Abstract
For the vast majority of AOSpine’s global members, nonoperative spine care is discussed and prescribed on a daily basis by everyone treating patients with degenerative disorders of the lumbar and cervical spine.
The same is found at virtually every spine meeting: Whenever discussing degenerative spine treatments, nonoperative modalities are part of the “standard care,” the indication for surgery when failed, the control group, the “natural” course, whatever is applicable.
There are as many perceptions and definitions of nonoperative spine care as there are medical environments around the world. While everything that does not involve a type of surgery or invasive intervention of any sort would qualify as “nonoperative,” the precise composition of those treatments remains to be debated.
Medications of various sorts have clear indications, properties, and focus, and therefore at least a certain degree of standardization. Analgesic, anti-inflammatory, muscle relaxing, antidepressant, and other variations are utilized most frequently globally. Physiotherapy, manual therapy, osteopathy, certain manipulative techniques, massage techniques, physical therapy, specific thermal application, hydrotherapy, taping or electricity-based treatments, as well as the use of braces, are part of an endless list of applied treatments.
Muscular training concepts are widespread with different approaches and intensities, as well as functional restoration, mindfulness and other key words come to mind. Additionally, bio-psycho-cognitive concepts for interdisciplinary chronic pain treatments are well established, inpatient and outpatient and day-care settings, rehabilitation of any type and focus.
Over the years, there is a growing body of literature looking at specific indications and effectiveness of all of these individual components. But what seems to be an unsolvable dilemma is a certain universal understanding of what is the “standard” of care. While surgical care is a step-by-step process from “skin to skin,” this is not the case with nonoperative care. Starting with indications, setting, duration, and intensity, picking individual components out of the bouquet of options creates a myriad of combinations.
Numerous stakeholders around the world have been addressing this issue with overall limited success. Professional medical societies are establishing guidelines with limited usefulness in regard to the individual treatment decision. Payors are trying to base reimbursement decisions on evidence but obviously they do not follow a medical agenda but instead have a purely financial interest, limiting available resources. Variations in health care environments globally have made a supranational approach to standardization nearly impossible.
Study populations in scientific settings have the highest degree of standardization for nonoperative care. However, these protocols have failed to evolve into an enduring standard once the study was finished. Consequently this shows the need to describe any nonoperative treatment mentioned in a scientific publication with much more detail to ensure at least a limited degree of transparency and comparability.
AOSpine, as the largest global organization for spine care professionals, has the unique opportunity to address this issue successfully. This needs a worldwide effort, endurance, creativity, tolerance, understanding, and funds, and certainly more than a number of debates. It will expose shortcomings of scientific evidence and might stay a work in progress. But it will certainly help to create knowledge and refine nonoperative care in the same way as surgical treatment gets ever refined. A global nonOP standard treatment protocol will need to provide a basis, a foundation, a reliable concept. Like establishing classifications in AO and AOSpine history were a giant step forward in fracture care, it will be the work for a generation. Take the first step today, it will be worth it!