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Cost-effectiveness of total disc replacement versus multidisciplinary rehabilitation in patients with chronic low back pain: A norwegian multicenter RCT


Study Design. Randomized clinical trial with 2-year follow-up.

Objective. To evaluate the cost-effectiveness of total disc replacement (TDR) versus multidisciplinary rehabilitation (MDR) in patients with chronic low back pain (CLBP).

Summary of Background Data. The existing studies on CLBP report cost-effectiveness of fusion surgery versus disc replacement and fusion versus rehabilitation. This study evaluated the cost-effectiveness of TDR versus MDR.

Methods. Between April 2004 and May 2007, 173 patients with CLBP (>1 yr) were randomized to TDR (n = 86) or MDR (n = 87). Treatment effects (Euro Qol 5D [EQ-5D] and Short Form 6D [SF-6D]) and relevant direct and indirect costs at 6 weeks and at 3, 6, 12, and 24 months after treatment were assessed. Gain in quality-adjusted life years (QALYs) after 2 years was estimated. Cost-effectiveness was expressed as an incremental cost-effectiveness ratio.

Results. The mean QALYs gained (standard deviation) using EQ-5D was 1.29 (0.53) in the TDR group and 0.95 (0.52) in the MDR group, a significant difference of 0.34 (95% confidence interval 0.18–0.50). The mean total cost per patient in the TDR group was €87,622 (58,351) compared with €74,116 (58,237) in the MDR group, which was not significantly different (95% confidence interval: −4041 to 31,755). The incremental cost-effectiveness ratio for the TDR procedure varied from €39,748 using EQ-5D (TDR cost-effective) to €128,328 using SF-6D (TDR not cost-effective). The dropout rate was 20% (15% TDR group, 24% MDR group). Five patients moved from the MDR to the TDR group, whereas 9 patients randomized to TDR declined surgery. Using per-protocol analysis instead of intention-to-treat analysis indicated that TDR was not cost-effective, irrespective of the use of EQ-5D or SF-6D.

Conclusion. In this study, TDR was cost-effective compared with MDR after 2 years when using EQ-5D for assessing QALYs gained and a willingness to pay of €74,600 (kr500,000/QALY). TDR was not cost-effective when SF-6D was used; therefore, our results should be interpreted with caution. Longer follow-up is needed to accurately assess the cost-effectiveness of TDR.


Academic article




  • Lars Gunnar Johnsen
  • Christian Hellum
  • Kjersti Storheim
  • Øystein Petter Nygaard
  • Jens Ivar Brox
  • Ivar Rossvoll
  • Magne Rø
  • Hege Andresen
  • Stian Lydersen
  • Oliver Grundnes
  • Marit Pedersen
  • Gunnar Leivseth
  • Gylfi Olafsson
  • Fredrik Borgstrôm
  • P Fritzell


  • Norwegian University of Science and Technology
  • St. Olavs Hospital, Trondheim University Hospital
  • Oslo University Hospital
  • University of Oslo
  • Aleris AS
  • SINTEF Digital
  • UiT The Arctic University of Norway
  • Karolinska Institutet
  • Sweden



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Wolters Kluwer






23 - 32

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