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For Release: December 16, 2008
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Spine Fusion Cost-effectiveness Questioned in Dartmouth-led Study

Dr. Anna N.A. Tosteson
Dr. Anna N.A. Tosteson

Hanover, N.H.—Rates of spinal fusion have increased by more than 250 percent in the last 15 years. But is the surgery cost-effective?

New research led by Dartmouth Medical School suggests that for patients with spinal stenosis with associated slipped vertebrae, the benefits of the fusion procedure are not enough to offset the costs. The work was published in the December 16 Annals of Internal Medicine.

Lumbar spine fusion, in which two or more vertebrae are permanently joined to decrease spine instability, accounts for more than 1/3 of all back surgeries in the United States. Between 1993 and 2004, the number of spine fusions and the associated costs rose dramatically. In 2004, spine fusion procedures totaled $16.9 billion, according to the Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project.

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

To perform the study, researchers followed patients who participated in the Spine Patient Outcomes Research Trial (SPORT). Specifically, they looked at two conditions, spinal stenosis, which was treated most commonly with laminectomy, and spinal stenosis with slipped vertebrae (spinal stenosis with degenerative spondylolisthesis) most commonly treated with spine fusion.

Given the tremendous increase in the number of spinal fusion procedures, the question of cost-effectiveness has critical implications for the health care system.

—Dr. Anna N.A. Tosteson

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. 344 out of 368 surgical patients with stenosis with degenerative spondylolisthesis had spinal fusion.

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.

Using 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 authors report that stenosis surgery (usually laminectomy) cost about $77,000 per QALY gained. In contrast, surgery for stenosis with slipped vertebrae (usually fusion) and cost about $115,000 per QALY gained. In the US, $100,000 is the threshold at which procedures are considered to be cost-effective.


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