Functional Outcomes and Economic Issues

Rehabilitation in acute care hospitals is focused on 'survival skills', those skills necessary for patients to be safe at home (transfers, mobility and minimal self-care activities). Patients undergoing lumbar fusion procedures and spinal trauma patients may require intensive inpatient rehabilitation after discharge from the hospital.

From an economic standpoint, the literature is beginning to reflect a concern for the costs associated with different spinal surgical procedures. One-stage versus two-stage anterior-posterior lumbar fusion procedures were compared with regard to blood loss, nutritional status, length of stay and hospital charges in a study of 24 patients. (148) The two-stage procedures had longer length of stays (20 days versus 13 days) and higher hospital charges by 30% than the one-stage anterior-posterior procedures. The one-stage procedures were associated with a significantly lower blood loss. Both one- and two-stage procedures were associated with malnutrition one week post-operatively (76% and 64%, respectively). However, the one-stage procedure patients did not have to undergo another surgical procedure in a malnourished state.

In a retrospective review of hospital charts, transforaminal lumbar interbody fusion (TLIF) was compared to anterior-posterior fusion with regard to operative time, blood loss, use of surgical intensive care, length of stay, and hospital charges. (149) The TLIF group had less operative time, less blood loss, lower use of the surgical intensive care unit, shorter length of stay and lower hospital charges. In a similar study, patients undergoing TLIF were compared to patients undergoing posterior lumbar interbody fusion (PLIF) for complication rates, blood loss, operative time, and length of stay. (150)

Among the patients in both groups with one-level fusions, there was no difference in blood loss, operative time, and length of stay. However, among patients with two-level fusions, those in the TLIF group had significantly less blood loss. There was a greater complication rate for the PLIF group as a whole.

Surgical versus non-surgical treatment for spinal fractures continues to spark debate. Surgical and non-surgical methods of treatment for patients with odontoid fractures (Type II and Type III) were retrospectively analyzed. (151) Some patients were placed in halo vest immobilization and others received immediate surgical intervention (posterior C1-C2 fusion). There was no significant difference in functional outcome between patients treated conservatively and patients treated with surgery, regardless of age or type of fracture, although, as expected, there was a greater nonunion rate for Type II fractures than for Type III fractures.

In a retrospective review of 235 patients with thoracolumbar burst fractures, there was no difference in rates of pulmonary embolus or deep venous thrombosis in patients treated surgically versus patients treated non-surgically (6-weeks of bed rest on a kinetic bed). Moreover, the overall complication rates in the surgically treated group of patients was greater than in the non-surgical group of patients (post-operative infections and mortality rates) and hospital charges were similar, although length of stay for the surgically treated patients was lower. (152)

Non-operative treatment for three-column burst fractures may even be a reasonable treatment option. Thirty-eight neurologically intact patients with three-column thoracolumbar burst fractures treated non-operatively were retrospectively reviewed for outcomes. (153) Follow-up averaged 4.1 years (range, 2.1-6.3 years). Only nine patients were treated with a brace and all were allowed to ambulate as tolerated. All patients remained neurologically intact. Sixteen patients returned to their previous employment in manual labor, 19 patients to some less strenuous form of work, and 3 were unable to work. Follow-up CT scans were available in 35 patients, all of whom showed some resorption of the retropulsed fragments. The average progression of kyphosis was 6%.

Patient reported outcomes are an important consideration in spine care. Instruments that have been used for patient-reported outcomes in spine care include the Roland and Morris Disability Scale, the Oswestry Disability Questionnaire, the Short-Form (SF)-36 and SF-12, the Sickness Impact Profile, the Million Visual Analog Scale, the Quebec Back Pain Disability Scale, the Dallas Pain Questionnaire, the Zung Depression Score, the Minnesota Multiphasic Personality Inventory (MMPI), MMPI-2, and many others. The North American Spine Society has created a directory of instruments applicable to the spine care setting. The Compendium of Outcome Instruments for Assessment and Research of Spinal Disorders (154) offers a valuable overview and critique of nearly 100 instruments reviewed by spine care professionals.