Cost-effectiveness analysis: comparing single-level cervical disc replacement and single-level anterior cervical discectomy and fusion

Clinical article

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In recent years, there has been increased interest in the use of cervical disc replacement (CDR) as an alternative to anterior cervical discectomy and fusion (ACDF). While ACDF is a proven intervention for patients with myelopathy or radiculopathy, it does have inherent limitations. Cervical disc replacement was designed to preserve motion, avoid the limitations of fusion, and theoretically allow for a quicker return to activity. A number of recently published systematic reviews and randomized controlled trials have demonstrated positive clinical results for CDR, but no studies have revealed which of the 2 treatment strategies is more cost-effective. The purpose of this study was to evaluate the cost-effectiveness of CDR and ACDF by using the power of decision analysis. Additionally, the authors aimed to identify the most critical factors affecting procedural cost and effectiveness and to define thresholds for durability and function to focus and guide future research.


The authors created a surgical decision model for the treatment of single-level cervical disc disease with associated radiculopathy. The literature was reviewed to identify possible outcomes and their likelihood following CDR and ACDF. Health state utility factors were determined from the literature and assigned to each possible outcome, and procedural effectiveness was expressed in units of quality-adjusted life years (QALYs). Using ICD-9 procedure codes and data from the Nationwide Inpatient Sample, the authors calculated the median cost of hospitalization by multiplying hospital charges by the hospital-specific cost-to-charge ratio. Gross physician costs were determined from the mean Medicare reimbursement for each current procedural terminology (CPT) code. Uncertainty as regards both cost and effectiveness numbers was assessed using sensitivity analysis.


In the reference case, the model assumed a 20-year duration for the CDR prosthesis. Cervical disc replacement led to higher average QALYs gained at a lower cost to society if both strategies survived for 20 years ($3042/QALY for CDR vs $8760/QALY for ACDF). Sensitivity analysis revealed that CDR needed to survive at least 9.75 years to be considered a more cost-effective strategy than ACDF. Cervical disc replacement becomes an acceptable societal strategy as the prosthesis survival time approaches 11 years and the $50,000/QALY gained willingness-to-pay threshold is crossed. Sensitivity analysis also indicated that CDR must provide a utility state of at least 0.796 to be cost-effective.


Both CDR and ACDF were shown to be cost-effective procedures in the reference case. Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF. Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR, future long-term studies are required to validate the present analysis.

Abbreviations used in this paper:ACDF = anterior cervical discectomy and fusion; CDR = cervical disc replacement; CEA = cost-effectiveness analysis; CER = cost-effectiveness ratio; CPT = current procedural terminology; DRG = diagnosis-related group; ICER = incremental CER; NDI = Neck Disability Index; NIS = Nationwide Inpatient Sample; QALY = quality-adjusted life year; SF-36 = 36-Item Short-Form Health Survey; WTP = willingness-to-pay.

Article Information

Address correspondence to: Sheeraz A. Qureshi, M.D., M.B.A., Mount Sinai Medical Center, Department of Orthopaedic Surgery, 5 E. 98th St., 9th Floor, Box 1188, New York, NY 10029. email:

Please include this information when citing this paper: published online September 6, 2013; DOI: 10.3171/2013.8.SPINE12623.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Decision model for the treatment of single-level degenerative disc disease (DDD) in the reference case. M = male; y/o = year old.

  • View in gallery

    Variation in prosthesis survival time to determine threshold cost-effectiveness level. Incr. = incremental.

  • View in gallery

    Results of sensitivity analysis of the effect of the cost variance of CDR. Red line represents ACDF; blue line, CDR.

  • View in gallery

    Results of sensitivity analysis of the effect of utility factor variance on the ICER of CDR. Red line represents ACDF; blue line, CDR.



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