Presidential address of the 32nd annual meeting of the International Society for the Study of the Lumbar Spine: spine care in a global world. A duality of priorities and challenges.

We do live in a global world. Information and transport technologies as well as economic environment have led to this globalization. This situation is hailed or cursed, but it is there to stay and extend. But how does health care and more specifically spine care fit in this global world? Has this globalization enabled us to reduce the health resources gap between western countries and poorer southern regions? How do challenges and priorities differ for spine care in those two components of a global world? As an example, I compared two countries, Belgium where we live and Burundi where my wife was born. These are two small countries covering a similar area. And one has been a colony of the other. But the similarities end there. Life expectancy is 79 years in Belgium against 42 years in Burundi and child mortality 5.4 of 1,000 against 197 of 1,000. The total health expenditures per capita are $2,515 against $16 and account for 9.1% of the Belgian GDP against 3.0% in Burundi. Of course, the age structure is vastly different, with 46% of the Burundese population under 14 and only 2.6% over 65 against 16.9% and 17.4% in Belgium. Moreover, this difference in the age pyramid is likely to increase with a population growth rate of 2.2% in Brurundi and 0.15% in Belgium. It is obvious from these numbers that the needs and priorities of healthcare nature and financing will be widely different between those two countries. How do those differences influence the need and nature of spine care? The aging of the population in industrialized countries appears to be a nonreversible phenomenon. Increase of life expectancy, due in great part to the improvement of health care, combined with a drastic decrease in birth rates have led to this situation. The world demographic situation has shifted from a pattern of high birth rates and high mortality rates to one of low birth rates and delayed mortality. In Europe, the proportion of subjects over 65 was 10.8% in 1950, 14% in 1970, 19.1% in 1995, and is projected by some sources at 30.1% in 2025 and 42.2% in 2050. The proportion of subjects over 75 years has grown from 2.7% in 1950 to 5.2% in 1995 and is projected at 9.1% in 2025 and 14.6% in 2050. The global consequences of this distortion of the age pyramid on healthcare development, access, and costs are huge. In the United States, approximately 80% of all individuals over 65 years have at least one chronic condition and 50% have two. Approximately 59% of U.S. residents over 65 years are affected by osteoarthritis, which is the main cause for disability. Aging alone will generate an increase of more than 30% in real per capita healthcare expenditures by 2030. Back and neck pain are among the most frequently encountered complaints of older people, and the nature of the spine renders those problems highly complex to investigate and to treat. However, the relation between aging, degenerative processes, and actual complaints is far from clear. The multifactorial nature of spinal degeneration, the complexity and multiplicity of treatment, the rapid evolution of medical technology, and the nature of patient’s expectations in terms of quality of life have also resulted in an escalation in costs. Osteoporosis is a good example. The aging of the western population has increased the number of severely osteoporotic subjects, mostly women. Recent studies have shown that osteoporotic vertebral fractures are associated with an increased risk of mortality and a decreased quality of life. The prevalence in those fractures is around 39% in subjects over 65 years. It does not appear that the preventive treatment strategies applied since a few decades did yield very spectacular results in the decrease of the frequency of osteoporotic fractures, including vertebral osteoporotic compression fractures. Whereas those lesions where long considered as a burden with which patients should live and which were treated with relatively inexpensive painkillers and/or physical therapy, there exist currently percutaneous treatment methods which not only deal with the problem of pain but also aim at restoring the compressed vertebral body height, thus trying to avoid possible kyphotic deformities. However, those treatments are expensive; and if all vertebral compression fractures were to be treated in From Hôpitaux Iris Sud/IRIS South Teaching Hospitals, Brussels, Belgium. This is the Presidential Address of the 32nd Annual Meeting of the International Society for the Study of the Lumbar Spine, New York, May 10–14, 2005. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Marek Szpalski, MD, Hôpitaux Iris Sud/IRIS South Teaching Hospitals, 142 rue Marconi, 1190 Brussels, Belgium; E-mail: mszp@win.be