Circumferential Technique Appears Superior to Posterolateral in Lumbar FusionsThe use of circumferential (CF) fusion is better than posterolateral fusion (PLF) in lumbar spinal fusion, say researchers of a recent study. Although many people experience chronic lower back pain, there has been little agreement on the best method of treatment until a recent study demonstrated the effectiveness of a particular spinal fusions technique.
The authors of this study set out to evaluate the posterolateral approach, from the sides and back, in order to determine the cost per quality-adjusted-life-year (QALY) compared with that of CF fusion, a more invasive surgery. Discovering the cost-effectiveness of two procedures allows doctors to analyze the difference between the procedures and helps in decision-making within certain budget constraints.
The researchers enrolled 148 patients, between the ages of 20 and 65 years (average 46), who had severe chronic low back pain and leg pain, from an instability in the back that required repair through surgery. All patients were examined through clinical and neurological examinations, as well as by x-ray, computed tomography scanning (CT scan) with myelography, or magnetic resonance imaging (MRI). Long-term follow up was done by mail; 125 patients were available to complete the study.
To perform the economic evaluation, the researchers used the EuroQol instrument EQ-5D. They report that to calculate the QALY, the patient's health state is assigned a certain value. All costs between January 1 of the year of the initial surgery to a fixed study endpoint of January 1, 2004, were recorded and discounted at an annual rate of three percent. Healthcare services used (initial surgery, repeat surgeries, repeat hospitalization, and clinic visits) were all recorded, as were visits with general physicians, specialists, physiotherapists, psychologists, and chiropractors. Prescribed medications, as well as over-the-counter medications were recorded. Finally, patient disability and absenteeism due to inability to work were also tracked.
During the surgery, eight patients who underwent the PLF experienced complications, as did 13 patients in the CF group. At two-year follow-up, 16 in the PLF group needed repeat surgeries, while five in the CF group also required repeat surgeries. Measurements for disability and pain were done with the Oswestry Disability Index, the Short-form 36, and a pain scale. After two years, the researchers found that the fusion rate was better in the patients who had undergone the CF approach than the patients who underwent the PLF. This was noted with both physical and psychosocial functional ability.
Regarding costs, the CF approach appeared to be more cost effective than the PLF. Although the cost of the CF surgery was a bit higher than the PLF (US$12,070 vs. US$11,990), the follow-up care was less expensive, particularly because of the repeat surgeries. The biggest difference was in the post-operative clinic visits because of back pain. In terms of societal cost, patients in the PLF group did not return to work as often as did the patients in the CF group. Interestingly, the CF patients did have more reported absences from work than did the PLF group, but the PLF group had a poorer return to work rate. At the same time, patients in the CF group reported a significantly better quality-of-life than did those in the PLF group.
The authors' goal was to assess if their hypothesis of CF fusion being more economical than PLF, despite the added cost of the initial surgery with the CL fusion. They concluded that the CF procedure was both less expensive and more effective. They caution, however, that this information might not necessarily be transferred to other parts of the world, or even to other parts of the country in terms of actual numbers.
Rikke Soegaard, MPH, et al. Circumferential Fusion is Dominant Over Posterolateral Fusion in a Long-term Perspective. In SPINE. Vol. 32. No. 22. Pp. 2405-2414.
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