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Assessing Cost-effectiveness of Surgery for Cervical Degenerative Diseases

Posted on: 11/30/1999
Value based health care is swiftly becoming a thing of the present and substantiation of treatments for spinal conditions will be necessary. Optimal treatment options need to be identified in value-based health care, where optimal can be defined as greatest gain in quality of life at the lowest cost to the patient and society. Overall there are very limited cost-effectiveness studies in spine surgery literature with cervical conditions being most neglected. A recent systematic review looked to identify if there is evidence present on the cost-effectiveness of operative treatment of cervical degenerative disc disease (DDD) conditions. Ultimately they stated that no definitive conclusion can be made secondary to the great limitations present in the small amount of current research on this topic.

Answers to four questions of interest were sought in performing this review to examine cost effectiveness of surgical treatment for cervical degenerative conditions. The first question looked at whether there was evidence present to suggest surgical intervention is cost-effective as compared with non-operative treatment for degenerative spinal conditions specifically cervical myelopathy (compression of the spinal cord within the neck) and cervical radiculopathy (compression or irritation of the spinal nerve roots in the neck). It was found that no full economic review existed relative to this question. The second question focused on evidence to suggest anterior cervical discectomy and fusion (ACDF) is cost-effective compared to cervical disc arthroplasty (CDR) for cervical myelopathy or radiculopathy. Only two economic evaluations were available which demonstrated that CDR is more cost-effective than ACDF for a patient with single-level cervical DDD and radiculopathy or myelopathy. The third question looked at whether evidence is present to suggest that surgeries based from the front of the neck were more cost-effective as compared to surgeries performed using a technique from the back of the neck for cervical myelopathy. Again only two economic evaluations were available. Surgery performed from the front did demonstrate increased cost-effectiveness at one-year postsurgery for patients with cervical myelopathy. The last question examined if evidence was present to suggest that surgeries performed from the front of the neck were more cost-effective as compared to surgical techniques performed from the back of the neck for cervical radiculopathy. In this case only one economic evaluation was available for analysis and this demonstrated that surgical techniques from the back are less costly than ACDF for patients with single-level radiculopathy.

There were several limitations found in this systematic review. Drawing conclusions off of only one or two studies is challenging and thus it was concluded that these questions must be further validated by additional high-quality investigations. Different types of surgical techniques (i.e. performed from the front or back) typically have a different subset of patients thus any conclusion made on cost-effectiveness may be influenced by patient demographics. Recent studies have further defined health utility indices in the study population as well as long-term complications. A repeat cost-effectiveness comparison utilizing this new information is still lacking.

Overall it was suggested that further analysis should adopt a standardized cost-utility methodology, which should include both comprehensive long-term follow-up costs and valid quality of life outcome questionnaire data. The authors of this review also recommended that the analyses should directly compare either non-operative versus operative intervention or two different surgical interventions using a cost-effectiveness ratio and being specific about whether it is a patient with myelopathy versus radiculopathy versus neck pain alone receiving treatment. They also felt that other surgical interventions should be explored and lastly that longer-term follow-up is necessary so that aspects such as adjacent level surgery, failure rates and clinical outcomes can be further defined.

Matthew D. Alvin, MBA, MA et al. Cervical Degenerative Disease Spine. Volume 39, No 225. pp 553-564.

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