Clinical Orthopaedics and Related Research®

, Volume 470, Issue 4, pp 1106–1123

Value-based Care in the Management of Spinal Disorders: A Systematic Review of Cost-utility Analysis

  • Santoshi S. Indrakanti
  • Michael H. Weber
  • Steven K. Takemoto
  • Serena S. Hu
  • David Polly
  • Sigurd H. Berven
Symposium: Value Based Healthcare



Spinal disorders are a major cause of disability and compromise in health-related quality of life. The direct and indirect costs of treating spinal disorders are estimated at more than $100 billion per year. With limited resources, the cost-utility of interventions is important for allocating resources.


We therefore performed a systematic review of the literature on cost-utility for nonoperative and operative interventions for treating spinal disorders.


We searched four databases for cost-utility analysis studies on low back pain management and identified 1004 items. The titles and abstracts of 752 were screened before selecting 27 studies for inclusion; full texts of these 27 studies were individually evaluated by five individuals.


Studies of nonoperative treatments demonstrated greater value for graded activity over physical therapy and pain management; spinal manipulation over exercise; behavioral therapy and physiotherapy over advice; and acupuncture and exercise over usual general practitioner care. Circumferential fusion and femoral ring allograft had greater value than posterolateral fusion and titanium cage, respectively. The relative cost-utility of operative versus nonoperative interventions was variable with the most consistent evidence indicating superior value of operative care for treating spinal disorders involving nerve compression and instability.


The literature on cost-utility for treating spinal disorders is limited. Studies addressing cost-utility of nonoperative and operative management of low back pain encompass a broad spectrum of diagnoses and direct comparison of treatments based on cost-utility thresholds for comparative effectiveness is limited by diversity among disorders and methods to assess cost-utility. Future research will benefit from uniform methods and comparison of treatments in cohorts with well-defined pathology.


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Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • Santoshi S. Indrakanti
    • 1
  • Michael H. Weber
    • 3
  • Steven K. Takemoto
    • 3
  • Serena S. Hu
    • 3
  • David Polly
    • 2
  • Sigurd H. Berven
    • 3
  1. 1.Washington University in St Louis School of MedicineSt LouisUSA
  2. 2.University of MinnesotaMinneapolisUSA
  3. 3.University of California-San FranciscoSan FranciscoUSA

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