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Study Design: A retrospective review of a multicenter comprehensive cervical deformity (CD) database., Objective: To develop a novel risk index specific to each patient to aid in patient counseling and surgical planning to minimize postop distal junctional kyphosis (DJK) occurrence., Background: DJK is a radiographic finding identified after patients undergo instrumented spinal fusions which can result in sagittal spinal deformity, pain and disability, and potentially neurological compromise. DJK is considered multifactorial in nature and there is a lack of consensus on the true etiology of DJK., Materials and Methods: CD patients with baseline (BL) and at least one-year postoperative radiographic follow-up were included. A patient-specific DJK score was created through use of unstandardized Beta weights of a multivariate regression model predicting DJK (end of fusion construct to the second distal vertebra change in this angle by <-10° from BL to postop)., Results: A total of 110 CD patients included (61 yr, 66.4% females, 28.8 kg/m 2 ). In all, 31.8% of these patients developed DJK (16.1% three males, 11.4% six males, 62.9% one-year). At BL, DJK patients were more frail and underwent combined approach more (both P <0.05). Multivariate model regression analysis identified individualized scores through creation of a DJK equation: -0.55+0.009 (BL inclination)-0.078 (preinflection)+5.9×10 -5 (BL lowest instrumented vertebra angle) + 0.43 (combine approach)-0.002 (BL TS-CL)-0.002 (BL pelvic tilt)-0.031 (BL C2 - C7) + 0.02 (∆T4-T12)+ 0.63 (osteoporosis)-0.03 (anterior approach)-0.036 (frail)-0.032 (3 column osteotomy). This equation has a 77.8% accuracy of predicting DJK. A score ≥81 predicted DJK with an accuracy of 89.3%. The BL reference equation correlated with two year outcomes of Numeric Rating Scales of Back percentage ( P =0.003), reoperation ( P =0.04), and minimal clinically importance differences for 5-dimension EuroQol questionnaire ( P =0.04)., Conclusions: This study proposes a novel risk index of DJK development that focuses on potentially modifiable surgical factors as well as established patient-related and radiographic determinants. The reference model created demonstrated strong correlations with relevant two-year outcome measures, including axial pain-related symptoms, occurrence of related reoperations, and the achievement of minimal clinically importance differences for 5-dimension EuroQol questionnaire., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: As corrective surgery for cervical deformity (CD) increases, so does the rate of complications and reoperations. To minimize suboptimal postoperative outcomes, it is important to develop a tool that allows for proper preoperative risk stratification., Objective: To develop a prognostic utility for identification of risk factors that lead to the development of major complications and unplanned reoperations., Methods: CD patients age 18 years or older were stratified into 2 groups based on the postoperative occurrence of a revision and/or major complication. Multivariable logistic regressions identified characteristics that were associated with revision or major complication. Decision tree analysis established cutoffs for predictive variables. Models predicting both outcomes were quantified using area under the curve (AUC) and receiver operating curve characteristics., Results: A total of 109 patients with CD were included in this study. By 1 year postoperatively, 26 patients experienced a major complication and 17 patients underwent a revision. Predictive modeling incorporating preoperative and surgical factors identified development of a revision to include upper instrumented vertebrae > C5, lowermost instrumented vertebrae > T7, number of unfused lordotic cervical vertebrae > 1, baseline T1 slope > 25.3°, and number of vertebral levels in maximal kyphosis > 12 (AUC: 0.82). For developing a major complication, a model included a current smoking history, osteoporosis, upper instrumented vertebrae inclination angle < 0° or > 40°, anterior diskectomies > 3, and a posterior Smith Peterson osteotomy (AUC: 0.81)., Conclusion: Revisions were predicted using a predominance of radiographic parameters while the occurrence of major complications relied on baseline bone health, radiographic, and surgical characteristics., (Copyright © Congress of Neurological Surgeons 2022. All rights reserved.)

Summary of Background Data: The influence of frailty on economic burden following corrective surgery for the adult cervical deformity (CD) is understudied and may provide valuable insights for preoperative planning., Objective: To assess the influence of baseline frailty status on the economic burden of CD surgery., Study Design: Retrospective cohort., Materials and Methods: CD patients with frailty scores and baseline and two-year Neck Disability Index data were included. Frailty score was categorized patients by modified CD frailty index into not frail (NF) and frail (F). Analysis of covariance was used to estimate marginal means adjusting for age, sex, surgical approach, and baseline sacral slope, T1 slope minus cervical lordosis, C2-C7 angle, C2-C7 sagittal vertical axis. Costs were derived from PearlDiver registry data. Reimbursement consisted of a standardized estimate using regression analysis of Medicare payscales for services within a 30-day window including length of stay and death. This data is representative of the national average Medicare cost differentiated by complication/comorbidity outcome, surgical approach, and revision status. Cost per quality-adjusted life-year (QALY) at two years was calculated for NF and F patients., Results: There were 126 patients included. There were 68 NF patients and 58 classified as F. Frailty groups did not differ by overall complications, instance of distal junctional kyphosis, or reoperations (all P >0.05). These groups had similar rates of radiographic and clinical improvement by two years. NF and F had similar overall cost ($36,731.03 vs. $37,356.75, P =0.793), resulting in equivocal costs per QALYs for both patients at two years ($90,113.79 vs. $80,866.66, P =0.097)., Conclusion: F and NF patients experienced similar complication rates and upfront costs, with equivocal utility gained, leading to comparative cost-effectiveness with NF patients based on cost per QALYs at two years. Surgical correction for CD is an economical healthcare investment for F patients when accounting for anticipated utility gained and cost-effectiveness following the procedure., Level of Evidence: III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To investigate normal curvature ratios of the cervicothoracic spine and to establish radiographic thresholds for severe myelopathy and disability, within the context of shape., Methods: Adult cervical deformity (CD) patients undergoing cervical fusion were included. C2-C7 Cobb angle (CL) and thoracic kyphosis (TK), using T2-T12 Cobb angle, were used as a ratio, ranging from -1 to + 1. Pearson bivariate r and univariate analyses analyzed radiographic correlations and differences in myelopathy(mJOA > 14) or disability(NDI > 40) across ratio groups., Results: Sixty-three CD patients included. Regarding CL:TK ratio, 37 patients had a negative ratio and 26 patients had a positive ratio. A more positive CL:TK correlated with increased TS-CL(r = 0.655, p =  < 0.001)and mJOA(r = 0.530, p = 0.001), but did not correlate with cSVA/SVA or NDI scores. A positive CL:TK ratio was associated with moderate disability(NDI > 40)(OR: 7.97[1.22-52.1], p = 0.030). Regression controlling for CL:TK ratio revealed cSVA > 25 mm increased the odds of moderate to severe myelopathy and cSVA > 30 mm increased the odds of significant neck disability. Lastly, TS-CL > 29 degrees increased the odds of neck disability by 4.1 × with no cutoffs for severe mJOA(p > 0.05)., Conclusions: Cervical deformity patients with an increased CL:TK ratio had higher rates of moderate neck disability at baseline, while patients with a negative ratio had higher rates of moderate myelopathy clinically. Specific thresholds for cSVA and TS-CL predicted severe myelopathy or neck disability scores, regardless of baseline neck shape. A thorough evaluation of the cervical spine should include exploration of relationships with the thoracic spine and may better allow spine surgeons to characterize shapes and curves in cervical deformity patients., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: With increasing interest in cost optimization, costs of adult spinal deformity (ASD) surgery intersections with frailty merit investigation., Objective: To investigate costs associated with ASD and frailty., Methods: Patients with ASD (scoliosis ≥20°, sagittal vertical axis [SVA] ≥5 cm, pelvic tilt ≥ 25°, or thoracic kyphosis ≥ 60°) with baseline and 2-yr radiographic data were included. Patients were severely frail (SF), frail (F), or not frail (NF). Utility data were converted from Oswestry Disability Index to Short-Form Six-Dimension. Quality-adjusted life years (QALYs) used 3% rate for decline to life expectancy. Costs were calculated using PearlDiver. Loss of work costs were based on SRS-22rQ9 and US Bureau of Labor Statistics. Accounting for complications, length of stay, revisions, and death, cost per QALY at 2 yr and life expectancy were calculated., Results: Five hundred ninety-two patients with ASD were included (59.8 ± 14.0 yr, 80% F, body mass index: 27.7 ± 6.0 kg/m2, Adult Spinal Deformity-Frailty Index: 3.3 ± 1.6, and Charlson Comorbidity Index: 1.8 ± 1.7). The average blood loss was 1569.3 mL, and the operative time was 376.6 min, with 63% undergoing osteotomy and 54% decompression. 69.3% had a posterior-only approach, 30% combined, and 0.7% anterior-only. 4.7% were SF, 22.3% F, and 73.0% NF. At baseline, 104 were unemployed losing $971.38 weekly. After 1 yr, 62 remained unemployed losing $50 508.64 yearly. With propensity score matching for baseline SVA, cost of ASD surgery at 2 yr for F/SF was greater than that for NF ($81 347 vs $69 722). Cost per QALY was higher for F/SF at 2 yr than that for NF ($436 473 vs $430 437). At life expectancy, cost per QALY differences became comparable ($58 965 vs $58 149)., Conclusion: Despite greater initial cost, F and SF patients show greater improvement. Cost per QALY for NF and F patients becomes similar at life expectancy., (Copyright © Congress of Neurological Surgeons 2021. All rights reserved.)

Study Design: Retrospective study of a prospective multicenter database., Objective: The purpose of this study was to identify predictors of lower total surgery costs at 3 years for adult spinal deformity (ASD) patients., Summary of Background Data: ASD surgery involves complex deformity correction., Methods: Inclusion criteria: surgical ASD (scoliosis ≥20°, sagittal vertical axis [SVA] ≥5 cm, pelvic tilt ≥25°, or thoracic kyphosis ≥60°) patients >18 years. Total costs for surgery were calculated using the PearlDiver database. Cost per quality-adjusted life year was assessed. A Conditional Variable Importance Table used nonreplacement sampling set of 20,000 Conditional Inference trees to identify top factors associated with lower cost surgery for low (LSVA), moderate (MSVA), and high (HSVA) SRS Schwab SVA grades., Results: Three hundred sixtee of 322 ASD patients met inclusion criteria. At 3-year follow up, the potential cost of ASD surgery ranged from $57,606.88 to $116,312.54. The average costs of surgery at 3 years was found to be $72,947.87, with no significant difference in costs between deformity groups (P > 0.05). There were 152 LSVA patients, 53 MSVA patients, and 111 HSVA patients. For all patients, the top predictors of lower costs were frailty scores <0.19, baseline (BL) SRS Activity >1.5, BL Oswestry Disability Index <50 (all P < 0.05). For LSVA patients, no history of osteoporosis, SRS Activity scores >1.5, age <64, were the top predictors of lower costs (all P < 0.05). Among MSVA patients, ASD invasiveness scores <94.16, no past history of cancer, and frailty scores <0.3 trended toward lower total costs (P = 0.071, P = 0.210). For HSVA, no history of smoking and body mass index <27.8 trended toward lower costs (both P = 0.060)., Conclusion: ASD surgery has the potential for improved cost efficiency, as costs ranged from $57,606.88 to $116,312.54. Predictors of lower costs included higher BL SRS activity, decreased frailty, and not having depression. Additionally, predictors of lower costs were identified for different BL deformity profiles, allowing for the optimization of cost efficiency for all patients.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: The aim of this study was to investigate the impact of cervical to thoracolumbar ratios on poor outcomes in cervical deformity (CD) corrective surgery., Summary of Background Data: Consideration of distal regional and global alignment is a critical determinant of outcomes in CD surgery. For operative CD patients, it is unknown whether certain thoracolumbar parameters play a significant role in poor outcomes and whether addressing such parameters is warranted., Methods: Included: surgical CD patients (C2-C7 Cobb >10°, cervical lordosis [CL] >10°, C2-C7 sagittal vertical axis (cSVA) >4 cm, or chin-brow vertical angle >25°) with baseline and 1-year data. Patients were assessed for ratios of preop cervical and global parameters including: C2 Slope/T1 slope, T1 slope minus C2-C7 lordosis (TS-CL)/mismatch between pelvic incidence and lumbar lordosis (PI-LL), cSVA/sagittal vertical axis (SVA). Deformity classification ratios of cervical (Ames-ISSG) to spinopelvic (SRS-Schwab) were investigated: cSVA modifier/SVA modifier, TS-CL modifier/PI-LL modifier. Cervical to thoracic ratios included C2-C7 lordosis/T4-T12 kyphosis. Correlations assessed the relationship between ratios and poor outcomes (major complication, reoperation, distal junctional kyphosis (DJK), or failure to meet minimal clinically important difference [MCID]). Decision tree analysis through multiple iterations of multivariate regressions assessed cut-offs for ratios for acquiring suboptimal outcomes., Results: A total of 110 CD patients were included (61.5 years, 66% F, 28.8 kg/m2). Mean preoperative radiographic ratios calculated: C2 slope/T1 slope of 1.56, TS-CL/PI-LL of 11.1, cSVA/SVA of 5.4, CL/thoracic kyphosis (TK) of 0.26. Ames-ISSG and SRS-Schwab modifier ratios: cSVA/SVA of 0.1 and TS-CL/PI-LL of 0.35. Pearson correlations demonstrated a relationship between major complications and baseline TS-CL/PI-LL, Ames TS-CL/Schwab PI-LL modifiers, and the CL/TK ratios (P < 0.050). Reoperation had significant correlation with TS-CL/PI-LL and cSVA/SVA ratios. Postoperative DJK correlated with C2 slope/T1 slope and CL/TK ratios. Not meeting MCID for Neck Disability Index (NDI) correlated with CL/TK ratio and not meeting MCID for EQ5D correlated with Ames TS-CL/Schwab PI-LL., Conclusion: Consideration of cervical to global alignment is a critical determinant of outcomes in CD corrective surgery. Key ratios of cervical to global alignment correlate with suboptimal clinical outcomes. A larger cervical lordosis to TK predicted postoperative complication, DJK, and not meeting MCID for NDI.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Age-adjusted alignment targets in the context of distal junctional kyphosis (DJK) development have yet to be investigated. Our aim was to assess age-adjusted alignment targets, reciprocal changes, and role of lowest instrumented level orientation in DJK development in cervical deformity (CD) patients. Methods: CD patients were evaluated based on lowest fused level: cervical (C7 or above), upper thoracic (UT: T1–T6), and lower thoracic (LT: T7–T12). Age-adjusted alignment targets were calculated using published formulas for sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), pelvic tilt (PT), T1 pelvic angle (TPA), and LL-thoracic kyphosis (TK). Outcome measures were cervical and global alignment parameters: Cervical SVA (cSVA), cervical lordosis, C2 slope, C2–T3 angle, C2–T3 SVA, TS-CL, PI-LL, PT, and SVA. Subanalysis matched baseline PI to assess age-adjusted alignment between DJK and non-DJK. Results: Seventy-six CD patients included. By 1Y, 20 patients developed DJK. Non-DJK patients had 27% cervical lowest instrumented vertebra (LIV), 68% UT, and 5% LT. DJK patients had 25% cervical, 50% UT, and 25% LT. There were no baseline or 1Y differences for PI, PI-LL, SVA, TPA, or PT for actual and age-adjusted targets. DJK patients had worse baseline cSVA and more severe 1Y cSVA, C2–T3 SVA, and C2 slope (P < 0.05). The distribution of over/under corrected patients and the offset between actual and ideal alignment for SVA, PT, TPA, PI-LL, and LL-TK were similar between DJK and non-DJK patients. DJK patients requiring reoperation had worse postoperative changes in all cervical parameters and trended toward larger offsets for global parameters. Conclusion: CD patients with severe baseline malalignment went on to develop postoperative DJK. Age-adjusted alignment targets did not capture differences in these populations, suggesting the need for cervical-specific goals. [ABSTRACT FROM AUTHOR]

The widely used definition for distal junctional kyphosis (DJK) includes the change in kyphosis between the lower instrument vertebra (LIV) and LIV-2 to be >10°. However, this cut-off has yet to be analyzed against other possible cut-offs in terms of accuracy, sensitivity, and specificity for various clinically relevant outcomes. Create thresholds that more accurately predict DJK than those currently used. Retrospective cohort study. Cervical deformity (CD) patients (C2-C7 Cobb >10°, CL>10°, cSVA >4cm, or CBVA >25°) with radiographic data at baseline (BL) and at least 1 year follow-up. DJK reoperation, minimal clinical important difference (MCID) for Neck Disability Index (NDI) and EQ5D. Surgically treated CD patients were enrolled into a prospective, multicenter database and evaluated at a minimum of 1-year follow-up for DJK. DJK was defined by the patient's DJK angle (DJKA) >10° change in kyphosis between LIV and LIV-2 and a >10° index angle. Sensitivity (true positive [TP]/TP+false negative [FN]), precision (true negative [TN]/(TN+False Positive [FP]), and accuracy (TN+TP/TN+TP+FN+FP) metrics were calculated from different combinations of angular changes above and below the lower instrumented vertebrae (LIV) from pre- to postop. The ability of these angular changes to predict different types of DJK failure (DJKF) [(1) reoperation for DJK (2) not meeting MCID for either NDI or Eq5D] and were compared against previously published definitions of DJK including absolute and ∆DJKA>10° and ∆DJKA >20°. A total of 160 CD patients with follow-up were included (57yrs, 29.1 kg/m2, 51.8%F). Eighteen percent of these patients developed DJK postop (33.4% 6M, 47.6% 1Y, 19% 2Y). The mean DJK angle prior to revision surgery was -1.7±7.4 (Minimum: -19.3, Maximum: 10.5). Baseline average pelvic parameters were: PT: 16.8±9.6, PI: 54.1±12.3, PI-LL: -2.0±13.5. The average cervical parameters were: TS-CL: 25.6±14.5, C2-C7: -0.9±14.4. Sensitivity, precision, and accuracy of previously used criteria of >10° to identify DJKF for outcome 1 demonstrated a sensitivity of 50%, specificity of 64.4% and an accuracy of 63.2%. For outcome 2 using this criterion resulted in a sensitivity of 55%, specificity 75.8%, and accuracy 67.3%. However, if the ∆DJKA was increased to 15.3, the predicted sensitivity for DJKF defined by reoperation was 50%, specificity 86.6% and with an accuracy of 83.6%. When DKF was defined by HRQLs the sensitivity was 35%, specificity 96.5% and accuracy of 71.4%. This newly established cut-off had greater ability to correctly identify true positives than the 20° cut-off (45.8% vs 27.1%), as well as for true negatives when compared to the 10° (39.2% vs 34.2%). A subanalysis identified 40.6% of patients with a DJKA >10° to be not clinically meaningful. When increasing the angle to the proposed 15.3° only 35.7% are not clinically meaningful. The newly established cut-off for DJK failure (∆DJKA>15.3°) demonstrated greater sensitivity, specificity, and precision than the previously established criteria of 10° when analyzing distal junctional kyphosis failure as described by reoperations or clinical deterioration. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Distal junctional kyphosis (DJK) remains a primary concern for surgeons performing cervical deformity (CD) surgery. Postoperative complications from CD surgeries often render patients with worse recovery profiles which require reoperation. It is paramount to understand possible DJK recovery profiles for various types of surgical patients. Identify if DJK patients successfully recover from treatment/reoperation. Retrospective review of prospectively collected database. This study included 145 cervical deformity (CD) patients with baseline and 1-year follow-up. Complications;reoperations; HRQL, alignment. CD patients(patients) were identified if they developed DJK. DJK angle (DJKA) was defined as >10° change in kyphosis between LIV and LIV-2 and a >10° index angle. Patients were stratified into two groups: 1) those who received a reoperation for DJK (Reop DJK) and those that did not have DJK (no DJK). Normalized HRQL scores at baseline and follow-up intervals (3 months, 6 months, 1 year, 2 years) were generated. Normalized HRQLs were plotted and area under the curve was calculated, generating one number describing overall recovery (Integrated Health State [IHS]). A total of 145 CD patients included. Of these patients, 32% developed DJK postop (56 years, 28.5kg/m2, 53% Female) with 12.8% of these cases being severe. By DJK occurrence: 24.2% within 3 months, 45.4% at 6 months, 31.4% by 1 year. Of these DJK patients, 25.5% received a reoperation. Upon presentation, Reop DJK patients had a worse PI-LL (-11.0 vs.11), worse NSR-Neck (8.7 vs 6.9), and a worse NDI (65.7 vs 53.9; all p<0.05). After receiving operation for their DJK, these patients displayed a worse pain recovery profile identified by their IHS-adjusted score when compared to No DJK patients for NRS-Neck between baseline to 3 months (19.7 vs 11.5; p<0.05). If these patients remain hyperkyphotic (T1-T12) postop, the IHS-adjust scores identified worse long-term recovery (3 months to 2 years) as identified by their EQ5D (52.5 vs 57.5; p<0.05). However, if reop DJK patients are matched according to their age-adjusted SVA (Lafage et al), they were identified to have better short-term recovery than DJK reop patients who were not matched by their NSR-Neck (7.0 vs 11; p<0.05) and then eventually normalizes with the latter's recovery course (p>0.05). Having DJK and not receiving a reop did not have much of an effect on recovery despite DJK angle, however; when compared to DJK reop, when nonop DJK angle was greater than 20°, the IHS-score mJOA adjusted resulted in greater long-term recovery (nonReop:59.9 vs Reop: 48.4; p<0.05). Of the total DJK patients in this study, 25.5% received a reoperation. These patients had a worse pain recovery profile than non-DJK patients. However; when matched to their age-adjusted SVA, reop DJK patients were shown to have an improved short-term recovery than if they went unmatched according to their IHS-adjusted NSR-Neck. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

With health care costs on the rise, hospitals have increasingly focused on providing economically efficient medical services. Adult spinal deformity surgery remains an expensive medical intervention with high risk for complications and revisions, especially following mechanical failure in the context of proximal junctional kyphosis (PJK). We sought to evaluate the impact of PJK on associated expenditures following an index surgery for ASD. To evaluate the effect of proximal junctional kyphosis on the cost effectiveness of corrective adult deformity surgery. Retrospective cohort study of a prospective single-center database of ASD patients. A total of 147 Adult Spinal Deformity Patients. Complications, HRQLs (Oswentry Disability Index [ODI]), Quality adjusted life years (QALY). Adult Spinal deformity patients with 2-year HRQL follow-up were included. Utility data was calculated using published conversion methods to convert ODI to SF-6D. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database incorporating complications and comorbidities classified according to CMS standard definitions. Reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for all services rendered within a 30-day window, including estimates regarding costs of postoperative complications, outpatient health care encounters, reoperations and revisions. After accounting for all postoperative events, including mortality, cost per QALY by 2Y was calculated for revisions that occurred due to proximal junctional kyphosis. A total of 147 adult spinal deformity patients met inclusion criteria (55.22years, 54% Female). At baseline, patients presented radiographically as: Pelvic Tilt (23.66±11.7), Pelvic Incidence- Lumbar Lordosis (-2.9±12.6), Sagittal Vertical Axis (60.5±76.8), T1 Pelvic Angle (22.6±14.3). Surgical details: EBL of 1823 mL, operative time of 327 min, with.4% undergoing an anterior approach, 90.2% posterior-only approach, and 9.3% combined approach. Overall, 54.3% of patients developed PJK within 2 years postoperatively, with 22% undergoing reoperation for PJK. Average cost of revision surgery due to PJK was $93,688 ± $21,467. The cost for PJK patients, including the cost associated with their revision surgery, was higher ($103,760 vs $71,000). Baseline ODI (39 vs 32) and 2Y ODI (39 vs 27) were higher for PJK patients, however, PJK patients did improve to a greater degree (-12 vs -10). The overall cost per QALY by 2Y was higher for PJK patients ($116,170 vs $95,347). Patients that developed PJK had an almost $30,000 higher initial cost at 2 years. When looking at the cost per quality adjusted life years by 2Y, PJK resulted in slightly more than $20,000 in cost. These findings suggest prophylactic measures to mitigate PJK may improve the cost utility of adult spinal deformity surgery and can help policy efforts for adequate resource allocation for these complex patients. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]