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Balmaceno-Criss M, Lafage R, Alsoof D, Daher M, Hamilton DK, Smith JS, Eastlack RK, Fessler RG, Gum JL, Gupta MC, Hostin R, Kebaish KM, Klineberg EO, Lewis SJ, Line BG, Nunley PD, Mundis GM, Passias PG, Protopsaltis TS, Buell T, Scheer JK, Mullin JP, Soroceanu A, Ames CP, Lenke LG, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Burton DC, Diebo BG, Daniels AH. Impact of Hip and Knee Osteoarthritis on Full Body Sagittal Alignment and Compensation for Sagittal Spinal Deformity. Spine (Phila Pa 1976) 2024; 49:743-751. [PMID: 38375611 DOI: 10.1097/brs.0000000000004957] [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: 12/27/2023] [Accepted: 01/26/2024] [Indexed: 02/21/2024]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To investigate the effect of lower extremity osteoarthritis on sagittal alignment and compensatory mechanisms in adult spinal deformity (ASD). BACKGROUND Spine, hip, and knee pathologies often overlap in ASD patients. Limited data exists on how lower extremity osteoarthritis impacts sagittal alignment and compensatory mechanisms in ASD. PATIENTS AND METHODS In total, 527 preoperative ASD patients with full body radiographs were included. Patients were grouped by Kellgren-Lawrence grade of bilateral hips and knees and stratified by quartile of T1-Pelvic Angle (T1PA) severity into low-, mid-, high-, and severe-T1PA. Full-body alignment and compensation were compared across quartiles. Regression analysis examined the incremental impact of hip and knee osteoarthritis severity on compensation. RESULTS The mean T1PA for low-, mid-, high-, and severe-T1PA groups was 7.3°, 19.5°, 27.8°, and 41.6°, respectively. Mid-T1PA patients with severe hip osteoarthritis had an increased sagittal vertical axis and global sagittal alignment ( P <0.001). Increasing hip osteoarthritis severity resulted in decreased pelvic tilt ( P =0.001) and sacrofemoral angle ( P <0.001), but increased knee flexion ( P =0.012). Regression analysis revealed that with increasing T1PA, pelvic tilt correlated inversely with hip osteoarthritis and positively with knee osteoarthritis ( r2 =0.812). Hip osteoarthritis decreased compensation through sacrofemoral angle (β-coefficient=-0.206). Knee and hip osteoarthritis contributed to greater knee flexion (β-coefficients=0.215, 0.101; respectively). For pelvic shift, only hip osteoarthritis significantly contributed to the model (β-coefficient=0.100). CONCLUSIONS For the same magnitude of spinal deformity, increased hip osteoarthritis severity was associated with worse truncal and full body alignment with posterior translation of the pelvis. Patients with severe hip and knee osteoarthritis exhibited decreased hip extension and pelvic tilt but increased knee flexion. This examines sagittal alignment and compensation in ASD patients with hip and knee arthritis and may help delineate whether hip and knee flexion is due to spinal deformity compensation or lower extremity osteoarthritis.
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Affiliation(s)
- Mariah Balmaceno-Criss
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell, New York, NY
| | - Daniel Alsoof
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Mohammad Daher
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - David Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA
| | | | - Richard G Fessler
- Department of Neurological Surgery, Rush University Medical School, Chicago, IL
| | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | | | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of Texas Health, Houston, TX
| | - Stephen J Lewis
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Canada
| | | | | | | | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | | | - Thomas Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, CA
| | | | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, Canada
| | | | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Shay Bess
- Denver International Spine Center, Denver, CO
| | | | - Frank J Schwab
- Department of Orthopedic Surgery, Northwell, New York, NY
| | | | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Bassel G Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
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Ani F, Sissman E, Woo D, Soroceanu A, Mundis G, Eastlack RK, Smith JS, Hamilton DK, Kim HJ, Daniels AH, Klineberg EO, Neuman B, Sciubba DM, Gupta MC, Kebaish KM, Passias PG, Hart RA, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Ames CP, Protopsaltis TS. Are insufficient corrections a major factor in distal junctional kyphosis? A simulated analysis of cervical deformity correction using in-construct measurements. J Neurosurg Spine 2024; 40:622-629. [PMID: 38364226 DOI: 10.3171/2023.12.spine23481] [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: 05/02/2023] [Accepted: 12/13/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE The present study utilized recently developed in-construct measurements in simulations of cervical deformity surgery in order to assess undercorrection and predict distal junctional kyphosis (DJK). METHODS A retrospective review of a database of operative cervical deformity patients was analyzed for severe DJK and mild DJK. C2-lower instrumented vertebra (LIV) sagittal angle (SA) was measured postoperatively, and the correction was simulated in the preoperative radiograph in order to match the C2-LIV by using the planning software. Linear regression analysis that used C2 pelvic angle (CPA) and pelvic tilt (PT) determined the simulated PT that matched the virtual CPA. Linear regression analysis was used to determine the C2-T1 SA, C2-T4 SA, and C2-T10 SA that corresponded to DJK of 20° and cervical sagittal vertical axis (cSVA) of 40 mm. RESULTS Sixty-nine cervical deformity patients were included. Severe and mild DJK occurred in 11 (16%) and 22 (32%) patients, respectively; 3 (4%) required DJK revision. Simulated corrections demonstrated that severe and mild DJK patients had worse alignment compared to non-DJK patients in terms of cSVA (42.5 mm vs 33.0 mm vs 23.4 mm, p < 0.001) and C2-LIV SVA (68.9 mm vs 57.3 mm vs 36.8 mm, p < 0.001). Linear regression revealed the relationships between in-construct measures (C2-T1 SA, C2-T4 SA, and C2-T10 SA), cSVA, and change in DJK (all R > 0.57, p < 0.001). A cSVA of 40 mm corresponded to C2-T4 SA of 10.4° and C2-T10 SA of 28.0°. A DJK angle change of 10° corresponded to C2-T4 SA of 5.8° and C2-T10 SA of 20.1°. CONCLUSIONS Simulated cervical deformity corrections demonstrated that severe DJK patients have insufficient corrections compared to patients without DJK. In-construct measures assess sagittal alignment within the fusion separate from DJK and subjacent compensation. They can be useful as intraoperative tools to gauge the adequacy of cervical deformity correction.
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Affiliation(s)
- Fares Ani
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ethan Sissman
- 2Department of Orthopedic Surgery, Chaim Sheba Medical Center Hospital, Tel Aviv University, Tel Aviv, Israel
| | - Dainn Woo
- 3Department of Orthopedic Surgery, Penn Medicine, Philadelphia, Pennsylvania
| | - Alex Soroceanu
- 4Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Robert K Eastlack
- 6Department of Orthopaedic Surgery, Scripps Spine Center, La Jolla, California
| | - Justin S Smith
- 7Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - D Kojo Hamilton
- 8The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Han Jo Kim
- 9Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Alan H Daniels
- 10Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Brian Neuman
- 12Department of Orthopaedics, Johns Hopkins University, Baltimore, Maryland
| | | | - Munish C Gupta
- 14Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Khaled M Kebaish
- 12Department of Orthopaedics, Johns Hopkins University, Baltimore, Maryland
| | - Peter G Passias
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Robert A Hart
- 15Swedish Neuroscience Institute, Seattle, Washington
| | - Shay Bess
- 16Denver International Spine Center, Denver, Colorado
| | - Christopher I Shaffrey
- 17Department of Orthopaedic Surgery, University of Virginia Medical Center, Charlottesville, Virginia; and
| | | | | | - Christopher P Ames
- 18Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
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Diebo BG, Alsoof D, Lafage R, Daher M, Balmaceno-Criss M, Passias PG, Ames CP, Shaffrey CI, Burton DC, Deviren V, Line BG, Soroceanu A, Hamilton DK, Klineberg EO, Mundis GM, Kim HJ, Gum JL, Smith JS, Uribe JS, Kebaish KM, Gupta MC, Nunley PD, Eastlack RK, Hostin R, Protopsaltis TS, Lenke LG, Hart RA, Schwab FJ, Bess S, Lafage V, Daniels AH. Impact of Self-Reported Loss of Balance and Gait Disturbance on Outcomes following Adult Spinal Deformity Surgery. J Clin Med 2024; 13:2202. [PMID: 38673475 PMCID: PMC11051140 DOI: 10.3390/jcm13082202] [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: 03/19/2024] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Background: The objective of this study was to evaluate if imbalance influences complication rates, radiological outcomes, and patient-reported outcomes (PROMs) following adult spinal deformity (ASD) surgery. Methods: ASD patients with baseline and 2-year radiographic and PROMs were included. Patients were grouped according to whether they answered yes or no to a recent history of pre-operative loss of balance. The groups were propensity-matched by age, pelvic incidence-lumbar lordosis (PI-LL), and surgical invasiveness score. Results: In total, 212 patients were examined (106 in each group). Patients with gait imbalance had worse baseline PROM measures, including Oswestry disability index (45.2 vs. 36.6), SF-36 mental component score (44 vs. 51.8), and SF-36 physical component score (p < 0.001 for all). After 2 years, patients with gait imbalance had less pelvic tilt correction (-1.2 vs. -3.6°, p = 0.039) for a comparable PI-LL correction (-11.9 vs. -15.1°, p = 0.144). Gait imbalance patients had higher rates of radiographic proximal junctional kyphosis (PJK) (26.4% vs. 14.2%) and implant-related complications (47.2% vs. 34.0%). After controlling for age, baseline sagittal parameters, PI-LL correction, and comorbidities, patients with imbalance had 2.2-times-increased odds of PJK after 2 years. Conclusions: Patients with a self-reported loss of balance/unsteady gait have significantly worse PROMs and higher risk of PJK.
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Affiliation(s)
- Bassel G. Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
| | - Daniel Alsoof
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY 10075, USA; (R.L.); (F.J.S.); (V.L.)
| | - Mohammad Daher
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
| | - Mariah Balmaceno-Criss
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
| | - Peter G. Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY 10016, USA; (P.G.P.); (T.S.P.)
| | - Christopher P. Ames
- Department of Neurosurgery, University of California, San Francisco, CA 94115, USA; (C.P.A.); (V.D.)
| | | | - Douglas C. Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA;
| | - Vedat Deviren
- Department of Neurosurgery, University of California, San Francisco, CA 94115, USA; (C.P.A.); (V.D.)
| | - Breton G. Line
- Denver International Spine Center, Denver, CO 80218, USA; (B.G.L.); (S.B.)
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - David Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Eric O. Klineberg
- Department of Orthopaedic Surgery, University of California, 1 Shields Ave., Davis, CA 95616, USA;
| | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY 10021, USA;
| | | | - Justin S. Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22903, USA;
| | - Juan S. Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA;
| | - Khaled M. Kebaish
- Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Munish C. Gupta
- Department of Orthopedics, Washington University in St Louis, St. Louis, MO 63110, USA;
| | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, 4708 Alliance Blvd #800, Plano, TX 75093, USA;
| | | | - Lawrence G. Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY 10032, USA;
| | | | - Frank J. Schwab
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY 10075, USA; (R.L.); (F.J.S.); (V.L.)
| | - Shay Bess
- Denver International Spine Center, Denver, CO 80218, USA; (B.G.L.); (S.B.)
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY 10075, USA; (R.L.); (F.J.S.); (V.L.)
| | - Alan H. Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
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4
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Dave P, Lafage R, Smith JS, Line BG, Tretiakov PS, Mir J, Diebo B, Daniels AH, Gum JL, Hamilton DK, Buell T, Than KD, Fu KM, Scheer JK, Eastlack R, Mullin JP, Mundis G, Hosogane N, Yagi M, Nunley P, Chou D, Mummaneni PV, Klineberg EO, Kebaish KM, Lewis S, Hostin RA, Gupta MC, Kim HJ, Ames CP, Hart RA, Lenke LG, Shaffrey CI, Bess S, Schwab FJ, Lafage V, Burton DC, Passias PG. Predictors of pelvic tilt normalization: a multicenter study on the impact of regional and lower-extremity compensation on pelvic alignment after complex adult spinal deformity surgery. J Neurosurg Spine 2024; 40:505-512. [PMID: 38215449 DOI: 10.3171/2023.11.spine23766] [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: 07/12/2023] [Accepted: 11/13/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVE The objective was to determine the degree of regional decompensation to pelvic tilt (PT) normalization after complex adult spinal deformity (ASD) surgery. METHODS Operative ASD patients with 1 year of PT measurements were included. Patients with normalized PT at baseline were excluded. Predicted PT was compared to actual PT, tested for change from baseline, and then compared against age-adjusted, Scoliosis Research Society-Schwab, and global alignment and proportion (GAP) scores. Lower-extremity (LE) parameters included the cranial-hip-sacrum angle, cranial-knee-sacrum angle, and cranial-ankle-sacrum angle. LE compensation was set as the 1-year upper tertile compared with intraoperative baseline. Univariate analyses were used to compare normalized and nonnormalized data against alignment outcomes. Multivariable logistic regression analyses were used to develop a model consisting of significant predictors for normalization related to regional compensation. RESULTS In total, 156 patients met the inclusion criteria (mean ± SD age 64.6 ± 9.1 years, BMI 27.9 ± 5.6 kg/m2, Charlson Comorbidity Index 1.9 ± 1.6). Patients with normalized PT were more likely to have overcorrected pelvic incidence minus lumbar lordosis and sagittal vertical axis at 6 weeks (p < 0.05). GAP score at 6 weeks was greater for patients with nonnormalized PT (0.6 vs 1.3, p = 0.08). At baseline, 58.5% of patients had compensation in the thoracic and cervical regions. Postoperatively, compensation was maintained by 42% with no change after matching in age-adjusted or GAP score. The patients with nonnormalized PT had increased rates of thoracic and cervical compensation (p < 0.05). Compensation in thoracic kyphosis differed between patients with normalized PT at 6 weeks and those with normalized PT at 1 year (69% vs 35%, p < 0.05). Those who compensated had increased rates of implant complications by 1 year (OR [95% CI] 2.08 [1.32-6.56], p < 0.05). Cervical compensation was maintained at 6 weeks and 1 year (56% vs 43%, p = 0.12), with no difference in implant complications (OR 1.31 [95% CI -2.34 to 1.03], p = 0.09). For the lower extremities at baseline, 61% were compensating. Matching age-adjusted alignment did not eliminate compensation at any joint (all p > 0.05). Patients with nonnormalized PT had higher rates of LE compensation across joints (all p < 0.01). Overall, patients with normalized PT at 1 year had the greatest odds of resolving LE compensation (OR 9.6, p < 0.001). Patients with normalized PT at 1 year had lower rates of implant failure (8.9% vs 19.5%, p < 0.05), rod breakage (1.3% vs 13.8%, p < 0.05), and pseudarthrosis (0% vs 4.6%, p < 0.05) compared with patients with nonnormalized PT. The complication rate was significantly lower for patients with normalized PT at 1 year (56.7% vs 66.1%, p = 0.02), despite comparable health-related quality of life scores. CONCLUSIONS Patients with PT normalization had greater rates of resolution in thoracic and LE compensation, leading to lower rates of complications by 1 year. Thus, consideration of both the lower extremities and thoracic regions in surgical planning is vital to preventing adverse outcomes and maintaining pelvic alignment.
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Affiliation(s)
- Pooja Dave
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Renaud Lafage
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton G Line
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Peter S Tretiakov
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Jamshaid Mir
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Bassel Diebo
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Alan H Daniels
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Jeffrey L Gum
- 6Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - D Kojo Hamilton
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas Buell
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Khoi D Than
- 8Departments of Neurosurgery and Orthopaedic Surgery, Spine Division, Duke University School of Medicine, Durham, North Carolina
| | - Kai-Ming Fu
- 9Department of Neurological Surgery, Weill Cornell Medicine Brain and Spine Center/NewYork-Presbyterian Lower Manhattan Hospital, New York, New York
| | - Justin K Scheer
- 10Department of Neurosurgery, Columbia University, New York, New York
| | - Robert Eastlack
- 11Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Jeffrey P Mullin
- 12Department of Neurosurgery at University at Buffalo Medical School, Buffalo, New York
| | - Gregory Mundis
- 11Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Naobumi Hosogane
- 13Division of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Mitsuru Yagi
- 14Department of Orthopedic surgery, Keio University School of Medicine, Shinjyuku, Tokyo, Japan
- 26Department of Orthopedic Surgery, International University of Health and Welfare School of Medicine, Chiba, Narita, Japan
| | - Pierce Nunley
- 15Spine Institute of Louisiana, Shreveport, Louisiana
| | - Dean Chou
- 10Department of Neurosurgery, Columbia University, New York, New York
| | - Praveen V Mummaneni
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Eric O Klineberg
- 17Department of Orthopedic Surgery, University of California Davis, Sacramento, California
| | - Khaled M Kebaish
- 18Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Stephen Lewis
- 19Department of Surgery, Division of Neurosurgery, University of Toronto, Ontario, Canada
| | - Richard A Hostin
- 20Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas
| | - Munish C Gupta
- 21Department of Orthopaedic Surgery, Washington University of St. Louis, Missouri
| | - Han Jo Kim
- 2Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | - Christopher P Ames
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert A Hart
- 22Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Lawrence G Lenke
- 23Department of Orthopaedic Surgery, Columbia College of Physicians and Surgeons, New York, New York
| | - Christopher I Shaffrey
- 8Departments of Neurosurgery and Orthopaedic Surgery, Spine Division, Duke University School of Medicine, Durham, North Carolina
| | - Shay Bess
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Frank J Schwab
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Virginie Lafage
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Douglas C Burton
- 25Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Peter G Passias
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
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Ani F, Ayres EW, Soroceanu A, Mundis GM, Smith JS, Gum JL, Daniels AH, Klineberg EO, Ames CP, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Protopsaltis TS. Functional Alignment Within the Fusion in Adult Spinal Deformity (ASD) Improves Outcomes and Minimizes Mechanical Failures. Spine (Phila Pa 1976) 2024; 49:405-411. [PMID: 37698284 DOI: 10.1097/brs.0000000000004828] [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: 06/08/2023] [Accepted: 09/03/2023] [Indexed: 09/13/2023]
Abstract
STUDY DESIGN Retrospective review of an adult deformity database. OBJECTIVE To identify pelvic incidence (PI) and age-appropriate physical function alignment targets using a component angle of T1-pelvic angle within the fusion to define correction and their relationship to proximal junctional kyphosis (PJK) and clinical outcomes. SUMMARY OF BACKGROUND DATA In preoperative planning, a patient's PI is often utilized to determine the alignment target. In a trend toward more patient-specific planning, age-specific alignment has been shown to reduce the risk of mechanical failures. PI and age have not been analyzed with respect to defining a functional alignment. METHODS A database of patients with operative adult spinal deformity was analyzed. Patients fused to the pelvis and upper-instrumented vertebrae above T11 were included. Alignment within the fusion correlated with clinical outcomes and PI. Short form 36-Physical Component Score (SF36-PCS) normative data and PI were used to compute functional alignment for each patient. Overcorrected, under-corrected, and functionally corrected groups were determined using T10-pelvic angle (T10PA). RESULTS In all, 1052 patients met the inclusion criteria. T10PA correlated with SF36-PCS and PI (R=0.601). At six weeks, 40.7% were functionally corrected, 39.4% were overcorrected, and 20.9% were under-corrected. The PJK incidence rate was 13.6%. Overcorrected patients had the highest PJK rate (18.1%) compared with functionally (11.3%) and under-corrected (9.5%) patients ( P <0.05). Overcorrected patients had a trend toward more PJK revisions. All groups improved in HRQL; however, under-corrected patients had the worst 1-year SF36-PCS offset relative to normative patients of equivalent age (-8.1) versus functional (-6.1) and overcorrected (-4.5), P <0.05. CONCLUSIONS T10PA was used to determine functional alignment, an alignment based on PI and age-appropriate physical function. Correcting patients to functional alignment produced improvements in clinical outcomes, with the lowest rates of PJK. This patient-specific approach to spinal alignment provides adult spinal deformity correction targets that can be used intraoperatively.
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Affiliation(s)
- Fares Ani
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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6
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Passias PG, Mir JM, Dave P, Smith JS, Lafage R, Gum J, Line BG, Diebo B, Daniels AH, Hamilton DK, Buell TJ, Scheer JK, Eastlack RK, Mullin JP, Mundis GM, Hosogane N, Yagi M, Schoenfeld AJ, Uribe JS, Anand N, Mummaneni PV, Chou D, Klineberg EO, Kebaish KM, Lewis SJ, Gupta MC, Kim HJ, Hart RA, Lenke LG, Ames CP, Shaffrey CI, Schwab FJ, Lafage V, Hostin RA, Bess S, Burton DC. Factors Associated with the Maintenance of Cost-Effectiveness at 5 Years in Adult Spinal Deformity Corrective Surgery. Spine (Phila Pa 1976) 2024:00007632-990000000-00613. [PMID: 38462731 DOI: 10.1097/brs.0000000000004982] [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: 11/06/2023] [Accepted: 01/07/2024] [Indexed: 03/12/2024]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To evaluate factors associated with the long-term durability of cost-effectiveness (CE) in ASD patients. BACKGROUND A substantial increase in costs associated with the surgical treatment for adult spinal deformity (ASD) has given precedence to scrutinize the value and utility it provides. METHODS We included 327 operative ASD patients with 5-year (5 Y) follow-up. Published methods were used to determine costs based on CMS.gov definitions and were based on the average DRG reimbursement rates. Utility was calculated using quality-adjusted life-years (QALY) utilizing the Oswestry Disability Index (ODI) converted to Short-Form Six-Dimension (SF-6D), with a 3% discount applied for its decline with life expectancy. The CE threshold of $150,000 was used for primary analysis. RESULTS Major and minor complication rates were 11% and 47% respectively, with 26% undergoing reoperation by 5 Y. The mean cost associated with surgery was $91,095±$47,003, with a utility gain of 0.091±0.086 at 1Y, QALY gained at 2 Y of 0.171±0.183, and at 5 Y of 0.42±0.43. The cost per QALY at 2 Y was $414,885, which decreased to $142,058 at 5 Y.With the threshold of $150,000 for CE, 19% met CE at 2 Y and 56% at 5 Y. In those in which revision was avoided, 87% met cumulative CE till life expectancy. Controlling analysis depicted higher baseline CCI and pelvic tilt (PT) to be the strongest predictors for not maintaining durable CE to 5 Y (CCI OR: 1.821 [1.159-2.862], P=0.009) (PT OR: 1.079 [1.007-1.155], P=0.030). CONCLUSIONS Most patients achieved cost-effectiveness after four years postoperatively, with 56% meeting at five years postoperatively. When revision was avoided, 87% of patients met cumulative cost-effectiveness till life expectancy. Mechanical complications were predictive of failure to achieve cost-effectiveness at 2 Y, while comorbidity burden and medical complications were at 5 Y.
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Affiliation(s)
- Peter G Passias
- Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center; New York Spine Institute, New York, NY, USA
| | - Jamshaid M Mir
- Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center; New York Spine Institute, New York, NY, USA
| | - Pooja Dave
- Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center; New York Spine Institute, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Renaud Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - David Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Jeffrey P Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Gregory M Mundis
- Division of Orthopedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Naobumi Hosogane
- Department of Orthopedic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Stephen J Lewis
- Division of Orthopedics, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Robert A Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, The Och Spine Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher I Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Richard A Hostin
- Department of Orthopedic Surgery, Southwest Scoliosis Institute, Dallas, TX, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
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7
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Azad TD, Schwab FJ, Lafage V, Soroceanu A, Eastlack RK, Lafage R, Kebaish KM, Hart RA, Diebo B, Kelly MP, Smith JS, Daniels AH, Hamilton DK, Gupta M, Klineberg EO, Protopsaltis TS, Passias PG, Bess S, Gum JL, Hostin R, Lewis SJ, Shaffrey CI, Burton D, Lenke LG, Ames CP, Scheer JK. Stronger association of objective physical metrics with baseline patient-reported outcome measures than preoperative standing sagittal parameters for adult spinal deformity patients. J Neurosurg Spine 2024:1-8. [PMID: 38457811 DOI: 10.3171/2024.1.spine231030] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/03/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Sagittal alignment measured on standing radiography remains a fundamental component of surgical planning for adult spinal deformity (ASD). However, the relationship between classic sagittal alignment parameters and objective metrics, such as walking time (WT) and grip strength (GS), remains unknown. The objective of this work was to determine if ASD patients with worse baseline sagittal malalignment have worse objective physical metrics and if those metrics have a stronger relationship to patient-reported outcome metrics (PROMs) than standing alignment. METHODS The authors conducted a retrospective review of a multicenter ASD cohort. ASD patients underwent baseline testing with the timed up-and-go 6-m walk test (seconds) and for GS (pounds). Baseline PROMs were surveyed, including Oswestry Disability Index (ODI), Patient-Reported Outcomes Measurement Information System (PROMIS), Scoliosis Research Society (SRS)-22r, and Veterans RAND 12 (VR-12) scores. Standard spinopelvic measurements were obtained (sagittal vertical axis [SVA], pelvic tilt [PT], and mismatch between pelvic incidence and lumbar lordosis [PI-LL], and SRS-Schwab ASD classification). Univariate and multivariable linear regression modeling was performed to interrogate associations between objective physical metrics, sagittal parameters, and PROMs. RESULTS In total, 494 patients were included, with mean ± SD age 61 ± 14 years, and 68% were female. Average WT was 11.2 ± 6.1 seconds and average GS was 56.6 ± 24.9 lbs. With increasing PT, PI-LL, and SVA quartiles, WT significantly increased (p < 0.05). SRS-Schwab type N patients demonstrated a significantly longer average WT (12.5 ± 6.2 seconds), and type T patients had a significantly shorter WT time (7.9 ± 2.7 seconds, p = 0.03). With increasing PT quartiles, GS significantly decreased (p < 0.05). SRS-Schwab type T patients had a significantly higher average GS (68.8 ± 27.8 lbs), and type L patients had a significantly lower average GS (51.6 ± 20.4 lbs, p = 0.03). In the frailty-adjusted multivariable linear regression analyses, WT was more strongly associated with PROMs than sagittal parameters. GS was more strongly associated with ODI and PROMIS Physical Function scores. CONCLUSIONS The authors observed that increasing baseline sagittal malalignment is associated with slower WT, and possibly weaker GS, in ASD patients. WT has a stronger relationship to PROMs than standing alignment parameters. Objective physical metrics likely offer added value to standard spinopelvic measurements in ASD evaluation and surgical planning.
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Affiliation(s)
- Tej D Azad
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Frank J Schwab
- 2Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Virginie Lafage
- 2Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Alex Soroceanu
- 3Department of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Robert K Eastlack
- 4Department of Orthopedic Surgery, Scripps Clinic, San Diego, California
| | - Renaud Lafage
- 2Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Khaled M Kebaish
- 5Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Hart
- 6Department of Orthopedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Bassel Diebo
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Michael P Kelly
- 8Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Justin S Smith
- 9Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Alan H Daniels
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - D Kojo Hamilton
- 10Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Munish Gupta
- 11Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Eric O Klineberg
- 12Department of Orthopedic Surgery, University of Texas Health Houston, Houston, Texas
| | | | - Peter G Passias
- 13Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Shay Bess
- 14Presbyterian St. Luke's Medical Center, Denver, Colorado
| | | | - Richard Hostin
- 16Department of Orthopedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | - Stephen J Lewis
- 17Department of Surgery, Division of Orthopedic Surgery, University of Toronto, and Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Douglas Burton
- 19Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Lawrence G Lenke
- 20Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York; and
| | - Christopher P Ames
- 21Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Justin K Scheer
- 21Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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8
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Mullin JP, Soliman MAR, Smith JS, Kelly MP, Buell TJ, Diebo B, Scheer JK, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias PG, Gum JL, Kebaish K, Eastlack RK, Daniels AH, Soroceanu A, Mundis G, Hostin R, Protopsaltis TS, Hamilton DK, Gupta MC, Lewis SJ, Schwab FJ, Lenke LG, Shaffrey CI, Bess S, Ames CP, Burton D. Analysis of tranexamic acid usage in adult spinal deformity patients with relative contraindications: does it increase the risk of complications? J Neurosurg Spine 2024:1-8. [PMID: 38457792 DOI: 10.3171/2024.1.spine231098] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/08/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Complex spinal deformity surgeries may involve significant blood loss. The use of antifibrinolytic agents such as tranexamic acid (TXA) has been proven to reduce perioperative blood loss. However, for patients with a history of thromboembolic events, there is concern of increased risk when TXA is used during these surgeries. This study aimed to assess whether TXA use in patients undergoing complex spinal deformity correction surgeries increases the risk of thromboembolic complications based on preexisting thromboembolic risk factors. METHODS Data were analyzed for adult patients who received TXA during surgical correction for spinal deformity at 21 North American centers between August 2018 and October 2022. Patients with preexisting thromboembolic events and other risk factors (history of deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, peripheral vascular disease, or cancer) were identified. Thromboembolic complication rates were assessed during the postoperative 90 days. Univariate and multivariate analyses were performed to assess thromboembolic outcomes in high-risk and low-risk patients who received intravenous TXA. RESULTS Among 411 consecutive patients who underwent complex spinal deformity surgery and received TXA intraoperatively, 130 (31.6%) were considered high-risk patients. There was no significant difference in thromboembolic complications between patients with and those without preexisting thromboembolic risk factors in univariate analysis (high-risk group vs low-risk group: 8.5% vs 2.8%, p = 0.45). Specifically, there were no significant differences between groups regarding the 90-day postoperative rates of DVT (high-risk group vs low-risk group: 1.5% vs 1.4%, p = 0.98), PE (2.3% vs 1.8%, p = 0.71), acute MI (1.5% vs 0%, p = 0.19), or stroke (0.8% vs 1.1%, p > 0.99). On multivariate analysis, high-risk status was not a significant independent predictor for any of the thromboembolic complications. CONCLUSIONS Administration of intravenous TXA during the correction procedure did not change rates of thromboembolic events, acute MI, or stroke in this cohort of adult spinal deformity surgery patients.
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Affiliation(s)
- Jeffrey P Mullin
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York
- 2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York
| | - Mohamed A R Soliman
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York
- 3Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Justin S Smith
- 4Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Michael P Kelly
- 5Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Thomas J Buell
- 6Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bassel Diebo
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Justin K Scheer
- 8Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Breton Line
- 9Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Virginie Lafage
- 10Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Renaud Lafage
- 10Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Eric Klineberg
- 11Department of Orthopedic Surgery, University of Texas Health Houston, Houston, Texas
| | - Han Jo Kim
- 12Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter G Passias
- 13Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | - Khaled Kebaish
- 15Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert K Eastlack
- 16Department of Orthopedic Surgery, Scripps Clinic, San Diego, California
| | - Alan H Daniels
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Alex Soroceanu
- 17Department of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Mundis
- 16Department of Orthopedic Surgery, Scripps Clinic, San Diego, California
| | - Richard Hostin
- 18Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | | | - D Kojo Hamilton
- 6Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Munish C Gupta
- 19Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Stephen J Lewis
- 20Department of Surgery, Division of Orthopedic Surgery, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Frank J Schwab
- 10Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Lawrence G Lenke
- 21Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Christopher I Shaffrey
- 22Departments of Neurosurgery and Orthopedic Surgery, Spine Division, Duke University, Durham, North Carolina; and
| | - Shay Bess
- 9Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Christopher P Ames
- 8Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Douglas Burton
- 23Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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9
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Daniels AH, Daher M, Singh M, Balmaceno-Criss M, Lafage R, Diebo BG, Hamilton DK, Smith JS, Eastlack RK, Fessler RG, Gum JL, Gupta MC, Hostin R, Kebaish KM, Klineberg EO, Lewis SJ, Line BG, Nunley PD, Mundis GM, Passias PG, Protopsaltis TS, Buell T, Scheer JK, Mullin JP, Soroceanu A, Ames CP, Lenke LG, Bess S, Shaffrey CI, Burton DC, Lafage V, Schwab FJ. The Case for Operative Efficiency in Adult Spinal Deformity Surgery: Impact of Operative Time on Complications, Length of Stay, Alignment, Fusion Rates, and Patient-Reported Outcomes. Spine (Phila Pa 1976) 2024; 49:313-320. [PMID: 37942794 DOI: 10.1097/brs.0000000000004873] [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: 08/30/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected data. OBJECTIVE To analyze the impact of operative room (OR) time in adult spinal deformity (ASD) surgery on patient outcomes. BACKGROUND It is currently unknown if OR time in ASD patients matched for deformity severity and surgical invasiveness is associated with patient outcomes. MATERIALS AND METHODS ASD patients with baseline and two-year postoperative radiographic and patient-reported outcome measures (PROM) data, undergoing a posterior-only approach for long fusion (>L1-Ilium) were included. Patients were grouped into short OR time (<40th percentile: <359 min) and long OR time (>60th percentile: >421 min). Groups were matched by age, baseline deformity severity, and surgical invasiveness. Demographics, radiographic, PROM data, fusion rate, and complications were compared between groups at baseline and two years follow-up. RESULTS In total, 270 patients were included for analysis: the mean OR time was 286 minutes in the short OR group versus 510 minutes in the long OR group ( P <0.001). Age, gender, percent of revision cases, surgical invasiveness, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt were comparable between groups ( P >0.05). Short OR had a slightly lower body mass index than the short OR group ( P <0.001) and decompression was more prevalent in the long OR time ( P =0.042). Patients in the long group had greater hospital length of stay ( P =0.02); blood loss ( P <0.001); proportion requiring intensive care unit ( P =0.003); higher minor complication rate ( P =0.001); with no significant differences for major complications or revision procedures ( P >0.5). Both groups had comparable radiographic fusion rates ( P =0.152) and achieved improvement in sagittal alignment measures, Oswestry disability index, and Short Form-36 ( P <0.001). CONCLUSION Shorter OR time for ASD correction is associated with a lower minor complication rate, a lower estimated blood loss, fewer intensive care unit admissions, and a shorter hospital length of stay without sacrificing alignment correction or PROMs. Maximizing operative efficiency by minimizing OR time in ASD surgery has the potential to benefit patients, surgeons, and hospital systems.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Mohammad Daher
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Manjot Singh
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Mariah Balmaceno-Criss
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell, New York, NY
| | - Bassel G Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - David K Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA
| | | | - Richard G Fessler
- Department of Neurological Surgery, Rush University Medical School, Chicago, IL
| | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX
| | | | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA
| | - Stephen J Lewis
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Canada
| | | | | | | | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | | | - Thomas Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, CA
| | | | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, Canada
| | | | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Shay Bess
- Denver International Spine Center, Denver, CO
| | | | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | | | - Frank J Schwab
- Department of Orthopedic Surgery, Northwell, New York, NY
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10
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Mohanty S, Hassan FM, Lenke LG, Lewerenz E, Passias PG, Klineberg EO, Lafage V, Smith JS, Hamilton DK, Gum JL, Lafage R, Mullin J, Diebo B, Buell TJ, Kim HJ, Kebaish K, Eastlack R, Daniels AH, Mundis G, Hostin R, Protopsaltis TS, Hart RA, Gupta M, Schwab FJ, Shaffrey CI, Ames CP, Burton D, Bess S. Machine learning clustering of adult spinal deformity patients identifies four prognostic phenotypes: a multicenter prospective cohort analysis with single surgeon external validation. Spine J 2024:S1529-9430(24)00073-1. [PMID: 38365004 DOI: 10.1016/j.spinee.2024.02.010] [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: 08/09/2023] [Revised: 01/11/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND CONTEXT Among adult spinal deformity (ASD) patients, heterogeneity in patient pathology, surgical expectations, baseline impairments, and frailty complicates comparisons in clinical outcomes and research. This study aims to qualitatively segment ASD patients using machine learning-based clustering on a large, multicenter, prospectively gathered ASD cohort. PURPOSE To qualitatively segment adult spinal deformity patients using machine learning-based clustering on a large, multicenter, prospectively gathered cohort. STUDY DESIGN/SETTING Machine learning algorithm using patients from a prospective multicenter study and a validation cohort from a retrospective single center, single surgeon cohort with complete 2-year follow up. PATIENT SAMPLE About 805 ASD patients; 563 patients from a prospective multicenter study and 242 from a single center to be used as a validation cohort. OUTCOME MEASURES To validate and extend the Ames-ISSG/ESSG classification using machine learning-based clustering analysis on a large, complex, multicenter, prospectively gathered ASD cohort. METHODS We analyzed a training cohort of 563 ASD patients from a prospective multicenter study and a validation cohort of 242 ASD patients from a retrospective single center/surgeon cohort with complete two-year patient-reported outcomes (PROs) and clinical/radiographic follow-up. Using k-means clustering, a machine learning algorithm, we clustered patients based on baseline PROs, Edmonton frailty, age, surgical history, and overall health. Baseline differences in clusters identified using the training cohort were assessed using Chi-Squared and ANOVA with pairwise comparisons. To evaluate the classification system's ability to discern postoperative trajectories, a second machine learning algorithm assigned the single-center/surgeon patients to the same 4 clusters, and we compared the clusters' two-year PROs and clinical outcomes. RESULTS K-means clustering revealed four distinct phenotypes from the multicenter training cohort based on age, frailty, and mental health: Old/Frail/Content (OFC, 27.7%), Old/Frail/Distressed (OFD, 33.2%), Old/Resilient/Content (ORC, 27.2%), and Young/Resilient/Content (YRC, 11.9%). OFC and OFD clusters had the highest frailty scores (OFC: 3.76, OFD: 4.72) and a higher proportion of patients with prior thoracolumbar fusion (OFC: 47.4%, OFD: 49.2%). ORC and YRC clusters exhibited lower frailty scores and fewest patients with prior thoracolumbar procedures (ORC: 2.10, 36.6%; YRC: 0.84, 19.4%). OFC had 69.9% of patients with global sagittal deformity and the highest T1PA (29.0), while YRC had 70.2% exhibiting coronal deformity, the highest mean coronal Cobb Angle (54.0), and the lowest T1PA (11.9). OFD and ORC had similar alignment phenotypes with intermediate values for Coronal Cobb Angle (OFD: 33.7; ORC: 40.0) and T1PA (OFD: 24.9; ORC: 24.6) between OFC (worst sagittal alignment) and YRC (worst coronal alignment). In the single surgeon validation cohort, the OFC cluster experienced the greatest increase in SRS Function scores (1.34 points, 95%CI 1.01-1.67) compared to OFD (0.5 points, 95%CI 0.245-0.755), ORC (0.7 points, 95%CI 0.415-0.985), and YRC (0.24 points, 95%CI -0.024-0.504) clusters. OFD cluster patients improved the least over 2 years. Multivariable Cox regression analysis demonstrated that the OFD cohort had significantly worse reoperation outcomes compared to other clusters (HR: 3.303, 95%CI: 1.085-8.390). CONCLUSION Machine-learning clustering found four different ASD patient qualitative phenotypes, defined by their age, frailty, physical functioning, and mental health upon presentation, which primarily determines their ability to improve their PROs following surgery. This reaffirms that these qualitative measures must be assessed in addition to the radiographic variables when counseling ASD patients regarding their expected surgical outcomes.
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Affiliation(s)
- Sarthak Mohanty
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | - Fthimnir M Hassan
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA.
| | - Lawrence G Lenke
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | - Erik Lewerenz
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | - Peter G Passias
- Department of Orthopaedic Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health Lenox Hill, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Northwell Health Lenox Hill, New York, NY, USA
| | - Jeffrey Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, University Orthopedics, Providence, RI, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Khalid Kebaish
- Department of Orthopaedic Surgery, John Hopkins Medical Institute, Baltimore, MD, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, University Orthopedics, Providence, RI, USA
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis and Spine Institute, Dallas, TX, USA
| | | | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Northwell Health Lenox Hill, New York, NY, USA
| | | | - Christopher P Ames
- Department of Neurosurgery, University of California San Francisco Spine Center, San Francisco, CA, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
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11
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Williamson TK, Dave P, Mir JM, Smith JS, Lafage R, Line B, Diebo BG, Daniels AH, Gum JL, Protopsaltis TS, Hamilton DK, Soroceanu A, Scheer JK, Eastlack R, Kelly MP, Nunley P, Kebaish KM, Lewis S, Lenke LG, Hostin RA, Gupta MC, Kim HJ, Ames CP, Hart RA, Burton DC, Shaffrey CI, Klineberg EO, Schwab FJ, Lafage V, Chou D, Fu KM, Bess S, Passias PG. Persistent Lower Extremity Compensation for Sagittal Imbalance After Surgical Correction of Complex Adult Spinal Deformity: A Radiographic Analysis of Early Impact. Oper Neurosurg (Hagerstown) 2024; 26:156-164. [PMID: 38227826 DOI: 10.1227/ons.0000000000000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/06/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Achieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The objective is to analyze lower extremity compensation after complex ASD surgery, its effect on outcomes, and whether correction can alleviate these mechanisms. METHODS We included patients with complex ASD with 6-week data. LE parameters were as follows: sacrofemoral angle, knee flexion angle, and ankle flexion angle. Each parameter was ranked, and upper tertile was deemed compensation. Patients compensating and not compensating postoperatively were propensity score matched for body mass index, frailty, and T1 pelvic angle. Linear regression assessed correlation between LE parameters and baseline deformity, demographics, and surgical details. Multivariate analysis controlling for baseline deformity and history of total knee/hip arthroplasty evaluated outcomes. RESULTS Two hundred and ten patients (age: 61.3 ± 14.1 years, body mass index: 27.4 ± 5.8 kg/m2, Charlson Comorbidity Index: 1.1 ± 1.6, 72% female, 22% previous total joint arthroplasty, 24% osteoporosis, levels fused: 13.1 ± 3.8) were included. At baseline, 59% were compensating in LE: 32% at hips, 39% knees, and 36% ankles. After correction, 61% were compensating at least one joint. Patients undercorrected postoperatively were less likely to relieve LE compensation (odds ratio: 0.2, P = .037). Patients compensating in LE were more often undercorrected in age-adjusted pelvic tilt, pelvic incidence, lumbar lordosis, and T1 pelvic angle and disproportioned in Global Alignment and Proportion (P < .05). Patients matched in sagittal age-adjusted score at 6 weeks but compensating in LE were more likely to develop proximal junctional kyphosis (odds ratio: 4.1, P = .009) and proximal junctional failure (8% vs 0%, P = .035) than those sagittal age-adjusted score-matched and not compensating in LE. CONCLUSION Perioperative lower extremity compensation was a product of undercorrecting complex ASD. Even in age-adjusted realignment, compensation was associated with global undercorrection and junctional failure. Consideration of lower extremities during planning is vital to avoid adverse outcomes in perioperative course after complex ASD surgery.
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Affiliation(s)
- Tyler K Williamson
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
| | - Pooja Dave
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
| | - Jamshaid M Mir
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, New York, USA
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | | | - D Kojo Hamilton
- Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Pierce Nunley
- Spine Institute of Louisiana, Shreveport, Louisiana, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Stephen Lewis
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia College of Physicians and Surgeons, New York, New York, USA
| | - Richard A Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University of St Louis, St Louis, Missouri, USA
| | - Han Jo Kim
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher I Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, California, USA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medicine Brain and Spine Center, New York, New York, USA
| | - Shay Bess
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Peter G Passias
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
- Rocky Mountain Scoliosis and Spine, Denver, Colorado, USA
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12
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Passias PG, Pierce KE, Williamson TK, Lebovic J, Schoenfeld AJ, Lafage R, Lafage V, Gum JL, Eastlack R, Kim HJ, Klineberg EO, Daniels AH, Protopsaltis TS, Mundis GM, Scheer JK, Park P, Chou D, Line B, Hart RA, Burton DC, Bess S, Schwab FJ, Shaffrey CI, Smith JS, Ames CP. Patient-specific Cervical Deformity Corrections With Consideration of Associated Risk: Establishment of Risk Benefit Thresholds for Invasiveness Based on Deformity and Frailty Severity. Clin Spine Surg 2024; 37:E43-E51. [PMID: 37798829 DOI: 10.1097/bsd.0000000000001540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 10/13/2022] [Accepted: 08/10/2023] [Indexed: 10/07/2023]
Abstract
STUDY DESIGN/SETTING This was a retrospective cohort study. BACKGROUND Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty. OBJECTIVE The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity. METHODS This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely. RESULTS A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P =0.002], and invasiveness increased with deformity severity ( P <0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P =0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P =0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P =0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group. CONCLUSIONS Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Katherine E Pierce
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Jordan Lebovic
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California-Davis, Davis, CA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
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13
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Diebo BG, Balmaceno-Criss M, Lafage R, Daher M, Singh M, Hamilton DK, Smith JS, Eastlack RK, Fessler R, Gum JL, Gupta MC, Hostin R, Kebaish KM, Lewis S, Line BG, Nunley PD, Mundis GM, Passias PG, Protopsaltis TS, Turner J, Buell T, Scheer JK, Mullin J, Soroceanu A, Ames CP, Bess S, Shaffrey CI, Lenke LG, Schwab FJ, Lafage V, Burton DC, Daniels AH. Lumbar Lordosis Redistribution and Segmental Correction in Adult Spinal Deformity (ASD): Does it Matter? Spine (Phila Pa 1976) 2024:00007632-990000000-00569. [PMID: 38270393 DOI: 10.1097/brs.0000000000004930] [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: 10/02/2023] [Accepted: 01/01/2024] [Indexed: 01/26/2024]
Abstract
STUDY DESIGN Retrospective analysis of prospectively collected data. OBJECTIVE Evaluate the impact of correcting to normative segmental lordosis values on post-operative outcomes. BACKGROUND Restoring lumbar lordosis magnitude is crucial in adult spinal deformity surgery, but the optimal location and segmental distribution remains unclear. METHODS Patients were grouped based on offset to normative segmental lordosis values, extracted from recent publications. Matched patients were within 10% of the cohort's mean offset, less than or over 10% were under- and over-corrected. Surgical technique, PROMs, and surgical complications were compared across groups at baseline and 2-year. RESULTS 510 patients with an average age of 64.6, mean CCI 2.08, and average follow-up of 25 months. L4-5 was least likely to be matched (19.1%), while L4-S1 was the most likely (24.3%). More patients were overcorrected at proximal levels (T10-L2; Undercorrected, U: 32.2% vs. Matched, M: 21.7% vs. Overcorrected, O: 46.1%) and undercorrected at distal levels (L4-S1: U: 39.0% vs. M: 24.3% vs. O: 36.8%). Postoperative ODI was comparable across correction groups at all spinal levels except at L4-S1 and T10-L2/L4-S1, where overcorrected patients and matched were better than undercorrected (U: 32.1 vs. M: 25.4 vs. O: 26.5, P=0.005; U: 36.2 vs. M: 24.2 vs. O: 26.8, P=0.001; respectively). Patients overcorrected at T10-L2 experienced higher rates of proximal junctional failure (PJF) (U: 16.0% vs. M: 15.6% vs. O: 32.8%, P<0.001) and had greater posterior inclination of the upper instrumented vertebra (UIV) (U: -9.2±9.4° vs. M: -9.6±9.1° vs. O: -12.2±10.0°, P<0.001), whereas undercorrection at these levels led to higher rates of revision for implant failure (U: 14.2% vs. M: 7.3% vs. O: 6.4%, P=0.025). CONCLUSIONS Patients undergoing fusion for adult spinal deformity suffer higher rates of PJF with overcorrection and increased rates of implant failure with undercorrection based on normative segmental lordosis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Bassel G Diebo
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mariah Balmaceno-Criss
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Mohammad Daher
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Manjot Singh
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Robert K Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | | | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, Kentucky
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen Lewis
- Department of Orthopedics, University of Toronto, Toronto, Canada
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Center, Denver, Colorado
| | | | - Gregory M Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | | | - Jay Turner
- Barrow Brain and Spine, Phoenix, Arizona
| | - Thomas Buell
- Department of Neurological Surgery, University of Pittsburgh
| | - Justin K Scheer
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Jeffery Mullin
- Department of Neurosurgery, University of Buffalo, Amherst, New York, New York
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Canada
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Denver, Colorado
| | | | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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14
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Passias PG, Passfall L, Moattari K, Krol O, Kummer NA, Tretiakov P, Williamson T, Joujon-Roche R, Imbo B, Burhan Janjua M, Jankowski P, Paulino C, Schwab FJ, Owusu-Sarpong S, Singh V, Ahmad S, Onafowokan T, Lebovic J, Tariq M, Saleh H, Vira S, Smith JS, Diebo B, Schoenfeld AJ. Factors Influencing Maintenance of Alignment and Functional Improvement Following Adult Spinal Deformity Surgery: A 3-Year Outcome Analysis. Spine (Phila Pa 1976) 2024; 49:90-96. [PMID: 37199423 DOI: 10.1097/brs.0000000000004717] [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: 09/13/2021] [Accepted: 12/07/2022] [Indexed: 05/19/2023]
Abstract
STUDY DESIGN This was a retrospective review. OBJECTIVE To assess the factors contributing to durability of surgical results following adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND Factors contributing to the long-term sustainability of ASD correction are currently undefined. MATERIALS AND METHODS Operative ASD patients with preoperatively (baseline) and 3-year postoperatively radiographic/health-related quality of life data were included. At 1 and 3 years postoperatively, a favorable outcome was defined as meeting at least three of four criteria: (1) no proximal junctional failure or mechanical failure with reoperation, (2) best clinical outcome (BCO) for Scoliosis Research Society (SRS) (≥4.5) or Oswestry Disability Index (ODI) (<15), (3) improving in at least one SRS-Schwab modifier, and (4) not worsening in any SRS-Schwab modifier. A robust surgical result was defined as having a favorable outcome at both 1 and 3 years. Predictors of robust outcomes were identified using multivariable regression analysis with conditional inference tree for continuous variables. RESULTS We included 157 ASD patients in this analysis. At 1 year postoperatively, 62 patients (39.5%) met the BCO definition for ODI and 33 (21.0%) met the BCO for SRS. At 3 years, 58 patients (36.9%) had BCO for ODI and 29 (18.5%) for SRS. Ninety-five patients (60.5%) were identified as having a favorable outcome at 1 year postoperatively. At 3 years, 85 patients (54.1%) had a favorable outcome. Seventy-eight patients (49.7%) met criteria for a durable surgical result. Multivariable adjusted analysis identified the following independent predictors of surgical durability: surgical invasiveness >65, being fused to S1/pelvis, baseline to 6-week pelvic incidence and lumbar lordosis difference >13.9°, and having a proportional Global Alignment and Proportion score at 6 weeks. CONCLUSIONS Nearly 50% of the ASD cohort demonstrated good surgical durability, with favorable radiographic alignment and functional status maintained up to 3 years. Surgical durability was more likely in patients whose reconstruction was fused to the pelvis and addressed lumbopelvic mismatch with adequate surgical invasiveness to achieve full alignment correction.
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Affiliation(s)
- Peter G Passias
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Lara Passfall
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Kevin Moattari
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Oscar Krol
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Nicholas A Kummer
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Peter Tretiakov
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Tyler Williamson
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Rachel Joujon-Roche
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Bailey Imbo
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | | | - Pawel Jankowski
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Carl Paulino
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Vivek Singh
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Salman Ahmad
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Tobi Onafowokan
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Jordan Lebovic
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Muhammad Tariq
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Hesham Saleh
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Shaleen Vira
- Departments of Orthopaedic and Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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15
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Iyer S, Steinhaus ME, Kazarian GS, Zgonis EM, Cunningham ME, Farmer JC, Kim HJ, Lebl DR, Huang RC, Lafage V, Schwab FJ, Qureshi S, Girardi FP, Rawlins BA, Beckman JD, Varghese JJ, Muzammil H, Lafage R, Sandhu HS. Intravenous Ketorolac Substantially Reduces Opioid Use and Length of Stay After Lumbar Fusion: A Randomized Controlled Trial. Spine (Phila Pa 1976) 2024; 49:73-80. [PMID: 37737686 PMCID: PMC10872662 DOI: 10.1097/brs.0000000000004831] [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: 06/29/2023] [Accepted: 09/05/2023] [Indexed: 09/23/2023]
Abstract
STUDY DESIGN A randomized, double-blinded, placebo-controlled trial. OBJECTIVE To examine the effect of intravenous ketorolac (IV-K) on hospital opioid use compared with IV-placebo (IV-P) and IV acetaminophen (IV-A). SUMMARY OF BACKGROUND DATA Controlling postoperative pain while minimizing opioid use after lumbar spinal fusion is an important area of study. PATIENTS AND METHODS Patients aged 18 to 75 years undergoing 1 to 2 level lumbar fusions between April 2016 and December 2019 were included. Patients with chronic opioid use, smokers, and those on systemic glucocorticoids or contraindications to study medications were excluded. A block randomization scheme was used, and study personnel, hospital staff, and subjects were blinded to the assignment. Patients were randomized postoperatively. The IV-K group received 15 mg (age > 65) or 30 mg (age < 65) every six hours (q6h) for 48 hours, IV-A received 1000 mg q6h, and IV-P received normal saline q6h for 48 hours. Demographic and surgical details, opioid use in morphine milliequivalents, opioid-related adverse events, and length of stay (LOS) were recorded. The primary outcome was in-hospital opioid use up to 72 hours. RESULTS A total of 171 patients were included (58 IV-K, 55 IV-A, and 58 IV-P) in the intent-to-treat (ITT) analysis, with a mean age of 57.1 years. The IV-K group had lower opioid use at 72 hours (173 ± 157 mg) versus IV-A (255 ± 179 mg) and IV-P (299 ± 179 mg; P = 0.000). In terms of opiate use, IV-K was superior to IV-A ( P = 0.025) and IV-P ( P = 0.000) on ITT analysis, although on per-protocol analysis, the difference with IV-A did not reach significance ( P = 0.063). When compared with IV-P, IV-K patients reported significantly lower worst ( P = 0.004), best ( P = 0.001), average ( P = 0.001), and current pain ( P = 0.002) on postoperative day 1, and significantly shorter LOS ( P = 0.009) on ITT analysis. There were no differences in opioid-related adverse events, drain output, clinical outcomes, transfusion rates, or fusion rates. CONCLUSIONS By reducing opioid use, improving pain control on postoperative day 1, and decreasing LOS without increases in complications or pseudarthrosis, IV-K may be an important component of "enhanced recovery after surgery" protocols.
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Affiliation(s)
- Sravisht Iyer
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael E. Steinhaus
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Gregory S. Kazarian
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Evangelia M Zgonis
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Matthew E. Cunningham
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - James C. Farmer
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Darren R. Lebl
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Russel C. Huang
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Frank J. Schwab
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Sheeraz Qureshi
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Federico P. Girardi
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Bernard A. Rawlins
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - James D. Beckman
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Jeffrey J. Varghese
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Hamna Muzammil
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Harvinder S. Sandhu
- Spine Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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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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17
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Passias PG, Ahmad W, Williamson TK, Lebovic J, Kebaish K, Lafage R, Lafage V, Line B, Schoenfeld AJ, Diebo BG, Klineberg EO, Kim HJ, Ames CP, Daniels AH, Smith JS, Shaffrey CI, Burton DC, Hart RA, Bess S, Schwab FJ, Gupta MC. Efficacy of Varying Surgical Approaches on Achieving Optimal Alignment in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2024; 49:22-28. [PMID: 37493057 DOI: 10.1097/brs.0000000000004784] [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: 05/17/2022] [Accepted: 06/21/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND The Roussouly, SRS-Schwab, and Global Alignment and Proportion (GAP) classifications define alignment by spinal shape and deformity severity. The efficacy of different surgical approaches and techniques to successfully achieve these goals is not well understood. PURPOSE Identify the impact of surgical approach and/or technique on meeting complex realignment goals in adult spinal deformity (ASD) corrective surgery. STUDY DESIGN/SETTING Retrospective study. MATERIALS AND METHODS Included patients with ASD fused to pelvis with 2-year data. Patients were categorized by: (1) Roussouly: matching current and theoretical spinal shapes, (2) improving in SRS-Schwab modifiers (0, +, ++), and (3) improving GAP proportionality by 2 years. Analysis of covariance and multivariable logistic regression analyses controlling for age, levels fused, baseline deformity, and 3-column osteotomy usage compared the effect of different surgical approaches, interbody, and osteotomy use on meeting realignment goals. RESULTS A total of 693 patients with ASD were included. By surgical approach, 65.7% were posterior-only and 34.3% underwent anterior-posterior approach with 76% receiving an osteotomy (21.8% 3-column osteotomy). By 2 years, 34% matched Roussouly, 58% improved in GAP, 45% in SRS-Schwab pelvic tilt (PT), 62% sagittal vertical axis, and 70% pelvic incidence-lumbar lordosis. Combined approaches were most effective for improvement in PT [odds ratio (OR): 1.7 (1.1-2.5)] and GAP [OR: 2.2 (1.5-3.2)]. Specifically, anterior lumbar interbody fusion (ALIF) below L3 demonstrated higher rates of improvement versus TLIFs in Roussouly [OR: 1.7 (1.1-2.5)] and GAP [OR: 1.9 (1.3-2.7)]. Patients undergoing pedicle subtraction osteotomy at L3 or L4 were more likely to improve in PT [OR: 2.0 (1.0-5.2)] and pelvic incidence-lumbar lordosis [OR: 3.8 (1.4-9.8)]. Clinically, patients undergoing the combined approach demonstrated higher rates of meeting SCB in Oswestry Disability Index by 2 years while minimizing rates of proximal junctional failure, most often with an ALIF at L5-S1 [Oswestry Disability Index-SCB: OR: 1.4 (1.1-2.0); proximal junctional failure: OR: 0.4 (0.2-0.8)]. CONCLUSIONS Among patients undergoing ASD realignment, optimal lumbar shape and proportion can be achieved more often with a combined approach. Although TLIFs, incorporating a 3-column osteotomy, at L3 and L4 can restore lordosis and normalize pelvic compensation, ALIFs at L5-S1 were most likely to achieve complex realignment goals with an added clinical benefit and mitigation of junctional failure.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital and New York Spine Institute, New York, NY
| | - Waleed Ahmad
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital and New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital and New York Spine Institute, New York, NY
| | - Jordan Lebovic
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Khaled Kebaish
- Department of Orthopedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA
| | - Han Jo Kim
- 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
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Christopher I Shaffrey
- Departments of Neurosurgery and Orthopedic Surgery, Spine Division, Duke University School of Medicine, Durham, NC
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Robert A Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, MO
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McCarthy MH, Lafage R, Smith JS, Bess S, Ames CP, Klineberg EO, Kim HJ, Shaffrey CI, Burton DC, Mundis GM, Gupta MC, Schwab FJ, Lafage V. How Much Lumbar Lordosis does a Patient Need to Reach their Age-Adjusted Alignment Target? A Formulated Approach Predicting Successful Surgical Outcomes. Global Spine J 2024; 14:41-48. [PMID: 35442842 PMCID: PMC10676150 DOI: 10.1177/21925682221092003] [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 Identify optimal lumbar lordosis in adult deformity correction to achieve age-adjusted targets and sustained alignment. METHODS Surgical adult spinal deformity patients reaching an age-adjusted ideal alignment at one year were identified. Multilinear regression analysis was used to identify the relationship between regional curvatures (LL and TK) that enabled achievement of a given global alignment (T1 pelvic angle, TPA) based on pelvic incidence (PI). RESULTS 347 patients out of 1048 available reached their age-adjusted TPA within 5° (60-year-old, 72% women, body mass index 29 ± 6.2). They had a significant improvement in all sagittal parameters (except PI) from pre-operative baseline to 1 year following surgery (P < .001). Multilinear regression predicting L1-S1 based on TK, TPA, and PI demonstrated excellent results (R2 = .85). Simplification of the coefficients of prediction combined with a conversion to an age-based formula led to the following: LL = PI - 0.3TK - 0.5Age + 10. Internal validation of the formula led to a mean error of -.4°, and an absolute error of 5.0°. Internal validation on patients with an age-adjusted alignment revealed similar accuracy across the entire age-adjusted TPA spectrum (ranges of LL errors: ME = .2° to 1.7°, AE = 4.0° to 5.3°). CONCLUSION This study provides a simple guideline to identify the amount of LL needed to reach a given alignment (i.e., age-adjusted target) based on PI and associated TK. Implementation of this predictive formula during pre-operative surgical planning may help to reduce unexpected sub-optimal post-operative alignment outcomes.
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Affiliation(s)
- Michael H. McCarthy
- Indiana Spine Group, Carmel, IN, USA; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Christopher P. Ames
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Eric O. Klineberg
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Han J. Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | | | - Douglas C. Burton
- Department of Orthopaedic Surgery, The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Manish C. Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | - Frank J. 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
| | - International Spine Study Group (ISSG)
- Indiana Spine Group, Carmel, IN, USA; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
- Denver International Spine Center, Denver, CO, USA
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, USA
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Department of Orthopaedic Surgery, The University of Kansas Medical Center, Kansas City, KS, USA
- San Diego Center for Spinal Disorders, La Jolla, CA, USA
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
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19
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Passias PG, Williamson TK, Kummer NA, Pellisé F, Lafage V, Lafage R, Serra-Burriel M, Smith JS, Line B, Vira S, Gum JL, Haddad S, Sánchez Pérez-Grueso FJ, Schoenfeld AJ, Daniels AH, Chou D, Klineberg EO, Gupta MC, Kebaish KM, Kelly MP, Hart RA, Burton DC, Kleinstück F, Obeid I, Shaffrey CI, Alanay A, Ames CP, Schwab FJ, Hostin RA, Bess S. Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery. Global Spine J 2023:21925682231212966. [PMID: 38081300 DOI: 10.1177/21925682231212966] [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: 12/22/2023] Open
Abstract
STUDY DESIGN/SETTING Retrospective cohort study. OBJECTIVE Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery. METHODS ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility. RESULTS By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001). CONCLUSIONS The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions.Level of evidence: III.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, NY, NY, USA
| | - Tyler K Williamson
- Department of Orthopaedic Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Nicholas A Kummer
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, NY, NY, USA
| | - Ferran Pellisé
- Spine Surgery Unit, Vall d'Hebron Hospital, Barcelona, Spain
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Miguel Serra-Burriel
- Center for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
| | - 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
| | - Shaleen Vira
- Department of Orthopedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Sleiman Haddad
- Spine Surgery Unit, Vall d'Hebron Hospital, Barcelona, Spain
| | | | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Frank Kleinstück
- Spine Center Division, Department of Orthopedics and Neurosurgery, Schulthess Klinik, Zürich, Switzerland
| | - Ibrahim Obeid
- Spine Surgery Unit, Bordeaux University Hospital, Bordeaux, France
| | - Christopher I Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acıbadem University, Istanbul, Turkey
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, New York, NY, USA
| | - Richard A Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
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20
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Ye J, Gupta S, Farooqi AS, Yin T, Soroceanu A, Schwab FJ, Lafage V, Kelly MP, Kebaish K, Hostin R, Gum JL, Smith JS, Shaffrey CI, Scheer JK, Protopsaltis TS, Passias PG, Klineberg EO, Kim HJ, Hart RA, Hamilton DK, Ames CP, Gupta MC. Predictive role of global spinopelvic alignment and upper instrumented vertebra level in symptomatic proximal junctional kyphosis in adult spinal deformity. J Neurosurg Spine 2023; 39:774-784. [PMID: 37542446 DOI: 10.3171/2023.6.spine23383] [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: 04/04/2023] [Accepted: 06/06/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE The authors of this study sought to evaluate the predictive role of global sagittal alignment and upper instrumented vertebra (UIV) level in symptomatic proximal junctional kyphosis (PJK) among patients with adult spinal deformity (ASD). METHODS Data on ASD patients who had undergone fusion of ≥ 5 vertebrae from 2008 to 2018 and with a minimum follow-up of 1 year were obtained from a prospectively collected multicenter database and evaluated (n = 1312). Radiographs were obtained preoperatively and at 6 weeks, 6 months, 1 year, 2 years, and 3 years postoperatively. The 22-Item Scoliosis Research Society Patient Questionnaire Revised (SRS-22r) scores were collected preoperatively, 1 year postoperatively, and 2 years postoperatively. Symptomatic PJK was defined as a kyphotic increase > 20° in the Cobb angle from the UIV to the UIV+2. At 6 weeks postoperatively, sagittal parameters were evaluated and patients were categorized by global alignment and proportion (GAP) score/category and SRS-Schwab sagittal modifiers. Patients were stratified by UIV level: upper thoracic (UT) UIV ≥ T8 or lower thoracic (LT) UIV ≤ T9. RESULTS Patients who developed symptomatic PJK (n = 260) had worse 1-year postoperative SRS-22r mental health (3.70 vs 3.86) and total (3.56 vs 3.67) scores, as well as worse 2-year postoperative self-image (3.45 vs 3.65) and satisfaction (4.03 vs 4.22) scores (all p ≤ 0.04). In the whole study cohort, patients with PJK had less pelvic incidence-lumbar lordosis (PI-LL) mismatch (-0.24° vs 3.29°, p < 0.001) but no difference in their GAP score/category or SRS-Schwab sagittal modifiers compared with the patients without PJK. Regression showed a higher risk of PJK with a pelvic tilt (PT) grade ++ (OR 2.35) and less risk with a PI-LL grade ++ (OR 0.35; both p < 0.01). When specifically analyzing the LT UIV cohort, patients with PJK had a higher GAP score (5.66 vs 4.79), greater PT (23.02° vs 20.90°), and less PI-LL mismatch (1.61° vs 4.45°; all p ≤ 0.02). PJK patients were less likely to be proportioned postoperatively (17.6% vs 30.0%, p = 0.015), and regression demonstrated a greater PJK risk with severe disproportion (OR 1.98) and a PT grade ++ (OR 3.15) but less risk with a PI-LL grade ++ (OR 0.45; all p ≤ 0.01). When specifically evaluating the UT UIV cohort, the PJK patients had less PI-LL mismatch (-2.11° vs 1.45°) but no difference in their GAP score/category. Regression showed a greater PJK risk with a PT grade + (OR 1.58) and a decreased risk with a PI-LL grade ++ (OR 0.21; both p < 0.05). CONCLUSIONS Symptomatic PJK leads to worse patient-reported outcomes and is associated with less postoperative PI-LL mismatch and greater postoperative PT. A worse postoperative GAP score and disproportion are only predictive of symptomatic PJK in patients with an LT UIV.
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Affiliation(s)
- Jichao Ye
- 1Department of Orthopaedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Sachin Gupta
- 2Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali S Farooqi
- 2Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tsung Yin
- 3Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Alex Soroceanu
- 4University of Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
| | - Frank J Schwab
- 5Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
| | - Virginie Lafage
- 5Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
| | - Michael P Kelly
- 7Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Khaled Kebaish
- 8Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Richard Hostin
- 9Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Dallas, Texas
| | - Jeffrey L Gum
- 10Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - Justin S Smith
- 11Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | | | - Justin K Scheer
- 13Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | | | - Peter G Passias
- 14Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Eric O Klineberg
- 15Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Han Jo Kim
- 6Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Robert A Hart
- 16Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington; and
| | - D Kojo Hamilton
- 17Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher P Ames
- 13Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Munish C Gupta
- 7Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
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21
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Protopsaltis TS, Ani F, Soroceanu A, Lafage R, Kim HJ, Balouch E, Norris Z, Smith JS, Daniels AH, Klineberg EO, Ames CP, Hart R, Bess S, Shaffrey CI, Schwab FJ, Lenke LG, Lafage V, Gupta MC. Clinical outcomes and proximal junctional failure in adult spinal deformity patients corrected to normative alignment versus functional alignment. J Neurosurg Spine 2023; 39:757-764. [PMID: 37503890 DOI: 10.3171/2023.5.spine221266] [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: 11/18/2022] [Accepted: 05/19/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE The objective of this study was to explore the rate of proximal junctional failure (PJF) and functional outcomes of normative alignment goals compared with alignment targets based on age-appropriate physical function. METHODS Baseline relationships between age, pelvic incidence (PI), and a component of the T1 pelvic angle (TPA) within the fusion were analyzed in adult spinal deformity (ASD) patients and compared with those of asymptomatic patients. Linear regression modeling was used to determine alignment based on PI and age in asymptomatic patients (normative alignment), and in ASD patients, alignment corresponding to age-appropriate functional status (functional alignment). A cohort of 288 ASD patients was split into two groups based on whether the patient was closer to their normative or functional alignment goal at their 6-week postoperative radiographic follow-up. The rates of proximal junctional kyphosis (PJK) and PJF were determined for each cohort. RESULTS In the 288 ASD patients included in this pre- to postoperative analysis, there was no difference in baseline alignment or health-related quality of life (HRQOL) between the normative alignment and functional alignment groups. At 6 weeks, patients with normative alignment had a smaller TPA (4.45° vs 14.1°) and PI minus lumbar lordosis (-7.24° vs 7.4°) (both p < 0.0001) and higher PJK (40% vs 27.2%, p = 0.03) and PJF (17% vs 6.8%, p = 0.008) rates than patients with functional alignment. CONCLUSIONS Correction in ASD patients to normative alignment resulted in higher rates of PJK and PJF without improvements in HRQOL. Correction in ASD patients to functional alignment that mirrors the physical function of their age-matched asymptomatic peers is recommended.
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Affiliation(s)
| | - Fares Ani
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | | | - Renaud Lafage
- 3Department of Orthopedic Surgery, Northwell Health, New York, New York
| | - Han Jo Kim
- 4Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eaman Balouch
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Zoe Norris
- 5Department of Orthopedic Surgery, George Washington University, Washington, DC
| | - Justin S Smith
- 6Department of Neurological Surgery, University of Virginia Health, Charlottesville, Virginia
| | - Alan H Daniels
- 7Department of Orthopedic Surgery, Brown University, East Providence, Rhode Island
| | - Eric O Klineberg
- 8Department of Orthopedic Surgery, University of California, Davis, California
| | - Christopher P Ames
- 9Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert Hart
- 10Department of Orthopedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Shay Bess
- 11Department of Spine Surgery, Denver International Spine Center, Denver, Colorado
| | | | - Frank J Schwab
- 3Department of Orthopedic Surgery, Northwell Health, New York, New York
| | - Lawrence G Lenke
- 13Department of Orthopedic Surgery, Columbia University, New York, New York; and
| | - Virginie Lafage
- 3Department of Orthopedic Surgery, Northwell Health, New York, New York
| | - Munish C Gupta
- 14Department of Orthopedic Surgery, Washington University in St. Louis, Missouri
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22
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Passfall L, Imbo B, Lafage V, Lafage R, Smith JS, Line B, Schoenfeld AJ, Protopsaltis T, Daniels AH, Kebaish KM, Gum JL, Koller H, Hamilton DK, Hostin R, Gupta M, Anand N, Ames CP, Hart R, Burton D, Schwab FJ, Shaffrey CI, Klineberg EO, Kim HJ, Bess S, Passias PG. The impact of baseline cervical malalignment on the development of proximal junctional kyphosis following surgical correction of thoracolumbar adult spinal deformity. J Neurosurg Spine 2023; 39:742-750. [PMID: 37503903 DOI: 10.3171/2023.5.spine22752] [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: 08/16/2022] [Accepted: 05/09/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE The objective of this study was to identify the effect of baseline cervical deformity (CD) on proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in patients with adult spinal deformity (ASD). METHODS This study was a retrospective analysis of a prospectively collected, multicenter database comprising ASD patients enrolled at 13 participating centers from 2009 to 2018. Included were ASD patients aged > 18 years with concurrent CD (C2-7 kyphosis < -15°, T1S minus cervical lordosis > 35°, C2-7 sagittal vertical axis > 4 cm, chin-brow vertical angle > 25°, McGregor's slope > 20°, or C2-T1 kyphosis > 15° across any three vertebrae) who underwent surgery. Patients were grouped according to four deformity classification schemes: Ames and Passias CD modifiers, sagittal morphotypes as described by Kim et al., and the head versus trunk balance system proposed by Mizutani et al. Mean comparison tests and multivariable binary logistic regression analyses were performed to assess the impact of these deformity classifications on PJK and PJF rates up to 3 years following surgery. RESULTS A total of 712 patients with concurrent ASD and CD met the inclusion criteria (mean age 61.7 years, 71% female, mean BMI 28.2 kg/m2, and mean Charlson Comorbidity Index 1.90) and underwent surgery (mean number of levels fused 10.1, mean estimated blood loss 1542 mL, and mean operative time 365 minutes; 70% underwent osteotomy). By approach, 59% of the patients underwent a posterior-only approach and 41% underwent a combined approach. Overall, 277 patients (39.1%) had PJK by 1 year postoperatively, and an additional 189 patients (26.7%) developed PJK by 3 years postoperatively. Overall, 65 patients (9.2%) had PJF by 3 years postoperatively. Patients classified as having a cervicothoracic deformity morphotype had higher rates of early PJK than flat neck deformity and cervicothoracic deformity patients (p = 0.020). Compared with the head-balanced patients, trunk-balanced patients had higher rates of PJK and PJF (both p < 0.05). Examining Ames modifier severity showed that patients with moderate and severe deformity by the horizontal gaze modifier had higher rates of PJK (p < 0.001). CONCLUSIONS In patients with concurrent cervical and thoracolumbar deformities undergoing isolated thoracolumbar correction, the use of CD classifications allows for preoperative assessment of the potential for PJK and PJF that may aid in determining the correction of extending fusion levels.
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Affiliation(s)
- Lara Passfall
- 1Division of Spine Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York, New York
| | - Bailey Imbo
- 1Division of Spine Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York, New York
| | - Virginie Lafage
- 2Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Renaud Lafage
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- 4Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton Line
- 5Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Andrew J Schoenfeld
- 6Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, Massachusetts
| | | | - Alan H Daniels
- 8Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Khaled M Kebaish
- 9Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Jeffrey L Gum
- 10Norton Leatherman Spine Center, Louisville, Kentucky
| | - Heiko Koller
- 11Department of Neurosurgery, Technical University of Munich (TUM), Klinikum Rechts Der Isar, Munich, Germany
- 21Department for Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria
| | - D Kojo Hamilton
- 12Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard Hostin
- 13Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas
| | - Munish Gupta
- 14Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Neel Anand
- 15Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, California
| | - Christopher P Ames
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert Hart
- 17Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Douglas Burton
- 18Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Frank J Schwab
- 2Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Christopher I Shaffrey
- 19Division of Spine Surgery, Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Eric O Klineberg
- 20Department of Orthopaedic Surgery, University of California, Davis, California; and
| | - Han Jo Kim
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- 5Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Peter G Passias
- 1Division of Spine Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York, New York
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23
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Shah NV, Moattari CR, Lavian JD, Gedailovich S, Krasnyanskiy B, Beyer GA, Condron N, Passias PG, Lafage R, Jo Kim H, Schwab FJ, Lafage V, Paulino CB, Diebo BG. The Impact of Isolated Preoperative Cannabis Use on Outcomes Following Cervical Spinal Fusion: A Propensity Score-Matched Analysis. Iowa Orthop J 2023; 43:117-124. [PMID: 38213849 PMCID: PMC10777691] [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] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Background Cannabis is the most commonly used recreational drug in the USA. Studies evaluating cannabis use and its impact on outcomes following cervical spinal fusion (CF) are limited. This study sought to assess the impact of isolated (exclusive) cannabis use on postoperative outcomes following CF by analyzing outcomes like complications, readmissions, and revisions. Methods The New York Statewide Planning and Research Cooperative System (SPARCS) was queried for patients who underwent CF between January 2009 and September 2013. Inclusion criteria were age ≥18 years and either a minimum 90-day (for complications and readmissions) or 2-year (for revisions) follow-up surveillance. Patients with systemic disease, osteomyelitis, cancer, trauma, and concomitant substance or polysubstance abuse/dependence were excluded. Patients with a preoperative International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis of isolated cannabis abuse (Cannabis) or dependence were identified. The primary outcome measures were 90-day complications, 90-day readmissions, and two-year revisions following CF. Cannabis patients were 1:1 propensity score-matched by age, gender, race, Deyo score, surgical approach, and tobacco use to non-cannabis users and compared for outcomes. Multivariate binary stepwise logistic regression models identified independent predictors of outcomes. Results 432 patients (n=216 each) with comparable age, sex, Deyo scores, tobacco use, and distribution of anterior or posterior surgical approaches were identified (all p>0.05). Cannabis patients were predominantly Black (27.8% vs. 12.0%), primarily utilized Medicaid (29.6% vs. 12.5%), and had longer LOS (3.0 vs. 1.9 days), all p≤0.001. Both cohorts experienced comparable rates of 90-day medical and surgical, as well as overall complications (5.6% vs. 3.7%) and two-year revisions (4.2% vs. 2.8%, p=0.430), but isolated cannabis patients had higher 90-day readmission rates (11.6% vs. 6.0%, p=0.042). Isolated cannabis use independently predicted 90-day readmission (Odds Ratio=2.0), but did not predict any 90-day complications or two year revisions (all p>0.05). Conclusion Isolated baseline cannabis dependence/abuse was associated with increased risk of 90-day readmission following CF. Further investigation of the physiologic impact of cannabis on musculoskeletal patients may elucidate significant contributory factors. Level of Evidence: III.
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Affiliation(s)
- Neil V. Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Cameron R. Moattari
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Joshua D. Lavian
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Samuel Gedailovich
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Benjamin Krasnyanskiy
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - George A. Beyer
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Nolan Condron
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Peter G. Passias
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Frank J. Schwab
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Carl B. Paulino
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
- Department of Orthopaedic Surgery, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Bassel G. Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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24
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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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25
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Smith JS, Kelly MP, Buell TJ, Ben-Israel D, Diebo B, Scheer JK, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias P, Gum JL, Kebaish K, Mullin JP, Eastlack R, Daniels A, Soroceanu A, Mundis G, Hostin R, Protopsaltis TS, Hamilton DK, Gupta M, Lewis SJ, Schwab FJ, Lenke LG, Shaffrey CI, Burton D, Ames CP, Bess S. Adult Cervical Deformity Patients Have Higher Baseline Frailty, Disability, and Comorbidities Compared With Complex Adult Thoracolumbar Deformity Patients: A Comparative Cohort Study of 616 Patients. Global Spine J 2023:21925682231214059. [PMID: 37948666 DOI: 10.1177/21925682231214059] [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: 11/12/2023] Open
Abstract
STUDY DESIGN Multicenter comparative cohort. OBJECTIVE Studies have shown markedly higher rates of complications and all-cause mortality following surgery for adult cervical deformity (ACD) compared with adult thoracolumbar deformity (ATLD), though the reasons for these differences remain unclear. Our objectives were to compare baseline frailty, disability, and comorbidities between ACD and complex ATLD patients undergoing surgery. METHODS Two multicenter prospective adult spinal deformity registries were queried, one ATLD and one ACD. Baseline clinical and frailty measures were compared between the cohorts. RESULTS 616 patients were identified (107 ACD and 509 ATLD). These groups had similar mean age (64.6 vs 60.8 years, respectively, P = .07). ACD patients were less likely to be women (51.9% vs 69.5%, P < .001) and had greater Charlson Comorbidity Index (1.5 vs .9, P < .001) and ASA grade (2.7 vs 2.4, P < .001). ACD patients had worse VR-12 Physical Component Score (PCS, 25.7 vs 29.9, P < .001) and PROMIS Physical Function Score (33.3 vs 35.3, P = .031). All frailty measures were significantly worse for ACD patients, including hand dynamometer (44.6 vs 55.6 lbs, P < .001), CSHA Clinical Frailty Score (CFS, 4.0 vs 3.2, P < .001), and Edmonton Frailty Scale (EFS, 5.15 vs 3.21, P < .001). Greater proportions of ACD patients were frail (22.9% vs 5.7%) or vulnerable (15.6% vs 10.9%) based on EFS (P < .001). CONCLUSIONS Compared with ATLD patients, ACD patients had worse baseline characteristics on all measures assessed (comorbidities/disability/frailty). These differences may help account for greater risk of complications and all-cause mortality previously observed in ACD patients and facilitate strategies for better preoperative optimization.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Thomas J Buell
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Ben-Israel
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Breton Line
- Presbyterian St Lukes Medical Center, Denver, CO, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of Texas Health Houston, Houston, TX, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | | | - Khal Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, USA
| | - Alan Daniels
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX, USA
| | | | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO, USA
| | - Stephen J Lewis
- Department of Surgery, Division of Orthopedic Surgery, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Shay Bess
- Presbyterian St Lukes Medical Center, Denver, CO, USA
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26
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Dalton J, Mohamed A, Akioyamen N, Schwab FJ, Lafage V. PreOperative Planning for Adult Spinal Deformity Goals: Level Selection and Alignment Goals. Neurosurg Clin N Am 2023; 34:527-536. [PMID: 37718099 DOI: 10.1016/j.nec.2023.06.016] [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] [Indexed: 09/19/2023]
Abstract
Adult Spinal Deformity (ASD) is a complex pathologic condition with significant impact on quality of life, including pain, loss of function, and fatigue. Achieving realignment goals is crucial for long-term results. Reliable preoperative planning strategies, including nomograms, measurement tools, and level selection, are key to maximizing the likelihood of achieving a good outcome following ASD corrective surgery. This review covers recent literature on such strategies, including review of the different targets for realignment and their association with outcomes (both patients-reported outcomes and complications), selection of upper and lower instrumented vertebrae, and the latest innovation in preoperative planning for deformity surgery.
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Affiliation(s)
- Jay Dalton
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - Ayman Mohamed
- Department of Orthopaedic Surgery, Lenox Hill Hospital, 130 East 77th Street, 11th Floor, New York, NY 10075, USA
| | - Noel Akioyamen
- Department of Orthopaedic Surgery, Monteriore Medical Center, 1250 Waters Place, Tower 1, 11th Floor, Bronx, NY 10461, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Lenox Hill Hospital, 130 East 77th Street, 11th Floor, New York, NY 10075, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, 130 East 77th Street, 11th Floor, New York, NY 10075, USA.
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27
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Diebo BG, Tataryn Z, Alsoof D, Lafage R, Hart RA, Passias PG, Ames CP, Scheer JK, Lewis SJ, Shaffrey CI, Burton DC, Deviren V, Line BG, Soroceanu A, Hamilton DK, Klineberg EO, Mundis GM, Kim HJ, Gum JL, Smith JS, Uribe JS, Kelly MP, Kebaish KM, Gupta MC, Nunley PD, Eastlack RK, Hostin R, Protopsaltis TS, Lenke LG, Schwab FJ, Bess S, Lafage V, Daniels AH. Height Gain Following Correction of Adult Spinal Deformity. J Bone Joint Surg Am 2023; 105:1410-1419. [PMID: 37478308 DOI: 10.2106/jbjs.23.00031] [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] [Indexed: 07/23/2023]
Abstract
BACKGROUND Height gain following a surgical procedure for patients with adult spinal deformity (ASD) is incompletely understood, and it is unknown if height gain correlates with patient-reported outcome measures (PROMs). METHODS This was a retrospective cohort study of patients undergoing ASD surgery. Patients with baseline, 6-week, and subanalysis of 1-year postoperative full-body radiographic and PROM data were examined. Correlation analysis examined relationships between vertical height differences and PROMs. Regression analysis was utilized to preoperatively estimate T1-S1 and S1-ankle height changes. RESULTS This study included 198 patients (mean age, 57 years; 69% female); 147 patients (74%) gained height. Patients with height loss, compared with those who gained height, experienced greater increases in thoracolumbar kyphosis (2.81° compared with -7.37°; p < 0.001) and thoracic kyphosis (12.96° compared with 4.42°; p = 0.003). For patients with height gain, sagittal and coronal alignment improved from baseline to postoperatively: 25° to 21° for pelvic tilt (PT), 14° to 3° for pelvic incidence - lumbar lordosis (PI-LL), and 60 mm to 17 mm for sagittal vertical axis (SVA) (all p < 0.001). The full-body mean height gain was 7.6 cm, distributed as follows: sella turcica-C2, 2.9 mm; C2-T1, 2.8 mm; T1-S1 (trunk gain), 3.8 cm; and S1-ankle (lower-extremity gain), 3.3 cm (p < 0.001). T1-S1 height gain correlated with the thoracic Cobb angle correction and the maximum Cobb angle correction (p = 0.002). S1-ankle height gain correlated with the corrections in PT, PI-LL, and SVA (p < 0.001). T1-ankle height gain correlated with the corrections in PT (p < 0.001) and SVA (p = 0.03). Trunk height gain correlated with improved Scoliosis Research Society (SRS-22r) Appearance scores (r = 0.20; p = 0.02). Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores correlated with S1-ankle height gain (r = -0.19; p = 0.03) and C2-T1 height gain (r = -0.18; p = 0.04). A 1° correction in a thoracic scoliosis Cobb angle corresponded to a 0.2-mm height gain, and a 1° correction in a thoracolumbar scoliosis Cobb angle resulted in a 0.25-mm height gain. A 1° improvement in PI-LL resulted in a 0.2-mm height gain. CONCLUSIONS Most patients undergoing ASD surgery experienced height gain following deformity correction, with a mean full-body height gain of 7.6 cm. Height gain can be estimated preoperatively with predictive ratios, and height gain was correlated with improvements in reported SRS-22r appearance and PROMIS scores. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bassel G Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Daniel Alsoof
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY
| | | | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | | | - Justin K Scheer
- University of California-San Francisco, San Francisco, California
| | - Stephen J Lewis
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Vedat Deviren
- University of California-San Francisco, San Francisco, California
| | - Breton G Line
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California-Davis, Davis, California
| | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, Kentucky
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael P Kelly
- Division of Orthopedics & Scoliosis at Rady Children's Hospital-San Diego, San Diego, California
| | - Khaled M Kebaish
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Dallas, Texas
| | | | - Lawrence G Lenke
- Department of Orthopaedic Surgery, The Och Spine Hospital/Columbia University Irving Medical Center, New York, NY
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY
| | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY
| | - Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Wick JB, Blandino A, Smith JS, Line BG, Lafage V, Lafage R, Kim HJ, Passias PG, Gum JL, Kebaish KM, Eastlack RK, Daniels A, Mundis G, Hostin R, Protopsaltis T, Hamilton DK, Kelly MP, Gupta M, Hart RA, Schwab FJ, Burton DC, Ames CP, Lenke LG, Shaffrey CI, Bess S, Klineberg E. The ISSG-AO Complication Intervention Score, but Not Major/Minor Designation, is Correlated With Length of Stay Following Adult Spinal Deformity Surgery. Global Spine J 2023:21925682231202782. [PMID: 37725904 DOI: 10.1177/21925682231202782] [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: 09/21/2023] Open
Abstract
STUDY DESIGN Retrospective review. OBJECTIVES The International Spine Study Group-AO (ISSG-AO) Adult Spinal Deformity (ASD) Complication Classification System was developed to improve classification, reporting, and study of complications among patients undergoing ASD surgery. The ISSG-AO system classifies interventions to address complications by level of invasiveness: grade zero (none); grade 1, mild (e.g., medication change); grade 2, moderate (e.g., ICU admission); grade 3, severe (e.g., reoperation related to surgery of interest). To evaluate the efficacy of the ISSG-AO ASD Complication Classification System, we aimed to compare correlations between postoperative length of stay (LOS) and complication severity as classified by the ISSG-AO ASD and traditional major/minor complication classification systems. METHODS Patients age ≥18 in a multicenter ASD database who sustained in-hospital complications were identified. Complications were classified with the major/minor and ISSG-AO systems and correlated with LOS using an ensemble-based machine learning algorithm (conditional random forest) and a generalized linear mixed model. RESULTS 490 patients at 19 sites were included. 64.9% of complications were major, and 35.1% were minor. By ISSG-AO classification, 20.4%, 66.1%, 6.7%, and 6.7% were grades 0-3, respectively. ISSG-AO complication grading demonstrated significant correlation with LOS, whereas major/minor complication classification demonstrated inverse correlation with LOS. In conditional random forest analysis, ISSG-AO classification had the greatest relative importance when assessing correlations across multiple variables with LOS. CONCLUSIONS The ISSG-AO system may help identify specific complications associated with prolonged LOS. Targeted interventions to avoid or reduce these complications may improve ASD surgical quality and resource utilization.
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Affiliation(s)
- Joseph B Wick
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Andrew Blandino
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Justin S Smith
- Department of Neurosurgery, Medical Center, University of Virginia, Charlottesville, VA, USA
| | - Breton G Line
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, CO, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Peter G Passias
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Jeffrey L Gum
- Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, KY, USA
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Robert K Eastlack
- Department of Orthopedics, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - Alan Daniels
- Department of Orthopedics, Brown University, Providence, RI, USA
| | - Gregory Mundis
- Department of Orthopedics, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - Richard Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | | | - D Kojo Hamilton
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Robert A Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Frank J Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University, New York, NY, USA
| | | | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of Texas, Houston, TX, USA
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29
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Ye J, Gupta S, Farooqi AS, Yin TC, Soroceanu A, Schwab FJ, Lafage V, Kelly MP, Kebaish K, Hostin R, Gum JL, Smith JS, Shaffrey CI, Scheer JK, Protopsaltis TS, Passias PG, Klineberg EO, Kim HJ, Hart RA, Hamilton DK, Ames CP, Gupta MC. Use of multiple rods and proximal junctional kyphosis in adult spinal deformity surgery. J Neurosurg Spine 2023; 39:320-328. [PMID: 37327142 DOI: 10.3171/2023.4.spine23209] [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: 02/20/2023] [Accepted: 04/25/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Multiple rods are utilized in adult spinal deformity (ASD) surgery to increase construct stiffness. However, the impact of multiple rods on proximal junctional kyphosis (PJK) is not well established. This study aimed to investigate the impact of multiple rods on PJK incidence in ASD patients. METHODS ASD patients from a prospective multicenter database with a minimum follow-up of 1 year were retrospectively reviewed. Clinical and radiographic data were collected preoperatively, at 6 weeks postoperatively, at 6 months postoperatively, at 1 year postoperatively, and at every subsequent year postoperatively. PJK was defined as a kyphotic increase of > 10° in the Cobb angle from the upper instrumented vertebra (UIV) to UIV+2 as compared with preoperative values. Demographic data, radiographic parameters, and PJK incidence were compared between the multirod and dual-rod patient cohorts. PJK-free survival analysis was performed using Cox regression to control for demographic characteristics, comorbidities, level of fusion, and radiographic parameters. RESULTS Overall, 307/1300 (23.62%) cases utilized multiple rods. Cases with multiple rods were more likely to be revisions (68.4% vs 46.5%, p < 0.001), to be posterior only (80.7% vs 61.5%, p < 0.001), involve more levels of fusion (mean 11.73 vs 10.60, p < 0.001), and include 3-column osteotomy (42.9% vs 17.1%, p < 0.001). Patients with multiple rods also had greater preoperative pelvic retroversion (mean pelvic tilt 27.95° vs 23.58°, p < 0.001), greater thoracolumbar junction kyphosis (-15.9° vs -11.9°, p = 0.001), and more severe sagittal malalignment (C7-S1 sagittal vertical axis 99.76 mm vs 62.23 mm, p < 0.001), all of which corrected postoperatively. Patients with multiple rods had similar incidence rates of PJK (58.6% vs 58.1%) and revision surgery (13.0% vs 17.7%). The PJK-free survival analysis demonstrated equivalent PJK-free survival durations among the patients with multiple rods (HR 0.889, 95% CI 0.745-1.062, p = 0.195) after controlling for demographic and radiographic parameters. Further stratification based on implant metal type demonstrated noninferior PJK incidence rates with multiple rods in the titanium (57.1% vs 54.6%, p = 0.858), cobalt chrome (60.5% vs 58.7%, p = 0.646), and stainless steel (20% vs 63.7%, p = 0.008) cohorts. CONCLUSIONS Multirod constructs for ASD are most frequently utilized in revision, long-level reconstructions with 3-column osteotomy. The use of multiple rods in ASD surgery does not result in an increased incidence of PJK and is not affected by rod metal type.
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Affiliation(s)
- Jichao Ye
- 1Department of Orthopaedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Sachin Gupta
- 2Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali S Farooqi
- 2Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tsung-Cheng Yin
- 3Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Alex Soroceanu
- 4University of Calgary Spine Program, University of Calgary, Alberta, Canada
| | - Frank J Schwab
- 5Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Virginie Lafage
- 5Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Michael P Kelly
- 7Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri
| | - Khaled Kebaish
- 8Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Richard Hostin
- 9Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Dallas, Texas
| | - Jeffrey L Gum
- 10Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - Justin S Smith
- 11Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Christopher I Shaffrey
- 12Departments of Neurological Surgery and Orthopedic Surgery, Division of Spine Surgery, Duke University, Durham, North Carolina
| | - Justin K Scheer
- 13Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Peter G Passias
- 14Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Eric O Klineberg
- 15Department of Orthopaedic Surgery, University of California Davis, Sacramento, California
| | - Han Jo Kim
- 6Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Robert A Hart
- 16Department of Orthopedic Surgery, Swedish Medical Center, Seattle, Washington; and
| | - D Kojo Hamilton
- 17Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher P Ames
- 13Department of Neurological Surgery, University of California, San Francisco, California
| | - Munish C Gupta
- 7Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri
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30
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Passias PG, Williamson TK, Mir JM, Smith JS, Lafage V, Lafage R, Line B, Daniels AH, Gum JL, Schoenfeld AJ, Hamilton DK, Soroceanu A, Scheer JK, Eastlack R, Mundis GM, Diebo B, Kebaish KM, Hostin RA, Gupta MC, Kim HJ, Klineberg EO, Ames CP, Hart RA, Burton DC, Schwab FJ, Shaffrey CI, Bess S. Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery. J Clin Med 2023; 12:5565. [PMID: 37685633 PMCID: PMC10488913 DOI: 10.3390/jcm12175565] [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: 06/26/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications. OBJECTIVE Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers. STUDY DESIGN/SETTING Retrospective cohort study of a prospectively collected multicenter database. METHODS ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility. RESULTS A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, p = 0.021) and major mechanical complications (12% vs. 22%, p = 0.002), and less reoperations (23% vs. 33%, p = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both p < 0.001) at two years. CONCLUSIONS Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.
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Affiliation(s)
- Peter G. Passias
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, NY 10003, USA
| | - Tyler K. Williamson
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, NY 10003, USA
| | - Jamshaid M. Mir
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, NY 10003, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22904, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY 10021, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO 80205, USA
| | - Alan H. Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USA
| | - Jeffrey L. Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY 40202, USA
| | - Andrew J. Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women’s Center for Surgery and Public Health, Boston, MA 02120, USA
| | - David Kojo Hamilton
- Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Justin K. Scheer
- Department of Neurosurgery, University of California, San Francisco, CA 94143, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA 92037, USA
| | - Gregory M. Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA 92037, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USA
| | - Khaled M. Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD 21205, USA
| | - Richard A. Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX 75243, USA
| | - Munish C. Gupta
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USA
| | - Han Jo Kim
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY 10021, USA
| | - Eric O. Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA 95819, USA
| | - Christopher P. Ames
- Department of Neurosurgery, University of California, San Francisco, CA 94143, USA
| | - Robert A. Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA 98122, USA
| | - Douglas C. Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Frank J. Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
| | - Christopher I. Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO 80205, USA
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Kazarian GS, Lovecchio F, Merrill R, Clohisy J, Zhang B, Du J, Jordan Y, Pajak A, Knopp R, Kim D, Samuel J, Elysee J, Akosman I, Shahi P, Johnson M, Schwab FJ, Lafage V, Kim HJ. Why Didn't You Walk Yesterday? Factors Associated With Slow Early Recovery After Adult Spinal Deformity Surgery. Global Spine J 2023:21925682231197976. [PMID: 37614144 DOI: 10.1177/21925682231197976] [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: 08/25/2023] Open
Abstract
STUDY DESIGN This is a retrospective case-control study. OBJECTIVES The objectives of this study are to identify (1) risk factors for delayed ambulation following adult spinal deformity (ASD) surgery and (2) complications associated with delayed ambulation. METHODS One-hundred and ninety-one patients with ASD who underwent posterior-only fusion (≥5 levels, LIV pelvis) were reviewed. Patients who ambulated with physical therapy (PT) on POD2 or later (LateAmb, n = 49) were propensity matched 1:1 to patients who ambulated on POD0-1 (NmlAmb, n = 49) based on the extent of fusion and surgical invasiveness score (ASD-S). Risk factors, as well as inpatient medical complications were compared. Logistic regressions were used to identify risk factors for late ambulation. RESULTS Of the patients who did not ambulate on POD0-1, 32% declined participation secondary to pain or dizziness/fatigue, while 68% were restricted from participation by PT/nursing due to fatigue, inability to follow commands, nausea/dizziness, pain, or hypotension. Logistic regression showed that intraoperative estimated blood loss (EBL) >2L (OR = 5.57 [1.51-20.55], P = .010) was independently associated with an increased risk of delayed ambulation, with a 1.25 times higher risk for every 250 mL increase in EBL (P = .014). Modified 5-Item Frailty Index (mFI-5) was also independently associated with delayed ambulation (OR = 2.53 [1.14-5.63], P = .023). LateAmb demonstrated a higher hospital LOS (8.4 ± 4.0 vs 6.2 ± 2.6, P < .001). The LateAmb group trended toward an increase in medical complications on POD3+ (14.3% vs 26.5%, P = .210). CONCLUSIONS EBL demonstrates a dose-response relationship with risk for delayed ambulation. Delayed ambulation increases LOS and may impact medical complications.
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Affiliation(s)
- Gregory S Kazarian
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Francis Lovecchio
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Robert Merrill
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - John Clohisy
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Bo Zhang
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jerry Du
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Yusef Jordan
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Anthony Pajak
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Rachel Knopp
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - David Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Justin Samuel
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan Elysee
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Izzet Akosman
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Pratyush Shahi
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Mitchell Johnson
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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32
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Passias PG, Williamson TK, Krol O, Tretiakov PS, Joujon-Roche R, Imbo B, Ahmad S, Bennett-Caso C, Owusu-Sarpong S, Lebovic JB, Robertson D, Vira S, Dhillon E, Schoenfeld AJ, Janjua MB, Raman T, Protopsaltis TS, Maglaras C, O'Connell B, Daniels AH, Paulino C, Diebo BG, Smith JS, Schwab FJ, Lafage R, Lafage V. Should Global Realignment Be Tailored to Frailty Status for Patients Undergoing Surgical Intervention for Adult Spinal Deformity? Spine (Phila Pa 1976) 2023; 48:930-936. [PMID: 36191091 DOI: 10.1097/brs.0000000000004501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 06/30/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes. SUMMARY OF BACKGROUND DATA The Global Alignment and Proportion (GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to the development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications. MATERIALS AND METHODS We included 412 surgical ASD patients with two-year follow-up. Frailty was quantified using the modified Adult Spinal Deformity Frailty Index (mASD-FI). Outcomes: proximal junctional kyphosis and proximal junctional failure (PJF), major mechanical complications, and "Best Clinical Outcome" (BCO), defined as Oswestry Disability Index<15 and Scoliosis Research Society 22-item Questionnaire Total>4.5. Logistic regression analysis established a six-week score based on GAP score, frailty, and Oswestry Disability Index US Norms. Logistic regression followed by conditional inference tree analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty-modified GAP score. RESULTS Baseline frailty categories: 57% not frail, 30% frail, 14% severely frail. Overall, 39 of patients developed proximal junctional kyphosis, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The mASD-FI demonstrated a correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at two years (all P <0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score (FAR Score)=0.49×mASD-FI+0.38×GAP Score. Thresholds for the FAR score (0-13): proportioned: <3.5, moderately disproportioned: 3.5-7.5, severely disproportioned: >7.5. Multivariable logistic regression assessing FAR score demonstrated associations with mechanical complications, reoperation, and meeting BCO by two years (all P <0.05), whereas the original GAP score was only significant for reoperation. CONCLUSION This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Peter S Tretiakov
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Bailey Imbo
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Salman Ahmad
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Claudia Bennett-Caso
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | | | - Jordan B Lebovic
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Djani Robertson
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Shaleen Vira
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Ekamjeet Dhillon
- Department of Orthopaedic Surgery, University of Washington Medical Center, Seattle, WA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical Center, Boston, MA
| | - Muhammad B Janjua
- Department of Neurosurgery, Washington University of St Louis, St Louis, MO
| | - Tina Raman
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | | | - Constance Maglaras
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Brooke O'Connell
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine/Brown University, Providence, RI
| | - Carl Paulino
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
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Diebo BG, Kovoor M, Alsoof D, Beyer GA, Rompala A, Balmaceno-Criss M, Mai DH, Segreto FA, Shah NV, Lafage R, Passias PG, Aaron RK, Daniels AH, Paulino CB, Schwab FJ, Lafage V. Metabolic Bone Disorders Are Predictors for 2-year Adverse Outcomes in Patients Undergoing 2-3 Level Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy or Myelopathy. Clin Spine Surg 2023; 36:120-126. [PMID: 36864582 DOI: 10.1097/bsd.0000000000001452] [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: 10/15/2022] [Accepted: 01/25/2023] [Indexed: 03/04/2023]
Abstract
STUDY DESIGN Retrospective cohort study utilizing the New York statewide planning and research cooperative system. STUDY OBJECTIVE To investigate postoperative complications of patients with metabolic bone disorders (MBDs) who undergo 2-3 levels of anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA MBDs and cervical degenerative pathologies, including cervical radiculopathy (CR) and cervical myelopathy (CM), are prevalent in the aging population. Complications with ACDF procedures can lead to increased hospitalization times, more expensive overhead, and worse patient outcomes. METHOD Patients with CM/CR who underwent an ACDF of 2-3 vertebrae from 2009 to 2011 with a minimum 2-year follow-up were identified. Patients diagnosed with 1 or more MBD at baseline were compared with a control cohort without any MBD diagnosis. Cohorts were compared for demographics, hospital-related parameters, and 2-year medical, surgical, and overall complications. Binary multivariate logistic regression was used to identify independent predictors. RESULTS A total of 22,276 patients were identified (MBD: 214; no-MBD: 22,062). Among MBD patients, the majority had vitamin D deficiency (n = 194, 90.7%). MBD patients were older (53.0 vs 49.7 y, P < 0.001), and with higher Deyo index (1.0 vs 0.5, P < 0.001). MBD patients had higher rates of medical complications, including anemia (6.1% vs 2.3%), pneumonia (4.7% vs 2.1%), hematoma (3.3% vs 0.7%), infection (2.8% vs 0.9%), and sepsis (3.7% vs 0.9%), as well as overall medical complications (23.8% vs 9.6%) (all, P ≤0.033). MBD patients also experienced higher surgical complications, including implant-related (5.7% vs 1.9%), wound infection (4.2% vs 1.2%), and wound disruption (0.9% vs 0.2%), and overall surgical complications (9.8% vs 3.2%) (all, P ≤0.039). Regression analysis revealed that a baseline diagnosis of MBD was independently associated with an increased risk of 2-year surgical complications (odds ratio = 2.10, P < 0.001) and medical complications (odds ratio = 1.84, P = 0.001). CONCLUSIONS MBD as a comorbidity was associated with an increased risk of 2-year postoperative complications after 2-3 level ACDF for CR or CM.
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Affiliation(s)
- Bassel G Diebo
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | - Matthew Kovoor
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | - Daniel Alsoof
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | | | | | - Mariah Balmaceno-Criss
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | - David H Mai
- Department of Orthopedics, SUNY Downstate, Brooklyn
| | | | - Neil V Shah
- Department of Orthopedics, SUNY Downstate, Brooklyn
| | | | | | - Roy K Aaron
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
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Smith JS, Elias E, Sursal T, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias P, Nasser Z, Gum JL, Eastlack R, Daniels A, Mundis G, Hostin R, Protopsaltis TS, Soroceanu A, Hamilton DK, Kelly MP, Lewis SJ, Gupta M, Schwab FJ, Burton D, Ames CP, Lenke LG, Shaffrey CI, Bess S. How Good Are Surgeons at Achieving Their Preoperative Goal Sagittal Alignment Following Adult Deformity Surgery? Global Spine J 2023:21925682231161304. [PMID: 36821516 DOI: 10.1177/21925682231161304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 02/24/2023] Open
Abstract
STUDY DESIGN Multicenter, prospective cohort. OBJECTIVES Malalignment following adult spine deformity (ASD) surgery can impact outcomes and increase mechanical complications. We assess whether preoperative goals for sagittal alignment following ASD surgery are achieved. METHODS ASD patients were prospectively enrolled based on 3 criteria: deformity severity (PI-LL ≥25°, TPA ≥30°, SVA ≥15 cm, TCobb≥70° or TLCobb≥50°), procedure complexity (≥12 levels fused, 3-CO or ACR) and/or age (>65 and ≥7 levels fused). The surgeon documented sagittal alignment goals prior to surgery. Goals were compared with achieved alignment on first follow-up standing radiographs. RESULTS The 266 enrolled patients had a mean age of 61.0 years (SD = 14.6) and 68% were women. Mean instrumented levels was 13.6 (SD = 3.8), and 23.2% had a 3-CO. Mean (SD) offsets (achieved-goal) were: SVA = -8.5 mm (45.6 mm), PI-LL = -4.6° (14.6°), TK = 7.2° (14.7°), reflecting tendencies to undercorrect SVA and PI-LL and increase TK. Goals were achieved for SVA, PI-LL, and TK in 74.4%, 71.4%, and 68.8% of patients, respectively, and was achieved for all 3 parameters in 37.2% of patients. Three factors were independently associated with achievement of all 3 alignment goals: use of PACs/equivalent for surgical planning (P < .001), lower baseline GCA (P = .009), and surgery not including a 3-CO (P = .037). CONCLUSIONS Surgeons failed to achieve goal alignment of each sagittal parameter in ∼25-30% of ASD patients. Goal alignment for all 3 parameters was only achieved in 37.2% of patients. Those at greatest risk were patients with more severe deformity. Advancements are needed to enable more consistent translation of preoperative alignment goals to the operating room.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Elias Elias
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, USA
| | - Tolga Sursal
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Breton Line
- Department of Orthopedic Surgery, Presbyterian St Lukes Medical Center, Denver, CO, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Zeina Nasser
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | - Jeffrey L Gum
- Department of Orthopedic Surgery, Leatherman Spine Center, Louisville, KY, USA
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | - Alan Daniels
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX, USA
| | | | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, AB, Canada
| | | | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Stephen J Lewis
- Department of Surgery, Division of Orthopedic Surgery, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO, USA
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Shay Bess
- Department of Orthopedic Surgery, Presbyterian St Lukes Medical Center, Denver, CO, USA
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Lafage R, Fourman MS, Smith JS, Bess S, Shaffrey CI, Kim HJ, Kebaish KM, Burton DC, Hostin R, Passias PG, Protopsaltis TS, Daniels AH, Klineberg EO, Gupta MC, Kelly MP, Lenke LG, Schwab FJ, Lafage V. Can unsupervised cluster analysis identify patterns of complex adult spinal deformity with distinct perioperative outcomes? J Neurosurg Spine 2023; 38:547-557. [PMID: 36806173 DOI: 10.3171/2023.1.spine221095] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/04/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE The objective of this study was to use an unsupervised cluster approach to identify patterns of operative adult spinal deformity (ASD) and compare the perioperative outcomes of these groups. METHODS A multicenter data set included patients with complex surgical ASD, including those with severe deformities, significant surgical complexity, or advanced age who underwent a multilevel fusion. An unsupervised cluster analysis allowing for 10% outliers was used to identify different deformity patterns. The perioperative outcomes of these clusters were then compared using ANOVA, Kruskal-Wallis, and chi-square tests, with p values < 0.05 considered significant. RESULTS Two hundred eighty-six patients were classified into four clusters of deformity patterns: hyper-thoracic kyphosis (hyper-TK), severe coronal, severe sagittal, and moderate sagittal. Hyper-TK patients had the lowest disability (mean Oswestry Disability Index [ODI] 32.9 ± 17.1) and pain scores (median numeric rating scale [NRS] back score 6, leg score 1). The severe coronal cluster had moderate functional impairment (mean physical component score 34.4 ± 12.3) and pain (median NRS back score 7, leg score 4) scores. The severe sagittal cluster had the highest levels of disability (mean ODI 49.3 ± 15.6) and low appearance scores (mean 2.3 ± 0.7). The moderate cluster (mean 68.8 ± 7.8 years) had the highest pain interference subscores on the Patient-Reported Outcomes Measurement Information System (mean 65.2 ± 5.8). Overall 30-day adverse events were equivalent among the four groups. Fusion to the pelvis was most common in the moderate sagittal (89.4%) and severe sagittal (97.5%) clusters. The severe coronal cluster had more osteotomies per case (median 11, IQR 6.5-14) and a higher rate of 30-day implant-related complications (5.5%). The severe sagittal and hyper-TK clusters had more three-column osteotomies (43% and 32.3%, respectively). Hyper-TK patients had shorter hospital stays. CONCLUSIONS This cohort of patients with complex ASD surgeries contained four natural clusters of deformity, each with distinct perioperative outcomes.
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Affiliation(s)
- Renaud Lafage
- 1Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Mitchell S Fourman
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, UVA Health, Charlottesville, Virginia
| | - Shay Bess
- 4Department of Orthopedic Surgery, NYU Langone Medical Center, New York, New York
| | | | - Han Jo Kim
- 2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Khaled M Kebaish
- 6Department of Orthopedic Surgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Douglas C Burton
- 7Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Richard Hostin
- 8Department of Orthopedic Surgery, Medical City Scoliosis & Advanced Spine Center, Plano, Texas
| | - Peter G Passias
- 4Department of Orthopedic Surgery, NYU Langone Medical Center, New York, New York
| | | | - Alan H Daniels
- 9Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Eric O Klineberg
- 10Department of Orthopedic Surgery, UC Davis Health, Sacramento, California
| | - Munish C Gupta
- 11Department of Orthopedic Surgery, Washington University Orthopedics, St. Louis, Missouri; and
| | - Michael P Kelly
- 11Department of Orthopedic Surgery, Washington University Orthopedics, St. Louis, Missouri; and
| | - Lawrence G Lenke
- 12Department of Orthopedic Surgery, Columbia Orthopedic Surgery, New York, New York
| | - Frank J Schwab
- 1Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Virginie Lafage
- 1Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
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Shah NV, Coste M, Wolfert AJ, Gedailovich S, Ford B, Kim DJ, Kim NS, Ikwuazom CP, Patel N, Dave AM, Passias PG, Schwab FJ, Lafage V, Paulino CB, Diebo BG. The Impact of Prematurity at Birth on Short-Term Postoperative Outcomes Following Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. J Clin Med 2023; 12:jcm12031210. [PMID: 36769858 PMCID: PMC9917850 DOI: 10.3390/jcm12031210] [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: 12/15/2022] [Revised: 01/20/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Prematurity is associated with surgical complications. This study sought to determine the risk of prematurity on 30-day complications, reoperations, and readmissions following ≥7-level PSF for AIS which has not been established. Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)-Pediatric dataset, all AIS patients undergoing ≥7-level PSF from 2012-2016 were identified. Cases were 1:1 propensity score-matched to controls by age, sex, and number of spinal levels fused. Prematurity sub-classifications were also evaluated: extremely (<28 weeks), very (28-31 weeks), and moderate-to-late (32-36 weeks) premature. Univariate analysis with post hoc Bonferroni compared demographics, hospital parameters, and 30-day outcomes. Multivariate logistic regression identified independent predictors of adverse 30-day outcomes. 5531 patients (term = 5099; moderate-to-late premature = 250; very premature = 101; extremely premature = 81) were included. Premature patients had higher baseline rates of multiple individual comorbidities, longer mean length of stay, and higher 30-day readmissions and infections than the term cohort. Thirty-day readmissions increased with increasing prematurity. Very premature birth predicted UTIs, superficial SSI/wound dehiscence, and any infection, and moderate-to-late premature birth predicted renal insufficiency, deep space infections, and any infection. Prematurity of AIS patients differentially impacted rates of 30-day adverse outcomes following ≥7-level PSF. These results can guide preoperative optimization and postoperative expectations.
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Affiliation(s)
- Neil V. Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Marine Coste
- Department of General Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Adam J. Wolfert
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Samuel Gedailovich
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Brian Ford
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT 06030, USA
| | - David J. Kim
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Nathan S. Kim
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Chibuokem P. Ikwuazom
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Neil Patel
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Amanda M. Dave
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Peter G. Passias
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY 10010, USA
| | - Frank J. Schwab
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
| | - Carl B. Paulino
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
- Department of Orthopaedic Surgery, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY 11215, USA
- Correspondence:
| | - Bassel G. Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY 11203, USA
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, East Providence, RI 02903, USA
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Yagi M, Ames CP, Hosogane N, Smith JS, Shaffrey CI, Schwab FJ, Lafage V, Bess S, Matsumoto M, Watanabe K. Comparable satisfaction and clinical outcomes after surgery for adolescent idiopathic scoliosis in the adult (AISA) between the US and Japan. J Orthop Sci 2023; 28:92-97. [PMID: 34625329 DOI: 10.1016/j.jos.2021.08.014] [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: 05/14/2021] [Revised: 08/05/2021] [Accepted: 08/29/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The impact of ethnicity on the surgery outcomes of adolescent idiopathic scoliosis in the adult (AISA) is poorly understood. This study aimed to compare the surgery outcomes for AISA between the United States (US) and Japan (JP). METHODS 171 surgically treated AISA (20-40y) were consecutively collected from 2 separate multicenter databases. Patients were propensity-score matched for age, gender, curve type, levels fused, and 2y postop spinal alignment. Demographic and radiographic parameters were compared between the US and JP at baseline and 2y post-op. RESULTS A total of 108 patients were matched by propensity score (age; US vs. JP: 29 ± 6 vs. 29 ± 7y, females: 76 vs. 76%, curve type [Schwab-SRS TypeT; TypeD; TypeL; TypeN]: 35; 35; 30; 0 vs. 37; 33; 30; 0%)] levels fused: 10 ± 4 vs. 10 ± 4, 2y thoracic curve:17 ± 13 vs. 17 ± 12°, 2y CSVL: 10 ± 8 vs. 11 ± 9 mm). Similar clinical improvement was achieved between US and JP (function; 4.2 ± 0.9 vs 4.3 ± 0.6, p = 0.60, pain; 3.8 ± 0.9 vs 4.1 ± 0.8, p = 0.13, satisfaction; 4.3 ± 0.9 vs 4.2 ± 0.7, p = 0.61, total; 4.0 ± 0.8 vs 4.1 ± 0.5, p = 0.60). The correlation analyzes indicated that postoperative SRS-22 subdomains correlated differently with satisfaction (all subdomains moderately correlated with satisfaction in the US while only pain and mental health correlated moderately with satisfaction in JP ([function: r = 0.61 vs 0.29, pain: r = . 72 vs 0.54, self-image: r = 0.72 vs 0.37, mental health: r = 0.64 vs 0.55]). CONCLUSIONS Surgery for AISA was similarly effective in the US and JP. Satisfaction for spinal surgery among patients in different countries may not be different unless the procedure limits an individual's unique lifestyle that the patient expected to resume.
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Affiliation(s)
- Mitsuru Yagi
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan; Department of Orthopedic Surgery, National Hospital Organization, Murayama Medical Center, Tokyo, Japan
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Naobumi Hosogane
- Department of Orthopedic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | | | - Frank J Schwab
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, CO, USA
| | - Morio Matsumoto
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kota Watanabe
- Department of Orthopedic Surgery, Keio University School of Medicine, Tokyo, Japan.
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Passias PG, Frangella NJ, Williamson TK, Moattari KA, Lafage R, Lafage V, Smith JS, Kebaish KM, Burton DC, Hart RA, Ames CP, Bess S, Shaffrey CI, Schwab FJ. Changes in health-related quality of life measures associated with degree of proximal junctional kyphosis. Spine Deform 2022; 11:699-706. [PMID: 36512314 DOI: 10.1007/s43390-022-00607-4] [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: 06/23/2021] [Accepted: 10/08/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To explore the changes in health-related quality of life parameters observed in patients experiencing varying degrees of proximal junctional kyphosis following corrective adult spinal deformity fusions. METHODS Inclusion: adult spinal deformity patients > 18 y/o, undergoing spinal fusion. PJK: ≥ 10° measure of the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the UIV + 2. Severe PJK: > 28° PJK. Mild PJK: ≥ 10oand ≤ 28°. ANOVA, followed by ANCOVA, compared the change in HRQoLs between time points (BL, 1Y, 2Y) among PJK groups. Correlation-related change in PJK and change in HRQoL for mild and severe groups. RESULTS 969 patients (age: 64.5 y/o,75% F, posterior levels fused:12.3) were studied. 59% no PJK, 32% mild PJK, 9% severe PJK. No differences in HRQoLs were seen between no PJK and PJK groups at baseline, one year, and 2 years. Adjusted analysis revealed Severe PJK patients improved less in SRS-22 Satisfaction (NoPJK: 1.6, MildPJK: 1.6, SeverePJK: 1.0; p = 0.022) scores at 2 years. Linear regression analysis only found clinical improvement in SRS-22 Satisfaction to correlate with the change of the PJK angle by 2 years (R = 0.176, P = 0.008). No other HRQoL metric correlated with either the incidence of PJK or the change in the PJK angle by one or 2 years. CONCLUSIONS These results maintain that patients presenting with and without proximal junctional kyphosis report similar health-related qualities of life following corrective adult spinal deformity surgery, and SRS-22 Satisfaction may be a clinical correlate to the degree of PJK. Rather than proving proximal junctional kyphosis to have a minimal clinical impact overall on HRQoL metrics, these data suggest that future analysis of this phenomenon requires different assessments. LEVEL OF EVIDENCE Level of evidence: III.
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Affiliation(s)
- Peter G Passias
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA. .,Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, New York Spine Institute, NYU Langone Medical Center, Orthopaedic Hospital-NYU School of Medicine, 301 East 17th St, New York, NY, 10003, USA.
| | | | - Tyler K Williamson
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Kevin A Moattari
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital
- Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital
- Northwell Health, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, Medical Center, University of Kansas, Kansas, KS, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital
- Northwell Health, New York, NY, USA
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Louie PK, Sheikh Alshabab B, McCarthy MH, Virk S, Dowdell JE, Steinhaus ME, Lovecchio F, Samuel AM, Morse KW, Schwab FJ, Albert TJ, Qureshi SA, Iyer S, Katsuura Y, Huang RC, Cunningham ME, Yao YC, Weissmann K, Lafage R, Lafage V, Kim HJ. Classification system for cervical spine deformity morphology: a validation study. J Neurosurg Spine 2022; 37:865-873. [PMID: 35901688 DOI: 10.3171/2022.5.spine211537] [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: 12/10/2021] [Accepted: 05/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to initially validate a recent morphological classification of cervical spine deformity pathology. METHODS The records of 10 patients for each of the 3 classification subgroups (flat neck, focal deformity, and cervicothoracic), as well as for 8 patients with coronal deformity only, were extracted from a prospective multicenter database of patients with cervical deformity (CD). A panel of 15 physicians of various training and professional levels (i.e., residents, fellows, and surgeons) categorized each patient into one of the 4 groups. The Fleiss kappa coefficient was utilized to evaluate intra- and interrater reliability. Accuracy, defined as properly selecting the main driver of deformity, was reported overall, by morphotype, and by reviewer experience. RESULTS The overall classification demonstrated a moderate to substantial agreement (round 1: interrater Fleiss kappa = 0.563, 95% CI 0.559-0.568; round 2: interrater Fleiss kappa = 0.612, 95% CI 0.606-0.619). Stratification by level of training demonstrated similar mean interrater coefficients (residents 0.547, fellows 0.600, surgeons 0.524). The mean intrarater score was 0.686 (range 0.531-0.823). A substantial agreement between rounds 1 and 2 was demonstrated in 81.8% of the raters, with a kappa score > 0.61. Stratification by level of training demonstrated similar mean intrarater coefficients (residents 0.715, fellows 0.640, surgeons 0.682). Of 570 possible questions, reviewers provided 419 correct answers (73.5%). When considering the true answer as being selected by at least one of the two main drivers of deformity, the overall accuracy increased to 86.0%. CONCLUSIONS This initial validation of a CD morphological classification system reiterates the importance of dynamic plain radiographs for the evaluation of patients with CD. The overall reliability of this CD morphological classification has been demonstrated. The overall accuracy of the classification system was not impacted by rater experience, demonstrating its simplicity.
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Affiliation(s)
- Philip K Louie
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,2Department of Neurosurgery, Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, Washington
| | - Basel Sheikh Alshabab
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael H McCarthy
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,3Department of Orthopaedic Surgery, Indiana Spine Group, University of Indiana, Carmel, Indiana
| | - Sohrab Virk
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,4Department of Orthopaedic Surgery, Northwell Health, New Hyde Park, New York
| | - James E Dowdell
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Michael E Steinhaus
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,5Spine Institute, MountainStar Healthcare, Murray, Utah
| | - Francis Lovecchio
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Andre M Samuel
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Kyle W Morse
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Frank J Schwab
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,4Department of Orthopaedic Surgery, Northwell Health, New Hyde Park, New York
| | - Todd J Albert
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Sheeraz A Qureshi
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Sravisht Iyer
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Yoshihiro Katsuura
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,6Department of Orthopedics, Adventist Health, Willits, California
| | - Russel C Huang
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Matthew E Cunningham
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Yu-Cheng Yao
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,7Department of Orthopedics, Taipei Veterans General Hospital, Taipei, Taiwan; and
| | - Karen Weissmann
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,8Department of Orthopedics and Traumatology, University of Chile, Santiago, Chile
| | - Renaud Lafage
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,4Department of Orthopaedic Surgery, Northwell Health, New Hyde Park, New York
| | - Virginie Lafage
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.,4Department of Orthopaedic Surgery, Northwell Health, New Hyde Park, New York
| | - Han Jo Kim
- 1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
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Passias PG, Ahmad W, Oh C, Imbo B, Naessig S, Pierce K, Lafage V, Lafage R, Hamilton DK, Protopsaltis TS, Klineberg EO, Gum J, Schoenfeld AJ, Line B, Hart RA, Burton DC, Bess S, Schwab FJ, Smith JS, Shaffrey CI, Ames CP. Development of Risk Stratification Predictive Models for Cervical Deformity Surgery. Neurosurgery 2022; 91:928-935. [PMID: 36250700 DOI: 10.1227/neu.0000000000002136] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 06/29/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As corrective surgery for cervical deformity (CD) increases, so does the rate of complications and reoperations. To minimize suboptimal postoperative outcomes, it is important to develop a tool that allows for proper preoperative risk stratification. OBJECTIVE To develop a prognostic utility for identification of risk factors that lead to the development of major complications and unplanned reoperations. METHODS CD patients age 18 years or older were stratified into 2 groups based on the postoperative occurrence of a revision and/or major complication. Multivariable logistic regressions identified characteristics that were associated with revision or major complication. Decision tree analysis established cutoffs for predictive variables. Models predicting both outcomes were quantified using area under the curve (AUC) and receiver operating curve characteristics. RESULTS A total of 109 patients with CD were included in this study. By 1 year postoperatively, 26 patients experienced a major complication and 17 patients underwent a revision. Predictive modeling incorporating preoperative and surgical factors identified development of a revision to include upper instrumented vertebrae > C5, lowermost instrumented vertebrae > T7, number of unfused lordotic cervical vertebrae > 1, baseline T1 slope > 25.3°, and number of vertebral levels in maximal kyphosis > 12 (AUC: 0.82). For developing a major complication, a model included a current smoking history, osteoporosis, upper instrumented vertebrae inclination angle < 0° or > 40°, anterior diskectomies > 3, and a posterior Smith Peterson osteotomy (AUC: 0.81). CONCLUSION Revisions were predicted using a predominance of radiographic parameters while the occurrence of major complications relied on baseline bone health, radiographic, and surgical characteristics.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Waleed Ahmad
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Cheongeun Oh
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Bailey Imbo
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Sara Naessig
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Katherine Pierce
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Themistocles S Protopsaltis
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, New York, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, California, USA
| | - Jeffrey Gum
- Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Breton Line
- Denver International Spine Center, Denver, Colorado, USA
| | - Robert A Hart
- Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shay Bess
- Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York, 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
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41
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Elias E, Bess S, Line BG, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias P, Nasser Z, Gum JL, Kebaish K, Eastlack R, Daniels AH, Mundis G, Hostin R, Protopsaltis TS, Soroceanu A, Hamilton DK, Kelly MP, Gupta M, Hart R, Schwab FJ, Burton D, Ames CP, Shaffrey CI, Smith JS. Operative treatment outcomes for adult cervical deformity: a prospective multicenter assessment with mean 3-year follow-up. J Neurosurg Spine 2022; 37:855-864. [PMID: 35901674 DOI: 10.3171/2022.6.spine22422] [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: 04/17/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adult cervical deformity (ACD) has high complication rates due to surgical complexity and patient frailty. Very few studies have focused on longer-term outcomes of operative ACD treatment. The objective of this study was to assess minimum 2-year outcomes and complications of ACD surgery. METHODS A multicenter, prospective observational study was performed at 13 centers across the United States to evaluate surgical outcomes for ACD. Demographics, complications, radiographic parameters, and patient-reported outcome measures (PROMs; Neck Disability Index, modified Japanese Orthopaedic Association, EuroQol-5D [EQ-5D], and numeric rating scale [NRS] for neck and back pain) were evaluated, and analyses focused on patients with ≥ 2-year follow-up. RESULTS Of 169 patients with ACD who were eligible for the study, 102 (60.4%) had a minimum 2-year follow-up (mean 3.4 years, range 2-8.1 years). The mean age at surgery was 62 years (SD 11 years). Surgical approaches included anterior-only (22.8%), posterior-only (39.6%), and combined (37.6%). PROMs significantly improved from baseline to last follow-up, including Neck Disability Index (from 47.3 to 33.0) and modified Japanese Orthopaedic Association score (from 12.0 to 12.8; for patients with baseline score ≤ 14), neck pain NRS (from 6.8 to 3.8), back pain NRS (from 5.5 to 4.8), EQ-5D score (from 0.74 to 0.78), and EQ-5D visual analog scale score (from 59.5 to 66.6) (all p ≤ 0.04). More than half of the patients (n = 58, 56.9%) had at least one complication, with the most common complications including dysphagia, distal junctional kyphosis, instrumentation failure, and cardiopulmonary events. The patients who did not achieve 2-year follow-up (n = 67) were similar to study patients based on baseline demographics, comorbidities, and PROMs. Over the course of follow-up, 23 of the total 169 enrolled patients were reported to have died. Notably, these represent all-cause mortalities during the course of follow-up. CONCLUSIONS This multicenter, prospective analysis demonstrates that operative treatment for ACD provides significant improvement of health-related quality of life at a mean 3.4-year follow-up, despite high complication rates and a high rate of all-cause mortality that is reflective of the overall frailty of this patient population. To the authors' knowledge, this study represents the largest and most comprehensive prospective effort to date designed to assess the intermediate-term outcomes and complications of operative treatment for ACD.
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Affiliation(s)
- Elias Elias
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Shay Bess
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Breton G Line
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Virginie Lafage
- 3Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Renaud Lafage
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric Klineberg
- 5Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Han Jo Kim
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter Passias
- 6Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Zeina Nasser
- 7Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | | | - Khaled Kebaish
- 9Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Alan H Daniels
- 11Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | | | - Richard Hostin
- 12Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | | | - Alex Soroceanu
- 13Department of Orthopedic Surgery, University of Calgary, Alberta, Canada
| | - D Kojo Hamilton
- 14Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Michael P Kelly
- 15Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Munish Gupta
- 16Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Robert Hart
- 17Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Frank J Schwab
- 3Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Douglas Burton
- 18Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher P Ames
- 19Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Christopher I Shaffrey
- 20Departments of Neurosurgery and Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Justin S Smith
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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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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Zuckerman SL, Cerpa M, Lenke LG, Shaffrey CI, Carreon LY, Cheung KMC, Kelly MP, Fehlings MG, Ames CP, Boachie-Adjei O, Dekutoski MB, Kabeaish KM, Lewis SJ, Matsuyama Y, Pellisé F, Qiu Y, Schwab FJ, Smith JS. Patient-Reported Outcomes After Complex Adult Spinal Deformity Surgery: 5-Year Results of the Scoli-Risk-1 Study. Global Spine J 2022; 12:1736-1744. [PMID: 33557622 PMCID: PMC9609523 DOI: 10.1177/2192568220988276] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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: 01/22/2023] Open
Abstract
STUDY DESIGN Prospective cohort. OBJECTIVE To prospectively evaluate PROs up to 5-years after complex ASD surgery. METHODS The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers. Inclusion criteria was Cobb angle of >80°, corrective osteotomy for congenital or revision deformity, and/or 3-column osteotomy. The following PROs were measured prospectively at intervals up to 5-years postoperative: ODI, SF36-PCS/MCS, SRS-22, NRS back/leg. Among patients with 5-year follow-up, comparisons were made from both baseline and 2-years postoperative to 5-years postoperative. PROs were analyzed using mixed models for repeated measures. RESULTS Seventy-seven patients (28.3%) had 5-year follow-up data. Comparing baseline to 5-year data among these 77 patients, significant improvement was seen in all PROs: ODI (45.2 vs. 29.3, P < 0.001), SF36-PCS (31.5 vs. 38.8, P < 0.001), SF36-MCS (44.9 vs. 49.1, P = 0.009), SRS-22-total (2.78 vs. 3.61, P < 0.001), NRS-back pain (5.70 vs. 2.95, P < 0.001) and NRS leg pain (3.64 vs. 2.62, P = 0.017). In the 2 to 5-year follow-up period, no significant changes were seen in any PROs. The percentage of patients achieving MCID from baseline to 5-years were: ODI (62.0%) and the SRS-22r domains of function (70.4%), pain (63.0%), mental health (37.5%), self-image (60.3%), and total (60.3%). Surprisingly, mean values (P > 0.05) and proportion achieving MCID did not differ significantly in patients with major surgery-related complications compared to those without. CONCLUSIONS After complex ASD surgery, significant improvement in PROs were seen at 5-years postoperative in ODI, SF36-PCS/MCS, SRS-22r, and NRS-back/leg pain. No significant changes in PROs occurred during the 2 to 5-year postoperative period. Those with major surgery-related complications had similar PROs and proportion of patients achieving MCID as those without these complications.
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Affiliation(s)
| | - Meghan Cerpa
- Columbia University Medical Center, New
York, NY, USA,Meghan Cerpa, MPH, Department of Orthopedic
Surgery, Columbia University Medical Center, The Spine Hospital at New York
Presbyterian, New York, NY 10032, USA.
| | | | | | | | | | | | - Michael G. Fehlings
- University of Toronto and Toronto
Western Hospital, Toronto, Ontario, Canada
| | | | | | | | | | - Stephen J. Lewis
- University of Toronto and Toronto
Western Hospital, Toronto, Ontario, Canada
| | | | | | - Yong Qiu
- Affiliated Drum Tower Hospital of
Nanjing University Medical School, Nanjing, China
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Passias PG, Pierce KE, Williamson TK, Krol O, Lafage R, Lafage V, Schoenfeld AJ, Protopsaltis TS, Vira S, Line B, Diebo BG, Ames CP, Kim HJ, Smith JS, Chou D, Daniels AH, Gum JL, Shaffrey CI, Burton DC, Kelly MP, Klineberg EO, Hart RA, Bess S, Schwab FJ, Gupta MC. Pelvic Non-Response Following Treatment of Adult Spinal Deformity: Influence of Realignment Strategies on Occurrence. Spine (Phila Pa 1976) 2022; 48:645-652. [PMID: 36102572 DOI: 10.1097/brs.0000000000004464] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/22/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Despite adequate correction, the pelvis may fail to readjust, deemed pelvic non-response. To assess alignment outcomes(pelvic non-response[PNR], PJK, postoperative cervical deformity[CD]) following ASD surgery utilizing different realignment strategies. METHODS ASD patients with 2-year(2Y) data were included. PNR defined as undercorrected in age-adjusted pelvic tilt(PT) at 6W and maintained at 2Y. Patients classified by alignment utilities: [a] Improvement in SRS-Schwab SVA,[b] Matching in age-adjusted PI-LL,[c] Matching in Roussouly,[d] aligning Global Alignment and Proportionality(GAP) score. Multivariable regression analyses, controlling for age, baseline deformity, and surgical factors, assessed rates of PNR, PJK, and CD development following realignment. RESULTS 686 patients met inclusion criteria. Rates of postop PJK and CD were not significant in the PNR group(both P>0.15). PNR patients less often met substantial clinical benefit in ODI by 2Y(OR: 0.6,[0.4-0.98]). Patients overcorrected in age-adjusted PI-LL, matching Roussouly, or proportioned in GAP at 6W had lower rates of PNR(all P<0.001). Incremental addition of classifications led to 0% occurrence of PNR, PJK and CD. Stratifying by baseline PT severity, Low and Moderate deformity demonstrated the least incidence of PNR(7.7%) when proportioning in GAP at 6W, while severe PT benefited most from matching in Roussouly(all P<0.05). CONCLUSIONS Following ASD corrective surgery, 24.9% of patients showed residual pelvic malalignment. This occurrence was often accompanied by undercorrection of lumbopelvic mismatch and less improvement of pain. However, overcorrection in any strategy incurred higher rates of PJK. We recommend surgeons identify a middle ground using one, or more, of the available classifications to inform correction goals in this regard. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Tyler K Williamson
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Oscar Krol
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Themistocles S Protopsaltis
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Shaleen Vira
- Department of Spine Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Han Jo Kim
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY, USA
| | - Christopher I Shaffrey
- Departments of Orthopaedic and Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Washington University of St Louis, St. Louis, MO, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University of St Louis, St. Louis, MO, USA
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Passias PG, Kummer N, Williamson TK, Moattari K, Lafage V, Lafage R, Kim HJ, Daniels AH, Gum JL, Diebo BG, Protopsaltis TS, Mundis GM, Eastlack RK, Soroceanu A, Scheer JK, Hamilton DK, Klineberg EO, Line B, Hart RA, Burton DC, Mummaneni P, Chou D, Park P, Schwab FJ, Shaffrey CI, Bess S, Ames CP, Smith JS. Highest Achievable Outcomes for Patients Undergoing Cervical Deformity Corrective Surgery by Frailty. Neurosurgery 2022; 91:693-700. [PMID: 36084195 DOI: 10.1227/neu.0000000000002091] [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] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Frailty is influential in determining operative outcomes, including complications, in patients with cervical deformity (CD). OBJECTIVE To assess whether frailty status limits the highest achievable outcomes of patients with CD. METHODS Adult patients with CD with 2-year (2Y) data included. Frailty stratification: not frail (NF) <0.2, frail (F) 0.2 to 0.4, and severely frail (SF) >0.4. Analysis of covariance established estimated marginal means based on age, invasiveness, and baseline deformity, for improvement, deterioration, or maintenance in Neck Disability Index (NDI), Modified Japanese Orthopaedic Association (mJOA), and Numerical Rating Scale Neck Pain. RESULTS One hundred twenty-six patients with CD included 29 NF, 83 F, and 14 SF. The NF group had the highest rates of deterioration and lowest rates of improvement in cervical Sagittal Vertical Axis and horizontal gaze modifiers. Two-year improvements in NDI by frailty: NF: -11.2, F: -16.9, and SF: -14.6 (P = .524). The top quartile of NF patients also had the lowest 1-year (1Y) NDI (7.0) compared with F (11.0) and SF (40.5). Between 1Y and 2Y, 7.9% of patients deteriorated in NDI, 71.1% maintained, and 21.1% improved. Between 1Y and 2Y, SF had the highest rate of improvement (42%), while NF had the highest rate of deterioration (18.5%). CONCLUSION Although frail patients improved more often by 1Y, SF patients achieve most of their clinical improvement between 1 and 2Y. Frailty is associated with factors such as osteoporosis, poor alignment, neurological status, sarcopenia, and other medical comorbidities. Similarly, clinical outcomes can be affected by many factors (fusion status, number of pain generators within treated levels, integrity of soft tissues and bone, and deformity correction). Although accounting for such factors will ultimately determine whether frailty alone is an independent risk factor, these preliminary findings may suggest that frailty status affects the clinical outcomes and improvement after CD surgery.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Nicholas Kummer
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Tyler K Williamson
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Kevin Moattari
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Themistocles S Protopsaltis
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, New York, USA
| | - Gregory M Mundis
- Division of Orthopaedic Surgery, Scripps Clinic Medical Group, La Jolla, California, USA
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, California, USA
| | - Alexandra Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - D Kojo Hamilton
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, UC Davis Health System, Sacramento, California, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's Medical Center/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - 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
| | - Paul Park
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Christopher I Shaffrey
- Division of Spine, Departments of Neurosurgery and Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's Medical Center/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Justin S Smith
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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Shah NV, Kim DJ, Patel N, Beyer GA, Hollern DA, Wolfert AJ, Kim N, Suarez DE, Monessa D, Zhou PL, Eldib HM, Passias PG, Schwab FJ, Lafage V, Paulino CB, Diebo BG. The 5-factor modified frailty index (mFI-5) is predictive of 30-day postoperative complications and readmission in patients with adult spinal deformity (ASD). J Clin Neurosci 2022; 104:69-73. [PMID: 35981462 DOI: 10.1016/j.jocn.2022.07.020] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/19/2022] [Accepted: 07/24/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is limited research regarding the association between the mFI-5 and postoperative complications among adult spinal deformity (ASD) patients. METHODS Using the National Surgical Quality Improvement Project (NSQIP) database, patients with Current Procedural Terminology (CPT) codes for > 7-level fusion or < 7-level fusion with International Classification of Diseases, Ninth Revision (ICD-9) codes for ASD were identified between 2008 and 2016. Univariate analyses with post-hoc Bonferroni correction for demographics and preoperative factors were performed. Logistic regression assessed associations between mFI-5 scores and 30-day post-operative outcomes. RESULTS 2,120 patients met criteria. Patients with an mFI-5 score of 4 or 5 were excluded, given there were<20 patients with those scores. Patients with mFI-5 scores of 1 and 2 had increased 30-day rates of pneumonia (3.5 % and 4.3 % vs 1.6 %), unplanned postoperative ventilation for > 48 h (3.1 % and 4.3 % vs 0.9 %), and UTIs (4.4 % and 7.4 % vs 2.0 %) than patients with a score of 0 (all, p < 0.05). Logistic regression revealed that compared to an mFI-5 of 0, a score of 1 was an independent predictor of 30-day reoperations (OR = 1.4; 95 % CI 1.1-18). A score of 2 was an independent predictor of overall (OR = 2.4; 95 % CI 1.4-4.1) and related (OR = 2.2; 95 % CI 1.2-4.1) 30-day readmissions. A score of 3 was not predictive of any adverse outcome. CONCLUSION The mFI-5 score predicted complications and postoperative events in the ASD population. The mFI-5 may effectively predict 30-day readmissions. Further research is needed to identify the benefits and predictive value of mFI-5 as a risk assessment tool.
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Affiliation(s)
- Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA.
| | - David J Kim
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Neil Patel
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - George A Beyer
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Douglas A Hollern
- Department of Orthopedic Surgery, USC Verdugo Hills Hospital, Los Angeles, CA, USA
| | - Adam J Wolfert
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Nathan Kim
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Daniel E Suarez
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Dan Monessa
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Peter L Zhou
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Hassan M Eldib
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA
| | - Peter G Passias
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Frank J Schwab
- 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
| | - Carl B Paulino
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA; Department of Orthopaedic Surgery, New York Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, NY, USA; Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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Dial BL, Hills JM, Smith JS, Sardi JP, Lazaro B, Shaffrey CI, Bess S, Schwab FJ, Lafage V, Lafage R, Kelly MP, Bridwell KH. The impact of lumbar alignment targets on mechanical complications after adult lumbar scoliosis surgery. Eur Spine J 2022; 31:1573-1582. [PMID: 35428916 DOI: 10.1007/s00586-022-07200-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/02/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to determine the discriminatory ability of age-adjusted alignment offset and the global alignment and proportion (GAP) score parameters to predict postoperative mechanical complications. METHODS Surgical patients from the Adult Symptomatic Lumbar Scoliosis cohort were reviewed at 2 year follow up. Age-adjusted alignment offsets and GAP parameters were calculated for each patient. A series of nonlinear logistic regression models were fit, and the odds of mechanical complications were calculated. The discriminatory ability of the GAP score, GAP score parameters, and age-adjusted alignment offsets were determined plotting receiver operative characteristic (ROC) with the C statistic (AUC). RESULTS A total of 165 patients were included. A total of 49 mechanical complications occurred in 41 patients (21 proximal junctional kyphosis and 28 pseudoarthrosis). The GAP score had no discriminatory ability in this cohort. Relative lumbar lordosis 15 degrees greater than ideal lumbar lordosis was associated with greater mechanical complications. A lumbar distribution index of 90% was associated with fewer mechanical complications compared to a lumbar distribution index of 65%. Age-adjusted offset alignment targets had no discriminatory ability to predict mechanical complications. CONCLUSION Radiographic alignment targets using either age-adjusted alignment target offset or GAP score parameters had minimal ability to predict mechanical complications in isolation. Mechanical complications following adult spinal deformity surgery are complex, and patient factors play a critical role. Clinical trial registeration This study was registered at ClinicalTrials.gov (number NCT00854828) in March 2009.
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Affiliation(s)
- Brian L Dial
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Jeffrey M Hills
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Juan Pablo Sardi
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Bruno Lazaro
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Frank J Schwab
- Spine Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Spine Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Renaud Lafage
- Spine Research Laboratory, Hospital for Special Surgery, New York, NY, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, University of California, San Diego, 3020 Children's Way, San Diego, CA, 92123, USA.
| | - Keith H Bridwell
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
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Passias PG, Pierce KE, Horn SR, Segar A, Passfall L, Kummer N, Krol O, Bortz C, Brown AE, Alas H, Segreto FA, Ahmad W, Naessig S, Buckland AJ, Protopsaltis TS, Gerling M, Lafage R, Schwab FJ, Lafage V. Cervical Deformity Correction Fails to Achieve Age-Adjusted Spinopelvic Alignment Targets. Int J Spine Surg 2022; 16:450-457. [PMID: 35772976 DOI: 10.14444/8260] [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
OBJECTIVE To assess whether surgical cervical deformity (CD) patients meet spinopelvic age-adjusted alignment targets, reciprocal, and lower limb compensation changes. STUDY DESIGN Retrospective review. METHODS CD was defined as C2-C7 lordosis >10°, cervical sagittal vertical angle (cSVA) >4 cm, or T1 slope minus cervical lordosis (TS-CL) >20°. Inclusion criteria were age >18 years and undergoing surgical correction with complete baseline and postoperative imaging. Published formulas were used to create age-adjusted alignment target for pelvic tilt (PT), pelvic incidence and lumbar lordosis (PI-LL), sagittal vertical angle (SVA), and lumbar lordosis and thoracic kyphosis (LL-TK). Actual alignment was compared with age-adjusted ideal values. Patients who matched ±10-year thresholds for age-adjusted targets were compared with unmatched cases (under- or overcorrected). RESULTS A total of 120 CD patients were included (mean age, 55.1 years; 48.4% women; body mass index, 28.8 kg/m2). For PT, only 24.4% of patients matched age-adjusted alignment, 51.1% overcorrected for PT, and 24.4% undercorrected. For PI-LL, only 27.6% of CD patients matched age-adjusted targets, with 49.4% overcorrected and 23% undercorrected postoperatively. Forty percent of patients matched age-adjusted target for SVA, 41.3% overcorrected, and 18.8% undercorrected. CD patients who had worsened in TS-CL or cSVA postoperatively displayed increased TK (-41.1° to -45.3°, P = 1.06). With lower extremity compensation, CD patients decreased in ankle flexion angle postoperatively (6.1°-5.5°, P = 0.036) and trended toward smaller sacrofemoral angle (199.6-195.6 mm, P = 0.286) and knee flexion (2.6° to -1.1°, P = 0.269). CONCLUSIONS In response to worsening CD postoperatively, patients increased in TK and recruited less lower limb compensation. Almost 75% of CD patients did not meet previously established spinopelvic alignment goals, of whom a subset of patients were actually made worse off in these parameters following surgery. This finding raises the question of whether we should be looking at the entire spine when treating CD. LEVEL OF EVIDENCE: 3
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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, USA
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY, USA
| | - Samantha R Horn
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY, USA
| | - Anand Segar
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Lara Passfall
- 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
| | - Oscar Krol
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY, USA
| | - Cole Bortz
- 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
| | - Haddy Alas
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY, USA
| | - Frank A Segreto
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY, USA
| | - Waleed Ahmad
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY, USA
| | - Sara Naessig
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY, USA
| | - Aaron J Buckland
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | - Michael Gerling
- Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Shah NV, Lavian JD, Moattari CR, Eldib H, Beyer GA, Mai DH, Challier V, Passias PG, Lafage R, Lafage V, Schwab FJ, Paulino CB, Diebo BG. The Impact of Isolated Baseline Cannabis Use on Outcomes Following Thoracolumbar Spinal Fusion: A Propensity Score-Matched Analysis. Iowa Orthop J 2022; 42:57-62. [PMID: 35821925 PMCID: PMC9210439] [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] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND There is limited literature evaluating the impact of isolated cannabis use on outcomes for patients following spinal surgery. This study sought to compare 90-day complication, 90-day readmission, as well as 2-year revision rates between baseline cannabis users and non-users following thoracolumbar spinal fusion (TLF) for adult spinal deformity (ASD). METHODS The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried between January 2009 and September 2013 to identify all patients who underwent TLF for ASD. Inclusion criteria were age ≥18 years and either minimum 90-day (for complications and readmissions) or 2-year (for revisions) follow-up surveillance. Cohorts were created and propensity score-matched based on presence or absence of isolated baseline cannabis use. Baseline demographics, hospital-related parameters, 90-day complications and readmissions, and two-year revisions were retrieved. Multivariate binary stepwise logistic regression identified independent outcome predictors. RESULTS 704 patients were identified (n=352 each), with comparable age, sex, race, primary insurance, Charlson/Deyo scores, surgical approach, and levels fused between cohorts (all, p>0.05). Cannabis users (versus non-users) incurred lower 90-day overall and medical complication rates (2.4% vs. 4.8%, p=0.013; 2.0% vs. 4.1%, p=0.018). Cohorts had otherwise comparable complication, revision, and readmission rates (p>0.05). Baseline cannabis use was associated with a lower risk of 90-day medical complications (OR=0.47, p=0.005). Isolated baseline cannabis use was not associated with 90-day surgical complications and readmissions, or two-year revisions. CONCLUSION Isolated baseline cannabis use, in the absence of any other diagnosed substance abuse disorders, was not associated with increased odds of 90-day surgical complications or readmissions or two-year revisions, though its use was associated with reduced odds of 90-day medical complications when compared to non-users undergoing TLF for ASD. Further investigations are warranted to identify the physiologic mechanisms underlying these findings. Level of Evidence: III.
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Affiliation(s)
- Neil V. Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Joshua D. Lavian
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Cameron R. Moattari
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Hassan Eldib
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - George A. Beyer
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - David H. Mai
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Vincent Challier
- Spine Unit 1, Orthopedic Surgery Department, Bordeaux University Hospital, Bordeaux, France
| | - Peter G. Passias
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Frank J. Schwab
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Carl B. Paulino
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
- Department of Orthopaedic Surgery, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Bassel G. Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
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Passias PG, Bortz C, Alas H, Moattari K, Brown A, Pierce KE, Manning J, Ayres EW, Varlotta C, Wang E, Williamson TK, Imbo B, Joujon-Roche R, Tretiakov P, Krol O, Janjua B, Sciubba D, Diebo BG, Protopsaltis T, Buckland AJ, Schwab FJ, Lafage R, Lafage V. Improved Surgical Correction Relative to Patient-Specific Ideal Spinopelvic Alignment Reduces Pelvic Nonresponse for Severely Malaligned Adult Spinal Deformity Patients. Int J Spine Surg 2022; 16:530-539. [PMID: 35772972 DOI: 10.14444/8254] [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 Persistent pelvic compensation following adult spinal deformity (ASD) corrective surgery may impair quality of life and result in persistent pathologic lower extremity compensation. Ideal age-specific alignment targets have been proposed to improve surgical outcomes, though it is unclear whether reaching these ideal targets reduces rates of pelvic nonresponse following surgery. Our aim was to assess the relationship between pelvic nonresponse, age-specific alignment, and lower-limb compensation following surgery for ASD. METHODS Single-center retrospective cohort study. ASD patients were grouped: those who did not improve in Scoliosis Research Society-Schwab pelvic tilt (PT) modifier (pelvic nonresponders [PNR]), and those who improved (pelvic responders [PR]). Groups were propensity score matched for preoperative PT and assessed for differences in spinal and lower extremity alignment. Rates of pelvic nonresponse were compared across patient groups who were undercorrected, overcorrected, or matched age-specific postoperative alignment targets. RESULTS A total of 146 surgical ASD patients, 47.9% of whom showed pelvic nonresponse following surgery, were included. After propensity score matching, PNR (N = 29) and PR (N = 29) patients did not differ in demographics, preoperative alignment, or levels fused; however, PNR patients have less preoperative knee flexion (9° vs 14°, P = 0.043). PNR patients had inferior postoperative pelvic incidence and lumbar lordosis (PI-LL) alignment (17° vs 3°) and greater pelvic shift (53 vs 31 mm). PNR and PR patients did not differ in rates of reaching ideal age-specific postoperative alignment for sagittal vertical axis (SVA) or PI-LL, though patients who matched ideal PT had lower rates of PNR (25.0% vs 75.0%). For patients with moderate and severe preoperative SVA, more aggressive correction relative to either ideal postoperative PT or PI-LL was associated with significantly lower rates of pelvic nonresponse (all P < 0.05). CONCLUSIONS For patients with moderate to severe baseline truncal inclination, more aggressive surgical correction relative to ideal age-specific PI-LL was associated with lower rates of pelvic nonresponse. Postoperative alignment targets may need to be adjusted to optimize alignment outcomes for patients with substantial preoperative sagittal deformity. CLINICAL RELEVANCE These findings increase our understanding of the poor outcomes that occur despite ideal realignment. Surgical correction of severe global sagittal deformity should be prioritized to mitigate these occurrences. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Cole Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Haddy Alas
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Kevin Moattari
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Avery Brown
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Katherine E Pierce
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Jordan Manning
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Ethan W Ayres
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | - Erik Wang
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Tyler K Williamson
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Bailey Imbo
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Rachel Joujon-Roche
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Peter Tretiakov
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Oscar Krol
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Burhan Janjua
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Daniel Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY, USA
| | | | - Aaron J Buckland
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, 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
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