Jon D Lurie

Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire, United States

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Publications (130)580.15 Total impact

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    ABSTRACT: Study Design. Retrospective cohort studyObjective. In older adults with a neuromusculoskeletal complaint, to evaluate risk of injury to the head, neck or trunk following an office visit for chiropractic spinal manipulation, as compared to office visit for evaluation by primary care physicianSummary of Background Data. The risk of physical injury due to spinal manipulation has not been rigorously evaluated for older adults, a population particularly vulnerable to traumatic injury in general.Methods. We analyzed Medicare administrative data on Medicare B beneficiaries aged 66-99 with an office visit in 2007 for a neuromusculoskeletal complaint. Using a Cox proportional hazards model, we evaluated for adjusted risk of injury within 7 days, comparing two cohorts: those treated by chiropractic spinal manipulation vs. those evaluated by a primary care physician. We used direct adjusted survival curves to estimate the cumulative probability of injury. In the chiropractic cohort only, we used logistic regression to evaluate the effect of specific chronic conditions on likelihood of injury.Results. The adjusted risk of injury in the chiropractic cohort was lower as compared to the primary care cohort (hazard ratio 0.24; 95% CI 0.23-0.25). The cumulative probability of injury in the chiropractic cohort was 40 injury incidents per 100,000 subjects, as compared to 153 incidents per 100,000 subjects in the primary care cohort. Among subjects who saw a chiropractic physician, the likelihood of injury was increased in those with a chronic coagulation defect, inflammatory spondylopathy, osteoporosis, aortic aneurysm and dissection, or long-term use of anticoagulant therapy.Conclusions. Among Medicare beneficiaries aged 66-99 with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.
    Spine 12/2014; · 2.16 Impact Factor
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    ABSTRACT: Spine Patient Outcomes Research Trial subgroup analysis.
    Spine 11/2014; 39(23):1975-80. · 2.16 Impact Factor
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    10/2014: chapter A Dartmouth Atlas of Health Care Series;
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    ABSTRACT: The Spine Patient Outcomes Research Trial aimed to determine the comparative effectiveness of surgical care versus nonoperative care by measuring longitudinal values: outcomes, satisfaction, and costs.
    Medical care. 10/2014;
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    Dana Kerr, Wenyan Zhao, Jon D Lurie
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    ABSTRACT: Although previous studies have illustrated improvements in surgical cohorts for patients with intervertebral disc herniation, there are limited data on predictors of long-term outcomes comparing surgical and nonsurgical outcomes.
    Clinical Orthopaedics and Related Research 07/2014; · 2.79 Impact Factor
  • Adam M Pearson, Jon D Lurie
    Pain management. 07/2014; 4(4):247-9.
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    ABSTRACT: Study Design. Retrospective analysis of Medicare claims linked to a multi-center clinical trial.Objective. The Spine Patient Outcomes Research Trial (SPORT) provided a unique opportunity to examine the validity of a claims-based algorithm for grouping patients by surgical indication. SPORT enrolled patients for lumbar disc herniation, spinal stenosis, and degenerative spondylolisthesis. We compared the surgical indication derived from Medicare claims to that provided by SPORT surgeons, the "gold standard".Summary of Background Data. Administrative data are frequently used to report procedure rates, surgical safety outcomes, and costs in the management of spinal surgery. However, the accuracy of using diagnosis codes to classify patients by surgical indication has not been examined.Methods. Medicare claims were link to beneficiaries enrolled in SPORT. The sensitivity and specificity of three claims-based approaches to group patients based on surgical indications were examined: 1) using the first listed diagnosis; 2) using all diagnoses independently; and 3) using a diagnosis hierarchy based on the support for fusion surgery.Results. Medicare claims were obtained from 376 SPORT participants, including 21 with disc herniation, 183 with spinal stenosis, and 172 with degenerative spondylolisthesis. The hierarchical coding algorithm was the most accurate approach for classifying patients by surgical indication, with sensitivities of 76.2%, 88.1%, and 84.3% for disc herniation, spinal stenosis, and degenerative spondylolisthesis cohorts, respectively. The specificity was 98.3% for disc herniation, 83.2% for spinal stenosis, and 90.7% for degenerative spondylolisthesis. Misclassifications were primarily due to codes attributing more complex pathology to the case.Conclusion. Standardized approaches for using claims data to accurately group patients by surgical indications has widespread interest. We found that a hierarchical coding approach correctly classified over 90% of spine patients into their respective SPORT cohorts. Therefore, claims data appears to be a reasonably valid approach to classifying patients by surgical indication.
    Spine (Philadelphia, Pa.: 1986) 04/2014;
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    ABSTRACT: Study Design. Retrospective analysis of Medicare claims linked to a multi-center clinical trial.Objective. The Spine Patient Outcomes Research Trial (SPORT) provided a unique opportunity to examine the validity of a claims-based algorithm for grouping patients by surgical indication. SPORT enrolled patients for lumbar disc herniation, spinal stenosis, and degenerative spondylolisthesis. We compared the surgical indication derived from Medicare claims to that provided by SPORT surgeons, the "gold standard".Summary of Background Data. Administrative data are frequently used to report procedure rates, surgical safety outcomes, and costs in the management of spinal surgery. However, the accuracy of using diagnosis codes to classify patients by surgical indication has not been examined.Methods. Medicare claims were link to beneficiaries enrolled in SPORT. The sensitivity and specificity of three claims-based approaches to group patients based on surgical indications were examined: 1) using the first listed diagnosis; 2) using all diagnoses independently; and 3) using a diagnosis hierarchy based on the support for fusion surgery.Results. Medicare claims were obtained from 376 SPORT participants, including 21 with disc herniation, 183 with spinal stenosis, and 172 with degenerative spondylolisthesis. The hierarchical coding algorithm was the most accurate approach for classifying patients by surgical indication, with sensitivities of 76.2%, 88.1%, and 84.3% for disc herniation, spinal stenosis, and degenerative spondylolisthesis cohorts, respectively. The specificity was 98.3% for disc herniation, 83.2% for spinal stenosis, and 90.7% for degenerative spondylolisthesis. Misclassifications were primarily due to codes attributing more complex pathology to the case.Conclusion. Standardized approaches for using claims data to accurately group patients by surgical indications has widespread interest. We found that a hierarchical coding approach correctly classified over 90% of spine patients into their respective SPORT cohorts. Therefore, claims data appears to be a reasonably valid approach to classifying patients by surgical indication.
    Spine 02/2014; · 2.16 Impact Factor
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    ABSTRACT: Objectives Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions: (1) What are the barriers to expand coverage for chiropractic services? (2) What could potentially be done to address these issues? (3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services? Methods A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage. Results The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health. Conclusions The barriers that were identified in this study can be addressed. To overcome these barriers, the chiropractic profession and individual physicians must assume responsibility for correcting deficiencies in compliance and documentation; further research needs to be done to evaluate chiropractic services; and effectiveness of extended episodes of preventive chiropractic care should be rigorously evaluated. Centers for Medicare and Medicaid Services policies related to chiropractic reimbursement should be reexamined using the same standards applicable to other health care providers. The integration of chiropractic physicians as fully engaged Medicare providers has the potential to enhance the capacity of the Medicare workforce to care for the growing population. We recommend that Medicare policy makers consider limited expansion of Medicare coverage to include, at a minimum, reimbursement for evaluation and management services by chiropractic physicians.
    Journal of Chiropractic Humanities 12/2013; 20(1):9–18.
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    ABSTRACT: A period of nonsurgical management is advocated before surgical treatment for most patients with lumbar spinal stenosis. Currently, little evidence is available to define optimal nonsurgical management. Physical therapy is often used, however its use and effectiveness relative to other nonsurgical strategies has not been adequately explored. Describe the use of physical therapy and other nonsurgical interventions by patients with lumbar spinal stenosis and examine the relationship between physical therapy and long-term prognosis. Secondary analysis of the Spine Patient Outcomes Research Trial (SPORT) combining data from randomized and observational studies. Thirteen spine clinics in 11 states in the United States. Patients with lumbar spinal stenosis receiving nonsurgical management including those who did or did not receive physical therapy within 6 weeks of enrollment. Primary outcome measures included crossover to surgery, the bodily pain and physical function scales changes from the Survey Short Form 36 (SF-36), and the modified Oswestry Disability Index. Secondary outcome measures were patient satisfaction and the Sciatica Bothersomeness Index. Baseline characteristics and rates of crossover to surgery were compared between patients who did or did not receive physical therapy. Baseline factors predictive of receiving physical therapy were examined with logistic regression. Mixed effects models were used to compare outcomes between groups at 3 and 6 months and 1 year after enrollment adjusted for baseline severity and patient characteristics. Physical therapy was used in the first 6 weeks by 90 of 244 patients (37%) and was predicted by the absence of radiating pain and being single instead of married. Physical therapy was associated with a reduced likelihood of crossover to surgery after 1 year (21% vs. 33%, p=.045), and greater reductions on the Short Form 36 physical functioning scale after 6 months (mean difference=6.0, 95% confidence interval: 0.2-11.7) and 1 year (mean difference=6.5, 95% confidence interval: 0.6-12.4). There were no differences in bodily pain or Oswestry scores across time. Many patients with lumbar spinal stenosis pursuing conservative management receive physical therapy. Using physical therapy was associated with reduced likelihood of patients receiving surgery within 1 year. Results for other outcomes were mixed with no differences in several measures. Further research is needed to examine the effectiveness of physical therapy relative to other nonsurgical management strategies for patients with lumbar spinal stenosis.
    The spine journal: official journal of the North American Spine Society 10/2013; · 2.90 Impact Factor
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    ABSTRACT: Purpose: There is no universally accepted standard of care for lumbar spinal stenosis. Several studies suggest surgical care results in better outcomes than conservative care, but the type of surgery (decompression vs. fusion) remains controversial. Interspinous spacer devices (“spacers”) have emerged as a new initial treatment alternative. Our objective was to assess the cost-effectiveness of spacers for lumbar stenosis and to identify thresholds for post-spacer health utility that would result in spacers being a cost-effective initial surgery. Method: A Markov model tracked health utility and costs for a hypothetical 65-year-old cohort followed over a 10-year time horizon under six care strategies: conservative care (C) and five surgical strategies defined by initial and up to two subsequent surgeries involving spacer (S), decompression (D), and/or fusion (F): S-D-D, S-D-F, S-F-F, D-D-F, and D-F-F. Incremental cost-effectiveness ratios (ICER) reported as cost per quality-adjusted life year (QALY) gained included direct medical costs for surgery (initial S: $8,227; D: $5,925; F: $20,101). Medicare claims data were used to estimate costs, complication rates (S: 4.8%; D: 6.6%; F: 9.4%) and reoperation within 3 years (S: 20.1%; D: 10.8%; F: 14%) for each surgery. Utilities were derived from published studies (C:0.71; S: 0.82; D: 0.77; F:0.74). Reoperation rates after 3 years for D and F were obtained from the literature. Spacer failure beyond 3 years is uncertain and was evaluated through sensitivity analyses. In the base-case, the spacer failure rate was held constant for years 4-10 (cumulative: 47%). In subsequent analyses, the 10-year failure rate was increased either moderately (to 56%) or steeply (to 90%). Additionally, since utility following spacer surgery is rarely reported, we performed threshold analyses on post-spacer utility to determine when spacer surgery fails to be cost-effective either because it is dominated or has an ICER> $100,000. Result: An initial spacer strategy (S-D-D) emerged as the most cost-effective ($14,400 per QALY gained) in base-case analyses. The ICER rose minimally ($16,800) when the failure rate was increased steeply. Spacer surgery remained cost-effective for post-spacer utilities ≥0.7695 in the base case and ≥0.773 under steeply increased failure. Conclusion: Post-spacer health utilities in the literature to date exceed the identified thresholds, suggesting that interspinous spacer devices are reasonably cost-effective when implemented as a first surgical intervention for patients with spinal stenosis.
    The 35th Annual Meeting of the Society for Medical Decision Making; 10/2013
  • Article: Letters.
    Jon D Lurie
    Spine 08/2013; 38(17):1525. · 2.16 Impact Factor
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    ABSTRACT: Study Design. Combined prospective randomized controlled trial and observational cohort study of degenerative spondylolisthesis (DS) with an as-treated analysis.Objective. To determine modifiers of the treatment effect (TE) of surgery (the difference between surgical and nonoperative outcomes) for DS using subgroup analysis.Summary of Background Data. SPORT demonstrated a positive surgical TE for DS at the group level. However, individual characteristics may affect TE.Methods. DS patients were treated with either surgery (n = 395) or nonoperative care (n = 206) and were analyzed according to treatment received. Fifty-five baseline variables were used to define subgroups for calculating the time-weighted average TE for the Oswestry Disability Index (ODI) over 4 years (TE = ΔODIsurgery-ΔODInonoperative). Variables with significant subgroup-by-treatment interactions (p<0.05) were simultaneously entered into a multivariate model to select independent TE predictors.Results. All analyzed subgroups that included at least 50 patients improved significantly more with surgery than with nonoperative treatment (p<0.05). Multivariate analyses demonstrated that age ≤ 67 (TE -15.7 vs. -11.8 for age>67, p = 0.014); female gender (TE -15.6 vs. -11.2 for males, p = 0.01); the absence of stomach problems (TE -15.2 vs. -11.3 for those with stomach problems, p = 0.035); neurogenic claudication (TE -15.3 vs. -9.0 for those without claudication, p = 0.004); reflex asymmetry (TE -17.3 vs. -13.0 for those without asymmetry, p = 0.016); opioid use (TE -18.4 vs. -11.7 for those not using opioids, p<0.001); not taking antidepressants (TE -14.5 vs. -5.4 for those on antidepressants, p = 0.014); dissatisfaction with symptoms (TE -14.5 vs. -8.3 for those satisfied or neutral, p = 0.039); and anticipating a high likelihood of improvement with surgery (TE -14.8 vs. -5.1 for anticipating a low likelihood of improvement with surgery, p = 0.019) were independently associated with greater TE.Conclusions. Patients who met strict inclusion criteria improved more with surgery than with nonoperative treatment, regardless of other specific characteristics. However, TE varied significantly across certain subgroups.
    Spine 07/2013; · 2.16 Impact Factor
  • Spine 06/2013; · 2.16 Impact Factor
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    ABSTRACT: BACKGROUND: Falls are the leading cause of fatal and non-fatal injuries among older adults. Exercise programs appear to reduce fall risk, but the optimal type, frequency, and duration of exercise is unknown. External perturbations such as tripping and slipping are a major contributor to falls, and task-specific perturbation training to enhance dynamic stability has emerged as a promising approach to modifying fall risk. The purpose of this pilot study was 1) to determine the feasibility of conducting a large pragmatic randomized trial comparing a multidimensional exercise program inclusive of the surface perturbation treadmill training (SPTT) to multidimensional exercise alone (Standard PT); and 2) to assess fall outcomes between the two groups to determine whether an effect size large enough to warrant further study might be present. METHODS: A randomized pilot study at two outpatient physical therapy clinics. Participants were over age 64 and referred for gait and balance training. Feasibility for a larger randomized trial was assessed based on the ability of therapists to incorporate the SPTT into their clinical practice and acceptance of study participation by eligible patients. Falls were assessed by telephone interview 3 months after enrollment. RESULTS: Of 83 patients who were screened, 73 met inclusion criteria. SPTT was successfully adapted into clinical practice and 88% of eligible subjects were willing to be randomized, although 10% of the SPTT cohort dropped out prior to treatment. The SPTT group showed fewer subjects having any fall (19.23% vs. 33.33% Standard PT; p < 0.227) and fewer having an injurious fall (7.69% vs. 18.18%; p < 0.243). These results were not statistically significant but this pilot study was not powered for hypothesis testing. CONCLUSIONS: Physical therapy inclusive of surface perturbation treadmill training appears clinically feasible, and randomization between these two PT interventions is acceptable to the majority of patients. These results appear to merit longer-term study in an adequately powered trial.Trial registration: clinicaltrials.gov: NCT01006967.
    BMC Geriatrics 05/2013; 13(1):49. · 2.34 Impact Factor
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    ABSTRACT: STRUCTURED ABSTRACT: Study Design. Subgroup analysis of prospective, randomized cohortObjective. To review the results of patients who received opioid pain medications during treatment compared to patients who did not receive opioid medications.Summary of Background Data. The SPORT trial is a prospective, multicenter study of surgical treatment versus nonoperative treatment for lumbar intervertebral disk herniation (IDH).Methods. The study population includes patients enrolled in SPORT for treatment of IDH in combined randomized and observational cohorts. Patients who received opioid medications at baseline (Opioid) were compared to those who did not. (No-Opioid)Results. There were 520 patients in the Non-Opioid group and 542 patients in the Opioid group. Among the opioid medication group there were significantly (p<0.001) worse baseline scores in primary and secondary outcome measures. There was an increased percentage of patients in the opioid medication group with the perception of worsening symptoms and neurological deficit (p<0.001). A higher percentage of the opioid patients received surgery (p<0.001)At four years follow-up, there were no significant differences in primary or secondary outcome measures or treatment effect of surgery between opioid and non-opioid medication patients. Opioid medications were associated with increased crossover to surgical treatment (p = 0.005) and decreased surgical avoidance. (p = 0.01) The incidence of opioid use at four years was 16% among patients who were using opioids at baseline and 5% among patients who were not using opioids at baseline.Conclusion. Patients who were treated with opioids had significantly worse baseline pain and quality of life. At final follow-up, there was no long term difference in outcome associated with opioid pain medication use. Opioid medications were not associated with surgical avoidance. The majority of patients who use opioids during the study did not continue usage at four years.
    Spine 04/2013; · 2.16 Impact Factor
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    ABSTRACT: Study Design: A retrospective cohort designObjective: To determine if baseline MRI findings including central/foraminal stenosis, Modic change, disc morphology, facet arthropathy, disc degeneration, nerve root impingement, and thecal sac compression are associated with differential surgical treatment effect.Summary of Background Data: Intervertebral Disc Herniation (IDH) remains the most common source of lumbar radiculopathy treated either with discectomy or non-operative intervention. Although MRI remains the reliable gold standard for diagnosis, uncertainty surrounds the relationship between MRI findings and treatment outcomes.Methods: Three-hundred-and-seven "complete" images from patients enrolled in a previous trial were de-identified and evaluated by one of 4 independent readers. Findings were compared to outcome measures including the Oswestry Disability Index. Differences in surgery and non-operative treatment outcomes were evaluated between image characteristic subgroups and TE determined by the difference in ODI scores.Results: The cohort was comprised of 40% females with an average age of 41.5 (±11.6), 61% of which underwent discectomy for IDH. Patients undergoing surgery with Modic type I endplate changes had worse outcomes (-26.4 versus -39.7 for none and -39.2 for type 2, p = 0.002) and smaller treatment effect (-3.5 versus -19.3 for none and -15.7 for type 2, p = 0.003). Those with compression > = 1/3 showed the greatest improvement within the surgical group (-41.9 for > = 1/3 versus -31.6 for none and -38.1 for <1/3, p = 0.007), and the highest TE (-23 compared to -11.7 for none and -15.2 for <1/3, p = 0.015). Furthermore, patients with minimal nerve root impingement demonstrated worse surgical outcomes (-26.5 versus -41.1 for "displaced" and -38.9 for "compressed", p = 0.016).Conclusion: Among patients with IDH, those with thecal sac compression > = 1/3 had greater surgical treatment effect than those with small disc herniations and Modic type I changes. Additionally, patients with nerve root "compression" and "displacement" benefit more from surgery than those with minimal nerve-root impingement.
    Spine 02/2013; · 2.16 Impact Factor
  • Jon D Lurie, Tamara S Morgan
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    ABSTRACT: Traditional randomized controlled trials are the 'gold standard' for evaluating health interventions and are typically designed to maximize internal validity, often at the cost of limited generalizability. Pragmatic randomized controlled trials should be designed with a conscious effort to generate evidence with a greater external validity by making the research question as similar as possible to the questions faced by clinical decision-makers (i.e., patients and their families, physicians, policy makers and administrators) and then answer that question with rigor. Clarity and transparency about the specifics of the research question are the keys to designing, as well as interpreting, any clinical trial.
    Journal of comparative effectiveness research. 01/2013; 2(1):53-8.
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    ABSTRACT: Study Design. Subgroup analysis of prospective, randomized databaseSummary of Background Data. Lumbar spinal stenosis is a common incidental finding among adults over the age of 60, The use of ESI in these patients is common, although there is little evidence in the literature to demonstrate the long-term benefit of ESI in the treatment of lumbar stenosis.Objective. The hypothesis of this study was that patients who received epidural steroid injections (ESI) during initial treatment as part of the Spine Patient Outcomes Research Trial (SPORT) would have improved clinical outcomes and a lower rate of crossover to surgery compared to patients who did not receive ESI.Methods. Patients with lumbar spinal stenosis who received epidural steroid injections within the first three months of enrollment in SPORT (ESI) were compared to patients who did not receive epidural injections during the first three months of the study (No ESI).Results. There were 69 ESI patients and 207 No-ESI patients. There were no significant differences in demographic factors, baseline clinical outcome scores, or operative details although there was a significant increase in baseline preference for nonsurgical treatment among ESI patients (62% vs. 33%, p <0.001). There was an average 26 minute increase in operative time and an increased length of stay by 0.9 days among the ESI patients who ultimately underwent surgical treatment. Averaged over four years, there was significantly less improvement in SF36 PF among surgically treated ESI patients (ESI 14.8 vs. No-ESI 22.5, p = 0.025). In addition, there was also significantly less improvement among the nonsurgically treated patients in SF36 BP (ESI 7.3 vs. No-ESI 16.7, p = 0.007) and SF36 PF (ESI 5.5 vs. No-ESI 15.2, p = 0.009). Of the patients assigned to surgical treatment, there was a significantly increased crossover to nonsurgical treatment among patients who received an ESI (ESI 33% vs. No ESI 11%, p = 0.012). Of the patients assigned to non-operative treatment, there was a significantly increased crossover to surgical treatment in the ESI patients (ESI 58% vs. No ESI 32%, p = 0.003).Conclusion. Despite equivalent baseline status, ESI were associated with significantly less improvement at four years among all patients with spinal stenosis in SPORT. Furthermore, ESI were associated with longer duration of surgery and longer hospital stay. There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically.
    Spine 12/2012; · 2.16 Impact Factor

Publication Stats

3k Citations
580.15 Total Impact Points

Institutions

  • 2003–2013
    • Dartmouth–Hitchcock Medical Center
      • Department of Surgery
      Lebanon, New Hampshire, United States
    • Dartmouth College
      • Dartmouth Institute for Health Policy and Clinical Practice
      Hanover, New Hampshire, United States
  • 2000–2013
    • Geisel School of Medicine at Dartmouth
      • • Department of Medicine
      • • Institute for Health Policy and Clinical Practice
      • • Department of Orthopaedics
      Hanover, New Hampshire, United States
  • 2012
    • Thomas Jefferson University
      • Department of Orthopaedic Surgery
      Philadelphia, PA, United States
  • 2011
    • Rothman Institute
      Philadelphia, Pennsylvania, United States
  • 2010
    • Rush University Medical Center
      • Department of Orthopaedic Surgery
      Chicago, IL, United States
  • 2009
    • Indiana University-Purdue University Indianapolis
      • Department of Medicine
      Indianapolis, IN, United States
  • 2008
    • Case Western Reserve University School of Medicine
      Cleveland, Ohio, United States
    • University of California, San Francisco
      San Francisco, California, United States
  • 1997–1999
    • White River Junction VA Medical Center
      White River Junction, Vermont, United States