10 Pivotal Cost-Effectiveness Studies on Spine Surgery to Know

Here are 10 studies published and presented in the past five years on cost-effectiveness of spine surgery.

Spinal Deformity: Dr. Richard Hostin. Published in May 2013, this article in Spine Deformity: The Official Journal of the Scoliosis Research Society includes several co-authors and the International Spine Study Group. The authors aimed to calculate the cost of improvement in health-related quality of life by examining consecutive patients with adult spinal deformity in a single center over a five year period: 2005 to 2010. They collected costs from hospital data on total costs incurred during the episode of care and found that cost-effectiveness ranged from an average of $5,658 per 1-point improvement in the SRS Self-image to an average cost of $25,918 per 1-point improvement in the SF-36 Physical Component Score. There were 164 patients examined in the study with an average of 3.2 years follow-up. Authors concluded surgical treatment for adult spinal deformity could be more cost effective for select proposes like pain reduction and less cost-effective for other purposes, such as improved functional activity.

Intervertebral disc herniation: SPORT. Jon D. Lurie, MD, Gunnar B. Andersson, MD, Sigurd Berven, MD, James Weinstein, DO, were co-authors on this article. As part of the Spine Patient Outcomes Research Trial, these surgeons and research partners examined the cost-effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over a two-year period. The researchers examined 775 patients who underwent surgery and 416 who underwent nonoperative treatment for intervertebral disc herniation and found the average difference in QALYs over the two-years after treatment was 0.21 in favor of surgery. Surgery was more costly than nonoperative care — $14,137 more expensive for adult surgery and $34,355 for Medicare populations. The estimated economic value of surgery varied considerably, according to the study authors, but overall found surgery moderately cost-effective.

Spinal stenosis: SPORT. Published in a 2011 Issue of Spine and reported in Medscape, this article examined cost-effectiveness of spinal stenosis and two other disorders as part of the Spine Patient Outcome Research Trial. The patients were followed for two years and researchers calculated cost per quality-adjusted life year gained in 2004 US dollars, comparing that number to nonoperative care using a societal perspective with costs and QALYs discounted at 3 percent per year. Surgery was performed initially or over a four-year period for 414 of the 634 patients for spinal stenosis. QALY gained for spinal stenosis patients was 0.22 and costs per QALY gained decreased for spinal stenosis from $77,600 at two years to $59,400 at four years. The study authors include Jon D. Lurie, MD, Gunnar B. Andersson, MD, Sigurd Berven, MD, James Weinstein, DO, Harry Herkowitz, MD, Todd Albert, MD, Keith Bridwell, MD, and other non-physician authors.

Degenerative spondylolisthesis: SPORT. Published in a 2011 Issue of Spine and reported in Medscape, this article examined cost-effectiveness of surgical treatment for degenerative spondylolisthesis and two other disorders as part of the Spine Patient Outcome Research Trial. The patients were followed for two years and researchers calculated cost per quality-adjusted life year gained in 2004 US dollars, comparing that number to nonoperative care using a societal perspective, with costs and QALYs discounted at 3 percent per year. Surgery was performed initially or over a four-year period for 391 of the 601 patients for degenerative spondylolisthesis. QALY gained for degenerative spondylolisthesis patients was 0.34 and costs per QALY gained decreased for degenerative spondylolisthesis from $115,600 at two years to $64,300 at four years. The study authors include Jon D. Lurie, MD, Gunnar B. Andersson, MD, Sigurd Berven, MD, James Weinstein, DO, Harry Herkowitz, MD, Todd Albert, MD, Keith Bridwell, MD, and other non-physician authors.

Outpatient cervical disc arthroplasty: Dr. Richard Wohns. Richard Wohns, MD, founder of NeoSpine in the Puget Sound Area, Wash., published an article describing the cost-effectiveness of outpatient cervical disc arthroplasty in Surgical Neurology International in 2010. The article reviewed 26 patients who underwent outpatient cervical disc arthroplasty and found 100 percent of patients improved after the surgery and no postoperative complications. The cost of outpatient single-level cervical disc arthroplasty was 62 percent less than outpatient single-level cervical anterior discectomy with fusion using allograft and plate. The arthroplasty procedure cost 84 percent less than inpatient single-level cervical disc arthroplasty.

Posterior spinal fusion compared to hip and knee arthroplasty: Sonoran Spine Research and Education Foundation. In 2012, researchers and surgeons at the Sonoran Spine Research and Education Foundation in Mesa, Ariz., published an article online examining the cost-effectiveness and outcomes for spinal fusion and joint replacement patients. The study used a Markov model of 1,000 patients for the three cohorts: spinal fusion, knee replacement and hip replacement. The cost of revision surgery was neglected. Researchers found the total hip arthroplasty group had a cost of $27,450.93 per change in QALY and the total knee arthroplasty group had a cost of $59,165.40 per change in QALY. The posterior spinal fusion group reported a cost of $34,110.03 per change in QALY. The cost of the index procedure was more expensive for the spinal surgery, but when adjusting for the improvements in quality of life, the spine surgery had similar costs to the total hip and knee arthroplasty.

Image-guided spine surgery: Dr. Robert G. Watkins IV. Robert G. Watkins IV, MD, teamed with Robert G. Watkins III, MD, and Akash Gupta, MD, to examine the cost-effectiveness of image-guided spine surgery in this study. The surgeons examined 100 patients undergoing thoracolumbar pedicle screw instrumentation using image guidance and compared them to a retrospective group of 100 patients who underwent screw placement prior to the use of image guidance. Revision reduced from 3 percent to 0 percent when the image guidance was used, and the cost-savings for the placement of pedicle screws as $71,286 per 100 cases. The time required to place screws with image guidance was 20 minutes for two screws, 29 minutes for four screws, 38 minutes for six screws and 50 minutes for eight screws. The researchers calculated cost-savings for the time spent placing pedicle screws with image guidance by subtracting the time required with the current non-guidance techniques from the averages with guidance and multiplying that number by $93 per minute. The article was published in The Open Orthopaedic Journal in 2010.

Spinal fusion surgery: The Ohio State University. Surgeons from the department of orthopedics at The Ohio State University published this 2012 article in the Journal of Bone and Joint Surgery examining the most cost-effective graft option for spinal fusion to treat L4-L5 degenerative spondylolisthesis. They used a Markov decision model to identify the cost and effectiveness of spinal fusion surgery and revision surgery associated with each graft option. The incremental cost-effectiveness ratio for each graft option when compared with living with chronic back pain was $21,308 per QALY for iliac crest bone graft; $16,595 per QALY for rhBMP-2; $21,204 per QALY for local bone alone; $21,287 per QALY for demineralized bone matrix with local bone; and $28,153 per QALY for corticocancellous allograft chips.

Artificial disc replacement: Dr. Richard Delamarter. Richard Delamarter, MD, co-director of the Cedars-Sinai Spine Center, reported a 2011 study in which he found that artificial disc replacement for patients with degenerative disc disease had a more positive economic impact than spinal fusions. The study examined 209 patients with damaged cervical spine discs who underwent either cervical disc replacement or spinal fusion. Four years after the surgery, the fusion patients were four times more likely to need additional surgery and half of those operations were necessary because of new disc complications occurring at levels adjacent to the fusion. Another study focused on patients suffering from three-level lower back disc disease, comparing the cost of care between disc replacement and fusion. The total hospital costs for the disc replacement patients were, on average, 49 percent lower than fusion patients.

Transforaminal lumbar interbody fusion: Dr. Matthew J. McGirt, MD. Dr. McGirt partnered with Alexandra Paul, MD, Brandon Davis, MD, Oran Aaronson, MD, Clint Devon, MD, and Joseph Cheng, MD, and non-physician researchers to conduct this study into the cost-effectiveness of transforaminal lumbar interbody fusion. The study was presented at the American Association of Neurological Surgeons annual meeting in April 2011, which discussed the economic benefits for patients with leg and back pain associated with grade 1 degenerative spondylolisthesis to receive TLIF. Researchers followed patients for two years to see where the postoperative economic impact lay:

•    Patients reported less disability and improved quality of life according to questionnaires they were given.


•    The mean two-year direct medical cost was $25,251.


•    The mean surgical cost was $21,311±2,086, and the mean outpatient resource cost was $3,940±2,720.


•    The average total two-year cost of TLIF was $36,835±11,800.


•    The average reported annual income prior to surgery was $50,000. Patients missed an average of 60 work days, representing a two-year societal cost of $11,584.


•    At two years after surgery, the total cost per Quality Adjusted Life Years gained of TLIF was $42,854, well below the accepted $50,000 cost-effective threshold.



Source : Becker's Spine Review , 4th October 2013