Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're highlighting the UF Health Comprehensive Spine Center, a multidisciplinary team of spine physicians and surgeons providing a patient-centered approach to enhance outcomes through medical, interventional, and surgical treatment.

Joining me is Dr. Daniel Hoh. He's a professor and Division Chief of Spine in the Department of Neurosurgery at the University of Florida College of Medicine. Dr. Hoh, thank you so much for joining us today. When we talk about spine disorders, we're really talking about a pretty broad spectrum of conditions. Can you give us a brief overview of the types of spinal conditions that you see most commonly?

Dr. Daniel Hoh: Absolutely. When we talk about spine, as you said, we are talking about a complex array of different conditions and whatnot. But in reality, when we're talking about the multidisciplinary spine center, what we're mostly talking about are the common types of problems that affect many people that we know. These are things like spinal pain related to the neck, back, lower back, and oftentimes will radiate into the arm or leg. And this is by far one of the most common reasons for patients to seek medical treatment today from their primary care doctor, the emergency room, or to be referred to our UF Health Comprehensive Spine Center.

Melanie Cole, MS: Well, thank you for that. So Dr. Hoh, as we know, pain is somewhat subjective. So when patients come to you, and this is for other providers, because sometimes it is the primary care who sees them first, and pain may be their primary complaint. I'd like you to speak about how you approach that when they first come to you and how these kinds of things can have that impact on physical function, quality of life, because we all know unless you have suffered back pain, it really can affect your quality of life in so many limiting ways. So, speak a little bit about how they present clinically when they come to you.

Dr. Daniel Hoh: You hit the nail on the head. When we talk about the most common reasons why individuals come to the UF Health Spine Center, it's typically for neck pain, back pain. And pain is a quality of life issue. And while you might say it's subjective, the reality is the impact on quality of life can be significant.

And so, our goal with our comprehensive spine center is to develop a patient-centered approach in how we evaluate, diagnose, and ultimately treat people for the conditions that affect their quality of life. It is complex. And oftentimes we see patients come to us in varying stages of the problem, the condition, the workup, and in treatment.

And our goal, like I said, is to take a patient-centered approach, meaning there's not one-size-fits-all approach to these patients. And so, with our comprehensive spine center, which is a multidisciplinary team that includes surgeons, medical spine providers, PM&R, which is sports medicine and rehabilitation, pain management. We view that we have the ability to view these conditions from all perspectives and then really provide a comprehensive approach to workup and provide the type of multidisciplinary care that can address patients where they're at.

Melanie Cole, MS: So, you've just told us a little bit about the UF Health Comprehensive Spine Center. Tell us what makes it so unique. You spoke a little bit about the multidisciplinary approach. What does that pathway look like for patients?

Dr. Daniel Hoh: So, when I think about our multidisciplinary spine center, I think to myself, the condition that we're addressing is spinal issues resulting in pain. And really, when we think about it, we've identified what I would say is two critical moments in a patient's journey.

The first is access to high-quality care. At the point at which a patient has a problem that's affecting their quality of life, can we facilitate access into our UF Health system to really be seen, evaluated, and treated by some of the best doctors for this particular problem? That's the first critical moment.

The second is we also know because of the nature of these types of conditions, that sometimes the initial treatment is successful. But other times, with a multidisciplinary approach, that other treatments are required.

And so, the second critical moment is when the first initial treatment does not work, how quickly are we able to pivot and provide another treatment that can be successful? And so, that's how we developed the spine center around this. The first was ease of access, getting patients into our system to be evaluated, and the second is to provide a multidisciplinary approach to offer a first treatment. And if that works successfully, great. But if not, then we can provide other types of treatment options.

And so, we have a single access point, which is through a single telephone number, in which patients can be referred to our center. And if a patient comes with a known diagnosis or requesting to see a specific type of specialty or provider, then we can facilitate an expedited appointment.

Alternatively, if a patient wants to just be seen and doesn't necessarily know what kind of provider they want to be seen by or is in the early stages of workup, we have them seen and expedited to see a provider that can initiate that workup. At that point in which a diagnosis has been made and a condition, a management plan has been determined, then one of our multidisciplinary spine center providers will initiate that treatment.

Now, again, this is, I think, the second critical moment, is that if that initial treatment does not succeed in resolving the patient's condition, then with our multidisciplinary team, we have twice monthly conferences and facilitated collaboration and communication between providers to then explore other options that can then put the patient on the right course. And I think that's what really allows our multidisciplinary spine center to stand out from other ways in which people oftentimes end up seeking treatment for spine problems.

Melanie Cole, MS: Well, I agree with you. And Dr. Hoh, one of the biggest misconceptions is that spine care means either medications or surgery. I'd like you to just give a brief overview of the continuum of treatment options available today, because there's so many more tools in your armamentarium than even just 10 years ago.

It's a pretty exciting time in spinal care and spinal surgery. And start with a little bit of some of the conservative modalities moving into some interventional pain procedures, which also have become a real burgeoning field. And we'll get into some of the surgery afterwards, but just kind of give us this little overview of some of the services that you offer at your spine center.

Dr. Daniel Hoh: I think most people are pretty familiar with conventional frontline conservative management. These can be something as simple as initial rest after a strenuous activity that may have initiated or triggered an event, but things like physical therapy, non-steroidal anti-inflammatory over-the-counter medications.

But really, I think in this day and age, we really have a better understanding of multimodal medication management treatment. So, this can include things like anti-inflammatories, but in addition, some other agents like neuropathic pain medications. These are things like pregabalin, duloxetine that have been shown to be incredibly effective and safe for the treatment of acute and chronic pain in individuals with spine problems.

We go beyond medication management. We really have a superb team of interventional pain spine physicians in our multidisciplinary spine center. This includes anesthesia pain management, PM&R, and neurology that can offer a comprehensive array of interventional options. And this can include some more conventional things like epidural steroid injections or trigger point injections, some more advanced innovative treatment options such as spinal cord stimulation, peripheral nerve stimulation, and other types of procedures.

So for patients that come to our multidisciplinary spine center with conditions for which they are seeking more conservative or less invasive options, I know that our multidisciplinary team has the ability to offer that full array of options to these patients.

Melanie Cole, MS: Thank you for telling us about all the options available when we think of conservative measures and interventional treatments. Now, tell us more about your field and some of the surgical options available today. There's so many, and it's pretty exciting.

Dr. Daniel Hoh: We live in a really exciting time now in which advances in spine surgical care is directly translating into improved outcomes for patients. And the reality is that because we have a better understanding now of the unique characteristics of patients, their condition, their priorities, things that may impact risk and benefit of surgery, the ability to offer a wide array of different types of surgical treatment options has been never more realized than now.

These can range from simple, less invasive surgical treatment options to address routine common conditions involving the spine, all the way up to complex surgical treatment options for some of our most complicated spinal conditions like spinal deformity or revision surgery for failed prior surgery.

Our surgical team has a broad range of surgeons with varying experiences and expertise in all these different areas with regards to surgical advancements in spine surgical care. We have a multidisciplinary surgical meeting in which we meet twice monthly and review cases to discuss as a group what is the best treatment option, whether it be surgical or non-surgical. But certainly, if it's surgical, what are the different types of surgical approaches that may best fit the needs of that particular patient?

Melanie Cole, MS: Well, they certainly do. And Dr. Hoh, you've spoken a few times about the integrated comprehensive multidisciplinary model. What does the literature tell us about that impact on outcomes when you are all working together?

Dr. Daniel Hoh: I know that a team approach that offers comprehensive multidisciplinary care has been proven to be effective and better than single siloed care for a number of medical conditions. We know this is certainly true when it comes to things like cancer care and other types of complex medical conditions. And we certainly see this when it comes to spine care.

I'll use one example. We first started looking at how we can optimize care for the perioperative surgical patient undergoing spine surgery. And we learned early on that collaboration between anesthesiology and neurosurgery and spine surgery and physical therapy and rehab for both preoperative and postoperative optimization would have a significant impact. And we ultimately implemented a multidisciplinary collaborative protocol for the optimization of patients undergoing spine surgery. We ended up studying this and publishing in multiple journals showing, through various studies, that a collaborative multidisciplinary approach can optimize patients undergoing spine surgery to reduce adverse events, reduce length of stay, facilitate earlier recovery of function, and improve overall outcomes.

We even explored this looking at our most vulnerable populations. So, these are patients that have frailty, and we found that frail patients, generally speaking, typically do worse than patients that are non-frail. And yet, when we implemented a multidisciplinary approach for optimization, patients even with frailty improved and did nearly as well as patients without frailty. So, that really bolstered us and gave us the understanding of how a multidisciplinary approach can really improve outcomes for our patients.

Now, what we do see with our Multidisciplinary Spine Center is that, without a doubt, things like patient satisfaction, throughput, meaning that patients get access to care and access to the treatment that they need, happens in a much more facilitated way. We also know that by through collaboration, that the ability of our physicians to work together to identify the best treatment for a patient typically happens more efficiently and in a more expedited manner.

Melanie Cole, MS: Well, it certainly is a comprehensive approach. And while we talk about this multidisciplinary approach really looking at the team that is working with these patients, Dr. Hoh, how important is shared decision-making with the patient themselves in helping them to understand their options because there are so many, and to participate in choosing the treatment strategy that aligns with their goals?

Dr. Daniel Hoh: That's a great question, and I think perfectly aligns with the philosophy and approach of our center. When we're talking about quality of life, paramount to that is an understanding of what an individual patient's priorities are. What's most important to them? We can look at MRIs, we can look at X-rays, we can look at our array of treatments, and we can say, "Here's what we have available to us to offer to the patient." But at the end of the day, the goal of this is to address what's most important to the patient.

So when we look at a patient-centered approach, what we really mean is, can we make the right diagnosis, identify the right set of options for management, present that to a patient in a way that makes sense, and say which of these, based on their advantages and expected risk and benefits, most aligns with their individual priorities?

There's no question that given the diversity of the patients we see and the variation of types of conditions we see, that we cannot assume that one treatment works for all individuals or that even one treatment works for different individuals with the same condition. Each patient comes with their own priorities, their own expectations for what is a best overall outcome.

So, patient-shared decision-making, I think, is paramount to that. And I think that starts with an open discussion in the clinic. What is most important to you? What is most important to your family? And with that sort of discussion, then oftentimes the types of options for treatment fall in alignment.

Melanie Cole, MS: Dr. Hoh, you've given us so much to think about and such great information. If there was one message you'd like clinicians, referring clinicians, and patients to take away about modern spine care today and the UF Health Comprehensive Spine Center, what would you like them to know?

Dr. Daniel Hoh: What I would say is that the condition of spine pain when it manifests as neck pain and back pain is a really significant issue for our communities. The UF Health Multidisciplinary Spine Center is dedicated to providing the utmost premier level of care for our patients. If you have patients that you feel are suffering from these conditions, we would be honored to have them referred to our center so that we can expedite access to care and provide that multidisciplinary approach of patient-centered care to give them the best outcome that they deserve.

Melanie Cole, MS: Thank you so much, Dr. Hoh, for joining us today and sharing not only your incredible expertise, but your passion for the Spine Center and for what you do. I can hear it, and thank you so much again for joining us. To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org, or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast. I'm Melanie Cole.