Spine Journal - 2026-07-21 - Journal Article
Cost-Effectiveness of Biportal Endoscopic Spine Surgery Compared with Microscopic Surgery for Lumbar Degenerative Diseases: A Pooled Analysis of Two Randomized Controlled Trials.
Park SM, Song KS, Kim HJ, Kang MS, You KH, Kim JS, Park HJ
Topics
Key Takeaway
At a Korean WTP threshold of USD 21,429/QALY, BESS had a 94.9% probability of cost-effectiveness versus microscopic surgery, with nearly identical total costs (USD 3,028 vs USD 3,080) and a 0.022 QALY advantage that did not reach statistical significance.
Summary Depth
Choose how much analysis to show on this article page.
Summary
This economic evaluation pooled two Korean multicenter RCTs (ENDO-BH for disc herniation, ENDO-BS for stenosis) to compare BESS versus MSS across 187 patients using cost per QALY from the healthcare provider perspective. Mean 1-year QALYs were 0.823 for BESS and 0.801 for MSS; total costs were USD 3,028 versus USD 3,080, with confidence intervals for both incremental costs and QALYs crossing zero. At the Korean WTP threshold, bootstrapped analysis (5,000 iterations) yielded a 94.9% probability that BESS is cost-effective.
Key Limitation
The WTP threshold of USD 21,429/QALY is specific to the Korean healthcare system and may not be transferable to higher-cost health systems (e.g., US, Western Europe), limiting generalizability of the cost-effectiveness conclusion.
Original Abstract
BACKGROUND CONTEXT
Although biportal endoscopic spine surgery (BESS) has shown clinical benefits for lumbar degenerative diseases, comprehensive cost-utility analyses comparing BESS with microscopic spine surgery (MSS) remain limited.
PURPOSE
We aimed to compare the cost-effectiveness of BESS and MSS for lumbar degenerative diseases from a healthcare provider's perspective using quality-adjusted life years (QALYs) as the effectiveness measure.
STUDY DESIGN
This economic evaluation was conducted alongside two multicenter, prospective, blinded, randomized controlled trials (ENDO-BH for lumbar disc herniation and ENDO-BS for lumbar spinal stenosis) at six tertiary hospitals in South Korea.
PATIENT SAMPLE
Overall, 220 patients aged 20-80 years requiring single-level lumbar surgery were randomized to the BESS or MSS groups, and 187 patients with complete 12-month follow-up data were included in the analysis (BESS, 96; MSS, 91).
OUTCOME MEASURES
The primary outcome was the incremental cost-effectiveness ratio expressed as cost per QALY gained. Secondary outcomes included net monetary benefit (NMB) and probability of cost-effectiveness at the Korean willingness-to-pay (WTP) threshold. QALYs were calculated using the area under the curve of EQ-5D-5L utility values measured at baseline, 2 weeks, 3 months, 6 months, and 12 months postoperatively.
METHODS
Costs were measured from the healthcare provider's perspective using institutional billing data adjusted to Korean won (KRW). Non-parametric bootstrapping (5,000 iterations) was performed to estimate uncertainty, and cost-effectiveness acceptability curves were constructed.
RESULTS
The mean 1-year QALYs were 0.823 ± 0.079 for BESS and 0.801 ± 0.112 for MSS. The total costs were USD 3,028 for BESS and USD 3,080 for MSS. Confidence intervals for incremental costs and QALYs crossed zero. At the WTP threshold of USD 21,429 (30,000,000 KRW) per QALY, the probability that BESS would be cost-effective was 94.9%.
CONCLUSIONS
BESS is a cost-effective alternative to MSS for treating lumbar degenerative diseases, with a cost-effectiveness probability of 94.9% at the WTP threshold during the 12-month follow-up. Neither technique showed a statistically significant advantage in terms of cost or QALYs, indicating that BESS can be adopted without increasing direct medical costs.
LEVEL OF EVIDENCE
I.