Cost-Effectiveness of Anterior and Posterior Surgical Approaches for Cervical Spondylotic Myelopathy: An Economic Evaluation of a Randomized Clinical Trial
Robert G. Whitmore, Stephen P. Miranda, Mohamad Bydon, Ruchita Dholakia, James P. Moriarty, Bijan J. Borah, Adam S. Kanter, Praveen V. Mummaneni, Erica F. Bisson, James S. Harrop, Subu N. Magge, Robert F. Heary, Michael G. Fehlings, Todd J. Albert, Paul M. Arnold, Kiehyun Daniel Riew, Michael P. Steinmetz, Edward C. Benzel, Marjorie C. Wang, John G. Heller, Zoher GhogawalaBACKGROUND AND OBJECTIVES:
Surgery for cervical spondylotic myelopathy improves quality of life but remains expensive. We conducted a cost-effectiveness analysis of patients treated with anterior cervical diskectomy/fusion (ACDF), posterior cervical decompression/fusion (PCDF), and laminoplasty (LP) in the Cervical Spondylotic Myelopathy Surgical (CSM-S) Trial, a randomized trial comparing surgical approaches for cervical spondylotic myelopathy.
METHODS:
In the trial, patients were randomized (2:3) to anterior (ACDF) or posterior surgery (LP or PCDF, at surgeon's discretion). A cost-effectiveness analysis was performed from a societal perspective with a 1-year time horizon, including only US patients as-treated. Cumulative costs were estimated using patient data on utilization and lost productivity using a human capital approach. Direct costs were calculated using 2022 Medicare rates for professional fees and cost-to-charge ratios for hospital services. Quality-adjusted life-years (QALYs) were calculated from patient responses to the EuroQol-5-Dimensions instrument at baseline and 3, 6, and 12 months postoperatively. Incremental cost-effectiveness ratio analysis was performed with bootstrapping to address uncertainty.
RESULTS:
Of 163 total patients enrolled in the CSM-S Trial, 153 from the United States (mean age, 62 years; 80 (52%) female) were included as-treated (ACDF = 61, PCDF = 64, LP = 28) in a cost-effectiveness analysis. Economic data were not available for 9 patients. The remaining 144 patients treated (ACDF = 55, PCDF = 61, LP = 28) had cost data through a 1-year follow-up. Mean hospitalization costs were higher after PCDF than ACDF and LP ($33 410 vs $26 468 vs $25 550;
CONCLUSION:
In the CSM-S Trial, LP yielded greater 1-year quality-of-life improvements at lower costs than PCDF and ACDF.