title: Biological substitutes/extenders for spinal arthrodesis: which agents are cost-effective?
abstract: METHODS
  Systematic review.
  
  
  OBJECTIVE
  To evaluate the cost-effectiveness of lumbar or cervical spinal arthrodesis using biological substitutes and extenders compared with iliac crest autograft for the treatment of degenerative spinal conditions.
  
  
  BACKGROUND
  The cost-effectiveness of using bone graft substitutes and extenders for spinal fusion compared with using iliac crest autograft is not yet well established.
  
  
  METHODS
  A systematic search of PubMed/MEDLINE, the Cochrane Collaboration Library, EMBASE, the CRD (Centre for Reviews and Dissemination) database, and Tuft's CEA registry for literature published through December 2013 was performed to identify full formal economic analyses comparing the use of biological grafts with iliac crest bone graft in spinal fusion for thoracolumbar or cervical degenerative, deformity, and traumatic spinal conditions. Economic outcomes such as cost per improved outcome or cost per quality-adjusted life year were reported in the context of the model type, analytic perspective clinical comparisons, and sensitivity analyses employed.
  
  
  RESULTS
  The search strategy yielded 88 citations, and 6 full economic analyses ultimately met our inclusion criteria. For the comparison of recombinant human bone morphogenetic protein-2 to iliac crest bone graft in the lumbar spine, data from 4 cost-effectiveness studies and 1 cost-utility study provided discordant conclusions that varied with type of data used, cost-measurement methods, and study design. In the cervical spine, one study suggested that from a societal perspective, anterior cervical discectomy and fusion (ACDF) with allograft is similarly cost-effective as ACDF with autograft.
  
  
  CONCLUSIONS
  The results suggest that compared with use of iliac crest bone graft in lumbar spinal fusion, use of recombinant human bone morphogenetic protein is not cost-effective from a payer perspective with higher upfront costs, but it may be cost-effective from a societal perspective due to a decrease in lost productivity. The data in this study also suggest that from a societal perspective, ACDF with allograft is similarly cost-effective to ACDF with autograft.
  
  
  METHODS
  3.
authors.affiliation: Departments of *Orthopaedic Surgery and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL †Spectrum Research Inc., Tacoma, WA ‡Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA; and §Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Wellington K
authors.initials: WK
authors.lastname: Hsu
authors.forename: Robin E
authors.initials: RE
authors.lastname: Hashimoto
authors.forename: Sigurd H
authors.initials: SH
authors.lastname: Berven
authors.forename: Ahmad
authors.initials: A
authors.lastname: Nassr
mesh_terms: D064591:Allografts / Q000191:economics; D064592:Autografts / Q000191:economics; D055396:Bone Morphogenetic Protein 2 / Q000191:economics / Q000627:therapeutic use; D018786:Bone Substitutes / Q000191:economics*; D016025:Bone Transplantation / Q000191:economics*; D002574:Cervical Vertebrae / Q000601:surgery; D003362:Cost-Benefit Analysis; D017048:Health Care Costs; D006801:Humans; D007085:Ilium / Q000601:surgery; D008159:Lumbar Vertebrae / Q000601:surgery; D011994:Recombinant Proteins / Q000191:economics / Q000627:therapeutic use; D013123:Spinal Fusion / Q000191:economics* / Q000379:methods*; D016212:Transforming Growth Factor beta / Q000191:economics / Q000627:therapeutic use
chemical_list: D055396:Bone Morphogenetic Protein 2; D018786:Bone Substitutes; D011994:Recombinant Proteins; D016212:Transforming Growth Factor beta; C499469:recombinant human bone morphogenetic protein-2