Introduction: Lumbar spinal stenosis (LSS) is a common lumbar degenerative disease in the elderly, usually requiring surgery if conservative treatment fails. Microscopic decompressive laminectomy (MDL) and percutaneous endoscopic decompressive laminectomy (PEDL) have been widely used to treat LSS. This study aims to provide a protocol for the evaluation and comparison of the efficacy, safety and applicability between MDL and PEDL. Methods and analysis: We will search for randomised controlled trials (RCTs) comparing MDL and PEDL for treating LSS from inception to December 2019 in the following databases: PubMed, The Cochrane Library, Web of Science, Embase and China Biology Medicine. The quality of included studies will be assessed using the risk of bias tool recommended by the Cochrane Handbook 5.2.0. Subsequently, a meta-analysis will be performed using RevMan 5.3 software. Ethics and dissemination: Given the nature of this study, no ethical approval will be required. The protocol will be disseminated via a peer-reviewed journal. Prospero registration number: CRD42020164765.

INTRODUCTION: Bundled payments offer a lump sum for management of particular conditions over a specified time period that has the potential to reduce healthcare payments. Additionally, bundled payments represent a shift toward patient-centered reimbursement that has the upside of improved care coordination among providers and may lead to improved outcomes. AIM: To review the challenges and sources of payment variation and opportunities for restructuring bundled payments plans in context of spine surgery. MATERIALS AND METHODS: We reviewed the current landscape of episodes of care over the past 10 years. We completed a search using PRISMA guidelines and the PICO model in PubMed and Ovid databases to identify studies that met our search criteria. RESULTS: A total of 10 studies met search criteria that were retrospective in design. The primary recipient of reimbursement was the hospital associated with the index procedure (59.7-77% of the bundled payment), followed by surgeon reimbursement (12.8-14%) and post-acute care rehabilitation (3.6-7.3%). On average, the index hospitalization was $32,467, ranging from $11,880 to $107,642, depending on number of levels fused, complications, and malignancy. Readmission was shown to increase the 90-day payment by 50%-200% for uncomplicated fusion. CONCLUSION: The implementation of spine surgery in bundled payment models offers opportunity for healthcare cost reduction. Patient heterogeneity, complications, and index hospitalization pricing are among factors that contribute to the challenge of payment variation. Development of standard care pathways, multi-disciplinary coordination between inpatient and outpatient postoperative care, and empowerment of patients are also key elements of progress in the evolution of bundled payments in spine surgery. We anticipate more individualized risk-adjusted prediction models of payment for spine surgery, contributing to more manageable variation in payment and favorable models of bundled payments for payers and providers.

BACKGROUND CONTEXT: Low back pain (LBP) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses. A common intervention for LBP is spinal manipulation, a technique that is not specific to one scope of practice or profession. PURPOSE: The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain. METHODS: A search of the current literature was conducted using PubMed, CINAHL, SPORTDiscus, Pro Quest Nursing and Allied Health Source, Scopus, and Cochrane Controlled Trials Register. Studies were included if each involved: 1) individuals with LBP; 2) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations; 3) measurable clinical outcomes or efficiency of treatment measures, and 4) randomized control trials. The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Database (PEDro). RESULTS: Six randomized control trials met the inclusion criteria of this systematic review. The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes. Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported statistically significantly less medication use, health care utilization, and lost work time. CONCLUSION: Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain.