Comparison of Lateral Decubitus versus Prone Lateral Lumbar Interbody Fusion Using Impact Scores: A Method to Quantify Intraoperative Supply Cost and Variability in Surgery.

Authors

Emaad Lala, Kenneth Nguyen, Kento Yamanouchi, Rafael Garcia de Oliveira, Mir Amaan Ali, Iyan Younus, Venu M Nemani, Jean-Christophe Leveque, Philip K Louie, Aiyush Bansal

Published in

The spine journal : official journal of the North American Spine Society. Oct 18, 2026. Epub Oct 18, 2026.

Abstract

Surgical value metrics report intraoperative supply costs as aggregate institutional dollars, which do not identify which supply categories drive cost.
To introduce the Impact Score, each supply category's percentage share of total intraoperative supply cost, as a descriptive framework and, using lateral decubitus (LD-LIF) versus prone lateral (PL-LIF) lateral lumbar interbody fusion as a proof of concept, to determine whether impact scores differ by supply category and align with median-cost rankings, whether exploratory outcome-based value metrics differ between approaches, and whether meaningful inter-surgeon variability exists.
Retrospective single-center cohort study at a tertiary center.
Seventy-eight single-level L4-5 lateral lumbar interbody fusion cases performed from 2021 to 2026 (32 LD-LIF, 46 PL-LIF).
Category-level impact score (percentage of total intraoperative supply cost), supply and total intraoperative cost, exploratory value metrics based on the Oswestry Disability Index and PROMIS-10-derived quality-adjusted life years (including the operative value index and unit price per outcome), and 90-day readmission.
Itemized intraoperative supply records were mapped to 33 standardized categories, and each category's impact score was computed as its percentage of total intraoperative supply cost. Time-driven activity-based costing provided staff costs. Category-level impact scores and costs were compared with unadjusted Wilcoxon rank-sum tests.
Impact-score and median-cost rankings were broadly concordant. LD-LIF showed higher impact for interbody, screw, biologic, and retractor/dilator, and PL-LIF for neuromonitoring and positioning (all p < 0.01). Navigation and rod did not differ. Total intraoperative cost did not differ between approaches (PL-LIF $17,206 vs LD-LIF $16,404, p = 0.462), nor did staff cost (p = 0.607), and exploratory value metrics did not establish a cost-effectiveness difference, whereas the impact score localized the between-approach difference to supply composition. Biologic impact varied most, with a more than two-fold range among the three surgeons (median approximately 5% to 19%) and higher biologic impact in LD-LIF within individual surgeons.
The impact score describes how intraoperative supply costs are distributed across categories. In this single-center, three-surgeon cohort, it identified a potentially modifiable cost driver that neither total cost nor exploratory value metrics revealed. Its use for cross-institutional benchmarking will require a multicenter study of how impact scores vary between institutions with differing vendor pricing and contracting. Because it reflects only the intraoperative phase, it complements, rather than replaces, episode-of-care and outcome-based value assessment.
Level III, retrospective comparative study.

PMID:
42893774
Bibliographic data and abstract were imported from PubMed on 19 Oct 2026.

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