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

Disclosures

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

In This Article

Discussion

Despite being a one of the most prevalent medical conditions in the general population, there remains uncertainty on the most effective and efficient approach to managing cervical radiculopathy. Although definitive management of patients with persistent symptoms is often surgical, many of these patients first undergo cervical epidural injections. However, evidence in the literature supporting the utilization of cervical epidural injections is inconsistent and varied. Systematic reviews performed by Manchikanti in 2014 and 2015 highlight the challenges in identifying consistent recommendations for relying on cervical epidural injections; they describe the inconsistencies between studies in the type of injection, technique of injection, indication, outcome measurement, and follow-up.[10,12] Furthermore, there are limited comparisons of invasive nonsurgical methods such as epidural injections against definitive management with surgery, in particular with regard to economics.[25–27]

We chose to analyze the question of whether to manage cervical radiculopathy resistant to noninvasive nonsurgical approach with definitive surgical treatment with ACDF or cervical epidural injections using a technique of decision tree Markov modeling. The current study found that when analyzed with variability of model estimates, both approaches, that is, surgery and nonsurgical treatment with epidural injections, remained cost-effective relative to accepted cost-effectiveness thresholds. This analysis suggests that either approach provides acceptable value from a societal perspective of $50,000/QALY[28] (Figure 2). Importantly, this model fundamentally highlights the importance of the success rate of cervical injections in their comparison against surgical management. Across the rates of success for epidural injections, surgery is favorable with regard to incremental QALYs gained over a lifetime. However, when the success rate of injections increases, the associated costs of management become lower relative to a strategy of ACDF, which subsequently drives cost-effectiveness ratios down; this is demonstrated by a falling ICER of $9,033 to $4,044 per QALY with an increase in the success rate of epidural injections. The ICER threshold for equivocacy of the two management strategies is a 50% durable success rate of cervical epidural injections. This is the point where the ICER associated with either surgical management or cervical epidural injections, is equivalent at approximately $6,700 per QALY. This suggest that if there is a greater than 50% chance that cervical epidural injections can lead to surgery avoidance and resolution of radiculopathy symptoms to the extent that baseline quality of life is achieved, then cervical epidural injections would be considered a cost-effective strategy with a role in the management of cervical radiculopathy before surgery. However, if these conditions are not met, our model supports ACDF without an attempt of cervical epidural injections as the favorable approach. Also, ACDF is a more cost-effective treatment strategy than cervical epidural injections if the surgical avoidance rate of such injections is less than 50%. These results remain robust through a PSA in which each variable (ie, probability or outcome value) in the model independently varied across a range of possibilities for each of 10,000 separate trials. These trials represent the range of reasonable outcomes of the model, and when graphically presented, they demonstrate the general tendency of surgical management to generate more incremental QALYs at lower cost than invasive nonsurgical therapy—the clustering of cases managed with cervical epidural injections is driven by their estimated success rate (Figure 2).

There are weaknesses inherent with this type of predictive economic modeling. Most notably, given the significant heterogeneity among studies in the literature on cervical epidural injections, we could not make a global recommendation regarding their utilization relative to ACDF. Instead a threshold of long-term success should help guide their usage. We hope that presenting the results in this manner will allow institutions and practitioners to apply their specific outcome rates to the framework we provide and make accurate institution- and region-specific decisions on care delivery. Further research to elucidate the outcome of specific cervical epidural injection techniques for specific radiological and clinical indications over the long term would further clarify the instances where epidural injections may be valuable and potentially allow for more absolute, globally generalizable policy statements.

Second, like any theoretical decision tree model, we relied on the literature estimates for probabilities and outcomes, and publicly available fee schedules for reimbursements. Therefore, any inherent weaknesses in the referenced studies may translate into our model. We relied on well-performed, high-level, evidence-based studies and systematic reviews to drive our model to optimize its applicability. Furthermore, we performed a very broad PSA across a range of reasonable values for each variable in the model to incorporate variability, and our model results remain consistent and robust with trends demonstrated in the PSA.

In addition, our model did not account for variable improvement after cervical epidural injections. We took the approach to patients when seeking treatment for the complete resolution of their symptoms. In some cases, it may be possible that a series of cervical epidural injections fails; however, the patient does not pursue subsequent surgery to optimize their outcomes. These patients would exist in a state of disability and would likely reduce the average incremental QALY gain accrued by the arm treated with cervical epidural injections; therefore, a dichotomous outcome approach as we took was in fact the more conservative method and slightly favored cervical injections.

Finally, our model did not account for variations in patient characteristics or symptomatic pathoanatomy Differences in clinical presentation, such as soft disk herniation versus spondylosis with foraminal stenosis, may have differential responses to both injections and surgery. Also, there are a host of other factors, including comorbidities, psychosocial issues, support networks, concurrent medical and neurological conditions, secondary gain concerns, and other patient-driven variables, that can influence treatment effect and outcomes. These are not parsed out in our study, and our aim was to provide results consistent with a pragmatic trial, with global in practice generalizability—therefore, the results may not be specifically generalizable to a patient subgroup.

Despite these limitations, we think that our analysis provides valuable insight into the long-term management of cervical radiculopathy that persists despite an initial 6-week noninvasive nonsurgical course of management. It is important to emphasize that the actual rate of long-term success of cervical epidural injections is crucial to their value, and our results should be seen as a tool for institutions and practitioners to apply their own specific outcome rate of cervical epidural injections. If a greater than 50% success rate is feasible, then there may be a role for attempts of cervical epidural injections before surgery. However, if this rate of success cannot be consistently achieved, then ACDF for recalcitrant cervical radiculopathy without a presurgical attempt of invasive nonsurgical management would be the most cost-effective course of management for these patients.

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