Spinal Fusion Cost-Effectiveness Questioned

A new study suggests that for patients with spinal stenosis with associated slipped vertebrae, the benefits of the fusion procedure are not enough to offset the costs.

Researchers at Dartmouth Medical School (DMS, Hanover, NH, USA) followed 762 patients who participated in the Spine Patient Outcomes Research Trial (SPORT). 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. Three hundred forty-four out of 368 surgical patients with stenosis with degenerative spondylolisthesis had spinal fusion. The researchers used 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 study results showed that two years out from surgery, although 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. The study was published in the December 16, 2008 issue of Annals of Internal Medicine.

"Given the tremendous increase in the number of spinal fusion procedures, the question of cost-effectiveness has critical implications for the health care system,” said lead author Anna Tosteson, M.D., a professor of medicine and community and family medicine at DMS. "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.”

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. However, while stenosis surgery (usually laminectomy) cost about $77,000 per QALY gained, surgery for stenosis with slipped vertebrae (which usually involves fusion) costs about $115,000 per QALY gained. In contrast, $100,000 is the threshold at which procedures are considered cost-effective In the United States.

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