Two-year comprehensive medical management of degenerative lumbar spine disease (lumbar spondylolisthesis, stenosis, or disc herniation): a value analysis of cost, pain, disability, and quality of life

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Current health care reform calls for a reduction of procedures and treatments that are less effective, more costly, and of little value (high cost/low quality). The authors assessed the 2-year cost and effectiveness of comprehensive medical management for lumbar spondylolisthesis, stenosis, and herniation by utilizing a prospective single-center multidisciplinary spine center registry in a real-world practice setting.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Analysis was performed on a prospective longitudinal quality of life spine registry. Patients with lumbar spondylolisthesis (n = 50), stenosis (n = 50), and disc herniation (n = 50) who had symptoms persisting after 6 weeks of medical management and who were eligible for surgical treatment were entered into a prospective registry after deciding on nonsurgical treatment. In all cases, comprehensive medical management included spinal steroid injections, physical therapy, muscle relaxants, antiinflammatory medication, and narcotic oral agents. Two-year patient-reported outcomes, back-related medical resource utilization, and occupational work-day losses were prospectively collected and used to calculate Medicare fee–based direct and indirect costs from the payer and societal perspectives. The maximum health gain associated with medical management was defined as the improvement in pain, disability, and quality of life experienced after 2 years of medical treatment or at the time a patient decided to cross over to surgery.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The maximum health gain in back pain, leg pain, disability, quality of life, depression, and general health state did not achieve statistical significance by 2 years of medical management, except for pain and disability in patients with disc herniation and back pain in patients with lumbar stenosis. Eighteen patients (36%) with spondylolisthesis, 11 (22%) with stenosis, and 17 (34%) with disc herniation eventually required surgical management due to lack of improvement. The 2-year improvement did not achieve a minimum clinically important difference in any outcome measure. The mean 2-year total cost (direct plus indirect) of medical management was $6606 for spondylolisthesis, $7747 for stenosis, and $7097 for herniation.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>In an institution-wide, prospective, longitudinal quality of life registry that measures cost and effectiveness of all spine care provided, comprehensive medical management did not result in sustained improvement in pain, disability, or quality of life for patients with surgically eligible degenerative lumbar spondylolisthesis, stenosis, or disc herniation. From both the societal and payer perspective, continued medical management of patients with these lumbar pathologies in whom 6 weeks of conservative therapy failed was of minimal value given its lack of health utility and effectiveness and its health care costs. The findings from this real-world practice setting may more accurately reflect the true value and effectiveness of nonoperative care in surgically eligible patient populations.</jats:p></jats:sec>

Bilateral Pars Defects at the L4 Vertebra Result in Increased Degeneration When Compared With Those at L5: An Anatomic Study

“…Lumbar spondylosis or degenerative spine disease is the most common etiology of low-back pain and can have a substantial effect on an individual's quality of life [40]. The medical costs associated with back pain in the US have doubled to more than $100 billion dollars during the past 7 years, with a 65% increase in national expenditure on backrelated issues [33].…”

“…We also showed that after correcting for the spondylolysis, there still is a larger degree of degenerative disc disease in patients with bilateral L4 pars defects compared with those with lesions at L5, and this is greater than what is accounted for based on the normal population. Degenerative spine disease is the most common etiology of low-back pain [40], and as this becomes an increasing source of disability and national spending [33], clinicians will need to be able to triage patients appropriately based on what can be expected for their disease progression. We found that patients with bilateral spondylolysis may be at an increased risk to have degenerative disc disease develop and special attention must be paid to patients with L4 spondylolysis, as they may have a more rapidly progressive and severe disease course.…”

Cost-effectiveness of three treatment strategies for lumbar spinal stenosis: Conservative care, laminectomy, and the Superion interspinous spacer

“…CC estimates were from a previously published paper. 22 The spacer treatment data came from the pivotal FDA IDE trial of the Superion Interspinous Spacer System sponsored by VertiFlex, Inc. 23 The primary outcome measure analyzed was qualityadjusted life years (QALYs) gained. A payer perspective was taken.…”

“…Baseline, three-month, one-year, and two-year Oswestry Disability Index (ODI), SF-12 quality of life, and follow-up utilization were assessed in phone interviews. 22 Similarly, the trial data included two-year follow-up after implant with the interspinous spacer. The details of this trial have been described in a previous publication.…”

“…22,23 The registry included patient demographics, disease characteristics, and treatment variables assessed prospectively for each case. Baseline, three-month, one-year, and two-year Oswestry Disability Index (ODI), SF-12 quality of life, and follow-up utilization were assessed in phone interviews.…”