Cost-effectiveness of anterior surgical decompression surgery for cervical degenerative disk disease: a systematic review of economic evaluations.

PURPOSE: No clear consensus exists on which anterior surgical technique is most cost-effective for treating cervical degenerative disk disease (CDDD). One of the most common treatment options is anterior cervical discectomy with fusion (ACDF). Anterior cervical discectomy with arthroplasty (ACDA) was developed in an effort to reduce the incidence of clinical adjacent segment pathology and associated additional surgeries by preserving motion. This systematic review aims to evaluate the evidence regarding the cost-effectiveness of anterior surgical decompression techniques used to treat radiculopathy and/or myelopathy caused by CDDD. METHODS: The search was conducted in PubMed, EMBASE, Web of Science, CINAHL, EconLit, NHS-EED and the Cochrane Library. Studies were included if healthcare costs and utility or effectivity measurements were mentioned. RESULTS: A total of 23 studies were included out of the 1327 identified studies. In 9 of the 13 studies directly comparing ACDA and ACDF, ACDA was the most cost-effective technique, with an incremental cost effectiveness ratio ranging from $2.900/QALY to $98.475/QALY. There was great heterogeneity between the costs of due to different in- and exclusion criteria of costs and charges, cost perspective, baseline characteristics, and calculation methods. The methodological quality of the included studies was moderate. CONCLUSION: The majority of studies report ACDA to be a more cost-effective technique in comparison with ACDF. The lack of uniform literature impedes any solid conclusions to be drawn. There is a need for high-quality cost-effectiveness research and uniformity in the conduct, design and reporting of economic evaluations concerning the treatment of CDDD. TRIAL REGISTRATION: PROSPERO Registration: CRD42020207553 (04.10.2020).

Reliability and Clinical Usefulness of Current Classifications in Traumatic Thoracolumbar Fractures: A Systematic Review of the Literature.

BACKGROUND: A validated classification remains the key to an appropriate treatment algorithm of traumatic thoracolumbar fractures. Considering the development of many classifications, it is remarkable that consensus about treatment is still lacking. We conducted a systematic review to investigate which classification can be used best for treatment decision making in thoracolumbar fractures. METHODS: A comprehensive search was conducted using PubMed, Embase, CINAHL, and Cochrane using the following search terms: classification (mesh), spinal fractures (mesh), and corresponding synonyms. All hits were viewed by 2 independent researchers. Papers were included if analyzing the reliability (kappa values) and clinical usefulness (specificity or sensitivity of an algorithm) of currently most used classifications (Magerl/AO, thoracolumbar injury classification and severity score [TLICS] or thoracolumbar injury severity score, and the new AO spine). RESULTS: Twenty articles are included. The presented kappa values indicate moderate to substantial agreement for all 3 classifications. Regarding the clinical usefulness, > 90% agreement between actual treatment and classification recommendation is reported for most fractures. However, it appears that over 50% of the patients with a stable burst fracture (TLICS 2, AO-A3/A4) in daily practice are operated, so in these cases treatment decision is not primarily based on classification. CONCLUSION: AO, TLICS, and new AO spine classifications have acceptable accuracy (kappa > 0.4), but are limited in clinical usefulness since the treatment recommendation is not always implemented in clinical practice. Differences in treatment decision making arise from several causes, such as surgeon and patient preferences and prognostic factors that are not included in classifications yet. The recently validated thoracolumbar AO spine injury score seems promising for use in clinical practice, because of inclusion of patient-specific modifiers. Future research should prove its definite value in treatment decision making. LEVEL OF EVIDENCE: 2. CLINICAL RELEVANCE: Without the appropriate treatment, the impact of traumatic thoracolumbar fractures can be devastating. Therefore it is important to achieve consensus in the treatment of thoracolumbar fractures.