Laminectomy plus instrumented fusion associated with higher costs and no superior long-term outcomes compared to laminectomy alone

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Surgical treatment with instrumented fusion as an adjunct to laminectomy is not associated with superior long-term clinical outcomes compared with laminectomy alone for patients with degenerative cervical myelopathy (DCM), according to a recent national study from Sweden.

The findings, which also highlighted that the cost–benefit analysis favoured treatment with laminectomy alone, were published in the European Spine Journal by Eddie de Dios (Uppsala University Hospital, Uppsala, Sweden) et al.

The purpose of the study was to compare patient-reported five-year clinical outcomes between laminectomy alone versus laminectomy with instrumented fusion in patients with DCM. All DCM patients in the Swedish national spine register, Swespine, from January 2006 until March 2009 were included in the study.

The primary outcome measure was the European Myelopathy Score (EMS), a disability scale similar to the modified Japanese Orthopedic Association (mJOA) score. The EMS is based on five items: gait, hand function, proprioception, paresthesia, and bladder function. The scale ranges from five to 18, with lower scores reflecting more severe myelopathy.

Secondary outcome measures were the Neck Disability Index (NDI), the European Quality of Life-5 Dimension Questionnaire (EQ-5D), the European Quality of Life-Visual Analogue Scale (EQ-VAS), and the Visual Analogue Scale (VAS) for neck and arm pain.

Among 967 eligible patients, a total of 717 (74%) were included. Laminectomy alone was performed on 412 patients (mean age 68 years; 149 women [36%]), while instrumented fusion was added for 305 patients (mean age 68 years; 119 women [39%]). After imputation and propensity score matching, there were on average 212 patients with a five-year follow-up in each group.

The EMS values were found to be similar in both groups: baseline 12.1 (95% confidence interval [CI], 11–13.3) to 12.7 (95% CI, 11.6–13.9) in the laminectomy-alone group and baseline 12 (95% CI, 10.8–13.2) to 12.1 (95% CI, 10.7–13.4) in the fusion group. The mean difference after five years was -0.6 (95% CI, -2.2–1; p=0.47). In addition, there were no clinically important differences between the groups in terms of NDI, EQ-5D, EQ-VAS, VAS-neck, or VAS-arm scores.

The study also found that, due to increased hospitalisation times and implant-related costs, the mean cost increase per instrumented patient was approximately US$4,700.


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