Does Transforaminal Endoscopic Lumbar Discectomy Provide More Value than Microdiscectomy? An Application of the Operative Value Index.

BACKGROUND AND OBJECTIVES

A few studies have compared the value (outcomes per dollar spent) provided by transforaminal endoscopic discectomy (TED) vs microdiscectomy (MD) for lumbar disc herniations. Here, we attempt to address this gap using a novel Operative Value Index (OVI), which combines a procedure-specific patient-reported outcome with intraoperative cost data based on time-driven activity-based costing.

METHODS

MD (n = 95) and TED (n = 23) performed by neurosurgeons at our institution from 2017 to 2022 were retrospectively identified. Time-driven activity-based costing was applied to identify both direct and indirect costs for all cases. Individual costs were obtained by direct observation, electronic medical records, and through consulting multiple departments (including business operations, sterile processing, plant operations, and pharmacy). Oswestry Disability Index (ODI) scores were prospectively collected at baseline and 3 months after surgery. Our primary outcome of interest was the OVI, defined as the percent change in the ODI per $1000 spent intraoperatively. Generalized linear mixed model regression was performed to assess whether TED was associated with significantly different OVI as compared to MD. Similar analyses were also performed for operative times and length of stay.

RESULTS

The average intraoperative cost of a TED was $3698, as compared to $3410 for an MD. For both procedures, this total cost was largely driven by the cost of supplies and personnel. Multivariable regression revealed that MD was associated with significantly higher OVI (β-coefficient: 7.2, P < .05) and lower operative times (β-coefficient: - 34.6 minutes, P < .01) compared with TED, with no significant differences in length of stay ( P = .17).

CONCLUSION

When performed by surgeons at our institution from 2017 to 2022, MD was associated with a 7% greater improvement in ODI per $1000 spent intraoperatively. Continual assessment of value over time (both for established procedures and new techniques) will become increasingly important with the emergence of value-based care.