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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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founders created a strong interdisciplinary team, a robust process of
coordinated communication and care, and outcomes-driven research. TBI is
currently considered one of the most comprehensive interdisciplinary spine
specialty institutions in the world.
In 2000, VMMC in Seattle, Washington, developed an innovative
performance improvement initiative after recognizing that its traditional
fragmented system of care was inefficient and financially not sustainable.
This institution created an integrated, interdisciplinary, and value-driven
model that achieved extraordinary success and now serves as a model for
other US institutions.49 VMMC made a commitment to ensuring that the
organization operated from the top down, with a common vision and mission
among local and national leadership to deliver quality health care and service.
VMMC performed a comprehensive analysis of its processes and resources to
develop a model of “lean” methodology similar to that used by the Toyota
Production System, with a determined focus on eliminating waste and
inefficiency. The model was called the Virginia Mason Production System;
implementation began in 2004. The stated vision and mission and the new
process of efficiency achieved enhanced patient outcomes, higher
performance ratings, greater employee satisfaction, and fiscal growth. In
addition, the system of interdisciplinary care inspired external collaborations
with nontraditional stakeholders such as employers, third-party payers,
community leaders, and political representatives. This marketplace
collaborative led to better aligned expectations and attention to favorable
mutual returns on investments, with an enhanced value proposition for all
stakeholders.
Table 4
The marketplace collaborative led to multiple plenary sessions that
resulted in the development of “clinical value streams” for various medical
conditions that represented high volume, high cost, and inadequate
outcomes.49 These clinical value streams represented optimal care plans and
were developed with consideration of the needs of all stakeholders (Figure
1). These shared needs formed the definition of quality within the VMMC
community collaborative. The five key domains included patient satisfaction,
evidence-based care, rapid access to care, rapid return to function, and cost.
Specific to the VMMC value stream for back care, the measurable
outputs include more efficient use of physician time, accommodation of a
64% increase in patient volume without the need for extra space, and more
efficient billing (an uptick to 58.3 relative value units on an average per day
basis compared with 28.1 under the old system).49 Costs to self-insured
employers also decreased. Rapid access to care resulted in a 50% decrease in
lost work days by patients and less use of healthcare resources. For patients
requiring spine surgery, the new approach resulted in lower complication
rates and enhanced patient safety50 (Figure 2).
The DHMC developed its integrated spine center in collaboration with
the Dartmouth Institute and launched the specialized facility in 1997. The
mission of the Spine Center is to provide a comprehensive program of
interdisciplinary care that is both high quality and cost-efficient.51 The
DHMC Spine Center publicly presents itself as a “one-stop shop” that
provides an interdisciplinary experience that is stratified and triaged from the
outset. Through this care continuum, 90% of patients complete the care
process without needing surgery. The DHMC Spine Center uses a
Figure 1
collaborative and cooperative approach that places a high value on team
member input and, in turn, leverages the skill sets and knowledge of each
team member to the highest level of his or her licensure. The result is an
inspired employee and patient experience that is supported by written care
pathways, data collection, outcomes analysis, and continuous refinement for
performance improvement and enhanced multi-stakeholder value attainment.
Illustration showing an example of a clinical value stream
and the associated savings.
The organizational vision of the DHMC Spine Center, the inclusive and
collaborative interdisciplinary environment, the recognition of unique and
important value propositions specific to all stakeholders, and a culture of
objective data collection and analytics have elevated the program to national
acclaim and serve as an excellent interdisciplinary model for other US spine
programs.
The Role of Medication in Managing Low Back Pain
Medications play a small but often important role in managing both acute and
chronic LBP. Some medications are used for both acute and chronic LBP,
whereas other medications are used for only acute or only chronic LBP.
Acute Low Back Pain
In patients with acute LBP, medication is used to decrease pain, maintain or
improve function, and lessen the chance of progression to a chronic state. To
date, most medications have not been shown to improve on the natural
history of LBP. Most patients with acute LBP recover fully, but one-third do
not recover.52 Patients with higher levels of initial pain, poorer function, and
only minimal pain improvement after 1 week seem to have the worst longterm outcomes.52 Patients should be reevaluated approximately 1 week after
their initial presentation for reassessment of pain, disability, and medication
use. If no improvement is seen, a different management approach should be
considered.
Acetaminophen
Acetaminophen had been recommended by multiple systematic reviews and
guidelines,
42,53
but a recent study showed acetaminophen to be no better than
placebo.54 In addition, many patients have already tried acetaminophen and
might be skeptical of a physician who recommends this over-the-counter
drug.
Figure 2
Illustration of the strategic plan of the Virginia Mason
Medical Center in Seattle, Washington. (Copyright Virginia
Mason, Seattle, WA.)
Nonsteroidal Anti-inflammatory Drugs
NSAIDs are also often recommended, but these drugs cannot be relied on.
Some studies and systematic reviews have suggested efficacy (although often
without a clinically meaningful improvement) in patients with acute LBP, but
others have not.
46,55,56
However, NSAIDs are used frequently to manage LBP
and appear to help some patients. No criteria are available that can help in the
selection of patients who might have a positive response to
NSAIDs.
42,46,53,55,56
It is clear that no one NSAID is better than any other.
Side effects of NSAIDs are more common than those of a placebo, but with
short-term use, adverse effects are rarely serious. No additional relief is
gained by using a skeletal muscle relaxant or low-dose opioid in addition to
an NSAID.57 A reasonable clinical strategy may be to try using an NSAID in
low-risk patients. If there is no benefit in approximately 7 days, NSAID use
should be discontinued in favor of other medication or nonpharmacologic
treatments. For radicular pain, NSAIDs do not appear to be helpful.
58
Skeletal Muscle Relaxants
Skeletal muscle relaxants are beneficial to some patients with acute LBP and
may be appropriate for initial treatment.
59,60
Even with short-term use,
adverse side effects, including dyspepsia, sedation, and dizziness are
common but usually not serious with short-term use. Elderly patients are
quite susceptible to the relaxants’ anticholinergic effects, and there is
potential for abuse and dependence on these medications. There is no benefit
to combining a skeletal muscle relaxant with an NSAID.57 No single skeletal
muscle relaxant is better than another. The use of skeletal muscle relaxants
should be limited to 10 to 14 days.
Corticosteroids
Corticosteroids are generally ineffective for acute LBP. A single dose of
intravenous dexamethasone can reduce pain for at least 24 hours and reduce
the length of stay in the emergency department, but benefits are neither
substantial nor sustained.61 The use of prednisone in the emergency
department has not proven helpful.
62
Opioid Analgesics
Opioid analgesics for acute LBP have not been specifically studied, but
opioids have been found to be effective in other acute musculoskeletal
conditions.63 Short-term use of opioids might reduce pain and help maintain
function.64 In a study of early users of opioids, 5% become long-term users,
although it is not known whether this resulted from the severity of injury,
opioid misuse, addictive disease, or other causes.
65
After weighing the benefits and risks, it seems reasonable to consider an
opioid trial if a patient continues to have moderate to severe pain at
approximately 1 week after initial presentation. Prior to initiating opioid
treatment, it is appropriate to obtain a history of any opioid, alcohol, or
chemical dependence; learn the psychosocial situation of the patient; and
consult a state prescription drug-monitoring database. For acute pain, only a
short-acting opioid should be used, preferably a drug without acetaminophen.
The dose should be sufficient to provide meaningful relief. Low-dose opioids
do not add analgesic benefits to naproxen.57 It is strongly recommended that
the initial prescription of opioids be for a maximum of 7 days and only
enough to last until a scheduled follow-up visit. The prescription should not
be automatically refilled without a patient visit. It is reasonable to assume
that it is not the first prescription of the opioid that creates the highest
potential for subsequent opioid misuse. Problems are more likely associated
with an unwarranted refill, too high a dose, allowing refill without a patient
visit, or oversupply without proper disposal.
65
Other Medications
Other medications such as antidepressants and anticonvulsants do not have a
role in managing acute LBP.
Chronic Low Back Pain
Most patients with acute LBP recover in approximately 3 months, although
recovery may take up to 6 months in some patients. After 3 months, however,
recovery is much less likely. Chronic LBP can be defined as LBP that is
present after 3 to 6 months. The pain can be primarily axial, primarily in an
extremity, or a combination of both. Causes can be nociceptive, neuropathic,
or mixed.
66,67
These distinctions affect the choice of medication.
Acetaminophen
Acetaminophen is not very helpful for chronic LBP, but many patients use it.
Because of potential liver toxicity, patients should be counselled against
using more than 2 g of over-the-counter acetaminophen per day. It is
especially important to determine if the patient is taking any prescription
drugs that also contain acetaminophen.
Nonsteroidal Anti-inflammatory Drugs
It is worthwhile for patients with chronic LBP to try NSAIDs, but benefits
and the degree of relief (if any) are unpredictable.
46,68
A small number of
patients respond well enough to consider long-term use. However, long-term
use has a high potential for adverse effects, some of which can be serious,
especially in elderly patients and those with medical comorbidities. After an
explanation of risks versus benefits, it seems reasonable to offer a low-risk
patient a therapeutic trial of NSAIDs. If a good response occurs, NSAID use
can be continued with frequent monitoring of the clinical response along with
renal, hepatic, and hematologic laboratory studies.
Skeletal Muscle Relaxants
Because the effectiveness of skeletal muscle relaxants usually wanes after
approximately 10 to 14 days, there is limited or no role for this type of
medication in chronic LBP, except perhaps for acute flares.
Corticosteroids
No studies are available evaluating corticosteroid use managing chronic LBP.
Anecdotally, there are some patients who benefit from oral prednisone for
severe flares.
Antidepressants
As opposed to earlier teachings, neither tricyclic antidepressants nor selective
serotonergic antidepressants improve pain or function in patients with chronic
LBP.46 However, duloxetine has been shown to lower the intensity of pain
and improve function in some patients with unspecified chronic LBP and
those with axial and extremity neuropathic pain.69 It appears that in some
patients with chronic axial LBP, the underlying mechanism is neuropathic
rather than nociceptive.
68,69
The prevalence of neuropathic pain in chronic
axial LBP is reported to be as high as 12% to 37%,
67,70
thus making it an
important problem to recognize and treat.
Anticonvulsants
In patients with a neuropathic component to their LBP, anticonvulsants such
as pregabalin can be helpful, especially for extremity pain. Pregabalin also
can be effective for managing LBP in patients with spinal stenosis by
reducing pain and improving walking distance, sleep quality, and gait.
71
However, pregabalin does not appear to be effective in patients with
sciatica.72 Topiramate has been useful for some patients with nonspecific
chronic LBP as well as patients with neuropathic leg pain.
73
Table 5
Opioid Analgesics
Long-term opioid analgesic therapy is fiercely debated. The serious increase
in opioid-related deaths, overdoses, and other adverse events has been well
publicized in professional journals and the lay press. Few discussions have
been published about patients taking opioids who have good pain control,
better quality of life, and few adverse events. The lack of evidence regarding
the efficacy and safety of long-term opioid analgesic therapy for chronic LBP
is well known, but is due in part to the paucity of studies on this subject. A
few observational and retrospective studies have suggested longer-term
efficacy and safety.
74,75
In well-selected patients, approximately one-third
will discontinue opioid use because of side effects, one-third will have
limited relief that may not justify continuing opioid therapy, and the
remainder will have meaningful improvement.75 A Cochrane review
reiterated that high-quality long-term studies are lacking, but in shorter-term
studies of patients with chronic LBP, opioids were better than placebo for
pain control and probably for function.
46,76
Based on the best available evidence, there is a role for long-term opioid
analgesic therapy in a small number of well-selected patients with chronic,
severe, and refractory spine pain
77-79
(Table 5). After selection, patients
should have a trial of opioid use, and only those with meaningful
improvement should continue long-term therapy.
It is essential to consider each patient individually and balance potential
risks and benefits. Risks to individual patients include death, overdose,
addiction, disability, and a path to illegal opioid use. Risks to public health
include diversion (purposeful misuse or theft), other adverse events, and
increased healthcare and disability costs.
77-79
Chronic severe intractable pain also has risks, including pain-related
disability, decreased quality of life, deteriorating family interactions,
psychological disorders, and even suicide.77 Risks to the public good include
lost work along with its sequelae and increased healthcare utilization. It is
probably best that patients requiring long-term opioid use be treated by a
physician who is experienced in medical pain management.
Summary
A systematic and consistent interdisciplinary process for lumbar spine care
that includes objective metrics, meaningful data collection, and actionable
analytics can optimize efficiencies, enhance patient outcomes, and decrease
costs. Strong and committed leadership is required because a paradigm shift
in providing spine care can be unsettling to those accustomed to the
fragmented, fee-for-service model. Considering the needs and expectations of
all stakeholders and communicating those requirements openly and honestly
can overcome many of the barriers to successful implementation.
Efficient and cost-effective interdisciplinary lumbar spine care models
incorporate a navigator and uniform thresholds at which spine specialist
providers become engaged within the coordinated team. By providing early
access to care, patients at risk for the development of chronic and disabling
syndromes can be identified early and given appropriate support. Rational
self-management can be encouraged, rapid return to function can be
achieved, overutilization of healthcare services can be prevented, and optimal
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