ABSTRACT: Spinal disorders are a major cause of disability and compromise in health-related quality of life. The direct and indirect costs of treating spinal disorders are estimated at more than $100 billion per year. With limited resources, the cost-utility of interventions is important for allocating resources.
We therefore performed a systematic review of the literature on cost-utility for nonoperative and operative interventions for treating spinal disorders.
We searched four databases for cost-utility analysis studies on low back pain management and identified 1004 items. The titles and abstracts of 752 were screened before selecting 27 studies for inclusion; full texts of these 27 studies were individually evaluated by five individuals.
Studies of nonoperative treatments demonstrated greater value for graded activity over physical therapy and pain management; spinal manipulation over exercise; behavioral therapy and physiotherapy over advice; and acupuncture and exercise over usual general practitioner care. Circumferential fusion and femoral ring allograft had greater value than posterolateral fusion and titanium cage, respectively. The relative cost-utility of operative versus nonoperative interventions was variable with the most consistent evidence indicating superior value of operative care for treating spinal disorders involving nerve compression and instability.
The literature on cost-utility for treating spinal disorders is limited. Studies addressing cost-utility of nonoperative and operative management of low back pain encompass a broad spectrum of diagnoses and direct comparison of treatments based on cost-utility thresholds for comparative effectiveness is limited by diversity among disorders and methods to assess cost-utility. Future research will benefit from uniform methods and comparison of treatments in cohorts with well-defined pathology.
Clinical Orthopaedics and Related Research 04/2012; 470(4):1106-23. · 2.53 Impact Factor
ABSTRACT: Prospective, cross-sectional study.
To determine Scoliosis Research Society (SRS)-30 health-related quality of life (HRQOL) reference values by age and gender in an adult population unaffected by scoliosis thereby allowing clinicians and investigators to compare individual and/or groups of spinal deformity patients to their generational peers.
Normative data are collected to establish means and standard deviations of health-related quality of life outcomes representative of a population. The SRS HRQOL questionnaire has become the standard for determining and comparing treatment outcomes in spinal deformity practices. With the establishment of adult SRS-30 HRQOL population values, clinicians, and investigators now have a reference for interpretation of individual scores and/or the scores of subgroups of adult patients with spinal deformities.
The SRS-30 HRQOL was issued prospectively to 1346 adult volunteers recruited from across the United States. Volunteers self-reported no history of scoliosis or prior spine surgery. Domain medians, means, confidence intervals, percentiles, and minimum/maximum values were calculated for six generational age-gender groups: male/female; 20-39, 40-59, and 60-80 years of age.
Median and mean domain values ranged from 4.1 to 4.6 for all age-gender groups. The older the age-gender group, the lower (worse) the reported domain median and mean scores. The only exception was the mental health domain scores in the female groups which improved slightly. Males reported higher (better) scores than females but only the younger males were significantly higher in all domains than their female counterparts. In addition, all male groups reported higher Mental Health domain scores than their female counterparts (P=0.003).
This study reports population medians, means, standard deviations, percentiles, and confidence intervals for the domains of the SRS-30 HRQOL instrument. Clinicians must be mindful of age-gender differences when assessing deformity populations. Generational decreases noted in the older adult volunteer scores may provide a basis for future investigators to interpret observed score decreases in patient cohorts at long-term follow-up.
Spine 02/2011; 36(14):1154-62. · 2.08 Impact Factor
ABSTRACT: The last decade has witnessed a dramatic change in management of metastatic spine disease, with an increased role for surgery and emerging use of stereotactic radiotherapy, often in combination. Patients may be treated with radiotherapy followed by surgery, or have surgery and then adjuvant radiotherapy. In both cases, the surgeon and oncologist need to select the optimal timing for surgery and radiotherapy to minimize wound complications while obtaining maximum oncolytic effects. The purpose of this review was to determine the optimal timing of surgery and radiotherapy in patients surgically treated for spinal metastases. A systematic review utilizing Medline, Embase, Paper First, Web of Science, Google Scholar, and the Cochrane Database of Systematic Reviews was performed. References were screened to further identify relevant studies and basic science literature reviewed. A total of 46 reports discussing the timing of surgery after radiotherapy, describing experience in 5836 patients, were identified. Only one retrospective study addressed the research question and suggested that surgery within seven days of radiation increases the rate of postoperative wound complications. Timing of adjuvant radiotherapy following surgery was addressed in 51 reports describing 7090 patients. None of the studies specifically answered the research question. The time interval between radiotherapy and surgery was reported as 5-21 days in nine studies. Based on this systematic review together with the understanding of general principles of wound healing and effects of radiation on wound healing, the optimal radiotherapy-surgery/surgery-radiotherapy time interval should be at least one week to minimize wound complications.
International Journal of Oncology 03/2010; 36(3):533-44. · 2.40 Impact Factor
ABSTRACT: An in vitro biomechanical study of different pedicle screw configuration usage on the thoracic spine using a cadaveric model.
To investigate the degree of motion afforded different pedicle screw configurations in the thoracic spine using a cadaveric model with 2 different degrees of intrinsic stability.
Recently, thoracic pedicle screws have become an alternative to hook and wire fixation, and have gained popularity. Clinically, pedicle screw use has ranged from application to every segment, to skipping every other level. There exists no clear consensus as to which strategy is most appropriate.
The load-displacement behavior of 6 different constructs was determined on 8 fresh frozen cadaver spine specimens (T4-T12). Each construct was evaluated on 2 destabilization models, including minimum destabilization (bilateral facetectomy) and maximum destabilization (facetectomy and annulotomy). Pure moments were applied, and the resultant range of motion for each scenario was determined.
Facetectomy did not significantly destabilize the thoracic spine. Annulotomy and facetectomy created gross instability that rendered testing of this destabilization model impossible. All constructs significantly reduced the range of motion compared to intact or facetectomized specimens (P < or = 0.001). When different constructs were compared to each other, a pattern of continuously increasing stability emerged, with the "maximum" construct being the most stable and "minimum" configuration being the least, with varying degrees of statistical significance.
Our results suggest that the most important factor for the acute postoperative stability of spinal fixation is the degree of preoperative or iatrogenic destabilization. The minimum amount of pedicle screws provides adequate stability when there is minimal destabilization of the spine. On the other hand, when anterior column release has been performed or instability exists before surgery, segmental pedicle screw fixation may be necessary to achieve adequate stability.
Spine 11/2005; 30(22):2530-7. · 2.08 Impact Factor
ABSTRACT: Patient-based quality of life scales have become a critical element of post-op assessment for lumbar fusion surgery. The most extensive outcomes data have been generated through FDA-regulated IDE trials for new technologies, which produce excellent data but are constrained by strict enrollment criteria and limited indications. This raises a question as to whether the excellent results seen in these IDE trials can be reproduced in standard clinical practice.
The purpose of this study was to analyze surgical results based upon standardized outcome tools, across a spectrum of interventions, for one- and two-level lumbar spine fusion procedures.
This study is a retrospective review of prospectively collected patient based outcomes data.
Four hundred ninety-seven patients, who underwent 1- or 2-level lumbar spine fusion at five participating spine centers, utilizing a variety of surgical techniques. Enrollment criteria included available demographic, surgical and clinical outcome data. At a minimum, patients had pre-op and one year post-op SF-36 data. In many cases two-year post-op SF-36 data and concomitant Oswestry Disability Index (ODI) data was available.
SF36 and ODI.
The patient population included 270 females and 227 males, with a mean age of 47 years. Sixty-five percent (N=324) had one level fusions and 35% (N=173) had two level fusions. Demographic data collected included age, gender, BMI, surgical history, smoking history and work status. Data was analyzed with repeated measures analysis of variance (ANOVA).
SF-36 Physical Composite Score (PCS) improved a mean 9.9 points at one year post-op and 9.5 points at two years post-op. ODI improved a mean 22.2 points at one year post-op and 22.1 points at two years post-op. SF-36 PCS data for surgical approach subgroups revealed greater improvement (p=.03) in the ALIF group as compared to the PSF, PLIF/TLIF, or 360 degrees fusion groups (12.6 points vs. 8.8, 9.3, 8.4 points) at 1 year post-op. At 2 years post-op, there was greater improvement (p=.02) in the ALIF and PSF groups as compared to the PLIF/TLIF and 360 degrees fusion groups (13.8 and 11.2 points vs. 7.7 and 6.3 points). SF-36 PCS data demonstrated similar baseline scores for patients with and without prior decompression, but a significantly greater rate of improvement (11.3 vs. 7.2 points, p=.002) for patients without prior lumbar decompression surgery. The ODI data indicated a significantly greater disability at baseline in the prior decompression group, with greater improvement (21.7 vs. 17.5 points) in patients without prior surgery.
This study documents improved outcomes, based on SF-36 and ODI scores, in patients undergoing lumbar fusion for one and two level degenerative disc disease. The findings also demonstrate efficacy for all of the surgical techniques studied, suggesting that surgeons can appropriately select the surgical strategy with which they are most adept.
The Spine Journal 6(1):21-6. · 3.29 Impact Factor