The Spine Therapy Network Conference LearningsGrant
In February I had the pleasure of attending the inaugural Spine Therapy Network symposium (www.spinetherapynetwork.com). This is an initiative spearheaded by Dr. Michael Fehlings, a neurosurgeon with an extremely impressive resume from Toronto Western Hospital. The impetus for the founding of this group is the recognition that spine care requires specific expertise and to create a virtual network connecting patients and practitioners with advanced skills and expertise in spine care.
The one day event saw talks on topics by some of the leading researchers, surgeons, and conservative care practitioners in the Toronto. Likely my favorite aspect of the program set up was the design. Each topic had a surgeon, and either a chiropractor or physiotherapist together to speak on the same topic bringing to light co-management and two different lenses upon which to look at spine injuries.
The topics were wide ranging and included traumatic spinal cord injuries, degenerative spinal conditions, the Ontario Government funded ISAEC (Inter-professional Spine Assessment and Education Clinics) initiative, scoliosis, stenosis, oncological spines, syringomyelia and cysts, and degenerative cervical myelopathy. This was a lot in one day, and speakers only had 22 minutes each to present compelling research on each topic.
Below is a ‘mind dump’ of some of the more eye opening points that I found interesting. These are by no means complete, and other attendees likely found other points more engaging and more applicable to their practices. These were just some points that spoke specifically to me.
- Toronto is full of geniuses: Hearing the medical advances and research right from the researchers and doctors themselves made me consistently take a step back and recognize how fortunate we are to live in and near Toronto. These people are truly incredible and have brilliant minds. Though some of the talks (acute traumatic spinal cord injuries, syringomyelia, oncological spine) were very specific and not overly applicable to many of the attendees practices, just hearing a brief talk on these subjects was not just enlightening, but left us all awestruck. A quick example; Dr. Yee’s presentation on oncological spines where he suggested a near future advance will be radioablating spinal tumors (heat) using the same needle as you use to perform a cement augmentation for a pathological segment that has caused a kyphoplasty. A lot of big words to essentially say blowing up the tumor at the same time as you fix the broken vertebrae. Crazy.
- Conservative care practitioners will play a vital role in the future of spine care in Ontario. An example; advanced care physiotherapy triage in orthopaedic clinics has been shown to improve the accuracy of surgical candidates from 30% to 80% (which saves tons of money). Most stakeholders benefit from this – surgeons love it as it saves them a ton of time. The province loves it as it saves us all a ton of money. Patients are ‘so-so’ on it as they only want to see the surgeon for an opinion.
- Injections play a role in managing back pain, however to what extent is still not known. Likely my favorite talk of the day was from Dr. Soneji, a pain specialist who enlightened the audience with contemporary research on injections for low back pain. Below are some highlights:
- There are 2 million epidural steroid injections in the US/year which has doubled from 2000-2008!
- We know 70% of people with radiculopathy resolve within 6 months and the same amount have the disc completely resorb within one year. The steroid injection should solely be provided to decrease pain to allow rehabilitation during this time.
- Indications: leg pain due to disc/stenosis and it must be in the first 6 months. This was one of my major take homes of the day. The obvious issue is that to even see a guy like Dr. Soneji currently would likely take well in excess of 6 months.
- There is no evidence for epidural injections for non-specific low back pain (This cannot be overstated – NO EVIDENCE!)
- Despite epidural injections being the most widely studied procedure in pain science with over 45 placebo controlled studies there is only weak to moderate evidence for their efficacy.
- They are best for disc, and worse for stenosis (a 2014 New England Journal of Medicine Study actually showed the risks outweigh the benefits for stenosis).
- In their own practice they are only offered if:
- The patient has low back pain and radicular pain and is not a surgical candidate or there is a long wait list for surgery
- They have failed conservative therapy
- They are only repeated if there is >50% reduction in pain
- Minimum interval between injections is 4 months (they start with 2 within a 2-3 week interval)
- For facet joint injections – because they are reliably innervated they use a diagnostic medial branch block at the root and if >50-70% reduction in pain they are then a good candidate for a thermal ablation of the nerve after the second nerve block (to rule out false positives). (I found this pretty cool)
- An interesting study by this group for SI joint pain – they showed equally good outcomes for using ultrasound to guide injections here as for x-ray guided. Because ultrasound guided are not as accurate (meaning you would be injecting extra-articular areas sometimes versus just in the joint like with an x-ray) it proves that there are extra-articular structures contributing to SI joint pain.
- “We now let the sagittal plane dictate the coronal plane in surgical management of scoliosis.” This was from Dr. Stephen Lewis who showed SUBSTANTIALLY better outcomes nowadays with his surgical techniques that incorporate the sagittal plane on scoliosis surgery. In short, before while using Harrington Rods we were making spines too straight, which led to poor outcomes.
- THE ISAEC MODEL IS REALLY COOL AND WILL CONTINUE TO GROW: Rampersaud and Andrew Bidos presented on this. The main talking points were on messaging. As Dr. Rampersaud said we do a poor job of this. Our typical for people with low back pain is to say “you’re going to get better” however research shows 60% of people with back pain will get recurrent back pain and this creates significant frustration and ‘blaming the therapist’ who told them they would get better! Other crazy stats were that 50% of imaging in Ontario is MSK related and primarily for low back pain. We have increased imaging capacity by ten times in the last decade, yet there is STILL WAIT LISTS. This means way too many unnecessary MRI’s. ISAEC directly impacts this. In this free model, patients can see an ISAEC practitioner (chiro or physio) who have direct referral rights to specialists. Stats from the first 3 years show over 96% of referrals from ISAEC to specialists were actual surgical candidates. Even more important – less then 5% of all referrals end up having MRI’S. How huge is this? The program has been cost neutral – essentially the decrease in imaging costs has offset the entire cost of the program alone! You can see why the government extended funding for 3 years. Very exciting program. For a refresher on why MRI’s are often useless read this prior blog.
- By 2031 there will be over 3 million Canadians with stenosis and 27 million Americans. This is just population demographics. As our population gets older this will be more and more of an issue so practitioners need to be equipped with the appropriate tools to treat it! Carlos Ammendolia (chiropractor and researcher) presented his BOOT camp approach to this and the research his group is doing on this program that is based primarily on postural alterations to improve people’s function.
- Mark Irwin and Dr Fehlings really scared me about degenerative cervical myelopathy. The reason this is scary is how seemingly commonplace they made it seem and the fact that conventional manual therapy would potentially have disastrous sequelae if you miss one. For the therapists – here were my take homes:
- This is very often misdiagnosed as bilateral carpal tunnel syndrome: They both stated it is common to see these people in clinic with bilateral scars from failed ‘carpal tunnel releases’
- The most common sign is gait disturbance: Irwin went as far as suggesting tandem gait should be part of any cervical spine exam.
- The second most common sign is ‘clumsy hands’: ie “I have trouble doing up my buttons at the top of my sweater.
- With bilateral hand numbness think CSM first and everything else second.
- There will commonly be issues walking, issues with their hands, but no neurological signs and symptoms
- Full diagnosis of CSM:
- 1 neurological sign
- 1 neurological symptoms
- Positive MRI
Overall it was a very useful day with a few key take homes to better navigate co-management which is something we should all be striving for. The Spine Therapy Network is in it’s infancy. They are attempting to establish a network of professionals with advanced training (their criteria of this was presented at the conference) for ease of referrals and information transfer. There is a membership fee attached to this. There will also be a yearly conference which I will likely continue to attend.