The Impact of Comorbid Mental Health Disorders on Complications Following Adult Spinal Deformity Surgery With Minimum 2-Year Surveillance

Spinal Cord Stimulators Adversely Affect Outcomes in Spinal Deformity Surgery. A Retrospective Case-Control Study

Study DesignRetrospective comparative analysis of prospective cohort.ObjectiveTo examine clinical outcomes of patients with preexisting SCS after adult spinal deformity surgery.MethodsA total of 94 patients with and without a previous history of spinal cord stimulator placement undergoing surgery for ASD with minimum 2-year follow-up. Thirty-three patients with SCS undergoing ASD surgery with minimum 2-year follow-up were compared with a matched cohort of 61 ASD patients without SCS.ResultsDespite similar baseline ODI (56 vs 50, P = .11) and back VAS (6.8 vs 6.6, P = .52), SCS patients did worse at all post-op time intervals. At 6 months, the SCS cohort had higher ODI (48 vs 31, P < .001) and VAS (4.8 vs 3.5, P = .01). This difference persisted at 1 year for ODI (46 vs 30, P < .001) but not for VAS (4.7 vs 4.0, P = .19). At 2 years, ODI remained significantly worse in the SCS cohort (49 vs 38, P = .004). Both cohorts had significant improvement at 2 years compared to baseline (SCS: -1.6 VAS, P < .001, -7 ODI, P = .03; Control: -2.5 VAS, P < .001, -13 ODI, P < .001). Radiographic parameters such as curve magnitude, curve correction, and balance were similar between the 2 groups.ConclusionDespite having substantial improvement after ASD surgery, patients with previous SCS placement did significantly worse in both back VAS and ODI postop compared with controls. They also did not experience a decrease in narcotic use at 2 years despite having similar overall radiographic results and complication rates.

Clinical Outcome after Endoscopic Facet Denervation in Patients with Chronic Low Back Pain

In mehreren Studien wurde berichtet, dass Kreuzschmerzen in der Bevölkerung mit bis zu 85% eine hohe Prävalenz aufweisen. Die perkutane Radiofrequenz-Facettengelenkdenervation (PRFD) ist heute der Goldstandard bei der Rhizotomie von chronischen Kreuzschmerzen (CLBP). Bisher veröffentlichte Studien zeigen jedoch kontroverse Ergebnisse über die Wirksamkeit der PRFD. Ziel dieser Studie war es daher, den Einsatz der endoskopischen Facettengelenkdenervation (EJE) zur Behandlung chronischer Kreuzschmerzen zu analysieren und potenzielle Risikofaktoren zu ermitteln, die die Indikationen für den Eingriff einschränken könnten.Wir haben retrospektiv 31 Patienten in die Studie eingeschlossen, die seit mindestens 24 Monaten an chronische Kreuzschmerzen leiden. Alle Patienten wurden einer endoskopischen Facettengelenkdenervation unterzogen und mussten postoperativ ODI-, COMI-, EQ-5D- und VRS-Scores ausfüllen, wobei die Nachbeobachtungszeit mindestens 12 Monate betrug. Zur Analyse der Korrelationen wurden grundlegende Patientendaten erfasst.Bei allen gemessenen klinischen Werten, wie ODI, COMI, EQ-5D und VRS, wurde eine signifikante Verbesserung festgestellt. Während das beste Ergebnis bei der 3-monatigen Nachuntersuchung erzielt wurde, wurde bei der 12-monatigen Nachuntersuchung eine leichte Verschlechterung festgestellt. Im Vergleich zu den präoperativen Scores wurde jedoch ein signifikanter Nutzen festgestellt. 28/31 Patienten (93,3%) berichteten bei der Nachuntersuchung nach 12 Monaten über geringere Schmerzen und waren mit dem Verfahren zufrieden. Älteres Alter und psychiatrische Vorerkrankungen wurden als potenzielle Risikofaktoren identifiziert, die mit einem schlechteren Ergebnis einhergehen. Postoperative Komplikationen wie Hämatome, eine Sensibilitätsstörung und eine vorübergehende Muskelschwäche der unteren Extremitäten wurden selten beobachtet.Die endoskopische Facettengelenkdenervation zeigte eine signifikante Verbesserung der klinischen Ergebnisse und der VRS im Vergleich zu den präoperativen Werten von Patienten mit einer mindestens 12 Monate bestehenden chronischen Kreuzschmerzen vor der Operation. Ältere Patienten und Patienten mit psychiatrischen Vorerkrankungen profitieren weniger von dem Eingriff.

Machine-learning models for the prediction of ideal surgical outcomes in patients with adult spinal deformity

Aims

Adult spinal deformity (ASD) surgery can reduce pain and disability. However, the actual surgical efficacy of ASD in doing so is far from desirable, with frequent complications and limited improvement in quality of life. The accurate prediction of surgical outcome is crucial to the process of clinical decision-making. Consequently, the aim of this study was to develop and validate a model for predicting an ideal surgical outcome (ISO) two years after ASD surgery.

Methods

We conducted a retrospective analysis of 458 consecutive patients who had undergone spinal fusion surgery for ASD between January 2016 and June 2022. The outcome of interest was achievement of the ISO, defined as an improvement in patient-reported outcomes exceeding the minimal clinically important difference, with no postoperative complications. Three machine-learning (ML) algorithms - LASSO, RFE, and Boruta - were used to identify key variables from the collected data. The dataset was randomly split into training (60%) and test (40%) sets. Five different ML models were trained, including logistic regression, random forest, XGBoost, LightGBM, and multilayer perceptron. The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC).

Results

The analysis included 208 patients (mean age 64.62 years (SD 8.21); 48 male (23.1%), 160 female (76.9%)). Overall, 42.8% of patients (89/208) achieved the ideal surgical outcome. Eight features were identified as key variables affecting prognosis: depression, osteoporosis, frailty, failure of pelvic compensation, relative functional cross-sectional area of the paraspinal muscles, postoperative sacral slope, pelvic tilt match, and sagittal age-adjusted score match. The best prediction model was LightGBM, achieving the following performance metrics: AUROC 0.888 (95% CI 0.810 to 0.966); accuracy 0.843; sensitivity 0.829; specificity 0.854; positive predictive value 0.806; and negative predictive value 0.872.

Conclusion

In this prognostic study, we developed a machine-learning model that accurately predicted outcome after surgery for ASD. The model is built on routinely modifiable indicators, thereby facilitating its integration into clinical practice to promote optimized decision-making.

Use of Supplemental Rod Constructs in Adult Spinal Deformity Surgery: A Review

Adult spinal deformity comprises a heterogeneous group of disorders that primarily affects older patients and can have a significant negative affect on health-related quality of life. Operative treatment for adult spinal deformity typically entails posterior instrumented fusions that have demonstrated the potential to significantly improve health-related quality of life outcomes. However, until fusion is achieved, the instrumentation providing structural support is subject to repetitive cyclical loading that disproportionately fatigues high-stress areas and can result in instrumentation failure. Despite considerable advances in surgical fixation techniques and technology, pseudarthrosis with subsequent implant failure still poses a challenge for surgeons and continues to be 1 of the most common complications, leading to revision surgery. The addition of supplemental rods to primary constructs has gained widespread popularity to mitigate implant failure. Theoretically, more rods will add stiffness, stability, and decreased surface strain, which will provide longer instrumentation lifespan to allow for osseous fusion. There is significant heterogeneity in these constructs, and different types of supplemental rods (eg, satellite, accessory, delta rods, "kickstand rod," and "iliac accessory rod") can be used independently or in combination to further increase strength. However, the use of supplemental rods may increase the rate of proximal junctional kyphosis/failure and paradoxically diminish anterior column fusion rates. Hence, indications and optimal configurations are still a matter of debate. The aim of this narrative review is to provide an overview of the supplemental rod constructs described in the literature and focus on the current evidence supporting their indications and potential impact.

Psychological distress does not predict decisional regret in patients undergoing spinal reconstruction for adult spinal deformity

PURPOSE

The study aimed to assess the link between preoperative psychological distress and postoperative decisional regret in adult spinal deformity (ASD) surgery patients. We hypothesized that greater pre-surgery distress would correlate with higher post-surgery regret. This evaluation was based on a retrospective case series from an institution with standardized surgical guidelines for ASD.

METHODS

This IRB-approved retrospective study analyzed our institution's ASD database from 2014 to 2020. Eligible patients had a minimum two-year post-op follow-up and preoperative psychological distress assessment. Patients were grouped based on psychological distress levels: green, yellow, and yellow minus. Regret post-surgery was assessed using the Decision Regret Scale and SRS-22 Question 22. Logistic regression evaluated the impact of distress levels on regret, controlling for age and sex.

RESULTS

Out of 167 eligible patients, 112 responded and were analyzed. No significant demographic differences were observed between responders and non-responders. Using the Decision Regret Scale, 41% expressed no regret, while 63% expressed no regret with the SRS-22 questionnaire's Single-Item scale. Only the yellow minus group showed significant regret difference based on osteotomy, with non-recipients more likely to express regret.

CONCLUSION

This study found no significant link between psychological distress and post-operative regret in adult spinal deformity surgery after a minimum 2-year follow-up. Although nearly 60% exhibited some post-surgery regret, predicting regret based on psychological burden or demographics remains challenging. Further research is essential to identify factors contributing to post-operative regret in spinal deformity surgery patients.

Which vacuum phenomenon is more predictive for future junctional disorders?: Intradiscal or Intrafacet?

Recent spine studies focused on identifying whether intradiscal vacuum phenomenon (VP) was associated with spinal instability. However, none of them reported a direct association between VP and spinal instability following fusion for degenerative lumbar spine disorders (DSDs), namely junctional disorders. In the present study, we aimed to evaluate whether the VP was predictive for junctional disorders in patients who underwent short-segment lumbar decompression and fusion for DSDs at a tertiary spine center. We retrospectively reviewed prospectively collected database of patients who underwent short-segment decompression and fusion for DSDs. Pre-operative sagittal and axial computed tomography (CT) scans were evaluated in terms of intradiscal and intrafacet VP at all lumbar levels, respectively. Each VP was scored as 1 point. Then, the total VP score was calculated as the sum of intradiscal VP score and intrafacet VP score. Then, we analyzed the possible predictivity of VP for junctional disorders at final follow-ups of the patients operated for short-segment lumbar decompression and fusion. Patients with junctional disorders had significantly higher total and intrafacet VP scores compared to those without junctional disorders. Total VP score had an OR of 1.217 (p = 0.014) and intrafacet VP score had an OR of 1.465 (p = 0.008). The ROC analysis depicted that the cut-offs value for total and intrafacet VP scores to predict junctional disorders following short-segment lumbar decompression and fusion were 1.5 points and 0.5 point, respectively. Vacuum phenomenon could be associated with junctional disorders in patients who underwent short-segment lumbar decompression and fusion for DSD. Intrafacet VP was more important than intradiscal VP in predicting junctional disorders. Proper surgical planning including the evaluation of both intrafacet and intradiscal VP at all lumbar levels is crucial to decrease the likelihood of junctional disorders.

An evidence based conceptual framework for the multifactorial understanding of proximal junctional kyphosis

Introduction

Adult spinal deformity (ASD) is a debilitating pathology that arises from a variety of etiologies. Spinal fusion surgery is the mainstay of treatment for those who do not achieve symptom relief with conservative interventions. Fusion surgery can be complicated by a secondary deformity termed proximal junctional kyphosis (PJK).

Research question

This scoping review evaluates the modern body of literature analyzing risk factors for PJK development and organizes these factors according to a multifactorial framework based on mechanical, tissue or demographic components.

Materials and methods

An extensive search of the literature was performed in PubMed and Embase back to the year 2010. Articles were assessed for quality. All risk factors that were evaluated and those that significantly predicted the development of PJK were compiled. The frequency that a risk factor was predictive compared to the number of times it was evaluated was calculated.

Results

150 articles were reviewed. 57.3% of papers were of low quality. 76% of risk factors analyzed were focusing on the mechanical contribution to development of PJK versus only 5% were focusing on the tissue-based contribution. Risk factors that were most frequently predictive compared to how often they were analyzed were Hounsfield Units of vertebrae, UIV disc degeneration, paraspinal muscle cross sectional area and fatty infiltration, ligament augmentation, instrument characteristics, postoperative hip and lower extremity radiographic metrics, and postoperative teriparatide supplementation.

Discussion and conclusion

This review finds a multifactorial framework accounting for mechanical, patient and tissue-based risk factors will improve the understanding of PJK development.

Impact of Self-Reported Loss of Balance and Gait Disturbance on Outcomes following Adult Spinal Deformity Surgery

Background: The objective of this study was to evaluate if imbalance influences complication rates, radiological outcomes, and patient-reported outcomes (PROMs) following adult spinal deformity (ASD) surgery. Methods: ASD patients with baseline and 2-year radiographic and PROMs were included. Patients were grouped according to whether they answered yes or no to a recent history of pre-operative loss of balance. The groups were propensity-matched by age, pelvic incidence-lumbar lordosis (PI-LL), and surgical invasiveness score. Results: In total, 212 patients were examined (106 in each group). Patients with gait imbalance had worse baseline PROM measures, including Oswestry disability index (45.2 vs. 36.6), SF-36 mental component score (44 vs. 51.8), and SF-36 physical component score (p < 0.001 for all). After 2 years, patients with gait imbalance had less pelvic tilt correction (-1.2 vs. -3.6°, p = 0.039) for a comparable PI-LL correction (-11.9 vs. -15.1°, p = 0.144). Gait imbalance patients had higher rates of radiographic proximal junctional kyphosis (PJK) (26.4% vs. 14.2%) and implant-related complications (47.2% vs. 34.0%). After controlling for age, baseline sagittal parameters, PI-LL correction, and comorbidities, patients with imbalance had 2.2-times-increased odds of PJK after 2 years. Conclusions: Patients with a self-reported loss of balance/unsteady gait have significantly worse PROMs and higher risk of PJK.

Use of Dynamic Spinal Instruments (Dynesys) in Adult Spinal Deformities According to Silva-Lenke and Berjano-Lamartina Classifications

BACKGROUND

Adult spinal deformities (ASD) present complex challenges in spine surgery. The diverse nature of these deformities requires a comprehensive understanding of their classification and treatment options. Traditional approaches, such as fusion and rigid stabilization are associated with complications, including screw loosening, breakage, proximal junctional kyphosis (PJK), and pseudoarthrosis. Dynamic stabilization techniques have emerged as promising alternatives, to reduce these complications and preserve spinal motion.

OBJECTIVE

This study investigated the effectiveness of dynamic stabilization using the Dynesys system in the surgical treatment of adult degenerative spinal deformities, with a particular emphasis on their classification.

METHODS

ASDs were classified according to the Berjano-Lamartina (BL) and Silva-Lenke (SL) classifications. We analyzed the efficacy of the Dynesys system in enhancing sagittal balance, radiological parameters, and clinical outcomes in this context.

RESULTS

Dynamic stabilization of patients with ASDs using the Dynesys system significantly improved the visual analog scale and Oswestry Disability Index scores and decreased the complication rates. Patients with BL types 2, 3, and 4 experienced a significant improvement in sagittal balance followed by sagittal vertical axis measurements (p = 0.045, p = 0.015, and p < 0.0001, respectively).

CONCLUSION

The SL and BL classifications, which were originally developed for rigid spinal stabilization, can be applied in dynamic stabilization. Furthermore, dynamic stabilization using the Dynesys system can be used as an alternative to rigid stabilization in SL levels 2 and 3, and BL types 1, 2, and 3, and in some patients with type 4 ASDs.

Height Gain Following Correction of Adult Spinal Deformity

BACKGROUND

Height gain following a surgical procedure for patients with adult spinal deformity (ASD) is incompletely understood, and it is unknown if height gain correlates with patient-reported outcome measures (PROMs).

METHODS

This was a retrospective cohort study of patients undergoing ASD surgery. Patients with baseline, 6-week, and subanalysis of 1-year postoperative full-body radiographic and PROM data were examined. Correlation analysis examined relationships between vertical height differences and PROMs. Regression analysis was utilized to preoperatively estimate T1-S1 and S1-ankle height changes.

RESULTS

This study included 198 patients (mean age, 57 years; 69% female); 147 patients (74%) gained height. Patients with height loss, compared with those who gained height, experienced greater increases in thoracolumbar kyphosis (2.81° compared with -7.37°; p < 0.001) and thoracic kyphosis (12.96° compared with 4.42°; p = 0.003). For patients with height gain, sagittal and coronal alignment improved from baseline to postoperatively: 25° to 21° for pelvic tilt (PT), 14° to 3° for pelvic incidence - lumbar lordosis (PI-LL), and 60 mm to 17 mm for sagittal vertical axis (SVA) (all p < 0.001). The full-body mean height gain was 7.6 cm, distributed as follows: sella turcica-C2, 2.9 mm; C2-T1, 2.8 mm; T1-S1 (trunk gain), 3.8 cm; and S1-ankle (lower-extremity gain), 3.3 cm (p < 0.001). T1-S1 height gain correlated with the thoracic Cobb angle correction and the maximum Cobb angle correction (p = 0.002). S1-ankle height gain correlated with the corrections in PT, PI-LL, and SVA (p < 0.001). T1-ankle height gain correlated with the corrections in PT (p < 0.001) and SVA (p = 0.03). Trunk height gain correlated with improved Scoliosis Research Society (SRS-22r) Appearance scores (r = 0.20; p = 0.02). Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores correlated with S1-ankle height gain (r = -0.19; p = 0.03) and C2-T1 height gain (r = -0.18; p = 0.04). A 1° correction in a thoracic scoliosis Cobb angle corresponded to a 0.2-mm height gain, and a 1° correction in a thoracolumbar scoliosis Cobb angle resulted in a 0.25-mm height gain. A 1° improvement in PI-LL resulted in a 0.2-mm height gain.

CONCLUSIONS

Most patients undergoing ASD surgery experienced height gain following deformity correction, with a mean full-body height gain of 7.6 cm. Height gain can be estimated preoperatively with predictive ratios, and height gain was correlated with improvements in reported SRS-22r appearance and PROMIS scores.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty

BACKGROUND CONTEXT

Surgery to correct adult spinal deformity (ASD) is performed by both neurological surgeons and orthopedic surgeons. Despite well-documented high costs and complication rates following ASD surgery, there is a dearth of research investigating trends in treatment according to surgeon subspeciality.

PURPOSE

The purpose of this investigation was to perform an analysis of surgical trends, costs and complications of ASD operations by physician specialty using a large, nationwide sample.

STUDY DESIGN/SETTING

Retrospective cohort study using an administrative claims database.

PATIENT SAMPLE

A total of 12,929 patients were identified with ASD that underwent deformity surgery performed by neurological or orthopedic surgeons.

OUTCOME MEASURES

The primary outcome was surgical case volume by surgeon specialty. Secondary outcomes included costs, medical complications, surgical complications, and reoperation rates (30-day, 1-year, 5-year, and total).

METHODS

The PearlDiver Mariner database was queried to identify patients who underwent ASD correction from 2010 to 2019. The cohort was stratified to identify patients who were treated by either orthopedic or neurological surgeons. Surgical volume, baseline characteristics, and surgical techniques were examined between cohorts. Multivariable logistic regression was employed to assess the cost, rate of reoperation and complication according to each subspecialty while controlling for number of levels fused, rate of pelvic fixation, age, gender, region and Charlson Comorbidity Index (CCI). Alpha was set to 0.05 and a Bonferroni correction for multiple comparisons was utilized to set the significance threshold at p ≤.000521.

RESULTS

A total of 12,929 ASD patients underwent deformity surgery performed by neurological or orthopedic surgeons. Orthopedic surgeons performed most deformity procedures accounting for 64.57% (8,866/12,929) of all ASD operations, while the proportion treated by neurological surgeons increased 44.2% over the decade (2010: 24.39% vs 2019: 35.16%; p<.0005). Neurological surgeons more frequently operated on older patients (60.52 vs 55.18 years, p<.0005) with more medical comorbidities (CCI scores: 2.01 vs 1.47, p<.0005). Neurological surgeons also performed higher rates of arthrodesis between one and six levels (OR: 1.86, p<.0005), three column osteotomies (OR: 1.35, p<.0005) and navigated or robotic procedures (OR: 3.30, p<.0005). Procedures performed by orthopedic surgeons had significantly lower average costs as compared to neurological surgeons (orthopedic surgeons: $17,971.66 vs neurological surgeons: $22,322.64, p=.253). Adjusted logistic regression controlling for number of levels fused, pelvic fixation, age, sex, region, and comorbidities revealed that patients within neurosurgical care had similar odds of complications to orthopaedic surgery.

CONCLUSIONS

This investigation of over 12,000 ASD patients demonstrates orthopedic surgeons continue to perform the majority of ASD correction surgery, although neurological surgeons are performing an increasingly larger percentage over time with a 44% increase in the proportion of surgeries performed in the decade. In this cohort, neurological surgeons more frequently operated on older and more comorbid patients, utilizing shorter-segment fixation with greater use of navigation and robotic assistance.

Comparison of staged lateral lumbar interbody fusion combined two-stage posterior screw fixation and two osteotomy strategies for adult degeneration scoliosis: a retrospective comparative study

AIMS

The commonly used treatments of adult degeneration scoliosis (ADS) were posterior long segment screw fixation with osteotomies. Recently, lateral lumbar intervertebral fusion combined two-stage posterior screw fixation (LLIF + PSF) as a new strategy without osteotomy. Herein, this study aimed to compare the clinical and radiological outcomes among LLIF + PSF and pedicle subtraction osteotomy (PSO), posterior column osteotomies (PCO).

METHODS

Totals of 139 ADS patients underwent operation with 2 years longer follow-up visit between January 2013 and January 2018 in Ningbo No.6 Hospital were enrolled into this study. 58 patients were included in PSO group, 45 in PCO group and 36 in LLIF + PSF group, The clinical and radiological data were reviewed from medical records. Baseline characteristic, perioperative radiological data (sagittal vertical axis (SVA), coronal balance (CB), Cobb angle of Mian curve (MC), Lumbar lordosis (LL), pelvic tilt (PT) and pelvic incidence-lumbar lordosis mismatch (PI-LL)), clinical outcomes (VAS of back and leg, Oswestry disability index (ODI) and Scoliosis Research Society 22-question Questionnaire (SRS-22)) and complications were evaluated and compared.

RESULT

There were no significantly difference in baseline characteristics, preoperative radiological parameters and clinical outcomes among three groups. LLIF + PSF group was significantly shorter in operation time than other two groups (P < 0.05), whereas significant longer hospital stay was observed in LLIF + PSF group (P < 0.05). As for radiological parameters, LLIF + PSF group had significantly improvement in SVA, CB, MC, LL and PI-LL (P < 0.05). Moreover, LLIF + PSF group achieved significantly less correction loss in SVA, CB and PT than PSO and PCO group (1.5 ± 0.7 VS 2.0 ± 0.9 VS 2.2 ± 0.8, P < 0.05; 1.0 ± 0.4 VS 1.3 ± 0.5 VS 1.1 ± 0.7, P < 0.05 and 4.2 ± 2.8 VS 7.2 ± 3.1 VS 6.0 ± 2.8, P < 0.05). Significantly recovery in VAS of back and leg, ODI score and SRS-22 were found among all groups, however, LLIF + PSF shown significant better clinical therapy maintain at follow-up visit than other two groups (P < 0.05). There were no significantly difference in complications among groups (P = 0.66).

CONCLUSION

Lateral lumbar interbody fusion combined two-stage posterior screw fixation (LLIF + PSF) can achieve comparable clinical therapy for adult degeneration scoliosis as osteotomy strategies. However, furthermore more studies need be taken for verifying the effect of LLIF + PSF in the future.

Comparison of C-Arm-Free Oblique Lumbar Interbody Fusion L5-S1 (OLIF51) with Transforaminal Lumbar Interbody Fusion L5-S1 (TLIF51) for Adult Spinal Deformity

Background and Objectives: Adult spinal deformity (ASD) surgery, L5-S1 lordosis is very important factor. The main objective of the research is to retrospectively compare symptomatic presentation and radiological presentation in the sequelae of oblique lumbar inter-body spinal fusion at L5-S1 (OLIF51) and transforaminal lumbar interbody fusion (TLIF) for ASD. Materials and Methods: We retrospectively evaluated 54 patients who underwent corrective spinal fusion for ASD between October 2019 and January 2021. Thirteen patients underwent OLIF51 (average 74.6 years old, group O) and 41 patients underwent TLIF51 (average 70.5 years old, group T). Mean follow-up period was 23.9 months for group O and 28.9 months for group T, ranging from 12 to 43 months. Clinical and radiographic outcomes are assessed using values including visual analogue scale (VAS) for back pain and Oswestry disability index (ODI). Radiographic evaluation was also collected preoperatively and at 6, 12, and 24 months postoperatively. Results: Surgical time in group O was less than that in group T (356 min vs. 492 min, p = 0.003). However, intraoperative blood loss of both groups were not significantly different (1016 mL vs. 1252 mL, p = 0.274). Changes in VAS and ODI were similar in both groups. L5-S1 angle gain and L5-S1 height gain in group O were significantly better than those of group T (9.4° vs. 1.6°, p = 0.0001, 4.2 mm vs. 0.8 mm, p = 0.0002). Conclusions: Clinical outcomes were not significantly different in both groups, but surgical time in OLIF51 was significantly less than that in TLIF51. The radiographic outcomes showed that OLIF51 created more L5-S1 lordosis and L5-S1 disc height compared with TLIF 51.

Association of First Metatarsal Phalangeal Joint Fusion for Hallux Rigidus With Patient-Reported Pain and Mental Health Outcomes in Patients Taking Psychotropic Medications

Background:

Limited literature examines the relationship between surgical outcomes in chronic foot and ankle conditions and concurrent psychiatric care. The present study aimed to investigate patient-reported and surgical outcomes of patients treated for a psychiatric disorder undergoing first metatarsophalangeal (MTP) fusion for hallux rigidus. We hypothesized that patients on psychotropic medications would have greater subjective pain preoperatively and less improvement in physical and mental functionality postoperatively when compared with nonmedicated patients.

Methods:

A single-center, retrospective review of prospectively collected data was conducted on 92 patients undergoing first MTP fusion with a preoperative diagnosis of hallux rigidus from 2015 to 2019. At their preoperative, 6-month postoperative, and 1-year postoperative visits, patients were administered visual analog pain scale (VAS) and 36-Item Short Form Health Survey (SF-36) functionality surveys. Patients were subsequently identified by chronic use of psychotropic medication preoperatively and grouped for analysis (MED, n = 42; NO MED, n = 50).

Results:

Postoperative mean VAS pain scores were lower for all studied patients at 6 months (VAS = 1.6 ± 2.3) and 1 year postoperatively (VAS = 1.1± 1.8) relative to the preoperative visit (VAS = 4.7 ± 2.8) (P ≤ .0001 and P ≤ .0001, respectively). No differences in mean VAS pain scores nor SF-36 physical component summary scores were detected at preoperative, 6-month, or 1-year visits between NO MED and MED groups. Mean SF-36 mental component summary scores for those in the MED group were lower at preoperative (NO MED = 83.8, MED = 71.8, P = .006) and 6-month postoperative (NO MED = 86.1, MED = 72.7, P = .037) visits than those in the NO MED group, a trend not observed at the 1-year postoperative mark (NO MED = 84.1, MED = 76.8, P = .228). There were no observed differences in operative time (P = .219), tourniquet time (P = .359), nor time to full weightbearing (P = .512) between MED and NO MED groups. Additionally, no differences in postoperative complication rates were observed between groups.

Conclusion:

In patients treated with psychotropically active medications with hallux rigidus, MTP Fusion appears to be a reasonable treatment choice with similar outcomes for patients requiring psychotropically active medications to the outcomes of those patients not requiring psychotropically active medications.

Level of Evidence:

Level III, retrospective comparative study.

Assessing the influence of modifiable patient-related factors on complication rates after adult spinal deformity surgery

Aims

Postoperative complication rates remain relatively high after adult spinal deformity (ASD) surgery. The extent to which modifiable patient-related factors influence complication rates in patients with ASD has not been effectively evaluated. The aim of this retrospective cohort study was to evaluate the association between modifiable patient-related factors and complications after corrective surgery for ASD.

Methods

ASD patients with two-year data were included. Complications were categorized as follows: any complication, major, medical, surgical, major mechanical, major radiological, and reoperation. Modifiable risk factors included smoking, obesity, osteoporosis, alcohol use, depression, psychiatric diagnosis, and hypertension. Patients were stratified by the degree of baseline deformity (low degree of deformity (LowDef)/high degree of deformity (HighDef): below or above 20°) and age (Older/Younger: above or below 65 years). Complication rates were compared for modifiable risk factors in each age/deformity group, using multivariable logistic regression analysis to adjust for confounders.

Results

A total of 480 ASD patients met the inclusion criteria. By two years, complication rates were 72% ≥ one complication, 28% major, 21% medical, 27% surgical, 11% major radiological, 8% major mechanical, and 22% required reoperation. Younger LowDef patients with osteoporosis were more likely to suffer either a major mechanical (odds ratio (OR) 5.9 (95% confidence interval (CI) 1.1 to 36.9); p = 0.048) or radiological complication (OR 7.0 (95% CI 1.9 to 25.9); p = 0.003). Younger HighDef patients were much more likely to develop complications if obese, especially major mechanical complications (OR 2.8 (95% CI 1.1 to 8.6); p = 0.044). Older HighDef patients developed more complications when diagnosed with depression, including major radiological complications (OR 3.5 (95% CI 1.1 to 10.6); p = 0.033). Overall, a diagnosis of depression proved to be a risk factor for the development of major radiological complications (OR 2.4 (95% CI 1.3 to 4.5); p = 0.005).

Conclusion

Certain modifiable patient-related factors, especially osteoporosis, obesity, and mental health status, are associated with an increased risk of complications after surgery for spinal deformity. Surgeons should look for these conditions when assessing a patient for surgery, and optimize them to the fullest extent possible before proceeding to surgical correction so as to minimize the prospect of postoperative morbidity. Cite this article: Bone Joint J 2022;104-B(11):1249–1255.

Determining the relationship between preoperative mental health scores and postoperative outcomes in adult spinal deformity surgeries

OBJECTIVE

The objective of this study was to examine the relationship between the mental health domain of the refined 22-item Scoliosis Research Society Outcome Questionnaire (SRS) and various postoperative outcome measures in the adult spinal deformity (ASD) population. Given the scale and involved nature of deformity surgery, some surgeons have proposed that preoperative mental health scores (MHSs) may assist in screening out poor surgical candidates. In this study, the authors aimed to further assess the SRS MHS as a preoperative metric and its association with postoperative outcomes and to comment on its potential use in patient selection and optimization for ASD surgery.

METHODS

The authors conducted a retrospective study of 100 consecutive patients who had undergone primary or revision ASD surgery at a single academic institution between 2015 and 2019. Each patient had a minimum 2-year follow-up. Patients were categorized on the basis of their baseline mental health per the SRS mental health domain, with a score < 4 indicating low baseline mental health (LMH) and a score ≥ 4 indicating high baseline mental health (HMH). Baseline and follow-up SRS and Oswestry Disability Index scores, surgical procedures, lengths of stay, discharge locations, intraoperative or postoperative complications, and other outcome metrics were then compared between the HMH and LMH groups, as well as these groups stratified by an age ≤ 45 and > 45 years.

RESULTS

Among patients aged ≤ 45 and those aged > 45, the LMH group had significantly worse baseline health-related quality-of-life (HRQOL) metrics in nearly all domains. The LMH group also had an increased median estimated blood loss (EBL; 1200 vs 800 ml, p = 0.0026) and longer average surgical duration (8.3 ± 2.8 vs 6.9 ± 2.6 hours, p = 0.014). Both LMH and HMH groups had significant improvements in nearly all HRQOL measures postoperatively. Despite their worse preoperative HRQOL baseline, patients in the LMH group actually improved the most and reached the same HRQOL endpoints as those in the HMH group.

CONCLUSIONS

While patients with lower baseline MHSs may require slightly longer hospital courses or more frequent discharges to rehabilitation facilities, these patients actually attain greater absolute improvements from their preoperative baseline and surprisingly have the same postoperative HRQOL metrics as the patients with high MHSs, despite their poorer starting point. This finding suggests that patients with LMH may be uniquely positioned to substantially benefit from surgical intervention and improve their HRQOL scores and thus should be considered for ASD surgery to an extent similar to patients with HMH.

Effect of COVID-19 on quality of life of persons aged >70 years with adult spinal deformity: A cross-sectional case-control study

This observational, cross-sectional case-control study evaluates the impact of coronavirus disease 2019 (COVID-19) on health-related quality of life (HRQoL) in elderly persons who have undergone surgery for adult spinal deformity (ASD). On December 31, 2019, the Chinese authorities first reported severe acute respiratory syndrome coronavirus 2, and on March 11, 2020, it was declared a pandemic. The pandemic seems to have had a negative effect on elderly patients who underwent ASD, in terms of functional and psychological quality of life. We selected patients with ASD aged > 70 years who had undergone surgery between 2010 and 2015 and compared them with age- and sex-matched patients who did not have ASD. We recorded sociodemographic variables, type of surgery, levels of spinal fusion, HRQoL (Scoliosis Research Society-22, Short Form 12 Health Survey, EuroQol-5D [EQ-5], Geriatric Depression Scale [Yesavage] [GDS], Modified Frailty Index-11, and Barthel index), fear of visiting a health center, fear of leaving one's house, and adherence to preventive measures. The study population comprised 174 patients (mean [standard deviation] age, 77.3 [5.9] years; 86% women), of whom 87 had undergone surgery for ASD. The incidence of COVID-19 was higher in patients aged > 85 years (P = .041), urban areas (P = .047), and in patients in long-term care (P = .03). Similarly, no differences were observed for the ability to cope with the pandemic (P > .05). Patients who underwent surgery also had a higher risk of depression (GDS, 6.7 [P = .02]), a lower EQ-5 score (P = .001), a higher body mass index (P = .004), greater consumption of drugs (P < .001), especially opiates (P < .001). Patients who underwent surgery constitute a vulnerable population during the COVID-19 pandemic, with poorer quality of life and had a much higher risk of depression. They are also polymedicated and prefrail, adhere well to COVID-19 preventive measures, and do not seem to fear visiting health centers.

A systematic review on the prevalence of preoperative and postoperative depression in lumbar fusion

BACKGROUND

Depression and Degenerative Spine Disease (DSD) frequently co-exist. Pooled prevalence estimates of depression before and after lumbar fusion surgery has not been analyzed before. The purpose of this systematic review was to estimate the pre- and post-operative prevalence of depression in patients with DSD undergoing lumbar fusion.

METHODS

A literature review until April 30th 2022 was performed. All studies on DSD patients undergoing lumbar spine fusion surgery with either a history of formal diagnosis of depression or a recording of depression using a validated tool were included. Patients with other psychiatric conditions or undergoing a different form of spinal surgery were excluded. Risk of bias of the included studies was evaluated using the Newcastle-Ottawa Scale.

RESULTS

Fifteen (15) studies with a total of 98.375 patients met the inclusion and exclusion criteria and were included in the analysis. The prevalence estimate of depression in patients before surgery was 15,35 % (95% CI: 10,56-20,86%). In the 7 studies including patients who had undergone lumbar fusion, the pooled prevalence was estimated 11,46% (95% CI: 8,11-15,30%).

CONCLUSION

An increased prevalence of depression in patients undergoing lumbar spine fusion was noted. Given the correlation between depression and poor surgical outcomes, strategies should be identified to prevent and treat depression in these patients.

Spinopelvic Adaptations in Standing and Sitting Positions in Patients With Adult Spinal Deformity

Purpose

To describe spinopelvic adaptations in the standing and sitting positions in patients with adult spinal deformity (ASD).

Methods

Ninety-five patients with ASD and 32 controls completed health-related quality of life (HRQOL) questionnaires: short form 36 (SF36), Oswestry Disability Index (ODI), and visual analog scale (VAS) for pain. They underwent biplanar radiography in both standing and sitting positions. Patients with ASD were divided into ASD-front (frontal deformity Cobb > 20°, n = 24), ASD-sag (sagittal vertical axis (SVA) > 50 mm, pelvic tilt (PT) > 25°, or pelvic incidence (PI)-lumbar lordosis (LL) > 10°, n = 40), and ASD-hyper thoracic kyphosis (TK >60°, n = 31) groups. Flexibility was defined as the difference (Δ) in radiographic parameters between the standing and sitting positions. The radiographic parameters were compared between the groups. Correlations between HRQOL scores were evaluated.

Results

All participants increased their SVA from standing to sitting (ΔSVA<0), except for patients with ASD-sag, who tended to decrease their SVA (78-62 mm) and maximize their pelvic retroversion (27-40° vs 10-34° in controls, p<0.001). They also showed reduced thoracic and lumbar flexibility (ΔLL = 3.4 vs 37.1°; ΔTK = −1.7 vs 9.4° in controls, p<0.001). ASD-hyperTK showed a decreased PT while sitting (28.9 vs 34.4° in controls, p<0.001); they tended to decrease their LL and TK but could not reach values for controls (ΔLL = 22.8 vs 37.1° and ΔTK = 5.2 vs 9.4°, p<0.001). The ASD-front had normal standing and sitting postures. ΔSVA and ΔLL were negatively correlated with the physical component scale (PCS of SF36) and ODI (r = −0.39 and r = −0.46, respectively).

Conclusion

Patients with ASD present with different spinopelvic postures and adaptations from standing to sitting positions, with those having sagittal malalignment most affected. In addition, changes in standing and sitting postures were related to HRQOL outcomes. Therefore, surgeons should consider patient sitting adaptations in surgical planning and spinal fusion. Future studies on ASD should evaluate whether physical therapy or spinal surgery can improve sitting posture and QOL, especially for those with high SVA or PT.

The Impact of Isolated Baseline Cannabis Use on Outcomes Following Thoracolumbar Spinal Fusion: A Propensity Score-Matched Analysis

BACKGROUND

There is limited literature evaluating the impact of isolated cannabis use on outcomes for patients following spinal surgery. This study sought to compare 90-day complication, 90-day readmission, as well as 2-year revision rates between baseline cannabis users and non-users following thoracolumbar spinal fusion (TLF) for adult spinal deformity (ASD).

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried between January 2009 and September 2013 to identify all patients who underwent TLF for ASD. Inclusion criteria were age ≥18 years and either minimum 90-day (for complications and readmissions) or 2-year (for revisions) follow-up surveillance. Cohorts were created and propensity score-matched based on presence or absence of isolated baseline cannabis use. Baseline demographics, hospital-related parameters, 90-day complications and readmissions, and two-year revisions were retrieved. Multivariate binary stepwise logistic regression identified independent outcome predictors.

RESULTS

704 patients were identified (n=352 each), with comparable age, sex, race, primary insurance, Charlson/Deyo scores, surgical approach, and levels fused between cohorts (all, p>0.05). Cannabis users (versus non-users) incurred lower 90-day overall and medical complication rates (2.4% vs. 4.8%, p=0.013; 2.0% vs. 4.1%, p=0.018). Cohorts had otherwise comparable complication, revision, and readmission rates (p>0.05). Baseline cannabis use was associated with a lower risk of 90-day medical complications (OR=0.47, p=0.005). Isolated baseline cannabis use was not associated with 90-day surgical complications and readmissions, or two-year revisions.

CONCLUSION

Isolated baseline cannabis use, in the absence of any other diagnosed substance abuse disorders, was not associated with increased odds of 90-day surgical complications or readmissions or two-year revisions, though its use was associated with reduced odds of 90-day medical complications when compared to non-users undergoing TLF for ASD. Further investigations are warranted to identify the physiologic mechanisms underlying these findings. Level of Evidence: III.

The 90-Day Reoperations and Readmissions in Complex Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVE

Identify surgical complex adult spine deformity patients who are at increased risk for an unplanned postoperative 90-day readmission and/or reoperation.

METHODS

A total of 227 consecutive records of complex adult (≥18 years old) spine deformity surgeries from 2015 to 2018 were reviewed. Demographics, comorbidities, operative details, and postoperative complication data was collected. Chi-square/Fisher's exact test and t tests were used for bivariate analysis. To determine independent predictors for readmissions/reoperations, stepwise multivariate logistic regressions were employed. The C-statistic and Hosmer-Lemeshow (HL) value was used to measure concordance and goodness of fit.

RESULTS

Average age was 50.5 ± 17.8 years and 67.8% were female. Ninety-day readmission and reoperation rates were 7.0% and 5.3%, respectively. Median number of days after index discharge date resulting in readmission and reoperation were 16.5 and 28, respectively. The multivariate regression for 90-day readmissions included pulmonary comorbidity, depression, history of deep vein thrombosis/pulmonary embolism (DVT/PE), and gastrointestinal comorbidity (C-statistic = 0.82; HL = 0.79). Pulmonary comorbidity, depression, and history of DVT/PE increased risk for 90-day readmission by 5-, 3.5-, and 10.2-fold, respectively. The multivariate regression for 90-day reoperations was similar to readmissions (C-statistic = 0.89; HL = 0.31). Operative time>7 hours and history of DVT/PE increased risk for early reoperation by 5.8- and 8.7-fold, respectively.

CONCLUSIONS

An emphasis on medically optimizing patients with preexisting pulmonary comorbidities, depression, and history of DVT/PE may have a substantial impact on improving short-term outcomes in this population. The present study provides benchmark data and may serve as an initial model to predict unplanned reoperations and readmissions.

Impact of Depression on Patient Reported Outcomes Following Primary Versus Revision ACDF

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To assess the relationship of depressive symptoms with patient reported outcome measures (PROMs) in patients undergoing either primary or revision anterior cervical discectomy and fusion (ACDF) procedures.

SUMMARY OF BACKGROUND

Depression has been associated with poorer outcomes following ACDF. However, research examining the relationship between depression and PROMs in revision ACDF procedures is limited.

METHODS

A prospective database was retrospectively reviewed for primary or revision, single- or multilevel ACDF procedures from 2016 to 2019. Patients lacking preoperative Patient Health Questionnaire-9 (PHQ-9) surveys were excluded. Demographic and perioperative characteristics were recorded and analyzed using Fisher's exact test or t test. Patient-reported outcome measures were collected preoperatively and postoperatively. Postoperative improvement from baseline scores (ΔPROM) was calculated at all postoperative timepoints. Differences in mean PROM and ΔPROM between groups and changes from baseline PROM scores within groups were assessed using Student's t test. Linear regression analyzed the impact of preoperative PHQ-9 on ΔPROM.

RESULTS

A total of 143 patients (121 primary and 22 revision) were included. Significant differences between groups were demonstrated at the preoperative timepoint for Neck Disability Index (NDI) (P = 0.022). ΔPROM values did not significantly differ between groups. Regression analysis revealed significant relationships between preoperative PHQ-9 and ΔPHQ-9 at all timepoints, ΔVAS neck at 6-weeks and 6-months, ΔVAS arm at 6-months, and ΔNDI at 6-weeks and 6-months for the primary group (all P < 0.05). Regression analysis revealed no significant associations for the revision group.

CONCLUSION

Primary or revision ACDF procedures did not significantly differ in depressive symptoms through 1-year. Primary ACDF patients significantly improved in all PROMs through all timepoints, while revision patients had limited improvement in PROMs. Preoperative depression may have a stronger association on postoperative outcomes for primary procedures.Level of Evidence: 3.

Severity of Preoperative HbA1c and Predicting Postoperative Complications in Spine Surgery

BACKGROUND

Diabetes mellitus (DM) is associated with a greater incidence of perioperative complications. The measurement of hemoglobin A1c (HbA1c) has not been routinely used in the preoperative assessment for spine surgeries.

METHODS

In the present single-institution, prospective study, HbA1c testing was included in the preoperative laboratory examination of patients undergoing spinal surgery from 2016 through 2018. The HbA1c levels were categorized using the American Diabetes Association guidelines as normal (HbA1c <5.7%), pre-DM (HbA1c 5.7%-6.4%), and diabetes (HbA1c >6.5%). Those with a HbA1c of ≥8% were separated as having poorly controlled DM for analysis. Perioperative complication and comorbidity data were collected to assess for associations with DM using logistic regression models. Odds ratios (ORs) and 95% confidence intervals were computed.

RESULTS

A total of 440 patients (238 men, mean age, 56.43 ± 13.28 years; mean body mass index, 30.80 ± 6.65 kg/m²) met the study criteria. The HbA1c was <5.7% in 206 patients (46.8%), 5.7%-6.4% in 148 (33.6%), 6.5%-7.9% in 64 (14.5%), and ≥8.0% in 23 patients (5.22%). Bivariate logistic modeling showed that patients with poorly controlled DM had a higher risk of complications (OR, 2.92) than did the patients with DM (OR, 2.13). Malignancy (OR, 2.62) and hypertension (OR, 1.86) were also significant risk factors for complications. However, smoking (OR, 0.83) was not significant. Poorly controlled DM remained associated with complications in multivariable logistic regression modeling (OR, 2.72).

CONCLUSIONS

Poorly control DM defined by the preoperative HbA1c was significantly associated with postoperative complications. Smoking, however, was not so associated. Preoperative HbA1c can be used to assess the risk of postoperative spine surgery complications.

Osteoporosis and Spine Surgery: A Critical Analysis Review

Despite being part of the aging process, early and adequate management of osteoporosis mitigates adverse outcomes associated with low bone mineral density. Although the health-care burden of osteoporosis is on the rise, screening and management of osteoporosis are not yet an integral part of preoperative patient evaluation in spine surgery. Patients with osteoporosis should undergo multidisciplinary evaluation and management, including lifestyle modifications and initiation of multiple therapeutic modalities. Integrating osteoporosis in preoperative optimization and surgical planning for patients undergoing spine surgery has the potential to mitigate osteoporosis-related postoperative complications.

Characterization of Patients with Poor Risk for Clinical Outcomes in Adult Symptomatic Lumbar Deformity Surgery

STUDY DESIGN

Retrospective review of 159 surgically treated consecutive adult symptomatic lumbar deformity (ASLD) (65 ± 9 years, female: 94%) from a multicenter database.

OBJECTIVE

The aim of this study was to provide a comprehensive analysis of the risk of a poor clinical outcome in ASLD surgery.

SUMMARY OF BACKGROUND DATA

Poor-risk patients with ASLD remain poorly characterized.

METHODS

ASLD was defined as age >40 years with a lumbar curve ≥30° or C7SVA ≥5 cm and Scoliosis Research Society 22 (SRS22) pain or function <4. Poor outcome was defined as 2y SRS22 total <4 or pain, function or satisfaction ≤3. The outcomes of interest included age, sex, body mass index, bone mineral density, Schwab-SRS type, frailty, history of arthroplasty, upper-instrumented vertebral, lower-instrumented vertebral, levels involved, pedicle subtraction osteotomy, lumbar interbody fusion, sagittal alignment, global alignment and proportion (GAP) score, baseline SRS22r score, estimated blood loss, time of surgery, and severe adverse event (SAE). Poisson regression analyses were performed to identify the independent risks for poor clinical outcome. A patient was considered at poor risk if the number of risks was >4.

RESULTS

All SRS22 domains were significantly improved after surgery. In total, 21% (n = 34) reported satisfaction ≤3 and 29% (n = 46) reported pain or function ≤3. Poisson regression analysis revealed that frailty (odds ratio [OR]: 0.2 [0.1-0.8], P = .03), baseline mental-health (OR: 0.6 [0.4-0.9], P = .01) and function (OR: 1.9 [1.0-3.6], P < .01), GAP score (OR: 4.6 [1.1-18.7], P = .03), and SAE (OR: 3.0 [1.7-5.2], P < .01) were identified as independent risk for poor clinical outcome. Only 17% (n = 6) of the poor-risk patients reached SRS22 total score >4.0 at 2 years.

CONCLUSION

The overall clinical outcome was favorable for ASLD surgery. Poor-risk patients continue to have inferior outcomes, and alternative treatment strategies are needed to help improve outcomes in this patient population. Recognition and optimization of modifiable risk factors, such as physical function and mental health, and reduced SAEs may improve overall clinical outcomes of ASLD surgery.Level of Evidence: 3.

Comparison of Reconstructive Plastic Surgery Rates and 30-Day Postoperative Complications Between Patients With and Without Psychiatric Diagnoses

BACKGROUND

Psychiatric comorbidity is associated with greater 30-day postoperative complication rates in various surgical specialties, but is not well characterized for reconstructive plastic surgery.

OBJECTIVES

The aim of this study was to compare reconstructive plastic surgery rates and 30-day postoperative complications between patients with and without psychiatric diagnoses.

METHODS

This was a retrospective cohort study comparing patients with and without psychiatric diagnoses. Data for January 1, 2007 to December 31, 2015 were collected from the IBM MarketScan Commercial and Medicare Supplemental Databases. Rates of reconstructive plastic surgery, demographic data, covariant diagnoses, and 30-day postoperative complications were collected. Differences between the 2 groups were assessed by multivariable logistic regression.

RESULTS

Among 1,019,128 patients (505,715 with psychiatric diagnoses and 513,423 without psychiatric diagnoses) assessed, reconstructive plastic surgery rates were between 4.8% and 7.0% in those with psychiatric diagnoses, compared with 1.6% in patients without psychiatric diagnoses. The greatest odds of undergoing reconstructive plastic surgery were in patients with body dysmorphic disorder (BDD) (adjusted odds ratio [aOR], 3.16; 95% confidence interval [CI], 1.76-5.67) and anxiety disorder (aOR, 3.08; 95% CI, 2.97-3.17). When assessing 1,234,206 patients (613,400 with psychiatric diagnoses and 620,806 without psychiatric diagnoses), all of whom underwent reconstructive plastic surgery, 2-fold greater odds of any 30-day postoperative complication was associated with psychiatric diagnoses (aOR, 2.01; 95% CI, 1.28-3.11), as well as greater odds of specific complications (surgical site infection, bleeding, and hospital admission). Eating disorder diagnosis was associated with the greatest odds of a complication (aOR, 4.17; 95% CI, 3.59-4.86), followed by nasal surgery (aOR, 3.65; 95% CI, 2.74-4.89), and BDD (aOR, 3.16; 95% CI, 1.76-5.67).

CONCLUSIONS

Diagnosis of a psychiatric condition is associated with greater rates of reconstructive plastic surgery, and 2-fold greater odds of 30-day postoperative complications.

LEVEL OF EVIDENCE: 4

Prevalence and Outcomes of Major Psychiatric Disorders Preceding Index Surgery for Degenerative Thoracic/Lumbar Spine Disease

The relationship between preexisting major psychiatric disorders and outcomes of spine surgery for degenerative thoracic/lumbar disease remains unclear. A 5% subset of inpatients was randomly selected from the Taiwan National Health Insurance Research Database. A total of 10,109 inpatients aged 18 years or over with degenerative thoracic/lumbar disease and underwent spine surgery met inclusion criteria. Major psychiatric disorders diagnosed by psychiatrists preceding index surgery, including anxiety disorder, depression disorder, bipolar disorder, schizophrenia and dementia, were identified. The prevalence of psychiatric disorders, and their differential risks on in-hospital and post-discharge outcomes were examined. 10.4% had major psychiatric disorders, of which depression (6.6%) and anxiety (4.9%) were most common. Logistic regression revealed increased risks of ventilator use in depression (OR = 1.62, 95% CI = 1.04-2.54, p < 0.05), extended hospitalization length in bipolar (OR = 1.77, 95% CI = 1.08-2.89, p < 0.05), and higher rehabilitation utilization in depression (OR = 1.25, 95% CI = 1.06-1.47, p < 0.01) and bipolar (OR = 1.69, 95% CI = 1.04-2.76, p < 0.05). Those patients with anxiety had a decreased risk of longer hospitalization duration (OR = 0.77, 95% CI = 0.60-0.98, p < 0.05), while those with dementia and schizophrenia had no change in risks. Preoperative recognition of major psychiatric disorders for risk and treatment assessment is suggested as people with preexisting depression or bipolar disorder have worse outcomes after spine surgery.

Sagittal imbalance and symptoms of depression in adults: Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study (LOHAS)

PURPOSE

With spinal deformities, mental health can deteriorate due to sagittal imbalance of the spine. The purpose of this study was to clarify the relationship between sagittal imbalance and symptoms of depression among local residents in the community.

METHODS

This study used data from the Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS) in 2010. The sagittal vertical axis (SVA) was identified as an indicator of sagittal imbalance. Symptoms of depression were assessed using the 5-item version of the Mental Health Inventory. Participants were classified into three categories based on the SVA balance as normal (< 40 mm), moderate imbalance (40-95 mm), and severe imbalance (> 95 mm). To evaluate the relationship between sagittal imbalance of the spine and symptoms of depression, the adjusted risk ratio (RR) and the 95% confidence interval (CI) were calculated using a generalized linear model with Poisson link.

RESULTS

There were 786 participants included in the statistical analysis. Overall, the mean age was 68.1 y (standard deviation, 8.8 y), and 39.4% were men. The prevalence of symptoms of depression by SVA category was 18.6% for normal, 23.8% for moderate, and 40.6% for severe. On multivariate analysis, the RR of SVA for symptoms of depression compared to the normal category was 1.12 (95% CI 0.7-1.70) for the moderate category and 2.29 (95% CI 1.01-5.17) for the severe category.

CONCLUSION

In local community residents, sagittal imbalance had a significant association with symptoms of depression.

Helping spine surgeons detect pre-surgical psychological distress in complex spine patients: an observational pilot study

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

Analysis of a standardized, pre-surgical psychological evaluation program for complex spine surgery. Adult spinal deformity (ASD) patients have a high rate of comorbid mental health conditions. Although there is a body of literature demonstrating the impact of psychological factors, including anxiety and depression, on spine surgery outcome, it is estimated that spine surgeons utilize a psychological assessment only about one third of the time prior to a patient's spine surgery. At this time, there is not a widely reported pre-surgical psychological evaluation program for ASD patients.

METHODS

129 consecutive complex spine surgery candidates receiving a pre-surgical psychological evaluation were analyzed between January 1st 2014 and December 31st 2018. Based on the available literature and professional experience in our facility, a color code for patients was developed from Green (low psychological or psychosocial co-morbidity) to Red (high psychological or psychosocial co-morbidity). Univariate analysis was used to evaluate between color grades and demographics, mental health disorders and outcomes.

RESULTS

83% of complex spine patients had at least one psychological disorder or psychosocial barrier. Only 17% had a combination of realistic expectations for surgery, a good support plan, and were without a history of mental illness. The pre-surgical psychological color criteria were validated in showing higher rates of major depression, anxiety disorder, and bipolar disorder in moderate to severe color grades (p < .001) in addition to higher PHQ-9 and GAD-7 scores (p < .001). Patients having a more severe color grade had lower rates of a discharge home and were taking higher morphine equivalent dosages (MEDs) at their six-month follow-up, though both did not reach statistical significance (p = .07 and p = .08; respectively).

CONCLUSION

A comprehensive pre-surgical psychological evaluation may be beneficial to risk stratify and counsel patients being evaluated for surgical reconstruction of adult spinal deformities.

LEVEL OF EVIDENCE

3.

Effect of Perioperative Mental Status on Health-related Quality of Life in Patients With Adult Spinal Deformities

STUDY DESIGN

A retrospective study.

OBJECTIVE

We aimed to evaluate the impact of mental status on the clinical outcomes of patients with adult spinal deformity (ASD).

SUMMARY OF BACKGROUND DATA

Limited information is currently available on how preoperative mental status affects postoperative health-related quality of life (HRQOL) in patients with ASD.

METHODS

We enrolled 165 patients with ASD who underwent corrective surgery at a single university hospital between March 2010 and September 2015. We compared Scoliosis Research Society-22r (SRS-22r) and Oswestry Disability Index (ODI) scores using various x-ray parameters at these time points: preoperative period and postoperative 2 years. Additionally, to determine the associations between perioperative complications and mental health disorders, we examined these x-ray parameters: lumbar lordosis, thoracic kyphosis, sacral slope, pelvic incidence, pelvic tilt, sagittal vertical axis (SVA), and T1 pelvic angle (TPA).

RESULTS

We found correlations between the preoperative SRS-22r total score and preoperative ODI (r = -0.692, P < 0.01) and postoperative ODI (r = -0.443, P < 0.01). Preoperative SRS-22r mental domain correlated with preoperative ODI (r = -0.561, P ≤ 0.01) and postoperative ODI (r = -0.315, P ≤ 0.01). Perioperative (preoperative and postoperative) SRS-22r mental domain did not correlate with the postoperative x-ray parameters except for SVA and TPA. Postoperative mental health correlated with early infection (P < 0.05), hematoma (P < 0.05), deep vein thrombosis (P < 0.05), and delirium (P < 0.05). Regression analysis revealed that preoperative SRS-22r mental health score correlated with preoperative ODI (P < 0.001) and postoperative ODI (P < 0.001). The regression coefficient number between preoperative SRS-22r mental health score and perioperative (preoperative and postoperative) ODI improved from -17.3 to -10.2 from preoperative to postoperative periods.

CONCLUSION

Diminished preoperative mental health worsened postoperative HRQOL. Perioperative complications influence postoperative mental status and HRQOL; hence, screening preoperative mental health is important.

LEVEL OF EVIDENCE

3.

Quality of life and objective functional impairment in lumbar spinal stenosis: a protocol for a systematic review and meta-analysis of moderators

BACKGROUND

Lumbar spinal stenosis (LSS) is a common degenerative spine disease associated with a strong impairment in various quality of life areas, particularly the ability to perform work-related activity. Depression is a condition frequently associated. There is no comprehensive review on quality of life and objective functional impairment in LSS. This paper presents the protocol of the first systematic review and meta-analysis summarising evidence about quality of life and functional impairment in patients with LSS compared with healthy controls. Comorbid depressive disorders, age, gender, LSS duration, disability, pain severity and study methodological quality will be investigated as moderators.

METHODS

The protocol is reported according to PRISMA-P guidelines. Studies will be included if they were conducted on patients aged 18 years old or older with primary LSS and if they reported data on differences in the levels of quality of life or objective functional impairment between patients with LSS and healthy controls. Independent reviewers will search published/unpublished studies through electronic databases and additional sources, will extract the data and assess the methodological quality. Random-effects meta-analysis will be carried out by calculating effect sizes as Cohen's d indices. Heterogeneity will be examined by the I² and the Q statistics. Moderators will be investigated through meta-regression.

CONCLUSIONS

A summary of the evidence on quality of life and functional impairment in LSS may suggest clinical and occupational health medicine strategies aimed to timely detect and prevent these outcomes. Higher percentages of patients with LSS with depression may be expected to be related to poorer quality of life. Depressive comorbidity might impact negatively on quality of life because it is associated with dysfunctional coping, disability and psychophysiological symptoms.

ETHICS AND DISSEMINATION

The current review does not require ethics approval. The results will be disseminated through publications in peer-reviewed journals.

REVIEW REGISTRATION

CRD42019132209.

Adult spinal deformity

Adult spinal deformity affects the thoracic or thoracolumbar spine throughout the ageing process. Although adolescent spinal deformities taken into adulthood are not uncommon, the most usual causes of spinal deformity in adults are iatrogenic flatback and degenerative scoliosis. Given its prevalence in the expanding portion of the global population aged older than 65 years, the disorder is of growing interest in health care. Physical examination, with a focus on gait and posture, along with radiographical assessment are primarily used and integrated with risk stratification indices to establish optimal treatment planning. Although non-operative treatment is regarded as the first-line response, surgical outcomes are considerably favourable. Global disparities exist in both the assessment and treatment of adults with spinal deformity across countries of varying incomes, which represents an area requiring further investigation. This Seminar presents evidence and knowledge that represent the evolution of data related to spinal deformity in adults over the past several decades.

Effect of Psychiatric Comorbidities on In-Hospital Outcomes and Cost for Cervical Spondylotic Myelopathy

OBJECTIVE

The present study examined the differences in outcomes of cervical spinal surgery for patients with and without a major psychiatric comorbidity using the Healthcare Cost and Utilization Project National Inpatient Sample database.

METHODS

Data were queried from the Healthcare Cost and Utilization Project National Inpatient Sample database from 2013 to 2014 for hospitalizations with a major psychiatric comorbidity and a diagnosis of cervical spondylotic myelopathy treated by an appropriate surgical procedure. The included psychiatric comorbidities were schizophrenia, episodic mood disorders (bipolar I and II disorders), delusional disorders, and psychoses not otherwise specified. Univariate and multivariate regression analyses were performed to determine the differences in outcomes between patients with and without a major psychiatric comorbidity.

RESULTS

A total of 18,335 hospitalizations met the inclusion criteria, of which 648 (3.5%) included a major psychiatric comorbidity. Multivariate regression analysis demonstrated that psychiatric comorbidity was an independent predictor of non-home discharge (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.43-2.30; P < 0.0001) and a longer hospital stay (+0.52 day; 95% CI, 0.43-0.61; P < 0.0001) but was not an independent predictor of overall complications (OR, 0.79; 95% CI, 0.58-1.07; P = 0.13) or total hospital charges ($1992; 95% CI, -$917-$4902; P = 0.18).

CONCLUSIONS

Psychiatric comorbidity was associated with an increased risk of non-home discharge and a longer length of stay for patients undergoing surgical intervention for cervical myelopathy. However, we did not find an associated increased risk of in-hospital mortality, complications, or total hospital charges. Psychiatric comorbidity should not be weighed against patients who require surgical treatment for cervical spondylotic myelopathy, and special attention should be given to postoperative care and discharge planning for this unique patient population.