An Overview of Chronic Spinal Pain: Revisiting Diagnostic Categories and Exploring an Evolving Role for Neurostimulation.

STUDY DESIGN: Topic overview. OBJECTIVE: To describe the varied etiologies resulting in chronic spinal pain and review the current available evidence for treatments. SUMMARY OF BACKGROUND DATA: Chronic pain conditions, especially those that affect the axial back and radiate to the extremities, affect a large population. This results in pronounced disability and a high socioeconomic burden. Our understanding of the underlying mechanisms for chronic pain is limited. This prevents a comprehensive diagnostic approach. Evidence from high-level clinical trials supporting treatments for chronic spinal pain is also limited. METHODS: Articles were identified through PubMed searches or already known to the author. The literature was reviewed and summarized, indicating the strength of evidence available for many treatment modalities. RESULTS: There are very few studies published that evaluate behavioral modifications for chronic spinal pain and only one long-term study investigating chronic pharmacological treatments. The data on the success of spinal surgeries to relieve chronic spinal pain suggest an unacceptably high failure rate. The best evidence (Level I) currently available suggests that spinal cord stimulation is a safe, effective, and durable treatment for chronic spinal pain. Recent clinical data support further investigation of new innovations and earlier therapeutic consideration of currently employed approaches. CONCLUSION: Currently, physicians are limited in the practice of evidence-based medicine regarding chronic spinal pain treatments due to both the paucity of data available and an inconsistent diagnostic nomenclature. The introduction of new neurostimulation modalities is promising but requires better characterization through ongoing prospective clinical investigation. LEVEL OF EVIDENCE: 5.

Cost-Effectiveness Data Regarding Spinal Cord Stimulation for Low Back Pain.

STUDY DESIGN: Review of published literature pertaining to spinal cord stimulation (SCS) cost data analysis. OBJECTIVE: To acquire, organize, and succinctly summarize the available literature regarding the costs associated with, and the cost-effectiveness of, SCS. SUMMARY OF BACKGROUND DATA: Chronic back and limb pain is a pervasive complaint in modern society, with estimated annual costs of medical care greater than $100 billion. The traditional standard medical management with or without intermittent surgical decompression/fusion has been plagued by high costs and inconsistent results, leading to poor patient satisfaction and functional outcome, and questions from policy makers regarding use of limited healthcare resources. Neuromodulation techniques, including SCS have recently become more common in the treatment of chronic back/leg pain, with clinical studies showing a high degree of efficacy in alleviating otherwise intractable pain. Given the relatively high upfront costs associated with the hardware and implantation, policy makers have, however, questioned their use in the framework of cost-containment and resource utilization. We reviewed the available literature summarizing cost data of SCS in chronic back and limb pain, as an understanding of these data will be vital to justify continued payment for this expensive, but often very effective, treatment modality. METHODS: We performed a PubMed literature search utilizing the following terms: "spinal cord stimulation," "SCS," "financial," "cost," "cost-effectiveness," and "cost-utility." All studies published in English and containing complete or partial cost evaluations of SCS for chronic back and limb pain were included. RESULTS: The search revealed 21 studies that evaluated cost data, with or without outcomes analysis and cost-utility analysis, for patients with chronic back and limb pain. The overwhelming majority of data presented shows that SCS is not only an effective treatment option for these patients, but also represents cost savings and efficient use of healthcare resources relative to current standards of care. Although not all studies performed cost-utility analyses, those that did tended to show SCS falling well within accepted thresholds of "willingness-to-pay" on the part of third-party payers. That being said, the articles included in this review were almost all small, retrospective, single-institution studies. In addition, many of them relied on modeling for their analyses, and published literature values for cost and/or outcomes data rather than prospectively collected patient data. Although the data presented in this review are encouraging, it should serve as a foundation for a thorough, prospective, cost-utility analysis of SCS in chronic back and limb pain so that the role of this important treatment modality may be cemented in the treatment paradigm for these patients without questions from third-party payers. CONCLUSION: The large majority of data covering costs of SCS argue in favor of the cost-effectiveness of this treatment modality for chronic neuropathic pain, especially in comparison to reoperation and medical management. Although most of the higher-quality evidence is relatively short-term, clinical experience with the durability of treatment benefit of SCS in these patients is promising. Given the pushback regarding high upfront costs of implantation, longer-term, prospective, randomized studies evaluating this topic will be important to help maintain third-party payer reimbursements for SCS. LEVEL OF EVIDENCE: 5.

Antifibrinolytics reduce blood loss in adult spinal deformity surgery: a prospective, randomized controlled trial.

STUDY DESIGN: This is a prospective, randomized, double-blinded comparison of tranexamic acid (TXA), epsilon aminocaproic acid (EACA), and placebo used intraoperatively in patients with adult spinal deformity. OBJECTIVE: The purpose of this study was to provide high-quality evidence regarding the comparative efficacies of TXA, EACA, and placebo in reducing blood loss and transfusion requirements in patients undergoing posterior spinal fusion surgery. SUMMARY OF BACKGROUND DATA: Spine deformity surgery usually involves substantial blood loss. The antifibrinolytics TXA and EACA have been shown to improve hemostasis in large blood loss surgical procedures. METHODS: Fifty-one patients undergoing posterior spinal fusion of at least 5 levels for correction of adult spinal deformity were randomized to 1 of 3 treatment groups. Primary outcome measures included intraoperative estimated blood loss, total loss, (estimated blood loss + postoperative blood loss), and transfusion rates. RESULTS: Patients received TXA (n = 19), EACA (n = 19), or placebo (n = 13) in the operating room (mean ages: 60, 47, and 43 yr, respectively); TXA patients were significantly older and had larger estimated blood volumes than both other groups. Total losses were significantly reduced for EACA versus control, and there was a demonstrable but nonsignificant trend toward reduced intraoperative blood loss in both antifibrinolytic arms versus control. EACA had significant reductions in postoperative blood transfusions versus TXA. CONCLUSION: The findings in this study support the use of antifibrinolytics to reduce blood loss in posterior adult spinal deformity surgery. LEVEL OF EVIDENCE: 1.