Patient Satisfaction Following Minimally Invasive and Open Surgeries for Adult Spinal Deformity

Outcome and complication following single-staged posterior minimally invasive surgery in adult spinal deformity

BACKGROUND

The aging population is experiencing a rising incidence of musculoskeletal problems and degenerative spinal deformities. Adult spinal deformity (ASD) presents challenges, with associated risks in open surgery. Minimally invasive surgery (MIS) is becoming increasingly popular due to its positive outcomes and potential benefits. This study aims to explore the clinical outcome and complications of posterior approach MIS in patients with ASD.

METHODS

We conducted a retrospective analysis of patients with adult spinal deformity who underwent posterior minimally invasive surgery. 46 patients meeting the criteria were identified between June 2017 and September 2023. Comprehensive data were collected, including demographic details, surgical information, full-length radiographic measurements, and visual analog scale (VAS) pain scores. These data were obtained preoperatively, postoperatively, and at the final follow-up.

RESULTS

A total of 46 patients were included in the study, with a mean age of 68.58 years and a minimum follow-up period of 6 months. The mean operative time was 327 min, and the mean blood loss was 307 ml. Preoperative radiographic measurements were as follows: Coronal Cobb angle, 18.60 ± 11.35°; lumbar lordosis (LL), 22.79 ± 21.87°; pelvic incidence (PI), 53.05 ± 14.13°; PI-LL mismatch, 30.26 ± 23.48°; pelvic tilt (PT), 32.53 ± 10.38°; T1 pelvic angle (TPA), 31.91 ± 12.39°; and sagittal vertical axis (SVA), 77.77 ± 60.47 mm. At the final follow-up, coronal Cobb angle was 10.08 ± 6.47° (P <0.0001), LL was 26.16 ± 16.92° (P = 0.4293), PI was 54.17 ± 12.13° (P = 0.6965), PI-LL mismatch was 28.00 ± 17.03° (P = 0.6144), PT was 27.74 ± 10.24° (P = 0.0345), TPA was 25.10 ± 10.95 (P = 0.0090) and SVA was 47.91 ± 46.94 mm (P = 0.0129). Functional outcomes improved as well, with the mean Oswestry Disability Index (ODI) decreasing from 34.9 to 23.6 and the Visual Analog Scale (VAS) score for back pain reducing from 8.4 to 3.4. Surgical complications occurred in 39.1% of cases, with a low reoperation rate of 4.3%.

CONCLUSION

Single-staged posterior MIS effectively corrects global alignment in adult spinal deformities, satisfying patient demand and yielding positive clinical outcome with low re-operation rate.

Post-operative shift in pain profile following fusion surgery for adult spinal deformity: a cluster analysis

PURPOSE

Adult spinal deformity (ASD) is associated with a combination of back and leg pain of various intensities. The objective of the present study was to investigate the diverse reaction of pain profiles following ASD surgery as well as post-operative patient satisfaction.

METHODS

Multicenter surveillance collected data for patients ≥ 19 years old who underwent primary thoracolumbar fusion surgery at > 5 spinal levels for ASD. Two-step cluster analysis was performed utilizing pre-operative numeric rating scale (NRS) for back and leg pain. Radiologic parameters and patient-reported outcome (PRO) scores were also obtained. One-year post-operative outcomes and satisfaction rates were compared among clusters, and influencing factors were analyzed.

RESULTS

Based on cluster analysis, 191 ASD patients were categorized into three groups: ClusterNP, mild pain only (n = 55); ClusterBP, back pain only (n = 68); and ClusterBLP, significant back and leg pain (n = 68). ClusterBLP (mean NRSback 7.6, mean NRSleg 6.9) was the oldest 73.4 years (p < 0.001) and underwent interbody fusion (88%, p < 0.001) and sacral/pelvic fixation (69%, p = 0.001) more commonly than the other groups, for the worst pelvis incidence-lumbar lordosis mismatch (mean 43.7°, p = 0.03) and the greatest sagittal vertical axis (mean 123 mm, p = 0.002). While NRSback, NRSleg and PRO scores were all improved postoperatively in ClustersBP and BLP, ClusterBLP showed the lowest satisfaction rate (80% vs. 80% vs. 63%, p = 0.11), which correlated with post-operative NRSback (rho = -0.357).

CONCLUSIONS

Cluster analysis revealed three clusters of ASD patients, and the cluster with the worst pain back and leg pain had the most advanced disease and showed the lowest satisfaction rate, affected by postoperative back pain.

Biomechanical analysis of a trans-discal, multi-level stabilization screw (MLSS) at the upper instrumented vertebra (UIV) of long posterior thoracolumbar instrumentations

PURPOSE

To evaluate proximal junctional biomechanics of a MLSS relative to traditional pedicle screw fixation at the proximal extent of T10-pelvis posterior instrumentation constructs (T10-p PSF).

METHODS

A previously validated three-dimensional osseoligamentous spinopelvic finite element (FE) model was used to compare proximal junctional range-of-motion (ROM), vertebral body stresses, and discal biomechanics between two groups: (1) T10-p with a T10-11 MLSS ("T10-11 MLSS") and (2) T10-p with a traditional T10 pedicle screw ("Traditional T10-PS").

RESULTS

The T10-11 MLSS had a 5% decrease in T9 cortical bone stress compared to Traditional T10-PS. Conversely, the T10 and T11 bone stresses increased by 46% and 98%, respectively, with T10-11 MLSS compared to Traditional T10-PS. Annular stresses and intradiscal pressures (IDP) were similar at T9-T10 between constructs. At the T10-11 disc, T10-11 MLSS decreased annular stresses by 29% and IDP by 48% compared to Traditional T10-PS. Adjacent ROM (T8-9 & T9-10) were similar between T10-11 MLSS and Traditional T10-PS. T10-11 MLSS had 39% greater ROM at T10-11 and 23% less ROM at T11-12 compared to Traditional T10-PS.

CONCLUSIONS

In this FE analysis, a T10-11 MLSS at the proximal extent of T10-pelvis posterior instrumentation resulted in increased T10 and T11 cortical bone stresses, decreased discal annular stress and IDP and increased ROM at T10-11, and no change in ROM at the adjacent level. Given the complex and multifactorial nature of proximal junctional kyphosis, these results require additional biomechanical and clinical evaluations to determine the clinical utility of MLSS on the proximal junctions of thoracolumbar posterior instrumented fusions.

Preoperative Robotics Planning Facilitates Complex Construct Design in Robot-Assisted Minimally Invasive Adult Spinal Deformity Surgery-A Preliminary Experience

(1) Background: The correction of adult spinal deformity (ASD) can require long, complex constructs with multiple rods which traverse important biomechanical levels to achieve multi-pelvic fixation. Minimally invasive (MIS) placement of these constructs has historically been difficult. Advanced technologies such as spinal robotics platforms can facilitate the design and placement of these constructs and further enable these surgical approaches in MIS deformity surgery. (2) Methods: A retrospective study was performed on a series of ASD patients undergoing MIS deformity correction with ≥eight fusion levels to the lower thoracic spine with preoperative robotic construct planning and robot-assisted pedicle screw placement. (3) Results: There were 12 patients (10 female, mean age 68.6 years) with a diagnosis of either degenerative scoliosis (8 patients) or sagittal imbalance (4 patients). All underwent preoperative robotic planning to assist in MIS robot-assisted percutaneous or transfascial placement of pedicle and iliac screws with multiple-rod constructs. Mean operative values per patient were 9.9 levels instrumented (range 8-11), 3.9 interbody cages (range 2-6), 3.3 iliac fixation points (range 2-4), 3.3 rods (range 2-4), 18.7 screws (range 13-24), estimated blood loss 254 cc (range 150-350 cc), and operative time 347 min (range 242-442 min). All patients showed improvement in radiographic sagittal, and, if applicable, coronal parameters. Mean length of stay was 5.8 days with no ICU admissions. Ten patients ambulated on POD 1 or 2. Of 224 screws placed minimally invasively, four breaches were identified on intraoperative CT and repositioned (three lateral, one medial) for a robot-assisted screw accuracy of 98.2%. (4) Conclusions: Minimally invasive long-segment fixation for adult spinal deformity surgery has historically been considered laborious and technically intensive. Preoperative robotics planning facilitates the design and placement of even complex multi-rod multi-pelvic fixation for MIS deformity surgery.

Proximal Junctional Kyphosis and Failure: Strategies for Prevention

Proximal junctional kyphosis (PJK) and proximal junctional failure/fractures (PJF) are common complications following long-segment posterior instrumented fusions for adult spinal deformity. As progression to PJF involves clinical consequences for patients and requires costly revisions that may undermine the utility of surgery and are ultimately unsustainable for health care systems, preventative strategies to minimize the occurrence of PJF are of tremendous importance. In this article, the authors present a detailed outline of PJK and PJF with a focus on surgical strategies aimed at preventing their occurrence..

Single-position Minimally Invasive Surgery for Correction of Adult Spinal Deformity

Minimally invasive adult spinal deformity (MIS ASD) surgery may offer benefits over conventional techniques in select circumstances. The success of the procedure is based on proper patient selection, restoring adequate alignment, and optimizing fusion. In the past, MIS techniques were limited because of the need to reposition the patient-a source of increased surgical time and potentially patient risk. New developments now allow for single-position, MIS correction of adult deformity. Additional research will be needed to determine the ideal patient for minimally invasive adult spinal deformity surgery and whether prone or lateral single-position confers the best outcomes.

Improvements in Outcomes and Cost After Adult Spinal Deformity Corrective Surgery Between 2008 and 2019

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To assess whether patient outcomes and cost-effectiveness of adult spinal deformity (ASD) surgery have improved over the past decade.

BACKGROUND

Surgery for ASD is an effective intervention, but one that is also associated with large initial healthcare expenditures. Changes in the cost profile for ASD surgery over the last decade has not been evaluated previously.

MATERIALS AND METHODS

ASD patients who received surgery between 2008 and 2019 were included. Analysis of covariance was used to establish estimated marginal means for outcome measures [complication rates, reoperations, health-related quality of life, total cost, utility gained, quality adjusted life years (QALYs), cost-efficiency (cost per QALY)] by year of initial surgery. Cost was calculated using the PearlDiver database and represented national averages of Medicare reimbursement for services within a 30-day window including length of stay and death differentiated by complication/comorbidity, revision, and surgical approach. Internal cost data was based on individual patient diagnosis-related group codes, limiting revisions to those within two years (2Y) of the initial surgery. Cost per QALY over the course of 2008-2019 were then calculated.

RESULTS

There were 1236 patients included. There was an overall decrease in rates of any complication (0.78 vs . 0.61), any reoperation (0.25 vs . 0.10), and minor complication (0.54 vs . 0.37) between 2009 and 2018 (all P <0.05). National average 2Y cost decreased at an annual rate of $3194 ( R2 =0.6602), 2Y utility gained increased at an annual rate of 0.0041 ( R2 =0.57), 2Y QALYs gained increased annually by 0.008 ( R2 =0.57), and 2Y cost per QALY decreased per year by $39,953 ( R2 =0.6778).

CONCLUSION

Between 2008 and 2019, rates of complications have decreased concurrently with improvements in patient reported outcomes, resulting in improved cost effectiveness according to national Medicare average and individual patient cost data. The value of ASD surgery has improved substantially over the course of the last decade.

Preoperative characteristics are associated with increased likelihood of low early postoperative mobility after adult spinal deformity surgery

BACKGROUND CONTEXT

Low early postoperative mobility (LEPOM) has been shown to be associated with increased length of hospital stay, complication rates, and likelihood of nonhome discharge. However, few studies have examined preoperative characteristics associated with LEPOM in adult spinal deformity (ASD) patients.

PURPOSE

To investigate which preoperative patient characteristics may be associated with LEPOM after ASD surgery.

DESIGN

Retrospective review.

PATIENT SAMPLE

Included were 86 ASD patients with fusion of ≥5 levels for whom immediate-postoperative AM-PAC Basic Mobility Inpatient Short Form (6-Clicks) scores had been obtained.

OUTCOME MEASURES

The primary outcome of this study was the likelihood of LEPOM, defined as an AM-PAC score ≤15, which is associated with inability to stand for more than 1 minute.

METHODS

Significant cutoffs for preoperative characteristics associated with LEPOM were determined via threshold linear regression. Multivariable logistic regression was used to assess the impact of preoperative characteristics on the likelihood of LEPOM.

RESULTS

LEPOM was recorded in 38 patients (44.2%). Threshold regression identified the following cutoffs to be associated with LEPOM: preoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores of ≥68 for Pain, <28.3 for Physical Function, and ≥63.4 for Anxiety; preoperative Oswestry disability index (ODI) score of ≥60; and body mass index (BMI) of ≥35.2. On multivariate analysis, preoperative PROMIS scores of ≥68 for Pain (odds ratio [OR] 5.3, confidence interval [CI] 1.2-22.8, p=.03), <28.3 for Physical Function (OR 10.1, CI 1.8-58.2, p=.01), and ≥63.4 for Anxiety (OR 4.7, CI 1.1-20.8, p=.04); preoperative ODI score ≥60 (OR 38.8, CI 4.0-373.6, p=.002); BMI ≥35.2 (OR 14.2, CI 1.3-160.0, p=.03), and male sex (OR 5.4, CI 1.2-23.7, p=.03) were associated with increased odds of LEPOM.

CONCLUSIONS

Preoperative PROMIS Pain, Physical Function, and Anxiety scores; ODI score; BMI; and male sex were associated with LEPOM. Several of these characteristics are modifiable risk factors and thus may be candidates for optimization before surgery.

LEVEL OF EVIDENCE

III.