Time for a true integrated approach to spine care

Spine disorders are a major cause of disability worldwide and its management involves many health care professionals including general practitioners, physiatrists, rheumatologists, orthopedic, trauma and neurosurgeons, physiotherapists, chiropractors, osteopaths, and kinesiotherapists. However, healthcare providers tend to work in isolation, duplicate services, and commonly deviate from evidence-based practice guidelines. Despite the publication of numerous evidence-based guidelines, the management of spine disorders remains characterized by large variability within and between specialties. In fact, it seems that the selection of intervention is more likely to be influenced by disciplinary preferences and traditions than evidence. More than ever, we need to integrate primary care, rehabilitation, and surgical care providers in the management of spinal disorders. But changing well entrenched practices and beliefs is challenging. Therefore, we argue that interprofessional education focused on the best available scientific evidence and patient centered care is one promising avenue to change the status quo.

Eurospine, a historically surgical society, recognizes this reality and has recently created a Rehabilitation Council as an integral part of its structure. This important step aims to realize Eurospine's vision “to be the driving force and the primary and preferred partner in Europe and beyond for all spinal care issues” and its mission to “optimize patient care and prevention of spinal disorders; provide and support “evidence best practice” spine-related lifelong learning, research and quality assurance; and bring together all spine-related European stakeholders across disciplines, cultures and countries.” The vision and mission of Eurospine align well with the World Health Organization's definition of rehabilitation: a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” (World Health Organization – Rehabilitation, 2023).

A recent survey of the membership suggests that Eurospine is predominantly composed of surgeons. This is at odds with the health care needs of patients with spinal disorders because less than 10% require surgery. Therefore, Eurospine is not well positioned to fulfill its vision and mission without broadening its membership to spine care providers who treat most patients with spine disorders or disability. This is particularly important because in Europe, conditions such as low back pain are a main reason for unmet rehabilitation needs (Cieza et al., 2021).

Historically, primary care, rehabilitation and surgical care have evolved in isolation and even competed for cultural authority. Fortunately, the growth of value-based care has prompted the need to delineate the complementary roles of various disciplines when developing patient-centered, multidisciplinary care pathways. The necessity for a change in paradigm is clearly highlighted by the aging population who commonly suffers from spine disorders such as spinal stenosis and degenerative deformities.

We suggest that a new integrated approach to the management of spine disorders and disability must focus on eliminating inefficiencies that have invaded our health care systems. An example of such inefficiencies is the use of discipline or profession specific classification systems to diagnose patients. This can be very confusing for patients who may visit different healthcare providers and be diagnosed with mechanical back pain, sagittal imbalance, subluxations, discogenic pain or myofascial pain. Because the accurate classification of patients is fundamental to optimize the diagnostic path and to provide effective treatment, such inefficiencies may lead to the prescription of multiple treatments with uncertain effectiveness and safety. Moreover, the “diagnosis” of spinal disorders is often based on extraneous and unhelpful imaging findings which are poorly correlated to symptoms. We all have seen ‘awful’ X-rays in patients with little or no complaints and other patients with “normal” MRIs for age and intractable pain and major disability. Obviously, imaging alone is not enough to guide treatment choices, and it is often pernicious, when creating a label/diagnosis that will accompany the patient throughout life.

Across disciplines and specialties, inefficient, ineffective, and even harmful interventions are common. An important proportion of clinicians and surgeons use or promote unsubstantiated conservative treatments or ineffective sophisticated surgical procedures that focus on treating imaging rather than the patient with all his or her expectations, psychosocial status, comorbidities, and intrinsic frailty due to advanced physiological age.

EUROSPINE argues that an integrated approach to spinal care that aims to improve patients’ outcomes must focus on function. While the multidisciplinary assessment of patients prior to therapeutic decisions is slowly becoming standard practice in large spine centers, this is certainly not the reality in all spine care facilities. Education programmes that are built on valid scientific evidence are not widely available, and the sponsorship by implant manufacturers or technique gurus of education programmes who promote new appealing technologies that may not be cost-effective or may even be harmful. The fascination for correcting spinal deformities and sagittal balance combined with the use of sophisticated intraoperative imaging has led to a dramatic increase of instrumented stabilization and major corrective procedures of the spine. Unfortunately, such approach is not always based on adequate indications or the best interest of the patients. In the hands of highly skilled teams, in carefully selected patients, surgery can improve function, reduce pain and correction deformity. However, poor patient selection, or inadequate surgery may lead to poor recovery, major complications and ultimately failed back syndrome for which we have no remedy. Similarly, theoretically irrelevant, ineffective, and endless conservative treatments promoted by so called “gurus” can delay recovery by creating iatrogenic pain and disability. Ignorance of evidence-based rehabilitation and surgical indications means denying the patient an effective solution. These ill-advised practices can be averted by an creating integrated, and interprofessional, patient-centered approach where the patient is presented with evidence-based options that meet their expectations and consent.

The goal of the EUROSPINE Diploma in Interdisciplinary Spine Care (EDISC) is to “provide health care practitioners engaged in non-surgical and surgical care with an interprofessional, harmonized and evidence-based curriculum on patient-centered collaborative care” (https://www.eurospine.org/edisc.htm" https). EDISC, a fully online program, delivers evidence-based education throughout the world and promotes the creation of networks among professions of all backgrounds. Therefore, EDISC represents a concerted effort to address the problems discussed above by promoting interprofessional collaboration between spine care clinicians regardless of their countries, training, profession, and health care setting. Brain and Spine intend to publish in the near future a special issue addressing the subject of interprofessional spine care. We invite all stakeholders to submit their work on this subject.

EDISC, which is part of the newly established Eurospine Rehabilitation Council is a concrete attempt at creating a qualified spine care workforce that will address the current reality faced by patients with spine disorders and disability. It is our hope that the new Rehabilitation Council and the EDISC programme will contribute to create the necessary bridges between all spinal care disciplines and professionals and promote a common language to improve the delivery of spinal care by clinicians to patients. Patients want those responsible for their care to communicate and collaborate.