Rates of spinal fusion have increased by more than 250 percent in the last 15 years. However, is the surgery cost-effective? New research published in the December 16 issue of the Annals of Internal Medicine suggests that for patients with spinal stenosis with associated slipped vertebrae, the benefits of the fusion procedure are not enough to offset the costs.
Lumbar spine fusion, in which two or more vertebrae are permanently joined to decrease spine instability, accounts for more than one-third of all back surgeries in the United States. Between 1993 and 2004, the number of spine fusions and the associated costs rose dramatically. In 2004, spine fusion procedures totaled $16.9 billion. (a)
“This study is significant because it is the first to systematically track people’s health care expenditures and health outcomes for these common and costly conditions,” said lead author Anna N.A. Tosteson, ScD. “Given the tremendous increase in the number of spinal fusion procedures, the question of cost-effectiveness has critical implications for the health care system.”
To perform the study, researchers followed patients who participated in the Spine Patient Outcomes Research Trial (SPORT). (b) Specifically, they looked at two conditions, spinal stenosis, which was treated most commonly with laminectomy, and spinal stenosis with slipped vertebrae (spinal stenosis with degenerative spondylolisthesis) most commonly treated with spine fusion.
Of 394 spinal stenosis patients receiving surgery, 320 underwent laminectomy, a procedure that relieves pressure on the nerves through removal of bone and soft tissue. In total, 344 out of 368 surgical patients with stenosis with degenerative spondylolisthesis had spinal fusion.
Two years after surgery, while patients in both groups who had the procedures had better clinical results than those treated non-operatively, the benefits gained in functionality and quality of life were not enough to offset the direct medical costs of fusion, combined with indirect costs such as work-time missed. In contrast, laminectomy for spinal stenosis proved to be effective clinically and economically.
Using the Quality Adjusted Life Year (QALY) scale to measure benefit to patients in comparison to the direct and indirect costs of the surgical procedures, the authors report that stenosis surgery (usually laminectomy) cost about $77,000 per QALY gained. In contrast, surgery for stenosis with slipped vertebrae (usually fusion) cost about $115,000 per QALY gained. In the US, $100,000 is the threshold at which procedures are considered to be cost-effective.
The authors note that their findings are based on measurement of outcomes two years after surgery. Continued follow-up is necessary to determine if cost-effectiveness improves over time.
“Current trends in spine surgery in the United States combined with continued escalation in health care expenditures highlight the importance of understanding the economic value of common surgical procedures,” they write. “Our comprehensive analysis suggests that surgical treatment of spinal stenosis with laminectomy provides reasonable value even over a limited two-year time frame. By contrast, surgery for stenosis associated with degenerative spondylolisthesis is much more costly and will need to show continued health benefit without ongoing costs before it could be considered as being cost-effective.”
In addition to Dr. Tosteson, authors were Jon D. Lurie, MD, MS; Tor D. Tosteson, ScD; Jonathan S. Skinner, PhD, all of Dartmouth and The Dartmouth Institute for Health Policy and Clinical Practice; Harry Herkowitz, MD of William Beaumont Hospital; Todd Albert, MD of the Rothman Institute at Thomas Jefferson University; Scott D. Boden, MD of Emory University; Keith Bridwell, MD, PhD of Washington University; Michael Longley, MD of Nebraska Spine Surgeons; Gunnar B. Andersson, MD, PhD of Rush-Presbyterian; Emily A. Blood, MS and Margaret R. Grove, MS for the SPORT investigators; and James N. Weinstein, DO, MS, for the SPORT Investigators and The Dartmouth Institute for Health Policy and Clinical Practice.
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