Clinical Guidelines and Payer Policies on Fusion for the Treatment of Chronic Low Back Pain

Cheng, Joseph; Lee, Michael J.; Massicotte, Eric M.; Ashman, Bryan; Gruenberg, Marcelo; Pilcher, Leslie E.; Skelly, Andrea C.

doi:10.1097/brs.0b013e31822ef5b4

Cited by 35 publications

(30 citation statements)

References 33 publications

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“…Patients with more than two abnormal discs typically have no surgical options based on a consensus against three-level or more fusion surgeries in the medical community. Many insurance companies will not authorise a lumbar fusion for discogenic back pain because of the expense (US$50,000-100,000) and the published results of patients averaging only a 35 % improvement in pain [8,9]. However, there remains a void between current nonoperative and surgical treatments [10].…”

Section: Introductionmentioning

confidence: 96%

Treatment of discogenic back pain with autologous bone marrow concentrate injection with minimum two year follow-up

Pettine¹,

Suzuki

Sand

et al. 2015

International Orthopaedics (SICOT)

107

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Section: Introductionmentioning

confidence: 96%

Treatment of discogenic back pain with autologous bone marrow concentrate injection with minimum two year follow-up

Pettine¹,

Suzuki

Sand

et al. 2015

International Orthopaedics (SICOT)

107

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“…Spinal fusion implants have become valuable hardware tools in orthopaedic surgery and are used for a variety of spine conditions, including traumatic and osteoporotic unstable vertebral fractures, symptomatic spondylolisthesis, spinal stenosis, and for the correction of spine deformities [1][2][3][4][5]. Complications of spinal fusion surgery comprise implant fracture, loosening, faulty placement and infections which may all be associated with substantial morbidity [6].…”

Section: Introductionmentioning

confidence: 99%

Metallic artefact reduction with monoenergetic dual-energy CT: systematic ex vivo evaluation of posterior spinal fusion implants from various vendors and different spine levels

et al. 2012

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Objectives To evaluate optimal monoenergetic dual-energy computed tomography (DECT) settings for artefact reduction of posterior spinal fusion implants of various vendors and spine levels. Methods Posterior spinal fusion implants of five vendors for cervical, thoracic and lumbar spine were examined ex vivo with single-energy (SE) CT (120 kVp) and DECT (140/100 kVp). Extrapolated monoenergetic DECT images at 64, 69, 88, 105 keV and individually adjusted monoenergy for optimised image quality (OPTkeV) were generated. Two independent radiologists assessed quantitative and qualitative image parameters for each device and spine level. Results Inter-reader agreements of quantitative and qualitative parameters were high (ICC00.81-1.00, κ00.54-0.77). HU values of spinal fusion implants were significantly different among vendors (P<0.001), spine levels (P<0.01) and among SECT, monoenergetic DECT of 64, 69, 88, 105 keV and OPTkeV (P<0.01). Image quality was significantly (P<0.001) different between datasets and improved with higher monoenergies of DECT compared with SECT (V 00.58, P < 0.001). Artefacts decreased significantly (V00.51, P<0.001) at higher monoenergies. OPTkeV values ranged from 123-141 keV. OPTkeV according to vendor and spine level are presented herein. Conclusions Monoenergetic DECT provides significantly better image quality and less metallic artefacts from implants than SECT. Use of individual keV values for vendor and spine level is recommended. Key Points• Artefacts pose problems for CT following posterior spinal fusion implants.• CT images are interpreted better with monoenergetic extrapolation using dual-energy (DE) CT.• DECT extrapolation improves image quality and reduces metallic artefacts over SECT.• There were considerable differences in monoenergy values among vendors and spine levels.• Use of individualised monoenergy values is indicated for different metallic hardware devices.

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“…Some have argued that the development of this policy was not transparent and that it failed to cite clinical evidence to support the coverage decision. [26] However, the new policy is similar to that previously initiated in Washington State, which has had similar effects.…”

Section: Discussionmentioning

confidence: 92%

Effects of a Commercial Insurance Policy Restriction on Lumbar Fusion in North Carolina and the Implications for National Adoption

Martin

Deyo

Lurie³

et al. 2016

Spine

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Study design Analysis of the State Inpatient Database of North Carolina, 2005–2012, and the Nationwide Inpatient Sample, including all inpatient lumbar fusion admissions from non-federal hospitals. Objective To examine the influence of a major commercial policy change that restricted lumbar fusion for certain indications, and to forecast the potential impact if the policy were adopted nationally. Summary of Background Data Few studies have examined the effects of recent changes in commercial coverage policies that restrict the use of lumbar fusion. Methods We included adults undergoing elective lumbar fusion or re-fusion operations in North Carolina. We aggregated data into a monthly time series to report changes in the rates and volume of lumbar fusion operations for disc herniation or degeneration, spinal stenosis, spondylolisthesis, or revision fusions. Time series regression models were used to test for significant changes in the use of fusion operation following a major commercial coverage policy change initiated on January 1st, 2011. Results There was a substantial decline in the use of lumbar fusion for disc herniation or degeneration following the policy change on January 1st, 2011. Overall rates of elective lumbar fusion operations in North Carolina (per 100,000 residents) increased from 103.2 in 2005 to 120.4 in 2009, before declining to 101.9 by 2012. The population rate (per 100,000 residents) of fusion among those under age 65 increased from 89.5 in 2005 to 101.2 in 2009, followed by a sharp decline to 76.8 by 2012. There was no acceleration in the already increasing rate of fusion for spinal stenosis, spondylolisthesis or revision procedures, but there was a coincident increase in decompression without fusion. Conclusions This commercial insurance policy change had its intended effect of reducing fusion operations for indications with less evidence of effectiveness without changing rates for other indications or resulting in an overall reduction in spine surgery. Nevertheless, broader adoption of the policy could significantly reduce the national rates of fusion operations and associated costs.

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Clinical Guidelines and Payer Policies on Fusion for the Treatment of Chronic Low Back Pain

Cited by 35 publications

References 33 publications

Treatment of discogenic back pain with autologous bone marrow concentrate injection with minimum two year follow-up

Treatment of discogenic back pain with autologous bone marrow concentrate injection with minimum two year follow-up

Metallic artefact reduction with monoenergetic dual-energy CT: systematic ex vivo evaluation of posterior spinal fusion implants from various vendors and different spine levels

Effects of a Commercial Insurance Policy Restriction on Lumbar Fusion in North Carolina and the Implications for National Adoption

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