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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 +
autograftCDI + 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 methodsBiological
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 +
autograftCDI + 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 costlyMore effective
Saving per QALY ofUSD 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
Rehabprotocol
Marginal costprimary sector
Total ofprotocol +primary sector
Cumulative costs
24 months postoperatively
Cost conscious
strategy???€ 37,249
€ 17,209
€ 17,885