Adogwa O, et al. - Between 2007 and 2016, 20.9 million people were studied to analyze the effectiveness and costs of maximal nonoperative therapy (MNT) earlier to spinal fusion surgery symptomatic lumbar stenosis or spondylolisthesis cases. They recorded 4133 candidates undergoing 1, 2, or 3-level posterior lumbar instrumented fusion. About 20.8% of subjects were smokers, 44.5% with type II DM, and 38.2% were obese with body mass index (BMI) >30 kg/m². They noticed the following MNT utilization: 66.7% used nonsteroidal anti-inflammatory drugs (NSAIDs), 84.4% used opioids, 58.6% practiced muscle relaxants, 65.5% were given lumbar epidural steroid injections (LESI), 66.6% attended 21.1% presented to the emergency department (ED), and 24.9% received chiropractor treatments. They measured the total direct cost correlated with all MNT previous to index spinal fusion, $9,000,968. They recorded LESI comprising largest portion of total cost of MNT ie, $4,094,646, 45.5%, followed by NSAIDs ,$1,624,217, 18.0% and opioid costs, $1,279,219. It indicated a highly unfavorable cost-effectiveness ratio (ICER) for MNTs.