Spine - 2026-04-15 - Journal Article
Navigated and Robotic-Assisted Pedicle Screw Placement Are More Cost-Effective Than Freehand Technique for Posterior Spinal Fusion in Idiopathic Scoliosis: A Payer's Perspective.
Umesh A, Nian PP, Lu SL, Senthilnathan IS, Amen TB, Nichols ET, Marsh IG, Dodwell ER, Widmann RF, Zhang Y, Heyer JH
Topics
Key Takeaway
Navigation (NAV) dominates freehand (FH) at a $50,000 willingness-to-pay threshold (ICUR: -$108,831/QALY) and saves payers an estimated $45 million over seven years for idiopathic scoliosis posterior fusion.
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Summary
This Markov cost-utility analysis compared freehand, image-guided navigation, and robotic-assisted navigation for posterior spinal fusion in idiopathic scoliosis from a public payer perspective. NAV was dominant over FH (ICUR: -$108,831/QALY) and reduced mean per-patient cost by $3,610; RAN was cost-effective vs. FH (ICUR: $10,672/QALY) but not vs. NAV at a $50,000 threshold (ICUR: $255,518/QALY), though RAN became the preferred strategy at all WTPTs above $50,000. Deterministic sensitivity analysis showed results were robust, with sensitivity to fewer than 25% of input variables.
Key Limitation
The model relies entirely on literature-derived probabilities and costs rather than real-world claims data, meaning institutional variation in complication rates, implant costs, and operative time are not captured.
Original Abstract
STUDY DESIGN
Retrospective cost-analysis study.
OBJECTIVE
The primary aim of this study was to determine the cost-effectiveness from a public payer's perspective between RAN, NAV, and FH.
BACKGROUND
Robotic-assisted navigation (RAN) and image-guided intraoperative navigation (NAV) are associated with higher pedicle screw placement accuracy and lower complication rates than freehand (FH) technique to treat idiopathic scoliosis. However, RAN and NAV are underutilized and payer coverage remains limited.
METHODS
A Markov decision-analysis model for a cost-utility analysis of FH/NAV/RAN for patients with IS was created, and a probability sensitivity analysis was performed. Probabilities of health states, associated reimbursement costs, and quality-adjusted life years (QALYs) were estimated from literature. For each technique, incremental cost-utility ratio (ICURs), net costs, incremental net monetary benefit, net monetary benefit, and QALYs were calculated. Cost-effectiveness acceptability (CEA) curve analysis was performed by varying WTPT between $10,000 and $250,000. Deterministic sensitivity analysis (DSA) was performed by varying probabilities, QALYs, and costs. For cost-effective treatment strategies, cost savings to payers, if present, were calculated over a seven-year horizon.
RESULTS
When compared with FH technique, the ICUR of RAN ($10,672/QALY) and NAV (-$108,831/QALY) were below the societal willingness-to-pay threshold (WTPT) of $50,000. RAN was not more cost-effective than NAV (ICUR: $255,518/QALY) at a WTPT of $50,000. However, CEA demonstrated that RAN was the most cost-effective strategy for all WTPTs above $50,000. The mean cost of NAV per patient was lower than FH by $3610 (95% CI: $3419-$3801; P < 0.001). Mean cost of RAN per patient was higher than FH by $527 (95% CI: $267-$786; P < 0.001) and NAV by $4137 (95% CI: $3953-4320; P < 0.001). DSA demonstrated sensitivity to < 25% of variables.
CONCLUSIONS
NAV and RAN are both more cost-effective than FH. NAV can save payers $45 million over seven years. Payers should consider increasing reimbursement coverage for NAV and RAN.
LEVEL OF EVIDENCE
Level III.