Cost-effectiveness of anterior surgical decompression surgery for cervical degenerative disk disease: a systematic review of economic evaluations

Restoration of Range of Motion in the Cervical Spine through Single-Segment Artificial Disc Replacement Using the Baguera®C Prosthesis

Background: Anterior cervical discectomy and fusion (ACDF) is a standard procedure for degenerative diseases of the cervical spine, providing nerve decompression and spinal stabilization. However, it limits cervical spine motility, restricts fused segment activity, and may lead to adjacent degeneration. Cervical disc arthroplasty (CDA) is an accepted alternative that preserves the structure and flexibility of the cervical spine. This study aimed to explore the dynamic changes in the range of motion (ROM) of the cervical spine after CDA using a viscoelastic artificial disc, as well as the factors affecting mobility restoration. Methods: A retrospective analysis was conducted on 132 patients who underwent single-level anterior cervical discectomy and CDA from January 2015 to June 2022. Result: Analysis of data from 132 patients revealed a significant improvement in clinical outcomes. The mean ROM of C2-C7 and functional spinal unit (FSU) segments significantly increased from 2 to 36 months post-operatively. Cervical spine flexibility was preserved and enhanced after prosthesis implantation. However, it took six months for the cervical spine motility to stabilize. In addition, sex and age were found to impact motility restoration, with female and younger patients exhibiting larger ROMs post-surgery. Additionally, CDA at the C5-C6 level resulted in the greatest increase in ROM, potentially improving overall kinematic ability. Conclusions: Single-segment artificial disc arthroplasty effectively restores the ROM in degenerative cervical spine conditions.

Advocating uniformity in spine surgery: a practical disease-specific guideline for trial-based economic evaluations

OBJECTIVES

Despite the availability of general and national guidelines for the conduct and reporting of economic evaluations, there is heterogeneity in economic evolutions concerning spine surgery. This is partly the result of differing levels of adherence to the existing guidelines and the lack of disease-specific recommendations for economic evaluations. The extensive heterogeneity in study design, follow-up duration and outcome measurements limit the comparability of economic evaluations in spine surgery. This study has three objectives: (1) to create disease-specific recommendations for the design and conduct of trial-based economic evaluations in spine surgery, (2) to define recommendations for reporting economic evaluations in spine surgery as a complement to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist and (3) to discuss methodological challenges and defining the need for future research.

DESIGN

A modified Delphi method according to the RAND/UCLA Appropriateness Method.

SETTING

A four-step process was followed to create and validate disease-specific statements and recommendations for the conduct and reporting of trial-based economic evaluations in spine surgery. Consensus was defined as >75% agreement.

PARTICIPANTS

A total of 20 experts were included in the expert group. Validation of the final recommendations was obtained in a Delphi panel, which consisted of 40 researchers in the field who were not included in the expert group.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure is a set of recommendations for the conduct and reporting, as a complement to the CHEERS 2022 checklist, of economic evaluations in spine surgery.

RESULTS

A total of 31 recommendations are made. The Delphi panel confirmed consensus on all of the recommendations in the proposed guideline.

CONCLUSION

This study provides an accessible and practical guideline for the conduct of trial-based economic evaluations in spine surgery. This disease-specific guideline is a complement to existing guidelines, and should aid in reaching uniformity and comparability.

Cost effectiveness of implanting a prosthesis after anterior cervical discectomy for radiculopathy: results of the NECK randomized controlled trial

BACKGROUND CONTEXT

In the treatment of cervical radiculopathy due to a herniated disc, potential surgical treatments include: anterior cervical discectomy (ACD), ACD and fusion using a cage (ACDF), and anterior cervical disc arthroplasty (ACDA). Previous publications yielded comparable clinical and radiological outcome data for the various implants, but research on their comparative costutility has been inconclusive.

PURPOSE

To evaluate the cost utility of ACD, ACDF, and ACDA.

STUDY DESIGN

Cost-utility analysis.

PATIENT SAMPLE

About 109 patients with cervical radiculopathy randomized to undergo ACD, ACDF, or ACDA as part of the NEtherlands Cervical Kinetics trial.

OUTCOME MEASURES

Quality-adjusted life-years (QALYs) estimated from patient-reported utilities using the EuroQol-5D questionnaire and EuroQol Visual Analogue Scale (EQ VAS), measured at baseline, 2, 4, 8, 12, 26, 52, and 104 weeks postprocedure. Societal costs including admissions to hospital (related and otherwise), GP visits, specialist visits, physical therapy, medications, home care, aids, informal care, productivity losses, and out of pocket condition-related expenses.

METHODS

The cost utility of the competing strategies over 1 and 2 years was assessed following a net benefit (NB) approach, whereby the intervention with the highest NB among competing strategies is preferred. Cost effectiveness acceptability curves were produced to reflect the probability of each strategy being the most cost effective across various willingness-to-pay (WTP) thresholds. Five sensitivity analyses were conducted to assess the robustness of results.

RESULTS

ACDF was more likely to be the most cost-effective strategy at WTP thresholds of €20,000 to 50,000/QALY in all but one of the analyses. The mean QALYs during the first year were 0.750, 0.817, and 0.807 for ACD, ACDF, and ACDA, respectively, with no significant differences between groups. Total healthcare costs over the first year were significantly higher for ACDA, largely due to the higher surgery and implant costs. The total societal costs of the three strategies were €12,173 for ACD, €11,195 for ACDF, and €13,746 for ACDA, with no significant differences between groups.

CONCLUSION

Our findings demonstrate that ACDF is likely to be more cost-effective than ACDA or ACD at most WTP thresholds, and this conclusion is robust to most sensitivity analyses conducted. It is demonstrated that the difference in costs is mainly caused by the initial surgical costs and that there are only minimal differences in other costs during follow-up. Since clinical data are comparable between the groups, it is to the judgment of the patient and surgeon which intervention is applied.

Anterior Cervical Discectomy and Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: One-Year Cost-Utility Analysis

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

Assess the cost-utility of anterior cervical discectomy and fusion (ACDF) performed in the ambulatory surgery center (ASC) versus inpatient hospital setting for Medicare and privately insured patients at one-year follow-up.

SUMMARY OF BACKGROUND DATA

Outpatient ACDF has gained popularity due to improved safety and reduced costs. Formal cost-utility studies for ambulatory versus inpatient ACDF are lacking, precluding an accurate assessment of cost-effectiveness.

MATERIALS AND METHODS

A total of 6504 patients enrolled in the Quality Outcomes Database (QOD) undergoing one-level to two-level ACDF at a single ASC (520) or the inpatient hospital setting (5984) were compared. Propensity matching generated 748 patients for analysis (374 per cohort). Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years (QALYs) were assessed. Direct costs (1-year resource use×unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays×average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated.

RESULTS

Complication rates and improvements in patient-reported outcome measures and QALYs were similar between groups. Ambulatory ACDF was associated with significantly lower total costs at 1 year for Medicare ($5879.46) and privately insured ($12,873.97) patients, respectively. The incremental cost-effectiveness ratios for inpatient ACDF was $3,674,662 and $8,046,231 for Medicare and privately insured patients, respectively, reflecting unacceptably poor cost-utility.

CONCLUSION

Inpatient ACDF is associated with significant increases in total costs compared to the ASC setting without a safety, outcome, or QALY benefit. The ASC setting is a dominant option from a health economy perspective for first-time one-l to two-level ACDF in select patients compared to the inpatient hospital setting.

A novel nanohydroxyapatite/polyamide-66 cage for reducing the subsidence rate after single-level anterior cervical discectomy and fusion: a comparative study of 7-year follow-up

BACKGROUND

A novel nanohydroxyapatite/polyamide-66 cage (n-HA/PA66 cage) with a horseshoe shape was designed to lower the subsidence rate of the traditional hollow cylindrical n-HA/PA66 cage. However, no studies have compared the incidence of subsidence in the two cages. The purpose of this study was to compare the long-term clinical and radiological outcomes of the novel n-HA/PA66 cage with the hollow cylindrical n-HA/PA66 cage after anterior cervical discectomy and fusion (ACDF) to treat single-level cervical degenerative disk disease (CDDD).

METHODS

Fifty-two patients with novel n-HA/PA66 cages (Group A) and fifty-five patients with hollow cylindrical n-HA/PA66 cages (Group B) were included. The radiological parameters included intervertebral height (IH), C2-7 angle (C2-7a), segmental alignment (SA), subsidence rate, and fusion rate. The clinical outcomes were visual analog scale (VAS) scores, Japanese Orthopedic Association (JOA) scores, and patient satisfaction rates.

RESULTS

The pre- and postoperative SA, C2-7a, and fusion rates of the patients in Groups A and B were similar. The preoperative and 6-month postoperative IHs in both groups were comparable. However, the final follow-up IH in Group B was significantly smaller than that in Group A (35.9 mm vs. 36.7 mm). The difference in the subsidence rates at the final follow-up between Group A (5.8%, 3/52) and Group B (18.2%, 10/55) was significant. The VAS score, JOA score, and patient satisfaction rate were not significantly different.

CONCLUSIONS

The novel n-HA/PA66 cage had similar favorable SA, C2-7a, fusion rate, and clinical outcomes compared to the hollow cylindrical n-HA/PA66 cage for treating single-level ACDF. Moreover, the novel n-HA/PA66 cage achieved a lower subsidence rate and higher IH than the hollow cylindrical n-HA/PA66 cage at the final follow-up.

Research protocol: Cervical Arthroplasty Cost Effectiveness Study (CACES): economic evaluation of anterior cervical discectomy with arthroplasty (ACDA) versus anterior cervical discectomy with fusion (ACDF) in the surgical treatment of cervical degenerative disc disease - a randomized controlled trial

Introduction

To date, there is no consensus on which anterior surgical technique is more cost-effective in treating cervical degenerative disc disease (CDDD). The most commonly used surgical treatment for patients with single- or multi-level symptomatic CDDD is anterior cervical discectomy with fusion (ACDF). However, new complaints of radiculopathy and/or myelopathy commonly develop at adjacent levels, also known as clinical adjacent segment pathology (CASP). The extent to which kinematics, surgery-induced fusion, natural history, and progression of disease play a role in the development of CASP remains unclear. Anterior cervical discectomy with arthroplasty (ACDA) is another treatment option that is thought to reduce the incidence of CASP by preserving motion in the operated segment. While ACDA is often discouraged, as the implant costs are higher while the clinical outcomes are similar to ACDF, preventing CASP might be a reason for ACDA to be a more cost-effective technique in the long term.

Methods and analysis

In this randomized controlled trial, patients will be randomized to receive ACDF or ACDA in a 1:1 ratio. Adult patients with single- or multi-level CDDD and symptoms of radiculopathy and/or myelopathy will be included. The primary outcome is cost-effectiveness and cost-utility of both techniques from a healthcare and societal perspective. Secondary objectives are the differences in clinical and radiological outcomes between the two techniques, as well as the qualitative process surrounding anterior decompression surgery. All outcomes will be measured at baseline and every 6 months until 4 years post-surgery.

Discussion

High-quality evidence regarding the cost-effectiveness of both ACDA and ACDF is lacking; to date, there are no prospective trials from a societal perspective. Considering the aging of the population and the rising healthcare costs, there is an urgent need for a solid clinical cost-effectiveness trial addressing this question.

Trial registration

ClinicalTrials.gov NCT04623593. Registered on 29 September 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06574-5.