Osteoporotic vertebral compression fractures (OVCF) are common and disabling. Augmentation techniques differ by access (uni vs. bi), trajectory (curved vs. straight), and implant platform, but direct head-to-head evidence is limited. We conducted a frequentist random-effects network meta-analysis (NMA) of randomized controlled trials (RCTs) with method-specific nodes (unipedicular percutaneous vertebroplasty (UPVP), bipedicular percutaneous vertebroplasty (BPVP), unipedicular percutaneous kyphoplasty (UPKP), bipedicular percutaneous kyphoplasty (BPKP), percutaneous curved vertebroplasty (PCVP), percutaneous curved kyphoplasty (PCKP), deflectable percutaneous kyphoplasty (DPKP), dual-plane UPVP, KIVA, TIVAD, and conservative care). Risk of bias was assessed using the Cochrane risk-of-bias tool. Outcomes were Visual Analog Scale score (VAS) (≤ 14 days, 1–3 months, > 6 months), the Oswestry Disability Index (ODI) (post-operative, long-term) (measured at the earliest post-procedural assessment and at long-term follow-up > 6 months), vertebral height restoration (

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.

OBJECTIVE:To identify which spine procedures are suitable for transition from the outpatient hospital setting to the ambulatory surgical center (ASC), it is essential to know their true costs. Using time-driven activity-based costing (TDABC), the authors sought to 1) determine the true costs of various spine surgeries performed in an outpatient hospital setting, and 2) compare these costs with Medicare ASC reimbursement to identify which procedures are most economically suitable for transition from the hospital to the ASC. METHODS:A retrospective cohort study (2020-2024) was conducted of spine procedures performed in an outpatient hospital setting (length of stay ≤ 1 day). Cervical procedures included disc arthroplasty and anterior cervical discectomy and fusion (ACDF), and lumbar procedures included laminectomy/decompression, microdiscectomy, endoscopic discectomy, and fusion. The true cost of each procedure was calculated using TDABC. Procedure-specific Medicare ASC reimbursement (including both facility and physician fees) was obtained. The primary exposure was procedure, while the primary outcomes were costs and the proportion of cases in which the total cost was below corresponding Medicare reimbursement. Multivariable logistic regression controlled for age, sex, BMI, and number of levels. RESULTS:A total of 2148 procedures (1274 lumbar, 59.3%; 874 cervical, 40.7%) were analyzed. The mean total episode cost for cervical procedures was $11,118 ± $5210. Most ACDFs (n = 574, 71.8%) were less expensive than their corresponding ASC reimbursement, compared with only 30 (40.0%) disc arthroplasties (p < 0.001). On multivariable analysis, ACDFs were significantly more likely than disc arthroplasties to cost less than reimbursement (OR 5.3, 95% CI 3.0-9.4; p < 0.001). The mean total episode cost for lumbar procedures was $4640 ± $6475. Fusion had the highest total cost ($25,042 ± $15,645), while microdiscectomy had the lowest ($3233 ± $2142) (p < 0.001). Microdiscectomy (n = 451, 95.3%) and laminectomy/decompression (n = 581, 94.5%) had the highest proportion of cases in which total cost was below the corresponding reimbursement. On multivariable analysis, endoscopic discectomy (OR 0.01, 95% CI 0.0-0.0; p < 0.001) and posterior lumbar fusion (OR 0.02, 95% CI 0.0-0.1; p < 0.001) were significantly less likely to keep costs below reimbursement, whereas laminectomy/decompression (OR 6.0, 95% CI 3.8-9.5; p < 0.001) and microdiscectomy (OR 4.7, 95% CI 2.8-7.9; p < 0.001) were significantly more likely. CONCLUSIONS:In existing payment structures, microdiscectomy, lumbar laminectomy/decompression, and ACDF might be most suitable for transitioning from the hospital to the ASC. However, to broaden the scope of procedures that can be feasibly performed in the ASC, there is a need for reimbursement reform.

BACKGROUND AND OBJECTIVES:The optimal timing of cranioplasty (CP) after craniectomy remains uncertain. We aimed to evaluate and compare functional outcomes and complication rates associated with early and late CP after craniectomy. METHODS:We systematically searched PubMed, Scopus, and Web of Science through June 2025. Fifty-five studies (n = 8602 patients) met inclusion criteria, comparing at least 2 distinct CP timing categories. Functional outcomes included Barthel Index (BI), functional independence measure, and modified motor assessment and enhancement scale. Patients were categorized as having undergone ultra-early CP (30-45 days), intermediate CP (45-70 days), early CP (80-100 days), or delayed CP (120-180 days). RESULTS:Early CP significantly improved functional outcomes in BI absolute scores, BI gain scores, absolute functional independence measure scores, and absolute modified motor assessment and enhancement scale scores compared with delayed CP. Ultra-early CP demonstrated the greatest benefit in absolute BI scores and significantly reduced bone flap resorption risk. No significant differences were found in rates of complications. Implant material (autologous vs prosthetic) and traumatic etiology did not significantly affect these outcomes. CONCLUSION:Earlier CP after craniectomy-particularly within 100 days-was associated with improved functional recovery without a significant increase in complications. Although bone flap resorption appeared lower with ultra-early timing, other adverse events such as infection, hydrocephalus, and hematoma did not vary meaningfully across timing windows. These findings suggest that, in carefully selected patients, earlier reconstruction may offer neurological benefits. Because timing was not randomized and may reflect clinical stability and treatment selection, these findings reflect associations and do not establish causality. Further studies are needed.

BACKGROUND AND OBJECTIVE:In the management of adult moyamoya disease (MMD), there is clinical equipoise regarding direct bypass (DB) vs indirect bypass (IB). One factor that may influence the choice of procedure is cost. Therefore, we sought to compare the true intraoperative costs (not charges or reimbursement) of DB vs. IB using a novel costing methodology, time-driven activity-based costing (TDABC). METHODS:A retrospective cohort study (2017-22) was conducted of all patients undergoing revascularization for symptomatic MMD. TDABC was used to calculate intraoperative costs. Supply cost was calculated as the aggregate of expenses related to implants, consumables, medications, and surgical tray sterilization. Personnel cost was determined by multiplying the per-minute wages of all intraoperative personnel by the amount of time they spent intraoperatively. Software was developed to automate this data from the electronic medical record. Multivariable regression was performed to compare the costs of DB vs. IB, adjusting for age, smoking status, hypertension, and coronary artery disease. RESULTS:Of 38 patients undergoing revascularization for MMD, 22 (57.9%) underwent DB, while 16 (42.1%) underwent IB. The median total cost of DB surgery was $7,802 (IQR: $7,802 - $9,881), compared to $6,120 (IQR: $5,609 - $6,900)for IB surgery (p < 0.05). On descriptive analysis, DB also had higher median supply cost ($3,793 vs. $2,855, p < 0.01), which was driven by higher cost of consumables ($2,268 vs. $1,996, p < 0.01), surgical tray sterilization ($137 vs. $129, p < 0.01), and implants ($1,022 vs. $568, p < 0.05). On multivariable analysis, DB was associated with significantly higher total cost (β:$1,758±$768, p = 0.027) and supply cost (β:$1,032±$333, p = 0.004), with no significant differences in personnel cost (β:$726±$526,p = 0.175). CONCLUSIONS:Using granular costing methodology, we demonstrate the individual drivers of cost which are responsible for differences in expenditures between DB and IB. This framework may inform surgical decision-making, guide institutional budgeting, and optimize resource allocation for the treatment of MMD.

INTRODUCTION:Glomuvenous malformations (GVMs), historically referred to as "glomangiomas," are rare venous malformations characterized by the presence of smooth muscle-like glomus cells around vein-like channels. A subset of these lesions arises due to heterozygous mutations in the glomulin (GLMN) gene. This case report describes the clinical presentation, surgical excision, and histopathologic evaluation of a glomuvenous malformation, highlighting the key role of genetic testing and the importance of differentiating GVMs from other vascular anomalies. METHODS:A 2-year-old male was found to have multiple small, flat, blue-gray lesions of the skin during his well-child visit. The patient underwent imaging studies to characterize the lesion's extent and vascularity, followed by complete surgical excision. Blood and biopsy samples from the procedure were sent to another institution for genetic testing. RESULTS:Genetic analysis of samples were positive for germline and somatic mutations of the GLMN gene at nucleotide positions c.157_161 and c.661, creating truncated glomulin proteins through premature stop codons. These genetic variants are consistent with a diagnosis of GVM. Postoperative follow-up demonstrated no evidence of recurrence. CONCLUSIONS:Glomuvenous malformations are clinically distinct from other venous malformations due to their histology, mutational etiology (GLMN), and characteristic appearance. Proper recognition of GVMs is critical to guide management, avoid unnecessary investigations, and offer genetic counseling for families. Complete surgical excision remains curative for symptomatic, localized lesions.

Purpose The advent of large language models (LLMs) like ChatGPT has introduced notable advancements in various surgical disciplines. These developments have led to an increased interest in the use of LLMs for Current Procedural Terminology (CPT) coding in surgery. With CPT coding being a complex and time-consuming process, often exacerbated by the scarcity of professional coders, there is a pressing need for innovative solutions to enhance coding efficiency and accuracy. Methods This observational study evaluated the effectiveness of five publicly available large language models—Perplexity.AI, Bard, BingAI, ChatGPT 3.5, and ChatGPT 4.0—in accurately identifying CPT codes for hand surgery procedures. A consistent query format was employed to test each model, ensuring the inclusion of detailed procedure components where necessary. The responses were classified as correct, partially correct, or incorrect based on their alignment with established CPT coding for the specified procedures. Results In the evaluation of artificial intelligence (AI) model performance on simple procedures, Perplexity.AI achieved the highest number of correct outcomes (15), followed by Bard and Bing AI (14 each). ChatGPT 4 and ChatGPT 3.5 yielded 8 and 7 correct outcomes, respectively. For complex procedures, Perplexity.AI and Bard each had three correct outcomes, whereas ChatGPT models had none. Bing AI had the highest number of partially correct outcomes (5). There were significant associations between AI models and performance outcomes for both simple and complex procedures. Conclusions This study highlights the feasibility and potential benefits of integrating LLMs into the CPT coding process for hand surgery. The findings advocate for further refinement and training of AI models to improve their accuracy and practicality, suggesting a future where AI-assisted coding could become a standard component of surgical workflows, aligning with the ongoing digital transformation in health care. Type of study/level of evidence Observational, IIIb.

INTRODUCTION:Accurate and efficient medical coding is essential for proper reimbursement and health care management. Current Procedural Terminology (CPT) codes, derived from operative notes, standardize medical billing but are often prone to variability and errors due to the complexity of surgical procedures. With advancements in artificial intelligence (AI), tools like ChatGPT and other large language models (LLMs) are being explored for their potential to automate coding tasks. This study evaluates the ability of LLMs to generate accurate CPT codes for craniofacial surgical procedures based on operative notes. METHODS:Operative notes for 10 craniofacial surgical cases were collected from a single surgeon at Nemours Children's Health. The notes were provided to AI tools (ChatGPT 4.0 and Gemini) to generate corresponding CPT codes. These AI-generated codes were compared against manually coded results by expert reviewers. Responses were evaluated for accuracy against manually generated CPT codes and classified as correct, partially correct, or incorrect. RESULTS:ChatGPT and Gemini demonstrated similar performance in generating CPT codes, with no statistically significant differences in accuracy or correctness between the models ( P > 0.999). Gemini produced a slightly higher proportion of correct responses (30% versus 20%), whereas ChatGPT had more partially correct responses (50% versus 40%). CONCLUSIONS:This study demonstrates that AI may be a clinically valuable resource for craniofacial CPT coding, reducing administrative burden and increasing coding accuracy. Findings from this research could inform the integration of AI into medical billing practices, promoting efficiency in surgical specialties. Future research will explore generalizability to other surgical domains and refinement of AI models for coding tasks.

INTRODUCTION:The objective of this article is to assess and describe the incidence of postoperative hemorrhage after cleft palate surgery (palatoplasty), specifically focusing on the need for a return to the operating room for the management of postoperative hemorrhage. METHODS:The TriNetX federated database was used to identify patients with a diagnosis of cleft lip and/or palate undergoing primary cleft palate repair over a 20-year period from 2003 until 2023. Primary endpoints assessed include postoperative hemorrhage resulting in blood transfusion and/or return to the operating room; Kaplan-Meier analysis was used for statistical analysis. RESULTS:A total of 13,161 patients with cleft lip or palate over the last 20 years underwent operative intervention (palatoplasty). Of those patients, 97 patients were found to have diagnosis of postoperative bleeding. One hundred seventy-five patients experienced postoperative hemorrhage requiring transfusion of blood product. Seventy patients required return to the operating room for postoperative bleeding in the immediate postoperative period. CONCLUSIONS:Historical reporting of postoperative bleeding suggests a moderate rate of postoperative hemorrhage rate after palatoplasty, occasionally necessitating transfusion and return to operating room after index palatoplasty. The authors' retrospective review of a national database demonstrates a lesser incidence of postoperative hemorrhage than previously noted.

INTRODUCTION:Accurate medical coding is vital for proper health care management and reimbursement, especially in craniofacial surgery. Although CPT codes standardize clinical services, modifiers are often required to capture procedural complexities and ensure fair compensation. Applying modifiers accurately can be time-intensive and error-prone, posing challenges for coding professionals. Recent advancements in natural language processing (NLP) and large language models (LLMs) have shown promise in automating coding tasks. However, the ability of LLMs to identify the need for CPT modifiers from operative notes remains unexplored. METHODS:This study evaluates the capability of LLMs, including ChatGPT and Google Gemini, to identify necessary CPT modifiers from craniofacial operative notes. The authors collected notes containing common modifiers, such as Modifier 22 (increased procedural complexity), and compared model outputs to expert-coded results. The study focused on key modifiers relevant to craniofacial surgery, with performance assessed based on precision. RESULTS:Of the 10 operative reports evaluated, neither ChatGPT nor Gemini correctly identified both the CPT code and modifier for any case. However, ChatGPT more frequently generated responses containing partially correct CPT and modifier codes and was the only model to correctly assign a modifier code with a partially correct CPT in one instance. Both models produced multiple responses with either partially or completely inaccurate codes, including 4 entirely incorrect submissions each. Notably, some LLM suggestions fell within the appropriate CPT range but did not account for procedural specifics such as the inclusion of a graft or the depth of tissue debridement. CONCLUSIONS:This study demonstrates the potential of LLMs as an ancillary tool for CPT modifier identification in craniofacial surgery. By reducing administrative burdens and improving accuracy, these tools could enhance efficiency and reimbursement for complex procedures. Future directions include refining LLM capabilities and evaluating their generalizability across other surgical subspecialties.

Background:The rising complexity and cost of healthcare in plastic surgery, particularly in resource-intensive procedures like free flap and breast reconstruction, pose significant financial challenges. Time-driven activity-based costing (TDABC) offers a method to accurately assess these costs by mapping each step of the care cycle based on time and resources consumed. Although TDABC has been utilized in high-cost fields such as neurosurgery and spine surgery, its application in plastic surgery remains underexplored. This systematic review evaluates the literature on TDABC use in plastic surgery to identify key cost drivers and propose strategies for cost-efficiency. Methods:A systematic review was conducted on studies applying TDABC, activity-based costing, and cost-to-charge ratio in plastic surgery, sourced from PubMed. Inclusion criteria focused on peer-reviewed studies from the last decade assessing costing strategies in aesthetic and reconstructive plastic surgery, resulting in 17 studies that provided empirical data on cost drivers and resource allocation. Results:Operating room time, staffing, and postoperative care are identified as primary cost contributors in complex reconstructive surgery, with TDABC highlighting inefficiencies such as prolonged operating room time and unnecessary intensive care unit stays. Cost-saving opportunities were found in optimizing postoperative care and reallocating tasks to lower-cost personnel. Conclusions:TDABC provides a framework for cost optimization in plastic surgery by offering granular insights into resource utilization, allowing for targeted interventions that reduce expenses without compromising care quality. Future research should explore the application of TDABC to cosmetic procedures and assess its long-term cost-effectiveness in plastic surgery.

BACKGROUND AND OBJECTIVES:Gliomas are among the most common primary brain tumors. Based on proximity to eloquent structures, surgeons may perform an awake craniotomy (AC) or an asleep craniotomy under general anesthesia (GA). To date, no study has used time-driven activity-based costing to compare costs of these procedures. METHODS:We identified all GA (n = 298) and AC (n = 67) performed for glioma resection at our institution from 2017 to 2022. Total costs were determined through interdepartmental collaboration (sterile processing, pharmacy, and plant operations departments) and automated extraction from the electronic medical record. Multivariable generalized linear mixed models were performed to compare costs between AC and GA, accounting for patient and tumor-specific factors. Differences in survival were evaluated using Kaplan-Meier curves and Cox proportional hazards models. RESULTS:The median total cost of surgery was $6600 (IQR: $2875), most of which was driven by the cost of supplies (median: $3178, IQR: $1798) and personnel (median: $3141, IQR: $1155). Although GA patients were older ( P = .025), no differences were found in World Health Organization tumor grade distribution ( P = .55) or extent of resection ( P = .17). After adjusting for confounders, AC was associated with $2175 of additional intraoperative cost ( P < .001) compared with GA. Kaplan-Meier analysis demonstrated greater overall survival (OS) for AC compared with GA (log-rank; P = .011), with no significant difference in progression-free survival (PFS) (log-rank; P = .106). However, when adjusting for confounders, multivariable Cox hazards ratios (HRs) revealed no significant differences in OS (HR = 0.84, P = .48) or PFS (HR = 0.9, P = .66) between the 2 modalities. CONCLUSION:Although AC was significantly more expensive than GA, it was not associated with a corresponding improvement in OS or PFS after adjusting for confounders. Continual reassessment of the cost-effectiveness of novel brain tumor approaches will be increasingly important in the era of value-based care.

Background:The increasing prevalence of obesity has raised concerns about its impact on surgical outcomes and healthcare costs. This study evaluates the influence of Body Mass Index (BMI) on intraoperative costs and operative times during open Transforaminal Lumbar Interbody Fusion (TLIF) procedures using a Time-Driven Activity-Based Costing (TDABC) approach. Methods:A retrospective analysis was conducted on 279 patients who underwent TLIF between 2019 and 2022. Patients were categorized into 5 BMI cohorts: healthy weight (BMI 18.5-24.99), overweight (BMI 25.0-29.99), Class I obese (BMI 30.0-34.99), Class II obese (BMI 35.0-39.99), and Class III obese (BMI >40). Intraoperative costs were calculated using TDABC methodology, with costs segmented into supply and personnel expenses. Operative times were measured in 3 phases: surgery time (incision to closure), OR time (patient entering to leaving), and turnover time. Multivariable regression models assessed the relationship between BMI and various intraoperative time and cost metrics, adjusting for potential confounders. Results:BMI was significantly associated with increased operative times and personnel costs. Each unit increase in BMI corresponded to an additional 1.90 minutes in the operating room (p = .01) and a $25.72 increase in personnel costs (p = .008). However, no significant association was found between BMI and total or supply costs. Regression analyses indicated that obese patients did not significantly differ from healthy weight patients in terms of total intraoperative costs. Conclusions:Higher BMI is associated with increased operative times and personnel costs in TLIF procedures, though it does not significantly impact total intraoperative costs when controlling for confounders. These findings suggest that BMI may not need to be a significant deterrent in patient selection for TLIF under bundled payment models.

Objective:This study aims to examine the impact of ear, nose, and throat (ENT) surgeons' involvement on intraoperative costs and operating room (OR) times for retrosigmoid craniotomies using time-driven activity-based costing (TDABC). Design:A retrospective, single-center analysis was conducted. TDABC methodology was utilized to calculate total intraoperative costs. Multiple linear regression analysis was performed to assess the independent effect of ENT surgeons' involvement on surgical costs and OR time. Setting:All procedures were performed at the Thomas Jefferson University Hospital and affiliated sites between 2017 and 2022. Participants:About 255 patients underwent retrosigmoid craniotomy (166 neurosurgery only, 89 with ENT surgeons' involvement). Main Outcome Measures:Main outcome measures include total intraoperative costs calculated using TDABC methodology, OR time, supply costs, and personnel costs. Results:Inclusion of ENT surgeons was significantly associated with increased total costs (B = $4,082 ± $1,015, p  < 0.001) and OR time (B = 135 ± 38 minutes, p  < 0.001). The mean total cost of neurosurgery-only cases was $7,538 ± $3,977, compared with $14,217 ± $3,485 for multidisciplinary cases. Personnel costs were the primary driver of this increase, with no significant difference in supply costs between groups. Conclusion:While ENT collaboration can enhance outcomes in select cases, such as those involving vestibular schwannomas, its routine inclusion may not be cost-effective. Our study demonstrates the marginal cost of ENT collaboration for retrosigmoid craniotomies. Future studies may build on our costing framework by integrating outcomes with costs to determine the true cost-effectiveness of cross-specialty collaboration.

BACKGROUND:Neurosurgeons lack precise insights into the true costs of transsphenoidal endoscopic surgery for sellar and suprasellar lesions (TESS), including pituitary adenomas, craniopharyngiomas, and apoplexy. To address this critical knowledge gap, we employ time-driven activity-based costing (TDABC) for TESS. METHODS:We analyzed 221 TESS procedures performed between 2017 and 2022 at a large academic medical center. Costs were calculated using TDABC. Software was developed to extract information regarding all resources utilized intraoperatively. Supply cost was calculated as the aggregate of expenses related to implants, consumables, medications, and surgical tray sterilization. Personnel cost was determined by multiplying the per-minute wages of all intraoperative personnel by the amount of time they spent in the operating room. Patient and disease-specific variables were collected. Multivariable regression models were performed to assess predictors of cost. RESULTS:The average total cost of a TESS procedure was $7557 ± $2,365, with primary cost drivers being supplies ($2,811, 37%) and personnel ($4,426, 59%). On multivariable regression, factors independently associated with higher total cost were hospital site (β-coefficient: $1,028, P < 0.001), intraoperative blood loss (β-coefficient: $12, P < 0.001), length of stay (β-coefficient: $23, P = 0.015), and the use of a nasoseptal flap (β-coefficient: $731, P = 0.012). Conversely, apoplexy was associated with lower total cost (β-coefficient: $-1,149, P = 0.001), which was explained by faster operating room times and lower personnel cost (β-coefficient: $-702, P = 0.003). CONCLUSIONS:This study represents the first application of intraoperative TDABC for transsphenoidal endoscopic surgery. Such efforts can promote value-based healthcare by identifying areas for cost reduction and surgical resource management.

BACKGROUND:Lumbar fusion is a common treatment for degenerative spine changes. Although both anterior-posterior (AP) and posterior-only approaches are used, their cost-effectiveness remains uncertain. This study aims to compare the costs and short-term "value" (outcomes per dollar spent) of AP and posterior-only lumbar fusions using time-driven activity-based costing and patient-reported outcomes. METHODS:A retrospective review of AP and posterior lumbar fusions from 2017 to 2022 was conducted. Time-driven activity-based costing was used to assign intraoperative costs based on resource utilization, and the Oswestry Disability Index (ODI) was collected preoperatively and 3 months postoperatively. The Operative Value Index (OVI) was defined as the percent improvement in ODI per $1000 spent. Kruskal-Wallis analysis and multivariable regression compared costs, operative times, and OVI between AP and posterior-only lumbar fusions. RESULTS:Among 108 analyzed patients, 33 underwent AP fusion and 75 underwent posterior-only fusion. The average cost of AP fusion ($22,590) was significantly higher than posterior-only fusion ($10,768) (P < 0.001), driven by greater supply (P < 0.001) and personnel costs (P < 0.001). AP procedures also had longer operative times but showed no significant difference in ODI improvement (P = 0.473). Although posterior-only was associated with significantly higher OVI (P < 0.05) on univariate analysis, multivariable regression revealed no significant difference in OVI between posterior-only fusions and AP fusions (P = 0.098). CONCLUSIONS:We provide a novel "value" metric that integrates granular costing methodology with prospectively collected patient-reported outcomes. Although AP fusions incur significantly greater cost than posterior-only fusions, there was no significant "value" difference between the two modalities when accounting for confounders.

Large language models (LLMs) have been utilized to automate tasks like writing discharge summaries and operative reports in neurosurgery. The present study evaluates their ability to identify current procedural terminology (CPT) codes from operative reports. Three LLMs (ChatGPT 4.0, AtlasGPT and Gemini) were evaluated in their ability to provide CPT codes for diagnostic or interventional procedures in endovascular neurosurgery at a single institution. Responses were classified as correct, partially correct or incorrect, and the percentage of correctly identified CPT codes were calculated. The Chi-Square test and Kruskal Wallis test were used to compare responses across LLMs. A total of 30 operative notes were used in the present study. AtlasGPT identified CPT codes for 98.3

The increasing prevalence of elective lumbar fusions has been accompanied by a steady rise in revision procedures. Few studies have identified the relative cost-effectiveness of revision lumbar fusion using detailed costing methodology. Here, we aim to compare the “value” (outcomes achieved per dollar spent) of primary versus revision lumbar fusion by integrating time-driven activity-based costing (TDABC) with patient-reported outcomes (PROs). 292 patients were prospectively enrolled to undergo elective lumbar fusion. Revision surgery was defined as any case of lumbar fusion after a previous lumbar spine surgery. TDABC was employed to identify intraoperative costs for all cases. Oswestry Disability Index (ODI) scores were collected both preoperatively and at 6-months postoperatively. “Value” was measured through the Operative Value Index (OVI), defined as the percent improvement in ODI per 1,000 spent intraoperatively. Multivariable linear regression, accounting for confounders, was performed to assess whether revision surgery was significantly associated with total cost and OVI. Secondary analyses were performed to compare costs and OVI between primary fusions, revisions for prior decompression and fusion, and revisions for prior decompression alone. The average total cost of a revision fusion was18,252 +/- 8,496, compared to18,073 +/- 8,894 for a primary fusion. The average OVI for these groups were 1.79 and 1.65, respectively. On multivariable regression analysis, there were no significant differences in OVI (p = 0.423) or total cost (p = 0.841) between primary and revision cohorts.In the era of value-based care, it is increasingly important for hospitals to identify drivers of variation in the cost-effectiveness of neurosurgical care. By integrating PROs with detailed cost data, we demonstrate that revision lumbar fusions may not significantly differ in cost or value compared to primary fusions. Not applicable.