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Thesis
Interventional Pain Management Focused on Zygapophysial Joint Pain: A Health-Economic Evaluation
Umeå University, 2023 – Faculty of Medicine, thesis no. 2222
Summary
Almost one in five people in the world (15–20%) live with pain that has lasted longer than three months. Excluding pain related to cancer, rheumatic diseases, operations or fractures, about half remain. According to WHO studies (1990–2017), low back pain, closely followed by headache, is the most common cause of disability globally. Between 30 and 50% of these cases originate in the facet joints.
Since the late 1980s, research has focused on developing evidence-based methods for the diagnosis and treatment of facet joint-related pain. When international guidelines are followed – i.e. repeated nerve blocks with at least 80% pain relief and correctly performed treatment of the affected nerve – the method is well documented and effective.
The thesis develops and evaluates this methodology, with a particular focus on the thoracic spine, where the state of knowledge has previously been limited.
Sub-studies and results
Method development for the thoracic spine
Treatments in the thoracic spine were compared with established methods for the cervical and lumbar spine. The outcome measure used was not only pain level but also quality of life. Patients who improved often described an almost normalized quality of life – an effect that persisted up to a year after treatment.
Patient experience and empowerment
Qualitative interviews showed that many patients experienced increased self-control (empowerment) through the investigation process. This experience was identified as a key factor in improved quality of life.
Cost-effectiveness
A health economic analysis of 873 patients was conducted, including all investigation and treatment costs. The result showed a cost of SEK 220,000 per QALY, which according to the Swedish National Board of Health and Welfare's classification corresponds to a moderate cost.
Comparison with pain rehabilitation
Using propensity score adjustment, 254 patients who underwent interventional treatment were compared with 15,357 patients in pain rehabilitation.Interventional treatment: +0.186 QALY/year, cost 119,000 SEK/QALY (moderate)
Pain rehabilitation: +0.164 QALY/year, cost 1,187,000 SEK/QALY (very high)
After two years, the cost of interventional treatment dropped to 49,000 SEK/QALY (low).
Conclusion
Interventional pain management is cost-effective, improves quality of life and strengthens patient self-control. If its share in specialized pain care increased from the current 2% to 25%, it could save approximately SEK 106 million annually and provide an overall health gain of approximately 14 QALYs per year.
Early diagnosis also makes it possible to identify treatable patients before they are referred to pain rehabilitation – which can result in further savings and improved care efficiency.
Author: Johan Eques
Supervisors: Lars Lindholm, Klas-Göran Sahlén, Anni-Maria Pulkki-Brännström
Opponent: Professor emeritus Risto Roine
Dissertation: March 17, 2023, Norrland University Hospital, Umeå
ISBN: 978-91-7855-982-4 (print), 978-91-7855-983-1 (online)