From the Editor's Desk

Wale A. R. Sulaiman

The theme for the spring issue of The Ochsner Journal is Multidisciplinary Approaches to Spine Care—Where Is the Value? In the current climate of healthcare reform, demonstrating excellent clinical outcomes at reasonable cost is crucial. To improve the efficiency and cost of healthcare delivery, value-based purchasing and reimbursement have emerged and require that more costly medical treatments prove their value by demonstrating a health benefit that is greater than its added cost. Health intervention that is more costly than its alternative but fails to provide added health benefit is considered cost ineffective. Health intervention that is more costly but provides a health benefit that is greater than its added cost is considered cost effective. Hence we have seen a resurgence of cost-utility analyses in the literature, especially for procedures, surgeries, and treatments that require placement of implantable devices. These types of treatments are often used in the management of patients suffering from spine problems.

Pain of spinal origin (especially low back pain) is a major public health problem that has increased in prevalence, expense, and impact over the past decade. Overall, 60%-80% of the population will be affected by this problem at least once in their lifetime. The majority will recover favorably and return to a normal active life within a few weeks without consequences, but 7%-10% will develop a chronic condition (pain lasting >3 months) associated with numerous incapacities in daily life. Spine and musculoskeletal disorders account for nearly 70 million physician office visits and 130 million outpatient, hospital, and emergency room visits. Annually, nearly 1.3 million people take time away from work to be treated and recover from work-related low back pain, resulting in lost wages and lost productivity with an estimated value of $45-$54 billion. Patients with chronic low back pain who have been off work have less than a 50% chance of ever returning to gainful employment, and those out for more than 2 years have less than a 1% chance of returning to work. According to the Institute of Medicine, pain costs society at least $560-$635 billion annually, an amount equal to about $2,000 for every US resident. This annual cost is the sum of the total incremental cost of healthcare due to pain ($261-$300 billion) plus $297-$336 billion due to lost productivity (based on days of work missed, hours of work lost, and lower wages).

Given the large population of patients affected by back pain and the expenses associated with its treatment, it is imperative that comprehensive and multimodality treatments be developed. The Ochsner Back and Spine Center was designed to do exactly this. The articles in this special volume are written by experts in the different specialties that manage patients with spine problems and they focus on (1) patient outcomes after treatment, (2) cost effectiveness, (3) innovative and less morbid ways of treating spine disease (eg, minimally invasive spine surgery), and (4) innovative and evidence-based approaches to the diagnosis and management of spine problems. This issue contains 9 excellent original research articles, 5 outstanding review articles, and 6 unique case reports.

The articles written by Frank Schwab's group carefully address the topic of patient outcomes and cost effectiveness of surgery for spinal deformity and compare it to nonoperative treatment. They demonstrated that for spinal deformity surgery to be cost effective, patients must have a greater preoperative disability, a diagnosis of idiopathic scoliosis, poor preoperative health-related quality of life scores, and fewer fusion levels. This area of spine surgery is likely the most invasive of all spine surgeries, and the authors have challenged all surgeons who perform this type of surgery to pay special attention to patient selection, follow outcomes closely, and demonstrate that their treatment is cost effective. Complications from deformity surgeries are still relatively high (30%-40%) and what is unclear is whether there is a threshold of surgical complications after which the benefits of surgical intervention are lost. Nonetheless, I applaud the authors for a job well done!

Neurosurgery members of the Back and Spine Center present their experience with minimally invasive approaches to the treatment of degenerative spondylolisthesis, and 1 of the 2 articles compares this approach to conventional open spinal surgeries and includes a cost-utility analysis of both surgical approaches. Minimally invasive surgery is a great example of a new and innovative approach to spine care that is also very cost effective. Our orthopedic spine surgeon, Dr Zavatsky, reviews his experience in treating high-risk patients with complex spinal deformity and demonstrates excellent radiographic outcomes.

The review article by Dr Hall is a must read because it presents an innovative approach to diagnosis and management of patients with back pain. This pattern-of-pain triage tool is effective and is currently being used in the Ochsner Healthy Back program, a service of the Back and Spine Center. Dr Benzel's outstanding review of adjacent segment disease questions whether this disease entity exists despite the fact that many spine companies have pushed their disc arthroplasty products solely on the existence of adjacent level disease. Our pain management group provides an excellent review of the anatomy, etiology, and management of a very difficult clinical problem—coccydynia—and in partnership with back and spine psychiatrist Dr Josephine Sabharwal, they provide a nice overview of a multidisciplinary chronic pain rehabilitation program.

The case report by Dr Bui et al on Ochsner's experience with in utero spinal bifida repair is excellent. Dr Bui and other members of the team have done an outstanding job of bringing this innovative and effective approach to microsurgical repair of spinal bifida in fetuses to Ochsner. The results have been outstanding as demonstrated in their case series. We look forward to future reports from this group on the long-term outcomes of their surgeries.

The Ochsner Journal is excited to announce our partnership with the Southern Hospital Medicine Association that will allow us to publish new and innovative research abstracts from the annual Southern Hospital Medicine Conference, starting this year with the group's 14^th annual meeting.

We must all focus on providing care that is “truly valuable,” meaning that it positively impacts patients' quality of life without emptying their pockets. A multidisciplinary and disease-based approach to care is one key route towards achieving this goal. The Ochsner Back and Spine Center is a great example of such an approach to spine care! In conclusion, I would like to congratulate and thank all the authors for their excellent contributions to this special volume of The Ochsner Journal dedicated to spine care.