Quantity and Quality of Economic Evaluations in U.S. Nursing Research, 1997-2015: A Systematic Review.

BACKGROUND: The United States has a complex healthcare system that is undergoing substantial reformations. There is a need for high-quality, economic evaluations of nursing practice. An updated review of completed economic evaluations relevant to the field of nursing within the U.S. healthcare system is timely and needed. OBJECTIVES: The purpose of this study was to evaluate and describe the quantity and quality of economic evaluations in nursing-relevant research performed in the United States between 1997 and 2015. METHODS: Four databases were searched. Titles, abstracts, and full-text content were reviewed to identify studies that analyzed both costs and outcomes, relevant to nursing, performed in the United States, and used the quality-adjusted life year to measure effectiveness. For included studies, data were extracted from full-text articles using criteria from U.S. Public Health Service's Panel on Cost-Effectiveness in Health and Medicine. RESULTS: Twenty-eight studies met the inclusion criteria. Most (n = 25, 89%) were published in the last decade of the analysis, from 2006 to 2015. Assessment of quality, based on selected items from the panel guidelines, found that the evaluations did not consistently use the recommended societal perspective, use multiple resource utilization categories, use constant dollars, discount future costs and outcomes, use a lifetime horizon, or include an indication of uncertainty in results. The only resource utilization category consistently included across studies was healthcare resources. DISCUSSION: Only 28 nursing-related studies meeting the inclusion criteria were identified as meeting robust health economic evaluation methodological criteria, and most did not include all important guideline items. Despite increases in absolute numbers of published studies over the past decade, economic evaluation has been underutilized in U.S. nursing-relevant research in the past two decades.

Transaction cost analysis of in-clinic versus telehealth consultations for chronic pain: preliminary evidence for rapid and affordable access to interdisciplinary collaborative consultation.

OBJECTIVES: With ever increasing mandates to reduce costs and increase the quality of pain management, health care institutions are faced with the challenge of adopting innovative technologies and shifting workflows to provide value-based care. Transaction cost economic analysis can provide comparative evaluation of the consequences of these changes in the delivery of care. The aim of this study was to establish proof-of-concept using transaction cost analysis to examine chronic pain management in-clinic and through telehealth. METHODS: Participating health care providers were asked to identify and describe two comparable completed transactions for patients with chronic pain: one consultation between patient and specialist in-clinic and the other a telehealth presentation of a patient's case by the primary care provider to a team of pain medicine specialists. Each provider completed two on-site interviews. Focus was on the time, value of time, and labor costs per transaction. Number of steps, time, and costs for providers and patients were identified. RESULTS: Forty-six discrete steps were taken for the in-clinic transaction, and 27 steps were taken for the telehealth transaction. Although similar in costs per patient ($332.89 in-clinic vs. $376.48 telehealth), the costs accrued over 153 business days in-clinic and 4 business days for telehealth. Time elapsed between referral and completion of initial consultation was 72 days in-clinic, 4 days for telehealth. CONCLUSIONS: U.S. health care is moving toward the use of more technologies and practices, and the information provided by transaction cost analyses of care delivery for pain management will be important to determine actual cost savings and benefits.

Cost-effectiveness of early versus delayed functional restoration for chronic disabling occupational musculoskeletal disorders.

PURPOSE: Despite extensive evidence for the treatment effectiveness of interdisciplinary functional restoration (FR) for chronic disabling occupational musculoskeletal disorders (CDOMD), there is little documentation on the cost-effectiveness of early rehabilitation using FR. METHODS: A total of 1,119 CDOMD patients were classified according to duration of disability on FR entry, corresponding to early rehabilitation (ER: 4-8 months of disability, N = 373), intermediate duration (ID: 9-18 months, N = 373), and delayed rehabilitation (DR: >18 months, N = 373). Groups were matched on sex, age, ethnicity, and injured musculoskeletal region. One-year post-rehabilitation outcomes included return-to-work, work retention and healthcare utilization. Economic analyses included a cost-effectiveness analysis of the FR program, and estimation of the total cost-of-illness. RESULTS: At 1-year post-rehabilitation, all groups were comparable on return-to-work (overall 88%), work retention (overall 80%), and additional healthcare utilization (overall, 2.2% of patients received re-operations/new surgeries, 2 visits to new healthcare provider). Savings of up to 64% in medical costs, and up to 80% in disability benefits and productivity losses was associated with the ER group. The cost of rehabilitation was also up to 56% lower when administered early. Overall, ER resulted in estimated cost savings of up to 72% (or almost $170,000 per claim). CONCLUSIONS: Duration of disability does not negatively impact objective work or healthcare utilization outcomes following interdisciplinary FR. However, early rehabilitation is more likely to be a cost-effective solution compared to cases that progress >8 months and receiving FR as a treatment of "last resort".

Mild Traumatic Brain Injuries and Risk for Affective and Behavioral Disorders.

OBJECTIVES: Recent studies document an association between mild traumatic brain injuries (mTBIs) in children and postinjury psychiatric disorders. However. these studies were subject to limitations in the design, lack of long-term follow-up, and poorly defined psychiatric outcomes. This study determines the incidence and relative risk of postinjury new affective and behavior disorders 4 years after mTBIs. METHODS: A cohort study of mTBI cases and matched comparisons within an integrated health care system. The mTBI group included patients ≤17 years of age, diagnosed with mTBI from 2000 to 2014 (N = 18 917). Comparisons included 2 unexposed patients (N = 37 834) per each mTBI-exposed patient, randomly selected and matched for age, sex, race/ethnicity, and date of medical visit (reference date to mTBI injury). Outcomes included a diagnosis of affective or behavioral disorders in the 4 years after mTBI or the reference date. RESULTS: Adjusted risks for affective disorders were significantly higher across the first 3 years after injury for the mTBI group, especially during the second year, with a 34% increase in risk. Adjusted risks for behavioral disorders were significant at years 2 and 4, with up to a 37% increase in risk. The age group with the highest risk for postinjury affective and behavioral disorders was 10- to 13-year-old patients. CONCLUSIONS: Sustaining an mTBI significantly increased the risks of having a new affective or behavioral disorder up to 4 years after injury. Initial and ongoing screening for affective and behavior disorders following an mTBI can identify persistent conditions that may pose barriers to recovery.

Redesigning delivery of opioids to optimize pain management, improve outcomes, and contain costs.

INTRODUCTION: Chronic pain is a public health concern, and in the last decade, there has been a dramatic increase in the use and abuse of prescription opioids for chronic non-cancer pain. METHODS: We present an overview of a five-component model of pain management implemented at the University of Washington Division of Pain Medicine designed to facilitate recent state guidelines to reduce the risks associated with long-term use of prescription opioids. RESULTS: Central to the model described are guidelines for best clinical practice, a collaborative care approach, telehealth solutions, comprehensive prescription-monitoring, and measurement-based care. DISCUSSION: The model presented is a patient-centered, efficient, and cost-effective approach to the management of chronic pain.

Pulsed radiofrequency of suprascapular nerve for chronic shoulder pain: a randomized double-blind active placebo-controlled study.

BACKGROUND: The suprascapular nerve block is frequently implemented to treat chronic shoulder pain. Although effective the nerve blockade provides only a short-term relief, and more compelling apaproaches have been investigated. Pulsed radiofrequency (pRF) has been anecdotally reported as safe and reliable method. However, formal efficacy study has not been published. Ostensibly evidence-based validation of a new method is necessary for both scholastic and practical purposes. METHODS: This study was designed as a randomized active placebo-control double-blind trial. Because of encountered difficulties in recruitment and high rate of dropout, the study was redesigned as to allow a smaller sample size and statistical analyses were performed utilizing the last observation carry forward method. Lidocaine injections alone or with combination of the pRF were performed. Participants were followed up during 6 months, and multiple subjective and objective outcome variables were recorded. RESULTS: Thirteen of 22 participants completed 6 months follow-up. Dropout rate was higher in the lidocaine group. A significant linear trend (P < 0.05) for improvement on the numeric rating scale, Shoulder Pain and Disability Index and Constant-Murley score was observed in the pRF group, but not in the lidocaine group. Patients in the pRF group were on average more satisfied than the lidocaine group at 1 month (P = 0.041) and at 3 months (P = 0.035). DISCUSSION: Considering limitations of the study design and statistics, it seems plausible to attribute better results in the pRF group to unique properties of this physical modality.

The preparedness assessment for the transition home after stroke predicts key domains of caregiver health.

BACKGROUND: Caregivers of stroke survivors often experience adverse health effects due to poor preparation. OBJECTIVES: We evaluate the concurrent and predictive validity of the Preparedness Assessment for the Transition Home after Stroke (PATH-s) family caregiver assessment tool relative to important domains of caregiver health and stroke survivor outcomes. METHODS: A convenience sample of caregivers (N = 183) was assessed on several health-related quality of life instruments prior to stroke survivor discharge (T1), and at 30-days (T2) and 90-days (T3) post-discharge. RESULTS: Caregivers completed assessments at T1 (N = 183), T2 (N = 116, 63%), and T3 (N = 97, 53%). At T1, the PATH-s demonstrated concurrent validity with depressive symptoms (r = -0.26, p < .001), global health (r = 0.45 p < .001) and activation (r = 0.34, p < .001). The PATH-s also has predicted improvements in T2 outcomes including depressive symptoms (radj = -0.21, p < .05), global health (radj = 0.30, p < .01), perceived stress (radj = -0.30, p < .01), activation (radj = 0.21, p < .05), caregiving-specific health-related quality of life (r = 0.23, p < .05), and caregiver strain (r = -0.36, p < .001). At T3, higher scores on the PATH-s were a significant predictor for improvements in activation (radj = 0.24, p < .05). CONCLUSION: The PATH-s demonstrates good concurrent and predictive validity and predicts important domains relevant to caregiver well-being. This can be used to identify gaps in caregiver preparedness so interventions can be tailored to optimize the transition home and mitigate adverse effects of caregiving.

Validation of self-reported pain reduction after diagnostic blockade.

OBJECTIVE: The criterion commonly used to determine whether radiofrequency neurotomy may be recommended is based on patient-reported, short-term pain relief following facet block injections. This study evaluated the concordance between two commonly used outcomes for pain relief: the pain numerical rating scale (NRS) and the global perceived improvement (GPI) scale. DESIGN: This is a retrospective cohort study. METHODS: Data were obtained from a consecutive cohort of patients through a review of the electronic medical records, with the following inclusion criteria: medial branch facet blocks at either cervical or lumbar spinal regions. OUTCOME MEASURES: Pain NRS (baseline, postprocedure, and hourly up to 6 hours) and GPI scale are expressed as percent improvement at 6 hours, relative to baseline. RESULTS: The percent improvement in pain NRS corresponded to 49%, 43%, 34%, 21%, and 36% for baseline vs immediately post-block, 1 hour, 3 hours, 6 hours and average of all postscores, respectively. Average GPI reported at 6 hours was 44%, and differed significantly only to the baseline vs 6 hours percent improvement on the NRS (P < 0.01). Multiple regression analysis indicated that there were no demographic or baseline factors that accounted for the discrepancy between GPI vs NRS. CONCLUSIONS: Asking patients about their pain relief in retrospect can be misleading. It is possible that patients' report on the GPI is weighed by their total experience of pain reduction and retrospective recall. Therefore, when choosing to address percent improvement on NRS measures, it is important to take into account multiple instances of NRS measures following treatment.

Prevalence of depression and anxiety disorders following mild traumatic brain injury.

BACKGROUND: Previous studies have identified an association between traumatic brain injuries and the development of psychiatric disorders in general. However, these studies were subject to limitations that demonstrate the need for a study of a large, clearly defined mild traumatic brain injury (mTBI) population within an integrated healthcare system. OBJECTIVE: To determine the prevalence and relative risk of postinjury affective disorders over 4 years following mTBI. DESIGN: Cohort study of mTBI cases and matched controls, over a 4-year period. SETTING: An integrated healthcare delivery system in California. PATIENTS: A total of 9428 adult health plan members diagnosed with mTBI from 2000-2007 and enrolled in the year before injury, during which no TBI was ascertained. Control participants included 18,856 individuals selected based on the following criteria: Two unexposed health plan members per each mTBI-exposed patient were randomly selected and individually matched for age, gender, race/ethnicity, and medical comorbidities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A diagnosis of affective disorder (depressive, anxiety, and adjustment disorders) in the 4 years after mTBI or the reference date, determined according to the International Classification of Diseases, Ninth Revision, Clinical Modification as well as the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. RESULTS: Affective disorders were most prominent during the first 12 months with 23% following mTBI and 14% in the control group. Four-year aggregate adjusted odds ratios for having an affective disorder following mTBI were 1.2 (95% CI: 1.1, 1.2; p < .001) and 1.5 (95% CI: 1.5, 1.6; p < .001) for patients with and without prior affective disorders, respectively. CONCLUSION: mTBI was associated with a significantly increased risk of having subsequent affective disorders. Screening for and addressing affective disorders at earlier stages following the injury is an important step to avoid persisting conditions that may pose a barrier to full recovery.

Improving Caregiver Health through Systematic Assessment and a Tailored Plan of Care.

Caregivers often experience strain and negative effects on their well-being. We tested the effects of a caregiver assessment and tailored care plan for caregivers of patients transitioning home from an inpatient rehabilitation facility (IRF), a study involving two groups: usual care (n = 225) (preimplementation) and intervention (postimplementation) (n = 215). Caregivers in the intervention group were assessed using the 25-item self-reported Preparedness Assessment for the Transition Home during the IRF stay. A tailored care plan was implemented in response to the assessment. Caregivers in both groups completed the Modified Caregiver Strain Index and Global Health Scale at 30- and 90-day postdischarge. After adjusting for baseline and demographics, caregivers in the intervention group reported lower strain (p < .01) and better overall health (p < .05) at 30-day post-IRF discharge, relative to usual care. Implementing a systematic caregiver assessment and tailored care plan in the IRF may mitigate the adverse effects of caregiving.

Psychometric Properties of the Preparedness Assessment for the Transition Home After Stroke Instrument.

PURPOSE: The aim of this study was to evaluate psychometric properties of the Preparedness Assessment for the Transition Home After Stroke (PATH-s), a novel instrument to assess stroke caregiver commitment and capacity. The PATH-s instrument can be obtained at www.rehabnurse.org/pathtool. DESIGN: The design of this study is cross-sectional. METHODS: The PATH-s, the Preparedness for Caregiving Scale (PCS), the Patient Health Questionnaire, the Perceived Stress Scale, and the Global Health Scale were self-reported from a convenience sample of caregiver-stroke survivor dyads (n = 183) during inpatient rehabilitation. RESULTS: Exploratory factor analysis revealed eight factors underlying the PATH-s structure. The PATH-s Cronbach's alpha of .90 demonstrated criterion-related validity with the PCS (r = .79, p < .01). Both the PATH-s and the PCS were negatively correlated with the Patient Health Questionnaire (r = -.26 and -.27, respectively; p < .01) and the Perceived Stress Scale (r = -.12 and -.15, respectively; p > .05) and positively correlated with the Global Health Scale (r = -.46 and .46, respectively; p < .01), indicating convergent validity. CONCLUSIONS: The PATH-s demonstrates excellent internal consistency and satisfactory criterion-related and convergent validity. CLINICAL RELEVANCE: The PATH-s may be used to assess the risk/needs of caregivers over time.

Intrathecal opioid therapy for chronic nonmalignant pain: a retrospective cohort study with 3-year follow-up.

OBJECTIVE: The objective of this study was the analysis of outcomes after intrathecal opioid treatment. Design. Retrospective chart review cohort study. Setting. Tertiary care university hospital and clinic. Patients. Adults of both sexes were included. Interventions. The intervention consisted of the implantation of intrathecal catheter and subcutaneous programmable pump to deliver opioids. OUTCOME MEASURES: These included intrathecal and oral opioid consumption, self-reported pain levels, and complications. RESULTS: We observed reduction of visual analog scale scores, decrease in oral opioid consumption. Stable long-term (3 year) pain reports. We also noted gradual increases in intrathecal opioid consumption. Pre-implant opioid consumption was inversely correlated with treatment success. The complication rate was approximately 20%. CONCLUSIONS: We conclude that intrathecal opioids without adjunctive intrathecal medications have a favorable outcome. Some patients are able to eliminate oral opioids. Results seem stable for prolonged periods, although some increase in intrathecal opioids dosing may be required.

Patients with chronic disabling occupational musculoskeletal disorder failing to complete functional restoration: analysis of treatment-resistant personality characteristics.

OBJECTIVE: To identify the risk factors for noncompletion of a functional restoration program for patients with chronic disabling occupational musculoskeletal disorders. DESIGN: Prospective cohort study. SETTING: Consecutive patients undergoing functional restoration treatment in a regional rehabilitation referral center. PARTICIPANTS: A sample of 3052 consecutive patients, classified as either completers (n=2367) or noncompleters (n=685), who entered a functional restoration program. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The measures used included medical evaluations, demographic data, Diagnostic and Statistical Manual of Mental Disorders psychiatric diagnoses, the Minnesota Multiphasic Personality Inventory, and validated questionnaires evaluating pain, depression, and occupational factors. RESULTS: The findings revealed that patients who did not complete the program had a longer duration of total disability between injury and admission to treatment (completers=20mo vs noncompleters=13mo; P<.001). Furthermore, patients who were opioid-dependent were 1.5 times more likely to drop out of rehabilitation, and patients diagnosed with a socially problematic Cluster B Personality Disorder were 1.6 times more likely to drop out. CONCLUSIONS: Although some risk factors associated with program noncompletion may be addressed in treatment, socially maladaptive personality disorders, long-neglected disability, and chronic opioid dependence are the major barriers to successful treatment completion. The patients identified with personality disorders may display resistance to treatment and may be difficult for the treatment staff to deal with. Early recognition of these treatment-resistant personality characteristics in the functional restoration process may assist the treatment team in developing more effective strategies to help this dysfunctional group.

Evidence-based outcomes in pain research and clinical practice.

The growing emphasis on evidence-based medicine dictates that reliable, evidence-based outcomes be utilized in documenting response to treatment, as well as determining the treatment efficacy and cost-effectiveness of different treatment modalities. The biopsychosocial model conceptualizes pain as a complex multifactorial interaction of biological, psychological, and social components that play a role in the development, exacerbation, and perpetuation of pain. As a result, outcomes relevant to pain management are necessarily complex and multifactorial in nature. Two broad categories of evidence-based outcomes relevant to pain management are discussed: patient-reported outcomes and objective outcomes. Patient-reported outcomes are discussed within the context of pain measures, health-related quality of life, and psychological constructs. Objective outcomes are discussed within the context of healthcare utilization and occupational status. The discussion within each section highlights the unique constructs measured by each category of outcome measure and highlights their consistency with current evidence-based guidelines and knowledge from pain research.

Management and interpretation of data obtained from clinical trials in pain management.

Conducting a clinical trial involves various stages of planning and implementation. The three major components involved in clinical trials are the management of data, the quality control to ensure data integrity, and the interpretation of the data at the conclusion of the trial. Although each process is distinct and involves different levels of effort and knowledge to implement, all processes are intimately linked. Data management techniques include the process of data entry and the implementation of an organized, comprehensive approach to quality control. Some guidelines for quality control screening are recommended to address various common issues related to clinical data, such as missing data, invalid cases, subject "outliers," and violation of distributional assumptions relevant to statistical analyses. In order to aid in interpreting the data, conditions that need to be met to make causal inferences are discussed. Taking into account baseline characteristics of the patient sample is also discussed as an extension to maintaining the internal validity of the study. Additionally, some common threats to statistical conclusion validity, including Type I error inflation and the problem of overpowered tests, are highlighted. Finally, the concept of the effect size as an important complement to statistical significance and how the various types of effect size measures can be interpreted within the context of a clinical trial are discussed.

Number and Type of Post-Traumatic Stress Disorder Symptom Domains Are Associated With Patient-Reported Outcomes in Patients With Chronic Pain.

Post-traumatic stress disorder (PTSD) commonly accompanies complex chronic pain, yet PTSD is often overlooked in chronic pain management. Using the 4-item Primary Care (PC)-PTSD screening tool, we evaluated the relationship between the number and type of PC-PTSD symptoms endorsed and a set of patient-reported outcomes, including: pain intensity and interference, function, mood, quality of life, and substance abuse risk in a consecutive sample of patients with chronic pain (n = 4,402). Patients completed PainTracker, a Web-based patient-reported outcome tool that provides a multidimensional evaluation of chronic pain, as part of their intake evaluation at a specialty pain clinic in a community setting. Twenty-seven percent of the sample met PC-PTSD screening criteria for PTSD by endorsing 3 of the 4 symptom domains. Significant ordinal trends were observed between increasing number of PTSD symptoms and all outcomes evaluated. The occurrence of even 1 PTSD symptom was associated with overall poorer outcomes, suggesting that subsyndromal PTSD is clinically significant in the context of chronic pain. Among the 4 PTSD domains assessed, "numbness/detachment" was most strongly associated with negative pain outcomes in relative weight analysis. Results from this cross-sectional study suggest that a range of pain-related outcomes may be significantly related to comorbid PTSD. PERSPECTIVE: We present evidence that PTSD symptoms are significantly related to a broad set of pain-related patient-reported outcomes. These findings highlight the need to evaluate for PTSD symptoms in patients with chronic pain, especially feelings of numbness or detachment from others, to improve understanding and management of chronic pain.

Reliability of a visual analog version of the QuickDASH.

BACKGROUND: The QuickDASH, an abbreviated form of the Disabilities of the Arm, Shoulder and Hand Questionnaire, uses a graded-adjectives ordinal measurement response scale. In order to improve the sensitivity of the measure and to make it compatible with widely used measures of pain and disability, a visual analog scale version was developed. The present study investigated the reliability of the new version over time when used for the evaluation of patients undergoing treatment. METHODS: A test-retest model with a two-day interval was used to evaluate a sample of thirty-eight consecutive patients in an interdisciplinary tertiary rehabilitation setting who were identified as having an upper extremity disorder. RESULTS: The intraclass correlation coefficient indicating test-retest reliability was 0.90 for the eleven-item QuickDASH visual analog scale questionnaire (without the work component) and 0.94 for the fifteen-item questionnaire (with the work component), neither of which was significantly different from the results reported for the original questionnaire. CONCLUSIONS: The QuickDASH visual analog scale questionnaire has acceptable reliability over time, and it can be used as an alternative to the original QuickDASH.

Lumbar surgery in work-related chronic low back pain: can a continuum of care enhance outcomes?

BACKGROUND CONTEXT: Systematic reviews of lumbar fusion outcomes in purely workers' compensation (WC) patient populations have indicated mixed results for efficacy. Recent studies on lumbar fusions in the WC setting have reported return-to-work rates of 26% to 36%, reoperation rates of 22% to 27%, and high rates of persistent opioid use 2 years after surgery. Other types of lumbar surgery in WC populations are also acknowledged to have poorer outcomes than in non-WC. The possibility of improving outcomes by employing a biopsychosocial model with a continuum of care, including postoperative functional restoration in this "at risk" population, has been suggested as a possible solution. PURPOSE: To compare objective socioeconomic and patient-reported outcomes for WC patients with different lumbar surgeries followed by functional restoration, relative to matched comparison patients without surgery. STUDY DESIGN/SETTING: A prospective cohort study of chronic disabling occupational lumbar disorder (CDOLD) patients with WC claims treated in an interdisciplinary functional restoration program. PATIENT SAMPLE: A consecutive cohort of 564 patients with prerehabilitation surgery completed a functional restoration and was divided into groups based on surgery type: lumbar fusion (F group, N=331) and nonfusion lumbar spine surgery (NF group, N=233). An unoperated comparison group was matched for length of disability (U group, N=349). OUTCOME MEASURES: Validated patient-reported measures of pain, disability, and depression were administered pre- and postrehabilitation. Socioeconomic outcomes were collected via a structured 1-year "after" interview. METHODS: All patients completed an intensive, medically supervised functional restoration program combining quantitatively directed exercise progression with a multimodal disability management approach. The writing of this article was supported in part by National Institutes of Health Grant 1K05-MH-71892; no conflicts of interest are noted among the authors. RESULTS: The F group had a longer length of disability compared with the NF and U groups (M=31.6, 21.7, and 25.9 months, respectively, p<.001). There were relatively few statistically significant differences for any socioeconomically relevant outcome among groups, with virtually identical postrehabilitation return-to-work (F=81%, NF=84%, U=85%, p=.409). The groups differed significantly after surgery on diagnosis of major depressive disorder and opioid dependence disorder as well as patient-reported depressive symptoms and pain intensity prerehabilitation. However, no significant differences in patient-reported outcomes were found postrehabilitation. Prerehabilitation opioid dependence disorder significantly predicted lower rates of work return and work retention as well as higher rates of treatment-seeking behavior. Higher levels of prerehabilitation perceived disability and depressive symptoms were significant risk factors for poorer work return and retention outcomes. CONCLUSIONS: Lumbar surgery in the WC system (particularly lumbar fusion) have the potential achieve positive outcomes that are comparable to CDOLD patients treated nonoperatively. This study suggests that surgeons have the opportunity to improve lumbar surgery outcomes in the WC system, even for complex fusion CDOLD patients with multiple prior operations, if they control postoperative opioid dependence and prevent an excessive length of disability. Through early referral of patients (who fail to respond to usual postoperative care) to interdisciplinary rehabilitation, the surgeon determining this continuum of care may accelerate recovery and achieve socioeconomic outcomes of relevance to the patient and WC jurisdiction through the combination of surgery and postoperative rehabilitation.

Magnetic positioning system and ultrasound guidance for lumbar zygapophysial radiofrequency neurotomy: a cadaver study.

BACKGROUND AND OBJECTIVES: Chronic low back pain related to degenerative spondylosis is commonly managed by the radiofrequency ablation of sensory nerves. Fluoroscopic guidance has been considered mandatory to ensure placement of the active tip of the cannula parallel to the nerve to provide adequate neurolysis. Conversely, analgesic (or diagnostic) blockade is usually accomplished by placing the needle perpendicular to the nerve using either fluoroscopy or ultrasound (US) guidance. The recently introduced disposable equipment of internally cooled radiofrequency allows the denervation procedure to be performed similarly to the routine diagnostic block. Consequently, US may now potentially be used for image-guided radiofrequency neurotomy. We sought to compare the accuracy using a novel US-based technique with the traditional fluoroscopy-guided placement. METHODS: The proof of concept study was performed using a magnetic positioning US-guided system. The precision of needle placements was compared with the standard fluoroscopic guidance. The primary outcome of this study was defined as the procedural accuracy. Procedural and radiation exposure time was also recorded. In addition, projected operational expenses were calculated. RESULTS: Ultrasound-guided procedural accuracy reached 97%. Both the imaging and procedure times were similar between the 2 forms of imaging guidance. Of significant importance, the US-guided approach (no radiation exposure) was quantitatively advantageous over fluoroscopy-guidance, which required an average of 170 seconds of radiation per procedure. Thus, the US method seems to be cost effective. CONCLUSIONS: A magnetic positioning system allows accurate and quick US-guided placement of radiofrequency cannula to the desired anatomical targets, sparing patients and personnel from exposure to ionized radiation.