Lumbal Spondylodese - orf- Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi

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Text of Lumbal Spondylodese - orf- Lumbal Spondylodese Indikationer •Spondylolisthese...

  • Lumbal Spondylodese

    Symposium 21/3/2011

  • Lumbal Spondylodese

    Indikationer • Spondylolisthese

    • DDD/spondylose

    • Postdiscectomi syndrom

    • Fraktursequelae

    • Skoliose

    • Spinalstenose

    Udredning. Effekt af konditionstræning. Mekaniske versus neurogene smerter. (Rtg, Dynamisk Rtg, MR, Livskvalitets/smerte-score) Obs red flags

  • Randomized prospective Study in 148 pat. 1996 – 2000

    University Hospital of Aarhus, Denmark.

    .- Spine 2002, 2006, 2007, 2010

    Brantigan ALIF +

    autograft CDI + autograft

  • CONCENSUS BASED

    MEDICIN

    VERSUS

    EVIDENCED BASED

    MEDICIN

  • Phase 4

    Phase 3

    Phase 2

    Phase 1

    Clinical studies not necessary for CE marking

    Henrik Malchou 1995

  • Cemented THA 1997-2007

  • Surgical options:

    Disc surgery

    Decompression

    Disc arthroplasty

    Total disc prosthesis

    Flexible intervertebral stabil.

    Fusion

    Conservative treatment ?

    Surgery ?

    Chronic Low Back Pain

  • Spinal fusion

    Patient selection

    Surgical methods Biological

    factors

    Surgical

    technique

    Growth factors

    Elements in Surgical Outcome

  • Regenerative Medicine

    Degenerative Disc Disease (DDD)

    MRI of the Lumbar Spine

  • The spectrum of treatment available for

    symptomatic DDD by total endplate score (TEPS). Rajasekaran S, et al. Eur Spine J. 2008

  • Costs of Orthopedic Disease

    Production loss from absenteeism and disability

    Loss of health-related life-quality

    Diagnostics, treatment, care and rehabilitation

    Patient's 'out-of-pocket' costs

    Informal care

    ?

  • Study Design in Economics

     Long term follow ups

     Outcomes measured by EQ-5D and converted into QALYs using weights of the general population (Dolan et al. 1996)

     Costs measured from a societal perspective and encompassed  Service utilisation in primary care

     Service utilisation in secondary care

     Patients’ costs

     Productivity costs

    Cb-2008

  • Incremental cost-effectiveness ratio

     Introduction  Materials and methods  Results  Discussion

    -25,000

    0

    25,000

    50,000

    -50 -25 0 25 50

    Incremental effects

    (score in DPQ)

    Incremental costs

    (DKK)

    Instrumented fusion

    ? Daily activities

    ? Work/leisure

    ? Anxiety/depression

    ? Social life

    cost-effective

    not

    cost-effective

    λ

  • Randomized prospective Study in 148 pat. 1996 – 2000

    University Hospital of Aarhus, Denmark.

    .- Spine 2002, 2006, 2007, 2010

    Brantigan ALIF +

    autograft CDI + autograft

  • Cost-effectiveness of circumferential versus posterolateral fusion

    -30,000

    -15,000

    0

    15,000

    30,000

    -0.5 0 0.5 1

    Incremental QALYs

    Incremental costs

    (2004-USD)

    Less costly More effective

    Saving per QALY of USD 49,306

    (27,183;2,735,712)

  • REHABILITATION

    AFTER SPINAL FUSION

  • Study design

    Follow up

    3 months

    (baseline)

    Follow up

    6 months

    Follow up

    12 months

    Follow up

    24 months

    Surgery

    n=115

    25 patients

    declined

    inclusion

    Drop out

    9 patients

    Group 1

    Video, n=29

    Group 2

    Café, n=26

    Group 3

    Training, n=26

    Randomization

    (n=90)

    Drop out

    2 patients

    Register data

    (n=90)

  • € 0

    € 5,000

    € 10,000

    € 15,000

    € 20,000

    € 25,000

    € 30,000

    € 35,000

    € 40,000

    € 45,000

    Video Café Training

    Rehab protocol

    Marginal cost primary sector

    Total of protocol + primary sector

    Cumulative costs

    24 months postoperatively

    Cost conscious

    strategy??? € 37,249

    € 17,209

    € 17,885