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Issa TZ, Tarawneh OH, Ezeonu T, Haider AA, Narayanan R, Canseco JA, Hilibrand AS, Vaccaro AR, Schroeder GD, Kepler CK. The attainment of a patient acceptable symptom state in patients undergoing revision spine fusion. 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 2024:10.1007/s00586-024-08358-8. [PMID: 38913182 DOI: 10.1007/s00586-024-08358-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 05/23/2024] [Accepted: 06/02/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes. The primary aim of this study was to assess whether patients achieved the patient acceptable symptom state (PASS) or minimal clinically important difference (MCID) after revision lumbar fusion and assess whether this was influenced by the indication for revision. METHODS We retrospectively identified all 1-3 level revision lumbar fusions at a single institution. Oswestry Disability Index (ODI) was collected at preoperative, three-month postoperative, and one-year postoperative time points. The MCID was calculated using a distribution-based method at each postoperative time point. PASS was set at the threshold of ≤ 22. RESULTS We identified 197 patients: 56% with ASD, 28% with recurrent stenosis, and 15% with pseudarthrosis. The MCID for ODI was 10.05 and 10.23 at three months and one year, respectively. In total, 61% of patients with ASD, 52% of patients with nonunion, and 65% of patients with recurrent stenosis achieved our cohort-specific MCID at one year postoperatively with ASD (p = 0.78). At one year postoperatively, 33.8% of ASD patients, 47.8% of nonunion patients, and 37% of patients with recurrent stenosis achieved PASS without any difference between indication (p = 0.47). CONCLUSIONS The majority of patients undergoing revision spine fusion experience significant postoperative improvements regardless of the indication for revision. However, a large proportion of these patients do not achieve the patient acceptable symptom state. While revision spine surgery may offer substantial benefits, these results underscore the need to manage patient expectations.
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Affiliation(s)
- Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Feinberg School of Medicine, Northwestern University, 420 E Superior St Chicago Il, Chicago, IL, 60611, USA.
| | - Omar H Tarawneh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Teeto Ezeonu
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ameer A Haider
- Department of Orthopaedic Surgery, Washington University Hospital, St. Louis, MO, USA
| | - Rajkishen Narayanan
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
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Samdani AF, Plachta SM, Pahys JM, Quinonez A, Samuel SP, Hwang SW. Results of posterior spinal fusion after failed anterior vertebral body tethering. Spine Deform 2024; 12:367-373. [PMID: 38142246 DOI: 10.1007/s43390-023-00796-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/18/2023] [Indexed: 12/25/2023]
Abstract
PURPOSE In patients with adolescent idiopathic scoliosis (AIS) undergoing anterior vertebral tethering (AVBT), some will subsequently require posterior spinal fusion (PSF). Limited data exist on clinical and radiographic outcomes of fusion after tether failure. METHODS 490 patients who underwent AVBT were retrospectively analyzed. Twenty patients (4.1%) subsequently underwent conversion to PSF. A control group of patients with primary PSF (no previous AVBT) was matched for comparison. Data were compared using paired t-tests and Fisher Exact Tests. RESULTS There was a significant increase in estimated blood loss (EBL) (p = 0.002), percent estimated blood volume (%EBV) (p = 0.013), operative time (p = 0.002), and increased amount of fluoroscopy (mGy) (p = 0.04) as well as number of levels fused (p = 0.02) in the AVBT conversion group compared to primary fusion. However, no difference was found in implant density (p = 0.37), blood transfusions (p = 0.11), or intraoperative neuromonitoring events (p > 0.99). Both groups attained similar thoracic and lumbar percent correction (major coronal curve angle) from pre-op to the latest follow-up (thoracic p = 0.507, lumbar p = 0.952). CONCLUSION A subset of patients with AVBT will require conversion to PSF. Although technically more challenging, revision surgery can be safely performed with similar clinical and radiographic outcomes to primary PSF. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Amer F Samdani
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA.
| | - Stephen M Plachta
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Joshua M Pahys
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Alejandro Quinonez
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Solomon P Samuel
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
| | - Stephen W Hwang
- Shriners Children's-Philadelphia, 3551 N Broad St, Philadelphia, PA, 19140, USA
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Passias PG, Krol O, Williamson TK, Lafage V, Lafage R, Smith JS, Line B, Vira S, Lipa S, Daniels A, Diebo B, Schoenfeld A, Gum J, Kebaish K, Park P, Mundis G, Hostin R, Gupta MC, Eastlack R, Anand N, Ames C, Hart R, Burton D, Schwab FJ, Shaffrey C, Klineberg E, Bess S. The Benefit of Addressing Malalignment in Revision Surgery for Proximal Junctional Kyphosis Following ASD Surgery. Spine (Phila Pa 1976) 2023; 48:1581-1587. [PMID: 36083599 DOI: 10.1097/brs.0000000000004476] [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: 02/08/2022] [Accepted: 06/23/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Understand the benefit of addressing malalignment in revision surgery for proximal junctional kyphosis (PJK). SUMMARY OF BACKGROUND DATA PJK is a common cause of revision surgery for adult spinal deformity patients. During a revision, surgeons may elect to perform a proximal extension of the fusion, or also correct the source of the lumbopelvic mismatch. MATERIALS AND METHODS Recurrent PJK following revision surgery was the primary outcome. Revision surgical strategy was the primary predictor (proximal extension of fusion alone compared with combined sagittal correction and proximal extension). Multivariable logistic regression determined rates of recurrent PJK between the two surgical groups with lumbopelvic surgical correction assessed through improving ideal alignment in one or more alignment criteria [Global Alignment and Proportionality (GAP), Roussouly-type, and Sagittal Age-Adjusted Score (SAAS)]. RESULTS A total of 151 patients underwent revision surgery for PJK. PJK occurred at a rate of 43.0%, and PJF at 12.6%. Patients proportioned in GAP postrevision had lower rates of recurrent PJK [23% vs. 42%; odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8, P =0.024]. Following adjusted analysis, patients who were ideally aligned in one of three criteria (Matching in SAAS and/or Roussouly matched and/or achieved GAP proportionality) had lower rates of recurrent PJK (36% vs. 53%; OR: 0.4, 95% CI: 0.1-0.9, P =0.035) and recurrent PJF (OR: 0.1, 95% CI: 0.02-0.7, P =0.015). Patients ideally aligned in two of three criteria avoid any development of PJF (0% vs. 16%, P <0.001). CONCLUSIONS Following revision surgery for PJK, patients with persistent poor sagittal alignment showed increased rates of recurrent PJK compared with patients who had abnormal lumbopelvic alignment corrected during the revision. These findings suggest addressing the root cause of surgical failure in addition to proximal extension of the fusion may be beneficial.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Oscar Krol
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Shaleen Vira
- Department of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, TX
| | - Shaina Lipa
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Alan Daniels
- Department of Orthopedics, Brown University, Warren Alpert Medical School, Providence, RI
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY
| | - Andrew Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, MD
| | - Paul Park
- Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, TX
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
| | - Robert Eastlack
- Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, CA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
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Park WT, Woo IH, Park SJ, Lee GW. Predictors of Vertebral Endplate Fractures after Oblique Lumbar Interbody Fusion. Clin Orthop Surg 2023; 15:809-817. [PMID: 37811501 PMCID: PMC10551679 DOI: 10.4055/cios23037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/25/2023] [Accepted: 03/25/2023] [Indexed: 10/10/2023] Open
Abstract
Background Cage subsidence after oblique lumbar interbody fusion (OLIF) induces restenosis and adversely affects patient outcomes. Many studies have investigated the causes of subsidence, one of which is endplate fracture (EF). This study aimed to identify predictors of EF after OLIF. Methods This retrospective study reviewed consecutive patients who underwent OLIF at a single institute between August 2019 and February 2022. A total of 104 patients were enrolled. The patients' demographic data and surgical details were collected through chart reviews. Radiographic variables were measured. Related variables were also analyzed using binomial logistic regression, dividing each group into those with versus without EF. Results EF occurred at 30 of 164 levels (18.3%), and the binary logistic analysis revealed that sex (odds ratio [OR], 11.07), inferior endplate concave depth (OR, 1.95), disc wedge angle (OR, 1.22), lumbar lordosis (OR, 1.09), pelvic incidence (OR, 1.07), sagittal vertical axis (OR, 1.02), sacral slope (OR, 0.9), L3-4 level (OR, 0.005), and L4-5 level (OR, 0.004) were significantly related to EF. Conclusions OLIF in older Asian patients should be performed carefully after recognizing the high possibility of EF and confirming the factors that should be considered preoperatively.
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Affiliation(s)
- Wook Tae Park
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - In Ha Woo
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung Jin Park
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Gun Woo Lee
- Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
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Revision lumbar fusions have higher rates of reoperation and result in worse clinical outcomes compared to primary lumbar fusions. Spine J 2023; 23:105-115. [PMID: 36064090 DOI: 10.1016/j.spinee.2022.08.018] [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: 06/10/2022] [Revised: 07/19/2022] [Accepted: 08/26/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT Indications for revision lumbar fusion are variable, but include recurrent stenosis (RS), adjacent segment disease (ASD), and pseudarthrosis. The efficacy of revision lumbar fusion has been well established, but their outcomes compared to primary procedures is not well documented. PURPOSE The purpose of this study was to compares surgical and clinical outcomes between (1) revision and primary lumbar fusion, (2) revision lumbar fusion based on indication (ASD, pseudarthrosis, or RS), and (3) revision lumbar fusion based on whether the index procedure included an isolated decompression or decompression with fusion. STUDY DESIGN/SETTING Retrospective single-institution cohort study. PATIENT SAMPLE Four thousand six hundred seventy-one consecutive lumbar fusions from 2011 to 2021, of which 892 (23.6%) were revision procedures. The indication for revision procedures included 502 (56.3%) for ASD, 153 (17.2%) for pseudarthrosis, and 237 (26.6%) for RS. Of the 892 revision procedures, 694 (77.8%) underwent an index fusion while 198 (22.2%) underwent an index decompression without fusion. OUTCOME MEASURES Hospital readmissions, all-cause reoperation, need for subsequent revision and patient reported outcome measures (PROMs) at baseline, 3-months postoperatively, and 1-year postoperatively, including the Mental Health Component score (MCS-12) and Physical Health Component score (PCS-12) of the Short Form 12 survey, the Oswestry Disability Index (ODI), and the Visual Analog Scale (VAS) for Back and Leg pain. METHODS Patient demographics, comorbidities, surgical characteristics, and outcomes were collected from electronic medical records. Twenty-eight percent of patients had preoperative and postoperative PROMs. A delta PROM score was calculated for the 3-month and 1-year postoperative timepoints, which was the change from the preoperative to postoperative value. Univariate comparisons were performed to compare revision fusions to primary fusions. Multivariate logistic regression was performed for all-cause reoperation and subsequent revision surgery, while multivariate linear regression was performed for ∆PROMs at 3-months and 1-year. Revision procedures were then separately regrouped based on indication for revision fusion and whether they underwent a fusion for their index procedure. Univariate comparisons and multivariate linear regressions for ∆PROMs were then repeated based on the new groupings. RESULTS There was no difference in hospital readmission rate (5.38% vs. 4.60%, p=.372) or length of stay (4.10 days vs. 3.94 days, p=.129) between revision and primary lumbar fusion, but revision fusions had a higher rate of all-cause reoperation (16.1% vs. 11.2%, p<.001) and subsequent revision (13.7% vs. 9.71%, p=.001), which was confirmed on multivariate logistic regression (Odds Ratio (OR): 1.42, p=.001 and OR: 1.37, p=.007, respectively). On multivariate analysis, a revision procedure was an independent risk factor for worse improvement ∆ODI, ∆VAS Back, ∆VAS Leg, and ∆PCS-12 and 1-year postoperatively. Regardless of the indication for revision lumbar fusion, patients significantly improved in the 3-month and 1-year postoperative PCS-12, ODI, VAS Back, and VAS Leg, with the exception of the 3-month PCS-12 for pseudarthrosis (p=.620). Patients undergoing revision for ASD had significantly worse 1-year postoperative PCS-12 (32.3 vs. Pseudarthrosis: 35.6 and RS: 37.0, p=.026), but there were no differences in ∆PROMs. There was no difference in hospital readmission, all-cause reoperation, or subsequent revision based on whether a patient had an index lumbar fusion or isolated decompression. Multivariate linear regression analysis found that a surgical indication of pseudarthrosis was a significant predictor of decreased improvement in 3-month ∆VAS Leg (ref: ASD, β=2.26, p=.036), but having an index fusion did not significantly predict worse improvement in ∆PROMs when compared to isolated decompressions. CONCLUSIONS Revision lumbar fusions had a higher rate of reoperation and subsequent revision surgery when compared to primary lumbar fusions, but there were no difference in hospital readmission rates. Patients undergoing revision lumbar fusion experience improvements in all patient reported outcome measures, but their baseline, postoperative, and magnitude of improvement are worse than primary procedures. Regardless of whether the lumbar fusion is a primary or revision procedure, all patients have significant improvements in pain, disability and physical function. Further, the indication for the revision procedure is not correlated with the expected magnitude of improvement in patient reported outcomes. Finally, no differences in baseline, postoperative, and ∆PROMs for revision fusions were identified when stratifying by whether the patient had an index decompression or fusion.
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