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Randomized Controlled Trial
. 2024 Aug;33(8):3087-3098.
doi: 10.1007/s00586-024-08340-4. Epub 2024 Jun 7.

Cost-effectiveness of posterior versus anterior surgery for cervical radiculopathy: results from a multicentre randomised non-inferiority trial (FACET)

A E H Broekema  1 , N F Simões de Souza  2 , R J M Groen  2 , R Soer  3   4 , M F Reneman  5 , J M A Kuijlen  2 , A D I van Asselt  6   7 ; FACET investigators
Affiliations
Randomized Controlled Trial

Cost-effectiveness of posterior versus anterior surgery for cervical radiculopathy: results from a multicentre randomised non-inferiority trial (FACET)

A E H Broekema et al. Eur Spine J. 2024 Aug.

Abstract

Purpose: For cervical nerve root compression, anterior cervical discectomy with fusion (anterior surgery) or posterior foraminotomy (posterior surgery) are safe and effective options. Posterior surgery might have a more beneficial economic profile compared to anterior surgery. The purpose of this study was to analyse if posterior surgery is cost-effective compared to anterior surgery.

Methods: An economic evaluation was performed as part of a multicentre, noninferiority randomised clinical trial (Foraminotomy ACDF Cost-effectiveness Trial) with a follow-up of 2 years. Primary outcomes were cost-effectiveness based on arm pain (Visual Analogue Scale (VAS; 0-100)) and cost-utility (quality adjusted life years (QALYs)). Missing values were estimated with multiple imputations and bootstrap simulations were used to obtain confidence intervals (CIs).

Results: In total, 265 patients were randomised and 243 included in the analyses. The pooled mean decrease in VAS arm at 2-year follow-up was 44.2 in the posterior and 40.0 in the anterior group (mean difference, 4.2; 95% CI, - 4.7 to 12.9). Pooled mean QALYs were 1.58 (posterior) and 1.56 (anterior) (mean difference, 0.02; 95% CI, - 0.05 to 0.08). Societal costs were €28,046 for posterior and €30,086 for the anterior group, with lower health care costs for posterior (€12,248) versus anterior (€16,055). Bootstrapped results demonstrated similar effectiveness between groups with in general lower costs associated with posterior surgery.

Conclusion: In patients with cervical radiculopathy, arm pain and QALYs were similar between posterior and anterior surgery. Posterior surgery was associated with lower costs and is therefore likely to be cost-effective compared with anterior surgery.

Keywords: Anterior cervical discectomy and fusion; Cervical radiculopathy; Cost-effectiveness; Health economics; Posterior cervical foraminotomy; Randomised controlled trial.

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Conflict of interest statement

AEH Broekema, NF Simões de Souza and ADI van Asselt received financial support from the FACET Grant. No other conflicts of interests that are relevant to the content of this paper were reported.

Figures

Fig. 1
Fig. 1
Flow-chart of randomised patients, their primary treatment and follow-up status. Abbreviations: Visual Analogue Scale (VAS) for arm pain, EuroQol 5-Dimensions 5-Level questionnaire (EQ-5D-5L), Participants received web-based questionnaires (assessing patient reported outcome measures, medical consumption and productivity loss) 6 weeks after surgery and every six months until 2 years after surgery
Fig. 2
Fig. 2
Incremental Cost-Effectiveness Planes. a Incremental Cost-Effectiveness Plane for Cost Difference versus Arm Pain from a Societal Perspective. b Incremental Cost-Effectiveness Plane for Cost Difference versus Arm Pain from a Health Care Perspective. c Incremental Cost-Effectiveness Plane for Cost Difference versus Quality Adjusted Life Years gained from a Societal Perspective. d Incremental Cost-Effectiveness Plane for Cost Difference versus Quality Adjusted Life Years gained from a Health Care Perspective. Abbreviations: Multiple imputation sets (MI)
Fig. 2
Fig. 2
Incremental Cost-Effectiveness Planes. a Incremental Cost-Effectiveness Plane for Cost Difference versus Arm Pain from a Societal Perspective. b Incremental Cost-Effectiveness Plane for Cost Difference versus Arm Pain from a Health Care Perspective. c Incremental Cost-Effectiveness Plane for Cost Difference versus Quality Adjusted Life Years gained from a Societal Perspective. d Incremental Cost-Effectiveness Plane for Cost Difference versus Quality Adjusted Life Years gained from a Health Care Perspective. Abbreviations: Multiple imputation sets (MI)
Fig. 3
Fig. 3
Cost-Effectiveness Acceptability Curves for the Posterior versus Anterior Group. a Cost-Effectiveness Acceptability Curve for the Posterior versus Anterior Group from a Societal Perspective. b Cost-Effectiveness Acceptability Curve for the Posterior versus Anterior Group from a Health Care Perspective. Abbreviations: Multiple imputation sets (MI), Incremental Cost-Effectiveness Ratio (ICER), Quality Adjusted Life Year (QALY)
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References

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