A Two-Year Cost Analysis of Maximum Nonoperative Treatments in Patients with Cervical Stenosis that Ultimately Required Surgery.

ABSTRACT

OBJECTIVE: The aim of this study is to characterize the use and associated costs of maximal nonoperative therapy (MNT) received within 2-years before anterior cervical discectomy and fusion (ACDF) surgery in patients with symptomatic cervical stenosis. METHODS: An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients undergoing 1-level, 2-level, or 3-level ACDF procedures between 2007 and 2016. Research records were searchable by International Classification of Diseases diagnosis and procedure, Current Procedural Terminology, and generic drug codes. The use of MNTs within 2 years before index ACDF surgery was assessed by cost billed to patients, prescriptions written, and number of units billed. RESULTS: Of 220,902 (7.16%) eligible patients, 15,825 underwent index surgery. Patient breakdown of the use of MNT modalities was as follows 5731 (36.2%) used nonsteroidal antiinflammatory drugs; 9827 (62.1%) used opioids; 7383 (46.7%) used muscle relaxants; 3609 (22.8%) received cervical epidural steroid injection; 5504 (34.8%) attended physical therapy/occupational therapy; 1663 (10.5%) received chiropractor treatments; and 200 (1.3%) presented to the emergency department. During the 2-year preoperative period, there were 51,675 prescriptions for diagnostic cervical imaging. The total direct cost associated with all MNTs before ACDF was $16,056,556. Cervical spine imaging comprised the largest portion of the total MNT cost ($8,677,110; 54.0%), followed by cervical epidural steroid injection ($3,315,913; 20.7%) and opioids ($2,228,221; 13.9%). Opiates were the most frequently prescribed therapy (71,602 prescriptions). DISCUSSION: Opioids are the most frequently prescribed and most used therapy in the preoperative period for cervical stenosis. Further studies and improved guidelines are necessary to determine which patients may benefit from ACDF earlier in the course of nonoperative therapies.