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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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Agarwal N, Letchuman V, Lavadi RS, Le VP, Aabedi AA, Shabani S, Chan AK, Park P, Uribe JS, Turner JD, Eastlack RK, Fessler RG, Fu KM, Wang MY, Kanter AS, Okonkwo DO, Nunley PD, Anand N, Mundis GM, Passias PG, Bess S, Shaffrey CI, Chou D, Mummaneni PV. What is the effect of preoperative depression on outcomes after minimally invasive surgery for adult spinal deformity? A prospective cohort analysis. J Neurosurg Spine 2024; 40:602-610. [PMID: 38364229 DOI: 10.3171/2023.12.spine221330] [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: 12/01/2022] [Accepted: 12/08/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Depression has been implicated with worse immediate postoperative outcomes in adult spinal deformity (ASD) correction, yet the specific impact of depression on those patients undergoing minimally invasive surgery (MIS) requires further clarity. This study aimed to evaluate the role of depression in the recovery of patients with ASD after undergoing MIS. METHODS Patients who underwent MIS for ASD with a minimum postoperative follow-up of 1 year were included from a prospectively collected, multicenter registry. Two cohorts of patients were identified that consisted of either those affirming or denying depression on preoperative assessment. The patient-reported outcome measures (PROMs) compared included scores on the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back and leg pain, Scoliosis Research Society Outcomes Questionnaire (SRS-22), SF-36 physical component summary, SF-36 mental component summary (MCS), EQ-5D, and EQ-5D visual analog scale. RESULTS Twenty-seven of 147 (18.4%) patients screened positive for preoperative depression. The nondepressed cohort had an average of 4.83 levels fused, and the depressed cohort had 5.56 levels fused per patient (p = 0.267). At 1-year follow-up, 10 patients still reported depression, representing a 63% decrease. Postoperatively, both cohorts demonstrated improvement in their PROMs; however, at 1-year follow-up, those without depression had statistically better outcomes based on the EQ-5D, MCS, and SRS-22 scores (p < 0.05). Patients with depression continued to experience higher NRS leg scores at 1-year follow-up (3.63 vs 2.22, p = 0.018). After controlling for covariates, the authors found that depression significantly impacted only 1-year follow-up MCS scores (β = 8.490, p < 0.05). CONCLUSIONS Depressed and nondepressed patients reported similar improvements after MIS surgery, except MCS scores were more likely to improve in nondepressed patients.
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Affiliation(s)
- Nitin Agarwal
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- 2Division of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Neurological Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Vijay Letchuman
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Raj Swaroop Lavadi
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Vivian P Le
- 5Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Alexander A Aabedi
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Saman Shabani
- 6Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew K Chan
- 5Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Paul Park
- 7Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee
| | - Juan S Uribe
- 8Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D Turner
- 8Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert K Eastlack
- 9Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California
| | - Richard G Fessler
- 10Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kai-Ming Fu
- 11Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael Y Wang
- 12Department of Neurosurgery, University of Miami, Florida
| | - Adam S Kanter
- 13Division of Neurosurgery, Hoag Neurosciences Institute, Newport Beach, California
| | - David O Okonkwo
- 2Division of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Neel Anand
- 15Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gregory M Mundis
- 9Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California
| | - Peter G Passias
- 16Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Shay Bess
- 17Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado; and
| | | | - Dean Chou
- 5Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Praveen V Mummaneni
- 4Department of Neurological Surgery, University of California, San Francisco, California
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3
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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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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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5
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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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6
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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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7
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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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8
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Mundis GM, Record NC, Shahidi B, Lakomkin N, Carnelian A, Brady KC, Jelousi M, Akbarnia BA, Eastlack RK. Incidence of postoperative neurological deficit with the use of an intraoperative neuromonitoring protocol for lateral lumbar interbody fusion. J Neurosurg Spine 2024; 40:162-168. [PMID: 37976512 DOI: 10.3171/2023.9.spine23263] [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: 03/11/2023] [Accepted: 09/05/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Intraoperative neuromonitoring (IONM) has become commonplace in assessing neurological integrity during lateral approaches to lumbar interbody fusion surgeries. Neuromonitoring is designed to aid surgeons in identifying the potential for intraoperative nerve injury and reducing associated postoperative complications. However, standardized protocols for neuromonitoring have not been provided, and outcomes are not well described. The purpose of this study was to provide a standardized protocol for IONM, and to describe clinical outcomes in a cohort of individuals who underwent lateral lumbar interbody fusion (LLIF) surgery. METHODS A retrospective review of 169 consecutive patients who underwent LLIF surgery at a single institution from October 2014 to October 2016 was performed. Patient characteristics, intraoperative details, clinical outcomes, and postoperative deficits (PODs) were compared between patients who did and did not trigger IONM alerts, and between patients who did and did not demonstrate a POD. A protocol for IONM decision-making was generated based on these observations. RESULTS Most patients (91.7%) underwent surgery for a degenerative spine condition. Twenty-three patients (13.6%) triggered neuromonitoring alerts, and 16 patients (9.5%) demonstrated a POD. Leg pain, back pain, and disability improved significantly (p < 0.045), and 2 patients had both motor and sensory deficits at the 12-week postoperative time point. Patients with a POD demonstrated greater operating room time (p = 0.034) and a greater number of interbody fusion levels (p = 0.015) but were less likely to have triggered a neuromonitoring alert (p = 0.04). There was no association between retractor time and POD (p = 0.98). When an IONM protocol was followed, individuals who experienced a POD were less likely to trigger an alert than those who did not experience a POD (p = 0.04). CONCLUSIONS This study provides a protocol algorithm for IONM alert responses in patients undergoing LLIF surgery. PODs are most associated with multilevel fusion, and patients with alerts had a low rate of persistent deficit. Future research is needed to validate these findings using a more rigorous comparative study design.
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Affiliation(s)
- Gregory M Mundis
- 1Scripps Health, San Diego, California
- 2San Diego Spine Foundation, San Diego, California
| | | | - Bahar Shahidi
- 3Department of Orthopaedic Surgery, University of California, San Diego, California
| | - Nikita Lakomkin
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota; and
| | - Alissa Carnelian
- 1Scripps Health, San Diego, California
- 5NeuroSound, Inc., San Diego, California
| | - Kristina C Brady
- 1Scripps Health, San Diego, California
- 5NeuroSound, Inc., San Diego, California
| | | | - Behrooz A Akbarnia
- 2San Diego Spine Foundation, San Diego, California
- 3Department of Orthopaedic Surgery, University of California, San Diego, California
| | - Robert K Eastlack
- 1Scripps Health, San Diego, California
- 2San Diego Spine Foundation, San Diego, California
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9
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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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10
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Lakomkin N, Eastlack RK, Uribe JS, Park P, Ryu SI, Kretzer R, Mimran RI, Holman P, Veeravagu A, Hassanzadeh H, Johnson MM, Sullivan L, Clark A, Mundis GM. An Integrated 3-Dimentional Navigation System Increases the Accuracy, Efficiency, and Safety of Percutaneous Thoracolumbar Pedicle Screw Placement in Minimally Invasive Approaches: A Randomized Cadaveric Study. Global Spine J 2024:21925682231224394. [PMID: 38165219 DOI: 10.1177/21925682231224394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
STUDY DESIGN Cadaveric study. OBJECTIVES The purpose of this study was to compare a novel, integrated 3D navigational system (NAV) and conventional fluoroscopy in the accuracy, efficiency, and radiation exposure of thoracolumbar percutaneous pedicle screw (PPS) placement. METHODS Twelve skeletally mature cadaveric specimens were obtained for twelve individual surgeons. Each participant placed bilateral PS at 11 segments, from T8 to S1. Prior to insertion, surgeons were randomized to the sequence of techniques and the side (left or right). Following placement, a CT scan of the spine was obtained for each cadaver, and an independent reviewer assessed the accuracy of screw placement using the Gertzbein grading system. Outcome metrics of interest included a comparison of breach incidence/severity, screw placement time, total procedure time, and radiation exposure between the techniques. Bivariate statistics were employed to compare outcomes at each level. RESULTS A total of 262 screws (131 using each technique) were placed. The incidence of cortical breaches was significantly lower with NAV compared to FG (9% vs 18%; P = .048). Of breaches with NAV, 25% were graded as moderate or severe compared to 39% in the FG subgroup (P = .034). Median time for screw placement was significantly lower with NAV (2.7 vs 4.1 min/screw; P = .012), exclusive of registration time. Cumulative radiation exposure to the surgeon was significantly lower for NAV-guided placement (9.4 vs 134 μGy, P = .02). CONCLUSIONS The use of NAV significantly decreased the incidence of cortical breaches, the severity of screw breeches, screw placement time, and radiation exposure to the surgeon when compared to traditional FG.
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Affiliation(s)
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Paul Park
- Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, TN, USA
| | - Stephen I Ryu
- Department of Neurosurgery, Sutter Health, Palo Alto, CA, USA
| | - Ryan Kretzer
- Department of Neurosurgery, Western Neuro, Phoenix, AZ, USA
| | - Ronnie I Mimran
- Department of Neurosurgery, Sutter Health, Palo Alto, CA, USA
| | - Paul Holman
- Department of Neurosurgery, Houston Methodist, Houston, TX, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University, Palo Alto, CA, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Michele M Johnson
- Department of Neurosurgery, Atlanta Brain and Spine, Atlanta, GA, USA
| | - Linda Sullivan
- Medical writing and Biostatistics, NuVasive, San Diego, CA, USA
| | - Aaron Clark
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Gregory M Mundis
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
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11
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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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12
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Ani F, Protopsaltis TS, Parekh Y, Odeh K, Lafage R, Smith JS, Eastlack RK, Lenke L, Schwab F, Mundis GM, Gupta MC, Klineberg EO, Lafage V, Hart R, Burton D, Ames CP, Shaffrey CI, Bess S. Determining the best vertebra for measuring pelvic incidence and spinopelvic parameters in adult spinal deformity patients with transitional anatomy. J Neurosurg Spine 2024; 40:92-98. [PMID: 37862715 DOI: 10.3171/2023.8.spine23432] [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: 04/18/2023] [Accepted: 08/08/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE The aim of this study was to determine if spinal deformity patients with L5 sacralization should have pelvic incidence (PI) and other spinopelvic parameters measured from the L5 or S1 endplate. METHODS This study was a multicenter retrospective comparative cohort study comprising a large database of adult spinal deformity (ASD) patients and a database of asymptomatic individuals. Linear regression modeling was used to determine normative T1 pelvic angle (TPA) and PI - lumbar lordosis (LL) mismatch (PI-LL) based on PI and age in a database of asymptomatic subjects. In an ASD database, patients with radiographic evidence of L5 sacralization had the PI, LL, and TPA measured from the superior endplate of S1 and then also from L5. The differences in TPA and PI-LL from normative were calculated in the sacralization cohort relative to L5 and S1 and correlated to the Oswestry Disability Index (ODI). Patients were grouped based on the Scoliosis Research Society (SRS)-Schwab PI-LL modifier (0, +, or ++) using the L5 PI-LL and S1 PI-LL. Baseline ODI and SF-36 Physical Component Summary (PCS) scores were compared across and within groups. RESULTS Among 1179 ASD patients, 276 (23.4%) had transitional anatomy, 176 with sacralized L5 (14.9%) and 100 (8.48%) with lumbarization of S1. The 176 patients with sacralized L5 were analyzed. When measured using the L5 superior endplate, pelvic parameters were significantly smaller than those measured relative to S1 (PI: 24.5° ± 11.0° vs 55.7° ± 12.0°, p = 0.001;TPA: 11.2° ± 12.0° vs 20.3° ± 12.5°, p = 0.001; and PI-LL: 0.67° ± 21.1° vs 11.4° ± 20.8°, p = 0.001). When measured from S1, 76 (43%), 45 (25.6%), and 55 (31.3%) patients had SRS-Schwab PI-LL modifiers of 0, +, and ++, respectively, compared with 124 (70.5%), 22 (12.5%), and 30 (17.0%), respectively, when measured from L5. There were significant differences in ODI and PCS scores as the SRS-Schwab grade increased regardless of L5 or S1 measurement. The L5 group had lower PCS functional scores for SRS-Schwab modifiers 0 and ++ relative to same grades in the S1 group. Offset from normative TPA (0.5° ± 11.1° vs 9.6° ± 10.8°, p = 0.001) and PI-LL (4.5° ± 20.4° vs 15.2° ± 19.3°, p = 0.001) were smaller when measuring from L5. Moreover, S1 measurements were more correlated with health status by ODI (TPA offset from normative: S1, R = 0.326 vs L5, R = 0.285; PI-LL offset from normative: S1, R = 0.318 vs L5, R = 0.274). CONCLUSIONS Measuring the PI and spinopelvic parameters at L5 in sacralized anatomy results in underestimating spinal deformity and is less correlated with health-related quality of life. Surgeons may consider measuring PI and spinopelvic parameters relative to S1 rather than at L5 in patients with a sacralized L5.
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Affiliation(s)
- Fares Ani
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | | | - Yesha Parekh
- 2Department of Orthopedic Surgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Khalid Odeh
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Renaud Lafage
- 3Department of Orthopedic Surgery, Lenox Hill, Northwell Health, New York, New York
| | - Justin S Smith
- 4Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert K Eastlack
- 5Department of Orthopedic Surgery, Scripps Memorial Hospital, La Jolla, California
| | - Lawrence Lenke
- 6Department of Orthopedic Surgery, Columbia University, New York, New York
| | - Frank Schwab
- 3Department of Orthopedic Surgery, Lenox Hill, Northwell Health, New York, New York
| | - Gregory M Mundis
- 5Department of Orthopedic Surgery, Scripps Memorial Hospital, La Jolla, California
| | - Munish C Gupta
- 7Department of Orthopedic Surgery, Washington University in St. Louis, Missouri
| | - Eric O Klineberg
- 8Department of Orthopedic Surgery, University of California, Davis, California
| | - Virginie Lafage
- 3Department of Orthopedic Surgery, Lenox Hill, Northwell Health, New York, New York
| | - Robert Hart
- 9Department of Orthopedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Douglas Burton
- 10Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher P Ames
- 11Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Shay Bess
- 13Department of Spine Surgery, Denver International Spine Center, Denver, Colorado
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13
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Lafage R, Song J, Diebo B, Daniels AH, Passias PG, Ames CP, Bess S, Eastlack R, Gupta MC, Hostin R, Kebaish K, Kim HJ, Klineberg E, Mundis GM, Smith JS, Shaffrey C, Schwab F, Lafage V, Burton D. Alterations in Magnitude and Shape of Thoracic Kyphosis Following Surgical Correction for Adult Spinal Deformity. Global Spine J 2023:21925682231218003. [PMID: 38031967 DOI: 10.1177/21925682231218003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
STUDY DESIGN Retrospective review of prospective multicenter data. OBJECTIVES This study aimed to investigate the shape of TK before and after fusion in ASD patients treated with long fusion. METHODS ASD patients undergoing posterior spinal fusions including at least T5 to L1 without prior fusion extending to the thoracic spine were included. Patients were categorized based on the preoperative T1-T12 kyphosis into: Hypo-TK (if < 30°), Normal-TK, and Hyper-TK (if > 70°). Regional kyphosis at T10-L1 (Distal), T5-T10 (Middle), and T1-T5 (Proximal) and their relative contributions to total kyphosis were compared between groups, and the pre-to postoperative changes were investigated using paired t test. RESULTS In total, 329 patients were included in this analysis (mean age: 57 ± 16 years, 79.6% female). Preoperative T1-T12 TK for the entire cohort was 40.9 ± 2° (32% Hypo-TK, 11% Hyper-TK, 57% Normal-TK). The Hypo-TK group had the smallest distal TK (5.9 vs 17.1 & 26.0), and middle TK (8.0 vs 25.3 & 45.4), but the percentage of contribution to total kyphosis was not significantly different (Distal: 24.1% vs 34.1% vs 32.8%; Middle: 46.6% vs 53.9% vs 56.8%, all P > .1). Postoperatively, T1-12 TK increased significantly (40.9 ± 2.0° vs 57.8 ± 17.6°). Each group had a decrease in distal kyphosis (Hypo-TK 2.6 ± 10.4°; Normal-TK 8.9 ± 11.5°; Hyper-TK 14.9 ± 12°, all P < .05). The middle kyphosis significantly decreased for Hyper-TK (11.8 ± 12.4) and increased for both Normal-TK and Hypo-TK (3.8 ± 11° and 14.2 ± 11°). Proximal TK increased significantly for all groups by 14-18°. Deterioration from Normal-TK to Hyper-TK postoperatively was associated with lower rate of patient satisfaction (59.6% vs 77.3%, P = .032). CONCLUSIONS Posterior spinal fusion for ASD alters the magnitude and shape of thoracic kyphosis. While 60% of patients had a normal TK at baseline, 30% of those patients developed iatrogenic hyperkyphosis postoperatively. Patients with baseline hypokyphosis were more likely to be corrected to normal TK than hyperkyphotic patients. Future research should investigate TK restoration in ASD and its impact on clinical outcomes and complications.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Junho Song
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | | | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic surgery, University of Texas Health, Houston, TX
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Frank Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Douglas Burton
- Department of Orthopedic Surgery and Sports Medicine, University of Kansas Medical Center, Kansas, KS, USA
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14
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Smith JS, Mundis GM, Osorio JA, Nicolau RJ, Temple-Wong M, Lafage R, Bess S, Ames CP. Analysis of Personalized Interbody Implants in the Surgical Treatment of Adult Spinal Deformity. Global Spine J 2023:21925682231216926. [PMID: 38124314 DOI: 10.1177/21925682231216926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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: 12/23/2023] Open
Abstract
STUDY DESIGN Multicenter cohort. OBJECTIVES A report from the International Spine Study Group (ISSG) noted that surgeons failed to achieve alignment goals in nearly two-thirds of 266 complex adult deformity surgery (CADS) cases. We assess whether personalized interbody spacers are associated with improved rates of achieving goal alignment following adult spinal deformity (ASD) surgery. METHODS ASD patients were included if their surgery utilized 3D-printed personalized interbody spacer(s) and they met ISSG CADS inclusion criteria. Planned alignment was personalized by the surgeon during interbody planning. Planned vs achieved alignment was assessed and compared with the ISSG CADS series that used stock interbodies. RESULTS For 65 patients with personalized interbodies, 62% were women, mean age was 70.3 years (SD = 8.3), mean instrumented levels was 9.9 (SD = 4.1), and the mean number of personalized interbodies per patient was 2.2 (SD = .8). Segmental alignment was achieved close to plan for levels with personalized interbodies, with mean difference between goal and achieved as follows: intervertebral lordosis = .9° (SD = 5.2°), intervertebral coronal angle = .1° (SD = 4.7°), and posterior disc height = -0.1 mm (SD = 2.3 mm). Achieved pelvic incidence-to-lumbar lordosis mismatch (PI-LL) correlated significantly with goal PI-LL (r = .668, P < .001). Compared with the ISSG CADS cohort, utilization of personalized interbodies resulted in significant improvement in achieving PI-LL <5° of plan (P = .046) and showed a significant reduction in cases with PI-LL >15° of plan (P = .012). CONCLUSIONS This study supports use of personalized interbodies as a means of better achieving goal segmental sagittal and coronal alignment and significantly improving achievement of goal PI-LL compared with stock devices.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Gregory M Mundis
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | - Joseph A Osorio
- Department of Neurological Surgery, University of California, San Diego, San Diego, CA, USA
| | | | | | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Shay Bess
- Presbyterian St Lukes Medical Center, Denver, CO, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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15
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Passias PG, Pierce KE, Dave P, Lafage R, Lafage V, Schoenfeld AJ, Line B, Uribe J, Hostin R, Daniels A, Hart R, Burton D, Kim HJ, Mundis GM, Eastlack R, Diebo BG, Gum JL, Shaffrey C, Schwab F, Ames CP, Smith JS, Bess S, Klineberg E, Gupta MC, Hamilton DK. When not to Operate in Spinal Deformity: Identifying Subsets of Patients With Simultaneous Clinical Deterioration, Major Complications, and Reoperation. Spine (Phila Pa 1976) 2023; 48:1481-1485. [PMID: 37470375 DOI: 10.1097/brs.0000000000004778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively enrolled adult spinal deformity (ASD) database. OBJECTIVE To investigate what patient factors elevate the risk of sub-optimal outcomes after deformity correction. BACKGROUND Currently, it is unknown what factors predict a poor outcome after adult spinal deformity surgery, which may require increased preoperative consideration and counseling. MATERIALS AND METHODS Patients >18 yrs undergoing surgery for ASD(scoliosis≥20°, SVA≥5 cm, PT≥25°, or TK≥60°). An unsatisfactory outcome was defined by the following categories met at two years: (1) clinical: deteriorating in ODI at two years follow-up (2) complications/reoperation: having a reoperation and major complication were deemed high risk for poor outcomes postoperatively (HR). Multivariate analyses assessed predictive factors of HR patients in adult spinal deformity patients. RESULTS In all, 633 adult spinal deformity (59.9 yrs, 79% F, 27.7 kg/m 2, CCI: 1.74) were included. Baseline severe Schwab modifier incidence (++): 39.2% pelvic incidence and lumbar lordosis, 28.8% sagittal vertical axis, 28.9% PT. Overall, 15.5% of patients deteriorated in ODI by two years, while 7.6% underwent reoperation and had a major complication. This categorized 11 (1.7%) as HR. HR were more comorbid in terms of arthritis (73%), heart disease (36%), and kidney disease (18%), P <0.001. Surgically, HR had greater EBL (4431ccs) and underwent more osteotomies (91%), specifically Ponte(36%) and Three Column Osteotomies(55%), which occurred more at L2(91%). HR underwent more PLIFs (45%) and had more blood transfusion units (2641ccs), all P <0.050. The multivariate regression determined a combination of a baseline Distress and Risk Assessment Method score in the 75th percentile, having arthritis and kidney disease, a baseline right lower extremity motor score ≤3, cSVA >65 mm, C2 slope >30.2°, CTPA >5.5° for an R2 value of 0.535 ( P <0.001). CONCLUSIONS When addressing adult spine deformities, poor outcomes tend to occur in severely comorbid patients with major baseline psychological distress scores, poor neurologic function, and concomitant cervical malalignment.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Pooja Dave
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Juan Uribe
- Department of Neurosurgery, University of South Florida, Tampa, FL
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY
| | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University of St Louis, St. Louis, MO
| | - D Kojo Hamilton
- Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Hosseini P, Akbarnia BA, Pawelek JB, Tran S, Zhang J, Johnston CE, Shah SA, Emans JB, Mundis GM, Yaszay B, Samdani AF, Sponseller PD, Sturm PF. Is spinal height gain associated with rod orientation and the use of cross-links in magnetically controlled growing rods in early-onset scoliosis? J Pediatr Orthop B 2023; 32:531-536. [PMID: 37278283 DOI: 10.1097/bpb.0000000000001103] [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: 06/07/2023]
Abstract
Optimal orientation for magnetically controlled growing rods (MCGRs) is unclear. The objective of this study was to investigate associations of rod orientation with implant-related complications (IRCs) and spinal height gains. Using an international early-onset scoliosis (EOS) database, we retrospectively reviewed 57 patients treated with dual MCGRs from May 2013 to July 2015 with minimum 2-year follow-up. Outcomes of interest were IRCs and left/right rod length gains and thoracic (T1-T12) and spinal (T1-S1) heights. We compared patients with two rods lengthened in the cephalad ( standard; n = 18) versus opposite ( offset; n = 39) directions. Groups did not differ in age, sex, BMI, duration of follow-up, EOS cause, ambulatory status, primary curve magnitude, baseline thoracic height, or number of distractions/year. We compared patients whose constructs used ≥1 cross-link (CL group; n = 22) versus no CLs (NCL group; n = 35), analyzing thoracic height gains per distraction ( α = 0.05). Offset and standard groups did not differ in left or right rod length gains overall or per year or in thoracic or spinal height gain. Per distraction, the CL and NCL groups did not differ significantly in left or right rod length or thoracic or spinal height gain. Complications did not differ significantly between rod orientation groups or between CL groups. MCGR orientation and presence of cross-links were not associated with differences in rod length gain, thoracic height, spinal height, or IRCs at 2-year follow-up. Surgeons should feel comfortable using either MCGR orientation. Level of evidence: 3, retrospective.
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Affiliation(s)
| | - Behrooz A Akbarnia
- San Diego Spine Foundation, San Diego, California
- Department of Orthopaedic Surgery, University of California, San Diego School of Medicine, La Jolla, California
| | | | - Stacie Tran
- San Diego Spine Foundation, San Diego, California
| | - Justin Zhang
- San Diego Spine Foundation, San Diego, California
| | - Charles E Johnston
- Department of Orthopedics, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Suken A Shah
- Spine & Scoliosis Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - John B Emans
- Division of Spine Surgery, Department of Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Gregory M Mundis
- San Diego Spine Foundation, San Diego, California
- Division of Spine Surgery, Department of Orthopedics, Scripps Clinic, La Jolla, California
| | - Burt Yaszay
- Department of Orthopedics, Rady Children's Hospital, San Diego, California
| | - Amer F Samdani
- Department of Orthopedics, Shriners Hospitals for Children, Philadelphia, Pennsylvania
| | - Paul D Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter F Sturm
- Department of Orthopaedics, Crawford Spine Center, Cincinnati Children's Hospital Medical Center, Crawford Spine Center, Cincinnati, Ohio, USA
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17
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Passias PG, Tretiakov PS, Smith JS, Lafage R, Diebo B, Scheer JK, Eastlack RK, Daniels AH, Klineberg EO, Khabeish KM, Mundis GM, Turner JD, Gupta MC, Kim HJ, Schwab F, Bess S, Lafage V, Ames CP, Shaffrey CI. Are we improving in the optimization of surgery for high-risk adult cervical spine deformity patients over time? J Neurosurg Spine 2023; 39:628-635. [PMID: 37548546 DOI: 10.3171/2023.5.spine23457] [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: 04/30/2023] [Accepted: 05/24/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE The aim of this study was to investigate whether surgery for high-risk patients is being optimized over time and if poor outcomes are being minimized. METHODS Patients who underwent surgery for cervical deformity (CD) and were ≥ 18 years with baseline and 2-year data were stratified by year of surgery from 2013 to 2018. The cohort was divided into two groups based on when the surgery was performed. Patients in the early cohort underwent surgery between 2013 and 2015 and those in the recent cohort underwent surgery between 2016 and 2018. High-risk patients met at least 2 of the following criteria: 1) baseline C2-7 Cobb angle > 15°, mismatch between T1 slope and cervical lordosis ≥ 35°, C2-7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°; 2) age ≥ 70 years; 3) severe baseline frailty (Miller index); 4) Charlson Comorbidity Index (CCI) ≥ 1 SD above the mean; 5) three-column osteotomy as treatment; and 6) fusion > 10 levels or > 7 levels for elderly patients. The mean comparison analysis assessed differences between groups. Stepwise multivariable linear regression described associations between increasing year of surgery and complications. RESULTS Eighty-two CD patients met high-risk criteria (mean age 62.11 ± 10.87 years, 63.7% female, mean BMI 29.70 ± 8.16 kg/m2, and mean CCI 1.07 ± 1.45). The proportion of high-risk patients increased with time, with 41.8% of patients in the early cohort classified as high risk compared with 47.6% of patients in the recent cohort (p > 0.05). Recent high-risk patients were more likely to be female (p = 0.008), have a lower BMI (p = 0.038), and have a higher baseline CCI (p = 0.013). Surgically, high-risk patients in the recent cohort were more likely to undergo low-grade osteotomy (p = 0.003). By postoperative complications, recent high-risk patients were less likely to experience any postoperative adverse events overall (p = 0.020) or complications such as dysphagia (p = 0.045) at 2 years. Regression analysis revealed increasing year of surgery to be correlated with decreasing minor complication rates (p = 0.030), as well as lowered rates of distal junctional kyphosis by 2 years (p = 0.048). CONCLUSIONS Over time, high-risk CD patients have an increase in frequency and comorbidity rates but have demonstrated improved postoperative outcomes. These findings suggest that spine surgeons have improved over time in optimizing selection and reducing potential adverse events in high-risk patients.
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Affiliation(s)
- Peter G Passias
- 1Departments of Orthopedic and Neurological Surgery, Division of Spine Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Peter S Tretiakov
- 1Departments of Orthopedic and Neurological Surgery, Division of Spine Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Renaud Lafage
- 4Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Bassel Diebo
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Justin K Scheer
- 6Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert K Eastlack
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Alan H Daniels
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Eric O Klineberg
- 8Department of Orthopaedic Surgery, University of California, Davis, California
| | - Khaled M Khabeish
- 9Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Gregory M Mundis
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Jay D Turner
- 10Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Munish C Gupta
- 11Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri
| | - Han Jo Kim
- 12Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Frank Schwab
- 4Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Shay Bess
- 13Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado; and
| | - Virginie Lafage
- 4Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Christopher P Ames
- 6Department of Neurological Surgery, University of California, San Francisco, California
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18
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Mundis GM, Eastlack RK, LaMae Price A. Anterior Column Realignment: Adult Sagittal Deformity Treatment Through Minimally Invasive Surgery. Neurosurg Clin N Am 2023; 34:633-642. [PMID: 37718109 DOI: 10.1016/j.nec.2023.06.010] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
This article focuses on the treatment of sagittal spinal deformity using a minimally invasive technique, anterior column realignment. Traditional methods to address sagittal spine deformity have been associated with high morbidity, long operative times, and excessive blood loss. This technique uses a minimally invasive lateral retroperitoneal approach to release the anterior longitudinal ligament and apply a hyperlordotic implant for interbody fusion to restore lumbar lordosis and sagittal alignment.
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Affiliation(s)
- Gregory M Mundis
- Scripps Clinic, Department of Spine Surgery, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA; San Diego Spine Foundation, Suite 212, 6190 Cornerstone Ct. East, San Diego, CA 92121, USA
| | - Robert Kenneth Eastlack
- Scripps Clinic, Department of Spine Surgery, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA; San Diego Spine Foundation, Suite 212, 6190 Cornerstone Ct. East, San Diego, CA 92121, USA
| | - Amber LaMae Price
- Scripps Clinic, Department of Spine Surgery, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA; San Diego Spine Foundation, Suite 212, 6190 Cornerstone Ct. East, San Diego, CA 92121, USA.
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19
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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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Blais M, Shahidi B, Anderson B, O'Brien E, Moltzen C, Iannacone T, Eastlack RK, Mundis GM. The influence of ligament biomechanics on proximal junctional kyphosis and failure in patients with adult spinal deformity. JOR Spine 2023; 6:e1277. [PMID: 37780835 PMCID: PMC10540824 DOI: 10.1002/jsp2.1277] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/04/2023] [Accepted: 08/03/2023] [Indexed: 10/03/2023] Open
Abstract
Purpose It is unknown whether the biomechanics of the posterior ligamentous complex (PLC) are impaired in individuals undergoing surgery for adult spinal deformity (ASD). Characterizing these properties may improve our understanding of proximal junctional kyphosis (PJK; defined as proximal junctional angle [PJA] of >10 deg from UIV-1 to UIV + 2), as well as proximal junctional failure (PJF; symptomatic PJK requiring revision). The purpose of this prospective observational study is to compare biomechanical properties of the PLC in individuals with ASD who do, and do not develop PJK or PJF within 1 year of spinal fusion surgery. Methods Intraoperative biopsies of PLC were obtained from 32 consecutive patients undergoing spinal fusions for ASD (>4 levels). Ligament peak force, tensile stress, tensile strain, and elastic modulus (EM) were measured with a materials testing system. Biomechanical properties and tissue dimensions were correlated with age, gender, BMI, vitamin D level, osteoporosis, sagittal alignment, PJA and change in PJA preoperatively, within 3 months, and at 1 year postoperatively. Results Longer ligaments were associated with greater PJA change at 3 months (p = 0.04), and thinner ligaments were associated with greater PJA change at 1 year (r = 0.57, p = 0.01). Greater EM was associated with greater PJA at both 3 months and 1 year (p = 0.03). Five participants had a change in PJA of >10 1 year postoperatively, and three participants demonstrated PJF. EM was significantly higher in individuals who required revision surgery (p = 0.003), and ligament length was greater (p = 0.03). Preoperative sagittal alignment was not related to incidence of revision surgery (p > 0.10). Conclusions The biomechanical properties of the PLC may be associated with higher risk for proximal failure. Ligaments that are longer, thinner, and less elastic are associated with higher postoperative PJA. Furthermore stiffer EM of the ligament is associated with the need for revision surgery.
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Affiliation(s)
- Micah Blais
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Bahar Shahidi
- Department of Orthopaedic SurgeryUC San DiegoLa JollaCaliforniaUSA
| | - Brad Anderson
- Department of Orthopaedic SurgeryUC San DiegoLa JollaCaliforniaUSA
| | - Eli O'Brien
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Courtney Moltzen
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Tina Iannacone
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Robert K. Eastlack
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
| | - Gregory M. Mundis
- Department of Orthopaedic SurgeryScripps Clinic Medical GroupSan DiegoCaliforniaUSA
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21
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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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22
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Ye J, Rider SM, Lafage R, Gupta S, Farooqi AS, Protopsaltis TS, Passias PG, Smith JS, Lafage V, Kim HJ, Klineberg EO, Kebaish KM, Scheer JK, Mundis GM, Soroceanu A, Bess S, Ames CP, Shaffrey CI, Gupta MC. Spinopelvic sagittal compensation in adult cervical deformity. J Neurosurg Spine 2023; 39:1-10. [PMID: 36964727 DOI: 10.3171/2023.2.spine221295] [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: 11/25/2022] [Accepted: 02/14/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate spinopelvic sagittal alignment and spinal compensatory changes in adult cervical kyphotic deformity. METHODS A database composed of 13 US spine centers was retrospectively reviewed for adult patients who underwent cervical reconstruction with radiographic evidence of cervical kyphotic deformity: C2-7 sagittal vertical axis > 4 cm, chin-brow vertical angle > 25°, or cervical kyphosis (T1 slope [T1S] cervical lordosis [CL] > 15°) (n = 129). Sagittal parameters were evaluated preoperatively and in the early postoperative window (6 weeks to 6 months postoperatively) and compared with asymptomatic control patients. Adult cervical deformity patients were further stratified by degree of cervical kyphosis (severe kyphosis, C2-T3 Cobb angle ≤ -30°; moderate kyphosis, ≤ 0°; and minimal kyphosis, > 0°) and severity of sagittal malalignment (severe malalignment, sagittal vertical axis T3-S1 ≤ -60 mm; moderate malalignment, ≤ 20 mm; and minimal malalignment > 20 mm). RESULTS Compared with asymptomatic control patients, cervical deformity was associated with increased C0-2 lordosis (32.9° vs 23.6°), T1S (33.5° vs 28.0°), thoracolumbar junction kyphosis (T10-L2 Cobb angle -7.0° vs -1.7°), and pelvic tilt (PT) (19.7° vs 15.9°) (p < 0.01). Cervicothoracic kyphosis was correlated with C0-2 lordosis (R = -0.57, p < 0.01) and lumbar lordosis (LL) (R = -0.20, p = 0.03). Cervical reconstruction resulted in decreased C0-2 lordosis, increased T1S, and increased thoracic and thoracolumbar junction kyphosis (p < 0.01). Patients with severe cervical kyphosis (n = 34) had greater C0-2 lordosis (p < 0.01) and postoperative reduction of C0-2 lordosis (p = 0.02) but no difference in PT. Severe cervical kyphosis was also associated with a greater increase in thoracic and thoracolumbar junction kyphosis postoperatively (p = 0.01). Patients with severe sagittal malalignment (n = 52) had decreased PT (p = 0.01) and increased LL (p < 0.01), as well as a greater postoperative reduction in LL (p < 0.01). CONCLUSIONS Adult cervical deformity is associated with upper cervical hyperlordotic compensation and thoracic hypokyphosis. In the setting of increased kyphotic deformity and sagittal malalignment, thoracolumbar junction kyphosis and lumbar hyperlordosis develop to restore normal center of gravity. There was no consistent compensatory pelvic retroversion or anteversion among the adult cervical deformity patients in this cohort.
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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
| | - Sean M Rider
- 13Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri; and
| | - Renaud Lafage
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Sachin Gupta
- 14Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali S Farooqi
- 14Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Peter G Passias
- 3Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Justin S Smith
- 4Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Virginie Lafage
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Han-Jo Kim
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric O Klineberg
- 5Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Khaled M Kebaish
- 6Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Justin K Scheer
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Gregory M Mundis
- 8Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, California
| | - Alex Soroceanu
- 9University of Calgary Spine Program, University of Calgary, Alberta, Canada
| | - Shay Bess
- 10Rocky Mountain Hospital for Children, Presbyterian/St. Luke's Medical Center, Denver, Colorado
| | - Christopher P Ames
- 7Department of Neurological Surgery, University of California, San Francisco, California
| | - Christopher I Shaffrey
- Departments of11Neurological Surgery and
- 12Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Munish C Gupta
- 13Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri; and
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23
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Mundis GM, Ito K, Lakomkin N, Shahidi B, Malone H, Iannacone T, Akbarnia B, Uribe J, Eastlack R. Establishing a Standardized Clinical Consensus for Reporting Complications Following Lateral Lumbar Interbody Fusion. Medicina (Kaunas) 2023; 59:1149. [PMID: 37374353 DOI: 10.3390/medicina59061149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/06/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Mitigating post-operative complications is a key metric of success following interbody fusion. LLIF is associated with a unique complication profile when compared to other approaches, and while numerous studies have attempted to report the incidence of post-operative complications, there is currently no consensus regarding their definitions or reporting structure. The aim of this study was to standardize the classification of complications specific to lateral lumbar interbody fusion (LLIF). Materials and Methods: A search algorithm was employed to identify all the articles that described complications following LLIF. A modified Delphi technique was then used to perform three rounds of consensus among twenty-six anonymized experts across seven countries. Published complications were classified as major, minor, or non-complications using a 60% agreement threshold for consensus. Results: A total of 23 articles were extracted, describing 52 individual complications associated with LLIF. In Round 1, forty-one of the fifty-two events were identified as a complication, while seven were considered to be approach-related occurrences. In Round 2, 36 of the 41 events with complication consensus were classified as major or minor. In Round 3, forty-nine of the fifty-two events were ultimately classified into major or minor complications with consensus, while three events remained without agreement. Vascular injuries, long-term neurologic deficits, and return to the operating room for various etiologies were identified as important consensus complications following LLIF. Non-union did not reach significance and was not classified as a complication. Conclusions: These data provide the first, systematic classification scheme of complications following LLIF. These findings may improve the consistency in the future reporting and analysis of surgical outcomes following LLIF.
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Affiliation(s)
| | - Kenyu Ito
- Aichi Spine Hospital, Aichi, Inuyama 484-0066, Japan
| | - Nikita Lakomkin
- Mayo Clinic College of Medicine and Science, Rochester, NY 55905, USA
| | - Bahar Shahidi
- San Diego Department of Orthopaedic Surgery, University of California, La Jolla, CA 92093, USA
| | - Hani Malone
- Scripps Clinic Medical Group, San Diego, CA 92037, USA
| | | | - Behrooz Akbarnia
- San Diego Department of Orthopaedic Surgery, University of California, La Jolla, CA 92093, USA
- San Diego Spine Foundation, San Diego, CA 92121, USA
| | - Juan Uribe
- Barrow Neurological Institute, Phoenix, AZ 85013, USA
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Ye J, Rider SM, Lafage R, Gupta S, Farooqi AS, Protopsaltis TS, Passias PG, Smith JS, Lafage V, Kim HJ, Klineberg EO, Kebaish KM, Scheer JK, Mundis GM, Soroceanu A, Bess S, Ames CP, Shaffrey CI, Gupta MC. Distal junctional kyphosis in adult cervical deformity patients: where does it occur? Eur Spine J 2023; 32:1598-1606. [PMID: 36928488 DOI: 10.1007/s00586-023-07631-6] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 01/19/2023] [Accepted: 02/28/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To evaluate the impact of the lowest instrumented vertebra (LIV) on Distal Junctional kyphosis (DJK) incidence in adult cervical deformity (ACD) surgery. METHODS Prospectively collected data from ACD patients undergoing posterior or anterior-posterior reconstruction at 13 US sites was reviewed up to 2-years postoperatively (n = 140). Data was stratified into five groups by level of LIV: C6-C7, T1-T2, T3-Apex, Apex-T10, and T11-L2. DJK was defined as a kyphotic increase > 10° in Cobb angle from LIV to LIV-1. Analysis included DJK-free survival, covariate-controlled cox regression, and DJK incidence at 1-year follow-up. RESULTS 25/27 cases of DJK developed within 1-year post-op. In patients with a minimum follow-up of 1-year (n = 102), the incidence of DJK by level of LIV was: C6-7 (3/12, 25.00%), T1-T2 (3/29, 10.34%), T3-Apex (7/41, 17.07%), Apex-T10 (8/11, 72.73%), and T11-L2 (4/8, 50.00%) (p < 0.001). DJK incidence was significantly lower in the T1-T2 LIV group (adjusted residual = -2.13), and significantly higher in the Apex-T10 LIV group (adjusted residual = 3.91). In covariate-controlled regression using the T11-L2 LIV group as reference, LIV selected at the T1-T2 level (HR = 0.054, p = 0.008) or T3-Apex level (HR = 0.081, p = 0.010) was associated with significantly lower risk of DJK. However, there was no difference in DJK risk when LIV was selected at the C6-C7 level (HR = 0.239, p = 0.214). CONCLUSION DJK risk is lower when the LIV is at the upper thoracic segment than the lower cervical segment. DJK incidence is highest with LIV level in the lower thoracic or thoracolumbar junction.
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Affiliation(s)
- Jichao Ye
- Department of Orthopaedic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Sean M Rider
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, St. Louis, MO, 63110, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sachin Gupta
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ali S Farooqi
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Han-Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Gregory M Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA, USA
| | - Alex Soroceanu
- University of Calgary Spine Program, University of Calgary, Alberta, Canada
| | - Shay Bess
- Rocky Mountain Hospital for Children, Presbyterian/St Luke's Medical Center, Denver, CO, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Christopher I Shaffrey
- Departments of Neurological Surgery and Orthopedic Surgery, Duke University, Durham, NC, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S. Euclid, Campus, Box 8233, St. Louis, MO, 63110, USA.
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Passias PG, Tretiakov PS, Nunley PD, Wang MY, Park P, Kanter AS, Okonkwo DO, Eastlack RK, Mundis GM, Chou D, Agarwal N, Fessler RG, Uribe JS, Anand N, Than KD, Brusko G, Fu KM, Turner JD, Le VP, Line BG, Ames CP, Smith JS, Shaffrey CI, Hart RA, Burton D, Lafage R, Lafage V, Schwab F, Bess S, Mummaneni PV. Incremental benefits of circumferential minimally invasive surgery for increasingly frail patients with adult spinal deformity. J Neurosurg Spine 2023:1-7. [PMID: 37086158 DOI: 10.3171/2023.2.spine221278] [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: 11/22/2022] [Accepted: 02/28/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE Circumferential minimally invasive surgery (cMIS) may provide incremental benefits compared with open surgery for patients with increasing frailty status by decreasing peri- and postoperative complications. METHODS Operative patients with adult spinal deformity (ASD) ≥ 18 years old with baseline and 2-year postoperative data were assessed. With propensity score matching, patients who underwent cMIS (cMIS group) were matched with similar patients who underwent open surgery (open group) based on baseline BMI, C7-S1 sagittal vertical axis, pelvic incidence to lumbar lordosis mismatch, and S1 pelvic tilt. The Passias modified ASD frailty index (mASD-FI) was used to determine patient frailty stratification as not frail, frail, or severely frail. Baseline and postoperative factors were assessed using two-way analysis of covariance (ANCOVA) and multivariate ANCOVA while controlling for baseline age, Charlson Comorbidity Index (CCI) score, and number of levels fused. RESULTS After propensity score matching, 170 ASD patients (mean age 62.71 ± 13.64 years, 75.0% female, mean BMI 29.25 ± 6.60 kg/m2) were included, split evenly between the cMIS and open groups. Surgically, patients in the open group had higher numbers of posterior levels fused (p = 0.021) and were more likely to undergo three-column osteotomies (p > 0.05). Perioperatively, cMIS patients had lower intraoperative blood loss and decreased use of cell saver across frailty groups (with adjustment for baseline age, CCI score, and levels fused), as well as fewer perioperative complications (p < 0.001). Adjusted analysis also revealed that compared to open patients, increasingly frail patients in the cMIS group were also more likely to demonstrate greater improvement in 1- and 2-year postoperative scores for the Oswestry Disability Index, SRS-36 (total), EQ-5D and SF-36 (all p < 0.05). With regard to postoperative complications, increasingly frail patients in the cMIS group were also noted to experience significantly fewer complications overall (p = 0.036) and fewer major intraoperative complications (p = 0.039). The cMIS patients were also less likely to need a reoperation than their open group counterparts (p = 0.043). CONCLUSIONS Surgery performed with a cMIS technique may offer acceptable outcomes, with diminishment of perioperative complications and mitigation of catastrophic outcomes, in increasingly frail patients who may not be candidates for surgery using traditional open techniques. However, further studies should be performed to investigate the long-term impact of less optimal alignment in this population.
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Affiliation(s)
- Peter G Passias
- 1Departments of Orthopedic and Neurological Surgery, Division of Spine Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York
| | - Peter S Tretiakov
- 1Departments of Orthopedic and Neurological Surgery, Division of Spine Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York
| | - Pierce D Nunley
- 2Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Michael Y Wang
- 3Department of Neurological Surgery, University of Miami, Florida
| | - Paul Park
- 4Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Adam S Kanter
- 5Department of Neurosurgery, Hoag Pickup Family Neurosciences Institute, Newport Beach, California
| | - David O Okonkwo
- 6Department of Neurological Surgery, Division of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert K Eastlack
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Gregory M Mundis
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Dean Chou
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Nitin Agarwal
- 6Department of Neurological Surgery, Division of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Richard G Fessler
- 9Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Juan S Uribe
- 10Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Neel Anand
- 11Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, California
| | - Khoi D Than
- 12Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Gregory Brusko
- 3Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 13Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Jay D Turner
- 10Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Vivian P Le
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Breton G Line
- 14Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Christopher P Ames
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Justin S Smith
- 15Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | | | - Robert A Hart
- 16Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Douglas Burton
- 17Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas; and
| | - Renaud Lafage
- 18Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Virginie Lafage
- 18Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Frank Schwab
- 18Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Shay Bess
- 14Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Praveen V Mummaneni
- 8Department of Neurological Surgery, University of California, San Francisco, California
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Lombardo JA, Russell N, He J, Larson MJ, Walsh WR, Mundis GM, Vizesi F. Autograft: Cellular Contribution to Spinal Fusion and Effects of Intraoperative Storage Conditions. Spine (Phila Pa 1976) 2023:00007632-990000000-00325. [PMID: 37078877 PMCID: PMC10368216 DOI: 10.1097/brs.0000000000004688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/07/2023] [Indexed: 04/21/2023]
Abstract
STUDY DESIGN Controlled animal study. OBJECTIVE To assess the cellular contribution of autograft to spinal fusion and determine the effects of intraoperative storage conditions on fusion. SUMMARY OF BACKGROUND DATA Autograft is considered the gold standard graft material in spinal fusion, purportedly due to its osteogenic properties. Autograft consists of adherent and non-adherent cellular components within a cancellous bone scaffold. However, the contribution of each component to bone healing is not well understood, nor are the effects of intraoperative storage of autograft. METHODS Posterolateral spinal fusion was performed in 48 rabbits. Autograft groups evaluated included: (i) viable, (ii) partially devitalized, (iii) devitalized, (iv) dried, and (v) hydrated iliac crest. Partially devitalized and devitalized grafts were rinsed with saline, removing non-adherent cells. Devitalized graft was additionally freeze/thawed, lysing adherent cells. For 90 minutes prior to implantation, air dried iliac crest was left on the back table while hydrated iliac crest was immersed in saline. At 8 weeks, fusion was assessed via manual palpation (MP), radiography, and μCT. Additionally, cellular viability of cancellous bone was assayed over 4 hours. RESULTS Spinal fusion rates by MP were not statistically different between viable (58%) and partially devitalized (86%) autograft (P=0.19). Both rates were significantly higher than devitalized and dried autograft (both 0%, P<0.001). In vitro bone cell viability reduced by 37% after 1 hour and by 63% after 4 hours when bone was left dry (P<0.001). Bone cell viability and fusion performance (88%, P<0.001 vs. dried autograft) was maintained when graft was stored in saline. CONCLUSION The cellular component of autograft is important for spinal fusion. Adherent graft cells appear to be the more important cellular component in the rabbit model. Autograft left dry on the back table showed rapid decline in cell viability and fusion but was maintained with storage in saline.
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Affiliation(s)
| | | | - Jiawei He
- SeaSpine Inc., Carlsbad, CA, United States
| | | | - William R Walsh
- Surgical and Orthopaedic Research Laboratories, Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Gregory M Mundis
- Scripps, La Jolla, CA, United States
- San Diego Spine Foundation, San Diego, CA, United States
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Anand N, Mummaneni PV, Uribe JS, Turner J, Than KD, Chou D, Nunley PD, Wang MY, Fessler RG, Le V, Robinson J, Walker C, Kahwaty S, Khanderhoo B, Eastlack RK, Okonkwo DO, Kanter AS, Fu KMG, Mundis GM, Passias P, Park P. Spinal Deformity Complexity Checklist for Minimally Invasive Surgery: Expert Consensus from the Minimally Invasive International Spine Study Group. World Neurosurg 2023; 173:e472-e477. [PMID: 36841536 DOI: 10.1016/j.wneu.2023.02.082] [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: 01/06/2023] [Revised: 02/17/2023] [Accepted: 02/18/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND We developed a spinal deformity complexity checklist (SDCC) to assess the difficulty in performing a circumferential minimally invasive surgery (MIS) for adult spinal deformity. METHODS A modified Delphi method of panel experts was used to construct an SDCC checklist of radiographic and patient-related characteristics that could affect the complexity of surgery via MIS approaches. Ten surgeons with expertise in MIS deformity surgery were queried to develop and refine the SDCC with 3 radiographic categories (x-ray, magnetic resonance imaging, computed tomography) and 1 patient-related category. Within each category, characteristics affecting MIS complexity were identified by initial roundtable discussion. Second-round discussion determined which characteristics substantially impacted complexity the most. RESULTS Thirteen characteristics within the x-ray category were determined. Spinopelvic characteristics, endpoints of instrumentation, and prior hardware/fusion were associated with increased complexity. Vertebral body rotation-as reflected by the Nash-Moe grade-added significant complexity. Psoas anatomy and spinal stenosis added the most complexity for the 5 magnetic resonance imaging characteristics. There were 3 characteristics in the CT category with pre-exisiting fusion, being the variable most highly selected. Of the 5 patient-related characteristics, osteoporosis and BMI were found to most affect complexity. CONCLUSIONS The SDCC is a comprehensive list of pertinent radiographic and patient-related characteristics affecting complexity level for MIS deformity surgery. The value of the SDCC is that it allows rapid assessment of key factors when determining whether MIS surgery can be performed effectively and safely. Patients with scores of 4 in any characteristic should be considered challenging to treat with MIS; open surgery may be a better alternative.
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Affiliation(s)
- Neel Anand
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California-San Francisco, San Francisco, California, USA
| | - Juan S Uribe
- Barrow Neurologic Institute, Phoenix, Arizona, USA
| | - Jay Turner
- Barrow Neurologic Institute, Phoenix, Arizona, USA
| | - Khoi D Than
- Departments of Orthopaedic Surgery and Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Dean Chou
- Department of Neurosurgery, University of California-San Francisco, San Francisco, California, USA
| | | | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami, Florida, USA
| | - Richard G Fessler
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Vivian Le
- Department of Neurosurgery, University of California-San Francisco, San Francisco, California, USA
| | - Jerry Robinson
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Corey Walker
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sheila Kahwaty
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Babak Khanderhoo
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kai-Ming G Fu
- Department of Neurosurgery, Cornell Medical Center, New York, New York, USA
| | - Gregory M Mundis
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Peter Passias
- Division of Spinal Surgery, Department of Orthopaedic and Neurological Surgery, NYU School of Medicine, New York Spine Institute, New York, New York, USA
| | - Paul Park
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA; Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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Mundis GM, Olsson EC, Hart RA, Williams SK, Martyn R, Orndorff DG, Berg AL, Russell NA, Vizesi F. Preliminary experience with a novel facet-based lateral mass drill guide for the placement of lateral mass screws compared to freehand technique: a cadaveric study. Spine J 2023; 23:912-920. [PMID: 36736741 DOI: 10.1016/j.spinee.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/28/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND CONTEXT Lateral mass screw fixation is the standard for posterior subaxial cervical fixation. Several freehand surgical techniques for placing lateral mass screws have been described which rely on anatomical landmarks and surgeon mastery of the technique to safely place screws. The accuracy of these freehand techniques is inherently variable and can be influenced by a surgeon's level of clinical experience. A novel technique was developed that utilizes the plane of the facet joint to create lateral mass screw pilot holes parallel with the joint line to improve the safety and accuracy of lateral mass screw placement regardless of experience. PURPOSE To assess the safety and accuracy of lateral mass screw placement using a novel lateral mass drill guide instrument (LM Guide), compared to standard freehand technique. STUDY DESIGN Randomized cadaveric study utilizing multiple surgeon evaluators to compare the safety and accuracy of guided cervical lateral mass placement compared to traditional freehand techniques. MATERIALS AND METHODS Lateral mass screws were placed from C3 to C7 in 20 cadaver specimens by 8 spine surgeons of varying levels of clinical experience (4 attendings, 4 fellows). Screws were placed bilaterally using standard anatomic landmarks ("freehand") randomly allocated on one side and using the LM Guide on the other. Cadaveric specimens were imaged with high-resolution CT to assess screw placement. Zone grading for safety was conducted based on screw tip position and clinical severity of screw breach was based on proximity to surrounding neurovascular anatomy. Screws were graded as safe, at-risk, or critical, with at-risk and critical screws considered malpositioned. To assess the accuracy of screw trajectory placed using the LM Guide compared to freehand, sagittal screw angle was measured and compared to an "ideal" screw path parallel to the facet joint line. Freehand and LM Guide groups were compared using Pearson's chi-square correlation. RESULTS Screw placement using the LM guide yielded a significantly lower rate of screw malpositioning, with 7 of 91 (7.7%) compared with 18 of 99 (18.2%) screws placed in the At-Risk or Critical Zones, p<.05. Of the 91 screws inserted using the LM Guide, 84 (92.3%) were in the Safe Zone, 7 (7.7%) were At-Risk, and 0 were in Critical zones. There was no incidence of neural or transverse foramen breaches with the LM Guide. In comparison, for the 99 screws inserted freehand, 81 (81.8%) were Safe, 14 (14.1%) were At-Risk, and 4 (4.1%) were in Critical zones. The 4 Critical zone freehand screw breaches included 1 neural foramen breach, 2 transverse foramen breaches, and 1 facet breach. The LM Guide also resulted in higher accuracy of screw trajectory, as indicated by a significant reduction in sagittal screw angle compared with freehand, p<.01. Notably, in the less-experienced surgeon cohort, the LM Guide significantly reduced the sagittal screw angle and resulted in no critical screw breaches compared to 3 critical breaches with freehand technique suggesting there might be a benefit in decreasing the learning curve associated with lateral mass screw placement. CONCLUSIONS Lateral mass screw placement with a novel LM Guide that uses the facet joint to control screw trajectory improved the accuracy and reproducibility of screw placement with a significant reduction in screw breach rate and sagittal screw angle compared to freehand techniques regardless of surgeon experience level. CLINICAL SIGNIFICANCE The inherent variability of freehand lateral mass screw placement can increase the risk of clinical complications associated with screw malpositioning. The technique presented in this cadaveric study may be a viable alternative to standard freehand technique that can improve the overall safety of lateral mass screw placement.
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Affiliation(s)
- Gregory M Mundis
- Scripps Health, 10140 Campus Point Dr. San Diego, CA 92121, USA; San Diego Spine Foundation, 6190 Cornerstone Ct E #212, San Diego, CA 92121, USA
| | - Eric C Olsson
- Margaret Pardee Memorial, 800 N Justice St, Hendersonville, NC 28791, USA
| | - Robert A Hart
- Swedish Medical Center, 1101 Madison St #700, Seattle, WA 98104, USA
| | - Seth K Williams
- University of Wisconsin-Madison School of Medicine and Public Health, 750 Highland Ave, Madison, WI 53726, USA
| | - Ryan Martyn
- Animas Surgical Hospital, 575 Rivergate Ln, Durango, CO 81301, USA
| | | | | | | | - Frank Vizesi
- SeaSpine, 5770 Armada Drive, Carlsbad, CA, 92008 USA.
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Durand WM, Daniels AH, DiSilvestro K, Lafage R, Diebo BG, Passias PG, Kim HJ, Protopsaltis T, Lafage V, Smith JS, Shaffrey CI, Gupta MC, Klineberg EO, Schwab F, Gum JL, Mundis GM, Eastlack RK, Kebaish K, Soroceanu A, Hostin RA, Burton D, Bess S, Ames CP, Hart RA, Hamilton DK. Patient satisfaction after multiple revision surgeries for adult spinal deformity. J Neurosurg Spine 2023; 38:75-83. [PMID: 36029263 DOI: 10.3171/2022.6.spine2273] [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: 01/16/2022] [Accepted: 06/17/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Revision surgery is often necessary for adult spinal deformity (ASD) patients. Satisfaction with management is an important component of health-related quality of life. The authors hypothesized that patients who underwent multiple revision surgeries following ASD correction would exhibit lower self-reported satisfaction scores. METHODS This was a retrospective cohort study of 668 patients who underwent ASD surgery and were eligible for a minimum 2-year follow-up. Visits were stratified by occurrence prior to the index surgery (period 0), after the index surgery only (period 1), after the first revision only (period 2), and after the second revision only (period 3). Patients were further stratified by prior spine surgery before their index surgery. Scoliosis Research Society-22 (SRS-22r) health-related quality-of-life satisfaction subscore and total satisfaction scores were evaluated at all periods using multiple linear regression and adjustment for age, sex, and Charlson Comorbidity Index. RESULTS In total, 46.6% of the study patients had undergone prior spine surgery before their index surgery. The overall revision rate was 21.3%. Among patients with no spine surgery prior to the index surgery, SRS-22r satisfaction scores increased from period 0 to 1 (from 2.8 to 4.3, p < 0.0001), decreased after one revision from period 1 to 2 (4.3 to 3.9, p = 0.0004), and decreased further after a second revision from period 2 to 3 (3.9 to 3.3, p = 0.0437). Among patients with spine surgery prior to the index procedure, SRS-22r satisfaction increased from period 0 to 1 (2.8 to 4.2, p < 0.0001) and decreased from period 1 to 2 (4.2 to 3.8, p = 0.0011). No differences in follow-up time from last surgery were observed (all p > 0.3). Among patients with multiple revisions, 40% experienced rod fracture, 40% proximal junctional kyphosis, and 33% pseudarthrosis. CONCLUSIONS Among patients undergoing ASD surgery, revision surgery is associated with decreased satisfaction, and multiple revisions are associated with additive detriment to satisfaction among patients initially undergoing primary surgery. These findings have direct implications for preoperative patient counseling and establishment of postoperative expectations.
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Affiliation(s)
- Wesley M Durand
- 1Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alan H Daniels
- 2Department of Orthopaedic Surgery, Brown University, Alpert Medical School, Providence, Rhode Island
| | - Kevin DiSilvestro
- 2Department of Orthopaedic Surgery, Brown University, Alpert Medical School, Providence, Rhode Island
| | - Renaud Lafage
- 3Department of Orthopaedic Surgery, Lenox Hill Hospital, New York
| | - Bassel G Diebo
- 2Department of Orthopaedic Surgery, Brown University, Alpert Medical School, Providence, Rhode Island
| | - Peter G Passias
- 4Department of Orthopaedic Surgery, New York University, Langone Medical Center, New York, New York
| | - Han Jo Kim
- 3Department of Orthopaedic Surgery, Lenox Hill Hospital, New York
| | | | - Virginie Lafage
- 3Department of Orthopaedic Surgery, Lenox Hill Hospital, New York
| | - Justin S Smith
- 5Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Munish C Gupta
- 7Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri
| | - Eric O Klineberg
- 8Department of Orthopaedic Surgery, University of California, UC Davis Medical Center, Sacramento, California
| | - Frank Schwab
- 3Department of Orthopaedic Surgery, Lenox Hill Hospital, New York
| | - Jeffrey L Gum
- 9Department of Orthopaedic Surgery, Leatherman Spine Center, Louisville, Kentucky
| | - Gregory M Mundis
- 10Department of Orthopaedic Surgery, San Diego Spine, La Jolla, California
| | - Robert K Eastlack
- 10Department of Orthopaedic Surgery, San Diego Spine, La Jolla, California
| | - Khaled Kebaish
- 1Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alex Soroceanu
- 11Department of Orthopaedic Surgery, University of Calgary, Alberta, Canada
| | - Richard A Hostin
- 12Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Plano, Texas
| | - Douglas Burton
- 13Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Shay Bess
- 14Department of Orthopaedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Christopher P Ames
- 15Department of Neurosurgery, University of California, San Francisco, California
| | - Robert A Hart
- 16Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington; and
| | - D Kojo Hamilton
- 17Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Walker CT, Agarwal N, Eastlack RK, Mundis GM, Alan N, Iannacone T, Akbarnia BA, Okonkwo DO. Surgical treatment of young adults with idiopathic scoliosis. J Neurosurg Spine 2023; 38:84-90. [PMID: 36057126 DOI: 10.3171/2022.7.spine2298] [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: 01/22/2022] [Accepted: 07/06/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE In this study, the authors report on their experience with the surgical treatment of young adults with idiopathic scoliosis (YAdISs) who did not have surgical treatment in adolescence but did require intervention after skeletal maturity. METHODS The medical records of YAdISs between 18 and 40 years of age who had been surgically treated at two institutions between 2009 and 2018 were retrospectively evaluated. Pre- and postoperative clinical and radiographic information was gathered and compared at 2 years after treatment. RESULTS Twenty-eight patients (9 male, 19 female) with a median age of 25 years (range 18-40 years) met the study inclusion criteria. Five patients (18%) had postoperative complications, including 2 deep venous thromboses, 1 ileus, and 2 reoperations, one for implant failure and the other for pseudarthrosis. The mean maximum coronal curve angle improved from 43° ± 12° to 17° ± 8° (p < 0.001), but there were no significant differences in sagittal vertical axis, lumbar lordosis, pelvic tilt, or thoracic kyphosis (p > 0.05). There was no relationship between the amount of correction obtained and patient age (p = 0.46). Significant improvements in the Oswestry Disability Index (31 vs 24, p = 0.02), visual analog scale score for both back pain (6.0 vs 4.0, p = 0.01) and leg pain (2.6 vs 1.1, p = 0.02), and self-image score (Δ1.1, p < 0.001) were seen. CONCLUSIONS YAdISs can present with pain, deformity progression, and/or appearance dissatisfaction because of their scoliosis despite successful nonoperative management during adolescence. Once the scoliosis becomes symptomatic, surgical correction can result in significant clinical and radiographic improvements at the 2-year follow-up with a relatively low complication rate compared to that for other types of adult spinal deformity.
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Affiliation(s)
- Corey T Walker
- 1Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nitin Agarwal
- 2Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | | | | | - Nima Alan
- 2Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Tina Iannacone
- 3Division of Orthopedics, Scripps Clinic, San Diego, California
| | | | - David O Okonkwo
- 2Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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Malone H, Mundis GM, Collier M, Kidwell RL, Rios F, Jelousi M, Galli S, Shahidi B, Akbarnia BA, Eastlack RK. Can a bioactive interbody device reduce the cost burden of achieving lateral lumbar fusion? J Neurosurg Spine 2022; 37:646-653. [PMID: 36303478 DOI: 10.3171/2022.4.spine211070] [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: 08/11/2021] [Accepted: 04/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intervertebral devices are increasingly utilized for fusion in the lumbar spine, along with a variety of bone graft materials. These various grafting materials often have substantial cost burdens for the surgical procedure, although they are necessary to overcome the limitations in healing capacity for many traditional interbody devices. The use of bioactive interbody fusion devices, which have demonstrable stimulatory capacity for the surrounding osteoblasts and osteoprogenitor cells and allow for osseointegration, may reduce this heavy reliance on osteobiologics for achieving interbody fusion. The objective of this study was to evaluate the rate of successful interbody fusion with a bioactive lateral lumbar interbody titanium implant with limited volume and low-cost graft material. METHODS The authors conducted a retrospective study (May 2017 to October 2018) of consecutively performed lateral lumbar interbody fusions with a bioactive 3D-printed porous titanium interbody device. Each interbody device was filled with 2-3 cm3/cage of a commercially available ceramic bone extender (β-tricalcium phosphate-hydroxyapatite) and combined with posterior pedicle screw fixation. No other biological agents or grafts were utilized. Demographic, clinical, and radiographic variables were captured. Fusion success was the primary endpoint of the study, with graft subsidence, fixation failure, and patient-reported outcomes (Oswestry Disability Index [ODI] and visual analog scale [VAS]-back and -leg pain scores) collected as secondary endpoints. The authors utilized a CT-based fusion classification system that accounted for both intervertebral through-growth (bone bridging) and ingrowth (integration of bone at the endplate-implant interface). RESULTS In total, 136 lumbar levels were treated in 90 patients. The mean age was 69 years, and 63% of the included patients were female. Half (50.0%) had undergone previous spinal surgery, and a third (33.7%) had undergone prior lumbar fusion. A third (33.7%) were treated at multiple levels (mean levels per patient 1.51). One year after surgery, the mean improvements in patient-reported outcomes (vs preoperative scores) were -17.8 for ODI (p < 0.0001), -3.1 for VAS-back pain (p < 0.0001), and -2.9 for VAS-leg pain (p < 0.0001). Bone bridging and/or appositional integrity was achieved in 99.3% of patients, including 97.8% who had complete bone bridging. No fixation loosening or implant failure was observed at any segment. Low-grade graft subsidence (Marchi grade ≤ I) occurred in 3 levels (2.2%), and intraoperative endplate violation occurred twice (1.5%). High-grade subsidence was not found. No implant failure or revision surgery for pseudarthrosis/subsidence was necessary. CONCLUSIONS The use of bioactive titanium interbody devices with a large surface footprint appears to result in a very high rate of effective fusion, despite the use of a small volume of low-cost biological material. This potential change in the osteobiologics required to achieve high fusion rates may have a substantially beneficial impact on the economic burden inherent to spinal fusion.
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Affiliation(s)
- Hani Malone
- 1Department of Neurosurgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Gregory M Mundis
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Martin Collier
- 3Department of Orthopedic Surgery, Naval Medical Center, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Reilly L Kidwell
- 1Department of Neurosurgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Fernando Rios
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Michael Jelousi
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Shae Galli
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
| | - Bahar Shahidi
- 4Department of Orthopedic Surgery, University of California, San Diego; and
- 5San Diego Spine Foundation, San Diego, California
| | | | - Robert K Eastlack
- 2Department of Orthopedic Surgery, Scripps Clinic, San Diego
- 5San Diego Spine Foundation, San Diego, California
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Lafage R, Schwab F, Elysee J, Smith JS, Alshabab BS, Passias P, Klineberg E, Kim HJ, Shaffrey C, Burton D, Gupta M, Mundis GM, Ames C, Bess S, Lafage V. Surgical Planning for Adult Spinal Deformity: Anticipated Sagittal Alignment Corrections According to the Surgical Level. Global Spine J 2022; 12:1761-1769. [PMID: 33567927 PMCID: PMC9609531 DOI: 10.1177/2192568220988504] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Establish simultaneous focal and regional corrective guidelines accounting for reciprocal global and pelvic compensation. METHODS 433 ASD patients (mean age 62.9 yrs, 81.3% F) who underwent corrective realignment (minimum L1-pelvis) were included. Sagittal parameters, and segmental and regional Cobb angles were assessed pre and post-op. Virtual postoperative alignment was generated by combining post-op alignment of the fused spine with the pre-op alignment on the unfused thoracic kyphosis and the pre-op pelvic retroversion. Regression models were then generated to predict the relative impact of segmental (L4-L5) and regional (L1-L4) corrections on PT, SVA (virtual), and TPA. RESULTS Baseline analysis revealed distal (L4-S1) lordosis of 33 ± 15°, flat proximal (L1-L4) lordosis (1.7 ± 17°), and segmental kyphosis from L2-L3 to T10-T11. Post-op, there was no mean change in distal lordosis (L5-S1 decreased by 2°, and L4-L5 increased by 2°), while the more proximal lordosis increased by 18 ± 16°. Regression formulas revealed that Δ10° in distal lordosis resulted in Δ10° in TPA, associated with Δ100 mm in SVA or Δ3° in PT; Δ10° in proximal lordosis yielded Δ5° in TPA associated with Δ50 mm in SVA; and finally Δ10° in thoraco-lumbar junction yielded Δ2.5° in TPA associated with Δ25 mm in SVA and no impact on PT correction. CONCLUSIONS Overall impact of lumbar lordosis restoration is critically determined by location of correction. Distal correction leads to a greater impact on global alignment and pelvic retroversion. More specifically, it can be assumed that 1° L4-S1 lordosis correction produces 1° change in TPA / 10 mm change in SVA and 0.5° in PT.
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Affiliation(s)
- Renaud Lafage
- Spine Service, Hospital for Special
Surgery, New York, NY, USA,Renaud Lafage, Spine Service, Hospital for
Special Surgery, 525 E 71st St., Belaire 4E, New York, NY 10021, USA.
| | - Frank Schwab
- Spine Service, Hospital for Special
Surgery, New York, NY, USA
| | - Jonathan Elysee
- Spine Service, Hospital for Special
Surgery, New York, NY, USA
| | - Justin S. Smith
- Department of Neurosurgery, University
of Virginia Medical Center, Charlottesville, VA, USA
| | | | - Peter Passias
- Department of Orthopaedics, NYU Langone
Orthopedic Hospital, New York, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery,
University of California, Davis, Sacramento, CA, USA
| | - Han Jo Kim
- Spine Service, Hospital for Special
Surgery, New York, NY, USA
| | | | - Douglas Burton
- Department of Orthopaedics, University
of Kansas Medical Center, Kansas City, KS, USA
| | - Munish Gupta
- Department of Orthopaedics, Washington
University, St Louis, MO, USA
| | | | - Christopher Ames
- Department of Neurological Surgery,
University of California, San Francisco, School of Medicine, San Francisco, CA,
USA
| | - Shay Bess
- Denver International Spine Center,
Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Virginie Lafage
- Spine Service, Hospital for Special
Surgery, New York, NY, USA
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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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Kim HJ, Alluri RK, Lafage R, Elysee J, Smith JS, Mundis GM, Shaffrey CI, Ames CP, Burton DC, Klineberg EO, Bess S, Schwab F, Gupta M, Lafage V. Upper versus Lower Lumbar Lordosis Corrections in Relation to Pelvic Tilt - An Essential Element in Surgical Planning for Sagittal Plane Deformity. Spine (Phila Pa 1976) 2022; 47:1145-1150. [PMID: 35472199 DOI: 10.1097/brs.0000000000004370] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/04/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study of a multicenter Adult Spinal Deformity (ASD) Database. OBJECTIVE To investigate the change in Pelvic tilt (PT) imparted by regional changes in lumbar lordosis at 2-year minimum follow up. SUMMARY OF BACKGROUND DATA The distribution of lumbar lordosis between L1-4 and L4-S1 is known to vary based on pelvic incidence (PI). However, the extent to which regional changes effect PT is not clearly elucidated. This information can be useful for ASD surgical planning. METHODS Operative patients from a multicenter ASD database were included with Lowest Instrumented Vertebrae (LIV) S1/Ilium, >5 levels of fusion, Proximal Junction Kyphosis (PJK) angle < 20, and >5 degrees of change in lumbar lordosis from L4-S1 and L1-4. Radiographic analysis was performed evaluating Thoracic Kyphosis (TK), T10-L2 kyphosis (TL), L1-S1 lordosis (LL), L4-S1 lordosis, L1-4 lordosis, sagittal vertical axis (SVA) and PI-LL from preoperative to postoperative, and change at 2-years follow-up. Stepwise regression analysis was performed in order to determine the relationship between PT and the above radiographic parameters. Health-related quality of life (HRQOL) outcomes were also compared between preoperative and postoperative timepoints at 2 years. RESULTS 103 patients met inclusion for the study. There was improvement in all the radiographic parameters and HRQOLs at 2 years follow-up (p < 0.01). Stepwise regression model showed an inverse relationship between PT and LL change (r = 0.71, p < 0.01). Regionally, an increase in 10 degrees from L4-S1 correlated with a 2.4 degree decrease in PT (p < 0.01), while an increase in 10 degrees from L1-4 resulted in a 1.6 degree decrease in PT (p < 0.01). CONCLUSION In the surgical planning for ASD, our data demonstrated significant correlational difference between corrections in the upper (L1-4) and lower (L4-S1) lumbar spine and PT changes. These calculations can be useful in planning sagittal plane corrections for ASD.
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Affiliation(s)
- Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - R Kiran Alluri
- USC Spine Center, Keck School of Medicine of USC, Los Angeles, California
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | | | - Christopher I Shaffrey
- Department of Orthopaedic Surgery, Spine Division, Duke University Medical Center, Durham, North Carolina
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, California
| | - Shay Bess
- Denver International Spine Clinic, Presbyterian St. Luke's Medical Center, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health- Lenox Hill Hospital, New York, NY, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health- Lenox Hill Hospital, New York, NY, USA
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Than KD, Mehta VA, Le V, Moss JR, Park P, Uribe JS, Eastlack RK, Chou D, Fu KM, Wang MY, Anand N, Passias PG, Shaffrey CI, Okonkwo DO, Kanter AS, Nunley P, Mundis GM, Fessler RG, Mummaneni PV. Role of obesity in less radiographic correction and worse health-related quality-of-life outcomes following minimally invasive deformity surgery. J Neurosurg Spine 2022; 37:222-231. [PMID: 35180705 DOI: 10.3171/2021.12.spine21703] [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: 05/18/2021] [Accepted: 12/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Minimally invasive surgery (MIS) for adult spinal deformity (ASD) can offer deformity correction with less tissue manipulation and damage. However, the impact of obesity on clinical outcomes and radiographic correction following MIS for ASD is poorly understood. The goal of this study was to determine the role, if any, that obesity has on radiographic correction and health-related quality-of-life measures in MIS for ASD. METHODS Data were collected from a multicenter database of MIS for ASD. This was a retrospective review of a prospectively collected database. Patient inclusion criteria were age ≥ 18 years and coronal Cobb angle ≥ 20°, pelvic incidence-lumbar lordosis mismatch ≥ 10°, or sagittal vertical axis (SVA) > 5 cm. A group of patients with body mass index (BMI) < 30 kg/m2 was the control cohort; BMI ≥ 30 kg/m2 was used to define obesity. Obesity cohorts were categorized into BMI 30-34.99 and BMI ≥ 35. All patients had at least 1 year of follow-up. Preoperative and postoperative health-related quality-of-life measures and radiographic parameters, as well as complications, were compared via statistical analysis. RESULTS A total of 106 patients were available for analysis (69 control, 17 in the BMI 30-34.99 group, and 20 in the BMI ≥ 35 group). The average BMI was 25.24 kg/m2 for the control group versus 32.46 kg/m2 (p < 0.001) and 39.5 kg/m2 (p < 0.001) for the obese groups. Preoperatively, the BMI 30-34.99 group had significantly more prior spine surgery (70.6% vs 42%, p = 0.04) and worse preoperative numeric rating scale leg scores (7.71 vs 5.08, p = 0.001). Postoperatively, the BMI 30-34.99 cohort had worse Oswestry Disability Index scores (33.86 vs 23.55, p = 0.028), greater improvement in numeric rating scale leg scores (-4.88 vs -2.71, p = 0.012), and worse SVA (51.34 vs 26.98, p = 0.042) at 1 year postoperatively. Preoperatively, the BMI ≥ 35 cohort had significantly worse frailty (4.5 vs 3.27, p = 0.001), Oswestry Disability Index scores (52.9 vs 44.83, p = 0.017), and T1 pelvic angle (26.82 vs 20.71, p = 0.038). Postoperatively, after controlling for differences in frailty, the BMI ≥ 35 cohort had significantly less improvement in their Scoliosis Research Society-22 outcomes questionnaire scores (0.603 vs 1.05, p = 0.025), higher SVA (64.71 vs 25.33, p = 0.015) and T1 pelvic angle (22.76 vs 15.48, p = 0.029), and less change in maximum Cobb angle (-3.93 vs -10.71, p = 0.034) at 1 year. The BMI 30-34.99 cohort had significantly more infections (11.8% vs 0%, p = 0.004). The BMI ≥ 35 cohort had significantly more implant complications (30% vs 11.8%, p = 0.014) and revision surgery within 90 days (5% vs 1.4%, p = 0.034). CONCLUSIONS Obese patients who undergo MIS for ASD have less correction of their deformity, worse quality-of-life outcomes, more implant complications and infections, and an increased rate of revision surgery compared with their nonobese counterparts, although both groups benefit from surgery. Appropriate counseling should be provided to obese patients.
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Affiliation(s)
- Khoi D Than
- 1Departments of Neurosurgery and Orthopedics, Division of Spine, Duke University Medical Center, Durham, North Carolina
| | - Vikram A Mehta
- 1Departments of Neurosurgery and Orthopedics, Division of Spine, Duke University Medical Center, Durham, North Carolina
| | - Vivian Le
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Jonah R Moss
- 12Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Paul Park
- 3Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Juan S Uribe
- 4Barrow Neurological Institute, Phoenix, Arizona
| | - Robert K Eastlack
- 5Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California
| | - Dean Chou
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Kai-Ming Fu
- 6Department of Neurosurgery, Cornell Medical Center, New York, New York
| | - Michael Y Wang
- 7Department of Neurosurgery, University of Miami, Florida
| | - Neel Anand
- 8Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Peter G Passias
- 9Department of Orthopedics, New York University Langone Health, New York, New York
| | - Christopher I Shaffrey
- 1Departments of Neurosurgery and Orthopedics, Division of Spine, Duke University Medical Center, Durham, North Carolina
| | - David O Okonkwo
- 10Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam S Kanter
- 10Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pierce Nunley
- 11Spine Institute of Louisiana, Shreveport, Louisiana; and
| | - Gregory M Mundis
- 5Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California
| | - Richard G Fessler
- 12Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Praveen V Mummaneni
- 2Department of Neurosurgery, University of California, San Francisco, California
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Katsuura Y, Lafage R, Kim HJ, Smith JS, Line B, Shaffrey C, Burton DC, Ames CP, Mundis GM, Hostin R, Bess S, Klineberg EO, Passias PG, Lafage V. Alignment Targets, Curve Proportion and Mechanical Loading: Preliminary Analysis of an Ideal Shape Toward Reducing Proximal Junctional Kyphosis. Global Spine J 2022; 12:1165-1174. [PMID: 33511871 PMCID: PMC9210254 DOI: 10.1177/2192568220987188] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Investigate risk factors for PJK including theoretical kyphosis, mechanical loading at the UIV and age adjusted offset alignment. METHODS 373 ASD patients (62.7 yrs ± 9.9; 81%F) with 2-year follow up and UIV of at least L1 and LIV of sacrum were included. Images of patients without PJK, with PJK and with PJF were compared using standard spinopelvic parameters before and after the application of the validated virtual alignment method which corrects for the compensatory mechanisms of PJK. Age-adjusted offset, theoretical thoracic kyphosis and mechanical loading at the UIV were then calculated and compared between groups. A subanalysis was performed based on the location of the UIV (upper thoracic (UT) vs. Lower thoracic (LT)). RESULTS At 2-years 172 (46.1%) had PJK, and 21 (5.6%) developed PJF. As PJK severity increased, the post-operative global alignment became more posterior secondary to increased over-correction of PT, PI-LL, and SVA (all P < 0.005). Also, a larger under correction of the theoretical TK (flattening) and a smaller bending moment at the UIV (underloading of UIV) was found. Multivariate analysis demonstrated that PI-LL and bending moment offsets from normative values were independent predictors of PJK/PJF in UT group; PT and bending moment difference were independent predictors for LT group. CONCLUSIONS Spinopelvic over correction, under correction of TK (flattening), and under loading of the UIV (decreased bending moment) were associated with PJK and PJF. These differences are often missed when compensation for PJK is not accounted for in post-operative radiographs.
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Affiliation(s)
| | - Renaud Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, USA,Renaud Lafage, 525 E 71st St., Belaire 4E, New York, NY 10021, USA.
| | - Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Breton Line
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | | | - Douglas C. Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Christopher P. Ames
- Department of Neurological Surgery, University of California School of Medicine, San Francisco, CA, USA
| | | | | | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric O. Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Peter G. Passias
- Department of Orthopaedic Surgery, New York University, New York, NY, USA
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, USA
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Kim HJ, Yao YC, Shaffrey CI, Smith JS, Kelly MP, Gupta M, Albert TJ, Protopsaltis TS, Mundis GM, Passias P, Klineberg E, Bess S, Lafage V, Ames CP. Neurological Complications and Recovery Rates of Patients With Adult Cervical Deformity Surgeries. Global Spine J 2022; 12:1091-1097. [PMID: 33222533 PMCID: PMC9210226 DOI: 10.1177/2192568220975735] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE This study aims to report the incidence, risk factors, and recovery rate of neurological complications (NC) in patients with adult cervical deformity (ACD) who underwent corrective surgery. METHODS ACD patients undergoing surgery from 2013 to 2015 were enrolled in a prospective, multicenter database. Patients were separated into 2 groups according to the presence of neurological complications (NC vs no-NC groups). The types, timing, recovery patterns, and interventions for NC were recorded. Patients' demographics, surgical details, radiographic parameters, and health-related quality of life (HRQOL) scores were compared. RESULTS 106 patients were prospectively included. Average age was 60.8 years with a mean of 18.2 months follow-up. The overall incidence of NC was 18.9%; of these, 68.1% were major complications. Nerve root motor deficit was the most common complication, followed by radiculopathy, sensory deficit, and spinal cord injury. The proportion of complications occurring within 30 days of surgery was 54.5%. The recovery rate from neurological complication was high (90.9%), with most of the recoveries occurring within 6 months and continuing even after 12 months. Only 2 patients (1.9%) had continuous neurological complication. No demographic or preoperative radiographic risk factors could be identified, and anterior corpectomy and posterior foraminotomy were found to be performed less in the NC group. The final HRQOL outcome was not significantly different between the 2 groups. CONCLUSIONS Our data is valuable to surgeons and patients to better understand the neurological complications before performing or undergoing complex cervical deformity surgery.
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Affiliation(s)
- Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, USA,Han Jo Kim, Spine Service, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021, USA.
| | - Yu-Cheng Yao
- Spine Service, Hospital for Special Surgery, New York, NY, USA,Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Beitou District, Taipei, Taiwan
| | | | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville, VA, USA
| | - Michael P. Kelly
- Department of Orthopaedic Surgery, Washington University in St. Louis, MO, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University in St. Louis, MO, USA
| | - Todd J. Albert
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | | | | | - Peter Passias
- Department of Orthopaedics, NYU Langone Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Shay Bess
- Paediatric and Adult Spine Surgery, Rocky Mountain Hospital for Children, Presbyterian St Luke’s Medical Center, Denver, CO, USA
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Christopher P. Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Mundis GM, Walker CT, Smith JS, Buell TJ, Lafage R, Shaffrey CI, Eastlack RK, Okonkwo DO, Bess S, Lafage V, Uribe JS, Lenke LG, Ames CP. Kickstand rods and correction of coronal malalignment in patients with adult spinal deformity. Eur Spine J 2022; 31:1197-1205. [PMID: 35292847 DOI: 10.1007/s00586-022-07161-7] [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] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/20/2022] [Accepted: 02/23/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Coronal malalignment (CM) is a challenging spinal deformity to treat. The kickstand rod (KR) technique is powerful for correcting truncal shift. This study tested the hypothesis that the KR technique provides superior coronal alignment correction in adult deformity compared with traditional rod techniques. METHODS A retrospective evaluation of a prospectively collected multicenter database was performed. A 2:1 matched cohort of non-KR accessory rod and KR patients was planned based on preoperative coronal balance distance (CBD) and a vector of global shift. Patients were subgrouped according to CM classification with a 30-mm CBD threshold defining CM, and comparisons of surgical and clinical outcomes among groups was performed. RESULTS Twenty-one patients with preoperative CM treated with a KR were matched to 36 controls. KR-treated patients had improved CBD compared with controls (18 vs. 35 mm, P < 0.01). The postoperative CBD did not result in clinical differences between groups in patient-reported outcomes (P ≥ 0.09). Eight (38%) of 21 KR patients and 12 (33%) of 36 control patients with preoperative CM had persistent postoperative CM (P = 0.72). CM class did not significantly affect the likelihood of treatment failure (postoperative CBD > 30 mm) in the KR cohort (P = 0.70), the control cohort (P = 0.35), or the overall population (P = 0.31). CONCLUSIONS Application of the KR technique to coronal spinal deformity in adults allows for successful treatment of CM. Compared to traditional rod techniques, the use of KRs did not improve clinical outcome measures 1 year after spinal deformity surgery but was associated with better postoperative coronal alignment.
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Affiliation(s)
- Gregory M Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Thomas J Buell
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, USA
| | | | | | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine Center, Denver, CO, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University, The Spine Hospital, New York, NY, USA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco Medical Center, San Francisco, CA, USA
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Mundis GM, Godzik J, Park P, Fu KM, Tran S, Uribe JS, Wang MY, Than KD, Okonkwo DO, Kanter AS, Nunley PD, Anand N, Fessler RG, Chou D, Lafage R, Eastlack RK, _ _. Prospective multicenter study of minimally invasive surgery for the treatment of adult spinal deformity. J Neurosurg Spine 2022. [DOI: 10.3171/2021.8.spine21369] [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] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Traditional surgery for adult spinal deformity (ASD) is effective but may result in exposure-related morbidity. Minimally invasive surgery (MIS) can potentially minimize this morbidity; however, high-level evidence is lacking. This study presents the first prospective multicenter investigation of MIS approaches for ASD.
METHODS
A prospective multicenter study was conducted. Inclusion criteria were age ≥ 18 years, with at least one of the following radiographic criteria: coronal Cobb (CC) angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, and thoracic kyphosis > 60°. Additional inclusion criteria were circumferential MIS, including interbody fusion (transforaminal lumbar interbody fusion [TLIF], lateral lumbar interbody fusion [LLIF], or anterior lumbar interbody fusion [ALIF]) with percutaneous posterior fixation on a minimum of 4 intervertebral levels. Radiographic and clinical outcomes (visual analog scale [VAS], Oswestry Disability Index [ODI], and Scoliosis Research Society–22 [SRS-22]) were collected preoperatively and at 12 months postoperatively; preoperative and postoperative values were compared using paired Student t-tests.
RESULTS
Seventy-five patients with a minimum 1-year follow-up were identified (75 of 111; 67.6%). The mean ± SD age was 68.8 ± 9.0 years, and 48 patients (64%) were female. Patients underwent a mean of 6.7 ± 2.9 levels of fusion with LLIF (85%), ALIF (55%), and TLIF (9%); the mean estimated blood loss was 547.6 ± 567.2 mL, and the mean length of stay was 7.0 ± 3.7 days. Significant improvements were observed in ODI (−19 ± 12.9, p < 0.001), SRS-22 (0.8 ± 0.66, p < 0.001), VAS back (−4.3 ± 2.8, p < 0.001), and VAS leg (−3.0 ± 3.2, p < 0.001) scores. Significant decreases in SVA (−26.4 ± 53.6 mm; p < 0.001), pelvic incidence–lumbar lordosis (−11.3° ± 14.9°, p < 0.001), and CC angle (−12.1° ± 11.8°, p < 0.001) were also observed. Complications occurred in 39 patients (52%); 11 patients (15%) experienced major complications, and 16 patients (21%) required reoperation.
CONCLUSIONS
MIS approaches for ASD resulted in meaningful symptomatic improvement. The complication rates were similar to historic norms, with a fairly high reoperation rate at 1 year. Longer follow-up will be necessary to evaluate the durability of this approach in the treatment of ASD.
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Affiliation(s)
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kai-Ming Fu
- Department of Neurosurgery, Weill Cornell Medical College, New York, New York
| | - Stacie Tran
- San Diego Spine Foundation, Scripps Clinic, La Jolla, California
| | - Juan S. Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Michael Y. Wang
- Department of Neurosurgery, University of Miami, Coral Gables, Florida
| | - Khoi D. Than
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam S. Kanter
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Neel Anand
- Anand Spine Group, Los Angeles, California
| | - Richard G. Fessler
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, California; and
| | - Renaud Lafage
- Department of Orthopedics, Hospital of Special Surgery, New York, New York
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Wick JB, Le HV, Lafage R, Gupta MC, Hart RA, Mundis GM, Bess S, Burton DC, Ames CP, Smith JS, Shaffrey CI, Schwab FJ, Passias PG, Protopsaltis TS, Lafage V, Klineberg EO. Assessment of Adult Spinal Deformity Complication Timing and Impact on 2-Year Outcomes Using a Comprehensive Adult Spinal Deformity Classification System. Spine (Phila Pa 1976) 2022; 47:445-454. [PMID: 34812199 DOI: 10.1097/brs.0000000000004289] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospectively collected multicenter registry data. OBJECTIVE To identify rates and timing of postoperative complications in adult spinal deformity (ASD) patients, the impact of complication type and timing on health related quality of life (HRQoL) outcomes, and the impact of complication timing on readmission and reoperation rates. Better understanding of complication timing and impact on HRQoL may improve patient selection, preoperative counseling, and postoperative complication surveillance. SUMMARY OF BACKGROUND DATA ASD is common and associated with significant disability. Surgical correction is often pursued, but is associated with high complication rates. The International Spine Study Group, AO Spinal Deformity Forum, and European Spine Study Group have developed a new complication classification system for ASD (ISSG-AO spine complications classification system). METHODS The ISSG-AO spine complications classification system was utilized to assess complications occurring over the 2-year postoperative time period amongst a multicenter, prospectively enrolled cohort of patients who underwent surgery for ASD. Kaplan-Meier survival curves were established for each complication type. Propensity score matching was performed to adjust for baseline disability and comorbidities. Associations between each complication type and HRQoL, and reoperation/readmission and complication timing, were assessed. RESULTS Of 584 patients meeting inclusion criteria, cardiopulmonary, gastrointestinal, infection, early adverse events, and operative complications contributed to a rapid initial decrease in complication-free survival. Implant-related, radiographic, and neurologic complications substantially decreased long-term complication-free survival. Only radiographic and implant-related complications were significantly associated with worse 2-year HRQoL outcomes. Need for readmission and/or reoperation was most frequent among those experiencing complications after postoperative day 90. CONCLUSION Surgeons should recognize that long-term complications have a substantial negative impact on HRQoL, and should carefully monitor for implant-related and radiographic complications over long-term follow-up.Level of Evidence: 4.
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Affiliation(s)
- Joseph B Wick
- Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento, CA
| | - Hai V Le
- Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento, CA
| | | | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Gregory M Mundis
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, KS
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, KS
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | | | | | - Peter G Passias
- Department of Orthopedic Surgery, New York University, Langone Health, New York, NY
| | | | | | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento, CA
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Durand WM, DiSilvestro KJ, Kim HJ, Hamilton DK, Lafage R, Passias PG, Protopsaltis TS, Lafage V, Smith JS, Shaffrey CI, Gupta MC, Klineberg EO, Schwab FJ, Gum JL, Mundis GM, Eastlack RK, Kebaish KM, Soroceanu A, Hostin RA, Burton DC, Bess S, Ames CP, Hart RA, Daniels AH. Low-Density Pedicle Screw Constructs Are Associated with Lower Incidence of Proximal Junctional Failure in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2022; 47:463-469. [PMID: 35019881 DOI: 10.1097/brs.0000000000004290] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Determine whether screws per level and rod material/diameter are associated with incidence of proximal junctional kyphosis (PJF). SUMMARY OF BACKGROUND DATA PJF is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF. METHODS Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing primary fusion of more than or equal to five levels with lower instrumented vertebrae (LIV) at the sacro-pelvis were included. Screws per level fused was analyzed with a cutoff of 1.8 (determined by receiver operating characteristic curve (ROC) analysis). Multivariable logistic regression was utilized, controlling for age, body mass index (BMI), 6-week postoperative change from baseline in lumbar lordosis, number of posterior levels fused, sex, Charlson comorbidity index, approach, osteotomy, upper instrumented vertebra (UIV), osteoporosis, preoperative TPA, and pedicle screw at the UIV (as opposed to hook, wire, etc.). RESULTS In total, 504 patients were included. PJF occurred in 12.7%. The mean screws per level was 1.7, and 56.8% of patients had less than 1.8 screws per level. No differences were observed between low versus high screw density groups for T1-pelvic angle or magnitude of lordosis correction (both P > 0.15). PJF occurred in 17.0% versus 9.4% of patients with more than or equal to 1.8 versus less than 1.8 screws per level, respectively (P < 0.05). In multivariable analysis, patients with less than 1.8 screws per level exhibited lower odds of PJF (odds ratio (OR) 0.48, P < 0.05), and a continuous variable for screw density was significantly associated with PJF (OR 3.87 per 0.5 screws per level, P < 0.05). Rod material and diameter were not significantly associated with PJF (both P > 0.1). CONCLUSION Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with less than 1.8 screws per level. This finding may be related to construct rigidity. Residual confounding by other patient and surgeon-specific characteristics may exist. Further biomechanical and clinical studies exploring this relationship are warranted.Level of Evidence: 3.
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Affiliation(s)
| | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | | | | | - Peter G Passias
- Langone Medical Center, New York University, New York City, NY
| | | | | | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA
| | | | | | - Eric O Klineberg
- University of California Davis Medical Center, University of California, Sacramento, CA
| | | | | | | | | | | | | | | | | | - Shay Bess
- Denver International Spine Center, Denver, CO
| | | | - Robert A Hart
- Swedish Medical Center, Swedish Neuroscience Institute, Seattle, WA
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Passias PG, Passfall L, Lafage V, Lafage R, Line BG, Vira S, Tretiakov PS, Gum JL, Kebaish K, Than KD, Mundis GM, Hostin RA, Gupta MC, Eastlack R, Anand N, Ames CP, Hart RA, Burton DC, Schwab F, Shaffrey CI, Smith JS, Klineberg E, Bess S. 440 Have We Made Temporal Advancements in Optimizing Surgical Outcomes and Recovery for High Risk Spinal Deformity Patients? Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Shahidi B, Anderson B, Malone H, Iannacone T, Moltzen C, Eastlack R, Mundis GM. 807 Peak Force of the Posterior Ligamentous Complex is Lower in Patients with Adult Spinal Deformity Requiring Revision Surgery. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Chou D, Lafage V, Chan AY, Passias P, Mundis GM, Eastlack RK, Fu KM, Fessler RG, Gupta MC, Than KD, Anand N, Uribe JS, Kanter AS, Okonkwo DO, Bess S, Shaffrey CI, Kim HJ, Smith JS, Sciubba DM, Park P, Mummaneni PV. Patient outcomes after circumferential minimally invasive surgery compared with those of open correction for adult spinal deformity: initial analysis of prospectively collected data. J Neurosurg Spine 2022; 36:203-214. [PMID: 34560634 DOI: 10.3171/2021.3.spine201825] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Circumferential minimally invasive spine surgery (cMIS) for adult scoliosis has become more advanced and powerful, but direct comparison with traditional open correction using prospectively collected data is limited. The authors performed a retrospective review of prospectively collected, multicenter adult spinal deformity data. The authors directly compared cMIS for adult scoliosis with open correction in propensity-matched cohorts using health-related quality-of-life (HRQOL) measures and surgical parameters. METHODS Data from a prospective, multicenter adult spinal deformity database were retrospectively reviewed. Inclusion criteria were age > 18 years, minimum 1-year follow-up, and one of the following characteristics: pelvic tilt (PT) > 25°, pelvic incidence minus lumbar lordosis (PI-LL) > 10°, Cobb angle > 20°, or sagittal vertical axis (SVA) > 5 cm. Patients were categorized as undergoing cMIS (percutaneous screws with minimally invasive anterior interbody fusion) or open correction (traditional open deformity correction). Propensity matching was used to create two equal groups and to control for age, BMI, preoperative PI-LL, pelvic incidence (PI), T1 pelvic angle (T1PA), SVA, PT, and number of posterior levels fused. RESULTS A total of 154 patients (77 underwent open procedures and 77 underwent cMIS) were included after matching for age, BMI, PI-LL (mean 15° vs 17°, respectively), PI (54° vs 54°), T1PA (21° vs 22°), and mean number of levels fused (6.3 vs 6). Patients who underwent three-column osteotomy were excluded. Follow-up was 1 year for all patients. Postoperative Oswestry Disability Index (ODI) (p = 0.50), Scoliosis Research Society-total (p = 0.45), and EQ-5D (p = 0.33) scores were not different between cMIS and open patients. Maximum Cobb angles were similar for open and cMIS patients at baseline (25.9° vs 26.3°, p = 0.85) and at 1 year postoperation (15.0° vs 17.5°, p = 0.17). In total, 58.3% of open patients and 64.4% of cMIS patients (p = 0.31) reached the minimal clinically important difference (MCID) in ODI at 1 year. At 1 year, no differences were observed in terms of PI-LL (p = 0.71), SVA (p = 0.46), PT (p = 0.9), or Cobb angle (p = 0.20). Open patients had greater estimated blood loss compared with cMIS patients (1.36 L vs 0.524 L, p < 0.05) and fewer levels of interbody fusion (1.87 vs 3.46, p < 0.05), but shorter operative times (356 minutes vs 452 minutes, p = 0.003). Revision surgery rates between the two cohorts were similar (p = 0.97). CONCLUSIONS When cMIS was compared with open adult scoliosis correction with propensity matching, HRQOL improvement, spinopelvic parameters, revision surgery rates, and proportions of patients who reached MCID were similar between cohorts. However, well-selected cMIS patients had less blood loss, comparable results, and longer operative times in comparison with open patients.
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Affiliation(s)
- Dean Chou
- 1Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Virginie Lafage
- 2Department of Orthopedic Surgery, New York University, New York, New York
| | - Alvin Y Chan
- 3Department of Neurosurgery, University of California, Irvine, Orange, California
| | - Peter Passias
- 2Department of Orthopedic Surgery, New York University, New York, New York
| | - Gregory M Mundis
- 4Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Robert K Eastlack
- 5Department of Orthopedic Surgery, Scripps Health, La Jolla, California
| | - Kai-Ming Fu
- 6Department of Neurosurgery, Weill Cornell Medical College, New York, New York
| | | | - Munish C Gupta
- 8Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Khoi D Than
- 9Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Neel Anand
- 10Department of Orthopedic Surgery, Cedars-Sinai, Los Angeles, California
| | - Juan S Uribe
- 11Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Adam S Kanter
- 12Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David O Okonkwo
- 12Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shay Bess
- 13Department of Orthopedic Surgery, Denver International Spine Center, Denver, Colorado
| | | | - Han Jo Kim
- 15Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York
| | - Justin S Smith
- 16Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Daniel M Sciubba
- 17Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland; and
| | - Paul Park
- 18Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Praveen V Mummaneni
- 1Department of Neurosurgery, University of California, San Francisco, San Francisco, California
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Lafage R, Fong AM, Klineberg E, Smith JS, Bess S, Shaffrey CI, Burton D, Kim HJ, Elysee J, Mundis GM, Passias P, Gupta M, Hostin R, Schwab F, Lafage V. Complication rate evolution across a 10-year enrollment period of a prospective multicenter database. J Neurosurg Spine 2021:1-11. [PMID: 35349975 DOI: 10.3171/2021.10.spine21795] [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: 06/10/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adult spinal deformity is a complex pathology that benefits greatly from surgical treatment. Despite continuous innovation, little is known regarding continuous changes in surgical techniques and the complications rate. The objective of the current study was to investigate the evolution of the patient profiles and surgical complications across a single prospective multicenter database. METHODS This study is a retrospective review of a prospective, multicenter database of surgically treated patients with adult spinal deformity (thoracic kyphosis > 60°, sagittal vertical axis > 5 cm, pelvic tilt > 25°, or Cobb angle > 20°) with a minimum 2-year follow-up. Patients were stratified into 3 equal groups by date of surgery. The three groups' demographic data, preoperative data, surgical information, and complications were then compared. A moving average of 320 patients was used to visualize and investigate the evolution of the complication across the enrollment period. RESULTS A total of 928/1260 (73.7%) patients completed their 2-year follow-up, with an enrollment rate of 7.7 ± 4.1 patients per month. Across the enrollment period (2008-2018) patients became older (mean age increased from 56.7 to 64.3 years) and sicker (median Charlson Comorbidity Index rose from 1.46 to 2.08), with more pure sagittal deformity (type N). Changes in surgical treatment included an increased use of interbody fusion, more anterior column release, and a decrease in the 3-column osteotomy rate, shorter fusion, and more supplemental rods and bone morphogenetic protein use. There was a significant decrease in major complications associated with a reoperation (from 27.4% to 17.1%) driven by a decrease in radiographic failures (from 12.3% to 5.2%), despite a small increase in neurological complications. The overall complication rate has decreased over time, with the lowest rate of any complication (51.8%) during the period from August 2014 to March 2017. Major complications associated with reoperation decreased rapidly in the 2014-2015. Major complications not associated with reoperation had the lowest level (21.0%) between February 2014 and October 2016. CONCLUSIONS Despite an increase in complexity of cases, complication rates did not increase and the rate of complications leading to reoperation decreased. These improvements reflect the changes in practice (supplemental rod, proximal junctional kyphosis prophylaxis, bone morphogenetic protein use, anterior correction) to ensure maintenance of status or improved outcomes.
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Affiliation(s)
- Renaud Lafage
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Alex M Fong
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric Klineberg
- 2Department of Orthopedic Surgery, School of Medicine, University of California, Davis, California
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Shay Bess
- 4Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | | | - Douglas Burton
- 6Department of Orthopedics, University of Kansas Medical Center, Kansas City, Kansas
| | - Han Jo Kim
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Jonathan Elysee
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Peter Passias
- 8Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Munish Gupta
- 9Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri; and
| | - Richard Hostin
- 10Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, Texas
| | - Frank Schwab
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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Saigal R, Akbarnia BA, Eastlack RK, Bagheri A, Tran S, Brown D, Bagheri R, Mundis GM. Anterior Column Realignment: Analysis of Neurological Risk and Radiographic Outcomes. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa064_s019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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47
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Buell TJ, Smith JS, Shaffrey CI, Kim HJ, Klineberg EO, Lafage V, Lafage R, Protopsaltis TS, Passias PG, Mundis GM, Eastlack RK, Deviren V, Kelly MP, Daniels AH, Gum JL, Soroceanu A, Hamilton DK, Gupta MC, Burton DC, Hostin RA, Kebaish KM, Hart RA, Schwab FJ, Bess S, Ames CP. Operative Treatment of Severe Scoliosis in Symptomatic Adults: Multicenter Assessment of Outcomes and Complications With Minimum 2-Year Follow-up. Neurosurgery 2021; 89:1012-1026. [PMID: 34662889 DOI: 10.1093/neuros/nyab352] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 07/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Few reports focus on adults with severe scoliosis. OBJECTIVE To report surgical outcomes and complications for adults with severe scoliosis. METHODS A multicenter, retrospective review was performed on operatively treated adults with severe scoliosis (minimum coronal Cobb: thoracic [TH] ≥ 75°, thoracolumbar [TL] ≥ 50°, lumbar [L] ≥ 50°). RESULTS Of 178 consecutive patients, 146 (82%; TH = 8, TL = 88, L = 50) achieved minimum 2-yr follow-up (mean age = 53.9 ± 13.2 yr, 92% women). Operative details included posterior-only (58%), 3-column osteotomy (14%), iliac fixation (72%), and mean posterior fusion = 13.2 ± 3.7 levels. Global coronal alignment (3.8 to 2.8 cm, P = .001) and maximum coronal Cobb improved significantly (P ≤.020): TH (84º to 57º; correction = 32%), TL (67º to 35º; correction = 48%), L (61º to 29º; correction = 53%). Sagittal alignment improved significantly (P < .001), most notably for L: C7-sagittal vertical axis 6.7 to 2.5 cm, pelvic incidence-lumbar lordosis mismatch 18º to 3º. Health-related quality-of-life (HRQL) improved significantly (P < .001), most notably for L: Oswestry Disability Index (44.4 ± 20.5 to 26.1 ± 18.3), Short Form-36 Physical Component Summary (30.2 ± 10.8 to 39.9 ± 9.8), and Scoliosis Research Society-22r Total (2.9 ± 0.7 to 3.8 ± 0.7). Minimal clinically important difference and substantial clinical benefit thresholds were achieved in 36% to 75% and 29% to 51%, respectively. Ninety-four (64%) patients had ≥1 complication (total = 191, 92 minor/99 major, most common = rod fracture [13.0%]). Fifty-seven reoperations were performed in 37 (25.3%) patients, with most common indications deep wound infection (11) and rod fracture (10). CONCLUSION Although results demonstrated high rates of complications, operative treatment of adults with severe scoliosis was associated with significant improvements in mean HRQL outcome measures for the study cohort at minimum 2-yr follow-up.
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Affiliation(s)
- Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christopher I Shaffrey
- Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, California, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | | | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York, USA
| | - Gregory M Mundis
- Scripps Clinic and San Diego Center for Spinal Disorders, La Jolla, California, USA
| | - Robert K Eastlack
- Scripps Clinic and San Diego Center for Spinal Disorders, La Jolla, California, USA
| | - Vedat Deviren
- Department of Orthopaedic Surgery, University of California, San Francisco, California, USA
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island, USA
| | - Jeff L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Richard A Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Baylor Scott and White Medical Center, Plano, Texas, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian/St. Luke's Medical Center and Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Chan AK, Eastlack RK, Fessler RG, Than KD, Chou D, Fu KM, Park P, Wang MY, Kanter AS, Okonkwo DO, Nunley PD, Anand N, Uribe JS, Mundis GM, Bess S, Shaffrey CI, Le VP, Mummaneni PV. Two- and three-year outcomes of minimally invasive and hybrid correction of adult spinal deformity. J Neurosurg Spine 2021; 36:595-608. [PMID: 34740175 DOI: 10.3171/2021.7.spine21138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous studies have demonstrated the short-term radiographic and clinical benefits of circumferential minimally invasive surgery (cMIS) and hybrid (i.e., minimally invasive anterior or lateral interbody fusion with an open posterior approach) techniques to correct adult spinal deformity (ASD). However, it is not known if these benefits are maintained over longer periods of time. This study evaluated the 2- and 3-year outcomes of cMIS and hybrid correction of ASD. METHODS A multicenter database was retrospectively reviewed for patients undergoing cMIS or hybrid surgery for ASD. Patients were ≥ 18 years of age and had one of the following: maximum coronal Cobb angle (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic incidence-lumbar lordosis mismatch (PI-LL) ≥ 10°, or pelvic tilt (PT) > 20°. Radiographic parameters were evaluated at the latest follow-up. Clinical outcomes were compared at 2- and 3-year time points and adjusted for age, preoperative CC, levels operated, levels with interbody fusion, presence of L5-S1 anterior lumbar interbody fusion, and upper and lower instrumented vertebral level. RESULTS Overall, 197 (108 cMIS, 89 hybrid) patients were included with 187 (99 cMIS, 88 hybrid) and 111 (60 cMIS, 51 hybrid) patients evaluated at 2 and 3 years, respectively. The mean (± SD) follow-up duration for cMIS (39.0 ± 13.3 months, range 22-74 months) and hybrid correction (39.9 ± 16.8 months, range 22-94 months) were similar for both cohorts. Hybrid procedures corrected the CC greater than the cMIS technique (adjusted p = 0.022). There were no significant differences in postoperative SVA, PI-LL, PT, and sacral slope (SS). At 2 years, cMIS had lower Oswestry Disability Index (ODI) scores (adjusted p < 0.001), greater ODI change as a percentage of baseline (adjusted p = 0.006), less visual analog scale (VAS) back pain (adjusted p = 0.006), and greater VAS back pain change as a percentage of baseline (adjusted p = 0.001) compared to hybrid techniques. These differences were no longer significant at 3 years. At 3 years, but not 2 years, VAS leg pain was lower for cMIS compared to hybrid techniques (adjusted p = 0.032). Those undergoing cMIS had fewer overall complications compared to hybrid techniques (adjusted p = 0.006), but a higher odds of pseudarthrosis (adjusted p = 0.039). CONCLUSIONS In this review of a multicenter database for patients undergoing cMIS and hybrid surgery for ASD, hybrid procedures were associated with a greater CC improvement compared to cMIS techniques. cMIS was associated with superior ODI and back pain at 2 years, but this difference was no longer evident at 3 years. However, cMIS was associated with superior leg pain at 3 years. There were fewer complications following cMIS, with the exception of pseudarthrosis.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Richard G Fessler
- 3Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Khoi D Than
- 4Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Kai-Ming Fu
- 5Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Paul Park
- 6Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Y Wang
- 7Department of Neurosurgery, University of Miami, Florida
| | - Adam S Kanter
- 8Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David O Okonkwo
- 8Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Neel Anand
- 10Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Juan S Uribe
- 11Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | | | - Shay Bess
- 12Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | | | - Vivian P Le
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
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Passias PG, Passfall L, Horn SR, Pierce KE, Lafage V, Lafage R, Smith JS, Line BG, Mundis GM, Eastlack R, Diebo BG, Protopsaltis TS, Kim HJ, Scheer J, Burton DC, Hart RA, Schwab FJ, Bess S, Ames CP, Shaffrey CI. Risk-benefit assessment of major versus minor osteotomies for flexible and rigid cervical deformity correction. J Craniovertebr Junction Spine 2021; 12:263-268. [PMID: 34728993 PMCID: PMC8501816 DOI: 10.4103/jcvjs.jcvjs_35_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 04/30/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Osteotomies are commonly performed to correct sagittal malalignment in cervical deformity (CD). However, the risks and benefits of performing a major osteotomy for cervical deformity correction have been understudied. The objective of this retrospective cohort study was to investigate the risks and benefits of performing a major osteotomy for CD correction. Methods: Patients stratified based on major osteotomy (MAJ) or minor (MIN). Independent t-tests and Chi-squared tests were used to assess differences between MAJ and MIN. A sub-analysis compared patients with flexible versus rigid CL. Results: 137 CD patients were included (62 years, 65% F). 19.0% CD patients underwent a MAJ osteotomy. After propensity score matching for cSVA, 52 patients were included. About 19.0% CD patients underwent a MAJ osteotomy. MAJ patients had more minor complications (P = 0.045), despite similar surgical outcomes as MIN. At 3M, MAJ and MIN patients had similar NDI, mJOA, and EQ5D scores, however by 1 year, MAJ patients reached MCID for NDI less than MIN patients (P = 0.003). MAJ patients with rigid deformities had higher rates of complications (79% vs. 29%, P = 0.056) and were less likely to show improvement in NDI at 1 year (0.95 vs. 0.54, P = 0.027). Both groups had similar sagittal realignment at 1 year (all P > 0.05). Conclusions: Cervical deformity patients who underwent a major osteotomy had similar clinical outcomes at 3-months but worse outcomes at 1-year as compared to minor osteotomies, likely due to differences in baseline deformity. Patients with rigid deformities who underwent a major osteotomy had higher complication rates and worse clinical improvement despite similar realignment at 1 year.
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Affiliation(s)
- Peter Gust Passias
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Lara Passfall
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Samantha R Horn
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's, Rocky Mountain Hospital for Children, Denver, CO, USA
| | | | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, USA
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY, USA
| | | | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Justin Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's, Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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50
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Alas H, Passias PG, Diebo BG, Brown AE, Pierce KE, Bortz C, Lafage R, Ames CP, Line B, Klineberg EO, Burton DC, Uribe JS, Kim HJ, Daniels AH, Bess S, Protopsaltis T, Mundis GM, Shaffrey CI, Schwab FJ, Smith JS, Lafage V. Cervical deformity patients with baseline hyperlordosis or hyperkyphosis differ in surgical treatment and radiographic outcomes. J Craniovertebr Junction Spine 2021; 12:279-286. [PMID: 34728995 PMCID: PMC8501813 DOI: 10.4103/jcvjs.jcvjs_29_21] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/07/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), though patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD-corrective surgery with regards to HK and hyperlordosis (HL). Materials and Methods: Operative CD patients (C2-C7 Cobb >10°, cervical lordosis [CL] >10°, cervical sagittal vertical axis [cSVA] >4 cm, chin-brow vertical angle >25°) with baseline (BL) and 1Y radiographic data. Patients were stratified based on BL C2-7 lordosis (CL) angle: those >1 standard deviation (SD) from the mean (−6.96° ±21.47°) were hyperlordotic (>14.51°) or hyperkyphotic (≤28.43°) depending on directionality. Patients within 1 SD were considered the control group. Results: One hundred and two surgical CD pts (61 years, 65%F, 30 kg/m2) with BL and 1Y radiographic data were included. Twenty pts met definitions for HK and 21 pts met definitions for HL. No differences in demographics or disability were noted. HK had higher estimated blood loss (EBL) with anterior approaches than HL but similar EBL with the posterior approach. Op-time did not differ between groups. Control, HL, and HK groups differed in BL TS-CL (36.6° vs. 22.5° vs. 60.7°, P < 0.001) and BL-sagittal vertical axis (SVA) (10.8 vs. 7.0 vs. −47.8 mm, P = 0.001). HL pts had less discectomies, less corpectomies, and similar osteotomy rates to HK. HL had × 3 revisions of HK and controls (28.6 vs. 10.0 vs. 9.2%, respectively, P = 0.046). At 1Y, HL pts had higher cSVA, and trended higher SVA and SS than HK. In terms of BL-upper cervical alignment, HK pts had higher McGregor's-slope (16.1° vs. −3.3°, P = 0.001) and C0-C2 Cobb (43.3° vs. 26.9°, P < 0.001), however postoperative differences in McGregor's slope and C0-C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary computed tomography (38.1%), upper thoracic (23.8%), and C (14.3%) drivers. Conclusions: Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1Y postoperative, perhaps due to undercorrection compared to kyphotic etiologies.
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Affiliation(s)
- Haddy Alas
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Peter Gust Passias
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Downstate Medical Center, State University of New York, Brooklyn, NY, USA
| | - Avery E Brown
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Katherine E Pierce
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Cole Bortz
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, San Francisco, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Juan S Uribe
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Themistocles Protopsaltis
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Orthopaedic Hospital, NY Spine Institute, New York City, USA
| | - Gregory M Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, USA
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