Lightning Podiums: Value and Outcomes in Spinal Surgery - Room 801B

Presented by: J. Ammerman


F. Martens(1), J. Ament(2), J. Fandino(3), The Anular Closure RCT Study Group

(1) OLV Hospital, Department of Neurosurgery, Alast, Belgium
(2) University of California, Davis, Department of Neurological Surgery, Sacramento, CA, United States
(3) Cantonal Hospital Aarau, Department of Neurosurgery, Aarau, Switzerland


Purpose: Lumbar herniation patients with large annular defects who undergo discectomy are at a high risk for reherniation, which often necessitates revision surgery. Some discrepancy exists among previous studies as to whether the clinical outcomes of reoperated patients are equivalent to those of non-reoperated patients. The purpose of this study was to examine the effects of reoperation following primary discectomy surgery, with or without an annular closure device (ACD), on patient reported outcomes as well as US socioeconomic costs.

Methods: This is a post-hoc analysis of a prospective multicenter randomized controlled trial (RCT) of an ACD compared to conventional lumbar discectomy (control). All 550 patients from the RCT, with follow-up data through 2 years, were included in this analysis (69 reoperated and 481 non-reoperated). Patient follow-up visits were at 6 weeks and 3, 6, 12, and 24 months after the index procedure. The current analysis divided the patients into four cohorts based on the intervention they received (Control or ACD), and reoperated or non-reoperated (regardless of index intervention) within 24 months. Reoperations were defined to include any revision surgery at the index level, regardless of reherniation, to ensure that any potential device revisions were also captured. Outcome measures included leg and back pain on the VAS pain scale, Oswestry Disability Index (ODI) scores, mental (MCS) and physical component scores (PCS) of the 36-Item Short Form Health Survey, working status, hours of missed work, physiotherapy time, and number of inpatient hospital days due to a serious adverse event.

Results: The reoperated patients had significantly worse scores for ODI and VAS leg and back pain as well as MCS and PCS scores compared to their non-reoperated counterparts (p < 0.0001). The rate of reoperated vs. non-reoperated patients who did not improve clinically was 2.9 times higher based on ODI (46% vs. 16%). Based on US payer data, post-operative costs were $69,484 per patient in the reoperated group compared with $9,697 per patient in the non-reoperated group. In the ACD and Control groups, 24/267 (9%) and 45/283 (16%) patients, respectively, underwent a revision surgery (p = 0.01). Based on this difference in re-operated rates between index interventions, the mean estimated cost per treated Control patient ($23,111) was 13.5% greater than each ACD-treated patient ($19,990), even after accounting for the estimated device cost and increased surgical time.

Conclusions: Post-discectomy reoperation results in significantly greater patient morbidity and socioeconomic costs in a high-risk population. Reducing the incidence of reoperation by nearly 50% through robust annular closure reduced the number of patients subject to persistent or recurring morbidity and reduced the overall per-patient costs among the ACD-treated group compared with Control patients.