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Bess S, Line BG, Nunley P, Ames C, Burton D, Mundis G, Eastlack R, Hart R, Gupta M, Klineberg E, Kim HJ, Kelly M, Hostin R, Kebaish K, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Postoperative Discharge to Acute Rehabilitation or Skilled Nursing Facility Compared With Home Does Not Reduce Hospital Readmissions, Return to Surgery, or Improve Outcomes Following Adult Spine Deformity Surgery. Spine (Phila Pa 1976) 2024; 49:E117-E127. [PMID: 37694516 DOI: 10.1097/brs.0000000000004825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/01/2023] [Indexed: 09/12/2023]
Abstract
STUDY DESIGN Retrospective review of a prospective multicenter adult spinal deformity (ASD) study. OBJECTIVE The aim of this study was to evaluate 30-day readmissions, 90-day return to surgery, postoperative complications, and patient-reported outcomes (PROs) for matched ASD patients receiving nonhome discharge (NON), including acute rehabilitation (REHAB), and skilled nursing facility (SNF), or home (HOME) discharge following ASD surgery. SUMMARY OF BACKGROUND DATA Postoperative disposition following ASD surgery frequently involves nonhome discharge. Little data exists for longer term outcomes for ASD patients receiving nonhome discharge versus patients discharged to home. MATERIALS AND METHODS Surgically treated ASD patients prospectively enrolled into a multicenter study were assessed for NON or HOME disposition following hospital discharge. NON was further divided into REHAB or SNF. Propensity score matching was used to match for patient age, frailty, spine deformity, levels fused, and osteotomies performed at surgery. Thirty-day hospital readmissions, 90-day return to surgery, postoperative complications, and 1-year and minimum 2-year postoperative PROs were evaluated. RESULTS A total of 241 of 374 patients were eligible for the study. NON patients were identified and matched to HOME patients. Following matching, 158 patients remained for evaluation; NON and HOME had similar preoperative age, frailty, spine deformity magnitude, surgery performed, and duration of hospital stay ( P >0.05). Thirty-day readmissions, 90-day return to surgery, and postoperative complications were similar for NON versus HOME and similar for REHAB (N=64) versus SNF (N=42) versus HOME ( P >0.05). At 1-year and minimum 2-year follow-up, HOME demonstrated similar to better PRO scores including Oswestry Disability Index, Short-Form 36v2 questionnaire Mental Component Score and Physical Component Score, and Scoliosis Research Society scores versus NON, REHAB, and SNF ( P <0.05). CONCLUSIONS Acute needs must be considered following ASD surgery, however, matched analysis comparing 30-day hospital readmissions, 90-day return to surgery, postoperative complications, and PROs demonstrated minimal benefit for NON, REHAB, or SNF versus HOME at 1- and 2-year follow-up, questioning the risk and cost/benefits of routine use of nonhome discharge. LEVEL OF EVIDENCE Level III-prognostic.
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Affiliation(s)
- Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Breton G Line
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Pierce Nunley
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas School of Medicine, Kansas City, KS
| | | | | | | | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael Kelly
- Department of Orthopedic Surgery, San Diego Children's Hospital, San Diego, CA
| | | | - Khaled Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Virgine Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Frank Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA
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Passias PG, Pierce KE, Mir JM, Krol O, Lafage R, Lafage V, Line B, Uribe JS, Hostin R, Daniels A, Hart R, Burton D, Shaffrey C, Schwab F, Diebo BG, Ames CP, Smith JS, Schoenfeld AJ, Bess S, Klineberg EO. Development of a modified frailty index for adult spinal deformities independent of functional changes following surgical correction: a true baseline risk assessment tool. Spine Deform 2024; 12:811-817. [PMID: 38305990 DOI: 10.1007/s43390-023-00808-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 12/16/2023] [Indexed: 02/03/2024]
Abstract
PURPOSE To develop a simplified, modified frailty index for adult spinal deformity (ASD) patients dependent on objective clinical factors. METHODS ASD patients with baseline (BL) and 2-year (2Y) follow-up were included. Factors with the largest R2 value derived from multivariate forward stepwise regression were including in the modified ASD-FI (clin-ASD-FI). Factors included in the clin-ASD-FI were regressed against mortality, extended length of hospital stay (LOS, > 8 days), revisions, major complications and weights for the clin-ASD-FI were calculated via Beta/Sullivan. Total clin-ASD-FI score was created with a score from 0 to 1. Linear regression correlated clin-ASD-FI with ASD-FI scores and published cutoffs for the ASD-FI were used to create the new frailty cutoffs: not frail (NF: < 0.11), frail (F: 0.11-0.21) and severely frail (SF: > 0.21). Binary logistic regression assessed odds of complication or reop for frail patients. RESULTS Five hundred thirty-one ASD patients (59.5 yrs, 79.5% F) were included. The final model had a R2 of 0.681, and significant factors were: < 18.5 or > 30 BMI (weight: 0.0625 out of 1), cardiac disease (0.125), disability employment status (0.3125), diabetes mellitus (0.0625), hypertension (0.0625), osteoporosis (0.125), blood clot (0.1875), and bowel incontinence (0.0625). These factors calculated the score from 0 to 1, with a mean cohort score of 0.13 ± 0.14. Breakdown by clin-ASD-FI score: 51.8% NF, 28.1% F, 20.2% SF. Increasing frailty severity was associated with longer LOS (NF: 7.0, F: 8.3, SF: 9.2 days; P < 0.001). Frailty independently predicted occurrence of any complication (OR: 9.357 [2.20-39.76], P = 0.002) and reop (OR: 2.79 [0.662-11.72], P = 0.162). CONCLUSIONS Utilizing an existing ASD frailty index, we proposed a modified version eliminating the patient-reported components. This index is a true assessment of physiologic status, and represents a superior risk factor assessment compared to other tools for both primary and revision spinal deformity surgery as a result of its immutability with surgery, lack of subjectivity, and ease of use.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, Orthopaedic Hospital - NYU School of Medicine, New York Spine Institute, 301 East 17th St, New York, NY, 10003, USA.
| | - Katherine E Pierce
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, Orthopaedic Hospital - NYU School of Medicine, New York Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Jamshaid M Mir
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, Orthopaedic Hospital - NYU School of Medicine, New York Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Oscar Krol
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, Orthopaedic Hospital - NYU School of Medicine, New York Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA, USA
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Bass RD, Lafage R, Smith JS, Ames C, Bess S, Eastlack R, Gupta M, Hostin R, Kebaish K, Kim HJ, Klineberg E, Mundis G, Okonkwo D, Shaffrey C, Schwab F, Lafage V, Burton D. Benchmark Values for Construct Survival and Complications by Type of ASD Surgery. Spine (Phila Pa 1976) 2024:00007632-990000000-00643. [PMID: 38616765 DOI: 10.1097/brs.0000000000005012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/24/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE Provide benchmarks for the rates of complications by type of surgery performed. STUDY DESIGN Prospective multicenter database. BACKGROUND We have previously examined overall construct survival and complication rates for ASD surgery. However, the relationship between type of surgery and construct survival warrants more detailed assessment. METHODS Eight surgical scenarios were defined based on the levels treated, previous fusion status (primary [P] vs. revision [R]), and 3-column osteotomy use [3CO]: Short Lumbar fusion, LT-Pelvis with 5-12 levels treated (P, R or 3CO), UT-Pelvis with 13 levels treated (P, R or 3CO), and Thoracic to Lumbar fusion without pelvic fixation, representing 92.4% of the case in the cohort. Complication rates for each type were calculated and Kaplan Meier curves with multivariate Cox regression analysis was used to evaluate the effect of the case characteristics on construct survival rate, while controlling for patient profile. RESULTS 1073 of 1494 patients eligible for 2-year follow-up (71.8%) were captured. Survival curves for major complications (with or without reoperation), while controlling for demographics differed significantly among surgical types (P<0.001). Fusion procedures short of the pelvis had the best survival rate, while UT-Pelvis with 3CO had the worst survival rate. Longer fusions and more invasive operations were associated with lower 2-year complication-free survival, however there were no significant associations between type of surgery and renal, cardiac, infection, wound, gastrointestinal, pulmonary, implant malposition or neurologic complications (all P>0.5). CONCLUSION This study suggests that there is an inherent increased risk of complication for some types of ASD surgery independent of patient profile. The results of this paper can be used to produce a surgery-adjusted benchmark for ASD surgery with regard to complications and survival. Such a tool can have very impactful applications for surgical decision making and more informed patient counseling.
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Affiliation(s)
- R Daniel Bass
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
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4
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Lafage R, Bass RD, Klineberg E, Smith JS, Bess S, Shaffrey C, Burton DC, Kim HJ, Eastlack R, Mundis G, Ames CP, Passias PG, Gupta M, Hostin R, Hamilton K, Schwab F, Lafage V. Complication Rates Following Adult Spinal Deformity Surgery: Evaluation of the Category of Complication and Chronology. Spine (Phila Pa 1976) 2024:00007632-990000000-00600. [PMID: 38375636 DOI: 10.1097/brs.0000000000004969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 02/12/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVE Provide benchmarks for the rates of complications by type and timing. STUDY DESIGN Prospective multicenter database. BACKGROUND Complication rates following adult spinal deformity (ASD) surgery have been previously reported. However, the interplay between timing and complication type warrants further analysis. METHODS The data for this study were sourced from a prospective, multicenter ASD database. Date and type of complication were collected and classified into three severity groups (minor, major, major leading to reoperation). Only complications occurring before the 2-year visit were retained for analysis. RESULTS Of the 1260 patients eligible for 2-year follow-up, 997 (79.1%) achieved 2-year follow-up. The overall complication rate was 67.4% (N=672). 247 patients (24.8%) experienced at least one complication on the day of surgery (including intra-operatively), 359 (36.0%) between post-op day 1 and 6 weeks post-op, 271 (27.2%) between 6 weeks and 1 one -year post-op, and finally 162 (16.3%) between 1 year and 2 years post-op. Using Kaplan-Meier survival analysis, the rate of remaining complication-free was estimated at different time points for different severities and types of complications. Stratification by type of complication demonstrated that most of the medical complications occurred within the first 60 days. Surgical complications presented over two distinct timeframes. Operative complications, incision-related complications, and infections occurred early (within 60 d), while implant-related and radiographic complications occurred at a constant rate over the 2-year follow-up period. Neurologic complications had the highest occurrence within the first 60 days but continued to increase up to the 2-year visit. CONCLUSION Only one-third of ASD patients remained complication-free by 2 years, and 2 out of 10 patients had a complication requiring a reoperation or revision. Estimation of timing and type of complication associated with surgical treatment may prove useful for more meaningful patient counseling and aid in assessing the cost-effectiveness of treatment.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - R Daniel Bass
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | | | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Christopher P Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Peter G Passias
- Departments of Orthopedic Surgery, NYU Langone, New York, NY
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO
| | | | - Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
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5
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Polly D, Mundis G, Eastlack R, Leveque JC, Elder BD, Martin C, Kent R, Snowden R, Kim HJ, Sembrano J, Herzog J, Lieberman I, Matheus V, Buchholz A, Franke J, Lee R, Shaffrey C. Randomized Trial of Augmented Pelvic Fixation in Patients Undergoing Thoracolumbar Fusion for Adult Spine Deformity: Initial Results from a Multicenter Randomized Trial. World Neurosurg 2024:S1878-8750(24)00177-3. [PMID: 38310950 DOI: 10.1016/j.wneu.2024.01.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/26/2024] [Accepted: 01/27/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND The optimal configuration for spinopelvic fixation during multilevel spine fusion surgery for adult spine deformity remains unclear. Postoperative sacroiliac (SI) joint pain, S2AI screw loosening and implant breakage could be related to continued motion of the SI joint with use of only a single point of fixation across the SI joint. METHODS Prospective, international, multicenter randomized controlled trial of 222 patients with adult spine deformity scheduled for multilevel (4 or more levels) spine fusion surgery with pelvic fixation. Subjects were randomized to S2AI screws alone for pelvic fixation or S2AI + triangular titanium implants placed cephalad to S2AI screws. Quad rod techniques were not allowed or used. Baseline spinal deformity measures were read by an independent radiologist. Site-reported perioperative adverse events were reviewed by a clinical events committee. Quality of life questionnaires and other clinical outcomes are in process with planned two-year follow-up. RESULTS 113 participants were assigned to S2AI and 109 to S2AI + TTI. 35/222 (16%) of all subjects had a history of SI joint pain or were diagnosed with SI joint pain during preoperative workup. 3-month follow-up was available in all but 4 subjects. TTI placement was successful in 106 of 109 (98%) subjects assigned to TTI. In 2 cases, TTI could not be placed due to anatomical considerations. Three TTI ventral iliac breaches were observed, all of which were managed non-surgically. One TTI subject had a transverse sacral fracture and one TTI subject had malposition of the implant requiring removal. CONCLUSIONS SI joint pain is common in patients with adult spinal deformity who are candidates for multilevel spine fusion surgery. Concurrent placement of TTI parallel to S2AI screws during multilevel spine fusion surgery is feasible and safe. Further follow-up will help to determine the clinical value of this approach to augment pelvic fixation.
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Affiliation(s)
- David Polly
- University of Minnesota, Minneapolis, MN, USA.
| | - Greg Mundis
- San Diego Spine Foundation, San Diego, CA, USA
| | | | | | | | | | | | - Ryan Snowden
- Tennessee Orthopaedics Associates, Nashville, TN, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | | | | | | | | | | | | | - Robert Lee
- Royal National Orthopaedic Hospital, Stanmore, UK
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6
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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] [What about the content of this article? (0)] [Affiliation(s)] [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, Naessig S, Williamson TK, Lafage R, Lafage V, Smith JS, Gupta MC, Klineberg E, Burton DC, Ames C, Bess S, Shaffrey C, Schwab FJ. Compensation from mild and severe cases of early proximal junctional kyphosis may manifest as progressive cervical deformity at two year follow-up. Spine Deform 2024; 12:221-229. [PMID: 38041769 DOI: 10.1007/s43390-023-00763-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/29/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Postoperative reciprocal changes (RC) in the cervical spine associated with varying factors of proximal junctional kyphosis (PJK) following fusions of the thoracopelvic spine are poorly understood. PURPOSE Explore reciprocal changes in the cervical spine associated with varying factors (severity, progression, patient age) of PJK in patients undergoing adult spinal deformity (ASD) correction. PATIENTS AND METHODS Retrospective review of a multicenter ASD database. INCLUSION ASD patients > 18 y/o, undergoing fusions from the thoracic spine (UIV: T6-T12) to the pelvis with two-year radiographic data. ASD was defined as: Coronal Cobb angle ≥ 20°, Sagittal Vertical Axis ≥ 5 cm, Pelvic Tilt ≥ 25°, and/or Thoracic Kyphosis ≥ 60°. PJK was defined as a ≥ 10° measure of the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the UIV + 2. Patients were grouped by mild (M; 10°-20°) and severe (S; > 20°) PJK at one year. Propensity Score Matching (PSM) controlled for CCI, age, PI and UIV. Unpaired and paired t test analyses determined difference between RC parameters and change between time points. Pearson bi-variate correlations analyzed associations between RC parameters (T4-T12, TS-CL, cSVA, C2-Slope, and T1-Slope) and PJK descriptors. RESULTS 284 ASD patients (UIV: T6: 1.1%; T7: 0.7%; T8: 4.6%; T9: 9.9%; T10: 58.8%; T11: 19.4%; T12: 5.6%) were studied. PJK analysis consisted of 182 patients (Mild = 91 and Severe = 91). Significant difference between M and S groups were observed in T4-T12 Δ1Y(- 16.8 v - 22.8, P = 0.001), TS-CLΔ1Y(- 0.6 v 2.8, P = 0.037), cSVAΔ1Y(- 1.8 v 1.9, P = 0.032), and C2 slopeΔ1Y(- 1.6 v 2.3, P = 0.022). By two years post-op, all changes in cervical alignment parameters were similar between mild and severe groups. Correlation between age and cSVAΔ1Y(R = 0.153, P = 0.034) was found. Incidence of severe PJK was found to correlate with TS-CLΔ1Y(R = 0.142, P = 0.049), cSVAΔ1Y(R = 0.171, P = 0.018), C2SΔ1Y(R = 0.148, P = 0.040), and T1SΔ2Y(R = 0.256, P = 0.003). CONCLUSIONS Compensation within the cervical spine differed between individuals with mild and severe PJK at one year postoperatively. However, similar levels of pathologic change in cervical alignment parameters were seen by two years, highlighting the progression of cervical compensation due to mild PJK over time. These findings provide greater evidence for the development of cervical deformity in individuals presenting with proximal junctional kyphosis.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA.
| | - Sara Naessig
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA
| | - Tyler K Williamson
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- 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
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | | | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine, Denver, CO, USA
| | | | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
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8
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Jackson-Fowl B, Hockley A, Naessig S, Ahmad W, Pierce K, Smith JS, Ames C, Shaffrey C, Bennett-Caso C, Williamson TK, McFarland K, Passias PG. Adult cervical spine deformity: a state-of-the-art review. Spine Deform 2024; 12:3-23. [PMID: 37776420 DOI: 10.1007/s43390-023-00735-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 07/01/2023] [Indexed: 10/02/2023]
Abstract
Adult cervical deformity is a structural malalignment of the cervical spine that may present with variety of significant symptomatology for patients. There are clear and substantial negative impacts of cervical spine deformity, including the increased burden of pain, limited mobility and functionality, and interference with patients' ability to work and perform everyday tasks. Primary cervical deformities develop as the result of a multitude of different etiologies, changing the normal mechanics and structure of the cervical region. In particular, degeneration of the cervical spine, inflammatory arthritides and neuromuscular changes are significant players in the development of disease. Additionally, cervical deformities, sometimes iatrogenically, may present secondary to malalignment or correction of the thoracic, lumbar or sacropelvic spine. Previously, classification systems were developed to help quantify disease burden and influence management of thoracic and lumbar spine deformities. Following up on these works and based on the relationship between the cervical and distal spine, Ames-ISSG developed a framework for a standardized tool for characterizing and quantifying cervical spine deformities. When surgical intervention is required to correct a cervical deformity, there are advantages and disadvantages to both anterior and posterior approaches. A stepwise approach may minimize the drawbacks of either an anterior or posterior approach alone, and patients should have a surgical plan tailored specifically to their cervical deformity based upon symptomatic and radiographic indications. This state-of-the-art review is based upon a comprehensive overview of literature seeking to highlight the normal cervical spine, etiologies of cervical deformity, current classification systems, and key surgical techniques.
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Affiliation(s)
- Brendan Jackson-Fowl
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Aaron Hockley
- Department of Neurosurgery, University of Alberta, Edmonton, AB, USA
| | - Sara Naessig
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Waleed Ahmad
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Katherine Pierce
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Claudia Bennett-Caso
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Tyler K Williamson
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Kimberly McFarland
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA.
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9
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Lafage R, Song J, Diebo B, Daniels AH, Passias PG, Ames CP, Bess S, Eastlack R, Gupta MC, Hostin R, Kebaish K, Kim HJ, Klineberg E, Mundis GM, Smith JS, Shaffrey C, Schwab F, Lafage V, Burton D. Alterations in Magnitude and Shape of Thoracic Kyphosis Following Surgical Correction for Adult Spinal Deformity. Global Spine J 2023:21925682231218003. [PMID: 38031967 DOI: 10.1177/21925682231218003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
STUDY DESIGN Retrospective review of prospective multicenter data. OBJECTIVES This study aimed to investigate the shape of TK before and after fusion in ASD patients treated with long fusion. METHODS ASD patients undergoing posterior spinal fusions including at least T5 to L1 without prior fusion extending to the thoracic spine were included. Patients were categorized based on the preoperative T1-T12 kyphosis into: Hypo-TK (if < 30°), Normal-TK, and Hyper-TK (if > 70°). Regional kyphosis at T10-L1 (Distal), T5-T10 (Middle), and T1-T5 (Proximal) and their relative contributions to total kyphosis were compared between groups, and the pre-to postoperative changes were investigated using paired t test. RESULTS In total, 329 patients were included in this analysis (mean age: 57 ± 16 years, 79.6% female). Preoperative T1-T12 TK for the entire cohort was 40.9 ± 2° (32% Hypo-TK, 11% Hyper-TK, 57% Normal-TK). The Hypo-TK group had the smallest distal TK (5.9 vs 17.1 & 26.0), and middle TK (8.0 vs 25.3 & 45.4), but the percentage of contribution to total kyphosis was not significantly different (Distal: 24.1% vs 34.1% vs 32.8%; Middle: 46.6% vs 53.9% vs 56.8%, all P > .1). Postoperatively, T1-12 TK increased significantly (40.9 ± 2.0° vs 57.8 ± 17.6°). Each group had a decrease in distal kyphosis (Hypo-TK 2.6 ± 10.4°; Normal-TK 8.9 ± 11.5°; Hyper-TK 14.9 ± 12°, all P < .05). The middle kyphosis significantly decreased for Hyper-TK (11.8 ± 12.4) and increased for both Normal-TK and Hypo-TK (3.8 ± 11° and 14.2 ± 11°). Proximal TK increased significantly for all groups by 14-18°. Deterioration from Normal-TK to Hyper-TK postoperatively was associated with lower rate of patient satisfaction (59.6% vs 77.3%, P = .032). CONCLUSIONS Posterior spinal fusion for ASD alters the magnitude and shape of thoracic kyphosis. While 60% of patients had a normal TK at baseline, 30% of those patients developed iatrogenic hyperkyphosis postoperatively. Patients with baseline hypokyphosis were more likely to be corrected to normal TK than hyperkyphotic patients. Future research should investigate TK restoration in ASD and its impact on clinical outcomes and complications.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Junho Song
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | | | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic surgery, University of Texas Health, Houston, TX
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Frank Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Douglas Burton
- Department of Orthopedic Surgery and Sports Medicine, University of Kansas Medical Center, Kansas, KS, USA
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Passias PG, Pierce KE, Dave P, Lafage R, Lafage V, Schoenfeld AJ, Line B, Uribe J, Hostin R, Daniels A, Hart R, Burton D, Kim HJ, Mundis GM, Eastlack R, Diebo BG, Gum JL, Shaffrey C, Schwab F, Ames CP, Smith JS, Bess S, Klineberg E, Gupta MC, Hamilton DK. When not to Operate in Spinal Deformity: Identifying Subsets of Patients With Simultaneous Clinical Deterioration, Major Complications, and Reoperation. Spine (Phila Pa 1976) 2023; 48:1481-1485. [PMID: 37470375 DOI: 10.1097/brs.0000000000004778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively enrolled adult spinal deformity (ASD) database. OBJECTIVE To investigate what patient factors elevate the risk of sub-optimal outcomes after deformity correction. BACKGROUND Currently, it is unknown what factors predict a poor outcome after adult spinal deformity surgery, which may require increased preoperative consideration and counseling. MATERIALS AND METHODS Patients >18 yrs undergoing surgery for ASD(scoliosis≥20°, SVA≥5 cm, PT≥25°, or TK≥60°). An unsatisfactory outcome was defined by the following categories met at two years: (1) clinical: deteriorating in ODI at two years follow-up (2) complications/reoperation: having a reoperation and major complication were deemed high risk for poor outcomes postoperatively (HR). Multivariate analyses assessed predictive factors of HR patients in adult spinal deformity patients. RESULTS In all, 633 adult spinal deformity (59.9 yrs, 79% F, 27.7 kg/m 2, CCI: 1.74) were included. Baseline severe Schwab modifier incidence (++): 39.2% pelvic incidence and lumbar lordosis, 28.8% sagittal vertical axis, 28.9% PT. Overall, 15.5% of patients deteriorated in ODI by two years, while 7.6% underwent reoperation and had a major complication. This categorized 11 (1.7%) as HR. HR were more comorbid in terms of arthritis (73%), heart disease (36%), and kidney disease (18%), P <0.001. Surgically, HR had greater EBL (4431ccs) and underwent more osteotomies (91%), specifically Ponte(36%) and Three Column Osteotomies(55%), which occurred more at L2(91%). HR underwent more PLIFs (45%) and had more blood transfusion units (2641ccs), all P <0.050. The multivariate regression determined a combination of a baseline Distress and Risk Assessment Method score in the 75th percentile, having arthritis and kidney disease, a baseline right lower extremity motor score ≤3, cSVA >65 mm, C2 slope >30.2°, CTPA >5.5° for an R2 value of 0.535 ( P <0.001). CONCLUSIONS When addressing adult spine deformities, poor outcomes tend to occur in severely comorbid patients with major baseline psychological distress scores, poor neurologic function, and concomitant cervical malalignment.
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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, NY
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Pooja Dave
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Juan Uribe
- Department of Neurosurgery, University of South Florida, Tampa, FL
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY
| | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University of St Louis, St. Louis, MO
| | - D Kojo Hamilton
- Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Theologis AA, Cummins DD, Kato S, Lewis S, Shaffrey C, Lenke L, Berven SH. Activity and sports resumption after long segment fusions to the pelvis for adult spinal deformity: survey results of AO Spine members. Spine Deform 2023; 11:1485-1493. [PMID: 37462878 PMCID: PMC10587314 DOI: 10.1007/s43390-023-00734-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/04/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE To assess recommendations for when adult spinal deformity (ASD) patients may return to athletic activities after surgery. METHODS A web-based survey was administered to members of AO Spine. The survey consisted of surgeon demographic information and questions asking when a patient undergoing a long thoracolumbar fusion (> 5 levels) with pelvic fixation for ASD would be allowed to resume unrestricted range of motion (ROM), non-contact sports, and contact sports postoperatively. Ordinal logistic regression was used to determine predictors for time to resume each activity. RESULTS One hundred twenty four members' responses were included for analysis. The majority of respondents would allow unrestricted ROM within 3 months postop (< 3 months: 81% vs > 3 months: 19%]. For when to return to non-contact sports, the most common responses were "2-3 months" (26.6%), "3-4 months" (26.6%), and "6-12 months" (18.5%). For when to return to contact sports, the majority advised > 4 months postop [> 4 months: "4-6 months" (19.2%), "6-12 months" (28.0%), " > 12 months" (28.8%) versus < 4 months: "1-2 months" (4.0%), "2-3 months" (1.6%), "3-4 months" (8.8%)]. 8.8% responded they would "never" allow resumption of contact sports. CONCLUSION There was significant variation between surgeons' recommendations for resumption of unrestricted range of motion and sports following long fusion with pelvic fixation for ASD. An evidence-based approach to activity recommendations will require information on outcomes and complications.
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Affiliation(s)
- Alekos A Theologis
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA.
| | - Daniel D Cummins
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - So Kato
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | - Stephen Lewis
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON, Canada
| | | | - Lawrence Lenke
- Department of Orthopedic Surgery, The Spine Hospital, Columbia University Medical Center, New York, NY, USA
| | - Sigurd H Berven
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
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13
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Lafage R, Smith JS, Soroceanu A, Ames C, Passias P, Shaffrey C, Mundis G, Alshabab BS, Protopsaltis T, Klineberg E, Elysee J, Kim HJ, Bess S, Schwab F, Lafage V. Predicting Mechanical Failure Following Cervical Deformity Surgery: A Composite Score Integrating Age-Adjusted Cervical Alignment Targets. Global Spine J 2023; 13:2432-2438. [PMID: 35350922 PMCID: PMC10538337 DOI: 10.1177/21925682221086535] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Investigate a composite score to evaluate the relationship between alignment proportionality and risk of distal junctional kyphosis (DJK). METHODS 84 patients with minimum 1 year follow-up were included (age = 61.1 ± 10.3 years, 64.3% women). The Cervical Score was constructed using offsets from age-adjusted normative values for sagittal vertical axis (SVA), T1 Slope (TS), and TS minus cervical lordosis (CL). Individual points were assigned based on offset with age-adjusted alignment targets and summed to generate the Cervical Score. Rates of mechanical failure (DJK revision or severe DJK [DJK> 20° and ΔDJK> 10°]) were assessed overall and based on Cervical Score. Logistical regressions assessed associations between early radiographic alignment and 1-year failure rate. RESULTS Mechanical failure rate was 21.4% (N = 18), 10.7% requiring revision. By multivariate logistical regression: 3-month T1S (OR: .935), TS-CL (OR:0.882), and SVA (OR:1.015) were independent predictors of 1-year failure (all P < .05). Cervical Score ranged (-6 to 6), 37.8% of patients between -1 and 1, and 50.0% with 2 or higher. DJK patients had significantly higher Cervical Score (4.1 ± 1.3 vs .6 ± 2.2, P < .001). Patients with a score ≥3 were significantly more likely to develop a failure (71.4%) with OR of 38.55 (95%CI [7.73; 192.26]) and Nagelkerke r2 .524 (P < .001). CONCLUSION This study developed a composite alignment score predictive of mechanical failures in CD surgery. A score ≥3 at 3 months following surgery was associated with a marked increase in failure rate. The Cervical Score can be used to analyze sagittal alignment and help define realignment objectives to reduce mechanical failure.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | | | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | | | - Basel Sheikh Alshabab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - On behalf of the International Spine Study Group (ISSG)
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
- Department of Surgery, University of Calgary, Calgary, AB, Canada
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- Scripps Clinic, San Diego, CA, USA
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
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Tkatschenko D, Hansen S, Koch J, Ames C, Fehlings MG, Berven S, Sekhon L, Shaffrey C, Smith JS, Hart R, Kim HJ, Wang J, Ha Y, Kwan K, Hai Y, Valacco M, Falavigna A, Taboada N, Guiroy A, Emmerich J, Meyer B, Kandziora F, Thomé C, Loibl M, Peul W, Gasbarrini A, Obeid I, Gehrchen M, Trampuz A, Vajkoczy P, Onken J. Prevention of Surgical Site Infections in Spine Surgery: An International Survey of Clinical Practices Among Expert Spine Surgeons. Global Spine J 2023; 13:2007-2015. [PMID: 35216540 PMCID: PMC10556889 DOI: 10.1177/21925682211068414] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
STUDY DESIGN Questionnaire-based survey. OBJECTIVES Surgical site infection (SSI) is a common complication in spine surgery but universal guidelines for SSI prevention are lacking. The objectives of this study are to depict a global status quo on implemented prevention strategies in spine surgery, common themes of practice and determine key areas for future research. METHODS An 80-item survey was distributed among spine surgeons worldwide via email. The questionnaire was designed and approved by an International Consensus Group on spine SSI. Consensus was defined as more than 60% of participants agreeing to a specific prevention strategy. RESULTS Four hundred seventy-two surgeons participated in the survey. Screening for Staphylococcus aureus (SA) is not common, whereas preoperative decolonization is performed in almost half of all hospitals. Body mass index (BMI) was not important for surgery planning. In contrast, elevated HbA1c level and hypoalbuminemia were often considered as reasons to postpone surgery. Cefazoline is the common drug for antimicrobial prophylaxis. Alcohol-based chlorhexidine is mainly used for skin disinfection. Double-gloving, wound irrigation, and tissue-conserving surgical techniques are routine in the operating room (OR). Local antibiotic administration is not common. Wound closure techniques and postoperative wound dressing routines vary greatly between the participating institutions. CONCLUSIONS With this study we provide an international overview on the heterogeneity of SSI prevention strategies in spine surgery. We demonstrated a large heterogeneity for pre-, peri- and postoperative measures to prevent SSI. Our data illustrated the need for developing universal guidelines and for testing areas of controversy in prospective clinical trials.
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Affiliation(s)
- Dimitri Tkatschenko
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sonja Hansen
- Department of Hygiene and Environmental Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Koch
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sigurd Berven
- Orthopedic Surgery, UCSF Spine Center, San Francisco, CA, USA
| | | | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke Medical Center, Durham, NC, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | | | - Yoon Ha
- Department of Neurosurgery, Spine, and Spinal Cord Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kenny Kwan
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Yong Hai
- Department of Orthopedics, Beijing Chao-yang Hospital, Capital Medical University, Beijing, China
| | - Marcelo Valacco
- Department of Orthopaedics, Churruca Hospital de Buenos Aires, Buenos Aires, Argentina
| | - Asdrubal Falavigna
- Department of Neurosurgery, University of Caxias do Sul, Caxias do Sul, Brazil
| | | | - Alfredo Guiroy
- Spine Unit, Orthopedic Department, Hospital Español, Mendoza, Argentina
| | - Juan Emmerich
- Department of Neurological Surgery, Children’s Hospital, La Plata, Argentina
| | - Bernhard Meyer
- Department of Neurosurgery, Technische Universität München, Munich, Germany
| | - Frank Kandziora
- Centre for Spinal Surgery and Neurotraumatology, BG Unfallklinik, Frankfurt am Main, Germany
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Tyrol, Austria
| | - Markus Loibl
- Department of Spine Surgery, Schulthess Klinik Zürich Switzerland and Department of Trauma Surgery, University Medical Center, Regensburg, Germany
| | - Wilco Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga Teaching Hospital, Leiden and The Hague, The Netherlands
| | - Alessandro Gasbarrini
- Department of Oncologic and Degenerative Spine Surgery, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Ibrahim Obeid
- Clinique du Dos, Elsan Jean Villar Private Hospital, Bordeaux, France
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andrej Trampuz
- Center for Musculoskeletal Surgery (CMSC), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Onken
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Lafage R, Passias P, Sheikh Alshabab B, Bess S, Smith JS, Klineberg E, Kim HJ, Elysee J, Shaffrey C, Burton D, Hostin R, Mundis G, Schwab F, Lafage V. Patterns of Lumbar Spine Malalignment Leading to Revision Surgery for Proximal Junctional Kyphosis: A Cluster Analysis of Over- Versus Under-Correction. Global Spine J 2023; 13:1737-1744. [PMID: 35225013 PMCID: PMC10556910 DOI: 10.1177/21925682211047461] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Investigate the patterns of fused lumbar alignment in patients requiring revision surgery for proximal junctional kyphosis (PJK). METHODS Fifty patients (67.8 yo, 76% female) with existing thoraco-lumbar fusion (T10/12 to pelvis) and indicated for surgical correction for PJK were included. To investigate patterns of radiographic alignment prior to PJK revision, unsupervised 2-step cluster analysis was run on parameters describing the fused lumbar spine (PI-LL) to identify natural independent groups within the cohort. Clusters were compared in terms of demographics, pre-operative alignment, surgical parameters, and post-operative alignment. Associations between pre- and post-revision PJK angles were investigated using a Pearson correlation analysis. RESULTS Analysis identified 2 distinct patterns: Under-corrected (UC, n = 12, 32%) vs over-corrected (OC, n = 34, 68%) with a silhouette of .5. The comparison demonstrated similar pelvic incidence (PI) and PJK angle but significantly greater deformity for the UC vs OC group in terms of PI-LL, PI-LL offset, pelvic tilt, and sagittal vertebral axis. The surgical strategy for PJK correction did not differ between the 2 groups in terms of approach, American Society of Anesthesiologists grade, decompression, use of osteotomy, interbody fusion, or fusion length. The post-revision PJK angle significantly correlated with the amount of PJK correction within the OC group but not within the UC group. CONCLUSIONS This study identified 2 patterns of lumbar malalignment associated with severe PJK: over vs under corrected. Despite the difference in PJK etiology, both patterns underwent the same revision strategy. Future analysis should look at the effect of correcting focal deformity alone vs correcting focal deformity and underlying malalignment simultaneously on recurrent PJK rate.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | - Shay Bess
- Denver International Spine Center, Presbyterian St Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | | | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | - Gregory Mundis
- Department Of Orthopedics, Scripps Clinic, San Diego, CA, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
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Passias PG, Ahmad W, Tretiakov P, Krol O, Segreto F, Lafage R, Lafage V, Soroceanu A, Daniels A, Gum J, Line B, Schoenfeld AJ, Vira S, Hart R, Burton D, Smith JS, Ames CP, Shaffrey C, Schwab F, Bess S. Identifying Subsets of Patients With Adult Spinal Deformity Who Maintained a Positive Response to Nonoperative Management. Neurosurgery 2023; 93:480-488. [PMID: 36942962 PMCID: PMC10586862 DOI: 10.1227/neu.0000000000002447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/11/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Adult spinal deformity (ASD) represents a major cause of disability in the elderly population in the United States. Surgical intervention has been shown to reduce disability and pain in properly indicated patients. However, there is a small subset of patients in whom nonoperative treatment is also able to durably maintain or improve symptoms. OBJECTIVE To examine the factors associated with successful nonoperative management in patients with ASD. METHODS We retrospectively evaluated a cohort of 207 patients with nonoperative ASD, stratified into 3 groups: (1) success, (2) no change, and (3) failure. Success was defined as a gain in minimal clinically importance difference in both Oswestry Disability Index and Scoliosis Research Society-Pain. Logistic regression model and conditional inference decision trees established cutoffs for success according to baseline (BL) frailty and sagittal vertical axis. RESULTS In our cohort, 44.9% of patients experienced successful nonoperative treatment, 22.7% exhibited no change, and 32.4% failed. Successful nonoperative patients at BL were significantly younger, had a lower body mass index, decreased Charlson Comorbidity Index, lower frailty scores, lower rates of hypertension, obesity, depression, and neurological dysfunction (all P < .05) and significantly higher rates of grade 0 deformity for all Schwab modifiers (all P < .05). Conditional inference decision tree analysis determined that patients with a BL ASD-frailty index ≤ 1.579 (odds ratio: 8.3 [4.0-17.5], P < .001) were significantly more likely to achieve nonoperative success. CONCLUSION Success of nonoperative treatment was more frequent among younger patients and those with less severe deformity and frailty at BL, with BL frailty the most important determinant factor. The factors presented here may be useful in informing preoperative discussion and clinical decision-making regarding treatment strategies.
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Affiliation(s)
- Peter G. Passias
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Waleed Ahmad
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Peter Tretiakov
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Oscar Krol
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Frank Segreto
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedics, Lenox Hill Hospital, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, New York, New York, USA
| | - Alex Soroceanu
- Department of Orthopedics, University of Calgary, Calgary, Alberta, Canada
| | - Alan Daniels
- Department of Orthopedics, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shaleen Vira
- Departments of Orthopaedic and Neurosurgery, Utah Southwestern Medical Center, Dallas, Texas, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Christopher P. Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Frank Schwab
- Department of Orthopedics, Lenox Hill Hospital, New York, New York, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
- Rocky Mountain Scoliosis and Spine, Denver, Colorado, USA
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17
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Passias PG, Ahmad W, Tretiakov PS, Lafage R, Lafage V, Schoenfeld AJ, Line B, Daniels A, Mir JM, Gupta M, Mundis G, Eastlack R, Nunley P, Hamilton DK, Hostin R, Hart R, Burton DC, Shaffrey C, Schwab F, Ames C, Smith JS, Bess S, Klineberg EO. Critical Analysis of Radiographic and Patient Reported Outcomes Following Anterior/Posterior Staged vs. Same Day Surgery in Patients Undergoing Identical Corrective Surgery for Adult Spinal Deformity. Spine (Phila Pa 1976) 2023:00007632-990000000-00415. [PMID: 37450674 DOI: 10.1097/brs.0000000000004774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
STUDYDESIGN Retrospective cohort study of a prospectively collected multi-center adult spinal deformity (ASD) database. OBJECTIVE To compare staged procedures to same-day interventions and identify the optimal time interval between staged surgeries for treatment of ASD. BACKGROUND Surgical intervention for ASD is invasive and complex procedure that surgeons often elect to perform on different days (staging). Yet, there remains a paucity of literature on the timing and effects of the interval between stages. METHODS ASD patients with two-year (2Y) data undergoing an anterior/posterior (A/P) fusion to the ilium were included. Propensity score matching (PSM) was performed for number of levels fused, number of interbody devices, surgical approaches, number of osteotomies/three-column osteotomy (3CO), frailty, Oswestry Disability Index (ODI), Charlson Comorbidity Index (CCI), revisions, sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), and UIV to create balanced cohorts of Same-Day and Staged surgical patients. Staged patients were stratified by intervening time-period between surgeries, using quartiles. RESULTS 176 PSM patients were included. Median interval between A/P staged procedures was 3 days. Staged patients had greater operative time and lower ICU stays postop (P<0.05). At 2Y, staged compared to same day showed a greater improvement in T1 slope - cervical lordosis (TS-CL), C2 sacral slope (C2SS), and SRS-Schwab SVA (P<0.05). Staged patients had higher rates of minimal clinically-important difference (MCID) for 1Y SRS-Appearance and 2Y physical component summary (PCS) scores. Assessing different intervals of staging, patients at the 75th percentile interval showed greater improvement in 1Y SRS Pain and Total postop as well as SRS Activity, Pain, Satisfaction, and Total scores (P<0.05) compared to patients in lower quartiles. Compared to the 25th percentile, patients reaching the 50th percentile interval were associated with increased odds of improvement in Global Alignment and Proportion (GAP) score proportionality (9.3[1.6-53.2], P=0.01). CONCLUSIONS This investigation is among the first to compare multicenter staged and same day surgery anterior/posterior adult spinal deformity patients fused to ilium using propensity-matching. Staged procedures resulted in significant improvement radiographically, reduced ICU admissions, and superior patient reported outcomes compared to same day procedures. An interval of at least three days between staged procedures is associated with superior outcomes in terms of GAP score proportionality.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Waleed Ahmad
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Peter S Tretiakov
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Alan Daniels
- Department of Orthopedics, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Jamshaid M Mir
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
| | - Gregory Mundis
- Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, CA
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Pierce Nunley
- Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, LA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | | | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
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Bess S, Line B, Ames C, Burton D, Mundis G, Eastlack R, Hart R, Gupta M, Klineberg E, Kim HJ, Hostin R, Kebaish K, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Would You Do It Again? Discrepancies Between Patient and Surgeon Perceptions Following Adult Spine Deformity Surgery. Spine J 2023:S1529-9430(23)00191-2. [PMID: 37149153 DOI: 10.1016/j.spinee.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Adult spinal deformity (ASD) surgery can improve patient pain and physical function but is associated with high complication rates and long postoperative recovery. Accordingly, if given a choice, patients may indicate they would not undergo ASD surgery again. PURPOSE Evaluate surgically treated ASD patients to assess if given the option 1) would surgically treated ASD patients choose to undergo the same ASD surgery again, 2) would the treating surgeon perform the same ASD surgery again and if not why, 3) evaluate for consensus and/or discrepancies between patient and surgeon opinions for willingness to perform/receive the same surgery, and 4) evaluate for associations with willingness to undergo or not undergo the same surgery again and patient demographics, patient reported outcomes, and postoperative complications. STUDY DESIGN Retrospective review of a prospective ASD study. PATIENT SAMPLE Surgically treated ASD patients enrolled into a multicenter prospective study. OUTCOME MEASURES Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form-36v2 questionnaire (SF-36) physical component summary (PCS) and mental component summary (MCS), Oswestry Disability Index (ODI), numeric pain rating for back pain (NRS back) and leg pain (NRS leg), minimal clinically important difference (MCID) for SRS-22r domains and ODI, intraoperative and postoperative complications, surgeon and patient satisfaction with surgery. METHODS Surgically treated ASD patients prospectively enrolled into a multicenter study were asked at minimum two year postoperative, if, based upon their hospital and surgical experiences and surgical recovery experiences, would the patient undergo the same surgery again. Treating surgeons were then matched to their corresponding patients, blinded to the patients' preoperative and postoperative patient reported outcome measures, and interviewed and asked if 1) the surgeon believed that the corresponding patient would undergo the surgery again, 2) if the surgeon believed the corresponding patient was improved by the surgery and 3) if the surgeon would perform the same surgery on the corresponding patient again, and if not why. ASD patients were divided into those indicating they would (YES), would not (NO) or were unsure (UNSURE) if they would have same surgery again. Agreement between patient and surgeon willingness to receive/perform the same surgery was assessed and correlations between patient willingness for same surgery, postoperative complications, spine deformity correction, patient reported outcomes (PROs). RESULTS 580 of 961 ASD patients eligible for study were evaluated. YES (n=472) had similar surgical procedures performed, similar duration of hospital and ICU stay, similar spine deformity correction and similar postoperative spinal alignment as NO (n=29; p>0.05). UNSURE (n=79) had greater preoperative depression and opioid use rates, UNSURE and NO had more postoperative complications requiring surgery, and UNSURE and NO had fewer percentages of patients reaching postoperative MCID for SRS-22r domains and MCID for ODI than YES (p<0.05). Comparison of patient willingness to receive the same surgery vs. surgeon perceptions on patient's willingness to receive the same surgery demonstrated surgeons accurately identified YES (91.1%) but poorly identified NO (13.8%; p<0.05). CONCLUSIONS If given a choice, 18.6% of surgically treated ASD patients indicated they were unsure or would not undergo the surgery again. ASD patients indicating they were unsure or would not undergo ASD surgery again had greater preoperative depression, greater preoperative opioid use, worse postoperative PROs, fewer patients reaching MCID, more complications requiring surgery, and greater postoperative opioid use. Additionally, patients that indicated they would not have the same surgery again were poorly identified by their treating surgeons compared to patients indicating they would be willing to receive the same surgery again. More research is needed to understand patient expectations and improve patient experiences following ASD surgery.
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Affiliation(s)
- Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO.
| | - Breton Line
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Christopher Ames
- University of California San Francisco School of Medicine, Department of Neurosurgery, San Francisco CA
| | - Douglas Burton
- University of Kansas School of Medicine, Department of Orthopedic Surgery, Kansas City KS
| | | | | | | | - Munish Gupta
- Washington University School of Medicine, Department of Orthopedic Surgery, St. Louis MO
| | - Eric Klineberg
- University of California Davis School of Medicine, Department of Orthopedic Surgery, Sacramento CA
| | - Han Jo Kim
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York NY
| | | | - Khaled Kebaish
- Johns Hopkins University School of Medicine, Department of Orthopedic Surgery, Baltimore, MD
| | - Virgine Lafage
- Lenox Hill Hospital, Department of Orthopedic Surgery, New York NY
| | - Renaud Lafage
- Lenox Hill Hospital, Department of Orthopedic Surgery, New York NY
| | - Frank Schwab
- Lenox Hill Hospital, Department of Orthopedic Surgery, New York, NY
| | | | - Justin S Smith
- University of Virginia School of Medicine, Department of Neurosurgery, Charlottesville VA
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Shaffrey C, Gilligan C. Effect of Restorative Neurostimulation on Major Drivers of Chronic Low Back Pain Economic Impact. Neurosurgery 2023; 92:716-724. [PMID: 36786565 PMCID: PMC9988326 DOI: 10.1227/neu.0000000000002305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/04/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND High-impact chronic low back pain (CLBP) correlates with high healthcare resource utilization. Therapies that can alter impact status may provide beneficial long-term economic benefits. An implantable restorative neurostimulation system (ReActiv8, Mainstay Medical) designed to over-ride multifidus inhibition to facilitate motor control restoration, thereby resolving mechanical low back pain symptoms, has shown significant durable clinical effects in moderately and severely impacted patients. OBJECTIVE To examine changes in high-impact chronic low back pain in patients treated with restorative neurostimulation at 2 years. METHODS ReActiv8-B is a prospective, international, multicenter trial to evaluate the safety and efficacy of restorative neurostimulation in patients with intractable CLBP and no prior surgery. For this longitudinal subanalysis, patients were stratified into low-, moderate-, and high-impact CLBP categories using the US Department of Health and Human Services definition comprising pain intensity, duration, and impact on work, self-care, and daily activities. RESULTS Of 2-year completers (n = 146), 71% had high-impact CLBP at baseline and this proportion reduced to 10%, with 85% reporting no or low impact. This corresponds with measurements of HRQoL returning to near-population norms. CONCLUSION In addition to clinically meaningful improvements in pain and function with long-term durability, the overwhelming majority of patients transitioned from a high- to a no- or low-impact CLBP state. This is typically associated with significantly lower healthcare-utilization levels. The of recovery trajectory is consistent with a restorative mechanism of action and suggests that over the long term, the improvement in these health states will be maintained.
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Affiliation(s)
- Christopher Shaffrey
- Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina, USA;
| | - Christopher Gilligan
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Chestnut Hill, Massachusetts, USA
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20
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Lafage R, Duvvuri P, Elysee J, Diebo B, Bess S, Burton D, Daniels A, Gupta M, Hostin R, Kebaish K, Kelly M, Kim HJ, Klineberg E, Lenke L, Lewis S, Ames C, Passias P, Protopsaltis T, Shaffrey C, Smith JS, Schwab F, Lafage V. Quantifying the Contribution of Lower Limb Compensation to Upright Posture: What Happens if Adult Spinal Deformity Patients Do Not Compensate? Spine (Phila Pa 1976) 2023; Publish Ahead of Print:00007632-990000000-00273. [PMID: 36972137 DOI: 10.1097/brs.0000000000004646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/03/2023] [Indexed: 06/18/2023]
Abstract
STUDY DESIGN This is a multicenter, prospective cohort study. OBJECTIVE This study tests the hypothesis that elimination of lower limb compensation in patients with adult spinal deformity (ASD) will significantly increase the magnitude of sagittal malalignment. SUMMARY OF BACKGROUND DATA ASD affects a significant proportion of the elderly population, impairing functional sagittal alignment and inhibiting overall quality of life. To counteract these effects, patients with ASD use their spine, pelvis, and lower limbs to create a compensatory posture that allows for standing and mobility. However, the degree to which each of the hips, knees, and ankles contributes to these compensatory mechanisms has yet to be determined. METHODS Patients undergoing corrective surgery for ASD were included if they met at least one of the following criteria: complex surgical procedure, geriatric deformity surgery, or severe radiographic deformity. Preoperative full-body x-rays were evaluated, and age and PI-adjusted normative values were used to model spine alignment based upon three positions: compensated (all lower extremity compensatory mechanisms maintained), partially compensated (removal of ankle dorsiflexion and knee flexion, with maintained hip extension), and uncompensated (ankle, knee, and hip compensation set to the age and PI norms). RESULTS 288 patients were included (mean age 60 y, 70.5% females). As the model transitioned from the compensated to uncompensated position, initial posterior translation of the pelvis decreased significantly to an anterior translation versus the ankle (P.Shift: 30 to -7.6 mm). This was associated with a decrease in pelvic retroversion (PT: 24.1 to 16.1), hip extension (SFA: 203 to 200), knee flexion (KA: 5.5 to-0.4), and ankle dorsiflexion (AA: 5.3 to 3.7). As a result, the anterior malalignment of the trunk significantly increased: SVA (65 to 120 mm) and G-SVA (C7-Ankle from 36 to 127 mm). CONCLUSION Removal of lower limbs compensation revealed an unsustainable truncal malalignment with two-fold greater SVA.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Priya Duvvuri
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jonathan Elysee
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Bassel Diebo
- Departments of Orthopaedic Surgery, Brown University, Providence, RI
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Alan Daniels
- Departments of Orthopaedic Surgery, Brown University, Providence, RI
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St Louis, MO
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins, Baltimore, MD
| | | | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA
| | - Lawrence Lenke
- Department of Orthopaedic Surgery, Columbia University, New York, NY
| | - Stephen Lewis
- Department of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - Christopher Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Peter Passias
- Departments of Orthopaedic Surgery, NYU Langone, New York, NY
| | | | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
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21
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Lovecchio F, Lafage R, Line B, Bess S, Shaffrey C, Kim HJ, Ames C, Burton D, Gupta M, Smith JS, Eastlack R, Klineberg E, Mundis G, Schwab F, Lafage V. Optimizing the Definition of Proximal Junctional Kyphosis: A Sensitivity Analysis. Spine (Phila Pa 1976) 2023; 48:414-420. [PMID: 36728798 DOI: 10.1097/brs.0000000000004564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/27/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Diagnostic binary threshold analysis. OBJECTIVE (1) Perform a sensitivity analysis demonstrating the test performance metrics for any combination of proximal junctional angle (PJA) magnitude and change; (2) Propose a new proximal junctional kyphosis (PJK) criteria. SUMMARY OF BACKGROUND DATA Previous definitions of PJK have been arbitrarily selected and then tested through retrospective case series, often showing little correlation with clinical outcomes. MATERIALS AND METHODS Surgically treated adult spinal deformity patients (≥4 levels fused) enrolled into a prospective, multicenter database were evaluated at a minimum 2-year follow-up for proximal junctional failure (PJF). Using PJF as the outcome of interest, test performance metrics including sensitivity, positive predictive value, and F1 metrics (harmonic mean of precision and recall) were calculated for all combinations of PJA magnitude and change using different combinations of perijunctional vertebrae. The combination with the highest F1 score was selected as the new PJK criteria. Performance metrics of previous PJK definitions and the new PJK definition were compared. RESULTS Of the total, 669 patients were reviewed. PJF rate was 10%. Overall, the highest F1 scores were achieved when the upper instrumented vertebrae -1 (UIV-1)/UIV+2 angle was measured. For lower thoracic cases, out of all the PJA and magnitude/change combinations tested, a UIV-1/UIV+2 magnitude of -28° and a change of -20° was associated with the highest F1 score. For upper thoracic cases, a UIV-1/UIV+2 magnitude of -30° and a change of -24° were associated with the highest F1 score. Using PJF as the outcome, patients meeting this new criterion (11.5%) at 6 weeks had the lowest survival rate (74.7%) at 2 years postoperative, compared with Glattes (84.4%) and Bridwell (77.4%). CONCLUSIONS Out of all possible PJA magnitude and change combinations, without stratifying by upper thoracic versus lower thoracic fusions, a magnitude of ≤-28° and a change of ≤-22° provide the best test performance metrics for predicting PJF.
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Affiliation(s)
- Francis Lovecchio
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Breton Line
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | | | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Christopher Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
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22
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Yeramaneni S, Wang K, Gum J, Line B, Jain A, Kebaish K, Shaffrey C, Smith JS, Lafage V, Schwab F, Passias P, Hamilton DK, Klineberg E, Ames C, Burton D, Bess S, Hostin R. Diagnosis-Related Group-Based Payments for Adult Spine Deformity Surgery Significantly Vary across Centers: Results from a Multicenter Prospective Cohort Study. World Neurosurg 2023; 171:e153-e161. [PMID: 36455841 DOI: 10.1016/j.wneu.2022.11.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND To investigate the variation in total episode-of-care (EOC) payment and quality-adjusted life-year (QALY) gain for complex adult spine deformity surgeries in the United States, adjusting for case type and surgeon preferences. METHODS Patients aged >18 years with adult spine deformity with Medicare Severity-Diagnosis-Related Groups (DRGs) 453-460 and a minimum of 2 years of follow-up from index surgery were included. Index and total payments were calculated using Medicare's Inpatient Prospective Payment System. All costs were adjusted for inflation to 2020 U.S. dollar values. QALYs gained were calculated using baseline, 1-year, and 2-year Short-Form 6D scores. Mixed-effect models were used to estimate the proportion of variation in total EOC payment and QALY gain. RESULTS A total of 330/543 patients from 6 sites were included. Mean age was 62.4 ± 11.9 years, 79% were women, and 92% were white. The mean index and total EOC payment were $77,302 and $93,182, respectively. Patients gained on average 0.15 QALY (P < 0.0001) 2 years after surgery. In unadjusted analysis, 39% of the variation in total EOC payment across the 6 centers was attributable to relative weight of DRG and base rate. Adjusting for patient and procedural factors increased the proportion of variation in total EOC payments across the centers to 56%. Less than 2% of the variation in QALY gain was observed across the 6 centers. CONCLUSIONS Medicare-based payments for complex spine deformity fusions are primarily driven by relative weight of the DRG and the hospital's base rate. Patient and procedural factors are unaccounted for in the DRG-based payments made to the providers.
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Affiliation(s)
- Samrat Yeramaneni
- Department of Orthopedic Surgery, Medical City Dallas, Dallas, Texas, USA.
| | - Kevin Wang
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Breton Line
- Department of Orthopedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Amit Jain
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Khaled Kebaish
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Virginia, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell, New York City, New York, USA
| | - Frank Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell, New York City, New York, USA
| | - Peter Passias
- Division of Spine Surgery, Department of Orthopedic Surgery, New York, New York, USA
| | - D Kojo Hamilton
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shay Bess
- Department of Orthopedic Surgery, Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Richard Hostin
- Department of Orthopedic Surgery, Medical City Dallas, Dallas, Texas, USA
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23
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Duvvuri P, Lafage R, Bannwarth M, Passias P, Bess S, Smith JS, Klineberg E, Kim HJ, Shaffrey C, Burton D, Gupta M, Protopsaltis T, Ames C, Schwab F, Lafage V. The Shape of the Fused Spine is Associated With Acute Proximal Junctional Kyphosis in Adult Spinal Deformity: An Assessment Based on Vertebral Pelvic Angles. Global Spine J 2023:21925682221150770. [PMID: 36625677 DOI: 10.1177/21925682221150770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN Retrospective review of prospective database. OBJECTIVES Vertebral pelvic angles (VPAs) account for complexity in spine shape by assessing the relative position of each vertebra with regard to the pelvis. This study uses VPAs to investigate the shape of the fused spine after T10-pelvis fusion, in patients with adult spinal deformity (ASD), and then explores its association with proximal junctional kyphosis (PJK). METHODS Included patients had radiographic evidence of ASD and underwent T10-pelvis realignment. VPAs were used to construct a virtual shape of the post-operative spine. VPA-predicted and actual shapes were then compared between patients with and without PJK. Logistic regression was used to identify components of the VPA-based model that were independent predictors of PJK occurrence and post-operative shape. RESULTS 287 patients were included. VPA-predicted shape was representative of the true post-operative contour, with a mean point-to-point error of 1.6-2.9% of the T10-S1 spine length. At 6-weeks follow-up, 102 patients (35.5%) developed PJK. Comparison of the true post-operative shapes demonstrated that PJK patients had more posteriorly translated vertebrae from L3 to T7 (P < .001). Logistic regression demonstrated that L3PA (P = .047) and T11PA (P < .001) were the best independent predictors of PJK and were, in conjunction with pelvic incidence, sufficient to reproduce the actual spinal contour (error <3%). CONCLUSIONS VPAs are reliable in reproducing the true, post-operative spine shape in patients undergoing T10-pelvis fusion for ASD. Because VPAs are independent of patient position, L3PA, T11PA, and PI measurements can be used for both pre- and intra-operative planning to ensure optimal alignment.
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Affiliation(s)
- Priya Duvvuri
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Peter Passias
- Departments of Orthopaedic Surgery, NYU Langone, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Justin S Smith
- Department of Neurosurgery, University of VirginiaMedical Center, Charlottesville, VA, 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, NY, USA
| | | | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
| | | | - Christopher Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA, USA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
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24
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Wondra JP, Kelly MP, Greenberg J, Yanik EL, Ames C, Pellise F, Vila-Casademunt A, Smith JS, Bess S, Shaffrey C, Lenke LG, Serra-Burriel M, Bridwell K. Validation of Adult Spinal Deformity Surgical Outcome Prediction Tools in Adult Symptomatic Lumbar Scoliosis. Spine (Phila Pa 1976) 2023; 48:21-28. [PMID: 35797629 PMCID: PMC9771887 DOI: 10.1097/brs.0000000000004416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/03/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A post hoc analysis. OBJECTIVE Advances in machine learning (ML) have led to tools offering individualized outcome predictions for adult spinal deformity (ASD). Our objective is to examine the properties of these ASD models in a cohort of adult symptomatic lumbar scoliosis (ASLS) patients. SUMMARY OF BACKGROUND DATA ML algorithms produce patient-specific probabilities of outcomes, including major complication (MC), reoperation (RO), and readmission (RA) in ASD. External validation of these models is needed. METHODS Thirty-nine predictive factors (12 demographic, 9 radiographic, 4 health-related quality of life, 14 surgical) were retrieved and entered into web-based prediction models for MC, unplanned RO, and hospital RA. Calculated probabilities were compared with actual event rates. Discrimination and calibration were analyzed using receiver operative characteristic area under the curve (where 0.5=chance, 1=perfect) and calibration curves (Brier scores, where 0.25=chance, 0=perfect). Ninety-five percent confidence intervals are reported. RESULTS A total of 169 of 187 (90%) surgical patients completed 2-year follow up. The observed rate of MCs was 41.4% with model predictions ranging from 13% to 68% (mean: 38.7%). RO was 20.7% with model predictions ranging from 9% to 54% (mean: 30.1%). Hospital RA was 17.2% with model predictions ranging from 13% to 50% (mean: 28.5%). Model classification for all three outcome measures was better than chance for all [area under the curve=MC 0.6 (0.5-0.7), RA 0.6 (0.5-0.7), RO 0.6 (0.5-0.7)]. Calibration was better than chance for all, though best for RA and RO (Brier Score=MC 0.22, RA 0.16, RO 0.17). CONCLUSIONS ASD prediction models for MC, RA, and RO performed better than chance in a cohort of adult lumbar scoliosis patients, though the homogeneity of ASLS affected calibration and accuracy. Optimization of models require samples with the breadth of outcomes (0%-100%), supporting the need for continued data collection as personalized prediction models may improve decision-making for the patient and surgeon alike.
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Affiliation(s)
- James P. Wondra
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael P. Kelly
- Department of Orthopaedic Surgery, Rady Children’s Hospital, University of California, San Diego, San Diego, CA
| | - Jacob Greenberg
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Elizabeth L. Yanik
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher Ames
- Department of Neurosurgery, University of California, San Francisco, California. Etc
| | | | | | - Justin S. Smith
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA
| | - Shay Bess
- Denver International Spine Center, Denver, Colorado
| | | | - Lawrence G. Lenke
- Och Spine Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Miquel Serra-Burriel
- Center for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
| | - Keith Bridwell
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
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25
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Yee TJ, Upadhyaya C, Coric D, Potts EA, Bisson EF, Turner J, Knightly JJ, Fu KM, Foley KT, Tumialan L, Shaffrey ME, Bydon M, Mummaneni P, Chou D, Chan A, Meyer S, Asher AL, Shaffrey C, Gottfried ON, Than KD, Wang MY, Buchholz AL, Haid R, Park P. Correlation of the Modified Japanese Orthopedic Association With Functional and Quality-of-Life Outcomes After Surgery for Degenerative Cervical Myelopathy: A Quality Outcomes Database Study. Neurosurgery 2022; 91:952-960. [PMID: 36149088 DOI: 10.1227/neu.0000000000002161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 07/06/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The modified Japanese Orthopedic Association (mJOA) score is a widely used and validated metric for assessing severity of myelopathy. Its relationship to functional and quality-of-life outcomes after surgery has not been fully described. OBJECTIVE To quantify the association of the mJOA with the Neck Disability Index (NDI) and EuroQol-5 Dimension (EQ-5D) after surgery for degenerative cervical myelopathy. METHODS The cervical module of the prospectively enrolled Quality Outcomes Database was queried retrospectively for adult patients who underwent single-stage degenerative cervical myelopathy surgery. The mJOA score, NDI, and EQ-5D were assessed preoperatively and 3 and 12 months postoperatively. Improvement in mJOA was used as the independent variable in univariate and multivariable linear and logistic regression models. RESULTS Across 14 centers, 1121 patients were identified, mean age 60.6 ± 11.8 years, and 52.5% male. Anterior-only operations were performed in 772 patients (68.9%). By univariate linear regression, improvements in mJOA were associated with improvements in NDI and EQ-5D at 3 and 12 months postoperatively (all P < .0001) and with improvements in the 10 NDI items individually. These findings were similar in multivariable regression incorporating potential confounders. The Pearson correlation coefficients for changes in mJOA with changes in NDI were -0.31 and -0.38 at 3 and 12 months postoperatively. The Pearson correlation coefficients for changes in mJOA with changes in EQ-5D were 0.29 and 0.34 at 3 and 12 months. CONCLUSION Improvements in mJOA correlated weakly with improvements in NDI and EQ-5D, suggesting that changes in mJOA may not be a suitable proxy for functional and quality-of-life outcomes.
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Affiliation(s)
- Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Cheerag Upadhyaya
- Saint Luke's Neurological and Spine Surgery, Kansas City, Missouri, USA
| | - Domagoj Coric
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Eric A Potts
- Goodman Campbell Brain and Spine, Carmel, Indiana, USA
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Jay Turner
- Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jack J Knightly
- Altair Health Spine and Wellness, Morristown, New Jersey, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
| | - Luis Tumialan
- Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Praveen Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Andrew Chan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Scott Meyer
- Altair Health Spine and Wellness, Morristown, New Jersey, USA
| | - Anthony L Asher
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Christopher Shaffrey
- Department of Neurological Surgery, Duke University, Raleigh, North Carolina, USA
| | - Oren N Gottfried
- Department of Neurological Surgery, Duke University, Raleigh, North Carolina, USA
| | - Khoi D Than
- Department of Neurological Surgery, Duke University, Raleigh, North Carolina, USA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Regis Haid
- Atlanta Brain and Spine, Atlanta, Georgia, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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26
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Passias PG, Krol O, Moattari K, Williamson TK, Lafage V, Lafage R, Kim HJ, Daniels A, Diebo B, Protopsaltis T, Mundis G, Kebaish K, Soroceanu A, Scheer J, Hamilton DK, Klineberg E, Schoenfeld AJ, Vira S, Line B, Hart R, Burton DC, Schwab FA, Shaffrey C, Bess S, Smith JS, Ames CP. Evolution of Adult Cervical Deformity Surgery Clinical and Radiographic Outcomes Based on a Multicenter Prospective Study: Are Behaviors and Outcomes Changing With Experience? Spine (Phila Pa 1976) 2022; 47:1574-1582. [PMID: 35797645 DOI: 10.1097/brs.0000000000004419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/02/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Assess changes in outcomes and surgical approaches for adult cervical deformity surgery over time. SUMMARY OF BACKGROUND DATA As the population ages and the prevalence of cervical deformity increases, corrective surgery has been increasingly seen as a viable treatment. Dramatic surgical advancements and expansion of knowledge on this procedure have transpired over the years, but the impact on cervical deformity surgery is unknown. MATERIALS AND METHODS Adult cervical deformity patients (18 yrs and above) with complete baseline and up to the two-year health-related quality of life and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were grouped into early (2013-2014) and late (2015-2017) by date of surgery. Univariate and multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical outcomes over time. RESULTS A total of 119 cervical deformity patients met the inclusion criteria. Early group consisted of 72 patients, and late group consisted of 47. The late group had a higher Charlson Comorbidity Index (1.3 vs. 0.72), more cerebrovascular disease (6% vs. 0%, both P <0.05), and no difference in age, frailty, deformity, or cervical rigidity. Controlling for baseline deformity and age, late group underwent fewer three-column osteotomies [odds ratio (OR)=0.18, 95% confidence interval (CI): 0.06-0.76, P =0.014]. At the last follow-up, late group had less patients with: a moderate/high Ames horizontal modifier (71.7% vs. 88.2%), and overcorrection in pelvic tilt (4.3% vs. 18.1%, both P <0.05). Controlling for baseline deformity, age, levels fused, and three-column osteotomies, late group experienced fewer adverse events (OR=0.15, 95% CI: 0.28-0.8, P =0.03), and neurological complications (OR=0.1, 95% CI: 0.012-0.87, P =0.03). CONCLUSION Despite a population with greater comorbidity and associated risk, outcomes remained consistent between early and later time periods, indicating general improvements in care. The later cohort demonstrated fewer three-column osteotomies, less suboptimal realignments, and concomitant reductions in adverse events and neurological complications. This may suggest a greater facility with less invasive techniques.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Kevin Moattari
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, NY, NY
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Alan Daniels
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Bassel Diebo
- Deparment of Orthopedic Surgery, SUNY Downstate, New York, NY
| | - Themistocles Protopsaltis
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Justin Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Shaleen Vira
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, TX
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert 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
| | - Frank A Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, NY, NY
| | | | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Passias PG, Krol O, Passfall L, Lafage V, Lafage R, Smith JS, Line B, Vira S, Daniels AH, Diebo B, Schoenfeld AJ, Gum J, Kebaish K, Than K, Kim HJ, Hostin R, Gupta M, Eastlack R, Burton D, Schwab FJ, Shaffrey C, Klineberg EO, Bess S. Three-Column Osteotomy in Adult Spinal Deformity: An Analysis of Temporal Trends in Usage and Outcomes. J Bone Joint Surg Am 2022; 104:1895-1904. [PMID: 35983998 DOI: 10.2106/jbjs.21.01172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Three-column osteotomies (3COs), usually in the form of pedicle subtraction or vertebral column resection, have become common in adult spinal deformity surgery. Although a powerful tool for deformity correction, 3COs can increase the risks of perioperative morbidity. METHODS Operative patients with adult spinal deformity (Cobb angle of >20°, sagittal vertical axis [SVA] of >5 cm, pelvic tilt of >25°, and/or thoracic kyphosis of >60°) with available baseline and 2-year radiographic and health-related quality-of-life (HRQoL) data were included. Patients were stratified into 2 groups by surgical year: Group I (2008 to 2013) and Group II (2014 to 2018). Patients with 3COs were then isolated for outcomes analysis. Severe sagittal deformity was defined by an SVA of >9.5 cm. Best clinical outcome (BCO) was defined as an Oswestry Disability Index (ODI) of <15 and Scoliosis Research Society (SRS)-22 of >4.5. Multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical parameters. RESULTS Seven hundred and fifty-two patients with adult spinal deformity met the inclusion criteria, and 138 patients underwent a 3CO. Controlling for baseline SVA, PI-LL (pelvic incidence minus lumbar lordosis), revision status, age, and Charlson Comorbidity Index (CCI), Group II was less likely than Group I to have a 3CO (21% versus 31%; odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4 to 0.97) and more likely to have an anterior lumbar interbody fusion (ALIF; OR = 1.6; 95% CI = 1.3 to 2.3) and a lateral lumbar interbody fusion (LLIF; OR = 3.8; 95% CI = 2.3 to 6.2). Adjusted analyses showed that Group II had a higher likelihood of supplemental rod usage (OR = 21.8; 95% CI = 7.8 to 61) and a lower likelihood of proximal junctional failure (PJF; OR = 0.23; 95% CI = 0.07 to 0.76) and overall hardware complications by 2 years (OR = 0.28; 95% CI = 0.1 to 0.8). In an adjusted analysis, Group II had a higher likelihood of titanium rod usage (OR = 2.7; 95% CI = 1.03 to 7.2). Group II had a lower 2-year ODI and higher scores on Short Form (SF)-36 components and SRS-22 total (p < 0.05 for all). Controlling for baseline ODI, Group II was more likely to reach the BCO for the ODI (OR = 2.8; 95% CI = 1.2 to 6.4) and the SRS-22 total score (OR = 4.6; 95% CI = 1.3 to 16). CONCLUSIONS Over a 10-year period, the rates of 3CO usage declined, including in cases of severe deformity, with an increase in the usage of PJF prophylaxis. A better understanding of the utility of 3CO, along with a greater implementation of preventive measures, has led to a decrease in complications and PJF and a significant improvement in patient-reported outcome measures. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY.,New York Spine Institute, New York, NY
| | - Oscar Krol
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY.,New York Spine Institute, New York, NY
| | - Lara Passfall
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York, NY.,New York Spine Institute, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Shaleen Vira
- Departments of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, Texas
| | - Alan H Daniels
- Department of Orthopedics, Brown University Warren Alpert Medical School, Providence, Rhode Island
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, Massachusetts
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, Kentucky
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Khoi Than
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Christopher Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California Davis, Davis, California
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
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Lafage R, Schwab F, Elysee J, Smith JS, Alshabab BS, Passias P, Klineberg E, Kim HJ, Shaffrey C, Burton D, Gupta M, Mundis GM, Ames C, Bess S, Lafage V. Surgical Planning for Adult Spinal Deformity: Anticipated Sagittal Alignment Corrections According to the Surgical Level. Global Spine J 2022; 12:1761-1769. [PMID: 33567927 PMCID: PMC9609531 DOI: 10.1177/2192568220988504] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Establish simultaneous focal and regional corrective guidelines accounting for reciprocal global and pelvic compensation. METHODS 433 ASD patients (mean age 62.9 yrs, 81.3% F) who underwent corrective realignment (minimum L1-pelvis) were included. Sagittal parameters, and segmental and regional Cobb angles were assessed pre and post-op. Virtual postoperative alignment was generated by combining post-op alignment of the fused spine with the pre-op alignment on the unfused thoracic kyphosis and the pre-op pelvic retroversion. Regression models were then generated to predict the relative impact of segmental (L4-L5) and regional (L1-L4) corrections on PT, SVA (virtual), and TPA. RESULTS Baseline analysis revealed distal (L4-S1) lordosis of 33 ± 15°, flat proximal (L1-L4) lordosis (1.7 ± 17°), and segmental kyphosis from L2-L3 to T10-T11. Post-op, there was no mean change in distal lordosis (L5-S1 decreased by 2°, and L4-L5 increased by 2°), while the more proximal lordosis increased by 18 ± 16°. Regression formulas revealed that Δ10° in distal lordosis resulted in Δ10° in TPA, associated with Δ100 mm in SVA or Δ3° in PT; Δ10° in proximal lordosis yielded Δ5° in TPA associated with Δ50 mm in SVA; and finally Δ10° in thoraco-lumbar junction yielded Δ2.5° in TPA associated with Δ25 mm in SVA and no impact on PT correction. CONCLUSIONS Overall impact of lumbar lordosis restoration is critically determined by location of correction. Distal correction leads to a greater impact on global alignment and pelvic retroversion. More specifically, it can be assumed that 1° L4-S1 lordosis correction produces 1° change in TPA / 10 mm change in SVA and 0.5° in PT.
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Affiliation(s)
- Renaud Lafage
- Spine Service, Hospital for Special
Surgery, New York, NY, USA,Renaud Lafage, Spine Service, Hospital for
Special Surgery, 525 E 71st St., Belaire 4E, New York, NY 10021, USA.
| | - Frank Schwab
- Spine Service, Hospital for Special
Surgery, New York, NY, USA
| | - Jonathan Elysee
- Spine Service, Hospital for Special
Surgery, New York, NY, USA
| | - Justin S. Smith
- Department of Neurosurgery, University
of Virginia Medical Center, Charlottesville, VA, USA
| | | | - Peter Passias
- Department of Orthopaedics, NYU Langone
Orthopedic Hospital, New York, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery,
University of California, Davis, Sacramento, CA, USA
| | - Han Jo Kim
- Spine Service, Hospital for Special
Surgery, New York, NY, USA
| | | | - Douglas Burton
- Department of Orthopaedics, University
of Kansas Medical Center, Kansas City, KS, USA
| | - Munish Gupta
- Department of Orthopaedics, Washington
University, St Louis, MO, USA
| | | | - Christopher Ames
- Department of Neurological Surgery,
University of California, San Francisco, School of Medicine, San Francisco, CA,
USA
| | - Shay Bess
- Denver International Spine Center,
Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Virginie Lafage
- Spine Service, Hospital for Special
Surgery, New York, NY, USA
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Ardeshiri A, Shaffrey C, Stein KP, Sandalcioglu IE. Real World Evidence for Restorative Neurostimulation in Chronic Low Back Pain- a Consecutive Cohort Study. World Neurosurg 2022; 168:e253-e259. [PMID: 36184040 DOI: 10.1016/j.wneu.2022.09.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Neuromuscular instability of the lumbar spine resulting from impaired motor control and degeneration of the multifidus muscle is a known root cause of refractory chronic low back pain (CLBP). An implantable neurostimulation system that aims to restore multifidus motor control by stimulating the L2 medial branch of the dorsal ramus (ReActiv8, Mainstay Medical) and thereby relieving pain and reducing disability has demonstrated clinically significant benefits in the clinical trial setting. The 1-year results of a single site real-world cohort study are presented here. METHODS Forty-four consecutive patients with refractory, predominantly nociceptive axial CLB, evidence of multifidus dysfunction and no surgical indications or history of surgical intervention for CLBP were recruited at a single site in Germany. Each patient was implanted with a neurostimulation device. Pain (NRS), disability (ODI) and quality of life (EQ-5D-5L) outcomes were collected at baseline, 3-, 6- and 12-months post-activation. RESULTS Statistically significant improvements in pain, disability, and quality of life from baseline were seen at all assessment times points. At 12 months post-activation, mean (±SE) NRS was reduced from 7.6±0.2 to 3.9±0.4 (p<0.001), mean ODI (±SE) from 43.0±2.8 to 25.8±3.9 (p<0.001) and mean EQ-5D-5L (±SE) index improved from 0.504±0.034 to 0.755±0.039 (p<0001). No lead migrations were observed. One patient required revision due to lead fracture. CONCLUSIONS Restorative neurostimulation is a new treatment option for well selected patients with refractory CLBP. The clinically meaningful improvements in pain, disability, and quality of life demonstrated in routine clinical practice are consistent with the published results of controlled trials.
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Affiliation(s)
| | - Christopher Shaffrey
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC, USA
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Katsuura Y, Lafage R, Kim HJ, Smith JS, Line B, Shaffrey C, Burton DC, Ames CP, Mundis GM, Hostin R, Bess S, Klineberg EO, Passias PG, Lafage V. Alignment Targets, Curve Proportion and Mechanical Loading: Preliminary Analysis of an Ideal Shape Toward Reducing Proximal Junctional Kyphosis. Global Spine J 2022; 12:1165-1174. [PMID: 33511871 PMCID: PMC9210254 DOI: 10.1177/2192568220987188] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Investigate risk factors for PJK including theoretical kyphosis, mechanical loading at the UIV and age adjusted offset alignment. METHODS 373 ASD patients (62.7 yrs ± 9.9; 81%F) with 2-year follow up and UIV of at least L1 and LIV of sacrum were included. Images of patients without PJK, with PJK and with PJF were compared using standard spinopelvic parameters before and after the application of the validated virtual alignment method which corrects for the compensatory mechanisms of PJK. Age-adjusted offset, theoretical thoracic kyphosis and mechanical loading at the UIV were then calculated and compared between groups. A subanalysis was performed based on the location of the UIV (upper thoracic (UT) vs. Lower thoracic (LT)). RESULTS At 2-years 172 (46.1%) had PJK, and 21 (5.6%) developed PJF. As PJK severity increased, the post-operative global alignment became more posterior secondary to increased over-correction of PT, PI-LL, and SVA (all P < 0.005). Also, a larger under correction of the theoretical TK (flattening) and a smaller bending moment at the UIV (underloading of UIV) was found. Multivariate analysis demonstrated that PI-LL and bending moment offsets from normative values were independent predictors of PJK/PJF in UT group; PT and bending moment difference were independent predictors for LT group. CONCLUSIONS Spinopelvic over correction, under correction of TK (flattening), and under loading of the UIV (decreased bending moment) were associated with PJK and PJF. These differences are often missed when compensation for PJK is not accounted for in post-operative radiographs.
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Affiliation(s)
| | - Renaud Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, USA,Renaud Lafage, 525 E 71st St., Belaire 4E, New York, NY 10021, USA.
| | - Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Breton Line
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | | | - Douglas C. Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Christopher P. Ames
- Department of Neurological Surgery, University of California School of Medicine, San Francisco, CA, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric O. Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Peter G. Passias
- Department of Orthopaedic Surgery, New York University, New York, NY, USA
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, USA
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Lafage R, Virk S, Elysee J, Passias P, Ames C, Hart R, Shaffrey C, Mundis G, Protopsaltis T, Gupta M, Klineberg E, Burton D, Schwab F, Lafage V. Radiographic Characteristics of Cervical Deformity (CD) Using a Discriminant Analysis: The Value of Extension Radiographs. Clin Spine Surg 2022; 35:E504-E509. [PMID: 35249971 DOI: 10.1097/bsd.0000000000001297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective review of a prospectively collected database. OBJECTIVE The aim of this study was to delineate radiographic parameters that distinguish severe cervical spine deformity (CSD). SUMMARY OF BACKGROUND DATA Our objective was to define parameters that distinguish severe CSD using a consensus approach combined with discriminant analysis as no system currently exists in the literature. METHODS Twelve CSD surgeons reviewed preoperative x-rays from a CSD database. A consensus was reached for categorizing patients into a severe cervical deformity (sCD), non-severe cervical deformity (non-sCD), or an indeterminate cohort. Radiographic parameters were found including classic cervical and spinopelvic parameters in neutral/flexion/extension alignment. To perform our discriminant analysis, we selected for parameters that had a significant difference between the sCD and non-sCD groups using the Student t test. A discriminant function analysis was used to determine which variables discriminate between the sCD versus non-sCD. A stepwise analysis was performed to build a model of parameters to delineate sCD. RESULTS A total of 146 patients with cervical deformity were reviewed (60.5±10.5 y; body mass index: 29.8 kg/m2; 61.3% female). There were 83 (56.8%) classified as sCD and 51 (34.9%) as non-sCD. The comparison analysis led to 16 radiographic parameters that were different between cohorts, and 5 parameters discriminated sCD and non-sCD. These parameters were cervical sagittal vertical axis, T1 slope, maximum focal kyphosis in extension, C2 slope in extension, and number of kyphotic levels in extension. The canonical coefficient of correlation was 0.689, demonstrating a strong association between our model and cervical deformity classification. The accuracy of classification was 87.0%, and cross-validation was 85.2% successful. CONCLUSIONS More than one third of a series of CSD patients were not considered to have a sCD. Analysis of an initial 17 parameters showed that a subset of 5 parameters can discriminate between sCD versus non-sCD with 85% accuracy. Our study demonstrates that flexion/extension images are critical for defining severe CD.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York
| | - Sohrab Virk
- Department of Orthopedic Surgery, Northwell Health, Great Neck
| | - Jonathan Elysee
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York
| | - Peter Passias
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Christopher Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Robert Hart
- Department of Orthopedic Surgery, CA Swedish Neuroscience Institute, Seattle, WA
| | | | | | | | - Munish Gupta
- Department of Orthopedics, Washington University School of Medicine, St. Louis, MO
| | - Eric Klineberg
- Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, CA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Frank Schwab
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York
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32
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Virk S, Lafage R, Bess S, Shaffrey C, Kim HJ, Ames C, Burton D, Gupta M, Smith JS, Eastlack R, Klineberg E, Mundis G, Schwab F, Lafage V. Are the Arbeitsgemeinschaft Für Osteosynthesefragen (AO) Principles for Long Bone Fractures Applicable to 3-Column Osteotomy to Reduce Rod Fracture Rates? Clin Spine Surg 2022; 35:E429-E437. [PMID: 34966036 DOI: 10.1097/bsd.0000000000001289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 11/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim was to determine whether applying Arbeitsgemeinschaft für Osteosynthesefragen (AO) principles for external fixation of long bone fracture to patients with a 3-column osteotomy (3CO) would be associated with reduced rod fracture (RF) rates. SUMMARY OF BACKGROUND DATA AO dictate principles to follow when fixating long bone fractures: (1) decrease bone-rod distance; (2) increase the number of connecting rods; (3) increase the diameter of rods; (4) increase the working length of screws; (5) use multiaxial fixation. We hypothesized that applying these principles to patients undergoing a 3CO reduces the rate of RF. METHODS Patients were categorized as having RF versus no rod fracture (non-RF). Details on location and type of instrumentation were collected. Dedicated software was used to calculate the distance between osteotomy site and adjacent pedicle screws, angle between screws and the distance between the osteotomy site and rod. Classic sagittal spinopelvic parameters were evaluated. RESULTS The study included 170 patients (34=RF, 136=non-RF). There was no difference in age (P=0.224), sagittal vertical axis correction (P=0.287), or lumbar lordosis correction (P=0.36). There was no difference in number of screws cephalad (P=0.62) or caudal (P=0.31) to 3CO site. There was a lower rate of RF for patients with >2 rods versus 2 rods (P<0.001). Patients with multiplanar rod fixation had a lower rod fracture rate (P=0.01). For patients with only 2 rods (N=68), the non-RF cohort had adjacent screws that trended to have less angulation to each other (P=0.06) and adjacent screws that had a larger working length (P=0.03). CONCLUSIONS A portion of AO principles can be applied to 3CO to reduce RF rates. Placing more rods around a 3CO site, placing rods in multiple planes, and placing adjacent screws with a larger working length around the 3CO site is associated with lower RF rates.
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Affiliation(s)
- Sohrab Virk
- Department of Orthopedic Surgery, North well Health, Great Neck
| | | | - Shay Bess
- Rocky Mountain Scoliosis and Spine Center, Denver, CO
| | | | - Han J Kim
- Hospital for Special Surgery, New York, NY
| | - Christopher Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Doug Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Munish Gupta
- Department of Orthopedics, Washington University School of Medicine, St. Louis, MO
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento
| | - Gregory Mundis
- Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, CA
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33
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Pellisé F, Vila-Casademunt A, Núñez-Pereira S, Haddad S, Smith JS, Kelly MP, Alanay A, Shaffrey C, Pizones J, Yilgor Ç, Obeid I, Burton D, Kleinstück F, Fekete T, Bess S, Gupta M, Loibl M, Klineberg EO, Sánchez Pérez-Grueso FJ, Serra-Burriel M, Ames CP. Surgeons' risk perception in ASD surgery: The value of objective risk assessment on decision making and patient counselling. Eur Spine J 2022; 31:1174-1183. [PMID: 35347422 DOI: 10.1007/s00586-022-07166-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/17/2022] [Accepted: 02/28/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgeons often rely on their intuition, experience and published data for surgical decision making and informed consent. Literature provides average values that do not allow for individualized assessments. Accurate validated machine learning (ML) risk calculators for adult spinal deformity (ASD) patients, based on 10 year multicentric prospective data, are currently available. The objective of this study is to assess surgeon ASD risk perception and compare it to validated risk calculator estimates. METHODS Nine ASD complete (demographics, HRQL, radiology, surgical plan) preoperative cases were distributed online to 100 surgeons from 22 countries. Surgeons were asked to determine the risk of major complications and reoperations at 72 h, 90 d and 2 years postop, using a 0-100% risk scale. The same preoperative parameters circulated to surgeons were used to obtain ML risk calculator estimates. Concordance between surgeons' responses was analyzed using intraclass correlation coefficients (ICC) (poor < 0.5/excellent > 0.85). Distance between surgeons' and risk calculator predictions was assessed using the mean index of agreement (MIA) (poor < 0.5/excellent > 0.85). RESULTS Thirty-nine surgeons (74.4% with > 10 years' experience), from 12 countries answered the survey. Surgeons' risk perception concordance was very low and heterogeneous. ICC ranged from 0.104 (reintervention risk at 72 h) to 0.316 (reintervention risk at 2 years). Distance between calculator and surgeon prediction was very large. MIA ranged from 0.122 to 0.416. Surgeons tended to overestimate the risk of major complications and reintervention in the first 72 h and underestimated the same risks at 2 years postop. CONCLUSIONS This study shows that expert surgeon ASD risk perception is heterogeneous and highly discordant. Available validated ML ASD risk calculators can enable surgeons to provide more accurate and objective prognosis to adjust patient expectations, in real time, at the point of care.
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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
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem University, Istanbul, Turkey
| | | | - Javier Pizones
- Spine Surgery Unit, La Paz University Hospital, Madrid, Spain
| | - Çaglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem University, Istanbul, Turkey
| | - Ibrahim Obeid
- Spine Surgery Unit, Bordeaux University Hospital, Bordeaux, France
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Tamas Fekete
- Spine Center Division, Schulthess Klinik, Zurich, Switzerland
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA
| | - Markus Loibl
- Spine Center Division, Schulthess Klinik, Zurich, Switzerland
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA, USA
| | | | - Miquel Serra-Burriel
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Christopher P Ames
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
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Louie PK, Iyer S, Khanna K, Harada GK, Khalid A, Gupta M, Burton D, Shaffrey C, Lafage R, Lafage V, Dewald CJ, Schwab FJ, Kim HJ. Revision Strategies for Harrington Rod Instrumentation: Radiographic Outcomes and Complications. Global Spine J 2022; 12:654-662. [PMID: 33000651 PMCID: PMC9109553 DOI: 10.1177/2192568220960759] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE The purpose of this study is to evaluate the clinical and radiographic outcomes following revision surgery following Harrington rod instrumentation. METHODS Patients who underwent revision surgery with a minimum of 1-year follow-up for flatback syndrome following Harrington rod instrumentation for adolescent idiopathic scoliosis were identified from a multicenter dataset. Baseline demographics and intraoperative information were obtained. Preoperative, initial postoperative, and most recent spinopelvic parameters were compared. Postoperative complications and reoperations were subsequently evaluated. RESULTS A total of 41 patients met the inclusion criteria with an average follow-up of 27.7 months. Overall, 14 patients (34.1%) underwent a combined anterior-posterior fusion, and 27 (65.9%) underwent an osteotomy for correction. Preoperatively, the most common lower instrumented vertebra (LIV) was at L3 and L4 (61%), whereas 85% had a LIV to the pelvis after revision. The mean preoperative pelvic incidence-lumbar lordosis mismatch and C7 sagittal vertical axis were 23.7° and 89.6 mm. This was corrected to 8.1° and 28.9 mm and maintained to 9.04° and 34.4 mm at latest follow-up. Complications included deep wound infection (12.2%), durotomy (14.6%), implant related failures (14.6%), and temporary neurologic deficits (22.0%). Eight patients underwent further revision surgery at an average of 7.4 months after initial revision. CONCLUSIONS There are multiple surgical techniques to address symptomatic flatback syndrome in patients with previous Harrington rod instrumentation for adolescent idiopathic scoliosis. At an average of 27.7 months follow-up, pelvic incidence-lumbar lordosis mismatch and C7 sagittal vertical axis can be successfully corrected and maintained. However, complication and reoperation rates remain high.
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Affiliation(s)
- Philip K. Louie
- Hospital for Special Surgery, New
York, NY, USA,Philip K. Louie, Hospital for Special
Surgery, 535 East 70th Street, Belaire 9J, New York, NY 10021, USA.
| | | | | | | | - Alina Khalid
- Rush University Medical Center,
Chicago, IL, USA
| | - Munish Gupta
- Washington University at St Louis,
St Louis, MO, USA
| | | | | | | | | | | | | | - Han Jo Kim
- Hospital for Special Surgery, New
York, NY, USA
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Passias PG, Poorman GW, Vasquez-Montes D, Kummer N, Mundis G, Anand N, Horn SR, Segreto FA, Passfall L, Krol O, Diebo B, Burton D, Buckland A, Gerling M, Soroceanu A, Eastlack R, Kojo Hamilton D, Hart R, Schwab F, Lafage V, Shaffrey C, Sciubba D, Bess S, Ames C, Klineberg E. Predictive Analytics for Determining Extended Operative Time in Corrective Adult Spinal Deformity Surgery. Int J Spine Surg 2022; 16:291-299. [PMID: 35444038 PMCID: PMC9930651 DOI: 10.14444/8174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND More sophisticated surgical techniques for correcting adult spinal deformity (ASD) have increased operative times, adding to physiologic stress on patients and increased complication incidence. This study aims to determine factors associated with operative time using a statistical learning algorithm. METHODS Retrospective review of a prospective multicenter database containing 837 patients undergoing long spinal fusions for ASD. Conditional inference decision trees identified factors associated with skin-to-skin operative time and cutoff points at which factors have a global effect. A conditional variable-importance table was constructed based on a nonreplacement sampling set of 2000 conditional inference trees. Means comparison for the top 15 variables at their respective significant cutoffs indicated effect sizes. RESULTS Included: 544 surgical ASD patients (mean age: 58.0 years; fusion length 11.3 levels; operative time: 378 minutes). The strongest predictor for operative time was institution/surgeon. Center/surgeons, grouped by decision tree hierarchy, a and b were, on average, 2 hours faster than center/surgeons c-f, who were 43 minutes faster than centers g-j, all P < 0.001. The next most important predictors were, in order, approach (combined vs posterior increases time by 139 minutes, P < 0.001), levels fused (<4 vs 5-9 increased time by 68 minutes, P < 0.050; 5-9 vs < 10 increased time by 47 minutes, P < 0.001), age (age <50 years increases time by 57 minutes, P < 0.001), and patient frailty (score <1.54 increases time by 65 minutes, P < 0.001). Surgical techniques, such as three-column osteotomies (35 minutes), interbody device (45 minutes), and decompression (48 minutes), also increased operative time. Both minor and major complications correlated with <66 minutes of increased operative time. Increased operative time also correlated with increased hospital length of stay (LOS), increased estimated intraoperative blood loss (EBL), and inferior 2-year Oswestry Disability Index (ODI) scores. CONCLUSIONS Procedure location and specific surgeon are the most important factors determining operative time, accounting for operative time increases <2 hours. Surgical approach and number of levels fused were also associated with longer operative times, respectively. Extended operative time correlated with longer LOS, higher EBL, and inferior 2-y ODI outcomes. CLINICAL RELEVANCE We further identified the poor outcomes associated with extended operative time during surgical correction of ASD, and attributed the useful predictors of time spent in the operating room, including site, surgeon, surgical approach, and the number of levels fused. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Peter G. Passias
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Gregory W. Poorman
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Dennis Vasquez-Montes
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Nicholas Kummer
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Gregory Mundis
- Department of Orthopaedics, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - Neel Anand
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Samantha R. Horn
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Frank A. Segreto
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Lara Passfall
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Oscar Krol
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Bassel Diebo
- Department of Orthopaedics, SUNY Downstate Medical Center, New York, NY, USA
| | - Doug Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Aaron Buckland
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Michael Gerling
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Alex Soroceanu
- Department of Orthopaedics, University of Calgary, Calgary, AB, Canada
| | - Robert Eastlack
- Department of Orthopaedics, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - D. Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert Hart
- Department of Orthopaedics, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Frank Schwab
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | | | - Daniel Sciubba
- Department of Neurologic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
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Wilkerson CG, Sherrod BA, Alvi MA, Asher AL, Coric D, Virk MS, Fu KM, Foley KT, Park P, Upadhyaya CD, Knightly JJ, Shaffrey ME, Potts EA, Shaffrey C, Wang MY, Mummaneni PV, Chan AK, Bydon M, Tumialán LM, Bisson EF. Differences in Patient-Reported Outcomes Between Anterior and Posterior Approaches for Treatment of Cervical Spondylotic Myelopathy: A Quality Outcomes Database Analysis. World Neurosurg 2022; 160:e436-e441. [PMID: 35051639 DOI: 10.1016/j.wneu.2022.01.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Surgery for cervical spondylotic myelopathy (CSM) may use anterior or posterior approaches. Our objective was to compare baseline differences and validated postoperative patient-reported outcome measures between anterior and posterior approaches. METHODS The NeuroPoint Quality Outcomes Database was queried retrospectively to identify patients with symptomatic CSM treated at 14 high-volume sites. Demographic, comorbidity, socioeconomic, and outcome measures were compared between treatment groups at baseline and 3 and 12 months postoperatively. RESULTS Of the 1151 patients with CSM in the cervical registry, 791 (68.7%) underwent anterior surgery and 360 (31.3%) underwent posterior surgery. Significant baseline differences were observed in age, comorbidities, myelopathy severity, unemployment, and length of hospital stay. After adjusting for these differences, anterior surgery patients had significantly lower Neck Disability Index score (NDI) and a higher proportion reaching a minimal clinically important difference (MCID) in NDI (P = 0.005 at 3 months; P = 0.003 at 12 months). Although modified Japanese Orthopaedic Association scores were lower in anterior surgery patients at 3 and 12 months (P < 0.001 and P = 0.022, respectively), no differences were seen in MCID or change from baseline. Greater EuroQol-5D improvement at 3 months after anterior versus posterior surgery (P = 0.024) was not sustained at 12 months and was insignificant on multivariate analysis. CONCLUSIONS In the largest analysis to date of CSM surgery data, significant baseline differences existed for patients undergoing anterior versus posterior surgery for CSM. After adjusting for these differences, patients undergoing anterior surgery were more likely to achieve clinically significant improvement in NDI at short- and long-term follow-up.
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Affiliation(s)
- Christopher G Wilkerson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Brandon A Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | | | - Anthony L Asher
- Department of Neurosurgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Domagoj Coric
- Department of Neurosurgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Carolinas HealthCare System, Charlotte, North Carolina, USA
| | - Michael S Virk
- Department of Neurosurgery, Weill Cornell Medical College, New York, New York, USA
| | - Kai-Ming Fu
- Department of Neurosurgery, Weill Cornell Medical College, New York, New York, USA
| | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee and Semmes Murphy Clinic, Memphis, Tennessee, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - John J Knightly
- Atlantic Neurosurgical Specialists, Morristown, New Jersey, USA
| | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Eric A Potts
- Department of Neurosurgery, Indiana University; Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | | | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami, Florida, USA
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Andrew K Chan
- Department of Neurosurgery, University of California, San Francisco, California, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Line B, Bess S, Gum JL, Hostin R, Kebaish K, Ames C, Burton D, Mundis G, Eastlack R, Gupta M, Klineberg E, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Opioid use prior to surgery is associated with worse preoperative and postoperative patient reported quality of life and decreased surgical cost effectiveness for symptomatic adult spine deformity; A matched cohort analysis. North American Spine Society Journal (NASSJ) 2022; 9:100096. [PMID: 35141660 PMCID: PMC8819939 DOI: 10.1016/j.xnsj.2021.100096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/07/2021] [Accepted: 12/07/2021] [Indexed: 11/06/2022]
Abstract
Multi-center, matched analysis of surgically treated SASD patients demonstrated preoperative opioid users reported greater pain, worse physical function, worse self-image preoperatively and at minimum 2-years postoperative and reported lower treatment satisfaction compared to opioid nonusers (p<0.05). Preoperative opioid users had longer ICU (40.8 vs 21.4 hours) and hospital stay (10.5 vs 8.0 days) than nonusers following SASD surgery, respectively (p<0.05). Preoperative opioid users demonstrated worse one and two-year postoperative cost/QALY following SASD surgery than nonusers (p<0.05). Preoperative opioid users reported greater opioid use at two-years following SASD surgery than preoperative nonusers (41.2% vs. 12.9%; odds ratio=4.5; 95% confidence interval=2.7-8.3; p<0.05).
Background Preoperative opioid is associated with poor postoperative outcomes for several surgical specialties, including neurosurgical, orthopedic, and general surgery. Patients with symptomatic adult spinal deformity (SASD) are among the highest patient populations reporting opioid use prior to surgery. Surgery for SASD has been demonstrated to improve patient reported quality of life, however, little medical economic data exists evaluating impact of preoperative opioid use upon surgical cost-effectiveness for SASD. The purpose of this study was to evaluate the impact that preoperative opioid use has upon SASD surgery including duration of intensive care unit (ICU) and hospital stay, postoperative complications, patient reported outcome measures (PROMs), and surgical cost-effectiveness using a propensity score matched analysis model. Methods Surgically treated SASD patients enrolled into a prospective multi-center SASD study were assessed for preoperative opioid use, and divided into two cohorts; preoperative opioid users (OPIOID) and preoperative opioid non-users (NON). Propensity score matching (PSM) was used to control for patient age, medical comorbidities, spine deformity type and magnitude, and surgical procedures for OPIOID vs NON. Preoperative and minimum 2-year postoperative PROMs, duration of ICU and hospital stay, postoperative complications, and opioid use at one and two years postoperative were compared for OPIOID vs NON. Preoperative, one year, and minimum two-year postoperative SF6D values were calculated, and one- and two-year postoperative QALYs were calculated using SF6D change from baseline. Hospital costs at the time of index surgery were calculated and cost/QALY compared at one and two years postop for OPIOID vs NON. Results 261/357 patients (mean follow-up 3.3 years) eligible for study were evaluated. Following the PSM control, OPIOID (n=97) had similar preoperative demographics, smoking and depression history, spine deformity magnitude, and surgery performed as NON (n=164; p>0.05). Preoperatively, OPIOID reported greater NRS back pain (7.7 vs 6.7) and leg pain (5.2 vs 3.9), worse ODI (50.8 vs 36.9), worse SF-36 PCS (28.8 vs 35.6), and worse SRS-22r self-image (2.3 vs 2.5) than NON, respectively (p<0.05). OPIOID had longer ICU (41.2 vs 21.4 hours) and hospital stay (10.6 vs 8.0 days) than NON, respectively (p<0.05). At last postoperative follow up, OPIOID reported greater NRS back pain (4.1 vs 2.3) and leg pain (2.9 vs 1.7), worse ODI (32.4 vs 19.4), worse SF-36 PCS (37.4 vs 47.0), worse SRS-22r self-image (3.5 vs 4.0), and lower SRS-22r treatment satisfaction score (2.5 vs 4.5) than NON, respectively (p<0.05). At last follow-up postoperative Cost/QALY was higher for OPIOID ($44,558.31) vs NON ($34,304.36; p<0.05). At last follow up OPIOID reported greater postoperative opioid usage than NON [41.2% vs. 12.9%, respectively; odds ratio =4.7 (95% CI=2.6-8.7; p<0.05)]. Conclusions Prospective, multi-center, matched analysis demonstrated SASD patients using opioids prior to SASD surgery reported worse preoperative and postoperative quality of life, had longer ICU and hospital stay, had less cost effectiveness of SASD surgery. Preoperative opioid users also reported lower treatment satisfaction, and reported greater postoperative opioid use than non-users. These data should be used to council patients on the negative impact preoperative opioid use can have on SASD surgery.
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Durand WM, Babu JM, Hamilton DK, Passias PG, Kim HJ, Protopsaltis T, Lafage V, Lafage R, Smith JS, Shaffrey C, Gupta M, Kelly MP, Klineberg EO, Schwab F, Gum JL, Mundis G, Eastlack R, Kebaish K, Soroceanu A, Hostin RA, Burton D, Bess S, Ames C, Hart RA, Daniels AH. Adult Spinal Deformity Surgery Is Associated with Increased Productivity and Decreased Absenteeism From Work and School. Spine (Phila Pa 1976) 2022; 47:287-294. [PMID: 34738986 DOI: 10.1097/brs.0000000000004271] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE We hypothesized that adult spinal deformity (ASD) surgery would be associated with improved work- and school-related productivity, as well as decreased rates of absenteeism. SUMMARY OF BACKGROUND DATA ASD patients experience markedly decreased health-related quality of life along many dimensions. METHODS Only patients eligible for 2-year follow-up were included, and those with a history of previous spinal fusion were excluded. The primary outcome measures in this study were Scoliosis Research Society-22r score (SRS-22r) questions 9 and 17. A repeated measures mixed linear regression was used to analyze responses over time among patients managed operatively (OP) versus nonoperatively (NON-OP). RESULTS In total, 1188 patients were analyzed. 66.6% were managed operatively. At baseline, the mean percentage of activity at work/school was 56.4% (standard deviation [SD] 35.4%), and the mean days off from work/school over the past 90 days was 1.6 (SD 1.8). Patients undergoing ASD surgery exhibited an 18.1% absolute increase in work/school productivity at 2-year follow-up versus baseline (P < 0.0001), while no significant change was observed for the nonoperative cohort (P > 0.5). Similarly, the OP cohort experienced 1.1 fewer absent days over the past 90 days at 2 years versus baseline (P < 0.0001), while the NON-OP cohort showed no such difference (P > 0.3). These differences were largely preserved after stratifying by baseline employment status, age group, sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), and deformity curve type. CONCLUSION ASD patients managed operatively exhibited an average increase in work/school productivity of 18.1% and decreased absenteeism of 1.1 per 90 days at 2-year follow-up, while patients managed nonoperatively did not exhibit change from baseline. Given the age distribution of patients in this study, these findings should be interpreted as pertaining primarily to obligations at work or within the home. Further study of the direct and indirect economic benefits of ASD surgery to patients is warranted.Level of Evidence: 3.
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Affiliation(s)
| | - Jacob M Babu
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Peter G Passias
- Langone Medical Center, New York University, New York City, NY
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | | | | | | | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA
| | | | - Munish Gupta
- Washington University in St Louis, St. Louis, MO
| | | | - Eric O Klineberg
- UC Davis Medical Center, University of California, Sacramento, CA
| | | | | | | | | | - Khaled Kebaish
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Doug Burton
- University of Kansas Medical Center, Kansas City, KS
| | - Shay Bess
- Denver International Spine Center, Denver, CO
| | | | - Robert A Hart
- Swedish Medical Center, Swedish Neuroscience Institute, Seattle, WA
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Daniels AH, Durand WM, Steinbaum AJ, Lafage R, Hamilton DK, Passias PG, Kim HJ, Protopsaltis T, Lafage V, Smith JS, Shaffrey C, Gupta M, Klineberg EO, Schwab F, Gum JL, Mundis G, Eastlack R, Kebaish K, Soroceanu A, Hostin RA, Burton D, Bess S, Ames C, Hart RA. Examination of Adult Spinal Deformity Patients Undergoing Surgery with Implanted Spinal Cord Stimulators and Intrathecal Pumps. Spine (Phila Pa 1976) 2022; 47:227-233. [PMID: 34310536 DOI: 10.1097/brs.0000000000004176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of a prospectively collected multi-center database of adult spinal deformity (ASD) patients. OBJECTIVE We hypothesized that patients undergoing ASD surgery with and without previous spinal cord stimulators (SCS)/ intrathecal medication pumps (ITP) would exhibit increased complication rates but comparable improvement in health-related quality of life. SUMMARY OF BACKGROUND DATA ASD patients sometimes seek pain management with SCS or ITP before spinal deformity correction. Few studies have examined outcomes in this patient population. METHODS Patients undergoing ASD surgery and eligible for 2-year follow-up were included. Preoperative radiographs were reviewed for the presence of SCS/ITP. Outcomes included complications, Oswestry Disability Index (ODI), Short Form-36 Mental Component Score, and SRS-22r. Propensity score matching was utilized. RESULTS In total, of 1034 eligible ASD patients, a propensity score-matched cohort of 60 patients (30 with SCS/ITP, 30 controls) was developed. SCS/ITP were removed intraoperatively in most patients (56.7%, n = 17). The overall complication rate was 80.0% versus 76.7% for SCS/ITP versus control (P > 0.2), with similarly nonsignificant differences for intraoperative and infection complications (all P > 0.2). ODI was significantly higher among patients with SCS/ITP at baseline (59.2 vs. 47.6, P = 0.0057) and at 2-year follow-up (44.4 vs. 27.7, P = 0.0295). The magnitude of improvement, however, did not significantly differ (P = 0.45). Similar results were observed for SRS-22r pain domain. Satisfaction did not differ between groups at either baseline or follow-up (P > 0.2). No significant difference was observed in the proportion of patients with SCS/ITP versus control reaching minimal clinically important difference in ODI (47.6% vs. 60.9%, P = 0.38). Narcotic usage was more common among patients with SCS/ITP at both baseline and follow-up (P < 0.05). CONCLUSION ASD patients undergoing surgery with SCS/ITP exhibited worse preoperative and postoperative ODI and SRS-22r pain domain; however, the mean improvement in outcome scores was not significantly different from patients without stimulators or pumps. No significant differences in complications were observed between patients with versus without SCS/ITP.Level of Evidence: 3.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School, Brown University, Providence, RI
| | - Wesley M Durand
- Warren Alpert Medical School, Brown University, Providence, RI
| | | | | | | | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | | | | | - Justin S Smith
- University of Virginia Health System, Charlottes-ville, VA
| | | | | | | | | | | | | | | | | | - Alex Soroceanu
- University of Calgary Spine Program, University of Calgary, Alberta, Canada
| | - Richard A Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Doug Burton
- University of Kansas Hospital, Kansas City, KS
| | - Shay Bess
- Denver International Spine Center, Denver, CO
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40
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Passias PG, Brown AE, Bortz C, Alas H, Pierce K, Ahmad W, Naessig S, Lafage R, Lafage V, Hassanzadeh H, Labaran LA, Ames C, Burton DC, Gum J, Hart R, Hostin R, Kebaish KM, Neuman BJ, Bess S, Line B, Shaffrey C, Smith J, Schwab F, Klineberg E. Increasing Cost Efficiency in Adult Spinal Deformity Surgery: Identifying Predictors of Lower Total Costs. Spine (Phila Pa 1976) 2022; 47:21-26. [PMID: 34392276 DOI: 10.1097/brs.0000000000004201] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study of a prospective multicenter database. OBJECTIVE The purpose of this study was to identify predictors of lower total surgery costs at 3 years for adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA ASD surgery involves complex deformity correction. METHODS Inclusion criteria: surgical ASD (scoliosis ≥20°, sagittal vertical axis [SVA] ≥5 cm, pelvic tilt ≥25°, or thoracic kyphosis ≥60°) patients >18 years. Total costs for surgery were calculated using the PearlDiver database. Cost per quality-adjusted life year was assessed. A Conditional Variable Importance Table used nonreplacement sampling set of 20,000 Conditional Inference trees to identify top factors associated with lower cost surgery for low (LSVA), moderate (MSVA), and high (HSVA) SRS Schwab SVA grades. RESULTS Three hundred sixtee of 322 ASD patients met inclusion criteria. At 3-year follow up, the potential cost of ASD surgery ranged from $57,606.88 to $116,312.54. The average costs of surgery at 3 years was found to be $72,947.87, with no significant difference in costs between deformity groups (P > 0.05). There were 152 LSVA patients, 53 MSVA patients, and 111 HSVA patients. For all patients, the top predictors of lower costs were frailty scores <0.19, baseline (BL) SRS Activity >1.5, BL Oswestry Disability Index <50 (all P < 0.05). For LSVA patients, no history of osteoporosis, SRS Activity scores >1.5, age <64, were the top predictors of lower costs (all P < 0.05). Among MSVA patients, ASD invasiveness scores <94.16, no past history of cancer, and frailty scores <0.3 trended toward lower total costs (P = 0.071, P = 0.210). For HSVA, no history of smoking and body mass index <27.8 trended toward lower costs (both P = 0.060). CONCLUSION ASD surgery has the potential for improved cost efficiency, as costs ranged from $57,606.88 to $116,312.54. Predictors of lower costs included higher BL SRS activity, decreased frailty, and not having depression. Additionally, predictors of lower costs were identified for different BL deformity profiles, allowing for the optimization of cost efficiency for all patients.Level of Evidence: 3.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Departments of Orthopedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Avery E Brown
- Division of Spinal Surgery/Departments of Orthopedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Cole Bortz
- Division of Spinal Surgery/Departments of Orthopedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Haddy Alas
- Division of Spinal Surgery/Departments of Orthopedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Katherine Pierce
- Division of Spinal Surgery/Departments of Orthopedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Waleed Ahmad
- Division of Spinal Surgery/Departments of Orthopedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Sara Naessig
- Division of Spinal Surgery/Departments of Orthopedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Hamid Hassanzadeh
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Lawal A Labaran
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Jeffrey Gum
- Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, KY
| | - Robert Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Richard Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, Johns Hopkins Medical Center, Baltimore, MD
| | - Brian J Neuman
- Department of Orthopedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Christopher Shaffrey
- Department of Neurosurgery and Orthopedic Surgery, Duke University Medical Center, Durham, NC
| | - Justin Smith
- Department of Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Frank Schwab
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Davis, CA
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Lafage R, Smith JS, Elysee J, Passias P, Bess S, Klineberg E, Kim HJ, Shaffrey C, Burton D, Hostin R, Mundis G, Ames C, Schwab F, Lafage V. Sagittal age-adjusted score (SAAS) for adult spinal deformity (ASD) more effectively predicts surgical outcomes and proximal junctional kyphosis than previous classifications. Spine Deform 2022; 10:121-131. [PMID: 34460094 DOI: 10.1007/s43390-021-00397-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/06/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Several methodologies have been proposed to determine ideal ASD sagittal spinopelvic alignment (SRS-Schwab classification) global alignment and proportion (GAP) score, patient age-adjusted alignment). A recent study revealed the ability and limitations of these methodologies to predict PJK. The aim of the study was to develop a new approach, inspired by SRS classification, GAP score, and age-alignment to improve the evaluation of the sagittal plane. METHOD A multi-center ASD database was retrospectively evaluated for surgically treated ASD patients with complete fusion of the lumbar spine, and minimum 2 year follow-up. The Sagittal age-adjusted score (SAAS) methodology was created by assigning numerical values to the difference between each patient's postoperative sagittal alignment and ideal alignment defined by previously reported age generational norms for PI-LL, PT, and TPA. Postoperative HRQOL and PJK severity between each SAAS categories were evaluated. RESULTS 409 of 667 (61.3%) patients meeting inclusion criteria were evaluated. At 2 year SAAS score showed that 27.0% of the patients were under-corrected, 51.7% over-corrected, and 21.3% matched their age-adjusted target. SAAS score increased as PJK worsened (from SAAS = 0.2 for no-PJK, to 4.0 for PJF, p < 0.001). Post-operatively, HRQOL differences between SAAS groups included ODI, SRS pain, and SRS total. CONCLUSION Inspired by SRS classification, the concept of the GAP score, and age-adjusted alignment targets, the results demonstrated significant association with PJK and patient reported outcomes. With a lower rate of failure and better HRQOL, the SAAS seems to represent a "sweet spot" to optimize HRQOL while mitigating the risk of mechanical complications.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA.
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Sacramento, Davis, CA, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | | | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas, KS, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | | | - Christopher Ames
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, CA, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
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Passias PG, Ahmad W, Kummer N, Lafage R, Lafage V, Kebaish K, Daniels A, Klineberg E, Soroceanu A, Gum J, Line B, Hart R, Burton D, Eastlack R, Jain A, Smith JS, Ames CP, Shaffrey C, Schwab F, Hostin R, Bess S. Examination of the Economic Burden of Frailty in Patients With Adult Spinal Deformity Undergoing Surgical Intervention. Neurosurgery 2022; 90:148-153. [PMID: 34982882 DOI: 10.1227/neu.0000000000001756] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With increasing interest in cost optimization, costs of adult spinal deformity (ASD) surgery intersections with frailty merit investigation. OBJECTIVE To investigate costs associated with ASD and frailty. METHODS Patients with ASD (scoliosis ≥20°, sagittal vertical axis [SVA] ≥5 cm, pelvic tilt ≥ 25°, or thoracic kyphosis ≥ 60°) with baseline and 2-yr radiographic data were included. Patients were severely frail (SF), frail (F), or not frail (NF). Utility data were converted from Oswestry Disability Index to Short-Form Six-Dimension. Quality-adjusted life years (QALYs) used 3% rate for decline to life expectancy. Costs were calculated using PearlDiver. Loss of work costs were based on SRS-22rQ9 and US Bureau of Labor Statistics. Accounting for complications, length of stay, revisions, and death, cost per QALY at 2 yr and life expectancy were calculated. RESULTS Five hundred ninety-two patients with ASD were included (59.8 ± 14.0 yr, 80% F, body mass index: 27.7 ± 6.0 kg/m2, Adult Spinal Deformity-Frailty Index: 3.3 ± 1.6, and Charlson Comorbidity Index: 1.8 ± 1.7). The average blood loss was 1569.3 mL, and the operative time was 376.6 min, with 63% undergoing osteotomy and 54% decompression. 69.3% had a posterior-only approach, 30% combined, and 0.7% anterior-only. 4.7% were SF, 22.3% F, and 73.0% NF. At baseline, 104 were unemployed losing $971.38 weekly. After 1 yr, 62 remained unemployed losing $50 508.64 yearly. With propensity score matching for baseline SVA, cost of ASD surgery at 2 yr for F/SF was greater than that for NF ($81 347 vs $69 722). Cost per QALY was higher for F/SF at 2 yr than that for NF ($436 473 vs $430 437). At life expectancy, cost per QALY differences became comparable ($58 965 vs $58 149). CONCLUSION Despite greater initial cost, F and SF patients show greater improvement. Cost per QALY for NF and F patients becomes similar at life expectancy.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
- Department of Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Waleed Ahmad
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
- Department of Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Nicholas Kummer
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
- Department of Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Khaled Kebaish
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
- Department of Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Alan Daniels
- Department of Orthopedics, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, California, USA
| | - Alex Soroceanu
- Department of Orthopedics, University of Calgary, Calgary, Canada
| | - Jeffrey Gum
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, 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
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Amit Jain
- Department of Neurologic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Justin S Smith
- Department of Orthopedics, University of Calgary, Calgary, Canada
| | - Christopher P Ames
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
- Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Christopher Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
- Department Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
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Foster N, Shaffrey C, Buchholz A, Turner R, Yang LZ, Niedzwiecki D, Goode A. Image quality and Dose Comparison of Three Mobile Intraoperative 3D imaging Systems in Spine Surgery. World Neurosurg 2021; 160:e142-e151. [PMID: 34979287 DOI: 10.1016/j.wneu.2021.12.103] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/24/2021] [Accepted: 12/27/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND This study evaluated the radiation exposure and image quality for three intraoperative imaging systems (Airo, Spin, O-arm) using varying radiation dose settings in a single cadaver model. METHODS Axial images of L4-5 instrumentation were obtained using three manufacturer dose protocols for each system. Measurements included scattered radiation dose, subjective and objective image quality (IQ) and estimates of patient effective dose (ED). Four images per system were selected at each dose level. Using the Likert scale (1- best, 5- worst), nine reviewers rated the same 36 images. Objective IQ measures the degree of streak artifacts (lines with incorrect data from metal objects) in each image. A composite figure of merit (FOM) was derived based on ED and subjective and objective scores. RESULTS The best subjective IQ scores were Spin medium (1.44), high dose (1.78), and Airo (2.22) low dose. The best objective IQ scores were Airo (87.3), followed by Spin (89.1). ED low dose results in mSv included Airo (1.6), Spin (1.9) and O-arm (3.3). The ED high-dose results in mSv included Spin (4.6), Airo (9.7) and O-arm (9.9). Scatter radiation measurements for low dose in μGy included Spin (21.9), Airo (31.8) and O-arm (33.9). Scatter radiation for high dose in μGy included Spin (55.9), O-arm (104.5) and Airo (200). The best FOM score was for the Airo low dose, followed by Spin medium and high dose. CONCLUSION The selection of intraoperative imaging systems requires a greater understanding of the risks and benefits of radiation exposure and IQ.
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Affiliation(s)
- Norah Foster
- Department of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Box 3077, Durham, NC 27710, USA.
| | - Christopher Shaffrey
- Department of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Box 3077, Durham, NC 27710, USA
| | - Avery Buchholz
- Department of Neurosciences Surgery, The University of Virginia, 415 Ray C Hunt Dr, Charlottesville, VA 22908
| | - Raymond Turner
- Department of Neurosurgery Prisma Health, 701 Grove Rd, Greenville, SC 29605
| | - Lexie Zidanyue Yang
- Department of Biostatistics and Bioinformatics, Duke University, 2424 Erwin Road Ste 1106, 11028E Hock Plaza, Durham, NC 27705
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, 2424 Erwin Road Ste 1106, 11028E Hock Plaza, Durham, NC 27705
| | - Allen Goode
- Department of Radiology and Medical Imaging, The University of Virginia, 1215 Lee St, Charlottesville, VA 22908
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Daniels AH, Durand WM, Lafage R, Zhang AS, Hamilton DK, Passias PG, Kim HJ, Protopsaltis T, Lafage V, Smith JS, Shaffrey C, Gupta M, Klineberg E, Schwab F, Burton D, Bess S, Ames C, Hart RA. Lateral Thoracolumbar Listhesis as an Independent Predictor of Disability in Adult Scoliosis Patients: Multivariable Assessment Before and After Surgical Realignment. Neurosurgery 2021; 89:1080-1086. [PMID: 34510202 DOI: 10.1093/neuros/nyab356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/31/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Lateral (ie, coronal) vertebral listhesis may contribute to disability in adult scoliosis patients. OBJECTIVE To assess for a correlation between lateral listhesis and disability among patients with adult scoliosis. METHODS This was a retrospective multi-center analysis of prospectively collected data. Patients eligible for a minimum of 2-yr follow-up and with coronal plane deformity (defined as maximum Cobb angle ≥20º) were included (n = 724). Outcome measures were Oswestry Disability Index (ODI) and leg pain numeric scale rating. Lateral thoracolumbar listhesis was measured as the maximum vertebral listhesis as a percent of the superior endplate across T1-L5 levels. Linear and logistic regression was utilized, as appropriate. Multivariable analyses adjusted for demographics, comorbidities, surgical invasiveness, maximum Cobb angle, and T1-PA. Minimally clinically important difference (MCID) in ODI was defined as 12.8. RESULTS In total, 724 adult patients were assessed. The mean baseline maximum lateral thoracolumbar listhesis was 18.3% (standard deviation 9.7%). The optimal statistical grouping for lateral listhesis was empirically determined to be none/mild (<6.7%), moderate (6.7-15.4%), and severe (≥15.4%). In multivariable analysis, listhesis of moderate and severe vs none/mild was associated with worse baseline ODI (none/mild = 33.7; moderate = 41.6; severe = 43.9; P < .001 for both comparisons) and leg pain NSR (none/mild = 2.9, moderate = 4.0, severe = 5.1, P < .05). Resolution of severe lateral listhesis to none/mild was independently associated with increased likelihood of reaching MCID in ODI at 2 yr postoperatively (odds ratio 2.1 95% confidence interval 1.2-3.7, P = .0097). CONCLUSION Lateral thoracolumbar listhesis is associated with worse baseline disability among adult scoliosis patients. Resolution of severe lateral listhesis following deformity correction was independently associated with increased likelihood of reaching MCID in ODI at 2-yr follow-up.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, Rhode Island, USA
| | - Wesley M Durand
- Department of Orthopedics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Renaud Lafage
- Hospital for Special Surgery, New York, New York, USA
| | - Andrew S Zhang
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, Rhode Island, USA
| | - David K Hamilton
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, New York, USA
| | | | | | - Justin S Smith
- University of Virginia Health System, Charlottesville, Virginia, USA
| | | | | | - Eric Klineberg
- University of California-Davis, Sacramento, California, USA
| | - Frank Schwab
- Hospital for Special Surgery, New York, New York, USA
| | - Doug Burton
- University of Kansas Hospital, Kansas City, Kansas, USA
| | - Shay Bess
- Denver International Spine Center, Denver, Colorado, USA
| | | | - Robert A Hart
- Swedish Neuroscience Institute, Seattle, Washington, USA
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45
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Pierce KE, Passias PG, Daniels AH, Lafage R, Ahmad W, Naessig S, Lafage V, Protopsaltis T, Eastlack R, Hart R, Burton D, Bess S, Schwab F, Shaffrey C, Smith JS, Ames C. Baseline Frailty Status Influences Recovery Patterns and Outcomes Following Alignment Correction of Cervical Deformity. Neurosurgery 2021. [DOI: 10.1093/neuros/nyab039_s131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Pierce KE, Passias PG, Brown AE, Bortz CA, Alas H, Lafage R, Krol O, Chou D, Burton DC, Line B, Klineberg E, Hart R, Gum J, Daniels A, Hamilton K, Bess S, Protopsaltis T, Shaffrey C, Schwab FA, Smith JS, Lafage V, Ames C. Prioritization of realignment associated with superior clinical outcomes for surgical cervical deformity patients. J Craniovertebr Junction Spine 2021; 12:311-317. [PMID: 34729000 PMCID: PMC8501814 DOI: 10.4103/jcvjs.jcvjs_26_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/22/2021] [Indexed: 11/05/2022] Open
Abstract
Background: To optimize quality of life in patients with cervical deformity (CD), there may be alignment targets to be prioritized. Objective: To prioritize the cervical parameter targets for alignment. Methods: Included: CD patients (C2–C7 Cobb >10°°, C2–C7 lordosis [CL] >10°°, cSVA > 4 cm, or chin-brow vertical angle >25°°) with full baseline (BL) and 1-year (1Y) radiographic parameters and Neck Disability Index (NDI) scores; patients with cervical (C) or cervicothoracic (CT) Primary Driver Ames type. Patients with BL Ames classified as low CD for both parameters of cSVA (<4 cm) and T1 slope minus CL (TS-CL) (<15°°) were excluded. Patients assessed: Meeting Minimal Clinically Important Difference (MCID) for NDI (<−15 ΔNDI). Ratios of correction were found for regional parameters categorized by Primary Ames Driver (C or CT). Decision tree analysis assessed cut-offs for differences associated with meeting NDI MCID at 1Y. Results: Seventy-seven CD patients (62.1 years, 64%F, 28.8 kg/m2). 41.6% met MCID for NDI. A backward linear regression model including radiographic differences as predictors from BL to 1Y for meeting MCID for NDI demonstrated an R2= 0.820 (P = 0.032) included TS-CL, cSVA, MGS, C2SS, C2-T3 angle, C2-T3 sagittal vertical axis (SVA), CL. By primary Ames driver, 67.5% of patients were C, and 32.5% CT. Ratios of change in predictors for MCID NDI patients for C and CT were not significant between the two groups (P > 0.050). Decision tree analysis determined cut-offs for radiographic change, prioritizing in the following order: ≥42.5° C2-T3 angle, >35.4° CL, <−31.76° C2 slope, <−11.57 mm cSVA, <−2.16° MGS, >−30.8 mm C2-T3 SVA, and ≤−33.6° TS-CL. Conclusions: Certain ratios of correction of cervical parameters contribute to improving neck disability. Prioritizing these radiographic alignment parameters may help optimize patient-reported outcomes for patients undergoing CD surgery.
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Affiliation(s)
- Katherine E Pierce
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Peter Gust Passias
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Avery E Brown
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Cole A Bortz
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Haddy Alas
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Oscar Krol
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Kojo Hamilton
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | | | - Christopher Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Frank A Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Kim HJ, Virk S, Elysee J, Ames C, Passias P, Shaffrey C, Mundis G, Protopsaltis T, Gupta M, Klineberg E, Hart R, Smith JS, Bess S, Schwab F, Lafage R, Lafage V. Surgical Strategy for the Management of Cervical Deformity Is Based on Type of Cervical Deformity. J Clin Med 2021; 10:jcm10214826. [PMID: 34768346 PMCID: PMC8584313 DOI: 10.3390/jcm10214826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives: Cervical deformity morphotypes based on type and location of deformity have previously been described. This study aimed to examine the surgical strategies implemented to treat these deformity types and identify if differences in treatment strategies impact surgical outcomes. Our hypothesis was that surgical strategies will differ based on different morphologies of cervical deformity. Methods: Adult patients enrolled in a prospective cervical deformity database were classified into four deformity types (Flatneck (FN), Focal kyphosis (FK), Cervicothoracic kyphosis (CTK) and Coronal (C)), as previously described. We analyzed group differences in demographics, preoperative symptoms, health-related quality of life scores (HRQOLs), and surgical strategies were evaluated, and postop radiographic and HROQLs at 1+ year follow up were compared. Results: 90/109 eligible patients (mean age 63.3 ± 9.2, 64% female, CCI 1.01 ± 1.36) were evaluated. Group distributions included FN = 33%, FK = 29%, CTK = 29%, and C = 9%. Significant differences were noted in the surgical approaches for the four types of deformities, with FN and FK having a high number of anterior/posterior (APSF) approaches, while CTK and C had more posterior only (PSF) approaches. For FN and FK, PSF was utilized more in cases with prior anterior surgery (70% vs. 25%). For FN group, PSF resulted in inferior neck disability index compared to those receiving APSF suggesting APSF is superior for FN types. CTK types had more three-column osteotomies (3CO) (p < 0.01) and longer fusions with the LIV below T7 (p < 0.01). There were no differences in the UIV between all deformity types (p = 0.19). All four types of deformities had significant improvement in NRS neck pain post-op (p < 0.05) with their respective surgical strategies. Conclusions: The four types of cervical deformities had different surgical strategies to achieve improvements in HRQOLs. FN and FK types were more often treated with APSF surgery, while types CTK and C were more likely to undergo PSF. CTK deformities had the highest number of 3COs. This information may provide guidelines for the successful management of cervical deformities.
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Affiliation(s)
- Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
- Correspondence:
| | - Sohrab Virk
- Department of Orthopedics, Northwell Health, Great Neck, New York, NY 11021, USA;
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
| | - Christopher Ames
- Department of Neurosurgery, University of San Francisco School of Medicine, San Francisco, CA 94143, USA;
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY 10016, USA; (P.P.); (T.P.)
| | - Christopher Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27708, USA;
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic Medical Group, La Jolla, CA 92037, USA;
| | | | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63010, USA;
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California Davis, Davis, CA 95616, USA;
| | - Robert Hart
- Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, OR 97239, USA;
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA 22904, USA;
| | - Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children at Presbyterian St. Luke’s, Denver, CO 80218, USA;
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
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Passias PG, Pierce KE, Naessig S, Ahmad W, Passfall L, Lafage R, Lafage V, Kim HJ, Daniels A, Eastlack R, Klineberg E, Line B, Mummaneni P, Hart R, Burton D, Bess S, Schwab F, Shaffrey C, Smith JS, Ames CP. At What Point Should the Thoracolumbar Region Be Addressed in Patients Undergoing Corrective Cervical Deformity Surgery? Spine (Phila Pa 1976) 2021; 46:E1113-E1118. [PMID: 34559752 DOI: 10.1097/brs.0000000000004045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate the impact of cervical to thoracolumbar ratios on poor outcomes in cervical deformity (CD) corrective surgery. SUMMARY OF BACKGROUND DATA Consideration of distal regional and global alignment is a critical determinant of outcomes in CD surgery. For operative CD patients, it is unknown whether certain thoracolumbar parameters play a significant role in poor outcomes and whether addressing such parameters is warranted. METHODS Included: surgical CD patients (C2-C7 Cobb >10°, cervical lordosis [CL] >10°, C2-C7 sagittal vertical axis (cSVA) >4 cm, or chin-brow vertical angle >25°) with baseline and 1-year data. Patients were assessed for ratios of preop cervical and global parameters including: C2 Slope/T1 slope, T1 slope minus C2-C7 lordosis (TS-CL)/mismatch between pelvic incidence and lumbar lordosis (PI-LL), cSVA/sagittal vertical axis (SVA). Deformity classification ratios of cervical (Ames-ISSG) to spinopelvic (SRS-Schwab) were investigated: cSVA modifier/SVA modifier, TS-CL modifier/PI-LL modifier. Cervical to thoracic ratios included C2-C7 lordosis/T4-T12 kyphosis. Correlations assessed the relationship between ratios and poor outcomes (major complication, reoperation, distal junctional kyphosis (DJK), or failure to meet minimal clinically important difference [MCID]). Decision tree analysis through multiple iterations of multivariate regressions assessed cut-offs for ratios for acquiring suboptimal outcomes. RESULTS A total of 110 CD patients were included (61.5 years, 66% F, 28.8 kg/m2). Mean preoperative radiographic ratios calculated: C2 slope/T1 slope of 1.56, TS-CL/PI-LL of 11.1, cSVA/SVA of 5.4, CL/thoracic kyphosis (TK) of 0.26. Ames-ISSG and SRS-Schwab modifier ratios: cSVA/SVA of 0.1 and TS-CL/PI-LL of 0.35. Pearson correlations demonstrated a relationship between major complications and baseline TS-CL/PI-LL, Ames TS-CL/Schwab PI-LL modifiers, and the CL/TK ratios (P < 0.050). Reoperation had significant correlation with TS-CL/PI-LL and cSVA/SVA ratios. Postoperative DJK correlated with C2 slope/T1 slope and CL/TK ratios. Not meeting MCID for Neck Disability Index (NDI) correlated with CL/TK ratio and not meeting MCID for EQ5D correlated with Ames TS-CL/Schwab PI-LL. CONCLUSION Consideration of cervical to global alignment is a critical determinant of outcomes in CD corrective surgery. Key ratios of cervical to global alignment correlate with suboptimal clinical outcomes. A larger cervical lordosis to TK predicted postoperative complication, DJK, and not meeting MCID for NDI.Level of Evidence: 4.
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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, NY
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Sara Naessig
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Waleed Ahmad
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Lara Passfall
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Praveen Mummaneni
- 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
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
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Pierce KE, Passias PG, Brown AE, Bortz CA, Alas H, Passfall L, Krol O, Kummer N, Lafage R, Chou D, Burton DC, Line B, Klineberg E, Hart R, Gum J, Daniels A, Hamilton K, Bess S, Protopsaltis T, Shaffrey C, Schwab FA, Smith JS, Lafage V, Ames C. Prioritization of Realignment Associated With Superior Clinical Outcomes for Cervical Deformity Patients. Neurospine 2021; 18:506-514. [PMID: 34610683 PMCID: PMC8497252 DOI: 10.14245/ns.2040540.270] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 06/15/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To prioritize the cervical parameter targets for alignment.
Methods Included: cervical deformity (CD) patients (C2–7 Cobb angle > 10°, cervical lordosis > 10°, cervical sagittal vertical axis [cSVA] > 4 cm, or chin-brow vertical angle > 25°) with full baseline (BL) and 1-year (1Y) radiographic parameters and Neck Disability Index (NDI) scores; patients with cervical [C] or cervicothoracic [CT] Primary Driver Ames type. Patients with BL Ames classified as low CD for both parameters of cSVA (< 4 cm) and T1 slope minus cervical lordosis (TS–CL) (< 15°) were excluded. Patients assessed: meeting minimum clinically important differences (MCID) for NDI (< -15 ΔNDI). Ratios of correction were found for regional parameters categorized by primary Ames driver (C or CT). Decision tree analysis assessed cutoffs for differences associated with meeting NDI MCID at 1Y.
Results Seventy-seven CD patients (mean age, 62.1 years; 64% female; body mass index, 28.8 kg/m2). Forty-one point six percent of patients met MCID for NDI. A backwards linear regression model including radiographic differences as predictors from BL to 1Y for meeting MCID for NDI demonstrated an R2 of 0.820 (p=0.032) included TS–CL, cSVA, McGregor’s slope (MGS), C2 sacral slope, C2–T3 angle, C2–T3 SVA, cervical lordosis. By primary Ames driver, 67.5% of patients were C, and 32.5% CT. Ratios of change in predictors for MCID NDI patients for C and CT were not significant between the 2 groups (p>0.050). Decision tree analysis determined cutoffs for radiographic change, prioritizing in the following order: ≥ 42.5° C2–T3 angle, > 35.4° cervical lordosis, < -31.76° C2 slope, < -11.57-mm cSVA, < -2.16° MGS, > -30.8-mm C2–T3 SVA, and ≤ -33.6° TS–CL.
Conclusion Certain ratios of correction of cervical parameters contribute to improving neck disability. Prioritizing these radiographic alignment parameters may help optimize patient-reported outcomes for patients undergoing CD surgery.
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Affiliation(s)
- Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Avery E Brown
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Cole A Bortz
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Haddy Alas
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Lara Passfall
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Oscar Krol
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Nicholas Kummer
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Breton Line
- Rocky Mountain Scoliosis and Spine, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | | | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Frank A Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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50
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Passias PG, Brown AE, Alas H, Pierce KE, Bortz CA, Diebo B, Lafage R, Lafage V, Burton DC, Hart R, Kim HJ, Bess S, Moattari K, Joujon-Roche R, Krol O, Williamson T, Tretiakov P, Imbo B, Protopsaltis TS, Shaffrey C, Schwab F, Eastlack R, Line B, Klineberg E, Smith J, Ames C. The impact of postoperative neurologic complications on recovery kinetics in cervical deformity surgery. J Craniovertebr Junction Spine 2021; 12:393-400. [PMID: 35068822 PMCID: PMC8740804 DOI: 10.4103/jcvjs.jcvjs_108_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: The objective of the study is to investigate which neurologic complications affect clinical outcomes the most following cervical deformity (CD) surgery. Methods: CD patients (C2-C7 Cobb >10°, CL >10°, cSVA >4 cm or chin-brow vertical angle >25°) >18 years with follow-up surgical and health-related quality of life (HRQL) data were included. Descriptive analyses assessed demographics. Neurologic complications assessed were C5 motor deficit, central neurodeficit, nerve root motor deficits, nerve sensory deficits, radiculopathy, and spinal cord deficits. Neurologic complications were classified as major or minor, then: intraoperative, before discharge, before 30 days, before 90 days, and after 90 days. HRQL outcomes were assessed at 3 months, 6 months, and 1 year. Integrated health state (IHS) for the neck disability index (NDI), EQ5D, and modified Japanese Orthopaedic Association (mJOA) were assessed using all follow-up time points. A subanalysis assessed IHS outcomes for patients with 2Y follow-up. Results: 153 operative CD patients were included. Baseline characteristics: 61 years old, 63% female, body mass index 29.7, operative time 531.6 ± 275.5, estimated blood loss 924.2 ± 729.5, 49% posterior approach, 18% anterior approach, 33% combined. 18% of patients experienced a total of 28 neurologic complications in the postoperative period (15 major). There were 7 radiculopathy, 6 motor deficits, 6 sensory deficits, 5 C5 motor deficits, 2 central neurodeficits, and 2 spinal cord deficits. 11.2% of patients experienced neurologic complications before 30 days (7 major) and 15% before 90 days (12 major). 12% of neurocomplication patients went on to have revision surgery within 6 months and 18% within 2 years. Neurologic complication patients had worse mJOA IHS scores at 1Y but no significant differences between NDI and EQ5D (0.003 vs. 0.873, 0.458). When assessing individual complications, central neurologic deficits and spinal cord deficit patients had the worst outcomes at 1Y (2.6 and 1.8 times worse NDI scores, P = 0.04, no improvement in EQ5D, 8% decrease in EQ5D). Patients with sensory deficits had the best NDI and EQ5D outcomes at 1Y (31% decrease in NDI, 8% increase in EQ5D). In a subanalysis, neurologic patients trended toward worse NDI and mJOA IHS outcomes (P = 0.263, 0.163). Conclusions: 18% of patients undergoing CD surgery experienced a neurologic complication, with 15% within 3 months. Patients who experienced any neurologic complication had worse mJOA recovery kinetics by 1 year and trended toward worse recovery at 2 years. Of the neurologic complications, central neurologic deficits and spinal cord deficits were the most detrimental.
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Affiliation(s)
- Peter Gust Passias
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Avery E Brown
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Haddy Alas
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Katherine E Pierce
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Cole A Bortz
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Bassel Diebo
- Deparment of Orthopaedic Surgery, SUNY Downstate, New York, NY, USA
| | - Renaud Lafage
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Lenox Hill Hospital, Northwell Health, Department of Orthopaedics, New York, NY, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Han Jo Kim
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Kevin Moattari
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Rachel Joujon-Roche
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Oscar Krol
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Tyler Williamson
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Peter Tretiakov
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Bailey Imbo
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Themistocles S Protopsaltis
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | | | - Frank Schwab
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
| | - Justin Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA,, USA
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