• Matthew D Alvin, Daniel Lubelski, Kalil G Abdullah, Robert G Whitmore, Edward C Benzel, and Thomas E Mroz.
• *Departments of Orthopaedic and Neurological Surgery, Neurological Institute, Cleveland Clinic Center for Spine Health, Cleveland Clinic†Case Western Reserve University School of Medicine‡Cleveland Clinic Lerner College of Medicine, Cleveland, OH§Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA∥Department of Neurological Surgery, Cleveland Clinic, Cleveland, OH.
• J Spinal Disord Tech. 2016 Mar 1; 29 (2): E80-6.

Study DesignRetrospective 1-year cost-utility analysis.ObjectiveTo determine the cost-effectiveness of decompression with and without instrumented fusion for patients with grade I degenerative L4-L5 spondylolisthesis at 1-year follow-up.Summary Of Background DataDespite its benefits to health outcomes, lumbar fusion is associated with substantial costs. This study analyzed the cost-effectiveness of instrumented fusion for grade I L4-L5 spondylolisthesis at 1-year follow-up.Materials And MethodsFour cohorts of 25 patients with grade I L4-L5 degenerative spondylolisthesis were analyzed: cohort 1 (decompression), cohort 2 (decompression with instrumented posterolateral fusion (PLF), cohort 3 (decompression with instrumented posterior lumbar interbody fusion/transforaminal lumbar interbody fusion), and cohort 4 (decompression with instrumented PLF and posterior lumbar interbody fusion/transforaminal lumbar interbody fusion). One-year postoperative health outcomes were assessed based on Visual Analogue Scale, Pain Disability Questionnaire, and EuroQol 5 Dimensions questionnaires. Direct medical costs were estimated using Medicare national payment amounts and indirect costs were based on patient missed work days. Postoperative 1-year cost/utility ratios and incremental cost-effectiveness ratios (ICERs) were calculated. Cost-effectiveness was assessed using a threshold of $100,000/QALY gained.ResultsCompared with preoperative health states, EuroQol 5 Dimensions QALY scores improved for all cohorts (P<0.01). The 1-year cost-utility ratio for cohort 1 was significantly lower ($56,610/QALY gained; P<0.01) than that for cohorts 2 ($116,991/QALY gained), 3 ($109,740/QALY gained), and 4 ($107,546/QALY gained). The 1-year ICERs relative to cohort 1 were: cohort 2 (dominated), cohort 3 ($1,060,549/QALY gained), and cohort 4 ($830,047/QALY gained).ConclusionsDecompression without fusion is cost-effective for patients with grade I L4-L5 spondylolisthesis. Decompression with fusion is not cost effective in a 1-year timeframe for these patients based on the threshold. Accordingly, although fusion is beneficial for improving health outcomes in patients with spondylolisthesis, it is not cost-effective when analyzing a 1-year timeframe based on the threshold. The durability of these results must be analyzed with longer term cost-utility analysis studies.

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