lumbal spondylodese - orf-aarhus.dk · lumbal spondylodese indikationer •spondylolisthese...
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Lumbal Spondylodese
Symposium 21/3/2011
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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
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Randomized prospective Study in 148 pat. 1996 – 2000
University Hospital of Aarhus, Denmark.
.- Spine 2002, 2006, 2007, 2010
Brantigan ALIF +
autograftCDI + autograft
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CONCENSUS BASED
MEDICIN
VERSUS
EVIDENCED BASED
MEDICIN
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Phase 4
Phase 3
Phase 2
Phase 1
Clinical studies not necessary for CE marking
Henrik Malchou 1995
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Cemented THA 1997-2007
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Surgical options:
Disc surgery
Decompression
Disc arthroplasty
Total disc prosthesis
Flexible intervertebral stabil.
Fusion
Conservative treatment ?
Surgery ?
Chronic Low Back Pain
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Spinal fusion
Patient selection
Surgical methodsBiological
factors
Surgical
technique
Growth factors
Elements in Surgical Outcome
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Regenerative Medicine
Degenerative Disc Disease (DDD)
MRI of the Lumbar Spine
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The spectrum of treatment available for
symptomatic DDD by total endplate score (TEPS).Rajasekaran S, et al. Eur Spine J. 2008
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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
?
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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
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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
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Randomized prospective Study in 148 pat. 1996 – 2000
University Hospital of Aarhus, Denmark.
.- Spine 2002, 2006, 2007, 2010
Brantigan ALIF +
autograftCDI + autograft
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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)
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REHABILITATION
AFTER SPINAL FUSION
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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)
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€ 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