Defining appropriate treatment and outcomes for spinal deformity patients

The AO Spine Knowledge Forum Deformity and AO Spine community, used a Delphi process to define consensus on optimal treatment and core outcomes sets for both adolescent and adult spinal deformity patients. The findings are published in the European Spine Journal and the Acta Orthopedica and offer the latest up-to-date knowledge.

17 October 2017

AOSpine Knowledge Forum Deformity and panel members at the final meeting of the ASD Consensus study in Kuala Lumpur, Malaysia, July 2015

AO Spine Knowledge Forum Deformity and panel members at the final meeting of the ASD Consensus study in Kuala Lumpur, Malaysia, July 2015

"The studies provide the AO Spine community and the spine deformity patient with new information to guide an evidence-based approach to optimal care", study investigator Dr. Sigurd Berven says.

The Delphi process is a methodology designed to establish consensus whereby the current opinions of a panel of experts are put forward in an iterative and anonymous process. Knowledge Forum Deformity Chairperson Prof. Marinus de Kleuver finds it extremely useful: "There is so much information out there these days. Consensus papers offer an extra layer of empirical opinion-leader-knowledge to literature reviews, which are, by definition, outdated."

De Kleuver reckons expert knowledge is years ahead of the newest papers published, because data acquisition is done years earlier. "The world keeps moving on! There is a huge gap between what is being published and what is at the forefront of innovation and new techniques." This gap can be bridged with consensus papers, literature reviews supplemented by a Delphi expert panel process. "Ultimately, you are also validating the large multi-center studies, where work takes years", de Kleuver adds.

AO Spine network is instrumental

With the involvement of approximately 50 members from the AO Spine community, representing close to 30 countries from around the world, we have learned that there is significant variability in the management of spinal deformity between centers around the world, even within centers, Berven says, and gives credit to the worldwide community of AO Spine physicians. "They are a valuable resource for developing an evidence-based approach to optimal care of deformity. This is unique to AO, that you can leverage the international network of so many experts, and produce a proper global representation."

The studies identified several areas of variability in care, and through the Delphi process and consensus opinion, the panel could determine specific management strategies that were appropriate or inappropriate. This information is useful in guiding an evidence-based approach to care across the continuum, from preoperative preparation to surgery, to intraoperative standardization of techniques, and to postoperative care. The results also reveal the needs for a global implementation and remaining gaps. "There are still several areas in which we do not have enough evidence to make consensus recommendations on what is most appropriate or optimal care", Berven concludes. "We need further research regarding strategies for preoperative optimization, intraoperative techniques, and postoperative care, to better define specific approaches that are optimal for the individual patient, and specific scenarios of care."

Importantly, the studies allow people to speak a common language, making comparative and collaborative research possible. "All these initiatives are aimed at creating a framework to communicate across different parties", de Kleuver explains. "There is a myriad of outcome studies and outcome instruments out there, and everybody uses different instruments to measure their quality of care. We help bring more rationale to the options that are available."

For the full articles, follow links below

  1. Berven SH, Kamper SJ, Germscheid NM, Dahl B, Shaffrey CI, Lenke LG, Lewis SJ, Cheung KM, Alanay A, Ito M, Polly DW, Qiu Y, De Kleuver M, AO Spine Knowledge Forum Deformity. An international consensus on the appropriate evaluation and treatment for adults with spinal deformity. Eur Spine J, 2017.
  2. De Kleuver M, Faraj S, Holewijn R, Germscheid N, Adobor R, Andersen M, Tropp H, Dahl B, Keskinen H, Olai A, Polly D, Hooff MV, Haanstra T. Defining a core outcome set for adolescent and young adult patients with a spinal deformity. A collaborative effort for the Nordic Spine Surgery Registries. Acta Orthopaedica [Epub ahead of print] 15 Sep 2017. 
  3. Faraj SSA, Van Hooff ML, Holewijn RM, Polly DW, Jr., Haanstra TM, De Kleuver M. Measuring outcomes in adult spinal deformity surgery: a systematic review to identify current strengths, weaknesses and gaps in patient-reported outcome measures. Eur Spine J 26(8): 2084-2093, 2017.
  4. De Kleuver M, Lewis SJ, Germscheid NM, Kamper SJ, Alanay A, Berven SH, Cheung KM, Ito M, Lenke LG, Polly DW, Qiu Y, Van Tulder M, Shaffrey C. Optimal surgical care for adolescent idiopathic scoliosis: an international consensus. Eur Spine J 23(12): 2603-2618, 2014.

The authors are grateful to the many AO Spine surgeons and collaborators who participated in these studies:

Adult Spinal Deformity (ASD) Consensus (see above Berven et al. ESJ 2017)

Richard Emery, Mater Hospital
Brian Hsu, North Shore Institute of Spinal Disorders
Dianming Jiang, The First Affiliated Hospital of Chongqing Medical University
Xie En, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine
Arvind Bhave, Deenanath Mangeshkar Hospital
Ajoy Prasad, Shetty Ganga Hospital
Suhail Afzal, Police Hospital
Saumyajit Basu, Park Clinic
Vishal Moudgil, Pims Medical College
Bhavuk Garg, All India Institute of Medical Sciences
Yoshiharu Kawaguchi, Toyama University
Tomoaki Toyone, Teikyo University Mizonokuchi Hospital
Takashi Kaito, Osaka University Graduate School of Medicine
Chung Chek Wong, Sarawaka General Hospital
John Chen, Singapore General Hospital
Josef Grohs, Medical University Vienna
Christoph Mehren, Schön Klinik München Harlaching
Dimos Bouramas, Athens Bioclinic
Massimo Balsano, Regional Spinal Department
Pedro Berjano, IRCCS Istituto Ortopedico Galeazzi
Andrea Piazzolla, AOU Consorziale Policlinico Di Bari
Cajetan Nwadinigwe, National Orthopaedic Hospital
Traian Ursu, Foisor Orthopedics Hospital
Salvador Fuster, Hospital clinic-university of Barcelona
Cumhur Oner, UMC Utrecht
Ufuk Aydinli, Medicabil Private Hospital
Alexandre Cristante, IOT HC FMUSP
Emiliano Vialle, Cajuru Hospital
Mauricio Campos Daziano, Pontificia Universidad Catholica de Chile
Nestor Adolfo Taboada Taboada, Clinica Portoazul
Herman Michael Dittmar, Hospital Puerta de Hierro
Mohamed Maziad, Faculty of Medicine AIn Shams University
Hany Soliman, Al Azhar University
Sherif Elghamry, Teachers Hospital
Amer Aziz, Lahore Medical and Dental College
Venugopal Menon, Khoula Hospital, Mina al Fahal
Vincent Arlet, University of Pennsylvania
John France, West Virginia University
Isador Lieberman, Texas Back Institute
Munish Gupta, University of California at Davis
Jeffrey Carlson, Orthopaedic and Spine Center
Jens-Peter Witt, University of Colorado Hospital
Dean Chou, University of California San Francisco
Ronald Lehman, Washington University School of Medicine
Justin Smith, University of Virginia
Jonathan Sembrano, University of Minnesota; Minneapolis VA Health Care System

Adolescent Idiopathic Scoliosis (AIS) Consensus (see above De Kleuver et al. ESJ 2014)

Ufuk Aydinli, Medicabil Hospital, Bursa
Amer Aziz, Ghurki Trust Teaching Hospital, Lahore 
Saumyajit Basu, Park Clinic, Kolkata
Ernesto Bersusky, Garrahan Pediatric Hospital, Buenos Aires
Benny Dahl, Rigshospitalet, University Hospital of Copenhagen
Evan Davies, University Hospital Southampton
Maximo-Alberto Diez Ulloa, Universitary Hospitalary Complex Santiago de Compostela
Ignacio Dockendorff, Clínica Alemana de Santiago
Mohammad El-Sharkawi, Assiut University Medical School
Andre Luis Fernandes Andujar, Hospital Infantil Joana de Gusmão, Florianopolis
Brian Freeman, The University of Adelaide
Bhavuk Garg, All India Institute of Medical Sciences, Delhi
Wilmer Godoy, Roosevelt Institute, Bogota
Poornanand Goru, University Hospital of Wales, Cardiff
Tiziana Greggi, Rizzoli Orthopaedic Institute, Bologna
Michael Grevitt, Center for Spinal Studies, Queens Medical Center, Nottingham
Yong Hai, Beijing Chaoyang Hospital, Capital Medical University of China
Carol-Claudius Hasler, University Children’s Hospital, Basel
Philip Horsting, Sint Maartenskliniek, Nijmegen
Kannan Kailash, Sri Ramachandra University
Khalil Kharrat, Hotel-Dieu Hospital
Claudio Lamartina, Istituto Ortopedico Galeazzi, Milan
Isador Lieberman, Texas Back Institute
Venugopal Menon, Khoula Hospital, Muscat, Sultanate of Oman
Roman Nowak, Orthopaedic Clinic of Silesian Medical University
Samuel Pantoja, Roberto de Rio Children's Hospital - Clinica Las Condes Private Hospital
Rolf Riise, Oslo University Hospital
Saeid Safaei, Milad Hospital / AZAD University
Dietrich Schlenzka, ORTON Orthopaedic Hospital, Helsinki
Alpaslan Senkoylu, Gazi University, Ankara
Masood Shafafy, Center for Spinal Studies, Queens Medical Center, Nottingham
Jianxiong Shen, Peking Union Medical College Hospital
John Smith, University of Utah
Shanmuganathan Rajasekaran, Ganga Medical Centre & Hospitals Ltd.
Daisuke Sakai, Tokai University School of Medicine
Paul Thorpe, Somerset Spinal Surgery Service, Taunton
Warat Tassanawipas, Phramongkuthklao Army Hospital, Bangkok
Traian Ursu, University Hospital Foisor, Bucharest
Seyed Hossein Vahid Tari, Tehran University of Medical Science
Emiliano Vialle, Cajuru Hospital, Curitiba
Chung Chek Wong, Sarawak General Hospital

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