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Pellisé F, Bayo MC, Ruiz de Villa A, Núñez-Pereira S, Haddad S, Barcheni M, Pizones J, Valencia MR, Obeid I, Alanay A, Kleinstueck FS, Mannion AF. The Impact of Unplanned Reoperation Following Adult Spinal Deformity Surgery: A Prospective Longitudinal Cohort Study with 5-Year Follow-up. J Bone Joint Surg Am 2024; 106:681-689. [PMID: 38630053 DOI: 10.2106/jbjs.23.00242] [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] [Indexed: 04/19/2024]
Abstract
BACKGROUND The long-term impact of reoperations following adult spinal deformity (ASD) surgery is still poorly understood. Our aim was to identify the relationship between unplanned reoperation and health-related quality of life (HRQoL) gain at 2 and 5 years of follow-up. METHODS We included patients enrolled in a prospective ASD database who underwent surgery ≥5 years prior to the start of the study and who had 2 years of follow-up data. Adverse events (AEs) leading to an unplanned reoperation, the time of reoperation occurrence, invasiveness (blood loss, surgical time, hospital stay), and AE resolution were assessed. HRQoL was measured with use of the Oswestry Disability Index, Scoliosis Research Society-22, and Short Form-36. Linear models controlling for baseline data and index surgery characteristics were utilized to assess the relationships between HRQoL gain at 2 and 5-year follow-up and the number and invasiveness of reoperations. The association between 5-year HRQoL gain and the time of occurrence of the unplanned reoperation and that between 5-year HRQoL gain and AE resolution were also investigated. RESULTS Of 361 eligible patients, 316 (87.5%) with 2-year follow-up data met the inclusion criteria and 258 (71.5%) had 5-year follow-up data. At the 2-year follow-up, 96 patients (30.4%) had a total of 165 unplanned reoperations (1.72 per patient). At the 5-year follow-up, 73 patients (28.3%) had a total of 117 unplanned reoperations (1.60 per patient). The most common cause of reoperations was mechanical complications (64.9%), followed by surgical site infections (15.7%). At the 5-year follow-up, the AE that led to reoperation was resolved in 67 patients (91.8%). Reoperation invasiveness was not associated with 5-year HRQoL scores. The number of reoperations was associated with lesser HRQoL gain at 5 years for all HRQoL measures. The mean associated reduction in HRQoL gain per unplanned reoperation was 41% (range, 19% to 66%). Reoperations resulting in no resolution of the AE or resolution with sequelae had a greater impact on 5-year follow-up HRQoL scores than reoperations resulting in resolution of the AE. CONCLUSIONS A postoperative, unplanned reoperation following ASD surgery was associated with lesser gain in HRQoL at 5 years of follow-up. The association did not diminish over time and was affected by the number, but not the magnitude, of reoperations. Resolution of the associated AE reduced the impact of the unplanned reoperation. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ferran Pellisé
- Spine Surgery Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | | | - Sleiman Haddad
- Spine Surgery Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maggie Barcheni
- Spine Research Unit, Vall d'Hebron Research Institute, Barcelona, Spain
| | | | | | | | - Ahmet Alanay
- Department of Orthopaedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | | | - Anne F Mannion
- Spine Center Division, Schulthess Klinik, Zurich, Switzerland
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Pizones J, Hills J, Kelly M, Yilgor C, Moreno-Manzanaro L, Perez-Grueso FJS, Kleinstück F, Obeid I, Alanay A, Pellisé F. Which sagittal plane assessment method is most predictive of complications after adult spinal deformity surgery? Spine Deform 2024:10.1007/s43390-024-00864-5. [PMID: 38607513 DOI: 10.1007/s43390-024-00864-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/16/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE Different methods of sagittal alignment assessment compete for predicting adverse events after adult spinal deformity (ASD) surgery. We wanted to study which method provides greater benefit. METHODS Retrospective study of 391 patients operated for ASD, with > 6 instrumented levels, fused to the pelvis, and 2 years of follow-up. Three alignment methods were analyzed 6-week postoperatively: (1) Roussouly mismatch; (2) GAP score/GAP categories; (3) T4-L1-Hip axis. Binary logistic regression generated models that best predict the following adverse events: mechanical complications (MC): in general and isolated (PJK, PJF, rod breakage); reinterventions (in general and after MC); and readmissions. ROC/AUC analysis was also implemented. In a second regression round, we added different variables that were selected on univariate analysis-demographic, surgical, and radiographic-to complete the models. RESULTS The best predictor parameters in most models were T4-L1PA mismatch and GAP score; we could not prove a predictive ability of the Roussouly mismatch. The T4-L1PA mismatch best predicted general MC, PJK, PJK + PJF, and readmission, while the GAP score best predicted PJF and reinterventions (for MC and for any complication). However, the variance explained by these models was limited (Nagelkerke's R2 = 0.031-0.113), with odds ratios ranging from 1.070 to 1.456. ROC curves plotted an AUC between 0.57 and 0.70. Introducing additional variables (demographic, surgical, and radiographic) improved prediction in all the models (Nagelkerke's R2 = 0.082-0.329) and allowed predicting rod breakage. CONCLUSION The T4-L1-Hip axis and GAP score show potential in predicting adverse events, surpassing the Roussouly method. Despite partial efficacy in complication anticipation, recognizing postoperative sagittal alignment as a key modifiable risk factor, the crucial need arises to integrate diverse variables, both modifiable and non-modifiable, for enhanced predictive accuracy. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Javier Pizones
- Spine Unit, Department of Orthopedic Surgery, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.
| | | | - Michael Kelly
- Rady Children Hospital San Diego, University of California, San Diego, CA, USA
| | - Caglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Lucía Moreno-Manzanaro
- Spine Unit, Department of Orthopedic Surgery, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | | | - Frank Kleinstück
- Department of Orthopedics, Schulthess Klinik, Zurich, Switzerland
| | - Ibrahim Obeid
- Spine Surgery Unit, Pellegrin University Hospital, Bordeaux, France
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ferran Pellisé
- Spine Surgery Unit, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Cho M, Lee S, Kim HJ. Assessing the predictive power of the GAP score on mechanical complications: a comprehensive 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 2024; 33:1311-1319. [PMID: 38367025 DOI: 10.1007/s00586-024-08135-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 12/08/2023] [Accepted: 01/04/2024] [Indexed: 02/19/2024]
Abstract
PURPOSE The prevention of mechanical complications (MC) is a major concern in adult spinal deformity (ASD) correction surgery; thus, the global alignment and proportion (GAP) score was developed to assess MC risk. Numerous studies have clarified the validity of the GAP score, but their contradictory results have prevented researchers from reaching compelling conclusions. This study aimed to analyze the predictive power of the GAP score on MC via a meta-analysis. METHODS A total of 1,617 patients were included in the meta-analysis. Studies relevant to the GAP score and MC were identified in PubMed, EMBASE, and Cochrane CENTRAL and screened according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The GAP score categories of the patients and their MC/revision surgery status were collected. The data collected for the meta-analysis of odds ratios (OR) included the number of patients in the GAP score subgroups and their MC/revision surgery status. To calculate the OR, three GAP score subgroups were combined into two groups; hence, the analysis was conducted twice (gap proportioned [GAP-P] and higher groups, and gap severely disproportioned [GAP-SD] and lower groups). RESULTS Eleven studies were collected; of them, revision surgery data were available for seven. The proportion of MC in the studies was 27.7-60.6%, while that of revision surgery was 11.7-34.9%. In the meta-analysis of the GAP-P and higher score groups, the difference in MC ratio was significant (OR = 2.83; 95% confidence interval [CI] = 1.20-6.67; P = 0.02), whereas that for revision surgery was not. For the GAP-SD and lower score groups, the GAP-SD group had significantly higher proportions of both MC (OR = 2.65; 95% CI = 1.57-4.45; P < 0.001) and revision surgery (OR = 2.27; 95% CI = 1.33-3.88; P = 0.003). Publication bias was significant only in the latter MC analysis. CONCLUSION The GAP score offers predictive value for the risk of mechanical complications.
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Affiliation(s)
- Minseong Cho
- Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sanghoon Lee
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam, 463-707, Republic of Korea
| | - Ho-Joong Kim
- Spine Center and Department of Orthopedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, 166 Gumiro, Bundang-gu, Sungnam, 463-707, Republic of Korea.
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Wang Y, Li J, Xi Y, Zeng Y, Yu M, Sun Z, Ma Y, Liu Z, Chen Z, Li W. Distal Junctional Failures in Degenerative Thoracolumbar Hyperkyphosis. Orthop Surg 2024; 16:830-841. [PMID: 38384146 PMCID: PMC10984817 DOI: 10.1111/os.13973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVE Degenerative thoracolumbar hyperkyphosis (DTH) is a disease that negatively affects individual health and requires surgical intervention, yet the ideal surgical approach and complications, especially distal junctional failures (DJF), remain poorly understood. This study aims to investigate DJF in DTH and to identify the risk factors for DJF so that we can improve surgical decision-making, and advance our knowledge in the field of spinal surgery to enhance patient outcomes. METHODS This study retrospectively reviewed 78 cases (late osteoporotic vertebral compression fracture [OVCF], 51; Scheuermann's kyphosis [SK], 17; and degenerative disc diseases [DDD], 10) who underwent corrective surgery in our institute from 2008 to 2019. Clinical outcomes were assessed using health-related quality of life (HRQOL) measures, including the visual analogue scale (VAS) scores for back and leg pain, the Oswestry disability index (ODI), and the Japanese Orthopaedic Association (JOA) scoring system. Multiple radiographic parameters, such as global kyphosis (GK) and thoracolumbar kyphosis (TLK), were assessed to determine radiographic outcomes. Multivariate logistic regression analysis was employed to identify the risk factors associated with DJF. RESULTS HRQOL improved, and GK, TLK decreased at the final follow-up, with a correction rate of 67.7% and 68.5%, respectively. DJF was found in 13 of 78 cases (16.7%), two cases had wedging in the disc (L3-4) below the instrumentation, one case had a fracture of the lowest instrumented vertebrae (LIV), one case had osteoporotic fracture below the fixation, nine cases had pull-out or loosening of the screws at the LIV and three cases (23.1%) required revision surgery. The DJF group had older age, lower computed tomography Hounsfield unit (CT HU), longer follow-up, more blood loss, greater preoperative sagittal vertical axis (SVA), and poorer postoperative JOA and VAS scores (back). The change in TLK level was larger in the non-DJF group. Post-sagittal stable vertebrae (SSV) moved cranially compared with pre-SSV. CONCLUSION Age, CT HU, length of follow-up, estimated blood loss, and preoperative SVA were independent risk factors for DJF. We recommend fixation of the two vertebrae below the apex vertebrae for DTH to minimize surgical trauma.
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Affiliation(s)
- Yongqiang Wang
- Department of OrthopedicsPeking University Third HospitalBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationPeking University Third HospitalBeijingChina
| | - Junyu Li
- Department of OrthopedicsPeking University Third HospitalBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationPeking University Third HospitalBeijingChina
| | - Yu Xi
- Peking University Health Science CenterBeijingChina
| | - Yan Zeng
- Department of OrthopedicsPeking University Third HospitalBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationPeking University Third HospitalBeijingChina
| | - Miao Yu
- Department of OrthopedicsPeking University Third HospitalBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationPeking University Third HospitalBeijingChina
| | - Zhuoran Sun
- Department of OrthopedicsPeking University Third HospitalBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationPeking University Third HospitalBeijingChina
| | - Yinghong Ma
- Peking University Health Science CenterBeijingChina
| | - Zhongjun Liu
- Department of OrthopedicsPeking University Third HospitalBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationPeking University Third HospitalBeijingChina
| | - Zhongqiang Chen
- Department of OrthopedicsPeking University Third HospitalBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationPeking University Third HospitalBeijingChina
| | - Weishi Li
- Department of OrthopedicsPeking University Third HospitalBeijingChina
- Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of EducationPeking University Third HospitalBeijingChina
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Williamson TK, Dave P, Mir JM, Smith JS, Lafage R, Line B, Diebo BG, Daniels AH, Gum JL, Protopsaltis TS, Hamilton DK, Soroceanu A, Scheer JK, Eastlack R, Kelly MP, Nunley P, Kebaish KM, Lewis S, Lenke LG, Hostin RA, Gupta MC, Kim HJ, Ames CP, Hart RA, Burton DC, Shaffrey CI, Klineberg EO, Schwab FJ, Lafage V, Chou D, Fu KM, Bess S, Passias PG. Persistent Lower Extremity Compensation for Sagittal Imbalance After Surgical Correction of Complex Adult Spinal Deformity: A Radiographic Analysis of Early Impact. Oper Neurosurg (Hagerstown) 2024; 26:156-164. [PMID: 38227826 DOI: 10.1227/ons.0000000000000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/06/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Achieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The objective is to analyze lower extremity compensation after complex ASD surgery, its effect on outcomes, and whether correction can alleviate these mechanisms. METHODS We included patients with complex ASD with 6-week data. LE parameters were as follows: sacrofemoral angle, knee flexion angle, and ankle flexion angle. Each parameter was ranked, and upper tertile was deemed compensation. Patients compensating and not compensating postoperatively were propensity score matched for body mass index, frailty, and T1 pelvic angle. Linear regression assessed correlation between LE parameters and baseline deformity, demographics, and surgical details. Multivariate analysis controlling for baseline deformity and history of total knee/hip arthroplasty evaluated outcomes. RESULTS Two hundred and ten patients (age: 61.3 ± 14.1 years, body mass index: 27.4 ± 5.8 kg/m2, Charlson Comorbidity Index: 1.1 ± 1.6, 72% female, 22% previous total joint arthroplasty, 24% osteoporosis, levels fused: 13.1 ± 3.8) were included. At baseline, 59% were compensating in LE: 32% at hips, 39% knees, and 36% ankles. After correction, 61% were compensating at least one joint. Patients undercorrected postoperatively were less likely to relieve LE compensation (odds ratio: 0.2, P = .037). Patients compensating in LE were more often undercorrected in age-adjusted pelvic tilt, pelvic incidence, lumbar lordosis, and T1 pelvic angle and disproportioned in Global Alignment and Proportion (P < .05). Patients matched in sagittal age-adjusted score at 6 weeks but compensating in LE were more likely to develop proximal junctional kyphosis (odds ratio: 4.1, P = .009) and proximal junctional failure (8% vs 0%, P = .035) than those sagittal age-adjusted score-matched and not compensating in LE. CONCLUSION Perioperative lower extremity compensation was a product of undercorrecting complex ASD. Even in age-adjusted realignment, compensation was associated with global undercorrection and junctional failure. Consideration of lower extremities during planning is vital to avoid adverse outcomes in perioperative course after complex ASD surgery.
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Affiliation(s)
- Tyler K Williamson
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
| | - Pooja Dave
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
| | - Jamshaid M Mir
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, New York, USA
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | | | - D Kojo Hamilton
- Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Pierce Nunley
- Spine Institute of Louisiana, Shreveport, Louisiana, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Stephen Lewis
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia College of Physicians and Surgeons, New York, New York, USA
| | - Richard A Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University of St Louis, St Louis, Missouri, USA
| | - Han Jo Kim
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher I Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, California, USA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medicine Brain and Spine Center, New York, New York, USA
| | - Shay Bess
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Peter G Passias
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
- Rocky Mountain Scoliosis and Spine, Denver, Colorado, USA
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Lovecchio F, Lafage R, Kim HJ, Bess S, Ames C, Gupta M, Passias P, Klineberg E, Mundis G, Burton D, Smith JS, Shaffrey C, Schwab F, Lafage V. Revision-Free Loss of Sagittal Correction Greater Than Three Years After Adult Spinal Deformity Surgery: Who and Why? Spine (Phila Pa 1976) 2024; 49:157-164. [PMID: 37847773 DOI: 10.1097/brs.0000000000004852] [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: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 10/19/2023]
Abstract
STUDY DESIGN Multicenter retrospective cohort study. OBJECTIVE To investigate risk factors for loss of correction within the instrumented lumbar spine after adult spinal deformity surgery. SUMMARY OF BACKGROUND DATA The sustainability of adult spinal deformity surgery remains a health care challenge. Malalignment is a major reason for revision surgery. PATIENTS AND METHODS A total of 321 patients who underwent fusion of the lumbar spine (≥5 levels, LIV pelvis) with a revision-free follow-up of ≥3 years were identified. Patients were stratified by a change in pelvic incidence-lumbar lordosis from 6 weeks to 3 years postoperative as "maintained" versus "loss" >5°. Those with instrumentation failure (broken rod, screw pullout, etc .) were excluded before comparisons. Demographics, surgical data, and radiographic alignment were compared. Repeated measure analysis of variance was performed to evaluate the maintenance of the correction for L1-L4 and L4-S1. Multivariate logistic regression was conducted to identify independent surgical predictors of correction loss. RESULTS The cohort had a mean age of 64 years, a mean Body Mass Index of 28 kg/m 2 , and 80% females. Eighty-two patients (25.5%) lost >5° of pelvic incidence-lumbar lordosis correction (mean loss 10±5°). After the exclusion of patients with instrumentation failure, 52 losses were compared with 222 maintained. Demographics, osteotomies, 3CO, interbody fusion, use of bone morphogenetic protein, rod material, rod diameter, and fusion length were not significantly different. L1-S1 screw orientation angle was 1.3 ± 4.1 from early postoperative to 3 years ( P = 0.031), but not appreciably different at L4-S1 (-0.1 ± 2.9 P = 0.97). Lack of a supplemental rod (odds ratio: 4.0, P = 0.005) and fusion length (odds ratio 2.2, P = 0.004) were associated with loss of correction. CONCLUSIONS Approximately, a quarter of revision-free patients lose an average of 10° of their 6-week correction by 3 years. Lordosis is lost proximally through the instrumentation ( i.e. tulip/shank angle shifts and/or rod bending). The use of supplemental rods and avoiding sagittal overcorrection may help mitigate this loss.
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Affiliation(s)
- Francis Lovecchio
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Han Jo Kim
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center/Presbyterian St. Luke's Medical Center, Denver, CO
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, IL
| | - Peter Passias
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Eric Klineberg
- Department of Orthopedic Surgery, The University of Texas Health Science Center of Houston, Houston, TX
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, La Jolla, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher Shaffrey
- Department of Neurosurgery and Orthopedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Frank Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
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7
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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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Xie J, Zhou F, Ouyang L, Li Q, Rao S, Su R, Yang S, Li J, Wan X, Yan L, Liu P, Cheng H, Li L, Du G, Feng C, Fan G. Insight into the effect of a heavy metal mixture on neurological damage in rats through combined serum metabolomic and brain proteomic analyses. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 895:165009. [PMID: 37353033 DOI: 10.1016/j.scitotenv.2023.165009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 05/26/2023] [Accepted: 06/17/2023] [Indexed: 06/25/2023]
Abstract
The heavy metals lead (Pb), cadmium (Cd), and mercury (Hg) that cause neurocognitive impairment have been extensively studied. These elements typically do not exist alone in the environment; they are often found with other heavy metals and can enter the body through various routes, thereby impacting health. Our previous research showed that low Pb, Cd, and Hg levels cause neurobehavioral impairments in weaning and adult rats. However, little is known about the biomarkers and mechanisms underlying Pb, Cd, and Hg mixture-induced neurological impairments. A combined analysis of metabolomic and proteomic data may reveal heavy metal-induced alterations in metabolic and protein profiles, thereby improving our understanding of the molecular mechanisms underlying heavy metal-induced neurological impairments. Therefore, brain tissue and serum samples were collected from rats exposed to a Pb, Cd, and Hg mixture for proteomic and metabolomic analyses, respectively. The analysis revealed 363 differential proteins in the brain and 206 metabolites in serum uniquely altered in the Pb, Cd, and Hg mixture exposure group, compared to those of the control group. The main metabolic impacted pathways were unsaturated fatty acids biosynthesis, linoleic acid metabolism, phenylalanine metabolism, and tryptophan metabolism. We further identified that the levels of arachidonic acid (C20:4 n-3) and, adrenic acid (C22:4 n-3) were elevated and that kynurenic acid (KA) and quinolinic acid (QA) levels and the KA/QA ratio, were decreased in the group exposed to the Pb, Cd, and Hg mixture. A joint analysis of the proteome and metabolome showed that significantly altered proteins such as LPCAT3, SLC7A11, ASCL4, and KYAT1 may participate in the neurological impairments induced by the heavy metal mixture. Overall, we hypothesize that the dysregulation of ferroptosis and kynurenine pathways is associated with neurological damage due to chronic exposure to a heavy metal mixture.
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Affiliation(s)
- Jie Xie
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Fankun Zhou
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Lu Ouyang
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Qi Li
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Shaoqi Rao
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Rui Su
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Shuo Yang
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Jiajun Li
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Xin Wan
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Lingyu Yan
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Peishan Liu
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Hui Cheng
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Lingling Li
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Guihua Du
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Chang Feng
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China
| | - Guangqin Fan
- Department of Occupational Health and Toxicology, School of Public Health, Nanchang University, Nanchang 330006, PR China; Jiangxi Province Key Laboratory of Preventive Medicine, Nanchang University, Nanchang 330006, PR China.
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Park C, Agarwal N, Mummaneni PV, Berven SH. Spinopelvic Alignment: Importance in Spinal Pathologies and Realignment Strategies. Neurosurg Clin N Am 2023; 34:519-526. [PMID: 37718098 DOI: 10.1016/j.nec.2023.05.001] [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
Sagittal spinal malalignment can lead to pain, decreased function, dynamic imbalance, and compromise of patient-reported health status. The goal of reconstructive spine surgery is to restore spinal alignment parameters, and an understanding of appropriate patient-specific alignment is important for surgical planning and approaches. Radiographic spinopelvic parameters are strongly correlated with pain and function. The relationship between spinopelvic parameters and disability in adult spinal deformity patients is well-established, and optimal correction of sagittal alignment results in improved outcomes regarding patient health status and mechanical complications of surgery.
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Affiliation(s)
- Christine Park
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA.
| | - Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Sigurd H Berven
- Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA
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10
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Bergin SM, Dibble CF, Lee HJ, Abd-El-Barr MM, Shaffrey CI, Than KD. Surgical technique of combined minimally invasive anterior column realignment at L1-L2 with open extension of prior fusion. JOURNAL OF SPINE SURGERY (HONG KONG) 2023; 9:288-293. [PMID: 37841785 PMCID: PMC10570644 DOI: 10.21037/jss-23-45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/12/2023] [Indexed: 10/17/2023]
Abstract
Surgical correction of fixed kyphotic deformity or severe sagittal imbalance traditionally involves three column osteotomies, which are associated with high morbidity rates. Anterior column realignment (ACR) has emerged as a minimally invasive alternative for restoring segmental lordosis. This technique involves a lateral approach and release of the anterior longitudinal ligament (ALL), followed by placement of a hyperlordotic interbody cage. In this study, we present a successful case of minimally invasive ACR for the treatment of flatback deformity and adjacent segment disease in a patient with prior L2-S1 fusion. Imaging revealed a flatback deformity, sagittal vertical axis elevation, and spinopelvic disharmony. The patient underwent a multistage procedure involving a lateral retropleural approach for ACR and interbody fusion, followed by open posterior instrumented fusion and vertebroplasties. Postoperatively, the patient experienced significant pain relief and improvement in lumbar lordosis, pelvic tilt, and pelvic incidence-lumbar lordosis mismatch. ACR combined with posterior release allows for manipulation of all three spinal columns, leading to spine reconstruction and improved spinopelvic harmony. We discuss the advantages of ACR, including its minimally invasive nature and potential benefits for patients with sagittal deformities. The presented surgical technique demonstrates the feasibility and efficacy of minimally invasive ACR in addressing flatback deformity and adjacent segment disease.
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Affiliation(s)
- Stephen M Bergin
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC, USA
| | | | - Ho Jin Lee
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC, USA
| | | | | | - Khoi D Than
- Division of Spine, Department of Neurosurgery, Duke University, Durham, NC, USA
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11
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Lee BJ, Bae SS, Choi HY, Park JH, Hyun SJ, Jo DJ, Cho Y. Proximal Junctional Kyphosis or Failure After Adult Spinal Deformity Surgery - Review of Risk Factors and Its Prevention. Neurospine 2023; 20:863-875. [PMID: 37798982 PMCID: PMC10562224 DOI: 10.14245/ns.2346476.238] [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: 04/28/2023] [Revised: 06/06/2023] [Accepted: 06/16/2023] [Indexed: 10/07/2023] Open
Abstract
Proximal junction kyphosis (PJK) is a common imaging finding after long-level fusion, and proximal junctional failure (PJF) is an aggravated form of the progressive disease spectrum of PJK. This includes vertebral fracture of upper instrumented vertebra (UIV) or UIV+1, instability between UIV and UIV+1, neurological deterioration requiring surgery. Many studies have reported on PJK and PJF after long segment instrumentation for adult spinal deformity (ASD). In particular, for spine deformity surgeons, risk factors and prevention strategies of PJK and PJF are very important to minimize reoperation. Therefore, this review aims to help reduce the occurrence of PJK and PJF by updating the latest contents of PJK and PJF by 2023, focusing on the risk factors and prevention strategies of PJK and PJF. We conducted a search on multiple database for articles published until February 2023 using the search keywords "proximal junctional kyphosis," "proximal junctional failure," "proximal junctional disease," and "adult spinal deformity." Finally, 103 papers were included in this study. Numerous factors have been suggested as potential risks for the development of PJK and PJF, including a high body mass index, inadequate postoperative sagittal balance and overcorrection, advanced age, pelvic instrumentation, and osteoporosis. Recently, with the increasing elderly population, sarcopenia has been emphasized. The quality and quantity of muscle in the surgical site have been suggested as new risk factor. Therefore, spine surgeon should understand the pathophysiology of PJK and PJF, as well as individual risk factors, in order to develop appropriate prevention strategies for each patient.
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Affiliation(s)
- Byung-Jou Lee
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Sung Soo Bae
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Ho Young Choi
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jin Hoon Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dae Jean Jo
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
| | - Yongjae Cho
- Department of Neurosurgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - Korean Spinal Deformity Society (KSDS)
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Neurosurgery, Ewha Womans University School of Medicine, Seoul, Korea
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12
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Park SJ, Lee CS, Park JS, Jeon CY, Ma CH. A Validation Study of Four Preoperative Surgical Planning Tools for Adult Spinal Deformity Surgery in Proximal Junctional Kyphosis and Clinical Outcomes. Neurosurgery 2023; 93:706-716. [PMID: 36999928 DOI: 10.1227/neu.0000000000002475] [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: 01/11/2023] [Accepted: 02/03/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Four guidelines have been suggested for optimal correction in adult spinal deformity surgery: Scoliosis Research Society (SRS)-Schwab classification, age-adjusted sagittal alignment goals, Global Alignment and Proportion (GAP) score, and the Roussouly algorithm. Whether these goals provide benefit in both proximal junctional kyphosis (PJK) reduction and clinical outcome improvement remains unclear. OBJECTIVE To validate 4 preoperative surgical planning tools in PJK development and clinical outcomes. METHODS We retrospectively reviewed patients who underwent ≥5-segment fusion including the sacrum for adult spinal deformity with a follow-up of ≥2-year. PJK development and clinical outcomes were compared among the groups separately using 4 surgical guidelines: SRS-Schwab pelvic incidence (PI)-lumbar lordosis (LL) modifier (Group 0, +, ++), age-adjusted PI-LL goal (undercorrection, matched correction, and overcorrection), GAP score (proportioned, moderately disproportioned, and severely disproportioned groups), and the Roussouly algorithm (restored and nonrestored groups). RESULTS A total of 189 patients were included in this study. The mean age was 68.3 years, and there were 162 women (85.7%). There were no differences in the rate of PJK development and clinical outcomes among SRS-Schwab PI-LL modifier and GAP score groups. With the age-adjusted PI-LL goal, PJK developed significantly less frequently in the matched group compared with the under- and overcorrection groups. Clinical outcomes were significantly better in the matched group compared with the under- and overcorrection groups. With the Roussouly algorithm, PJK developed significantly less frequently in the restored group than in the nonrestored group. However, there were no differences in clinical outcomes between the 2 Roussouly groups. CONCLUSION Correction according to the age-adjusted PI-LL goal and the restored Roussouly type was associated with reduced PJK development. However, differences in clinical outcomes were only observed in the age-adjusted PI-LL groups.
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Affiliation(s)
- Se-Jun Park
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul , South Korea
| | - Chong-Suh Lee
- Department of Orthopedic Surgery, Haeundae Bumin Hospital, Busan , South Korea
| | - Jin-Sung Park
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul , South Korea
| | - Chung-Youb Jeon
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul , South Korea
| | - Chang-Hyun Ma
- Department of Orthopedic Surgery, Spine Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul , South Korea
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Passias PG, Williamson TK, Krol O, Tretiakov PS, Joujon-Roche R, Imbo B, Ahmad S, Bennett-Caso C, Owusu-Sarpong S, Lebovic JB, Robertson D, Vira S, Dhillon E, Schoenfeld AJ, Janjua MB, Raman T, Protopsaltis TS, Maglaras C, O'Connell B, Daniels AH, Paulino C, Diebo BG, Smith JS, Schwab FJ, Lafage R, Lafage V. Should Global Realignment Be Tailored to Frailty Status for Patients Undergoing Surgical Intervention for Adult Spinal Deformity? Spine (Phila Pa 1976) 2023; 48:930-936. [PMID: 36191091 DOI: 10.1097/brs.0000000000004501] [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: 06/30/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes. SUMMARY OF BACKGROUND DATA The Global Alignment and Proportion (GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to the development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications. MATERIALS AND METHODS We included 412 surgical ASD patients with two-year follow-up. Frailty was quantified using the modified Adult Spinal Deformity Frailty Index (mASD-FI). Outcomes: proximal junctional kyphosis and proximal junctional failure (PJF), major mechanical complications, and "Best Clinical Outcome" (BCO), defined as Oswestry Disability Index<15 and Scoliosis Research Society 22-item Questionnaire Total>4.5. Logistic regression analysis established a six-week score based on GAP score, frailty, and Oswestry Disability Index US Norms. Logistic regression followed by conditional inference tree analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty-modified GAP score. RESULTS Baseline frailty categories: 57% not frail, 30% frail, 14% severely frail. Overall, 39 of patients developed proximal junctional kyphosis, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The mASD-FI demonstrated a correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at two years (all P <0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score (FAR Score)=0.49×mASD-FI+0.38×GAP Score. Thresholds for the FAR score (0-13): proportioned: <3.5, moderately disproportioned: 3.5-7.5, severely disproportioned: >7.5. Multivariable logistic regression assessing FAR score demonstrated associations with mechanical complications, reoperation, and meeting BCO by two years (all P <0.05), whereas the original GAP score was only significant for reoperation. CONCLUSION This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity. LEVEL OF EVIDENCE III.
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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
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Peter S Tretiakov
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Bailey Imbo
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Salman Ahmad
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Claudia Bennett-Caso
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | | | - Jordan B Lebovic
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Djani Robertson
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Shaleen Vira
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Ekamjeet Dhillon
- Department of Orthopaedic Surgery, University of Washington Medical Center, Seattle, WA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical Center, Boston, MA
| | - Muhammad B Janjua
- Department of Neurosurgery, Washington University of St Louis, St Louis, MO
| | - Tina Raman
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | | | - Constance Maglaras
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Brooke O'Connell
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine/Brown University, Providence, RI
| | - Carl Paulino
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
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Raganato R, Pizones J, Yilgor C, Moreno-Manzanaro L, Vila-Casademunt A, Sánchez-Márquez JM, Fernández-Baíllo N, Sánchez Pérez-Grueso FJ, Kleinstück F, Alanay A, Obeid I, Pellisé F. Sagittal realignment: surgical restoration of the global alignment and proportion score parameters: a subgroup analysis. What are the consequences of failing to realign? 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; 32:2238-2247. [PMID: 37000217 DOI: 10.1007/s00586-023-07649-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/18/2023] [Accepted: 03/09/2023] [Indexed: 04/01/2023]
Abstract
INTRODUCTION The Global Alignment and Proportion (GAP) score incorporates three domains directly modified with surgery (relative pelvic version-RPV, relative lumbar lordosis-RLL, lumbar distribution index-LDI) and one indirectly restored (relative spinopelvic alignment-RSA). We analyzed our surgical realignment performance and the consequences of domain-specific realignment failure on mechanical complications and PROMs. MATERIALS AND METHODS From an adult spinal deformity prospective multicenter database, we selected patients: fused to pelvis, upper instrumented vertebra at or above L1, and 2 years of follow-up. Descriptive, univariate and multivariate analyses were employed. RESULTS The sample included 333 patients. RLL-6w showed the highest success rate (58.3% aligned), but 16.5% of patients were classified in the "Severe hypolordosis" and "Hyperlordosis" subgroups. RPV-6w was the most challenging to realign, with 51.6% moderate or severe retroversion. Regarding RSA-6w, 21.9% had severe positive malalignment. Correct alignment of RPV-6w (p = 0.025) and RSA-6w (p = 0.002) proved to be protective factors against the development of mechanical complications. Severe pelvic retroversion (p = 0.026) and severe positive malalignment (p = 0.007) were risk factors for mechanical complications. RSA-6w "Severe positive malalignment" was associated with less improvement in PROMs: ∆ODI (8.83 vs 17.2; p = 0.011), ∆SRS-22 total (0.54 vs 0.87; p = 0.007), and ∆SF-36PCS (3.47 vs 7.76; p = 0.04); MCID for ODI (37.0 vs 55.5%; p = 0.023), and SRS-22 (40.8 vs 60.1%; p = 0.015); and PASS for ODI (17.6 vs 31.7%; p = 0.047). CONCLUSIONS RPV was the most underperformed modifiable parameter. Severe pelvic retroversion and severe positive malalignment influenced the occurrence of mechanical complications. Severe positive malalignment affected PROMs improvement.
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Affiliation(s)
- Riccardo Raganato
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain
| | - Javier Pizones
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain.
| | - Caglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Lucía Moreno-Manzanaro
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain
| | | | - José Miguel Sánchez-Márquez
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain
| | - Nicomedes Fernández-Baíllo
- Spine Unit, Department of Orthopedic Surgery, Hospital La Paz, Paseo de La Castellana 261, 28046, Madrid, Spain
| | | | - Frank Kleinstück
- Department of Orthopedics, Schulthess Klinik, Zurich, Switzerland
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ibrahim Obeid
- Spine Surgery Unit, Pellegrin University Hospital, Bordeaux, France
| | - Ferran Pellisé
- Spine Surgery Unit, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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15
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Noh SH, Lee HS, Park GE, Ha Y, Park JY, Kuh SU, Chin DK, Kim KS, Cho YE, Kim SH, Kim KH. Predicting Mechanical Complications After Adult Spinal Deformity Operation Using a Machine Learning Based on Modified Global Alignment and Proportion Scoring With Body Mass Index and Bone Mineral Density. Neurospine 2023; 20:265-274. [PMID: 37016873 PMCID: PMC10080453 DOI: 10.14245/ns.2244854.427] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 12/28/2022] [Indexed: 04/03/2023] Open
Abstract
Objective: This study aimed to create an ideal machine learning model to predict mechanical complications in adult spinal deformity (ASD) surgery based on GAPB (modified global alignment and proportion scoring with body mass index and bone mineral density) factors.Methods: Between January 2009 and December 2018, 238 consecutive patients with ASD, who received at least 4-level fusions and were followed-up for ≥ 2 years, were included in the study. The data were stratified into training (n = 167, 70%) and test (n = 71, 30%) sets and input to machine learning algorithms, including logistic regression, random forest gradient boosting system, and deep neural network.Results: Body mass index, bone mineral density, the relative pelvic version score, the relative lumbar lordosis score, and the relative sagittal alignment score of the global alignment and proportion score were significantly different in the training and test sets (p < 0.05) between the complication and no complication groups. In the training set, the area under receiver operating characteristics (AUROCs) for logistic regression, gradient boosting, random forest, and deep neural network were 0.871 (0.817–0.925), 0.942 (0.911–0.974), 1.000 (1.000–1.000), and 0.947 (0.915–0.980), respectively, and the accuracies were 0.784 (0.722–0.847), 0.868 (0.817–0.920), 1.000 (1.000–1.000), and 0.856 (0.803–0.909), respectively. In the test set, the AUROCs were 0.785 (0.678–0.893), 0.808 (0.702–0.914), 0.810 (0.710–0.910), and 0.730 (0.610–0.850), respectively, and the accuracies were 0.732 (0.629–0.835), 0.718 (0.614–0.823), 0.732 (0.629–0.835), and 0.620 (0.507–0.733), respectively. The random forest achieved the best predictive performance on the training and test dataset.Conclusion: This study created a comprehensive model to predict mechanical complications after ASD surgery. The best prediction accuracy was 73.2% for predicting mechanical complications after ASD surgery.
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Affiliation(s)
- Sung Hyun Noh
- Department of Neurosurgery, Ajou University College of Medicine, Suwon, Korea
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Go Eun Park
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ha
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Uk Kuh
- Department of Neurosurgery, Spine and Spinal Cord Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Kyu Chin
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Keun Su Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Eun Cho
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hyun Kim
- Department of Neurosurgery, Ajou University College of Medicine, Suwon, Korea
- Corresponding Author Kyung Hyun Kim Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Kyung Hyun Kim
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Co-corresponding Author Sang Hyun Kim Department of Neurosurgery, Ajou University Hospital, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea
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16
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Mechanical complications and reoperations after adult spinal deformity surgery: a clinical analysis with the GAP score. 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; 32:1421-1428. [PMID: 36862220 DOI: 10.1007/s00586-023-07593-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/20/2022] [Accepted: 02/07/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE Adult spinal deformity (ASD) surgery is prone to postoperative complications, leading to high reoperation rates. The global alignment and proportion (GAP) score is a novel method to predict mechanical complications (MC) based on the optimal parameters related to individual pelvic incidence. The aim of this study was to determine the cut-off point and the predictive value of the GAP score for those MCs that require reoperation. A secondary aim was to investigate the cumulative incidence of MCs requiring reoperation during a long follow-up period. METHODS In total, 144 ASD patients were operated at our institution due to marked symptomatic spinal deformity between 2008 and 2020. The cut-off point and the predictive value of the GAP score for the MCs that required reoperation and the cumulative incidence of reoperated MCs after index surgery were determined. RESULTS A total of 142 patients were included in the analysis. The risk for having an MC that required reoperation was significantly lower when the postoperative GAP score was < 5 (HR = 3.55, 95% CI: 1.40-9.02). The discriminative power of the GAP score to predict MCs that require reoperation was good with an AUC of 0.70 (95% CI: 0.58-0.81). The cumulative incidence of reoperated MCs was 18%. CONCLUSION The GAP score was associated with the risk for MCs that require reoperation. The best predictive value for surgically treated MC was with the GAP score [Formula: see text] 5. The cumulative incidence of the reoperated MCs was 18%.
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17
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Ye J, Yin TC, Gupta S, Farooqi AS, Wan W, Yilgor C, Sides BA, Gupta MC. Use of the Global Alignment and Proportion score to predict postoperative health-related quality of life in adult spinal deformity surgery. J Neurosurg Spine 2023; 38:340-347. [PMID: 36683189 DOI: 10.3171/2022.9.spine22809] [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] [Received: 07/18/2022] [Accepted: 09/30/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE The purpose of this study was to validate the Global Alignment and Proportion (GAP) score as a predictor of health-related quality of life (HRQOL) outcomes for patients undergoing adult spinal deformity (ASD) surgery. METHODS This was a retrospective cohort study of patients with ASD undergoing long-segment spine fusions (≥ 5 vertebrae fused) at a single institution over a 2-year period (n = 85). Radiographic parameters were measured at preoperative, 6-week postoperative, 1-year postoperative, and 2-year postoperative visits. GAP scores were calculated using 4 sagittal parameters: relative pelvic version, relative lumbar lordosis, lordosis distribution index, and relative spinopelvic alignment. Patients were stratified into 3 GAP categories at each time point: proportioned (score 0-2), moderately disproportioned (score 3-6), and severely disproportioned (score ≥ 7). HRQOL outcomes were collected at preoperative, 1-year postoperative, and 2-year postoperative visits; these measures included patient self-reported outcome measures (i.e., PROMIS), Scoliosis Research Society-22 spinal deformity questionnaire (SRS-22), and Oswestry Disability Index (ODI) scores. RESULTS Overall, 42% of cases were revision surgeries and 96.5% of patients underwent fusion to the sacrum. The mean preoperative GAP score significantly improved from preoperative (7.84) to immediate postoperative (3.31) assessment (p < 0.001). Similarly, the percentage of patients categorized as proportioned improved from 9.4% at preoperative to 45.9% at immediate postoperative evaluation. The preoperative GAP score or category was not significantly associated with any preoperative HRQOL outcome metrics. The immediate postoperative GAP score was not correlated with any 1-year HRQOL outcomes. However, the immediate postoperative GAP score was significantly associated with 2-year SRS-22 outcomes, including SRS-22 function (r = -0.35, p < 0.01), self-image (r = -0.27, p = 0.044), and subtotal (r = -0.35, p < 0.01) scores. As compared to severely disproportioned patients, proportioned patients had better SRS-22 pain (4.08 vs 3.17, p = 0.04), satisfaction (4.40 vs 3.50, p = 0.02), and subtotal (4.01 vs 3.27, p = 0.036) scores. The immediate postoperative GAP score was also significantly associated with 2-year PROMIS outcomes, including PROMIS pain (r = 0.31, p = 0.023) and physical function (r = -0.35, p < 0.01) scores. As compared to severely disproportioned patients, proportioned patients had better PROMIS pain (53.18 vs 63.60, p = 0.025) and physical function (41.66 vs 34.18, p = 0.017) scores. Postoperative GAP score or category did not predict any ODI outcomes. CONCLUSIONS The postoperative GAP score is a predictor of long-term HRQOL outcomes following ASD surgery, and proportioned patients are more likely to have less pain and be satisfied with their surgery. However, the postoperative GAP score does not predict outcomes as measured by ODI.
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Affiliation(s)
- Jichao Ye
- 1Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tsung-Cheng Yin
- 2Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sachin Gupta
- 3Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali S Farooqi
- 3Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wenbing Wan
- 4The Second Affiliated Hospital of Nanchang University, Nanchang, Jangxi, China
| | - Caglar Yilgor
- 5Department of Orthopedics and Traumatology, Acibadem University, Istanbul, Turkey; and
| | - Brenda A Sides
- 6Department of Orthopaedic Surgery, Barnes-Jewish Hospital, Washington University in St. Louis, Missouri
| | - Munish C Gupta
- 6Department of Orthopaedic Surgery, Barnes-Jewish Hospital, Washington University in St. Louis, Missouri
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18
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Balaban B, Yilgor C, Yucekul A, Zulemyan T, Obeid I, Pizones J, Kleinstueck F, Perez-Grueso FJS, Pellise F, Alanay A, Sezerman OU. Building clinically actionable models for predicting mechanical complications in postoperatively well-aligned adult spinal deformity patients using XGBoost algorithm. INFORMATICS IN MEDICINE UNLOCKED 2023. [DOI: 10.1016/j.imu.2023.101191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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19
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Ignasiak D, Behm P, Mannion AF, Galbusera F, Kleinstück F, Fekete TF, Haschtmann D, Jeszenszky D, Zimmermann L, Richner-Wunderlin S, Vila-Casademunt A, Pellisé F, Obeid I, Pizones J, Sánchez Pérez-Grueso FJ, Karaman MI, Alanay A, Yilgor Ç, Ferguson SJ, Loibl M. Association between sagittal alignment and loads at the adjacent segment in the fused spine: a combined clinical and musculoskeletal modeling study of 205 patients with 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 2023; 32:571-583. [PMID: 36526952 DOI: 10.1007/s00586-022-07477-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 11/18/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Sagittal malalignment is a risk factor for mechanical complications after surgery for adult spinal deformity (ASD). Spinal loads, modulated by sagittal alignment, may explain this relationship. The aims of this study were to investigate the relationships between: (1) postoperative changes in loads at the proximal segment and realignment, and (2) absolute postoperative loads and postoperative alignment measures. METHODS A previously validated musculoskeletal model of the whole spine was applied to study a clinical sample of 205 patients with ASD. Based on clinical and radiographic data, pre-and postoperative patient-specific alignments were simulated to predict loads at the proximal segment adjacent to the spinal fusion. RESULTS Weak-to-moderate associations were found between pre-to-postop changes in lumbar lordosis, LL (r = - 0.23, r = - 0.43; p < 0.001), global tilt, GT (r = 0.26, r = 0.38; p < 0.001) and the Global Alignment and Proportion score, GAP (r = 0.26, r = 0.37; p < 0.001), and changes in compressive and shear forces at the proximal segment. GAP score parameters, thoracic kyphosis measurements and the slope of upper instrumented vertebra were associated with changes in shear. In patients with T10-pelvis fusion, moderate-to-strong associations were found between postoperative sagittal alignment measures and compressive and shear loads, with GT showing the strongest correlations (r = 0.75, r = 0.73, p < 0.001). CONCLUSIONS Spinal loads were estimated for patient-specific full spinal alignment profiles in a large cohort of patients with ASD pre-and postoperatively. Loads on the proximal segments were greater in association with sagittal malalignment and malorientation of proximal vertebra. Future work should explore whether they provide a causative mechanism explaining the associated risk of proximal junction complications.
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Affiliation(s)
- Dominika Ignasiak
- Institute for Biomechanics, ETH Zurich, HPP O13, Hönggerbergring 64, 8093, Zurich, Switzerland.
| | - Pascal Behm
- Institute for Biomechanics, ETH Zurich, HPP O13, Hönggerbergring 64, 8093, Zurich, Switzerland
| | - Anne F Mannion
- Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland
| | - Fabio Galbusera
- Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland
| | - Frank Kleinstück
- Department of Spine Surgery, Schulthess Klinik, Zurich, Switzerland
| | - Tamás F Fekete
- Department of Spine Surgery, Schulthess Klinik, Zurich, Switzerland
| | | | - Dezsö Jeszenszky
- Department of Spine Surgery, Schulthess Klinik, Zurich, Switzerland
| | - Laura Zimmermann
- Department of Teaching, Research and Development, Schulthess Klinik, Zurich, Switzerland
| | | | | | - Ferran Pellisé
- Spine Surgery Unit, Hospital Vall d'Hebron, Barcelona, Spain
| | - Ibrahim Obeid
- Pellegrin Bordeaux University Hospital, 33000, Bordeaux, France
| | - Javier Pizones
- Spine Surgery Unit, Hospital Universitario La Paz, Madrid, Spain
| | | | | | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Çaglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Stephen J Ferguson
- Institute for Biomechanics, ETH Zurich, HPP O13, Hönggerbergring 64, 8093, Zurich, Switzerland
| | - Markus Loibl
- Department of Spine Surgery, Schulthess Klinik, Zurich, Switzerland
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20
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Passias PG, Krol O, Owusu-Sarpong S, Tretiakov P, Passfall L, Kummer N, Ani F, Imbo B, Joujon-Roche R, Williamson TK, Sagoo NS, Vira S, Schoenfeld A, De la Garza Ramos R, Janjua MB, Sciubba D, Diebo BG, Paulino C, Smith J, Lafage R, Lafage V. The Effects of Global Alignment and Proportionality Scores on Postoperative Outcomes After Adult Spinal Deformity Correction. Oper Neurosurg (Hagerstown) 2023; 24:533-541. [PMID: 36688681 DOI: 10.1227/ons.0000000000000572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 10/06/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Recent studies have suggested achieving global alignment and proportionality (GAP) alignment may influence mechanical complications after adult spinal deformity (ASD) surgery. OBJECTIVE To investigate the association between the GAP score and mechanical complications after ASD surgery. METHODS Patients with ASD with at least 5-level fusion to pelvis and minimum 2-year data were included. Multivariate analysis was used to find an association between proportioned (P), GAP-moderately disproportioned, and severely disproportioned (GAP-SD) states and mechanical complications (inclusive of proximal junctional kyphosis [PJK], proximal junctional failure [PJF], and implant-related complications [IC]). Severe sagittal deformity was defined by a "++" in the Scoliosis Research Society (SRS)-Schwab criteria for sagittal vertebral axis or pelvic incidence and lumbar lordosis. RESULTS Two hundred ninety patients with ASD were included. Controlling for age, Charlson comorbidity index, invasiveness and baseline deformity, and multivariate analysis showed no association of GAP-moderately disproportioned patients with proximal junctional kyphosis, PJF, or IC, while GAP-SD patients showed association with IC (odds ratio [OR]: 1.7, [1.1-3.3]; P = .043). Aligning in GAP-relative pelvic version led to lower likelihood of all 3 mechanical complications (all P < .04). In patients with severe sagittal deformity, GAP-SD was predictive of IC (OR: 2.1, [1.1-4.7]; P = .047), and in patients 70 years and older, GAP-SD was also predictive of PJF development (OR: 2.5, [1.1-14.9]; P = .045), while improving in GAP led to lower likelihood of PJF (OR: 0.2, [0.02-0.8]; P = .023). CONCLUSION Severely disproportioned in GAP is associated with development of any IC and junctional failure specifically in older patients and those with severe baseline deformity. Therefore, incorporation of patient-specific factors into realignment goals may better strengthen the utility of this novel tool.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Oscar Krol
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Stephane Owusu-Sarpong
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Peter Tretiakov
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Lara Passfall
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Nicholas Kummer
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Fares Ani
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Bailey Imbo
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Rachel Joujon-Roche
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Tyler K Williamson
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Navraj S Sagoo
- Departments of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Shaleen Vira
- Departments of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, Massachusetts, USA
| | - Rafael De la Garza Ramos
- Department of Neurological Surgery Montefiore Medical Center/Albert Einstein College of Medicine Bronx, New York, USA
| | - Muhammad Burhan Janjua
- Department of Neurotrauma, Neuro-oncology, and Spine, Mercy Health, Chicago, Illinois, USA
| | - Daniel Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore Maryland, USA
| | - Bassel G Diebo
- Deparment of Orthopedic Surgery, SUNY Downstate, New York, New York, USA
| | - Carl Paulino
- Deparment of Orthopedic Surgery, SUNY Downstate, New York, New York, USA
| | - Justin Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
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21
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Gendelberg D, Rao A, Chung A, Jimenez-Almonte JH, Anand A, Robinson J, Khandehroo B, Khandehroo B, Kahwaty S, Anand N. Does the Global Alignment and Proportion score predict mechanical complications in circumferential minimally invasive surgery for adult spinal deformity? Neurosurg Focus 2023; 54:E11. [PMID: 36587408 DOI: 10.3171/2022.10.focus22600] [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: 09/01/2022] [Accepted: 10/26/2022] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The Global Alignment and Proportion (GAP) score was developed to serve as a tool to predict mechanical complication probability in patients undergoing surgery for adult spinal deformity (ASD), serving as an aid for setting surgical goals to decrease the prevalence of mechanical complications in ASD surgery. However, it was developed using ASD patients for whom open surgical techniques were used for correction. Therefore, the purpose of this study was to assess the applicability of the score for patients undergoing circumferential minimally invasive surgery (cMIS) for correction of ASD. METHODS Study participants were patients undergoing cMIS ASD surgery without the use of osteotomies with a minimum of four levels fused and 2 years of follow-up. Postoperative GAP scores were calculated for all patients, and the association with mechanical failure was analyzed. RESULTS The authors identified 182 patients who underwent cMIS correction of ASD. Mechanical complications were found in 11.1% of patients with proportioned spinopelvic states, 20.5% of patients with moderately disproportioned spinopelvic states, and 18.8% of patients with severely disproportioned spinopelvic states. Analysis with a chi-square test showed a significant difference between the cMIS and original GAP study cohorts in the moderately disproportioned and severely disproportioned spinopelvic states, but not in the proportioned spinopelvic states. CONCLUSIONS For patients stratified into proportioned, moderately disproportioned, and severely disproportioned spinopelvic states, the GAP score predicted 6%, 47%, and 95% mechanical complication rates, respectively. The mechanical complication rate in patients undergoing cMIS ASD correction did not correlate with the calculated GAP spinopelvic state.
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Affiliation(s)
- David Gendelberg
- 1Department of Orthopaedics, University of California, San Francisco-Orthopaedic Trauma Institute, San Francisco
| | - Arya Rao
- 2Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew Chung
- 3Department of Orthopaedics, Sonoran Spine Institute, Tempe, Arizona
| | - Jose H Jimenez-Almonte
- 4Department of Orthopaedics, Central Florida Bone and Joint Institute, Orange City, Florida
| | - Anita Anand
- 2Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jerry Robinson
- 2Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bardia Khandehroo
- 2Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Babak Khandehroo
- 2Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sheila Kahwaty
- 2Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Neel Anand
- 2Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
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22
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Lopez Poncelas M, La Barbera L, Rawlinson JJ, Polly DW, Aubin CE. Influence of spinal lordosis correction location on proximal junctional failure: a biomechanical study. Spine Deform 2023; 11:49-58. [PMID: 36083462 DOI: 10.1007/s43390-022-00571-z] [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] [Received: 12/22/2021] [Accepted: 08/13/2022] [Indexed: 10/14/2022]
Abstract
STUDY DESIGN Assessment of sagittal lordosis distribution on mechanical proximal junctional failure-related risks through computer-based biomechanical models. OBJECTIVE To biomechanically assess how lordosis distribution influences radiographical and biomechanical indices related to Proximal Junctional Failure (PJF). The "optimal" patient-specific targets to restore the sagittal balance in posterior spinal fusion are still not known. Among these, the effect of the lumbar lordosis correction strategy on complications such as PJF remain uncertain. METHODS In this computational biomechanical study, five adult spinal deformity patients who underwent posterior spinal fixation were retrospectively reviewed. Their surgery, first erect posture and flexion movement were simulated with a patient-specific multibody model. Three pedicle subtraction osteotomy (PSO) levels (L3, L4, and L5) were simulated, with consistent global lordosis for a given patient and pelvic tilt adjusted accordingly to the actual surgery. Computed loads on the anterior spine and instrumentation were analyzed and compared using Kruskal-Wallis statistical tests and Spearman correlations. RESULTS In these models, no significant correlations were found between the lordosis distribution index (LDI), PSO level and biomechanical PJF-related indices. However, increasing the sagittal vertical axis (SVA) and thoracolumbar junction angle (TLJ) and decreasing the sacral slope (SS) increased the bending moment sustained by the rods at the proximal instrumented level (r = 0.52, 0.57, - 0.56, respectively, p < 0.05). There was a negative correlation between SS and the bending moment held by the adjacent proximal segment (r = - 0.71, p < 0.05). CONCLUSION Based on these biomechanical simulations, there was no correlation between the lordosis distribution and PJF-associated biomechanical factors. However, increasing SS and flattening the TLJ, as postural adjustment strategies required by a more distal PSO, did decrease such PJF-related factors. Sagittal restoration and PJF risks remain multifactorial, and the use of patient-specific biomechanical models may help to better understand the complex interrelated mechanisms.
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Affiliation(s)
- Maeva Lopez Poncelas
- Department of Mechanical Engineering, Polytechnique Montréal, Downtown Station, P.O. Box 6079, Montreal, QC, H3C 3A7, Canada.,Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, QC, H3T 1C5, Canada
| | - Luigi La Barbera
- Department of Mechanical Engineering, Polytechnique Montréal, Downtown Station, P.O. Box 6079, Montreal, QC, H3C 3A7, Canada.,Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, QC, H3T 1C5, Canada.,Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Piazza Leonardo da Vinci, 32 20133, Milan, MI, Italy
| | - Jeremy J Rawlinson
- Department of Mechanical Engineering, Polytechnique Montréal, Downtown Station, P.O. Box 6079, Montreal, QC, H3C 3A7, Canada.,Spine Applied Research, Cranial and Spinal Technologies Medtronic, 18400 Pyramid Place, Memphis, TN, 38132, USA
| | - David W Polly
- Department of Orthopaedic Surgery, University of Minnesota, 2512 South 7th Street, Suite R200, Minneapolis, MN, 55455, USA
| | - Carl-Eric Aubin
- Department of Mechanical Engineering, Polytechnique Montréal, Downtown Station, P.O. Box 6079, Montreal, QC, H3C 3A7, Canada. .,Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, QC, H3T 1C5, Canada.
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23
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The validation study of preoperative surgical planning for corrective target in adult spinal deformity surgery with 5-year follow-up for mechanical complications. 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; 31:3662-3672. [PMID: 36245039 DOI: 10.1007/s00586-022-07420-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/05/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE We used the Hamamatsu formula as an indicator of correction goals in surgery for adult spinal deformity (ASD). However, it is reported that correction according to Global Alignment and Proportion (GAP) score and the Roussouly algorithm reduces implant-related complications. The purpose of this study was to validate three preoperative plannings for the incidence of complications. METHODS Patients who underwent ASD surgery and followed up for 5 years were included. The Hamamatsu formula was also divided into three groups: ideal (I), moderate (M), and under (U). The GAP score was divided into three groups: proportioned (P), moderately disproportioned (MD), and severely disproportioned (SD). Patients who met the postoperative Roussouly classification algorithm were defined as the restored (R) group and those who did not were defined as the non-restored (NR) group. Proximal junctional kyphosis (PJK) and rod fractures were investigated. RESULTS In the Hamamatsu formula, there were 51, 108, and 44 patients in Groups I, M, and U, respectively, with no significant differences in their complications. In the GAP score, there were 45, 71, and 87 patients in the P, MD, and SD group, respectively, with no significant differences in their complications. In the Roussouly classification, there were 102 and 101 patients in the R and NR group, respectively, with a significant difference in their complication rate (R/NR = 51%:70%; P = 0.005). PJK was significantly lower in the R group (R/NR = 15%:30%; P = 0.010). CONCLUSION Correction according to the Roussouly algorithm is useful for the prevention of mechanical complications, especially PJK.
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24
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Quarto E, Zanirato A, Pellegrini M, Vaggi S, Vitali F, Bourret S, Le Huec JC, Formica M. GAP score potential in predicting post-operative spinal mechanical complications: a systematic review of the literature. 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; 31:3286-3295. [PMID: 36153789 DOI: 10.1007/s00586-022-07386-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 07/18/2022] [Accepted: 09/10/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In 2017, the GAP score was proposed as a tool to reduce mechanical complications (MC) in adult spinal deformity (ASD) surgery: the reported MC rate for the GAP proportioned category was only 6%, which is clearly lower to the MC rate reported in the literature. The aim of this study is to analyse if the most recent literature confirms the promising results of the original article. MATERIALS AND METHODS Using the PRISMA flow chart, we reviewed the literature to analyse GAP score capacity in predicting MC occurrence. We included articles clearly reporting ASD surgery MC stratified by GAP categories and the score's overall capacity to predict MC using the area under the curve (AUC). The quality of the included studies was evaluated using GRADE and MINORS systems. RESULTS Eleven retrospective articles (1,517 patients in total) were included. The MC distribution per GAP category was as follows: GAP-P, 32.8%; GAP-MD, 42.3%; GAP-SD, 55.4%. No statistically significant difference was observed between the different categories using the Kruskal-Wallis test (p = 0.08) and the two-by-two Pearson-Chi square test (P Vs MD, p = 0.300; P Vs SD, p = 0.275; MD Vs SD, p = 0.137). The global AUC was 0.68 ± 0.2 (moderate accuracy). The included studies were of poor quality according to the GRADE system and had a high risk of bias based on the MINORS criteria. CONCLUSION The actual literature does not corroborate the excellent results reported by the original GAP score article. Further prospective studies, possibly stratified by type of MC and type of surgery, are necessary to validate this score.
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Affiliation(s)
- E Quarto
- Clinica Ortopedica, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy.
| | - A Zanirato
- Clinica Ortopedica, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - M Pellegrini
- Clinica Ortopedica, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - S Vaggi
- Clinica Ortopedica, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - F Vitali
- Clinica Ortopedica, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
| | - S Bourret
- Vertebra, Polyclinique Bordeaux Nord Aquitaine, 15 Rue Boucher, 33300, Bordeaux, France
| | - J C Le Huec
- Vertebra, Polyclinique Bordeaux Nord Aquitaine, 15 Rue Boucher, 33300, Bordeaux, France
| | - M Formica
- Clinica Ortopedica, IRCCS Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, GE, Italy
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25
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Dial BL, Hills JM, Smith JS, Sardi JP, Lazaro B, Shaffrey CI, Bess S, Schwab FJ, Lafage V, Lafage R, Kelly MP, Bridwell KH. The impact of lumbar alignment targets on mechanical complications after adult lumbar scoliosis surgery. 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; 31:1573-1582. [PMID: 35428916 DOI: 10.1007/s00586-022-07200-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/02/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to determine the discriminatory ability of age-adjusted alignment offset and the global alignment and proportion (GAP) score parameters to predict postoperative mechanical complications. METHODS Surgical patients from the Adult Symptomatic Lumbar Scoliosis cohort were reviewed at 2 year follow up. Age-adjusted alignment offsets and GAP parameters were calculated for each patient. A series of nonlinear logistic regression models were fit, and the odds of mechanical complications were calculated. The discriminatory ability of the GAP score, GAP score parameters, and age-adjusted alignment offsets were determined plotting receiver operative characteristic (ROC) with the C statistic (AUC). RESULTS A total of 165 patients were included. A total of 49 mechanical complications occurred in 41 patients (21 proximal junctional kyphosis and 28 pseudoarthrosis). The GAP score had no discriminatory ability in this cohort. Relative lumbar lordosis 15 degrees greater than ideal lumbar lordosis was associated with greater mechanical complications. A lumbar distribution index of 90% was associated with fewer mechanical complications compared to a lumbar distribution index of 65%. Age-adjusted offset alignment targets had no discriminatory ability to predict mechanical complications. CONCLUSION Radiographic alignment targets using either age-adjusted alignment target offset or GAP score parameters had minimal ability to predict mechanical complications in isolation. Mechanical complications following adult spinal deformity surgery are complex, and patient factors play a critical role. Clinical trial registeration This study was registered at ClinicalTrials.gov (number NCT00854828) in March 2009.
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Affiliation(s)
- Brian L Dial
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Jeffrey M Hills
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Juan Pablo Sardi
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Bruno Lazaro
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Frank J Schwab
- Spine Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Spine Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Renaud Lafage
- Spine Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, University of California, San Diego, 3020 Children's Way, San Diego, CA, 92123, USA.
| | - Keith H Bridwell
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
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26
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Yagi M, Hosogane N, Ames CP, Smith JS, Shaffrey CI, Schwab FJ, Lafage V, Bess S, Suzuki S, Satoshi N, Takahashi Y, Tsuji O, Nagoshi N, Nakamura M, Matsumoto M, Watanabe K. Improvement and International Validation of the Predictive Probability of the Patient Demographics, Radiographic Index, and Surgical Invasiveness for Mechanical Failure (PRISM) Model for Preventive Procedures in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2022; 47:680-690. [PMID: 34816814 DOI: 10.1097/brs.0000000000004295] [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] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is an international multicenter retrospective review of 219 surgically treated consecutive adult spinal deformity (ASD) patients who had a minimum of five fused segments, completed a 2-year follow-up. OBJECTIVE The purpose of this study was to add the indices of preventive procedures to improve and to validate the predictive probability of the PRISM (patient demographics, radiographic index, and surgical invasiveness for mechanical failure) for mechanical failure (MF) following ASD surgery. SUMMARY OF BACKGROUND DATA The PRISM was developed from the data of 321 ASD patients, which stratified the risk of MF from six types of risk. METHODS Data from 136 Japanese ASD patients (age 49 ± 21 yr, 88% female) were used to develop PRISM2, and data from 83 US ASD patients (age 58 ± 12 yr, 86% female) were used for the external validation. We analyzed the associations between three preventive procedures (UIV+1 tethering [TH], teriparatide [TP], and multirod [MR]) and MF by multivariate logistic regression analysis (MRA). The values for the nearest integer of the β of the procedures were added to the six indices of the original PRISM to establish the PRISM2. The discriminative ability of the PRISM/ PRISM2 for MF was evaluated using the area under the receiver operating characteristic curve (AUC) and the precision-recall (PR) curve. The Cochran-Armitage test was used to analyze the trend between PRISM/PRISM2 scores and MF. RESULTS MF developed in 25% (34 cases). The β values for the preventive procedures calculated by MRA were TH: -2.5, TP: -3.0, and MR: -2.1. The Cochran-Armitage test showed an excellent trend between MF and PRISM/2. The diagnostic ability was superior for the PRISM2 compared with the PRISM (PRISM2; AUC = 0.94 [0.90-0.98], PRISM; AUC = 0.87 [0.81-0.93], difference = -0.07 [-0.11 to -0.03], P < 0.01). The AUC of the PRISM2 was 0.70 [0.59-0.81, P < 0.01] in the US patient cohort. CONCLUSION We refined the PRISM by adding preventive procedures to the risk indices. Further validation and adjustment in a large different patient cohorts may improve the predictive probability of PRISM2.Level of Evidence: 3.
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Affiliation(s)
- Mitsuru Yagi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Naobumi Hosogane
- Department of Orthopaedic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | | | - Frank J Schwab
- Spine Service, Hospital for Special Surgery, New York, NY
| | | | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, CO
| | - Satoshi Suzuki
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Nori Satoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Takahashi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Osahiko Tsuji
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
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27
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Zileli M, Akıntürk N, Yaman O. Complications of adult spinal deformity surgery: A literature review. J Craniovertebr Junction Spine 2022; 13:17-26. [PMID: 35386240 PMCID: PMC8978850 DOI: 10.4103/jcvjs.jcvjs_159_21] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/03/2022] [Indexed: 11/15/2022] Open
Abstract
Purpose: Adult spinal deformity incidence increases accordingly as the population ages. Even though surgery is the best option for the treatment, the complications due to surgery are pretty challenging. This study aims to review the complication rates of adult spinal deformity surgery. Methods: A literature review of the last decade was performed searching for the query “Adult spine deformity and complication.” This search yielded 2781 results, where 79 articles were chosen to investigate the complications of adult spinal deformity surgery. In addition, the demographic data, surgical interventions, and complications were extracted from the publications. Results: A total of 26,207 patients were analyzed, and 9138 complications were found (34.5%). Implant failure, including screw loosening, breakage, distal and proximal junctional kyphosis, were the most common complications. The neurologic complications were about 10.8%, and the infection rate was 3.6%. Cardiac and pulmonary complications were about 4.8%. Discussion: Age, body mass index, smoking, osteoporosis, and other comorbidities are the significant risk factors affecting adult spinal deformity surgery. Presurgical planning and preoperative risk factor assessment must be done to avoid complications. Furthermore, intra and postoperative complications affect the patients’ quality of life and length of stay, and hospital readmissions. Revision surgery also increases the risk of complications. Conclusion: Good patient evaluation before surgery and careful planning of the surgery are essential in avoiding complications of adult spinal deformity.
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28
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Chou D. Commentary on "Modified Global Alignment and Proportion Scoring With Body Mass Index and Bone Mineral Density Analysis in Global Alignment and Proportion Score of Each 3 Categories for Predicting Mechanical Complications After Adult Spinal Deformity Surgery". Neurospine 2021; 18:492-494. [PMID: 34610680 PMCID: PMC8497246 DOI: 10.14245/ns.2142932.466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Dean Chou
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
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29
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Kim HJ, Yang JH, Chang DG, Suk SI, Suh SW, Kim SI, Song KS, Park JB, Cho W. Proximal Junctional Kyphosis in Adult Spinal Deformity: Definition, Classification, Risk Factors, and Prevention Strategies. Asian Spine J 2021; 16:440-450. [PMID: 33910320 PMCID: PMC9260397 DOI: 10.31616/asj.2020.0574] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/15/2021] [Indexed: 12/03/2022] Open
Abstract
Proximal junctional problems are among the potential complications of surgery for adult spinal deformity (ASD) and are associated with higher morbidity and increased rates of revision surgery. The diverse manifestations of proximal junctional problems range from proximal junctional kyphosis (PJK) to proximal junctional failure (PJF). Although there is no universally accepted definition for PJK, the most common is a proximal junctional angle greater than 10° that is at least 10° greater than the preoperative measurement. PJF represents a progression from PJK and is characterized by pain, gait disturbances, and neurological deficits. The risk factors for PJK can be classified according to patient-related, radiological, and surgical factors. Based on an understanding of the modifiable factors that contribute to reducing the risk of PJK, prevention strategies are critical for patients with ASD.
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Affiliation(s)
- Hong Jin Kim
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jae Hyuk Yang
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Se-Il Suk
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Seung Woo Suh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang-Il Kim
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwang-Sup Song
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jong-Beom Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woojin Cho
- Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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30
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Ham DW, Kim HJ, Choi JH, Park J, Lee J, Yeom JS. Validity of the global alignment proportion (GAP) score in predicting mechanical complications after adult spinal deformity surgery in elderly patients. 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; 30:1190-1198. [PMID: 33528658 DOI: 10.1007/s00586-021-06734-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/30/2020] [Accepted: 01/11/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE This study aimed to validate the usefulness of the global alignment proportion (GAP) score to predict postoperative mechanical failure in the elderly (mean age, 70.5 years) individuals with severe sagittal imbalance. METHODS A total of 84 patients were enrolled: mechanical complications (MC), minor mechanical complications (mMC), proximal junctional failure (PJF), and revision surgery occurred in 61% (51/84), 58% (49/84), 44% (37/84), and 13% (11/84) of the patients, respectively. The GAP score was calculated using the X-ray obtained in the early postoperative period. The validity of the GAP score's predictive ability was evaluated by calculating the area under the curve (AUC) of the receiver operating characteristics curve. Univariate logistic regression analysis and Cochran-Armitage test of trend were performed to determine the association between mechanical complications and GAP score. RESULTS The discriminatory power of GAP score to predict MC, mMC, and PJF was "moderately accurate," with an AUC of 0.839 (confidence interval [CI] 0.755-0.824, p < 0.001), 0.836 (CI 0.749-0.923, p < 0.001), and 0.702 (CI 0.588-0.851, p < 0.001), respectively. The GAP score showed a statistically significant association with MC, mMC, and PJF in univariate logistic regression analysis and Cochran-Armitage test for trend. However, it was not significantly associated with revision surgery. CONCLUSION This study showed promising results regarding the GAP score's predictive power for MC, mMC, and PJF in the elderly population with degenerative kyphoscoliosis. Using the GAP score, we can determine the patient's specific correction goal preoperatively to prevent mechanical failure based on individual patient's characteristics such as pelvic incidence.
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Affiliation(s)
- Dae-Woong Ham
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho-Joong Kim
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Seoul National University Bundang Hospital, 166 Gumiro Bundang-gu, Seongnam, 463-707, Republic of Korea.
| | - Jae Heouk Choi
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jiwon Park
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Junpyo Lee
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin S Yeom
- Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
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