Economic and Outcomes Analysis of Recalcitrant Cervical Radiculopathy

Is Nonsurgical Management or Surgery More Cost-Effective?

Jeffrey A. Rihn, MD; Suneel Bhat, MD; Jonathan Grauer, MD; James Harrop, MD; Zoher Ghogawala, MD; Alexander R. Vaccaro, MD, PhD; Alan S. Hilibrand, MD


J Am Acad Orthop Surg. 2019;27(14):533-540. 

In This Article

Abstract and Introduction


Introduction: This study directly compares the economical and clinical effectiveness of the use of cervical epidural injections and continued physical therapy versus surgical management in cases of cervical radiculopathy that have failed 6 weeks of conservative management.

Methods: A theoretical cohort of patients with cervical radiculopathy resistant to 6 weeks of noninvasive conservative management were simulated to treatment with either anterior cervical diskectomy and fusion (ACDF) or cervical epidural injections and continued physical therapy and analyzed with Markov chain decision tree Monte Carlo simulation.

Results: The average incremental cost-effectiveness ratio associated with ACDF was $6,768 per quality-adjusted life year over the lifetime of the patient, whereas the incremental cost-effectiveness ratio associated with cervical injections ranged from $9,033 to $4,044 per quality-adjusted life year based on the success rate.

Discussion: Our study suggests that for the management of recalcitrant cervical radiculopathy, ACDF remains the dominant strategy compared with cervical epidural injections if the surgical avoidance rate of such injections is less than 50%. If there is a greater than 50% surgery avoidance rate with injections, then cervical epidural injections would be considered a cost-effective strategy with a role in the management of cervical radiculopathy before surgery.


Cervical radiculopathy is a relatively common condition with an age-adjusted incidence of 83 per 100,000, with neck pain and radiculopathy representing the fourth most significant burden of disease in the US population.[1,2] Most patients with acute radiculopathy obtain relief with nonsurgical treatment, such as oral steroidal and nonsteroidal anti-inflammatory medication, physical therapy, and cervical traction.[3,4] For patients with persistent radicular symptoms resistant to a nonsurgical treatment, anterior cervical diskectomy and fusion (ACDF) has been a reliable surgical intervention resulting in durable long-term symptom resolution.[5–7] However, many patients with persistent cervical radiculopathy undergo a prolonged course of nonsurgical management, which may be supplemented with cervical epidural injections before or in lieu of surgery. Epidural injections are performed through either an interlaminar or a transforaminal approach; these approaches are used at an increasing rate of 123% and 142%, respectively, between 2000 and 2011.[8]

Despite their increasing utilization, epidural injections in the cervical spine remain controversial, with a number of systematic reviews drawing mixed conclusions on the strength of effectiveness.[9–12] Given the paucity of high-quality literature, the role and indications for epidural injections in the continuum of care of cervical radiculopathy remain unclear, and the economic effect of their utilization is unknown.

Evaluating the question of whether epidural injections are clinically beneficial and/or cost-effective in addition to or in lieu of surgery poses a challenge. First, the length of follow-up required to capture morbidity and cost for a lifelong condition with the expected risk of recurrent symptomatology or same/adjacent level disease would not be feasible using current study approaches. Second, the anticipated high rate of crossover between injection groups and surgery groups would potentially confound the results. Finally, incorporating economic end points and capturing the aspects of cost-effectiveness can be difficult in standard clinical trials.

The current study evaluates whether cervical radiculopathy with significant persistent symptoms after 6 weeks of nonsurgical management should be addressed with additional invasive nonsurgical management versus surgery. Our approach to evaluate the cost-effectiveness of epidural injections against ACDF was to use a Markov chain decision model where individual theoretical patients are followed across different health states and interventions over simulated time.[13,14] Decision models can be synthesized using parameters, utilities, and economic data from multiple sources, and this models can follow patients and cohorts over entire theoretical life spans.