Article Abstract

Cost-utility of revisions for cervical deformity correction warrants minimization of reoperations

Authors: Samantha R. Horn, Peter G. Passias, Aaron Hockley, Renaud Lafage, Virginie Lafage, Hamid Hassanzadeh, Jason A. Horowitz, Cole A. Bortz, Frank A. Segreto, Avery E. Brown, Justin S. Smith, Daniel M. Sciubba, Gregory M. Mundis, Michael P. Kelley, Alan H. Daniels, Douglas C. Burton, Robert A. Hart, Frank J. Schwab, Shay Bess, Christopher I. Shaffrey, Richard A. Hostin, Christopher P. Ames, International Spine Study Group

Abstract

Background: Cervical deformity (CD) surgery has become increasingly more common and complex, which has also led to reoperations for complications such as distal junctional kyphosis (DJK). Cost-utility analysis has yet to be used to analyze CD revision surgery in relation to the cost-utility of primary CD surgeries. The aim of this study was to determine the cost-utility of revision surgery for CD correction.
Methods: Retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: C2–C7 Cobb >10°, cervical lordosis (CL) >10°, cervical sagittal vertical axis (cSVA) >4 cm, chin-brow vertical angle (CBVA) >25°. Quality-adjusted life year (QALY) were calculated by EuroQol Five-Dimensions questionnaire (EQ-5D) and Neck Disability Index (NDI) mapped to SF-6D index and utilized a 3% discount rate to account for residual decline to life expectancy (men: 76.9 years, women: 81.6 years). Medicare reimbursement at 30 days assigned costs for index procedures (9+ level posterior fusion, 4–8 level posterior fusion with anterior fusion, 2–3 level posterior fusion with anterior fusion, 4–8 level anterior fusion) and revision fusions (2–3 level, 4–8 level, or 9+ level posterior refusion). Cost per QALY gained was calculated.
Results: Eighty-nine CD patients were included (61.6 years, 65.2% female). CD correction for these patients involved a mean 7.7±3.7 levels fused, with 34% combined approach surgeries, 49% posterior-only and 17% anterior-only, 19.1% three-column osteotomy. Costs for index surgeries ranged from $20,001–55,205, with the average cost for this cohort of $44,318 and cost per QALY of $27,267. Eleven revision surgeries (mean levels fused 10.3) occurred up to 1-year, with an average cost of $41,510. Indications for revisions were DJK (5/11), neurologic impairment [4], infection [1], prominent/painful instrumentation [1]. Average QALYs gained was 1.62 per revision patient. Cost was $28,138 per QALY for reoperations.
Conclusions: CD revisions had a cost of $28,138 per QALY, in addition to the $27,267 per QALY for primary CD surgeries. For primary CD patients, CD surgery has the potential to be cost effective, with the caveats that a patient livelihood extends long enough to have the benefits and durability of the surgery is maintained. Efforts in research and surgical technique development should emphasize minimization of reoperation causes just as DJK that significantly affect cost utility of these surgeries to bring cost-utility to an acceptable range.

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