Long Term Costs of Maximum Non-Operative Treatments in Patients with Symptomatic Lumbar Stenosis or Spondylolisthesis that Ultimately Required Surgery: A Five-Year Cost Analysis.

METHODS

Retrospective cohort study OBJECTIVE.: The purpose of this study is to characterize the utilization and costs of MNTs prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis.

BACKGROUND

The costs and utilization of long-term maximal non-operative therapy (MNT) can be substantial, and in the current era of bundled payments, the duration of conservative therapy trials should be reassessed.

METHODS

A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. Only patients with lumbar stenosis or spondylolisthesis and those continuously active within the insurance system for at least 5 years prior to the index operation were eligible.

RESULTS

A total of 4,133 out of 497,822 (0.8%) eligible patients underwent 1, 2, or 3-level posterior lumbar instrumented fusion. 20.8% of patients were smokers, 44.5% had type II DM, and 38.2% were obese (BMI > 30 kg/m). Patient maximal non-operative therapy (MNT) utilization was as follows: 66.7% used NSAIDs, 84.4% used opioids, 58.6% used muscle relaxants, 65.5% received LESI, 66.6% attended 21.1% presented to the ED, and 24.9% received chiropractor treatments. The total direct cost associated with all MNT prior to index spinal fusion was $9,000,968; LESI comprised the largest portion of the total cost of MNT ($4,094,646, 45.5%), followed by NSAIDS ($1,624,217, 18.0%) and opioid costs ($1,279,219, 14.2%). At the patient level, when normalized per patient utilizing therapy, an average $4,010 was spent on non-operative treatments prior to index lumbar surgery.

CONCLUSIONS

Assuming minimal improvement in pain and functional disability after maximum non-operative therapies, the incremental cost effectiveness ratio (ICER) for MNTs could be highly unfavorable.

METHODS

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