Only about 10% to 15% of patients with low back pain who are referred to a spine surgeon actually require a surgical procedure. And because low back pain is such a common presenting complaint, many such patients often wait a long time for a surgery consult. In the December 19, 2018 issue of JBJS, Coyle et al. demonstrate that a simple, 3-item patient-administered questionnaire can identify those better suited for nonoperative management—and thus increase the likelihood that surgical candidates are seen by spine surgeons in an acceptable time frame.
All 227 of the Canadian patients enrolled in this randomized controlled trial received the questionnaire, which elicited information to distinguish between patients with leg-dominant radicular pain and those with back-dominant pain. Evidence-based guidelines recommend nonoperative management for most back-dominant pain, while patients with leg-dominant pain are more likely to need surgery. Researchers randomized 116 patients into an intervention group; these patients were triaged by a spine surgeon and then had their triage status upgraded if responses to the questionnaire indicated leg-dominant symptoms. The 111 patients in the control group were triaged only by a spine surgeon.
After triage, 33 of the 227 patients (15%) were recommended for a surgical procedure—16 from the intervention group and 17 from the control group. Of the 16 surgical candidates identified from the intervention group, 9 (56%) were re-prioritized on the basis of questionnaire results.
The median wait time for a consultation among the 16 surgical candidates in the intervention group was 2.5 months, compared with 4.5 months for the 17 surgical candidates in the control group. A significantly greater percentage of patients in the intervention group than in the control group were seen for a consult with a spine surgeon within the “acceptable” time frame of 3 months. Another benefit of the questionnaire approach evaluated in this study is that it helps identify nonsurgical candidates early, so they can be directed toward more appropriate treatment (such as physical therapy) rather than delaying treatment while waiting for a consult with a spine surgeon.
Although this study was conducted in the setting of the “nationalized” Canadian health care system, wait times to see orthopaedic surgeons and neurosurgeons are also long for many patients in many regions of the US. This questionnaire enhancement to triage could therefore be viable throughout North America, and perhaps beyond.
Often in life, when there are many potential solutions for a single problem, none of them is found to be universally better than the others. That certainly seems to be the case when it comes to treating type III- and -IV acromioclavicular (AC) joint dislocations. Multiple studies have tried to clarify whether nonoperative or operative management is superior in this relatively common injury, but it is becoming increasingly clear that there is no single “right” answer. Many patients do fine with nonoperative treatment; others report being highly satisfied with an operation.
In the November 21, 2018 issue of The Journal, Murray et al. try to provide further guidance for treating these injuries. They performed a prospective, randomized controlled trial that compared nonoperative treatment with open reduction and tunneled suspensory device fixation among 60 patients with a type-III or type-IV AC joint dislocation. The authors used DASH, OSS, and SF-12 scores to quantify functional differences between the groups at 6 weeks, 3 months, 6 months, and 1 year post-injury. They found that, while the operative group showed improved radiographic alignment of the AC joint compared to the nonoperative group, there were no differences in functional outcomes between the two groups at any time beyond the 6-week mark (at which point the nonoperative group had better outcomes).
Notably, 5 of the 31 patients allocated to nonoperative treatment ended up requesting surgical treatment for the injury because of persistent discomfort (4 patients) or cosmesis (1 patient). Also, not surprisingly, the mean economic expenditure in the fixation group was significantly greater than that in the nonoperative group.
Whether to provide operative or nonoperative treatment for type-III and -IV acromioclavicular joint dislocations is not an easy decision, and it entails multiple factors. While this study evaluates only one modern surgical technique for treating this injury, the data is valuable nonetheless for informing a shared decision-making process to help patients choose the most appropriate treatment for them. The good news is that, whether managed operatively or not, patients tend to improve significantly after these injuries, and after 1 year end up with a shoulder that functions well. The authors conclude that “the routine use of [this surgical procedure] for displaced AC joint injuries is not justified,” and that “treatment should be individualized on the basis of [patient] age, activity level, and expectations.”
Chad A. Krueger, MD
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