Cost-effectiveness of minimally invasive midline lumbar interbody fusion versus traditional open transforaminal lumbar interbody fusion

Restricted access

OBJECTIVE

The midline transforaminal lumbar interbody fusion (MIDLIF) using cortical screw fixation is a novel, minimally invasive procedure that may offer enhanced recovery over traditional open transforaminal lumbar interbody fusion (TLIF). Little information is available regarding the comparative cost-effectiveness of the MIDLIF over conventional TLIF. The purpose of this study was to compare cost-effectiveness of minimally invasive MIDLIF with open TLIF.

METHODS

From a prospective, multisurgeon, surgical database, a consecutive series of patients undergoing 1- or 2-level MIDLIF for degenerative lumbar conditions was identified and propensity matched to patients undergoing TLIF based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists Physical Status Classification System (ASA) class, and levels fused. Direct costs at 1 year were collected, including costs associated with the index surgical visit as well as costs associated with readmission. Improvement in health-related quality of life was measured using EQ-5D and SF-6D.

RESULTS

Of 214 and 181 patients undergoing MIDLIF and TLIF, respectively, 33 cases in each cohort were successfully propensity matched. Consistent with propensity matching, there was no difference in age, sex, BMI, diagnosis, ASA class, smoking status, or levels fused. Spondylolisthesis was the most common indication for surgery in both cohorts. Variable direct costs at 1 year were $2493 lower in the MIDLIF group than in the open TLIF group (mean $15,867 vs $17,612, p = 0.073). There was no difference in implant (p = 0.193) or biologics (p = 0.145) cost, but blood utilization (p = 0.015), operating room supplies (p < 0.001), hospital room and board (p < 0.001), pharmacy (p = 0.010), laboratory (p = 0.004), and physical therapy (p = 0.009) costs were all significantly lower in the MIDLIF group. Additionally, the mean length of stay was decreased for MIDLIF as well (3.21 vs 4.02 days, p = 0.05). The EQ-5D gain at 1 year was 0.156 for MIDLIF and 0.141 for open TLIF (p = 0.821). The SF-6D gain at 1 year was 0.071 for MIDLIF and 0.057 for open TLIF (p = 0.551).

CONCLUSIONS

Compared with patients undergoing traditional open TLIF, those undergoing MIDLIF have similar 1-year gains in health-related quality of life, with total direct costs that are $2493 lower. Although the findings were not statistically significant, minimally invasive MIDLIF showed improved cost-effectiveness at 1 year compared with open TLIF.

ABBREVIATIONS ASA = American Society of Anesthesiologists Physical Status Classification System; HRQOL = health-related quality of life; MIDLIF = midline TLIF; ODI = Oswestry Disability Index; TLIF = transforaminal lumbar interbody fusion.
Article Information

Contributor Notes

Correspondence Leah Y. Carreon: Norton Leatherman Spine Center, Louisville, KY. leah.carreon@nortonhealthcare.org.INCLUDE WHEN CITING Published online September 13, 2019; DOI: 10.3171/2019.6.SPINE1965.Disclosures Dr. Djurasovic: consultant for Medtronic and NuVasive. Dr. Gum: employee of Norton Healthcare; consultant for Medtronic, DePuy, Stryker, Acuity, K2M, PacMed, and NuVasive; clinical or research support for the study described: Intellirod, Integra, Pfizer, and International Spine Study Group; direct stock ownership in Cingulate Therapeutics; patent holder with Medtronic; and royalties from Acuity. Dr. Crawford: consultant for Alphatec, DePuy-Synthes, Medtronic, and NuVasive. Dr. Owens: consultant for NuVasive and Medtronic; and research support from Pfizer, Intellirod, and Texas Scottish Rite Hospital. Mr. Brown: employee of Norton Healthcare. Dr. Glassman: employee of Norton Healthcare, consultant for Medtronic and K2M, patent holder with Medtronic, and royalties from Medtronic. Dr. Carreon: employee of Norton Healthcare; consultant for AOSpine; funds for travel from University of Southern Denmark and University of Louisville; editorial advisory board of Spine Deformity, The Spine Journal, and Spine; member of the University of Louisville IRB and research committee of the Scoliosis Research Society; and funds from Orthopedic Research and Education Foundation, NIH, International Spine Study Group, Scoliosis Research Society, Texas Scottish Rite Hospital for Children, Pfizer, Lifesciences Corp., Intellirod, Cerapedics, and NeuroPoint Alliance.
Headings
References
  • 1

    Andersson G: The Burden of Musculoskeletal Diseases in the United Statesed 3. Rosemont, IL: United States Bone and Joint Initiative2014 (https://www.boneandjointburden.org/docs/The%20Burden%20of%20Musculoskeletal%20Diseases%20in%20the%20United%20States%20%28BMUS%29%203rd%20Edition%20%28Dated%2012.31.16%29.pdf) [Accessed July 29 2019]

    • Search Google Scholar
    • Export Citation
  • 2

    Brazier JDeverill MGreen C: A review of the use of health status measures in economic evaluation. J Health Serv Res Policy 4:1741841999

    • Search Google Scholar
    • Export Citation
  • 3

    Brazier JRoberts JDeverill M: The estimation of a preference-based measure of health from the SF-36. J Health Econ 21:2712922002

    • Search Google Scholar
    • Export Citation
  • 4

    Brazier JRoberts JTsuchiya ABusschbach J: A comparison of the EQ-5D and SF-6D across seven patient groups. Health Econ 13:8738842004

    • Search Google Scholar
    • Export Citation
  • 5

    Carreon LYGlassman SDGhogawala ZMummaneni PVMcGirt MJAsher AL: Modeled cost-effectiveness of transforaminal lumbar interbody fusion compared with posterolateral fusion for spondylolisthesis using N(2)QOD data. J Neurosurg Spine 24:9169212016

    • Search Google Scholar
    • Export Citation
  • 6

    Carreon LYGlassman SDMcDonough CMRampersaud RBerven SShainline M: Predicting SF-6D utility scores from the Oswestry Disability Index and numeric rating scales for back and leg pain. Spine (Phila Pa 1976) 34:208520892009

    • Search Google Scholar
    • Export Citation
  • 7

    Christensen AHøy KBünger CHelmig PHansen ESAndersen T: Transforaminal lumbar interbody fusion vs. posterolateral instrumented fusion: cost-utility evaluation along side an RCT with a 2-year follow-up. Eur Spine J 23:113711432014

    • Search Google Scholar
    • Export Citation
  • 8

    Drummond MFSculpher MJTorrance GWO’Brien BJStoddart GL: Methods for the Economic Evaluation of Health Care Programmes. Oxford: Oxford University Press2005

    • Search Google Scholar
    • Export Citation
  • 9

    EuroQol Group: EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 16:1992081990

  • 10

    Fairbank JCTPynsent PB: The Oswestry Disability Index. Spine (Phila Pa 1976) 25:294029522000

  • 11

    Gold MRSiegel JERussell BWeinstein MC: Cost-Effectiveness in Health and Medicine. New York: Oxford University Press1990

  • 12

    Goldstein CLPhillips FMRampersaud YR: Comparative effectiveness and economic evaluations of open versus minimally invasive posterior or transforaminal lumbar interbody fusion: a systematic review. Spine (Phila Pa 1976) 41 (Suppl 8):S74S892016

    • Search Google Scholar
    • Export Citation
  • 13

    Lee GWSon JHAhn MWKim HJYeom JS: The comparison of pedicle screw and cortical screw in posterior lumbar interbody fusion: a prospective randomized noninferiority trial. Spine J 15:151915262015

    • Search Google Scholar
    • Export Citation
  • 14

    Matsukawa KYato YNemoto OImabayashi HAsazuma TNemoto K: Morphometric measurement of cortical bone trajectory for lumbar pedicle screw insertion using computed tomography. J Spinal Disord Tech 26:E248E2532013

    • Search Google Scholar
    • Export Citation
  • 15

    McCaffery MBeebe A: Pain: Clinical Manual for Nursing Practice. Baltimore: VV Mosby Company1993

  • 16

    McDonough CMGrove MRTosteson TDLurie JDHilibrand ASTosteson AN: Comparison of EQ-5D, HUI, and SF-36-derived societal health state values among spine patient outcomes research trial (SPORT) participants. Qual Life Res 14:132113322005

    • Search Google Scholar
    • Export Citation
  • 17

    Ninomiya KIwatsuki KOhnishi YYoshimine T: Radiological evaluation of the initial fixation between cortical bone trajectory and conventional pedicle screw technique for lumbar degenerative spondylolisthesis. Asian Spine J 10:2512572016

    • Search Google Scholar
    • Export Citation
  • 18

    Orita SInage KKubota GSainoh TSato JFujimoto K: One-year prospective evaluation of the technique of percutaneous cortical bone trajectory spondylodesis in comparison with percutaneous pedicle screw fixation: a preliminary report with technical note. J Neurol Surg A Cent Eur Neurosurg 77:5315372016

    • Search Google Scholar
    • Export Citation
  • 19

    Parker SLMendenhall SKShau DNZuckerman SLGodil SSCheng JS: Minimally invasive versus open transforaminal lumbar interbody fusion for degenerative spondylolisthesis: comparative effectiveness and cost-utility analysis. World Neurosurg 82:2302382014

    • Search Google Scholar
    • Export Citation
  • 20

    Phan KRamachandran VTran TMShah KPFadhil MLackey A: Systematic review of cortical bone trajectory versus pedicle screw techniques for lumbosacral spine fusion. J Spine Surg 3:6796882017

    • Search Google Scholar
    • Export Citation
  • 21

    Sach THBarton GRJenkinson CDoherty MAvery AJMuir KR: Comparing cost-utility estimates: does the choice of EQ-5D or SF-6D matter? Med Care 47:8898942009

    • Search Google Scholar
    • Export Citation
  • 22

    Santoni BGHynes RAMcGilvray KCRodriguez-Canessa GLyons ASHenson MA: Cortical bone trajectory for lumbar pedicle screws. Spine J 9:3663732009

    • Search Google Scholar
    • Export Citation
  • 23

    Takenaka SMukai YTateishi KHosono NFuji TKaito T: Clinical outcomes after posterior lumbar interbody fusion: comparison of cortical bone trajectory and conventional pedicle screw insertion. Clin Spine Surg 30:E1411E14182017

    • Search Google Scholar
    • Export Citation
  • 24

    Vertuani SNilsson JBorgman BBuseghin GLeonard CAssietti R: A cost-effectiveness analysis of minimally invasive versus open surgery techniques for lumbar spinal fusion in Italy and the United Kingdom. Value Health 18:8108162015

    • Search Google Scholar
    • Export Citation
  • 25

    Ware J JrKosinski MKeller SDA: A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care 34:2202331996

    • Search Google Scholar
    • Export Citation
  • 26

    Ware JE JrSherbourne CD: The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30:4734831992

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 91 91 91
Full Text Views 46 46 46
PDF Downloads 64 64 64
EPUB Downloads 0 0 0
PubMed
Google Scholar