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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Ann Intern Med. Author manuscript; available in PMC 2009 March 19.
Published in final edited form as:
PMCID: PMC2658642

Surgical Treatment of Spinal Stenosis with and without Degenerative Spondylolisthesis: Cost-Effectiveness after 2 Years



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.


To assess the short-term cost-effectiveness of spine surgery relative to nonoperative care for stenosis alone and for stenosis with spondylolisthesis.


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.




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 non-operative 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.


The study used self-reported utilization data, 2-year time horizon, and as-treated analysis to address treatment non-adherence among randomly assigned participants.


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.

Marked growth in lumbar spine surgery rates over the past 15 years is well documented (1, 2). Although Medicare spent more than $1 billion on spine surgery in 2003, the economic value of these surgeries remains poorly understood. In particular, the value of instrumented lumbar fusion surgery, which increased rapidly in the mid-1990s (3), remains controversial.

Kuntz and colleagues (4) combined published evidence in a model-based analysis of 10-year cost and health outcomes for persons with stenosis, with and without degenerative spondylolisthesis. The analysis showed reasonable value for noninstrumented fusion relative to laminectomy alone, but unfavorable value (costs per quality-adjusted life-year [QALY] gained in excess of $1 million) for instrumented fusion (4). However, the analysis was not based on longitudinal resource utilization or health outcome data appropriate for estimating costs or QALYs and did not consider the value of operative care relative to nonoperative treatment. Other economic analyses have addressed the value of spinal fusion for various populations but have not measured health gains using a QALY scale (5).

The SPORT (Spine Patient Outcomes Research Trial) includes randomized and observational cohorts with confirmed diagnoses of spinal stenosis, with and without degenerative spondylolisthesis (68). Primary functional health status outcomes for these participants showed differences in favor of surgery when examined over the first 2 years (7, 8). We report corresponding cost-effectiveness data for each diagnosis—stenosis alone or stenosis with spondylolisthesis—to compare the value of surgery for diagnoses that have often been combined.


More than 70 physicians enrolled study participants from 13 participating U.S. multidisciplinary spine practices in 11 states between March 2000 and March 2005. Participants were enrolled in either a randomized cohort (treatment randomized) or an observational cohort (treatment chosen). Eligible participants were age 18 years or older with symptoms for at least 12 weeks (neurogenic claudication or radicular leg pain with associated neurologic signs) and image-confirmed diagnosis of spinal stenosis on cross-sectional imaging, either alone or associated with degenerative spondylolisthesis. All were judged to be surgical candidates. We excluded patients with stenosis who also had lumbar instability, defined as more than 4 mm or 10 degrees of angular motion between flexion and extension on upright lateral radiographs. For stenosis alone, the protocol surgical intervention was a standard posterior laminectomy. For degenerative spondylolisthesis, the protocol surgery was the same procedure with or without bilateral single-level fusion (iliac crest bone grafting with or without instrumentation). We considered nonoperative treatments, determined by patients’ and physicians’ choice, to be usual care. A human subjects committee at each institution approved the protocol. An independent data safety and monitoring board oversaw the study. Further details on the design and conduct of SPORT are provided elsewhere (610).

Treatment Effectiveness

To measure health outcomes, we used QALYs to account for both quality and length of life (11). We estimated QALYs by using mean health state values at baseline; 6 weeks; and 3, 6, 12, and 24 months with EuroQol EQ-5D (U.S. scoring) (12, 13).

Treatment Cost

Health care diaries helped participants track resource use and work or activities. Total costs included direct medical costs (based on patient-reported utilization and limited to spine-related problems except for physician visits and hospitalizations) and indirect costs (based on patient-reported time away from work or usual activities because of spine-related problems). Information was collected from patients via questionnaires at 6 weeks and 3, 6, 12, and 24 months by using either a 6-week (at 6 weeks and 3 months) or 1-month recall period. Care involving hospitalization, surgery, and devices was not confined to a recall window.

Direct Medical Costs

These costs included any emergency department or outpatient visit (to surgeons, chiropractors, other physicians, physical therapists, acupuncturists, or other health care providers); spine-related diagnostic tests (radiography, computed tomography, magnetic resonance imaging, or electromyography); injections; devices, such as braces, canes, or walkers; medications; and rehabilitation or nursing home days.

To estimate direct medical costs, we assigned unit costs to each visit, test, and procedure on the basis of 2004 Medicare national allowable payment amounts (14) (Appendix Table, available at We based medication costs on 2004 average wholesale prices (15). For each participant, we multiplied medical resource use by unit costs to obtain an estimate of total direct medical cost at each time point. All costs are reported in 2004 U.S. dollars.

Appendix Table
Unit Costs for Specific Items, in 2004 U.S. Dollars

Surgery costs depended on the procedure performed and occurrence of complications, which in turn determined the diagnosis-related group. We used the observed 2004 Medicare mean total diagnosis-related group payment to reflect hospital-related surgery costs. We based surgeon costs on 2004 Medicare allowable amounts according to the resource-based relative value scale (16). We estimated anesthesiology costs by using operative time. For hospitalizations not associated with a spine surgery, we based costs on the diagnosis-related group by using mean observed 2004 Medicare payments.

Indirect Costs

At each follow-up, we assessed the effect of spine-related problems on productivity. We asked participants to report missed work days if they were employed outside of the home and missed homemaking days if they designated housekeeping as their primary work activity. We also obtained data on use of unpaid caregivers for spine-related problems, including spousal caregiving. We estimated costs by using the standard human capital approach (17) of multiplying the change in hours worked by the gross of tax wage rate, on the basis of self-reported wages at study entry. We valued costs for missed days of housekeeping and unpaid caregivers on the basis of average wages plus non-health benefits for persons age 35 years or older (1820).

Statistical Analysis

We pooled data from the SPORT randomized and observational cohorts for this analysis. We analyzed data separately by disease group according to treatment received by using longitudinal regression models fitted with generalized estimating equations (21, 22). We fit separate models for EuroQol EQ-5D and for 30-day costs as measured at 6 weeks and 3, 6, 12, and 24 months after surgery or the beginning of nonoperative therapy. If a visit was missing, all other available visits for that patient were included in the analysis.

The treatment indicator (surgery vs. nonoperative care) was a time-dependent covariate, which allowed for variable surgery times. We assigned outcomes to the surgical group after surgery, with follow-up times measured from the date of surgery. To adjust for potential confounding in each model and the possible effects of missing data, we included baseline variables associated with missing data or treatment received as covariates. All models included a fixed effect for center. To account for correlations among repeated measurements for individuals, including observations before and after surgery, we fit the longitudinal regression models by using the PROC GENMOD function in SAS, version 9.1 (SAS Institute, Cary, North Carolina), specifying a compound symmetry assumption for the working covariance matrix.

Cost-Effectiveness Analysis

The primary cost-effectiveness end point was the cost per QALY gained for surgery relative to nonoperative treatment. We estimated mean total costs and QALYs from baseline to 2 years for each diagnosis and treatment group by using a 3% annualized discount rate for both end points. We used a time-weighted average to estimate the difference in QALYs between the surgical and nonoperative treatments on the basis of adjusted mean differences in EuroQol EQ-5D that we estimated from longitudinal regression models at each follow-up. For costs, we based mean differences on adjusted mean costs summed across time points for each treatment group. Estimates of cost and QALY differences assumed no deaths over 2 years.

To address the economic value of surgery type, we performed incremental analyses to rank interventions by mean costs and compute mean change in cost divided by mean difference in QALYs. To estimate a confidence interval for the cost per QALY gained, we applied a bootstrap method that used 1000 samples taken with replacement from the original sample with the individual as the unit of observation. For each sample, we estimated both costs and QALYs simultaneously. Bootstrapped confidence intervals have nominal coverage probabilities that are robust to deviations from the data covariance structure as long as missing-completely-at-random assumptions are met after adjustment for predictors of missingness.

Sensitivity analyses of analytic assumptions included restricting analyses to the randomized or observational cohort, limiting cost type, increasing surgery costs to 70% of the amount billed to Medicare, using the Short Form-6D (SF-6D) to estimate effectiveness, and accounting for observed mortality. For the most influential factors we plotted cost-effectiveness acceptability curves. These characterize the cumulative distribution function for the bootstrapped cost-effectiveness ratios as the willingness-to-pay per QALY gained is varied.

Role of the Funding Source

The National Institute of Arthritis and Musculoskeletal and Skin Diseases; Office of Research on Women’s Health, National Institutes of Health; and the National Institute of Occupational Safety and Health, Centers for Disease Control and Prevention provided funding for the study. The study funding sources had no role in study design or conduct; data collection, management, analysis, or interpretation; or manuscript development or approval.


Our cost-effectiveness analysis included 634 participants with stenosis and 601 participants with degenerative spondylolisthesis with associated stenosis. On the basis of follow-up through 14 May 2007, 394 (62%) participants with stenosis and 368 (61%) participants with degenerative spondylolisthesis had surgery. Disease groups were remarkably similar across most characteristics at baseline, except that the degenerative spondylolisthesis group had more women (69% vs. 39%; P < 0.001) and was slightly older (average age, 66.1 vs. 64.6 years; P = 0.021). At baseline, patients in each disease group who went on to have surgery had significantly worse self-rated health trends, health status, and stenosis bothersomeness index scores than patients who received nonoperative treatment but were similar for most other characteristics (Table 1).

Table 1
Baseline Participant Characteristics

For both disease and treatment groups, mean health state values improved over time (Figure 1). Mean discounted QALYs ranged from 1.33 to 1.55 over 2 years of follow-up (Table 2).

Figure 1
Adjusted mean EuroQol EQ-5D health state values and 95% CIs over time, by treatment received
Table 2
Adjusted Mean Quality-Adjusted Life-Years (QALYs) and Costs (95% CIs) over 2 Years*

Total adjusted mean nonoperative care costs were similar across diagnoses (Table 2). Health care visits, reported by 97% of participants, did not differ by treatment or disease group. Approximately half of all participants reported physical therapy; chiropractor visits were infrequent (10% in each group), and 6% reported use of acupuncture. Diagnostic tests were reported more frequently among those treated surgically (among patients with stenosis, 71% for surgery recipients vs. 57% for nonoperative management recipients [P < 0.001]; among patients with degenerative spondylolisthesis, 79% for surgery recipients vs. 56% for nonoperative management recipients [P < 0.001]). For both disease groups, injection use (such as epidural or trigger point) was higher among patients treated nonoperatively (among patients with stenosis, 45% for nonoperative management recipients vs. 30% for surgery recipients [P < 0.001]; among patients with degenerative spondylolisthesis, 46% for nonoperative management recipients vs. 29% for surgery recipients [P < 0.001]). Patterns of medication use showed greater use of nonsteroidal anti-inflammatory medication and cyclooxygenase-2 inhibitors in patients with degenerative spondylolisthesis who received nonoperative management (80%) than in other groups. Narcotic use was higher among those receiving surgery in both groups (among patients with stenosis, 71% of surgery recipients vs. 35% of nonoperative management recipients [P < 0.001]; among patients with degenerative spondylolisthesis, 74% of surgery recipients vs. 29% of nonoperative management recipients [P < 0.001]), whereas use of muscle relaxants was lowest among nonoperatively treated patients with stenosis (5%). Assistive device use was similar in both groups among patients with stenosis (54%). Among patients with degenerative spondylolisthesis, device use was significantly more common in those undergoing surgery (74% for surgery recipients vs. 46% for nonoperative management recipients; P < 0.001), with braces, canes, and walkers reported most commonly.

Total adjusted mean costs for surgical treatment were $26 222 (95% CI, $24 308 to $28 129) for patients with stenosis and $42 081 (CI, $39 800 to $44 373) for patients with degenerative spondylolisthesis (Table 2). Most stenosis surgeries (320 of 394 [81%]) were decompressive laminectomies, with mean surgery costs for uncomplicated cases of $7159 (CI, $7133 to $7185). A total of 35 repeated stenosis surgeries were performed on 27 (6.9%) patients, with a mean cost of $19 152 ($10 627 to $27 677) per patient. Fusion was uncommon among patients with stenosis, with only 43 occurrences. Most degenerative spondylolisthesis surgeries (344 of 368 [93%]) involved fusion with instrumentation, with mean costs for uncomplicated cases of $21 489 (CI, $21 318 to $21 660). A total of 48 repeated surgeries were performed on 37 (10.1%) patients, with a mean cost of $17 045 per patient (CI, $13 493 to $20 597).

Work loss costs tended to be higher for surgically treated patients (Table 2), with a higher proportion of surgically treated patients reporting any missed work days (among patients with stenosis, 25% of surgery recipients vs. 17% of nonoperative management recipients [P = 0.024]; among patients with degenerative spondylolisthesis, 26% of surgery recipients vs. 10% of nonoperative management recipients [P < 0.001]). Although unpaid caregiver costs were minimal, missed homemaking costs were substantial for both treatment groups and diagnoses.

Incremental cost per QALY gained for surgical treatment relative to nonoperative care was $77 600 for stenosis and $115 600 for degenerative spondylolisthesis (Table 3). Study cohort, cost type, and mortality made little difference to the value of surgical intervention (Table 4). In contrast, changing surgery cost or estimating effectiveness with the SF-6D led to less favorable cost-effectiveness estimates (Figure 2).

Figure 2
Cost-effectiveness acceptability curves, by disease group and analytic assumption
Table 3
Adjusted Mean 2-Year Costs, Quality-Adjusted Life-Years (QALYs), and Cost per QALY Gained Relative to Nonoperative Treatment*
Table 4
Sensitivity Analysis Results

Examining cost-effectiveness by surgery type, decompression without fusion had the most favorable value among patients with stenosis (Table 3). Although fusion surgery was significantly more costly than decompression alone (cost difference, $17 545 [CI, $11 074 to $24 090]), it resulted in no QALY gain over 2 years (QALY difference, −0.01 [CI, −0.14 to 0.11]). In the 48% of bootstrapped samples in which a QALY gain was observed for fusion relative to decompression alone, the mean cost-effectiveness ratio exceeded $4 million.

Fusion with instrumentation surgery in patients with degenerative spondylolisthesis was more costly than laminectomy alone (mean cost difference, $21 266 [CI, $7854 to $32 631), but health outcome did not significantly differ by surgery type (mean QALY difference, 0.01 [CI, −0.21 to 0.24]). In the 66% of samples in which fusion resulted in a QALY gain, it did so at a mean cost per QALY gained of $997 400 (CI, $48 300 to $4 672 000). Relative to nonoperative treatment, instrumented fusion had slightly more favorable economic value than noninstrumented fusion and circumferential fusion seems most efficient, but these differences were not statistically significant (Table 3). Comparing instrumented with noninstrumented fusion, costs (difference, $2258 [CI, −$3812 to $7826]) and QALYs (difference, 0.02 [CI, −0.07 to 0.09) did not significantly differ. In the 68% of bootstrapped samples in which instrumentation was associated with a QALY gain, the mean cost was $448 600 per QALY gained (CI, −$177 200 to $1 691 000).


We used longitudinally collected, patient-reported data on resource utilization, work loss, and health-related quality of life to estimate cost per QALY gained for surgical treatment relative to nonoperative care for patient populations with persistent back and leg symptoms due to stenosis alone or degenerative spondylolisthesis with stenosis. Given the eligibility criteria for these 2 disease groups, it is not surprising that surgical procedures differed between groups, with fusion being common only among those with degenerative spondylolisthesis. As a result, the economic value of surgery differed between diagnoses, something that previous research studies with pooled diagnoses could not highlight. Although surgery was more costly than non-operative treatment, health outcomes over 2 years were significantly better among those treated surgically. Although the ratios we report for spine surgery ($77 600 for stenosis and $115 600 for degenerative spondylolisthesis) are high compared with those for well-accepted elective orthopedic procedures, such as total hip replacement for osteoarthritis (costs <$10 000 per QALY gained over a lifetime [23]), it is important to emphasize that our analysis, with its limited 2-year time horizon, did not address lifetime QALY gains. Nonetheless, the value of stenosis surgery was below the $100 000 per QALY limit sometimes used to deem interventions as “costly” (24). In contrast, surgery for stenosis secondary to degenerative spondylolisthesis, which involved fusion in most cases, exceeded $100 000 over the first 2 years. If the difference in health state values observed at 2 years between those treated surgically and those treated nonoperatively was maintained over the longer term, this would improve the value of surgery— unless higher ongoing costs also incurred.

Our findings regarding cost-effectiveness of surgery for stenosis at 2 years are consistent with the favorable value suggested by Katz and colleagues (25), who examined laminectomy and noninstrumented fusion among patients with degenerative spinal stenosis. An important distinction, however, is our access to primary patient-reported data and use of the validated EuroQol instrument to obtain the societal health state values we used to estimate QALYs (26). Consistent with a cost-effectiveness study of surgery for lumbar disc herniation (27), which estimated effectiveness with both EuroQol EQ-5D and SF-6D, we found that QALY gains were somewhat lower when estimated with SF-6D.

To compare our findings with those of other reports, we must consider the type of surgery within each cohort. However, caution must be used in interpreting cost-effectiveness by surgery type because relatively few patients with stenosis had fusion (43 of 394 [11%]), relatively few patients with degenerative spondylolisthesis had noninstrumented fusion (75 of 368 [20%]), and few patients with degenerative spondylolisthesis had decompression alone (19 of 368 [5%]). Kuntz and colleagues (4) used Markov modeling to project cost-effectiveness over a 10-year period for mixed groups of patients with stenosis with and without degenerative spondylolisthesis and reported costs per QALY gained of $56 500 for noninstrumented fusion relative to laminectomy alone ($74 700 in 2004 U.S. dollars). We report higher ratios for fusion relative to decompression alone (mean costs per QALY gained >$300 000 in each group), but because only 19 patients with degenerative spondylolisthesis in SPORT had laminectomy without fusion, it is difficult to draw definitive conclusions. In addition, we do not know all the clinical factors that led to the decision to perform decompression alone or how such factors may have affected outcomes.

Although our analysis was not powered to detect differences by fusion type, we found some evidence that instrumented fusion may be more efficient than noninstrumented fusion and that circumferential (anterior–posterior) fusion may be most efficient. Although our findings differ from those of Kuntz and colleagues (4), who reported costs greater than $2 million per QALY gained for instrumented fusion relative to noninstrumented fusion, we found no statistically significant differences in either costs or QALYs by type of fusion surgery over 2 years. A previous clinical study of instrumented versus noninstrumented fusion (28) also showed no outcome differences at 2 years. However, a recent case series reporting on the long-term outcomes of patients with degenerative spondylolisthesis who had noninstrumentated fusion (29) found inferior results in patients with pseudoarthrosis compared with patients with a solid fusion. This suggests that the higher rate of fusion obtained with instrumentation may lead to improved outcomes over a longer time. Nonetheless, in the absence of definitive findings regarding health gains, the economic value of such surgeries should not be viewed as favorable.

Our analysis has several limitations. First, because of the high degree of crossover in both the observational and randomized cohorts, we present a pooled analysis that utilized longitudinal modeling to evaluate costs and outcomes of participants as they were treated. Thus, although we carefully adjusted for baseline differences between treatment groups, our analysis does not fully benefit from the protection against bias offered by randomized designs. Of note, a recent systematic review of treatment effects in low back pain studies (30), which included some patients similar to those in SPORT, reported that clinical and social factors (such as pain duration, presence of spondylolisthesis, or involvement with worker’s compensation) may affect estimated treatment effects more than study design (such as randomized vs. observational).

Second, we used patient-reported resource utilization and productivity losses to estimate total costs. Although more complete capture of resource use may have been possible through linkage with electronic billing records, such an approach may have resulted in biased cost ascertainment with near complete capture of some treatments (such as surgery) and less complete capture of other, less traditional treatments (such as acupuncture). In addition, the limited recall windows for most non–hospital-based care (6 weeks and 1 month) may have underestimated costs associated with ongoing nonoperative care.

Finally, we relied on Medicare payment schedules to estimate costs. Although these regulated payments may more accurately represent the resources necessary to produce a service than charges, they do not reflect actual costs and do not allow us to differentiate between costs of different types of instrumentation. The latter was the focus of a recent United Kingdom study (31), which showed that circumferential fusion with titanium cages is cost-ineffective compared with femoral ring allograft but did not consider uninstrumented fusion or nonoperative care. We characterized the substantial effect that higher costs associated with surgery would have on the value of surgical intervention in sensitivity analyses. However, the Medicare costing perspective has policy relevance because most persons studied were age 65 years or older.

Current trends in spine surgery in the United States, combined with continued escalation in health care expenditures, highlight the importance of understanding the economic value of common surgical interventions. Our comprehensive analysis suggests that surgical treatment of spinal stenosis with laminectomy provides reasonable value even over a limited 2-year time frame. By contrast, surgery for stenosis associated with degenerative spondylolisthesis is much more costly and will need to show continued health benefit without ongoing costs before it could be characterized as being cost-effective.


The authors thank Catherine C. Lindsay, SM, for extensive work in the development of the cost weights utilized in this analysis; Tamara S. Morgan for creation of the patient diaries and assistance in preparing this manuscript; and Loretta Pearson for editorial assistance.

Grant Support: By the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (U01-AR45444); Office of Research on Women’s Health, National Institutes of Health; and the National Institute of Occupational Safety and Health, Centers for Disease Control and Prevention. The Multidisciplinary Clinical Research Center in Musculoskeletal Diseases is funded by NIAMS (P60-AR048094). Dr. Lurie is supported by a Research Career Award from NIAMS (K23 AR 048138).


Dartmouth College, Hanover, New Hampshire: James N. Weinstein, DO, MS; Jon D. Lurie, MD, MS; Anna N.A. Tosteson, ScD; Tor D. Tosteson, ScD; Jonathan S. Skinner, PhD; William A. Abdu, MD, MS; Kevin F. Spratt, PhD; Judith L. Forman, MPH (Project Coordinator).

William Beaumont Hospital, Royal Oak, Michigan: Harry Herkowitz, MD; Gloria Bradley, BSN; Melissa Lurie, RN.

Hospital for Special Surgery, New York, New York: Frank Cammisa, MD; Brenda Green, RN, BSN.

Emory University, Emory Orthopaedics and Spine Center, Atlanta, Georgia: Scott Boden, MD; Sally Lashley, BSN, MSA.

Rothman Institute at Thomas Jefferson Hospital, Philadelphia, Pennsylvania: Todd Albert, MD; Allan Hilibrand, MD; Carol Simon, RN, MS.

Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire: William A Abdu, MD, MS; Barbara Butler-Schmidt, RN, MSN; J.J. Hebb, RN, BSN.

Washington University, St. Louis, Missouri: Lawrence Lenke, MD; Keith Bridwell, MD; Georgia Stobbs, RN, BA.

University of California, San Francisco, San Francisco, California: Serena Hu, MD; Pat Malone, RN, MSN, ANP.

University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio: Chris Furey, MD; Kathy Higgins, RN, PhD, CNS, C.

Nebraska Foundation for Spinal Research, Omaha, Nebraska: Michael Longley, MD; Nancy Fullmer, RN; Ann Marie Fredericks, RN, MSN, CPNP.

Kaiser Permanente, Oakland, California: Harley Goldberg, DO; Pat Malone, RN, MSN, ANP.

NYU Hospital for Joint Diseases, New York, New York: Thomas Errico, MD; Alex Lee, RN, BSN.

Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois: Gunnar Andersson, MD, PhD; Margaret Hickey, RN, MS.

Maine Spine & Rehabilitation, Scarborough, Maine: Robert Keller, MD.


Author Contributions: Conception and design: A.N.A. Tosteson, T.D. Tosteson, T. Albert, S.D. Boden, K. Bridwell, J.N. Weinstein. Analysis and interpretation of the data: A.N.A. Tosteson, J.D. Lurie, T.D. Tosteson, J.S. Skinner, S.D. Boden, E.A. Blood, M.R. Grove, J.N. Weinstein.

Drafting of the article: A.N.A. Tosteson, J.D. Lurie, E.A. Blood, J.N. Weinstein.

Critical revision of the article for important intellectual content: A.N.A. Tosteson, J.D. Lurie, J.S. Skinner, H. Herkowitz, T. Albert, S.D. Boden, K. Bridwell, M. Longley, G.B. Andersson, E.A. Blood, J.N. Weinstein. Final approval of the article: A.N.A. Tosteson, J.D. Lurie, T.D. Tosteson, J.S. Skinner, H. Herkowitz, T. Albert, M. Longley, G.B. Andersson, E.A. Blood, J.N. Weinstein.

Provision of study materials or patients: J.D. Lurie, J.S. Skinner, T. Albert, S.D. Boden, M. Longley, G.B. Andersson, J.N. Weinstein. Statistical expertise: A.N.A. Tosteson, T.D. Tosteson, E.A. Blood, J.N. Weinstein.

Obtaining of funding: A.N.A. Tosteson, J.N. Weinstein. Administrative, technical, or logistic support: J.N. Weinstein. Collection and assembly of data: J.N. Weinstein.


A recent large study that examined patient outcomes 2 years after spine surgery for spinal stenosis or degenerative spondylolisthesis suggested that patients who had surgery had better outcomes than patients who did not. However, whether the magnitude of the benefit observed is worth the high cost of surgery remains unclear.


This analysis used 2-year follow-up data from the study to estimate the cost-effectiveness of surgery and found that surgery for spinal stenosis costs about $77 000 per quality-adjusted life-year gained and surgery for degenerative spondylolisthesis costs about $115 000 per quality-adjusted life-year gained.


The data were available for only 2 years; the cost-effectiveness could be better or worse when examined over a longer period.

Potential Financial Conflicts of Interest: Consultancies: T. Albert (DePuy Spine), S.D. Boden (Medtronic), K. Bridwell (DePuy, Medtronic). Grants received: M. Longley (Medtronic), J.N. Weinstein (National Institutes of Health). Patents pending: T. Albert (screw device for possible use in fusion operations). Royalties: S.D. Boden (Osteotech).

Reproducible Research Statement: Study protocol: Available upon request (e-mail, ude.htuomtrad@TROPS). Statistical code and data set: Not available.

Requests for Single Reprints: Anna N.A. Tosteson, ScD, Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, HB7505, Dartmouth Medical School, One Medical Center Drive, Lebanon, NH 03756.

Current author addresses and author contributions are available at

Current Author Addresses: Drs. A.N.A. Tosteson, Lurie, T.D. Tosteson, and Weinstein; Ms. Blood; and Ms. Grove: Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756. Dr. Skinner: Dartmouth College, 317 Rockefeller Hall, Hanover, NH 03755.

Dr. Herkowitz: William Beaumont Hospital, 3535 West 13 Mile Road Royal Oak, MI 48073.

Dr. Albert: Rothman Institute at Thomas Jefferson University, 952 Chestnut Street, Philadelphia, PA 19107.

Dr. Boden: Emory University, Emory Orthopaedics and Spine Center, 59 Executive Park South, Suite 3000, Atlanta, GA 30329.

Dr Bridwell: Washington University, Suite 11300 West Pavilion, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63110.

Dr. Longley: Nebraska Spine Surgeons, 11819 Miracle Hills Drive, Suite 102, Omaha, NE 68154-4438.

Dr. Andersson: Rush-Presbyterian-St. Luke’s Medical Center, 1653 West Congress Parkway, Chicago, IL 60612-3833.


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