Cost-effectiveness of microdiscectomy versus endoscopic discectomy for lumbar disc herniation

ABSTRACT

BACKGROUND CONTEXT

Microdiscectomy is a standard technique for the surgical treatment of lumbar disc herniation (LDH). Endoscopic discectomy (ED) is another surgical option that has become popular owing to reports of shorter hospitalization and earlier return to work. No study has evaluated health care costs associated with lumbar discectomy techniques and compared cost-effectiveness.

PURPOSE

To assess the cost-effectiveness of four surgical techniques for LDH: microdiscectomy (MD), transforaminal endoscopic lumbar discectomy (TELD), interlaminar endoscopic lumbar discectomy (IELD), and unilateral biportal endoscopic discectomy (UBED).

STUDY DESIGN AND SETTING

Retrospective analysis.

PATIENT SAMPLE

Patients who underwent either MD or ED for primary LDH with 1-year follow-up between the ages of 20 and 60 years old.

OUTCOME MEASURES

Incremental cost-effectiveness ratio (ICER).

METHODS

Five hundred sixty-five patients aged 20–60 years who underwent treatment using one of the four surgical techniques with at least 1-year follow-up were reviewed. Health care costs were defined as the sum of direct and indirect costs. The former included the covered and uncovered costs of the National Health Insurance from operation to 1-year follow-up; indirect costs included costs incurred by work loss. Direct and indirect costs were evaluated separately. ICER was determined using cost/quality-adjusted life year (QALY). Health care costs and ICER were compared statistically among the four surgical groups. Cost-effectiveness was compared statistically between MD and ED.

RESULTS

One hundred fifty-seven patients who underwent TELD, 132 for IELD, 140 for UBED, and 136 for MD were enrolled. The direct costs of TELD, IELD, UBED, and MD were $3,452.2±1,211.5, $3,907.3±895.3, $4,049.2±1,134.6, and $4,302.1±1,028.9, respectively (p<.01). The indirect costs of TELD, IELD, UBED, and MD were $574.5±495.9, $587.8±488.3, $647.4±455.6, and $759.7±491.7, respectively (p<.01). The 1-year QALY gains were 0.208 for TELD, 0.211 for IELD, 0.194 for UBED, and 0.186 for MD. ICER (costs/QALY) was the highest for MD ($34,840.4±25,477.9, p<.01). Compared with MD, ED saved an additional net of $8,064 per QALY (p<.01). There was no significant difference in the ICERs among the three endoscopic techniques.

CONCLUSIONS

ED was more cost-effective compared with MD at 1-year follow up.

Introduction

Microdiscectomy is a standard technique for the surgical treatment of lumbar disc herniation. Since 1980 [1], different types of endoscopic discectomy, such as transforaminal endoscopic lumbar discectomy (TELD) and interlaminar endoscopic lumbar discectomy (IELD), have been introduced and evolved [1]. Unilateral biportal endoscopic discectomy (UBED) has been recently introduced using a two portal system, with one portal for the endoscope and another for the entry of surgical instruments, similar to joint arthroscopy [2], [3]. This technique, although not a full-endoscopic discectomy, combines the advantages of standard open and endoscopic spinal surgery. Endoscopic discectomy has become more popular with surgeons and patients as it is associated with lesser postoperative pain, shorter hospital stays and earlier returns to work [4], [5], [6]. No study has been conducted to evaluate health care costs associated with lumbar discectomy techniques and compare cost-effectiveness. The purpose of this study was to compare total hospital costs among microdiscectomy and three different endoscopic techniques and to analyze cost-effectiveness using the incremental cost-effectiveness ratio (ICER).