Is Less Really More? Economic Evaluation of Minimally Invasive Surgery

A novel endoscope-port unit for lumbar microendoscopic surgery: a single-center case series review

Minimally invasive spinal surgery has shown benefits not only from a clinical standpoint but also in some cost-effectiveness metrics. Microendoscopic procedures combine optical advantages of endoscopy with the preservation of bimanual surgical maneuvers that are not feasible with full percutaneous endoscopic procedures. TELIGEN is a new endoscopic platform designed to optimize these operations. Our aim was to present a retrospective review of surgical data from the first consecutive cases applying this device in our institution and describe some of its technical details. 25 patients have underwent procedures using this device at our institution to the date, with a mean follow-up of 341.7 ± 45.1 days. 17 decompression-only procedures, including microendoscopic discectomies (MED) and decompression of stenosis (MEDS), with or without foraminotomies (± MEF) and 8 microendoscopic transforaminal lumbar interbody fusions (ME-TLIF) were performed. Mean age and body mass index (BMI) were respectively 58.8 ± 17.4 years and 27.6 ± 5.3 kg/m2. Estimated blood loss (13 ± 4.8, 12.8 ± 6.98 and 76.3 ± 35.02 mL), postoperative length of hospital stay (11.2 ± 21.74, 22.1 ± 26.85 and 80.7 ± 44.60 h), operative time (130.3 ± 58.53, 121 ± 33.90 and 241.5 ± 45.27 min) and cumulative intraprocedural radiation dose (14.2 ± 6.36, 15.4 ± 12.17 and 72.8 ± 12.26 mGy) are reported in this paper for MED ± MEF, MEDS ± MEF and ME-TLIF, respectively. TELIGEN affords an expanded surgical field of view with unique engineered benefits that provide a promissing platform to enhance minimally invasive spine surgery.

Cost-effectiveness of a second opinion program on spine surgeries: an economic analysis

BACKGROUND

In this study we proposed a new strategy to measure cost-effectiveness of second opinion program on spine surgery, using as measure of effectiveness the minimal important change (MIC) in the quality of life reported by patients, including the satisfaction questionnaire regarding the treatment and direct medical costs.

METHODS

Retrospective analysis of patients with prior indication for spine surgery included in a second opinion program during May 2011 to May 2019. Treatment costs and outcomes were compared considering each patients' recommended treatment before and after the second opinion. Costs were measured under the perspective of the hospital, including hospital stay, surgical room, physician and staff fees and other costs related to hospitalization when surgery was performed and physiotherapy or injection costs when a conservative treatment was recommended. Reoperation costs were also included. For comparison analysis, we used data based on our clinical practice, using data from patients who underwent the same type of surgical procedure as recommended by the first referral. The measure of effectiveness was the percentage of patients who achieved the MIC in quality of life measured by the EQ-5D-3 L 2 years after starting treatment. An incremental cost-effectiveness ratio (ICER) was calculated.

RESULTS

Based upon the assessment of 1,088 patients that completed the entire second opinion process, conservative management was recommended for 662 (60.8%) patients; 49 (4.5%) were recommended to injection and 377 (34.7%) to surgery. Complex spine surgery, as arthrodesis, was recommended by second opinion in only 3.7% of cases. The program resulted in financial savings of -$6,705 per patient associated with appropriate treatment indication, with an incremental effectiveness of 0.077 patients achieving MIC when compared to the first referral, resulting in an ICER of $-87,066 per additional patient achieving the MIC, ranging between $-273,016 and $-41,832.

CONCLUSION

After 2 years of treatment, the second opinion program demonstrated the potential for cost-offsets associated with improved quality of life.

[Translated article] The role of minimally invasive spine surgery in the treatment of vertebral metastasis (Part 1): A clinical review

Spinal metastases represent a significant burden on the quality of life in patients affected by active oncological disease due to the high incidence of pain syndromes, spinal deformity, and neurological impairment. Surgery plays a decisive role in improving quality of life by controlling pain, restoring neurological function and maintaining spinal stability, as well as contributing to the response to medical therapy. Minimally invasive surgery (MIS) is a treatment option in certain patients with high surgical risk since it has a low rate of complications, intraoperative bleeding, hospital stay, and offers similar results to open surgery. In this review, we present the role of MIS in this pathology and some cases treated in our hospital.

The role of minimally invasive spine surgery in the treatment of vertebral metastasis (part 1): A clinical review

Spinal metastases represent a significant burden on the quality of life in patients affected by active oncological disease due to the high incidence of pain syndromes, spinal deformity, and neurological impairment. Surgery plays a decisive role in improving quality of life by controlling pain, restoring neurological function and maintaining spinal stability, as well as contributing to the response to medical therapy. Minimally invasive surgery (MIS) is a treatment option in certain patients with high surgical risk since it has a low rate of complications, intraoperative bleeding, hospital stay, and offers similar results to open surgery. In this review, we present the role of MIS in this pathology and some cases treated in our hospital.

Cost and Effectiveness of Percutaneous Endoscopic Interlaminar Discectomy versus Microscope-Assisted Tubular Discectomy for L5-S1 Lumbar Disc Herniation

OBJECTIVE

To assess the cost and effectiveness of percutaneous endoscopic interlaminar discectomy (PEID) and microscope-assisted tubular discectomy (MATD) for patients with L5/S1 lumbar disc herniation (LDH).

METHODS

The medical and financial records of patients diagnosed with L5/S1 LDH and who underwent either PEID or MATD from April 2021 to April 2022 were retrospectively collected. Demographic and baseline information, perioperative observational index, clinical outcomes, and inpatient costs were analyzed.

RESULTS

Sixty patients were included, with 30 patients in the PEID group and 30 patients in the MATD group. No significant difference was found in demographic and baseline information between the 2 groups (P > 0.05). The PEID group showed significantly shorter incision length, less intraoperative blood loss, shorter hospital stays, and higher intraoperative fluoroscopy frequency compared with the MATD group (P < 0.05). There were no significant differences in visual analog scale back/leg score, Oswestry Disability Index, and 36-Item Short-Form Survey score between PEID and MATD groups before the surgery and at any follow-up time points (P > 0.05). The total cost, surgery cost, and surgical instruments/materials cost were significantly higher in the PEID group compared with the MATD group (P < 0.05). In contrast, the drug and nursing costs were significantly higher in the MATD group than in the PEID group (P < 0.05).

CONCLUSIONS

PEID and MATD provide equivalent clinical efficacy and safety in treating LDH at L5/S1 segment within a 1-year follow-up. However, PEID is less invasive and MATD is less costly. No one surgical technique is superior in all aspects and patients should make decisions according to their top concern.

Development of an Endoscopic Spine Surgery Program: Overview and Basic Considerations for Implementation

Endoscopic spine surgery (ESS) is an innovative technique allowing for minimally invasive, direct visualization of spinal abnormalities. The growth of ESS in the United States has been stunted by high start-up costs, low reimbursement rates, and the steep learning curve associated with mastering endoscopic techniques. Hergrae, we describe the current state and future direction of ESS and provide key action items for ESS program implementation.

Full-endoscopic foraminotomy in low-grade degenerative and isthmic spondylolisthesis: a patient-specific tailored approach

PURPOSE

To describe the surgical technique and methodology to successfully plan and execute an endoscopic foraminotomy in patients with isthmic or degenerative spondylolisthesis, according to each patient's unique characteristics.

METHODS

Thirty patients with degenerative or isthmic spondylolisthesis (SL) with radicular symptoms were included from March 2019 to September 2022. Treating physician registered patients' baseline and imaging characteristics, as well as preoperative back pain VAS, leg pain VAS and ODI. Subsequently, authors treated the included patients with an endoscopic foraminotomy according to a "patient-specific" tailored approach.

RESULTS

Nineteen patients (63.33%) had isthmic SL and 11 patients (36.67%) had degenerative SL. 75.86% of the cases had a Meyerding Grade 1 listhesis. One of the transforaminal foraminotomies with lateral recess decompression in degenerative SL had to be aborted because of intense osseous bleeding. Of the remaining 29 patients, one patient experienced recurrence of the sciatica pain that required subsequent reintervention and fusion. No other intraoperative or post-operative complications were observed. None of the patients developed post-operative dysesthesia. In 86.67% of the patients, the foraminotomy was implemented using a transforaminal approach. In the remaining 13.33% of the cases, an interlaminar contralateral approach was used. Lateral recess decompression was performed in half of the cases. Mean follow-up time was 12.69 months, reaching a maximum of 40 months in some patients. Outcome variables such as VAS for leg and back pain, as well as ODI, showed statistically significant reduction since the 3-month follow-up visit.

CONCLUSION

In the presented case series, endoscopic foraminotomy achieved satisfactory outcomes without sacrificing segmental stability. The proposed patient-specific "tailored" approach allowed to successfully design and execute the surgical strategy to perform an endoscopic foraminotomy through transforaminal or interlaminar contralateral approaches.

Methodology of economic evaluations in spine surgery: a systematic review and qualitative assessment

OBJECTIVES

The present study is a systematic review conducted as part of a methodological approach to develop evidence-based recommendations for economic evaluations in spine surgery. The aim of this systematic review is to evaluate the methodology and quality of currently available clinical cost-effectiveness studies in spine surgery.

STUDY DESIGN

Systematic literature review.

DATA SOURCES

PubMed, Web of Science, Embase, Cochrane, Cumulative Index to Nursing and Allied Health Literature, EconLit and The National Institute for Health Research Economic Evaluation Database were searched through 8 December 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they met all of the following eligibility criteria: (1) spine surgery, (2) the study cost-effectiveness and (3) clinical study. Model-based studies were excluded.

DATA EXTRACTION AND SYNTHESIS

The following data items were extracted and evaluated: pathology, number of participants, intervention(s), year, country, study design, time horizon, comparator(s), utility measurement, effectivity measurement, costs measured, perspective, main result and study quality.

RESULTS

130 economic evaluations were included. Seventy-four of these studies were retrospective studies. The majority of the studies had a time horizon shorter than 2 years. Utility measures varied between the EuroQol 5 dimensions and variations of the Short-Form Health Survey. Effect measures varied widely between Visual Analogue Scale for pain, Neck Disability Index, Oswestry Disability Index, reoperation rates and adverse events. All studies included direct costs from a healthcare perspective. Indirect costs were included in 47 studies. Total Consensus Health Economic Criteria scores ranged from 2 to 18, with a mean score of 12.0 over all 130 studies.

CONCLUSIONS

The comparability of economic evaluations in spine surgery is extremely low due to different study designs, follow-up duration and outcome measurements such as utility, effectiveness and costs. This illustrates the need for uniformity in conducting and reporting economic evaluations in spine surgery.

Perioperative Complications of Open Spine Surgery in Older Adults over 90 Years of Age

Introduction

Despite perioperative risks in nonagenarian patients who undergo open spine surgery for degeneration disorder or spinal trauma being of great interest, the prevalence of complications in this group remains unclear. This study aims to examine the perioperative complications of open spine surgery in the elderly over 90 years of age.

Methods

Preoperative and intraoperative characteristics including the American Society of Anesthesiologists Physical Status (ASA-PS) class, type of surgery, and complications within 30 postoperative days were retrospectively collected from the medical records of nonagenarians who underwent open spine surgery between April 2004 and July 2019 at our spine centers.

Results

A total of 48 patients met the inclusion criteria of this study. All belong to ASA-PS class 2 (69%) or 3. Preoperative American Spinal Injury Association Impairment Scale grades in trauma group were grade A in 4 cases, B in 1 case, C in 5 cases, D in 11 cases, and E in 1 case. Major complications (deep surgical site infection, cardiac event, respiratory disorder, gastrointestinal hemorrhage, and renal failure) occurred in 13 cases, and the rate of overall perioperative complications was 45.8%. One patient who underwent cervical stabilization for cervical fracture dislocation died at postoperative 13 days due to respiratory disorder. The rates of major complications and overall perioperative complications were 3.6% and 14.3% in the degenerative group and 45.5% and 81.8% in the trauma group, respectively. Especially in the trauma group, respiratory disorder occurred in 7 cases, delirium in 11 cases, and urinary tract infection in 5 cases.

Conclusions

Although the perioperative complication rate reached 81.8% in spinal trauma cases, the complication rate in degenerative disorders was relatively low as 14.3%. Open spine surgery for degenerative disorders can be relatively safe even in nonagenarians, whereas the risks of perioperative complications, including respiratory disorder and delirium, were high in spinal trauma cases.

[Current status and progress of minimally invasive percutaneous endoscopic lumbar interbody fusion]

OBJECTIVE

To summarize the progress of percutaneous endoscopic lumbar interbody fusion in the treatment of lumbar degenerative diseases.

METHODS

The relevant literature about percutaneous endoscopic lumbar interbody fusion at home and abroad in recent years was reviewed, the approaches, technical characteristics, short- and long-term effectiveness, and complications of different surgical procedures were summarized.

RESULTS

Percutaneous endoscopic lumbar interbody fusion is a safe and reliable treatment. At present, the main surgical methods in clinical application can be roughly summarized as percutaneous endoscopic posterior transforaminal lumbar interbody fusion (Endo-PTLIF), percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF), percutaneous endoscopic oblique lumbar interbody fusion (Endo-OLIF), percutaneous endoscopic lumbar interbody fusion/Z's percutaneous endoscopic lumbar interbody fusion (Endo-LIF/ZELIF), and unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF). Each surgical method has its own technical characteristics and development.

CONCLUSION

Percutaneous endoscopic lumbar interbody fusion is a kind of combined technology based on the individualization of the patient's anatomical structure and the technical differentiation of the surgeon. Surgical experience, choosing adaptive indication and operative way reasonably are the key for the success.

Comparative study of the efficacy and safety of minimally invasive interlaminar full-endoscopic discectomy versus conventional microscopic discectomy in single-level lumbar herniated intervertebral disc (ENDO-F Trial): a multicenter, prospective, randomized controlled trial protocol

Background

Advances in minimally invasive surgery have expanded the indications for interlaminar full-endoscopic discectomy. Although the clinical outcomes for this approach may be equivalent to those of conventional microscopic discectomy, the supporting evidence is still based on small, single-center, prospective, and retrospective studies. Therefore, a multicenter randomized controlled trial is warranted.

Methods

This will be a prospective, multicenter, randomized controlled trial comparing the efficacy and safety of interlaminar full-endoscopic discectomy to those of conventional microscopic discectomy. The trial will enroll 100 participants with a lumbar disc herniation, 50 in each group. The primary outcome will be the Oswestry Disability Index (ODI) score at 12 months post-surgery. Secondary outcomes will be back and leg pain (visual analog scale); the ODI; the EuroQol-5-dimension score; patient satisfaction; and walking distance/time and time to return to daily activities post-surgery. Surgical outcomes will include postoperative drainage, operative time, duration of hospital stay, postoperative creatine kinase level as an indicator of muscle injury, and postoperative scarring. Postoperative magnetic resonance imaging, computed tomography, and simple radiography will be performed to evaluate radiographic outcomes between the two surgical approaches. Surgery-related complications and adverse effects will be evaluated as safety outcomes. A single assessor at each participating hospital, blinded to group allocation, will assess the enrolled participants at baseline, at 2 weeks, and at 3, 6, and 12 months postoperatively.

Discussion

This trial is designed to determine whether interlaminar full-endoscopic discectomy is clinically comparable to microscopic discectomy to treat lumbar disc herniations. All efforts will be made to reduce bias, including adequate sample size, blinded analyses, and multicenter prospective registration. The outcomes will inform practice, providing the evidence needed for using interlaminar full-endoscopic over microscopic discectomy by confirming the potential of this technique to improve patient satisfaction and clinical outcomes.

Trial registration: Clinical Research Information Service; cris.nih.go.kr. (KCT0006277); protocol version (v1, June 8, 2021).