To Operate or Not To Operate for Adult Symptomatic Lumbar Scoliosis?

NIH-funded intent-to-treat study finds surgery may be more cost-effective after five years

Radiographs of spinal deformity

Although operative care for adult symptomatic lumbar scoliosis (ASLS) is more costly for patients than nonoperative modalities, a November 2019 study published in Spine found that it may be more cost-effective over time, representing a major shift in thinking around long-term treatment options for complex adult spinal deformity.

Christopher I. Shaffrey, MD, chief of Duke’s Spine Division and co-author of the study, says it was somewhat of a surprise that surgery compared as favorably as it did, even in the short term. “Traditionally, it’s been thought that patients with ASLS had few options because the potential risk for complications from the surgery was too high,” he says. “But this research has shown that there’s a chance that surgery may make a dramatic difference in a patient’s quality-adjusted life years.”

The intent-to-treat cost-effectiveness study analyzed randomized and observational data on patients with ASLS with at least five years of follow-up data from an NIH-sponsored study. Results indicated that operative care was above the threshold for cost-effectiveness in the first three years of the study but improved over time, becoming highly effective by years four and five, despite the potential need for revision surgery.

Patients who pursued nonoperative interventions—including physical therapy, epidural steroid injections, and neuroleptic medications—showed only incremental cost-effectiveness and slight improvement in quality of life over time, but in some cases, their condition continued to deteriorate. The study indicates that even if the cost of nonoperative care is low relative to operative care, it may not be of value if a patient’s prognosis does not improve.

According to the study, neither treatment is considered dominant, as the greater gains in quality-adjusted life years for those patients undergoing surgery come at a greater cost—including a longer recovery time and potential complications to their health. However, Shaffrey says the potential benefit of surgery has grown in the past decade while nonoperative care has remained static; the trend of operative care outcomes for patients with ASLS indicates that it may eventually be worth the cost, though more long-term follow-up research is needed.

“These surgical treatments are fairly durable at the five-year mark, but most people feel you need to have a 10-year durability of surgery to make the case that this is truly an effective treatment,” he says. “I think if we can continue to reduce the complications and improve the outcomes, it’s going to be an even more compelling argument for how these patients should be treated.” A follow-on study will analyze cost-effectiveness for both seven and 10 years post-surgery, Shaffrey adds.

Shaffrey says that surgical intervention for ASLS is on its way to dominance at Duke: “Our outcomes are 50% better and our complications are 50% less, despite operating on sicker and more debilitated patients,” he says. “We’ve also improved the way we’ve treated and managed these patients over time and are doing surgery better and safer with better results than we did 10 years ago.”

Duke is also involved in the second International Spine Study Group Foundation’s complex adult deformity surgery study, which is looking at ways to further reduce complications and improve outcomes in this patient population. “We’re continuing to do active clinical research to improve outcomes and improve safety with the surgeries we’re doing,” Shaffrey says. “Duke is going to be on the cutting edge of all of the major innovations occurring in the field of spinal surgery.”