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Smuck M, McCormick ZL, Gilligan C, Hailey MK, Quinn ML, Bentley A, Metcalfe K, Bradbury B, Lukes DJ, Taylor RS. A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain. Spine J 2024:S1529-9430(24)01040-4. [PMID: 39332685 DOI: 10.1016/j.spinee.2024.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 09/20/2024] [Indexed: 09/29/2024]
Abstract
BACKGROUND CONTEXT Randomized trials have demonstrated the superiority of intraosseous basivertebral nerve ablation (BVNA) compared with sham and standard care in terms of improvements in pain, disability, and health-related quality of life in patients with vertebrogenic chronic low back pain (cLBP). PURPOSE To assess the cost effectiveness of BVNA in patients with vertebrogenic cLBP compared to standard care alone. STUDY DESIGN/SETTING A model-based economic analysis. PATIENT SAMPLE Base case analysis used INTRACEPT, a randomized trial comparing BVNA with standard care in 140 patients with vertebrogenic cLBP, recruited from 23 sites across the United States, with a follow-up, up to 5 years. Scenario analyses compared data from the Surgical Multi-center Assessment of Radiofrequency Ablation for the Treatment of Vertebrogenic Back Pain (SMART) randomized trial against a sham control, and a single-arm study. OUTCOME MEASURES Costs and quality-adjusted life years (QALYs) were calculated to determine the incremental cost-effectiveness ratio (ICER). METHODS A cost-effectiveness model was built in Microsoft Excel® to evaluate the costs and health outcomes of patients undergoing BVNA using the Intracept Procedure (Relievant Medsystems) to treat vertebrogenic cLBP from a US payor perspective. Alternative scenario sensitivity analyses and probabilistic sensitivity analyses were conducted to assess the robustness of the model results. QALYs were discounted at 3.0% per year. RESULTS Base case analysis showed that BVNA relative to standard care alone was a cost-effective strategy for the management of patients with vertebrogenic cLBP, with an ICER of US$11,376 per QALY at a 5-year time horizon from introduction of the procedure. Modeling demonstrated a >99% probability that this was cost effective in the US, based on a willingness-to-pay threshold of US$100,000 to US$150,000. Various sensitivity and scenario analyses produced ICERs that all remained below this threshold. CONCLUSIONS BVNA with the Intracept Procedure offers patients with vertebrogenic cLBP, clinicians, and healthcare systems a cost-effective treatment compared to standard care alone.
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Key Words
- BMI, body mass index
- EQ-5D, EuroQol 5-Dimension 5-level
- ESI, epidural steroid injection
- MCS, mental component summary
- N/A, not applicable
- ODI, Oswestry Disability Index
- PCS, physical component summary
- QALY, Quality adjusted life year,APC, Ambulatory Payment Classification
- SD, standard deviation
- SF36v2®, Short Form 36 Version 2
- SMART, Surgical Multi-center Assessment of Radiofrequency Ablation for the Treatment of Vertebrogenic Back Pain
- VAS, visual analog scale,BVNA, Basivertebral nerve ablation
- WTP, Willingness to pay
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Affiliation(s)
- Matthew Smuck
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Redwood City, CA, 94063, USA.
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT 84108, USA
| | - Chris Gilligan
- Office of the Chief Medical Officer, Robert Wood Johnson University Hospital, New Brunswick, NJ 08903, USA
| | - Mary K Hailey
- Relievant Medsystems, Inc. Corporate Headquarters, 7201 Metro Blvd #300, Edina, MN 55439, USA
| | - Michelle L Quinn
- Relievant Medsystems, Inc. Corporate Headquarters, 7201 Metro Blvd #300, Edina, MN 55439, USA
| | | | | | | | | | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, University of Glasgow, Glasgow, G12 8QQ, UK
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Sayed D, Beall DP, Gulati A, Hyman E, Block JE. Computed Tomographic Characterization for Basivertebral Nerve Ablation Utilizing a Radiofrequency Multitined Expandable Electrode. MEDICAL DEVICES (AUCKLAND, N.Z.) 2024; 17:323-337. [PMID: 39301449 PMCID: PMC11412689 DOI: 10.2147/mder.s487201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 09/09/2024] [Indexed: 09/22/2024]
Abstract
Background A growing body of clinical evidence has demonstrated that intraosseous minimally invasive basivertebral nerve (BVN) ablation results in significant and durable improvements in vertebrogenic back pain. Thus, it is important to develop, refine and validate new and additional devices to accomplish this procedure. Methods Using reconstructions of 31 patient computed tomography (CT) scans of the lumbosacral spine (L1-S1), the primary objective was to simulate the intravertebral placement of a novel multitined expandable electrode in bipolar configuration at the targeted ablation site and determine if the proper trajectories could be achieved in order for the device tips to be in the correct position for lesion formation at the BVN plexus. Successful device deployment required that the distance between tips was between 10 mm and 20 mm. Results The mean distances between device tips ranged from 11.35 mm (L5) to 11.87 mm (L3), and there were no statistically significance differences across the six vertebral levels (F = 0.72, p = 0.61). The percentage of successful intraosseous device placements within the tip distance acceptable range (≥ 10 mm to ≤ 20 mm) was 90% (162 of 180), with no tip-to-tip distances > 20 mm. There was a notable association between decreasing vertebral level and mean degree of angulation between contralateral devices ranging from 50.90° at L1 to 91.51° at S1, and the difference between across the six vertebral levels was significant (F = 89.5, p < 0.01). Conclusion Feasibility evidence is provided from real world CT imaging data that validates using the multitined electrode for proper intraosseous placement within the vertebral body to effectively ablate the BVN plexus.
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Miller S, Caragea M, Carson D, McFarland MM, Teramoto M, Cushman DM, Cooper AN, Burnham T, McCormick ZL, Conger A. The effectiveness of intradiscal corticosteroid injection for the treatment of chronic discovertebral low back pain: a systematic review. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:33-46. [PMID: 37740319 DOI: 10.1093/pm/pnad127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/24/2023]
Abstract
OBJECTIVE Determine the effectiveness of intradiscal corticosteroid injection (IDCI) for the treatment of discovertebral low back pain. DESIGN Systematic review. POPULATION Adults with chronic low back pain attributed to disc or vertebral end plate pain, as evidenced by positive provocation discography or Modic 1 or 2 changes on magnetic resonance imaging. INTERVENTION Fluoroscopically guided or computed tomography-guided IDCI. COMPARISON Sham/placebo procedure including intradiscal saline, anesthetic, discography alone, or other active treatment. OUTCOMES Reduction in chronic low back pain reported on a visual analog scale or numeric rating scale and reduction in disability reported by a validated scale such as the Oswestry Disability Index. METHODS Four reviewers independently assessed articles published before January 31, 2023, in Medline, Embase, CENTRAL, and CINAHL. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The risk of bias in randomized trials was evaluated with the Cochrane Risk of Bias tool (version 2). RESULTS Of the 7806 unique records screened, 6 randomized controlled trials featuring 603 total participants ultimately met the inclusion criteria. In multiple randomized controlled trials, IDCI was found to reduce pain and disability for 1-6 months in those with Modic 1 and 2 changes but not in those selected by provocation discography. CONCLUSION According to GRADE, there is low-quality evidence that IDCI reduces pain and disability for up to 6 months in individuals with chronic discovertebral low back pain as evidenced by Modic 1 and 2 changes but not in individuals selected by provocation discography. STUDY REGISTRATION PROSPERO (CRD42021287421).
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Affiliation(s)
- Scott Miller
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Marc Caragea
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Dan Carson
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Mary M McFarland
- Eccles Health Sciences Library, University of Utah, Salt Lake City, UT 84112, United States
| | - Masaru Teramoto
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Daniel M Cushman
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Amanda N Cooper
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Taylor Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, UT 84108, United States
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Smuck M, Truumees E, Macadaeg K, Jaini AM, Chatterjee S, Levin J. Intraosseous basivertebral nerve ablation: Pooled long-term outcomes from two prospective clinical trials. INTERVENTIONAL PAIN MEDICINE 2023; 2:100256. [PMID: 39238665 PMCID: PMC11373002 DOI: 10.1016/j.inpm.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 09/07/2024]
Abstract
Background Vertebrogenic pain is an established source of anterior column chronic low back pain (CLBP) resulting from damaged vertebral endplates with pain signals transmitted by the basivertebral nerve (BVN). Type 1 or Type 2 Modic changes on magnetic resonance imaging (MRI) are objective biomarkers for vertebrogenic pain. Radiofrequency ablation of the BVN (BVNA) has demonstrated both efficacy and effectiveness for the treatment of vertebrogenic pain in two randomized trials. Here, we report 3-year aggregate results from two prospective studies of BVNA-treated patients. Methods Pooled results at 3 years post-BVNA are reported for two studies with similar inclusion/exclusion criteria and outcomes measurements: 1) a prospective, open label, single-arm follow-up of the treatment arm of a randomized controlled trial (RCT) comparing BVNA to standard care (INTRACEPT Trial), and 2) a prospective, open label, single cohort long-term follow-up study of BVNA-treated patients. Paired datasets (baseline and 3-years) for mean changes in Oswestry disability index (ODI) and numeric pain scores (NPS) were analyzed using a two-sided t-test with a 0.05 level of significance. Results There were 95/113 (84%) BVNA patients who completed a 3-year visit across 22 study sites. At baseline, 71% of patients reported back pain for ≥5 years, 28% were taking opioids, 34% had spinal injections in the prior 12 months, and 14% had prior low back surgery. Pain and functional improvements were significant at 3 years with a mean reduction in NPS of 4.3 points from 6.7 at baseline (95% CI 3.8, 4.8; p<0.0001) and a mean reduction in ODI of 31.2 points from 46.1 at baseline (95% CI 28.4, 34.0; p<0.0001). Responder rates, using minimal clinically important differences of ≥15-points for ODI and ≥50% reduction in NPS from baseline to three years, were 85.3% and 72.6%, respectively (combined response 69.5%), with 26.3% of patients reporting 100% pain relief at 3 years. There was a 74% reduction in the use of opioids and 84% reduction in the use of therapeutic spinal interventions from baseline to 3 years. There were no serious device or device-procedure related adverse events reported through three years. Conclusion Intraosseous BVNA demonstrates statistically significant, clinically meaningful, and durable improvements in pain and function through 3 years in patients with primary vertebrogenic low back pain. BVNA-treated patients significantly reduced opioid use and interventions for low back pain.
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Affiliation(s)
- Matthew Smuck
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
| | - Eeric Truumees
- Ascension Texas Spine & Scoliosis, 1004 W 32nd St Suite 200, TX, 78705, USA
| | - Kevin Macadaeg
- Indiana Spine Group, 13225 N Meridian St, Carmel, IN, 46032, USA
| | - Ashwin M Jaini
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
| | - Susmita Chatterjee
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
| | - Joshua Levin
- Department of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford University, 430 Broadway Street, Pavilion C 4th For, Redwood City, CA, 94063, USA
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Levin J, Schirmer D, Garcia R, Levi D. Is a history of episodic low back pain an indicator of Modic changes? INTERVENTIONAL PAIN MEDICINE 2023; 2:100239. [PMID: 39239605 PMCID: PMC11372870 DOI: 10.1016/j.inpm.2023.100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 09/07/2024]
Abstract
Background Prior work demonstrated that a history of episodic low back pain was highly indicative of discogenic pain. Recently, there has been more focus on vertebrogenic pain, however little is known about the clinical features of this condition. Purpose To determine if a history of severe episodic low back pain correlates with Modic endplate changes on lumbar spine magnetic resonance imaging (MRI), presumed to be a marker of vertebrogenic pain. Study design /setting: Retrospective, observational, in vivo study of consecutive patients at outpatient Physical Medicine & Rehabilitation clinics at a single academic spine center. Patient sample Consecutive patients who received a lumbar spine MRI between January 1, 2020, and December 31, 2020. Methods A retrospective chart review identified patients who received a lumbar spine MRI in 2020. Chart review then determined if patients had a history of episodes of low back pain lasting at least 2 days, or if they had non-episodic low back pain (pain beginning with a gradual onset or after a specific event with continuous symptoms for >3 months). Patients were excluded if they had prior lumbar spine surgery, radicular leg pain without low back pain, indeterminate presentations based on chart review, acute spine fractures, or metastatic spine lesions. For the primary analysis, the MRIs were reviewed and were dichotomized into positive (having for either type 1 or type 2 Modic changes at any level) or negative (no Modic changes at any level). Results A total of 111 patients were analyzed. Inter-rater reliability for determining whether a patient's low back pain was episodic was strong (kappa = 0.83), as was inter-rater reliability for determining if a patient had any levels with type 1 or type 2 Modic changes (kappa = 0.81). Seventy-one out of 111 patients had type 1 and/or type 2 Modic changes at one or more spinal levels. The sensitivity of the test (episodic vs non-episodic low back pain) in finding patients with Modic changes was 20% and the specificity was 70%. The diagnostic confidence odds were 1.2, with a diagnostic confidence of 55%. Subgroup analyses for type 1 Modic changes, and for type 2 Modic changes, showed similar values. Conclusions A history of episodic low back pain is not a strong indicator for a vertebrogenic etiology.
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Affiliation(s)
- Josh Levin
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St., Pavilion C, 4 Floor, MC 6342, Redwood City, CA, 94063, USA
- Department of Neurosurgery, Stanford University, USA
| | - Derek Schirmer
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St., Pavilion C, 4 Floor, MC 6342, Redwood City, CA, 94063, USA
| | - Roxana Garcia
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway St., Pavilion C, 4 Floor, MC 6342, Redwood City, CA, 94063, USA
| | - David Levi
- Jordan Young Institute, Virginia Beach, VA, 5716 Cleveland St., Suite 200, Virginia Beach, VA, 23462, USA
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