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Economics of Minimally Invasive Spine Surgery
Minimally invasive surgery (MIS) in spine care encompasses techniques that achieve the goals of traditional open surgery while reducing soft tissue disruption and preserving stabilizing structures.[1,2] Utilization of MIS techniques has accelerated in recent years, supported by evidence of reduced perioperative morbidity, shorter hospitalizations, and faster recovery.[3,4] While these clinical advantages are important, the broader impact of MIS lies in its potential to reshape the economics of spine care. Spine care is facing increasing pressures around value-based care, cost containment, and resource allocation.[5–7] Thus, beyond clinical effectiveness, it is essential to understand how MIS influences cost drivers, short- and long-term economic outcomes, and the overall value to patients, providers, and society. This review aims to examine the contemporary economic implications of MIS utilization in spine surgery.
Cost Drivers and Savings in MIS
The costs of spine surgery can be highly variable, ranging from $8,286 to $120,394.[8,9]
The major drivers of cost include medical devices/implants, facility and operating room expenses, hospitalization, and surgeon compensation.[8–10] In more complex cases, which often involve a greater number of levels, longer operating times and more intensive postoperative care further increase costs. Complications, such as infection or hardware-related sequelae, can compound these costs by requiring further treatments, readmission, or even reoperations.[11] Additionally, indirect costs, such as those relating to extended postoperative care needs, rehabilitation, and loss of productivity, should be considered to comprehensively evaluate the economic costs of undergoing spine surgery.
MIS has the potential to alter the cost profile of spine procedures substantially and in several important ways. By reducing the procedural invasiveness, MIS can decrease surgical morbidity and speed up recovery in the immediate postoperative period, which may translate into lower hospital care costs.[12,13] Reduced length of stay (LOS) is consistently cited as one of the most significant cost savings associated with MIS, in addition to lowered use of narcotics and inpatient rehabilitation needs.[14–16] Furthermore, smaller incisions decrease the risk of surgical site infections, while earlier and improved patient mobilization can reduce medical complications such as deep vein thrombosis (DVT).[17,18] Moreover, the utilization of robotic technologies in MIS can enhance the accuracy of instrumentation and thus potentially reduce hardware-related complications.[19,20] Reduced medical and hardware complications and fewer readmissions further lower downstream direct expenditures for both hospitals and patients.[17,21] As a result of the above, MIS techniques can also facilitate outpatient procedures, enabling a shift to specialized ambulatory surgical centers, which are generally more efficient and can further enhance overall economic value.[22–24] Indirect costs, such as patient productivity loss and caregiver burden, may also be improved, as MIS has been associated with lower perioperative care dependency and faster return to work.[25,26] However, it is important to recognize that savings and added costs are not universal and vary by procedure type: simple decompression, single-level fusion, multilevel fusion, and deformity corrections have distinct cost structures and likely different MIS value propositions. For example, the latter two procedure types tend to have longer operative times and greater implant or instrumentation requirements, which may erode theoretical cost savings offered by MIS.[27] Although MIS may reduce downstream costs, high upfront investments may offset early savings. There are high upfront capital investments for surgeon education and training, as well as expensive infrastructure such as microscopes, endoscopic equipment, intraoperative imaging systems, and navigation or robotic platforms.[28] An individual set of endoscopic equipment, for instance, can cost up to $300,000[29] (Figure 1). In addition to one-time capital expenditures, MIS is associated with higher variable per-case costs, including specialized implants, devices, and other consumables, compared with traditional open techniques.[30,31] Additionally, the steep learning curve for surgeons adopting MIS techniques often necessitates longer operative times early in the adoption process, potentially diminishing initial cost-effectiveness. However, the learning curve for MIS is typically short, with proficiency achieved after 20–40 cases for nondeformity cases, suggesting that any early increases in operative time or costs are temporary and can be quickly offset.[32–34] Importantly, while upfront costs are substantial, higher procedural volumes help dilute these expenses on a per-case basis, reinforcing the role of surgical volume and the potential for higher economic efficiency by implementing MIS in high-volume settings.
Economic Evaluation Methods in MIS
Because the conclusions of economic studies in MIS are largely determined by their methodological approach, a clear understanding of the analytic frameworks used is essential for accurate interpretation. Several analytic methods are used to evaluate the economics of MIS, considering both clinical outcomes and economic impacts across the healthcare system. One such method is cost-effectiveness analysis (CEA), which compares the relative costs and outcomes between interventions. Costs are measured in monetary units, while effectiveness is measured in nonmonetary outcomes, such as LOS, complication rates, and readmissions.[35] A cost-effectiveness ratio is then established to compare different interventions. Cost-utility analysis (CUA) is a subtype of CEA that focuses on a composite measure of both quantity and quality of life outcome, in quality-adjusted life years (QALYs), instead of a specific health outcome.[36] QALYs are calculated by multiplying the number of life-years gained by a chosen utility value, reflecting prefer- ences for specific health outcomes.[37] CEA and CUA present results based on impact on patients and enables clear comparisons between diverse interventions that aim for similar outcomes. They highlight the opportunity costs implicit in resource allocation, helping providers and patients choose between treatments, and guiding policymakers on whether investing in MIS delivers greater health gains per dollar.[38,39]
However, significant limitations exist for both CEA and CUA. Their outcomes depend heavily on methodologies used, involve confounding cross-study comparisons, and often conflict with societal values and other perspectives when used as the primary foundation for decision-making.[40,41] For all methodologies, the choice of economic evaluation method reflects decisions about what constitutes “success” and how it should be valued. They typically evaluate average costs and outcomes across general populations, yet MIS may be highly cost-effective for certain patient subgroups, such as younger patients or high-risk patients, and not for others, causing interpretation to be inherently subjective even when underlying data are objective.[41] The quality and comparability of CUAs remain problematic, with many studies in spine care exhibiting substantial heterogeneity in interventions compared, cost components measured, and methodological approaches, with mixed reporting quality that fails to provide sufficient concluding evidence.[42,43] Although conceptually simple, CEA/CUA can be difficult to apply and does not capture all value judgments, so results should be interpreted alongside budgetary, feasibility, and stakeholder considerations in transparent, context-specific decision-making.
In contrast to CEA and CUA, CBA differs by expressing both costs and benefits in monetary terms. Net benefit is measured in monetary terms as the total benefits minus total costs. This can be expressed as a cost-benefit ratio: the dollar value of benefit received for every dollar spent.[44] The main advantage of CBA over CEA/CUA is in its interpretability by framing the entire conversation in strictly monetary terms. This is particularly valuable in the context of MIS, where the benefits are real but often subtle, and trade-offs are significant. By converting benefits to monetary terms, CBA makes opportunity costs explicit and helps identify which groups stand to gain or lose from an intervention, supporting transparent and socially accountable resource allocation. However, among the methods mentioned, CBA faces the most significant methodological and ethical limitations, as human life and health are assigned arbitrary monetary values and calculations may be structured to favor industry interests over public health.[45] From an ethical perspective, Kelman et al contend that many health and safety decisions may be morally correct even when benefits don’t outweigh costs, and they oppose monetizing nonmarketed benefits and costs.[46] As is with the other methods, CBA is best used in tandem with other types of analysis, not as a standalone tool in clinical decision-making.
Stakeholder Perspectives in Economic Evaluation
The chosen stakeholder perspectives determine which costs and outcomes are included, as well as which factors are prioritized in the analysis. Patient-focused analyses tend to emphasize health-related quality of life, complications costs, and out-of-pocket expenses. Narain et al found that long-term outcomes, the surgeon’s recommendation, and complication risk are most important for patients choosing between open and MIS; thus, patient-centered studies should prioritize long-term quality-of-life measures and preference-based outcomes, for which CEA and CUA are most applicable.[47] Another perspective to consider would be the health care provider. The provider’s perspective includes all costs incurred by a provider in delivering care to patients, including procedure, device/implant, staffing, facility and capital costs. While it may sometimes overlap with the patient perspective, it is typically broader and better suited for evaluating the financial implications of hospital policies.[48] This perspective is often applied in CBA and commonly adopted by hospital administrators and policymakers to guide resource allocation. The societal perspective is the most comprehensive, accounting for all potential costs and benefits to society such as productivity, caregiver burden, and non-medical costs, regardless of who incurs the costs or receives the benefits. However, its breadth requires longer time horizons, includes additional assumptions, and often sacrifices precision for comprehensiveness.
Short-Term Economic Impacts
As MIS’ primary advantage is to reduce surgical morbidity in the immediate postoperative period and accelerate recovery, its economic impact is also expected to be greatest in the short term. Currently, studies suggest that acute care costs for MIS spine surgery are lower than those of traditional open surgeries.[49,50] Safaee et al found that open decompression was associated with higher total cost than MIS ($21,280 vs $14,407), which was driven by care pathway and length of stay.[51] For lumbar fusions, studies showed that while single-level lumbar fusions yield no significant cost difference between MIS and open approaches, MIS demonstrates substantial savings in two-level fusions (up to $2825 per operation in savings), attributed to lower LOS and facility costs, suggesting MIS’s benefits may be more pronounced in procedures with greater surgical morbidity.[13,52] When comparing MIS and open procedures for adult degenerative scoliosis (ADS), Uddin et al demonstrated that the inpatient charge for MIS, including complications and revision surgeries, was on average $122,081 less expensive for MIS than for the open cohort.[53] The quoted savings (~$120,000) are strikingly higher than savings reported in other studies (~$3000-$7000), likely reflecting in part the prolonged length of stay associated with deformity surgeries. While this may point to a genuine economic advantage of MIS in such cases, the analysis emphasized the provider perspective, extensively including pre-insurance hospital costs rather than reimbursement/patient charges, which may have inflated the reported savings, and the methodological limitations noted above decrease the strength of this conclusion. MIS appears to generate substantial immediate postoperative savings, and with increasing surgical volume, these savings are expected to offset the initial investment and eventually yield net cost benefits. However, short-term impacts cannot be directly extrapolated, and the long-term economic effects of MIS warrant separate consideration, particularly given its potential to preserve spinal stability and reduce complications and reoperations in the long run.
Long-Term Economic Impacts
Current evidence regarding long-term economic impacts of various procedures utilizing MIS presents mixed findings when compared with traditional open surgery. Many studies find long-term clinical outcome differences are often small or inconsistent. [17,54] Studies differ in perspective (hospital charges vs costs vs societal), time horizon, inclusion of capital or implant costs, and whether they perform formal CEA/CUA or simple cost comparisons, and therefore caution should be exercised when interpreting these results.
A systematic review that included 3 studies assessed outcomes of MIS vs open discectomy, where each reported statistically significant lower total costs in MIS compared with the open group, with similar reported gains in QALYs.[30] In a 2-year CEA, Parker et al found that MIS multilevel hemilaminectomy incurred costs comparable to the open approach for lumbar stenosis, with both groups achieving the same cumulative gain of 0.72 QALYs at 2 years postoperatively.[55]
For fusion surgeries, Vertuani et al evaluated the cost-effectiveness of MIS and open one- to two-level lumbar fusions in the United Kingdom and Italy, reporting a more modest total cost saving per procedure in favor of MIS ($1080 for Italy and $1849 for the United Kingdom, 2015 USD), with only an improvement of 0.04 QALYs over 2 years.[56] Another study found that mean total costs (accounting for complications, revisions, and operating fees) were similar for open and MIS lumbar fusions ($42,500 vs $41,500), with its subanalysis suggesting lower cost-per-QALY for MIS ($115,912 vs $296,624 at 1 year; $5,825 vs $14,906 extrapolated to lifetime), though results should be interpreted cautiously given sample size and assumptions.[49] For more specific fusion approaches, a pooled summary by Chung et al of five CEAs suggested MIS TLIF produced greater savings over open TLIF, ranging from $3,569 to $9,295, with direct hospital cost savings between $1,758 and $2,820, though not all differences reached statistical significance.[31] Transpsoas approaches (LLIF) have been associated with better outcomes in terms of postoperative health-related quality of life and lower costs over 1-year follow-up compared with the more invasive open technique, though the study is of limited size.[57] For longer segment fusions, Passias et al found that while patients receiving T11-Pelvis fusions had similar baseline EQ-5D (health-related quality of life) scores, MIS patients had a significantly better improvement at 1-year postoperative follow-up.[49] Overall, despite consistent evidence of immediate postoperative cost savings and value, longer-term economic evidence remains uncertain because of methodological heterogeneity across studies.
Conclusion and Future Directions
Minimally invasive spine surgery offers meaningful opportunities to improve value in spine care by reducing morbidity, length of stay, complications, and indirect costs, though these gains must be weighed against substantial upfront investment, higher per-case expenditures, and procedure-specific variability in benefits. While short-term evidence consistently supports cost savings and faster recovery, long-term data remain limited and heterogeneous. Future standardized economic evaluations should adopt rigorous methodologies that integrate multiple stakeholder perspectives, as well as capture long-term differences in economic value between MIS and open surgery across procedure types with distinct cost-benefit profiles.
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Contributors:
Adrian T.H. Lui, MBBS[1]
Nicholas J. Giattino, BA[1]
Tomoyuki Asada, MD, PhD[1,2]
Sheeraz A. Qureshi, MD, MBA[1,3]
From the 1Department of Orthopaedics at the Hospital for Special Surgery in New York City, New York; 2Department of Orthopedics at the University of Tsukuba Hospital in Tsukuba, Japan; and 3Weill Cornell Medical College in New York City, New York.
