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Li WS, Li GY, Yan Q, Chen WT, Cong L. The effectiveness and safety of annulus closure device implantation in lumbar discectomy for patients with lumbar disc herniation: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:2377-2386. [PMID: 37010608 DOI: 10.1007/s00586-023-07629-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE The objective of this study was to systematically estimate the effectiveness and safety of annulus closure device (ACD) implantation in discectomy for patients with lumbar disc herniation (LDH). METHODS A systematic search was performed on PubMed, EMBASE and the Cochrane Library for randomized controlled trial (RCT) from inception until April 16, 2022. Trials which investigated comparisons between with and without ACD implantation in discectomy for LDH patients were identified. RESULTS In total, five RCTs involving 2380 patients with LDH underwent discectomy were included. The included patients were divided into ACD group and control group (CTL). Significant differences were found in the rate of re-herniation (ACD: 7.40%, CTL: 17.58%), reoperation (ACD: 5.39%, CTL: 13.58%) and serious adverse event (ACD: 10.79%, CTL: 17.14%) between ACD group and CTL group. No significant difference was found in VAS-BACK, VAS-LEG, ODI and SF-12 PCS between ACD and CTL. The surgical time of ACD was longer than CTL with statistical significance. In subgroup analyses based on discectomy type, significant differences were found in the rate of re-herniation (ACD: 10.73%, CTL: 21.27%), reoperation (ACD: 4.96%, CTL: 13.82%) and serious adverse event (ACD: 7.59%, CTL: 16.89%) between ACD and CTL in limited lumbar discectomy (LLD). CONCLUSION Discectomy either with or without ACD implantation is considered to achieve similar clinical outcomes. Whereas, the ACD implantation in LLD is associated with lower re-herniation and reoperation rate but prolonged surgical time for LDH patients. Researches on cost-effectiveness and effect of ACD implantation in different discectomy are needed in the future.
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Affiliation(s)
- Wei-Shang Li
- Department of Orthopedic Surgery, The First Hospital of China Medical University, No.155, Nanjing Bei Street, Shenyang, 110001, People's Republic of China
| | - Gao-Yu Li
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, No.36, Sanhao Street, Shenyang, 110001, People's Republic of China
| | - Qi Yan
- Departments of Surgery, University of Texas Health San Antonio, 7703 Floyd Curl Drive, MC 7741, San Antonio, TX, 78229-3900, USA
| | - Wen-Ting Chen
- Disease Control and Prevention Center of China Railway Shenyang Bureau Group Corporation, No.4, Taiyuan Bei Street, Shenyang, 110001, People's Republic of China
| | - Lin Cong
- Department of Orthopedic Surgery, The First Hospital of China Medical University, No.155, Nanjing Bei Street, Shenyang, 110001, People's Republic of China.
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Wang Z, Huang S, Xu L, Bu J, Liu G, Wang H, Liang J, Xia M, Chen T, Ma C, Dai K, Liu G. A retrospective study of the mid-term efficacy of full-endoscopic annulus fibrosus suture following lumbar discectomy. Front Surg 2022; 9:1011746. [DOI: 10.3389/fsurg.2022.1011746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022] Open
Abstract
AimsFull-endoscopic discectomy is associated with a high risk of disc reherniation due to the poor mechanical strength of the annulus fibrosus after scar healing. It is technically difficult to place a full-endoscopic annulus fibrosus suture. We designed an annulus fibrosus suture device that can be used to suture annulus defects under microendoscopy. The present study investigated the safety and feasibility of this technology.Patients and MethodsWe retrospectively analyzed the outcomes of patients who underwent surgical treatment for lumbar disc herniation (LDH) from January 2018 to October 2020. We compared 40 patients with LDH treated with full-endoscopic annulus fibrosus suture following lumbar discectomy (LD + AFS group) with 42 patients treated with lumbar discectomy alone (LD group) regarding demographic data, symptoms, and recurrence and reoperation rates. Lumbar MRI and CT were performed 3 and 12 months. A 10-point visual analog scale (VAS) and the Oswestry Disability Index (ODI) was used to evaluate pain and the lumbar spine function.ResultsThe cohort comprised 82 patients, including 40 patients in the LD + AFS group and 42 in the LD group. All operations were successfully completed without serious complications. Reherniation occurred in no patients in the LD + AFS group and three patients in the LD group. The VAS scores for lumbar and leg pain and ODI score were significantly improved postoperatively (p < 0.05).ConclusionCompared with conventional lumbar discectomy, full-endoscopic annulus fibrosus suture following full-endoscopic lumbar discectomy is a safe and effective minimally invasive technique that reduces the LDH recurrence rate.
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Canseco JA, Karamian BA, Minetos PD, Paziuk TM, Gabay A, Reyes AA, Bechay J, Xiao KB, Nourie BO, Kaye ID, Woods BI, Rihn JA, Kurd MF, Anderson DG, Hilibrand AS, Kepler CK, Schroeder GD, Vaccaro AR. Risk Factors for 30-day and 90-day Readmission After Lumbar Decompression. Spine (Phila Pa 1976) 2022; 47:672-679. [PMID: 35066538 DOI: 10.1097/brs.0000000000004325] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To assess readmission rates and risk factors for 30-day and 90-day readmission after elective lumbar decompression at a single institution. SUMMARY OF BACKGROUND DATA Hospital readmission is an undesirable aspect of interventional treatment. Studies evaluating readmissions after elective lumbar decompression typically analyze national databases, and therefore have several drawbacks inherent to their macroscopic nature that limit their clinical utility. METHODS Patients undergoing primary one- to four-level lumbar decompression surgery were retrospectively identified. Demographic, surgical, and readmission data within "30-days" (0-30 days) and "90-days" (31-90 days) postoperatively were extracted from electronic medical records. Patients were categorized into four groups: (1) no readmission, (2) readmission during the 30-day or 90-day postoperative period, (3) complication related to surgery, and (4) Emergency Department (ED)/Observational (OBs)/Urgent (UC) care. RESULTS A total of 2635 patients were included. Seventy-six (2.9%) were readmitted at some point within the 30- (2.3%) or 90-day (0.3%) postoperative periods. Patients in the pooled readmitted group were older (63.1 yr, P < 0.001), had a higher American Society of Anesthesiologists (ASA) grade (31.2% with ASA of 3, P = 0.03), and more often had liver disease (8.1%, P = 0.004) or rheumatoid arthritis (12.0%, P = 0.02) than other cohorts. A greater proportion of 90-day readmissions and complications had surgical-related diagnoses or a diagnosis of recurrent disc herniation than 30-day readmissions and complications (66.7% vs. 44.5%, P = 0.04 and 33.3% vs. 5.5%, P < 0.001, respectively). Age (Odds ratio [OR]: 1.02, P = 0.01), current smoking status (OR: 2.38, P < 0.001), longer length of stay (OR: 1.14, P < 0.001), and a history of renal failure (OR: 2.59, P = 0.03) were independently associated with readmission or complication. CONCLUSION Increased age, current smoking status, hospital length of stay, and a history of renal failure were found to be significant independent predictors of inpatient readmission or complication after lumbar decompression.
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Affiliation(s)
- Jose A Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Brian A Karamian
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Paul D Minetos
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Taylor M Paziuk
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alyssa Gabay
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA
| | - Ariana A Reyes
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Joseph Bechay
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Kevin B Xiao
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Blake O Nourie
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - I David Kaye
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Barrett I Woods
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jeffrey A Rihn
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mark F Kurd
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - D Greg Anderson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alan S Hilibrand
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Gregory D Schroeder
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Peredo AP, Gullbrand SE, Mauck RL, Smith HE. A challenging playing field: Identifying the endogenous impediments to annulus fibrosus repair. JOR Spine 2021; 4:e1133. [PMID: 33778407 PMCID: PMC7984000 DOI: 10.1002/jsp2.1133] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/31/2022] Open
Abstract
Intervertebral disc (IVD) herniations, caused by annulus fibrosus (AF) tears that enable disc tissue extrusion beyond the disc space, are very prevalent, especially among adults in the third to fifth decade of life. Symptomatic herniations, in which the extruded tissue compresses surrounding nerves, are characterized by back pain, numbness, and tingling and can cause extreme physical disability. Patients whose symptoms persist after nonoperative intervention may undergo surgical removal of the herniated tissue via microdiscectomy surgery. The AF, however, which has a poor endogenous healing ability, is left unrepaired increasing the risk for re-herniation and pre-disposing the IVD to degenerative disc disease. The lack of understanding of the mechanisms involved in native AF repair limits the design of repair systems that overcome the impediments to successful AF restoration. Moreover, the complexity of the AF structure and the challenging anatomy of the repair environment represents a significant challenge for the design of new repair devices. While progress has been made towards the development of an effective AF repair technique, these methods have yet to demonstrate long-term repair and recovery of IVD biomechanics. In this review, the limitations of endogenous AF healing are discussed and key cellular events and factors involved are highlighted to identify potential therapeutic targets that can be integrated into AF repair methods. Clinical repair strategies and their limitations are described to further guide the design of repair approaches that effectively restore native tissue structure and function.
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Affiliation(s)
- Ana P. Peredo
- Department of BioengineeringSchool of Engineering and Applied Science, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic SurgeryPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Translational Musculoskeletal Research CenterCorporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPennsylvaniaUSA
| | - Sarah E. Gullbrand
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic SurgeryPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Translational Musculoskeletal Research CenterCorporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPennsylvaniaUSA
| | - Robert L. Mauck
- Department of BioengineeringSchool of Engineering and Applied Science, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic SurgeryPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Translational Musculoskeletal Research CenterCorporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPennsylvaniaUSA
| | - Harvey E. Smith
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic SurgeryPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Translational Musculoskeletal Research CenterCorporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPennsylvaniaUSA
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Burkhardt BW, Oertel JM. Annular closure device breakage due to recurrent lumbar disc herniation: a case report. Acta Neurochir (Wien) 2021; 163:269-273. [PMID: 33222009 DOI: 10.1007/s00701-020-04651-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
Detailed surgical management, magnetic resonance imaging (MRI), and computer tomography (CT) images of a broken annular closure device (ACD) have not been reported yet. In this case, a 28-year-old male presented with a new onset of radiculopathy three years after lumbar discectomy and placement of an ACD. The CT-myelography and MRI revealed a recurrent disc herniation (RDH) and dislocation of a broken ACD. ACD removal was performed and confirmed breakage due to RDH with scarring around the RDH and displaced ACD. Implant-associated complications and management should be reported in detail in order to enhance knowledge on device-related complications.
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Miller LE, Allen RT, Duhon B, Radcliff KE. Expert review with meta-analysis of randomized and nonrandomized controlled studies of Barricaid annular closure in patients at high risk for lumbar disc reherniation. Expert Rev Med Devices 2020; 17:461-469. [PMID: 32237917 DOI: 10.1080/17434440.2020.1745061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Introduction: Patients with lumbar disc herniation and associated sciatica are often referred for lumbar discectomy. The surgical defect in the annulus fibrosus is typically left unrepaired after lumbar discectomy. Patients with large postsurgical annular defects (≥6 mm width) have a higher risk of symptom recurrence and reoperation compared to those with small defects. In these high-risk patients, a treatment gap exists due to the lack of effective treatments for durable annulus fibrosus repair.Areas covered: This article highlights the therapeutic need and summarizes the clinical results of a bone-anchored annular closure device (Barricaid) that was designed to fill the treatment gap in patients with large postsurgical annular defects. Clinical results were summarized by means of a systematic review with meta-analysis of two randomized and two nonrandomized controlled studies.Expert opinion: Professional societal recommendations and clinical study results support the adoption of bone-anchored annular closure for use in properly selected patients undergoing lumbar discectomy who are at high-risk for reherniation due to a large postsurgical defect in the annulus fibrosus. The risks of symptomatic reherniation and reoperation are approximately 50% lower in patients treated with lumbar discectomy and the Barricaid device compared to lumbar discectomy only, representing a clinically effective treatment strategy.
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Affiliation(s)
| | - R Todd Allen
- Department of Orthopaedic Surgery, UC San Diego Health System, San Diego, CA, USA
| | - Brad Duhon
- Department of Neurosurgery, University of Colorado, Lone Tree, CO, USA
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Lorio M, Kim C, Araghi A, Inzana J, Yue JJ. International Society for the Advancement of Spine Surgery Policy 2019-Surgical Treatment of Lumbar Disc Herniation with Radiculopathy. Int J Spine Surg 2020; 14:1-17. [PMID: 32128297 DOI: 10.14444/7001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Lumbar disc herniation (LDH) is a frequent cause of low back pain and radiculopathy, disability, and diminution in quality of life. While nonsurgical care remains the mainstay of initial treatment, symptoms that persist for prolonged periods of time are well treated with discectomy surgery. A large body of evidence shows that, in patients with unremitting symptoms despite a reasonable period of nonsurgical treatment, discectomy surgery is safe and efficacious. In patients with symptoms lasting greater than 6 weeks, various forms of discectomy (open, microtubular, and endoscopic) are superior to continued nonsurgical treatment. The small but significant proportion of patients with recurrent disc herniation experience less improvement overall than patients who do not experience reherniation after primary discectomy. Lumbar discectomy patients with large annular defects (≥6 mm wide) are at a higher risk for recurrent herniation and revision surgery. Annular closure via a bone-anchored device has been shown to decrease the rate of recurrent disc herniation and associated reoperation in these high-risk patients. After a detailed review of the literature, current clinical evidence supports discectomy (open, microtubular, or endoscopic discectomy) as a medically necessary procedure for the treatment of LDH with radiculopathy in indicated patients. Furthermore, there is new scientific evidence that supports the use of bone-anchored annular closure in patients with large annular defects, who are at greater risk for recurrent disc herniation.
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Affiliation(s)
- Morgan Lorio
- Advanced Orthopedics, Altamonte Springs, Florida
| | - Choll Kim
- Spine Institute of San Diego, San Diego, California
| | - Ali Araghi
- The CORE Institute, Sun City West, Arizona
| | | | - James J Yue
- CT Orthopaedics; Frank H. Netter School of Medicine, Hamden, Connecticut
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Ammerman J, Watters WC, Inzana JA, Carragee G, Groff MW. Closing the Treatment Gap for Lumbar Disc Herniation Patients with Large Annular Defects: A Systematic Review of Techniques and Outcomes in this High-risk Population. Cureus 2019; 11:e4613. [PMID: 31312540 PMCID: PMC6615588 DOI: 10.7759/cureus.4613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Lumbar disc herniation (LDH) is one of the most common spinal pathologies and can be associated with debilitating pain and neurological dysfunction. Discectomy is the primary surgical intervention for LDH and is typically successful. Yet, some patients experience recurrent LDH (RLDH) after discectomy, which is associated with worse clinical outcomes and greater socioeconomic burden. Large defects in the annulus fibrosis are a significant risk factor for RLDH and present a critical treatment challenge. It is essential to identify reliable and cost-effective treatments for this at-risk population. A systematic review of the PubMed and Embase databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies describing the treatment of LDH patients with large annular defects. The incidence of large annular defects, measurement technique, RLDH rate, and reoperation rate were compiled and stratified by surgical technique. The risk of bias was scored for each study and for the identification of RLDH and reoperation. Study heterogeneity and pooled estimates were calculated from the included articles. Fifteen unique studies describing 2,768 subjects were included. The pooled incidence of patients with a large annular defect was 44%. The pooled incidence of RLDH and reoperation following conventional limited discectomy in this population was 10.6% and 6.0%, respectively. A more aggressive technique, subtotal discectomy, tended to have lower rates of RLDH (5.8%) and reoperation (3.8%). However, patients treated with subtotal discectomy reported greater back and leg pain associated with disc degeneration. The quality of evidence was low for subtotal discectomy as an alternative to limited discectomy. Each report had a high risk of bias and treatments were never randomized. A recent randomized controlled trial with 550 subjects examined an annular closure device (ACD) and observed significant reductions in RLDH and reoperation rates (>50% reduction). Based on the available evidence, current discectomy techniques are inadequate for patients with large annular defects, leaving a treatment gap for this high-risk population. Currently, the strongest evidence indicates that augmenting limited discectomy with an ACD can reduce RLDH and revision rates in patients with large annular defects, with a low risk of device complications.
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Affiliation(s)
| | - William C Watters
- Clinical Orthopedic Surgery, Institute of Academic Medicine, Houston Methodist Hospital, Houston, USA
| | | | - Gene Carragee
- Orthopaedic Surgery, Stanford University Medical Center, Stanford, USA
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Thaci B, McGirt MJ, Ammerman JM, Thomé C, Kim KD, Ament JD. Reduction of direct costs in high-risk lumbar discectomy patients during the 90-day post-operative period through annular closure. CLINICOECONOMICS AND OUTCOMES RESEARCH 2019; 11:191-197. [PMID: 30881066 PMCID: PMC6400234 DOI: 10.2147/ceor.s193603] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Despite being an extremely successful procedure, recurrent disc herniation is one of the most common post-discectomy complications in the lumbar spine and contributes significant health care and socioeconomic costs. Patients with large annular defects are at a high risk for reherniation, but an annular closure device (ACD) has been designed to reduce reherniation risk in this population and may, in turn, help control direct health care costs after discectomy. Patients and methods This analysis examined the 90-day post-discectomy cost estimates among ACD-treated (n=272) and control (discectomy alone; n=278) patients in a randomized controlled trial (RCT). Direct medical costs were estimated based on 2017 Humana and Medicare claims. Index discectomies were assumed to occur in an outpatient (OP) setting, whereas repeat discectomies were assumed to be 60% in OP and 40% in inpatient (IP). A sensitivity analysis was performed on this assumption. The device cost was not included in the analysis in order to focus on costs in the 90-day post-operative period. Results Within 90 days of follow-up, post-operative complications occurred in 3.3% of the ACD patients and 8.6% of the control patients (P=0.01). The average 90-day cost to treat an ACD patient was $10,257 compared to $11,299 per control patient for a 80:20 distribution of Commercial:Medicare coverage ($1,042 difference). This difference varied from $687 with 100% Medicare to $1,132 with 100% Commercial coverage. Varying the IP vs OP distribution resulted in a cost difference range of $968 to $1,156 with the ACD. Conclusion Augmenting discectomy with an ACD in high-risk patients with a large annular defect reduced reherniation and reoperation rates, which translated to a reduction of direct health care costs between $687 and $1,156 per patient during the 90-day post-operative period. Large annular defect patients are an easily identifiable high-risk population. Operative strategies that reduce complication risks in these patients, such as the ACD, could be advantageous from both patient care and economic perspectives.
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Affiliation(s)
- Bart Thaci
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA, USA
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, NC, USA
| | | | - Claudius Thomé
- Deparment of Neurosurgery, Innsbruck Medical University, Innsbruck, Austria
| | - Kee D Kim
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA, USA
| | - Jared D Ament
- Sierra Neuroscience Institute, Los Angeles, CA, USA,
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Ament J, Thaci B, Yang Z, Kulubya E, Hsu W, Bouma G, Kim KD. Cost-effectiveness of a Bone-anchored Annular Closure Device Versus Conventional Lumbar Discectomy in Treating Lumbar Disc Herniations. Spine (Phila Pa 1976) 2019; 44:5-16. [PMID: 29927860 DOI: 10.1097/brs.0000000000002746] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cost-utility analysis of an annular closure device (ACD) based on data from a prospective, multicenter randomized controlled trial (RCT) OBJECTIVE.: The aim of this study was to determine the cost-effectiveness of a novel ACD in a patient population at high risk for recurrent herniation following discectomy. SUMMARY OF BACKGROUND DATA Lumbar disc herniation patients with annular defect widths ≥6 mm are at high risk for recurrent herniation following limited discectomy. Recurrent herniation is associated with worse clinical outcomes and greater healthcare costs. A novel ACD may reduce the incidence of recurrent herniation and the associated burdens. METHODS A decision analytical modeling approach with a Markov method was used to evaluate the cost-effectiveness of the ACD versus conventional discectomy. Health states were created by projecting visual analogue scale (VAS) onto Oswestry Disability Index (ODI). Direct costs were calculated based on Humana and Medicare 2014 claims to represent private and public payer data, respectively. Indirect costs were calculated for lost work days using 2016 US average annual wages. The incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life year (QALY) was compared to willingness-to-pay thresholds. Sensitivity analyses were also conducted. RESULTS Patients with the ACD had less symptomatic reherniations, reoperations, and complications and gained 0.0328 QALYs within the first 2 years. Total direct medical costs for the ACD group were similar to control. When productivity loss was considered, using the ACD became $2076 cheaper, per patient, than conventional discectomy. Based on direct costs alone, the ICER comparing ACD to control equaled $6030 per QALY. When indirect costs are included, the ICER became negative, which indicates that superior quality of life was attained at less cost. CONCLUSION For lumbar disc herniations patients with annular defects ≥6 mm, the ACD was, at 2 years, a highly cost-effective surgical modality compared to conventional lumbar discectomy. LEVEL OF EVIDENCE 1.
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Affiliation(s)
- Jared Ament
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
| | - Bart Thaci
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
| | - Zhuo Yang
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
| | - Edwin Kulubya
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
| | - Wellington Hsu
- Department of Orthopedic Surgery, Northwestern University, Chicago, IL
| | - Gerrit Bouma
- Department of Neurosurgery, OLVG Hospital Amsterdam, the Netherlands
| | - Kee D Kim
- Department of Neurological Surgery, University of California, Davis, Sacramento, CA
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Kuršumović A, Kienzler JC, Bouma GJ, Bostelmann R, Heggeness M, Thomé C, Miller LE, Barth M. Morphology and Clinical Relevance of Vertebral Endplate Changes Following Limited Lumbar Discectomy With or Without Bone-anchored Annular Closure. Spine (Phila Pa 1976) 2018. [PMID: 29538243 DOI: 10.1097/brs.0000000000002632] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Post hoc analysis of a randomized controlled trial. OBJECTIVE To characterize the morphology and clinical relevance of vertebral endplate changes (VEPC) following limited lumbar discectomy with or without implantation of a bone-anchored annular closure device (ACD). SUMMARY OF BACKGROUND DATA Implantation of an ACD following limited lumbar discectomy has shown promise in reducing the risk of recurrent herniation in patients with large annular defects. However, the interaction between the ACD and the lumbar endplate over time is not well understood. METHODS Patients undergoing limited lumbar discectomy with large postsurgical annular defects were randomized intraoperatively to receive additional ACD implantation or limited lumbar discectomy only (Controls). VEPC morphology, area, and volume were assessed with low-dose computed tomography preoperatively and at 1 and 2 years follow-up. RESULTS Of 554 randomized patients, the as-treated population consisted of 550 patients (267 ACD, 283 Controls). VEPC were preoperatively identified in 18% of patients in the ACD group and in 15% of Controls. At 2 years, VEPC frequency increased to 85% with ACD and 33% in Controls. Device- or procedure-related serious adverse event (8% vs. 17%, P = 0.001) and secondary surgical intervention (5% vs. 13%, P < 0.001) favored the ACD group over Controls. In the ACD group, clinical outcomes were comparable in patients with and without VEPC at 2 years follow-up. In the Control group, patients with VEPC at 2 years had higher risk of symptomatic reherniation versus patients without VEPC (35% vs. 19%, P < 0.01) CONCLUSION.: In patients with large annular defects following limited lumbar discectomy, additional implantation with a bone-anchored ACD reduces risk of postoperative complications despite a greater frequency of VEPC. VEPC were associated with higher risk of symptomatic reherniation in patients treated with limited lumbar discectomy, but not in those who received additional ACD implantation. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Adisa Kuršumović
- Department of Neurosurgery, Donauisar Klinikum Deggendorf, Deggendorf, Germany
| | - Jenny C Kienzler
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Gerrit J Bouma
- Neurosurgical Center Amsterdam, Neurosurgery Spine Clinic, OLVG Hospital, Amsterdam, The Netherlands
| | - Richard Bostelmann
- Department of Neurosurgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Michael Heggeness
- Department of Orthopedics, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | | | - Martin Barth
- Department of Neurosurgery, University Hospital Bochum, Bochum, Germany
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Choy WJ, Phan K, Diwan AD, Ong CS, Mobbs RJ. Annular closure device for disc herniation: meta-analysis of clinical outcome and complications. BMC Musculoskelet Disord 2018; 19:290. [PMID: 30115053 PMCID: PMC6097319 DOI: 10.1186/s12891-018-2213-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/31/2018] [Indexed: 12/13/2022] Open
Abstract
Background Lumbar intervertebral disc herniation is a common cause of lower back and leg pain, with surgical intervention (e.g. discectomy to remove the herniated disc) recommended after an appropriate period of conservative management, however the existing or increased breach of the annulus fibrosus persists with the potential of reherniation. Several prosthesis and techniques to reduce re-herniation have been proposed including implantation of an annular closure device (ACD) – Barricaid™ and an annular tissue repair system (AR) – Anulex-Xclose™. The aim of this meta-analysis is to assist surgeons determine a potential approach to reduce incidences of recurrent lumbar disc herniation and assess the current devices regarding their outcomes and complications. Methods Four electronic full-text databases were systematically searched through September 2017. Data including outcomes of annular closure device/annular repair were extracted. All results were pooled utilising meta-analysis with weighted mean difference and odds ratio as summary statistics. Results Four studies met inclusion criteria. Three studies reported the use of Barricaid (ACD) while one study reported the use of Anulex (AR). A total of 24 symptomatic reherniation were reported among 811 discectomies with ACD/AR as compared to 51 out of 645 in the control group (OR: 0.34; 95% CI: 0.20,0.56; I2 = 0%; P < 0.0001). Durotomies were lower among the ACD/AR patients with only 3 reported cases compared to 7 in the control group (OR: 0.54; 95% CI: 0.13, 2.23; I2 = 11%; P = 0.39). Similar outcomes for post-operative Oswestry Disability Index and visual analogue scale were obtained when both groups were compared. Conclusion Early results showed the use of Barricaid and Anulex devices are beneficial for short term outcomes demonstrating reduction in symptomatic disc reherniation with low post-operative complication rates. Long-term studies are required to further investigate the efficacy of such devices.
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Affiliation(s)
- Wen Jie Choy
- Faculty of Medicine, University of New South Wales (UNSW), Sydney, Australia.,NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Kevin Phan
- Faculty of Medicine, University of New South Wales (UNSW), Sydney, Australia.,NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia.,Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia
| | - Ashish D Diwan
- Spine Service, Department of Orthopaedic Surgery, St. George & Sutherland Clinical School, University of New South Wales, Kogarah, 2217, New South Wales, Australia
| | - Chon Sum Ong
- Newcastle University Medicine Malaysia (NUMed), Johor, Malaysia
| | - Ralph J Mobbs
- Faculty of Medicine, University of New South Wales (UNSW), Sydney, Australia. .,NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia. .,Department of Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia.
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Reoperation of decompression alone or decompression plus fusion surgeries for degenerative lumbar diseases: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:1371-1385. [DOI: 10.1007/s00586-018-5681-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/23/2018] [Indexed: 10/28/2022]
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Kuršumović A, Rath SA. Effectiveness of an annular closure device in a "real-world" population: stratification of registry data using screening criteria from a randomized controlled trial. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2018; 11:193-200. [PMID: 29922099 PMCID: PMC5995288 DOI: 10.2147/mder.s167381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Increased focus has been put on the use of “‘real-world” data to support randomized clinical trial (RCT) evidence for clinical decision-making. The objective of this study was to assess the performance of an annular closure device (ACD) after stratifying a consecutive series of “real-world” patients by the screening criteria of an ongoing RCT. Materials and methods This was a single-center registry analysis of 164 subjects who underwent limited discectomy combined with ACD for symptomatic lumbar disc herniation. Patients were stratified into two groups using the selection criteria of a pivotal RCT on the same device: Trial (met inclusion; n=44) or non-Trial (did not meet inclusion; n=120). Patient-reported outcomes, including Oswestry Disability Index (ODI) and visual analog scale (VAS) for leg and back pain, and adverse events were collected from baseline to last follow-up (mean: Trial – 15.6 months; non-Trial – 14.6 months). Statistical analyses were performed with significance set at p<0.05. Results Patient-reported outcomes were not significantly different between groups at last (p≥0.15) and clinical success (≥15-point improvement in ODI score; ≥20-point improvement in VAS scores) was achieved in both the groups. Three non-Trial (2.5%) and three Trial (6.8%) patients experienced symptomatic reherniation (p=0.34). Rates of reoperation, ACD mesh dislocation/separation, and other radiographic findings were similar between groups (p=1.00). Conclusion Outcomes with the ACD appeared advantageous in both the groups, particularly in comparison with historical reherniation rates reported in the same high-risk, large annular defect population. Stratification of this “real-world” series on the basis of RCT screening criteria did not result in significant between-group differences. These findings suggest that the efficacy of the ACD extends beyond the strictly defined patient population being studied in the RCT of this device. Furthermore, reducing the reherniation rate following lumbar discectomy has positive clinical and economic implications.
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Affiliation(s)
- Adisa Kuršumović
- Department of Neurosurgery, Spinal Surgery and Interventional Neuroradiology, Donauisar Klinikum Deggendorf, Deggendorf, Germany
| | - Stefan A Rath
- Department of Neurosurgery, Spinal Surgery and Interventional Neuroradiology, Donauisar Klinikum Deggendorf, Deggendorf, Germany
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