Surgical Treatment of Spinal Stenosis with and without Degenerative Spondylolisthesis: Cost-Effectiveness after 2 Years

  1. Anna N.A. Tosteson, ScD;
  2. Jon D. Lurie, MD, MS;
  3. Tor D. Tosteson, ScD;
  4. Jonathan S. Skinner, PhD;
  5. Harry Herkowitz, MD;
  6. Todd Albert, MD;
  7. Scott D. Boden, MD;
  8. Keith Bridwell, MD, PhD;
  9. Michael Longley, MD;
  10. Gunnar B. Andersson, MD, PhD;
  11. Emily A. Blood, MS;
  12. Margaret R. Grove, MS;
  13. James N. Weinstein, DO, MS; and
  14. for the SPORT Investigators*
  1. From Dartmouth Medical School, Hanover, New Hampshire; William Beaumont Hospital, Royal Oak, Michigan; Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Emory University, Atlanta, Georgia; Washington University School of Medicine, St. Louis, Missouri; The Nebraska Foundation for Spinal Research, Omaha, Nebraska; and Rush University Medical Center, Chicago, Illinois.

    Abstract

    Background: The SPORT (Spine Patient Outcomes Research Trial) reported favorable surgery outcomes over 2 years among patients with stenosis with and without degenerative spondylolisthesis, but the economic value of these surgeries is uncertain.

    Objective: To assess the short-term cost-effectiveness of spine surgery relative to nonoperative care for stenosis alone and for stenosis with spondylolisthesis.

    Design: Prospective cohort study.

    Data Sources: Resource utilization, productivity, and EuroQol EQ-5D score measured at 6 weeks and at 3, 6, 12, and 24 months after treatment among SPORT participants.

    Target Population: Patients with image-confirmed spinal stenosis, with and without degenerative spondylolisthesis.

    Time Horizon: 2 years.

    Perspective: Societal.

    Intervention: Nonoperative care or surgery (primarily decompressive laminectomy for stenosis and decompressive laminectomy with fusion for stenosis associated with degenerative spondylolisthesis).

    Outcome Measures: Cost per quality-adjusted life-year (QALY) gained.

    Results of Base-Case Analysis: Among 634 patients with stenosis, 394 (62%) had surgery, most often decompressive laminectomy (320 of 394 [81%]). Stenosis surgeries improved health to a greater extent than nonoperative care (QALY gain, 0.17 [95% CI, 0.12 to 0.22]) at a cost of $77 600 (CI, $49 600 to $120 000) per QALY gained. Among 601 patients with degenerative spondylolisthesis, 368 (61%) had surgery, most including fusion (344 of 368 [93%]) and most with instrumentation (269 of 344 [78%]). Degenerative spondylolisthesis surgeries significantly improved health versus nonoperative care (QALY gain, 0.23 [CI, 0.19 to 0.27]), at a cost of $115 600 (CI, $90 800 to $144 900) per QALY gained.

    Result of Sensitivity Analysis: Surgery cost markedly affected the value of surgery.

    Limitation: The study used self-reported utilization data, 2-year time horizon, and as-treated analysis to address treatment nonadherence among randomly assigned participants.

    Conclusion: The economic value of spinal stenosis surgery at 2 years compares favorably with many health interventions. Degenerative spondylolisthesis surgery is not highly cost-effective over 2 years but could show value over a longer time horizon.

    Article and Author Information

    • Acknowledgment: The authors thank Catherine C. Lindsay, SM, for extensive work in the development of the cost weights utilized in this analysis; Tamara S. Morgan for creation of the patient diaries and assistance in preparing this manuscript; and Loretta Pearson for editorial assistance.

    • Grant Support: By the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (U01-AR45444); Office of Research on Women's Health, National Institutes of Health; and the National Institute of Occupational Safety and Health, Centers for Disease Control and Prevention. The Multidisciplinary Clinical Research Center in Musculoskeletal Diseases is funded by NIAMS (P60-AR048094). Dr. Lurie is supported by a Research Career Award from NIAMS (K23 AR 048138).

    • Potential Financial Conflicts of Interest: Consultancies: T. Albert (DePuy Spine), S.D. Boden (Medtronic), K. Bridwell (DePuy, Medtronic). Grants received: M. Longley (Medtronic), J.N. Weinstein (National Institutes of Health). Patents pending: T. Albert (screw device for possible use in fusion operations). Royalties: S.D. Boden (Osteotech).

    • Reproducible Research Statement: Study protocol: Available upon request (e-mail, SPORT{at}dartmouth.edu). Statistical code and data set: Not available.

    • Requests for Single Reprints: Anna N.A. Tosteson, ScD, Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, HB7505, Dartmouth Medical School, One Medical Center Drive, Lebanon, NH 03756.

    • Current Author Addresses: Drs. A.N.A. Tosteson, Lurie, T.D. Tosteson, and Weinstein; Ms. Blood; and Ms. Grove: Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756.

    • Dr. Skinner: Dartmouth College, 317 Rockefeller Hall, Hanover, NH 03755.

    • Dr. Herkowitz: William Beaumont Hospital, 3535 West 13 Mile Road Royal Oak, MI 48073.

    • Dr. Albert: Rothman Institute at Thomas Jefferson University, 952 Chestnut Street, Philadelphia, PA 19107.

    • Dr. Boden: Emory University, Emory Orthopaedics and Spine Center, 59 Executive Park South, Suite 3000, Atlanta, GA 30329.

    • Dr Bridwell: Washington University, Suite 11300 West Pavilion, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110.

    • Dr. Longley: Nebraska Spine Surgeons, 11819 Miracle Hills Drive, Suite 102, Omaha, NE 68154-4438.

    • Dr. Andersson: Rush-Presbyterian-St. Luke's Medical Center, 1653 West Congress Parkway, Chicago, IL 60612-3833.

    • Author Contributions: Conception and design: A.N.A. Tosteson, T.D. Tosteson, T. Albert, S.D. Boden, K. Bridwell, J.N. Weinstein.

    • Analysis and interpretation of the data: A.N.A. Tosteson, J.D. Lurie, T.D. Tosteson, J.S. Skinner, S.D. Boden, E.A. Blood, M.R. Grove, J.N. Weinstein.

    • Drafting of the article: A.N.A. Tosteson, J.D. Lurie, E.A. Blood, J.N. Weinstein.

    • Critical revision of the article for important intellectual content: A.N.A. Tosteson, J.D. Lurie, J.S. Skinner, H. Herkowitz, T. Albert, S.D. Boden, K. Bridwell, M. Longley, G.B. Andersson, E.A. Blood, J.N. Weinstein.

    • Final approval of the article: A.N.A. Tosteson, J.D. Lurie, T.D. Tosteson, J.S. Skinner, H. Herkowitz, T. Albert, M. Longley, G.B. Andersson, E.A. Blood, J.N. Weinstein.

    • Provision of study materials or patients: J.D. Lurie, J.S. Skinner, T. Albert, S.D. Boden, M. Longley, G.B. Andersson, J.N. Weinstein.

    • Statistical expertise: A.N.A. Tosteson, T.D. Tosteson, E.A. Blood, J.N. Weinstein.

    • Obtaining of funding: A.N.A. Tosteson, J.N. Weinstein.

    • Administrative, technical, or logistic support: J.N. Weinstein.

    • Collection and assembly of data: J.N. Weinstein.

    • ↵* For a list of the SPORT (Spine Patient Outcomes Research Trial) investigators, see the Appendix.

    Responses to this article

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    • IN RESPONSE:
      • Anna N. A. Tosteson and
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    • Cost-Effectiveness of Spinal Stenosis Surgery
      • Neil H Shusterman and
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    • SPORT study/cost effectiveness analysis
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