Revisiting the Posterior Approach for Cervical Radiculopathy Utilizing Endoscopic Techniques: A Favorable Short-Term Outcome and Cost Comparison With Anterior Cervical Discectomy and Fusion

Abstract

Background: Cervical radiculopathy is a spine ailment frequently requiring surgical decompression via anterior cervical discectomy and fusion (ACDF) or posterior foraminotomy/discectomy. While endoscopic posterior foraminotomy/discectomy is gaining popularity, its financial impact remains understudied despite equivalent randomized long-term outcomes to ACDF. In a cohort of patients undergoing ACDF vs endoscopic posterior cervical foraminotomy/discectomy, we sought to compare the total cost of the surgical episode while confirming an equivalent safety profile and perioperative outcomes.

Methods: A single-center retrospective cohort study of patients with unilateral cervical radiculopathy undergoing ACDF or endoscopic cervical foraminotomy between 2018 and 2023 was undertaken. Primary outcomes included the total cost of care for the initial surgical episode (not charges or reimbursement). Perioperative variables and neurological recovery were recorded. Multivariable analysis tested age, body mass index, race, gender, insurance type, operative time, and length of stay.

Results: A total of 38 ACDF and 17 endoscopic foraminotomy/discectomy operations were performed. All patients underwent single-level surgery except for 2 two-level endoscopic decompressions. No differences were found in baseline characteristics and symptom length except for younger age (46.8 ± 9.4 vs 57.6 ± 10.3, P = 0.002) and more smokers (18.4% vs 11.8%, P = 0.043) in the ACDF group. Actual hospital costs for the episode of surgical care were markedly higher in the ACDF cohort (mean ±95% CI; $27,782 ± $2011 vs $10,103 ± $720, P < 0.001) driven by the ACDF approach (β = $17,723, P < 0.001) on multivariable analysis. On sensitivity analysis, ACDF was never cost-efficient compared with endoscopic foraminotomy, and endoscopic failure rates of 64% were required for break-even cost. ACDF was associated with significantly longer operative time (167.7 ± 22.0 vs 142.7 ± 27.4 minutes, P < 0.001) and length of stay (1.1 ± 0.5 vs 0.1 ± 0.2 days, P < 0.001). No significant difference was found regarding 90-day neurological improvement, readmission, reoperation, or complications.

Conclusion: Compared with patients treated with a single-level ACDF for unilateral cervical radiculopathy, endoscopic posterior cervical foraminotomy/discectomy can achieve a similar safety profile, pain relief, and neurological recovery at considerably less cost. These findings may help patients and surgeons revisit offering the posterior cervical foraminotomy/discectomy utilizing endoscopic techniques.

Clinical relevance: Endoscopic posterior cervical foraminotomy/discectomy offers comparable safety, pain relief, and neurological recovery to traditional methods but at a significantly lower cost.

Keywords: ACDF; cost; endoscopic; foraminotomy; minimally invasive; open; outcomes.

Figure 1

A 44-year-old man with several months of worsening left C7 radiculopathy despite conservative management was found to have large paramedian C6–C7 disc rupture seen on parasagittal (A) and axial magnetic resonance imaging (B). The patient underwent a right-side anterior cervical discectomy and fusion with structural allograft (C and D) followed by complete resolution of his radicular symptoms 5 weeks after the operation.

Figure 2

A 46-year-old man with a history of fibromyalgia and postural orthostatic tachycardia syndrome presented with 10 months of left C7 distribution radiculopathy with left triceps and wrist extension weakness despite conservative management. Preoperative imaging showing bony left C6–C7 foraminal stenosis due to uncovertebral joint hypertrophy on sagittal oblique and axial cervical spine computed tomography (A and B) with concomitant stenosis from a C6–C7 paracentral disc bulge on axial and sagittal oblique magnetic resonance imaging (C and D). The patient underwent full endoscopic left C6–C7 posterior foraminotomy (E) with subsequent improvement in C7 radicular pain and full motor recovery at 90 days postoperatively.

Figure 3

Total initial anterior cervical discectomy and fusion (ACDF) vs endoscopic foraminotomy cost (mean ± 95% CI total surgical costs for each cohort).

Figure 4

Sensitivity analysis of anterior cervical discectomy and fusion (ACDF) vs endoscopic foraminotomy shows the potential impact of surgical costs and revision rates on overall cost differences between ACDF and endoscopic cervical foraminotomy ($0 on X-axis). No input variability brought ACDF costs below endoscopic cervical foraminotomy costs. Median surgical costs were used as base values with variation between the highest (gray) and lowest (black) studied costs in each variable. Revision rate base values was the percentage of each cohort undergoing revision surgery with variation tested at ±10 absolute percentage points. For sensitivity analysis, all surgical failures were eventually assumed to undergo ACDF revision. Modeled incremental cost after including revision rates was higher for ACDF (+$16,743 [$28,557 ACDF vs $11,814 endoscopic foraminotomy/discectomy]).

Figure 5

Break-even analysis. Univariate sensitivity analysis testing endoscopic cervical foraminotomy failure rates (x axis) against the total cost of surgical care (y axis, including revisions), showed that break-even costs between initial ACDF and endoscopic foraminotomy occurred at a 64% endoscopic foraminotomy failure rate (solid gray line, x axis). Analysis assumes no ACDF failures and that every endoscopic foraminotomy failure was ultimately treated with an ACDF. Dashed gray lines show the currently observed endoscopic foraminotomy failure rate (x axis, 5.9%) and the corresponding modeled weighted-average total endoscopic foraminotomy cost including revisions with ACDF after failure ($11,814).