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Background: The objective of this study was to compare the cost-effectiveness of minimally invasive surgery (MIS) for patients with degenerative lumbar spondylolisthesis (DLS) relative to failed medical management with the cost-effectiveness of hip and knee arthroplasty for matched cohorts of patients with osteoarthritis. Methods: A cohort of patients with DLS undergoing MIS procedures with decompression alone or decompression and instrumented fusion between 2008 and 2014 was matched to cohorts of patients with hip osteoarthritis (OA) and knee OA undergoing total joint replacement. Incremental cost-utility ratios (ICURs) were calculated from the perspective of the Ontario Ministry of Health, using prospectively collected Short Form-6 Dimension utility data. Costs and quality-adjusted life years (QALYs) were discounted at 3% and sensitivity analyses were performed. Results: Sixty-six patients met the inclusion criteria for the DLS cohort (n = 35 for decompression alone), with a minimum follow-up time of 1 year (mean 1.7 yr). The mean age of patients in the DLS cohort was 64.76 years, and 45 patients (68.2%) were female. For each cohort, utility scores improved from baseline to follow-up and the magnitude of the gain did not differ by group. Lifetime ICURs comparing surgical with nonsurgical care were Can$7946/QALY, Can$7104/QALY and Can$5098/QALY for the DLS, knee OA and hip OA cohorts, respectively. Subgroup analysis yielded an increased ICUR for the patients with DLS who underwent decompression and fusion (Can$9870/QALY) compared with that for the patients with DLS who underwent decompression alone (Can$5045/QALY). The rank order of the ICURs by group did not change with deterministic or probabilistic sensitivity analyses. Conclusion: Lifetime ICURs for MIS procedures for DLS are similar to those for total joint replacement. Future research should adopt a societal perspective and potentially capture further economic benefits of MIS procedures. Contexte: L'objectif de cette etude etait de comparer le rapport cout-efficacite de la chirurgie minimalement effractive (CME) chez les patients atteints de spondylolisthesis lombaire degeneratif (SLD) en lien avec un echec de la prise en charge medicale a celui de l'arthroplastie de la hanche et du genou pour des cohortes assorties de patients atteints d'arthrose. Methodes: Une cohorte de patients atteints de SLD soumis a une CME avec decompression seule ou decompression avec arthrodese entre 2008 et 2014 a ete assortie a des cohortes de patients soumis a une arthroplastie totale pour arthrose de la hanche et du genou. Les rapports cout-utilite differentiels (RCUD) ont ete calcules du point de vue du ministere de la Sante de l'Ontario a l'aide des donnees d'utilite du questionnaire Short Form-6 Dimension recueillies de maniere prospective. Les couts et les annees de vie ajustees en fonction de la qualite (AVAQ) ont ete actualises a un taux de 3 % et des analyses de sensibilite ont ete effectuees. Resultats: Soixante-six patients repondaient aux criteres d'inclusion pour la cohorte SLD (n = 35, decompression seule), avec un suivi d'une duree minimale de 1 an (moy-enne 1,7 an). L'age moyen des gens de la cohorte SLD etait de 64,76 ans, et 45 patients (68,2 %) etaient de sexe feminin. Pour chaque cohorte, les scores d'utilite se sont ame-liores entre les valeurs de depart et les valeurs de suivi et l'ampleur du gain n'a pas differe entre les groupes. Les RCUD pour la vie entiere entre les soins chirurgicaux et non chirurgicaux ont ete 7946 SCA/QALY, 7104 SCA/QALY et 5098 SCA/QALY pour les cohortes SLD, arthrose du genou et de la hanche, respectivement. L'analyse de sous-groupes a genere un RCUD accru pour les patients atteints de SLD qui ont subi la decompression avec arthrodese (9870 SCA/QALY comparativement a la decompression seule (5045 SCA/QALY). Le classement des RCUD par groupe n'a pas change en fonction des analyses de sensibilite deterministes ou probabilistes. Conclusion: Les RCUD pour la vie entiere associes a la CME dans les cas de SLD sont similaires a ceux de l'arthroplastie totale. Les recherches futures devraient adopter une perspective societale et refleter davantage les bienfaits economiques de la CME., In recent years there has been an increasing demand for hip and knee replacement surgery; the same is true of surgical procedures for degenerative conditions of the spine. Moreover, it [...]

Study Design: Retrospective cohort study. Objective: The primary objective was to evaluate the impact of the upper instrumented level (UIV) being at C2 vs C3 in posterior cervical construct on patient reported outcomes (PROs) up to 24 months after surgery for cervical degenerative myelopathy (DCM). Secondary objectives were to compare operative time, intra-operative blood loss (IOBL), length of stay (LOS), adverse events (AEs) and re-operation. Methods: Patients who underwent a posterior cervical instrumented fusion (3 and + levels) with a C2 or C3 UIV, with 24 months follow-up were analyzed. PROs (NDI, EQ5D, SF-12 PCS/MCS, NRS arm/neck pain) were compared using ANCOVA. Operative duration, IOBL, AEs, and re-operation were compared. Subgroup analysis was performed on patient presenting with pre-operative malalignment (cervical sagittal vertical axis ≥40 mm and/or T1slope- cervical lordosis >15°). Results: 173 patients were included, of which 41 (24%) had a C2 UIV and 132 (76%) a C3 UIV. There was no statistically significant difference between the groups for the changes in PROs up to 24 months. Subgroup analysis of patients with pre-operative malalignment showed a trend towards greater improvement in the NDI at 12 months with a C2 UIV (P =.054). Operative time, IOBL and peri-operative AEs were more in C2 group (P <.05). There was no significant difference in LOS and re-operation (P >.05). Conclusion: In this observational study, up to 24 months after surgery for posterior cervical fusion in DCM greater than 3 levels, PROs appear to evolve similarly. [ABSTRACT FROM AUTHOR]

Objective: To assess the impact of diabetes on physical and mental health status, as well as patient satisfaction, one-year following knee and hip total joint arthroplasty (TJA) for osteoarthritis (OA). Methods: Participants were 626 hip and 754 knee TJA patients. Pre-surgery data were collected on socio-demographics and health status. The 12-item Short Form Health Survey (SF-12) was collected pre- and one year post-surgery, and physical (PCS) and mental component (MCS) summary scores computed. One-year patient satisfaction was also recorded. Four regression models tested the effect of diabetes on: 1) PCS change score; 2) MCS change score; 3) achieving minimal clinically important improvement (MCII) on PCS; and 4) patient satisfaction ('Somewhat or Very Satisfied' vs. 'Somewhat or Very Dissatisfied'). An interaction between surgical joint and diabetes was tested in each model. Results: Self-reported diabetes prevalence was 13.0% (95% CI: 11.2%-14.7%) and was more common in knee 16.1% (95% CI: 13.4%-18.7%) than hip 9.3% (95% CI: 7.0%-11.5%) patients. In adjusted analyses, change scores were 2.3 units less on the PCS for those with diabetes compared to those without (p = 0.005). Patients with diabetes were about half as likely to achieve MCII as patients without diabetes (p = 0.004). Diabetes was not significantly associated with satisfaction or changes in MCS scores. Diabetes effects did not differ by surgical joint. Conclusions: Findings support that diabetes has a negative impact on improvements in physical health after TJA. Considering the growing prevalence of OA and diabetes in the population, our findings support the importance of perioperative screening and management of diabetes in patients undergoing TJA. [ABSTRACT FROM AUTHOR]

Background: The characterization and influence of preoperative health care use on quality-of-care indicators (e.g., readmissions) has received limited attention in populations with musculoskeletal disorders. The purpose of this study was to characterize preoperative health care use and examine its effect on quality-of-care indicators among patients undergoing elective surgery for osteoarthritis. Methods: Data on health care use for 124,750 patients with elective surgery for osteoarthritis in Ontario, Canada, from April 1, 2015 to March 31, 2018 were linked across health administrative databases. Using total health care use one-year previous to surgery, patients were grouped from low to very high users. We used Poisson regression models to estimate rate ratios, while examining the relationship between preoperative health care use and quality-of-care indicators (e.g., extended length of stay, complications, and 90-day hospital readmissions). We controlled for covariates (age, sex, neighborhood income, rural/urban residence, comorbidities, and surgical anatomical site). Results: We found a statistically significant trend of increasing worse outcomes by health care use gradients that persisted after controlling for patient demographics and comorbidities. Findings were consistent across surgical anatomical sites. Moreover, very high users have relatively large numbers of visits to non-musculoskeletal specialists. Conclusions: Our findings highlight that information on patients' preoperative health care use, together with other risk factors (such as comorbidities), could help decision-making when benchmarking or reimbursing hospitals caring for complex patients undergoing surgery for osteoarthritis. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective analysis was performed of a multi-center Canadian Spine Outcomes and Research Network (CSORN) surgical database. Objective: To determine the rate and time to return to work (RTW) based on workload intensity after elective degenerative lumbar spine surgery. Methods: Patients working pre-operatively, aged greater than 18, who underwent a primary one- or two-level elective lumbar spine surgery for degenerative conditions between January 2015 and October 2020 were evaluated. The percentage of patients who returned to work at 1 year and the time to RTW post-operatively were analyzed based on workload intensity. Results: Of the 1290 patients included in the analysis, the overall rate of RTW was 82% at 1 year. Based on workload there was no significant difference in time to RTW after a fusion procedure, with median time to RTW being 10 weeks. For non-fusion procedure, the sedentary group had a statistically significantly quicker time to RTW than the light-moderate (P <.005) and heavy-very heavy (<.027) groups. Conclusions: The rate of RTW ranged between 84% for patients with sedentary work to 77% for patient with a heavy-very heavy workload. Median time to resumption of work was about 10 weeks following a fusion regardless of work intensity. There was more variability following non-fusion surgeries such as laminectomy and discectomy reflecting the patient's job demands. [ABSTRACT FROM AUTHOR]

Study Design: Ambispective cohort study. Objective: Canada has a government-funded universal health care system. The United States utilizes a multitier public and private system. The objective is to investigate differences in clinical outcomes between those surgically treated for lumbar disc herniation in a universal health care and multitier health system. Methods: Surgical lumbar disc herniation patients enrolled in the Canadian Spine Outcome Research Network (CSORN) were compared with the surgical cohort enrolled in the Spine Patients Outcome Research Trial (SPORT) study. Baseline demographics and spine-related patient-reported outcomes (PROs) were compared at 3 months and 1 year post-operatively. Results: The CSORN cohort consisted of 443 patients; the SPORT cohort had 763 patients. Patients in the CSORN cohort were older (46.4 ± 13.5 vs 41.0 ± 10.8, P <.001) and were more likely to be employed (69.5% vs 60.3%, P =.003). The CSORN cohort demonstrated significantly greater rates of satisfaction after surgery at 3 months (87.2% vs 64.8%, P <.0001) and 1 year (85.6% vs 69.6%, P <.0001). Improvements in back and leg pain followed similar trajectories in the two cohorts, but there was less improvement on ODI in the CSORN cohort (P <.01). On multivariable logistic regression, the CSORN cohort was a significant independent predictor of patient satisfaction at 1-year follow-up (P <.001). Conclusions: Despite less improvement on ODI, patients enrolled in CSORN, as part of a universal health care system, reported higher rates of satisfaction at 3 months and 1 year post-operatively compared to patients enrolled within a multitier health system. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort. Objectives: To compare outcomes of minimally invasive surgery (MIS) vs open surgery (OPEN) for lumbar spinal stenosis (LSS) in patients with diabetes. Methods: Patients with diabetes who underwent spinal decompression alone or with fusion for LSS within the Canadian Spine Outcomes and Research Network (CSORN) database were included. MIS vs OPEN outcomes were compared for 2 cohorts: (1) patients with diabetes who underwent decompression alone (N = 116; MIS n = 58 and OPEN n = 58), (2) patients with diabetes who underwent decompression with fusion (N = 108; MIS n = 54 and OPEN n = 54). Modified Oswestry Disability Index (mODI) and back and leg pain were compared at baseline, 6–18 weeks, and 1-year post-operation. The number of patients meeting minimum clinically important difference (MCID) or minimum pain/disability at 1-year was compared. Results: MIS approaches had less blood loss (decompression alone difference 100 mL, P =.002; with fusion difference 244 mL, P <.001) and shorter length of stay (LOS) (decompression alone difference 1.2 days, P =.008; with fusion difference 1.2 days, P =.026). MIS compared to OPEN decompression with fusion had less patients experiencing adverse events (AEs) (difference 13 patients, P =.007). The MIS decompression with fusion group had lower 1-year mODI (difference 14.5, 95% CI [7.5, 21.0], P <.001) and back pain (difference 1.6, 95% CI [.6, 2.7], P =.002) compared to OPEN. More patients in the MIS decompression with fusion group exceeded MCID at 1-year for mODI (MIS 75.9% vs OPEN 53.7%, P =.028) and back pain (MIS 85.2% vs OPEN 70.4%, P =.017). Conclusions: MIS approaches were associated with more favorable outcomes for patients with diabetes undergoing decompression with fusion for LSS. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study. Objective: We evaluated the effectiveness of minimally invasive (MIS) tubular discectomy in comparison to conventional open surgery among patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN). Methods: We performed an observational analysis of data that was prospectively collected. We implemented Minimum Clinically Important Differences (MCIDs), and we adjusted for potential confounders with multiple logistic regression. Adverse events were collected according to the Spinal Adverse Events Severity (SAVES) protocol. Results: Three hundred thirty-nine (62%) patients underwent MIS tubular discectomy and 211 (38%) underwent conventional open discectomy. There were no significant differences between groups for improvement of leg pain and disability, but the MIS technique was associated with reduced odds of achieving the MCID for back pain (OR 0.66, 95% CI 0.44 to 0.99, P < 0.05). We identified statistically significant differences in favor of MIS for each of operating time (MIS mean (SD) 72.2 minutes (30.0) vs open 93.5 (40.9)), estimated blood loss (MIS 37.9 mL (36.7) vs open 76.8 (71.4)), length of stay in hospital (MIS 73% same-day discharge vs open 40%), rates of incidental durotomy (MIS 4% vs open 8%), and wound-related complications (MIS 3% vs open 9%); but not for overall rates of reoperation. Conclusions: Open and MIS techniques yielded similar improvements of leg pain and disability at up to 12 months of follow-up, but MIS patients were less likely to experience improvement of associated back pain. Small differences favored MIS for operating time, blood loss, and adverse events but may have limited clinical importance. [ABSTRACT FROM AUTHOR]