Vaccaro AR, Eck JC, eds. Controversies in Spine Surgery: Best Evidence Recommendations. Thieme, New York, Stuttgart. 279 pages, $139.95.
This an important book because it attempts to answer the most perplexing questions which face any large spine service.
The book is edited by two orthopedic spine surgeons (Drs. Vaccaro and Eck) and contains contributions from a total of 61 authors, who are primarily orthopedic or neurological surgeons. The first chapter appropriately describes the meaning of the measures for evidence based medicine (EBM). The authors describe the 5 steps in EBM evaluation starting with what is the question to be answered or addressed. The authors go on to define levels I-V evidence. This scale allows investigators to communicate and discuss what and how rigorous are the studies which involve either therapeutic, prognostic (disease outcome), prognostic (diagnostic test efficacy), or economic/decision analysis. Finally, we are shown the levels (1A-2C) of recommendation for any given study.
With that material behind us, the authors tackle 10 questions involving spinal trauma, 10 questions involving degenerative disease of the cervical and thorocolumbar spine, 6 questions involving the use of devices and new technology and 3 questions involving spine infections. This reviewer is certain that most, if not all of these questions have been discussed in combined spine surgery and radiology conferences in virtually every academic medical center.
Each issue is posed, diagnostic criteria described, treatments discussed and then different Levels of Evidence data is presented. Admixed in the chapters are Tables, images (CT/MR/radiographs), flow charts (algorithms), consensus statements, “pearls,” conclusions, and references.
Great discussions and evidence for various options abound. Here are some examples: For recurrent HNP what is best – repeat discectomy or fusion; for back pain – ALIF or PLIF or TLIF; for cervical myelopathy – anterior or posterior approach; for compression fractures – kyphoplasty or vertebroplasty. These are just 4 of the 29 questions posed.
This is exactly the book one should have ready access to since decisions in the clinical area are most often made on the basis of “experience” or “war stories,” not on evidence. Here is a way to work through many of these vexing problems.
