Abstract
Recurrent lumbar disc herniation (RLDH) is a common complication after discectomy, occurring in 2%–25% of patients and contributing to higher reoperation rates, reduced satisfaction, and substantial direct and indirect costs. This review evaluates the economic consequences of RLDH and the relative cost-effectiveness of available management strategies. A systematic search of OVID, MEDLINE, and the Cochrane Library was performed through August 2025. Peer-reviewed, English-language studies were included if they examined adults (≥18 years) with RLDH and reported economic data. Exclusion criteria were studies limited to primary, cervical, or thoracic herniations; animal or cadaveric models; and abstracts. Extracted variables included study design, sample size, follow-up duration, and cost components. Of 283 records identified, 220 were screened and 35 underwent full-text review. Six studies met inclusion criteria, with 2 added through citation searching. Reported costs varied considerably: repeat discectomy added $6,907 in one analysis, while fusion increased expenses by more than 350%. Across studies, repeat discectomy remained the most cost-efficient option, providing comparable outcomes with reduced perioperative expenditures. Conservative management had the lowest immediate direct costs (≈$2,300) but likely underestimates the overall burden due to unmeasured productivity losses. Annular closure devices demonstrated potential cost savings of $2,000–5,000 over 2–5 years. RLDH imposes a substantial economic burden. Heterogeneity in costing methods remains a major limitation which hinders evidence-based determinations. Greater transparency, methodological standardization, and incorporation of societal perspectives are essential to accurately assess the socioeconomic impact of RLDH.
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Keywords: Intervertebral disc displacement, Reoperation, Costs and cost analysis, Quality of life
INTRODUCTION
Lumbar disc herniation (LDH) is one of the most common spine conditions for which patients seek treatment and can result in significant pain, disability, and reduced quality of life (QoL). Many patients experience relief with initial nonoperative measures such as rest, physical therapy (PT), multimodal pain medications, and targeted epidural steroid injections. Approximately 85%–90% of acute LDHs resolve in the first 6–12 weeks with conservative management [
1,
2]. But for those who fail conservative treatment, surgery via lumbar microdiscectomy or other techniques may be indicated.
There are a multitude of studies which suggest favorable outcomes of operative treatment for LDH [
2,
3]. However, a subset of individuals suffers from recurrent lumbar disc herniation (RLDH) which can lead to prolonged and chronic symptoms including recalcitrant pain, paresthesia and/or weakness. The overall risk of RLDH following surgery is well-studied and reported between 2%–25% [
4] with risk factors including younger age, smoking, diabetes, and higher baseline Oswestry Disability Index (ODI) [
5,
6]. RLDHs not only have profound physical and psychological effects on patients but also place considerable socioeconomic burden on individuals and healthcare systems.
Ambrossi et al. [
7] estimated the additional direct cost associated with diagnosing and treating recurrence at $289,797 per 100 cases of primary single-level discectomy. But the economic impact of RLDHs extends beyond the direct costs associated with medical treatment, surgery, and rehabilitation. Indirect costs, such as lost productivity, long-term disability, and reduced workforce participation, further contribute to the financial strain. As defined by Alvin et al. [
8], the societal perspective of cost evaluation is more comprehensive through its additional consideration of indirect costs, whereas the healthcare perspective solely measures direct costs. Notably, RLDHs often lead to prolonged periods of work absenteeism, disability claims, and an increased demand for future healthcare services [
9]. As a result, the socioeconomic burden is not limited to individuals directly impacted by the condition; patients’ families, employers, and public health systems also experience significant consequences as a result.
This narrative review aims to explore the socioeconomic implications of RLDH, focusing on the direct and indirect costs, the cost-effectiveness of conservative therapies, surgical techniques, and technologies, and the long-term economic consequences for individuals and society. We seek to provide a comprehensive understanding of how RLDH influences economic outcomes, highlight the need for targeted interventions and preventative strategies, and emphasize future directions for research.
MATERIALS AND METHODS
1. Inclusion Criteria
All peer-reviewed, English studies on RLDHs and cost in human adults (≥18 years old) were included in the review.
2. Exclusion Criteria
Studies that focused solely on index disc herniations, cervical, or thoracic herniations, and animal or cadaveric studies were excluded from the review.
3. Search Protocol
A systematic literature search was performed following the Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) guidelines. The articles included in this review were gathered from OVID, MEDLINE, and the Cochrane Library on August 2, 2025. A combination of keywords was utilized to capture a comprehensive array of studies related to RLDH and economic data. Keywords include “Intervertebral Disc Displacement,” “Reoperation,” “Costs and Cost Analysis,” and “Quality of Life.” The comprehensive search strategy is presented in Supplemental Material 1. The references of included studies were further queried to identify additional articles that met our study criteria.
4. Study Selection
We exported articles into Rayyan (Cambridge, MA, USA), a professional research software commonly used by investigators for ease of study decision making, where duplicates were identified and removed. Two independent reviewers (AR and EW) used the described search protocol to select relevant articles for this review. After removing duplicates, the eligible manuscripts were analyzed based on their titles and abstracts, followed by a full-text review.
5. Data Extraction
Data were extracted on the following variables: authors, year, study design, sample size, cohort characteristics, follow-up period, intervention, cost perspective, cost calculation method, discount rate (%), direct costs (United States dollars, USD), definitions of direct cost, indirect costs/ICER (incremental cost-effectiveness ratio), and outcome/QoL metrics assessed. Since the costs in Selva-Sevilla et al. [
10] were expressed in 2011 euros, they were converted to USD using an average 2011 exchange rate (1 EUR=1.39 USD). The chosen variables have been demonstrated to be crucial to cost-effectiveness analyses (CEA) in prior studies [
8].
Study quality was assessed using the Cochrane risk of bias tool and Newcastle-Ottawa Scale [
11]. The Newcastle-Ottawa Quality Assessment Form for Cohort Studies was conducted on all nonrandomized studies, and the results are presented in
Supplemental Table 1. Scores on the Newcastle-Ottawa Scale were converted to AHRQ (Agency for Healthcare Research and Quality) standards (good, fair, and poor). The Cochrane risk of bias tool was completed for the parent randomized controlled trial [
12] from which the CEA of Ament et al. [
13] was derived, and the results are presented in
Supplemental Table 2.
RESULTS
1. Study Selection
We identified a total of 283 studies. After removing 63 duplicates, a total of 220 studies were screened. Overall, 185 studies were excluded based on their titles and abstracts, and 35 full-text articles were assessed for eligibility. Of these, 29 were excluded for the following reasons: abstracts only (n=7), not focused on cost (n=7), not focused on RLDH (n=14), duplicate manuscript on the same cohort (n=1). At the conclusion of the process, 6 articles were included in the review. Two additional studies were identified from citation searching and included. These findings are illustrated in the PRISMA flow diagram (
Fig. 1).
Table 1 presents the cost variables extracted from included literature. Regarding study design, three were retrospective claims-based or registry analyses [
2,
14,
15], two were prospective cohorts [
9,
16], one was a
post hoc CEA on data from a European randomized controlled trial [
13], one was an ambispective cost-utility analysis [
10], and one was a retrospective institutional cost study [
7]. Sample sizes ranged widely from 37 to 13,654 patients. Most authors defined RLDH as same-level recurrence, with laterality (ipsilateral vs. contralateral) specified in 2 studies. Exclusion criteria commonly omitted multilevel procedures, prior lumbar surgeries, infections, or tumors.
Follow-up periods varied considerably across studies, ranging from 12 to 66 months. Hospital-based or prospective analyses [
9,
10,
16] generally provided fixed 12- to 24-month surveillance, while claims-based studies [
2,
14,
15] captured longitudinal costs over 3–4 years, and Ament et al. [
13] extended modeling to 5 years. The institutional review of Ambrossi et al. [
7] provided the shortest median follow-up (13 months).
Six studies (75%) adopted a payer perspective, 2 (25%) incorporated both payer and societal viewpoints [
9,
13]. Claims-based sources predominated (e.g., Ohio Bureau of Workers’ Compensation, Humana PearlDiver, Reden & Anders), while Selva-Sevilla et al. [
10] employed hospital case costing, Ambrossi et al. [
7] relied on institutional billing data, and Guan et al. [
16] used the National Neurosurgery Quality and Outcomes Database (N2QOD) registry data.
One study [
10] explicitly applied a discount rate (3%), consistent with European health-economic convention. All other United States-based analyses did not report discounting.
All studies reported direct costs, though estimates differed substantially. Mean per-patient costs for repeat discectomy (RD) ranged from $6,907 to $109,799 [
14,
15], while fusion procedures ranged from $24,375 to about $145,000. The 5-year model of Ament et al. [
13] showed $13,141 for annular closure device (ACD) versus $18,455 for control, and Parker et al. [
9] estimated $17,920–$30,464 per recurrence. Selva-Sevilla et al. [
10] reported €6,718 (~$9,338) for discectomy and €9,364 (~$13,016) for fusion.
Two studies [
9,
13] included indirect costs. Ament et al. [
13] estimated savings of $5,076–$12,256 over 2–5 years with ACD use, while Parker et al. [
9] reported $3,778 in indirect costs per recurrence. Other analyses omitted productivity losses, disability claims, or opportunity costs. Parker et al. [
9] estimated indirect costs by the standard human capital approach, which multiplies the change in hours worked by the gross-of-tax wage rate. In their analysis, the mean duration of missed work after surgery was estimated using the reported value from the SPORT trial (27.7 days), and the gross-of-tax wage rate was estimated using the 2009 median annual U.S. household income ($49,777). Conversely, Ament et al. [
13] estimated indirect costs in a sensitivity analysis using expected complication and reoperation rates beyond 2 years.
Postoperative functional and QoL outcomes were reported in 3 studies (37.5%) [
10,
13,
16]. The most common metrics were the ODI, visual analogue scale, and EQ-5D (EuroQol 5-Dimension). Guan et al. [
16] and Selva-Sevilla et al. [
10] incorporated quality-adjusted life years (QALYs), while O’Donnell et al. [
14] included return-to-work endpoints or opioid utilization as alternative health measures. Others only included reherniation and reoperation rates. Across studies, RD achieved comparable functional outcomes to fusion at substantially lower cost.
Table 2 demonstrates wide variability in what is considered a “direct cost.” Follow-up costs were reported in 6 of 9 studies (67%) [
2,
7,
10,
13-
15]. These analyses incorporated costs incurred beyond the index hospitalization, with follow-up durations ranging from 12 months [
7] to 5 years [
13]. Claims-based studies [
2,
14,
15] captured longitudinal expenditures across episodes of care, while charge-based studies [
9,
16] reported only index hospitalization costs. The reported reimbursements of Heindel et al. [
2] include the costs of the index surgery along with reoperations, hospitalizations, and any other care provided to the patient within the follow-up period.
Outpatient visit costs were explicitly included in 3 studies (33%) [
9,
10,
13]. In the case-costing model Selva-Sevilla et al. [
10], external consultations were directly costed, whereas Ament et al. [
13] and Parker et al. [
9] incorporated both scheduled and unscheduled postoperative visits based on claims and Medicare allowable payments. The remaining studies either bundled outpatient encounters within aggregated charges or did not specify their inclusion.
Medication costs were reported in 2 studies (22%) [
13,
15]. Both incorporated perioperative analgesics and postoperative prescription costs into their models. Other studies, including those using claims-based and hospital charge data, did not itemize medication expenditures, likely embedding them within overall reimbursements.
Laboratory testing costs were the least frequently reported variable, identified in 1 study (11%) [
10]. The model itemized standard laboratory tests performed during hospitalization and follow-up. All other analyses, including those based on claims or bundled hospital data, omitted laboratory testing as a separate component.
PT costs were reported in 5 studies (56%) [
7,
9,
10,
13-
15]. These studies quantified rehabilitation sessions as discrete line items, either through hospital billing data or modeled unit costs. Inclusion of PT costs was most consistent among prospective or case-costing designs and least common in claims-based studies, where rehabilitation was subsumed into total reimbursements.
Imaging costs were included in 5 studies (56%) [
7,
9,
10,
13-
15]. Modalities most frequently costed were magnetic resonance imaging (MRI), computed tomography (CT), and radiographs performed for diagnosis or postoperative surveillance. In contrast, claims-based datasets reported aggregated costs [
2,
14,
16].
Surgeon and anesthesia costs were explicitly delineated in 4 studies (44%) [
7,
9,
10,
13]. These were typically estimated using procedural tariffs or itemized billing data. In contrast, claims-based studies bundled these fees within total reimbursements, obscuring their relative contribution to overall expenditures [
2,
14,
15].
Reoperation or readmission costs were reported in 4 studies (44%) [
9,
10,
13,
15]. Selva-Sevilla et al. [
10] included second recurrences in the base case, while Ament et al. [
13] and Parker et al. [
9] modeled costs for revision discectomy and fusion. Claims-based studies reported reoperation rates but did not isolate associated costs [
2,
14].
Complication-related costs were included in 3 studies (33%) [
9,
13,
15]. These analyses modeled perioperative events such as wound infection, hematoma, and device failure as distinct cost components. The remaining studies either reported no complications or utilized aggregated claims data that did not allow itemization [
7].
DISCUSSION
1. Primary and RLDHs
Discectomy for LDH is well established as a highly cost-effective procedure [
17]. However, RLDHs represent a significant socioeconomic burden, driving direct medical costs predominantly from repeat interventions and societal costs through lost productivity and prolonged disability. Using data from the Swedish Spine Registry (Swespine), Fritzell et al. [
18] compared outcomes between patients undergoing surgery for primary herniation versus those receiving RD for RLDH. Although both groups experienced meaningful improvement, satisfaction rates were notably lower among the recurrent cohort (58% vs. 79%, p<0.001), and fewer reported resolution or improvement of leg pain (65% vs. 74%, p=0.008). While some smaller retrospective studies have reported comparable outcomes, their methodological limitations weaken the strength of these findings. Moreover, the altered anatomy in RLDH cases raises concerns about directly applying treatment paradigms designed for primary herniations [
4,
19]. These challenges underscore the need for large, prospective studies using validated outcome measures to better guide management. In the meantime, surgical techniques and emerging technologies are being explored to reduce the risk of reherniation and improve both the clinical and socioeconomic outcomes of patients with RLDH.
The optimal surgical management of RLDH remains controversial, with RD and repeat discectomy with fusion (RDF) representing the most common approaches. While RD is less invasive, motion-preserving, and associated with shorter recovery times and lower direct costs, it carries a risk of rerecurrence and potential postoperative instability. Fusion offers greater segmental stability but is linked to longer operative times, higher complication rates, and increased healthcare expenditures.
Although both approaches are supported by clinical evidence, several studies highlight their substantial socioeconomic variability. O’Donnell et al. [
14], in a large retrospective cohort from the Ohio Bureau of Workers’ Compensation database, demonstrated that RDF patients incurred nearly 32% higher medical costs ($34,914) than RD patients, required opioids for a significantly longer duration (252.3 days longer, p<0.01), and were less likely to return to work (27.0% vs. 40.2%; p=0.03). As a result, the authors urged that fusion to treat RLDH be reserved for workers’ compensation (WC) patients with strong indications for its use. Regarding clinical indications for discectomy versus fusion, they speculate that including the entire population of Ohio WC subjects likely resulted in a range of disease severity; it is possible that the fusion cohort did worse due to a higher proportion of patients with low back pain.
Guan et al. [
16], using the national N2QOD registry, corroborated these findings by showing that fusion patients experienced significantly higher hospital charges (mean ≈$54,458 vs. $11,567 for RD), longer operative times, greater lengths of stay, and were more likely to be discharged to inpatient rehabilitation, yet achieved comparable patient-reported outcomes and return-to-work rates. They found that no patient demonstrated radiographic instability prior to surgery in either group and treatment decisions were based on a variety of clinical and radiographic variables at the discretion of the operating surgeon.
Heindel et al. [
2], analyzing more than 13,000 patients from a private payer claims database, similarly reported markedly higher long-term costs for fusion compared with RD, with 4-year expenditures averaging over $106,000 for fusion versus $49,192 for RD. Due to the nature of the database, they were unable to determine each patient’s indication for surgery. Together, these studies highlight how the choice of fusion can amplify both direct (e.g., hospital, surgical, pharmaceutical) and indirect (e.g. workforce productivity, disability) costs without clear superiority in clinical benefit.
Variability in surgeon practice patterns also contributes to cost heterogeneity. In a survey of United States spine surgeons, Mroz et al. [
20] revealed considerable disagreement regarding the role of fusion in 1- and 2-time RLDHs. Alvin et al. [
21] quantified the economic impact of this variability, showing that treatment costs for a single RLDH scenario could range from $10,442 for RD to $23,713 for RDF, reflecting a >$10,000 discrepancy in direct expenditures depending on surgeon preference.
Despite the increased costs associated with spine fusions, systematic reviews and meta-analyses have not demonstrated clear superiority in outcomes. Dower et al. [
19] and Kerezoudis et al. [
22] both found comparable functional results, reoperation rates, and patient satisfaction between RD and RDF, though fusion was consistently associated with longer length of stay, greater blood loss, and increased operative times—all factors that drive higher healthcare spending. O’Donnell et al. [
14] notes that many authors have found high satisfaction rates (75%–92%) with fusion to treat RLDH, but these are retrospective studies with small sample sizes and represent low-level evidence. These findings suggest that fusion is difficult to justify from a cost-effectiveness perspective.
However, we must recognize that regardless of cost, fusion may be necessary in select cases of instability, concern for excessive facet resection, foraminal stenosis, or severe back pain [
14]. So, a cheaper RD may inevitably lead to a third surgery, substantially increasing the total burden. For example, Heindel et al. [
2] found that 38.4% of patients who underwent re-exploration discectomy subsequently received lumbar fusions within 4 years. Despite this, the authors maintained RD as the preferred initial treatment due to the high cost of fusion.
The debate extends to surgical techniques, as minimally invasive surgery (MIS) has been proposed to reduce morbidity. Dower et al. [
19] reported lower complication rates and fewer durotomies with MIS compared to conventional open discectomy, which could translate into reduced hospital costs and improved return-to-work rates. However, subsequent analyses by Kerezoudis et al. [
22] found no significant difference in complication profiles, emphasizing the need for longitudinal randomized controlled trials to clarify whether MIS provides meaningful economic benefit. A narrative review on risk factors and surgical management of RLDH by Shepard and Cho [
4] also found no clear consensus on the ideal operative technique (e.g., open vs. MIS; discectomy with or without fusion) and emphasized the need for high-level evidence. Importantly, reducing complications and postoperative morbidity through MIS could help mitigate direct and indirect treatment costs.
Aside from clinical indications for RD versus fusion, cost can vary substantially by region. In East Asia, the cost baseline is much lower than in the United States. A Taiwanese cost-utility analysis (CUA) [
23] comparing transforaminal (PETD) and interlaminar (PEID) percutaneous endoscopic discectomy found mean total direct care costs of $5,275.58 and $5,494.45, respectively, with corresponding direct surgical costs of only $785.82 (PETD) and $696.52 (PEID). In the Republic of Korea, a 2-year CUA [
24] of full-endoscopic lumbar discectomy (FELD) reported mean direct costs of $3,459 and a cost of $5,241 per QALY gained, with the surgical portion averaging only $625. In Japan, the mean total direct cost 1 year after fenestration surgery for lumbar canal stenosis was 1,254,300 Japanese yen (JPY) ($11,403), with the operative cost being 406,800 JPY ($3,698). From a public payer perspective over a 5-year time horizon, lumbar fenestration cost 1,268,600 JPY (~$11,532) per QALY, which is far below the commonly accepted Japanese cost-effectiveness threshold of ~5–6.5 million JPY (~$45,000–$59,000).
Even fusion surgeries are significantly cheaper in East Asian countries compared to the US. In Japan, Fujimori et al. [
25] reported a cost per QALY of 2,697,500 JPY (~$24,522) for PLIF with instrumentation—more than twice the cost of fenestration, but still within accepted cost-effectiveness thresholds. They contrasted this with a United States-based analysis which showed much higher costs for similar interventions. Over a 2-year time horizon, decompression-only surgery for spinal stenosis yielded a cost per QALY of $77,600, while instrumented fusion for degenerative spondylolisthesis reached $115,600 per QALY [
26]. Given these figures, the authors concluded that instrumented fusion was not a particularly cost-effective intervention in the United States healthcare system.
Further, the healthcare economics in East Asian countries are very different from those of the United States. In the Republic of Korea, the National Health Insurance System strictly regulates reimbursement and allowable supplies, including those used for FELD. Since the costs of endoscopic supplies (e.g., $700 for electrodes) and the upfront expense of the endoscopic system are not reimbursed, offering FELD creates financial losses for both hospitals and providers [
24]. Japan faces similar challenges: despite partial reimbursement of supplies, the structure of its national insurance system makes endoscopic spine surgery economically unfavorable for institutions, even though the country otherwise delivers high-quality care at relatively low overall cost [
24]. While the costs of fusion and discectomy are certainly greater in the USA than in East Asian countries, CEAs must be conducted in the context of each country’s unique economy and healthcare system [
25]. While RD and RDF yield similar patient-reported outcomes, the addition of fusion substantially increases both medical costs and socioeconomic burden. But the limited evidence base allows only for low-level observations. Similarly, the potential cost advantages of MIS remain promising but inconclusive. High-quality CEAs, which also consider clinical indications and regional economic differences, are critical to inform surgical decision-making and optimize resource allocation.
The decision between RD and conservative management for RLDH also carries large socioeconomic implications, yet the evidence base is marked by methodological limitations and inconsistent findings.
At a single-institution level, Ambrossi et al. [
7] retrospectively examined 156 patients who had undergone primary discectomy, with 17 (12%) developing symptomatic same-level recurrence by one year. While 11 underwent RD and 6 were managed conservatively, the total cost of diagnosing and treating these recurrences exceeded $450,000. Cost categories included diagnostic testing (MRIs and CTs), conservative management (PT and injections), and operative treatment (surgery, hospitalization, and postoperative rehabilitation). Ultimately, the mean cost per patient was significantly higher for surgical management ($39,836) compared to conservative care ($2,315, p<0.001). None of the patients with recurrent discectomy required fusion at the time of revision and did not progress to fusion within the follow-up period. The authors concluded that when clinically feasible, extended conservative management may help to reduce the economic burden of RLDHs. Of note, only billed healthcare costs were included, while outpatient medications and indirect costs were excluded, suggesting the true economic burden was underestimated.
Using a broader perspective, Sherman et al. [
15] analyzed a large database combining public and private insurance claims to assess the economic burden of ‘less-than-favorable’ outcomes after lumbar discectomy. Of 494 patients, 137 (28%) required either reoperation (11%)—in a ratio of roughly 80:20 RD to RDF —or ongoing conservative care (17%) within 18 months. Reoperations added an average of $6,907 in costs, while the inclusion of fusion increased expenses by 350% to $24,375. Complications occurred in 13% of reoperations, contributing an additional $11,571 in hospital costs per admission. Excluding surgery, each failed discectomy generated substantial expenditures: average medical treatment costs to diagnose or manage a poor outcome requiring another procedure were $3,365, while patients managed nonoperatively still incurred about $2,200 per patient in added costs from diagnostics, injections, and medications. In total, each failed discectomy added more than $8,000 to commercial health plan expenditures within the 18-month period, and it is likely that some patients eventually underwent further surgery outside of the follow-up window. Like Heindel et al. [
2], they were unable to determine each patient’s indication for surgery due to the nature of an insurance claims database. Although limited by this and the lack of indirect cost analysis, this study highlights the considerable financial toll of both surgical and nonsurgical management, particularly when complications, prolonged diagnostics, and repeat interventions are factored in.
A CUA was provided by Selva-Sevilla et al. [
10], who prospectively studied 50 RLDH patients managed with conservative therapy, RD, or RDF. They found conservative care to be more economical than discectomy (€904 vs. €6,718; ~$1,257 vs. ~$9,338; p<0.001) but with slightly worse QALYs (QALY: 3.48 vs. 3.18; p=0.887). Discectomy, in turn, was both less costly and more effective than fusion (€6,718 vs. €9,364; ~$9,338 vs. ~$13,016; QALY: 3.18 vs. 1.92). Regarding clinical indications for discectomy versus fusion, the authors note that at recurrence, all patients presented with radiographic signs of foraminal stenosis, but no one presented with definite radiographic instability, spinal deformity, listhesis, or iatrogenic pars fracture. Although results were generally worse for the fusion group, who presented with significantly greater lumbar and leg pain, 2 sensitivity analyses corroborated the original results. One of the analyses only included patients suffering from similar back and leg pain, while the other excluded patients suspicious for having instability based on pain scores and Modic changes. However, the study’s small sample size and exclusive focus on direct costs limit generalizability. Again, employing the healthcare perspective leaves indirect costs unaccounted for, raising concerns that the economic impact of RLDHs is incompletely captured.
The narrative review Shepard and Cho [
4] found that while revision surgery is appropriate for patients who have failed conservative care, whether it is more cost-effective remains unsettled. Indeed, while Selva-Sevilla et al. [
10] found conservative therapy more cost-effective, other studies—particularly in primary herniation populations—suggest that surgery may be superior when long-term outcomes and indirect costs are considered [
17]. However, direct comparison across CEAs on RLDH is challenging, as Selva-Sevilla et al. [
10] were unable to identify another CUA specific to RLDH patients.
Taken together, these studies demonstrate that RLDH imposes a considerable financial burden regardless of management strategy. While conservative care may offer short-term cost advantages, incomplete accounting for indirect costs, coupled with methodological variability across studies, makes it difficult to establish definitive cost-effectiveness. Moreover, much of the available literature addressing the cost implications of RLDH is low-level evidence, typically retrospective in design, and with small cohorts [
4,
10,
19]. High-quality, prospective economic analyses incorporating both direct and indirect costs are needed to clarify the financial burden and the most cost-efficient approach to managing RLDH.
ACDs have been proposed as an adjunct to discectomy to reduce the risk of RLDH and thereby potentially lessen both clinical morbidity and financial burden. By mechanically closing or supporting the weakened annulus fibrosus, ACDs aim to preserve disc integrity, improve long-term outcomes, and ultimately reduce the socioeconomic burden associated with repeat discectomies and/or fusions. The Barricaid device (Intrinsic Therapeutics, Inc., USA) represents the sole U.S. Food and Drug Administration-approved ACD currently available in the United States market [
27].
Ament et al. [
13] conducted a
post hoc cost-effectiveness study using data from a multicenter randomized controlled trial. The trial was conducted across 21 European hospitals, included 554 patients with large annular defects, and used the Barricaid device. At 2 years, symptomatic reherniation was reduced to 13% in the ACD group compared to 25% in the control group (p<0.001), producing an estimated savings of $2,802 per patient in healthcare costs at 2 years and $5,315 per patient at 5 years. These savings were primarily driven by reductions in reoperations and other services such as imaging, injections, and PT, which added $900–$1,600 in costs for conservatively managed recurrences in the control group. Under the societal perspective, cost savings increased to $5,075 per patient at 2 years and $12,255 per patient at 5 years. Sensitivity analyses also demonstrated that cost savings were maintained across different public-private insurance models, with the magnitude of benefit increasing under higher private payer assumptions. Importantly, however, this trial only modeled indirect costs, assumed index procedure costs were identical, and did not include the cost of the ACD, outcome scales, or disability measures, limiting its ability to fully assess cost-effectiveness at the societal level.
Complementary evidence was similarly found by Parker et al. [
9], who performed a multicenter cohort analysis of 76 patients (46 ACD, 30 controls) with 2 years of follow-up. They estimated the average healthcare cost of surgically treating RLDHs to be $17,920 under Medicare and $30,464 under private insurance, with estimated productivity losses adding $3,778 per recurrence. This yielded an overall societal burden of $34,242 per recurrence for private payers. While projected savings of $2,226 per discectomy ($222,573 per 100 discectomies) were similar in magnitude to those reported by Ament et al. [
13], the difference in re-herniation rate was not statistically significant (p=0.27), reflecting limited power from the small sample size. Methodological issues—such as extrapolating United States Medicare costs to a small European cohort and failing to assess patient outcomes —also limit the generalizability of these findings.
These studies underscore the significant direct and indirect costs of managing RLDHs and suggest that ACDs may reduce healthcare expenditures by lowering reherniation and reoperation rates, despite the added cost of the ACD implant itself. However, variability in methodology, sample size, and payer models complicates interpretation, and neither study incorporated robust patient-reported outcomes or long-term disability costs. Further large-scale, prospective CEAs are needed to clarify whether ACDs can consistently deliver durable clinical benefit alongside meaningful reductions in costs.
5. Limitations and Future Directions
This narrative review has several limitations. Since it focuses primarily on the socioeconomic impact of RLDH, many studies focusing on surgical outcomes and debates over techniques or fusions may have been excluded, despite the presence of some economic data on RLDH patients included in those studies. Further, some databases were not searched and studies on primary herniation, which may include cost data regarding RLDH, may not have been captured within our search strategy. To offset these limitations, citation searching of the included studies was conducted.
The major limitation highlighted by our synthesis is the substantial heterogeneity across economic evaluations of RLDH, which complicates direct comparisons and allows only for low-level observations. This issue is not unique to RLDH; a systematic review of CUAs in spine care by Kepler et al. [
28] also highlighted that methodological inconsistency in cost measurement as the most significant barrier to high-quality CEAs. Moreover, uncertainty from the heterogeneity of CEAs has been demonstrated by Alvin et al. [
8] where they note extensive variability across 3 main domains: cost perspective (the hospital, the payer, or societal), time frame, and cost definition. As this was observed in our synthesis, we did not conduct statistical meta-analysis.
From a cost perspective, institutional billing, national claims databases, and modeled reimbursements each yielded different absolute cost estimates. Additionally, WC populations consistently demonstrate higher expenditures, likely reflecting payer-specific incentives and different case mixes. Further, studies often used different units, varying between charges, reimbursements, and true costs.
Other important sources of variability come from discounting and currency. Alvin et al. [
8] emphasize the importance of considering inflation and currency fluctuations when comparing CEAs from different years and countries. All but 1 study reported raw or inflated costs without the recommended 3% annual discount rate [
10]. Moreover, United States dollars were inflated to 2006 in Sherman et al. [
15], contemporary Medicare/private payer costs were used in Parker et al. [
9], and Spanish euros were used in Selva-Sevilla et al. [
10].
Beyond discounting and currency, cross-country comparisons are further complicated by international variability in healthcare system structure, reimbursement mechanisms, and unit cost composition (e.g., what is included in hospital charges vs. professional fees). These differences hinder standardized cost analyses and limit direct comparisons of absolute costs or cost-effectiveness across countries. The potential cost-effectiveness of ACDs in the United States versus East Asian health systems illustrates this challenge: in some Asian settings, the device cost may approach the total procedural cost (e.g., endoscopic surgery in Korea and Japan) [
24]. However, because we were unable to identify publicly available, country-specific ACD pricing for East Asian health systems, any extrapolation of ACD cost-effectiveness to these contexts remains highly uncertain.
Outcome measures and QALY calculations were additional sources of heterogeneity. Some studies incorporated robust patient-reported outcomes while others used proxies like return-to-work or modeled “poor outcomes” from claims. Only Guan et al. [
16] and Selva-Sevilla et al. [
10] measured QALYs, but even these methodologies differed as Selva-Sevilla et al. [
10] converted multiple utility indices into QALYs. Some studies lacked standardized quality-of-life endpoints altogether.
The follow-up period also has a significant impact on the results of CEAs. Short-term analyses often report more modest cost differentials, whereas longer follow-up reveals the cumulative burden of recurrences and especially of fusion procedures. Failure to capture long-term outcomes risks underestimating the true economic implications of RLDH.
Further, none of the studies compared the direct and indirect costs of treating primary LDH with RLDH. Except for the 2 studies investigating ACDs [
9,
13], most omitted indirect costs entirely. There is also some uncertainty as to whether the fusion cases were elective choices when decompression was a viable alternative, or if they were medically necessary; some authors could not determine what guided surgical decisions due to retrospective study designs or use of claims databases.
Such inconsistencies contribute to interstudy variability and hinder conclusive recommendations. As Alvin et al. [
8] advise, future research into cost-effectiveness and socioeconomic implications must be transparent about cost definitions, calculation methods, and data sources to allow comparability across studies. Methodological standardization is also essential for more reliable cross-study comparisons, meta-analyses, and policy guidance on cost-effective strategies for RLDH prevention and management. Concurrently, to address the gap in high-level evidence, researchers should prioritize prospective, long-term CEAs studies with large cohorts.
In parallel, innovation in surgical techniques and technologies holds promise for reducing the socioeconomic burden of RLDH. Advancements in ACDs may help prevent or reduce the incidence of reherniation altogether, thereby lowering both healthcare resource utilization and facilitating return to work. Similarly, determining whether MIS provides superior value compared with traditional approaches remains an open question, as does the role of RD versus discectomy with fusion; conclusive evidence can produce cost savings through reduced incidence of complications and accelerated recovery. Simultaneously, more rigorous evaluation of recurrence risk factors is needed to better guide patient selection [
4].
CONCLUSION
RLDH represents a multifactorial condition with significant clinical and socioeconomic implications. Although RD incurs lower costs with comparable patient-reported outcomes to fusion, determinations about relative cost-efficiency are not possible without high-level evidence. Innovations such as ACDs demonstrate potential to reduce recurrence rates and long-term expenditures, warranting continued high-quality evaluation. Conservative management remains valuable for certain patients and may offer short-term savings, though future analyses should comprehensively capture indirect costs to define its overall value. However, the heterogeneity in the included studies and existing CEAs allows only for low-level observations rather than evidence-based conclusions. Crucially, this presents an opportunity for greater transparency and standardization in large, prospective, long-term studies. To improve the comparability and applicability of economic evidence, future research should adopt a societal approach to cost, incorporate robust patient-centered outcomes, and evaluate novel surgical technologies and techniques. Indeed, cost-effectiveness comparisons would be a welcome obligatory part of randomized controlled trials comparing different treatment modalities. Ultimately, optimizing RLDH management will depend on translating these insights into evidence-based strategies that align clinical benefit with economic sustainability.
NOTES
-
Conflict of Interest
The authors have nothing to disclose.
-
Funding/Support
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
-
Author Contribution
Conceptualization: RB, AR, CAI, RH; Data curation: RB, AR, EW; Formal analysis: RB, AR, LKC, AKD, SHL; Methodology: RB, AR, EW, CAI, NW, RH; Project administration: RB, AR; Visualization: AR, RH; Writing – original draft: RB, AR; Writing – review & editing: RB, AR, EW, CAI, LKC, NW, AKD, SHL, RH.
Supplementary Materials
Fig. 1.PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram.
Table 1.Cost analysis of RLDH studies
Table 1.
|
Study |
Study design |
Sample size |
Cohort characteristics |
Follow-up (mo) |
Perspective |
CCM source |
Discount rate (%) |
Direct costs (USD) |
Indirect costs/ICER |
Outcome/QoL measures |
|
O’Donnell et al., [14] 2017 |
Retrospective cohort study |
298 (102 RD, 196 RDF) |
Workers’ Comp patients with recurrent lumbar disc herniation; claims-based, no laterality specified; ≥18 yr, excluded primary cases. |
≥36 |
Payer |
Ohio Bureau of Workers’ Compensation claims database |
Not specified |
RD group: mean $109,799; RDF group: mean $144,713; RDF+$34,914 higher |
Not included |
Outcome measures not included. RTW: RD 40.2% vs. RDF 27.0% (p=0.03). Opioid days supplied: RD 408.5 ± 515.2 vs. RDF 660.8 ± 637.0 (p<0.01). |
|
Guan et al., [16] 2017 |
Prospective cohort study |
37 (25 RD, 12 fusion) |
RLDH patients; defined as same-level recurrence, ipsilateral or contralateral; excluded primary herniations, multilevel procedures. |
12 |
Hospital |
N2QOD registry+institutional billing charges |
Not specified |
RD $11,567 ± 2,937; Fusion $54,458 ± 6,160 |
Not included |
*Similar ODI, VAS, and QALY measurements. Reoperation rates: RD 12% vs. fusion 0% (p=0.211). Discharge to inpatient rehab: RD 0% vs. fusion 17% (p=0.036). |
|
Length of stay (day): RD 1.0 ± 0.3 vs. fusion 3.7 ± 0.9 (p<0.001). Operative time (minutes): RD 82.7 ± 29.1 vs. fusion 229.6 ± 42.1 (p<0.001). |
|
Ambrossi et al., [7] 2009 |
Retrospective cost analysis |
156 (141 followed; 17 recurrent, 11 revisions, 6 conservative) |
Postdiscectomy patients; 14 ipsilateral, 3 contralateral recurrences; excluded multilevel, prior surgery, nonlumbar pathology. |
Median, 13 |
Hospital |
Institutional billing/cost records |
Not specified |
Mean cost per recurrent case $26,593; revision surgery $39,836; conservative $2,315; estimated $289,797 per 100 discectomies |
Not included |
Outcome measures not included. Recurrence 12% (17/141) at median 8 mo; revision discectomy 7% (11/141) at median 17 mo; conservative-only recurrence 3.9% (6/141). |
|
Sherman et al., [15] 2010 |
Retrospective insurance claims analysis |
494 analyzed (137 poor outcomes, 52 reoperations) |
Modeled U.S. claims population of discectomy patients; recurrence type not specified; inclusion/exclusion based on CPT/ICD codes. |
18 |
Payer |
Public and private insurance claims database (CPT/ICD codes; Reden & Anders database, Medicare, NIS) |
Costs inflated to 2006 USD |
RD $6,907; fusion $24,375; medical mgmt $3,365; complications ~$3,939; overall poor outcome added ~$8,000 per patient |
Not included |
Outcome measures not included. Recurrence: “less-than-favorable outcome” 28% (11% second operation; 17% medical management). |
|
Selva-Sevilla et al., [10] 2019 |
Ambispective CUA |
50 (11 conservative, 20 RD, 19 fusion) |
Adults with recurrent lumbar disc herniation at L4–5 or L5–S1; same-level recurrence (ipsilateral/contralateral not specified); excluded primary herniations. |
Median, ~66 |
Payer |
Hospital case costing+public health tariffs |
3 |
Conservative: €904 (~$1,257); RD: €6718 (~$9,338) (or €4978 [~$6,919] excluding 2nd recurrences); fusion: €9364 (~$13,016) |
Not included |
NRS, ODI, SF-36, EQ-5D. †SF-36-based QALYs: 3.48 (conservative), 3.18 (RD), 1.92 (fusion). |
|
Ament et al., [13] 2019 |
Post hoc CEA on a multicenter RCT |
554 (276 ACD, 278 control) |
High-risk annular defect patients at primary discectomy; single-level; ipsilateral risk emphasized; excluded multilevel disease, prior surgery, infection, tumor. |
24 (partial to 60) |
Payer & societal |
PearlDiver Medicare & Humana claims |
Not specified |
Per-patient (50/50 payer mix) 2 yr $11,488 (ACD) vs. $14,290 (Ctrl) (Δ $2,802); 5 yr $13,141 vs. $18,455 (Δ $5,315); device cost excluded |
‡2-yr savings $5,076; 5-yr savings $12,256 |
§Similar VAS, ODI, SF-36 scores over 2-yr follow-up. Symptomatic reherniation rate at 6 mo: 6% ACD vs. 13% control (p=0.005); at 2 yr: 13% ACD vs. 25% control (p<0.001). |
|
At 2 yr: 29 reoperations in 24 ACD patients vs. 61 reoperations in 45 control patients. |
|
Parker et al., [9] 2013 |
Prospective multicenter cohort study |
76 (30 ACD, 46 control) |
Patients with large annular defects after discectomy; high risk of ipsilateral recurrence; excluded multilevel disease, prior surgery, infection, tumor, foraminal or extraforaminal disc herniation. |
24 |
Payer & societal |
Medicare national allowable payments+human capital method |
Not specified |
Direct: $17,920 (Medicare) to $30,464 (private) per recurrence; estimated $222,573 savings per 100 discectomies |
Indirect cost estimated: $3,778 per recurrence |
Postoperative outcome measures not included. Symptomatic recurrence 6.5% control vs. 0% ACD (p=0.27). |
|
Heindel et al., [2] 2017 |
Retrospective insurance claims analysis |
13,654 (index discectomy cohort) |
Single-level discectomy patients from Humana claims; defined as same-level recurrence; laterality not specified; excluded multilevel, cervical/thoracic disease. |
48 |
Payer |
PearlDiver Humana insurance claims |
Not specified |
4 yr w/o reop: $33,192; w/reop: $77,837; fusion: $106,318; laminectomy: $69,308; RD: $49,192 |
Not reported |
Outcome measures not included. Reoperation rates: 3.95% (539/13,654) within 3 mo; 12.2% (766/6,274) within 48 mo. |
|
38.4% progress to fusion within 4 yr after re-exploration discectomy. |
Table 2.‘Direct Cost’ definitions of included recurrent lumbar disc herniation studies
Table 2.
|
Study |
Intervention |
Includes follow-up |
OVs |
Meds |
Labs |
PT |
Imaging |
Surgeon |
Anesthesia |
RRCs |
IPCs |
|
O’Donnell et al., [14] 2017 |
Revision Discectomy vs. Revision Discectomy+Fusion |
✓ |
|
|
|
|
|
|
|
|
|
|
Guan et al., [16] 2017 |
Repeat Discectomy vs. Instrumented Fusion for RLDH |
|
|
|
|
|
|
|
|
|
|
|
Ambrossi et al., [7] 2009 |
Primary single-level discectomy; recurrent cases: conservative vs. revision discectomy |
✓ |
|
|
|
✓ |
✓ |
✓ |
✓ |
✓ |
|
|
Sherman et al., [15] 2010 |
Primary discectomy; subset with poor outcomes and/or reoperation |
✓ |
|
✓ |
|
✓ |
✓ |
✓ |
✓ |
✓ |
✓ |
|
Selva-Sevilla et al., [10] 2019 |
Conservative vs. Discectomy vs. Discectomy+Fusion |
✓ |
✓ |
|
|
✓ |
✓ |
✓ |
|
✓ |
|
|
Ament et al., [13] 2019 |
Discectomy vs. Discectomy+ACD |
✓ |
✓ |
✓ |
|
✓ |
✓ |
✓ |
|
✓ |
✓ |
|
Parker et al., [9] 2013 |
Discectomy vs. Discectomy+ACD |
|
✓ |
|
|
✓ |
✓ |
✓ |
|
✓ |
✓ |
|
Heindel et al., [2] 2017 |
Single-level discectomy; reoperation (discectomy, laminectomy, fusion) |
✓ |
|
|
|
|
|
|
|
✓ |
|
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, Anthony Robayo2,*
