Wrapping Up Excellence: Final NASS 2024 Best Paper Q&As
NASS is pleased to present the last installment of our Q&A series with the authors of the Best Papers from the upcoming NASS Annual Meeting. This series has offered an in-depth look into the groundbreaking research and clinical advancements that are shaping the future of spine care. Each installment has highlighted significant research contributions, providing insights into the methodologies and clinical implications of the award-winning studies. Through this series, NASS aims to foster a deeper understanding and dialogue within the spine care community, supporting the ongoing pursuit of excellence in both research and clinical practice. In this third and final article, we turn our focus to the remaining Best Paper authors, whose innovative work continues to push the boundaries of spine research. Their detailed responses provide valuable perspectives on the challenges and opportunities within the field, contributing to the knowledge base that drives quality, cost-effective patient care. We encourage you to explore the insights shared by these distinguished researchers as we conclude this series. Their contributions underscore the importance of collaborative efforts in advancing spine care. For further information on the articles and the authors featured in this series, please visit SpineLine and the NASS Annual Meeting sections on the official NASS website.
68. Health economic analysis of neurologically intact thoracolumbar A3 and A4 fractures is dominant in supporting surgery over nonsurgical treatment
Author: Charlotte Dandurand, MD, MSc,
What question is your research attempting to answer?
The goal of the current study was to perform a cost-utility analysis comparing surgical and nonsurgical treatment for neurologically intact patients with thoracolumbar A3 and A4 fractures.
Please summarize your key findings and comment on the clinical significance.
At one-year postoperative, the ICER for surgical treatment was $191,648.00 USD per QALY while at 2-years, surgical treatment was dominant with a $28,978.50 saving per QALY. At 2-year follow-up, the nonsurgical group had more frequent physician and allied health visits and higher medication utilization, including opioids (2.66 vs 2.39 for NSAIDS) (1.52 vs 0.75 Opioids). The average workdays lost remained higher in the nonsurgical group (143.12 vs 114.78). The caregiver days taken off work remained higher in the nonsurgical group (29.86 vs 2.39). Surgical treatment provided a $25,530.18 saving per QALY over a working lifetime Surgery is the dominant treatment approach at 2-years post-treatment and through working lifetime in neurologically intact TL burst fractures from a societal perspective. Surgery is cost-effective largely due to the greater productivity loss of patients and caregivers within the nonsurgical group.Our findings suggest that a goal albumin of >3.7 g/dL for lumbar operations may improve postoperative outcomes and decrease healthcare costs in elective spine surgery.
What is surprising/exciting/different about your research results?
Literature comparing surgical and nonsurgical treatment has failed to show a substantial benefit in patient outcomes with surgery versus nonoperative management. Studies have highlighted the cost and rate of complications implicit in surgical treatment. Most comparative large-scale clinical studies have not found a difference in the rate of return to work and other clinical outcomes between surgical and nonsurgical management. Therefore, finally approaching consensus via health economics in this ongoing debate is exciting. How can this research ultimately apply to or benefit spine patients?
The unique finding in this investigation is to what degree the cost for surgical intervention were offset largely due to the productivity loss and higher caregiver costs of nonsurgical patients. For young patients and caregivers where productivity is important, our study shows that surgical management is beneficial from a societal perspective. In what ways do you envision your research influencing or shaping future directions in spine-related research, clinical practice, or health policy?
This is the largest prospective international cost-utility analysis of thoracolumbar burst fractures. This health economics study relies on a societal perspective that measures healthcare utilization and future direct and indirect costs and benefits, particularly those that impact the patient and caregivers’ ability to return to sustained and productive work. The study includes all costs regardless of who paid. In societies valuing productivity and faster return to work, we can anticipate a shift towards a higher rate of surgical management for those fractures. Is there anything else you would like readers to know about this paper?
This paper provides exciting new information that may help settle the ongoing debate between surgical management and nonsurgical management in thoracolumbar burst fractures without neurological deficits.
69. The relationship between paraspinal muscle atrophy and degenerative lumbar spondylolisthesis at the L4/5 level 1
Author: Paul Köhli, MD
What question is your research attempting to answer?
What is the relationship between the degeneration of the paraspinal musculature and the development of degenerative lumbar spondylolisthesis at the L4/5 level? Please summarize your key findings and comment on the clinical significance.
We observed that patients with more degenerative slippage at the L4/5 level, had more degeneration of the posterior paraspinal muscles, which are responsible for the stabilization of the lumbar spine. This effect was still observed when adjusting our analysis for potential confounders. This points towards a direct interrelationship between muscle degeneration and higher degree of relative slippage in degenerative spondylolisthesis. What is surprising/exciting/different about your research results?
Surprisingly, the anterior muscle, the psoas, showed a relatively higher functional cross-sectional area with a higher degree of slippage. This could mean that an imbalance between the relatively weakened posterior stabilizers and the anterior psoas muscle could result in an unfavorable load distribution on the L4/L5 segment, leading to a vicious cycle of ongoing segmental degeneration and progressive slippage.
How can this research ultimately apply to or benefit spine patients?
If future studies further support our findings, therapeutic interventions that improve paraspinal muscle health could potentially be used to delay or even halt the progression of early-stage degenerative spondylolisthesis. In what ways do you envision your research influencing or shaping future directions in spine-related research, clinical practice, or health policy?
Improvements in spinal health require increased efforts in primary and secondary prevention and disease modification. The paraspinal musculature may be a promising target for interventions. Novel MRI-based paraspinal muscle measurements may provide a more objective, early measure to determine the efficacy of preventive interventions. However, further studies are needed to verify this. Is there anything else you would like readers to know about this paper?
We would like to encourage large cohort, longitudinal studies on the role of paraspinal muscle quality in low back pain and lumbar degeneration. A more nuanced understanding of the differential pathogenesis of lumbar pathologies may help to develop personalized treatment approaches in the future.
Figure. Simplified model of the findings on the potential role of the paraspinal muscles in degenerative lumbar spondylolisthesis L4/5. The degeneration of the dorsal stabilizers, coupled with relatively stronger psoas, could lead to ventralizing and kyphosising forces on the L4 vertebra, thus contributing to the progression of slippage in degenerative lumbar spondylolisthesis. The psoas is depicted red, multifidus in green, and erector spinae in violet.
70. Survival analysis of patients with metastatic osteosarcoma: a surveillance, epidemiology, and end results population-based study
Author: Kaiyuan Lin, MD
What question is your research attempting to answer?
The present study is aimed at investigating whether 1) primary tumor surgery confers an improved survival on patients with metastatic osteosarcoma, and 2) primary tumor surgery influences survival of patients with metastatic osteosarcoma differently according to primary tumor site. Please summarize your key findings and comment on the clinical significance.
- Primary tumor surgery is associated with improved overall survival (OS) and cancer-specific survival (CSS) in metastatic osteosarcoma patients.
- Stratified analysis by primary tumor site reveals that primary tumor surgery confers a survival advantage in extremity osteosarcoma cases but not in axial osteosarcoma.
- There is no significant difference in survival outcomes between different types of surgery (resection vs amputation).
- The clinical significance of these findings lies in providing evidence for the prognostic benefit of primary tumor surgery in metastatic osteosarcoma patients. Understanding that the survival advantage varies based on the primary tumor site can help guide treatment decisions, potentially leading to more tailored and effective management strategies for these patients.
What is surprising/exciting/different about your research results?
Our research results affirm the importance of primary tumor surgery in improving survival outcomes for metastatic osteosarcoma patients, particularly those with extremity tumors. However, the lack of survival benefit in axial osteosarcoma patients may challenge traditional treatment approaches and necessitate a reevaluation of current practices for this subgroup of patients. How can this research ultimately apply to or benefit spine patients?
Our research can ultimately benefit spine patients by informing treatment decisions and improving prognostic outcomes. By demonstrating the varying impact of primary tumor surgery based on the primary tumor site, clinicians can better personalize treatment plans, potentially leading to improved survival rates and quality of life for spine patients with metastatic osteosarcoma. In what ways do you envision your research influencing or shaping future directions in spine-related research, clinical practice, or health policy?
This study may influence future directions in spine-related research, clinical practice, and health policy by highlighting the importance of considering primary tumor site in treatment decision-making for metastatic osteosarcoma patients. It may stimulate further research into tailored treatment approaches for different tumor locations and foster discussions around optimizing healthcare policies to support such personalized treatments. Is there anything else you would like readers to know about this paper?
Readers should note that while the study provides valuable insights into the role of primary tumor surgery in metastatic osteosarcoma, it is retrospective in nature and has certain limitations, including the lack of data on chemotherapy response and the retrospective design. Future prospective studies are warranted to validate and expand upon these findings.
71. Difference in the Cobb angle between standing and supine position as a prognostic factor after vertebral augmentation in osteoporotic vertebral compression fractures
Author: In-Suk Bae, MD, PhD
What question is your research attempting to answer?
This study aims to analyze factors affecting the clinical outcome after vertebral augmentation in patients with osteoporotic vertebral compression fracture (OVCF). We retrospectively analyzed patients with OVCF undergoing vertebral augmentation to compare the Cobb angle changes in the supine and standing positions and the clinical outcomes. We hypothesized that the degree of difference in the Cobb angle according to the posture would affect the clinical outcomes after vertebral augmentation. Please summarize your key findings and comment on the clinical significance.
To the best of our knowledge, this study is the first to suggest that the difference in Cobb angle between the standing and supine positions is related to the clinical outcomes after vertebral augmentation in patients with OVCF. We found that the differences in the Cobb angle and compression ratio between the standing and supine positions were related to clinical outcomes after vertebral augmentation in patients with OVCF.
What is surprising/exciting/different about your research results?
The outcome after vertebral augmentation was better when there was a difference of approximately 35% or more in the Cobb angle between the standing and supine positions. Surgeons should pay attention to the difference in the Cobb angle depending on the posture when deciding to perform vertebral augmentation in patients with OVCF.
How can this research ultimately apply to or benefit spine patients?
OVCF can be managed with cement augmentation, which is a less invasive procedure than spinal fusion. However, the most appropriate method should be selected based on the patient’s condition and understanding of each surgical method. It is thought to be helpful in determining treatment methods in patients with OVCF.
In what ways do you envision your research influencing or shaping future directions in spine-related research, clinical practice, or health policy?
It is thought to be helpful in determining treatment methods in patients with OVCF. Depending on the degree of Cobb angle change, it can be decided whether to perform conservative treatment or surgical treatment. Is there anything else you would like readers to know about this paper?
Doctors and patients should pay attention to the difference in the Cobb angle depending on the posture when deciding to perform vertebral augmentation in patients with OVCF.
72. Physical activity intervention to improve surgical spine outcomes (PASS Trial)
Author: Kristin Archer, PhD, DPT
What question is your research attempting to answer?
We wanted to know if a telehealth physical activity intervention focused on walking that includes wearable technology and goal-setting with a physical therapist improves outcomes after lumbar spine surgery. Please summarize your key findings and comment on the clinical significance.
We found that individuals in the remote physical activity intervention group had better outcomes at 6-months after surgery when compared to usual care. Patients engaging in a structured remote physical activity program spent more time in moderate-to-vigorous activity, reported better physical function, had less back pain, and were more likely to return to physical activity by 6-months postop. The intervention seemed to be most effective for patient-reported physical function and back pain at 6-months after surgery. What is surprising/exciting/different about your research results?
We were excited to see meaningful changes in physical activity, physical function, and back pain at 6-months after surgery, which is what we hypothesized. However, we were surprised there were no differences in steps per day between the groups, especially as we found a difference in physical activity intensity (ie, more time in moderate-to-vigorous activity). The majority of participants in the intervention group engaged with their physical therapist remotely and met their step goals. Fitbit data showed improvement in steps per day over the 8-week intervention; however, steps per day were lower than expected when assessed over a 7-day period by an accelerometer. How can this research ultimately apply to or benefit spine patients?
This research highlights the importance of walking after spine surgery to improve outcomes that are meaningful to patients. In addition, the research shows the benefits of using wearable technology, such as a Fitbit or activity watch, to improve patient engagement in physical activity. In what ways do you envision your research influencing or shaping future directions in spine-related research, clinical practice, or health policy?
We envision this research influencing rehabilitation after surgery and shaping surgeon recommendations to patients. Walking is an accessible and cost-effective way for patients to improve their outcomes. Physical therapists can easily incorporate walking and goal-setting into rehabilitation programs, while surgeons can discuss the importance of walking soon after surgery and the benefits of tracking their steps with patients. Is there anything else you would like readers to know about this paper?
This research adds to the growing literature on the safety and effectiveness of telehealth rehabilitation programs and the importance of engaging patients in activity that is meaningful to them.
73. Defining the normative level of functional low back pain disability in the American population: A crowdsourced evaluation of the Oswestry Disability Index
Author: Rakesh Kumar, M.Ch, MS, MBBS
What question is your research attempting to answer?
The research aims to determine the normative range of functional low back pain disability, as measured by the Oswestry Disability Index (ODI), within the diverse American population. Please summarize your key findings and comment on the clinical significance.
- The mean ODI score for the American population is 14.35.
- ODI scores increase with age, peaking at ages 70-79.
- Females have higher mean ODI scores in certain age groups (18-29, 50-59, 60-69).
- A weak positive correlation exists between BMI and ODI scores (r = 0.22, P < .001).
Clinical Significance: These findings provide a benchmark for assessing low back pain disability in the US, enabling health care professionals to tailor interventions based on age and sex. This can improve patient care and inform treatment strategies for LBP-related thoracolumbar pathology.
What is surprising/exciting/different about your research results?
Our research provides the first comprehensive normative data for the ODI across a diverse American population. This is exciting because it establishes a baseline for functional low back pain disability, allowing for more accurate assessment and comparison of patient outcomes. Additionally, the findings reveal specific age and sex differences in ODI scores, which can refine and personalize treatment strategies. The weak positive correlation between BMI and ODI scores also offers new insights into the role of body weight in low back pain disability, potentially influencing future preventative and therapeutic approaches. How can this research ultimately apply to or benefit spine patients?
This research can benefit spine patients in several ways:
- Improved Diagnosis: By providing normative ODI values, clinicians can better identify and quantify the severity of a patient's low back pain disability compared to a standardized baseline.
- Personalized Treatment: The insights into age- and sex-specific ODI variations enable more tailored treatment plans, improving the effectiveness of interventions.
- Outcome Evaluation: Health care providers can use the normative data to more accurately assess treatment efficacy, ensuring that interventions lead to meaningful improvements in patient outcomes.
- Cost Efficiency: Enhanced diagnostic precision and personalized treatment approaches can potentially reduce unnecessary tests and treatments, leading to cost savings for both patients and healthcare systems.
- Insurance and Payment: Normative data can support the development of standardized guidelines for insurance coverage and reimbursement, making the process more consistent and potentially less burdensome for patients.
Overall, these benefits can lead to better care, more effective treatments, and reduced healthcare costs for spine patients. In what ways do you envision your research influencing or shaping future directions in spine-related research, clinical practice, or health policy?
Our research can influence and shape future directions in several ways:
- Research Foundations: Establishing normative ODI values provides a benchmark for future studies to compare patient populations and assess the impact of various interventions on low back pain disability.
- Clinical Guidelines: The data can inform clinical practice guidelines, leading to more standardized assessments and treatments for low back pain across diverse populations.
- Personalized Medicine: Insights into age- and sex-specific differences in ODI scores can drive research into tailored treatment approaches, potentially leading to more personalized and effective care strategies.
- Preventative Strategies: The correlation between BMI and ODI scores highlights the importance of weight management in preventing and managing low back pain, encouraging further research into preventative measures and lifestyle interventions.
- Health Policy: Normative data can support the development of evidence-based health policies, influencing insurance coverage, reimbursement rates, and resource allocation for spine-related healthcare services.
- Patient Education: Understanding the typical progression of low back pain disability can aid in educating patients about their condition, setting realistic expectations, and promoting engagement in their treatment plans.
Overall, this research sets the stage for more precise, effective, and equitable management of low back pain, ultimately improving patient outcomes and optimizing healthcare resources.
74. Performance comparison between Hounsfield Units and DEXA in predicting lumbar interbody cage subsidence after circumferential lumbar fusion
Author: Lindsay D. Orosz, MSPA-C
What question is your research attempting to answer?
This study aimed to determine if Hounsfield Unit (HU) cutoff value HU<135 was associated with lumbar interbody cage subsidence and to compare the predictive performance of subsidence between HU and DXA in the lumbar degenerative population.
Please summarize your key findings and comment on the clinical significance.
Among this cohort of lumbar fusions for degenerative pathologies, HU<135 was associated with interbody subsidence while DXA lowest T-score was not. The odds of developing subsidence were 4.0 times higher for HU<135 after controlling for other subsidence risk factors, supporting this cutoff value. This study demonstrates that HU is a reliable predictor of interbody subsidence and outperformed DXA, suggesting that in the degenerative lumbar population, DXA may not accurately represent lumbar spine bone quality. Spine surgeons should consider adding HU measurements into their preoperative routine when CT scans are available. What is surprising/exciting/different about your research results?
As bone health awareness among spine surgeons is increasing, the tools to measure bone quality are under greater scrutiny based on the potential value they add to the surgical planning process. While DXA is the gold standard measurement of bone mineral density (BMD), T-scores are often falsely elevated in the degenerative population, which can be misleading. If a CT scan is available, which it often is today, then it takes only seconds to obtain an additional BMD data point using HUs at the surgical region of interest. This information can lead to more appropriate surgical planning and improved surgical outcomes. How can this research ultimately apply to or benefit spine patients?
Better surgical planning based on accurate bone density has the potential to avoid bone-related complications and improve surgical outcomes for patients. In what ways do you envision your research influencing or shaping future directions in spine-related research, clinical practice, or health policy?
We envision this study contributing to the increasing awareness among spine surgeons of the utmost importance of bone health assessment and optimization prior to surgery. Routine consideration and screening for osteoporosis will undoubtedly lead to more diagnoses being made. This may help move the needle in terms of broader treatment availability for patients with osteoporosis. Is there anything else you would like readers to know about this paper?
Once you start routinely measuring Hounsfield Units on patients with lumbar degenerative pathologies, it becomes much clearer how often DXA overestimates BMD, as shown in the case example (below).
75. Epidemiology of recreation-related cervical and thoracic fracture
Author: Alan Daniels, MD (CONFIRM)
What question is your research attempting to answer?
Our project aimed to identify recreational activities that are high-risk for cervical and thoracic spinal fractures in order to better inform activity specific public safety interventions. Please summarize your key findings and comment on the clinical significance.
This study identified a higher rate of recreation-related cervical fractures in male sex but no sex difference in the rate of recreation-related thoracic fracture, which may suggest male sex dominated sports have greater risk for cervical trauma. Overall, football and horseback riding were the most common causative activities for cervical and thoracic fracture. When stratified by age, football was the most common causative activity in individuals <18 years old whereas horseback riding was the predominant causative activity in patients >18 years old.
What is surprising/exciting/different about your research results?
While some studies have categorized patterns of spinal fractures, many are limited to single centers. Comprehensive analyses of large, multi-center samples of recreation-related cervicothoracic fracture cases have not previously been performed. Our findings reaffirm the need for sport-specific and potentially even participant-tailored improvements in prevention efforts to mitigate recreational injuries. In what ways do you envision your research influencing or shaping future directions in spine-related research, clinical practice, or health policy?
These results support developing improved safety precautions and improving communication with participants regarding fracture risk. In football for cervical fracture, helmet modifications can be considered and in horseback riding for thoracic fracture increased utilization of back protection may prove beneficial. Additionally, given the heightened axial loading of the spine during horseback riding, elderly individuals with comorbid osteopenia/osteoporosis should be well-informed of the potential risk of injury.
76. Clinical and patient-reported outcomes of adult spinal deformity surgery with 10-year follow-up
Author: Peter Passias, MD
What question is your research attempting to answer?
Adult spinal deformity (ASD) surgery is a niche arena of spine surgery, but the population of patients with ASD necessitating correction is ever-expanding. As surgeons gain more experience with ASD corrective deformity and as new techniques and tools, including robotic and AI assistance, are being incorporated, we aim to better understand how does this growing body of knowledge influence long-term patient outcomes. Currently, there are many studies focusing on short- to mid-term outcomes, but our work represents one of the first cohorts with such long-term follow-up.
Please summarize your key findings and comment on the clinical significance.
We found 75.6% of patients were able to attain the minimum clinically important difference across multiple quality-of-life measures at 10 years, indicating the long-term durability of benefits conferred by adult spinal deformity. There was a high rate of complications, although the minority of these were considered "major", but overall the mortality remained low (6.1%) at 10 years. What is surprising/exciting/different about your research results?
The low mortality rate at 10 years is extremely encouraging, especially considering this cohort of patients can tend to be elderly and frail. With advances in preoperative optimization and given the trend towards more minimally invasive ASD surgery, it is our ultimate hope that patients who need ASD surgery can successfully undergo surgery that leads to a long, improved life. How can this research ultimately apply to or benefit spine patients?
We are in a continual effort to minimize the morbidity and mortality of adult spinal deformity and associated surgeries. This study informs the expected long-term benefits and risks associated with such intensive surgery, with the hopes of allowing patients and their families some ease of mind and more information when weighing the anticipated clinical benefit of pain relief, improved quality of life, and increased functionality with the risks of surgery. In what ways do you envision your research influencing or shaping future directions in spine-related research, clinical practice, or health policy?
Better understanding the relative risk posed by various ASD-related complications may help surgeons better anticipate possible complications and try to mitigate these pre- and intra-operatively such as preoperative prehabilitation, frailty optimization, and utilization of alignment planning tools or novel technologies/approaches. Also, as ASD surgery can pose a large financial burden not only in-hospital but also post-operatively in terms of rehabilitation, perhaps studies like ours can justify why upfront investment in greater pre- and post-operative resources and coverage might minimize the risk of costly readmissions and reoperations.