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Lumbal Spondylodese Symposium 21/3/2011

Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

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Page 1: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

Lumbal Spondylodese

Symposium 21/3/2011

Page 2: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

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

Page 3: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

Randomized prospective Study in 148 pat. 1996 – 2000

University Hospital of Aarhus, Denmark.

.- Spine 2002, 2006, 2007, 2010

Brantigan ALIF +

autograftCDI + autograft

Page 4: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

CONCENSUS BASED

MEDICIN

VERSUS

EVIDENCED BASED

MEDICIN

Page 5: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

Phase 4

Phase 3

Phase 2

Phase 1

Clinical studies not necessary for CE marking

Henrik Malchou 1995

Page 6: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

Cemented THA 1997-2007

Page 7: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

Surgical options:

Disc surgery

Decompression

Disc arthroplasty

Total disc prosthesis

Flexible intervertebral stabil.

Fusion

Conservative treatment ?

Surgery ?

Chronic Low Back Pain

Page 8: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

Spinal fusion

Patient selection

Surgical methodsBiological

factors

Surgical

technique

Growth factors

Elements in Surgical Outcome

Page 9: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

Regenerative Medicine

Degenerative Disc Disease (DDD)

MRI of the Lumbar Spine

Page 10: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

The spectrum of treatment available for

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

Page 11: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

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

?

Page 12: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

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

Page 13: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

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

Page 14: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

Randomized prospective Study in 148 pat. 1996 – 2000

University Hospital of Aarhus, Denmark.

.- Spine 2002, 2006, 2007, 2010

Brantigan ALIF +

autograftCDI + autograft

Page 15: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

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 costlyMore effective

Saving per QALY ofUSD 49,306

(27,183;2,735,712)

Page 16: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

REHABILITATION

AFTER SPINAL FUSION

Page 17: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

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)

Page 18: Lumbal Spondylodese - orf-aarhus.dk · Lumbal Spondylodese Indikationer •Spondylolisthese •DDD/spondylose •Postdiscectomi syndrom •Fraktursequelae •Skoliose •Spinalstenose

€ 0

€ 5,000

€ 10,000

€ 15,000

€ 20,000

€ 25,000

€ 30,000

€ 35,000

€ 40,000

€ 45,000

Video Café Training

Rehabprotocol

Marginal costprimary sector

Total ofprotocol +primary sector

Cumulative costs

24 months postoperatively

Cost conscious

strategy???€ 37,249

€ 17,209

€ 17,885