Study finds nonsurgical treatment has high cost–low benefit ratio

According to a study presented at the AAOS 2010 Annual Meeting, 2 years of nonsurgical treatment in adult scoliosis patients results in substantial expenditures and yields no improvement in health status.

Scoliosis is often found in adult patients, many of whom are treated nonsurgically. Few data exist, however, about the frequency and duration of such treatments, nor their impact on patient health. Steven D. Glassman, MD, study author, noted that the purpose of this study was to more specifically quantify the use and effectiveness of nonsurgical treatment for adult scoliosis.

Study design
The prospective study included 123 patients (90 percent female, 8.1 percent smokers, mean age of 53 years) enrolled in the nonsurgical arm of a multicenter database for adult spinal deformity for which complete pretreatment and 2-year post-enrollment health related quality of life (HRQOL) measures existed. Each patient had a primary diagnosis of adult idiopathic scoliosis, primary Cobb angle greater than 30 degrees, and no history of prior scoliosis surgery.

Based on pretreatment Oswestry Disability Index (ODI) scores, patients were divided into a high-symptom group (n = 24), a mid-symptom group (n = 43), and a low-symptom group (n = 56).

Nonsurgical resource utilization data were collected on the following treatment alternatives: medication, including dose and frequency; exercise therapy; modality physical therapy; injections/blocks; chiropractic care; bracing; and bed rest. Sixty-eight patients received at least one of the treatments, generally delivered through their local health system, during the 2-year observation; 55 patients received no treatment.

Little improvement in clinical outcomes
The most frequently used nonsurgical treatment interventions were medication, exercise therapy, modality physical therapy, chiropractic treatment, and injections. Outcome scores for patients in the symptom subgroups who received treatment and those who did not were evaluated to determine the effect of nonsurgical alternatives on clinical outcome.

“Unfortunately, none of these treatments demonstrated any significant benefit based upon change in HRQOL measures over the 2-year observation period,” said Dr. Glassman.

The only statistically significant difference, the researchers noted, was in the Scoliosis Research Society (SRS) pain subscore. The low-symptom group demonstrated a 0.14-point improvement; the mid-symptom group demonstrated a 0.23-point deterioration, and the high-symptom group showed a 0.17-point deterioration (p = 0.002).

Outcomes were also assessed based on the number of patients in each group who achieved a minimal clinically important difference (MCID) improvement at 2 years after treatment. A higher percentage of untreated patients reached the threshold on two measures (ODI and Physical Component Summary of the Short Form 36). A statistically significant difference was found in the SRS activity subscore, with a 0.06-point improvement in the no-treatment group compared to a 0.14-point deterioration in the treatment group (p = 0.038) (Table 1). No significant differences were found between treatment and nontreatment groups for the other HRQOL measures.

Substantial costs
Treatment costs were determined using the most current Medicare fee schedule. The least expensive drug in each class was used to determine medication costs; dose, frequency, and the length of time taken by the patient were also factors. Indirect costs were not included.

Comparisons were made based on estimated treatment costs for each modality and between each of the symptom level subgroups. The mean treatment cost for the nonsurgically treated patients was $10,815 over the 2-year period; mean treatment costs were $9,704 for patients in the low-symptom group, $11,116 for those in the mid-symptom group, and $14,022 for those in the high-symptom group.

The researchers concluded that evidence for nonsurgical care of adult scoliosis was lacking. Costs associated with nonsurgical treatment alternatives were substantial, and yielded no improvement in health status, raising significant questions as to the value of nonsurgical treatment for adult scoliosis patients. Because treatment was not randomized, however, better controlled studies evaluating more targeted use of nonsurgical treatment in adult scoliosis patients are needed.

Dr. Glassman’s coauthors for “The Cost and Benefits of nonoperative Management for Adult Scoliosis” include: Leah Y. Carreon, MD; Christopher I. Shaffrey, MD; David W. Polly Jr., MD; Stephen L. Ondra, MD; Sigurd H. Berven, MD; and Keith H. Bridwell, MD.

Dr. Glassman reports the following conflicts: Scoliosis Research Society; Professional Society Coalition Task Force on Lumbar Fusion; Lumbar Spine Study Group Executive Committee; Medtronic Sofamor Danek; Depuy.

Leah Y. Carreon, MD—Medtronic Sofamor Danek Norton Healthcare; Christopher I. Shaffery, MD—JNS: Spine Neurosurgery Journal of Spinal Disorders and Techniques; Medtronic Sofamor Danek; Biomet; DePuy, A Johnson & Johnson Company; JNS: Spine; Globus Medical; David W. Polly, MD—Scoliosis Research Society; Medtronic; Smith & Nephew; Synthes; Stephen L. Ondra, MD—No conflicts reported; Sigurd H. Berven, MD—Orthopedics Today; Spine; Scientx, Pioneer; DePuy, A Johnson & Johnson Company; Kyphon Inc.; Medtronic Sofamor Danek; Osteotech; Keith H. Bridwell, MD—Wolters Kluwer Health - Lippincott Williams & Wilkins; Biomet; Breg; Cerapedics; Medtronic Sofamor Danek; Smith & Nephew; Stryker; Synthes; Wright Medical Technology, Inc.; Wyeth; Axial Biotech; Midwest Stone Institute; K2M; DePuy, A Johnson & Johnson Company.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org