Defining the value of elective lumbar fusion: a systematic review of existing methodologies and framework for the Operative Value Index.

Authors

• Advith Sarikonda
• Anthony Y Chen
• Theo S Biddle
• Danyal A Quraishi
• Preston Carey
• Arbaz Momin
• Matthews Lan
• D Mitchell Self
• Ashmal S Kabani
• Ahilan Sivaganesan

Publication/Presentation Date

8-1-2026

Abstract

BACKGROUND: Despite wide variation in the outcomes and costs of lumbar fusion, few studies have integrated these domains together within a single metric to assess "value" (outcomes achieved per dollar spent). In this review, we sought to 1) characterize existing metrics of cost-effectiveness for lumbar fusion, 2) evaluate all applications of time-driven activity-based costing (TDABC) in spine surgery, and 3) outline the conceptual foundation for a standardized Operative Value Index (OVI).

METHODS: Two PRISMA-concordant systematic reviews were performed on PubMed and Scopus databases. The first review examined all studies which reported a cost-effectiveness metric for lumbar fusion. The second review examined all applications of TDBAC in spine surgery.

RESULTS: Among 366 screened studies, 40 (21 for cost-effectiveness in lumbar fusion, 19 for TDABC in spine surgery) fulfilled inclusion criteria. The incremental cost-effectiveness ratio (ICER) was the most common metric, followed by OVI. Costs were frequently defined as reimbursement or charges; few studies assessed actual costs or TDABC. TDABC studies consistently demonstrated that costs were driven primarily by surgeon-level and procedure-specific factors, not patient characteristics. OVI studies uniformly used TDABC costs combined with disease-specific outcomes, but were limited to short-term follow-up and primarily intraoperative costs.

CONCLUSIONS: Current value assessments in lumbar fusion are limited by heterogeneous outcomes and imprecise costing. A standardized framework integrating pathology-specific outcomes with episode-level costing (not charges or reimbursement) may enable more generalizable and accurate comparisons of operative value.

Volume

70

Issue

4

First Page

318

Last Page

331

ISSN

1827-1855

Published In/Presented At

Sarikonda, A., Chen, A. Y., Biddle, T. S., Quraishi, D. A., Carey, P., Momin, A., Lan, M., Self, D. M., Kabani, A. S., & Sivaganesan, A. (2026). Defining the value of elective lumbar fusion: a systematic review of existing methodologies and framework for the Operative Value Index. Journal of neurosurgical sciences, 70(4), 318–331. https://doi.org/10.23736/S0390-5616.26.06769-X

Disciplines

Business Administration, Management, and Operations | Health and Medical Administration | Management Sciences and Quantitative Methods

PubMedID

41883320

Department(s)

Administration and Leadership

Document Type

Article