Editorial

Abstract

Lumbar spinal stenosis (LSS) is one of the most common reasons why patients in their middle and later years seek a consultation with a neurosurgeon or spine surgeon. The surgical correction of LSS is also predictably satisfying, with consistent relief of symptoms of neurogenic claudication. The factors that most significantly affect the surgical outcome include patient selection and meticulous attention to technical detail.8 First performed by Professor Victor Alexander Haden Horsley of University College London in 1887, spinal laminectomy has been a standard surgical practice for decades. Until the past decade, the primary alternatives to the use of laminectomy or variations such as laminotomies or laminoplasty were nonoperative, including a host of pharmaceutical alternatives, physiotherapy, and various types of spinal injection. With the advent of X-STOP and other types of interspinous spacers,14 spine surgeons suddenly found themselves with a whole new “less-invasive” surgical alternative. The X-STOP was approved by the FDA in November 2005,11 and the Centers for Medicare and Medicaid Services have approved a special add-on payment since October 2006.2 Although the shortand medium-term results of the X-STOP have been made available,13–15 the long-term results and outcome of similar interspinous spacers are still unknown, and longer-term clinical follow-up studies are needed to more clearly define the role of these devices in the management of lumbar spinal stenosis.3 It is arguable that interspinous spacers might only be a temporary solution, delaying the eventuality of a laminectomy, which has been the “gold standard” for years. The options for treating LSS span the spectrum of nonsurgical care and decompressive laminectomy/laminotomies with the X-STOP lodged in between—seemingly bridging the 2 extremes. It is therefore interesting to consider what it would mean for health care costs when one chooses each option. Does new mean better, or does traditional open surgery triumph? Does the cost of interspinous spacers justify their use? Given this background, Burnett et al.,1 in this issue of the Journal of Neurosurgery: Spine, seek to identify the most cost-effective strategies to deal with LSS. With the escalating health care costs today in North America, their article reminds us to always consider the economic aspect and impact of the myriad treatment modalities available in medicine today. Rising health care costs are a global phenomenon, especially in North America. The US spent approximately $2.2 trillion on health care in 2007, or $7421 per person.10 This comes to 16.2% of the gross domestic product (GDP), nearly twice the average of other developed nations.6 Health care costs doubled from 1996 to 2006, and are projected to rise to 25% of GDP in 2025 and 49% in 2082.7 Canada spent approximately 10.1% of its GDP on health care in 2007, more than 1 percentage point higher than the average of 8.9% in OECD (Organisation for Economic Co-operation and Development) countries.4 Recently, the Spine Patient Outcomes Research Trial (SPORT)12 reported favorable outcomes for surgical intervention of spinal stenosis over 2 years, and Tosteson et al.9 used the same set of patients who suffered from LSS from the SPORT to compare nonoperative care versus surgery—primarily decompressive laminectomy for stenosis and decompressive laminectomy with fusion for stenosis associated with degenerative spondylolisthesis. They used cost per quality-adjusted life-year (QALY) gained as the outcome measure, and concluded that surgical treatment of spinal stenosis with laminectomy provided reasonable value over a 2-year time frame and compared favorably with many health care interventions. In contrast, relatively little has been published related to the cost-effectiveness of X-STOP versus decompressive surgery. Kondrashov et al.4 recently compared 4-year Oswestry Disability Index outcomes of X-STOP versus laminectomy and suggested that use of the XSTOP device for the treatment of LSS is clinically at least as effective as standard laminectomy at 4 years postoperatively and provides substantial direct cost savings compared with decompressive surgery. In the article in this issue, Burnett et al.1 conducted an in-depth systematic review of the literature related to J Neurosurg Spine 13:36–38, 2010 See the corresponding article in this issue, pp 39–46.