A Cost-Effectiveness Analysis of Minimally Invasive versus Open Surgery Techniques for Lumbar Spinal Fusion in Italy and the United Kingdom

Cost Difference Between Open Surgery and Minimally Invasive Surgery for the Treatment of Traumatic Thoracolumbar Fractures

OBJECTIVE

Spinal vertebral fractures pose a significant healthcare burden due to their frequency and impact on quality of life, resulting in substantial social costs. Minimally invasive surgery (MIS) offers advantages over traditional open surgery (OS), such as reduced tissue damage, less postoperative pain, and shorter hospital stays, although it involves higher implant costs. Research comparing the overall direct costs of these interventions is limited. This study aims to compare the direct hospital-care costs associated with OS and MIS for thoracolumbar vertebral fractures in Spain.

METHODS

We conducted an ambispective analysis of patients treated for thoracolumbar unstable fractures at our hospital from January 2004 to July 2022. Patients were categorized into OS and MIS groups. We performed analyses on the entire cohort, patients with minor trauma, and applied propensity score matching. Direct hospital costs were documented and adjusted for inflation.

RESULTS

Out of 218 patients, 75 underwent OS and 143 received MIS. Cost analysis indicated that MIS patients had shorter hospital stays and lower admission costs, though total costs did not differ significantly. Multivariate analysis showed OS was slightly more expensive but not significantly so. Propensity score matching confirmed similar findings. For patients with minor trauma, MIS again showed shorter stays and lower costs, with no significant difference in total costs. All cohorts exhibited significantly lower blood expenditure with MIS.

CONCLUSIONS

The study demonstrates that MIS is not inferior to OS in terms of costs, with some advantages like reduced blood bank expenses. Further high-quality randomized controlled trials with economic evaluations are needed for more definitive conclusions.

Surgical versus nonsurgical treatment of thoracolumbar burst fractures in neurologically intact patients: a cost-utility analysis

BACKGROUND CONTEXT

Many efforts have been made to determine what is the best treatment strategy for neurologically intact patients with TL burst fractures: surgery or nonoperative management. Studies comparing clinical outcomes have produced mixed and inconclusive results creating lack of consensus in the expert community.

PURPOSE

Therefore, it is necessary to explore other important components of healthcare such as economics to settle this controversial debate. The goal of the current study was to perform a cost-utility analysis comparing surgical treatment to nonoperative treatment for neurologically intact TL burst fractures (AOSpine classification types A3 and A4) from a societal perspective in a multicenter and international setting.

STUDY DESIGN/SETTING

We performed a cost-utility analysis from a societal perspective comparing the cost-utility of surgical treatment versus nonsurgical treatment of thoracolumbar (TL) burst fractures in neurologically intact patients.

PATIENT SAMPLE

Patient demographics and all clinical and outcome data were taken from an observational, prospective multicenter cohort study comparing surgical versus nonsurgical treatment of TL burst fractures in neurological intact patients.

OUTCOME MEASURES

The ICER was calculated comparing surgical versus nonsurgical treatment for the full analysis population with a 1-year time horizon, two-year time horizon as well as the working-life time horizon. Costs were taken from the clinical study, patient diaries with productivity loss documented, current scientific literature in addition to national and international healthcare costing guidelines and databases.

METHODS

The mean difference in cost between the two treatment groups were calculated, firstly by applying the central limit theorem, and secondly by using bootstrapping. To calculate the average cost per patient in each treatment group, the Kaplan-Meier Sample Average (KMSA) estimator was used in order to take account of the censored patients. To evaluate the derived models and to explore uncertainty, sensitivity analysis was used.

RESULTS

Eleven sites from different regions (North America, Europe, Middle east, and Asia) completed the recruitment and follow-up for 213 patients. One hundred and thirty patients were treated surgically (61.0%) and eighty-three patients (39.0%) were treated nonsurgically. At 1-year, the ICER for surgical treatment was $191,648.00 USD per QALY. Compared to a willingness to pay threshold of $100,000, surgical treatment was not cost-effective within the 1-year timeframe. At 2-years, the nonsurgical group had visited the surgeon or general practitioner more often (0.31 vs. 0.25). The nonsurgical group had visited physiotherapist and other allied health more often (3.68 vs. 1.68). The utilization of NSAIDs and opioids remained higher in the nonsurgical group (2.66 vs. 2.39) (1.52 vs. 0.75). The average workdays lost remained higher in the nonsurgical group (143.12 vs. 114.78). The caregiver days taken off work remained higher in the nonsurgical group (29.86 vs. 2.39). At 2 years, surgical treatment showed to be a dominant strategy with a $28,978.50 savings per QALY. At lifetime horizon, surgical treatment remained the cost-effective strategy at $25,530.18 savings per QALY.

CONCLUSION

Our cost-utility analysis showed surgical management to be cost-effective at 2 years compared to nonoperative management in neurologically intact TL burst fractures from a societal perspective. This finding was maintained through the working-lifetime horizon. Surgical treatment became cost-effective largely due to the greater productivity loss of patients and caregivers within the nonsurgical group. This investigation highlights the viability for surgical management of TL burst fractures to provide societal benefit especially when productivity is valued.

Cost-utility of lumbar interbody fusion surgery: A systematic review

BACKGROUND CONTEXT

Lumbar interbody fusion (LIF) is a common surgical intervention for treating lumbar degenerative disorders. Increasing demand has contributed to ever-increasing healthcare expenditure and economic burden. To address this, cost-utility analyses (CUAs) compare value in the context of patient outcomes. CUAs quantify health improvements using quality-adjusted life years (QALYs), allowing decision-makers to determine procedure value.

PURPOSE

While there is a growing body of literature assessing LIF value, a comprehensive synthesis of LIF CUAs is lacking. This systematic review aims to address this gap by assessing all available CUAs of LIF techniques, to support evidence-based practices that improve outcomes and promote efficient resource use.

STUDY DESIGN

Systematic review.

STUDY SAMPLE

This study sample consisted of adult patients with lumbar degenerative conditions specifically treated with lumbar interbody fusion, including grade I or II degenerative spondylolisthesis, lumbar spinal stenosis, disc degeneration, and spondylosis, with or without low back and/or leg pain.

OUTCOME MEASURES

Direct (healthcare) and indirect (non-healthcare) costs, cost sources and calculation methods, utility scores, QALY gain, cost-utility, incremental cost-effectiveness ratios, and willingness-to-pay thresholds. Outcomes were reported as median and interquartile ranges (IQR).

METHODS

A systematic review was conducted following PRISMA guidelines. PubMed, Web of Science, and Embase were searched from inception to October 23, 2023, for CUAs reporting QALYs and costs of LIF procedures. Relevant studies were selected and data extracted. Subgroup analyses compared minimally invasive versus open surgery and anterior versus posterior approaches. Study quality was assessed using the CHEC-Extended tool. Quantitative meta-analysis was not performed due to methodological heterogeneity.

RESULTS

Out of 2047 identified studies, 14 met inclusion criteria. The mean CHEC-Extended score was 72.1%. Most studies reported on TLIF (n=11) and utilized EQ-5D questionnaire to calculate utility (n=9). Direct costs were sourced from institutional databases, Medicare, DRGs, Redbook, and a variety of other sources. Most indirect costs were estimated from productivity loss. TLIF demonstrated the highest median QALY gain over 1 year (0.43, IQR 0.121-0.705), while PLIF was highest over 2 years (1.33). ALIF was most favorable over 1 year ($30901/QALY) and OLIF was most favorable over 2 years ($11187/QALY). PLIF, TLIF, and LLIF exhibited similar cost-utility over 2 years ($44383, $45628, $48576/QALY). MIS was substantially favorable to OS at 1 year ($42635 vs. $226304), though similar at 2 years ($48576 vs. $45628/QALY). Anterior approach was favorable to posterior approach at 1 year ($30901.5 vs. $81038) and 2 years ($29881.9 vs. $44383). Cost-utility comparisons substantially varied and were sensitive to utility measures, study methodology, cost sourcing, and follow-up duration.

CONCLUSIONS

This is the first systematic review to comprehensively assess CUAs of all LIF approaches in the existing literature. While certain approaches, such as ALIF and OLIF, may demonstrate favorable outcomes, these conclusions are limited by high methodological heterogeneity and a limited study pool. By addressing existing gaps in study design and reporting, future comparative cost-utility research can better inform evidence-based decision-making and optimize the value of spinal surgical care.

Lumbar Spinal Fusion Outcomes in Patients With Cancer Compared to Matched Peers Without Cancer

STUDY DESIGN

Retrospective Matched Cohort Study.

OBJECTIVES

Optimization of medical comorbidities is an essential part of preoperative management. However, the isolated effects of individual comorbidities have not been evaluated within a homogenous spine surgery population. This exact matching study aims to assess the independent effects of cancer on outcomes following single-level lumbar fusions for non-cancer surgery.

METHODS

4680 consecutive patients undergoing single-level posterior-only lumbar fusion were retrospectively enrolled. Univariate statistics and coarsened exact matching (CEM) were computed to evaluate outcomes between cancer patients and those without comorbidities.

RESULTS

By logistic regression, malignancy conferred a higher risk of surgical complication (P = 0.016, OR = 2.64, CI = [1.200,5.790]), 30- and 90- day readmission (P = 0.012, OR = 2.025, CI = [1.170-3.510]; P < 0.001, OR = 2.34, CI = [1.430, 3.830], respectively), 90-day reoperation (P < 0.001, OR = 2.16, [1.110, 4.200]), and death at 90-days (P = 0.032, OR = 8.27, CI = [1.200, 56.850]). After matching, malignancy was associated with increased odds of incidental durotomy (6 vs 0 cases, P = 0.048) and death at both 30 and 90 days (both: OR = 8.0, P = 0.020, CI = [1.00, 63.960]). No cases of durotomy occurred in cases with mortality in the matched sample, suggesting independent relationships. There were no differences in length of stay, non-home discharge, ED evaluation, readmission, or reoperations.

CONCLUSION

Among otherwise exact-matched patients undergoing single level lumbar fusion, history of malignancy conferred a higher risk of short-term mortality, but not other outcomes suggestive of surgical failure. Increased mortality after lumbar fusion should be studied further and may play a role in surgical decision-making and patient discussions.

Cost-effectiveness and budget impact of cement augmentation for the fixation of unstable trochanteric fractures from a European perspective: Cost-effectiveness and budget impact of cement augmentation in Europe

INTRODUCTION

Hip fractures have a high patient burden and mortality rate, particularly following revision surgery. Cement augmentation of cephalomedullary nails has been shown to lower the risk of cut-out, aiming to reduce the need and expense of revision surgeries. The aim of this study was to assess the economic impact of cement augmentation for the fixation of trochanteric hip fractures in fragile, elderly patients, across a range of European countries (UK, Spain, Italy, Germany, and France), from both a provider (hospital) and a payer perspective.

METHOD

The budget impact (hospital perspective) and cost-effectiveness (payer perspective) analyses were informed by clinical outcomes from a meta-analysis published in 2021, additional published literature, registries, and clinical experts. Economic inputs included length of stay and operating time for the hospital perspective, revision surgery, outpatient, and rehabilitation days costs for the payer perspective. Outcomes included the breakeven cost below which using cement augmentation would begin to generate cost savings for the hospital, and potential cost savings for the payer with incremental costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Deterministic and probabilistic sensitivity analyses were conducted to assess model uncertainty.

RESULTS

From a hospital perspective, the breakeven cost below which the hospital would start saving money using cement augmentation was £491 (UK), €1490 (Spain), €1075 (Italy), €852 (Germany), and €834 (France) per patient, driven by reduced length of hospital stay. From a payer perspective, cost savings were £1675 (UK), €2202 (Spain), €993 (Italy), €944 (Germany), and €892 (France) per patient, mainly driven by fewer revision surgeries. Payer cost savings, coupled with incremental QALY gain of 0.004 across all regions, led to cement augmentation being the dominant strategy. These budget impact and cost-effectiveness results were rigorously tested in sensitivity analyses and were found to be robust.

CONCLUSION

These models support the wider adoption of cement augmentation to reduce the healthcare system costs associated with length of stay and revision surgery. These results provide useful information to providers, payers, and policymakers to ultimately influence choice surrounding the 'gold-standard' treatment of an unstable trochanteric fracture following low energy trauma.

Is minimally invasive surgery a game changer in spinal surgery?

Minimally invasive spine surgery (MISS) has revolutionized the treatment of spinal disorders over the past few decades. This review provides an in-depth analysis of MISS techniques, technologies, outcomes, and future directions. The evolution of MISS techniques-including tubular retractor systems, percutaneous pedicle screw fixation, minimally invasive transforaminal lumbar interbody fusion, lateral lumbar interbody fusion, and endoscopic spine surgery-has expanded the scope of treatable spinal pathologies while minimizing tissue trauma. Technological advancements such as intraoperative navigation, robotics, and augmented reality applications have enhanced precision and capabilities. Clinical evidence supports the efficacy and safety of MISS techniques for various spinal pathologies, demonstrating comparable or superior outcomes to traditional open approaches with reduced tissue trauma, blood loss, and hospital stays. Cost-effectiveness analyses also favor MISS over open techniques. Future directions in MISS include expanding indications, integrating artificial intelligence and machine learning, advancing tissue engineering and biologics, and refining robotic and augmented reality applications. As MISS continues to evolve, it is poised to play an increasingly important role in the treatment of spinal disorders, offering improved patient outcomes with reduced morbidity. However, ongoing rigorous evaluation of new techniques and technologies is crucial to balance potential benefits with associated risks and costs.

Comparative Evaluation of Postoperative Epidural Hematoma after Lumbar Microendoscopic Laminotomy: The Utility of Ultrasonography versus Magnetic Resonance Imaging

Introduction

Postoperative spinal epidural hematoma (PSEH) is a severe complication of spinal surgery that necessitates accurate and timely diagnosis. This study aimed to assess the accuracy of ultrasonography as an alternative diagnostic tool for PSEH after microendoscopic laminotomy (MEL) for lumbar spinal stenosis, comparing it with magnetic resonance imaging (MRI).

Methods

A total of 65 patients who underwent MEL were evaluated using both ultrasound- and MRI-based classifications for PSEH. Intra- and interrater reliabilities were analyzed. Furthermore, ethical standards were strictly followed, with spine surgeons certified by the Japanese Orthopaedic Association performing evaluations.

Results

Among the 65 patients, 91 vertebral segments were assessed. The intra- and interrater agreements for PSEH classification were almost perfect for both ultrasound (κ=0.824 [95% confidence interval (CI) 0.729-0.918] and κ=0.810 [95% CI 0.712-0.909], respectively) and MRI (κ=0.839 [95% CI 0.748-0.931] and κ=0.853 [95% CI 0.764-0.942], respectively). The results showed high concordance between ultrasound- and MRI-based classifications, validating the reliability of ultrasound in postoperative PSEH evaluation.

Conclusions

This study presents a significant advancement by introducing ultrasound as a precise and practical alternative to MRI for PSEH evaluation. The comparable accuracy of ultrasound to MRI, rapid bedside assessments, and radiation-free nature make it valuable for routine postoperative evaluations. Despite the limitations related to specific surgical contexts and clinical outcome assessment, the clinical potential of ultrasound is evident. It offers clinicians a faster, cost-effective, and repeatable diagnostic option, potentially enhancing patient care. This study establishes the utility of ultrasound in evaluating postoperative spinal epidural hematomas after MEL. With high concordance to MRI, ultrasound emerges as a reliable, practical, and innovative tool, promising improved diagnostic efficiency and patient outcomes. Further studies should explore its clinical impact across diverse surgical scenarios.

Budget Impact Analysis of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease: A European Hospital Perspective

Purpose

When traditional therapies fail to provide relief from debilitating lower back pain, surgeries such as transforaminal lumbar interbody fusion (TLIF) may be required. This budget impact analysis (BIA) compared minimally-invasive (MI)-TLIF versus open (O)-TLIF for single-level fusion from an Italian hospital perspective.

Methods

The BIA compared costs of 100 MI-TLIF and 100 O-TLIF procedures from an Italian hospital perspective over a one-year time horizon. The base case included costs for length of hospital stay (LOS), blood loss, and sterilizing surgical trays. The scenario analysis also included operating room (OR) time and complication costs. Base case inputs were from the Miller et al meta-analysis; scenario analysis inputs were from the Hammad et al meta-analysis. The device costs for MI-TLIF and O-TLIF procedures were from Italian tender prices for Viper Prime™ System and Expedium™ Spine System, respectively.

Results

Base case deterministic analysis results showed cost savings of €207,370 for MI-TLIF compared with O-TLIF. MI-TLIF costs were lower for LOS (€215,277), transfusion for blood loss (€16,881), and surgical tray sterilization (€28,232), whereas device costs were lower for O-TLIF (€53,020). The probabilistic result was similar, with MI-TLIF resulting in savings of €211,026 (95% credible interval [CR]: €208,725 - €213,327). All 1000 base case probabilistic sensitivity analysis runs were cost saving. Deterministic scenario analysis results showed cost savings of €166,719 for MI-TLIF. MI-TLIF costs were lower for LOS (€190,813), transfusion for blood loss (€16,881), surgical tray sterilization (€28,232), and complications (€2076), whereas O-TLIF costs were lower for OR time (€18,263) and devices used (€53,020).

Conclusion

Despite the increase incremental cost for medical device innovation and OR time, this study demonstrates the economic savings of MI-TLIF compared to O-TLIF from a European hospital perspective. The findings will be useful to policy and hospital decision makers in assessing purchasing, funding and reimbursement decisions.

Surgical Outcomes and Medical Costs Associated with Spinal Cord Tumors: Comparison of Extramedullary and Intramedullary Tumors

OBJECTIVE

This study aimed to clarify the differences in the perioperative data of patients with extramedullary and intramedullary tumors and estimate the impact of surgery on medical costs.

METHODS

This single-center retrospective study included consecutive patients who underwent spinal tumor resection between September 2020 and December 2022. The perioperative medical information and medical costs for individual patients were obtained from their medical records.

RESULTS

Thirty-two patients with extramedullary spinal cord tumors and 18 with intramedullary spinal cord tumors were included in the study. The 2 groups had no difference in surgery-related or major systemic complications. However, the operation time and the length of hospital stay were significantly longer and activities of daily living at discharge tended to worsen in the intramedullary tumor group compared to those in the extramedullary tumor group. As a result, the discharge outcome was significantly different between the 2 groups. The total medical costs for intramedullary tumors were approximately 1.43 times higher than those for extramedullary tumors. Further, a better functional outcome at discharge can save medical costs, regardless of extramedullary or intramedullary tumors.

CONCLUSIONS

Surgery for intramedullary tumors can be performed with similar perioperative risks as for extramedullary tumors. However, intramedullary tumors are associated with concerns, such as prolonged hospitalization and worsening of activities of daily living at discharge, which ultimately result in higher medical costs.

[Translated article] The role of minimally invasive spine surgery in the treatment of vertebral metastasis (Part 1): A clinical review

Spinal metastases represent a significant burden on the quality of life in patients affected by active oncological disease due to the high incidence of pain syndromes, spinal deformity, and neurological impairment. Surgery plays a decisive role in improving quality of life by controlling pain, restoring neurological function and maintaining spinal stability, as well as contributing to the response to medical therapy. Minimally invasive surgery (MIS) is a treatment option in certain patients with high surgical risk since it has a low rate of complications, intraoperative bleeding, hospital stay, and offers similar results to open surgery. In this review, we present the role of MIS in this pathology and some cases treated in our hospital.

[Translated article] The role of minimally invasive spine surgery in the treatment of vertebral metastasis: A narrative review

BACKGROUND

Spinal metastases are a very common problem which dramatically affects the quality of life of cancer patients. The objective of this review is to address the issue of how minimally invasive surgery can play an important role in treating this pathology.

METHODS

A literature review was performed, searching in the Google Scholar, PubMed, Scopus and Cochrane databases. Relevant and quality papers published within the last 10 years were included in the review.

RESULTS

After screening the 2184 initially identified registers, a total of 24 articles were included for review.

CONCLUSION

Minimally invasive spine surgery is specially convenient for fragile cancer patients with spinal metastases, because of its reduced comorbidity compared to conventional open surgery. Technological advances in surgery, such as navigation and robotics, improve accuracy and safety in this technique.

The role of minimally invasive spine surgery in the treatment of vertebral metastasis: A narrative review

BACKGROUND

Spinal metastases are a very common problem which dramatically affects the quality of life of cancer patients. The objective of this review is to address the issue of how minimally invasive surgery can play an important role in treating this pathology.

METHODS

A literature review was performed, searching in the Google Scholar, PubMed, Scopus and Cochrane databases. Relevant and quality papers published within the last 10 years were included in the review.

RESULTS

After screening the 2184 initially identified registers, a total of 24 articles were included for review.

CONCLUSION

Minimally invasive spine surgery is specially convenient for fragile cancer patients with spinal metastases, because of its reduced comorbidity compared to conventional open surgery. Technological advances in surgery, such as navigation and robotics, improve accuracy and safety in this technique.

The role of minimally invasive spine surgery in the treatment of vertebral metastasis (part 1): A clinical review

Spinal metastases represent a significant burden on the quality of life in patients affected by active oncological disease due to the high incidence of pain syndromes, spinal deformity, and neurological impairment. Surgery plays a decisive role in improving quality of life by controlling pain, restoring neurological function and maintaining spinal stability, as well as contributing to the response to medical therapy. Minimally invasive surgery (MIS) is a treatment option in certain patients with high surgical risk since it has a low rate of complications, intraoperative bleeding, hospital stay, and offers similar results to open surgery. In this review, we present the role of MIS in this pathology and some cases treated in our hospital.

Anterolateral versus posterior minimally invasive lumbar interbody fusion surgery for spondylolisthesis: comparison of outcomes from a global, multicenter study at 12-months follow-up

BACKGROUND CONTEXT

Several minimally invasive lumbar interbody fusion techniques may be used as a treatment for spondylolisthesis to alleviate back and leg pain, improve function and provide stability to the spine. Surgeons may choose an anterolateral or posterior approach for the surgery however, there remains a lack of real-world evidence from comparative, prospective studies on effectiveness and safety with relatively large, geographically diverse samples and involving multiple surgical approaches.

PURPOSE

To test the hypothesis that anterolateral and posterior minimally invasive approaches are equally effective in treating patients with spondylolisthesis affecting one or two segments at 3-months follow-up and to report and compare patient reported outcomes and safety profiles between patients at 12-months post-surgery.

DESIGN

Prospective, multicenter, international, observational cohort study.

PATIENT SAMPLE

Patients with degenerative or isthmic spondylolisthesis who underwent 1- or 2-level minimally invasive lumbar interbody fusion.

OUTCOME MEASURES

Patient reported outcomes assessing disability (ODI), back pain (VAS), leg pain (VAS) and quality of life (EuroQol 5D-3L) at 4-weeks, 3-months and 12-months follow-up; adverse events up to 12-months; and fusion status at 12-months post-surgery using X-ray and/or CT-scan. The primary study outcome is improvement in ODI score at 3-months.

METHODS

Eligible patients from 26 sites across Europe, Latin America and Asia were consecutively enrolled. Surgeons with experience in minimally invasive lumbar interbody fusion procedures used, according to clinical judgement, either an anterolateral (ie, ALIF, DLIF, OLIF) or posterior (MIDLF, PLIF, TLIF) approach. Mean improvement in disability (ODI) was compared between groups using ANCOVA with baseline ODI score used as a covariate. Paired t-tests were used to examine change from baseline in PRO for both surgical approaches at each timepoint after surgery. A secondary ANCOVA using a propensity score as a covariate was used to test the robustness of conclusions drawn from the between group comparison.

RESULTS

Participants receiving an anterolateral approach (n=114) compared to those receiving a posterior approach (n=112) were younger (56.9 vs 62.0 years, p <.001), more likely to be employed (49.1% vs 25.0%, p<.001), have isthmic spondylolisthesis (38.6% vs 16.1%, p<.001) and less likely to only have central or lateral recess stenosis (44.9% vs 68.4%, p=.004). There were no statistically significant differences between the groups for gender, BMI, tobacco use, duration of conservative care, grade of spondylolisthesis, or the presence of stenosis. At 3-months follow-up there was no difference in the amount of improvement in ODI between the anterolateral and posterior groups (23.2 ± 21.3 vs 25.8 ± 19.5, p=.521). There were no clinically meaningful differences between the groups on mean improvement for back- and leg-pain, disability, or quality of life until the 12-months follow-up. Fusion rates of those assessed (n=158; 70% of the sample), were equivalent between groups (anterolateral, 72/88 [81.8%] fused vs posterior, 61/70 [87.1%] fused; p=.390).

CONCLUSIONS

Patients with degenerative lumbar disease and spondylolisthesis who underwent minimally invasive lumbar interbody fusion presented statistically significant and clinically meaningful improvements from baseline up to 12-months follow-up. There were no clinically relevant differences between patients operated on using an anterolateral or posterior approach.

Erector spinae plane block for perioperative pain management in neurosurgical lower-thoracic and lumbar spinal fusion: a single-centre prospective randomised controlled trial

BACKGROUND

Erector spinae plane block is a locoregional anaesthetic technique widely used in several different surgeries due to its safety and efficacy. The aim of this study is to assess its utility in spinal degenerative and traumatic surgery in western countries and for patients of Caucasian ethnicity.

METHODS

Patients undergoing elective lower-thoracic and lumbar spinal fusion were randomised into two groups: the case group (n = 15) who received erector spinae plane block (ropivacaine 0.4% + dexamethasone 4 mg, 20 mL per side at the level of surgery) plus postoperative opioid analgesia, and the control group (n = 15) who received opioid-based analgesia.

RESULTS

The erector spinae plane block group showed significantly lower morphine consumption at 48 h postoperatively, lower need for intraoperative fentanyl (203.3 ± 121.7 micrograms vs. 322.0 ± 148.2 micrograms, p-value = 0.021), lower NRS score at 2, 6, 12, 24, and 36 h, and higher satisfaction rates of patients (8.4 ± 1.2 vs. 6.0 ± 1.05, p-value < 0.0001). No differences in the duration of the hospitalisation were observed. No erector spinae plane block-related complications were observed.

CONCLUSIONS

Erector spinae plane block is a safe and efficient opioid-sparing technique for postoperative pain control after spinal fusion surgery. This study recommends its implementation in everyday practice and incorporation as a part of multimodal analgesia protocols.

TRIAL REGISTRATION

The study was approved by the local ethical committee of Romagna (CEROM) and registered on ClinicalTrials.gov (NCT04729049). It also adheres to the principles outlined in the Declaration of Helsinki and the CONSORT 2010 guidelines.

Population-Level Impact of Omitting Axillary Lymph Node Dissection in Early Breast Cancer Women: Evidence from an Economic Evaluation in Germany

BACKGROUND

The American College of Surgeons Oncology Group Z0011 trial showed that complete axillary lymph node dissection (cALND) did not improve survival benefits in patients with one or two tumour-involved sentinel lymph nodes and undergoing breast conservation. Still, a considerable number of the Z0011-eligible patients continue to be treated with cALND in various countries. Given the potential economic gain from implementation of the Z0011 recommendations, we quantified population-level impacts of omitting cALND among Z0011-eligible patients in clinical practice.

METHODS

This 2-year economic analysis adopted both the perspective of patients under statutory insurance and the societal perspective, using data collected prospectively from 179 German breast cancer units between 2008 and 2015. The estimation of cost savings and health gain relied on a single decision tree, which considered three scenarios: clinical practice at the baseline; actual implementation in routine care; and hypothetical full implementation in all eligible patients.

RESULTS

Data for 188,909 patients with primary breast cancer were available, 13,741 (7.3%) of whom met the Z0011 inclusion criteria. The use of cALND decreased from 94.3% in 2010 to 46.9% in 2015, resulting in a gain of 335 quality-adjusted life-years and a saving of EUR50,334,756 for the society. Had cALND been omitted in all eligible patients, the total gain would have been more than double.

CONCLUSIONS

The implementation of the Z0011 recommendations resulted in substantial savings and health gain in Germany. Our findings suggest that it is beneficial to introduce additional policy measures to promote further uptake of the Z0011 recommendations in clinical practice.

Recovery Kinetics After Commonly Performed Minimally Invasive Spine Surgery Procedures

STUDY DESIGN

Single-center, multisurgeon, retrospective review.

OBJECTIVE

To evaluate the timing of return to commonly performed activities following minimally invasive spine surgery. Identify preoperative factors associated with these outcomes.

SUMMARY OF BACKGROUND DATA

Studies have reported return to activities with open techniques, but the precise timing of when patients return to these activities after minimally invasive surgery remains uncertain.

MATERIALS AND METHODS

Patients who underwent either minimally invasive lumbar laminectomy (MI-L) or minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) were included. Patient-reported outcome measures, return to drive, return to work, and discontinuation of opioids data were reviewed. Regression was conducted to identify factors associated with return to driving by 15 days, return to work by 30 days, and for discontinuing opioids by 15 days. A composite group analysis was also performed for patients who returned to all three activities by 30 days.

RESULTS

In total, 123 MI-L patients and 107 MI-TLIF patients were included. Overall, 88.8% of MI-L patients and 96.4% of MI-TLIF patients returned to driving in 11 and 18.5 days, respectively. In all, 91.9% of MI-L patients and 85.7% of MI-TLIF patients returned to work in 14 and 25 days. In all, 88.7% of MI-L patients and 92.6% of MI-TLIF patients discontinued opioids in a median of seven and 11 days. Overall, 96.2% of MI-L patients and 100% of MI-TLIF patients returned to all three activities, with a median of 27 and 31 days, respectively. Male sex [odds ratio (OR)=3.57] and preoperative 12-Item Short Form Physical Component Score (OR=1.08) are associated with return to driving by 15 days. Male sex (OR=3.23) and preoperative 12-Item Short Form Physical Component Score (OR=1.07) are associated with return to work by 30 days. Preoperative Visual Analog Scale back was associated with decreased odds of discontinuing opioids by 15 days (OR=0.84).

CONCLUSION

Most patients return to activity following MI-L and MI-TLIF. These findings serve as an important compass for preoperative counseling.

Minimally invasive versus open surgery for degenerative lumbar pathologies:a systematic review and meta-analysis

Introduction

With the increase in life expectancy and consequent aging of the population, degenerative lumbar spine diseases tend to increase its number exponentially. Several treatment options are available to treat degenerative spinal diseases, such as laminectomies, posterior fusions, and interbody fusions, depending on their locations, correction necessities, and surgeon philosophy. With the advance in technology and surgical knowledge, minimally invasive techniques (MIS) arose as a solution to reduce surgical morbidity, while maintaining the same benefits as the traditionally/open surgeries. Several studies investigated the possible advantages of MIS techniques against the traditional open procedures. However, those articles are usually focused only on one technique or on one pathology.

Methods

The electronic databases, including PubMed, Google Scholar, Ovid, and BVS, were systematically reviewed. Only original articles in English or Portuguese were added to the review, the revision was performed following the PRISMA guideline.

Results

Fifty-three studies were included in the meta-analysis. Of the studied outcomes the Length of Stay Odds of complications, Blood Loss, and Surgery costs presented significantly favored MIS approaches, while the Last FUP ODI score, and Surgery Time did not differ among the groups.

Conclusion

Minimally invasive techniques are a remarkably interesting option to traditional open surgeries, as these procedures showed a significant reduction in blood loss, hospitalization time, complications, and surgical costs.

Postoperative Spinal Implant Infections (PSII)-A Systematic Review: What Do We Know So Far and What is Critical About It?

STUDY DESIGN

Systematic review.

OBJECTIVES

Postoperative spinal implant infections (PSII) are an increasing challenge in the daily clinical routine. This review summarizes existing knowledge in the field of PSII, including definitions, epidemiology, classifications, risk factors, pathogenesis, symptoms, diagnosis, and treatment.

METHODS

A systematic review was performed using a structured PubMed analysis, based on the PRISMA criteria. The search terminology was set as: "spinal implant associated infection OR spinal implant infection OR spinal instrumentation infection OR peri spinal implant infection." PubMed search was limited to the categories randomized controlled trials (RCT), clinical trials, meta-analysis and (systematic) reviews, whereas case reports were excluded. Studies from January 2000 to December 2020 were considered eligible. A total of 572 studies were identified, 82 references included for qualitative synthesis, and 19 for detailed sub analysis (12 meta-analysis, 7 prospective RCT).

RESULTS

Structural problems in the field of PSII were revealed, including (1) limited level of evidence in clinical studies (missing prospective RCT, metanalyzes), (2) small patient numbers, (3) missing standardized definitions, (4) heterogeneity in patient groups, and (5) redundancy in cited literature.

CONCLUSION

Evidence-based knowledge about spinal implant-associated infections is lacking. All involved medical fields should come together to define the term PSII and to combine their approaches toward research, training, and patient care.

Budget impact analysis of HARMONIC FOCUS™+ Shears for mastectomy and breast-conserving surgery with axillary lymph node dissection compared with monopolar electrocautery from an Italian hospital perspective

Background

Mastectomy or breast conserving surgery, both with axillary lymph node dissection, are common treatments for early-stage breast cancer. Monopolar electrocautery is typically used for both procedures, despite evidence of improved clinical outcomes with HARMONIC FOCUS™+. This analysis evaluated the budget impact of adopting HARMONIC FOCUS™+ versus monopolar electrocautery for patients undergoing these procedures from an Italian hospital perspective.

Methods

Total costs for an annual caseload of 100 patients undergoing mastectomy or breast conserving surgery, with axillary lymph node dissection, with either the intervention or comparator were calculated. Italian clinical and cost input data were utilised. The analysis included costs for the device, operating room time, postoperative length of stay, treating seroma and managing postoperative chest wall drainage. Deterministic and probabilistic sensitivity analyses assessed uncertainty of model input values. Two scenario analyses investigated the impact of conservative estimates of postoperative length of stay reduction and daily hospital cost on the simulated cost difference.

Results

HARMONIC FOCUS™+ achieves annual savings of EUR 100,043 compared with monopolar electrocautery, derived from lower costs for operating room time, postoperative length of stay and seroma and postoperative chest wall drainage management, offsetting the incremental device cost increase (EUR 43,268). Cost savings are maintained in scenario analyses and across all variations in parameters in deterministic sensitivity analysis, with postoperative hospital stay costs being key drivers of budget impact. The mean (interquartile range) cost savings with HARMONIC FOCUS™+ versus monopolar electrocautery in probabilistic sensitivity analysis are EUR 101,637 (EUR 64,390–137,093) with a 98% probability of being cost saving.

Conclusions

The intervention demonstrates robust cost savings compared with monopolar electrocautery for mastectomy or breast conserving surgery, with axillary lymph node dissection, in an Italian hospital setting, and improved clinical and resource outcomes. These findings, with other clinical and cost analyses, support HARMONIC FOCUS™+ use in this setting.

Minimally Invasive Surgery for Spinal Metastasis: A Review

OBJECTIVE

Minimally invasive surgery (MIS) techniques have advanced the treatment of metastatic diseases to the spine. The objective of this review is to describe clinical outcomes, benefits, and complications of these techniques.

METHODS

All relevant clinical studies describing the role of MIS, computer-assisted navigation (CAN), robot-assisted (RA) procedures, and laser interstitial thermal therapy (LITT) in the treatment of metastatic spine diseases were identified from PubMed, MEDLINE, and relevant article bibliographies.

RESULTS

For MIS articles, we filtered 1480 results and identified 26 studies. For CAN, we searched 464 articles to identify 18 articles for review. For RA, we searched 321 results to identify 7 studies for review. For LITT, we identified 21 articles for review.

CONCLUSIONS

MIS for the treatment of spine metastasis has significant potential benefits in reducing surgical site infections, hospital stay, and blood loss without compromising instrument accuracy or overall outcomes. Overall, MIS and its adjuncts have the potential to reduce the risks involved in the treatment of patients with metastatic disease to the spinal column without compromising the benefits of decompression and stabilization of the spine.

Minimally Invasive versus Open Surgery for Spinal Metastasis: A Systematic Review and Meta-Analysis

Bones are the third most common location for solid tumor metastasis affecting up to 10% of patients with solid tumors. When the spine is involved, thoracic and lumbar vertebrae are frequently affected. Access to spinal lesions can be through minimally invasive surgery (MIS) or traditional open surgery (OS). This study aims to determine which method provides an advantage. Following the PRISMA (Preferred Inventory for Systematic Reviews and Meta-Analysis) guidelines, a systematic review was conducted to identify studies that compare MIS with OS in patients with spinal metastatic disease. Data were analyzed using Review Manager ver. 5.3 (RevMan; Cochrane, London, UK). Ten studies were included. Operative time was similar among groups at −35.23 minutes (95% confidence interval [CI], −73.36 to 2.91 minutes; p=0.07). Intraoperative bleeding was lower in MIS at −562.59 mL (95% CI, −776.97 to −348.20 mL; p<0.00001). OS procedures had higher odds of requiring blood transfusions at 0.26 (95% CI, 0.15 to 0.45; p<0.00001). Both approaches instrumented similar numbers of levels at −0.05 levels (95% CI, −0.75 to 0.66 levels; p=0.89). We observed a decreased need for postoperative bed rest at −1.60 days (95% CI, −2.46 to −0.74 days; p=0.0003), a shorter length of stay at −3.08 days (95% CI, −4.50 to −1.66 days; p=0.001), and decreased odds of complications at 0.60 (95% CI, 0.37 to 0.96; p=0.03) in the MIS group. Both approaches revealed similar reintervention rates at 0.65 (95% CI, 0.15 to 2.84; p=0.57), effective rates of reducing metastasis-related pain at −0.74 (95% CI, −2.41 to 0.94; p=0.39), and comparable scores of the Tokuhashi scale at −0.52 (95% CI, −2.08 to 1.05; p=0.41), Frankel scale at 1.00 (95% CI, 0.60 to 1.68; p=1.0), and American Spinal Injury Association Scale at 0.53 (95% CI, 0.21 to 1.37; p=0.19). MIS appears to provide advantages over OS. Larger and prospective studies should fully detail the role of MIS as a treatment for spine metastasis.

A Prospective Randomized Study of the Safety and Efficacy of Transforaminal Lumbar Interbody Fusion Versus Posterior Lumbar Interbody Fusion in the Treatment of Lumbar Spondylolisthesis: A Cost utility from a Lower-middle-income Country Perspective and Review of Literature

BACKGROUND: The safety and efficacy of transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) in lumbar spondylolisthesis have not been validated in many prospective randomized trials. AIM: We aimed to validate the safety and efficacy of TLIF and PLIF surgery in lumbar spondylolisthesis using the clinical, radiographic, and cost-utility outcomes. METHODS: The data of surgically treated single-level spondylolisthesis patients were randomized prospectively into two groups. The groups were compared regarding demographics, perioperative complications, hospital stay, total expenditure, fusion rate, and clinical outcomes (visual analog scale, Oswestry disability index, Zurich claudication scale, and Odom’s criteria). A review of literature was done to compare the outcomes with the ones from higher-income nations. RESULTS: Thirty-three patients underwent prospective randomization. The improvement in the clinical outcomes at 12-month follow-up showed improvement in the TLIF group more than the PLIF group but with no significant difference. The mean operative time was significantly longer in the PLIF (p < 0.05), also, the blood loss was significantly less in the TLIF (p < 0.001). The complications frequency did not show any statistical significance between both groups and no significant difference in the patient’s post-operative patient satisfaction (p = 0.6). The mean hospital stay was non-significantly longer in the PLIF (p = 0.7). At 12-month follow-up, 93.3% of the TLIF patients were fused versus 86.7% of the PLIF (p = 0.5). The total cost of the TLIF was significantly less (p < 0.001). CONCLUSION: Both PLIF and TLIF could achieve similar fusion rates and clinical satisfaction in the management of lumbar spondylolisthesis. The TLIF group was significantly better in terms of financial burden, operative time, and blood loss.

Microdiscectomy compared with transforaminal epidural steroid injection for persistent radicular pain caused by prolapsed intervertebral disc: the NERVES RCT

BACKGROUND

Sciatica is a common condition reported to affect > 3% of the UK population at any time and is most often caused by a prolapsed intervertebral disc. Currently, there is no uniformly adopted treatment strategy. Invasive treatments, such as surgery (i.e. microdiscectomy) and transforaminal epidural steroid injection, are often reserved for failed conservative treatment.

OBJECTIVE

To compare the clinical effectiveness and cost-effectiveness of microdiscectomy with transforaminal epidural steroid injection for the management of radicular pain secondary to lumbar prolapsed intervertebral disc for non-emergency presentation of sciatica of < 12 months' duration.

INTERVENTIONS

Patients were randomised to either (1) microdiscectomy or (2) transforaminal epidural steroid injection.

DESIGN

A pragmatic, multicentre, randomised prospective trial comparing microdiscectomy with transforaminal epidural steroid injection for sciatica due to prolapsed intervertebral disc with < 1 year symptom duration.

SETTING

NHS services providing secondary spinal surgical care within the UK.

PARTICIPANTS

A total of 163 participants (aged 16-65 years) were recruited from 11 UK NHS outpatient clinics.

MAIN OUTCOME MEASURES

The primary outcome was participant-completed Oswestry Disability Questionnaire score at 18 weeks post randomisation. Secondary outcomes were visual analogue scores for leg pain and back pain; modified Roland-Morris score (for sciatica), Core Outcome Measures Index score and participant satisfaction at 12-weekly intervals. Cost-effectiveness and quality of life were assessed using the EuroQol-5 Dimensions, five-level version; Hospital Episode Statistics data; medication usage; and self-reported cost data at 12-weekly intervals. Adverse event data were collected. The economic outcome was incremental cost per quality-adjusted life-year gained from the perspective of the NHS in England.

RESULTS

Eighty-three participants were allocated to transforaminal epidural steroid injection and 80 participants were allocated to microdiscectomy, using an online randomisation system. At week 18, Oswestry Disability Questionnaire scores had decreased, relative to baseline, by 26.7 points in the microdiscectomy group and by 24.5 points in the transforaminal epidural steroid injection. The difference between the treatments was not statistically significant (estimated treatment effect -4.25 points, 95% confidence interval -11.09 to 2.59 points). Nor were there significant differences between treatments in any of the secondary outcomes: Oswestry Disability Questionnaire scores, visual analogue scores for leg pain and back pain, modified Roland-Morris score and Core Outcome Measures Index score up to 54 weeks. There were four (3.8%) serious adverse events in the microdiscectomy group, including one nerve palsy (foot drop), and none in the transforaminal epidural steroid injection group. Compared with transforaminal epidural steroid injection, microdiscectomy had an incremental cost-effectiveness ratio of £38,737 per quality-adjusted life-year gained and a probability of 0.17 of being cost-effective at a willingness to pay threshold of £20,000 per quality-adjusted life-year.

LIMITATIONS

Primary outcome data was invalid or incomplete for 24% of participants. Sensitivity analyses demonstrated robustness to assumptions made regarding missing data. Eighteen per cent of participants in the transforaminal epidural steroid injection group subsequently received microdiscectomy prior to their primary outcome assessment.

CONCLUSIONS

To the best of our knowledge, the NErve Root Block VErsus Surgery trial is the first trial to evaluate the comparative clinical effectiveness and cost-effectiveness of microdiscectomy and transforaminal epidural steroid injection. No statistically significant difference was found between the two treatments for the primary outcome. It is unlikely that microdiscectomy is cost-effective compared with transforaminal epidural steroid injection at a threshold of £20,000 per quality-adjusted life-year for sciatica secondary to prolapsed intervertebral disc.

FUTURE WORK

These results will lead to further studies in the streamlining and earlier management of discogenic sciatica.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN04820368 and EudraCT 2014-002751-25.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 24. See the NIHR Journals Library website for further project information.

Transvaginal minimally invasive approach: An update on safety from an anatomical, anatomopathological and clinical point of view

INTRODUCTION

The aim of this work was to analyze the transvaginal approach in minimally invasive surgery in terms of anatomical, histopathological and functional characteristics, to show the safety of this surgical approach.

METHODS

Anatomical study was first conducted by dissection on fresh cadavers of adult women in order to measure the distance between the vaginal incision and the ureters, rectum and hypogastric nerves. In parallel, an anatomopathological study detailed and compared the macroscopic and histological characteristics of the anterior and posterior surfaces of vaginal samples obtained from cadavers and patients in the context of a hysterectomy for benign pathology. Finally, patients who underwent a transvaginal approach nephrectomy or transplantation were retrospectively enrolled for a clinical examination and an evaluation of their sexuality.

RESULTS

The anatomical study conducted on seventeen cadavers showed that the posterior vaginal fornix was remote from the major structures of the pelvis such as rectum, ureters, hypogastric plexus, which allowed a safe incision. Mechanical tests further demonstrated that the posterior vaginal fornix was more extensible than the anterior and histological features showed no major vascular or nervous structures. Ten patients were included in the retrospective clinical study. Long-term follow up showed no negative impact on the texture of the vagina or satisfaction from sexual intercourse.

CONCLUSIONS

Anatomical, histological and functional data supported that transvaginal approach by posterior vagina fornix incision is a minimally invasive surgery that can be performed safely and effectively by a skilled surgeon in cases with a specific surgical indication for this approach.

Complications associated with L4-5 anterior retroperitoneal trans-psoas interbody fusion: a single institution series

Background

Lateral lumbar interbody fusion (LLIF), first described in the literature in 2006 by Ozgur et al., involves direct access to the lateral disc space via a retroperitoneal trans-psoas tubular approach. Neuromonitoring is vital during this approach since the surgical corridor traverses the psoas muscle where the lumbar plexus lies, risking injury to the lumbosacral plexus that could result in sensory or motor deficits. The risk of neurologic injury is especially higher at L4-5 due to the anatomy of the plexus at this level. Here we report our single-center clinical experience with L4-5 LLIF.

Methods

A retrospective chart review of all patients who underwent an L4-5 LLIF between May 2016 and March 2019 was performed. Baseline demographics and clinical characteristics, such as body mass index (BMI), medical comorbidities, surgical history, tobacco status, operative time and blood loss, length of stay (LOS), and post-op complications were recorded.

Results

A total of 220 (58% female and 42% male) cases were reviewed. The most common presenting pathology was spondylolisthesis. The average age, BMI, operative time, blood loss, and LOS were 64.6 years, 29 kg/m², 214 min, 75 cc, and 2.5 days respectively. A review of post-operative neurologic deficits revealed 31.4% transient hip flexor weakness and 4.5% quadricep weakness on the approach side. At 3-week follow-up, 9.1% of patients experienced mild hip flexor weakness (4 or 4+/5), 0.9% reported mild quadricep weakness, and 9.5% reported anterior thigh dysesthesias; 93.2% of patients were discharged home and 2.3% were readmitted within the first 30 days post discharge. Female sex, higher BMI and longer operative time were associated with hip flexor weakness.

Conclusions

LLIF at L4-5 is a safe, feasible, and versatile approach to the lumbar spine with an acceptable approach-related sensory and motor neurologic complication rates.

Cost-effectiveness Applications of Patient-reported Outcome Measures (PROMs) in Spine Surgery

Because of the rising health care costs in the United States, there has been a focus on value-based care and improving the cost-effectiveness of surgical procedures. Patient-reported outcome measures (PROMs) can not only give physicians and health care providers immediate feedback on the well-being of the patients but also be used to assess health and determine outcomes for surgical research purposes. Recently, PROMs have become a prominent tool to assess the cost-effectiveness of spine surgery by calculating the improvement in quality-adjusted life years (QALY). The cost of a procedure per QALY gained is an essential metric to determine cost-effectiveness in universal health care systems. Common patient-reported outcome questionnaires to calculate QALY include the EuroQol-5 dimensions, the SF-36, and the SF-12. On the basis of the health-related quality of life outcomes, the cost-effectiveness of various spine surgeries can be determined, such as cervical fusions, lumbar fusions, microdiscectomies. As the United States attempts to reduce costs and emphasize value-based care, PROMs may serve a critical role in spine surgery moving forward. In addition, PROM-driven QALYs may be used to analyze novel spine surgical techniques for value-based improvements.

Index episode-of-care propensity-matched comparison of transforaminal lumbar interbody fusion (TLIF) techniques: open traditional TLIF versus midline lumbar interbody fusion (MIDLIF) versus robot-assisted MIDLIF

OBJECTIVE

Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In an attempt to expedite recovery by limiting muscle dissection, midline lumbar interbody fusion (MIDLIF) has been described. More recently, the authors have developed a robot-assisted MIDLIF (RA-MIDLIF) technique. The purpose of this study was to compare the index episode-of-care (iEOC) parameters between patients undergoing traditional open transforaminal lumbar interbody fusion (tTLIF), MIDLIF, and RA-MIDLIF.

METHODS

A retrospective review of a prospective, multisurgeon surgical database was performed. Consecutive patients undergoing 1- or 2-level tTLIF, MIDLIF, or RA-MIDLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity matched based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists (ASA) class, and number of levels fused. Index EOC parameters such as length of stay (LOS), estimated blood loss (EBL), operating room (OR) time, and actual, direct hospital costs for the index surgical visit were analyzed.

RESULTS

Of 281 and 249 patients undergoing tTLIF and MIDLIF, respectively, 52 cases in each cohort were successfully propensity matched to the authors' first 55 RA-MIDLIF cases. Consistent with propensity matching, there was no significant difference in age, sex, BMI, diagnosis, ASA class, or levels fused. Spondylolisthesis was the most common indication for surgery in all cohorts. The mean total iEOC was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) than those undergoing either MIDLIF (2.71 days) or tTLIF (3.58 days). Both MIDLIF and RA-MIDLIF were associated with lower EBL and less OR time compared with tTLIF.

CONCLUSIONS

Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of the authors' first 52 RA-MIDLIF surgeries with tTLIF and MIDLIF showed promising results for reducing OR time, EBL, and LOS without increasing cost.

Minimally Invasive Surgery for Clinical Crown Lengthening Using Piezoelectric Ultrasound

This case report is aimed at describing a flapless, minimally invasive clinical crown lengthening with an osteotomy performed using a piezoelectric ultrasound. A female patient complained about the amount of gum that was exposed when she smiled, which caused aesthetic discomfort. After a clinical examination, it was confirmed that the patient had excessive gum exposure in the upper arch of the dental region for teeth 14 to 24 when she smiled. The tomographic exam showed that bone tissue was at the level of the enamel-cementum junction, and gingival tissue covered a part of the anatomic crown. Virtual analysis using digital smile design (DSD) demonstrated that enlarging the clinical crowns would provide better aesthetics. The excess gingival tissue was removed from the gingival margin region with the aid of a mockup without interference to the interdental papillae. Then, osteotomy was performed using piezoelectric ultrasound until there was a 2.5 mm distance from the top of the bone crest to the new gingival margin. In the postoperative period, good repositioning of the gingival margin, absence of postoperative complications, and rapid healing of the gingival tissue were verified. After 6 months, a good aesthetic outcome was observed with stability in the level of the periodontal tissues obtained via the crown-lengthening technique. It can be concluded that the minimally invasive clinical crown-lengthening technique was effective in repositioning the gingival margin with no postoperative complications.

Cost-effectiveness of minimally invasive midline lumbar interbody fusion versus traditional open transforaminal lumbar interbody fusion

OBJECTIVE

The midline transforaminal lumbar interbody fusion (MIDLIF) using cortical screw fixation is a novel, minimally invasive procedure that may offer enhanced recovery over traditional open transforaminal lumbar interbody fusion (TLIF). Little information is available regarding the comparative cost-effectiveness of the MIDLIF over conventional TLIF. The purpose of this study was to compare cost-effectiveness of minimally invasive MIDLIF with open TLIF.

METHODS

From a prospective, multisurgeon, surgical database, a consecutive series of patients undergoing 1- or 2-level MIDLIF for degenerative lumbar conditions was identified and propensity matched to patients undergoing TLIF based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists Physical Status Classification System (ASA) class, and levels fused. Direct costs at 1 year were collected, including costs associated with the index surgical visit as well as costs associated with readmission. Improvement in health-related quality of life was measured using EQ-5D and SF-6D.

RESULTS

Of 214 and 181 patients undergoing MIDLIF and TLIF, respectively, 33 cases in each cohort were successfully propensity matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA class, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. Variable direct costs at 1 year were $2493 lower in the MIDLIF group than in the open TLIF group (mean $15,867 vs $17,612, p = 0.073). There was no difference in implant (p = 0.193) or biologics (p = 0.145) cost, but blood utilization (p = 0.015), operating room supplies (p < 0.001), hospital room and board (p < 0.001), pharmacy (p = 0.010), laboratory (p = 0.004), and physical therapy (p = 0.009) costs were all significantly lower in the MIDLIF group. Additionally, the mean length of stay was decreased for MIDLIF as well (3.21 vs 4.02 days, p = 0.05). The EQ-5D gain at 1 year was 0.156 for MIDLIF and 0.141 for open TLIF (p = 0.821). The SF-6D gain at 1 year was 0.071 for MIDLIF and 0.057 for open TLIF (p = 0.551).

CONCLUSIONS

Compared with patients undergoing traditional open TLIF, those undergoing MIDLIF have similar 1-year gains in health-related quality of life, with total direct costs that are $2493 lower. Although the findings were not statistically significant, minimally invasive MIDLIF showed improved cost-effectiveness at 1 year compared with open TLIF.

Operating Costs of Full-endoscopic Lumbar Spine Surgery in Japan

For full-endoscopic lumbar discectomy, operating costs are also important because expensive equipment are necessary. We surveyed the operating costs of surgical equipment necessary for full-endoscopic surgery together with surgical procedure reimbursement fees. A total of 295 cases of full-endoscopic surgery via a transforaminal approach were retrospectively analyzed. We calculated the frequency of damage and the unit purchase price of devices such as endoscopes, and surgical instruments such as grasping forceps for nucleotomy, high-speed drill bar, and bipolar forceps, and examined the operating costs in Japanese yen against the procedure fee per case. Endoscope breakage occurred seven times, and a payment of ¥760,000 was necessary for trade-in and purchase of a new endoscope. The total breakage number of grasping forceps was 58, and the purchase price per unit was ¥116,000. Therefore, a total of ¥12,020,000 was required for the 295 cases, and the calculated operating cost that accompanies equipment breakage was ¥40,000 per case. In addition, about ¥118,000 was required for disposable bipolar forceps and high-speed drill bar to be used intraoperatively for each case. Thus, for one case it is calculated that total ¥158,000 is utilized for equipment from the surgical reimbursement fee per case specified by the Japanese Ministry of Health being ¥303,900. Minimally invasive procedures provide great benefit to patients; however, the eventual contribution to hospital profits is small and may not be sufficient. To resolve this issue, the cost of surgical equipment should be lowered and/or the surgical reimbursement fee of the full-endoscopic surgery should be raised.

Systematic Review of Decision Analytic Modelling in Economic Evaluations of Low Back Pain and Sciatica

BACKGROUND

Low back pain (LBP) and sciatica place significant burden on individuals and healthcare systems, with societal costs alone likely to be in excess of £15 billion. Two recent systematic reviews for LBP and sciatica identified a shortage of modelling studies in both conditions.

OBJECTIVES

The aim of this systematic review was to document existing model-based economic evaluations for the treatment and management of both conditions; critically appraise current modelling techniques, analytical methods, data inputs, and structure, using narrative synthesis; and identify unresolved methodological problems and gaps in the literature.

METHODS

A systematic literature review was conducted whereby 6512 records were extracted from 11 databases, with no date limits imposed. Studies were abstracted according to a predesigned protocol, whereby they must be economic evaluations that employed an economic decision model and considered any management approach for LBP and sciatica. Study abstraction was initially performed by one reviewer who removed duplicates and screened titles to remove irrelevant studies. Overall, 133 potential studies for inclusion were then screened independently by other reviewers. Consensus was reached between reviewers regarding final inclusion.

RESULTS

Twenty-one publications of 20 unique models were included in the review, five of which were modelling studies in LBP and 16 in sciatica. Results revealed a poor standard of modelling in both conditions, particularly regarding modelling techniques, analytical methods, and data quality. Specific issues relate to inappropriate representation of both conditions in terms of health states, insufficient time horizons, and use of inappropriate utility values.

CONCLUSION

High-quality modelling studies, which reflect modelling best practice, as well as contemporary clinical understandings of both conditions, are required to enhance the economic evidence for treatments for both conditions.

Determining the Operating Costs of a Medical Surveillance Program for Copper Miners Exposed to High Altitude-Induced Chronic Intermittent Hypoxia in Chile Using a Combination of Microcosting and Time-Driven Activity-Based Costing

BACKGROUND

Copper mining installations in Chile use a large number of workers who do their jobs at high altitudes, exposing them to the conditions of chronic intermittent hypobaric hypoxia. The Chilean Safety Association implements the surveillance program.

OBJECTIVE

This organization, under the sponsorship of the Chilean Superintendency of Social Security, was interested in determining the costs involved in this program to support its decision-making processes and to improve its performance.

METHODS

Direct operating costs of the Hypoxia Medical Surveillance Program were determined through on-site surveys applied to the organization's local agencies in charge. The microcosting method was used, quantifying personnel costs, consumables, and equipment and overhead costs. Time-driven activity-based costing was partially adapted for the allocation of personnel and equipment costs. Costs concerning activities, groups of activities and items, and average cost per exposed worker were determined.

RESULTS

The annual costs of the program were $127 299.58. The highest costs corresponded to the assessment activities, which were $89 192.13, representing 60.06% of the total. The labor factor costs were $77 568.50, which represents 60.93% of the total. The average cost per worker in the program is $21.17.

CONCLUSIONS

The partial adaptation of the time-driven activity-based costing method in combination with the microcosting method provides a suitable solution to determine the total costs of running a healthcare program of this kind. The information generated by this study will aid in the decision-making and management processes of the Hypoxia Medical Surveillance Program.

A 1-Year Cost Analysis of Spinal Surgical Procedures in Spain: Neurosurgeons Versus Orthopedic Surgeons

Objective

To evaluate the direct costs of various spinal surgical procedures within 1 year of follow-up and to compare the profiles of neurosurgeons and orthopedic surgeons.

Methods

All spinal procedures performed within a 10-month period in patients covered by a private insurance company were included. Costs related to the spinal interventions were systematically registered in the company database. Associated costs during the 1-year follow-up were recorded.

Results

In total, 1,862 patients were included, with a total cost of €11,050,970, of whom 34.8% underwent noninstrumented lumbar decompression (€3,473), 27.1% dorsolumbar instrumented fusion (€6,619), 14.6% nucleoplasty (€1,323), 13.5% cervical surgery (€4,463), 3.4% kyphoplasty (€4,200), 2.9% scoliosis (€15,414), 1.2% oncologic surgery (€5,590), 0.5% traumatic compression (€7,844), and 4.7% (€1,343) other minor interventions (mainly rhizotomies). Approximately 42% of patients required reinterventions within the first year, with a global extra cost of €7,280,073; 11% were referred to the pain clinic, with a €114,663 cost; 55.5% were men; and the most common age range of patients who received an intervention was 65–75 years. Neurosurgeons performed 60% of all interventions. Noninstrumented lumbar operations were performed by neurosurgeons twice as often as instrumented operations, and they performed 76% of cervical operations. Orthopedic surgeons performed 2.5 times more instrumented than noninstrumented lumbar operations, and almost all scoliosis and rhizotomy procedures.

Conclusion

The direct costs of spinal surgery in Spain were generally lower than those reported in other European Union countries and the United States. Neurosurgeons and orthopedic surgeons had different spine surgical profiles and costs.

Economic Value in Minimally Invasive Spine Surgery

PURPOSE OF REVIEW

The field of spine surgery remains a unique target in the transition to value-based care. While spine surgery has benefited from new medical technologies, including minimally invasive surgery (MIS), these technologies may be a key driver in rising US healthcare costs. As such, MIS needs to clear an economic value threshold through a rigorous evaluation of the outcomes they provide and costs they incur. In this article, we review recent MIS surgery literature from the perspective of economic value.

RECENT FINDINGS

Many studies report modest all-in cost savings and direct procedural cost equivalence for minimally invasive approaches relative to open surgeries. In terms of quality, studies found lower blood loss, length of stay, and infectious complications with MIS surgery but evidence on QALYs was mixed. In the past 5 years, there has been increasing research interest in defining economic value in MIS surgery. However, a significant amount of heterogeneity in research quality and methodology persists. Therefore, MIS surgery has the potential to be of high economic value, though this is not yet definitive. Future research should continue to focus on high-quality cost-effectiveness studies with clear methodologies to further elucidate economic value in MIS surgery.

Using minimally invasive techniques adds to the value equation for select patients

Conditions of the spine are one of the most prevalent causes of global disability, and result in a considerable portion of total health expenditures. Surgical treatment of the spine has been demonstrated in multiple studies to be a cost-effective treatment option for many patients, especially with continuing improvements in surgical technique and instrumentation. Minimally invasive spine surgery (MISS), in particular, has evolved as a valuable option in treating certain patients. Numerous studies have analyzed minimally invasive techniques in regards to cost-effectiveness and other purported advantages. These advantages include conduciveness to outpatient settings, better perioperative and immediate post-operative benefits, and faster time to recovery. This article will describe the current literature on the advantages of MISS, specifically in regards to value and cost savings.

A Cost-utility Analysis of Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Lumbar Disc Herniation: Transforaminal versus Interlaminar

STUDY DESIGN

A cost-utility analysis (CUA).

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) techniques for the treatment of L5-S1 lumbar disc herniation (LDH).

SUMMARY OF BACKGROUND DATA

The annual cost of treatment for lumbar disc herniation is staggering. As the two major approaches of percutaneous endoscopic lumbar discectomy (PELD): percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) have gained recognition for the treatment of L5-S1 lumbar disc herniation (LDH) and showed similar clinical outcome. ost-utility analysis (CUA) can help clinicians make appropriate decisions about optimal health care for L5-S1 LDH.

METHODS

Fifty and 25 patients were included in the PETD and PEID groups of the study. Patients' basic characteristics, health care costs, and clinical outcome of PETD and PEID group were collected and analyzed. Quality-adjusted life-years (QALYs) were calculated and validated by EuroQol five-dimensional (EQ-5D) questionnaire. Cost-effectiveness was determined by the incremental cost per QALY gained.

RESULTS

The mean total cost of the PETD group was $5275.58 ± 292.98 and the PEID group was $5494.45 ± 749.24. No significant differences were observed in hospitalization expenses, laboratory and radiographic evaluations expenses, surgical expenses, and drug costs. Surgical equipment and materials costs, and anesthesia expense in the PEID group were significantly higher than in the PETD group (P < 0.001). Clinical outcomes, including Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) scores, and Japanese Orthopaedic Association (JOA), also showed no significant differences between the two groups. The cost-effectiveness ratio of PETD and PEID were $6816.05 ± 717.90/QALY and $7073.30 ± 1081.44/QALY, respectively. The incremental cost-effectiveness ratios (ICERs) of PEID over PETD was $21887.00/QALY.

CONCLUSION

Observed costs per QALY gained for L5-S1 LDH with PETD or PEID were similar for patients, demonstrating that the two different approaches of PELD are equally cost-effective and valuable interventions.

LEVEL OF EVIDENCE

5.

Evidence Based Medicine Review of Posterior Thoracolumbar Minimally Invasive Technology

Background

Evaluate the current evidence in meta-analyses on posterior thoracolumbar minimally invasive surgery techniques and outcomes for degenerative conditions.

Methods

A systematic review of the literature from 1950 to 2015.

Results

The review of the literature yielded 34 meta-analysis studies evaluating posterior thoracolumbar minimally invasive techniques and outcomes for degenerative conditions. There were 11 studies included which investigated minimally invasive surgery (MIS) versus open posterior lumbar decompressions. There were 14 studies included which investigated MIS versus open posterior lumbar interbody fusions. Finally, there were 9 studies focused on navigation techniques and radiation safety within MIS procedures.

Conclusions

There are 34 meta-analysis studies evaluating minimally invasive to open thoracolumbar surgery for degenerative disease. The studies show a trend toward decreased estimated blood loss, decreased length of stay, decreased complications, similar fusion rates, improved accuracy, and decreased radiation when minimally invasive techniques are used.

Accuracy of percutaneous pedicle screws for thoracic and lumbar spine fractures compared with open technique

BACKGROUND

This study aimed to compare the accuracy of screw placement between open pedicle screw fixation and percutaneous pedicle screw fixation (MIS) for the treatment of thoracolumbar spine fractures (TSF).

METHODS

forty-nine patients with acute TSF who were treated with transpedicular screw fixation from January 2013 to December 2016 were retrospectively reviewed. The patients were divided into Open and MIS groups. Laminectomy was performed in either group if needed. The accuracy of the screw placement, the evolution of the Cobb sagittal angle postoperatively and at 12-month follow-up and the neurological status were recorded. AO type of fracture and TLICS score were also recorded.

RESULTS

Mean age was 42 years old. Mean TLICS score was 6.29 and 5.96 for open and MIS groups respectively. Twenty-five MIS and 24 open surgeries were performed, and 350 (175 in each group) screws were inserted (7.14 per patient). Twenty-four and 13 screws were considered "out" in the open and MIS groups respectively (Odds ratio 1.98. 0.97-4,03 P=0.056). The Cobb sagittal angle went from 13.3º to 4.5º and from 14.9º to 8.2º in the Open and MIS groups respectively (both P<0.0001). Loss of correction at 12-month follow-up was 3.2º and 4.2º for the open and MIS groups, respectively. No neurological worsening was observed.

CONCLUSIONS

For the treatment of acute thoracolumbar fractures, the MIS technique seems to achieve similar results to the open technique in relation to neurological improvement and deformity correction, while placing the screws more accurately.

Is MIS-TLIF superior to open TLIF in obese patients?: A systematic review and meta-analysis

PURPOSE

Obesity is a global health problem. It increases the risk of surgical complications and re-operations. While both MIS-TLIF and O-TLIF are reported to have comparably good long-term outcomes for non-obese patients, no consensus has been reached for obese patients.

METHODS

A comprehensive search of the published literature was performed: PubMed, Scopus, Web of Science and Cochrane Central Register of Controlled Trials database in accordance to the PRISMA 2009 checklist. Data were collected with attention to baseline demographics, intra-operative blood loss, duration of surgery, surgical complications, hospitalization stay, VAS and Oswestry disability index (ODI) pre- and postoperatively.

RESULTS

A total of 863 abstracts were identified from the databases, of which 4 articles were included in the meta-analysis. A total of 430 patients were identified, of which 217(50.5%) underwent the O-TLIF, while 213(49.5%) underwent MIS-TLIF. One hundred and ninety-four (45.1%) patients were males, while 236(54.9%) were females. The average age was 54.8 ± 12.0 years. The pooled BMI was 33.4 ± 4.7 for the open-TLIF group, and 32.7 ± 3.9 for MIS-TLIF group (p = 0.22). When comparing O-TLIF to MIS-TLIF: Patients who underwent O-TLIF had 383 mls more blood loss (95% CI: 329.5-437.4, p < 0.00001), 1.2-day longer hospitalization stay (95% CI: 0.80-1.62, p < 0.00001) and 3.8 times higher risk of dural tear (95% CI: 1.61-9.87, p = 0.003) when compared to MIS-TLIF patients. A trend toward higher postoperative wound infection rates (O-TLIF: 4.5%, MIS-TLIF: 2.4%) and an inferior improvement in ODI score (O-TLIF: 39.3, MIS-TLIF: 44.1) was found in O-TLIF patients when compared to MIS-TLIF patients. However, these were not statistically significant.

CONCLUSION

MIS-TLIF is safe and may be a better option for lumbar fusion in obese patients. These slides can be retrieved under Electronic Supplementary Material.

Assessment of cost drivers and cost variation for lumbar interbody fusion procedures using the Value Driven Outcomes database

OBJECTIVE

Efforts to examine the value of care—combining both costs and quality—are gaining importance in the current health care climate. This thrust is particularly evident in treating common spinal disease where both incidences and costs are generally high and practice patterns are variable. It is often challenging to obtain direct surgical costs for these analyses, which hinders the understanding of cost drivers and cost variation. Using a novel tool, the authors sought to understand the costs of posterior lumbar arthrodesis with interbody devices.

METHODS

The Value Driven Outcomes (VDO) database at the University of Utah was used to evaluate the care of patients who underwent open or minimally invasive surgery (MIS), 1- and 2-level lumbar spine fusion (Current Procedural Terminology code 22263). Patients treated from January 2012 through June 2017 were included.

RESULTS

A total of 276 patients (mean age 58.9 ± 12.4 years) were identified; 46.7% of patients were men. Most patients (82.2%) underwent 1-level fusion. Thirteen patients (4.7%) had major complications and 11 (4.1%) had minor complications. MIS (β = 0.16, p = 0.002), length of stay (β = 0.47, p = 0.0001), and number of operated levels (β = 0.37, p = 0.0001) predicted costs in a multivariable analysis. Supplies and implants (55%) and facility cost (36%) accounted for most of the expenditure. Other costs included pharmacy (7%), laboratory (1%), and imaging (1%).

CONCLUSIONS

These results provide direct cost accounting for lumbar fusion procedures using the VDO database. Efforts to improve the value of lumbar surgery should focus on high cost areas, i.e., facility and supplies/implant.

Minimally invasive spine surgery for degenerative spine disease and deformity correction: a literature review

During the last two decades, minimally invasive techniques and instruments in spine surgery have undergone serious development in all fields. Specific advantages of these minimally invasive methods have put them forward in spine surgery in recent times. Preservation of important anatomical structures of the spine is a major factor for the evolution of these procedures. The lower prevalence of complications and faster rehabilitation of patients are some of the advantages of minimally invasive spine surgery (MISS). Due to the increasing use of minimally invasive methods in the clinical practice worldwide, there is a strong need for clarification of basic principles, tips and tricks, complications, and clinical outcomes. This review is an effort to provide a better understanding of some of these procedures.

Robotic paravertebral schwannoma resection at extreme locations of the thoracic cavity

Solitary paravertebral schwannomas in the thoracic spine and lacking an intraspinal component are uncommon. These benign nerve sheath tumors are typically treated using complete resection with an excellent outcome. Resection of these tumors is achieved by an anterior approach via open thoracotomy or minimally invasive thoracoscopy, by a posterior approach via laminectomy, or by a combination of both approaches. These tumors most commonly occur in the midthoracic region, for which surgical removal is usually straightforward. The authors of this report describe 2 cases of paravertebral schwannoma at extreme locations of the posterior mediastinum, one at the superior sulcus and the other at the inferior sulcus of the thoracic cavity, for which the usual surgical approaches for safe resection can be challenging. The tumors were completely resected with robot-assisted thoracoscopic surgery. This report suggests that single-stage anterior surgery for this type of tumor in extreme locations is safe and effective with this novel minimally invasive technique.

Minimally invasive "separation surgery" plus adjuvant stereotactic radiotherapy in the management of spinal epidural metastases

Aim:

This study aimed to describe the application of minimally invasive surgery (MIS) in separation surgery combined with postoperative stereotactic body radiation therapy (SBRT) in patients with symptomatic metastatic epidural spinal disease.

Methods:

Three techniques are described: (1) MIS posterior separation surgery alone, (2) MIS posterolateral separation surgery with percutaneous pedicle screw placement, and (3) MIS lateral corpectomy with percutaneous pedicle screw placement. Seven representative cases are presented in which the above techniques were applied and after which postoperative SBRT was performed.

Results:

The seven representative patients (3 male, 4 female) had a mean age of 54 years (range, 46–62 years). Two patients had a primary diagnosis of cholangiocarcinoma and in one patient each a diagnosis of breast, renal, lung adenocarcinoma, melanoma, and urothelial squamous cell carcinoma as their primary tumor. All patients had additional multiorgan disease apart from the metastatic spine involvement. Three patients underwent operations in the lumbar spine, two in the thoracic spine, and one in each of the thoraco-lumbar and lumbo-sacral spine. The average operating time was 149 ± 60.3 min (range, 90–240 min). The mean estimated blood loss was 188.8 cc. The mean length of stay in the hospital was 4 days (range, 3–7 days). There were no surgical complications. All patients received postoperative SBRT (typically 24 Gy in 3 fractions) at a mean of 43.2 days after surgery (range, 30–83).

Conclusions:

Early reports such as this suggest that MIS techniques can be successfully and safely applied in accomplishing “separation surgery” with adjuvant SBRT in the management of metastatic spinal disease. The potential advantages conferred by MIS techniques such as shortened hospital stay, decreased blood loss, reduced perioperative complications, and earlier initiation of adjuvant radiation are highly desirable in the treatment of this challenging patient population.