Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: Cost-effectiveness after 2 years

Anna N.A. Tosteson, Jon D. Lurie, Tor D. Tosteson, Jonathan S. Skinner, Harry Herkowitz, Todd Albert, Scott D. Boden, Keith Bridwell, Michael Longley, Gunnar B. Andersson, Emily A. Blood, Margaret R. Grove, James N. Weinstein

Research output: Contribution to journalArticlepeer-review

225 Scopus citations


Background: The SPORT (Spine Patient Outcomes Research Trial) reported favorable surgery outcomes over 2 years among patients with stenosis with and without degenerative spondylolisthesis, but the economic value of these surgeries is uncertain. Objective: To assess the short-term cost-effectiveness of spine surgery relative to nonoperative care for stenosis alone and for stenosis with spondylolisthesis. Design: Prospective cohort study. Data Sources: Resource utilization, productivity, and EuroQol EQ-5D score measured at 6 weeks and at 3, 6, 12, and 24 months after treatment among SPORT participants. Target Population: Patients with image-confirmed spinal stenosis, with and without degenerative spondylolisthesis. Time Horizon: 2 years. Perspective: Societal. Intervention: Nonoperative care or surgery (primarily decompressive laminectomy for stenosis and decompressive laminectomy with fusion for stenosis associated with degenerative spondylolisthesis). Outcome Measures: Cost per quality-adjusted life-year (QALY) gained. Results of Base-Case Analysis: Among 634 patients with stenosis, 394 (62%) had surgery, most often decompressive laminectomy (320 of 394 [81%]). Stenosis surgeries improved health to a greater extent than nonoperative care (QALY gain, 0.17 [95% CI, 0.12 to 0.22]) at a cost of $77 600 (CI, $49 600 to $120 000) per QALY gained. Among 601 patients with degenerative spondylolisthesis, 368 (61%) had surgery, most including fusion (344 of 368 [93%]) and most with instrumentation (269 of 344 [78%]). Degenerative spondylolisthesis surgeries significantly improved health versus nonoperative care (QALY gain, 0.23 [CI, 0.19 to 0.27]), at a cost of $115 600 (CI, $90 800 to $144 900) per QALY gained. Result of Sensitivity Analysis: Surgery cost markedly affected the value of surgery. Limitation: The study used self-reported utilization data, 2-year time horizon, and as-treated analysis to address treatment nonadherence among randomly assigned participants. Conclusion: The economic value of spinal stenosis surgery at 2 years compares favorably with many health interventions. Degenerative spondylolisthesis surgery is not highly cost-effective over 2 years but could show value over a longer time horizon.

Original languageEnglish
Pages (from-to)845-853
Number of pages9
JournalAnnals of internal medicine
Issue number12
StatePublished - Dec 16 2008


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