Cost-Effectiveness of Full Endoscopic
versus Open Discectomy for Sciatic

With a lifetime prevalence of up to 43% in the general population, sciatica carries a substantial burden on both individuals and society. At the individual level, patients may endure leg pain, sensory or motor loss, and a diminished quality of life.

This is especially challenging for active adults between the ages of 30 and 50. Societally, sciatica imposes significant financial strains due to costs related to sick leave and hospitalization.

Although most sciatica cases improve with conservative treatment, surgery for lumbar disc herniation is commonly performed due to the high prevalence of the condition.

The standard surgical procedure is open microdiscectomy, but percutaneous transforaminal endoscopic discectomy (PTED) is a less invasive alternative. PTED is performed as outpatient surgery under local anesthesia, but its adoption is limited due to challenges such as the learning curve and unclear advantages over conventional microdiscectomy.

Previous research has found no significant differences in leg pain and functional status between PTED and open microdiscectomy. PTED has the advantage of less blood loss and shorter hospital stays.

However, PTED is associated with higher overall costs, primarily due to expenses related to endoscopes. Hospitalization costs, on the other hand, are lower for PTED compared to open microdiscectomy. A comprehensive economic evaluation comparing the costs and effects of both procedures is lacking.

The PTED study assessed the effectiveness and cost-effectiveness of PTED versus open microdiscectomy for lumbar disc herniation. PTED was found to be non-inferior to open microdiscectomy in reducing leg pain and showed better outcomes for patient-reported leg pain and quality of life.

However, the cost differences and their relationship to these outcomes remain unclear. An economic evaluation comparing the two procedures is needed, especially considering the coverage of PTED by insurance providers.

The study aims to explore the cost-effectiveness of PTED from a societal perspective and includes a sensitivity analysis from the healthcare perspective for decision-making in relevant countries.

During the period from February 2016 to April 2019, literature reported a study that compared PTED and open microdiscectomy included 613 eligible patients out of 711 assessed. The study had to be concluded before reaching the estimated sample size due to meeting the predetermined inclusion criteria.

Among the participants, 304 underwent PTED while 309 underwent open microdiscectomy. A subgroup of 125 patients in the PTED group, classified as part of the learning curve, was excluded from the primary analysis.

The final sample consisted of 179 patients in the PTED group and 309 patients in the open microdiscectomy group, with similar patient characteristics between the two groups. Follow-up questionnaires were completed by 313 patients, although some individuals in both groups had missing data.

There were variations in factors such as gender, employment status, treatment preference, depression, anxiety, duration of symptoms, probability of second surgery, and baseline utility between participants with complete and incomplete data.

Significant differences were found between the PTED and open microdiscectomy groups in terms of leg pain reduction and QALYs. PTED patients experienced a larger reduction in leg pain (6.9 on the VAS scale) and gained 0.040 QALYs at the 12-month follow-up compared to the open microdiscectomy group.

Additionally, a higher percentage of PTED patients (94.2%) were discharged on the same day of surgery. The rate of repeated surgery within one year was similar between the two groups (5.3% for PTED, 5.6% for open microdiscectomy).

Surgery costs were higher for PTED compared to open microdiscectomy, but other costs such as primary healthcare, informal care, absenteeism, and presenteeism were lower for PTED. Total societal costs for PTED were significantly lower than for open microdiscectomy by €2787. Presenteeism and absenteeism were identified as the main cost drivers.

At the 12-month mark, PTED was found to be a cost-effective and dominant treatment option compared to open microdiscectomy for reducing leg pain and improving QALYs. The probability of PTED being both cost-effective and superior to open microdiscectomy was high, ranging from 99.2% to 99.4%.

In all six sensitivity analyses conducted, PTED consistently showed favorable outcomes as a cost-effective and often dominant treatment option compared to open microdiscectomy. It effectively reduced leg pain and improved QALYs.

Even when adopting the healthcare perspective without considering productivity losses, PTED remained highly likely to be a cost-effective choice at reasonable willingness-to-pay thresholds for both leg pain reduction and QALY improvement.

The study reported by literature suggests that PTED is a cost-effective and dominant treatment compared to open microdiscectomy for patients with lumbar disc herniation.

PTED was found to be more effective and less costly for leg pain and QALYs. The results were consistent across sensitivity analyses, confirming the robustness of the findings.

Randomized controlled trials comparing the cost-effectiveness of PTED with open microdiscectomy or other surgical techniques for lumbar disc herniation are currently lacking.

However, a recent non-randomized study found that endoscopic surgery, including PTED, showed favorable cost-effectiveness compared to open microdiscectomy. It should be noted that the study had limitations, such as its retrospective design and focus on the healthcare perspective only.

The PTED study findings have important implications for both individuals and society. PTED was shown to be comparable to open microdiscectomy in treating leg pain, with some advantages such as avoiding general anesthesia and faster recovery.

The study also highlighted lower costs associated with PTED, leading to its inclusion in the Dutch basic health insurance package. Internationally, challenges remain in terms of reimbursement and implementation, but the study suggests a need to reconsider the effectiveness of endoscopic techniques.

Adequate training and close monitoring are crucial during the learning curve of adopting PTED.

The study findings indicate that PTED is a cost-effective treatment option for patients with lumbar disc herniation compared to open microdiscectomy.

PTED is not only more effective but also less expensive from a societal perspective. These results strongly support the inclusion of PTED in the range of treatments available for managing sciatica.

Dr. Nakul Karkare

I am fellowship trained in joint replacement surgery, metabolic bone disorders, sports medicine and trauma. I specialize in total hip and knee replacements, and I have personally written most of the content on this page.

You can see my full CV at my profile page.