SPINE20 recommendations 2021: spine care for people's health and prosperity

PURPOSE: The focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability. METHODS: On September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10 days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments. RESULTS: In total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes. CONCLUSIONS: SPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe

Comparison of intrathecal and intravenous morphine for post-operative analgesia after single level spinal fusion surgery

Thesis (PhD)--Stellenbosch University, 2020.ENGLISH ABSTRACT: The purpose of this study was to evaluate the efficacy, safety and cost effectiveness of a 0.005mg/kg, up to a maximum of 0.45mg, dose of intrathecal morphine in first-time single level spinal surgery. The study was conducted, and results apply, to a tertiary care public service hospital in South Africa. This experimental intervention was compared to the institutional standard of care being the use of intravenous morphine via a patient-controlled device, administering 1mg of morphine intravenously every 7 minutes as required. Efficacy was measured with reference to validated scoring systems which included the Oswestry disability index, Roland Morris questionnaire, EQ-5 score and visual analogue scale (VAS) to assess pain, analgesia and disability in the post-operative phase and subsequent follow up. A standardised physiotherapy regime was used to mobilize patients and the patients was discharged directly to their homes, specifically skipping a step-down facility. Safety was assessed by monitoring the known side-effects of morphine (nausea, vomiting, pruritis), oxygen saturation, respiratory rate and sedation during the stay in the ICU. Inter alia, blood gases were analysed on 11 occasions within the first 24 hours. General patient follow-up occurred at 6 weeks, 3 and 6 months. The study was conducted in a prospective double-blind, randomized placebo controlled fashion. 40 patients were enrolled (20 per group). The time to discharge for the intrathecal morphine group (IT) was statistically significantly shorter (3.68 days) compared to 5.61 days for the patient-controlled analgesia (PCA) group. This translated into a 43.5% saving for general ward stay costs. VAS was assessed when lying still and moving and the difference between these values was used to quantify the intensity of pain. A significant difference was noted at 24 hours favouring the IT group. Significantly less supplemental analgesia was used in the IT group during the first 24 post-operative hours. No significant difference in side-effects were noted between the groups. The initially elevated mean PaCO2 in the IT group demonstrated a significant decrease from 4 hours up to 24 hours. An increase in mean respiratory rate was demonstrated from 10 hours onwards in both groups. Seven incidents of hypoxia (PaO2 < 8kPa) were observed (IT=4, PCA=3). The 7 incidents were explained by either a low FiO2 or a decrease in functional residual capacity (FRC) as proven by the A-a gradient. No overt sedation was clinically demonstrated at the time the PaO2 was less than 8.0 kPa. Six week, 3-month and 6-month follow-up demonstrated significant improvement in all scoring modalities in both groups. The intrathecal use of morphine had a direct effect on the μ-receptors in the spinal cord resulting in segmental analgesia allowing the patients to mobilize faster compared to the more central acting analgesic effects offered by intravenous morphine. The proposed dose proved to be safe with minimal side-effects, all of which were comparable to the PCA group. The application will be particularly useful in obese patients where the calculation of a safe intravenous dose can be challenging because of excess adipose tissue. When using IT or PCA morphine, supplemental oxygen is suggested for the first 4 hours post-operatively and continuous monitoring of respiratory rate, saturation and sedation should be done. Finally, it is recommended that it will be safer practice to reset the minimum cut-off value for saturation at a higher value than the conventional 90% level.AFRIKAANSE OPSOMMING: Die doel van die studie was om die effektiwiteit, veiligheid en koste-effektiwiteit van ‘n 0.005mg/kg, tot ‘n maksimum van 0.45mg, dosering van intratekale morfien te evalueer in eerste operasie, enkel vlak lumbale spinale fusie chirurgie. Die studie is uitgevoer in en resultate relevant tot ‘n tersiere vlak publieke diens hospitaal in Suid Afrika. Die eksperimentele intervensie was vergelyk met standaard sorg vir hierdie tipe gevalle wat bestaan uit intraveneuse morfien toegedien deur ‘n pasient-beheerde toestel wat 1mg intravenuese morfien elke 7 minute toedien soos benodig. Effektiwiteit is gemeet deur gevalideerde evaluerings sisteme wat insluit die “Oswestry disability index”, “Roland Morris questionnaire”, “EQ-5” telling asook die “visual analogue score (VAS)” om pyn en ongeskiktheid te evalueer, beide post-operatief asook tydens opvolg besoeke. ‘n Gestandardiseerde fisioterapie regime was gebruik om die pasiënte te mobiliseer en pasiënte is direk tuis ontslaan, sonder enige rehabilitasie fasiliteit. Veiligheid is evalueer deur monitering van die bekende newe-effekte van morfien (naarheid, braking, pruritis), suurstof saturasie, asemhalingspoed en sedasie gedurende die intensiewe sorgeenheid verblyf. Bloedgas analises is gedoen op 11 geleenthede gedurende die eerste 24 post-operatiewe ure. Pasiënt opvolg het geskied op 6 weke, 3maande en 6 maande. Die studie is uitgevoer as ‘n prospektiewe, dubbel-blind, gerandomiseerde placebo beheerde studie. 40 pasiënte is ingesluit (20 per groep). Die tyd tot ontslag vir die intratekale morfien (IT) groep was statisties beduidend minder (3.68 dae) as die 5.61 dae in die pasiënt-beheerde analgesie (PCA) groep. Dit het gelei tot ‘n 43.5% kostebesparing in algemene saal verblyf. VAS was gemeet beide as die pasiënt stil lê en as hulle beweeg. Die verskil in die waardes is gebruik om intensiteit van pyn aan te dui. ‘n Statisties beduidende verskil is op 24 uur identifiseer ten gunste van die IT groep. Betekenisvol minder reddings-analgesie is gebruik in die IT groep oor die eerste 24 uur. Geen beduidende verkil in newe-effekte kon identifiseer word nie. Die aanvanklike verhoogde gemiddelde PaCO2 in die IT groep het ‘n statisties betekenisvolle uur tot uur daling getoon vanaf 4 tot 24 uur. Beide groepe het ‘n gemiddelde asemhalingspoed verbetering getoon vanaf 10 ure post-operatief aanwaards. Sewe insidente van hipoksie (PaO2 < 8kPa) is identifiseer (IT=4, PCA=3). Die 7 insidente kon verduidelik word deur of ‘n lae FiO2, of ‘n lae funksionele residuele kapasiteit aangedui deur die A-a gradient. Geen sedasie was assosieer met die insidente van PaO2 < 8kPa nie. Die 6 weke, 3 maande en 6 maande opvolge het statisties beduidende verbetering getoon in al die evaluerings sisteme. Die intratekale gebruik van morfien het ‘n direkte effek op die μ-reseptore in die spinal koord wat lei tot segmentele analgesie wat die pasiente vinniger laat mobiliseer vergeleke met intraveneuse morfien wat ‘n meer sentrale meganisme van werking het. Die voorgestelde dosis is bewys as veilig met minimale newe-effekte vergeleke met die PCA groep. Dit is veral van belang in obees pasiënte waar dosis bepaling uitdagend is met die addisionele vetweefsel wat teenwoordig is. Supplementele suurstof word aanbeveel vir die eerste 4 ure vir beide groepe, met volgehoue monitering van asemhalingspoed, saturasie en sedasie. Laastens sal dit veiliger wees om die minimum aanvaarde waarde vir saturasie op ‘n hoër vlak te stel as die konvesionele 90%.Doctora

The Global Spine Care Initiative: care pathway for people with spine-related concerns.

PURPOSE: The purpose of this report is to describe the development of an evidence-based care pathway that can be implemented globally. METHODS: The Global Spine Care Initiative (GSCI) care pathway development team extracted interventions recommended for the management of spinal disorders from six GSCI articles that synthesized the available evidence from guidelines and relevant literature. Sixty-eight international and interprofessional clinicians and scientists with expertise in spine-related conditions were invited to participate. An iterative consensus process was used. RESULTS: After three rounds of review, 46 experts from 16 countries reached consensus for the care pathway that includes five decision steps: awareness, initial triage, provider assessment, interventions (e.g., non-invasive treatment; invasive treatment; psychological and social intervention; prevention and public health; specialty care and interprofessional management), and outcomes. The care pathway can be used to guide the management of patients with any spine-related concern (e.g., back and neck pain, deformity, spinal injury, neurological conditions, pathology, spinal diseases). The pathway is simple and can be incorporated into educational tools, decision-making trees, and electronic medical records. CONCLUSION: A care pathway for the management of individuals presenting with spine-related concerns includes evidence-based recommendations to guide health care providers in the management of common spinal disorders. The proposed pathway is person-centered and evidence-based. The acceptability and utility of this care pathway will need to be evaluated in various communities, especially in low- and middle-income countries, with different cultural background and resources. These slides can be retrieved under Electronic Supplementary Material

SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY

Introduction: The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of “One Earth, One Family, One Future WITHOUT Spine DISABILITY”. Research question: Not applicable. Material and methods: Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels. Results: Seven recommendations were delivered to the G20 countries calling them to: - establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes. - eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty. - implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes. - monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity. - develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs. - ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan. - promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health. Discussion and conclusion: SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations

SPINE20 recommendations 2021: spine care for people's health and prosperity.

PurposeThe focus of SPINE20 is to develop evidence-based policy recommendations for the G20 countries to work with governments to reduce the burden of spine disease, and disability.MethodsOn September 17-18, 2021, SPINE20 held its annual meeting in Rome, Italy. Prior to the meeting, the SPINE20 created six proposed recommendations. These recommendations were uploaded to the SPINE20 website 10&nbsp;days before the meeting and opened to the public for comments. The recommendations were discussed at the meeting allowing the participants to object and provide comments.ResultsIn total, 27 societies endorsed the following recommendations. SPINE20 calls upon the G20 countries: (1) to expand telehealth for the access to spine care, especially in light of the current situation with COVID-19. (2) To adopt value-based interprofessional spine care as an approach to improve patient outcomes and reduce disability. (3) To facilitate access and invest in the development of a competent rehabilitation workforce to reduce the burden of disability related to spine disorders. (4) To adopt a strategy to promote daily physical activity and exercises among the elderly population to maintain an active and independent life with a healthy spine, particularly after COVID-19 pandemic. (5) To engage in capacity building with emerging countries and underserved communities for the benefit of spine patients. (6) To promote strategies to transfer evidence-based advances into patient benefit through effective implementation processes.ConclusionsSPINE20's initiatives will make governments and decision makers aware of efforts to reduce needless suffering from disabling spine pain through education that can be instituted across the globe

The Global Spine Care Initiative: methodology, contributors, and disclosures.

PURPOSE: The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations. METHODS: World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative\u27s mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care. RESULTS: Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest. CONCLUSION: The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. These slides can be retrieved under Electronic Supplementary Material

The Global Spine Care Initiative: model of care and implementation.

PURPOSE: Spine-related disorders are a leading cause of global disability and are a burden on society and to public health. Currently, there is no comprehensive, evidence-based model of care for spine-related disorders, which includes back and neck pain, deformity, spine injury, neurological conditions, spinal diseases, and pathology, that could be applied in global health care settings. The purposes of this paper are to propose: (1) principles to transform the delivery of spine care; (2) an evidence-based model that could be applied globally; and (3) implementation suggestions. METHODS: The Global Spine Care Initiative (GSCI) meetings and literature reviews were synthesized into a seed document and distributed to spine care experts. After three rounds of a modified Delphi process, all participants reached consensus on the final model of care and implementation steps. RESULTS: Sixty-six experts representing 24 countries participated. The GSCI model of care has eight core principles: person-centered, people-centered, biopsychosocial, proactive, evidence-based, integrative, collaborative, and self-sustaining. The model of care includes a classification system and care pathway, levels of care, and a focus on the patient\u27s journey. The six steps for implementation are initiation and preparation; assessment of the current situation; planning and designing solutions; implementation; assessment and evaluation of program; and sustain program and scale up. CONCLUSION: The GSCI proposes an evidence-based, practical, sustainable, and scalable model of care representing eight core principles with a six-step implementation plan. The aim of this model is to help transform spine care globally, especially in low- and middle-income countries and underserved communities. These slides can be retrieved under Electronic Supplementary Material

The Global Spine Care Initiative: methodology, contributors, and disclosures.

PURPOSE: The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations. METHODS: World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative\u27s mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care. RESULTS: Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest. CONCLUSION: The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. These slides can be retrieved under Electronic Supplementary Material