Evidence Based Medicine in Spine Surgery

Byung-Chul Park

doi:10.4184/jkss.2011.18.3.174

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Park: Evidence Based Medicine in Spine Surgery

Review Article

Journal of Korean Spine Surg 2011;18(3):174-178.

Published online: 21 September 2011

DOI: https://doi.org/10.4184/jkss.2011.18.3.174

Evidence Based Medicine in Spine Surgery

Byung-Chul Park, M.D.

Department of Orthopedic Surgery, School of Medicine, Kyungpook University, Daegu, Korea

Corresponding author: Byung-Chul Park, M.D. Department of Orthopaedic Surgery, School of Medicine, Kyungpook University, 50 Samdok-2-ga, Chung-gu, Taegu 700-721, Korea TEL: 82-53-420-5628, FAX: 82-53-422-6605 E-mail: bcpark@knu.ac.kr

Received 5 September 2011 Revised 10 September 2011 Accepted 10 September 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Study Design

A review of literature regarding evidence-based medicine in spinal surgery.

Objectives

To understand the philosophy of evidence-based medicine (EBM) in order to support clinical decision making.

Summary of Literature Review

Evidence-based medicine is a commonplace phrase representing the hallmark of excellence in clinical practice. However, there has been misunderstanding and indiscriminate use of the concept of EBM in clinical practice. It is necessary to understand true philosophy of EBM.

Materials and Methods

Narrative and review of the literature.

Results

EBM is not for research to supplant individual clinical experience and the patients’ informed preference but to integrate these factors with the best available research.

Conclusions

Treatment recommendations are no longer based on level of evidence, but also the risk benefit ratio and cost effectiveness.

Keywords: Evidence-based medicine, Spine surgery

REFERENCES

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Figures and Tables%

Fig. 1.

Hierarchy of research designs in evidence-based medicine.

Fig. 2.

Diagram showing basic design of case-control study. Study groups are determined by outcomes: Patients with a particular outcome are cases, whereas patients without the outcome are controls. This study design looks retrospectively to determine if there is a difference in rate of exposure to a particular variable between cases and controls.

Fig. 3.

Diagram showing basic design of observational cohort study. Treatment is chosen by patient and physician rather than through randomization. Study groups are defined by treatment, and outcomes are compared. Cohort studies can be prospective or retrospective

Fig. 4.

Diagram showing basic design of randomized controlled trial. Study sample is randomized to different treatments, and outcomes are prospectively determined

Table 1

Level	Therapeutic Studies: Investigating the Results of Treatment	Prognostic Studies: Investigating The Outcome of Disease	Diagnostic Studies: Investigating a Diagnostic Test	Economic and Decision Analyses: Developing an Economic or Decision Model
I	1. randomized controlled trial a. significant difference b. No significant difference but confidence intervals 2. Systematic review of Level I Randomized controlled trial (studies were homogenous)	1. prospective study*2. Systematic review of Level I studies	1. Testing of previously developed diagnostic criteria in series of consecutive patient (with universally applied reference ‘‘gold’'standard)2. Systematic review of Level I Studies	1. Clinically sensible costs and alternatives: values obtained from many studies; multiway sensitivity analyses 2. Systematic review of Level I studies
II	1. Prospective cohort study‡2. Poor-quality randomized controlled trial (eg, < 80% followup)3. Systematic review† a. Level II studies b. Nonhomogenous Level I studies	1. Retrospective study§2. Study of Untreated controls from a randomized controlled trial 3. Systematic review of Level II studies	1. Development of diagnostic criteria on basis of consecutive patients (with universally applied reference ‘‘gold’'standard)2. Systematic review of Level III studies	1. Clinically sensible costs and alternatives: values obtained from limited studies; multiway sensitivity analyses 2. Systematic review of Level II studies
III	1. Case-control study#2. Retrospective cohort study 3. Systematic review† of Level III studies		1. Study of nonconsecutive patients (no consistently applied reference ‘‘gold’'standard)2. Systematic review of Level III studies	1. Limited alternatives and costs; poor estimates 2. Systematic review of Level III studies
IV	Case series (non, or historical, control groups)	Case series	1. Case-control study 2. Poor reference standard	No sensitivity analyses
V	Expert opinion	Expert opinion	Expert opinion	Expert opinion

* All patients were enrolled at the same point in their disease with ≥80% followup of enrolled patients.† A study of results from two or more previous studies.‡ Patients were compared with a control group of patients treated at the same time and institution § The study was started after treatment was performed.# Patients with a particular outcome (“cases” with, for example, a failed arthroplasty were compared with those who did not have the outcome (‘‘controls’'with, for example, a total hip arthroplasty that did not fail)

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