Spine surgeons debate safety and cost effectiveness of sagittal plane realignment

They noted that weighing potential risks against health outcomes is important when determining if this treatment is right for a patient.

Sagittal plane imbalance in adults can lead to deformity and health problems. Two spine surgeons recently debated whether sagittal plane realignment surgery is safe for patients with such an imbalance to undergo. They also addressed issues related to the cost of such procedures.

Joseph H. Perra

Steven D. Glassman

During the presentations, Joseph H. Perra, MD, who took the “pro” point of view, noted that cost effectiveness is a relative concept in terms of supporting sagittal plane spine realignment.

Steven D. Glassman, MD, presented the “con” point of view during the debate held at the American Academy of Orthopaedic Surgeons Annual Meeting.

It is all relative

Cost effectiveness of a procedure, Perra said, has to be looked at in terms of a ratio. If a procedure is cheap but provides no positive effect it results in an infinite cost effectiveness ratio. It needs to be looked at on a case-by-case basis in terms of the cost vs. quality of life outcome measures, he said.

Perra presented the case of a 63-year-old woman with progressive signs and symptoms of coronal and sagittal imbalance who opted for the realignment surgery 7 years ago. Perra and colleagues, and the patient, weighed the risks of the surgery for her and opted for the procedure. She had a nice balance improvement, her Oswestry Disability Index scores improved from 56 points to 24 points and she felt great afterwards, Perra said.

In her case, the ratio of cost compared with outcomes was favorable.

Revisions affect cost-effectiveness

Glassman, disagreed with Perra’s assessment that cost effectiveness “is an obscure thing that does not have a definition,” and noted that health care economists have defined cost effectiveness in procedures.

“Health care economists say that cost per quality-adjusted life year should probably be less than $50,000 dollars, and certainly less than $100,000, for something to be cost effective,” he said.

While there are cost effective procedures in spinal surgery, such as single-level fusions, Glassman said adult scoliosis surgery is not cost effective primarily because of the number of revisions that are likely for patients. Data from the Medicare database and the United Healthcare database show about 19% of patients need revision surgery within 4 years post operation, according to Glassman.

“Cost effectiveness relies on durability. It works if you have no revisions. That is the basis of this model. But, as we know, we do not have no revisions,” he said.

Is it worth the risk?

Perra said also safety is a relative definition when it comes to these procedures. He cited the Merriam Webster dictionary definition of safety as, “Not able or likely to hurt or harm in any way.”

“There is not a single thing we do, not even observation, that necessarily falls in that category. We have to look at relative safety in medicine. It is a description of risk compared to other options we may have or choices. Nothing in life comes without some risk,” Perra said in his attempt to support the use of sagittal plane realignment.

In a patient with the correct symptoms, a risk assessment score that makes them a potential candidate, and the correct surgeon and surgical team, the sagittal plane realignment procedure can be safe and effective, according to Perra.

Complication rates concerning

Glassman countered that a study in which he was involved showed sagittal plane realignment procedures were associated with a high rate of postoperative complications. Major complications were found in 10% of patients, he said, which he would not necessarily define as being safe. Joseph H. Perra

“Unfortunately when you put the numbers to it, it is not working for us at the present. Now, can we change the paradigm? Yes, I think we can change the paradigm. We need to decrease our complication rates, reduce revision rates, and improve our durability and then we have a chance to demonstrate the cost effectiveness,” Glassman said. “But, we need to stop shooting ourselves in the foot and at the moment I think it is pretty clear that sagittal plane realignment is not particularly safe and certainly not cost effective.” – by Robert Linnehan

Reference:

Glassman SD. Symposium D: Are sagittal plane re-alignment procedures safe, cost effective? Con.

Perra JH.Symposium D: Are sagittal plane re-alignment procedures safe, cost effective? Pro. Both presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 11-15, 2014; New Orleans.

For more information:

Steven D. Glassman, MD, can be reached at the Norton Leatherman Spine Center, 210 E. Gray St., Suite 900, Louisville, KY 40202; email: tana.allgeyer@nortonhealthcare.org.

Joseph H. Perra, MD, can be reached at the Twin Cities Spine Center, 913 E. 26th St., #602, Minneapolis, MN 55404; email: jhperra@tcspine.com.

Disclosures: Glassman receives royalties from Medtronic and research support from Nuvasive and Norton Healthcare. Perra receives royalties from Medtronic and receives research support from DePuy Synthes.