Abstract
Lumbar discectomy remains the most common surgical treatment for lumbar disc herniation, potentially providing quick pain relief for patients. However, while pain resolution is a key measure of short-term success, it does not guarantee long-term recovery. In patients with large annular defects (≥6 mm), the structural vulnerability left by discectomy predisposes patients to recurrent herniation, which can trigger a return of severe pain, diminished function, and the need for additional surgery. Revision surgeries for recurrent herniations are costly and are associated with a lower chance of positive patient outcomes compared with primary procedures.
Bone-anchored annular closure devices aim to address the root structural cause of recurrent herniation by sealing the annular defect during discectomy to preserve disc integrity. Adding a bone-anchored annular closure device to discectomy reduces symptomatic reherniation and reoperation rates by more than 50%, prolonging pain-free intervals and improving quality of life. Patients treated with bone-anchored annular closure devices report low pain scores over long-term follow-up, faster return to work, and reduced opioid requirements.
Cost-effectiveness analyses demonstrate that in patients with a large annular defect, bone-anchored annular closure devices achieve cost neutrality, or savings, within 2 to 5 years, with incremental cost-effectiveness ratios below accepted thresholds. By preventing the recurrence of lumbar herniation and the need for reoperation, bone-anchored annular closure technologies offer a clinically validated, economically prudent solution aligned with value-based care principles and durable, patient-centered success.
Introduction
Pain has traditionally served as the primary endpoint in the evaluation of clinical success following spine surgery for conditions such as lumbar disc herniation,1 but this focus does not always align with value-based care principles, which prioritize long-term functional recovery and reduced health care utilization.2
Lumbar discectomy, the most common surgical treatment for lumbar disc herniation,3 illustrates the disconnect between short-term pain relief and long-term structural repair. While discectomy effectively alleviates acute nerve compression and pain, it does not address the annular defect that predisposes patients to future complications. Revision surgeries for recurrent lumbar disc herniation are more technically challenging than the primary procedure and are associated with higher complication rates, inferior outcomes, and greater use of opioids and health care resources.4,5
A shift in spinal surgery outcome assessment that moves beyond short-term pain relief and instead prioritizes long-term health outcomes and efficient health care utilization is needed. Bone-anchored annular closure devices (ACDs) offer a promising approach to preventing reherniation. By providing a physical barrier at the site of the annular defect, these bone-anchored devices reduce the risk of nucleus pulposus extrusion, thereby lowering rates of reherniation and revision surgery and improving long-term patient outcomes.6,7 This technology aligns with the principles of value-based health care and more durable, preventive, patient-centered outcomes in lumbar spine surgery.
Literature Review
Redefining Pain: Beyond the Visual Analog Scale
Patient-reported outcomes such as the visual analog scale and the numerical rating scale are widely used to assess pain relief following discectomy; however, these tools do not adequately capture long-term outcomes that represent the multidimensional nature of recovery, such as quality of life, return to activity/work, and the need for subsequent surgeries.8 Particularly in high-risk surgical populations in whom positive outcomes may not correlate with pain, there may be better metrics to measure success, such as reherniation rates.9 Functional status provides a stable and objective indicator of clinical recovery. Instruments such as the Oswestry Disability Index, Patient-Reported Outcomes Measurement Information System physical function scores, and return-to-work timelines reflect the real-world impact of surgical intervention. By realigning outcomes, clinicians can better measure treatment success. Interventions that address the structural causes of symptoms may more effectively target long-term functional outcomes.
Annular Closure: Clinical Evidence of Risk Mitigation
Lumbar disc herniation is a degenerative condition in which the nucleus pulposus of the intervertebral disc protrudes through a tear in the outer annulus fibrosus.10 This promotes inflammation of adjacent lumbosacral nerve roots and can compress nearby nerves, causing symptoms such as pain, paresthesias, and/or motor deficits. Left untreated, this can result in weakness and permanent disability.11,12 Spinal surgery is indicated when patients experience recalcitrant, progressive, and/or severe symptoms that resist conservative measures.3 While discectomies decompress neural elements, the procedure can also enlarge the annular defect, increasing the risk of reherniation.13,14 Approximately 30% of patients undergoing lumbar discectomy present with large annular defects (≥6 mm), which are associated with more than double the risk of reherniation compared with those with smaller defects.15
The Barricaid (Intrinsic Therapeutics, Woburn, MA) was developed to address this biomechanical vulnerability. The implant consists of a woven polymer occlusion membrane anchored to the adjacent vertebral body via a titanium bone anchor. After discectomy, the device is inserted into the annular defect to reduce the risk of further nucleus extrusion while allowing natural disc healing. This intervention aims to restore the integrity of the disc space, maintain disc height, and preserve segmental biomechanics, which reduces the likelihood of collapse or progression of degenerative changes.
Randomized controlled trials and real-world observational data have demonstrated the effectiveness of using a bone-anchored ACD in high-risk populations.16–18 Compared with discectomy alone, addition of an ACD has consistently shown more than 50% reduction in symptomatic reherniation and reoperation; maintenance of disc height and segmental stability; improved patient satisfaction and functional recovery; and preservation of quality-adjusted life year (QALY) over more than 5 years postoperatively, reflecting durable benefit.
These benefits are particularly compelling when evaluating return-to-function outcomes. Patients receiving ACDs report faster return-to-work, fewer opioid prescriptions, and more favorable Oswestry Disability Index and Patient-Reported Outcomes Measurement Information System scores at long-term follow-up compared with discectomy-only cohorts.16,19–22 These results illustrate a shift from symptomatic palliation to structural restoration, which is more aligned with modern value-based health care.
Despite this favorable evidence base, ACDs are not without limitations. Implant-related complications, such as endplate changes, have been reported, though at low incidence rates, and have not been found to be clinically significant.23,24 Additionally, regulatory hurdles and payor skepticism, often rooted in outdated pain-centric approval frameworks, continue to limit widespread adoption.6 While discectomies performed with the addition of bone-anchored ACDs reduce pain similarly to discectomies performed without, symptomatic reherniation and the need for reoperation are significantly reduced compared with discectomy alone.9
Health Care Burden, Cost-Effectiveness, and Policy Alignment
Spine-related conditions account for more than $86 billion in annual health care spending in the United States.25 Recurrent lumbar disc herniation and its management represent an estimated 2% to 7% of that cost, with more than 25,000 spinal reoperations undertaken in any 2-year period.6 Reherniation occurs in 5% to 18% of patients following discectomy, with rates markedly higher among those with large annular defects.13 These high-risk patients often require more complex revision procedures. Revision surgery is more technically demanding, with higher complication rates and lower clinical outcomes, while placing a larger burden on the health care system. Additionally, more than half of reoperations involve spinal fusion, which further increases clinical risk and worsens patient outcomes.26 The diagnosis and management of recurrent disc herniation costs upward of $30,000 per patient.14,27,28 Beyond direct procedural costs, reoperation contributes to substantial indirect burdens, including missed work, diminished quality of life, and long-term opioid reliance.29,30
Bone-anchored ACDs offer a clinically and economically sound strategy to reduce these burdens.28,31 By reinforcing structural integrity at the annular defect, ACDs significantly lower reherniation and reoperation rates in high-risk patients.32 Clinical studies have shown that discectomy augmented with annular closure can reduce 90-day postoperative costs by $687 to $1,156 per patient,32 while longer-term economic models demonstrate cost neutrality or savings over 2 to 5 years in high-risk populations.18,33 One analysis calculated a cost-effectiveness ratio of $6030 per QALY,18 well below the commonly accepted willingness-to-pay threshold of $50,000 per QALY. Another analysis showed a negative incremental cost-effectiveness ratio when accounting for societal costs, indicating superior outcomes at lower total cost.33 Patients treated with bone-anchored ACDs experienced fewer complications, fewer opioid prescriptions, and greater functional gains, with a cost of $2076 less per patient in total indirect costs.33
Discussion
The evolving focus of value-based care necessitates a redefinition of success in spine surgery, particularly for lumbar disc herniation. While short-term pain relief has long been a dominant outcome measure, it does not account for recurrent herniation and escalating downstream health care costs. As highlighted in this article, preventing reherniation through a bone-anchored annular defect closure device is a move toward interventions that prioritize structural preservation and sustained functional recovery.
The evidence supporting annular closure is compelling. Both randomized controlled trials and real-world data show significant reductions in symptomatic reherniation and reoperation, preservation of disc height, and improvements in patient-reported function. These outcomes align directly with payor priorities: fewer complications, reduced need for high-cost revision procedures, and lower opioid reliance. The cost-effectiveness of bone-anchored annular closure, particularly in high-risk patients with large annular defects, suggests that broader adoption could contribute to systemic savings without compromising quality of care.
A significant barrier to adoption is the malalignment between regulatory and reimbursement frameworks, which can prioritize short-term pain metrics and offer limited support for preventive strategies. Despite a well-defined clinical indication and US Food and Drug Administration premarket approval, widespread adoption of annular closure remains hampered by reimbursement models that undervalue prevention of reoperation. This disconnect mirrors challenges seen in other surgical domains, such as ACL repair, where restoring function is the primary goal. A step in the right direction would be for payors to update evaluation criteria to incorporate risk stratification based on defect size. Such a change would create an opportunity to support more sustainable care by incorporating bone-anchored ACDs into bundled payment models and risk-adjusted pathways. Tools already exist to identify high-risk patients intraoperatively, offering a precision medicine approach that can be seamlessly integrated into current surgical workflows.
Future research should focus on long-term outcomes beyond 2 years to reinforce the durability of annular closure, as well as real-world implementation studies assessing cost and care efficiencies at the system level. Comparative effectiveness research against other reoperation mitigation strategies (eg, fusion, biologics, and extended rehabilitation) may further clarify the role of annular closure in comprehensive spine care models. Policy efforts should explore bundled payment or value-based incentive structures that reward risk-reducing technologies and improve access for appropriately selected patients.
Ultimately, the integration of annular closure into standard discectomy protocols for high-risk populations is not only clinically justified but economically prudent. Redefining surgical success through the lens of long-term consideration and health care utilization aligns with payor objectives and presents an actionable opportunity to enhance outcomes across the care continuum.
Conclusion
In the era of value-based care, redefining surgical success in lumbar disc herniation requires moving beyond short-term pain relief and instead promoting interventions that prioritize long-term health care efficiency. Annular closure technologies such as Barricaid represent a clinically validated and economically sound strategy to prevent reherniation in high-risk patients with large annular defects. Clinical evidence demonstrates reduced reoperation rates, improved functional outcomes, and meaningful cost savings, including lower reliance on opioids and fewer downstream interventions. Yet, despite US Food and Drug Administration approval and demonstrated value, adoption remains limited. To align with payor priorities, policy innovation is needed to support preventive, function-preserving technologies through risk-based reimbursement pathways and bundled payment models. Broader integration of annular closure into surgical protocols is not only supported by clinical and economic data but also represents a practical, high-impact opportunity to improve patient outcomes and reduce the overall burden on the health care system.
Footnotes
Funding Medical writing (Laura C. Shum) support was provided by Intrinsic Therapeutics.
Declaration of Conflicting Interests Parker Babington reports consulting fees from Intrinsic Therapeutics (bone-anchored annular closure) and travel support for Barricaid symposium. Jason Zook reports royalties/licenses with Cutting Edge Spine, Globus Medical, and Accelus. K. Brandon Strenge reports royalties/licenses with ATEC, Zavation, K2M Stryker, Restor3d Inc, and Globus NuVasive; consulting fees from Intrinsic Therapeutics, ATEC, Expanding Innovations, OssDesign, Centinel, Kuros Biosciences, Globus NuVasive, Atlas, Bioventus, Spineart, Alafair, Elevation Spine, Medtronic, OsteoCentric, Providence Medical, and Highridge; and stock/stock options from ATEC, Restor3d Inc, and Expanding Innovations. Pierce Nunley reports grants/contracts from Globus, Centinel Spine, Providence Medical, 3Spine, and SAIL Fusion; royalties/licenses from Stryker, High Ridge, Camber Spine, Accelus, Spineology, Spinal Elements, NG Medical, and Nevro; consulting fees from Spineology, Camber Spine, Accelus, Centinel Spine, Intrinsic Therapeutics, Providence Medical, Spinal Elements, NG Medical, Regeltec, 3Spine, Redrock, SAIL Fusion, SST, Medical Metrics, SeeALL, Nevro, and Discure; and payment/honoraria from Camber Spine, Accelus, Providence Medical, Neo Spine, and Medical Metrics. Juliette Beristain reports consulting fees for Intrinsic (bone-anchored annular closure) and support for attending meetings and/or travel from Barricaid/Intrinsic. Marcus Stone reports consulting fees from 3Spine, Bioventus, Kuros Biosciences BV, NuVasive, Ossifi, Providence Medical Technology, and Spinal Stabilization Technologies. Laura C. Shum reports consulting fees from Intrinsic and stock/stock options in Orthopediatrics. Michael Musacchio reports payment/honoraria for serving on the speakers bureaus for Intrinsic Therapeutics and Medtronic.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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