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Smith JS, Elias E, Sursal T, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias P, Nasser Z, Gum JL, Eastlack R, Daniels A, Mundis G, Hostin R, Protopsaltis TS, Soroceanu A, Hamilton DK, Kelly MP, Lewis SJ, Gupta M, Schwab FJ, Burton D, Ames CP, Lenke LG, Shaffrey CI, Bess S. How Good Are Surgeons at Achieving Their Preoperative Goal Sagittal Alignment Following Adult Deformity Surgery? Global Spine J 2024; 14:1924-1936. [PMID: 36821516 DOI: 10.1177/21925682231161304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
STUDY DESIGN Multicenter, prospective cohort. OBJECTIVES Malalignment following adult spine deformity (ASD) surgery can impact outcomes and increase mechanical complications. We assess whether preoperative goals for sagittal alignment following ASD surgery are achieved. METHODS ASD patients were prospectively enrolled based on 3 criteria: deformity severity (PI-LL ≥25°, TPA ≥30°, SVA ≥15 cm, TCobb≥70° or TLCobb≥50°), procedure complexity (≥12 levels fused, 3-CO or ACR) and/or age (>65 and ≥7 levels fused). The surgeon documented sagittal alignment goals prior to surgery. Goals were compared with achieved alignment on first follow-up standing radiographs. RESULTS The 266 enrolled patients had a mean age of 61.0 years (SD = 14.6) and 68% were women. Mean instrumented levels was 13.6 (SD = 3.8), and 23.2% had a 3-CO. Mean (SD) offsets (achieved-goal) were: SVA = -8.5 mm (45.6 mm), PI-LL = -4.6° (14.6°), TK = 7.2° (14.7°), reflecting tendencies to undercorrect SVA and PI-LL and increase TK. Goals were achieved for SVA, PI-LL, and TK in 74.4%, 71.4%, and 68.8% of patients, respectively, and was achieved for all 3 parameters in 37.2% of patients. Three factors were independently associated with achievement of all 3 alignment goals: use of PACs/equivalent for surgical planning (P < .001), lower baseline GCA (P = .009), and surgery not including a 3-CO (P = .037). CONCLUSIONS Surgeons failed to achieve goal alignment of each sagittal parameter in ∼25-30% of ASD patients. Goal alignment for all 3 parameters was only achieved in 37.2% of patients. Those at greatest risk were patients with more severe deformity. Advancements are needed to enable more consistent translation of preoperative alignment goals to the operating room.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Elias Elias
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, USA
| | - Tolga Sursal
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Breton Line
- Department of Orthopedic Surgery, Presbyterian St Lukes Medical Center, Denver, CO, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Zeina Nasser
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | - Jeffrey L Gum
- Department of Orthopedic Surgery, Leatherman Spine Center, Louisville, KY, USA
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | - Alan Daniels
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX, USA
| | | | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, AB, Canada
| | | | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Stephen J Lewis
- Department of Surgery, Division of Orthopedic Surgery, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO, USA
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Shay Bess
- Department of Orthopedic Surgery, Presbyterian St Lukes Medical Center, Denver, CO, USA
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Diebo BG, Balmaceno-Criss M, Lafage R, Daher M, Singh M, Hamilton DK, Smith JS, Eastlack RK, Fessler R, Gum JL, Gupta MC, Hostin R, Kebaish KM, Lewis S, Line BG, Nunley PD, Mundis GM, Passias PG, Protopsaltis TS, Turner J, Buell T, Scheer JK, Mullin J, Soroceanu A, Ames CP, Bess S, Shaffrey CI, Lenke LG, Schwab FJ, Lafage V, Burton DC, Daniels AH. Lumbar Lordosis Redistribution and Segmental Correction in Adult Spinal Deformity: Does it Matter? Spine (Phila Pa 1976) 2024; 49:1187-1194. [PMID: 38270393 DOI: 10.1097/brs.0000000000004930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/01/2024] [Indexed: 01/26/2024]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE Evaluate the impact of correcting normative segmental lordosis values on postoperative outcomes. BACKGROUND Restoring lumbar lordosis magnitude is crucial in adult spinal deformity surgery, but the optimal location and segmental distribution remain unclear. PATIENTS AND METHODS Patients were grouped based on offset to normative segmental lordosis values, extracted from recent publications. Matched patients were within 10% of the cohort's mean offset, less than or over 10% were undercorrected and overcorrected. Surgical technique, patient-reported outcome measures, and surgical complications were compared across groups at baseline and two years. RESULTS In total, 510 patients with a mean age of 64.6, a mean Charlson comorbidity index 2.08, and a mean follow-up of 25 months. L4-5 was least likely to be matched (19.1%), while L4-S1 was the most likely (24.3%). More patients were overcorrected at proximal levels (T10-L2; undercorrected, U: 32.2% vs. matched, M: 21.7% vs. overcorrected, O: 46.1%) and undercorrected at distal levels (L4-S1: U: 39.0% vs. M: 24.3% vs. O: 36.8%). Postoperative Oswestry disability index was comparable across correction groups at all spinal levels except at L4-S1 and T10-L2/L4-S1, where overcorrected patients and matched were better than undercorrected (U: 32.1 vs. M: 25.4 vs. O: 26.5, P =0.005; U: 36.2 vs. M: 24.2 vs. O: 26.8, P =0.001; respectively). Patients overcorrected at T10-L2 experienced higher rates of proximal junctional failure (U: 16.0% vs. M: 15.6% vs. O: 32.8%, P <0.001) and had greater posterior inclination of the upper instrumented vertebrae (U: -9.2±9.4° vs. M: -9.6±9.1° vs. O: -12.2±10.0°, P <0.001), whereas undercorrection at these levels led to higher rates of revision for implant failure (U: 14.2% vs. M: 7.3% vs. O: 6.4%, P =0.025). CONCLUSIONS Patients undergoing fusion for adult spinal deformity suffer higher rates of proximal junctional failure with overcorrection and increased rates of implant failure with undercorrection based on normative segmental lordosis. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Bassel G Diebo
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Mariah Balmaceno-Criss
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Mohammad Daher
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Manjot Singh
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | | | - Richard Fessler
- Department of Neurosurgery, Rush Medical College, Chicago, IL
| | | | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, MO
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, TX
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen Lewis
- Department of Orthopedics, University of Toronto, Toronto, Canada
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Center, Denver, CO
| | | | | | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | | | | | - Thomas Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin K Scheer
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
| | - Jeffery Mullin
- Department of Neurosurgery, University of Buffalo, Amherst, New York, NY
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, Canada
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Denver, CO
| | | | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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Hyun SJ, An S, Park BJ, Lee JK, Yang SH, Kim KJ. Gravity Line-Hip Axis Offset as a Guide for Global Alignment to Prevent Recurrent Proximal Junctional Kyphosis/Failure. Oper Neurosurg (Hagerstown) 2024; 26:268-278. [PMID: 37856767 DOI: 10.1227/ons.0000000000000962] [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: 07/05/2023] [Accepted: 09/08/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Proximal junctional kyphosis/failure (PJK/F) is a potentially serious complication after adult spinal deformity (ASD) corrective surgery. Recurrent PJK/F is especially troublesome, necessitating fusion extension and occasionally resulting in irreversible neurological deficits. The gravity line (GL) offers valuable insights into global sagittal balance. This study aims to examine the postoperative GL-hip axis (GL-HA) offset as a critical risk factor for recurrent PJK/F. METHODS We retrospectively reviewed patients with ASD who had undergone revision surgery for initial PJK/F at a single academic center. Patients were categorized into 2 groups: nonrecurrent PJK/F group and recurrent PJK/F group. Demographics, surgical characteristics, preoperative and postoperative parameters of spinopelvic and global alignment, and the Scoliosis Research Society-22 scores were assessed. We examined these measures for differences and correlations with recurrent PJK/F. RESULTS Our study included 32 patients without recurrent PJK/F and 28 patients with recurrent PJK/F. No significant differences were observed in baseline demographics, operative characteristics, or Scoliosis Research Society-22 scores before and after surgery. Importantly, using a cutoff of -52.6 mm from logistic regression, there were considerable differences and correlations with recurrent PJK/F in the postoperative GL-HA offset, leading to an odds ratio of 7.0 (95% CI: 1.94-25.25, P = .003). CONCLUSION Postoperative GL-HA offset serves as a considerable risk factor for recurrent PJK/F in patients with ASD who have undergone revision surgery. Overcorrection, with GL-HA offset less than -5 cm, is associated with recurrent PJK/F. The instrumented spine tends to align the GL near the HA, even at the cost of proximal junction.
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Affiliation(s)
- Seung-Jae Hyun
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam , Korea
| | - Sungjae An
- Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul , Korea
| | | | - Jae-Koo Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam , Korea
| | | | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam , Korea
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Smith JS, Mundis GM, Osorio JA, Nicolau RJ, Temple-Wong M, Lafage R, Bess S, Ames CP. Analysis of Personalized Interbody Implants in the Surgical Treatment of Adult Spinal Deformity. Global Spine J 2023:21925682231216926. [PMID: 38124314 DOI: 10.1177/21925682231216926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
STUDY DESIGN Multicenter cohort. OBJECTIVES A report from the International Spine Study Group (ISSG) noted that surgeons failed to achieve alignment goals in nearly two-thirds of 266 complex adult deformity surgery (CADS) cases. We assess whether personalized interbody spacers are associated with improved rates of achieving goal alignment following adult spinal deformity (ASD) surgery. METHODS ASD patients were included if their surgery utilized 3D-printed personalized interbody spacer(s) and they met ISSG CADS inclusion criteria. Planned alignment was personalized by the surgeon during interbody planning. Planned vs achieved alignment was assessed and compared with the ISSG CADS series that used stock interbodies. RESULTS For 65 patients with personalized interbodies, 62% were women, mean age was 70.3 years (SD = 8.3), mean instrumented levels was 9.9 (SD = 4.1), and the mean number of personalized interbodies per patient was 2.2 (SD = .8). Segmental alignment was achieved close to plan for levels with personalized interbodies, with mean difference between goal and achieved as follows: intervertebral lordosis = .9° (SD = 5.2°), intervertebral coronal angle = .1° (SD = 4.7°), and posterior disc height = -0.1 mm (SD = 2.3 mm). Achieved pelvic incidence-to-lumbar lordosis mismatch (PI-LL) correlated significantly with goal PI-LL (r = .668, P < .001). Compared with the ISSG CADS cohort, utilization of personalized interbodies resulted in significant improvement in achieving PI-LL <5° of plan (P = .046) and showed a significant reduction in cases with PI-LL >15° of plan (P = .012). CONCLUSIONS This study supports use of personalized interbodies as a means of better achieving goal segmental sagittal and coronal alignment and significantly improving achievement of goal PI-LL compared with stock devices.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Gregory M Mundis
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | - Joseph A Osorio
- Department of Neurological Surgery, University of California, San Diego, San Diego, CA, USA
| | | | | | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Shay Bess
- Presbyterian St Lukes Medical Center, Denver, CO, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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Balmaceno-Criss M, Alsoof D, Lafage R, Diebo BG, Daniels AH, Schwab F, Lafage V. Proximal Junctional Kyphosis Prevention Strategies Focused on Alignment. Int J Spine Surg 2023; 17:S38-S46. [PMID: 37364936 PMCID: PMC10626131 DOI: 10.14444/8513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Adult spinal deformity (ASD) is a complex pathology associated with spinal malalignment in the coronal, sagittal, and axial planes. Proximal junction kyphosis (PJK) is a complication of ASD surgery, affecting 10%-48% of patients, and can result in pain and neurological deficit. It is defined radiographically as a greater than 10° Cobb angle between the upper instrumented vertebrae and the 2 vertebrae proximal to the superior endplate. Risk factors are classified according to the patient, surgery, and overall alignment, but it is important to consider the interplay between various factors. This article reviews the risk factors of PJK and considers alignment-focused prevention strategies.
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Affiliation(s)
- Mariah Balmaceno-Criss
- Department of Orthopedics, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Daniel Alsoof
- Department of Orthopedics, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Renaud Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Bassel G Diebo
- Department of Orthopedics, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopedics, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Frank Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
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