NASS 2022: Percutaneous transforaminal endoscopic discectomy a more cost-effective treatment than microdiscectomy for sciatica

Percutaneous transforaminal endoscopic discectomy (PTED) is more cost-effective from a societal perspective at 24 months than microdiscectomy for patients with sciatica. This is according to research presented at the North American Spine Society’s (NASS) annual meeting (12–15 October, Chicago, USA) by Pravesh Gadjradj (Weill Cornell, Brain and Spine Centre, New York, USA), where it was a Value Award winner.

Microdiscectomy is a frequently performed surgical procedure for sciatica caused by lumbar disc herniation. However, PTED has been introduced as a less invasive alternative and two-year results show non-inferiority in leg pain reduction and dominancy in cost-effectiveness, notes Gadjradj.

This particular randomised controlled trial was conducted at four clinics in the Netherlands and ran from February 2016 to April 2019. Patients were aged from 18 to 70 years and had at least six weeks of radiating leg pain caused by lumbar disc herniation.

The trial included a predetermined set of 125 PTED patients who were the early cases performed by three surgeons who had not performed PTED before the trial. Eventually 304 patients were allocated to PTED and 309 to open microdiscectomy.

The primary effect measures included leg pain as measured on the Visual Analogue Scale (VAS) and health-related quality of life (QALYs). Costs were measured from a societal perspective.

At the 24-month time point, 92% of follow-up data were available. The results show statistically significant differences in leg pain and QALYs in favour of PTED at 24 months (leg pain: 7.3; QALYs: 0.043).

Surgery costs were shown to be higher for PTED than for open microdiscectomy (€4,500 per patient vs. €4,095 per patient respectively). However, all other disaggregate costs as well as total societal costs were lower for PTED than for open microdiscectomy, namely primary care, secondary care, medication, informal care, absenteeism, presenteeism and productivity loss.

In addition, €138 in health care costs and €2,787 in societal costs were saved per PTED procedure performed. Cost-effectiveness acceptability curves indicated that the probability of PTED being cost-effective compared with open microdiscectomy (meaning on average less costly and more effective) was 99.4% for leg pain and 99.2% for QALYs, regardless of the willingness-to-pay.

Speaking to Spinal News International, Gadjradj said: “Previously we showed non-inferiority of PTED in leg pain reduction, compared to microdiscectomy one year after surgery. As we showed merits over microdiscectomy, some concerns were still raised about the long-term effectiveness and particularly the risk of recurrent surgery.

“In the current study we address these issues by confirming the non-inferiority of PTED in leg pain reduction, and the dominance in cost-effectiveness two years after surgery. I hope these results encourage surgeons to consider providing full-endoscopic techniques more frequently for sciatica.”