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Passias PG, Pierce KE, Williamson TK, Lebovic J, Schoenfeld AJ, Lafage R, Lafage V, Gum JL, Eastlack R, Kim HJ, Klineberg EO, Daniels AH, Protopsaltis TS, Mundis GM, Scheer JK, Park P, Chou D, Line B, Hart RA, Burton DC, Bess S, Schwab FJ, Shaffrey CI, Smith JS, Ames CP. Patient-specific Cervical Deformity Corrections With Consideration of Associated Risk: Establishment of Risk Benefit Thresholds for Invasiveness Based on Deformity and Frailty Severity. Clin Spine Surg 2024; 37:E43-E51. [PMID: 37798829 DOI: 10.1097/bsd.0000000000001540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 08/10/2023] [Indexed: 10/07/2023]
Abstract
STUDY DESIGN/SETTING This was a retrospective cohort study. BACKGROUND Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty. OBJECTIVE The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity. METHODS This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely. RESULTS A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P =0.002], and invasiveness increased with deformity severity ( P <0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P =0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P =0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P =0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group. CONCLUSIONS Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Katherine E Pierce
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Jordan Lebovic
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California-Davis, Davis, CA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
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Salottolo K, Betancourt A, Banton KL, Acuna D, Panchal R, Bar-Or D, Palacio CH. Epidemiology of C2 fractures and determinants of surgical management: analysis of a national registry. Trauma Surg Acute Care Open 2023; 8:e001094. [PMID: 37342819 PMCID: PMC10277549 DOI: 10.1136/tsaco-2023-001094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/26/2023] [Indexed: 06/23/2023] Open
Abstract
Objective Operative management of axis fractures (C2) usually depend on the stability and location of the break and individual patient characteristics. We sought to describe the epidemiology of C2 fractures and hypothesized that determinants for surgery would differ by fracture diagnosis. Methods Patients with C2 fractures were identified from the US National Trauma Data Bank from January 1, 2017, to January 1, 2020. Patients were classified by C2 fracture diagnosis: odontoid type II, odontoid types I and III, and non-odontoid fracture (hangman's fracture or fractures through base of the axis). The primary comparison was C2 fracture surgery versus non-operative management. Multivariate logistic regression was used to identify independent associations with surgery. Decision tree-based models were developed to identify determinants for surgery. Results There were 38 080 patients; 42.7% had an odontoid type II fracture; 16.5% had an odontoid type I/III fracture; and 40.8% had a non-odontoid fracture. All examined patient demographics, clinical characteristics, outcomes, and interventions differed by C2 fracture diagnosis. Overall, 5292 (13.9%) were surgically managed (17.5% odontoid type II, 11.0% odontoid type I/III, and 11.2% non-odontoid; p<0.001). The following covariates increased odds of surgery for all three fracture diagnoses: younger age, treatment at a level I trauma center, fracture displacement, cervical ligament sprain, and cervical subluxation. Determinants of surgery differed by fracture diagnosis: for odontoid type II, age ≤80 years, a displaced fracture, and cervical ligament sprain were determinants; for odontoid type I/III, age ≤85 years, a displaced fracture, and cervical subluxation were determinants; for non-odontoid fractures, cervical subluxation and cervical ligament sprain were the strongest determinants for surgery, by hierarchy. Conclusions This is the largest published study of C2 fractures and current surgical management in the USA. Odontoid fractures, regardless of type, had age and fracture displacement as the strongest determinants for surgical management, whereas associated injuries were determinants of surgery for non-odontoid fractures. Level of evidence III.
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Affiliation(s)
| | | | | | - David Acuna
- Trauma Services, Wesley Medical Center, Wichita, Kansas, USA
| | - Ripul Panchal
- Neurosurgery, American Neurospine Institute, PLLC, Plano, Texas, USA
- Neurosurgery, Medical City Plano, Plano, Texas, USA
| | - David Bar-Or
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
| | - Carlos H Palacio
- Trauma Services, South Texas Health System McAllen, McAllen, TX, USA
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Lemos JL, Welch JM, Xiao M, Shapiro LM, Adeli E, Kamal RN. Is Frailty Associated with Adverse Outcomes After Orthopaedic Surgery?: A Systematic Review and Assessment of Definitions. JBJS Rev 2021; 9:01874474-202112000-00006. [PMID: 34936580 DOI: 10.2106/jbjs.rvw.21.00065] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND There is increasing evidence supporting the association between frailty and adverse outcomes after surgery. There is, however, no consensus on how frailty should be assessed and used to inform treatment. In this review, we aimed to synthesize the current literature on the use of frailty as a predictor of adverse outcomes following orthopaedic surgery by (1) identifying the frailty instruments used and (2) evaluating the strength of the association between frailty and adverse outcomes after orthopaedic surgery. METHODS A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were searched to identify articles that reported on outcomes after orthopaedic surgery within frail populations. Only studies that defined frail patients using a frailty instrument were included. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Study demographic information, frailty instrument information (e.g., number of items, domains included), and clinical outcome measures (including mortality, readmissions, and length of stay) were collected and reported. RESULTS The initial search yielded 630 articles. Of these, 177 articles underwent full-text review; 82 articles were ultimately included and analyzed. The modified frailty index (mFI) was the most commonly used frailty instrument (38% of the studies used the mFI-11 [11-item mFI], and 24% of the studies used the mFI-5 [5-item mFI]), although a large variety of instruments were used (24 different instruments identified). Total joint arthroplasty (22%), hip fracture management (17%), and adult spinal deformity management (15%) were the most frequently studied procedures. Complications (71%) and mortality (51%) were the most frequently reported outcomes; 17% of studies reported on a functional outcome. CONCLUSIONS There is no consensus on the best approach to defining frailty among orthopaedic surgery patients, although instruments based on the accumulation-of-deficits model (such as the mFI) were the most common. Frailty was highly associated with adverse outcomes, but the majority of the studies were retrospective and did not identify frailty prospectively in a prediction model. Although many outcomes were described (complications and mortality being the most common), there was a considerable amount of heterogeneity in measurement strategy and subsequent strength of association. Future investigations evaluating the association between frailty and orthopaedic surgical outcomes should focus on prospective study designs, long-term outcomes, and assessments of patient-reported outcomes and/or functional recovery scores. CLINICAL RELEVANCE Preoperatively identifying high-risk orthopaedic surgery patients through frailty instruments has the potential to improve patient outcomes. Frailty screenings can create opportunities for targeted intervention efforts and guide patient-provider decision-making.
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Affiliation(s)
- Jacie L Lemos
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Jessica M Welch
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Michelle Xiao
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, California
| | - Ehsan Adeli
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, California
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Kim SK, Rhee JM, Park ET, Seo HY. Surgical Outcomes for C 2 Tear Drop Fractures: Clinical Relevance to Hangman's Fracture and C 2-3 Discoligamentous Injury. Orthop Surg 2021; 13:2363-2372. [PMID: 34791834 PMCID: PMC8654653 DOI: 10.1111/os.13163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/24/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To analyze characteristics of surgically managed tear drop (TD) fractures of the C2 axis associated with other injuries such as hangman's fracture and C2‐3 discoligamentous injury as well as treatment outcomes. Methods A total of 14 patients (eight men and six women) with TD fractures of the C2, who were surgically treated at four national trauma centers of tertiary university hospitals from January 2000 to December 2017, were included in this retrospective study. The mean age of the patients was 45.5 years (ranging from 19 to 74 years). The characteristics, surgical treatment methods (anterior fusion vs posterior fusion), and results of 14 TD fractures of the C2 were analyzed retrospectively. And the clinical relevance between C2 TD fracture and hangman's fracture and C2‐3 discoligamentous injury was investigated through the co‐occurrence between injuries. The mean follow‐up time after surgery was 22.6 months (ranging from 12 to 60 months). Results Among 14 patients with TD fracture of the C2, four patients (28.6%) had anterior TD fracture and 10 patients (71.4%) had posterior TD fracture. All 10 posterior TD fracture patients had anterior C2‐3 displacement. While two of four anterior TD fracture patients had posterior C2‐3 displacement, the remaining two did not. All 14 patients of TD fracture had at least two or more other associated C2 injuries as well as C2‐3 discoligamentous injuries. About 92.9% (13/14) of the patients had typical or atypical hangman's fracture; 100% (10/10) of the posterior TD fracture patients had hangman's fracture, but 75% (3/4) of the anterior TD fracture had hangman's fracture. At admission, 13 patients were neurologically intact. However, the remaining patient had spinal cord injury with American Spinal Injury Association (ASIA) impairment scale B with C2‐3 bilateral facet dislocation. All four anterior TD fracture patients underwent posterior C2‐3 fusion. While four of 10 posterior TD fracture patients underwent C2‐3 anterior fusion, the remaining six underwent posterior fusion. At last follow‐up, 100% (14/14) of the patients achieved solid fusion, and visual analog scale for neck pain was significantly improved (5.9 vs 2.2, P < 0.001). One patient with ASIA impairment scale B had significantly improved to scale D. No major complications occurred. Conclusion Our study showed that surgically managed TD fractures of the C2 showed a high incidence of other associated spine injuries including hangman's fracture and C2‐3 discoligamentous injury. Therefore, special attention and careful radiologic evaluation are needed to investigate the presence of other associated spine injuries including hangman's fracture and C2‐3 discoligamentous injury, which are likely to require surgery.
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Affiliation(s)
- Sung-Kyu Kim
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea.,Department of Orthopaedic Surgery, Emory Spine Center, Emory University, Atlanta, Georgia, USA
| | - John M Rhee
- Department of Orthopaedic Surgery, Emory Spine Center, Emory University, Atlanta, Georgia, USA
| | - Eric T Park
- Department of Biology, College of Arts and Sciences, Emory University, Atlanta, Georgia, USA
| | - Hyoung-Yeon Seo
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
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Park JB, Kim SK, Seo HY, Ko JH, Hong TM. Proposal of Treatment Strategy for Pedicle Fractures of the C2: An Analysis of 49 Cases. J Clin Med 2021; 10:jcm10173987. [PMID: 34501435 PMCID: PMC8432505 DOI: 10.3390/jcm10173987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 11/16/2022] Open
Abstract
Spine surgeons often confuse C2 pedicle fractures (PFs) with pars interarticularis fractures. In addition, little information is available about the characteristics and treatment strategies for C2 PFs. We sought to investigate the characteristics of C2 PFs and to propose an appropriate treatment strategy. A total of forty-nine patients with C2 PFs were included in this study. We divided these patients into unilateral and bilateral C2 PF groups. The incidence rates and characteristics of other associated C2 and C2-3 injuries, and other cervical injuries, were evaluated. In addition, treatment methods and outcomes were analyzed. Twenty-two patients had unilateral C2 PFs and twenty-seven patients had bilateral C2 PFs. Among the cases of unilateral C2 PFs, all patients had one or more other C2 fractures, and twenty patients (90.9%) had one or two C2 body fractures. Meanwhile, among the cases of bilateral C2 PF, all patients had two or more other C2 fractures and one or two C2 body fractures. In unilateral C2 PFs, three patients with C2-3 anterior slip or adjacent cervical spine (C1-3) injury underwent surgery and nineteen patients (86.4%) were treated with conservative methods. In bilateral C2 PFs, three patients with C2-3 anterior slip or SCI at C2-3 underwent surgery and twenty-four patients (88.9%) were treated with conservative methods. Our results showed that C2 PFs do not occur alone and are always accompanied by other associated C2 injuries. C2 PFs should, generally, be thought of as a more complex fracture type than hangman's fracture or dens fracture. Despite the complex fracture characteristics, most C2 PFs can be managed with conservative treatment. However, surgical treatments should be considered if the C2 PFs are accompanied by the C2-3 anterior slip and adjacent cervical spine injury.
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Affiliation(s)
- Jong-Beom Park
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.-B.P.); (T.-M.H.)
| | - Sung-Kyu Kim
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju 61469, Korea;
- Correspondence:
| | - Hyoung-Yeon Seo
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hospital, Gwangju 61469, Korea;
| | - Jong-Hyun Ko
- Department of Orthopaedic Surgery, Chonbuk National University Hospital, Jeonju 54907, Korea;
| | - Tae-Min Hong
- Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (J.-B.P.); (T.-M.H.)
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Analysis of Nonunion in Conservatively Managed Anterior Tear Drop Fractures of C2 Vertebra. J Clin Med 2021; 10:jcm10092037. [PMID: 34068661 PMCID: PMC8126078 DOI: 10.3390/jcm10092037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/06/2021] [Accepted: 05/05/2021] [Indexed: 11/16/2022] Open
Abstract
Many anterior C2 (2nd cervical vertebra) tear drop (TD) fractures can be successfully managed with conservative treatment. However, due to the occurrence of nonunion, large-sized or complex anterior C2 TD fractures undergo surgical treatment. To date, no surgical treatment guidelines are available about anterior C2 TD fractures. Therefore, we performed this study to investigate the factors that may affect nonunion for anterior C2 TD fractures and to suggest surgical treatment guidelines. Thirty-three patients with anterior C2 TD fractures, who underwent conservative treatment and had a minimum 1-year follow-up, were divided into union (N = 26) and nonunion (N = 7) groups. Their radiological and clinical data were analyzed retrospectively and compared between the two groups. The avulsion fracture ratio (29.5% vs. 43.3%, p < 0.05) and fracture displacement (3.6 mm vs. 5.1 mm, p < 0.05) were higher in the nonunion group compared to the union group. Incidence of associated C2 injury was higher in the nonunion group compared to the union group (15.4% vs. 57.1%, p < 0.05). Union status was negatively correlated with associated C2 injury (correlation coefficient, CC = -0.398, p < 0.05). Our results suggest that surgical treatment could be considered for anterior C2 TD fractures with an avulsion fracture ratio > 43%, fracture displacement > 5 mm, or associated C2 injury.
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