Guest post written by multiple members of the AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves. Erica F. Bisson, MD, MPH, FAANS; Zoher Ghogawala, MD, FAANS; Vijay M. Ravindra, MD, MSPH; and Robert G. Whitmore, MD, FAANS.
”What are we paying for and it is worth it?”
This is a fundamental question in all of health care, with the necessary focus shift towards improving the quality and decreasing the cost of treatments. The rising costs and variable practice patterns of spinal surgery have led to increased public scrutiny. Inflammatory headlines proclaim how the same spinal disorder is treated in various ways depending on geography. Of course, this leads to significant cost differences as well. However, cost is just one side of the value equation! While the initial hospital cost associated with surgical care can seem high, patients often show significant improvement after surgery with return to work and re-establishment of their productivity. Unfortunately, there is no good head-to-head value analysis of nonsurgical care versus surgical treatment for spinal disorders. Examining the quality of the treatment delivered, defined by real-life patient outcomes, and the costs of the various therapies gives a real measure of the overall value of the treatment. This article reviews the literature to examine the cost-effectiveness of spinal surgery in our society.
Ruptured Disc: What’s best?
Almost every American will suffer the symptoms of a ruptured disc (also called herniated disc) sometime in their lives. Lumbar discectomy is a surgery commonly performed for patients suffering the symptoms of this. In 2006, the Surgical vs Non-operative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial compared surgical to non-operative care.3 SPORT demonstrated that patients improved with both surgery and non-operative treatment over a two-year period. However, the study had a significant limitation because patients often did NOT adhere to assigned treatments:
- Only 50 percent of patients assigned to surgery received surgery within three months of enrollment; and
- Nearly 30 percent of those assigned to non-operative treatment received surgery in the same period (3).
Analysis based on the treatments intended for the patients demonstrated substantial improvements for all measured outcomes in both treatment groups. There was also a small and insignificant trend toward superior outcomes in the surgical group. Unfortunately, the large number of crossovers makes any conclusion about this initial study difficult.
Further analysis of the SPORT trial (Observational Cohort) revealed more significant improvement in surgical patients.4 This includes the primary outcome measures of bodily pain, physical function, and disability which persisted at 12 months following surgery. This cohort continued to be followed at four and eight years with greater improvement in surgically-treated patients compared to non-operatively treated patients in all primary and secondary outcomes except work status.5,6
A comprehensive cost-effectiveness analysis of patients with lumbar disc herniation who underwent either surgery or conservative management over a two-year period was also done. Although costs were higher in the surgical group, outcomes were also better compared to the nonoperative cohort. The cost per quality-adjusted life year (QALY) gained with surgery compared to nonoperative care was $34,355 in the Medicare population, which compares very favorably to other cost-effective interventions such as hip or knee replacement.3 At four years, the cost/QALY for lumbar discectomy falls to $20,600.3
Lumbar Spinal Stenosis
In 2008, the Surgical versus Non-Surgical Therapy for Lumbar Spinal Stenosis study was published in the New England Journal of Medicine.13 This study included both a randomized and observational cohort. Like the ruptured disc trial, patients didn’t always get the intended treatment. At two years:
- 67 percent of patients who were randomly assigned to surgery had undergone surgery; and
- 43 percent of those who were randomly assigned to receive nonsurgical care had also undergone surgery.
Despite the high level of crossover, the intention-to-treat analysis of the randomized group showed surgery did significantly better with improvement in bodily pain.13 Combining both the randomized and observational groups based on how the patients were truly treated, by three months patients having surgery fared dramatically better in all primary outcomes, with continued improvement two years later.13 The cost/QALY gained for surgical treatment of lumbar stenosis was $77,600 at two years and $59,400 at four years, which is considered a cost-effective treatment according to common societal thresholds. Follow-up study demonstrated the clinically significant advantages for surgery previously reported were maintained through four years. The early advantages for surgical treatment for secondary measures such as bothersomeness, satisfaction with symptoms and self-rated progress also were maintained at four years.
Degenerative Spondylolisthesis: Complexity Increased
The management of degenerative spondylolisthesis has been a topic of recent controversy. In 2007, the Surgical versus Nonsurgical Treatment of Lumbar Degenerative Spondylolisthesis study was published in the New England Journal of Medicine.7 In this nonrandomized cohort study, patients with degenerative spondylolisthesis and spinal stenosis treated surgically showed substantially greater improvement in pain and function during a period of two years than patients treated non-surgically. The four-year results demonstrated maintenance of the findings of greater pain relief and improvement in function for those patients who underwent surgery.12
Recently, two randomized controlled trials evaluated the utility of adding fusion (pedicle screw fixation) to decompressive laminectomy for patients with lumbar stenosis with grade I lumbar spondylolisthesis.8,9 The Spinal Laminectomy versus Instrumented Pedicle Screw (SLIP) Trial, which was performed in the United States, demonstrated that adding fusion was associated with improved health-related quality of life versus laminectomy alone. Additionally, as in previous studies, reoperation rates were 14 percent lower in the fusion group (14 percent) versus the laminectomy group (34 percent).9
Rigorous studies looking at lumbar fusion outcomes are limited. A sub-analysis from the SPORT trial comparing lumbar fusion with laminectomy showed the cost of surgery per QALY was nearly triple than that for laminectomy alone.10 However, the cost/QALY for fusion decreased by almost 50 percent at four-years,11 and at $64,300 is cost-effective, indicating the long-term results of fusion surgery afford a significant economic benefit.
Take Away Message
Today’s health care environment makes it imperative to understand these studies and the potential for economic benefit that comes from improved patient outcomes. It is also incumbent upon us to critically evaluate the actual cost of these interventions. Clearly, with high upfront costs, durability is the key concept. Many studies have demonstrated that spinal surgery for disc herniation, stenosis, and spondylolisthesis have long-term outcomes that are superior to medical therapy. While surgery will cost more initially, long-term studies generally find that durable surgery is cost-effective over a long time horizon. Too often overlooked are the significant costs many patients incur when doing prolonged nonsurgical therapy (physical therapy, injections, medications) while losing significant work-related productivity as well. From all of the studies reviewed, an overlying theme is the importance of collecting long-term patient-reported outcomes and costs following treatment for spinal disorders.
Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #SpineMonth.
- Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG: Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 303:1259-1265, 2010
- Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingworth W, et al: Expenditures and health status among adults with back and neck problems. JAMA 299:656-664, 2008
- Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs. Nonoperative Treatment for Lumbar disk herniation. The spine patient outcomes research trial (SPORT): A Randomized Trial. JAMA. 2006; 296(20):2441-2450.
- Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs. Nonoperative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT): Observational Cohort. JAMA. 2006; 296 (20): 2451-2459.
- Wenstenin JN, Lurie JD, Tosteson TD, Tosteson ANA, Blood E, et al. Surgical versus Non-Operative Treatment for Lumbar Disc Herniation: Four-Year Results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2008 Dec 1; 33(25):2789-2800.
- Lurie JD, Tosteson TD, Tosteson ANA, Zhao W, Morgan TS, Abdu WA, et al. Surgial versus Non-Operative Treatment for Lumbar Disc Herniation: Eight-Year Results for the Spine Patients Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2014 Jan 1; 39(1):3-16.
- Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, et al. Surgical versus Nonsurgical Treatment for Lumbar Degenerative Spondylolisthesis. N Engl J Med 2007; 356: 2257-2270.
- Forsth P, Olafsson G, Carlsson T, Frost A, Borgstrom F, Fritzell P, et al: A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med 374:1413-1423, 2016
- Ghogawala Z, Dziura J, Butler WE, Dai F, Terrin N, Magge SN, et al: Laminectomy plus Fusion versus Laminectomy Alone for Lumbar Spondylolisthesis. N Engl J Med 374:1424-1434, 2016
- Tosteson AN, Lurie JD, Tosteson TD, Skinner JS, Herkowitz H, Albert T, et al: Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Intern Med 149:845-853, 2008
- Tosteson AN, Tosteson TD, Lurie JD, Abdu W, Herkowitz H, Andersson G, et al: Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation. Spine (Phila Pa 1976) 36:2061-2068, 2011
- Weinstein JN, Lurie JD, Tosteson TD, Zhao W, et al. Surgical Compared with Non-operative Treatment for Lumbar Degenerative Spondylolisthesis. Four-Year Results in the Spine Patient Outcomes Research Trial (SPORT) Randomized and Observational Cohorts. J Bone Joint Surg Am. 2009 Jun 1: 91(6): 1295-1304.
- Weinstein JN, Tosteson TD, Lurie JD, et al. Surgial versus Nonsurgical Therapy for Lumbar Spinal Stenosis. N Engl J Med. 2008 Feb 21; 358(8): 794-810.
- Weinstein JN, Tosteson TD, Lurie JD, Tosteson A. Surgical versus Non-Operative Treatment for Lumbar Spinal Stenosis Four-Year Results of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2010 Jun 15; 35(14): 1329-1338.