Early Versus Late Initiation of Rehabilitation After Lumbar Spinal Fusion

This study was conducted to examine the cost-effectiveness of beginning rehabilitation 6 weeks after surgery rather than 12 weeks after surgery. In a previously published randomised controlled trial, the authors assessed the effect of timing of rehabilitation after a lumbar spinal fusion and found that a fast-track strategy led to poorer functional ability. Before making recommendations, the societal perspective including return to work, quality of life, and costs seemed pertinent points to deal with. The authors performed a cost-effectiveness analysis and a cost-utility analysis. 82 individuals undergoing instrumented lumbar spinal fusion due to degenerative disc disease or spondylolisthesis (grade I or II) were randomised to an identical protocol of four sessions of group-based rehabilitation and were instructed in home exercises focusing on active stability training. Outcome parameters included functional disability (Oswestry Disability Index) and quality-adjusted life years. Health care and productivity costs were estimated from national registries and reported in Euros (EUR). Costs and effects were transformed into net benefit. Bootstrapping was used to estimate 95% confidence intervals (95% CI).Results. The fast-track strategy tended to be more costly by 6,869 EUR (95% CI -4,640;18,378) while at the same time leading to significantly poorer outcomes of functional disability by 9 points (95% CI 1;16) and a tendency for a reduced gain in quality-adjusted life years by -.04 (95% CI -.11;.03). The overall probability for the fast-track strategy being cost-effective does not reach 10% at conventional thresholds for cost-effectiveness.

The authors concluded that beginning rehabilitation 6 weeks instead of 12 weeks post surgery is on average more costly and less effective. They added that the uncertainty of their result did not seem to be sensitive to methodological issues, and clinical managements who have already adapted fast-track rehabilitation strategies have reason to reconsider their choice.