18
SPINE
SURGEONS
American College of
Physicians Releases New
Guidelines for Treating
Low Back Pain: 5 Key
Points
By Megan Wood
A
merican College of Physicians offers new
guidelines for how physicians should
treat low back pain, in an article pub-
lished in Annals of Internal Medicine. The guide-
lines are based on randomized controlled trials
and systematic reviews on noninvasive pharma-
cological and non-pharmacological treatments
of nonradicular low back pain.
Here are five key points:
1. The evidence-based clinical practice guide-
line, "Noninvasive Treatments for Acute, Sub-
acute, and Chronic Low Back Pain," recommends
treatment of acute or subacute low back pain
with non-drug therapies.
2. Some of these non-drug therapies include
superficial heat, massage, acupuncture or spinal
manipulation.
3. The society recommends providers prescribe
anti-inflammatory drugs or skeletal muscle relax-
ants if pursuing a drug therapy.
4. American College of Physicians suggests pa-
tients with chronic low back pain first try non-
drug therapy with exercise, multidisciplinary
rehabilitation, acupuncture, mindfulness-based
stress reduction, tai chi, yoga, motor control
exercise, progressive relaxation, electromyog-
raphy biofeedback, low level laser therapy, op-
erant therapy, cognitive behavioral therapy or
spinal manipulation.
5. Those chronic low back pain patients who
have experienced no response to non-drug
therapies should take NSAIDs first, and then tra-
madol or duloxetine as second line therapy.
"Physicians should consider opioids as a last
option for treatment and only in patients who
have failed other therapies, as they are associ-
ated with substantial harms, including the risk of
addiction or accidental overdose," said Nitin S.
Damle, MD, MS, MACP, president, American Col-
lege of Physicians. n
On June 7, 2016, Warsaw, Ind.-based Zimmer Biomet bought France-based
LDR, a medical device company with sales of $164.5 million in 2015, according
to Bloomberg. e acquisition strengthened Zimmer Biomet's MIS disc replace-
ment and spinal fusion portfolio.
13. Digital fluoroscopy, image guidance, high resolution endoscopy and mini-
mally invasive surgical tools all play a vital role in conducting minimally invasive
spine surgery. In addition, a recent study shows that patients benefit from a 61.6
percent to 83.5 percent radiation reduction when they undergo cannulation and
K-wire placement procedures.
14. According to the American Academy of Orthopaedic Surgeons, tubular re-
tractors create passageways for the surgeon to reach problematic areas in the
lower back while operating microscopes illuminate and magnify the target areas
during procedures.
15. Minimally invasive techniques can't treat everything or everyone, according to
Cleveland Clinic. Many minimally invasive spine surgeons limit their practice to
otherwise health patients under a certain BMI, ASA score and age.
16. Dr. Singh recently founded the Minimally Invasive Spine Study Group. MISSG
is a multi-institutional organization that promotes research and advancement of
minimally invasive spine surgery and houses REDCAP, an online patient registry
containing data from 3,000 patients treated with MIS techniques.
17. e Society for Minimally Invasive Spine Surgery was formed in 2007. e
organization strives to define and advance the field of minimally invasive spine
surgery. Greg Anderson, MD, serves as international chairperson; William Taylor,
MD, is the founder and current education chair; Kevin Foley, MD, is the research
chair; Larry Khoo, MD, currently serves as marketing chair; Roger Härtl, MD,
is centers of excellence chair; and Frank Phillips, MD, is regional chair (North
America).
e organization advocates on behalf of education, clinical research and docu-
mentation, marketing, MIS centers of excellence and governance as they pertain
to the ever-evolving MIS field.
18. MIS is more cost effective than open spine surgery, according to a 2011 study
published in SAS Journal, now known as the International Journal of Spine Sur-
gery. e study showed that minimally invasive transforaminal lumbar interbody
fusion was $14,183 on average while open lumbar fusion came out at $18,633.
A separate study, published in Journal of Spinal Disorders & Techniques in 2012,
found total inflation-adjusted acute hospitalization costs averaged at $20,187 for
one-level MIS procedures, whereas open surgery costs averaged out at $29,947.
19. Radiation exposure is a concern for spine surgeons and OR teams. A study pub-
lished in e Journal of Spinal Disorders and Techniques examined radiation ex-
posure during transforaminal lumbar interbody fusion, comparing MIS and open
techniques. e study authors found average fluoroscopy time during the open
procedure was 39.42 seconds, compared to 94.21 seconds during MIS procedures.
Patients who underwent the MIS procedure were exposed to 2.4-fold more radi-
ation than the open surgery patients. e increased radiation exposure could be
tolerable for patients, concluded the study authors, but surgeons performing a
high volume of these procedures throughout their career are taking precautions
to limit exposure.
20. All spine surgeries performed in ASCs are MIS. Between 1994 and 2006, pro-
cedures for intervertebral disc disorders increased 540 percent and spinal steno-
sis procedures increased 926 percent. During the same time, intervertebral disc
disorder cases in ASCs jumped 340 percent. Lumbar disc disease was the most
common diagnosis for spine patients during this time period. n
