Introduction: Proximal junctional failure (PJF) after fusions for ASD is a major cause of post-op disability. While clinical sequelae are described, PJF-revision operation costs are incompletely defined. We therefore evaluated the economic impact of revision surgery for PJF.
Methods: We performed a retrospective analysis of consecutive adults who underwent thoracolumbar fusions for ASD from 8/2003 to 1/2013 at our institution. Inclusion criteria included instrumentation extending from pelvis to L2 or above, and minimum 2 years follow-up. Direct costs were calculated for the index ASD operation and subsequent operations for PJF. Direct costs included surgical supplies/implants, room/care, and medications, but did not include indirect costs, surgeon fees, or revision operations for indications other than PJF (i.e., infection, pseudarthrosis). Student t-tests were used to compare patients based on the construct’s upper instrumented vertebra (UIV): upper thoracic (UT: T1-6) vs. thoracolumbar junction (TLjxn: T9-L2).
Results: Of 578 ASD patients, 464 had complete radiographic, clinical, and economic data. Seventy patients (index surgery UT=19; TLjxn=51) underwent revision operations for PJF, with a total direct cost of $3.9 million. Average direct cost of index operations for the cohort ($69,817) was significantly greater than that for PJF-revisions ($57,443; p<0.01). Compared to the TLjxn group, UT patients had a significantly higher average cost for index operations ($81,306 vs. $65,965; p<0.01). However, PJF-revision cases were similar in average cost between groups (UT: $63,247; TLjxn: $55,182; p=0.19).
Conclusions: Revisions for PJF after ASD surgery represent a major economic burden with an average cost of nearly $60,000 per case. Revision costs for PJF are similar based on the index procedure UIV level. PJF comes at very significant economic cost amounting to nearly 4 million dollars at a major tertiary center over a 10-year period.
Patient Care: The goal of this research is to identify the economic cost associated with proximal junctional failures. Given the high economic burden, future endeavors to prevent PJF will likely be cost-effective endeavors.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the economic cost associated with proximal junctional failures in adult spinal deformity patients
2) Identify the difference in cost between index and revision surgeries for upper thoracic versus thoracolumbar adult spinal deformity surgeries