Assessment of spine and nerve surgeries
Prof.Dr W.C. Peul, Prof.Dr. M.J.A. Malessy, Dr. C.L.A. Vleggeert-Lankamp
Aim and focus
The spinal surgery research group focuses on efficacy of spinal surgical interventions, effectiveness of new devices, shared decision making in spine surgery and epidemiology. It is represented as the Spine Intervention Prognostic Study (SIPS) Group, which is supervised by a neurosurgeon (Dr. C. Vleggeert-Lankamp) and an epidemiologist (Drs. W. Jacobs), supported by a senior data manager (Drs. L. Smakman). Momentarily 6 PhD students and 2 excellent trace students and several students are appointed to this program. The Leiden group is closely collaborating with neurosurgeons from the Medisch Centrum Haaglanden, the Hague (MCH) in the spine studies, and Dr. M. Arts from the MCH is added to the SIPS management team. This team is responsible for the quality and progress of the randomized clinical trials (RCTs) that are sponsored by ZonMw, College voor Zorgverzekeraars (Dutch Insurers collective; CVZ) and industry: the Sciatica Trial (ZonMw), Sciatica MED (CVZ), Sciatica PLDD (CVZ), The Delphi Trial (Rheuma Fonds and Cervical Spine Research Society (CSRS-USA), The Felix Study (Paradigm; InSpine), Sciatica Health Decision Making Video (ZonMw) The Neck Trial (Braun-Aesculaap), The Gill Trial (Medtronic), Verbiest RCT (ZonMw-LUMC & EUR), implementation and shared decision making studies (ZonMw), systematic reviews in spinal interventions (CVZ), postoperative physiotherapy in surgery for sciatica (ZonMw, VU-LUMC) and achondroplasia. Recently another RCT to evaluate timing of cervical disc surgery was funded (ZonMw). The research at the neurosurgical department is increasingly involved in research in the context of evidence based medicine by performing (Cochrane) systematic reviews on spinal interventions (surgical techniques for discectomies, disc arthroplasty, spondylolisthesis, cauda syndrome, odontoid fractures and spinal stenosis) and studies into methodological aspects of research in surgical sciences. This further professionalizes the research at the department with a dedicated full-time epidemiologist.
The nerve surgery research program consists of clinically oriented and basic science research. Both are strongly interwoven. The clinical research is focused on the improvement of the selection of patients for nerve surgery and the analysis of (new) surgical reconstruction techniques. A thesis on this topic was recently defended. Currently, three PhD students are involved. Despite refined microsurgical repair techniques, only 10% of adult patients regain normal function after reconstruction of a major peripheral nerve lesion. The nerve surgery basic science program is focussed on the improvement of regeneration of an injured nerve by combining refined surgical repair with gene therapy-based, regenerative molecular delivery strategy. The basic research is performed in close collaboration with the Netherlands Institute for Neurosciences in Amsterdam and the department of Molecular Cell biology. The basic research has a strong translational character. The basic research team consists of four PhD students and two post docs. Funding consists of LUMC hospital resources, benchmarked for promising fundamental research, ZonMw Top Grant and funding from the neurosurgical department itself.
The neurosurgical department scores scientifically below the LUMC average, but a trend is visible to an increase in the number of publications, an increase in impact factor and a decrease in the number of self citations. The increase in efficacy studies will increase the social interest in our studies and this will affect the citation index.
Position in (inter)national context
The multidisciplinary nature and low incidence of many disorders encountered in neurosurgery necessarily leads to intensified cooperation with other institutes and disciplines. In the context of effectiveness research we collaborate with universities in Rotterdam, Utrecht and Amsterdam and perform our RCTs in 11 cooperating hospitals in the region. In the field of “Public Health” we collaborate with the VU Amsterdam (Physiotherapy versus surgery), UMC Utrecht (Achondroplasia) and Erasmus MC Rotterdam (prognostic aspects of sciatica). For methodological research we collaborate nationally with TU Twente, Erasmus University Rotterdam and UMC Utrecht, and internationally with British neurosurgeons for the development of outcome parameters in cervical radiculopathy and London Queensquare for tumor outcome research.
The spine research is executed by neurosurgeons that cooperate with international colleagues in education and research programs. This leads to research programs with an international character (Delphi trial, Cochrane studies), Professor Peul (editorial board) and drs Jacobs (associate editor) are members of The Cochrane Back Review Group (Toronto). All Cochrane studies have international reviewers/co-authors in the team. The GSTSG group analyzes results of surgery for metastasis in the spine. We have a coordinating role in this international study.
The nerve surgery program combines 1/ gene therapy in animal research models that mimic the clinical situation, 2/ basic research in human material focused on the unraveling of factors that play a role in regeneration, 3/ optimization of translation of gene therapy to the clinic and 4/ optimization of clinical treatment. Currently, there are only a few programs around the world with comparable cohesion and interaction between clinical and basic science. The combined approach of sophisticated molecular biological analysis of clinically obtained nerve tissues in order to find new targets for therapy is unique. In this regard, the set-up of the LUMC program can be regarded as one of the frontrunners. It is expected that the investments to set-up and organize the network this approach will proof fruitful in the years to come. The LUMC Nerve Surgery Center is internationally recognized as one of the leaders in the field of obstetric and adult brachial plexus surgery.
- It was shown that after one year, no differences could be found between lumbar disc surgery or prolonged conservative treatment for sciatica but that surgery results in a faster pain relief. No differences could be found in cost-effectiveness between the two interventions. The results changed international guidelines
- The MED trial showed that tubular discectomy resulted in more complications and recurrent herniations with no added clinical effect.
- From several systematic reviews, including Cochrane reviews it was shown that the evidence for spinal surgical interventions suffers from limitations and that there is limited evidence for most surgical interventions, especially the more aggressive, instrumented and industry driven approaches.
- A useful hand function can be surgically restored in infants with a flail arm caused by an obstetrical brachial plexus lesion.
- Sural nerve segments can be genetically modified by a lentiviral vector encoding nerve growth factor
- Poly-Lactic-co-Glycolic-Acid scaffold containing Nerve Growth Factor and Glial cell-line Derived Neurotrophic Factor releasing microspheres improve short term regeneration.
- Intraoperative nerve action and compound motor action potential recordings in patients with obstetric brachial plexus lesions. Do not ad to decision making,
- Severe obstetric brachial plexus palsies can be identified at one month of age.
- The results of the current multicentre RCTs on Gill’s procedure versus spondylodesis, positioning of a prosthesis, a cage or no device in the intervertebral cervical space after cervical herniated disc surgery, interspinous spacer versus interlaminar decompression, surgical versus prolonged conservative care of lumbar spinal stenosis, will be available and this will generate multiple publications.
- An RCT comparing surgical versus prolonged conservative care of cervical herniated disc surgery will start in January 2012.
- Increased ageing of the population prioritizes research on age related disorders, such as odontoid fractures, spinal stenosis, degenerative scoliosos and chronic subdural haematomas. Multiple projects are anticipated and funding for these projects will be pursued.
- Vascular surgery such as coiling, is already performed in cooperation with Rotterdam hospitals, a vascular neurosurgeon and an interventional radiologist have been appointed. Efficacy and effectiveness of these interventions will be analyzed in future projects.
- Intraoperative CT scanning device (Body Tom, 2nd in the world) has been purchased to facilitate spine surgery and offers possibilities for research.
- The incidence of thromboembolic complications will be analyzed and we will assess the relation with peroperative medication use.
- The methodology of surgical research will be studies in meta-epidemiological approach in international cooperation.
- Outcome & Quality Research for Neurosurgical Themes
Cohesion within LUMC
Data management and analysis of studies are performed in collaboration with Medical Decision Making and Medical Statistics of the LUMC. Research is performed in collaboration with the Department of Orthopedic Surgery (brachial plexus, ROM, spinal metastases and primary tumors), Department of Neuro-Pathology (nerve histology, chordomas), Neuro-radiology (root avulsions) vascular surgery and MRI assessments, Endocrinology (Thyroid, Diabetic Neuropathy), Throut-Ear-Nose (Vestibular Schwannoma), Urology (cauda syndrome) and Neurology (Clinical Neurophysiology). Moreover, research is performed in collaboration with the department of Anatomy in the field of spine and skull base surgery,