The Economics of Minimally Invasive Spine Surgery The Value Perspective

Study Design. Review of the literature. Objective. To summarize current cost and clinical efficacy data in minimally invasive spine (MIS) surgery. Summary of Background Data. Cost effectiveness (CE), using cost per quality-adjusted life-years gained, has been shown for lumbar discectomy, decompressive laminectomy, and for instrumented and noninstrumented lumbar fusions in several high-quality studies using conventional, open surgical procedures. Currently, comparisons of costs and clinical outcomes of MIS surgery to open (or nonoperative) approaches are rare and of lesser quality, but suggest that a potential for cost benefits exist using less-invasive surgical approaches. Methods. A literature review was performed using the database of the National Center for Biotechnology Information (NCBI), PUBMED/Medline. Results. Reports of clinical results of MIS approaches are far more common than economic evaluations. MIS techniques can be classified as endoscopic or nonendoscopic. Although endoscopic approaches decrease some approach morbidities, the high cost of instrumentation, steep learning curves, and new complication profiles introduced have prevented widespread adoption. Additionally, the high costs have not been shown to be justified by superior clinical benefits. Nonendoscopic MIS approaches, such as percutaneous posterior or lateral, and mini-open lateral and anterior approaches, use direct visualization, standard operative techniques, and report lower complication rates, reduced length of stay, and faster recovery time. For newer MIS and mini-open techniques, significantly lower acute and subacute costs were observed compared with open techniques, mainly due to lower rates of complications, shorter length of stay, and less blood loss, as well as fewer discharges to rehab. Although this suggests that certain MIS procedures produce early cost benefits, the quality of the existing data are low. Conclusion. Although the CE of MIS surgery is yet to be carefully studied, the few economic studies that do exist suggest that MIS has the potential to be a cost-effective intervention, but only if improved clinical outcomes are maintained (durable). Longer follow-up and better outcome and cost data are needed to determine if incremental CE exists with MIS techniques, versus open or nonsurgical interventions.