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tomography, and operative findings. Spine (Phila Pa 1976) 1990;15(6):540-543.
Orthop Scand Suppl 1993;64(suppl 251):61-63.
root block: Correlation with clinical symptoms and MRI-pathology. Acta Neurochir
(Wien) 2004;146(6):559-565, discussion 565.
predict surgical outcome for lumbar and cervical radiculopathy: Comparison to
magnetic resonance imaging. J Spinal Disord Tech 2005;18(6):471-478.
Section 3
Medical Management of
Spine Disorders
SECTION EDITOR:
Scott R. Laker, MD
Chapter 9
Transdisciplinary Care for
Cervical Spine Disorders
Gregory Whitcomb, DC
Abstract
The neck comprises a system of highly integrated biomechanical,
neurophysiologic, and vascular functions that cannot be considered in
isolation. Overlapping cervical spine pathologies exist, and a variety of
interventions have evolved for each. In contrast, the clinical care systems
developed for patients with neck disorders have resulted in a relatively
segregated approach, which has been influenced by the training and biases
of the healthcare providers. In addition to physical factors, psychosocial
influences are equally critical to achieve effective care and outcomes.
Healthcare providers disregard the sum of these variables at potentially
great cost to patients and society. In the context of cervical spine disorders,
it is increasingly important to address the mounting evidence for the broader
and more dynamic framework of transdisciplinary care.
Keywords: care models; cervical spine; transdisciplinary care
Neither Dr. Whitcomb nor any immediate family member has received anything of
value from or has stock or stock options held in a commercial company or
institution related directly or indirectly to the subject of this chapter.
Introduction
Transdisciplinary care is not purely situational. Rather, it is dynamic and
additive, resulting in collective problem solving in the milieu of evidencebased care. Transdisciplinarity is a process that extends beyond simple
provider juxtaposition or the latest biotechnologic advances; it is based on the
recognition that no single best approach exists to treat neck pain,1 and that
fundamental change is needed in the care delivery process to improve access,
augment evaluation and diagnosis, and coordinate treatment in ways that can
effectively and affordably meet the myriad needs of patients with cervical
spine disorders and the communities in which they live and work.
Epidemiologic Considerations
The reach of cervical spine disorders is substantial and extends beyond
affected individuals to families, communities, healthcare organizations,
employers, governmental agencies, and health insurance systems.
Neck pain ranks as the fourth leading cause of disability globally,
2
following low back pain, depression, and arthralgias; notably, these
conditions often overlap. Up to one-half of adults will experience a clinically
meaningful episode of neck pain during their lifetime.3 Data show similarly
high rates of neck pain in the adolescent population.4 Study design variables
have resulted in wide variability in population–based prevalence rates,
ranging from 12% to as high as 70% and affecting up to 48% of workers,
11% to 14% of whom report related functional limitation. Neck pain and
headaches are strongly correlated.5 Disability from neck pain is present in up
to 12% of adults, and a progressive increase in emergency department visits
for neck pain has occurred over the past 3 decades.
6
Presenteeism, or working while sick, can cause productivity loss, poor
health, exhaustion, and workplace epidemics. Absenteeism has historically
received extensive attention in the human resource sciences; however,
presenteeism only recently has received scientific attention.7 Presenteeism
rates are among the highest for individuals with neck and upper back pain,
and psychosocial factors have a substantial relationship to reporting,
recovery,8 and disability.
9
Although disability caused by neck pain has a greater effect in the
industrialized world, data now show that it is a global problem, with a greater
effect on women than men. Neck problems are expected to compound
substantially in the future because of increasing child survival and aging
rates.
2
The costs related to treatment of neck pain are substantial, with
precipitous increases in surgical and nonsurgical treatment over the past 2
decades. Moreover, disparity in access to services10 as well as looming
changes related to reimbursement and medical malpractice11 reflect the cost
ineffectiveness of the current spine care system.12 Compounded by a crisis in
opioid use,13 this perceived lack of value has resulted in governmental,
institutional, and even public criticism of spine care providers, particularly
spine surgeons.
14*
At the same time, the overall well-being of physicians in the United
States is in decline, with high rates of stress, impaired work-life balance, and
burnout. Burnout in physicians is twice as high as in the general working
population.15 Although the dynamics associated with this trend are complex,
an increasingly corporatized16 and productivity-driven healthcare delivery
system is clearly associated with physical and psychologic stress,17 and spine
surgeons are among those most directly affected.
18
Traditionally, decision making for spine surgery is an individualized
process, with many options resulting in essentially equivalent outcomes.
19
When serious structural neck pathology may cause irreversible impairment,
surgery may ultimately be the most conservative approach.
Given the comparatively small percentage of patients likely to benefit
from surgery, optimal patient selection has resulted in strained access to
surgeons who spend substantial time treating distinctly nonsurgical spine
issues in high-volume outpatient clinics. Given the increasing emphasis on
optimizing patient-provider alignment and value, a spine surgeon’s time and
skills are clearly most effective when providing truly tertiary care. Intuitively,
data confirm that the time spent performing surgery is associated with higher
work satisfaction for surgeons.
15
Given the prevalence and personal and societal costs of cervical spine
conditions, as well as the associated stresses on those who care for patients
with these conditions, current patient care models clearly are not sustainable.
New thinking and broad systemic changes are needed to optimize outcomes
and reduce costs for patients with neck disorders.
Spine Care in a World of Global Transformation
The ability of emerging technologies to quickly disseminate information is
accelerating profound change at every level of human interaction, including
healthcare delivery and patient expectations. Internet access has resulted in a
fundamental transition from the patient as a passive recipient to an active
consumer of health care.20 Patients can be overwhelmed by the volume of
information (often of variable quality) and multiple treatment options.
21
Compounding work stress for healthcare providers,22 electronic medical
record (EMR) technologies now allow almost immediate contact between
providers and their patients, who are demanding faster access to clinical care.
Accordingly, spine clinicians are often tasked with rapid decision making that
can extend beyond the scope of their training and have potential medicolegal
ramifications.
Although marketed as a public benefit, information technologies are
progressively being used to monitor provider financial performance against
patient satisfaction, with powerful ramifications for healthcare systems. This
data management will likely result in new reimbursement strategies with
direct effects on providers and healthcare institutions.23 In addition, an
increasingly diverse patient population is demanding new competencies to
resolve disparities in health care.
24
Viewed collectively, these broad and compounding systemic effects
require integrated problem-solving across the disciplinary spectrum, and new
healthcare management strategies must play a central role in meeting the
needs of patients and those who bear the costs of their care.25 This will
require a shift from historically silo-oriented biomedical neck care to vastly
different strategies. For example, a recent study showed the relative
superiority of mindfulness-based stress reduction and cognitive behavioral
therapy compared with usual spine care,26 which led to the observation that
“there is an urgent need to rethink and reorganize care (for axial pain) at all
levels, so that the safest and most effective treatments are the most readily
accessible.”
27
Achieving Transdisciplinarity: The Chaordic Management Model
The following three questions were central to the foundation of Visa
International, which has risen to become the largest single block of consumer
purchasing power in the global economy.28 (1) Why are institutions
everywhere, whether political, commercial, or social, increasingly unable to
manage their affairs? (2) Why are individuals, everywhere, increasingly in
conflict with, and alienated from the institutions of which they are part? (3)
Why are the society and the biosphere in disarray? The essence of
transdisciplinarity systems resides in a narrow overlap between chaos and
order, termed chaordic, and is generally defined as any self-organizing, selfgoverning organization, community, or system with behavior that
harmoniously blends characteristics of both chaos and order.
28
Proponents of chaordic management propose that the newtonian
hierarchical command and control strategies of the Industrial Age have
resulted in most of the larger problems currently confronting society, and
integrated heterarchical solutions achieved through a constitution and
defining mission of a variety of invested stakeholders are necessary to meet
these problems. This thinking has direct relevance to the complexities of
spine care in a rapidly evolving and global healthcare system.
A Historical Perspective on Care Models
The Biomedical Model and the Importance of the Intervertebral
Disk
The Greco-Roman tradition of medicine was grounded in holism, which is
the concept of treating the whole person by considering spiritual, mental, and
sociocultural factors, rather than just the physical symptoms of a disease.
This view of patient care was lost in the orthodoxy of the Middle Ages. By
the 17th century, Vesalius and Descartes had laid the foundations for modern
anatomic study and mind-body dualism. With the rapid advancement in the
natural and biologic sciences in the 1800s, Koch, Pasteur, and Virchow
effectively codified the biomedical model as the centerpiece of 20th-century
Western health care.
29
Arguably, the single largest step toward the pathology model of spine
pain was Mixter and Barr’s 1934 publication, Herniation or Rupture of the
Intervertebral Disk with Involvement of the Spinal Canal.30 In a profoundly
biomedical fashion, their work made structural pathology the basis for axial
disorders and ultimately paved the way for the use of arthrodesis in treating
neck and back pain.
Given the advancements in instrumented and genetically enhanced fusion,
infection control, and anesthesia, and compounded by the infusion of
corporate capital and aggressive hospital marketing, the rate of spine surgery
in the United States (as opposed to much of the world) increased at a greater
rate than even that of total hip arthroplasty between 1998 and 2008. Costs
also soared.31 Despite evidence showing good outcomes for select
candidates, the massive increase in surgery has not yielded proportional
benefits.12 Payer and public repercussions have been strident. Criteria and
consensus for optimal surgical candidate selection remain priorities for the
spine surgical research community.
A Return to Holism, Complementary Alternative Medicine, and
Physical Therapy
Holism and vitalism (the doctrine that living organisms possess a nonphysical
inner force or energy that gives them the property of life) was popular during
the 18th and 19th centuries, and evidence confirms the use of manual
treatment of spinal disorders throughout history and across widely disparate
cultures. Counter to biomedical sensibilities, osteopathic and chiropractic
practitioners were soon attributing spine pain and systemic disease to such
entities as somatic dysfunction and vertebral subluxation, without an
objective basis for these conditions, let alone the wide-ranging effects
attributed to them. Legislation quickly became an agent to define and regulate
the practice of medicine, and such practices were effectively outlawed as
ineffective quackery. However, in contrast to biomedical models, perhaps the
most important contribution of these professions was the philosophy that
health is a part of the natural expression of the vitality innate in life. Wellness
through lifestyle is increasingly supported by science, and since 1948, the
World Health Organization’s constitution has defined health as “a state of
complete physical, mental, and social well-being and not merely the absence
of disease or infirmity.”
32
By the 1990s, increasing numbers of patients were seeking care for axial
pain outside standard medical practice. In addition, patients were willing to
obtain this care at substantial out-of-pocket expense.33 This exodus
powerfully demonstrated patient dissatisfaction with the limitations of
biomedical spine care.
Accompanying the expansion of care in other nonmedical spine
specialties has been the rapid growth of physical therapy. After World War II,
physical therapists assumed a critical role in the rehabilitation of thousands of
US soldiers, which resulted in the increasing awareness of the functional
aspects of musculoskeletal disorders. Particularly in countries other than the
United States, physical therapists also expanded the use of manual treatment.
For decades, the physical therapy profession functioned largely in the shadow
of medical physicians; however, physical therapists are now contributing to
musculoskeletal research, and the profession has become integral with spine
care in most healthcare systems.
This constellation of nonmedical healthcare providers has contributed to
the scientific understanding of neck pain and options for its treatment.
However, the competition for cultural authority among these professions
often has proved confusing for both patients and medical physicians. Systems
are needed to identify and align the benefits of each.
The Biopsychosocial Model
With advancement in the mental health sciences, the concept of biomedicine
was critically challenged at another level. In the late 1970s, a more
comprehensive approach to patient care was proposed34 and the
biopsychosocial model has since been validated and widely embraced in
spine care.
Subsequent work expanded on the concept of “illness behavior,” and
extensive research by spine-oriented psychologists has validated that
nonphysical factors are equally if not more influential on recovery and
progression from acute to chronic axial pain and related disability than is
physical pathology.35 Despite recognition of the importance of psychosocial
factors in best-evidence clinical guidelines, incorporation of the
biopsychosocial model has lagged.
36
In addition, advances in pain research have confirmed that nociception is
centrally processed and interpreted in complex ways, and chronic pain results
in functional changes in the brain.37 These discoveries are blurring the
margins of psychology and neuroscience, and reinforce the importance of a
better understanding of disability attributed to spinal pain. Evidence supports
the importance of mind-body approaches such as cognitive-based therapy as
critical to effective spine care.38 Strategies to address central pain processing
are gaining validity in biopsychosocial neck and back pain management.
39
From Monodisciplinary to Transdisciplinary Care
As a consequence of a long-standing silo-orientated approach to axial pain,
patients have been confronted by a daunting array of treatments and
confusion about selecting the best care.21 Multidisciplinary spine programs
became increasingly prevalent in the 1990s, partly as a result of the
disproportionate costs associated with the care of a small subset of spine
patients. These programs were often lengthy, intensive, and focused on the
small percentage of patients with the most chronic and debilitating back and
neck pain. Although outcomes were generally favorable, the expense and
duration of these programs compromised their value, necessitating alternative
strategies.
40
Subsequently, an interdisciplinary approach to spine care has gained
momentum. Intrinsic to both multidisciplinary and interdisciplinary program
approaches are structured multiprovider team evaluations and prescriptive
clinical pathways that can create bottlenecks to access and duplicative or
overlap services. Efforts to improve effectiveness have resulted in other
strategies. Optimal provider-patient alignment through subgrouping has
shown some promise, but more work is needed.
41,42
Large healthcare systems have promoted management of axial pain at the
primary care level; however, family and primary medical practitioners are in
short supply and musculoskeletal skills sets are lacking at this level.43 Direct
access to subspecialty spine care should not be limited to patients with
complex conditions, and evidence suggests that early care for patients with
comparatively straightforward neck problems may limit the progression to
chronicity.
44
Globalization and integration have resulted in an increasing recognition
of the importance of transdisciplinary research and organizational
management. Paralleling nature, transdisciplinary systems spontaneously
self-organize in response to both external and internal challenges. In the
clinical setting, transdisciplinarity offers flexibility and expediency in both
access and patient care.
Transdisciplinary Care for Cervical Spine Disorders
Implicit in transdisciplinary care is an understanding that the needs of
patients exceed the knowledge, training, and skills of any single provider.
The transdisciplinary approach is responsive on its margins, allowing
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