title: Cost-utility analysis of posterior minimally invasive fusion compared with conventional open fusion for lumbar spondylolisthesis.
abstract: BACKGROUND
  The utility and cost of minimally invasive surgical (MIS) fusion remain controversial. The primary objective of this study was to compare the direct economic impact of 1- and 2-level fusion for grade I or II degenerative or isthmic spondylolisthesis via an MIS technique compared with conventional open posterior decompression and fusion.
  
  
  METHODS
  A retrospective cohort study was performed by use of prospective data from 78 consecutive patients (37 with MIS technique by 1 surgeon and 41 with open technique by 3 surgeons). Independent review of demographic, intraoperative, and acute postoperative data was performed. Oswestry disability index (ODI) and Short Form 36 (SF-36) values were prospectively collected preoperatively and at 1 year postoperatively. Cost-utility analysis was performed by use of in-hospital micro-costing data (operating room, nursing, imaging, laboratories, pharmacy, and allied health cost) and change in health utility index (SF-6D) at 1 year.
  
  
  RESULTS
  The groups were comparable in terms of age, sex, preoperative hemoglobin, comorbidities, and body mass index. Groups significantly differed (P < .01) regarding baseline ODI and SF-6D scores, as well as number of 2-level fusions (MIS, 12; open, 20) and number of interbody cages (MIS, 45; open, 14). Blood loss (200 mL vs 798 mL), transfusions (0% vs 17%), and length of stay (LOS) (6.1 days vs 8.4 days) were significantly (P < .01) lower in the MIS group. Complications were also fewer in the MIS group (4 vs 12, P < .02). The mean cost of an open fusion was 1.28 times greater than that of an MIS fusion (P = .001). Both groups had significant improvement in 1-year outcome. The changes in ODI and SF-6D scores were not statistically different between groups. Multivariate regression analysis showed that LOS and number of levels fused were independent predictors of cost. Age and MIS were the only predictors of LOS. Baseline outcomes and MIS were predictors of 1-year outcome.
  
  
  CONCLUSIONS
  MIS posterior fusion for spondylolisthesis does reduce blood loss, transfusion requirements, and LOS. Both techniques provided substantial clinical improvements at 1 year. The cost utility of the MIS technique was considered comparable to that of the open technique.
  
  
  METHODS
  Level III.
authors: Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada ; Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors: Y Raja
authors: YR
authors: Rampersaud
authors: Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors: Randolph
authors: R
authors: Gray
authors: Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada ; Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors: Steven J
authors: SJ
authors: Lewis
authors: Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada ; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors: Eric M
authors: EM
authors: Massicotte
authors: Spinal Program, Krembil Neuroscience Center, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada ; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors: Michael G
authors: MG
authors: Fehlings
keywords: Cost-utility analysis; Economic; Lumbar fusion; Minimally invasive; Open