What’s a More Cost Effective Treatment for Cervical Radiculopathy: Epidural Injections or Surgery?

31st Annual Meeting of the North American Spine Society Highlights

Though cervical radiculopathy is a common spinal problem, most acute cases improve within six weeks using conservative treatment. However, some patients have persistent symptoms that don’t respond to such therapies. At this point, patients and providers must decide whether to proceed with more invasive nonoperative treatments or perform surgery. To shed light on this clinical decision making, Jeffrey A. Rihn, MD presented the results of a study comparing the cost effectiveness of epidural injections to anterior cervical discectomy and fusion (ACDF) at the 31st Annual Meeting of the North American Spine Society, October 26-29, in Boston.  

Referring to neck pain and radicular pain as “one of the greatest burdens of disease in the American population,” Dr. Rihn said the goal of this study was to evaluate the cost effectiveness of surgery versus nonoperative management for treating cervical radiculopathy. It’s unclear in current literature whether either of these approaches is a better choice from both clinical and cost perspectives.

cost effective circular symbolThe researchers used Medicare payment data to estimate direct costs, and they estimated private payor data using a conversion factor of the Medicare data.A Look at the Study
Researchers evaluated a cohort of patients aged 18 to 84 who had persistent cervical radiculopathy despite six weeks of conservative treatment. The cohort was broken into two groups: One group was treated with ACDF, and the other group had cervical epidural injections and physical therapy. The average patient age was 55 across the two groups.

The authors used a Markov chain decision tree model to analyze the results, and they obtained the transition probabilities for the model as well as the quality-adjusted life years (QALYs) for the various health states in the literature. Outcomes, reoperation rates, and complication rates were also obtained from the literature.

The researchers used Medicare payment data to estimate direct costs, and they estimated private payor data using a conversion factor of the Medicare data. Indirect costs were estimated using a wages lost model.

“The [Markov] model was analyzed with Monte Carlo simulation with 10,000 unique iterations,” said Dr. Rihn, who practices spine surgery at The Rothman Institute in Philadelphia. “The results were extrapolated to the at-risk population of the United States, and a sensitivity analysis was performed.”

The team performed a probabilistic sensitivity analysis in which all factors in their model were varied independently, including all probabilities and outcomes.

ACDF is the Dominant Cost-Effective Strategy
The results of the base case analysis found that ACDF for cervical radiculopathy was the dominant strategy, as it provided increased QALYs at a cheaper cost compared to epidural injections and physical therapy.

Lifetime per case direct cost of ACDF was $24,181 versus $26,503 for epidural injections and physical therapy. QALYs gained were 3.54 for ACDF and 3.22 for the nonoperative treatments. Total cost per QALY was $11,274 for ACDF and $13,103 for the epidural injections and physical therapy.

The team varied the follow-up time periods at which cost effectiveness was calculated—the cohort follow-ups were at four years, 10 years, and the total lifetime of the cohort (approximately 27 years). ACDF was identified as the dominant strategy as early as the four-year follow up.

“The surgical intervention is associated, in general, with increased qualities and lower associated costs, whereas the nonoperative strategy has slightly higher associated costs and lower qualities,” Dr. Rihn said. “Also, it should be noted that both these treatment strategies tend to fall to the right of the $50,000 [QALY] threshold line, suggesting they are both cost effective.”

Applying the Findings
Both epidural injections/physical therapy and ACDF surgery are cost effective against the $50,000 QALYs threshold in patients whose persistent symptoms did not respond to six weeks of conservative treatment. However, ACDF was the dominant cost-effective strategy in managing cervical radiculopathy. These results suggest that requiring a more invasive nonoperative treatment, such as cervical epidural injections, before considering surgery may not be the appropriate approach from a cost and quality standpoint.

To view additional meeting highlights from the 31st Annual Meeting of NASS, click here.

Updated on: 02/28/18
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