The value and cost-effectiveness of adult degenerative lumbar surgery

Patients often seek surgical treatment for relief of their chronic lower back pain, generally caused by spinal stenosis, disc herniation, or spondylolisthesis. Many studies have reported the effectiveness of these surgical procedures in terms of health-related quality-of-life (HRQOL) measures; however, little has been published regarding the value and cost-effectiveness of surgical intervention. In this systematic review of the literature: (1) we identified studies that reported economic interventional outcomes, specifically cost per quality-adjusted life years (QALY) or incremental cost-effectiveness ratios (ICER) and (2) we determined whether this literature demonstrates the cost-effectiveness of surgical intervention in treating degenerative lumbar conditions. A systematic search of databases such as PubMed and Cochrane Library, as well as hand searching the references of selected works, was focused on surgical and non-operative treatments for degenerative lumbar conditions, specifically spinal stenosis, lumbar disc herniation, and degenerative spondylilolysthesis. Outcomes were collected as cost-effectiveness values reported, as cost per quality-adjusted life years (QALY) gained in cohort studies, and as incremental cost-effectiveness ratios (ICER) in comparative studies. Five studies directly compared the cost-effectiveness of surgery to non-operative treatment. Twelve others simply reported cost-effectiveness in a single cohort manner. From the comparative studies, the mean ICER value was $45,962. From the single cohort studies, the mean cost/QALY was $75,017. Interventions with a value between $50,000 and $100,000, or less, are generally considered cost effective. The results of our literature review suggest that surgical intervention for degenerative lumbar conditions is indeed cost-effective. In fact, the value of surgery appears to increase with additional follow-up time. That is, surgery is more cost effective in the later years of follow-up. Our review also revealed a paucity of quality studies evaluating cost-effectiveness. With the economic burden of degenerative lumbar conditions being so great to the patient and society, we encourage clinicians to continue to report outcomes from an economic standpoint, using cost/QALY and ICER values.