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Gadjradj PS, Harhangi BS, Amelink J, van Susante J, Kamper S, van Tulder M, Peul WC, Vleggeert-Lankamp C, Rubinstein SM. Percutaneous Transforaminal Endoscopic Discectomy Versus Open Microdiscectomy for Lumbar Disc Herniation: A Systematic Review and Meta-analysis. Spine (Phila Pa 1976) 2021; 46:538-549. [PMID: 33290374 PMCID: PMC7993912 DOI: 10.1097/brs.0000000000003843] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/12/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023]
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To give a systematic overview of effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) compared with open microdiscectomy (OM) in the treatment of lumbar disk herniation (LDH). SUMMARY OF BACKGROUND DATA The current standard procedure for the treatment of sciatica caused by LDH, is OM. PTED is an alternative surgical technique which is thought to be less invasive. It is unclear if PTED has comparable outcomes compared with OM. METHODS Multiple online databases were systematically searched up to April 2020 for randomized controlled trials and prospective studies comparing PTED with OM for LDH. Primary outcomes were leg pain and functional status. Pooled effect estimates were calculated for the primary outcomes only and presented as standard mean differences (SMD) with their 95% confidence intervals (CI) at short (1-day postoperative), intermediate (3-6 months), and long-term (12 months). RESULTS We identified 2276 citations, of which eventually 14 studies were included. There was substantial heterogeneity in effects on leg pain at short term. There is moderate quality evidence suggesting no difference in leg pain at intermediate (SMD 0.05, 95% CI -0.10-0.21) and long-term follow-up (SMD 0.11, 95% CI -0.30-0.53). Only one study measured functional status at short-term and reported no differences. There is moderate quality evidence suggesting no difference in functional status at intermediate (SMD -0.09, 95% CI -0.24-0.07) and long-term (SMD -0.11, 95% CI -0.45-0.24). CONCLUSION There is moderate quality evidence suggesting no difference in leg pain or functional status at intermediate and long-term follow-up between PTED and OM in the treatment of LDH. High quality, robust studies reporting on clinical outcomes and cost-effectiveness on the long term are lacking.Level of Evidence: 2.
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Affiliation(s)
- Pravesh S. Gadjradj
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, the Netherlands
| | - Biswadjiet S. Harhangi
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jantijn Amelink
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, the Netherlands
| | - Job van Susante
- Department of Orthopedic Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Steven Kamper
- School of Public Health, University of Sydney, Camperdown, Australia
- Centre for Pain, Health and Lifestyle, Australia
| | - Maurits van Tulder
- Faculty Behavioral & Movement Sciences, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Wilco C. Peul
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, the Netherlands
| | - Carmen Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, the Netherlands
| | - Sidney M. Rubinstein
- Faculty Behavioral & Movement Sciences, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Bernstein DN, Merchan N, Fear K, Rubery PT, Mesfin A. Greater Socioeconomic Disadvantage Is Associated with Worse Symptom Severity at Initial Presentation in Patients Seeking Care for Lumbar Disc Herniation. Spine (Phila Pa 1976) 2021; 46:464-471. [PMID: 33181773 DOI: 10.1097/brs.0000000000003811] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, observational study. OBJECTIVE To determine the association of patient socioeconomic disadvantage, insurance type, and other characteristics on presenting symptom severity in patients with isolated lumbar disc herniation. SUMMARY OF BACKGROUND DATA Little is known of the impact of socioeconomic disadvantage and other patient characteristics on the level of self-reported symptom severity when patients first seek care for lumbar disc herniation. METHODS Between April 2015 and December 2018, 734 patients newly presenting for isolated lumbar disc herniation who completed the Patient-Reported Outcomes Measurement Information System Physical Function (PF), Pain Interference (PI), and Depression Computer Adaptive Tests (CATs) were identified. Socioeconomic disadvantage was determined using the Area Deprivation Index, a validated measure of socioeconomic disadvantage at the census block group level (0-100, 100 = highest socioeconomic disadvantage). Bivariate analyses were used. Multivariable linear regression was used to determine if there was an association between socioeconomic disadvantage, insurance type, and other patient factors and presenting patient-reported health status. RESULTS Significant differences in age, insurance type, self-reported race, marital status, and county of residence were appreciated when comparing patient characteristics by socioeconomic disadvantage levels (all comparisons, P < 0.01). In addition, significant differences in age, insurance type, marital status, and county of residence were appreciated when comparing patient characteristics by self-reported race (all comparisons, P < 0.01). Being in the most socioeconomically disadvantaged cohort was associated with worse presenting Patient-Reported Outcomes Measurement Information System scores (Physical Function: β = -3.27 (95% confidence interval [CI]: -4.89 to -1.45), P < 0.001; Pain Interference: β = 3.20 (95% CI: 1.58-4.83), P < 0.001; Depression: β = 3.31 (95% CI: 1.08-5.55), P = 0.004. CONCLUSION The most socioeconomically disadvantaged patients with symptomatic lumbar disc herniations present with worse functional limitations, pain levels, and depressive symptoms as compared to patients from the least socioeconomically disadvantaged cohort when accounting for other key patient factors.Level of Evidence: 3.
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Affiliation(s)
- David N Bernstein
- Department of Orthopedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Nelson Merchan
- Department of Orthopedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Kathleen Fear
- UR Health Lab, University of Rochester Medical Center, Rochester, NY
| | - Paul T Rubery
- Department of Orthopedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Addisu Mesfin
- Department of Orthopedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
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Peolsson A, Peterson G, Hermansen A, Ludvigsson ML, Dedering Å, Löfgren H. Physiotherapy after anterior cervical spine surgery for cervical disc disease: study protocol of a prospective randomised study to compare internet-based neck-specific exercise with prescribed physical activity. BMJ Open 2019; 9:e027387. [PMID: 30782952 PMCID: PMC6377535 DOI: 10.1136/bmjopen-2018-027387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/12/2018] [Accepted: 11/16/2018] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Patients suffering from remaining disability after anterior cervical decompression and fusion (ACDF) surgery for cervical disc disease may be prescribed physical activity (PPA) or neck-specific exercises (NSEs). Currently, we lack data for the success of either approach. There is also a knowledge gap concerning the use of internet-based care for cervical disc disease. The scarcity of these data, and the high proportion of patients with various degrees of incapacity following ACDF, warrant increased efforts to investigate and improve cost-effective rehabilitation. The objective is to compare the effectiveness of a structured, internet-based NSE programme, versus PPA following ACDF surgery. METHODS AND ANALYSIS This is a prospective, randomised, multicentre study that includes 140 patients with remaining disability (≥30% on the Neck Disability Index, NDI) following ACDF for radiculopathy due to cervical disc disease. Patient recruitment occurs following attendance at routine clinical appointments, scheduled at 3 months postsurgery. Patients are then randomised to one of two groups (70 patients/group) for a 3-month treatment programme/period of either internet-based NSE or PPA. Questionnaires on background data, pain and discomfort, physical and mental capacity, satisfaction with care, and health and workplace factors are completed, along with physical measures of neck-related function conducted by independent test leaders blinded to randomisation. Measures are collected at inclusion, after the 3-month treatments (end of treatment) and at a 2-year follow-up. Radiography will be completed at the 2-year follow-up. Preoperative data will be collected from the Swedish Spine Registry. Data on healthcare consumption, drug use and sick leave will be requested from the relevant national registers. ETHICAL CONSIDERATIONS This study was approved by the Regional Ethical Review Board in Linköping Ref. 2016/283-31 and 2017/91- 32. The scientists are independent with no commercial ties. Patients are recruited after providing written informed consent. Patient data are presented at group level such that no connection to any individual can be made. All data are anonymised when reported, and subject to the Swedish Official Secrets Health Acts. The test leaders are independent and blinded for randomisation. Exercises, both general and neck-specific, have been used extensively in clinical practice and we anticipate no harm from their implementation other than a risk of muscle soreness. Both randomisation groups will receive care that is expected to relieve pain, although the group receiving NSE is expected to demonstrate a greater and more cost-effective improvement versu s the PPA group. Any significant harm or unintended effects in each group will be collected by the test leaders. All questionnaires and test materials are coded by the research group, with code lists stored in locked, fireproof file cabinets, housed at the university in a room with controlled (card-based) access. Only individuals in receipt of a unique website address posted by the researchers can access the programme; patients can neither communicate with each other nor with caregivers via the programme.Study participation might lead to improved rehabilitation versus non-participation, and might therefore be of benefit. The results of this study should also contribute to more effective and flexible rehabilitation, shorter waiting times, lower costs and the possibility to implement our findings on a wider level. DISSEMINATION If effective, the protocols used in this study can be implemented in existing healthcare structures. The results of the study will be presented in scientific journals and popular science magazines of relevance to health. The findings will also be presented at local, regional, national and international conferences and meetings, as well as in the education of university students and at public lectures. Information about the results will be communicated to the general population in cooperation with patient organisations and the media. TRIAL REGISTRATION NCT03036007.
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Affiliation(s)
- Anneli Peolsson
- Department of Medical and Health Sciences, Physiotherapy, Linköping University, Linköping, Sweden
| | - Gunnel Peterson
- Department of Medical and Health Sciences, Physiotherapy, Linköping University, Linköping, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Anna Hermansen
- Department of Medical and Health Sciences, Physiotherapy, Linköping University, Linköping, Sweden
| | - Maria Landén Ludvigsson
- Department of Medical and Health Sciences, Physiotherapy, Linköping University, Linköping, Sweden
- Department of Rehabilitation and Department of Medical and Health Sciences, Rehab Väst, Region Council of Östergötland, Linkoping, Sweden
| | - Åsa Dedering
- Allied Health Professionals Function, Occupational Therapy and Physiotherapy, University Hospital, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Löfgren
- Neuro-Orthopedic Center, Ryhov Hospital, Jönköping, Sweden
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Bozzio AE, Johnson CR, Fattor JA, Kleck CJ, Patel VV, Burger EL, Noshchenko A, Cain CMJ. Stand-alone Anterior Lumbar Interbody, Transforaminal Lumbar Interbody, and Anterior/Posterior Fusion: Analysis of Fusion Outcomes and Costs. Orthopedics 2018; 41:e655-e662. [PMID: 30011051 DOI: 10.3928/01477447-20180711-06] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 04/11/2018] [Indexed: 02/03/2023]
Abstract
Fusion outcomes and costs of stand-alone anterior lumbar interbody fusion (ALIF), transforaminal lumbar interbody fusion (TLIF) in association with posterior fusion, and anterior/posterior (A/P) fusion were compared using clinical, radiographic, and billing data. Adult patients with symptomatic 1- or 2-level degenerative disk disease in isolation or in association with a grade 1 or 2 degenerative or lytic spondylolisthesis and canal and/or foraminal stenosis who underwent elective stand-alone ALIF, TLIF, or A/P fusion were compared. The analysis focused primarily on fusion rates and costs and secondarily on radiographic and clinical parameters. One hundred six patients at least 2 years beyond surgery (ALIF, 53; TLIF, 17; A/P fusion, 36) were reviewed. Demographics were similar except for age, with the ALIF group being younger (mean, 37.8 years) than the other groups (TLIF, 53.1 years; A/P fusion, 48.2 years). There were no differences between the groups in fusion rates or outcomes as assessed by the Numeric Rating Scale. Compared with the other 2 groups, the ALIF group had a significantly shorter operative time, less blood loss, and a shorter stay (P<.0001). Evaluation of radiographic parameters revealed significant differences regarding disk angle (P<.001), disk height (P<.0001), and pelvic tilt (P=.001) favoring ALIF and A/P fusion over TLIF. Stand-alone ALIF should be considered in the management of patients with 1- or 2-level lumbar degenerative disk disease for which the pathology can be addressed adequately via this approach. [Orthopedics. 2018; 41(5):e655-e662.].
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Steinmetz M, Dittrich V, Röser K. [Principles of intervertebral disc assessment in private accident insurance]. Versicherungsmedizin 2015; 67:126-129. [PMID: 26548005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Due to the spread of intervertebral disc degeneration, insurance companies and experts are regularly confronted with related assessments of insured persons under their private accident insurance. These claims pose a particular challenge for experts, since, in addition to the clinical assessment of the facts, extensive knowledge of general accident insurance conditions, case law and current study findings is required. Each case can only be properly assessed through simultaneous consideration of both the medical and legal facts. These guidelines serve as the basis for experts and claims.managers with respect to the appropriate individual factual assessment of intervertebral disc degeneration in private accident insurance.
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Singh K, Nandyala SV, Marquez-Lara A, Fineberg SJ, Oglesby M, Pelton MA, Andersson GB, Isayeva D, Jegier BJ, Phillips FM. A perioperative cost analysis comparing single-level minimally invasive and open transforaminal lumbar interbody fusion. Spine J 2014; 14:1694-701. [PMID: 24252237 DOI: 10.1016/j.spinee.2013.10.053] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 10/19/2013] [Accepted: 10/29/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Emerging literature suggests superior clinical short- and long-term outcomes of MIS (minimally invasive surgery) TLIFs (transforaminal lumbar interbody fusion) versus open fusions. Few studies to date have analyzed the cost differences between the two techniques and their relationship to acute clinical outcomes. PURPOSE The purpose of the study was to determine the differences in hospitalization costs and payments for patients treated with primary single-level MIS versus open TLIF. The impact of clinical outcomes and their contribution to financial differences was explored as well. STUDY DESIGN/SETTING This study was a nonrandomized, nonblinded prospective review. PATIENT SAMPLE Sixty-six consecutive patients undergoing a single-level TLIF (open/MIS) were analyzed (33 open, 33 MIS). Patients in either cohort (MIS/open) were matched based on race, sex, age, smoking status, medical comorbidities (Charlson Comorbidity index), payer, and diagnosis. Every patient in the study had a diagnosis of either degenerative disc disease or spondylolisthesis and stenosis. OUTCOME MEASURES Operative time (minutes), length of stay (LOS, days), estimated blood loss (EBL, mL), anesthesia time (minutes), Visual Analog Scale (VAS) scores, and hospital cost/payment amount were assessed. METHODS The MIS and open TLIF groups were compared based on clinical outcomes measures and hospital cost/payment data using SPSS version 20.0 for statistical analysis. The two groups were compared using bivariate chi-squared analysis. Mann-Whitney tests were used for non-normal distributed data. Effect size estimate was calculated with the Cohen d statistic and the r statistic with a 95% confidence interval. RESULTS Average surgical time was shorter for the MIS than the open TLIF group (115.8 minutes vs. 186.0 minutes respectively; p=.001). Length of stay was also reduced for the MIS versus the open group (2.3 days vs. 2.9 days, respectively; p=.018). Average anesthesia time and EBL were also lower in the MIS group (p<.001). VAS scores decreased for both groups, although these scores were significantly lower for the MIS group (p<.001). Financial analysis demonstrated lower total hospital direct costs (blood, imaging, implant, laboratory, pharmacy, physical therapy/occupational therapy/speech, room and board) in the MIS versus the open group ($19,512 vs. $23,550, p<.001). Implant costs were similar (p=.686) in both groups, although these accounted for about two-thirds of the hospital direct costs in the MIS cohort ($13,764) and half of these costs ($13,778) in the open group. Hospital payments were $6,248 higher for open TLIF patients compared with the MIS group (p=.267). CONCLUSIONS MIS TLIF technique demonstrated significant reductions of operative time, LOS, anesthesia time, VAS scores, and EBL compared with the open technique. This reduction in perioperative parameters translated into lower total hospital costs over a 60-day perioperative period. Although hospital reimbursements appear higher in the open group over the MIS group, shorter surgical times and LOS days in the MIS technique provide opportunities for hospitals to reduce utilization of resources and to increase surgical case volume.
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Affiliation(s)
- Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA.
| | - Sreeharsha V Nandyala
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Alejandro Marquez-Lara
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Steven J Fineberg
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Mathew Oglesby
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Miguel A Pelton
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Gunnar B Andersson
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Darya Isayeva
- Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Briana J Jegier
- Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
| | - Frank M Phillips
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Chicago, IL 60612, USA
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