scholarly journals The unreimbursed costs of preventing revision surgery in adult spinal deformity: analysis of cost-effectiveness of proximal junctional failure prevention with ligament augmentation

2018 ◽  
Vol 44 (5) ◽  
pp. E13 ◽  
Author(s):  
Michael M. Safaee ◽  
Cecilia L. Dalle Ore ◽  
Corinna C. Zygourakis ◽  
Vedat Deviren ◽  
Christopher P. Ames
Keyword(s):  
Spinal Deformity ◽  
Revision Surgery ◽  
Adult Spinal Deformity ◽  
Cost Savings ◽  
Cost Effective ◽  
Prevention Strategies ◽  
Ligament Augmentation ◽  
Proximal Junctional Failure ◽  
The Mean ◽  
Upper Instrumented Vertebra

OBJECTIVEProximal junctional kyphosis (PJK) is a well-recognized complication of surgery for adult spinal deformity and is characterized by increased kyphosis at the upper instrumented vertebra (UIV). PJK prevention strategies have the potential to decrease morbidity and cost by reducing rates of proximal junctional failure (PJF), which the authors define as radiographic PJK plus clinical sequelae requiring revision surgery.METHODSThe authors performed an analysis of 195 consecutive patients with adult spinal deformity. Age, sex, levels fused, upper instrumented vertebra (UIV), use of 3-column osteotomy, pelvic fixation, and mean time to follow-up were collected. The authors also reviewed operative reports to assess for the use of surgical adjuncts targeted toward PJK prevention, including ligament augmentation, hook fixation, and vertebroplasty. The cost of surgery, including direct and total costs, was also assessed at index surgery and revision surgery. Only revision surgery for PJF was included.RESULTSThe mean age of the cohort was 64 years (range 25–84 years); 135 (69%) patients were female. The mean number of levels fused was 10 (range 2–18) with the UIV as follows: 2 cervical (1%), 73 upper thoracic (37%), 108 lower thoracic (55%), and 12 lumbar (6%). Ligament augmentation was used in 99 cases (51%), hook fixation in 60 cases (31%), and vertebroplasty in 71 cases (36%). PJF occurred in 18 cases (9%). Univariate analysis found that ligament augmentation and hook fixation were associated with decreased rates of PJF. However, in a multivariate model that also incorporated age, sex, and UIV, only ligament augmentation maintained a significant association with PJF reduction (OR 0.196, 95% CI 0.050–0.774; p = 0.020). Patients with ligament augmentation, compared with those without, had a higher cost of index surgery, but ligament augmentation was overall cost effective and produced significant cost savings. In sensitivity analyses in which we independently varied the reduction in PJF, cost of ligament augmentation, and cost of reoperation by ± 50%, ligament augmentation remained a cost-effective strategy for PJF prevention.CONCLUSIONSPrevention strategies for PJK/PJF are limited, and their cost-effectiveness has yet to be established. The authors present the results of 195 patients with adult spinal deformity and show that ligament augmentation is associated with significant reductions in PJF in both univariate and multivariate analyses, and that this intervention is cost-effective. Future studies will need to determine if these clinical results are reproducible, but for high-risk cases, these data suggest an important role of ligament augmentation for PJF prevention and cost savings.

scholarly journals Ligament augmentation for prevention of proximal junctional kyphosis and proximal junctional failure in adult spinal deformity

2018 ◽  
Vol 28 (5) ◽  
pp. 512-519 ◽  
Author(s):  
Michael M. Safaee ◽  
Vedat Deviren ◽  
Cecilia Dalle Ore ◽  
Justin K. Scheer ◽  
Darryl Lau ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Revision Surgery ◽  
Adult Spinal Deformity ◽  
Consecutive Series ◽  
Proximal Junctional Kyphosis ◽  
Historical Cohort ◽  
Ligament Augmentation ◽  
Proximal Junctional Failure ◽  
The Mean ◽  
Junctional Kyphosis

OBJECTIVEProximal junctional kyphosis (PJK) is a well-recognized, yet incompletely defined, complication of adult spinal deformity surgery. There is no standardized definition for PJK, but most studies describe PJK as an increase in the proximal junctional angle (PJA) of greater than 10°–20°. Ligament augmentation is a novel strategy for PJK reduction that provides strength to the upper instrumented vertebra (UIV) and adjacent segments while also reducing junctional stress at those levels.METHODSIn this study, ligament augmentation was used in a consecutive series of adult spinal deformity patients at a single institution. Patient demographics, including age; sex; indication for surgery; revision surgery; surgical approach; and use of 3-column osteotomies, vertebroplasty, or hook fixation at the UIV, were collected. The PJA was measured preoperatively and at last follow-up using 36-inch radiographs. Data on change in PJA and need for revision surgery were collected. Univariate and multivariate analyses were performed to identify factors associated with change in PJA and proximal junctional failure (PJF), defined as PJK requiring surgical correction.RESULTSA total of 200 consecutive patients were included: 100 patients before implementation of ligament augmentation and 100 patients after implementation of this technique. The mean age of the ligament augmentation cohort was 66 years, and 67% of patients were women. Over half of these cases (51%) were revision surgeries, with 38% involving a combined anterior or lateral and posterior approach. The mean change in PJA was 6° in the ligament augmentation group compared with 14° in the control group (p < 0.001). Eighty-four patients had a change in PJA of less than 10°. In a multivariate linear regression model, age (p = 0.016), use of hook fixation at the UIV (p = 0.045), and use of ligament augmentation (p < 0.001) were associated with a change in PJA. In a separate model, only ligament augmentation (OR 0.193, p = 0.012) showed a significant association with PJF.CONCLUSIONSLigament augmentation represents a novel technique for the prevention of PJK and PJF. Compared with a well-matched historical cohort, ligament augmentation is associated with a significant decrease in PJK and PJF. These data support the implementation of ligament augmentation in surgery for adult spinal deformity, particularly in patients with a high risk of developing PJK and PJF.

Estimating a price point for cost-benefit of bone morphogenetic protein in pseudarthrosis prevention for adult spinal deformity surgery

2019 ◽  
Vol 30 (6) ◽  
pp. 814-821 ◽  
Author(s):  
Michael M. Safaee ◽  
Cecilia L. Dalle Ore ◽  
Corinna C. Zygourakis ◽  
Vedat Deviren ◽  
Christopher P. Ames
Keyword(s):  
Direct Cost ◽  
Spinal Deformity ◽  
Revision Surgery ◽  
Adult Spinal Deformity ◽  
Cost Benefit ◽  
Primary Surgery ◽  
Morphogenetic Protein ◽  
The Mean ◽  
Upper Instrumented Vertebra ◽  
The Cost

OBJECTIVEBone morphogenetic protein (BMP) is associated with reduced rates of pseudarthrosis and has the potential to decrease the need for revision surgery. There are limited data evaluating the cost-benefit of BMP for pseudarthrosis-related prevention surgery in adult spinal deformity.METHODSThe authors performed a single-center retrospective review of 200 consecutive patients with adult spinal deformity. Demographic data and costs of BMP, primary surgery, and revision surgery for pseudarthrosis were collected. Patients with less than 12 months of follow-up or with infection, tumor, or neuromuscular disease were excluded.RESULTSOne hundred fifty-one patients (107 [71%] women) with a mean age of 65 years met the inclusion criteria. The mean number of levels fused was 10; BMP was used in 98 cases (65%), and the mean follow-up was 23 months. Fifteen patients (10%) underwent surgical revision for pseudarthrosis; BMP use was associated with an 11% absolute risk reduction in the rate of reoperation (17% vs 6%, p = 0.033), with a number needed to treat of 9.2. There were no significant differences in age, sex, upper instrumented vertebra, or number of levels fused in patients who received BMP. In a multivariate model including age, sex, number of levels fused, and the upper instrumented vertebra, only BMP (OR 0.250, 95% CI 0.078–0.797; p = 0.019) was associated with revision surgery for pseudarthrosis. The mean direct cost of primary surgery was $87,653 ± $19,879, and the mean direct cost of BMP was $10,444 ± $4607. The mean direct cost of revision surgery was $52,153 ± $26,985. The authors independently varied the efficacy of BMP, cost of BMP, and cost of reoperation by ± 50%; only reductions in the cost of BMP resulted in a cost savings per 100 patients. Using these data, the authors estimated a price point of $5663 in order for BMP to be cost-neutral.CONCLUSIONSUse of BMP was associated with a significant reduction in the rates of revision surgery for pseudarthrosis. At its current price, the direct in-hospital costs for BMP exceed the costs associated with revision surgery; however, this likely underestimates the true value of BMP when considering the savings associated with reductions in rehabilitation, therapy, medication, and additional outpatient costs.

scholarly journals Proximal junctional failure prevention in adult spinal deformity surgery utilizing interlaminar fixation constructs

2019 ◽  
Vol 11 (2) ◽  
Author(s):  
Alan H. Daniels ◽  
Shyam A. Patel ◽  
Daniel B.C. Reid ◽  
Burke Gao ◽  
Eren O. Kuris ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Operative Time ◽  
Adult Spinal Deformity ◽  
Neurological Injury ◽  
Spinal Deformity Surgery ◽  
Proximal Junctional Failure ◽  
Upper Instrumented Vertebra ◽  
Tissue Trauma ◽  
Posterior Soft Tissue ◽  
Junctional Kyphosis

Proximal junctional kyphosis (PJK) is a common complication following fusion for Adult Spinal Deformity. PJK and proximal junctional failure (PJF) may lead to pain, neurological injury, reoperation, and increased healthcare costs. Efforts to prevent PJK and PJF have aimed to preserve or reconstruct the posterior spinal tension band and/or modifying instrumentation to allow for more gradual transitions in stiffness at the cranial end of long spinal constructs. We describe placement of an interlaminar fixation construct at the upper instrumented vertebra which may decrease PJK/PJF severity, and is placed with little additional operative time and minimal posterior soft tissue trauma.

scholarly journals Association between bicortical screw fixation at upper instrumented vertebra and risk for upper instrumented vertebra fracture

2017 ◽  
Vol 26 (5) ◽  
pp. 638-644 ◽  
Author(s):  
Young-Seop Park ◽  
Seung-Jae Hyun ◽  
Ho Yong Choi ◽  
Ki-Jeong Kim ◽  
Tae-Ahn Jahng
Keyword(s):  
Spinal Deformity ◽  
Pelvic Incidence ◽  
Screw Fixation ◽  
Adult Spinal Deformity ◽  
Vertical Axis ◽  
Sagittal Vertical Axis ◽  
The Mean ◽  
Upper Instrumented Vertebra ◽  
Bicortical Screw

OBJECTIVEThe aim of this study was to investigate the risk of upper instrumented vertebra (UIV) fractures associated with UIV screw fixation (unicortical vs bicortical) and polymethylmethacrylate (PMMA) augmentation after adult spinal deformity surgery.METHODSA single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥ 4 levels (that is, the lower instrumented vertebra at the sacrum or pelvis and the UIV of the thoracolumbar spine [T9–L2]) were retrospectively reviewed. Age, sex, follow-up duration, sagittal UIV angle immediately postoperatively including several balance-related parameters (lumbar lordosis [LL], pelvic incidence, and sagittal vertical axis), bone mineral density, UIV screw fixation type, UIV PMMA augmentation, and UIV fracture were evaluated. Patients were divided into 3 groups: Group U, 15 patients with unicortical screw fixation at the UIV; Group P, 16 with bicortical screw fixation and PMMA augmentation at the UIV; and Group B, 21 with bicortical screw fixation without PMMA augmentation at the UIV.RESULTSThe mean number of levels fused was 6.5 ± 2.5, 7.5 ± 2.5, and 6.5 ± 2.5; the median age was 50 ± 29, 72 ± 6, and 59 ± 24 years; and the mean follow-up was 31.5 ± 23.5, 13 ± 6, and 24 ± 17.5 months in Groups U, P, and B, respectively (p > 0.05). There were no significant differences in balance-related parameters (LL, sagittal vertical axis, pelvic incidence–LL, and so on) among the groups. UIV fracture rates in Groups U (0%), P (31.3%), and B (42.9%) increased in sequence by group (p = 0.006). UIV bicortical screw fixation increased the risk for UIV fracture (OR 5.39; p = 0.02).CONCLUSIONSBicortical screw fixation at the UIV is a major risk factor for early UIV compression fracture, regardless of whether a thoracolumbosacral orthosis is used. To reduce the proximal junctional failure, unicortical screw fixation at the UIV is essential in adult spinal deformity correction surgery.

Reduced proximal junctional failure with ligament augmentation in adult spinal deformity: a series of 242 cases with a minimum 1-year follow-up

2021 ◽  
pp. 1-9
Author(s):  
Michael M. Safaee ◽  
Alexander F. Haddad ◽  
Marissa Fury ◽  
Patrick R. Maloney ◽  
Justin K. Scheer ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Consecutive Series ◽  
Historical Cohort ◽  
Valuable Adjunct ◽  
Ligament Augmentation ◽  
Proximal Junctional Failure ◽  
Upper Thoracic

OBJECTIVE Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are well-recognized complications of long-segment spinal fusion. Previous studies have suggested that ligament augmentation can decrease rates of PJF by reducing junctional stress and strengthening upper instrumented vertebrae (UIVs) and adjacent segments. However, there is a paucity of long-term data on the efficacy of ligament augmentation in preventing PJF. In this study, the authors sought to determine the effect of ligament augmentation on rates of PJF in a cohort of adult spinal deformity patients with at least 1 year of follow-up. METHODS They conducted a retrospective analysis of ligament augmentation in a consecutive series of surgical patients with adult spinal deformity. Data on patient demographics, surgical characteristics, and surgery for PJF were collected. The minimum follow-up was 12 months. Univariate and multivariate analyses were performed to identify factors associated with reoperation for PJF. RESULTS The authors identified a total of 242 patients (166 women [68.6%]) with ligament augmentation whose mean age was 66 years. The mean number of fused levels was 10, with a UIV distribution as follows: 90 upper thoracic UIVs (37.2%) and 152 lower thoracic UIVs (62.8%). Compared to a historical cohort of 77 patients treated before implementation of ligament augmentation, reoperation for PJF was significantly lower with ligament augmentation (15.6% vs 3.3%, p < 0.001). In a multivariate model, only ligament augmentation (OR 0.184, 95% CI 0.071–0.478, p = 0.001) and number of fused levels (OR 0.762, 95% CI 0.620–0.937, p = 0.010) were associated with reductions in reoperation for PJF. CONCLUSIONS Ligament augmentation was associated with significant reductions in the rate of reoperation for PJF at 12 months in a cohort of adult spinal deformity patients. The most dramatic reduction was seen among patients with lower thoracic UIV. These data suggest that in appropriately selected patients, ligament augmentation may be a valuable adjunct for PJF reduction; however, long-term follow-up is needed.

Sign in / Sign up

Export Citation Format

Share Document