Cost-effectiveness of circumferential fusion for lumbar spondylolisthesis: propensity-matched comparison of transforaminal lumbar interbody fusion with anterior-posterior fusion

Publication date: November 2018

Source: The Spine Journal, Volume 18, Issue 11

Author(s): Ehsan Jazini, Jeffrey L. Gum, Steven D. Glassman, Charles H. Crawford, Mladen Djurasovic, Roge Kirk Owens, John R. Dimar, Katlyn E. McGraw, Leah Y. Carreon

Abstract

Background Context

Transforaminal lumbar interbody fusion (TLIF) and dual-approach anteroposterior (AP) are common techniques to achieve circumferential fusion for lumbar spondylolisthesis. It is unclear which approach is more cost-effective.

Purpose

Our goal was to determine the incremental cost-effectiveness ratio (ICER) by calculating the cost per quality-adjusted life year (QALY) for each approach.

Study Design/Setting

This study is a propensity-matched cost-effectiveness comparison.

Patient Sample

Patients with lumbar spondylolisthesis undergoing single-level AP fusion or TLIF and enrolled in a prospective observational surgical database were included in this study.

Outcome Measures

The outcome measures in this study were the Oswestry Disability Index (ODI) and the Short Form-6D (SF-6D).

Methods

From a prospective surgical database, patients with lumbar spondylolisthesis undergoing single-level AP fusion were propensity matched to a TLIF cohort based on age, gender, body mass index, smoking status, workers compensation, preoperative ODI, and back and leg pain numeric scores. Quality-adjusted life years gained were determined using baseline and 1- and 2-yearpostoperative SF-6D scores. Cost was calculated from actual, direct hospital costs and included subsequent postsurgical costs (epidural spinal injections, spine-related emergency department visits, readmissions, and revision surgery).

Results

Thirty-one cases of AP fusions were identified and propensity matched to 31 TLIF patients. Patients undergoing TLIF had a shorter mean operative time (270 vs. 328 minutes, p=.039) but no difference in estimated blood loss (526 vs. 548 cc, p=.804) or hospital length of stay (4.5 vs. 6.1 days, p=.146). Quality-adjusted life years gained at 2 years were also similar (0.140 vs. 0.130, p=.672). The mean index surgery and the total 2-year costs were lower for TLIF compared with AP (index: $29,428 vs. $31,466; final: $30,684 vs. $331,880). As overall costs were lower and QALYs gained were similar for TLIF compared with AP fusion, TLIF was the dominant intervention with an ICER of $116,327.

Conclusions

Under our study parameters, surgical treatment of lumbar spondylolisthesis with TLIF is more cost-effective compared with AP fusion. Because of the short-term follow-up, the longevity of this should be further investigated.

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