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Laminoplasty compared to laminectomy and fusion for degenerative cervical myelopathy: a cost-utility analysis
Christopher S Lozano1,2,3, Vishwathsen Karthikeyan1,2,3, Armaan K Malhotra1,2,3
1Division of Neurosurgery, Department of Surgery, University of Toronto, 27 King's College Cir, Toronto, Ontario M5S1A, Canada.
Background:
Degenerative cervical myelopathy (DCM) is a leading cause of spinal cord dysfunction in adults. Posterior surgical options include laminoplasty (LP), a motion-preserving procedure, and laminectomy with fusion (LF), which offers stabilization but at higher cost. A cost-utility comparison of these approaches is lacking.
Methods:
We conducted a cost-utility analysis using a 5-year Markov state-transition model from a healthcare payer perspective. The study cohort was drawn from 3 multicenter prospective studies of patients with DCM. To reduce baseline confounding, patients who underwent LF or LP were matched 2:1 using propensity score matching. Quality-adjusted life years (QALYs) were derived from SF-6D utilities calculated from SF-36 scores at baseline and 12 months. Costs and transition probabilities were derived from meta-analysis and registry data. We calculated incremental cost-utility ratios (ICURs) and net monetary benefit (NMB) using a willingness-to-pay (WTP) threshold of $100,000 per QALY. Sensitivity analyses included deterministic variation and 1,000-iteration Monte Carlo microsimulation.
Results:
240 matched patients were included (87 LP, 153 LF). Baseline mJOA, NDI and SF6D scores were similar between groups. In the base-case, LP cost $24,283, yielding 3.53 QALYs, while LF cost $35,902, yielding 3.72 QALYs, resulting in an incremental cost-utility ratio (ICUR) of $59,796 per QALY, favouring LF. In probabilistic microsimulation, LP had a mean cost of $24,579 (95% confidence interval (CI): $23,933-$25,225) and a mean NMB of $326,281 (95% CI: $322,672-$329,891), while LF cost $35,936 (95% CI: $35,583-$36,288) with a mean NMB of $333,189 (95% CI: $328,629-$337,748). LP was the optimal strategy in 47% of simulations versus 53% for LF.
Conclusions:
Both LP and LF can be cost-effective for DCM. While the base-case favored LF, probabilistic sensitivity analysis revealed no clear cost-utility advantage with comparable NMBs. Economic considerations alone should not drive surgical decision-making and treatment choice should be tailored to individual patient factors and local resource contexts.
