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SPINE Volume 39, Numher 5, pp 388-393 ©2014, Lippincott Williams & Wilkins
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Cost and Value of Spinal Deformity Surgery Megan Carroll Paulus, MD,* Seyed Babak Kalantar, MD,* and Kris Radcliff, M D t
Study Design. Literature review. Objective. To assess (1) quality of life in patients with adult scoliosis who underwent nonoperative and/or surgical treatment, and (2) cost-effectiveness of different scoliosis treatment modalities. Summary of Background Data. Recently there has been an interest in examining quality of life of patients undergoing treatment for adult scoliosis, comparing the value of nonoperative versus operative management. This article reviews the current literature on treatment of adult scoliosis, in the hopes of drawing conclusions for the best approach to these patients. M e t h o d s . MEDLINE and PubMed databases were searched to identify articles. Health-related quality of life measures included Oswestry Disability Index scores, Scoliosis Research Society (SRS) instrument scores, 12-ltem Short Form Health Survey, and numerical rating scale for leg and/or back pain. Studies included were those involving patients with adult scoliosis who underwent primary surgery or nonoperative management. The studies that focused on the change in validated outcome scores from the onset of the study to final follow-up were found to be valuable. Studies on predominantly adolescent scoliosis and those that only measured postoperative outcomes scores were excluded. Results. The SRS-22, Oswestry Disability Index, 12-ltem Short Form Health Survey, and numerical rating scale were found to be validated for measuring quality of life in patients with scoliosis. Thirteen studies were included, which evaluated changes in healthrelated quality of life outcomes from baseline in surgical and nonsurgical treatment of adult scoliosis. There was a trend toward improved quality of life measures in patients undergoing surgical treatment for adult scoliosis. Conclusion. Adults with painful and disabling scoliosis may benefit from surgical treatment compared with nonsurgical treatment, given
From the 'Department of Orthopaedics, Medstar Georgetown University Hospital, Washington, DC; and tRothman Institute, Thomas Jefferson University, Philadelphia, PA. Acknowledgment date: July 9, 2013. First revision date: September 10, 2013. Second revision date: November 11, 2013. Acceptance date: November 19, 2013. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: consultancy, royalties, stock/stock options and travel/accommodations/meeting expenses. Address correspondence and reprint requests to Megan Carroll Paulus, MD, Medstar Georgetown University Hospital, Department of Orthopaedics, 3800 Reservoir Road, 1 Gorman, Washington, DC 20007; E-mail: meganjcarroll® gmail.com DOI: 10.1097/BRS.OOOOOOOOOOOOOl 50 388
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the proper indications. Nonsurgical treatment does not seem to be cost-effective and has not shown to have a positive impact on quality of life, although there is a possibility that patients' health may have deteriorated if they did not receive the nonsurgical treatment. Future prospective studies focusing on the cost-effectiveness of adult scoliosis treatment and improvement of quality of life are needed to confirm the assertion of the current retrospective literature that surgery provides better quality of life than nonoperative treatment. Key w o r d s : adult scoliosis surgery quality of life, nonoperative, operative, outcomes, cost, adult, spine deformity, QALY, surgery, HRQOL.
Level of Evidence: N/A Spine 2014;39:388-393
A
dult scoliosis may be a de novo deformity associated with degenerative changes, or a progression of adolescent idiopathic scoliosis into adulthood. ' In both cases, disc and/or facet degeneration can lead to increased deformity contributing to pain and disability. Adults with scoliosis have reported worse health-related quality of life (HRQOL), limitations in function, increased analgesic use, and increased incidence of back pain compared with adults without scoliosis.^-^ In contrast to adolescents with scoliosis in which asymptomatic curves are treated on the basis of measurement and progression, adults with scoliosis are primarily treated for pain and disability."* Nonoperative treatment measures are often exhausted before surgical treatment is considered in adult scoliosis. The decision to undergo surgical treatment is ultimately made after thorough discussion between physician and patient because the complexity of the surgery and its high risk of complications should be well understood. With the growing elderly population, physicians can expect to see an increase of patients with scoliosis and an evidencebased approach to treatment of these patients is essential. Adult spinal deformity presents a challenging situation for the treating orthopedic surgeon because there is lack of clear evidence-based recommendations for nonoperative versus operative treatment. The purpose of this article is to review the current literature to (1) assess quality of life in patients with adult scoliosis who underwent nonoperative and/or surgical treatment, and (2) assess the cost-effectiveness of different scoliosis treatment modalities reported in the hteratiire.
MATERIALS AND METHODS MEDLINE and PubMed databases were searched to identify articles using the following keywords: "adult scoliosis," March 2014
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"adult spine deformity," "adult scoliosis surgery," "QALY," "surgery," "nonoperative," "outcomes," and "cost." HRQOL measures searched included Oswestry Disability Index (ODI) scores, Scoliosis Researcb Society (SRS) instrument scores, 12-Item Sbort Eorm Health Survey (SE-12), and numerical rating scale (NRS) for leg and/or back pain. Abstracts were screened and tbe studies included primarily involve patients witb adult scoliosis, who underwent primary surgery or nonoperative management. Studies that focused on the change in validated outcome scores from the onset of the study to final follow-up were found to be valuable. Studies on predominantly adolescent scoliosis and tbose that only measured postoperative outcomes scores were excluded. RESULTS Quality of Life Assessment To quantify the impact of scoliosis on affected individuals, self-assessment of measures such as health status, pain, disability, and self-image must be establisbed. In tbe adult witb scoliosis, measurements in tbese domains elucidate tbe value of surgical or nonsurgical care. The SRS instrument, particularly the SRS-22 (http:// www.srs.org/professionals/SRS_outcomes/srs-22_ sample.pdf, accessed December 26, 2013), has proven to be a reliable and valid instrument used in measuring outcomes and bealtb status in adults witb spinal deformity.^ The SRS-22 is a questionnaire containing 22 questions that cover 5 domains: 5 questions each on pain, self-perceived image, function, and mental health, and 2 questions on satisfaction with management.' Baldus et al^ validated the use of the SRS instrument in patients witb adult spinal deformity making it a valuable HRQOL tool. When compared with "normal" volunteers, adults diagnosed with idiopathic or de novo scoliosis had significant differences in terms of pain, appearance, and activity SRS domains. Of note, the mental healtb domain scores of males of ages 61 to 80 were not found to be statistically different between patients witb deformity and tbose with no deformity.* Otber measures sucb as tbe ODI, SE-12, and tbe Cbarlson Comorbidity Index may be useful in identifying patients who would benefit from surgical treatment.'' Tbe Cbarlson Comorbidity Index is considered a validated and reproducible metbod of determining comorbidity and predicting outcome in tbe elderly and the ODI is thought to be a validated condition-specific outcome measure in spine-related disability.*-' Tbe SRS-22 bas also been found to correlate well witb tbe SE-12 and the ODI in assessing patients with adult spinal deformity.'" However, the SRS has been found to be more responsive to change brougbt on by primary surgical treatment of adult scoliosis wben compared witb ODI and SE-12." Tbe psychometric qualities of the SRS instrument such as concurrent validity, internal consistency, reliability over time, and sensitivity to cbange bave been confirmed in patients witb adult deformity.' Eurthermore, the SRS-22, ODI, and NRS for leg and/or back pain bave been shown to accurately predict SE-6D scores, allowing for cost-utility analysis.^^-'^ Tbese tools can be useful in Spine
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quantifying the effect of treatment on the patients' quality of life and for evaluation of quality-adjusted life-years values and thus, cost-effectiveness. Current literature supports the use of these tools to place a value on treatment choices. Nonoperative Treatment Nonoperative treatment of adult scoliosis includes a range of options from no intervention at all to physical therapy, exercise therapy, injections, chiropractic care, and pain management. Glassman et aP'* evaluated the resource utilization in nonsurgical patients with adult spinal deformity. He divided the nonsurgical patients into distinct high- and low-symptom patients, demonstrating 90% utilization of nonsurgical resources in the high-symptom patients with a greater use of narcotics, epidural blocks, analgesics, pain management referral, bed rest, strength training, nerve root blocks, and stabilization exercises. Surprisingly, there was 70% utilization in nonsurgical treatment modalities in the low-symptom group as well. Despite the popularity of resource utilization, the efficacy of these modalities remains unclear. Another study by Glassman et aP^ reviewed 123 patients wbo underwent nonoperative treatment for adult scoliosis. Of tbe 55 patients wbo had no intervention there was a small increase in the SRS satisfaction subscore, but all other HRQOL measures remained stable. Surprisingly, among tbe 68 patients wbo bad at least 1 nonoperative treatment modality, the most common being medication, exercise therapy, physical therapy, chiropractic treatment, and injections, there was no statistically significant mean change in any of the HRQOL outcome parameters during tbe 2-year observation period. Altbougb patient outcomes did not improve, tbere was no decline in tbeir quality of life, wbicb should not be disregarded. Mean treatment cost in this 2-year time frame was $10,815. This study brings to question tbe value of nonoperative treatment metbods, bowever, future studies need to measure the benefit of nonsurgical treatment modalities in a randomized manner to better delineate its wortb and cost-effectiveness. In 2007, Everett and Patel'* published a comprehensive systematic review of tbe literature pertaining to nonoperative treatment of adult scoliosis. In their search for clinical studies on adults with degenerative scoliosis treated with various nonoperative treatment modalities, only 2 articles for bracing, 3 articles for physical/exercise therapy, 2 articles on cbiropractic care, and 1 article on epidural steroid injections fit the criteria for review. Weak, level IV evidence was found for the role of bracing, pbysical therapy, and chiropractic care in treatment. The use of transforaminal epidural steroid injections in treating radiculopatby was supported witb one level III evidence study. This review emphasized the lack of evidence and quality clinical research supporting conservative care for adult scoliosis. These studies lack any cohesiveness in terms of using similar HRQOL outcome measures making it difficult to compare them to other studies. Eurtbermore, tbe SRS, ODI, and SE-12, wbicb we know to be valid measures for adult scoliosis, were not used as end points in any nonoperative management studies in tbis systematic review. www.spinejournal.com
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Value of Spinal Deformity Surgery • Paulus et al
Operative Treatment operative treatment had no change in either. In a review of There are no strict criteria stating when and when not to 317 patients with adult scoliosis and associated back pain operate on adult patients with scoliosis. However, adults by Smith et al,-^ 147 patients chose to be managed surgiwith spinal deformity will often present with pain and funccally, whereas the remaining 170 chose nonoperative treattional limitations, negatively impacting their quality of life. ment. The operative group started with significantly greater Bess et al'* retrospectively assessed 290 patients with adult back pain and disability with worse health status measured scoliosis who had undergone either operative or nonoperaby the SRS-22, ODI, and NRS scores for back pain. At the tive treatment. He concluded that pain and disability were time of 2-year follow-up, they had significantly less back predictors of operative treatment in older adults, as opposed pain and disability with improved health status compared to coronal deformity in adolescents and young adults. Recent with the nonoperative group. The authors concluded that studies have focused on the importance of correcting sagitoperative treatment offers the potential to improve back pain tal imbalance in adult spinal deformity because it seems to and quality of life significantly. Smith et aP^ retrospectively be directly related to worse HRQOL scores.'^'"* Mac-Thiong reviewed 208 patients with adult scoliosis and back pain: et aP found that a poor ODI was associated with a sagittal 96 of these patients underwent operative treatment and 112 C7 plumb line greater than 6 cm, a sagittal gravity line greater were managed nonoperatively. At 2-year follow-up, the nonthan 6 cm, and a C7 plumb line in front of the gravity line. operative group had no significant change in ODI or pain, Blondel et ap° evaluated the pre- and postoperative sagittal whereas the operative group had a significant improvement vertical axis in adult spinal deformity and found that the best in both ODI and pain. Li et aF compared self-reported and HRQOL outcomes were found in patients with sagittal vertiradiographical outcomes in adults older than 65 managed cal axis correction more than 120 mm and at least 66% of operatively versus nonoperatively. After 2-year follow-up, correction. Lafage et aP found that there is an even greater only the operative group had significant improvements in correlation with HRQOL and T l spinopelvic inclination SRS-22, ODI, and SF-12, despite there being a 17% compli(angle between Tl-hip axis and vertical) versus the sagittal cation rate. Direct comparison of the groups demonstrated vertical axis. These studies suggest that improving the sagittal significantly less pain, better HRQOL, self-image, mental balance with surgical correction will lead to improved overhealth, and greater satisfaction measured with the SRS-22 all outcomes; however, there does not seem to be any clear in the operative group. Although all of these studies support threshold for surgical intervention. the use for operative interventions, they are retrospective analyses. Well-designed, high-quality, prospective studies are Quality of life assessments are extremely important in essential to make recommendations for or against surgical demonstrating effectiveness of surgery and its improvetreatment. ment on the patients' well-being. In 2010, a systematic hterature review of surgical treatment in adult scoliosis conThere are a limited number of prospective reports of the cluded that there is evidence showing an improvement in results of surgical treatment of adult scoliosis. In a review by radiographical and clinical outcomes at 2-year follow-up.-' Bridwell et al.,^'^ the literature published in the Journal of Bone There was a complication rate of 4 1 % in this pooled analyand Joint Surgery from 1996 to 2006 lacked prospective studsis, consistent with other reports, however, there was no ies regarding the operative treatment of adult scoliosis. They consensus among the different studies regarding the classifisubsequently published a prospective study of 56 patients cation of complications. Several studies only mentioned the with adult scoliosis who underwent surgical treatment and number of complications, and it is unclear from this sysdemonstrated a significant improvement in the SRS-22, ODI, tematic review what the actual complications were. Despite and SF-12 physical health scores." In a larger study in 2009, this limitation, the high rate of complications did not seem Bridwell et aP^ assessed 160 consecutive patients with adult to affect outcome. symptomatic lumbar scoliosis who underwent operative versus Dickson et aP compared the results of 111 patients with nonoperative treatment. At 2-year follow-up, the operative adult scoliosis who were recommended operative treatment. group significantly improved in all quality of life measures, Of these patients, 81 underwent surgery, whereas the other 30 whereas the nonoperative group had no change in quality of declined. At the average 5-year follow-up, the surgical group life. This study, however, was limited with only 45% followhad significantly decreased pain and fatigue, as well as a sigup in the nonoperative group. Albert et aP° prospectively nificantly improved self-image and ability to perform physistudied outcome measures in 68 adults before and after spinal cal, functional, and positional tasks when compared with deformity surgery. At 2-year follow-up, they found significant the nonoperative group. Kluba et a P evaluated 55 patients improvements in scores for physical function, social funcwith painful degenerative lumbar scoliosis who underwent tion, bodily pain, and perceived health. Of note, the results either surgical or nonsurgical management after being recof patients who experienced complications were no different ommended surgery. Nonsurgical management included oral than those that did not have any complications. analgesics with nonsteroidal anti-infiammatory drugs, and Operative techniques for the treatment of scoliosis have opioids, PT, bracing, corticoid infiltrations, and acupuncture. evolved throughout the years. Rose etaP' analyzed 68 patients At mean follow-up of about 4 years, the operative group had treated surgically for adult idiopathic scoliosis with either significant improvement in walking distance and decreased pedicle screws or traditional hook/hybrid instrumentation. In use of analgesics, whereas the patients who underwent nonall patients, there was a significant improvement in the SRS 390 www.spinejournal.com March 2014
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TABLE 1.
Value of Spinal Deformity Surgery • Paulus et al
jjigffljryg
Author and Year
Operative Nonoperative Minimum Follow-up (No.) (No.)
Classman et al,^^ 2010 Zimmerman etat,^~ 2010
123
Fifty-five patients with no treatment: significant improvement in SRS satisfaction, no change in SF-12 and ODI 2yr
Sixty-eight patients used nonoperative resources: no significant change in SRS-22, SF-12, and ODI 2yr
35
Change in HRQOL Scores
Significant improvement in the ODI and SF-36 physical and mental health measures Significant improvements in ODI, SRS, and NRS in operative group compared with nonoperative group
Bridwell eta/," 2009
85
75
2yr
Operative group had significant improvement in ODI, SRS, and NRS compared with baseline. Nonoperative group had no significant change in ODI, SRS, and NRS compared with baseline Nonoperative group had no significant change in ODI or NRS
Smith et a/,2'2009
96
112
2yr
Operative group showed significant improvement in ODI, NRS Operative group had significantly lower NRS scores and ODI compared with nonoperative group Nonoperative group had no significant change in SRS-22, ODI, and NRS
Smith ef a/," 2009
147
170
2yr
Operative group showed significant improvement in SRS-22, ODI, and NRS Operative group had significantly lower NRS and ODI, and higher SRS-22 compared with nonoperative group
Rose eta/,'' 2009
2yr
68
SRS significantly improved in all patients SRS and ODI significantly improved between 6 mo and 1 yr postoperatively
Glassman etal,^'' 2009
2yr
283
Worsening NRS leg pain and trend toward improved SF-12 between 6 mo and 1 yr postoperatively No significant difference in SRS, ODI, NRS, and SF-12 between 1 and 2 yr postoperatively Operative group had significantly better SRS-22
49
2yr
L\ et al," 2009
34
Peelleefa/,"2008
30
2yr
Significant improvement in pain and self-image domains, no significant change in function or mental health domains of SRS
Bridwell eta/," 2007
56
2yr
Significant improvement in SRS-22, ODI, and SF-12 physical component
Bess et a/," 2007
56
2yr
Significant improvement in SRS scores after pedicle screw or hook instrumentation
Shapiro etal,'" 2003
16
2yr
Significant improvement in SRS and ODI
Albert ef a/,» 1995
55
lyr
Statistically significant improvements in postoperative scores for SF-36 physical function, social function, bodily pain, and perceived health change
No statistical difference between operative and nonoperative group in terms of ODI and SF-12
HROOL indicates heakh-related quality of life; ODI, Oswestry Disability Index; SRS, Scoliosis Research Society; SF-12, 12-ltem Short Form Health Survey: SF-36, 36-ltem Short Form Health Survey; NRS, numerical rating scale.
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outcome scores despite the different techniques used for correction and fixation. Zimmerman et aP^ completed a prospective study evaluating functional outcomes and complications in 35 adults undergoing primary spinal surgery for scoliosis. At 2-year follow-up, there was a significant improvement in the ODI and SF-36 physical and mental health measures. Even with a 49% complication rate, there were no differences in outcomes when comparing patients with and those without complications. It has been previously thought that the risks of operative treatment in the adult with scoliosis outweigh the benefits due to the large number of complications.^ The SRS database was used to assess the major complication rate in adult scoliosis surgery cases from 2004 to 2007.^^ The overall complication rate was 13.4%. This number was likely significantly less than previously published complication rates as minor complications were not reported. Despite reported complication rates, multiple studies have shown no difference in quality of life assessment of patients who had complications compared with those who did not.^'^^-^^ Therefore, although it is vital for the spinal surgeon to discuss the risks of surgery along with complications, the high rate should not deter the surgeon or patient from undergoing surgery if it is indicated and the patient has been appropriately counseled.
Value of Spinal Deformity Surgery • Paulus et al
uating the incremental cost-effectiveness ratio during a 4-year period.^^ The design and execution of the Spine Patient Outcomes Research Trial could be reproduced in the future for adult scoliosis to draw conclusions on the cost-effectiveness of treatment. Translation of the SRS, ODI, and NRS outcome scores to a utility score may allow for this cost-effective analysis evaluating quality-adjusted life-years, placing an objective value on the management of scoliosis.
DISCUSSION
Adult scoliosis continues to be a growing challenge for the orthopedic surgeon as the hterature to support treatment is sparse. Nonoperative treatment modalities are used in the majority of patients presenting with pain and disability; however, there is no clear consensus to whether they are even effective at all. There is a paucity of literature on nonoperative treatment that uses validated HRQOL outcome measures. Current available literature demonstrates a trend that nonoperative treatment for adult scoliosis is ineffective. On the contrary, it does not worsen the patients' quality of life suggesting there may be some benefit. The lack of highquality, randomized studies makes the value of scoliosis care difficult to assess. There seems to be a trend toward improved quality of life measures, pain, and disability in those patients who undergo surgical treatment (Table 1). Future studies with randomization and longer-term followup are necessary to make a strong recommendation for Costs or against surgery in the adult with scoliosis. As for costCost-effectiveness for treatment of adult scoliosis is not well effectiveness, although literature exists on cost of surgical understood. In an effort to understand the value of nonoperative management, Glassman et aP'* investigated nonopera- treatment in adolescent scoliosis, no studies could be found pertaining to adults. An incremental cost-effectiveness ratio tive resource utilization and cost of treatment during a 2-year for surgical versus nonsurgical treatment of adult scoliosis, observation period in adult scoliosis. The mean cost of treatsimilar to that done in the Spine Patient Outcomes Research ment during a 2-year period was in the range from $9,704 to Trial for intervertebral herniated discs, would further eluci$14,022 in the low and high symptom groups, respectively date the value of scoliosis care. with no significant change in HRQOL. This study highlights the value of nonoperative management with respect to quality of life outcomes as well as cost. CONCLUSION In terms of surgical treatment of adult scoliosis, studies On the basis of the available literature, the authors conclude evaluating cost-effectiveness are lacking in the current literathat adults with painful and disabling scoliosis may benefit ture. Kamerlink et aP'' published a retrospective review of the from surgical treatment compared with nonsurgical treatment. hospital costs of surgical treatment of adolescent idiopathic Nonsurgical treatment does not seem to be cost-effective, and scoliosis. The hospital costs were in the range from $29,955 it has not shown to have a positive impact on the quality of to $60,754 with the main contributors being implants used, life of these patients. There is convincing evidence that surintensive care unit stays, operating room time, and bone graft gical treatment improves the quality of life of patients with use. It may be possible to extrapolate cost analysis for adults in adult scoliosis causing pain and disability. Surgery could be this way, however, evaluating the change in quality of life after cost-effective; however, strong conclusions cannot be drawn surgery is necessary in understanding the benefit of those costs. because of the lack of literature regarding this topic. Future The Spine Patient Outcomes Research Trial may serve studies are needed to evaluate the cost-effectiveness of surgias a model for analysis of cost-effectiveness of surgical vercal versus nonsurgical treatment in the adult with scoliosis. sus nonsurgical treatment in adult scoliosis. Tosteson et aP^ evaluated the cost-effectiveness of surgical versus nonoperative treatment among patients with spinal stenosis, degeneraKey Points tive spondylolisthesis, and intervertebral disc herniation. The investigators analyzed the impact of treatment on quality• The lack of high-quality, randomized studies adjusted life-years using a validated instrument (EQ-5D), makes the value of scoliosis care difficult to resource utilization, and indirect costs. The study concluded assess. that surgery for these conditions was cost-effective after eval392 www.spinejournal.com March 2014
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ü Adults with painful and disabling scoliosis may benefit from surgical compared with nonsurgical treatnnent given the proper indications. •
Nonsurgical treatnnent does not seem to be cost-effective and has not shown to have a positive impact on quality of life, although there is a possibility that patients' health may have deteriorated if they did not receive the nonsurgical treatment.
•
Future studies are needed to evaluate the cost-effectiveness of surgical versus nonsurgical treatment in the adult with scoliosis.
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16. Everett CR, Patel RK. A systematic literature review of nonsurgical treatment in adult scoliosis. Spine 2007;32:S130^. 17. Glassman SD, Bridwell K, Dimar JR, et al. The impact of positive sagittal balance in adult spinal deformity. Spine 2005;30:2024-9. 18. Glassman SD, Berven S, Bridwell K, et al. Correlation of radiographic parameters and clinical symptoms in adult scoliosis. Spine 2005;30:682-8. 19. Mac-Thiong JM, Transfeldt EE, Mehbod AA, et al. Can C7 plumb line and gravity line predict health-related quality of life in adult scoKosis? Spine 2009;34:E519-27. 20. Blondel B, Schwab F, Ungar B, et al. Impact of magnitude and percentage of global sagittal plane correction on health-related quality of life at 2-years follow-up. Neurosurgery 2012;71:341-8. 21. Lafage V, Schwab F, Patel A, et al. Pelvic tilt and truncal inclination: two key radiographie parameters in the setting of adults with spinal deformity. Spine 2009;34:E599-606. 22. Yadla S, Maltenfort MG, Ratliff JK, et al. Adult scoliosis surgery outcomes: a systematic review. Neurosurg Focus 2010;28:E3. 23. Dickson JH, Mirkovic S, Noble PC, et al. Results of operative treatment of idiopathic scoliosis in adults. / Bone Joint Surg Am 1995;77:513-23. 24. Kluba T, Dikmenli G, Dietz K, et al. Comparison of surgical and conservative treatment for degenerative lumbar scoliosis. Arch Orthop Trauma Surg 2009;129:l-5. 25. Smith JS, Shaffrey CI, Berven S, et al. Improvement of back pain with operative and nonoperative treatment in adults with scoliosis. Neurosurgery 2009;65:86-93. 26. Smith JS, Shaffrey CI, Berven S, et al. Operative versus nonoperative treatment of leg pain in adults with scoliosis. Spine 2009;34: 1693-8. 27. Li G, Passias P, Kozanek M, et al. Adult scoliosis in patients over sixty-five years of age: outcomes of operative versus nonoperative treatment at a minimum two-year follow-up. Spine 2009;34: 2165-70. 28. Bridwell KH, Berven S, Edwards CII, et al. The problems and limitations of applying evidence-based medicine to primary surgical treatment of adult spinal deformity. Spine 2007;32(suppl 19):S135-9. 29. Bridwell KH, Glassman S, Horton W, et al. Does treatment (nonoperative and operative) improve the two-year quality of life in patients with adult symptomatic lumbar scoliosis. Spine 2009;34:2171—8. 30. Albert TJ, Purtill J, Mesa J, et al. Health outcome assessment before and after adult deformity surgery. Spine 1995;20:2002-5. 31. Rose PS, Lenke LG, Bridwell KH, et al. Pedicle screw instrumentation for adult idiopathic scoliosis: an improvement over hook/ hybrid fixation. Spine 2009;34:852-8. 32. Zimmerman RM, Mohamed AS, Skolasky RL, et al. Functional outcomes and complications after primary spinal surgery for scoliosis in adults aged forty years or older. Spine 2010;35:1861-6. 33. Sansur CA, Smith JS, Coe JD, et al. Scoliosis Research Society morbidity and mortality of adult scoliosis surgery. Spine 2011;36: E593-7. 34. Kamerlink JR, Quirno M, Auerbach JD, et al. Hospital cost analysis of adolescent idiopathic scoliosis correction surgery in 125 consecutive cases. / Bone Joint Surg Am 2010;92:1097-104. 35. Tosteson AN, Tosteson TD, Lurie JD, et al. Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation. Spine 2011;36:2061-8. 36. Glassman SD, Schwab R, Bridwell KH, et al. Do 1-year outcomes predict 2-year outcomes for adult deformity surgery? Spine J 2009;9:317-22. 37. Peelle MW, Boachie-Adjei O, Charles G, et al. Lumbar curve response to selective thoracic fusion in adult idiopathic scoliosis. SpmeJ 100S;8:897-903. 38. Shapiro GS, Taira G, Boachie-Adjei O. Results of surgical treatment of adult idiopathic scoliosis with low back pain and spinal stenosis: a study of long-term clinical radiographie outcomes. Spine 2003;28:358-63.
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SPINE Volume 39, Numher 5, pp 388-393 ©2014, Lippincott Williams & Wilkins
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Cost and Value of Spinal Deformity Surgery Megan Carroll Paulus, MD,* Seyed Babak Kalantar, MD,* and Kris Radcliff, M D t
Study Design. Literature review. Objective. To assess (1) quality of life in patients with adult scoliosis who underwent nonoperative and/or surgical treatment, and (2) cost-effectiveness of different scoliosis treatment modalities. Summary of Background Data. Recently there has been an interest in examining quality of life of patients undergoing treatment for adult scoliosis, comparing the value of nonoperative versus operative management. This article reviews the current literature on treatment of adult scoliosis, in the hopes of drawing conclusions for the best approach to these patients. M e t h o d s . MEDLINE and PubMed databases were searched to identify articles. Health-related quality of life measures included Oswestry Disability Index scores, Scoliosis Research Society (SRS) instrument scores, 12-ltem Short Form Health Survey, and numerical rating scale for leg and/or back pain. Studies included were those involving patients with adult scoliosis who underwent primary surgery or nonoperative management. The studies that focused on the change in validated outcome scores from the onset of the study to final follow-up were found to be valuable. Studies on predominantly adolescent scoliosis and those that only measured postoperative outcomes scores were excluded. Results. The SRS-22, Oswestry Disability Index, 12-ltem Short Form Health Survey, and numerical rating scale were found to be validated for measuring quality of life in patients with scoliosis. Thirteen studies were included, which evaluated changes in healthrelated quality of life outcomes from baseline in surgical and nonsurgical treatment of adult scoliosis. There was a trend toward improved quality of life measures in patients undergoing surgical treatment for adult scoliosis. Conclusion. Adults with painful and disabling scoliosis may benefit from surgical treatment compared with nonsurgical treatment, given
From the 'Department of Orthopaedics, Medstar Georgetown University Hospital, Washington, DC; and tRothman Institute, Thomas Jefferson University, Philadelphia, PA. Acknowledgment date: July 9, 2013. First revision date: September 10, 2013. Second revision date: November 11, 2013. Acceptance date: November 19, 2013. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. Relevant financial activities outside the submitted work: consultancy, royalties, stock/stock options and travel/accommodations/meeting expenses. Address correspondence and reprint requests to Megan Carroll Paulus, MD, Medstar Georgetown University Hospital, Department of Orthopaedics, 3800 Reservoir Road, 1 Gorman, Washington, DC 20007; E-mail: meganjcarroll® gmail.com DOI: 10.1097/BRS.OOOOOOOOOOOOOl 50 388
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the proper indications. Nonsurgical treatment does not seem to be cost-effective and has not shown to have a positive impact on quality of life, although there is a possibility that patients' health may have deteriorated if they did not receive the nonsurgical treatment. Future prospective studies focusing on the cost-effectiveness of adult scoliosis treatment and improvement of quality of life are needed to confirm the assertion of the current retrospective literature that surgery provides better quality of life than nonoperative treatment. Key w o r d s : adult scoliosis surgery quality of life, nonoperative, operative, outcomes, cost, adult, spine deformity, QALY, surgery, HRQOL.
Level of Evidence: N/A Spine 2014;39:388-393
A
dult scoliosis may be a de novo deformity associated with degenerative changes, or a progression of adolescent idiopathic scoliosis into adulthood. ' In both cases, disc and/or facet degeneration can lead to increased deformity contributing to pain and disability. Adults with scoliosis have reported worse health-related quality of life (HRQOL), limitations in function, increased analgesic use, and increased incidence of back pain compared with adults without scoliosis.^-^ In contrast to adolescents with scoliosis in which asymptomatic curves are treated on the basis of measurement and progression, adults with scoliosis are primarily treated for pain and disability."* Nonoperative treatment measures are often exhausted before surgical treatment is considered in adult scoliosis. The decision to undergo surgical treatment is ultimately made after thorough discussion between physician and patient because the complexity of the surgery and its high risk of complications should be well understood. With the growing elderly population, physicians can expect to see an increase of patients with scoliosis and an evidencebased approach to treatment of these patients is essential. Adult spinal deformity presents a challenging situation for the treating orthopedic surgeon because there is lack of clear evidence-based recommendations for nonoperative versus operative treatment. The purpose of this article is to review the current literature to (1) assess quality of life in patients with adult scoliosis who underwent nonoperative and/or surgical treatment, and (2) assess the cost-effectiveness of different scoliosis treatment modalities reported in the hteratiire.
MATERIALS AND METHODS MEDLINE and PubMed databases were searched to identify articles using the following keywords: "adult scoliosis," March 2014
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"adult spine deformity," "adult scoliosis surgery," "QALY," "surgery," "nonoperative," "outcomes," and "cost." HRQOL measures searched included Oswestry Disability Index (ODI) scores, Scoliosis Researcb Society (SRS) instrument scores, 12-Item Sbort Eorm Health Survey (SE-12), and numerical rating scale (NRS) for leg and/or back pain. Abstracts were screened and tbe studies included primarily involve patients witb adult scoliosis, who underwent primary surgery or nonoperative management. Studies that focused on the change in validated outcome scores from the onset of the study to final follow-up were found to be valuable. Studies on predominantly adolescent scoliosis and tbose that only measured postoperative outcomes scores were excluded. RESULTS Quality of Life Assessment To quantify the impact of scoliosis on affected individuals, self-assessment of measures such as health status, pain, disability, and self-image must be establisbed. In tbe adult witb scoliosis, measurements in tbese domains elucidate tbe value of surgical or nonsurgical care. The SRS instrument, particularly the SRS-22 (http:// www.srs.org/professionals/SRS_outcomes/srs-22_ sample.pdf, accessed December 26, 2013), has proven to be a reliable and valid instrument used in measuring outcomes and bealtb status in adults witb spinal deformity.^ The SRS-22 is a questionnaire containing 22 questions that cover 5 domains: 5 questions each on pain, self-perceived image, function, and mental health, and 2 questions on satisfaction with management.' Baldus et al^ validated the use of the SRS instrument in patients witb adult spinal deformity making it a valuable HRQOL tool. When compared with "normal" volunteers, adults diagnosed with idiopathic or de novo scoliosis had significant differences in terms of pain, appearance, and activity SRS domains. Of note, the mental healtb domain scores of males of ages 61 to 80 were not found to be statistically different between patients witb deformity and tbose with no deformity.* Otber measures sucb as tbe ODI, SE-12, and tbe Cbarlson Comorbidity Index may be useful in identifying patients who would benefit from surgical treatment.'' Tbe Cbarlson Comorbidity Index is considered a validated and reproducible metbod of determining comorbidity and predicting outcome in tbe elderly and the ODI is thought to be a validated condition-specific outcome measure in spine-related disability.*-' Tbe SRS-22 bas also been found to correlate well witb tbe SE-12 and the ODI in assessing patients with adult spinal deformity.'" However, the SRS has been found to be more responsive to change brougbt on by primary surgical treatment of adult scoliosis wben compared witb ODI and SE-12." Tbe psychometric qualities of the SRS instrument such as concurrent validity, internal consistency, reliability over time, and sensitivity to cbange bave been confirmed in patients witb adult deformity.' Eurthermore, the SRS-22, ODI, and NRS for leg and/or back pain bave been shown to accurately predict SE-6D scores, allowing for cost-utility analysis.^^-'^ Tbese tools can be useful in Spine
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quantifying the effect of treatment on the patients' quality of life and for evaluation of quality-adjusted life-years values and thus, cost-effectiveness. Current literature supports the use of these tools to place a value on treatment choices. Nonoperative Treatment Nonoperative treatment of adult scoliosis includes a range of options from no intervention at all to physical therapy, exercise therapy, injections, chiropractic care, and pain management. Glassman et aP'* evaluated the resource utilization in nonsurgical patients with adult spinal deformity. He divided the nonsurgical patients into distinct high- and low-symptom patients, demonstrating 90% utilization of nonsurgical resources in the high-symptom patients with a greater use of narcotics, epidural blocks, analgesics, pain management referral, bed rest, strength training, nerve root blocks, and stabilization exercises. Surprisingly, there was 70% utilization in nonsurgical treatment modalities in the low-symptom group as well. Despite the popularity of resource utilization, the efficacy of these modalities remains unclear. Another study by Glassman et aP^ reviewed 123 patients wbo underwent nonoperative treatment for adult scoliosis. Of tbe 55 patients wbo had no intervention there was a small increase in the SRS satisfaction subscore, but all other HRQOL measures remained stable. Surprisingly, among tbe 68 patients wbo bad at least 1 nonoperative treatment modality, the most common being medication, exercise therapy, physical therapy, chiropractic treatment, and injections, there was no statistically significant mean change in any of the HRQOL outcome parameters during tbe 2-year observation period. Altbougb patient outcomes did not improve, tbere was no decline in tbeir quality of life, wbicb should not be disregarded. Mean treatment cost in this 2-year time frame was $10,815. This study brings to question tbe value of nonoperative treatment metbods, bowever, future studies need to measure the benefit of nonsurgical treatment modalities in a randomized manner to better delineate its wortb and cost-effectiveness. In 2007, Everett and Patel'* published a comprehensive systematic review of tbe literature pertaining to nonoperative treatment of adult scoliosis. In their search for clinical studies on adults with degenerative scoliosis treated with various nonoperative treatment modalities, only 2 articles for bracing, 3 articles for physical/exercise therapy, 2 articles on cbiropractic care, and 1 article on epidural steroid injections fit the criteria for review. Weak, level IV evidence was found for the role of bracing, pbysical therapy, and chiropractic care in treatment. The use of transforaminal epidural steroid injections in treating radiculopatby was supported witb one level III evidence study. This review emphasized the lack of evidence and quality clinical research supporting conservative care for adult scoliosis. These studies lack any cohesiveness in terms of using similar HRQOL outcome measures making it difficult to compare them to other studies. Eurtbermore, tbe SRS, ODI, and SE-12, wbicb we know to be valid measures for adult scoliosis, were not used as end points in any nonoperative management studies in tbis systematic review. www.spinejournal.com
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Value of Spinal Deformity Surgery • Paulus et al
Operative Treatment operative treatment had no change in either. In a review of There are no strict criteria stating when and when not to 317 patients with adult scoliosis and associated back pain operate on adult patients with scoliosis. However, adults by Smith et al,-^ 147 patients chose to be managed surgiwith spinal deformity will often present with pain and funccally, whereas the remaining 170 chose nonoperative treattional limitations, negatively impacting their quality of life. ment. The operative group started with significantly greater Bess et al'* retrospectively assessed 290 patients with adult back pain and disability with worse health status measured scoliosis who had undergone either operative or nonoperaby the SRS-22, ODI, and NRS scores for back pain. At the tive treatment. He concluded that pain and disability were time of 2-year follow-up, they had significantly less back predictors of operative treatment in older adults, as opposed pain and disability with improved health status compared to coronal deformity in adolescents and young adults. Recent with the nonoperative group. The authors concluded that studies have focused on the importance of correcting sagitoperative treatment offers the potential to improve back pain tal imbalance in adult spinal deformity because it seems to and quality of life significantly. Smith et aP^ retrospectively be directly related to worse HRQOL scores.'^'"* Mac-Thiong reviewed 208 patients with adult scoliosis and back pain: et aP found that a poor ODI was associated with a sagittal 96 of these patients underwent operative treatment and 112 C7 plumb line greater than 6 cm, a sagittal gravity line greater were managed nonoperatively. At 2-year follow-up, the nonthan 6 cm, and a C7 plumb line in front of the gravity line. operative group had no significant change in ODI or pain, Blondel et ap° evaluated the pre- and postoperative sagittal whereas the operative group had a significant improvement vertical axis in adult spinal deformity and found that the best in both ODI and pain. Li et aF compared self-reported and HRQOL outcomes were found in patients with sagittal vertiradiographical outcomes in adults older than 65 managed cal axis correction more than 120 mm and at least 66% of operatively versus nonoperatively. After 2-year follow-up, correction. Lafage et aP found that there is an even greater only the operative group had significant improvements in correlation with HRQOL and T l spinopelvic inclination SRS-22, ODI, and SF-12, despite there being a 17% compli(angle between Tl-hip axis and vertical) versus the sagittal cation rate. Direct comparison of the groups demonstrated vertical axis. These studies suggest that improving the sagittal significantly less pain, better HRQOL, self-image, mental balance with surgical correction will lead to improved overhealth, and greater satisfaction measured with the SRS-22 all outcomes; however, there does not seem to be any clear in the operative group. Although all of these studies support threshold for surgical intervention. the use for operative interventions, they are retrospective analyses. Well-designed, high-quality, prospective studies are Quality of life assessments are extremely important in essential to make recommendations for or against surgical demonstrating effectiveness of surgery and its improvetreatment. ment on the patients' well-being. In 2010, a systematic hterature review of surgical treatment in adult scoliosis conThere are a limited number of prospective reports of the cluded that there is evidence showing an improvement in results of surgical treatment of adult scoliosis. In a review by radiographical and clinical outcomes at 2-year follow-up.-' Bridwell et al.,^'^ the literature published in the Journal of Bone There was a complication rate of 4 1 % in this pooled analyand Joint Surgery from 1996 to 2006 lacked prospective studsis, consistent with other reports, however, there was no ies regarding the operative treatment of adult scoliosis. They consensus among the different studies regarding the classifisubsequently published a prospective study of 56 patients cation of complications. Several studies only mentioned the with adult scoliosis who underwent surgical treatment and number of complications, and it is unclear from this sysdemonstrated a significant improvement in the SRS-22, ODI, tematic review what the actual complications were. Despite and SF-12 physical health scores." In a larger study in 2009, this limitation, the high rate of complications did not seem Bridwell et aP^ assessed 160 consecutive patients with adult to affect outcome. symptomatic lumbar scoliosis who underwent operative versus Dickson et aP compared the results of 111 patients with nonoperative treatment. At 2-year follow-up, the operative adult scoliosis who were recommended operative treatment. group significantly improved in all quality of life measures, Of these patients, 81 underwent surgery, whereas the other 30 whereas the nonoperative group had no change in quality of declined. At the average 5-year follow-up, the surgical group life. This study, however, was limited with only 45% followhad significantly decreased pain and fatigue, as well as a sigup in the nonoperative group. Albert et aP° prospectively nificantly improved self-image and ability to perform physistudied outcome measures in 68 adults before and after spinal cal, functional, and positional tasks when compared with deformity surgery. At 2-year follow-up, they found significant the nonoperative group. Kluba et a P evaluated 55 patients improvements in scores for physical function, social funcwith painful degenerative lumbar scoliosis who underwent tion, bodily pain, and perceived health. Of note, the results either surgical or nonsurgical management after being recof patients who experienced complications were no different ommended surgery. Nonsurgical management included oral than those that did not have any complications. analgesics with nonsteroidal anti-infiammatory drugs, and Operative techniques for the treatment of scoliosis have opioids, PT, bracing, corticoid infiltrations, and acupuncture. evolved throughout the years. Rose etaP' analyzed 68 patients At mean follow-up of about 4 years, the operative group had treated surgically for adult idiopathic scoliosis with either significant improvement in walking distance and decreased pedicle screws or traditional hook/hybrid instrumentation. In use of analgesics, whereas the patients who underwent nonall patients, there was a significant improvement in the SRS 390 www.spinejournal.com March 2014
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TABLE 1.
Value of Spinal Deformity Surgery • Paulus et al
jjigffljryg
Author and Year
Operative Nonoperative Minimum Follow-up (No.) (No.)
Classman et al,^^ 2010 Zimmerman etat,^~ 2010
123
Fifty-five patients with no treatment: significant improvement in SRS satisfaction, no change in SF-12 and ODI 2yr
Sixty-eight patients used nonoperative resources: no significant change in SRS-22, SF-12, and ODI 2yr
35
Change in HRQOL Scores
Significant improvement in the ODI and SF-36 physical and mental health measures Significant improvements in ODI, SRS, and NRS in operative group compared with nonoperative group
Bridwell eta/," 2009
85
75
2yr
Operative group had significant improvement in ODI, SRS, and NRS compared with baseline. Nonoperative group had no significant change in ODI, SRS, and NRS compared with baseline Nonoperative group had no significant change in ODI or NRS
Smith et a/,2'2009
96
112
2yr
Operative group showed significant improvement in ODI, NRS Operative group had significantly lower NRS scores and ODI compared with nonoperative group Nonoperative group had no significant change in SRS-22, ODI, and NRS
Smith ef a/," 2009
147
170
2yr
Operative group showed significant improvement in SRS-22, ODI, and NRS Operative group had significantly lower NRS and ODI, and higher SRS-22 compared with nonoperative group
Rose eta/,'' 2009
2yr
68
SRS significantly improved in all patients SRS and ODI significantly improved between 6 mo and 1 yr postoperatively
Glassman etal,^'' 2009
2yr
283
Worsening NRS leg pain and trend toward improved SF-12 between 6 mo and 1 yr postoperatively No significant difference in SRS, ODI, NRS, and SF-12 between 1 and 2 yr postoperatively Operative group had significantly better SRS-22
49
2yr
L\ et al," 2009
34
Peelleefa/,"2008
30
2yr
Significant improvement in pain and self-image domains, no significant change in function or mental health domains of SRS
Bridwell eta/," 2007
56
2yr
Significant improvement in SRS-22, ODI, and SF-12 physical component
Bess et a/," 2007
56
2yr
Significant improvement in SRS scores after pedicle screw or hook instrumentation
Shapiro etal,'" 2003
16
2yr
Significant improvement in SRS and ODI
Albert ef a/,» 1995
55
lyr
Statistically significant improvements in postoperative scores for SF-36 physical function, social function, bodily pain, and perceived health change
No statistical difference between operative and nonoperative group in terms of ODI and SF-12
HROOL indicates heakh-related quality of life; ODI, Oswestry Disability Index; SRS, Scoliosis Research Society; SF-12, 12-ltem Short Form Health Survey: SF-36, 36-ltem Short Form Health Survey; NRS, numerical rating scale.
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outcome scores despite the different techniques used for correction and fixation. Zimmerman et aP^ completed a prospective study evaluating functional outcomes and complications in 35 adults undergoing primary spinal surgery for scoliosis. At 2-year follow-up, there was a significant improvement in the ODI and SF-36 physical and mental health measures. Even with a 49% complication rate, there were no differences in outcomes when comparing patients with and those without complications. It has been previously thought that the risks of operative treatment in the adult with scoliosis outweigh the benefits due to the large number of complications.^ The SRS database was used to assess the major complication rate in adult scoliosis surgery cases from 2004 to 2007.^^ The overall complication rate was 13.4%. This number was likely significantly less than previously published complication rates as minor complications were not reported. Despite reported complication rates, multiple studies have shown no difference in quality of life assessment of patients who had complications compared with those who did not.^'^^-^^ Therefore, although it is vital for the spinal surgeon to discuss the risks of surgery along with complications, the high rate should not deter the surgeon or patient from undergoing surgery if it is indicated and the patient has been appropriately counseled.
Value of Spinal Deformity Surgery • Paulus et al
uating the incremental cost-effectiveness ratio during a 4-year period.^^ The design and execution of the Spine Patient Outcomes Research Trial could be reproduced in the future for adult scoliosis to draw conclusions on the cost-effectiveness of treatment. Translation of the SRS, ODI, and NRS outcome scores to a utility score may allow for this cost-effective analysis evaluating quality-adjusted life-years, placing an objective value on the management of scoliosis.
DISCUSSION
Adult scoliosis continues to be a growing challenge for the orthopedic surgeon as the hterature to support treatment is sparse. Nonoperative treatment modalities are used in the majority of patients presenting with pain and disability; however, there is no clear consensus to whether they are even effective at all. There is a paucity of literature on nonoperative treatment that uses validated HRQOL outcome measures. Current available literature demonstrates a trend that nonoperative treatment for adult scoliosis is ineffective. On the contrary, it does not worsen the patients' quality of life suggesting there may be some benefit. The lack of highquality, randomized studies makes the value of scoliosis care difficult to assess. There seems to be a trend toward improved quality of life measures, pain, and disability in those patients who undergo surgical treatment (Table 1). Future studies with randomization and longer-term followup are necessary to make a strong recommendation for Costs or against surgery in the adult with scoliosis. As for costCost-effectiveness for treatment of adult scoliosis is not well effectiveness, although literature exists on cost of surgical understood. In an effort to understand the value of nonoperative management, Glassman et aP'* investigated nonopera- treatment in adolescent scoliosis, no studies could be found pertaining to adults. An incremental cost-effectiveness ratio tive resource utilization and cost of treatment during a 2-year for surgical versus nonsurgical treatment of adult scoliosis, observation period in adult scoliosis. The mean cost of treatsimilar to that done in the Spine Patient Outcomes Research ment during a 2-year period was in the range from $9,704 to Trial for intervertebral herniated discs, would further eluci$14,022 in the low and high symptom groups, respectively date the value of scoliosis care. with no significant change in HRQOL. This study highlights the value of nonoperative management with respect to quality of life outcomes as well as cost. CONCLUSION In terms of surgical treatment of adult scoliosis, studies On the basis of the available literature, the authors conclude evaluating cost-effectiveness are lacking in the current literathat adults with painful and disabling scoliosis may benefit ture. Kamerlink et aP'' published a retrospective review of the from surgical treatment compared with nonsurgical treatment. hospital costs of surgical treatment of adolescent idiopathic Nonsurgical treatment does not seem to be cost-effective, and scoliosis. The hospital costs were in the range from $29,955 it has not shown to have a positive impact on the quality of to $60,754 with the main contributors being implants used, life of these patients. There is convincing evidence that surintensive care unit stays, operating room time, and bone graft gical treatment improves the quality of life of patients with use. It may be possible to extrapolate cost analysis for adults in adult scoliosis causing pain and disability. Surgery could be this way, however, evaluating the change in quality of life after cost-effective; however, strong conclusions cannot be drawn surgery is necessary in understanding the benefit of those costs. because of the lack of literature regarding this topic. Future The Spine Patient Outcomes Research Trial may serve studies are needed to evaluate the cost-effectiveness of surgias a model for analysis of cost-effectiveness of surgical vercal versus nonsurgical treatment in the adult with scoliosis. sus nonsurgical treatment in adult scoliosis. Tosteson et aP^ evaluated the cost-effectiveness of surgical versus nonoperative treatment among patients with spinal stenosis, degeneraKey Points tive spondylolisthesis, and intervertebral disc herniation. The investigators analyzed the impact of treatment on quality• The lack of high-quality, randomized studies adjusted life-years using a validated instrument (EQ-5D), makes the value of scoliosis care difficult to resource utilization, and indirect costs. The study concluded assess. that surgery for these conditions was cost-effective after eval392 www.spinejournal.com March 2014
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ü Adults with painful and disabling scoliosis may benefit from surgical compared with nonsurgical treatnnent given the proper indications. •
Nonsurgical treatnnent does not seem to be cost-effective and has not shown to have a positive impact on quality of life, although there is a possibility that patients' health may have deteriorated if they did not receive the nonsurgical treatment.
•
Future studies are needed to evaluate the cost-effectiveness of surgical versus nonsurgical treatment in the adult with scoliosis.
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