Would disc replacement be utilized more if it had higher reimbursement vs. spinal fusion?
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Reimbursement may incentivize surgeons
We would see this more readily in the lumbar spine in particular. Currently, many surgeons who do not do lumbar artificial disc replacement still perform cervical disc replacements.
Abundant level-1 data supports cervical artificial disc replacement over anterior cervical discectomy and fusion in appropriately selected patients which, combined with patient demand, has driven many surgeons to incorporate this into their practice. It helps that the approach to the cervical spine is already familiar to surgeons, so less of a learning curve is required. Additional incentivization from higher reimbursement would likely increase the numbers further.
With lumbar artificial disc replacement, there is equally compelling level-1 data supporting its use, yet adoption has been slower and less widespread. Studies have shown decreased incidence of radiographic adjacent segment degeneration and lower reoperation rates in patients with a lumbar artificial disc replacement compared to fusion. The evidence is not equivocal. Patients consistently report higher satisfaction scores compared to their fusion counterparts. Thus, for surgeons who believe that axial back pain at one or two levels that has failed appropriate conservative management can be treated with surgery: What is the obstacle for artificial disc replacement? I believe the biggest factor in lack of adoption is the disparity in reimbursement between lumbar artificial disc replacement and fusion.
With a single code for an artificial disc replacement, as opposed to many “add-on” codes depending on the fusion type, instrumentation, biologics, etc., reimbursement is considerably less. The procedure is technically demanding if done well and is less “forgiving” than a fusion, especially in a two-level case (where the CPT code for the second level lacks in relative value units). Many surgeons who only fuse via posterior or lateral approaches would have to adopt the anterior approach and find an access surgeon to partner with. Though many training opportunities exist, this entails time and effort, which may not seem like a reasonable economic investment for a procedure that will likely take more operative time than the already-familiar fusion, requires higher precision for an optimal outcome, necessitates coordinating schedules (and sharing fees) with an access surgeon and for which you will get paid less.
I think if reimbursement for lumbar disc replacement was increased or even equivalent to that of lumbar fusion, there would be more incentive for surgeons to learn and adopt a procedure that has scientifically proven merit for patients and health economics alike.
Jessica Shellock, MD, FAAOS, is a spine surgeon at the Texas Back Institute and co-director of the Center for Disc Replacement in McKinney, Texas.
Reimbursement not the deciding factor
No, disc replacement would not be significantly more utilized if reimbursements were higher than fusion.
There are several more compelling reasons that have prevented lumbar total disc replacement from achieving the popularity of cervical total disc replacement. The rate-limiting factor in the adoption of lumbar total disc replacement is the inherent difficulty in diagnosing and treating the primary indication for lumbar total disc replacement, namely, discogenic low back pain. The etiology of axial low back pain is heterogeneous with multiple potential pain generators (eg, disc, facets, basivertebral nerve, sacroiliac joint, musculoskeletal and rheumatologic conditions). Furthermore, diagnostic tests are unreliable. Provocative discography is invasive and has largely fallen out of favor. MRI does not provide a clinical correlation and promising alternatives, such as MR spectroscopy, have not been validated.
The controversy surrounding the surgical treatment of axial low back pain further impedes the adoption of lumbar total disc replacement. Low back pain is a ubiquitous condition, which does not threaten neurological function. Additionally, lumbar total disc replacement necessitates an anterior surgical approach, which is relatively more precarious compared to the workhorse posterior approach to the lumbar spine and requires a separate exposure surgeon. Furthermore, overall success rates are dramatically lower for the surgical treatment of low back pain (lumbar total disc replacement = 50% to 60%; lumbar fusion = 40% to 55%) compared to cervical radiculopathy (cervical total disc replacement = 85% to 95%; anterior cervical discectomy and fusion = 70% to 85%), the primary indication of cervical total disc replacement. In fact, proof of concept that lower reimbursement rate is not the deciding factor in utilization is demonstrated by cervical arthroplasty. Cervical total disc replacement has achieved acceptance and high market penetrance despite surgeon reimbursement rates that are generally one-third less than anterior cervical discectomy and fusion.
Of course, more favorable reimbursement would likely improve utilization of any procedure, but it is not the primary driving factor behind adoption, or lack thereof, of this particular technique. Instead, a firm evidence basis for efficacy as well as straightforward diagnosis, rationale for treatment and surgical approach are the rate-limiting factors. Continued focus on posterior lumbar arthroplasty, including artificial facet replacement, and treating clinical symptoms related to nerve compression (ie, neurogenic claudication or radiculopathy) from a traditional approach is more likely to lead to adoption that is more widespread.
- References:
- Coric D, et al. J Neurosurg Spine. 2022;doi:10.3171/2022.1.SPINE211264.
- Coric D, et al. J Neurosurg Spine. 2022;doi:10.3171/2022.7.SPINE22536.
- Garcia R, et al. Spine (Phila Pa 1976). 2015;doi:10.1097/BRS.0000000000001245.
- Guyer R, et al. Spine J. 2008;doi:10.1016/j.spinee.2008.08.007
- Phillips F, et al. Spine J. 2023;doi:10.1016/j.spinee.2023.10.020.
Dom Coric, MD, is the Jerry and Audrey Petty Endowed Professor of spine surgery at Atrium Health and medical director at Atrium Health, Southeast Region Spine Center of Excellence in Charolotte, North Carolina.
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