To determine the cost-effectiveness of Lumbar Total Disc Replacement (LTDR) with circumferential spinal fusion surgery.

Cost utility analysis.

We prospectively reviewed a cohort of 32 consecutive patients who underwent LTDR between 2004 and 2008 with a mean follow-up for 3.75 years. Identical data was compared to a similar group of patients (n=37) who underwent fusion in our institution.

Oswestry Disability Index, visual analogue scale, quality of life (SF-36) and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained. QALY gains were estimated from SF-36 data using standard algorithms.

There was no significant intergroup difference in the ODI, VAS and SF-36 pre and post-op. Both treatments produced statistically significant and equivalent improvements in mean health state utility at the 24-month follow-up (0.078 for LTDR, 0.087 for fusion). Costs were significantly lower with LTDR than with fusion due to a shorter mean procedure time (193.6 vs 377.4 minutes) and shorter length of stay (5.8 vs 7 days). The mean cost difference was £2,878 per patient. At 2 years, the cost per QALY gain of the lower-cost option (LTDR) was £48,892 although the cost effectiveness ratio would fall to below £30,000 if it is assumed that the patient benefits of LTDR last for at least 4 years.

Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with LTDR which is effective and a more cost-effective alternative.

To review blood transfusion practices during elective spinal surgery procedures

Prospective clinical audit

All patients who underwent elective spinal surgery between January 2009 and March 2009.

Crossmatch: Transfusion ratio (C: T ratio); Transfusion index (TI) (Evaluates cost-effective crossmatch). British Haematological society standards are C:T ratio= 2.5:1 and TI>0.5

Data was collected from electronic records of blood bank, pathology system (NOTIS) and review of patient notes. A total of 194 patients underwent elective spinal surgery in our unit. (Cervical spine = 15, Thoracic spine = 3, Vertebroplasty = 10, Lumbar spine = 142, Deformity = 31, other = 8). Of these, 62 patients had 197 blood products crossmatched but only 37 units were used. C:T ratio in lumbar spine surgery was 22:1. However C: T ratio in cervical spine procedures, thoracic spine and deformity correction were 6:1, 11:0 and 4:1 respectively. TI was <0.5 in all procedures except deformity surgery (TI=1).

Over- ordering of blood products is still common in spinal surgery as routine blood transfusion may not be required in most elective procedures. Therefore implementing Electronic Issue (EI) of blood products for elective spinal procedures for non deformity procedures can be a cost effective and safe practice.

Study design

Economic evaluation alongside a prospective, randomised, controlled trial from a two-year National Health Service (NHS) perspective.

Purpose: There is no consensus regarding indications for anterior release and causative factors of junction kyphosis(JK) in Scheuermann’s Kyphosis(SK).

Methods: A retrospective review of 35 patients(19♂; 16♀) who underwent surgery for SK with a minimum follow-up of 5 years was undertaken. The mean age & follow-up were 20.5(13.25–45.75y) and 9 years(5–22y) respectively. Patient demographics, clinicoradiological parameters & functional outcomes (ODI/SRS-22) were assessed. The incidence of JK was correlated with radiographic parameters & instrumentation levels. Outcomes of posterior instrumentation(GroupI-13) were compared with anterior release & posterior instrumentation(GroupII-22).

Results: Cobb Λle of ≥600 hyperextension radiographs and presence of anterior bony bridge required anterior release. JK(≥100) was seen in 12 cases (7 proximal & 5 distal). PJK was seen in cases where T3-4 was the upper instrumented vertebra(UIV). DJK was seen in patients with body mass index(BMI) of ≥30 and when LIV did not include 1st lordotic disc. There was significant difference in mean thoracic kyphosis(TK) correction between the 2 groups (35.70vs44.50;p=0.003). The mean loss of correction at 9 yrs was 5.90 and 3.40 respectively. 33/35 were subjectively satisfied with cosmesis and 28/35 patients returned to their previous occupation. Three were off work due to chronic back pain and four patients had job modifications.

Conclusion: Stiff curves require anterior release. PJK could be overcome by including T2 as UIV.

DJK could be prevented by including 1st lordotic disc in LIV. Extending lower Instrumentation to L3 would reduce the risk of implant failure in obese patients. There was no advantage of cages over rib grafts.

Ethics approval: Not applicable

Interest Statement: None (No grants obtained from any agency)

Purpose: To review the existing practice of coding in spinal surgery and ascertain its accuracy for surgical procedures, co-morbidities and complications.

Methods: A retrospective review of 70 cervical and 100 lumbar consecutive spinal surgeries performed since April 2006 was conducted. The clinical coding data and hospital notes were reviewed.

Results: Coding data of 5 cervical spine surgeries were not available. Of the 165 cases, the accuracy of primary procedural codes was 93.9% (90.8% cervical & 96% lumbar). This reduced to 77.6% (75.4% cervical & 79% lumbar) when the accuracy for entire description of performed surgery was considered. Medical co-morbidities were coded appropriately in 64.2% of the patients (55% cervical & 70% lumbar). The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Surgical levels were coded incorrectly in 9% of the cases. Cervical surgeries were coded as lumbar in 4 and posterior surgery as anterior in 3 cases respectively. The commonly missed co-morbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 75% of the cases (16/20 cervical & 5/8 lumbar). The accuracy was better for lumbar as compared to cervical spinal surgeries.

Conclusion: Coding is a universal language of communication and its accuracy is important not just for PbR, but for data quality, audit and research purposes too. The financial implications regarding PbR governed by HRG codes (dictated by OPCS 4.4 & ICD–10 codes) are discussed. Following this study, a clinical coding facilitation form has been introduced to improve data quality.

Ethics approval: None

Interest statement: None

Introduction: Accurate & ethical coding is challenging and directly impacts on Payment by Results (PbR). The objectives were to review the existing pattern of coding for lumbar spinal surgery and ascertain its appropriateness & accuracy for surgical procedures, medical comorbidities and post-op complications.

Methods: A retrospective review of 100 consecutive lumbar spine surgeries operated from Apr2006–Jan2007 was conducted. The coding excel sheet, hospital notes and laboratory reports were reviewed.

Results: The primary procedural accuracy was 96%, however this reduced to 79% for the entire description of performed surgery. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Spinal fusion codes were omitted and revision cases were coded as primary surgeries in 2 instances each. Surgical levels were coded incorrectly in 12 and harvest of iliac crest bone graft omitted in 4 cases respectively. Medical comorbidities were coded appropriately in 70%. The commonly missed comorbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 62.5% of the cases(5/8).

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for PbR, but also for data quality, audit and research. The financial implications regarding PbR governed by Healthcare Resource Group (HRG) codes (dictated by Official population and census surveys [OPCS4.4] & International classification of diseases [ICD–10] codes) are discussed. The awareness of clinical coding is low amongst junior doctors. Literature emphasises qualification of coders, legible documentation by physicians and interaction between coders & clinicians.

Introduction: A prospective randomised controlled trial of circumferantial spinal fusion has shown superior clinical outcome when a femoral ring allograft (FRA) is used compared to when a titanium cage (TC) is used. The implant cost of the TC is nearly ten fold that of the FRA. However the additional costs of surgery and related costs also need to be considered to determine if there is a real cost advantage of FRA over TC. We can find no previously reported studies which economically evaluate the TC and the FRA in circumferential lumbar spinal fusion. The aim of this study was to investigate cost-effectiveness of TCs in comparison to FRAs for circumferential lumbar spinal fusion over a two year National Health Service (NHS) perspective using a cost-utility evaluation

Methods: This randomised study had the approval of the local ethical committee and the institutional research and development board (Reference OR059844) prior to its commencement. Eighty-three patients were randomly allocated to receive either the TC or FRA as part of a circumferential lumbar fusion between 1998 and 2002. NHS costs related to the surgery and revision surgery needed during the trial period were monitored and adjusted to the base year (2005/6 pounds sterling). The Short Form-6D (SF-6D) was administered preoperatively and at 6, 12 and 24 months in order to elicit patient utility and subsequently Quality-Adjusted Life Years (QALYs) for the trial period. Return to paid employment was also monitored. Bootstrapped mean differences in discounted costs and benefits were generated in order to explore cost-effectiveness.

Results: Baseline demographic data including age, sex, smoking history, previous surgery history and number of operated levels did not differ between the two groups. A significant cost difference of £1,942 (AUD4,255), (95% CI £849 (AUD1,860) to £3,145 (AUD6,891)) in favour of FRA was found. Mean QALYs per patient over the 24 month trial period were 0.0522 (SD 0.0326) in the TC group and 0.1914 (SD 0.0398) in the FRA group, producing a significant difference of −0.1392 (95% CI 0.2349 to 0.0436). With regard to employment, incremental productivity costs were estimated at £185,171 (AUD 405,745) in favour of FRA.

Discussion: From an NHS perspective, the trial data show that TC is not cost-effective in circumferential lumbar fusion. The use of FRA was found to dominate (generating greater QALY gains and less cost). In addition FRA patients reported a greater return to work rate and hence, productivity costs were also in favour of FRA.

Introduction: Accurate and ethical coding is challenging and directly impacts on Payment by Results (PbR). The aims & objectives of this study were to review the existing pattern of coding for spinal surgery and ascertain its appropriateness & accuracy for surgical procedures, medical co-morbidities and post-op complications.

Methods: A retrospective review of 70 consecutive cervical and 100 consecutive lumbar spine patients who were operated from April 2006 onwards was conducted. The excel sheet provided by coding department, hospital notes – clinic letters, physicians’ entries, theatre notes and laboratory reports (biochemistry/microbiology/histology) – were reviewed. Of the 170 cases, 165 were available for analysis.

Results: Coding data of 5 patients who underwent cervical spine surgeries were not available. Of the 165 cases, the accuracy of primary procedural codes was 93.9% (90.8% cervical & 96% lumbar). However this reduced to 77.6% (75.4% cervical & 79% lumbar) when the accuracy for entire description of performed surgery was considered. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Surgical levels were coded incorrectly in 9% of the cases. Cervical surgeries were coded as lumbar in 4 and posterior surgery as anterior in 3 cases respectively. Harvest of iliac crest bone graft was not coded in 5 cases. Medical comorbidities were coded appropriately in 64.2% of the patients (55% cervical & 70% lumbar). The commonly missed comorbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 75% of the cases (16/20 cervical & 5/8 lumbar). The accuracy was better for lumbar as compared to cervical spinal surgeries.

Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for PbR, but for data quality, audit and research purposes too. The financial implications regarding PbR governed by HRG codes (dictated by OPCS 4.4 & ICD–10 codes) are discussed. The awareness of clinical coding is low amongst junior doctors. Following this study, a clinical coding facilitation form has been introduced to improve data quality. Our plan is to close the audit loop and re-evaluate. Literature emphasises qualification of coders, legible documentation by physicians and interaction between coders and clinicians.

Aim: The clinical and radiological outcomes of a prospective randomised controlled trial comparing Femoral Ring Allografts (FRA) to Titanium Cages (TC) for circumferential fusion are presented.

Methods: Eighty-three patients were recruited fulfilling strict entry requirements (> 6 months chronic discogenic Low Back Pain (LBP), failure of conservative treatment, one or two level discographically-proven discogenic pain). Five patients were excluded on technical infringements (unable to insert TC or FRA). From 78 patients randomised, 37 received FRA and 41 received TC. Posterior stabilisation was achieved with translaminar or pedicle screws. Patients completed the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back and leg pain, the Short-Form 36 (SF-36) pre-operatively and 6, 12 and 24 months post-operatively. Assessment of fusion was made by a panel of 6 individuals examining radiographs taken at the same specified time points.

Results: Clinical outcomes were available for all 83 patients (mean follow-up 28 months, range 24–75). Baseline demographic data showed no statistical difference between groups (p< 0.05). For patients receiving FRA, mean VAS (back pain) improved 2.0 points (p< 0.01), mean ODI improved 15 points (p=< 0.01), and mean SF-36 scores improved by > 11 points in 6 of 8 domains (p< 0.03). For patients receiving TC, mean VAS improved 1.1 points (p=0.004), mean ODI improved 6 points (p=0.01), and SF-36 improved significantly in only two of eight domains. Revision procedures and complications were similar in both groups. For the FRA group, 27 levels were fused from a total of 42 assessed (64.2%). For the TC group, 33 levels were fused from a total of 55 assessed (60%). This difference was not statistically significant p> 0.2.

Conclusion: The use of FRA in circumferential lumbar fusion was associated with superior clinical outcomes when compared to those observed following the use of TC. Both groups had similar fusion rates.

Study Design: Economic evaluation alongside a prospective, randomized, controlled trial from a 2-year NHS perspective.

Objective: To determine the cost-effectiveness of Titanium Cages (TC) compared to Femoral Ring Allografts (FRA) in circumferential lumbar fusion.

Summary of background data: A randomised controlled trial has shown the use of TC to be clinically inferior to the established practice of using FRA in circumferential lumbar fusion. Health economic evaluation is urgently needed to justify the continued use of TC, given that this treatment is less effective and, all things being equal, more costly than FRA.

Methods: Eighty-three patients were randomly allocated to receive either the TC or FRA as part of a circumferential lumbar fusion between 1998 and 2002. NHS costs related to the surgery and revision surgery needed during the trial period were monitored and adjusted to the base year (2005/6 pounds sterling). The Short Form-6D (SF- 6D) was administered preoperatively and at 6, 12 and 24 months in order to elicit patient utility and subsequently Quality-Adjusted Life Years (QALYs). Return to paid employment was also monitored. Bootstrapped mean differences in discounted costs and benefits were generated in order to explore cost-effectiveness.

Results: A significant cost difference of £1,942 (95% CI £849 to £3,145) in favour of FRA was found. Mean QALYs per patient over the 24 month trial period were 0.0522 (SD 0.0326) in the TC group and 0.1914 (SD 0.0398) in the FRA group, producing a significant difference of 0.1392 (95% CI 0.2349 to 0.0436). With regard to employment, incremental productivity costs were estimated at £185,171 in favour of FRA.

Conclusion: From an NHS perspective, the trial data show that TC is not cost-effective in circumferential lumbar fusion. The use of FRA was both cheaper and generated greater QALY gains. FRA patients reported a greater return to work rate.

The objective of our study was to assess the efficacy of infection control measures (pre-admission screening and patient segregation) on reducing inpatient exposure to methicillin-resistant Staphylococcus aureus (MRSA).

A prospective case-control study was undertaken, analysing all admissions to three wards over an 83-month period from September 1995 to July 2002 inclusive (a total of approximately 34 000 patients). An orthopaedic ward with active infection control measures was compared with two controls, an orthopaedic ward with no measures and a general surgical ward with no measures. A statistical analysis was performed of the difference between the 3 wards in numbers of new cases of MRSA infection or colonisation. There was a statistically significant difference in numbers of new cases between the ward with the active infection control measures and the two control wards.

The infection control methods described are shown to reduce the exposure of patients to MRSA, which is of importance in orthopaedics, and has further benefits that may be applied in other surgical specialties, notably the choice of antibiotic used with the associated risk of side-effects of the specific anti-MRSA agents, the cost for surgical prophylaxis and patients’ confidence in the admitting surgical unit. As a useful by-product, such segregated inpatient beds are effectively ring-fenced, ensuring availability even during a hospital bed-shortage.

Introduction Surgeons request cross-match based on habit not evidence. The spinal unit requested 686 units of blood during 2002–2003 and transfused only 42 for elective lumbar spine surgery. This wastes money, time and blood.

Aim Optimise the transfusion requests in elective lumbar spinal surgery by creating evidence based guidelines.

Methods The data on elective operations performed on the lumbar spine during the period June 2002 to June 2003 was collected from the spinal unit database and cross-referenced with the records of blood transfusion. Cross-match: Transfusion ratios (C:T Ratio) and Transfusion Index (TI) for common procedures were calculated. Based on these results, a Maximum Surgical Blood Ordering Schedule (MSBOS) was created and prospectively audited for six months.

Conclusion Eighty units were cross-matched during the prospective audit. Therefore, in one year one hundred and sixty units would be requested. This represents a reduction of over five hundred units.

Purpose of study. To compare the cost and outcome of Intradiscal Elecrothermal Therapy (IDET) with fusion (anterior lumbar interbody fusion with posterior translaminar screws) at one year, in single level lumbar disc disease.

Methods. 49 patients were prospectively enrolled for IDET. The 49 fusion group patients had either a Syncage or Femoral Ring Allograft. All patients had at least 6 months of LBP with single level disease on MRI or positive discography.

Results. The two groups were demographically similar. Pre-treatment ODI, VAS and SF-36 for physical function were significantly worse in the fusion group (p< 0.05). At 1 year, IDET patients had clinically important improvement in ODI (47 to 37, p< 0.001), SF-36 pain (26 to 42, p< 0.001) and physical function (40 to 54, p< 0.001), with a significant drop in VAS (5.4 to 4.2, p=0.012). Fusion patients had clinically important improvement in ODI (54 to 44, p< 0.001) and SF-36 pain (25 to 37, p< 0.001) but not in physical function (32 to 39, p=0.08), with a significant improvement in VAS (7.2 to 5.7, p=0.001). Within 1 year, 11 patients in the IDET group had further interventions (4 nerve root blocks, 1 fusion, 2 disc replacements, 2 posterior interbody fusions) and 9 further procedures were carried out in the fusion group (2 epidurals, 1 facet injection, 4 wound washouts, 1 revision posterior instrumentation, 1 repair pseudomeningocoele). Cost per patient at 1year, including all secondary procedures, was £7,545 for fusion and £2,851 for IDET patients.

Conclusions. Fusion is substantially more expensive than IDET with comparable clinical outcome.