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Colonna S, Casacci F, Borghi C. Scoliosis and Lower Limb Inequality: To Lift or Not to Lift, That Is the Question. Cureus 2024; 16:e58443. [PMID: 38633141 PMCID: PMC11022167 DOI: 10.7759/cureus.58443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 04/19/2024] Open
Abstract
In subjects with scoliotic alterations of the spine, asymmetrical lengths of the lower limbs are frequently observed, a condition commonly referred to as leg length inequality (LLI) or discrepancy (LLD). This asymmetry can induce pelvic misalignments, manifested by an asymmetric height of the iliac crests, and consequently an alteration of the spine's axis. Although correcting this discrepancy might appear to be a straightforward solution, further investigation may reveal other indications. The purpose of this article is to aid clinicians confronted with the decision of whether to compensate for an LLI in individuals with scoliosis, encompassing both adolescents and adults. It presents a literature review on the incidence of LLIs in the general population, distinguishing between structural LLI (sLLI) and functional LLI (fLLI) types of LLIs, and quantifying their magnitude with clinical and instrumental evaluation. Additionally, it links these two types of LLIs to the type of scoliosis (structural or functional). From a clinical perspective, it also examines the compensatory mechanisms employed by the pelvis in the presence of structural or functional LLIs in order to draw useful indications for therapeutic decisions. Moreover, it proposes an additional evaluation parameter in the coronal plane, namely the central sacral vertical line (CSVL), to aid in the decision-making process regarding LLI compensation. Although this parameter has been documented in the literature, it has been little associated with LLIs. The findings indicate that scoliotic discrepancies should be compensated (conservatively or surgically) only when the imbalance of the femoral heads is on the same side as the imbalance of the sacrum and the iliac crests; this corrective action should result in a reduction of the overhang in the coronal plane.
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Affiliation(s)
- Saverio Colonna
- Rehabilitation Medicine, Spine Center, Bologna, ITA
- Research and Development, Osteopathic Spine Center Education, Bologna, ITA
| | - Fabio Casacci
- Rehabilitation Medicine, Spine Center, Bologna, ITA
- Research and Development, Osteopathic Spine Center Education, Bologna, ITA
| | - Corrado Borghi
- Rehabilitation Medicine, Spine Center, Bologna, ITA
- Research and Development, Osteopathic Spine Center Education, Bologna, ITA
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Aguirre AO, Soliman MAR, Kuo CC, Ruggiero N, Im J, Chintaluru Y, Khan AMA, Khan A, Hess RM, Rho K, Smolar DE, Mullin JP, Pollina J. Cervical Vertebral Bone Quality Score Independently Predicts Distal Junctional Kyphosis After Posterior Cervical Fusion. Neurosurgery 2024; 94:461-469. [PMID: 37823666 DOI: 10.1227/neu.0000000000002714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Posterior cervical fusion is the surgery of choice when fusing long segments of the cervical spine. However, because of the limited presence of this pathology, there is a paucity of data in the literature about the postoperative complications of distal junctional kyphosis (DJK). We aimed to identify and report potential associations between the preoperative cervical vertebral bone quality (C-VBQ) score and the occurrence of DJK after posterior cervical fusion. METHODS The authors retrospectively reviewed records of patients who underwent posterior cervical fusion at a single hospital between June 1, 2010, and May 31, 2020. Patient data were screened to include patients who were >18 years old, had baseline MRI, had baseline standing cervical X-ray, had immediate postoperative standing cervical X-ray, and had clinical and radiographic follow-ups of >1 year, including a standing cervical X-ray at least 1 year postoperatively. Univariate analysis was completed between DJK and non-DJK groups, with multivariate regression completed for relevant clinical variables. Simple linear regression was completed to analyze correlation between the C-VBQ score and total degrees of kyphosis angle change. RESULTS Ninety-three patients were identified, of whom 19 (20.4%) had DJK and 74 (79.6%) did not. The DJK group had a significantly higher C-VBQ score than the non-DJK group (2.97 ± 0.40 vs 2.26 ± 0.46; P < .001). A significant, positive correlation was found between the C-VBQ score and the total degrees of kyphosis angle change (r 2 = 0.26; P < .001). On multivariate analysis, the C-VBQ score independently predicted DJK (odds ratio, 1.46; 95% CI, 1.27-1.67; P < .001). CONCLUSION We found that the C-VBQ score was an independent predictive factor of DJK after posterior cervical fusion.
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Affiliation(s)
- Alexander O Aguirre
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo , Egypt
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Nicco Ruggiero
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Justin Im
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | | | - Ali M A Khan
- Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - Ryan M Hess
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - Kyungduk Rho
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - David E Smolar
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo , New York , USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo , New York , USA
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3
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Passias PG, Pierce KE, Williamson TK, Lebovic J, Schoenfeld AJ, Lafage R, Lafage V, Gum JL, Eastlack R, Kim HJ, Klineberg EO, Daniels AH, Protopsaltis TS, Mundis GM, Scheer JK, Park P, Chou D, Line B, Hart RA, Burton DC, Bess S, Schwab FJ, Shaffrey CI, Smith JS, Ames CP. Patient-specific Cervical Deformity Corrections With Consideration of Associated Risk: Establishment of Risk Benefit Thresholds for Invasiveness Based on Deformity and Frailty Severity. Clin Spine Surg 2024; 37:E43-E51. [PMID: 37798829 DOI: 10.1097/bsd.0000000000001540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 08/10/2023] [Indexed: 10/07/2023]
Abstract
STUDY DESIGN/SETTING This was a retrospective cohort study. BACKGROUND Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty. OBJECTIVE The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity. METHODS This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely. RESULTS A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P =0.002], and invasiveness increased with deformity severity ( P <0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P =0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P =0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P =0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group. CONCLUSIONS Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Katherine E Pierce
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Jordan Lebovic
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California-Davis, Davis, CA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
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Passias PG, Williamson TK, Pierce KE, Schoenfeld AJ, Krol O, Imbo B, Joujon-Roche R, Tretiakov P, Ahmad S, Bennett-Caso C, Mir J, Dave P, McFarland K, Owusu-Sarpong S, Lebovic JA, Janjua MB, de la Garza-Ramos R, Vira S, Diebo B, Koller H, Protopsaltis TS, Lafage R, Lafage V. The Importance of Incorporating Proportional Alignment in Adult Cervical Deformity Corrections Relative to Regional and Global Alignment: Steps Toward Development of a Cervical-Specific Score. Spine (Phila Pa 1976) 2024; 49:116-127. [PMID: 37796161 DOI: 10.1097/brs.0000000000004843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
STUDY DESIGN/SETTING Retrospective single-center study. BACKGROUND The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD). PURPOSE Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD. METHODS Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years. RESULTS One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF. CONCLUSION The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Andrew J Schoenfeld
- New York Spine Institute, New York, NY
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Oscar Krol
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Bailey Imbo
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Peter Tretiakov
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Salman Ahmad
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Claudia Bennett-Caso
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Jamshaid Mir
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Pooja Dave
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Kimberly McFarland
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | | | - Jordan A Lebovic
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | | | - Rafael de la Garza-Ramos
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Shaleen Vira
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Heiko Koller
- International Center for Spinal Disorders and Deformity, Orthopedic Department II, Asklepios Clinics Bad Abbach, Bad Tölz, Germany
| | | | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
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Jackson-Fowl B, Hockley A, Naessig S, Ahmad W, Pierce K, Smith JS, Ames C, Shaffrey C, Bennett-Caso C, Williamson TK, McFarland K, Passias PG. Adult cervical spine deformity: a state-of-the-art review. Spine Deform 2024; 12:3-23. [PMID: 37776420 DOI: 10.1007/s43390-023-00735-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 07/01/2023] [Indexed: 10/02/2023]
Abstract
Adult cervical deformity is a structural malalignment of the cervical spine that may present with variety of significant symptomatology for patients. There are clear and substantial negative impacts of cervical spine deformity, including the increased burden of pain, limited mobility and functionality, and interference with patients' ability to work and perform everyday tasks. Primary cervical deformities develop as the result of a multitude of different etiologies, changing the normal mechanics and structure of the cervical region. In particular, degeneration of the cervical spine, inflammatory arthritides and neuromuscular changes are significant players in the development of disease. Additionally, cervical deformities, sometimes iatrogenically, may present secondary to malalignment or correction of the thoracic, lumbar or sacropelvic spine. Previously, classification systems were developed to help quantify disease burden and influence management of thoracic and lumbar spine deformities. Following up on these works and based on the relationship between the cervical and distal spine, Ames-ISSG developed a framework for a standardized tool for characterizing and quantifying cervical spine deformities. When surgical intervention is required to correct a cervical deformity, there are advantages and disadvantages to both anterior and posterior approaches. A stepwise approach may minimize the drawbacks of either an anterior or posterior approach alone, and patients should have a surgical plan tailored specifically to their cervical deformity based upon symptomatic and radiographic indications. This state-of-the-art review is based upon a comprehensive overview of literature seeking to highlight the normal cervical spine, etiologies of cervical deformity, current classification systems, and key surgical techniques.
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Affiliation(s)
- Brendan Jackson-Fowl
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Aaron Hockley
- Department of Neurosurgery, University of Alberta, Edmonton, AB, USA
| | - Sara Naessig
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Waleed Ahmad
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Katherine Pierce
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Claudia Bennett-Caso
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Tyler K Williamson
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Kimberly McFarland
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA.
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Lee JK, Hyun SJ, Kim KJ. Optimizing Surgical Strategy for Cervical Spinal Deformity: Global Alignment and Surgical Targets. Neurospine 2023; 20:1246-1255. [PMID: 38171292 PMCID: PMC10762390 DOI: 10.14245/ns.2346744.372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 01/05/2024] Open
Abstract
Cervical spinal deformity (CSD) is a complex condition characterized by abnormal curvature and cervical spine alignment. It can lead to a multitude of symptoms, including chronic pain, neurological deficits, and functional impairments, severely impacting an individual's health-related quality of life (HRQoL). Surgical intervention is often necessary to address the deformity and alleviate symptoms, but optimal surgical strategies remain a topic of ongoing research and debate. This narrative review aims to provide an in-depth overview of the surgical management of CSD, focusing on optimizing patient outcomes and enhancing readers' understanding of the complexities involved. We begin by discussing the importance of preoperative assessment, including comprehensive radiographic evaluation and careful consideration of the global spinal alignment. The relationship between the cervical spine and the reciprocal changes that occur are explored to guide surgeons in their decision-making process. Furthermore, we delve into the selection of fusion levels, emphasizing the significance of identifying the primary driver of deformity. We review the current literature on optimal alignment targets and strategies to optimize surgical planning. By providing a comprehensive analysis of the surgical management of CSD, this review aims to enhance the readers' knowledge and assist surgeons in making informed decisions when planning and executing surgical interventions. Understanding the intricacies of CSD correction and the latest advancements in the field can ultimately improve patient outcomes and enhance HRQoL for individuals suffering from this challenging condition.
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Affiliation(s)
- Jae-Koo Lee
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Foley D, Hardacker P, McCarthy M. Emerging Technologies within Spine Surgery. Life (Basel) 2023; 13:2028. [PMID: 37895410 PMCID: PMC10608700 DOI: 10.3390/life13102028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/02/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
New innovations within spine surgery continue to propel the field forward. These technologies improve surgeons' understanding of their patients and allow them to optimize treatment planning both in the operating room and clinic. Additionally, changes in the implants and surgeon practice habits continue to evolve secondary to emerging biomaterials and device design. With ongoing advancements, patients can expect enhanced preoperative decision-making, improved patient outcomes, and better intraoperative execution. Additionally, these changes may decrease many of the most common complications following spine surgery in order to reduce morbidity, mortality, and the need for reoperation. This article reviews some of these technological advancements and how they are projected to impact the field. As the field continues to advance, it is vital that practitioners remain knowledgeable of these changes in order to provide the most effective treatment possible.
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Affiliation(s)
- David Foley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Pierce Hardacker
- Indiana University School of Medicine, Indianapolis, IN 46202, USA;
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Lafage R, Smith JS, Soroceanu A, Ames C, Passias P, Shaffrey C, Mundis G, Alshabab BS, Protopsaltis T, Klineberg E, Elysee J, Kim HJ, Bess S, Schwab F, Lafage V. Predicting Mechanical Failure Following Cervical Deformity Surgery: A Composite Score Integrating Age-Adjusted Cervical Alignment Targets. Global Spine J 2023; 13:2432-2438. [PMID: 35350922 PMCID: PMC10538337 DOI: 10.1177/21925682221086535] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Investigate a composite score to evaluate the relationship between alignment proportionality and risk of distal junctional kyphosis (DJK). METHODS 84 patients with minimum 1 year follow-up were included (age = 61.1 ± 10.3 years, 64.3% women). The Cervical Score was constructed using offsets from age-adjusted normative values for sagittal vertical axis (SVA), T1 Slope (TS), and TS minus cervical lordosis (CL). Individual points were assigned based on offset with age-adjusted alignment targets and summed to generate the Cervical Score. Rates of mechanical failure (DJK revision or severe DJK [DJK> 20° and ΔDJK> 10°]) were assessed overall and based on Cervical Score. Logistical regressions assessed associations between early radiographic alignment and 1-year failure rate. RESULTS Mechanical failure rate was 21.4% (N = 18), 10.7% requiring revision. By multivariate logistical regression: 3-month T1S (OR: .935), TS-CL (OR:0.882), and SVA (OR:1.015) were independent predictors of 1-year failure (all P < .05). Cervical Score ranged (-6 to 6), 37.8% of patients between -1 and 1, and 50.0% with 2 or higher. DJK patients had significantly higher Cervical Score (4.1 ± 1.3 vs .6 ± 2.2, P < .001). Patients with a score ≥3 were significantly more likely to develop a failure (71.4%) with OR of 38.55 (95%CI [7.73; 192.26]) and Nagelkerke r2 .524 (P < .001). CONCLUSION This study developed a composite alignment score predictive of mechanical failures in CD surgery. A score ≥3 at 3 months following surgery was associated with a marked increase in failure rate. The Cervical Score can be used to analyze sagittal alignment and help define realignment objectives to reduce mechanical failure.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | | | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | | | - Basel Sheikh Alshabab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - On behalf of the International Spine Study Group (ISSG)
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
- Department of Surgery, University of Calgary, Calgary, AB, Canada
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- Scripps Clinic, San Diego, CA, USA
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
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9
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Marciano GF, Simhon ME, Lehman RA, Lenke LG. Strategies to Avoid Distal Junctional Pathology. Neurosurg Clin N Am 2023; 34:585-597. [PMID: 37718105 DOI: 10.1016/j.nec.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Distal junctional pathology remains an unsolved issue in spine surgery. Distal junctional pathology can occur on a spectrum from asymptomatic radiographic finding to catastrophic distal construct failure. It is significant to address as postoperative sagittal balance has been shown to be correlated with patient-reported outcomes. Current literature and clinical experience suggest there are techniques that can be implemented regardless of setting to avoid distal junctional pathology. Much of the avoidant strategy relies on understanding the deformity pathology, selection of the lowest instrumented vertebra (LIV), health of the segments caudal to the LIV, and methods of fixation.
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Affiliation(s)
- Gerard F Marciano
- Department of Orthopedics, Columbia University Medical Center, 622 West 168th Street, PH 11- Center, New York, NY 10032, USA.
| | - Matthew E Simhon
- Department of Orthopedics, Columbia University Medical Center, 622 West 168th Street, PH 11- Center, New York, NY 10032, USA
| | - Ronald A Lehman
- The Daniel and Jane Och Spine Hospital at New York-Presbyterian/Allen, 5141 Broadway, New York, NY 10034, USA
| | - Lawrence G Lenke
- The Daniel and Jane Och Spine Hospital at New York-Presbyterian/Allen, Och Spine/Allen NYP Hospital, 5141 Broadway, New York, NY 10034, USA
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10
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Murphy TP, Colantonio DF, Le AH, Fredericks DR, Schlaff CD, Holm EB, Sebastian AS, Pisano AJ, Helgeson MD, Wagner SC. Biomechanical Analysis of Multilevel Posterior Cervical Spinal Fusion Constructs. Clin Spine Surg 2023; 36:E212-E217. [PMID: 36823698 DOI: 10.1097/bsd.0000000000001429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 12/13/2022] [Indexed: 02/25/2023]
Abstract
STUDY DESIGN Controlled Laboratory Study. OBJECTIVE To compare multilevel posterior cervical fusion (PCF) constructs stopping at C7, T1, and T2 under cyclic load to determine the range of motion (ROM) between the lowest instrumented level and lowest instrumented-adjacent level (LIV-1). SUMMARY OF BACKGROUND DATA PCF is a mainstay of treatment for various cervical spine conditions. The transition between the flexible cervical spine and rigid thoracic spine can lead to construct failure at the cervicothoracic junction. There is little evidence to determine the most appropriate level at which to stop a multilevel PCF. METHODS Fifteen human cadaveric cervicothoracic spines were randomly assigned to 1 of 3 treatment groups: PCF stopping at C7, T1, or T2. Specimens were tested in their native state, following a simulated PCF, and after cyclic loading. Specimens were loaded in flexion-extension), lateral bending, and axial rotation. Three-dimensional kinematics were recorded to evaluate ROM. RESULTS The C7 group had greater flexion-extension motion than the T1 and T2 groups following instrumentation (10.17±0.83 degree vs. 2.77±1.66 degree and 1.06±0.55 degree, P <0.001), and after cyclic loading (10.42±2.30 degree vs. 2.47±0.64 degree and 1.99±1.23 degree, P <0.001). There was no significant difference between the T1 and T2 groups. The C7 group had greater lateral bending ROM than both thoracic groups after instrumentation (8.81±3.44 degree vs. 3.51±2.52 degree, P =0.013 and 1.99±1.99 degree, P =0.003) and after cyclic loading. The C7 group had greater axial rotation motion than the thoracic groups (4.46±2.27 degree vs. 1.26±0.69 degree, P =0.010; and 0.73±0.74 degree, P =0.003) following cyclic loading. CONCLUSION Motion at the cervicothoracic junction is significantly greater when a multilevel PCF stops at C7 rather than T1 or T2. This is likely attributable to the transition from a flexible cervical spine to a rigid thoracic spine. Although this does not account for in vivo fusion, surgeons should consider extending multilevel PCF constructs to T1 when feasible. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
| | | | - Anthony H Le
- DoD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
| | | | | | - Erik B Holm
- Uniformed Services University of the Health Sciences, Bethesda, MD
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11
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Ye J, Rider SM, Lafage R, Gupta S, Farooqi AS, Protopsaltis TS, Passias PG, Smith JS, Lafage V, Kim HJ, Klineberg EO, Kebaish KM, Scheer JK, Mundis GM, Soroceanu A, Bess S, Ames CP, Shaffrey CI, Gupta MC. Distal junctional kyphosis in adult cervical deformity patients: where does it occur? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1598-1606. [PMID: 36928488 DOI: 10.1007/s00586-023-07631-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 01/19/2023] [Accepted: 02/28/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To evaluate the impact of the lowest instrumented vertebra (LIV) on Distal Junctional kyphosis (DJK) incidence in adult cervical deformity (ACD) surgery. METHODS Prospectively collected data from ACD patients undergoing posterior or anterior-posterior reconstruction at 13 US sites was reviewed up to 2-years postoperatively (n = 140). Data was stratified into five groups by level of LIV: C6-C7, T1-T2, T3-Apex, Apex-T10, and T11-L2. DJK was defined as a kyphotic increase > 10° in Cobb angle from LIV to LIV-1. Analysis included DJK-free survival, covariate-controlled cox regression, and DJK incidence at 1-year follow-up. RESULTS 25/27 cases of DJK developed within 1-year post-op. In patients with a minimum follow-up of 1-year (n = 102), the incidence of DJK by level of LIV was: C6-7 (3/12, 25.00%), T1-T2 (3/29, 10.34%), T3-Apex (7/41, 17.07%), Apex-T10 (8/11, 72.73%), and T11-L2 (4/8, 50.00%) (p < 0.001). DJK incidence was significantly lower in the T1-T2 LIV group (adjusted residual = -2.13), and significantly higher in the Apex-T10 LIV group (adjusted residual = 3.91). In covariate-controlled regression using the T11-L2 LIV group as reference, LIV selected at the T1-T2 level (HR = 0.054, p = 0.008) or T3-Apex level (HR = 0.081, p = 0.010) was associated with significantly lower risk of DJK. However, there was no difference in DJK risk when LIV was selected at the C6-C7 level (HR = 0.239, p = 0.214). CONCLUSION DJK risk is lower when the LIV is at the upper thoracic segment than the lower cervical segment. DJK incidence is highest with LIV level in the lower thoracic or thoracolumbar junction.
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Affiliation(s)
- Jichao Ye
- Department of Orthopaedic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Sean M Rider
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, St. Louis, MO, 63110, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sachin Gupta
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ali S Farooqi
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Han-Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Gregory M Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA, USA
| | - Alex Soroceanu
- University of Calgary Spine Program, University of Calgary, Alberta, Canada
| | - Shay Bess
- Rocky Mountain Hospital for Children, Presbyterian/St Luke's Medical Center, Denver, CO, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Christopher I Shaffrey
- Departments of Neurological Surgery and Orthopedic Surgery, Duke University, Durham, NC, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, St. Louis, MO, 63110, USA.
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12
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Merrill RK, Clohisy JC, Albert TJ, Qureshi SA. Concepts and Techniques to Prevent Cervical Spine Deformity After Spine Surgery: A Narrative Review. Neurospine 2023; 20:221-230. [PMID: 37016868 PMCID: PMC10080418 DOI: 10.14245/ns.2244780.390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/22/2022] [Indexed: 04/03/2023] Open
Abstract
Adult cervical spine deformity is associated with decreased health-related quality of life, disability, and myelopathy. A number of radiographic parameters help to characterize cervical deformity and aid in the diagnosis and treatment. There are several etiologies for cervical spine deformity, the most common being iatrogenic. Additionally, spine surgery can accelerate adjacent segment degeneration which may lead to deformity. It is therefore important for all spine surgeons to be aware of the potential to cause iatrogenic cervical deformity. The aim of this review is to highlight concepts and techniques to prevent cervical deformity after spine surgery.
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Affiliation(s)
- Robert K. Merrill
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - John C. Clohisy
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Todd J. Albert
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sheeraz A. Qureshi
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
- Corresponding Author Sheeraz A. Qureshi Department of Orthopedic Surgery, Minimally Invasive Spine Surgery, Hospital for Special Surgery, 535 East 70th Street, 4th Floor, New York, NY 10021, USA
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13
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Predicting the Magnitude of Distal Junctional Kyphosis Following Cervical Deformity Correction. Spine (Phila Pa 1976) 2023; 48:232-239. [PMID: 36149856 DOI: 10.1097/brs.0000000000004492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/08/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of a cervical deformity database. OBJECTIVE This study aimed to develop a model that can predict the postoperative distal junctional kyphosis angle (DJKA) using preoperative and postoperative radiographic measurements. SUMMARY OF BACKGROUND DATA Distal junctional kyphosis (DJK) is a complication following cervical deformity correction that can reduce of patient quality of life and functional status. Although researchers have identified the risk factors for DJK, no model has been proposed to predict the magnitude of DJK. MATERIALS AND METHODS The DJKA was defined as the Cobb angle from the lower instrumented vertebra (LIV) to LIV-2 with traditional DJK having a DJKA change >10°. Models were trained using 66.6% of the randomly selected patients and validated in the remaining 33.3%. Preoperative and postoperative radiographic parameters associated with DJK were identified and ranked using a conditional variable importance table. Linear regression models were developed using the factors most strongly associated with postoperative DJKA. RESULTS A total of 131 patients were included with a mean follow-up duration of 14±8 months. The mean postoperative DJKA was 14.6±14° and occurred in 35% of the patients. No significant differences between the training and validation cohort were observed. The variables most associated with postoperative DJK were: preoperative DJKA (DJKApre), postoperative C2-LIV, and change in cervical lordosis (∆CL). The model identified the following equation as predictive of DJKA: DJKA=9.365+(0.123×∆CL)-(0.315×∆C2-LIV)-(0.054×DJKApre). The predicted and actual postoperative DJKA values were highly correlated ( R =0.871, R2 =0.759, P <0.001). CONCLUSIONS The variables that most increased the DJKA were the preoperative DJKA, postoperative alignment within the construct, and change in cervical lordosis. Future studies can build upon the model developed to be applied in a clinical setting when planning for cervical deformity correction.
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14
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Miyamoto H, Ikeda T, Aoyama S, Toriumi K, Akagi M. Dropped head syndrome: a treatment strategy and surgical intervention. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1275-1281. [PMID: 36781488 DOI: 10.1007/s00586-023-07563-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/12/2023] [Accepted: 01/24/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE The pathology of dropped head syndrome (DHS) is diverse, and reports of surgery for DHS are scarce. We aimed to describe surgery for DHS and to investigate the surgical outcomes thereof. METHODS We enrolled 40 consecutive patients (six males and 34 females; average age at surgery, 72.0 years) with DHS who underwent correction surgeries at a single institute. Short fusion (SF), with the extent of fixation mainly at the cervical region, was performed for 27 patients; long fusion (LF), involving the cervical and thoracic spine, for 13. Clinical and radiological outcomes were investigated, and factors analyzed using the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ). RESULTS All patients were able to gaze horizontally at the follow-up. Instances of five transient C5 palsy results, and five distal junctional kyphosis results were found, but no revisions were reported due to recurrence. Patients whose T1 slope-20° was smaller than the C2-7 angle postoperatively exhibited better clinical outcomes in the three domains of the JOACMEQ, regardless of the extent of fixation. CONCLUSION For cases where the T1 slope is relatively small, and approximately 10° of cervical lordosis is predicted to be obtained postoperatively, SF is appropriate. Alternatively, for cases with higher T1 slope, obtaining a cervical lordosis over 20° has a risk of postoperative complications. For such cases, it is an option to perform an LF involving the cervical and thoracic spine.
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Affiliation(s)
- Hiroshi Miyamoto
- Department of Orthopedic Surgery, Kindai University Hospital, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-851, Japan.
| | - Terumasa Ikeda
- Department of Orthopedic Surgery, Kindai University Hospital, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-851, Japan
| | - Shingo Aoyama
- Department of Orthopedic Surgery, Kindai University Hospital, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-851, Japan
| | - Kensuke Toriumi
- Department of Orthopedic Surgery, Kindai University Hospital, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-851, Japan
| | - Masao Akagi
- Department of Orthopedic Surgery, Kindai University Hospital, 377-2 Ohno-higashi, Osaka-Sayama, Osaka, 589-851, Japan
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15
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MacDowall A, Löfgren H, Edström E, Brisby H, Parai C, Elmi-Terander A. Comparison of posterior muscle-preserving selective laminectomy and laminectomy with fusion for treating cervical spondylotic myelopathy: study protocol for a randomized controlled trial. Trials 2023; 24:106. [PMID: 36765352 PMCID: PMC9921403 DOI: 10.1186/s13063-023-07123-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 01/28/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Cervical spondylotic myelopathy (CSM) is the predominant cause of spinal cord dysfunction in the elderly. The patients are often frail and susceptible to complications. Posterior surgical techniques involving non-fusion are complicated by postlaminectomy kyphosis and instrumented fusion techniques by distal junction kyphosis, pseudarthrosis, or implant failure. The optimal surgical approach is still a matter of controversy. Since anterior and posterior fusion techniques have been compared without presenting any superiority, the objective of this study is to compare stand-alone laminectomy with laminectomy and fusion to determine which treatment has the lowest frequency of reoperations. METHODS This is a multicenter randomized, controlled, parallel-group non-inferiority trial. A total of 300 adult patients are allocated in a ratio of 1:1. The primary endpoint is reoperation for any reason at 5 years of follow-up. Sample size and power calculation were performed by estimating the reoperation rate after laminectomy to 3.5% and after laminectomy with fusion to 7.4% based on the data from the Swedish spine registry (Swespine) on patients with CSM. Secondary outcomes are the patient-derived Japanese Orthopaedic Association (P-mJOA) score, Neck Disability Index (NDI), European Quality of Life Five Dimensions (EQ-5D), Numeric Rating Scale (NRS) for neck and arm pain, Hospital Anxiety and Depression Scale (HADS), development of kyphosis measured as the cervical sagittal vertical axis (cSVA), and death. Clinical and radiological follow-up is performed at 3, 12, 24, and 60 months after surgery. The main inclusion criterium is 1-4 levels of CSM in the subaxial spine, C3-C7. The REDcap software will be used for safe data management. Data will be analyzed according to the modified intention to treat (mITT) population, defined as randomized patients who are still alive without having emigrated or left the study after 2 and 5 years. DISCUSSION This will be the first randomized controlled trial comparing two of the most common surgical treatments for CSM: the posterior muscle-preserving selective laminectomy and posterior laminectomy with instrumented fusion. The results of the myelopathy randomized controlled (MyRanC) study will provide surgical treatment recommendations for CSM. This may result in improvements in surgical treatment and clinical practice regarding CSM. TRIAL REGISTRATION ClinicalTrials.gov NCT04936074 . Registered on 23 June 2021.
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Affiliation(s)
- Anna MacDowall
- Department of Surgical Sciences, Uppsala University, Entrance 61, 6th floor, 75185, Uppsala, Sweden.
| | - Håkan Löfgren
- grid.5640.70000 0001 2162 9922Neuro-Orthopedic Center, Jönköping, Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Erik Edström
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,Capio, Spine Center Stockholm, Upplands-Väsby, Sweden
| | - Helena Brisby
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Catharina Parai
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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16
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Benzakour A, Altsitzioglou P, Lemée JM, Ahmad A, Mavrogenis AF, Benzakour T. Artificial intelligence in spine surgery. INTERNATIONAL ORTHOPAEDICS 2023; 47:457-465. [PMID: 35902390 DOI: 10.1007/s00264-022-05517-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/11/2022] [Indexed: 01/28/2023]
Abstract
The continuous progress of research and clinical trials has offered a wide variety of information concerning the spine and the treatment of the different spinal pathologies that may occur. Planning the best therapy for each patient could be a very difficult and challenging task as it often requires thorough processing of the patient's history and individual characteristics by the clinician. Clinicians and researchers also face problems when it comes to data availability due to patients' personal information protection policies. Artificial intelligence refers to the reproduction of human intelligence via special programs and computers that are trained in a way that simulates human cognitive functions. Artificial intelligence implementations to daily clinical practice such as surgical robots that facilitate spine surgery and reduce radiation dosage to medical staff, special algorithms that can predict the possible outcomes of conservative versus surgical treatment in patients with low back pain and disk herniations, and systems that create artificial populations with great resemblance and similar characteristics to real patients are considered to be a novel breakthrough in modern medicine. To enhance the body of the related literature and inform the readers on the clinical applications of artificial intelligence, we performed this review to discuss the contribution of artificial intelligence in spine surgery and pathology.
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Affiliation(s)
- Ahmed Benzakour
- Centre Orléanais du Dos - Pôle Santé Oréliance, Saran, France
| | - Pavlos Altsitzioglou
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Jean Michel Lemée
- Department of Neurosurgery, University Hospital of Angers, Angers, France
| | | | - Andreas F Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
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17
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Azzam MM, Guiroy AJ, Galgano MA. Surgical Correction of Distal Junctional Kyphosis. World Neurosurg 2023; 170:157. [PMID: 36400358 DOI: 10.1016/j.wneu.2022.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022]
Abstract
Distal junctional kyphosis (DJK) is defined as the development of a kyphotic angulation over 10 degrees below a fusion construct and has been described as a complication of the treatment of adolescent idiopathic scoliosis, Scheuermann kyphosis, adult spinal deformity, and cervical deformity. There are some inherent risk factors to DJK: multilevel fusions, damage to the midline soft tissues including interspinous/supraspinous ligaments, T5-T12 thoracic kyphosis, T11-L2 thoracolumbar kyphosis, and increased mismatch between cervical lordosis and T1 slope. A 53-year-old male presented with cervicalgia, inability to sustain horizontal gaze, and kyphosis-enabled forward head posture. He underwent C3-T1 posterior decompression and fusion as treatment for cervical myelopathy 18 months prior. Neurologic examination was normal, with appreciable protrusion of the T1 vertebral spinous process. Surgery was initiated through subperiosteal exposure of C2-T6, followed by removal of previously set instrumentation, placement of new screws, and posterior column osteotomies of selected segments. Final steps involved compression across excised portions, locking pedicle screws, and a multirod insertion after closure of the posterior column osteotomies by compression maneuvers. Correction for DJK encompasses sagittal alignment restoration, a stable construct, and a good biological environment for healing. Failure of DJK realignment can occur if the patient's ligaments deteriorate distal to the construct or fractures develop in vertebral bodies at the lowest instrumented vertebra or lowest instrumented vertebra +1. One year after surgery, the patient's condition improved, evidenced from both patient self-report and a standing posture radiograph.
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Affiliation(s)
- Moatasem M Azzam
- School of Medicine, St. George's University, Grenada, West Indies.
| | - Alfredo J Guiroy
- Spinal Pathology Unit, Spanish Hospital of Mendoza, Mendoza, Argentina
| | - Michael A Galgano
- Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina, USA
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18
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Establishment of an Individualized Distal Junctional Kyphosis Risk Index following the Surgical Treatment of Adult Cervical Deformities. Spine (Phila Pa 1976) 2023; 48:49-55. [PMID: 35853172 DOI: 10.1097/brs.0000000000004372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/06/2022] [Indexed: 02/01/2023]
Abstract
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.
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Trends in Outcomes of a Prospective Consecutively Enrolled Single-Center Adult Cervical Deformity Series. Spine (Phila Pa 1976) 2022; 47:1694-1700. [PMID: 36007013 DOI: 10.1097/brs.0000000000004457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/20/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE The aim was to describe the two-year outcomes for patients undergoing surgical correction of cervical deformity (CD). BACKGROUND Adult CD has been shown to compromise health-related quality of life. While advances in spinal realignment have shown promising short-term clinical results in this parameter, the long-term outcomes of CD corrective surgery remain unclear. MATERIALS AND METHODS Operative CD patients >18 years with two-year (2Y) health-related quality of life/radiographic data were included. Improvement in radiographic, neurologic, and health-related quality of life outcomes were reported. Patients with a prior cervical fusion and patients with the greatest and smallest change based on Neck Disability Index (NDI), numeric rating scale (NRS) neck, modified Japanese Orthopaedic Association (mJOA) were compared using multivariable analysis controlling for age, and frailty, and invasiveness. RESULTS One hundred and fifty-eight patients were included in this study. By 2Y, 96.3% of patients improved in Ames cervical sagittal vertical axis modifier, 34.2% in T1 slope minus cervical lordosis (TS-CL), 42.0% in horizontal gaze modifier, and 40.9% in SVA modifier. In addition, 65.5% of patients improved in Passias CL modifier, 53.3% in TS-CL modifier, 100% in C2-T3 modifier, 88.9% in C2S modifier, and 81.0% in MGS modifier severity by 2Y. The cohort significantly improved from baseline to 2Y in NDI, NRS Neck, and mJOA, all P <0.05. 59.3% of patients met minimal clinically important difference for NDI, 62.3% for NRS Neck, and 37.3% for mJOA. Ninety-seven patients presented with at least one neurologic deficit at baseline and 63.9% no longer reported that deficit at follow-up. There were 45 (34.6%) cases of distal junctional kyphosis (DJK) (∆DJKA>10° between lower instrumented vertebra and lower instrumented vertebra-2), of which 17 were distal junctional failure (distal junctional failure-DJK requiring reoperation). Patients with the greatest beneficial change were less likely to have had a complication in the two-year follow-up period. CONCLUSION Correction of CD results in notable clinical and radiographic improvement with most patients achieving favorable outcomes after two years. However, complications including DJK or failure remain prevalent.
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Risk Factors for Adjacent Segment Problems after Posterior Instrumentation of the Cervical Spine. SURGERIES 2022. [DOI: 10.3390/surgeries3040037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Adjacent segment problems after cervical spine instrumentation are widely reported. They can range from asymptomatic adjacent segment degeneration (ASD) noted on radiographs to symptomatic adjacent segment disease and even instability. While ASD following anterior instrumentation is well studied, there is a paucity of literature on ASD following posterior instrumentation. We intended to identify the risk factors associated with ASD following posterior instrumentation, focusing on pre-operative and surgical parameters. Eighty-seven patients who underwent posterior instrumentation of the cervical spine were recruited. Clinical and radiological examination was performed preoperatively and up to 24 months postoperatively. The collected data included patient demographics, indication for surgery, sagittal parameters (cervical lordosis, C2–7 sagittal-vertical axis), technique of surgery, number of levels instrumented and fused, number of levels decompressed, and the level at which the instrumentation ended. Based on postoperative evaluation, ASD was found in 29.9% of the patients, of which, one patient was symptomatic and required reoperation. Even though, according to our univariate analysis, reduced pre-operative cervical lordosis and the indication of degenerative spondylosis seemed to significantly influence the occurrence of ASD, multivariate regression analysis did not identify any independent risk factors. We also noted that, even though patients may develop ASD after the instrumented fusion of the cervical spine, this may not necessarily develop into symptomatic adjacent segment disease requiring revision surgery.
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21
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de Dios E, Laesser M, Björkman-Burtscher IM, Lindhagen L, MacDowall A. Improvement rates, adverse events and predictors of clinical outcome following surgery for degenerative cervical myelopathy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3433-3442. [PMID: 36053323 DOI: 10.1007/s00586-022-07359-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/20/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To investigate improvement rates, adverse events and predictors of clinical outcome after laminectomy alone (LAM) or laminectomy with instrumented fusion (LAM + F) for degenerative cervical myelopathy (DCM). METHODS This is a post hoc analysis of a previously published DCM cohort. Improvement rates for European myelopathy score (EMS) and Neck Disability Index (NDI) at 2- and 5-year follow-ups and adverse events are presented descriptively for available cases. Predictor endpoints were EMS and NDI scores at follow-ups, surgeon- and patient-reported complications, and reoperation-free interval. For predictors, univariate and multivariable models were fitted to imputed data. RESULTS Mean age of patients (LAM n = 412; LAM + F n = 305) was 68 years, and 37.4% were women. LAM + F patients had more severe spondylolisthesis and less severe kyphosis at baseline, more surgeon-reported complications, more patient-reported complications, and more reoperations (p ≤ 0.05). After imputation, the overall EMS improvement rate was 43.8% at 2 years and 36.3% at 5 years. At follow-ups, worse EMS scores were independent predictors of worse EMS outcomes and older age and worse NDI scores were independent predictors of worse NDI outcomes. LAM + F was associated with more surgeon-reported complications (ratio 1.81; 95% CI 1.17-2.80; p = 0.008). More operated levels were associated with more patient-reported complications (ratio 1.12; 95% CI 1.02-1.22; p = 0.012) and a shorter reoperation-free interval (hazard ratio 1.30; 95% CI 1.08-1.58; p = 0.046). CONCLUSIONS These findings suggest that surgical intervention at an earlier myelopathy stage might be beneficial and that less invasive procedures are preferable in this patient population.
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Affiliation(s)
- Eddie de Dios
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Bruna stråket 11, 41345, Gothenburg, Sweden.
| | - Mats Laesser
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Bruna stråket 11, 41345, Gothenburg, Sweden
| | - Isabella M Björkman-Burtscher
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Bruna stråket 11, 41345, Gothenburg, Sweden
| | - Lars Lindhagen
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Anna MacDowall
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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22
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McDonnell JM, Evans SR, Ahern DP, Cunniffe G, Kepler C, Vaccaro A, Kaye ID, Morrissey PB, Wagner SC, Sebastian A, Butler JS. Risk factors for distal junctional failure in long-construct instrumentation for adult spinal deformity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3654-3661. [PMID: 36178547 DOI: 10.1007/s00586-022-07396-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/02/2022] [Accepted: 09/19/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this study is to identify risk factors associated with postoperative DJF in long constructs for ASD. METHODS A retrospective review was performed at a tertiary referral spine centre from 01/01/2007 to 31/12/2016. Demographic, clinical and radiographic parameters were collated for patients with DJF in the postoperative period and compared to those without DJF. Survival analyses were performed using univariate logistic regression to identify variables with a p value < 0.05 for inclusion in multivariate analysis. Spearman's correlations were performed where applicable. RESULTS One hundred two patients were identified. 41 (40.2%) suffered DJF in the postoperative period, with rod fracture being the most common sign of DJF (13/65; 20.0%). Mean time to failure was 32.4 months. On univariate analysis, pedicle subtraction osteotomy (p = 0.03), transforaminal lumbar interbody fusion (p < 0.001), pre-op LL (p < 0.01), pre-op SVA (p < 0.01), pre-op SS (p = 0.02), postop LL (p = 0.03), postop SVA (p = 0.01), postop PI/LL (p < 0.001), LL correction (p < 0.001), SVA correction (p < 0.001), PT correction (p = 0.03), PI/LL correction (p < 0.001), SS correction (p = 0.03) all proved significant. On multivariate analysis, pedicle subtraction osteotomy (OR 27.3; p = 0.03), postop SVA (p < 0.01) and LL correction (p = 0.02) remained statistically significant as independent risk factors for DJF. CONCLUSION Recently, DJF has received recognition as its own entity due to a notable postoperative incidence. Few studies to date have evaluated risk factors for DJF. The results of our study highlight that pedicle subtraction osteotomy, poor correction of lumbar lordosis, and sagittal vertical axis are significantly associated with postoperative occurrence of DJF.
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Affiliation(s)
- Jake M McDonnell
- Royal College of Surgeons in Ireland, Dublin, Ireland. .,National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Shane R Evans
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Daniel P Ahern
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Gráinne Cunniffe
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Christopher Kepler
- Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Alexander Vaccaro
- Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Ian D Kaye
- Department of Orthopaedics, Thomas Jefferson University Hospital, Philadelphia, USA
| | | | - Scott C Wagner
- Department of Orthopaedics, Walter Reed National Military Medical Center, Washington, DC, USA
| | | | - Joseph S Butler
- National Spinal Injuries Unit, Mater Misericordiae University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
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Lee JJ, Park JH, Oh YG, Shin HK, Jung SK. Should cervicothoracic junctions be avoided in long cervical posterior fusion surgery? Analysis of clinical and radiologic outcomes over two years. J Orthop Surg (Hong Kong) 2022; 30:10225536221137751. [PMID: 36315967 DOI: 10.1177/10225536221137751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE This study aimed to confirm the usefulness of surgery that avoids the cervicothoracic junction (CTJ) by comparing the clinical and radiographic outcomes after posterior cervical fusion at C5/6 with those at C7/T1. METHODS Patients who underwent laminectomy and posterior cervical instrument fusion for cervical spondylotic myelopathy (CSM) from 2012 to 2019 were retrospectively reviewed and divided according to whether the end level was at C5/6 (group 1) or C7/T1 (group 2). Demographic variables and incidence of distal junctional kyphosis (DJK) were compared between the groups. Clinical outcomes (visual analog scale [VAS] score for arm and neck pain and the Neck Disability Index value) and radiologic outcomes (T1 slope, cervical lordosis, segmental lordosis, C2-7 sagittal vertical axis, T1 slope-cervical lordosis mismatch) were compared over time. RESULTS Sixty-seven patients were included. There were 32 patients in group 1 and 35 in group 2. The VAS score for neck pain was significantly lower in group 1 than in group 2 at 2 years after surgery (p = 0.03). The C2-7 sagittal vertical axis was significantly larger in group 2 than in group 1 at 1 year and 2 years postoperatively (p = 0.04). The incidence of DJK was higher in group 2 than in group 1 (28.57% vs 9.37%, p = 0.04). CONCLUSION This study found that when CTJs are included in the posterior cervical long fusion surgery, although it would be better than preoperation, postoperative kyphosis and consequent neck pain may progress. The results of this study advocate the concept of avoiding CTJ fusion if possible.
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Affiliation(s)
- Jung Jae Lee
- Department of Neurosurgery, 65443Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Gyu Oh
- Department of Neurosurgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hong Kyung Shin
- Department of Neurosurgery, 65526Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ku Jung
- Department of Emergency Medicine, 65443Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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Passfall L, Williamson TK, Krol O, Lebovic J, Imbo B, Joujon-Roche R, Tretiakov P, Dangas K, Owusu-Sarpong S, Koller H, Schoenfeld AJ, Diebo BG, Vira S, Lafage R, Lafage V, Passias PG. Do the newly proposed realignment targets for C2 and T1 slope bridge the gap between radiographic and clinical success in corrective surgery for adult cervical deformity? J Neurosurg Spine 2022; 37:368-375. [PMID: 35426823 DOI: 10.3171/2022.2.spine211576] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical correction of cervical deformity (CD) has been associated with superior alignment and functional outcomes. It has not yet been determined whether baseline or postoperative T1 slope (T1S) and C2 slope (C2S) correlate with health-related quality-of-life (HRQoL) metrics and radiographic complications, such as distal junctional kyphosis (DJK) and distal junctional failure (DJF). The objective of this study was to determine the impact of T1S and C2S deformity severity on HRQoL metrics and DJF development in patients with CD who underwent a cervical fusion procedure. METHODS All operative CD patients with upper instrumented vertebra above C7 and preoperative (baseline) and up to 2-year postoperative radiographic and HRQoL data were included. CD was defined as meeting at least one of the following radiographic parameters: C2-7 lordosis < -15°, TS1-cervical lordosis mismatch > 35°, segmental cervical kyphosis > 15° across any 3 vertebrae between C2 and T1, C2-7 sagittal vertical axis > 4 cm, McGregor's slope > 20°, or chin-brow vertical angle > 25°. Spearman's rank-order correlation and linear regression analysis assessed the impact of T1S and C2S on HRQoL metrics (Neck Disability Index [NDI], modified Japanese Orthopaedic Association [mJOA] scale, EuroQOL 5-Dimension Questionnaire [EQ-5D] visual analog scale [VAS] score, and numeric rating scale [NRS]-neck) and complications (DJK, DJF, reoperation). Logistic regression and a conditional inference tree (CIT) were used to determine radiographic thresholds for achieving optimal clinical outcome, defined as meeting good clinical outcome criteria (≥ 2 of the following: NDI < 20 or meeting minimal clinically important difference, mild myelopathy [mJOA score ≥ 14], and NRS-neck ≤ 5 or improved by ≥ 2 points), not undergoing reoperation, or developing DJF or mechanical complication by 2 years. RESULTS One hundred five patients with CD met inclusion criteria. By surgical approach, 14.7% underwent an anterior-only approach, 46.1% a posterior-only approach, and 39.2% combined anterior and posterior approaches. The mean baseline radiographic parameters were T1S 28.3° ± 14.5° and C2S 25.9° ± 17.5°. Significant associations were found between 3-month C2S and mJOA score (r = -0.248, p = 0.034), NDI (r = 0.399, p = 0.001), EQ-5D VAS (r = -0.532, p < 0.001), NRS-neck (r = 0.239, p = 0.040), and NRS-back (r = 0.264, p = 0.021), while significant correlation was also found between 3-month T1S and mJOA score (r = -0.314, p = 0.026), NDI (r = 0.445, p = 0.001), EQ-5D VAS (r = -0.347, p = 0.018), and NRS-neck (r = 0.269, p = 0.049). A significant correlation was also found between development of DJF and 3-month C2S (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.01-1.1, p = 0.015) as well as for T1S (OR 1.1, 95% CI 1.01-1.1, p = 0.023). Logistic regression with CIT identified thresholds for optimal outcome by 2 years: optimal 3-month T1S < 26° (OR 5.6) and C2S < 10° (OR 10.4), severe 3-month T1S < 45.5° (OR 0.2) and C2S < 38.0° (no patient above this threshold achieved optimal outcome; all p < 0.05). Patients below both optimal thresholds achieved rates of 0% for DJK and DJF, and 100% met optimal outcome. CONCLUSIONS The severity of CD, defined by T1S and C2S at baseline and especially at 3 months, can be predictive of postoperative functional improvement and occurrence of worrisome complications in patients with CD, necessitating the use of thresholds in surgical planning to achieve optimal outcomes.
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Affiliation(s)
- Lara Passfall
- 1Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Tyler K Williamson
- 1Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Oscar Krol
- 1Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Jordan Lebovic
- 1Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Bailey Imbo
- 1Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Rachel Joujon-Roche
- 1Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Peter Tretiakov
- 1Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | | | - Stephane Owusu-Sarpong
- 1Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Heiko Koller
- 4Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Andrew J Schoenfeld
- 5Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bassel G Diebo
- 6Department of Orthopedics, SUNY Downstate, Brooklyn, New York
| | - Shaleen Vira
- 7Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Renaud Lafage
- 8Department of Orthopedics, Hospital for Special Surgery, New York, New York; and
| | - Virginie Lafage
- 9Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Peter G Passias
- 1Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
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Hamada T, Matsubara H, Kato S, Hikichi T, Shimokawa K, Demura S, Tsuchiya H. Correlation Analysis between Leg-length Discrepancy and Lumbar Scoliosis Using Full-length Standing Radiographs. Strategies Trauma Limb Reconstr 2022; 17:144-147. [PMID: 36756290 PMCID: PMC9886032 DOI: 10.5005/jp-journals-10080-1566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 08/17/2022] [Indexed: 01/02/2023] Open
Abstract
Aim When a leg-length discrepancy (LLD) is severe enough, it can result in lumbar scoliosis and other postural defects. To our knowledge, no study has demonstrated associations between LLD and lumbar curvature using full-length standing radiographs of the lower limbs and lumbar spine. This study aimed to examine the correlations between LLD and lateral curvature of the lumbar spine using standing radiographs. Materials and methods Full-length standing radiographs of the lower limbs and spinal column of 113 participants (age range: 10-65 years) obtained between November 2006 and September 2019 were reviewed. Leg length was measured as the linear distance from the centre of the femoral head to the centre of the tibial plafond and converted to millimetres using a radiographic ruler captured in the images. Leg-length discrepancy was analysed as the absolute difference (mm) between the left and right leg lengths. Inequality was also evaluated as leg-length discrepancy ratio (LLDR), calculated as leg-length discrepancy/length of the unaffected (longer) leg × 100 (%). Lateral lumbar curvature was evaluated with the Cobb angle (°). The association between LLD or LLDR and lumbar Cobb angle was analysed by correlation analysis. Statistical analysis was performed by simple regression in SPSS. Results Both LLD and LLDR exhibited a robust and positive correlation with lumbar Cobb angle (γ = 0.53, γ = 0.62), as illustrated by the following regression equations: lumbar Cobb angle (°) = 0.316 × leg-length discrepancy (mm) + 2.83 and lumbar Cobb angle (°) = 2.19 × leg-length discrepancy ratio (%) + 3.0. Conclusion Using objective imaging data, we found that the lumbar Cobb angle tends to be >10° if the difference in leg lengths is >20 mm. How to cite this article Hamada T, Matsubara H, Kato S, et al. Correlation Analysis between Leg-length Discrepancy and Lumbar Scoliosis Using Full-length Standing Radiographs. Strategies Trauma Limb Reconstr 2022;17(3):144-147.
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Affiliation(s)
- Tomo Hamada
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Japan
| | - Hidenori Matsubara
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Japan
| | - Satoshi Kato
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Japan
| | - Toshifumi Hikichi
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Japan
| | - Kanu Shimokawa
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Japan
| | - Satoru Demura
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Japan
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Lee JJ, Park JH, Oh YG, Shin HK, Park BG. Change in the Alignment and Distal Junctional Kyphosis Development after Posterior Cervical Spinal Fusion Surgery for Cervical Spondylotic Myelopathy - Risk Factor Analysis. J Korean Neurosurg Soc 2022; 65:549-557. [PMID: 35505460 PMCID: PMC9271806 DOI: 10.3340/jkns.2021.0192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 10/24/2021] [Indexed: 12/03/2022] Open
Abstract
Objective This study analyzed the risk factors in patients who developed distal junctional kyphosis (DJK) after posterior cervical fusion.
Methods We retrospectively analyzed the clinical and radiographic outcomes of 64 patients, aged ≥18 years (51 and 13 male and female patients, respectively), who underwent single-staged multilevel (3–6 levels) posterior cervical fusion surgery due to multiple cervical spondylotic myelopathy. The surgeries were performed by a single spinal surgeon between January 2012 and December 2017. Demographic data, clinical outcomes, and radiological results were collected. We divided the patients into a DJK group and a non-DJK group according to the presence of DJK and investigated the risk factors by comparing the differences between the two groups.
Results Of the 64 patients, 13 developed DJK. No significant differences in clinical results were observed between the two groups before and immediately after the surgery. At the final follow-up, a higher visual analog score for neck pain was observed in the DJK group compared to the non-DJK group (p<0.01). The DJK group had a significantly lower T1 slope and a significantly higher C2-7 sagittal vertical axis (SVA) before surgery compared to the non-DJK group (p=0.03 and p<0.01, respectively). Immediately after surgery, the difference between the two groups decreased and no significant difference was observed. However, at the last followup, a significantly higher C2-7 SVA was observed in the DJK group (p<0.01). At the last follow up, there is no discrepancy in T1S-CL. In multiple logistic regression analysis, preoperative higher C2-7 SVA and preoperative lower T1 slope were identified as independent risk factors (p=0.03 and p<0.01, respectively). As a result, it was confirmed that DJK occurred along the process of returning to preoperative values.
Conclusion DJK can be considered to be caused by cervical misalignment due to excessive change in the surgical site in patients with low T1 slope and high C2-7 SVA before surgery. This also affects the clinical outcome after surgery. It is recommended to refrain from excessive segmental lordosis changes during multilevel cervical post fusion surgery, especially in patients with a small preoperative T1 slope and a large SVA value.
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Affiliation(s)
- Jung Jae Lee
- Department of Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Gyu Oh
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hong Kyung Shin
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Gon Park
- Department of Physiology, College of Medicine, Catholic Kwandong University, Gangneung, Korea
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Saravi B, Hassel F, Ülkümen S, Zink A, Shavlokhova V, Couillard-Despres S, Boeker M, Obid P, Lang GM. Artificial Intelligence-Driven Prediction Modeling and Decision Making in Spine Surgery Using Hybrid Machine Learning Models. J Pers Med 2022; 12:jpm12040509. [PMID: 35455625 PMCID: PMC9029065 DOI: 10.3390/jpm12040509] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/18/2022] [Accepted: 03/19/2022] [Indexed: 12/22/2022] Open
Abstract
Healthcare systems worldwide generate vast amounts of data from many different sources. Although of high complexity for a human being, it is essential to determine the patterns and minor variations in the genomic, radiological, laboratory, or clinical data that reliably differentiate phenotypes or allow high predictive accuracy in health-related tasks. Convolutional neural networks (CNN) are increasingly applied to image data for various tasks. Its use for non-imaging data becomes feasible through different modern machine learning techniques, converting non-imaging data into images before inputting them into the CNN model. Considering also that healthcare providers do not solely use one data modality for their decisions, this approach opens the door for multi-input/mixed data models which use a combination of patient information, such as genomic, radiological, and clinical data, to train a hybrid deep learning model. Thus, this reflects the main characteristic of artificial intelligence: simulating natural human behavior. The present review focuses on key advances in machine and deep learning, allowing for multi-perspective pattern recognition across the entire information set of patients in spine surgery. This is the first review of artificial intelligence focusing on hybrid models for deep learning applications in spine surgery, to the best of our knowledge. This is especially interesting as future tools are unlikely to use solely one data modality. The techniques discussed could become important in establishing a new approach to decision-making in spine surgery based on three fundamental pillars: (1) patient-specific, (2) artificial intelligence-driven, (3) integrating multimodal data. The findings reveal promising research that already took place to develop multi-input mixed-data hybrid decision-supporting models. Their implementation in spine surgery may hence be only a matter of time.
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Affiliation(s)
- Babak Saravi
- Department of Orthopedics and Trauma Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79108 Freiburg, Germany; (S.Ü.); (P.O.); (G.M.L.)
- Department of Spine Surgery, Loretto Hospital, 79100 Freiburg, Germany; (F.H.); (A.Z.)
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, 5020 Salzburg, Austria;
- Correspondence:
| | - Frank Hassel
- Department of Spine Surgery, Loretto Hospital, 79100 Freiburg, Germany; (F.H.); (A.Z.)
| | - Sara Ülkümen
- Department of Orthopedics and Trauma Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79108 Freiburg, Germany; (S.Ü.); (P.O.); (G.M.L.)
- Department of Spine Surgery, Loretto Hospital, 79100 Freiburg, Germany; (F.H.); (A.Z.)
| | - Alisia Zink
- Department of Spine Surgery, Loretto Hospital, 79100 Freiburg, Germany; (F.H.); (A.Z.)
| | - Veronika Shavlokhova
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Sebastien Couillard-Despres
- Institute of Experimental Neuroregeneration, Spinal Cord Injury and Tissue Regeneration Center Salzburg (SCI-TReCS), Paracelsus Medical University, 5020 Salzburg, Austria;
- Austrian Cluster for Tissue Regeneration, 1200 Vienna, Austria
| | - Martin Boeker
- Intelligence and Informatics in Medicine, Medical Center Rechts der Isar, School of Medicine, Technical University of Munich, 81675 Munich, Germany;
| | - Peter Obid
- Department of Orthopedics and Trauma Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79108 Freiburg, Germany; (S.Ü.); (P.O.); (G.M.L.)
| | - Gernot Michael Lang
- Department of Orthopedics and Trauma Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79108 Freiburg, Germany; (S.Ü.); (P.O.); (G.M.L.)
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DelSole EM, Keck WL, Patel AA. The State of Machine Learning in Spine Surgery: A Systematic Review. Clin Spine Surg 2022; 35:80-89. [PMID: 34121074 DOI: 10.1097/bsd.0000000000001208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/14/2021] [Indexed: 11/27/2022]
Abstract
STUDY DESIGN This was a systematic review of existing literature. OBJECTIVE The objective of this study was to evaluate the current state-of-the-art trends and utilization of machine learning in the field of spine surgery. SUMMARY OF BACKGROUND DATA The past decade has seen a rise in the clinical use of machine learning in many fields including diagnostic radiology and oncology. While studies have been performed that specifically pertain to spinal surgery, there have been relatively few aggregate reviews of the existing scientific literature as applied to clinical spine surgery. METHODS This study utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to review the scientific literature from 2009 to 2019 with syntax specific for machine learning and spine surgery applications. Specific data was extracted from the available literature including algorithm application, algorithms tested, database type and size, algorithm training method, and outcome of interest. RESULTS A total of 44 studies met inclusion criteria, of which the majority were level III evidence. Studies were grouped into 4 general types: diagnostic tools, clinical outcome prediction, surgical assessment tools, and decision support tools. Across studies, a wide swath of algorithms were used, which were trained across multiple disparate databases. There were no studies identified that assessed the ethical implementation or patient perceptions of machine learning in clinical care. CONCLUSIONS The results reveal the broad range of clinical applications and methods used to create machine learning algorithms for use in the field of spine surgery. Notable disparities exist in algorithm choice, database characteristics, and training methods. Ongoing research is needed to make machine learning operational on a large scale.
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Affiliation(s)
- Edward M DelSole
- Department of Orthopaedic Surgery, Division of Spine Surgery, Geisinger Musculoskeletal Institute
| | - Wyatt L Keck
- Geisinger Commonwealth School of Medicine, Scranton
| | - Aalpen A Patel
- Department of Radiology (Geisinger), Steele Institute for Health Innovation and Geisinger, Danville, PA
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Parrish JM, Jenkins NW, Cha EDK, Lynch CP, Geoghegan CE, Jadczak CN, Mohan S, Singh K. Epidemiological Relevance of Elevated Preoperative Patient Health Questionnaire-9 Scores on Clinical Improvement Following Lumbar Decompression. Int J Spine Surg 2022; 16:159-167. [PMID: 35314511 PMCID: PMC9519078 DOI: 10.14444/8184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Limited research exists regarding the influence of preoperative depression on postoperative mental health, physical function, and pain in lumbar decompression (LD) patients. This study aims to evaluate the association of depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) with other mental health and physical function clinical outcomes among patients undergoing LD. METHODS A prospectively maintained surgical registry was reviewed for primary LD from March 2016 to May 2019. Patients were stratified into 3 preoperative PHQ-9 score subgroups. Higher PHQ-9 scores indicated greater depressive symptoms. We assessed demographic and perioperative characteristics among subgroups with appropriate statistical testing. We also evaluated outcome instruments and postoperative improvement for the following outcomes: PHQ-9, Short Form 12 (SF-12), Veterans RAND 12-Item (VR-12), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) leg, and VAS back. RESULTS The 351-subject cohort was 70.4% men with an average age of 47 years; 186 subjects had minimal preoperative depressive symptoms (PHQ-9 <5), 94 had moderate (5≤ PHQ-9 ≤10), and 71 had severe (PHQ-9 >10). Subgroups with more severe symptoms of depression had worse mental health outcome scores (PHQ-9, 12-Mental Health Composite Score [12-MCS], and VR-12-MCS) and a positive linear association with greater pre- to postoperative mental health improvements at all timepoints. Subgroups with more severe symptoms of depression had worse PROMIS-PF scores at all timepoints, though VAS pain scores had no depression symptom association by 1 year. CONCLUSION Patients with more severe preoperative depressive symptoms, as evaluated by PHQ-9, have a greater improvement in PHQ-9, SF-12, and VR-12 scores, but more severe PHQ-9 scores are associated with worse overall physical function scores. This study demonstrates the relevance of preoperative depressive symptoms and their necessity in future risk factor models. CLINICAL RELEVANCE Severity of preoperative PHQ-9 acts as a significant risk factor to postoperative pain and mental and physical health improvement.
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Affiliation(s)
- James M Parrish
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Nathaniel W Jenkins
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Elliot D K Cha
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Conor P Lynch
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Cara E Geoghegan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Caroline N Jadczak
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Shruthi Mohan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, United States
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30
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Lau D, Joshi RS, Haddad AF, Deviren V, Ames CP. Incidence and Risk Factors of Mechanical Complications After Posterior-Based Osteotomies for Correction of Moderate to Severe Adult Cervical Deformity: 1-Year and 2-Year Follow-up. Neurosurgery 2022; 90:207-214. [PMID: 34995272 DOI: 10.1227/neu.0000000000001781] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 09/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Rigid cervical deformity (CD) requires multilevel and/or high-grade osteotomies and long-construct fusions to achieve adequate correction. The incidence of mechanical complications (MCs) remains incompletely studied. OBJECTIVE To define the incidence and risk factors for MC. METHODS A retrospective review of consecutive patients with CD who underwent correction from 2010 to 2018 was performed. Inclusion criteria were cervical kyphosis >20° and/or cervical sagittal vertical axis (cSVA) >4 cm. MCs (junctional kyphosis/failure, pseudarthrosis, and implant failure) and reoperation at 1 and 2 yr were examined. RESULTS Eighty-three patients were included. The mean age was 63.4 yr, and 61.0% were female. Fifty-three percent underwent 3-column osteotomies. After surgery, cervical parameters were significantly improved: cSVA (6.2 vs 3.8 cm, P < .001), cervical lordosis (6.3 vs -8.3°, P < .001), cervical scoliosis (CS) (6.5 vs 2.2°, P < .001), and T1 slope (41.7 vs 36.3°, P = .007). The MC rate was 28.9%: junctional (18.1%), implant (16.9%), and pseudarthrosis (10.8%). MC rates at 1 and 2 yr were 14.5% and 25.5%, respectively: junctional (9.6% and 17.6%), implant (9.6% and 17.6%), and pseudarthrosis (2.4% and 7.8%). The overall reoperation rate was 24.1%: 14.5% at 1 yr and 19.6% at 2 yr. Body mass index (BMI) (P = .015) and preoperative CS (P = .040) were independently associated with higher odds of MC. Receiver operating characteristic curves defined CS >5° to be the threshold of risk for MCs and reoperation. CONCLUSION Correction of CD is effective by posterior-based osteotomes, but MCs are relatively high at 1 and 2 yr. BMI >30 and preoperative CS >5° predispose patients for MC and reoperation.
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Affiliation(s)
- Darryl Lau
- Department of Neurological Surgery, New York University, New York, New York, USA
| | - Rushikesh S Joshi
- Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Passias PG, Naessig S, Kummer N, Passfall L, Lafage R, Lafage V, Line B, Diebo BG, Protopsaltis T, Kim HJ, Eastlack R, Soroceanu A, Klineberg EO, Hart RA, Burton D, Bess S, Schwab F, Shaffrey CI, Smith JS, Ames CP. Predicting development of severe clinically relevant distal junctional kyphosis following adult cervical deformity surgery, with further distinction from mild asymptomatic episodes. J Neurosurg Spine 2021:1-8. [PMID: 34920417 DOI: 10.3171/2021.8.spine21533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This retrospective cohort study aimed to develop a formal predictive model distinguishing between symptomatic and asymptomatic distal junctional kyphosis (DJK). In this study the authors identified a DJK rate of 32.2%. Predictive models were created that can be used with high reliability to help distinguish between severe symptomatic DJK and mild asymptomatic DJK through the use of surgical factors, radiographic parameters, and patient variables. METHODS Patients with cervical deformity (CD) were stratified into asymptomatic and symptomatic DJK groups. Symptomatic: 1) DJK angle (DJKA) > 10° and either reoperation due to DJK or > 1 new-onset neurological sequela related to DJK; or 2) either a DJKA > 20° or ∆DJKA > 20°. Asymptomatic: ∆DJK > 10° in the absence of neurological sequelae. Stepwise logistic regressions were used to identify factors associated with these types of DJK. Decision tree analysis established cutoffs. RESULTS A total of 99 patients with CD were included, with 32.2% developing DJK (34.3% asymptomatic, 65.7% symptomatic). A total of 37.5% of asymptomatic patients received a reoperation versus 62.5% symptomatic patients. Multivariate analysis identified independent baseline factors for developing symptomatic DJK as follows: pelvic incidence (OR 1.02); preoperative cervical flexibility (OR 1.04); and combined approach (OR 6.2). Having abnormal hyperkyphosis in the thoracic spine, more so than abnormal cervical lordosis, was a factor for developing symptomatic disease when analyzed against asymptomatic patients (OR 1.2). Predictive modeling identified factors that were predictive of symptomatic versus no DJK, as follows: myelopathy (modified Japanese Orthopaedic Association score 12-14); combined approach; uppermost instrumented vertebra C3 or C4; preoperative hypermobility; and > 7 levels fused (area under the curve 0.89). A predictive model for symptomatic versus asymptomatic disease (area under the curve 0.85) included being frail, T1 slope minus cervical lordosis > 20°, and a pelvic incidence > 46.3°. Controlling for baseline deformity and disability, symptomatic patients had a greater cervical sagittal vertical axis (4-8 cm: 47.6% vs 27%) and were more malaligned according to their Scoliosis Research Society sagittal vertical axis measurement (OR 0.1) than patients without DJK at 1 year (all p < 0.05). Despite their symptomatology and higher reoperation rate, outcomes equilibrated in the symptomatic cohort at 1 year following revision. CONCLUSIONS Overall, 32.2% of patients with CD suffered from DJK. Symptomatic DJK can be predicted with high reliability. It can be further distinguished from asymptomatic occurrences by taking into account pelvic incidence and baseline cervicothoracic deformity severity.
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Affiliation(s)
- Peter G Passias
- 1Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Sara Naessig
- 1Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Nicholas Kummer
- 1Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Lara Passfall
- 1Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Renaud Lafage
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- 3Lenox Hill Hospital, Northwell Health, Department of Orthopaedics, New York, New York
| | - Breton Line
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Bassel G Diebo
- 5Department of Orthopedics, SUNY Downstate Medical Center, Brooklyn, New York
| | | | - Han Jo Kim
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Robert Eastlack
- 6Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Alex Soroceanu
- 7Department of Orthopaedic Surgery, University of Calgary, Alberta, Canada
| | - Eric O Klineberg
- 8Department of Orthopaedic Surgery, University of California, Davis, California
| | - Robert A Hart
- 9Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Douglas Burton
- 10Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Shay Bess
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Frank Schwab
- 3Lenox Hill Hospital, Northwell Health, Department of Orthopaedics, New York, New York
| | | | - Justin S Smith
- 12Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia; and
| | - Christopher P Ames
- 13Department of Neurological Surgery, University of California, San Francisco, California
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Artificial Intelligence in Adult Spinal Deformity. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 134:313-318. [PMID: 34862555 DOI: 10.1007/978-3-030-85292-4_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Artificial Intelligence is gaining traction in medicine for its ease of use and advancements in technology. This study evaluates the current literature on the use of artificial intelligence in adult spinal deformity.
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Laminectomy alone versus laminectomy with fusion for degenerative cervical myelopathy: a long-term study of a national cohort. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:334-345. [PMID: 34853923 DOI: 10.1007/s00586-021-07067-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/14/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare patient-reported 5-year clinical outcomes between laminectomy alone versus laminectomy with instrumented fusion in patients with degenerative cervical myelopathy in a population-based cohort. METHODS All patients in the national Swedish Spine Register (Swespine) from January 2006 until March 2019, with degenerative cervical myelopathy, were assessed. Multiple imputation and propensity score matching based on clinicodemographic and radiographic parameters were used to compare patients treated with laminectomy alone with patients treated with laminectomy plus posterior-lateral instrumented fusion. The primary outcome measure was the European Myelopathy Score, a validated patient-reported outcome measure. The scale ranges from 5 to 18, with lower scores reflecting more severe myelopathy. RESULTS Among 967 eligible patients, 717 (74%) patients were included. Laminectomy alone was performed on 412 patients (mean age 68 years; 149 women [36%]), whereas instrumented fusion was added for 305 patients (mean age 68 years; 119 women [39%]). After imputation, the propensity for smoking, worse myelopathy scores, spondylolisthesis, and kyphosis was slightly higher in the fusion group. After imputation and propensity score matching, there were on average 212 pairs patients with a 5-year follow-up in each group. There were no important differences in patient-reported clinical outcomes between the methods after 5 years. Due to longer hospitalization times and implant-related costs, the mean cost increase per instrumented patient was approximately $4700 US. CONCLUSIONS Instrumented fusions generated higher costs and were not associated with superior long-term clinical outcomes. These findings are based on a national cohort and can thus be regarded as generalizable.
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Passias PG, Alas H, Pierce KE, Galetta M, Krol O, Passfall L, Kummer N, Naessig S, Ahmad W, Diebo BG, Lafage R, Lafage V. The impact of the lower instrumented level on outcomes in cervical deformity surgery. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:306-310. [PMID: 34728999 PMCID: PMC8501812 DOI: 10.4103/jcvjs.jcvjs_23_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/07/2021] [Indexed: 11/24/2022] Open
Abstract
Background: The lower instrumented vertebrae (LIVs) in cervical deformity (CD) constructs may have varying effects on patient outcomes that are still poorly understood. Objective: The objective of the study is to compare outcomes in CD patients undergoing instrumented correction according to the relation of LIV with primary driver (PD). Methods: Patients who met radiographic criteria for CD were included in the study. Patients were stratified by PD of deformity: cervical (C) through AMES classification (TS-CL >20 or cervical sagittal vertical axis >40) and thoracic (T) through hyper/hypokyphosis (TK) from T4-T12 (60 < TK < 40). Patients were further stratified by LIV in relation to curve apex (above/below). Univariate and multivariate analyses identified group differences in postoperative health-related quality-of-life and distal junctional kyphosis (DJK) (>10° LIV and LIV + 2) rate up to 1 year. Results: Sixty-two patients were analyzed. Twenty-one patients had a C-PD and 41 had a T-PD by definition. 100% of C-PDs had LIVs below CL apex, while 9.2% of T-PDs had LIVs below (caudal) to TK apex and 90.8% had LIVs above TK apex. By 1 year, C patients trended lower Neck Disability Index (NDI) (21.9 vs. 29.0, P = 0.245), lower numeric rating scales neck pain (4.2 vs. 5.1, P = 0.358), and significantly higher EuroQol five-dimensional questionnaire Visual Analog Scale (69.2 vs. 52.4, P = 0.040). When T patients with LIVs below TK apex were excluded, remaining T patients with LIV above apex had significantly higher 1-year NDI than C patients (37.5 vs. 21.9, P = .05). T patients also trended higher rates of postoperative DJK than C (19.5% vs. 4.8%, P = 0.119). Conclusions: Stopping before apex was more common in patients with a primary thoracic driver (T) and associated with deleterious effects. Primary cervical driver (C) tended to have LIVs inclusive of CL apex with lower rates of DJK.
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Affiliation(s)
- Peter Gust Passias
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Haddy Alas
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Katherine E Pierce
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Matthew Galetta
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Oscar Krol
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Lara Passfall
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Nicholas Kummer
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Sara Naessig
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Waleed Ahmad
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
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McDonnell JM, Ahern DP, Wagner SC, Morrissey PB, Kaye ID, Sebastian AS, Butler JS. A Systematic Review of Risk Factors Associated With Distal Junctional Failure in Adult Spinal Deformity Surgery. Clin Spine Surg 2021; 34:347-354. [PMID: 34232153 DOI: 10.1097/bsd.0000000000001224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The surgical management of adult spinal deformity (ASD) is a major surgical undertaking associated with considerable perioperative risk and a substantial complication profile. Although the natural history and risk factors associated with proximal junctional kyphosis (PJK) and proximal junctional failure are widely reported, distal junctional failure (DJF) is less well understood. STUDY DESIGN A systematic review was carried out. OBJECTIVES The primary objective is to identify the risk factors associated with DJF. The secondary objective is to delineate the incidence rate and causative factors associated with DJF. METHODS A systematic review of articles in Medline/PubMed and The Cochrane Library databases was performed according to preferred reporting items for systematic reviews and meta-analyses guidelines. Data was collated to determine the prevalence of DJF and overall revision rates, and identify potential risk factors for development of DJF. RESULTS Twelve studies were included for systematic review. There were 81/2261 (3.6%) cases of DJF. Overall, DJF represented 27.3% of all revision surgeries. Anterior-posterior surgery had a reduced incidence of postoperative DJF [5.0% vs. 8.7%; P=0.08; relative risk (RR)=1.73], as did patients below 60 years of age at the time of surgery (2.9% vs. 3.9%; P=0.09; RR=1.34). There was a higher incidence of DJF among those patients who received interbody fusion (9.9% vs. 5.1%; P=0.06; RR=1.93) compared with those who did not. However, none of these findings reached statistical significance. There were significantly more rates of DJF for fusions ending on L5 compared with constructs fused to the sacrum (11.7% vs. 3.6%; P=0.02; RR=3.28). CONCLUSIONS Cohorts 60 years and above of age at the time of surgery and patients managed with posterior-only fusion or interbody fusion have increased incidences of DJF. Fusion to L5 instead of the sacrum significantly influences DJF rates. However, the quality of available evidence is low and further high-quality studies are required to more robustly analyze the clinical, radiographic, and surgical risk factors associated with the development of DJF after ASD surgery.
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Affiliation(s)
| | - Daniel P Ahern
- School of Medicine, Trinity College Dublin
- National Spinal Injuries Unit, Department of Trauma and Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Scott C Wagner
- Division of Orthopedics, Walter Reed National Military Medical Center, Washington, DC
| | - Patrick B Morrissey
- Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA
| | - Ian D Kaye
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | | | - Joseph S Butler
- National Spinal Injuries Unit, Department of Trauma and Orthopaedic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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36
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Kim HJ, Yao YC, Bannwarth M, Smith JS, Klineberg EO, Mundis GM, Protopsaltis TS, Charles-Elysee J, Bess S, Shaffrey CI, Passias PG, Schwab FJ, Ames CP, Lafage V. Cervicothoracic Versus Proximal Thoracic Lower Instrumented Vertebra Have Comparable Radiographic and Clinical Outcomes in Adult Cervical Deformity. Global Spine J 2021; 13:1056-1063. [PMID: 34013765 DOI: 10.1177/21925682211017478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Comparative cohort study. OBJECTIVE Factors that influence the lower instrumented vertebra (LIV) selection in adult cervical deformity (ACD) are less reported, and outcomes in the cervicothoracic junction (CTJ) and proximal thoracic (PT) spine are unclear. METHODS A prospective ACD database was analyzed using the following inclusion criteria: LIV between C7 and T5, upper instrumented vertebra at C2, and at least a 1-year follow-up. Patients were divided into CTJ (LIV C7-T2) and PT groups (LIV T3-T5) based on LIV levels. Demographics, operative details, radiographic parameters, and the health-related quality of life (HRQOL) scores were compared. RESULTS Forty-six patients were included (mean age, 62 years), with 22 and 24 patients in the CTJ and PT groups, respectively. Demographics and surgical parameters were comparable between the groups. The PT group had a significantly higher preoperative C2-C7 sagittal vertical axis (cSVA) (46.9 mm vs 32.6 mm, P = 0.002) and T1 slope minus cervical lordosis (45.9° vs 36.0°, P = 0.042) than the CTJ group and was more likely treated with pedicle-subtraction osteotomy (33.3% vs 0%, P = 0.004). The PT group had a larger correction of cSVA (-7.7 vs 0.7 mm, P = 0.037) and reciprocal change of increased T4-T12 kyphosis (8.6° vs 0.0°, P = 0.001). Complications and reoperations were comparable. The HRQOL scores were not different preoperatively and at 1-year follow-up. CONCLUSIONS The selection of PT LIV in cervical deformities was more common in patients with larger baseline deformities, who were more likely to undergo pedicle-subtraction osteotomy. Despite this, the complications and HRQOL outcomes were comparable at 1-year follow-up.
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Affiliation(s)
- Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Yu-Cheng Yao
- Spine Service, Hospital for Special Surgery, New York, NY, USA.,Department of Orthopaedic, 46615Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mathieu Bannwarth
- Spine Service, Hospital for Special Surgery, New York, NY, USA.,Neurosurgery, University Hospital Reims, Reims, France
| | - Justin S Smith
- Department of Neurosurgery, 2358University of Virginia Health Sciences Center, Charlottesville, VA, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | | | | | | | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
| | | | - Peter G Passias
- Division of Spine Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY, USA
| | - Frank J Schwab
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, USA
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Pierce KE, Passias PG, Brown AE, Bortz CA, Alas H, Lafage R, Lafage V, Ames C, Burton DC, Hart R, Hamilton K, Gum J, Scheer J, Daniels A, Bess S, Soroceanu A, Klineberg E, Shaffrey C, Line B, Schwab FA, Smith JS. Predictors of Superior Recovery Kinetics in Adult Cervical Deformity Correction: An Analysis Using a Novel Area Under the Curve Methodology. Spine (Phila Pa 1976) 2021; 46:559-566. [PMID: 33595260 DOI: 10.1097/brs.0000000000003971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of a prospective database. OBJECTIVE The aim of this study was to identify demographic, surgical, and radiographic factors that predict superior recovery kinetics following cervical deformity (CD) corrective surgery. SUMMARY OF BACKGROUND DATA Analyses of CD corrective surgery use area under the curve (AUC) to assess health-related quality of life (HRQL) metrics throughout recovery. METHODS Outcome measures were baseline (BL) to 1-year (1Y) health-related quality of life (HRQL) (Neck Disability Index [NDI]). CD criteria were C2-7 Cobb angle >10°, coronal Cobb angle >10°, C2-C7 sagittal vertical axis (cSVA) >4 cm, TS-CL >10°, or chin-brow vertical angle >25°. AUC normalization divided BL and postoperative outcomes by BL. Normalized scores (y axis) were plotted against follow-up (x axis). AUC was calculated and divided by cumulative follow-up length to determine overall, time-adjusted recovery (Integrated Health State [IHS]). IHS NDI was stratified by quartile, uppermost 25% being "Superior" Recovery Kinetics (SRK) versus "Normal" Recovery Kinetics (NRK). BL demographic, clinical, and surgical information predicted SRK using generalized linear modeling. RESULTS Ninety-eight patients included (62 ± 10 years, 28 ± 6 kg/m2, 65% females, Charlson Comorbidity Index: 0.95), 6% smokers, 31% smoking history. Surgical approach was: combined (33%), posterior (49%), anterior (18%). Posterior levels fused: 8.7, anterior: 3.6, estimated blood loss: 915.9ccs, operative time: 495 minutes. Ames BL classification: cSVA (53.2% minor deformity, 46.8% moderate), TS-CL (9.8% minor, 4.3% moderate, 85.9% marked), horizontal gaze (27.4% minor, 46.6% moderate, 26% marked). Relative to BL NDI (Mean: 47), normalized NDI decreased at 3 months (0.9 ± 0.5, P = 0.260) and 1Y (0.78 ± 0.41, P < 0.001). NDI IHS correlated with age (P = 0.011), sex (P = 0.042), anterior approach (P = 0.042), posterior approach (P = 0.042). Greater BL pelvic tilt (PT) (SRK: 25.6°, NRK: 17°, P = 0.002), pelvic incidence-lumbar lordosis (PI-LL) (SRK: 8.4°, NRK: -2.8°, P = 0.009), and anterior approach (SRK: 34.8%, NRK: 13.3%; P = 0.020) correlated with SRK. 69.4% met MCID for NDI (<Δ-15) and 63.3% met substantial clinical benefit for NDI (<Δ-10); 100% of SRK met both MCID and substantial clinical benefit. The predictive model for SRK included (AUC = 88.1%): BL visual analog scale (VAS) EuroQol five-dimensional descriptive system (EQ5D) (odds rario [OR] 0.96, 95% confidence interval [CI]: 0.92-0.99), BL swallow sleep score (OR: 1.04, 95% CI: 1.01-1.06), BL PT (OR: 1.12, 95% CI: 1.03-1.22), BL modified Japanese Orthopedic Association scale (mJOA) (OR: 1.5, 95% CI: 1.07-2.16), BL T4-T12, BL T10-L2, BL T12-S1, and BL L1-S1. CONCLUSION Superior recovery kinetics following CD surgery was predicted with high accuracy using BL patient-reported (VAS EQ5D, swallow sleep, mJOA) and radiographic factors (PT, TK, T10-L2, T12-S1, L1-S1). Awareness of these factors can improve decision-making and reduce postoperative neck disability.Level of Evidence: 3.
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Affiliation(s)
- Katherine E Pierce
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Peter G Passias
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Avery E Brown
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Cole A Bortz
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Haddy Alas
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Robert Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY
| | - Justin Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Alan Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine, Denver, CO
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Davis, CA
| | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopedic Surgery, Duke University Medical Center, Durham, NC
| | - Breton Line
- Rocky Mountain Scoliosis and Spine, Denver, CO
| | - Frank A Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
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Sagittal balance of the cervical spine: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:1411-1439. [PMID: 33772659 DOI: 10.1007/s00586-021-06825-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 09/26/2020] [Accepted: 03/20/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this systematic review and meta-analysis was to compare the cervical sagittal parameters between patients with cervical spine disorder and asymptomatic controls. METHODS Two independent authors systematically searched online databases including Pubmed, Scopus, Cochrane library, and Web of Science up to June 2020. Cervical sagittal balance parameters, such as T1 slope, cervical SVA (cSVA), and spine cranial angle (SCA), were compared between the cervical spine in healthy, symptomatic, and pre-operative participants. Where possible, we pooled data using random-effects meta-analysis, by CMA software. Heterogeneity and publication bias were assessed using the I-squared statistic and funnel plots, respectively. RESULTS A total of 102 studies, comprising 13,802 cases (52.7% female), were included in this meta-analysis. We used the Newcastle-Ottawa Scale (NOS) to evaluate the quality of studies included in this review. Funnel plot and Begg's test did not indicate obvious publication bias. The pooled analysis reveals that the mean (SD) values were: T1 slope (degree), 24.5 (0.98), 25.7 (0.99), 25.4 (0.34); cSVA (mm), 18.7 (1.76), 22.7 (0.66), 22.4 (0.68) for healthy population, symptomatic, and pre-operative assessment, respectively. The mean value of the SCA (degree) was 79.5 (3.55) and 75.6 (10.3) for healthy and symptomatic groups, respectively. Statistical differences were observed between the groups (all P values < 0.001). CONCLUSION The findings showed that the T1 slope and the cSVA were significantly lower among patients with cervical spine disorder compared to controls and higher for the SCA. Further well-conducted studies are needed to complement our findings.
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Passias PG, Horn SR, Lafage V, Lafage R, Smith JS, Line BG, Protopsaltis TS, Soroceanu A, Bortz C, Segreto FA, Ahmad W, Naessig S, Pierce KE, Brown AE, Alas H, Kim HJ, Daniels AH, Klineberg EO, Burton DC, Hart RA, Schwab FJ, Bess S, Shaffrey CI, Ames CP. Effect of age-adjusted alignment goals and distal inclination angle on the fate of distal junctional kyphosis in cervical deformity surgery. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:65-71. [PMID: 33850384 PMCID: PMC8035585 DOI: 10.4103/jcvjs.jcvjs_170_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Peter Gust Passias
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Samantha R Horn
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Clinic, Denver, Colorado, USA
| | | | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Canada
| | - Cole Bortz
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Frank A Segreto
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Waleed Ahmad
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Sara Naessig
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Katherine E Pierce
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Avery E Brown
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Haddy Alas
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Denver, Colorado, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Severe, rigid cervical kyphotic deformity associated with SAPHO syndrome successfully treated with three-stage correction surgery combined with C7 vertebral column resection: a technical case report. Spine Deform 2021; 9:285-292. [PMID: 32946068 DOI: 10.1007/s43390-020-00203-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
STUDY DESIGN Case report. OBJECTIVES To describe the first reported use of corrective surgery combined with C7 vertebral column resection (VCR) to treat an extremely rare case of severe, rigid cervical kyphotic deformity associated with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. BACKGROUND DATA Spinal lesions reportedly occur in 32-45% in SAPHO syndrome. However, bone and joint lesions are usually repaired such that severe joint destruction is rare. Therefore, there have been few reported cases of surgical treatment for spinal lesions. METHODS A 22-year-old woman had been diagnosed with cervical kyphotic deformity associated with SAPHO syndrome. She had difficulty looking upward. On radiography, the C4-C7 vertebral bodies were fused and exhibited severe rigid kyphotic deformity. Right convex scoliosis with a Cobb angle of 22° was apparent at C5-T2, and the C2-C7 angle of kyphosis was 75°. Corrective three-stage surgery was carried out from the anterior, posterior, and anterior, with C7 VCR. RESULTS The C2-T1 angle improved to 21° and the patient was capable of looking up. At present, 2 years postoperatively, complete bony fusion has been achieved. Her cervical spine function and quality of life were markedly improved. CONCLUSION Only a very limited number of patients have a deformity sufficiently severe that VCR of cervical vertebra is required, but as this is the technique that provides the greatest multiplanar alignment correction, its choice in the present case was appropriate. LEVEL OF EVIDENCE IV.
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Incidence and predictors of kyphotic deformity following resection of cervical intradural tumors in adults: a population-based cohort study. Acta Neurochir (Wien) 2020; 162:2905-2913. [PMID: 32556521 PMCID: PMC7550319 DOI: 10.1007/s00701-020-04416-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND The first line of treatment for most cervical intradural tumors is surgical resection through laminotomy or laminectomy. This may cause a loss of posterior pulling force leading to kyphosis, which is associated with decreased functional outcome. However, the incidence and predictors of kyphosis in these patients are poorly understood. OBJECT To assess the incidence of posterior fixation (PF), as well as predictors of radiological kyphosis, following resection of cervical intradural tumors in adults. METHODS A population-based cohort study was conducted on adult patients who underwent intradural tumor resection via cervical laminectomy with or without laminoplasty between 2005 and 2017. Primary outcome was kyphosis requiring PF. Secondary outcome was radiological kyphotic increase, measured by the change in the C2-C7 Cobb angle between pre- and postoperative magnetic resonance images. RESULTS Eighty-four patients were included. Twenty-four percent of the tumors were intramedullary, and the most common diagnosis was meningioma. The mean laminectomy range was 2.4 levels, and laminoplasty was performed in 40% of cases. No prophylactic PF was performed. During a mean follow-up of 4.4 years, two patients (2.4%) required delayed PF. The mean radiological kyphotic increase after surgery was 3.0°, which was significantly associated with laminectomy of C2 and C3. Of these, C3 laminectomy demonstrated independent risk association. CONCLUSIONS There was a low incidence of delayed PF following cervical intradural tumor resection, supporting the practice of not performing prophylactic PF. Kyphotic increase was associated with C2 and C3 laminectomy, which could help identify at-risk patients were targeted follow-up is indicated.
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Lee SH, Hyun SJ, Jain A. Cervical Sagittal Alignment: Literature Review and Future Directions. Neurospine 2020; 17:478-496. [PMID: 33022153 PMCID: PMC7538362 DOI: 10.14245/ns.2040392.196] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/13/2020] [Indexed: 12/26/2022] Open
Abstract
Cervical alignment as a concept has come to the forefront for spine deformity research in the last decade. Studies on cervical sagittal alignment started from normative data, and expanded into correlation with global sagittal balance, prognosis of various conditions, outcomes of surgery, definition and classification of cervical deformity, and prediction of targets for ideal cervical reconstruction. Despite the recent robust research efforts, the definition of normal cervical sagittal alignment and cervical spine deformity continues to elude us. Further, many studies continue to view cervical alignment as a continuation of thoracolumbar deformity and do not take into account biomechanical features unique to the cervical spine that may influence cervical alignment, such as the importance of musculature connecting cranium-cervical-thoracic spine and upper extremities. In this article, we aim to summarize the relevant literature on cervical sagittal alignment, discuss key results, and list potential future direction for research using the '5W1H' framework; "WHO" are related?, "WHY" important?, "WHAT" to evaluate and "WHAT" is normal?, "HOW" to evaluate?, "WHEN" to apply sagittal balance?, and "WHERE" to go in the future?
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Affiliation(s)
- Sang Hun Lee
- Department of Orthopaedic Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
| | - Seung-Jae Hyun
- Department of Neurological Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Durand WM, Daniels AH, Hamilton DK, Passias P, Kim HJ, Protopsaltis T, LaFage V, Smith JS, Shaffrey C, Gupta M, Klineberg E, Schwab F, Burton D, Bess S, Ames C, Hart R. Artificial Intelligence Models Predict Operative Versus Nonoperative Management of Patients with Adult Spinal Deformity with 86% Accuracy. World Neurosurg 2020; 141:e239-e253. [PMID: 32434029 DOI: 10.1016/j.wneu.2020.05.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Patients with ASD show complex and highly variable disease. The decision to manage patients operatively is largely subjective and varies based on surgeon training and experience. We sought to develop models capable of accurately discriminating between patients receiving operative versus nonoperative treatment based only on baseline radiographic and clinical data at enrollment. METHODS This study was a retrospective analysis of a multicenter consecutive cohort of patients with ASD. A total of 1503 patients were included, divided in a 70:30 split for training and testing. Patients receiving operative treatment were defined as those undergoing surgery up to 1 year after their baseline visit. Potential predictors included available demographics, past medical history, patient-reported outcome measures, and premeasured radiographic parameters from anteroposterior and lateral films. In total, 321 potential predictors were included. Random forest, elastic net regression, logistic regression, and support vector machines (SVMs) with radial and linear kernels were trained. RESULTS Of patients in the training and testing sets, 69.0% (n = 727) and 69.1% (n = 311), respectively, received operative management. On evaluation with the testing dataset, performance for SVM linear (area under the curve =0.910), elastic net (0.913), and SVM radial (0.914) models was excellent, and the logistic regression (0.896) and random forest (0.830) models performed very well for predicting operative management of patients with ASD. The SVM linear model showed 86% accuracy. CONCLUSIONS This study developed models showing excellent discrimination (area under the curve >0.9) between patients receiving operative versus nonoperative management, based solely on baseline study enrollment values. Future investigations may evaluate the implementation of such models for decision support in the clinical setting.
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Affiliation(s)
- Wesley M Durand
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopaedics, Division of Spine Surgery, Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - David K Hamilton
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter Passias
- Department of Orthopedics, New York University Langone Orthopedic Hospital, New York, New York, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | | | - Virginie LaFage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | | | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California-Davis, Sacramento, California, USA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Doug Burton
- Department of Orthopaedic Surgery, University of Kansas Hospital, Kansas City, Kansas, USA
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, Colorado, USA
| | - Christopher Ames
- Department of Neurosurgery, University of California-San Francisco, California, USA
| | - Robert Hart
- Division of Spine Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
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Development of a Risk Prediction Model With Improved Clinical Utility in Elective Cervical and Lumbar Spine Surgery. Spine (Phila Pa 1976) 2020; 45:E542-E551. [PMID: 31770338 DOI: 10.1097/brs.0000000000003317] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE We present a universal model of risk prediction for patients undergoing elective cervical and lumbar spine surgery. SUMMARY OF BACKGROUND DATA Previous studies illustrate predictive risk models as possible tools to identify individuals at increased risk for postoperative complications and high resource utilization following spine surgery. Many are specific to one condition or procedure, cumbersome to calculate, or include subjective variables limiting applicability and utility. METHODS A retrospective cohort of 177,928 spine surgeries (lumbar (L) Ln = 129,800; cervical (C) Cn = 48,128) was constructed from the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Cases were identified by Current Procedural Terminology (CPT) codes for cervical fusion, lumbar fusion, and lumbar decompression laminectomy. Significant preoperative risk factors for postoperative complications were identified and included in logistic regression. Sum of odds ratios from each factor was used to develop the Universal Spine Surgery (USS) score. Model performance was assessed using receiver-operating characteristic (ROC) curves and tested on 20% of the total sample. RESULTS Eighteen risk factors were identified, including sixteen found to be significant outcomes predictors. At least one complication was present among 11.1% of patients, the most common of which included bleeding requiring transfusion (4.86%), surgical site infection (1.54%), and urinary tract infection (1.08%). Complication rate increased as a function of the model score and ROC area under the curve analyses demonstrated fair predictive accuracy (lumbar = 0.741; cervical = 0.776). There were no significant deviations between score development and testing datasets. CONCLUSION We present the Universal Spine Surgery score as a robust, easily administered, and cross-validated instrument to quickly identify spine surgery candidates at increased risk for postoperative complications and high resource utilization without need for algorithmic software. This may serve as a useful adjunct in preoperative patient counseling and perioperative resource allocation. LEVEL OF EVIDENCE 3.
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Teo AQA, Thomas AC, Hey HWD. Sagittal alignment of the cervical spine: do we know enough for successful surgery? JOURNAL OF SPINE SURGERY 2020; 6:124-135. [PMID: 32309651 DOI: 10.21037/jss.2019.11.18] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Over the past decade, there has been growing interest in the sagittal alignment of the cervical spine and its correlation to clinical outcomes. It is now known that cervical lordosis is not universally physiological and should not be pursued in all patients undergoing surgery. Rather, it is increasingly understood that it is how these angular parameters (lordosis or kyphosis) interact with translational parameters that is reflective of overall cervical spine and whole spine balance, which in turn impacts patient outcomes. This review synthesises currently available evidence relating to the sagittal alignment of the cervical spine. Radiographic assessment of the cervical spine including horizontal gaze is discussed and alignment in physiological and pathological states analysed. The interdependence of spinal segments is reviewed, with cervical alignment correction influencing the adjacent thoracic spine, and similarly lumbar lordosis (LL) and global balance correction changing cervical spine alignment. Cervical kyphosis with associated cervical sagittal imbalance is known to lead to poorer post-operative outcomes, and this dichotomy in outcomes has not been shown to improve even with alignment correction. Further work is required to uncover the extent to which cervical spine alignment correction should be attempted toward improved patient outcomes, in order to plan and deliver patient-specific surgical realignment targets.
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Affiliation(s)
- Alex Quok An Teo
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Andrew Cherian Thomas
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Hwee Weng Dennis Hey
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
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Badiee RK, Mayer R, Pennicooke B, Chou D, Mummaneni PV, Tan LA. Complications following posterior cervical decompression and fusion: a review of incidence, risk factors, and prevention strategies. JOURNAL OF SPINE SURGERY 2020; 6:323-333. [PMID: 32309669 DOI: 10.21037/jss.2019.11.01] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Posterior cervical decompression and fusion (PCF) is a common surgical technique used to treat various cervical spine pathologies. However, there are various complications associated with PCF that can negatively impact patient outcome. We performed a comprehensive literature review to identify the most common complications following PCF using PubMed, Cochrane Database of Systematic Reviews, and Google Scholar. The overall complication rates of PCF are estimated to range from about 15% to 25% in the current literature. The most common immediate complications include acute blood loss anemia, surgical site infection (SSI), C5 palsy, and incidental durotomy; the most common long-term complications include adjacent segment degeneration, junctional kyphosis, and pseudoarthrosis. Three principal mechanisms are thought to contribute to complications. First, higher number of fusion levels, obesity, and more complex pathologies can increase the invasiveness of the planned procedure, thus increase complications. Second, wound healing and arthrodesis may be impaired due to poor blood flow due to various patient factors such as smoking, diabetes, increased frailty, steroid use, and other medical comorbidities. Finally, increased biomechanical stress on the upper instrumented vertebra (UIV) and lowest instrumented vertebra (LIV) may predispose patient to chronic degeneration and result in adjacent level degeneration and/or junctional problems. Reducing the modifiable risk factors pre-operatively can decrease the overall complication rate. Neurologic deficits may be reduced with adequate intraoperative decompression of neural elements. SSI may be reduced with meticulous wound closure that minimizes dead space, drain placement, and the use of intra-wound antibiotics. Careful design of the fusion construct with consideration in spinal alignment and biomechanics can help to reduce the rate of junctional problems. Spine surgeons should be aware of these complications associated with PCF and the corresponding prevention strategies optimize patient outcomes.
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Affiliation(s)
- Ryan K Badiee
- School of Medicine, University of California, San Francisco, CA, USA
| | - Rory Mayer
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, CA, USA
| | - Brenton Pennicooke
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, CA, USA
| | - Dean Chou
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, CA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, CA, USA
| | - Lee A Tan
- Department of Neurological Surgery, UCSF Medical Center, San Francisco, CA, USA
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Horn SR, Passias PG, Oh C, Lafage V, Lafage R, Smith JS, Line B, Anand N, Segreto FA, Bortz CA, Scheer JK, Eastlack RK, Deviren V, Mummaneni PV, Daniels AH, Park P, Nunley PD, Kim HJ, Klineberg EO, Burton DC, Hart RA, Schwab FJ, Bess S, Shaffrey CI, Ames CP, _ _. Predicting the combined occurrence of poor clinical and radiographic outcomes following cervical deformity corrective surgery. J Neurosurg Spine 2020; 32:182-190. [DOI: 10.3171/2019.7.spine18651] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/09/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVECervical deformity (CD) correction is clinically challenging. There is a high risk of developing complications with these highly complex procedures. The aim of this study was to use baseline demographic, clinical, and surgical factors to predict a poor outcome following CD surgery.METHODSThe authors performed a retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: cervical kyphosis (C2–7 Cobb angle > 10°), cervical scoliosis (coronal Cobb angle > 10°), C2–7 sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical angle (CBVA) > 25°. Patients were categorized based on having an overall poor outcome or not. Health-related quality of life measures consisted of Neck Disability Index (NDI), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scale scores. A poor outcome was defined as having all 3 of the following categories met: 1) radiographic poor outcome: deterioration or severe radiographic malalignment 1 year postoperatively for cSVA or T1 slope–cervical lordosis mismatch (TS-CL); 2) clinical poor outcome: failing to meet the minimum clinically important difference (MCID) for NDI or having a severe mJOA Ames modifier; and 3) complications/reoperation poor outcome: major complication, death, or reoperation for a complication other than infection. Univariate logistic regression followed by multivariate regression models was performed, and internal validation was performed by calculating the area under the curve (AUC).RESULTSIn total, 89 patients with CD were included (mean age 61.9 years, female sex 65.2%, BMI 29.2 kg/m2). By 1 year postoperatively, 18 (20.2%) patients were characterized as having an overall poor outcome. For radiographic poor outcomes, patients’ conditions either deteriorated or remained severe for TS-CL (73% of patients), cSVA (8%), horizontal gaze (34%), and global SVA (28%). For clinical poor outcomes, 80% and 60% of patients did not reach MCID for EQ-5D and NDI, respectively, and 24% of patients had severe symptoms (mJOA score 0–11). For the complications/reoperation poor outcome, 28 patients experienced a major complication, 11 underwent a reoperation, and 1 had a complication-related death. Of patients with a poor clinical outcome, 75% had a poor radiographic outcome; 35% of poor radiographic and 37% of poor clinical outcome patients had a major complication. A poor outcome was predicted by the following combination of factors: osteoporosis, baseline neurological status, use of a transition rod, number of posterior decompressions, baseline pelvic tilt, T2–12 kyphosis, TS-CL, C2–T3 SVA, C2–T1 pelvic angle (C2 slope), global SVA, and number of levels in maximum thoracic kyphosis. The final model predicting a poor outcome (AUC 86%) included the following: osteoporosis (OR 5.9, 95% CI 0.9–39), worse baseline neurological status (OR 11.4, 95% CI 1.8–70.8), baseline pelvic tilt > 20° (OR 0.92, 95% CI 0.85–0.98), > 9 levels in maximum thoracic kyphosis (OR 2.01, 95% CI 1.1–4.1), preoperative C2–T3 SVA > 5.4 cm (OR 1.01, 95% CI 0.9–1.1), and global SVA > 4 cm (OR 3.2, 95% CI 0.09–10.3).CONCLUSIONSOf all CD patients in this study, 20.2% had a poor overall outcome, defined by deterioration in radiographic and clinical outcomes, and a major complication. Additionally, 75% of patients with a poor clinical outcome also had a poor radiographic outcome. A poor overall outcome was most strongly predicted by severe baseline neurological deficit, global SVA > 4 cm, and including more of the thoracic maximal kyphosis in the construct.
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Affiliation(s)
- Samantha R. Horn
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Peter G. Passias
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Cheongeun Oh
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Virginie Lafage
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Renaud Lafage
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Justin S. Smith
- 3Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Breton Line
- 4Denver International Spine Center, Presbyterian/St. Luke’s Medical Center and Rocky Mountain Hospital for Children, Denver, Colorado
| | - Neel Anand
- 5Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Frank A. Segreto
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Cole A. Bortz
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Justin K. Scheer
- 6Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Robert K. Eastlack
- 7Department of Orthopaedic Surgery, Scripps Health, La Jolla, California
| | - Vedat Deviren
- 8Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Praveen V. Mummaneni
- 8Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Alan H. Daniels
- 9Department of Orthopaedic Surgery, Brown University Medical Center, Providence, Rhode Island
| | - Paul Park
- 10Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Pierce D. Nunley
- 11Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Han Jo Kim
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric O. Klineberg
- 12Department of Orthopedic Surgery, University of California Davis, Sacramento, California
| | - Douglas C. Burton
- 13Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Robert A. Hart
- 14Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington; and
| | - Frank J. Schwab
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- 4Denver International Spine Center, Presbyterian/St. Luke’s Medical Center and Rocky Mountain Hospital for Children, Denver, Colorado
| | - Christopher I. Shaffrey
- 3Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher P. Ames
- 15Department of Neurological Surgery, University of California, San Francisco, California
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Berjano P, Damilano M, Pejrona M, Langella F, Lamartina C. Revision surgery in distal junctional kyphosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:86-102. [DOI: 10.1007/s00586-020-06304-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/18/2020] [Accepted: 01/18/2020] [Indexed: 10/25/2022]
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Dru AB, Lockney DT, Vaziri S, Decker M, Polifka AJ, Fox WC, Hoh DJ. Cervical Spine Deformity Correction Techniques. Neurospine 2019; 16:470-482. [PMID: 31607079 PMCID: PMC6790735 DOI: 10.14245/ns.1938288.144] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/18/2019] [Indexed: 11/19/2022] Open
Abstract
Cervical kyphotic deformity can be a debilitating condition with symptoms ranging from mechanical neck pain, radiculopathy, and myelopathy to impaired swallowing and horizontal gaze. Surgical correction of cervical kyphosis has the potential to halt progression of neurological and clinical deterioration and even restore function. There are various operative approaches and deformity correction techniques. Choosing the optimal strategy is predicated on a fundamental understanding of spine biomechanics. Preoperative characterization of cervical malalignment, assessment of deformity rigidity, and defining postoperative clinical and radiographic objectives are paramount to formulating a surgical plan that balances clinical benefit with morbidity. This review of cervical deformity treatment provides an overview of the biomechanics of cervical kyphosis, radiographic classification, algorithm-based management, surgical techniques, and current surgical outcome studies.
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Affiliation(s)
- Alexander B Dru
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Dennis Timothy Lockney
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Sasha Vaziri
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Matthew Decker
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Adam J Polifka
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - W Christopher Fox
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
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50
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Goyal A, Ngufor C, Kerezoudis P, McCutcheon B, Storlie C, Bydon M. Can machine learning algorithms accurately predict discharge to nonhome facility and early unplanned readmissions following spinal fusion? Analysis of a national surgical registry. J Neurosurg Spine 2019; 31:568-578. [PMID: 31174185 DOI: 10.3171/2019.3.spine181367] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Nonhome discharge and unplanned readmissions represent important cost drivers following spinal fusion. The authors sought to utilize different machine learning algorithms to predict discharge to rehabilitation and unplanned readmissions in patients receiving spinal fusion. METHODS The authors queried the 2012-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) for patients undergoing cervical or lumbar spinal fusion. Outcomes assessed included discharge to nonhome facility and unplanned readmissions within 30 days after surgery. A total of 7 machine learning algorithms were evaluated. Predictive hierarchical clustering of procedure codes was used to increase model performance. Model performance was evaluated using overall accuracy and area under the receiver operating characteristic curve (AUC), as well as sensitivity, specificity, and positive and negative predictive values. These performance metrics were computed for both the imputed and unimputed (missing values dropped) datasets. RESULTS A total of 59,145 spinal fusion cases were analyzed. The incidence rates of discharge to nonhome facility and 30-day unplanned readmission were 12.6% and 4.5%, respectively. All classification algorithms showed excellent discrimination (AUC > 0.80, range 0.85-0.87) for predicting nonhome discharge. The generalized linear model showed comparable performance to other machine learning algorithms. By comparison, all models showed poorer predictive performance for unplanned readmission, with AUC ranging between 0.63 and 0.66. Better predictive performance was noted with models using imputed data. CONCLUSIONS In an analysis of patients undergoing spinal fusion, multiple machine learning algorithms were found to reliably predict nonhome discharge with modest performance noted for unplanned readmissions. These results provide early evidence regarding the feasibility of modern machine learning classifiers in predicting these outcomes and serve as possible clinical decision support tools to facilitate shared decision making.
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Affiliation(s)
- Anshit Goyal
- 1Mayo Clinic Neuro-Informatics Laboratory
- 2Department of Neurosurgery, and
| | - Che Ngufor
- 3Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Curtis Storlie
- 3Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 1Mayo Clinic Neuro-Informatics Laboratory
- 2Department of Neurosurgery, and
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