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Similarities and Differences in the Treatment of Spine Trauma Between Surgical Specialties and Location of Practice.

Health Services Research
Spine. 29(6):685-696, March 15, 2004.
Grauer, Jonathan N. MD; Vaccaro, Alexander R. MD; Beiner, John M. MD; Kwon, Brian K. MD; Hilibrand, Alan S. MD; Harrop, James S. MD; Anderson, Greg MD; Hurlbert, John MD, PhD, FRCSC, FACS; Fehlings, Michael G. MD, PhD; Ludwig, Steve C. MD; Hedlund, Rune MD; Arnold, Paul M. MD, FACS; Bono, Christopher M. MD; Brodke, Darrel S. MD; Dvorak, Marcel F. S. MD, FRCSC; Fischer, Charles G. MD; Sledge, John B. MD; Shaffrey, Christopher I. MD; Schwartz, David G. MD; Sears, William R. MD; Dickman, Curtis MD; Sharan, Alok MD; Albert, Todd J. MD; Rechtine, Glenn R. II, MD

Abstract:
Study Design. Questionnaires administered to practicing orthopedic and neurosurgical spine surgeons from various regions of the United States and abroad.

Objectives. To determine similarities and differences in the treatment of spinal trauma.

Summary of Background Data. Spinal trauma is generally referred to subspecialists of orthopedic or neurosurgical training. Prior studies have suggested that there is significant variability in the management of such injuries.

Methods. Questionnaires based on eight clinical scenarios of commonly encountered cervical, thoracic, and lumbar injuries were administered to 35 experienced spinal surgeons. Surgeons completed profile information and answered approximately one dozen questions for each case. Data were analyzed with SPSS software to determine the levels of agreement and characteristics ofrespondents that might account for a lack of agreement on particular aspects of management.

Results. Of the 35 surgeons completing the questionnaire, 63% were orthopedists, 37% were neurosurgeons, and 80% had been in practice for more than 5 years. Considerable agreement was found in the majority of clinical decisions, including whether or not to operate and the timing of surgery. Of the differences noted, neurosurgeons were more likely to obtain a MRI, and orthopedists were more likely to use autograft as a sole graft material. Physicians from abroad were, in general, more likely to operate and to use an anterior approach during surgery than physicians from the northeastern United States.

Conclusions. More commonalities were identified in the management of spinal trauma than previously reported. When found, variability in opinion was related to professional and regional differences. Spine 2004;29:685-696

(C) 2004 Lippincott Williams & Wilkins, Inc.

Buteyko UK trial funded by National Asthma Campaign (now Asthma UK)

Lifesource taught Buteyko breathing exercises in the first UK clinical trial to investigate the efficacy of Buteyko and yogic pranayama breathing as asthma treatments.

Science in its ideal form would remain open to reality, no matter what it would prefer that reality to be. However, the researchers, led by Professor Anne Tattersfield at the University of Nottingham's Division of Respiratory Medicine at the City Hospital, reported the Buteyko group’s reduction in bronchodilators in a way that was difficult to interpret. The reduction in asthma reliever medication was stated as being an average of two puffs per day. But if you look carefully through the whole article you will eventually find that the patients started with an average of two puffs per day; that is a 100% reduction in bronchodilators! There was no reduction in bronchodilators in the pranayamic or placebo groups.

The paper, published in Thorax, also includes the great improvement in asthma symptom scores and the reduction in inhaled corticosteroid use achieved by the Buteyko group. Out of twenty Buteyko participants involved in the steroid reduction phase of the study (attempted after six months) eight patients reduced inhaled steroid dose by 75-100% and three by 25-50%. Whilst this is almost double the improvement of the other two groups, the result is described as “non-significant.”

Indeed Asthma UK’s website reports that Susan Cooper, one of the leading researchers involved in the Nottingham trial, said that “there was no improvement to their [the Buteyko group’s] lung function and they were not able to reduce their dosage of inhaled steroids taken to keep their asthma under control.”

The first assertion is probably correct. Although the Buteyko method is successful at controlling asthma symptoms, Lifesource accepts that the Buteyko group’s reaction to irritating stuff being stuck down their airways after six months was no different to the reaction of the placebo or pranayamic groups. But so what? Lifesource did not expect that the reaction to provocation by the Buteyko group would change so dramatically in such a short space of time. It would take a long time for such huge changes to occur. The point is that Buteyko helps a person control symptoms, which reduces their need for medication and therefore the unpleasant side effects of asthma drugs.

The second statement that “they were not able to reduce their dosage of inhaled steroids” contradicts the researcher’s own findings, as published in their ‘scientific’ paper so should need no further explanation from us!

Interestingly, the Division of Respiratory Medicine at Nottingham City Hospital is currently engaged in yet another long-winded and expensive study to investigate the therapeutic effects on asthma of taping the mouth at night. This proved to be one of the most contentious aspects of the Buteyko method in the Nottingham trial, where participants were actively persuaded by the researchers not to bother with mouth-taping if they found it too distressing!

To date, the widespread and very powerful effects of the Buteyko method have been largely ignored or resisted by mainstream medicine, which continues to maintain that the symptoms of asthma, allergy and other breathing problems should be medicated away.

Having assumed this to be ‘true’, scientific research and so-called ‘non-profit’ asthma organisations, largely funded by pharmaceutical companies, spend millions of pounds analysing data in support of their existing beliefs.

Lifesource and increasing numbers of asthma and allergy sufferers, disillusioned with conventional asthma treatments, can only measure the effectiveness of the Breathology Programme experientially. In truth, if the glowing testimonials Lifesource receives supported orthodox medicine’s view, then doctors would call them case studies. Because they don’t they are dismissed as anecdotal.

This is the view of one of the Buteyko trial participants, three years after the study ended:

“I’m now the wrong side of 40 and still no inhalers. It was interesting to see the reports into our study. Does this mean that asthma sufferers are still at the mercy of doctors enjoying golfing weekends supplied by the pharmaceutical giants? What utter tosh! Good job we know
better. Still succeeding, still in control, still available as a living testimonial. Keep up the good work.”

A very large study, the Spine Patient Outcomes Research Trial (SPORT) has recently concluded and found that both surgical and non-surgical treatments tend to help patients with pain from a lumbar herniated disc. Due to problems with the study design, however, it is difficult to say much more than that. Unfortunately, because the trial did not demonstrate that surgery is superior to non-surgical treatments for a lumbar herniated disc, there is new concern among spine physicians that insurance companies may now cite this study as “evidence” that surgery is not necessary.

Lumbar laminectomy or microsurgical discectomy for lumbar disc herniations is the most common spine operation performed in the United States. Although this operation has a long history of safety and reliability, there are large variations in the frequency of the procedure in the U.S. There have been several studies in the past that have compared non-surgical treatment of lumbar herniated discs with surgical treatment, but none have been on the scale of the recently released Spine Patient Outcomes Research Trial (SPORT). Published in the Journal of the American Medical Association in November, 2006, this study was coordinated by Dr. James Weinstein of the University of Vermont. It began in 2000, and included 13 different sites. 500 patients who agreed to participate in the study were randomized into either surgical vs. none surgical treatment arms.

The purpose of the study was to determine if there was either equivalence or superiority betweeen the two types of treatment (surgery vs no surgery). The data were collected at multiple time intervals for 2 years and the two treatment arms were compared. Overall, both patient treatment groups had substantially improved by two years, and while there was a general tendency for the surgical group to do better, the differences between the two groups were not statistically significant.

Athough the two groups fared roughly the same, the authors could not conclude that surgical and non-surgical outcomes were equivalent, because:

* 45% of the patients randomized to the no-surgery group switched to having surgery, and
* 40% who were randomize to the surgery group declined the surgery.

With this amount of crossover, it was difficult to draw any solid conclusion as to whether or not the two treatment options were equivalent or if one is superior.

The main problem with non-adherence to randomization and the crossover between groups is that there was a general tendency for patients with severe symptoms to choose surgery even though they had been randomized to the no-surgery group.

Patients who had been randomized to surgery and subsequently declined to proceed with surgery tended to have less severe symptoms. The authors also very wisely followed the patients who declined to be randomized during the two year follow up. These patients chose to have surgery at a better than 5:2 ratio. Basically, if a patient has severe symptoms and cannot manage their pain through non-surgical treatment options they will choose to proceed with surgery.

Both treatment options did eventually lead to satisfactory results in the majority of patients, so it can be concluded that a patient with leg pain due to a disc herniation can expect a favorable outcome. This study also was consistent with past studies in that surgery leads to a quicker resolution of symptoms. Lastly, both treatment options are relatively safe. The surgery group had no complications in 95% of the cases, and not having surgery did not lead to any episodes of serious neurological damage (e.g. cauda equina syndrome).

What patients can conclude from this study is that if they have pain from a disc herniation, trying non-surgical treatment is a reasonable option. If they can control their pain with non-surgical treatment options (medicines, injections, therapy, manipulation, etc…) continuing with this type of treatment is reasonable. If not, surgery is a reasonable option and can be expected to lead to quick and reliable resolution of the patient’s symptoms.

For physicians, this study is useful in that it confirms that not all patients with leg pain (radiculopathy) from a lumbar disc herniation need surgery. It also confirms that surgery is safe and reliable for those patients who fail conservative treatment.

The real danger of a randomized controlled study of this magnitude that did not show superior results with the more expensive surgical treatment option, is the federal and private health care systems of this country may use this information to deny patients surgical treatment. Payors of all kinds are trying to ration care they will pay for based on “evidenced based” guidelines from the literature. What is not provided, however, by the literature is that not all diseases have the same severity. There was little stratification in this study as to severity of symptoms, and what little stratification there was showed a general tendency for patients with more severe symptoms to choose surgery, even when randomized to the no-surgery group.

In an effort to save money, payors would like to deny patients’ requests for invasive interventions. They will claim the treatment is medically “unnecessary”. Of course, they have not seen or examined the patient, and are simply following an algorithm. In our practice, we are already seeing insurance companies denying surgery for patients with severe leg pain due to a disc herniation unless they first have three epidural injections. We have observed that patients with a lot of tethering of their nerve root (a positive straight leg raise) actually have increased pain after trying to inject around the nerve root. I have also noted over the years that patients with a very shallow canal are less likely to benefit from non-surgical treatment. Patients who have already had their pain for several months can expect little benefit from an epidural injection. At any rate, there are always extenuating circumstances, and this should not be a decision made by the insurance company, but a decision made by the patient after consulting a spine expert. It would be a travesty if this very Herculean effort at a large research study such as the SPORT study was used to deny patients care that is beneficial in certain circumstances.