Evaluating Outcomes and Costs of Surgical vs. Non-surgical Treatment for Spinal Stenosis
A study published online ahead of print by The Journal of Bone & Joint Surgery suggests that for patients with spinal stenosis, operative treatment is associated with a lower risk of death and lower costs over 2 years compared with non-operative treatment.
This study, from New England Baptist Hospital and the Health Data Analytics Institute, is one of the first to directly compare the outcomes and costs of operative treatment (eg, laminectomy to decompress the spinal canal, spinal fusion to stabilize the spine, or a combination of both) and non-operative treatment (eg, medications, steroid injections, physical therapy) for patients with spinal stenosis.
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Prior research has shown that spine surgery is cost-effective in reducing pain and restoring function. Many patients, in fact, experience improved quality of life and mobility following surgery, which might promote general health and thus lead to a reduced risk of death.
“However, the effect of spine surgery relative to nonsurgical management on these important outcomes has not been well described,” the study authors said.
Study Methods and Findings
For this study, the researchers analyzed data on more than 145,000 Medicare patients with either spinal stenosis alone (n=61,534) or stenosis and spondylolisthesis (n=83,813):
- 37% of patients with stenosis alone underwent surgery, with the most common procedure being laminectomy
- 52% of patients with stenosis and spondylolisthesis underwent surgery, with the most common procedures being spinal fusion
Operative and non-operative patients were matched for demographic characteristics and health status based on the Risk Stratification Index. Predicted mortality rates were similar between the groups, indicating that they were well matched.
In most comparisons, however, the actual 2-year mortality risk was higher in the non-operative group:
- Among patients with stenosis alone, mortality rates were 3.7% for non-operative treatment versus 2.5% for laminectomy, as assessed in matched cohorts.
- For patients with stenosis and spondylolisthesis, mortality rates were 2.3% for non-operative treatment versus 1.3% for laminectomy and fusion.
- In adjusted analyses, the relative risk of death was 28% lower in operatively managed patients.
Non-operatively treated patients tended to require more healthcare, including more pain medication, magnetic resonance imaging scans, and physical therapy, than operatively treated patients.
- Among patients with spinal stenosis and spondylolisthesis, Medicare costs were lower with surgical treatment, with the average 2-year costs at $47,667 for patients who underwent a laminectomy compared with $68,890 for non-operative management.
- Among patients with stenosis alone, costs were lower in those who underwent laminectomy compared with non-operative treatment: $34,998 versus $59,071, respectively. Costs were higher, however, in patients who underwent spinal fusion compared with non-operative treatment: $67,451 versus $60,540, respectively
Mortality was similar for patients undergoing combined fusion and laminectomy, compared with either procedure alone. “However,” the researchers said, “laminectomy alone was associated with significantly lower 2-year payments when treating stenosis with or without spondylolisthesis.”
Increased Number of Surgeries
The study provides new evidence linking spine surgery to lower mortality and lower costs among Medicare patients with spinal stenosis. For those without spondylolisthesis, costs are lower with laminectomy and higher with fusion. The researchers noted limitations of their study, including the possible effects of unrecognized confounding factors.
These findings may have important implications for clinical practice, especially considering recent increases in the use and costs of lumbar fusion surgery. Based on the observed mortality and cost reductions, “[t]he current study suggests that this trend may be justified within the Medicare population” for well-selected patients, the researchers concluded.
Hwant RW, Briggs CM, Greenwald SD, Manberg PJ, Chamoun NG, Tromanhauser SG. Surgical treatment of single-level lumbar stenosis is associated with lower 2-year mortality and total cost compared with nonsurgical treatment: a risk-adjusted, paired analysis. J Bone Joint Surg Am. January 12, 2023. doi: 10.2106/JBJS.22.00181. Online ahead of print