Cost-Effectiveness of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Degenerative Spondylolisthesis Associated Low-Back and Leg Pain Over Two Years

OBJECTIVE: Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for lumbar spondylolisthesis allows for surgical treatment of back and leg pain while theoretically minimizing tissue injury and accelerating overall recovery. Although the authors of previous studies have demonstrated shorter length of hospital stay and reduced blood loss with MIS versus open-TLIF, short- and long-term outcomes have been similar. No studies to date have evaluated the comprehensive health care costs associated with TLIF procedures or assessed the cost-utility of MIS-versus open-TLIF. As such, we set out to assess previously unstudied end points of health care cost and cost-utility associated with MIS-versus open-TLIF. METHODS: Thirty patients undergoing MIS-TLIF (n = 15) or open-TLIF (n = 15) for grade I degenerative spondylolisthesis associated back and leg pain were prospectively studied. Total back-related medical resource use, missed work, and health-state values (quality-adjusted life years [QALYs], calculated from EQ-5D with U.S. valuation) were assessed after two-year follow-up. Two-year resource use was multiplied by unit costs on the basis of Medicare national allowable payment amounts (direct cost) and work-day losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Difference in mean total cost per QALY gained for MIS-versus open-TLIF was assessed as incremental cost-effectiveness ratio (ICER: COSTmis - COSTopen/QALYmis - QALYopen). RESULTS: MIS versus open-TLIF cohorts were similar at baseline. By two years postoperatively, patients undergoing MIS-versus open-TLIF reported similar mean QALYs gained (0.50 vs. 0.41, P = 0.17). Mean total two-year cost of MIS- and open-TLIF was $35,996 and $44,727, respectively. The $8,731 two-year cost savings of MIS-versus open-TLIF did not reach statistical significance (P = 0.18) for this sample size. CONCLUSIONS: Although our limited sample size prevented statistical significance, MIS-versus open-TLIF was associated with reduced costs over two years while providing equivalent improvement in QALYs. MIS-TLIF allows patients to leave the hospital sooner, achieve narcotic independence sooner, and return to work sooner than open-TLIF. In our experience, MIS-versus open-TLIF is a cost reducing technology in the surgical treatment of medically refractory low-back and leg pain from grade I lumbar spondylolisthesis.