What Are the Costs of Cervical Radiculopathy Prior to Surgical Treatment?

Cameron Barton, MD; Piyush Kalakoti, MD; Nicholas A. Bedard, MD; Nathan R. Hendrickson, MD; Comron Saifi, MD; Andrew J. Pugely, MD

Disclosures

Spine. 2019;44(13):937-942. 

In This Article

Abstract and Introduction

Abstract

Study Design: Retrospective, observational study.

Objective: To examine the costs associated with nonoperative management (diagnosis and treatment) of cervical radiculopathy in the year prior to anterior cervical discectomy and fusion (ACDF).

Summary of Background Data: While the costs of operative treatment have been previously described, less is known about nonoperative management costs of cervical radiculopathy leading up to surgery.

Methods: The Humana claims dataset (2007–2015) was queried to identify adult patients with cervical radiculopathy that underwent ACDF. Outcome endpoint was assessment of cumulative and per-capita costs for nonoperative diagnostic (x-rays, computed tomographic [CT], magnetic resonance imaging [MRI], electromyogram/nerve conduction studies [EMG/NCS]) and treatment modalities (injections, physical therapy [PT], braces, medications, chiropractic services) in the year preceding surgical intervention.

Results: Overall 12,514 patients (52% female) with cervical radiculopathy underwent ACDF. Cumulative costs and per-capita costs for nonoperative management, during the year prior to ACDF was $14.3 million and $1143, respectively. All patients underwent at least one diagnostic test (MRI: 86.7%; x-ray: 57.5%; CT: 35.2%) while 73.3% patients received a nonoperative treatment. Diagnostic testing comprised of over 62% of total nonoperative costs ($8.9 million) with MRI constituting the highest total relative spend ($5.3 million; per-capita: $489) followed by CT ($2.6 million; per-capita: $606), x-rays ($0.54 million; per-capita: $76), and EMG/NCS ($0.39 million; per-capita: $467). Conservative treatments comprised of 37.7% of the total nonoperative costs ($5.4 million) with injections costs constituting the highest relative spend ($3.01 million; per-capita: $988) followed by PT ($1.13 million; per-capita: $510) and medications (narcotics: $0.51 million, per-capita $101; gabapentin: $0.21 million, per-capita $93; NSAIDs: 0.107 million, per-capita $47), bracing ($0.25 million; per-capita: $193), and chiropractic services ($0.137 million; per-capita: $193).

Conclusion: The study quantifies the cumulative and per-capital costs incurred 1-year prior to ACDF in patients with cervical radiculopathy for nonoperative diagnostic and treatment modalities. Approximately two-thirds of the costs associated with cervical radiculopathy are from diagnostic modalities. As institutions begin entering into bundled payments for cervical spine disease, understanding condition specific costs is a critical first step.

Level of Evidence: 3

Introduction

Cervical radiculopathy is a condition caused by compression of cervical nerve roots resulting in burning upper extremity pain, weakness, altered sensation, and impairment of deep tendon reflexes.[1,2] The majority of patients experiencing cervical radiculopathy have symptom resolution within 3 months with nonoperative management. For patients failing nonoperative management, the gold standard treatment is anterior cervical discectomy and fusion (ACDF) which is associated with a high clinical success.[3–6] The number of ACDF procedures has been shown to be increasing yearly, with one studying revealing a 184% increase in Medicare beneficiaries from 12.6 in 1992 to 35.8 per 100,000 in 2005.[7] While the costs of ACDF have been previously described,[8–12] less is known about the nonoperative costs associated with cervical spine disorders including radiculopathy leading up to ACDF. Long-term costs societal costs in a middle-aged patient undergoing ACDF is estimated to be $31,178;[13] however, little or no literature exist that comprehensively describes the costs preceding cervical spine surgery. A recent study noted the cumulative nonoperative intervention charges including halo-placement and spinal traction in patients with axis (C2) fracture to be approximately $24.3 million in 2011, translating to a mean per-capita overhead charge of $62,396 (inflation-adjusted to 2013-dollar values).[14]

Direct costs associated with cervical radiculopathy before operative intervention can be attributed to diagnostic modalities and operative planning, as well as conservative treatments. Diagnostic modalities of cervical radiculopathy include radiographs, computed tomographic (CT) scans including CT myelogram, magnetic resonance imaging (MRI), and electromyogram/nerve conduction studies (EMG/NCS). A trial of conservative therapy for cervical radiculopathy is often a prerequisite prior to surgical intervention. Nonoperative treatments for cervical radiculopathy may consist of medications, physical therapy, injections, bracing, and even services such as chiropractic manipulation. Unfortunately, low quality evidence exists to guide clinicians in the workup and treatment of cervical radiculopathy. The North American Spine Society (NASS) complied current data pertaining to diagnosis and management of cervical radiculopathy in their most recent Clinical Practice Guideline (CPG).[1] The NASS CPGs included no grade "A" recommendations for the diagnostic tests or nonoperative treatments identified. For diagnostic tests, CT and MRI received grade "B" recommendations for use, while EMG/NCS received grade "I" recommendation. For nonoperative treatments, no studies were available to provide specific recommendations for pharmaceutical management, chiropractic manipulation, or epidural steroid injections; therefore, no recommendation grades were given. Physical therapy and bracing received a grade "I" recommendation while transforaminal injections received a grade of "C" for their use.[1] The scarcity of evidence acts as a major barrier to decreasing variability in treatment among those diagnosed with cervical radiculopathy.

As the national emphasis on value improvement grows, uncovering the cost drivers during clinical episodes is an important step towards improvement and the cost-containment debate. For cervical radiculopathy, the nonoperative costs prior to ACDF remain ill defined. Furthermore, the uncertainty of evidence to guide nonoperative care should illicit pause in treating clinicians. Thus, we sought to define the presurgical resource utilization associated with diagnostic and therapeutic interventions in patients with cervical radiculopathy using a longitudinal claims registry.

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