Economic burden of nonoperative treatment of adult spinal deformity

J Neurosurg Spine 39:751–756, 2023

OBJECTIVE The purpose of this study was to investigate the cost utility of nonoperative treatment for adult spinal deformity (ASD).

METHODS Nonoperatively and operatively treated patients who met database criteria for ASD and in whom complete radiographic and health-related quality of life data at baseline and at 2 years were available were included. A cost analysis was completed on the PearlDiver database assessing the average cost of nonoperative treatment prior to surgical intervention based on previously published treatments (NSAIDs, narcotics, muscle relaxants, epidural steroid injections, physical therapy, and chiropractor). Utility data were calculated using the Oswestry Disability Index (ODI) converted to SF-6D with published conversion methods. Quality-adjusted life years (QALYs) used a 3% discount rate to account for residual decline in life expectancy (78.7 years). Minor and major comorbidities and complications were assessed according to the CMS.gov manual’s definitions. Successful nonoperative treatment was defined as a gain in the minimum clinically importance difference (MCID) in both ODI and Scoliosis Research Society (SRS)–pain scores, and failure was defined as a loss in MCID or conversion to operative treatment. Patients with baseline ODI ≤ 20 and continued ODI of ≤ 20 at 2 years were considered nonoperative successful maintenance. The average utilization of nonoperative treatment and cost were applied to the ASD cohort.

RESULTS A total of 824 patients were included (mean age 58.24 years, 81% female, mean body mass index 27.2 kg/m 2 ). Overall, 75.5% of patients were in the operative and 24.5% were in the nonoperative cohort. At baseline patients in the operative cohort were significantly older, had a greater body mass index, increased pelvic tilt, and increased pelvic incidence–lumbar lordosis mismatch (all p < 0.05). With respect to deformity, patients in the operative group had higher rates of severe (i.e., ++) sagittal deformity according to SRS–Schwab modifiers for pelvic tilt, sagittal vertical axis, and pelvic incidence–lumbar lordosis mismatch (p < 0.05). At 2 years, patients in the operative cohort showed significantly increased rates of a gain in MCID for physical component summary of SF-36, ODI, and SRS-activity, SRS-pain, SRSappearance, and SRS-mental scores. Cost analysis showed the average cost of nonoperative treatment 2 years prior

to surgical intervention to be $2041. Overall, at 2 years patients in the nonoperative cohort had again in ODI of 0.36, did not show a gain in QALYs, and nonoperative treatment was determined to be cost-ineffective. However, a subset of patients in this cohort underwent successful maintenance treatment and had a decrease in ODI of 1.1 and a gain in utility of 0.006 at 2 years. If utility gained for this cohort was sustained to full life expectancy, patients’ cost per QALY was $18,934 compared to a cost per QALY gained of $70,690.79 for posterior-only and $48,273.49 for combined approach in patients in the operative cohort.

CONCLUSIONS Patients with ASD undergoing operative treatment at baseline had greater sagittal deformity and greater improvement in health-related quality of life postoperatively compared to patients treated nonoperatively. Additionally, patients in the nonoperative cohort overall had an increase in ODI and did not show improvement in utility gained. Patients in the nonoperative cohort who had low disability and sagittal deformity underwent successful maintenance and cost-effective treatment.

Evidence-based management of traumatic thoracolumbar burst fractures

Thoracolumbar burst fracture

Neurosurg Focus 37 (1):E1, 2014

The overall evidence for nonoperative management of patients with traumatic thoracolumbar burst fractures is unknown. There is no agreement on the optimal method of conservative treatment. Recent randomized controlled trials that have compared nonoperative to operative treatment of thoracolumbar burst fractures without neurological deficits yielded conflicting results. By assessing the level of evidence on conservative management through validated methodologies, clinicians can assess the availability of critically appraised literature. The purpose of this study was to examine the level of evidence for the use of conservative management in traumatic thoracolumbar burst fractures.

Methods. A comprehensive search of the English literature over the past 20 years was conducted using PubMed (MEDLINE). The inclusion criteria consisted of burst fractures resulting from a traumatic mechanism, and fractures of the thoracic or lumbar spine. The exclusion criteria consisted of osteoporotic burst fractures, pathological burst fractures, and fractures located in the cervical spine. Of the studies meeting the inclusion/exclusion criteria, any study in which nonoperative treatment was used was included in this review.

Results. One thousand ninety-eight abstracts were reviewed and 447 papers met inclusion/exclusion criteria, of which 45 were included in this review. In total, there were 2 Level-I, 7 Level-II, 9 Level-III, 25 Level-IV, and 2 Level- V studies. Of the 45 studies, 16 investigated conservative management techniques, 20 studies compared operative to nonoperative treatments, and 9 papers investigated the prognosis of conservative management.

Conclusions. There are 9 high-level studies (Levels I–II) that have investigated the conservative management of traumatic thoracolumbar burst fractures. In neurologically intact patients, there is no superior conservative management technique over another as supported by a high level of evidence. The conservative technique can be based on patient and surgeon preference, comfort, and access to resources. A high level of evidence demonstrated similar functional outcomes with conservative management when compared with open surgical operative management in patients who were neurologically intact. The presence of a neurological deficit is not an absolute contraindication for conservative treatment as supported by a high level of evidence. However, the majority of the literature excluded patients with neurological deficits. More evidence is needed to further classify the appropriate burst fractures for conservative management to decrease variables that may impact the prognosis.

Management of Type II Odontoid Fractures in the Geriatric Population

J Spinal Disord Tech 2010;23:317–320

Objective: To analyze geriatric patients with Type II odontoid fractures treated either with rigid cervical orthosis (CO) or surgery (Odontoid Screw or Transarticular screw).

Summary of Background Data: Our literature search did not yield any studies on the outcome of Type II odontoid fractures in geriatric population treated with the rigid CO. We therefore designed a study to analyze geriatric patients with Type II odontoid fractures treated with either rigid cervical collar or surgery.

Materials and Methods: This is a retrospective chart review of patients with Type II odontoid fractures between July 1998 and June 2006. Inclusion criteria consists of males and females of 70 years of age or older with Type II odontoid fractures who were treated with rigid cervical collar or surgery. Exclusion criteria were displacement >4mm, posteriorly displaced fracture, neurologic compromise, multilevel cervical spine injury, and treatment in a halo vest. Medical comorbidities were assessed using the Modified Cumulative Illness Rating Scale for Geriatrics. Primary outcomes were mortality and fusion (union, stable nonunion, nonunion). Minimum of 3 months follow-up was acceptable.

Results: One hundred eighty four odontoid fractures were identified in 8 years. Twenty patients met our inclusion criteria (9 treated in rigid collar and 11 treated surgically). Median follow-up was 5.5 months. Out of 20 patients, 4 patients died (1 treated in CO, 3 treated surgically). Cumulative Illness Rating Scale for Geriatrics index was highest in patient treated in CO. In the rigid collar group, 6 patients had union (66.6%), and 2 developed stable nonunion (22.2%); whereas in the surgically treated group, 7 patients had union (87.5%), and 1 patient developed nonunion (12.5%).

Conclusions: Patients treated nonoperatively in rigid collar seem to have an overall favorable outcome. A well-designed prospective study, to compare the outcomes of surgical intervention with nonsurgical management of Type II odontoid in elderly is recommended