A decision analysis to identify the ideal treatment for adult spinal deformity: is surgery better than non-surgical treatment in improving health-related quality of life and decreasing the disease burden?

摘要

BackgroundAdult spinal deformity (ASD) is a major public health problem. There are pros and cons of the available treatment alternatives (surgical or non-surgical) and it had been difficult to identify the best treatment modality.AimTo construct a statistical DA model to identify the optimum overall treatment in ASD.MethodsFrom an international multicentre database of ASD patients (968 pts), 535 who had completed 1?year follow-up (371 non-surgical—NS, 164 surgical—S), constitute the population of this study. DA was structured in two main steps of: (1) baseline analysis (assessing the probabilities of outcomes, assessing the values of preference—utilities-, combining information on probability and utility and assigning the quality adjusted life expectancy (QALE) for each treatment) and (2) sensitivity analysis.ResultsFour hundred and thirty-two patients (309 NS, 123 S) had baseline and 1?year follow-up ODI measurements. Overall, 104 (24.1?%) were found to be improved (a decrease in ODI??8 points), 225 (52.1?%) unchanged (?8??ODI??8) and 65 deteriorated. Surgery presented with a higher chance of improvement (54.2?%) versus NS (9.7?%). The overall QALE ranged from 56 to 69 (of 100?years) and demonstrated better final QALE in the NS group (60 vs. 65, P?=?0.0038), this group having started with higher QALE as well (56 vs. 65?years, P??0.0001). There were improvements in overall QALE in both groups but this was significant only in the surgical group (S from 56 to 60?years, P??0.0001; NS from 65 to 65?years, P?=?0.27). In addition, in the subgroup of patients with significant baseline disability (ODI??25) surgery appeared to yield marginally better final QALE (58 vs. 56?years, P?=?0.1) despite very a similar baseline (54 vs. 54?years, P?=?0.93).Discussion and conclusionsThis study demonstrated that a single best treatment modality for ASD may not exist. Conservative treatment appears to yield higher (up to 6?%) QALE compared to surgery, most probably secondary to a higher baseline QALE. On the other hand, surgery provides a significantly higher increase in QALE. Especially in patients with significant disability at baseline, the final QALE tended higher in the S group (although not significant). Finally, chances of a relevant improvement at first year turned out to be significantly lower with NS treatment...