Daniel Lubelski1, Kathryn E Mihalovich, Andrea C Skelly, Michael G Fehlings, James S Harrop, Praveen V Mummaneni, Michael Y Wang, Michael P Steinmetz. 1. *Cleveland Clinic Lerner College of Medicine and Cleveland Clinic Center for Spine Health, Cleveland, OH †Spectrum Research, Inc., Tacoma, WA ‡Krembil Neuroscience Center, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada §Institutes of Medical Science, University of Toronto, University Health Network Toronto, Ontario, Canada ¶Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA ∥Department of Neurological Surgery, University of California, San Francisco **Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL; and ††Department of Neurological Surgery, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH.
Abstract
STUDY DESIGN: Systematic review. OBJECTIVE: To summarize and critically review the economic literature evaluating the cost-effectiveness of minimal access surgery (MAS) compared with conventional open procedures for the cervical and lumbar spine. SUMMARY OF BACKGROUND DATA: MAS techniques may improve perioperative parameters (length of hospital stay and extent of blood loss) compared with conventional open approaches. However, some have questioned the clinical efficacy of these differences and the associated cost-effectiveness implications. When considering the long-term outcomes, there seem to be no significant differences between MAS and open surgery. METHODS: PubMed, EMBASE, the Cochrane Collaboration database, University of York, Centre for Reviews and Dissemination (NHS-EED and HTA), and the Tufts CEA Registry were reviewed to identify full economic studies comparing MAS with open techniques prior to December 24, 2013, based on the key questions established a priori. Only economic studies that evaluated and synthesized the costs and consequences of MAS compared with conventional open procedures (i.e., cost-minimization, cost-benefit, cost-effectiveness, or cost-utility) were considered for inclusion. Full text of the articles meeting inclusion criteria were reviewed by 2 independent investigators to obtain the final collection of included studies. The Quality of Health Economic Studies instrument was scored by 2 independent reviewers to provide an initial basis for critical appraisal of included economic studies. RESULTS: The search strategy yielded 198 potentially relevant citations, and 6 studies met the inclusion criteria, evaluating the costs and consequences of MAS versus conventional open procedures performed for the lumbar spine; no studies for the cervical spine met the inclusion criteria. Studies compared MAS tubular discectomy with conventional microdiscectomy, minimal access transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion, and multilevel hemilaminectomy via MAS versus open approach. CONCLUSION: Overall, the included cost-effectiveness studies generally supported no significant differences between open surgery and MAS lumbar approaches. However, these conclusions are preliminary because there was a paucity of high-quality evidence. Much of the evidence lacked details on methodology for modeling, related assumptions, justification of economic model chosen, and sources and types of included costs and consequences. The follow-up periods were highly variable, indirect costs were not frequently analyzed or reported, and many of the studies were conducted by a single group, thereby limiting generalizability. Prospective studies are needed to define differences and optimal treatment algorithms. LEVEL OF EVIDENCE: 3.
STUDY DESIGN: Systematic review. OBJECTIVE: To summarize and critically review the economic literature evaluating the cost-effectiveness of minimal access surgery (MAS) compared with conventional open procedures for the cervical and lumbar spine. SUMMARY OF BACKGROUND DATA: MAS techniques may improve perioperative parameters (length of hospital stay and extent of blood loss) compared with conventional open approaches. However, some have questioned the clinical efficacy of these differences and the associated cost-effectiveness implications. When considering the long-term outcomes, there seem to be no significant differences between MAS and open surgery. METHODS: PubMed, EMBASE, the Cochrane Collaboration database, University of York, Centre for Reviews and Dissemination (NHS-EED and HTA), and the Tufts CEA Registry were reviewed to identify full economic studies comparing MAS with open techniques prior to December 24, 2013, based on the key questions established a priori. Only economic studies that evaluated and synthesized the costs and consequences of MAS compared with conventional open procedures (i.e., cost-minimization, cost-benefit, cost-effectiveness, or cost-utility) were considered for inclusion. Full text of the articles meeting inclusion criteria were reviewed by 2 independent investigators to obtain the final collection of included studies. The Quality of Health Economic Studies instrument was scored by 2 independent reviewers to provide an initial basis for critical appraisal of included economic studies. RESULTS: The search strategy yielded 198 potentially relevant citations, and 6 studies met the inclusion criteria, evaluating the costs and consequences of MAS versus conventional open procedures performed for the lumbar spine; no studies for the cervical spine met the inclusion criteria. Studies compared MAS tubular discectomy with conventional microdiscectomy, minimal access transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion, and multilevel hemilaminectomy via MAS versus open approach. CONCLUSION: Overall, the included cost-effectiveness studies generally supported no significant differences between open surgery and MAS lumbar approaches. However, these conclusions are preliminary because there was a paucity of high-quality evidence. Much of the evidence lacked details on methodology for modeling, related assumptions, justification of economic model chosen, and sources and types of included costs and consequences. The follow-up periods were highly variable, indirect costs were not frequently analyzed or reported, and many of the studies were conducted by a single group, thereby limiting generalizability. Prospective studies are needed to define differences and optimal treatment algorithms. LEVEL OF EVIDENCE: 3.
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