Cervical Artificial Disc Replacement Versus Fusion for Cervical Degenerative Disc Disease: A Health Technology Assessment

Health Quality Ontario
Record ID 32018000444
Authors' objectives: This health technology assessment examined the effectiveness, safety, durability, and cost-effectiveness of cervical artificial disc replacement (C-ADR) versus fusion for treating cervical degenerative disc disease. It also examined the preferences, values, and experiences of people with cervical degenerative disc disease.
Authors' results and conclusions: Results: Eight studies of C-ADR for one-level cervical degenerative disc disease and two studies of C-ADR for two-level disease satisfied the criterion of statistical noninferiority compared with fusion on the primary outcome of 2-year overall treatment success (GRADE: Moderate). In two studies of C-ADR for two-level disease, C-ADR was statistically superior to fusion surgery for the same primary outcome (GRADE: Moderate). C-ADR was also noninferior to fusion for perioperative outcomes (e.g., operative time, blood loss), patient satisfaction, and health-related quality of life (GRADE: Moderate). C-ADR was superior to fusion for recovery and return to work, had higher technical success, and had lower rates of re-operation at the index site (GRADE: Moderate). C-ADR also maintained motion at the index-treated cervical level (GRADE: Moderate), but evidence was insufficient to determine if adjacent-level surgery rates differed between C-ADR and fusion. Current evidence is also insufficient to determine the long-term durability of C-ADR. The primary economic analysis shows that C-ADR is likely to be cost-effective compared with fusion for both one-level ($11,607/quality-adjusted life-year [QALY]) and two-level ($16,782/QALY) degeneration. Various sensitivity and scenario analyses confirm the robustness of the results. The current uptake for one-level and two-level C-ADR in Ontario is about 8% of the total eligible. For one-level involvement, the estimated net budget impact increases from $7,243 (18 procedures) in the first year to $395,623 (196 procedures) in the fifth year following public funding, for a total budget impact over 5 years of $916,326. For two-level involvement, the corresponding values are $5,460 (7 procedures) in the first year and $283,689 (76 procedures) in the fifth year, for an estimated total budget impact of $705,628 over 5 years. People with cervical degenerative disc disease reported that symptoms of pain and numbness can have a negative impact on their quality of life. People with whom we spoke had tried a variety of treatments with minor success; surgery was perceived as the most effective and permanent solution. Those who had undergone C-ADR spoke positively of its impact on their quality of life and ability to move their neck after surgery. The limited availability of C-ADR in Ontario was viewed as a barrier to receiving this treatment. Conclusions: For carefully selected patients with cervical degenerative disc disease, C-ADR provides patient-important and statistically significant reductions in pain and disability. Further, unlike fusion, C-ADR allows people to maintain relatively normal cervical spine motion. Compared with fusion, C-ADR appears to represent good value for money for adults with one-level cervical degenerative disc disease ($11,607/QALY) and for adults with two-level disease ($16,782/QALY). In Ontario, publicly funding C-ADR could result in total additional costs of $916,326 for one-level procedures and $705,628 for two-level procedures over the next 5 years. People with whom we spoke who had undergone C-ADR surgery spoke positively of its impact on their quality of life and ability to move their neck after surgery. The limited availability of C-ADR in Ontario was viewed as a barrier to receiving this treatment.
Authors' recomendations: Health Quality Ontario, under the guidance of the Ontario Health Technology Advisory Committee, recommends publicly funding cervical artificial disc replacement for cervical degenerative disc disease
Authors' methods: We performed a systematic literature search of the clinical evidence comparing C-ADR with fusion. We assessed the risk of bias in each study and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic review of the economic literature and assessed the cost-effectiveness of C-ADR compared with fusion. We also estimated the budget impact of publicly funding C-ADR in Ontario over the next 5 years. To contextualize the potential value of C-ADR, we spoke with people with cervical degenerative disc disease.
Project Status: Completed
Year Published: 2019
Requestor: Ontario Health Technology Advisory Committee (OHTAC); Ontario Ministry of Health
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: Canada
Province: Ontario
Pubmed ID: 30847009
MeSH Terms
  • Quality of Life
  • Quality-Adjusted Life Years
  • Cost-Benefit Analysis
  • Patient Satisfaction
  • Intervertebral Disc Degeneration
  • Cervical Vertebrae
  • Spinal Fusion
  • Total Disc Replacement
  • Blood Loss, Surgical
  • Operative Time
  • Technology Assessment, Biomedical
  • cervical disc
  • artificial disc replacement
  • health technology assessment
  • spinal fusion
  • economic analysis
  • degenerative disc disease
Organisation Name: Health Quality Ontario
Contact Address: Evidence Development and Standards, Health Quality Ontario, 130 Bloor Street West, 10th floor, Toronto, Ontario Canada M5S 1N5
Contact Name: EDSinfo@hqontario.ca
Contact Email: OH-HQO_hta-reg@ontariohealth.ca
Copyright: Health Quality Ontario
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.