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Cost-Effectiveness Assessment in Spine Surgery
Cost-effectiveness analysis (CEA) is a critical tool in healthcare, offering insights into the value of medical interventions relative to their costs. As healthcare systems worldwide face increasing economic pressures, CEA has become integral in guiding decision-making, resource allocation, and policy development.1 In the field of spine surgery, where procedures often involve substantial costs and complex care pathways, cost-effectiveness assessments are particularly valuable.2 They help determine whether interventions provide meaningful clinical benefits relative to their financial impact, ultimately supporting evidence-based practices.
A cornerstone of CEA is the use of standardized metrics to quantify value. Among these, quality-adjusted life years are widely used to capture the balance between the quality and length of life achieved through an intervention.3 The incremental cost-effectiveness ratio, another key metric, compares the additional cost of an intervention to its incremental benefit, helping to identify treatments that offer the most value. These metrics provide a foundation for comparing diverse treatment options in spine surgery, from traditional approaches to advanced technologies.4,5
To analyze the complexities of cost and outcomes in spine surgery, several analytical frameworks are employed. Markov models and decision trees, for example, are used to simulate patient outcomes and associated costs over time, accounting for uncertainties and variations in clinical pathways.6 These methodologies enable a nuanced understanding of cost-effectiveness, guiding the selection of interventions that optimize both patient outcomes and economic efficiency in spine surgery practice.
Spine Surgery Procedures and Cost Considerations
Spine surgery costs vary widely, ranging between $8,286 to $120,394.7,8 These costs are distributed across several major components, including surgeon compensation, medical devices, implants, hospitalization, facility fees, and operating room expenses. Operating time and hospital length of stay also significantly influence costs, especially in complex cases requiring extensive preparation and postoperative care.9,10 Complications, including infections or hardware failures, escalate expenses by prolonging surgeries, extending hospital stays, or necessitating revision procedures. For example, postoperative readmissions due to infections and hardware failures can add $2,817 and $5,354, respectively.9
Spinal fusion, one of the most commonly performed procedures, exemplifies the cost distribution in spine surgery. In lumbar fusion surgeries, medical supplies constitute the largest expense, accounting for 43.8% of total costs. Instrumentation, interbody cages, and biological implants alone contribute up to 37.2% of total costs.7 Service costs, including operating room expenses, represent the second-highest cost driver at 36% to 37.6%.7,11 The surgical approach also impacts costs. For example, circumferential approaches are generally more expensive than posterior approaches due to longer operative times and additional instrumentation requirements.7
Moreover, anterior cervical discectomy and fusions (ACDFs) follow a similar cost distribution pattern, with medical supplies and facility fees accounting for 39% and 37% of total costs, respectively.12 Among all spine procedures, adult spinal deformity (ASD) surgeries are the most costly, with an average cost of $103,143 for primary ASD procedures.8 This high cost is attributed to the involvement of multiple surgical levels, extensive instrumentation, and prolonged operative times. Additionally, ASD surgeries are associated with higher complication and construct failure rates, particularly among elderly and comorbid patients, further increasing total expenses.13
Disc replacement is an increasingly adopted alternative to fusion surgeries.14 For instance, Leibold et al found that cervical disc replacement (CDR) incurred £3,885 in additional costs compared to ACDF, primarily due to implant expenses.15 Although disc replacement procedures typically incur higher up-front costs due to expensive implants, many studies suggest CDR may offer long-term cost benefits by reducing the need for secondary surgeries.16,17
In contrast, decompression surgeries are generally less expensive because they do not require instrumentation or implants.18 Instead, their primary cost drivers include the surgical setting and hospital length of stay. Safaee et al reported total costs for lumbar decompression surgeries ranging from $10,609 to $11,074 for same-day surgeries, compared to $24,507 to $27,929 for inpatient procedures.18
Emerging Technologies
Emerging technologies in spine surgery have also influenced cost considerations. Osteobiologics such as bone grafts (autografts and allografts), demineralized bone matrix, and bone morphogenic proteins (BMP) are designed to enhance bone fusion rates. While bone morphogenic proteins show promise in reducing complications such as pseudoarthrosis, its cost-effectiveness remains controversial due to inconsistent findings in the literature.19,20 Similarly, platelet-rich plasma has been introduced to promote tissue regeneration and reduce pseudoarthrosis rates, but its cost-effectiveness remains inconclusive due to limited supporting evidence.21
Minimally invasive surgery (MIS) techniques offer another avenue for cost optimization. Lucio et al demonstrated that MIS reduced costs by 10.4% compared to open techniques in posterior lumbar interbody fusions.22 Uddin et al also highlighted MIS as a cost-effective option in ASD surgery, citing shorter operative times, reduced intraoperative blood loss, and shorter hospital stays.23 However, conflicting data exist; Twitchell et al found MIS could increase overall costs mediated by facility cost and supplies through a value-driven outcomes database.11 These discrepancies underscore the need for further high-quality research to clarify the cost implications of MIS compared to traditional open techniques.
Factors Influencing Cost-Effectiveness
Variability in spine surgery costs can arise due to a combination of patient-specific, surgical, and healthcare system factors. Key cost drivers include procedural complexity, the number of spinal levels involved, and the adoption of advanced technologies such as specialized instrumentation and implants.9
The cost-effectiveness of spine surgical procedures and perioperative care is significantly influenced by patient characteristics, which can vary widely even within the same region or healthcare system. Key factors include older age, higher body mass index (BMI), and comorbidities. These elements contribute to increased severity, higher risks of complications, and greater overall costs.24
Age is a particularly important factor, as it often correlates with increased resource utilization, including longer operating times and extended hospital stays, which drives up costs.24,25 The presence of two or more comorbidities further exacerbates this impact by heightening the risk of complications and adverse outcomes, thereby increasing resource utilization and costs.24,25
Whitmore et al demonstrated that comorbidities are closely associated with advanced age and higher BMI. These factors collectively elevate the risk of complications and are significantly associated with increased direct costs.26 Postoperative wound infections represent another major contributor to healthcare costs because they increase the likelihood of readmission and impose a substantial financial burden.27
Intraoperative neuromonitoring, advanced imaging, and costly innovations such as robotic-assisted technologies introduce additional financial considerations.9,28 Primary surgeries tend to be more cost-effective, as they require less intraoperative time, have fewer complications, and result in shorter hospital stays.29 Conversely, revision surgeries often entail longer care timelines, higher risks of complications, and the need for more extensive procedures, leading to increased costs. The number of fusion levels is a critical determinant of cost. Surgeries involving multiple fusion levels demand greater resources, including extended operating times, additional instrumentation, longer hospital stays, and increased complication risks. Yamamoto et al demonstrated a direct relationship between the number of fusion levels and higher costs.30
Healthcare system factors, such as regional variations, insurance coverage, and payment models, significantly influence cost-effectiveness in spine surgery. Geographical variations in costs and payment structure can be attributed to varying demands based on local population demographics as well as hospital volumes.31 Lean methodologies, increasingly adopted by large hospital systems, have proven effective in minimizing waste, reducing errors, enhancing staff productivity, and lowering complication rates.32 These practices have shown notable cost-saving potential in spine surgery. Additionally, bundled payment models have emerged as a promising strategy for reducing overall healthcare costs while maintaining or improving care quality.33 However, implementing these models in spine surgery is challenging due to the inherent variability in clinical decision-making and cost structures. 33 Outpatient and ambulatory surgical practices for pre-selected patients have further contributed to cost-effectiveness by reducing hospitalization and facility expenses.34
Challenges and Future Directions
Key challenges in evaluating cost-effectiveness in spine surgery include a lack of standardized costing methodologies, which complicates the development of universal guidelines or recommendations.35 Many studies fail to clearly define or include indirect costs in their analyses, despite these costs potentially adding significant value to the results and their generalizability.36 Additionally, the absence of sensitivity analyses that account for the complexity of clinical scenario in many reports limits the robustness of the conclusions.35
Future research should focus on employing standardized health economics-based methodologies and advanced statistical analyses across larger datasets to better understand cost-effectiveness trends in spine surgery. Defining and incorporating both direct and indirect costs into analyses would enhance consistency and provide more comprehensive insights.
Conclusion
Cost-effectiveness in spine surgery is shaped by patient-specific, surgical, and healthcare system factors. Key drivers include age, comorbidities, procedural complexity, and technological advancements, with revision surgeries and multiple fusion levels significantly increasing costs. Emerging practices such as lean methodologies, outpatient surgeries, and bundled payments show promise in reducing expenses but face challenges due to variability in clinical decision-making. Standardizing costing methodologies, incorporating indirect costs, and using larger datasets in future research are essential to develop consistent guidelines and enhance cost-effectiveness while maintaining high-quality care and outcomes.
References
1. Jacobs J. HERC: Cost-Effectiveness Analysis. https://www.herc. research.va.gov/include/page.asp?id=cost-effectiveness-analysis
2. Wali AR, Brandel MG, Santiago-Dieppa DR, et al. Markov modeling for the neurosurgeon: a review of the literature and an introduction to cost-effectiveness research. Neurosurg Focus. 2018;44(5):E20.
3. Sailer AM, van Zwam WH, Wildberger JE, Grutters JP. Cost-effectiveness modelling in diagnostic imaging: a stepwise approach. Eur Radiol. 2015;25(12):3629–3637.
4. Yagi M, Ames CP, Keefe M, et al. A cost-effectiveness comparisons of adult spinal deformity surgery in the United States and Japan. Eur Spine J. 2018;27(3):678–684.
5. Al-Khouja LT, Baron EM, Johnson JP, Kim TT, Drazin D. Cost-effectiveness analysis in minimally invasive spine surgery. Neurosurg Focus. 2014;36(6):E4.
6. McAnany SJ, Anwar MA, Qureshi SA. Decision analytic modeling in spinal surgery: a methodologic overview with review of current published literature. Spine J. 2015;15(10):2254–2270.
7. Beckerman D, Esparza M, Lee SI, et al. Cost analysis of single-level lumbar fusions. Global Spine J. 2020;10(1):39–46.
8. McCarthy IM, Hostin RA, Ames CP, et al. Total hospital costs of surgical treatment for adult spinal deformity: an extended follow-up study. Spine J. 2014;14(10):2326–2333.
9. Sivaganesan A, Chotai S, Parker SL, McGirt MJ, Devin CJ. Drivers of variability in 90-day cost for elective laminectomy and fusion for lumbar degenerative disease. Neurosurgery. 2019;84(5):1043–1049.
10. Salas-Vega S, Chakravarthy VB, Winkelman RD, et al. Late-week surgery and discharge to specialty care associated with higher costs and longer lengths of stay after elective lumbar laminectomy. J Neurosurg Spine. 2021;34(6):864–870.
11. Twitchell S, Karsy M, Reese J, et al. Assessment of cost drivers and cost variation for lumbar interbody fusion procedures using the value driven outcomes database. Neurosurg Focus. 2018;44(5):E10.
12. Reese JC, Karsy M, Twitchell S, Bisson EF. Analysis of anterior cervical discectomy and fusion healthcare costs via the value-driven outcomes tool. Neurosurgery. 2019;84(2):485–490.
13. Williamson TK, Owusu-Sarpong S, Imbo B, et al. An economic analysis of early and late complications after adult spinal deformity correction. Global Spine J. 2024;14(3):789–795.
14. McAfee PC. The indications for lumbar and cervical disc replacement. Spine J. 2004;4(6 Suppl):177S–181S.
15. Leibold A, Glener S, Sarikonda A, et al. What is the true cost of motion preservation? A time-driven activity-based cost analysis of anterior cervical discectomy and fusion versus disc replacement. World Neurosurg. 2024;192:e506–e512.
16. Radcliff K, Guyer RD. Economics of cervical disc replacement. Int J Spine Surg. 2020;14(s2):S67–S72.
17. Radcliff K, Zigler J, Zigler, J. Costs of cervical disc replacement versus anterior cervical discectomy and fusion for treatment of single-level cervical disc disease: an analysis of the Blue Health Intelligence database for acute and long-term costs and complications. Spine. 2015;40(8):521–529.
18. Safaee MM, Chang D, Hillman JM, et al. Implementation of outpatient minimally invasive lumbar decompression at an academic medical center without ambulatory surgery centers: a cost analysis and systematic review. World Neurosurg. 2021;146:e961–e971.
19. Safaee MM, Dalle Ore CL, Zygourakis CC, Deviren V, Ames CP. Estimating a price point for cost-benefit of bone morphogenetic protein in pseudarthrosis prevention for adult spinal deformity surgery. J Neurosurg Spine. 2019;30(6):814–821.
20. Hsu WK, Hashimoto RE, Berven SH, Nassr A. Biological substitutes/extenders for spinal arthrodesis: which agents are cost-effective? Spine. 2014;39(22 Suppl 1):S86–S98.
21. Wang H, Zhu J, Xia Y, Li Y, Fu C. Application of platelet-rich plasma in spinal surgery. Front Endocrinol. 2023;14:1138255.
22. Lucio JC, Vanconia RB, Deluzio KJ, et al. Economics of less invasive spinal surgery: an analysis of hospital cost differences between open and minimally invasive instrumented spinal fusion procedures during the perioperative period. Risk Manag Healthc Policy. 2012;5:65–74.
23. Uddin OM, Haque R, Sugrue PA, et al. Cost minimization in treatment of adult degenerative scoliosis. J Neurosurg Spine. 2015;23(6):798–806.
24. Eli I, Whitmore RG, Ghogawala Z. Spine Instrumented Surgery on a Budget-Tools for Lowering Cost Without Changing Outcome. Global Spine J. 2021;11(1 suppl):45S–55S. https://doi.org/10.1177/21925682211004895
25. Butrico C, Meisel HJ, Sage K. Patient comorbidities, their influence on lumbar spinal fusion surgery, and recommendations to reduce unfavorable outcomes. J Am Acad Orthop Surg. 2024;32(24):1115–1121.
26. Whitmore RG, Stephen JH, Vernick C, et al. ASA grade and Charlson Comorbidity Index of spinal surgery patients: correlation with complications and societal costs. Spine J. 2014;14(1):31–38.
27. Rosenthal NA, Heinrich KH, Chung J, Yu H. Cost and hospital resource utilization of Staphylococcus aureus infection post elective posterior instrumented spinal fusion surgeries in U.S. hospitals: a retrospective cohort study. Spine. 2019;44(9):637–646.
28. Philipp LR, Leibold A, Mahtabfar A, et al. Achieving value in spine surgery: 10 major cost contributors. Global Spine J. 2021;11(1_suppl):14S–22S. https:// doi.org/10.1177/2192568220971288
29. Padula WV, Smith GA, Gordon Z, Pronovost PJ. Value defects in spine surgery: how to reduce wasteful care and improve value. J Am Acad Orthop Surg. 2024;32(18):833–839.
30. Yamamoto T, Yagi M, Suzuki S, et al. Limited cost benefit of lateral interbody fusion for adult spinal deformity surgery. Spine. 2021;46(1):48–53.
31. Reyes SG, Bajaj PM, Alvandi BA, et al. Impact of social determinants of health in spine surgery. Curr Rev Musculoskelet Med. 2023;16(1):24–32.
32. Sethi R, Yanamadala V, Burton DC, Bess RS. Using lean process improvement to enhance safety and value in orthopaedic surgery: the case of spine surgery. J Am Acad Orthopaedic Surg. 2017;25(11):e244–e250.
33. Hines K, Mouchtouris N, Getz C, et al. Bundled payment models in spine surgery. Global Spine J. 2021;11(1 suppl):7S–13S.
34. Purger DA, Pendharkar AV, Ho AL, et al. Outpatient vs inpatient anterior cervical discectomy and fusion: a population-level analysis of outcomes and cost. Neurosurgery. 2018;82(4):454–464.
35. Chang D, Zygourakis CC, Wadhwa H, Kahn JG. Systematic review of cost-effectiveness analyses in U.S. spine surgery. World Neurosurg. 2020;142:e32–e57.
36. Alvin MD, Miller JA, Lubelski D, et al. Variations in cost calculations in spine surgery cost-effectiveness research. Neurosurg Foc. 2014;36(6):E1.
37. Eseonu K, Oduoza U, Monem M, Tahir M. Systematic review of cost-effectiveness analyses comparing open and minimally invasive lumbar spinal surgery. Int J Spine Surg. 2022;16(4):612–624. https://doi.org/10.14444/8297
Contributors:
Sereen Halayqeh, MD1
Adrian Lui, MBBS1
Ruvjee Patel, MBBS1
Tomoyuki Asada, MD1,2
Sravisht Iyer, MD1,2
From the 1Hospital for Special Surgery and 2Weill Cornell Medical College, both in New York, New York.
