Becker's Spine Review

15 New Trends in Post-Spine Surgery Pain Management The Economics of Spine Surgery: How Pain Management Makes a Difference By Laura Dyrda S pine surgery is an expensive procedure, but for patients who would benefit from surgical correction the long-term economic benefits can far outweigh the initial cost of care. Especially with new mini- mally invasive and outpatient spine procedures, the cost of spine surgery has dramatically decreased over the past few years. For example, a November 2013 study published in The Spine Journal showed the direct hospital costs were $19,512 for patients who underwent minimally invasive transforaminal lumbar interbody fusion, compared with $23,550 for the open procedure. Another article published in 2012 in Spine examined the cost and quality-ad- justed life year for single-level instrumented posterolateral lumbar fusion for patients with degenerative lumbar spine conditions. The researchers found: • Cost per QALY gained at the five-year postoperative interval was $33,018. • The analogous average direct cost based on Medicare reimbursement for five years was $20,669, with a resultant cost per QALY gained of $30,053. • The average total work productivity cost for five years was $14,377 with a resultant total cost per QALY gained from $53,949 to $53,914. "Compared to other fields of medicine, there continues to be a relative pau- city of high-level evidence available to direct the care of patients with spinal conditions," says Peter Whang, MD, FACS, an associate professor in the de- partment of orthopedics and rehabilitation at the Yale University School of Medicine in New Haven, Conn. "However, we have been trying to make up for lost time and this is reflected in the quality of research that has recently been published. One obvious example is the considerable amount of data derived from the Spine Patient Outcomes Research Trial." When surgery is indicated, there are several factors that increase the cost of care for spine surgery patients. Implants and fusion material are a huge expense, along with resource management costs like operative time and length of stay. When patients have poor pain control or experience complications, costs ex- ceed several thousands of dollars for each additional day in the hospital. "Despite our best efforts, complications will inevitably occur and they cer- tainly have the potential to prolong hospital stay, increase costs and ultimate- ly compromise patient outcomes," says Dr. Whang. "Obviously the best treat- ment for any complication is prevention which requires constant vigilance on our part before, during and after the operation. This involves adhering to proper patient selection, identifying significant risk factors and implement- ing preemptive measures." Improved pain control can have several economic benefits: • Quicker discharge from the hospital • Reduced readmissions for acute pain • Reduced costs for chronic pain treatment • Improved patient satisfaction scores • Reduced legal liability Reducing narcotics-related side-effects and complications could mean sub- stantial savings. However, some of the non-narcotic alternatives still have high costs; a Frost & Sullivan white paper shows the average cost for pain pumps, supplies and drugs is $450 on average. An additional $196 is neces- sary for the pharmacy to fill the pump, bringing the total cost to $646 for drug administration. Nurse time to monitor the patient is 3.3 hours on aver- age, valued at $165 per case. Another option for orthopedic and spine surgeons is bupivacaine extend- ed-release liposome injections in conjunction with other pain management techniques to reduce pain for up to 72 hours, allowing patients to return home sooner. John Barrington, MD, from the Center for Joint Replacement in Plano, Texas, compared patients who received bupivacaine extended-release liposome in- jections with patients who received femoral nerve blocks to relieve pain. The patients who received the bupivacaine extended-release liposome injections reduced patient falls from 10 to two and saved $1,246 per patient on average. Physicians are beginning to learn the risk factors for complications and an- ticipating adverse events to aggressively treat patients earlier. "We certainly cannot eliminate complications in spine surgery, but we can hopefully de- crease their incidence and mitigate their consequences," says Dr. Whang. "For the most part, surgeons have recognized the importance of clinical outcomes and strived to incorporate them into their practice." Electronic medical records make collecting data easier and clinicians can pinpoint the source of negative trends or outliers in their data. One of the biggest opportunities to reduce complications and associated costs is through postoperative pain management. "I think the importance of establishing an effective postsurgical pain man- agement regimen cannot be overstated. While no surgeon wants their pa- tients to be uncomfortable after surgery, it has become increasingly clear that poorly-controlled pain is associated with a wide range of perioperative com- plications — immobility, falls and mental status changes," says Dr. Whang. "Another challenge we face is that many analgesics we commonly use may also give rise to any number of adverse events." For complications such as respiratory depression, recovery adds 3.3 days in the hospital on average. Patients who experience nausea and/or vomiting due to poor postoperative pain control spend another 2.5 days in the hospital on average. Ileus and/or constipation causes 3.4 extra days, and delayed ambula- tion can mean patients are staying in the hospital for three extra days. "In the end, inadequate treatment of this pain may even lead to worsening clinical outcomes, both in the immediate postoperative period and possibly even over the long term as well," says Dr. Whang. "The issue is certainly an area of active research and in the future it is likely that we will need to utilize a multimodal strategy including longer-acting local anesthetics and novel an- algesics in an attempt to address postsurgical pain." n "I think the importance of establishing an effective postsurgical pain management regimen cannot be overstated. While no surgeon wants their patients to be uncomfortable after surgery, it has become increasingly clear that poorly- controlled pain is associated with a wide range of perioperative complications — immobility, falls and mental status changes." – Dr. Peter Whang, Yale University School of Medicine

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