of microsurgical bilateral decompression via unilateral approach for lumbar canal stenosis: minimum five-year follow-up. Spine (Phila Pa 1976) 36(5):410–415

    Google Scholar 

  15. Waddell G, Morris EW, Di Paola MP, Bircher M, Finlayson D (1986) A concept of illness tested as an improved basis for surgical decisions in low-back disorders. Spine (Phila Pa 1976) 11:712–719

    Article  CAS  Google Scholar 

  16. Mannion AF, Elfering A (2006) Predictors of surgical outcome and their assessment. Eur Spine J 15(Suppl 1):S93–S108

    Article  PubMed Central  PubMed  Google Scholar 

  17. Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lazaro P, van het Loo M, McDonell J, Vader J, Kahan JP (2001) The RAND/UCLA appropriateness method user’s manual. RAND Corporation, Santa Monica

    Google Scholar 

  18. Fletcher SW, Fletcher RH (1998) Development of clinical guidelines. Lancet 352:1876

    Article  CAS  PubMed  Google Scholar 

  19. Brook RH, Chassin MR, Fink A, Solomon DH, Kosecoff J, Park RE (1986) A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care 2:53–63

    Article  CAS  PubMed  Google Scholar 

  20. Naylor CD (1998) What is appropriate care? N Engl J Med 338:1918–1920

    Article  CAS  PubMed  Google Scholar 

  21. Deyo RA, Nachemson A, Mirza SK (2004) Spinal-fusion surgery—the case for restraint. N Engl J Med 350:722–726

    Article  CAS  PubMed  Google Scholar 

  22. Steiger F, Becker H-J, Standaert CJ, Balague F, Vader J-P, Porchet F, Mannion AF (2014) Surgery in lumbar degenerative spondylolisthesis—indications, outcomes and complications: a systematic review. Eur Spine J [Epub ahead of print]

  23. Tan C, Treasure T, Browne J, Utley M, Davies CW, Hemingway H (2007) Seeking consensus by formal methods: a health warning. J R Soc Med 100:10–14

    Article  PubMed Central  PubMed  Google Scholar 

  24. Kendall NA, Linton SJ (1997) Guide to assessing psychosocial Yellow Flags in acute low back pain: risk factors for long-term disability and work loss. In: Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Advisory Committee on Health and Disability Wellington, New Zealand

  25. Boutron I, Ravaud P, Nizard R (2007) The design and assessment of prospective randomised, controlled trials in orthopaedic surgery. J Bone Joint Surg Br 89:858–863

    Article  CAS  PubMed  Google Scholar 

  26. Fairbank J (1999) Randomized controlled trials in the surgical management of spinal problems. Spine (Phila Pa 1976) 24:2556–2561 discussion 2562–2553

    Article  CAS  Google Scholar 

  27. Winter RB (1999) The prospective, randomized, controlled clinical trial in spine surgery: fact or fiction? Spine (Phila Pa 1976) 24:2550–2552

    Article  CAS  Google Scholar 

  28. Ahn H, Bhandari M, Schemitsch EH (2009) An evidence-based approach to the adoption of new technology. J Bone Joint Surg Am 91(Suppl 3):95–98

    Article  PubMed  Google Scholar 

  29. Ahn H, Court-Brown CM, McQueen MM, Schemitsch EH (2009) The use of hospital registries in orthopaedic surgery. J Bone Joint Surg Am 91(Suppl 3):68–72

    Article  PubMed  Google Scholar 

  30. Hoppe DJ, Schemitsch EH, Morshed S, Tornetta P 3rd, Bhandari M (2009) Hierarchy of evidence: where observational studies fit in and why we need them. J Bone Joint Surg Am 91(Suppl 3):2–9

    Article  PubMed  Google Scholar 

  31. Horwitz RI (1987) Complexity and contradiction in clinical trial research. Am J Med 82:498–510

    Article  CAS  PubMed  Google Scholar 

  32. Anderson PA, Sasso RC, Riew KD (2008) Comparison of adverse events between the Bryan artificial cervical disc and anterior cervical arthrodesis. Spine 33:1305–1312

    Article  PubMed  Google Scholar 

  33. Heller JG, Sasso RC, Papadopoulos SM, Anderson PA, Fessler RG, Hacker RJ, Coric D, Cauthen JC, Riew DK (2009) Comparison of BRYAN cervical disc arthroplasty with anterior cervical decompression and fusion: clinical and radiographic results of a randomized, controlled, clinical trial. Spine 34:101–107

    Article  PubMed  Google Scholar 

  34. Kahn KL, Park RE, Vennes J, Brook RH (1992) Assigning appropriateness ratings for diagnostic upper gastrointestinal endoscopy using two different approaches. Med Care 30:1016–1028

    Article  CAS  PubMed  Google Scholar 

  35. Porchet F, Vader JP, Larequi-Lauber T, Costanza MC, Burnand B, Dubois RW (1999) The assessment of appropriate indications for laminectomy. J Bone Joint Surg Br 81:234–239

    Article  CAS  PubMed  Google Scholar 

  36. Nicholas MK, Linton SJ, Watson PJ, Main CJ (2011) Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Phys Ther 91:737–753. doi:10.2522/ptj.20100224

    Article  PubMed  Google Scholar 

  37. Carragee EJ (2001) Psychological screening in the surgical treatment of lumbar disc herniation. Clin J Pain 17:215–219

    Article  CAS  PubMed  Google Scholar 

  38. Vader JP, Porchet F, Larequi-Lauber T, Dubois RW, Burnand B (2000) Appropriateness of surgery for sciatica: reliability of guidelines from expert panels. Spine (Phila Pa 1976) 25:1831–1836

    Article  CAS  Google Scholar 

  39. Findlay JM, Deis N (2010) Appropriateness of lumbar spine referrals to a neurosurgical service. Can J Neurol Sci 37:843–848

    PubMed  Google Scholar 

  40. Deyo RA, Mirza SK (2009) The case for restraint in spinal surgery: does quality management have a role to play? Eur Spine J 18(Suppl 3):331–337

    Article  PubMed Central  PubMed  Google Scholar 

  41. Keller RB, Atlas SJ, Soule DN, Singer DE, Deyo RA (1999) Relationship between rates and outcomes of operative treatment for lumbar disc herniation and spinal stenosis. J Bone Joint Surg Am 81:752–762

    CAS  PubMed  Google Scholar 

  42. Volinn E, Mayer J, Diehr P, Van Koevering D, Connell FA, Loeser JD (1992) Small area analysis of surgery for low-back pain. Spine (Phila Pa 1976) 17:575–581

    Article  CAS  Google Scholar 

  43. Danon-Hersch N, Samartzis D, Wietlisbach V, Porchet F, Vader JP (2010) Appropriateness criteria for surgery improve clinical outcomes in patients with low back pain and/or sciatica. Spine 35(6):672–683

    Google Scholar 

  44. Vader JP, Burnand B, Froehlich F, Dupriez K, Larequi-Lauber T, Pache I, Dubois RW, Gonvers JJ, Brook RH (1997) Appropriateness of upper gastrointestinal endoscopy: comparison of American and Swiss criteria. Int J Qual Health Care 9:87–92

    CAS  PubMed  Google Scholar 

  45. Burnand B, Vader JP, Froehlich F, Dupriez K, Larequi-Lauber T, Pache I, Dubois RW, Brook RH, Gonvers JJ (1998) Reliability of panel-based guidelines for colonoscopy: an international comparison. Gastrointest Endosc 47:162–166

    Article  CAS  PubMed  Google Scholar 

  46. Szpalski M (1996) The mysteries of segmental instability. Bull Hosp Jt Dis 55:147–148

    CAS  PubMed  Google Scholar 

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Acknowledgments

This study was supported by grants from “Eurospine, the Spine Society of Europe”, and the “Swiss National Science Foundation” (IZ32Z0_141535).

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Spine Center, Schulthess Klinik Zürich, Lengghalde 2, 8008, Zürich, Switzerland

    A. F. Mannion, F. Steiger, H.-J. Becker & F. Porchet

  2. Institute of Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland

    V. Pittet & J.-P. Vader

Authors
  1. A. F. Mannion
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  2. V. Pittet
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  3. F. Steiger
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  4. J.-P. Vader
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  6. F. Porchet
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Consortia

The Zürich Appropriateness of Spine Surgery (ZASS) Group

Corresponding author

Correspondence to A. F. Mannion.

Additional information

The Zürich Appropriateness of Spine Surgery (ZASS) Group: F. Balagué, J. I. Brox, C. Cedraschi, J. Fairbank, T. F. Fekete, P. Fritzell, D. Jeszenszky, J. Lurie, F. Pellisé, C. Reitmann, V. Sonntag, C. Standaert, M. Szpalski.

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Mannion, A.F., Pittet, V., Steiger, F. et al. Development of appropriateness criteria for the surgical treatment of symptomatic lumbar degenerative spondylolisthesis (LDS). Eur Spine J 23, 1903–1917 (2014). https://doi.org/10.1007/s00586-014-3284-0

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  • DOI: https://doi.org/10.1007/s00586-014-3284-0

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