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  • Comparative Effectiveness between Primary and Revision Foraminotomy for the Treatment of Lumbar Foraminal Stenosis

    Final Number:

    Emily Hu BA; Jianning Shao; Heath P Gould BS; Roy Xiao BA; Colin Haines; Don K Moore; Thomas E. Mroz MD; Michael P. Steinmetz MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2017 Annual Meeting

    Introduction: Foraminotomy has demonstrated clinical benefit for the management of lumbar foraminal stenosis (LFS). Although many patients undergo multiple foraminotomies, there is little data comparing primary foraminotomy (PF) and revision foraminotomy (RF) in terms of cost and quality of life (QOL) outcomes.

    Methods: A retrospective cohort study was conducted among patients undergoing foraminotomy for LFS. QOL instruments (EQ-5D, PDQ, and PHQ-9) were prospectively collected between 2008 and 2016. Outcome measures included improvement in postoperative QOL, perioperative cost, and QOL minimum clinically important difference (MCID).

    Results: 579 procedures were eligible – 476 (82%) PF and 103 (18%) RF. A significantly higher proportion of males underwent RF than PF (71% vs. 59%, p=0.03) and PF was done on a significantly higher number of vertebral levels (2.2 vs. 2.0, p=0.04). There were no other significant differences in demographics. Preoperatively, mean PDQ-Functional scores (50 vs. 54, p=0.04), demonstrated significantly poorer QOL in the RF cohort. Postoperatively, EQ-5D index showed significant improvement in both the PF (0.547?0.648, p<0.0001) and the RF (0.507?0.648, p<0.0001) cohorts. Similarly, total PHQ-9 improved significantly in the PF cohort (7.84?5.91, p<0.001) and in the RF cohort (8.55?5.53, p=0.02), as did total PDQ (PF: 77?63, p<0.0001; RF: 85?70, p=0.04). QOL scores were also compared between groups preoperatively and postoperatively. The only significant difference between PF and RF was observed in preoperative PDQ-Functional score (50 vs. 54, p=0.04). The proportion of patients achieving an MCID was not significantly associated with cohort. Finally, perioperative cost did not differ significantly between cohorts (PF: $13,383 vs. RF: $13,595, p=0.82).

    Conclusions: RF patients had poorer preoperative PDQ-Functional scores, but both PF and RF produce significant improvement in all measures. There was no difference in QOL outcomes or cost between PF and RF. Therefore, while one procedure does not clearly have superior cost effectiveness than the other, both achieved significant effectiveness.

    Patient Care: This project informs surgeons on the cost effectiveness of lumbar foraminotomy to treat lumbar spinal stenosis, which a common cause of impaired quality of life and diminished functional capacity in the elderly.

    Learning Objectives: By the conclusion of this session, participants should be able to 1) Understand the effectiveness of primary foraminotomy and revision foraminotomy separately as treatment for lumbar foraminal stenosis, 2) Understand the comparative effects on postoperative quality of life between primary and revision foraminotomy, 3) Understand the relative costs between the two procedures, and 4) Ultimately be better informed on how often surgeons should recommend foraminotomy for the treatment of lumbar foraminal stenosis.

    References: Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, Saunders LD, Beck CA, Feasby TE, Ghali WA. Coding Algorithms for Defining Comorbidities in ICD-9-CM and ICD-10 Administrative Data. Norman GR, Sloan JA, Wyrwich KW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care 2003;41:582-92. Parker SL, Godil SS, Shau DN, Mendenhall SK, McGirt MJ. Assessment of the minimum clinically important difference in pain, disability, and quality of life after anterior cervical discectomy and fusion: clinical article. J Neurosurg Spine 2013; 18:154-60. Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the patient health questionnaire-9. Med Care 2004;42:1194–201. Wilson H. Minimum clinical important differences of health outcomes in a chronic pain population: Are they predictive of poor outcomes? University of Texas at Arlington, 2007.

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