Cost-Effectiveness of Anterior Cervical Discectomy vs Fusion Versus Cervical Disc Arthroplasty Interview with:

Dr. Samuel Cho, MD Associate Professor of Orthopaedics Icahn School of Medicine at Mount Sinai  

Dr. Cho

Dr. Samuel Cho, MD
Associate Professor of Orthopaedics
Icahn School of Medicine at Mount Sinai What is the background for this study? What are the main findings?

Response: Anterior cervical discectomy and fusion (ACDF), first implemented in 1957, has been considered the “gold standard” for decades for the treatment of cervical degenerative disc disease after conservative options have been exhausted.

For patients presenting with neck and radiating arm pain, motor weakness, and sensory loss due to cervical disc herniation or compressive pathologies, ACDF has been shown to be generally well-tolerated and associated with a high clinical success rate. Despite the proven long-term radiographic and clinical success of ACDF, however, our literature has shown the procedure to be associated with certain drawbacks including neurological complications, rapid development of adjacent segment disease, and decreased range of motion owing to solid bony arthrodesis. More recently, cervical disc replacement (CDR) has also become an acceptable surgical option for similar cervical spine pathologies as ACDF. CDR was developed as a motion-sparing alternative to ACDF with purported advantages including minimization of adjacent segment disease and obviation of pseudoarthrosis.

Multiple large investigational device exemption (IDE) studies showing the non-inferiority of cervical disc replacement, the cost-effectiveness of this procedure has increasingly become a topic of interest. For this reason, we sought to determine the seven-year cost-effectiveness of single level ACDF versus CDR for the treatment of cervical disc degeneration. What should readers take away from your report?

  1. Based on a Markov model analysis of the LDR Mobi-C Investigational Device Exemption (IDE) study, anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) were both found to be cost-effective strategies for treating degenerative disc disease at 7 years following surgery. –
  2. However, cervical disc replacement was the more cost-effective strategy with an incremental cost-effectiveness ratio (ICER) less than the $50,000/quality-adjusted life year (QALY) willingness-to-pay threshold. –
  3. Further long-term studies >10 years are needed to evaluate clinical and quality of life outcomes in order to validate the findings of this model, as adjacent segment disease and other postoperative complications may occur later than 7 years following surgery. What recommendations do you have for future research as a result of this work?

Response: Cost-effectiveness analysis (CEA) of ACDF and CDR at seven years after surgery has demonstrated that CDR may be the preferred treatment option. However, as complications following cervical disc replacement may occur greater than seven years following operation, analysis of longer term follow up data is necessary.

Long term studies >10 years will be needed to re-evaluate clinical and quality of life outcomes between the two groups. Further follow up is needed into the rate of failure per annum for CDR as this could greatly impact cost effective analyses in future studies. This is because the ICER can be sensitive to revision surgery rates and complication rates.

Citations: AAOS March 2018

 The Seven Year Cost-Effectiveness of Anterior Cervical Discectomy and Fusion Versus Cervical Disc Arthroplasty 

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