Costs and effects in lumbar spinal fusion. A follow-up study in 136 consecutive patients with chronic low back pain

Erector spinae plane block for perioperative pain management in neurosurgical lower-thoracic and lumbar spinal fusion: a single-centre prospective randomised controlled trial

BACKGROUND

Erector spinae plane block is a locoregional anaesthetic technique widely used in several different surgeries due to its safety and efficacy. The aim of this study is to assess its utility in spinal degenerative and traumatic surgery in western countries and for patients of Caucasian ethnicity.

METHODS

Patients undergoing elective lower-thoracic and lumbar spinal fusion were randomised into two groups: the case group (n = 15) who received erector spinae plane block (ropivacaine 0.4% + dexamethasone 4 mg, 20 mL per side at the level of surgery) plus postoperative opioid analgesia, and the control group (n = 15) who received opioid-based analgesia.

RESULTS

The erector spinae plane block group showed significantly lower morphine consumption at 48 h postoperatively, lower need for intraoperative fentanyl (203.3 ± 121.7 micrograms vs. 322.0 ± 148.2 micrograms, p-value = 0.021), lower NRS score at 2, 6, 12, 24, and 36 h, and higher satisfaction rates of patients (8.4 ± 1.2 vs. 6.0 ± 1.05, p-value < 0.0001). No differences in the duration of the hospitalisation were observed. No erector spinae plane block-related complications were observed.

CONCLUSIONS

Erector spinae plane block is a safe and efficient opioid-sparing technique for postoperative pain control after spinal fusion surgery. This study recommends its implementation in everyday practice and incorporation as a part of multimodal analgesia protocols.

TRIAL REGISTRATION

The study was approved by the local ethical committee of Romagna (CEROM) and registered on ClinicalTrials.gov (NCT04729049). It also adheres to the principles outlined in the Declaration of Helsinki and the CONSORT 2010 guidelines.

Lumbar Decompression Versus Spinal Fusion in a Private Outpatient Setting: A Retrospective Study with Three Years of Follow-up

Objective  To compare pain, function, quality of life and adverse events of lumbar decompression and spinal fusion in patients with degenerative spinal pathologies who participated in a second opinion program for spinal surgeries with a 36-month follow-up.

Methods  The data for this retrospective cohort were withdrawn from a private healthcare system between June 2011 and January 2014. The study sample consisted of 71 patients with a lumbar spine surgical referral. The outcomes for the comparisons between lumbar decompression and spinal fusion were quality of life (evaluated through the EuroQoL 5D), pain (measured by the Numerical Rating Scale) and function (assessed through the Roland Morris Disability Questionnaire) measured at baseline, and at 12 and 36 months after the surgical procedures. The definitions of recovery were established by the minimal clinically important difference (MCID). The baseline differences between the groups were analyzed by non-paired t -test, and the differences in instrument scores between time points, by generalized mixed models. The results were presented as mean values adjusted by the models and 95% confidence intervals.

Results  Concerning the surgical techniques, 22 patients were submitted to spinal fusion and 49 patients, to lumbar decompression. As for the comparisons of the findings before and after the surgical interventions, the MCID was achieved in all outcomes regarding quality of life, pain and function at both time points when compared to baseline scores Moreover, concerning the complication rates, only lumbar decompression presented a surgical rate of 4% ( n  = 3) for recurrence of lumbar disc hernia.

Conclusion  Patients with degenerative spinal pathologies present improvements in long-term outcomes of pain, function and quality of life which are clinically significant, no matter the surgical intervention.

Outpatient Minimally Invasive Lumbar Fusion Using Multimodal Analgesic Management in the Ambulatory Surgery Setting

BACKGROUND

The transition of minimally invasive (MIS) spine surgery from the inpatient to outpatient setting has been aided by advances in multimodal analgesic (MMA) protocols. This clinical case series of patients demonstrates the feasibility of ambulatory MIS transforaminal lumbar interbody fusion (TLIF) and lateral lumbar interbody fusion (LLIF) procedures while using an enhanced MMA protocol.

METHODS

Consecutive MIS TLIF or LLIF procedures with percutaneous pedicle screw fixation and direct decompression in the ambulatory setting were reviewed. The procedures were performed using an MMA protocol. The ambulatory surgery center (ASC) did not allow for observation of patients for periods of time greater than 23 hours. We recorded patient demographics, perioperative, and postoperative characteristics.

RESULTS

Fifty consecutive patients were identified from September 2016 to July 2019. Forty-one patients (82%) underwent MIS TLIF, and 9 patients underwent MIS LLIF (18.0%). All patients were discharged on the same day of surgery. The mean length of stay was 4.5 hours and 3.8 hours for the TLIF and LLIF cohorts, respectively. Our review of medical records revealed no postoperative complications following either the TLIF or the LLIF procedures.

CONCLUSIONS

The present study of 50 consecutive patients is the largest clinical series of ASC patients undergoing lumbar fusion procedures in a stand-alone facility with no extended postoperative observation capability. While using MMA protocol within the ASC, no postoperative complications were observed for either MIS TLIF or LLIF procedures. All patients were discharged from the ambulatory surgical center on the day of surgery with well-controlled postoperative pain.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

The MMA protocol is an essential aspect in transitioning minimally invasive lumbar spine surgery to the ASC. Our findings indicate that MIS lumbar fusion spine surgery with an enhanced MMA protocol can lead to safe and timely ASC discharge while minimizing hospital admission.

Preoperative and Postoperative Spending Among Working-Age Adults Undergoing Posterior Spinal Fusion Surgery for Degenerative Disease

OBJECTIVE

To investigate the health care resource utilization and the associated 6 months preoperative and 6 months postoperative spending among patients undergoing posterior lumbar fusion.

METHODS

We retrospectively reviewed a private insurance claims database for patients who underwent single-level posterior spinal fusion from January 2011 to December 2015. Outpatient health services, prescription pain medications, and inpatient admissions were assessed.

RESULTS

Among 25,401 patients (mean age, 52 years; 58% female) in the final cohort, median spending during the period from 6 months before surgery to 6 months after surgery was $60,714 (interquartile range [IQR], $46,961-$79,892)/patient. Preoperative spending accounted for 7% ($121 million) of the total costs, and postoperative spending accounted for 8% ($135 million). Median preoperative spending was $3566 (IQR, $2144-$5857) per patient, with imaging accounting for the highest proportion (33%) of preoperative spending. In the 6 months period preceding surgery, 46% patients received injections and 47% received physical therapy. The median postoperative spending was $1954/patient (IQR, $735-$4416). Total postoperative spending was significantly higher among those not discharged home (median, $7525; IQR, $6779-$19,602) compared with those discharged home (median, $1617/patient; IQR, $648-$4033) and home with home care services (median, $2921; IQR, $1406-$5662) (P < 0.001).

CONCLUSIONS

Unplanned readmission after posterior spinal fusion was the highest contributor to postoperative spending and the second highest contributor to overall costs. Understanding factors that contribute to the costs in the preoperative and postoperative period in patients undergoing single-level posterior lumbar fusion for degenerative pathology is essential to identify targets for cost containment.

Risk classification of patients referred to secondary care for low back pain

Background

Nonspecific low back pain is characterized by a wide range of possible triggering and conserving factors, and initial screening needs to scope widely with multilevel addressment of possible factors contributing to the pain experience. Screening tools for classification of patients have been developed to support clinicians. The primary aim of this study was to assess the criterion validity of STarT Back Screening Tool (STarT Back) against the more comprehensive Örebro Musculoskeletal Pain Questionnaire (ÖMPSQ), in a Norwegian sample of patients referred to secondary care for low back pain. Secondary aims were to assess risk classification of the patients, as indicated by both instruments, and to compare pain and work characteristics between patients in the different STarT Back risk categories.

Methods

An observational, cross-sectional survey among patients with low back pain referred to outpatient secondary care assessment at Trondheim University Hospital, Norway. Cohen’s Kappa coefficient, Pearson’s r and a Bland-Altman plot were used to assess criterion validity of STarT Back against ÖMPSQ. Furthermore, linear regression was used to estimate mean differences with 95% CI in pain and work related variables between the risk groups defined by the STarT Back tool.

Results

A total of 182 persons participated in the study. The Pearsons correlation coefficient for correspondence between scores on ÖMPSQ and STarT Back was 0.76. The Kappa value for classification agreement between the instruments was 0.35. Risk group classification according to STarT Back allocated 34.1% of the patients in the low risk group, 42.3% in the medium risk, and 23.6% in the high risk group. According to ÖMPSQ, 24.7% of the participants were allocated in the low risk group, 28.6% in the medium risk, and 46.7% in the high risk group. Patients classified with high risk according to Start Back showed a higher score on pain and work related characteristics as measured by ÖMPSQ.

Conclusion

The correlation between score on the screening tools was good, while the classification agreement between the screening instruments was low. Screening for work factors may be important in patients referred to multidisciplinary management in secondary care.

A comparative analysis of a disposable and a reusable pedicle screw instrument kit for lumbar arthrodesis: integrating HTA and MCDA

OBJECTIVE

Lumbar arthrodesis is a common surgical technique that consists of the fixation of one or more motion segments with pedicle screws and rods. However, spinal surgery using these techniques is expensive and has a significant impact on the budgets of hospitals and Healthcare Systems. While reusable and disposable instruments for laparoscopic interventions have been studied in literature, no specific information exists regarding instrument kits for lumbar arthrodesis. The aim of the present study was to perform a complete health technology assessment comparing a disposable instrument kit for lumbar arthrodesis (innovative device) with the standard reusable instrument.

METHODS

A prospective and observational study was implemented, by means of investigation of administrative records of patients undergoing a lumbar arthrodesis surgical procedure. The evaluation was conducted in 2013, over a 12- month time horizon, considering all the procedures carried out using the two technologies. A complete health technology assessment and a multi-criteria decision analysis approach were implemented in order to compare the two alternative technologies. Economic impact (with the implementation of an activity based costing approach), social, ethical, organisational, and technology-related aspects were taken into account.

RESULTS

Although the cost analysis produced similar results in the comparison of the two technologies (total cost equal to € 4,279.1 and € 4,242.6 for reusable instrument kit and the disposable one respectively), a significant difference between the two instrument kits was noted, in particular concerning the organisational impact and the patient safety.

CONCLUSIONS

The replacement of a reusable instrument kit for lumbar arthrodesis, with a disposable one, could improve the management of this kind of devices in hospital settings.

Quality of life and disability: can they be improved by active postoperative rehabilitation after spinal fusion surgery in patients with spondylolisthesis? A randomised controlled trial with 12-month follow-up

PURPOSE

The aim of the study was to investigate the effectiveness of the postoperative 12-month exercise program compared to usual care on disability and health-related quality of life (HRQoL) in patients after lumbar spine fusion surgery (LSF).

METHODS

Altogether, 98 patients with isthmic (31) or degenerative (67) spondylolisthesis were randomised to exercise therapy group (EG) (n = 48) or usual care group (UCG) (n = 50) 3 months after LSF. EG patients had home-based progressive strength and aerobic training program for 12 months. UCG patients received only oral and written instructions of exercises. Oswestry Disability Index (ODI) and HRQoL (RAND-36) were evaluated at the time of randomization, at the end of the intervention and 1 year after intervention.

RESULTS

The mean ODI score decreased from 24 (12) to 18 (14) in the EG and from 18 (12) to 13 (11) in the UCG during intervention (between-groups p = 0.69). At 1-year follow-up, 25 % of the EG and 28 % of the UCG had an ODI score ≥20. No between-group differences in HRQoL change were found at any time point. The mean (95 % CI) physical functioning dimension of the HRQoL improved by 10.0 (4.6-15.3) in the EG and by 7.8 (2.5-13.0) in the UCG. In addition, the role physical score improved by 20.0 (7.7-32.3) in the EG and by 16.4 (4.4-28.4) in the UCG during the intervention.

CONCLUSIONS

The exercise intervention did not have an impact on disability or HRQoL beyond the improvement achieved by usual care. However, disability remained at least moderate in considerable proportion of patients.

Predictors of discharge to an inpatient rehabilitation facility after a single-level posterior spinal fusion procedure

PURPOSE

To determine perioperative characteristics of patients undergoing single-level spinal fusion surgery that could help predict discharge to an inpatient rehabilitation facility (IRF).

METHODS

Demographic, peri- and postoperative characteristics were reviewed for 107 patients who underwent single-level spinal fusion surgery at a high-volume level I trauma center between January 2011 and December 2013. The relationships between discharge to IRF and gender, age, body mass index (BMI), Charlson Comorbidity Index (CCI), insurance provider, length of stay (LOS), intra- and postoperative outcomes and readmission rates in patients undergoing single-level spinal fusion surgery were analyzed using unpaired and paired t testing.

RESULTS

21.5 % (n = 23) of patients were discharged to an IRF. By using unpaired and paired t tests, it was determined that age, BMI, CCI, LOS and insurance provider were all correlated with a higher probability of being discharged to an IRF. Additionally, a logistic regression model demonstrated a correlation between lower CCI and discharge to an IRF.

CONCLUSIONS

Statistically significant differences were seen regarding age, BMI, CCI, LOS and insurance provider when determining the necessity of a patient being discharged to an IRF. These characteristics can be used to begin the process of setting up discharge disposition preoperatively rather than postoperatively. There were no perioperative characteristics that were statistically significant in determining discharge disposition; therefore, physicians can utilize these preoperative demographics in deciding and organizing discharge before the day of surgery, which can diminish LOS and lead to substantial health system savings.

Feasibility and patient-reported outcomes after outpatient single-level instrumented posterior lumbar interbody fusion in a surgery center: preliminary results in 16 patients

STUDY DESIGN

Retrospective study.

OBJECTIVE

To report surgical and patient-reported outcomes after outpatient lumbar fusions in an ambulatory setting.

SUMMARY OF BACKGROUND DATA

There is growing interest in the potential benefits of outpatient spine surgery such as reduced costs, consistent operative team, and decreased postoperative complications during in-hospital recovery. However, there are limited studies on outcomes after outpatient lumbar fusions, to guide patient selection, treatment techniques and postoperative expectations.

METHODS

Medical records of 16 consecutive patients, who underwent outpatient direct open, single-level, posterior lumbar interbody fusions, were examined by a single surgeon. Outcome measures included visual analogue scale (VAS) scores for lower back and Oswestry Disability Indices (ODIs). Mean body mass indices (BMIs), estimated blood loss, surgical times and complications, and fusion rates were evaluated.

RESULTS

Males represented 56% of patients. Mean age was 42.81 ± 3.05 years (mean ± standard error) and mean body mass index was 28.95 ± 1.04. History of smoking and narcotics use were statistically noncontributory. Mean final follow-up was 15 (range, 5.52-34.2 mo) months. Mean postoperative scores were determined by the final follow-up VAS and ODI. L5-S1 was the most common level of the 16 levels operated on (69%). Preoperative and postoperative VAS and ODI scores for lower back were obtained for 15 patients (93.75%). Mean lower back VAS score of 8.4 ± 0.37 preoperatively reduced to 4.96 ± 0.73 postoperatively, (P = 0.001). Mean ODI improved from 52.71 ± 0.04 preoperatively, to 37.43 ± 0.06 postoperatively, (P = 0.04). One patient experienced postoperative worsened back pain with clinical and radiological signs of possible aseptic discitis. Estimated blood loss was 161 ± 32 mL and average operating time was 124.85 ± 7.10 minutes. The overall fusion rate was 87.5%.

CONCLUSION

Direct open posterior lumbar interbody fusions were done safely with statistically significant reduction in average pain and ODI scores. Surgical times were approximately 2 hours with minimal blood loss, allowing patients to be comfortably discharged the same day without a drain.

The case for orthopaedic medicine in Israel

BACKGROUND

Musculoskeletal complaints are probably the most frequent reasons for visiting a doctor. They comprise more than a quarter of the complaints to primary practitioners and are also the most common reason for referral to secondary or tertiary medicine. The clinicians most frequently consulted on musculoskeletal problems, and probably perceived to know most on the topic are orthopaedic surgeons. But in Israel, there is significant ambivalence with various aspects of the consultations provided by orthopaedic surgeons, both among the public and among various groups of clinicians, particularly family practitioners and physiotherapists.

METHODS

In order to understand this problem we integrate new data we have collected with previously published data. New data include the rates of visits to orthopaedic surgeons per annum in one of Israel's large non-profit HMO's, and the domains of the visits to an orthopaedic surgeon.

RESULTS

Orthopaedic surgeons are the third most frequently contracted secondary specialists in one of the Israeli HMO's. Between 2009 and 2012 there was a 1.7% increase in visits to orthopaedists per annum (P < 0.0001, after correction for population growth). Almost 80% of the domains of the problems presented to an orthopaedic surgeon were in fields orthopaedic surgeons have limited formal training.

DISCUSSION

While orthopaedic surgeons are clearly the authority on surgical problems of the musculoskeletal system, most musculoskeletal problems are not surgical, and the orthopaedic surgeon often lacks training in these areas which might be termed orthopaedic medicine. Furthermore, in Israel and in many other developed countries there is no accessible medical specialty that studies these problems, trains medical students in the subject and focuses on treating these problems. The neglect of this area which can be called the "Orthopaedic Medicine Lacuna" is responsible for inadequate treatment of non-surgical problems of the musculoskeletal system with immense financial implications. We present a preliminary probe into possible solutions which could be relevant to many developed countries.

Activity-based costing in services: literature bibliometric review

This article is aimed at structuring a bibliography portfolio to treat the application of the ABC method in service and contribute to discussions within the scientific community. The methodology followed a three-stage procedure: Planning, execution and Synthesis. Also, the process ProKnow-C (Knowledge Process Development - Constructivist) was used in the execution stage. International databases were used to collect information (ISI Web of Knowledge and Scopus). As a result, we obtained a bibliography portfolio of 21 articles (with scientific recognition) dealing with the proposed theme.

Cost-utility analysis in spine care: a systematic review

BACKGROUND CONTEXT

Despite the importance of the information provided by cost-utility analyses (CUAs), there has been a lack of these types of studies performed in the area of spinal care.

PURPOSE

To systematically review cost-utility studies published on spinal care between 1976 and 2010.

STUDY DESIGN

Systematic review.

METHODS

All CUAs pertaining to spinal care published between 1976 and 2010 were identified using the cost-effectiveness analysis (CEA) registry database (Tufts Medical Center, Institute for Clinical Research and Health Policy) and National Health Service Economic Evaluation Database (NHS EED). The keywords used to search both the registry databases were the following: spine, spinal, neck, back, cervical, lumbar, thoracic, and scoliosis. Search of the CEA registry provided a total of 28 articles, and the NHS EED yielded an additional 5, all of which were included in this review. Each article was reviewed for the study subject, methodology, and results. Data contained within the databases for each of the 33 articles were recorded, and the manuscripts were reviewed to provide insight into the funding source, analysis perspective, discount rate, and cost-utility ratios.

RESULTS

There was wide variation among the 33 studies in methodology. There were 17 operative, 13 nonoperative, and 3 imaging studies. Study subjects included lumbar spine (n=27), cervical spine (n=4), scoliosis (n=1), and lumbar and cervical spine (n=1). Twenty-three of the studies were based on the clinical data from prospective randomized studies, 7 on decision models, 2 on prospective observational data, and 1 on a retrospective case series. Sixty cost-utility ratios were reported in the 33 articles. Of the ratios, 19 of 60 (31.6%) were cost saving, 27 of 60 (45%) were less than $100,000/quality-adjusted life year (QALY) gain, and 14 of 60 (23.3%) were greater than $100,000/QALY gain. Only four of 33 (12%) studies contained the four key criteria of cost-effectiveness research recommended by the US Panel on Cost-Effectiveness in Health and Medicine.

CONCLUSIONS

Thirty-three CUA studies and 60 cost-utility ratios have been published on various aspects of spinal care over the last 30 years. Certain aspects of spinal care have been shown to be cost effective. Further efforts, however, are needed to better define the value of many aspects of spinal care. Future CUA studies should consider societal cost perspective and carefully consider the durability of clinical benefit in determining a study time horizon.

The cost effectiveness of single-level instrumented posterolateral lumbar fusion at 5 years after surgery

STUDY DESIGN

Cost effectiveness analysis for single-level instrumented fusion during a 5-year postoperative interval.

OBJECTIVE

To determine the cost/quality-adjusted life year (QALY) gained for single-level instrumented posterolateral lumbar fusion for degenerative lumbar spine conditions during a 5-year period.

SUMMARY OF BACKGROUND DATA

Cost/QALY has become a standard measure among healthcare economists because it is generic and can be used across medical treatments. Prior studies have reported widely variable estimates of cost/QALY for lumbar spine fusion. This variability may be related to factors including study design, sample population, baseline assumptions, and length of the observation period.

METHODS

To determine QALY, the Short Form 6D (SF-6D), a utility index derived from the Short Form (36) Health Survey (SF-36) was used. Cost analysis was performed based on actual reimbursements from third-party payors, including those for the index surgical procedure, treatment of complications, emergency room outpatient visits, and revision surgery. A second cost analysis using only the contemporaneous Medicare Fee schedule was also performed, in addition to a subanalysis including indirect costs from days off work.

RESULTS

The mean SF-6D health utility value showed a gradual increase throughout the follow-up period. The mean health utility value gained in each year postoperatively was 0.12, 0.14, 0.13, 0.15, and 0.15, for a cumulative 0.69 QALY improvement during the 5-year interval. Mean direct medical costs based on actual reimbursements for 5 years after surgery, including the index and revision procedures, was $22,708. The resultant cost per QALY gained at the 5-year postoperative interval was $33,018. The analogous mean direct cost based on Medicare reimbursement for 5 years was $20,669, with a resultant cost per QALY gained of $30,053. The mean total work productivity cost for 5 years was $14,377. The resultant total cost (direct and indirect) per QALY gained ranged from $53,949 to $53,914 at 5 years postoperatively.

CONCLUSION

In the future, surgeons will need to demonstrate cost-effectiveness as well as clinical efficacy in order to justify payment for medical and surgical interventions, including lumbar spine fusion. This study indicates that at 5-year follow-up, single-level instrumented posterolateral spine fusion is both effective and durable, resulting in a favorable cost/QALY gain compared to other widely accepted healthcare interventions.

The economics of minimally invasive spine surgery: the value perspective

STUDY DESIGN

Review of the literature.

OBJECTIVE

To summarize current cost and clinical efficacy data in minimally invasive spine (MIS) surgery.

SUMMARY OF BACKGROUND DATA

Cost effectiveness (CE), using cost per quality-adjusted life-years gained, has been shown for lumbar discectomy, decompressive laminectomy, and for instrumented and noninstrumented lumbar fusions in several high-quality studies using conventional, open surgical procedures. Currently, comparisons of costs and clinical outcomes of MIS surgery to open (or nonoperative) approaches are rare and of lesser quality, but suggest that a potential for cost benefits exist using less-invasive surgical approaches.

METHODS

A literature review was performed using the database of the National Center for Biotechnology Information (NCBI), PUBMED/Medline.

RESULTS

Reports of clinical results of MIS approaches are far more common than economic evaluations. MIS techniques can be classified as endoscopic or nonendoscopic. Although endoscopic approaches decrease some approach morbidities, the high cost of instrumentation, steep learning curves, and new complication profiles introduced have prevented widespread adoption. Additionally, the high costs have not been shown to be justified by superior clinical benefits. Nonendoscopic MIS approaches, such as percutaneous posterior or lateral, and mini-open lateral and anterior approaches, use direct visualization, standard operative techniques, and report lower complication rates, reduced length of stay, and faster recovery time. For newer MIS and mini-open techniques, significantly lower acute and subacute costs were observed compared with open techniques, mainly due to lower rates of complications, shorter length of stay, and less blood loss, as well as fewer discharges to rehab. Although this suggests that certain MIS procedures produce early cost benefits, the quality of the existing data are low.

CONCLUSION

Although the CE of MIS surgery is yet to be carefully studied, the few economic studies that do exist suggest that MIS has the potential to be a cost-effective intervention, but only if improved clinical outcomes are maintained (durable). Longer follow-up and better outcome and cost data are needed to determine if incremental CE exists with MIS techniques, versus open or nonsurgical interventions.

[Minimally invasive spine arthrodesis in degenerative spinal disorders]

BACKGROUND AND PURPOSE

As in many other surgical fields, new minimally invasive techniques have been developed over the past 20 years, with reducing the muscular trauma associated with the traditional surgical approach and reducing related morbidity as the main goals. Initially limited to the laparoscopic or video-assisted approaches of the anterior spine, these techniques have been extended to the posterior transmuscular access of the lumbar spine. This article reviews the value of these approaches in the treatment of degenerative lumbar spine disorders.

METHODS

We describe the main techniques used in minimally invasive lumbar spine surgery, including posterior pedicle screwing as well as anterior (ALIF), posterior (PLIF), transforaminal (TLIF), extreme lateral (XLIf), and presacral (AxiaLIF) interbody fusion. The results of recently published series are reported.

RESULTS

Percutaneous pedicle screwing is reported to be an effective technique of lumbar spine arthrodesis associated with a low rate of screw misplacement. Minimally invasive PLIF, TLIF, and ALIF have been associated with shorter mean operative time, less postoperative pain, reduction of the estimated blood loss, a shorter hospital stay, and quicker functional recovery. Despite these encouraging early clinical results, no prospective, randomized published scientific study has proved that minimally invasive techniques are better than standard techniques. Larger clinical series with a longer follow-up could fill this gap.

Defining value in spine care

Spinal disorders are extremely common, debilitating, and costly to the payer and to society as a whole. The rate and cost of various spinal treatments are increasing at an astonishing rate, but it is unclear whether the resulting quality of spinal care is improving. Rather than focusing solely on quality improvement measures or cost-saving measures, there is a recent emphasis on the value of health care. Defining the value of spine care depends on a standardized, accurate method of measuring outcomes and costs. It is important that the outcomes measured are patient centered and that both the outcomes and costs are measured over time with long-term follow-up. The purpose of this article is to review current methods for measuring outcomes and propose a means by which the value of spine care can be more clearly defined.

The impact of economic evaluation on quality management in spine surgery

Health care expenditures are substantially increasing within the last two decades prompting the imperative need for economic evaluations in health care. Historically, economic evaluations in health care have been carried out by four approaches: (1) the human-capital approach (HCA), (2) cost-effectiveness analysis (CEA), (3) cost-utility analysis (CUA) and (4) cost-benefit analysis (CBA). While the HCA cannot be recommended because of methodological shortcomings, CEA and CUA have been used frequently in healthcare. In CEA, costs are measured in monetary terms and health effects are measured in a non-monetary unit, e.g. number of successfully treated patients. In an attempt to develop an effectiveness measure that incorporates effects on both quantity and quality of life, so-called Quality Adjusted Life Years (QUALYs) were introduced. Contingent valuation surveys are used in cost-benefit analyses (CBA) to elicit the consumer's monetary valuations for program benefits by applying the willingness-to-pay approach. A distinguished feature of CBA is that costs and benefits are expressed in the same units of value, i.e. money. Only recently, economic evaluations have started to explore various spinal interventions particularly the very expensive fusion operations. While most of the studies used CEA or CUA approaches, CBAs are still rare. Most studies fail to show that sophisticated spinal interventions are more cost-effective than conventional treatments. In spite of the lack of therapeutic or cost-effectiveness for most spinal surgeries, there is rapidly growing spinal implant market demonstrating market imperfection and information asymmetry. A change can only be anticipated when physicians start to focus on the improvement of health care quality as documented by outcome research and economic evaluations of cost-effectiveness and net benefits.

Physical demand levels in individuals completing a sports performance-based work conditioning/hardening program after lumbar fusion

BACKGROUND CONTEXT

Pain and disability after lumbar fusion surgery contributes to the over $20 billion dollars spent in health-care costs and estimated $28 billion in lost wages annually. With the goal of returning to work, an intensive program designed to build functional strength may be used. Previous interventions for this subgroup report the outcome measure of return to work (RTW), but do not account for the physical demand of the job to which they are returning. This may account for varying RTW and re-injury rates.

PURPOSE

To examine the effectiveness of a sports performance-based work conditioning/hardening (SPWC/H) program on increasing an individual's strength measured by achievement of physical demand level (PDL) job classification of individuals followed by workers' compensation having had lumbar fusion surgery.

STUDY DESIGN/SETTING

An uncontrolled multicenter, retrospective observational study of visits from 1999-2002 in an outpatient physical therapy setting.

PATIENT SAMPLE

Fifty-four patients having undergone lumbar fusion surgery, managed by workers' compensation, that successfully completed a SPWC/H program.

OUTCOME MEASURE

Physiologic measures: Deadlift and overhead press lifts, defined as maximum weight, a patient is able to lift between 8 and 15 repetitions. Functional measures: Calculated deadlift and overhead press volume (DLv, OHv) and estimated one repetition maximum (DLm, OHm). Physical demand level (PDL) for first (pre) and last week (post) are defined as: light (L<20lb occasionally), light/medium (LM>20lb occasionally), medium (M, 50lb occasionally), medium heavy (MH, 75lb occasionally), heavy (H, 100lb occasionally), and very heavy (VH>100lb occasionally), where 'occasionally' for the purposes of this article, is defined as in the 8-15 repetition range.

METHODS

Patients completed a greater than or equal to 4 week, 4-5 days/wk, SPWC/H program. This program combines traditional concepts of strength and endurance training of work conditioning (WC) and hardening (WH) programs, with the sports performance concept of periodization in resistance training volume and intensity. Best set overhead and press lifts were obtained from each patient during the first and last week of the program.

RESULTS

Significant increase between pre- and post-DLv, DLm, OHv, and OHm (all p<0.0001) existed when grouping all subjects. When adjacent groups are merged into M/MH and H/VH, significant differences existed between groups and pre- and postlifts (p<0.05). There was a median increase of three classifications when grouping by pre-PDL. There was no difference in outcomes found by grouping by single or multiple levels fused. Overall, numbers in each starting PDL were: 41 (75.9%) light, 6 (11.1%) LM, and 7 (13%) in medium. Numbers ending in each PDL group were: 1 (1.9%) light, 2 (3.7%) LM, 7 (13%) medium, 19 (35.2%) medium/heavy, 5 (9.3%) heavy, and 20 (37%) at very high.

CONCLUSIONS

Post-lumbar spinal fusion patients are typically at the light PDL (<20lb occasionally) on completion of traditional physical therapy program. After an SPWC/H program, significant increase strength of deadlift and overhead lift volume and one repetition maximum demonstrated a median three-level increase in classification of PDL. We were also able to determine that there was no difference in strength outcome between those with a single- vs. multiple-level fusion surgery. Although the vast majority of individuals entered the program at the lowest PDL (20lb or less occasionally), more than 80% of patients completed the program at PDL of medium (50lb occasionally) or above, and 37% of patients achieved the maximum PDL (over 100lb occasionally). Future studies are needed to determine if increases in strength determined by PDL classification such as these relates to increased RTW rates and decreased re-injury rates.

Utility of spine surgery: a comparison of common elective orthopaedic surgical procedures

STUDY DESIGN

A 1-year prospective observational cohort study.

OBJECTIVE

To compare the utility before and 1 year after elective spine surgery with some other common orthopaedic surgical procedures.

SUMMARY OF BACKGROUND DATA

By using global measures like EQ-5D and SF-36 for the determination of the utility, the changes in quality of life, quality of life (QoL) after an intervention different diagnoses, and treatments can be compared. Total hip replacement (THR) has become almost golden standard in this respect.

METHODS

Seven hundred seventy-seven subjects with different common orthopaedic diagnoses scheduled for elective surgery were just before surgery and 1 year after surgery answering both EQ-5D and SF-36. Four groups with different spine diagnoses and procedures were formed and compared with 8 other diagnoses and treatment groups.

RESULTS

Before surgery, subjects with spine diagnoses reported the lowest QoL of all diagnoses compared. Surgery for spinal stenosis, spondylolisthesis, and instability meant the largest improvement of all surgical interventions. Surgery for NHP gave a moderately good improvement, whereas surgery for CLBP only marginally improved those operated. Particularly THR but also TKR more or less completely normalized QoL but made it from a relatively high preoperative level. The greatest improvements after spine surgery, other surgical procedures, and different diagnoses were in the pain/discomfort domain.

CONCLUSION

Spinal surgery in spinal stenosis, spondylolisthesis, and instability had in comparison to other types of elective orthopaedic surgery an outstanding better ability to improve the operated subject's health-related quality of life than other types of elective orthopaedic surgery. The utility of HNP surgery was somewhat lower and was rather marginal for those operated for nonspecific CLBP.

Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine

During the recent years improved operation techniques and administrative procedures have been developed for early rehabilitation. At the same time preoperative lifestyle intervention (prehabilitation) has revealed a large potential for additional risk reduction.

The aim was to assess the quality of life and to estimate the cost-effectiveness of standard care versus an integrated programme including prehabilitation and early rehabilitation.

A survey of the "surgical and research" articles in the European Spine Journal, 2007

Over the last couple of years the European Spine Journal has become truly international with papers from all over the world, and at the same time it has increased its size. Professor Mulholland has selected and reviewed some 40 papers from over 200 published in 2007 and that he felt were of particular interest to practicing surgeons and would influence their management of patients, or papers that challenged established beliefs. Papers dealing with back pain, spondylolysis, tumors, spinal stenosis, spinal infection, clinical examination, lumbar disc herniation, spinal fractures, etc. are reviewed and their significance assessed. The aim of the review is to encourage readers to read the papers themselves, hopefully stimulated by the trenchant comments of the reviewer, both critical and laudatory.

The positive effect of posterolateral lumbar spinal fusion is preserved at long-term follow-up: a RCT with 11-13 year follow-up

INTRODUCTION

Few studies have investigated the long-term effect of posterolateral lumbar spinal fusion on functional outcome.

AIM

To investigate the long-term result after posterolateral lumbar spinal fusion with and without pedicle screw instrumentation.

METHODS

Questionnaire survey of 129 patients originally randomised to posterolateral lumbar spinal fusion with or without pedicle screw instrumentation. Follow-up included Dallas Pain Questionnaire (DPQ), Oswestry Disability Index (ODI), SF-36 and a question regarding willingness to undergo the procedure again knowing the result as global outcome parameter.

RESULTS

Follow-up was 83% of the original study population (107 patients). Average follow-up time was 12 years (range 11-13 years). DPQ-scores were significantly lower than preoperatively in both groups (P < 0.005) and no drift towards the preoperative level was seen. No difference between the two groups were observed (instrumented vs. non-instrumented): DPQ Daily Activity mean 37.0 versus 32.0, ODI mean 33.4 versus 30.6, SF-36 PCS mean 38.8 versus 39.8, SF-36 MCS mean 49.0 versus 53.3. About 71% in both groups were answered positively to the global outcome question. Patients who had retired due to low back pain had poorer outcome than patients retired for other reasons, best outcome was seen in patients still at work (P = 0.01 or less in all questionnaires, except SF-36 MCS P = 0.08).

DISCUSSION

Improvement in functional outcome is preserved for 10 or more years after posterolateral lumbar spinal fusion. No difference between instrumented fusion and non-instrumented fusion was observed. Patients who have to retired due to low back pain have the smallest improvement.

Cost-effectiveness evaluation of an RCT in rehabilitation after lumbar spinal fusion: a low-cost, behavioural approach is cost-effective over individual exercise therapy

Recently, Christensen et al. reported the clinical effects of a low-cost rehabilitation program equally efficient to a relatively intensive program of individual, physiotherapist-guided exercise therapy. Yet, the low-cost approach is not fully supported as an optimal strategy until a full-scale economic evaluation, including extra-hospital effects such as service utilization in the primary health care sector and return-to-work, is conducted. The objective of this study was to conduct such evaluation i.e. investigate the cost-effectiveness of (1) a low-cost rehabilitation regimen with a behavioural element and (2) a regimen of individual exercise therapy, both in comparison with usual practice, from a health economic, societal perspective. Study design was a cost-effectiveness evaluation of an RCT with a 2-year follow-up. Ninety patients having had posterolateral or circumferential fusion (indicated by chronic low back pain and localized pathology) were randomized 3 months after their spinal fusion. Validated pain- and disability index scales were applied at baseline and at 2 years postoperative. Costs were measured in a full-scale societal perspective. The probability of the behavioural approach being cost-effective was close to 1 given pain as the prioritized effect measure, and 0.8 to 0.6 (dependent on willingness to pay per effect unit) given disability as the prioritized effect measure. The probability of the exercise therapy approach being cost-effective was modest due to inferior effectiveness. Results proved robust to relevant sensitivity analysis although a differentiated cost-effectiveness ratio between males and females was suspected. In conclusion, a simple behavioural extension, of setting up group meetings for patients, to a regimen with a strict physiotherapeutic focus was found cost-effective, whereas the cost-effectiveness of increasing frequency and guidance of a traditional physiotherapeutic regimen was unlikely in present trial setting.

Determinants of cost-effectiveness in lumbar spinal fusion using the net benefit framework: a 2-year follow-up study among 695 patients

Up to one third of patients undergoing lumbar spinal fusion show no improvement after the procedure and thus, despite evidence from RCTs, there might be a rationale for observational studies clarifying indications. Similarly, selection of the right patients for the right procedure could have significant impact on cost-effectiveness, which in some countries, in turn, affects whether procedures are to be available through the National Health Service. The aim of this study was to investigate determinants of cost-effectiveness in lumbar spinal fusion. An observational cohort study with 2-year follow-up was conducted: 695 patients who underwent lumbar spinal fusion from 1996 to 2002 were included and followed for 2 years. Patients had a localized segmental pathology and were diagnosed with MRI-verified isthmic spondylolisthesis (26%) or disc degeneration (74%). The surgical techniques were non-instrumented posterolateral fusion (14%), instrumented posterolateral fusion (54%), and circumferential fusion (32%). Societal costs and improvement in functional disability (Dallas Pain Questionnaire) were transformed into a net benefit measure. Classical linear regression of the net benefit was conducted using predictors of age, sex, diagnosis, duration of pain, smoking habits, occupational status, severity of disability, emotional distress, surgical technique, and number of levels fused. The main results were that two determinants were found to negatively influence net benefit: smoking and diagnosis, whereas two others were found to be positively associated with the net benefit: severe disability and emotional distress. In conclusion, predicting net benefit reverses the picture usually seen in studies predicting clinical outcomes, because the response variable is based on improvement over time rather than end-point measures alone. Smoking habits, diagnosis, pre-operative disability, and pre-operative emotional distress were found to be significantly associated with the net benefit of spinal fusion.