16 things to know about spinal fusions


Here are 16 points on spinal fusions.

Learn more about spinal fusions and spine in ASCs from the experts at the Becker's 15th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine event, June 22-24, 2017 in Chicago. To learn more and register for the event, click here.


1. Between 1998 and 2011, the number of spinal fusion procedures more than doubled, from 204,000 to 457,000. The percentage increase is 113 percent, according to The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Costs, produced by the United States Bone and Joint Initiative in collaboration with a number of organizations.


2. The Burden of Musculoskeletal Diseases in the United States report also notes that the mean length of stay for spinal fusion decreased from 4.7 days in 1998 to 3.8 days in 2011. However, the mean hospitalization charge increased from $26,000 in 1998 to $102,000 in 2011. The Spine Patient Outcomes Research Trial found the quality-adjusted life year for spinal fusion is $115,000 per QALY gained; however, in the U.S., $100,000 is considered the threshold for procedures to be cost-effective, according to a Spine-health report.


3. The average cost for single-level anterior cervical discectomy and fusion among Medicare patients is $14,000, according to a study published in Spine. The average single-level posterior lumbar fusion cost $26,000 per Medicare patient. The ACDF costs ranged from $11,000 to $25,000 while PLF costs were $20,000 to $37,000. The lowest cost region was the Midwest and highest costs were in the Northeast. Total charges for spinal fusions in the United States from 2001 to 2010 were $287 billion, according to a Wolters Kluwer report.


4. The increased use of instruments and biologics contributed to the significant rise in cost of spinal fusion. In particular, use of one controversial biologic, bone morphogenetic protein, has grown significantly. The global BMP market size is expected to reach $644.6 million by 2024, according to a new report by Grand View Research.


5. A 2016 study published in Spine found 7.8 percent of surgeons use rhBMP-2 when performing open L4-L5 posterolateral fusion for degenerative spondylolisthesis. For open L4-L5 interbody fusion, 6.2 percent of surgeons use rhBMP-2. For minimally invasive interbody fusion at L4-L5, 12.1 percent of surgeons used rhBMP-2.


6. A 2015 study published in Spine found the use of low dose BMP-2 at the L5-S1 level in combination with sacropelvic fixation "achieved satisfactory fusion rates in adult deformity surgery." The fusion rate for patients undergoing surgery at L5-S1 was 97 percent. 


7. Instrument materials can also play a key factor in ensuring good outcomes for spinal fusion patients. A February 2017 study published in Clinical Spine Surgery compared PEEK cages with an Acrylic cage for anterior cervical discectomy and fusion. The patients who received the Acrylic cage had a higher fusion rate — 96.9 percent — than the PEEK cage patients — 93.8 percent. Another study, published in Spine in October 2016, examined bone union after lumbar interbody fusion with titanium or PEEK cages to evaluate vertebral endplate cysts as a predictor of nonunion. It shows that two years after surgery there was an 82.8 percent union rate among the titanium group and 80.4 percent union rate in the PEEK group. Additionally, the researchers found a positive cyst sign in 17.2 percent of the titanium patients and 13.7 percent of the PEEK patients.


8. Spinal fusion can be linked to longer hospital stays and higher costs. A study published in the Journal of Neurosurgery: Spine in January 2017 shows that repeat discectomy and spinal fusion for recurrent disc herniation patients resulted in hospital stays of one day and 3.7 days respectively. The study authors found the fusion patients also had longer operative times (229.6 minutes) compared to the repeat discectomy patients (82.7 minutes).


9. Spinal fusions can also be associated with greater hospital resource use if comorbidities are present. In the case of pediatric spinal fusions, median length-of-stay, median hospital costs and readmission rates all increased among patients who reported one to three comorbidities, and among patients with more than 10 comorbidities, according to a study in Pediatrics.


10. The global spinal fusion market is anticipated to reach $9 billion by 2023, based on GlobalData research. Valued at $7.1 billion in 2016, the market will likely grow at a compound annual growth rate of 3.4 percent through 2023.


11. The U.S. market for lateral lumbar interbody fusion is expected grow at a compound annual growth rate of 7.05 percent in between 2016 and 2020.


12. There are a number of different types of spinal fusions, including posterior lumbar interbody fusion, anterior lumbar interbody fusion, transforaminal lumbar interbody fusion, extreme lateral interbody fusion as well as sacroiliac joint fusion. SI joint fusion can be performed using different systems, such as the iFuse system or the Zyga SImmetry system.


13. SI-Bone, creator of the iFuse implant system, launched a warranty program for it. SI-Bone offers a free iFuse implant if a primary procedure using iFuse fails within one year of the initial procedure. Titan Spine, with a product line focused on anterior lumbar interbody fusion, transforaminal lumbar interbody fusion and more, also has a warranty program. The company offers a one-time free replacement for any eligible product if revision surgery required within the product's warranty period.


14. With new techniques and enhanced pain management capabilities, the number of spine procedures that can be safely performed in the outpatient setting is growing. A study in Clinical Spine Surgery compared 30-day complications of inpatient and outpatient single-level anterior cervical discectomy and fusion. It shows that the overall complication rate for the inpatient group was 2.5 percent, compared to only 1.2 percent for the outpatient group.


15. CMS has been adding spine codes to the ASC payable list every year for the past few years. The agency added nine codes in 2015, including were minimally invasive fusions and decompressions, lateral spinal fusions and anterior cervical fusions. For the ASC payable list in 2017, CMS has added another eight spine codes.


16. Robotic technology is also furthering the use of spinal fusion procedures in the outpatient setting. William Tobler, MD, performed the first U.S. sacroiliac joint fusion at an outpatient surgery center utilizing Medtronic's RIALTO system in 2016.


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