Department of Neurosurgery, University Hospital Schleswig-Holstein, Lübeck, Germany.
Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK.
Eur Spine J. 2019 Jan;28(1):31-45. doi: 10.1007/s00586-018-5711-0. Epub 2018 Aug 4.
Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS.
Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1-3 and 7-9).
Appropriateness outcomes showed clear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability.
Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. These slides can be retrieved under Electronic Supplementary Material.
脊柱手术后持续性疼痛（PPSS）患者的管理存在显著差异，临床研究中几乎没有证据支持日常实践中的治疗选择。本研究旨在制定针对 PPSS 管理的患者特异性建议。
使用 RAND/UCLA 适宜性方法（RUAM），由 6 名神经外科医生、6 名疼痛专家和 6 名骨科医生组成的国际小组评估了 4 种治疗选择（保守治疗、微创治疗、神经刺激和再次手术）对 210 种临床情况的适宜性。这些情况是考虑到治疗选择的相关患者特征的独特组合。适宜性必须在 9 分制上进行评估（1=极不合适，9=极合适）。如果没有分歧（每个相反的 1-3 节和 7-9 节中的评分各有 1/3 以上），中位数评分≥7，则认为治疗是合适的。
适宜性结果显示出清晰而具体的模式。在 48%的情况下，只有 4 种治疗方法之一是合适的。对于没有明确解剖异常且新疼痛与原始症状不同的患者，保守治疗通常被认为是合适的。在没有需要手术干预的情况下，神经刺激被认为是治疗（主要）神经源性腿部疼痛的合适方法。对于复发性椎间盘、脊柱/椎间孔狭窄或脊柱不稳定的患者，可以考虑再次手术。
使用 RUAM，一个国际多学科小组为 PPSS 患者的合适治疗选择制定了标准。这些标准可能有助于教育医生，并提高一致性和护理质量。这些幻灯片可以在电子补充材料中找到。
