Introduction: Surgery for cervical radiculopathy is typically approached by either anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF). ACDF is more common, however recent single center studies suggest comparable efficacy and significant cost savings with PCF in appropriately selected patients. (1,2) To compare ACDF and PCF in terms of approach related morbidity and costs from a national perspective.

Methods: A sequential algorithm was used to identify those undergoing ACDF or PCF for cervical radiculopathy from the Truven Health MarketScan Research Database spanning 2003 to 2014. Outcomes consisted of mortality, adverse events and readmission to hospital over a 30-day post-intervention horizon. Hospital length of stay and total payments to the health provider by the individual, a third party payer or Medicare were assessed. Propensity score matching was used to balance groups on baseline covariates.

Results: The PCF cohort comprised 4,851 subjects and the ACDF cohort included 46,147. Time in hospital was 0.28 days [95% CI: 0.25, 0.31, p <0.001] shorter for the PCF cohort. A significantly greater proportion of PCF cases were discharged on the same day (70.6% vs. 46.1%; p<0.001). Mortality (0.1/1000, p=0.012), vascular injury (0.2/1000, p=0.001), post-operative dysphagia/dysphonia (14.5/1000, p<0.001), cutaneous cerebrospinal fluid leak (0.2/1000, p = 0.002) and deep venous thrombosis (0.9/1000, p=0.013) occurred more frequency in the ACDF cohort. Conversely, wound infections (14.6/1000, p<0.001) and 30-day readmissions to hospital (9.8/1000, p<0.001) were significantly more frequent in the PCF cohort. Unadjusted total payments for PCF were $15,281 ± 12,225 and $26,849 ± 16,309 for ACDF. Matched difference was -$11,726 [95% CI: -$12,221, -$11,232, p<0.001] over a 30 day horizon; favoring PCF.

Conclusions: These findings, from a national sample of commercially-insured patients, suggest an opportunity for value improvement in the management of cervical radiculopathy and indicate a need for large scale comparative study of clinical outcomes and costs.

Patient Care: The findings of this study will serve to inform surgeons and policymakers of the potential for substantial cost savings with a posterior cervical foraminotomy for the treatment of cervical radiculopathy in appropriately selected patients. In the current era of value-based surgical care, identification of potential sources of resource optimization such as this will help improve the allocation of increasingly scarce healthcare resources.

Learning Objectives: By the conclusion of this session, participants should be able to 1) describe the estimated costs associated with treatment of cervical radiculopathy with either an anterior cervical discectomy and fusion or a posterior cervical foraminotomy, 2) discuss potential strengths and limitations to using nationally representative databases to compare surgical interventions for cervical radiculopathy, and 3) recognize the need for large, prospective comparative study of clinical outcomes and costs for both procedures.

References: 1) Mansfield HE, Canar WJ, Gerard CS, O'Toole JE. Single-level anterior cervical discectomy and fusion versus minimally invasive posterior cervical foraminotomy for patients with cervical radiculopathy: a cost analysis. Neurosurg Focus. 2014;37(5):E9. 2) Tumialan LM, Ponton RP, Gluf WM. Management of unilateral cervical radiculopathy in the military: the cost effectiveness of posterior cervical foraminotomy compared with anterior cervical discectomy and fusion. Neurosurg Focus. 2010;28(5):E17.