1156 Myelopathic Versus Non-Myelopathic Cervical Patients: Different Value Propositions for ACDF Across Disability Levels

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INTRODUCTION: Previous research in anterior cervical discectomy and fusion (ACDF) has established that patients with severe preoperative neck disability derive greater value from surgery when compared to mildly disabled patients. However, these analyses treated preoperative diagnosis as a confounder rather than exploring potential interaction effects. METHODS: We analyzed 429 patients who underwent ACDF between 2017-2022. Using time-driven activity-based costing, we calculated total intraoperative costs for each procedure. Neck Disability index (NDI) was measured preoperatively and at 3-months postoperatively. Operative Value index (OVI), defined as percent NDI improvement per $1,000 spent, was our metric for surgical value. We performed multivariable regression with interaction terms while controlling for age, sex, BMI, comorbidities, smoking status, number of levels fused, location, and surgeon. RESULTS: After adjusting for all confounders, we found a significant interaction between preoperative NDI and myelopathy status (p = 0.004). For myelopathic patients, higher preoperative NDI strongly predicted better value (B-coefficient: 0.34, p < 0.001). In contrast, for non-myelopathic patients, this relationship was not significant (p = 0.22). Additionally, myelopathic patients with minimal disability had worse outcomes per dollar spent than nonmyelopathic patients with similar disability (OVI: -3.2 vs +2.4). This pattern reversed for severe-to-complete disability, where myelopathic patients demonstrated superior value (OVI: 9.4 vs 5.8). CONCLUSIONS: Myelopathic and non-myelopathic patients exhibit opposing cost-effectiveness patterns across disability levels, a finding that persists after adjustment for multiple confounders. Myelopathic patients demonstrate significantly increasing value with greater disability while non-myelopathic patients achieve substantial positive value regardless of baseline disability severity. This fundamental interaction challenges current selection paradigms for value-based spine surgery initiatives and suggests the need for pathology-specific criteria when evaluating ACDF candidates for bundled payment models.

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