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Mohanty S, Hassan FM, Lenke LG, Lewerenz E, Passias PG, Klineberg EO, Lafage V, Smith JS, Hamilton DK, Gum JL, Lafage R, Mullin J, Diebo B, Buell TJ, Kim HJ, Kebaish K, Eastlack R, Daniels AH, Mundis G, Hostin R, Protopsaltis TS, Hart RA, Gupta M, Schwab FJ, Shaffrey CI, Ames CP, Burton D, Bess S. Machine learning clustering of adult spinal deformity patients identifies four prognostic phenotypes: a multicenter prospective cohort analysis with single surgeon external validation. Spine J 2024; 24:1095-1108. [PMID: 38365004 DOI: 10.1016/j.spinee.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/11/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND CONTEXT Among adult spinal deformity (ASD) patients, heterogeneity in patient pathology, surgical expectations, baseline impairments, and frailty complicates comparisons in clinical outcomes and research. This study aims to qualitatively segment ASD patients using machine learning-based clustering on a large, multicenter, prospectively gathered ASD cohort. PURPOSE To qualitatively segment adult spinal deformity patients using machine learning-based clustering on a large, multicenter, prospectively gathered cohort. STUDY DESIGN/SETTING Machine learning algorithm using patients from a prospective multicenter study and a validation cohort from a retrospective single center, single surgeon cohort with complete 2-year follow up. PATIENT SAMPLE About 805 ASD patients; 563 patients from a prospective multicenter study and 242 from a single center to be used as a validation cohort. OUTCOME MEASURES To validate and extend the Ames-ISSG/ESSG classification using machine learning-based clustering analysis on a large, complex, multicenter, prospectively gathered ASD cohort. METHODS We analyzed a training cohort of 563 ASD patients from a prospective multicenter study and a validation cohort of 242 ASD patients from a retrospective single center/surgeon cohort with complete two-year patient-reported outcomes (PROs) and clinical/radiographic follow-up. Using k-means clustering, a machine learning algorithm, we clustered patients based on baseline PROs, Edmonton frailty, age, surgical history, and overall health. Baseline differences in clusters identified using the training cohort were assessed using Chi-Squared and ANOVA with pairwise comparisons. To evaluate the classification system's ability to discern postoperative trajectories, a second machine learning algorithm assigned the single-center/surgeon patients to the same 4 clusters, and we compared the clusters' two-year PROs and clinical outcomes. RESULTS K-means clustering revealed four distinct phenotypes from the multicenter training cohort based on age, frailty, and mental health: Old/Frail/Content (OFC, 27.7%), Old/Frail/Distressed (OFD, 33.2%), Old/Resilient/Content (ORC, 27.2%), and Young/Resilient/Content (YRC, 11.9%). OFC and OFD clusters had the highest frailty scores (OFC: 3.76, OFD: 4.72) and a higher proportion of patients with prior thoracolumbar fusion (OFC: 47.4%, OFD: 49.2%). ORC and YRC clusters exhibited lower frailty scores and fewest patients with prior thoracolumbar procedures (ORC: 2.10, 36.6%; YRC: 0.84, 19.4%). OFC had 69.9% of patients with global sagittal deformity and the highest T1PA (29.0), while YRC had 70.2% exhibiting coronal deformity, the highest mean coronal Cobb Angle (54.0), and the lowest T1PA (11.9). OFD and ORC had similar alignment phenotypes with intermediate values for Coronal Cobb Angle (OFD: 33.7; ORC: 40.0) and T1PA (OFD: 24.9; ORC: 24.6) between OFC (worst sagittal alignment) and YRC (worst coronal alignment). In the single surgeon validation cohort, the OFC cluster experienced the greatest increase in SRS Function scores (1.34 points, 95%CI 1.01-1.67) compared to OFD (0.5 points, 95%CI 0.245-0.755), ORC (0.7 points, 95%CI 0.415-0.985), and YRC (0.24 points, 95%CI -0.024-0.504) clusters. OFD cluster patients improved the least over 2 years. Multivariable Cox regression analysis demonstrated that the OFD cohort had significantly worse reoperation outcomes compared to other clusters (HR: 3.303, 95%CI: 1.085-8.390). CONCLUSION Machine-learning clustering found four different ASD patient qualitative phenotypes, defined by their age, frailty, physical functioning, and mental health upon presentation, which primarily determines their ability to improve their PROs following surgery. This reaffirms that these qualitative measures must be assessed in addition to the radiographic variables when counseling ASD patients regarding their expected surgical outcomes.
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Affiliation(s)
- Sarthak Mohanty
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | - Fthimnir M Hassan
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA.
| | - Lawrence G Lenke
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | - Erik Lewerenz
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | - Peter G Passias
- Department of Orthopaedic Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health Lenox Hill, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Northwell Health Lenox Hill, New York, NY, USA
| | - Jeffrey Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, University Orthopedics, Providence, RI, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Khalid Kebaish
- Department of Orthopaedic Surgery, John Hopkins Medical Institute, Baltimore, MD, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, University Orthopedics, Providence, RI, USA
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis and Spine Institute, Dallas, TX, USA
| | | | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Northwell Health Lenox Hill, New York, NY, USA
| | | | - Christopher P Ames
- Department of Neurosurgery, University of California San Francisco Spine Center, San Francisco, CA, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
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Pierce KE, Mir JM, Dave P, Lafage R, Lafage V, Park P, Nunley P, Mundis G, Gum J, Tretiakov P, Uribe J, Hostin R, Eastlack R, Diebo B, Kim HJ, Smith JS, Ames CP, Shaffrey C, Burton D, Hart R, Bess S, Klineberg E, Schwab F, Gupta M, Hamilton DK, Passias PG. The Incremental Clinical Benefit of Adding Layers of Complexity to the Planning and Execution of Adult Spinal Deformity Corrective Surgery. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01169. [PMID: 38771063 DOI: 10.1227/ons.0000000000001192] [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: 06/19/2023] [Accepted: 03/01/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES For patients with surgical adult spinal deformity (ASD), our understanding of alignment has evolved, especially in the last 20 years. Determination of optimal restoration of alignment and spinal shape has been increasingly studied, yet the assessment of how these alignment schematics have incrementally added benefit to outcomes remains to be evaluated. METHODS Patients with ASD with baseline and 2-year were included, classified by 4 alignment measures: Scoliosis Research Society (SRS)-Schwab, Age-Adjusted, Roussouly, and Global Alignment and Proportion (GAP). The incremental benefits of alignment schemas were assessed in chronological order as our understanding of optimal alignment progressed. Alignment was considered improved from baseline based on SRS-Schwab 0 or decrease in severity, Age-Adjusted ideal match, Roussouly current (based on sacral slope) matching theoretical (pelvic incidence-based), and decrease in proportion. Patients separated into 4 first improving in SRS-Schwab at 2-year, second Schwab improvement and matching Age-Adjusted, third two prior with Roussouly, and fourth improvement in all four. Comparison was accomplished with means comparison tests and χ2 analyses. RESULTS Sevenhundredthirty-two. patients met inclusion. SRS-Schwab BL: pelvic incidence-lumbar lordosis mismatch (++:32.9%), sagittal vertical axis (++: 23%), pelvic tilt (++:24.6%). 640 (87.4%) met criteria for first, 517 (70.6%) second, 176 (24%) third, and 55 (7.5%) fourth. The addition of Roussouly (third) resulted in lower rates of mechanical complications and proximal junctional kyphosis (48.3%) and higher rates of meeting minimal clinically important difference (MCID) for physical component summary and SRS-Mental (P < .05) compared with the second. Fourth compared with the third had higher rates of MCID for ODI (44.2% vs third: 28.3%, P = .011) and SRS-Appearance (70.6% vs 44.8%, P < .001). Mechanical complications and proximal junctional kyphosis were lower with the addition of Roussouly (P = .024), while the addition of GAP had higher rates of meeting MCID for SRS-22 Appearance (P = .002) and Oswestry Disability Index (P = .085). CONCLUSION Our evaluation of the incremental benefit that alignment schemas have provided in ASD corrective surgery suggests that the addition of Roussouly provided the greatest reduction in mechanical complications, while the incorporation of GAP provided the most significant improvement in patient-reported outcomes.
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Affiliation(s)
- Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Jamshaid M Mir
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Pooja Dave
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedic, Lenox Hill Hospital, Northwell, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedic, Lenox Hill Hospital, Northwell, New York, New York, USA
| | - Paul Park
- Department of Neurologic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Pierce Nunley
- Spine Institute of Louisiana, Shreveport, Louisiana, USA
| | - Gregory Mundis
- San Diego Center for Spinal Disorders, La Jolla, California, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Peter Tretiakov
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Juan Uribe
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, New York, USA
| | - Han Jo Kim
- Department of Orthopedic, Lenox Hill Hospital, Northwell, New York, New York, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, California, USA
| | - Frank Schwab
- Department of Orthopedic, Lenox Hill Hospital, Northwell, New York, New York, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri, USA
| | - D Kojo Hamilton
- Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
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Bess S, Line BG, Nunley P, Ames C, Burton D, Mundis G, Eastlack R, Hart R, Gupta M, Klineberg E, Kim HJ, Kelly M, Hostin R, Kebaish K, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Postoperative Discharge to Acute Rehabilitation or Skilled Nursing Facility Compared With Home Does Not Reduce Hospital Readmissions, Return to Surgery, or Improve Outcomes Following Adult Spine Deformity Surgery. Spine (Phila Pa 1976) 2024; 49:E117-E127. [PMID: 37694516 DOI: 10.1097/brs.0000000000004825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/01/2023] [Indexed: 09/12/2023]
Abstract
STUDY DESIGN Retrospective review of a prospective multicenter adult spinal deformity (ASD) study. OBJECTIVE The aim of this study was to evaluate 30-day readmissions, 90-day return to surgery, postoperative complications, and patient-reported outcomes (PROs) for matched ASD patients receiving nonhome discharge (NON), including acute rehabilitation (REHAB), and skilled nursing facility (SNF), or home (HOME) discharge following ASD surgery. SUMMARY OF BACKGROUND DATA Postoperative disposition following ASD surgery frequently involves nonhome discharge. Little data exists for longer term outcomes for ASD patients receiving nonhome discharge versus patients discharged to home. MATERIALS AND METHODS Surgically treated ASD patients prospectively enrolled into a multicenter study were assessed for NON or HOME disposition following hospital discharge. NON was further divided into REHAB or SNF. Propensity score matching was used to match for patient age, frailty, spine deformity, levels fused, and osteotomies performed at surgery. Thirty-day hospital readmissions, 90-day return to surgery, postoperative complications, and 1-year and minimum 2-year postoperative PROs were evaluated. RESULTS A total of 241 of 374 patients were eligible for the study. NON patients were identified and matched to HOME patients. Following matching, 158 patients remained for evaluation; NON and HOME had similar preoperative age, frailty, spine deformity magnitude, surgery performed, and duration of hospital stay ( P >0.05). Thirty-day readmissions, 90-day return to surgery, and postoperative complications were similar for NON versus HOME and similar for REHAB (N=64) versus SNF (N=42) versus HOME ( P >0.05). At 1-year and minimum 2-year follow-up, HOME demonstrated similar to better PRO scores including Oswestry Disability Index, Short-Form 36v2 questionnaire Mental Component Score and Physical Component Score, and Scoliosis Research Society scores versus NON, REHAB, and SNF ( P <0.05). CONCLUSIONS Acute needs must be considered following ASD surgery, however, matched analysis comparing 30-day hospital readmissions, 90-day return to surgery, postoperative complications, and PROs demonstrated minimal benefit for NON, REHAB, or SNF versus HOME at 1- and 2-year follow-up, questioning the risk and cost/benefits of routine use of nonhome discharge. LEVEL OF EVIDENCE Level III-prognostic.
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Affiliation(s)
- Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Breton G Line
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Pierce Nunley
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas School of Medicine, Kansas City, KS
| | | | | | | | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael Kelly
- Department of Orthopedic Surgery, San Diego Children's Hospital, San Diego, CA
| | | | - Khaled Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Virgine Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Frank Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA
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4
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Ani F, Sissman E, Woo D, Soroceanu A, Mundis G, Eastlack RK, Smith JS, Hamilton DK, Kim HJ, Daniels AH, Klineberg EO, Neuman B, Sciubba DM, Gupta MC, Kebaish KM, Passias PG, Hart RA, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Ames CP, Protopsaltis TS. Are insufficient corrections a major factor in distal junctional kyphosis? A simulated analysis of cervical deformity correction using in-construct measurements. J Neurosurg Spine 2024; 40:622-629. [PMID: 38364226 DOI: 10.3171/2023.12.spine23481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 12/13/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE The present study utilized recently developed in-construct measurements in simulations of cervical deformity surgery in order to assess undercorrection and predict distal junctional kyphosis (DJK). METHODS A retrospective review of a database of operative cervical deformity patients was analyzed for severe DJK and mild DJK. C2-lower instrumented vertebra (LIV) sagittal angle (SA) was measured postoperatively, and the correction was simulated in the preoperative radiograph in order to match the C2-LIV by using the planning software. Linear regression analysis that used C2 pelvic angle (CPA) and pelvic tilt (PT) determined the simulated PT that matched the virtual CPA. Linear regression analysis was used to determine the C2-T1 SA, C2-T4 SA, and C2-T10 SA that corresponded to DJK of 20° and cervical sagittal vertical axis (cSVA) of 40 mm. RESULTS Sixty-nine cervical deformity patients were included. Severe and mild DJK occurred in 11 (16%) and 22 (32%) patients, respectively; 3 (4%) required DJK revision. Simulated corrections demonstrated that severe and mild DJK patients had worse alignment compared to non-DJK patients in terms of cSVA (42.5 mm vs 33.0 mm vs 23.4 mm, p < 0.001) and C2-LIV SVA (68.9 mm vs 57.3 mm vs 36.8 mm, p < 0.001). Linear regression revealed the relationships between in-construct measures (C2-T1 SA, C2-T4 SA, and C2-T10 SA), cSVA, and change in DJK (all R > 0.57, p < 0.001). A cSVA of 40 mm corresponded to C2-T4 SA of 10.4° and C2-T10 SA of 28.0°. A DJK angle change of 10° corresponded to C2-T4 SA of 5.8° and C2-T10 SA of 20.1°. CONCLUSIONS Simulated cervical deformity corrections demonstrated that severe DJK patients have insufficient corrections compared to patients without DJK. In-construct measures assess sagittal alignment within the fusion separate from DJK and subjacent compensation. They can be useful as intraoperative tools to gauge the adequacy of cervical deformity correction.
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Affiliation(s)
- Fares Ani
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ethan Sissman
- 2Department of Orthopedic Surgery, Chaim Sheba Medical Center Hospital, Tel Aviv University, Tel Aviv, Israel
| | - Dainn Woo
- 3Department of Orthopedic Surgery, Penn Medicine, Philadelphia, Pennsylvania
| | - Alex Soroceanu
- 4Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Robert K Eastlack
- 6Department of Orthopaedic Surgery, Scripps Spine Center, La Jolla, California
| | - Justin S Smith
- 7Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - D Kojo Hamilton
- 8The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Han Jo Kim
- 9Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Alan H Daniels
- 10Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Brian Neuman
- 12Department of Orthopaedics, Johns Hopkins University, Baltimore, Maryland
| | | | - Munish C Gupta
- 14Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Khaled M Kebaish
- 12Department of Orthopaedics, Johns Hopkins University, Baltimore, Maryland
| | - Peter G Passias
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Robert A Hart
- 15Swedish Neuroscience Institute, Seattle, Washington
| | - Shay Bess
- 16Denver International Spine Center, Denver, Colorado
| | - Christopher I Shaffrey
- 17Department of Orthopaedic Surgery, University of Virginia Medical Center, Charlottesville, Virginia; and
| | | | | | - Christopher P Ames
- 18Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
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Bass RD, Lafage R, Smith JS, Ames C, Bess S, Eastlack R, Gupta M, Hostin R, Kebaish K, Kim HJ, Klineberg E, Mundis G, Okonkwo D, Shaffrey C, Schwab F, Lafage V, Burton D. Benchmark Values for Construct Survival and Complications by Type of ASD Surgery. Spine (Phila Pa 1976) 2024:00007632-990000000-00643. [PMID: 38616765 DOI: 10.1097/brs.0000000000005012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/24/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE Provide benchmarks for the rates of complications by type of surgery performed. STUDY DESIGN Prospective multicenter database. BACKGROUND We have previously examined overall construct survival and complication rates for ASD surgery. However, the relationship between type of surgery and construct survival warrants more detailed assessment. METHODS Eight surgical scenarios were defined based on the levels treated, previous fusion status (primary [P] vs. revision [R]), and 3-column osteotomy use [3CO]: Short Lumbar fusion, LT-Pelvis with 5-12 levels treated (P, R or 3CO), UT-Pelvis with 13 levels treated (P, R or 3CO), and Thoracic to Lumbar fusion without pelvic fixation, representing 92.4% of the case in the cohort. Complication rates for each type were calculated and Kaplan Meier curves with multivariate Cox regression analysis was used to evaluate the effect of the case characteristics on construct survival rate, while controlling for patient profile. RESULTS 1073 of 1494 patients eligible for 2-year follow-up (71.8%) were captured. Survival curves for major complications (with or without reoperation), while controlling for demographics differed significantly among surgical types (P<0.001). Fusion procedures short of the pelvis had the best survival rate, while UT-Pelvis with 3CO had the worst survival rate. Longer fusions and more invasive operations were associated with lower 2-year complication-free survival, however there were no significant associations between type of surgery and renal, cardiac, infection, wound, gastrointestinal, pulmonary, implant malposition or neurologic complications (all P>0.5). CONCLUSION This study suggests that there is an inherent increased risk of complication for some types of ASD surgery independent of patient profile. The results of this paper can be used to produce a surgery-adjusted benchmark for ASD surgery with regard to complications and survival. Such a tool can have very impactful applications for surgical decision making and more informed patient counseling.
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Affiliation(s)
- R Daniel Bass
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
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6
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Dave P, Lafage R, Smith JS, Line BG, Tretiakov PS, Mir J, Diebo B, Daniels AH, Gum JL, Hamilton DK, Buell T, Than KD, Fu KM, Scheer JK, Eastlack R, Mullin JP, Mundis G, Hosogane N, Yagi M, Nunley P, Chou D, Mummaneni PV, Klineberg EO, Kebaish KM, Lewis S, Hostin RA, Gupta MC, Kim HJ, Ames CP, Hart RA, Lenke LG, Shaffrey CI, Bess S, Schwab FJ, Lafage V, Burton DC, Passias PG. Predictors of pelvic tilt normalization: a multicenter study on the impact of regional and lower-extremity compensation on pelvic alignment after complex adult spinal deformity surgery. J Neurosurg Spine 2024; 40:505-512. [PMID: 38215449 DOI: 10.3171/2023.11.spine23766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/13/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVE The objective was to determine the degree of regional decompensation to pelvic tilt (PT) normalization after complex adult spinal deformity (ASD) surgery. METHODS Operative ASD patients with 1 year of PT measurements were included. Patients with normalized PT at baseline were excluded. Predicted PT was compared to actual PT, tested for change from baseline, and then compared against age-adjusted, Scoliosis Research Society-Schwab, and global alignment and proportion (GAP) scores. Lower-extremity (LE) parameters included the cranial-hip-sacrum angle, cranial-knee-sacrum angle, and cranial-ankle-sacrum angle. LE compensation was set as the 1-year upper tertile compared with intraoperative baseline. Univariate analyses were used to compare normalized and nonnormalized data against alignment outcomes. Multivariable logistic regression analyses were used to develop a model consisting of significant predictors for normalization related to regional compensation. RESULTS In total, 156 patients met the inclusion criteria (mean ± SD age 64.6 ± 9.1 years, BMI 27.9 ± 5.6 kg/m2, Charlson Comorbidity Index 1.9 ± 1.6). Patients with normalized PT were more likely to have overcorrected pelvic incidence minus lumbar lordosis and sagittal vertical axis at 6 weeks (p < 0.05). GAP score at 6 weeks was greater for patients with nonnormalized PT (0.6 vs 1.3, p = 0.08). At baseline, 58.5% of patients had compensation in the thoracic and cervical regions. Postoperatively, compensation was maintained by 42% with no change after matching in age-adjusted or GAP score. The patients with nonnormalized PT had increased rates of thoracic and cervical compensation (p < 0.05). Compensation in thoracic kyphosis differed between patients with normalized PT at 6 weeks and those with normalized PT at 1 year (69% vs 35%, p < 0.05). Those who compensated had increased rates of implant complications by 1 year (OR [95% CI] 2.08 [1.32-6.56], p < 0.05). Cervical compensation was maintained at 6 weeks and 1 year (56% vs 43%, p = 0.12), with no difference in implant complications (OR 1.31 [95% CI -2.34 to 1.03], p = 0.09). For the lower extremities at baseline, 61% were compensating. Matching age-adjusted alignment did not eliminate compensation at any joint (all p > 0.05). Patients with nonnormalized PT had higher rates of LE compensation across joints (all p < 0.01). Overall, patients with normalized PT at 1 year had the greatest odds of resolving LE compensation (OR 9.6, p < 0.001). Patients with normalized PT at 1 year had lower rates of implant failure (8.9% vs 19.5%, p < 0.05), rod breakage (1.3% vs 13.8%, p < 0.05), and pseudarthrosis (0% vs 4.6%, p < 0.05) compared with patients with nonnormalized PT. The complication rate was significantly lower for patients with normalized PT at 1 year (56.7% vs 66.1%, p = 0.02), despite comparable health-related quality of life scores. CONCLUSIONS Patients with PT normalization had greater rates of resolution in thoracic and LE compensation, leading to lower rates of complications by 1 year. Thus, consideration of both the lower extremities and thoracic regions in surgical planning is vital to preventing adverse outcomes and maintaining pelvic alignment.
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Affiliation(s)
- Pooja Dave
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Renaud Lafage
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton G Line
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Peter S Tretiakov
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Jamshaid Mir
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Bassel Diebo
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Alan H Daniels
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Jeffrey L Gum
- 6Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - D Kojo Hamilton
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas Buell
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Khoi D Than
- 8Departments of Neurosurgery and Orthopaedic Surgery, Spine Division, Duke University School of Medicine, Durham, North Carolina
| | - Kai-Ming Fu
- 9Department of Neurological Surgery, Weill Cornell Medicine Brain and Spine Center/NewYork-Presbyterian Lower Manhattan Hospital, New York, New York
| | - Justin K Scheer
- 10Department of Neurosurgery, Columbia University, New York, New York
| | - Robert Eastlack
- 11Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Jeffrey P Mullin
- 12Department of Neurosurgery at University at Buffalo Medical School, Buffalo, New York
| | - Gregory Mundis
- 11Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Naobumi Hosogane
- 13Division of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Mitsuru Yagi
- 14Department of Orthopedic surgery, Keio University School of Medicine, Shinjyuku, Tokyo, Japan
- 26Department of Orthopedic Surgery, International University of Health and Welfare School of Medicine, Chiba, Narita, Japan
| | - Pierce Nunley
- 15Spine Institute of Louisiana, Shreveport, Louisiana
| | - Dean Chou
- 10Department of Neurosurgery, Columbia University, New York, New York
| | - Praveen V Mummaneni
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Eric O Klineberg
- 17Department of Orthopedic Surgery, University of California Davis, Sacramento, California
| | - Khaled M Kebaish
- 18Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Stephen Lewis
- 19Department of Surgery, Division of Neurosurgery, University of Toronto, Ontario, Canada
| | - Richard A Hostin
- 20Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas
| | - Munish C Gupta
- 21Department of Orthopaedic Surgery, Washington University of St. Louis, Missouri
| | - Han Jo Kim
- 2Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | - Christopher P Ames
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert A Hart
- 22Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Lawrence G Lenke
- 23Department of Orthopaedic Surgery, Columbia College of Physicians and Surgeons, New York, New York
| | - Christopher I Shaffrey
- 8Departments of Neurosurgery and Orthopaedic Surgery, Spine Division, Duke University School of Medicine, Durham, North Carolina
| | - Shay Bess
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Frank J Schwab
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Virginie Lafage
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Douglas C Burton
- 25Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Peter G Passias
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
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Mullin JP, Soliman MAR, Smith JS, Kelly MP, Buell TJ, Diebo B, Scheer JK, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias PG, Gum JL, Kebaish K, Eastlack RK, Daniels AH, Soroceanu A, Mundis G, Hostin R, Protopsaltis TS, Hamilton DK, Gupta MC, Lewis SJ, Schwab FJ, Lenke LG, Shaffrey CI, Bess S, Ames CP, Burton D. Analysis of tranexamic acid usage in adult spinal deformity patients with relative contraindications: does it increase the risk of complications? J Neurosurg Spine 2024:1-8. [PMID: 38457792 DOI: 10.3171/2024.1.spine231098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/08/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Complex spinal deformity surgeries may involve significant blood loss. The use of antifibrinolytic agents such as tranexamic acid (TXA) has been proven to reduce perioperative blood loss. However, for patients with a history of thromboembolic events, there is concern of increased risk when TXA is used during these surgeries. This study aimed to assess whether TXA use in patients undergoing complex spinal deformity correction surgeries increases the risk of thromboembolic complications based on preexisting thromboembolic risk factors. METHODS Data were analyzed for adult patients who received TXA during surgical correction for spinal deformity at 21 North American centers between August 2018 and October 2022. Patients with preexisting thromboembolic events and other risk factors (history of deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, peripheral vascular disease, or cancer) were identified. Thromboembolic complication rates were assessed during the postoperative 90 days. Univariate and multivariate analyses were performed to assess thromboembolic outcomes in high-risk and low-risk patients who received intravenous TXA. RESULTS Among 411 consecutive patients who underwent complex spinal deformity surgery and received TXA intraoperatively, 130 (31.6%) were considered high-risk patients. There was no significant difference in thromboembolic complications between patients with and those without preexisting thromboembolic risk factors in univariate analysis (high-risk group vs low-risk group: 8.5% vs 2.8%, p = 0.45). Specifically, there were no significant differences between groups regarding the 90-day postoperative rates of DVT (high-risk group vs low-risk group: 1.5% vs 1.4%, p = 0.98), PE (2.3% vs 1.8%, p = 0.71), acute MI (1.5% vs 0%, p = 0.19), or stroke (0.8% vs 1.1%, p > 0.99). On multivariate analysis, high-risk status was not a significant independent predictor for any of the thromboembolic complications. CONCLUSIONS Administration of intravenous TXA during the correction procedure did not change rates of thromboembolic events, acute MI, or stroke in this cohort of adult spinal deformity surgery patients.
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Affiliation(s)
- Jeffrey P Mullin
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York
- 2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York
| | - Mohamed A R Soliman
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York
- 3Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Justin S Smith
- 4Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Michael P Kelly
- 5Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Thomas J Buell
- 6Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bassel Diebo
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Justin K Scheer
- 8Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Breton Line
- 9Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Virginie Lafage
- 10Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Renaud Lafage
- 10Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Eric Klineberg
- 11Department of Orthopedic Surgery, University of Texas Health Houston, Houston, Texas
| | - Han Jo Kim
- 12Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter G Passias
- 13Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | - Khaled Kebaish
- 15Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert K Eastlack
- 16Department of Orthopedic Surgery, Scripps Clinic, San Diego, California
| | - Alan H Daniels
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Alex Soroceanu
- 17Department of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Mundis
- 16Department of Orthopedic Surgery, Scripps Clinic, San Diego, California
| | - Richard Hostin
- 18Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | | | - D Kojo Hamilton
- 6Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Munish C Gupta
- 19Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Stephen J Lewis
- 20Department of Surgery, Division of Orthopedic Surgery, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Frank J Schwab
- 10Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Lawrence G Lenke
- 21Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Christopher I Shaffrey
- 22Departments of Neurosurgery and Orthopedic Surgery, Spine Division, Duke University, Durham, North Carolina; and
| | - Shay Bess
- 9Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Christopher P Ames
- 8Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Douglas Burton
- 23Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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8
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Lafage R, Bass RD, Klineberg E, Smith JS, Bess S, Shaffrey C, Burton DC, Kim HJ, Eastlack R, Mundis G, Ames CP, Passias PG, Gupta M, Hostin R, Hamilton K, Schwab F, Lafage V. Complication Rates Following Adult Spinal Deformity Surgery: Evaluation of the Category of Complication and Chronology. Spine (Phila Pa 1976) 2024:00007632-990000000-00600. [PMID: 38375636 DOI: 10.1097/brs.0000000000004969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 02/12/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVE Provide benchmarks for the rates of complications by type and timing. STUDY DESIGN Prospective multicenter database. BACKGROUND Complication rates following adult spinal deformity (ASD) surgery have been previously reported. However, the interplay between timing and complication type warrants further analysis. METHODS The data for this study were sourced from a prospective, multicenter ASD database. Date and type of complication were collected and classified into three severity groups (minor, major, major leading to reoperation). Only complications occurring before the 2-year visit were retained for analysis. RESULTS Of the 1260 patients eligible for 2-year follow-up, 997 (79.1%) achieved 2-year follow-up. The overall complication rate was 67.4% (N=672). 247 patients (24.8%) experienced at least one complication on the day of surgery (including intra-operatively), 359 (36.0%) between post-op day 1 and 6 weeks post-op, 271 (27.2%) between 6 weeks and 1 one -year post-op, and finally 162 (16.3%) between 1 year and 2 years post-op. Using Kaplan-Meier survival analysis, the rate of remaining complication-free was estimated at different time points for different severities and types of complications. Stratification by type of complication demonstrated that most of the medical complications occurred within the first 60 days. Surgical complications presented over two distinct timeframes. Operative complications, incision-related complications, and infections occurred early (within 60 d), while implant-related and radiographic complications occurred at a constant rate over the 2-year follow-up period. Neurologic complications had the highest occurrence within the first 60 days but continued to increase up to the 2-year visit. CONCLUSION Only one-third of ASD patients remained complication-free by 2 years, and 2 out of 10 patients had a complication requiring a reoperation or revision. Estimation of timing and type of complication associated with surgical treatment may prove useful for more meaningful patient counseling and aid in assessing the cost-effectiveness of treatment.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - R Daniel Bass
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | | | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Christopher P Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Peter G Passias
- Departments of Orthopedic Surgery, NYU Langone, New York, NY
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO
| | | | - Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
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9
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Lovecchio F, Lafage R, Kim HJ, Bess S, Ames C, Gupta M, Passias P, Klineberg E, Mundis G, Burton D, Smith JS, Shaffrey C, Schwab F, Lafage V. Revision-Free Loss of Sagittal Correction Greater Than Three Years After Adult Spinal Deformity Surgery: Who and Why? Spine (Phila Pa 1976) 2024; 49:157-164. [PMID: 37847773 DOI: 10.1097/brs.0000000000004852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 10/19/2023]
Abstract
STUDY DESIGN Multicenter retrospective cohort study. OBJECTIVE To investigate risk factors for loss of correction within the instrumented lumbar spine after adult spinal deformity surgery. SUMMARY OF BACKGROUND DATA The sustainability of adult spinal deformity surgery remains a health care challenge. Malalignment is a major reason for revision surgery. PATIENTS AND METHODS A total of 321 patients who underwent fusion of the lumbar spine (≥5 levels, LIV pelvis) with a revision-free follow-up of ≥3 years were identified. Patients were stratified by a change in pelvic incidence-lumbar lordosis from 6 weeks to 3 years postoperative as "maintained" versus "loss" >5°. Those with instrumentation failure (broken rod, screw pullout, etc .) were excluded before comparisons. Demographics, surgical data, and radiographic alignment were compared. Repeated measure analysis of variance was performed to evaluate the maintenance of the correction for L1-L4 and L4-S1. Multivariate logistic regression was conducted to identify independent surgical predictors of correction loss. RESULTS The cohort had a mean age of 64 years, a mean Body Mass Index of 28 kg/m 2 , and 80% females. Eighty-two patients (25.5%) lost >5° of pelvic incidence-lumbar lordosis correction (mean loss 10±5°). After the exclusion of patients with instrumentation failure, 52 losses were compared with 222 maintained. Demographics, osteotomies, 3CO, interbody fusion, use of bone morphogenetic protein, rod material, rod diameter, and fusion length were not significantly different. L1-S1 screw orientation angle was 1.3 ± 4.1 from early postoperative to 3 years ( P = 0.031), but not appreciably different at L4-S1 (-0.1 ± 2.9 P = 0.97). Lack of a supplemental rod (odds ratio: 4.0, P = 0.005) and fusion length (odds ratio 2.2, P = 0.004) were associated with loss of correction. CONCLUSIONS Approximately, a quarter of revision-free patients lose an average of 10° of their 6-week correction by 3 years. Lordosis is lost proximally through the instrumentation ( i.e. tulip/shank angle shifts and/or rod bending). The use of supplemental rods and avoiding sagittal overcorrection may help mitigate this loss.
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Affiliation(s)
- Francis Lovecchio
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Han Jo Kim
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center/Presbyterian St. Luke's Medical Center, Denver, CO
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, IL
| | - Peter Passias
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Eric Klineberg
- Department of Orthopedic Surgery, The University of Texas Health Science Center of Houston, Houston, TX
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, La Jolla, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher Shaffrey
- Department of Neurosurgery and Orthopedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Frank Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
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Passias PG, Krol O, Williamson TK, Lafage V, Lafage R, Smith JS, Line B, Vira S, Lipa S, Daniels A, Diebo B, Schoenfeld A, Gum J, Kebaish K, Park P, Mundis G, Hostin R, Gupta MC, Eastlack R, Anand N, Ames C, Hart R, Burton D, Schwab FJ, Shaffrey C, Klineberg E, Bess S. The Benefit of Addressing Malalignment in Revision Surgery for Proximal Junctional Kyphosis Following ASD Surgery. Spine (Phila Pa 1976) 2023; 48:1581-1587. [PMID: 36083599 DOI: 10.1097/brs.0000000000004476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/23/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Understand the benefit of addressing malalignment in revision surgery for proximal junctional kyphosis (PJK). SUMMARY OF BACKGROUND DATA PJK is a common cause of revision surgery for adult spinal deformity patients. During a revision, surgeons may elect to perform a proximal extension of the fusion, or also correct the source of the lumbopelvic mismatch. MATERIALS AND METHODS Recurrent PJK following revision surgery was the primary outcome. Revision surgical strategy was the primary predictor (proximal extension of fusion alone compared with combined sagittal correction and proximal extension). Multivariable logistic regression determined rates of recurrent PJK between the two surgical groups with lumbopelvic surgical correction assessed through improving ideal alignment in one or more alignment criteria [Global Alignment and Proportionality (GAP), Roussouly-type, and Sagittal Age-Adjusted Score (SAAS)]. RESULTS A total of 151 patients underwent revision surgery for PJK. PJK occurred at a rate of 43.0%, and PJF at 12.6%. Patients proportioned in GAP postrevision had lower rates of recurrent PJK [23% vs. 42%; odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8, P =0.024]. Following adjusted analysis, patients who were ideally aligned in one of three criteria (Matching in SAAS and/or Roussouly matched and/or achieved GAP proportionality) had lower rates of recurrent PJK (36% vs. 53%; OR: 0.4, 95% CI: 0.1-0.9, P =0.035) and recurrent PJF (OR: 0.1, 95% CI: 0.02-0.7, P =0.015). Patients ideally aligned in two of three criteria avoid any development of PJF (0% vs. 16%, P <0.001). CONCLUSIONS Following revision surgery for PJK, patients with persistent poor sagittal alignment showed increased rates of recurrent PJK compared with patients who had abnormal lumbopelvic alignment corrected during the revision. These findings suggest addressing the root cause of surgical failure in addition to proximal extension of the fusion may be beneficial.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Oscar Krol
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Shaleen Vira
- Department of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, TX
| | - Shaina Lipa
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Alan Daniels
- Department of Orthopedics, Brown University, Warren Alpert Medical School, Providence, RI
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY
| | - Andrew Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, MD
| | - Paul Park
- Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, TX
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
| | - Robert Eastlack
- Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, CA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
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Smith JS, Kelly MP, Buell TJ, Ben-Israel D, Diebo B, Scheer JK, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias P, Gum JL, Kebaish K, Mullin JP, Eastlack R, Daniels A, Soroceanu A, Mundis G, Hostin R, Protopsaltis TS, Hamilton DK, Gupta M, Lewis SJ, Schwab FJ, Lenke LG, Shaffrey CI, Burton D, Ames CP, Bess S. Adult Cervical Deformity Patients Have Higher Baseline Frailty, Disability, and Comorbidities Compared With Complex Adult Thoracolumbar Deformity Patients: A Comparative Cohort Study of 616 Patients. Global Spine J 2023:21925682231214059. [PMID: 37948666 DOI: 10.1177/21925682231214059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
STUDY DESIGN Multicenter comparative cohort. OBJECTIVE Studies have shown markedly higher rates of complications and all-cause mortality following surgery for adult cervical deformity (ACD) compared with adult thoracolumbar deformity (ATLD), though the reasons for these differences remain unclear. Our objectives were to compare baseline frailty, disability, and comorbidities between ACD and complex ATLD patients undergoing surgery. METHODS Two multicenter prospective adult spinal deformity registries were queried, one ATLD and one ACD. Baseline clinical and frailty measures were compared between the cohorts. RESULTS 616 patients were identified (107 ACD and 509 ATLD). These groups had similar mean age (64.6 vs 60.8 years, respectively, P = .07). ACD patients were less likely to be women (51.9% vs 69.5%, P < .001) and had greater Charlson Comorbidity Index (1.5 vs .9, P < .001) and ASA grade (2.7 vs 2.4, P < .001). ACD patients had worse VR-12 Physical Component Score (PCS, 25.7 vs 29.9, P < .001) and PROMIS Physical Function Score (33.3 vs 35.3, P = .031). All frailty measures were significantly worse for ACD patients, including hand dynamometer (44.6 vs 55.6 lbs, P < .001), CSHA Clinical Frailty Score (CFS, 4.0 vs 3.2, P < .001), and Edmonton Frailty Scale (EFS, 5.15 vs 3.21, P < .001). Greater proportions of ACD patients were frail (22.9% vs 5.7%) or vulnerable (15.6% vs 10.9%) based on EFS (P < .001). CONCLUSIONS Compared with ATLD patients, ACD patients had worse baseline characteristics on all measures assessed (comorbidities/disability/frailty). These differences may help account for greater risk of complications and all-cause mortality previously observed in ACD patients and facilitate strategies for better preoperative optimization.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Thomas J Buell
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Ben-Israel
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Breton Line
- Presbyterian St Lukes Medical Center, Denver, CO, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of Texas Health Houston, Houston, TX, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | | | - Khal Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, USA
| | - Alan Daniels
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX, USA
| | | | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO, USA
| | - Stephen J Lewis
- Department of Surgery, Division of Orthopedic Surgery, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Shay Bess
- Presbyterian St Lukes Medical Center, Denver, CO, USA
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12
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Lafage R, Smith JS, Soroceanu A, Ames C, Passias P, Shaffrey C, Mundis G, Alshabab BS, Protopsaltis T, Klineberg E, Elysee J, Kim HJ, Bess S, Schwab F, Lafage V. Predicting Mechanical Failure Following Cervical Deformity Surgery: A Composite Score Integrating Age-Adjusted Cervical Alignment Targets. Global Spine J 2023; 13:2432-2438. [PMID: 35350922 PMCID: PMC10538337 DOI: 10.1177/21925682221086535] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Investigate a composite score to evaluate the relationship between alignment proportionality and risk of distal junctional kyphosis (DJK). METHODS 84 patients with minimum 1 year follow-up were included (age = 61.1 ± 10.3 years, 64.3% women). The Cervical Score was constructed using offsets from age-adjusted normative values for sagittal vertical axis (SVA), T1 Slope (TS), and TS minus cervical lordosis (CL). Individual points were assigned based on offset with age-adjusted alignment targets and summed to generate the Cervical Score. Rates of mechanical failure (DJK revision or severe DJK [DJK> 20° and ΔDJK> 10°]) were assessed overall and based on Cervical Score. Logistical regressions assessed associations between early radiographic alignment and 1-year failure rate. RESULTS Mechanical failure rate was 21.4% (N = 18), 10.7% requiring revision. By multivariate logistical regression: 3-month T1S (OR: .935), TS-CL (OR:0.882), and SVA (OR:1.015) were independent predictors of 1-year failure (all P < .05). Cervical Score ranged (-6 to 6), 37.8% of patients between -1 and 1, and 50.0% with 2 or higher. DJK patients had significantly higher Cervical Score (4.1 ± 1.3 vs .6 ± 2.2, P < .001). Patients with a score ≥3 were significantly more likely to develop a failure (71.4%) with OR of 38.55 (95%CI [7.73; 192.26]) and Nagelkerke r2 .524 (P < .001). CONCLUSION This study developed a composite alignment score predictive of mechanical failures in CD surgery. A score ≥3 at 3 months following surgery was associated with a marked increase in failure rate. The Cervical Score can be used to analyze sagittal alignment and help define realignment objectives to reduce mechanical failure.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | | | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | | | - Basel Sheikh Alshabab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - On behalf of the International Spine Study Group (ISSG)
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
- Department of Surgery, University of Calgary, Calgary, AB, Canada
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- Scripps Clinic, San Diego, CA, USA
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
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13
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Wick JB, Blandino A, Smith JS, Line BG, Lafage V, Lafage R, Kim HJ, Passias PG, Gum JL, Kebaish KM, Eastlack RK, Daniels A, Mundis G, Hostin R, Protopsaltis T, Hamilton DK, Kelly MP, Gupta M, Hart RA, Schwab FJ, Burton DC, Ames CP, Lenke LG, Shaffrey CI, Bess S, Klineberg E. The ISSG-AO Complication Intervention Score, but Not Major/Minor Designation, is Correlated With Length of Stay Following Adult Spinal Deformity Surgery. Global Spine J 2023:21925682231202782. [PMID: 37725904 DOI: 10.1177/21925682231202782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
STUDY DESIGN Retrospective review. OBJECTIVES The International Spine Study Group-AO (ISSG-AO) Adult Spinal Deformity (ASD) Complication Classification System was developed to improve classification, reporting, and study of complications among patients undergoing ASD surgery. The ISSG-AO system classifies interventions to address complications by level of invasiveness: grade zero (none); grade 1, mild (e.g., medication change); grade 2, moderate (e.g., ICU admission); grade 3, severe (e.g., reoperation related to surgery of interest). To evaluate the efficacy of the ISSG-AO ASD Complication Classification System, we aimed to compare correlations between postoperative length of stay (LOS) and complication severity as classified by the ISSG-AO ASD and traditional major/minor complication classification systems. METHODS Patients age ≥18 in a multicenter ASD database who sustained in-hospital complications were identified. Complications were classified with the major/minor and ISSG-AO systems and correlated with LOS using an ensemble-based machine learning algorithm (conditional random forest) and a generalized linear mixed model. RESULTS 490 patients at 19 sites were included. 64.9% of complications were major, and 35.1% were minor. By ISSG-AO classification, 20.4%, 66.1%, 6.7%, and 6.7% were grades 0-3, respectively. ISSG-AO complication grading demonstrated significant correlation with LOS, whereas major/minor complication classification demonstrated inverse correlation with LOS. In conditional random forest analysis, ISSG-AO classification had the greatest relative importance when assessing correlations across multiple variables with LOS. CONCLUSIONS The ISSG-AO system may help identify specific complications associated with prolonged LOS. Targeted interventions to avoid or reduce these complications may improve ASD surgical quality and resource utilization.
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Affiliation(s)
- Joseph B Wick
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Andrew Blandino
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Justin S Smith
- Department of Neurosurgery, Medical Center, University of Virginia, Charlottesville, VA, USA
| | - Breton G Line
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, CO, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Peter G Passias
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Jeffrey L Gum
- Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, KY, USA
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Robert K Eastlack
- Department of Orthopedics, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - Alan Daniels
- Department of Orthopedics, Brown University, Providence, RI, USA
| | - Gregory Mundis
- Department of Orthopedics, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - Richard Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | | | - D Kojo Hamilton
- Department of Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Robert A Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Frank J Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University, New York, NY, USA
| | | | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of Texas, Houston, TX, USA
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14
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Tretiakov PS, Lafage R, Smith JS, Line BG, Diebo BG, Daniels AH, Gum J, Protopsaltis T, Hamilton DK, Soroceanu A, Scheer JK, Eastlack RK, Mundis G, Nunley PD, Klineberg EO, Kebaish K, Lewis S, Lenke L, Hostin R, Gupta MC, Ames CP, Hart RA, Burton D, Shaffrey CI, Schwab F, Bess S, Kim HJ, Lafage V, Passias PG. Calibration of a comprehensive predictive model for the development of proximal junctional kyphosis and failure in adult spinal deformity patients with consideration of contemporary goals and techniques. J Neurosurg Spine 2023; 39:311-319. [PMID: 37310039 DOI: 10.3171/2023.4.spine221412] [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: 12/24/2022] [Accepted: 04/17/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The objective of this study was to calibrate an updated predictive model incorporating novel clinical, radiographic, and prophylactic measures to assess the risk of proximal junctional kyphosis (PJK) and failure (PJF). METHODS Operative patients with adult spinal deformity (ASD) and baseline and 2-year postoperative data were included. PJK was defined as ≥ 10° in sagittal Cobb angle between the inferior uppermost instrumented vertebra (UIV) endplate and superior endplate of the UIV + 2 vertebrae. PJF was radiographically defined as a proximal junctional sagittal Cobb angle ≥ 15° with the presence of structural failure and/or mechanical instability, or PJK with reoperation. Backstep conditional binary supervised learning models assessed baseline demographic, clinical, and surgical information to predict the occurrence of PJK and PJF. Internal cross validation of the model was performed via a 70%/30% cohort split. Conditional inference tree analysis determined thresholds at an alpha level of 0.05. RESULTS Seven hundred seventy-nine patients with ASD (mean 59.87 ± 14.24 years, 78% female, mean BMI 27.78 ± 6.02 kg/m2, mean Charlson Comorbidity Index 1.74 ± 1.71) were included. PJK developed in 50.2% of patients, and 10.5% developed PJF by their last recorded visit. The six most significant demographic, radiographic, surgical, and postoperative predictors of PJK/PJF were baseline age ≥ 74 years, baseline sagittal age-adjusted score (SAAS) T1 pelvic angle modifier > 1, baseline SAAS pelvic tilt modifier > 0, levels fused > 10, nonuse of prophylaxis measures, and 6-week SAAS pelvic incidence minus lumbar lordosis modifier > 1 (all p < 0.015). Overall, the model was deemed significant (p < 0.001), and internally validated receiver operating characteristic analysis returned an area under the curve of 0.923, indicating robust model fit. CONCLUSIONS PJK and PJF remain critical concerns in ASD surgery, and efforts to reduce the occurrence of PJK and PJF have resulted in the development of novel prophylactic techniques and enhanced clinical and radiographic selection criteria. This study demonstrates a validated model incorporating such techniques that may allow for the prediction of clinically significant PJK and PJF, and thus assist in optimizing patient selection, enhancing intraoperative decision making, and reducing postoperative complications in ASD surgery.
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Affiliation(s)
- Peter S Tretiakov
- 1Department of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 8Department of Orthopaedic Surgery, New York Spine Institute, New York, New York
| | - Renaud Lafage
- 2Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Breton G Line
- 4Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Bassel G Diebo
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Alan H Daniels
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Jeffrey Gum
- 6Norton Leatherman Spine Center, Louisville, Kentucky
| | - Themistocles Protopsaltis
- 1Department of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - D Kojo Hamilton
- 7Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alex Soroceanu
- 7Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Justin K Scheer
- 9Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert K Eastlack
- 10Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Gregory Mundis
- 10Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | | | - Eric O Klineberg
- 12Department of Orthopaedic Surgery, University of California, Davis, California
| | - Khaled Kebaish
- 13Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Stephen Lewis
- 14Division of Orthopaedic Surgery, University of Toronto, Ontario, Canada
| | - Lawrence Lenke
- 15Department of Orthopaedic Surgery, Columbia University, New York, New York
| | - Richard Hostin
- 16Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas
| | - Munish C Gupta
- 17Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Christopher P Ames
- 9Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert A Hart
- 18Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Douglas Burton
- 19Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher I Shaffrey
- 20Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
| | - Frank Schwab
- 2Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Shay Bess
- 4Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Han Jo Kim
- 21Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- 2Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Peter G Passias
- 1Department of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 8Department of Orthopaedic Surgery, New York Spine Institute, New York, New York
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15
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Lafage R, Passias P, Sheikh Alshabab B, Bess S, Smith JS, Klineberg E, Kim HJ, Elysee J, Shaffrey C, Burton D, Hostin R, Mundis G, Schwab F, Lafage V. Patterns of Lumbar Spine Malalignment Leading to Revision Surgery for Proximal Junctional Kyphosis: A Cluster Analysis of Over- Versus Under-Correction. Global Spine J 2023; 13:1737-1744. [PMID: 35225013 PMCID: PMC10556910 DOI: 10.1177/21925682211047461] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Investigate the patterns of fused lumbar alignment in patients requiring revision surgery for proximal junctional kyphosis (PJK). METHODS Fifty patients (67.8 yo, 76% female) with existing thoraco-lumbar fusion (T10/12 to pelvis) and indicated for surgical correction for PJK were included. To investigate patterns of radiographic alignment prior to PJK revision, unsupervised 2-step cluster analysis was run on parameters describing the fused lumbar spine (PI-LL) to identify natural independent groups within the cohort. Clusters were compared in terms of demographics, pre-operative alignment, surgical parameters, and post-operative alignment. Associations between pre- and post-revision PJK angles were investigated using a Pearson correlation analysis. RESULTS Analysis identified 2 distinct patterns: Under-corrected (UC, n = 12, 32%) vs over-corrected (OC, n = 34, 68%) with a silhouette of .5. The comparison demonstrated similar pelvic incidence (PI) and PJK angle but significantly greater deformity for the UC vs OC group in terms of PI-LL, PI-LL offset, pelvic tilt, and sagittal vertebral axis. The surgical strategy for PJK correction did not differ between the 2 groups in terms of approach, American Society of Anesthesiologists grade, decompression, use of osteotomy, interbody fusion, or fusion length. The post-revision PJK angle significantly correlated with the amount of PJK correction within the OC group but not within the UC group. CONCLUSIONS This study identified 2 patterns of lumbar malalignment associated with severe PJK: over vs under corrected. Despite the difference in PJK etiology, both patterns underwent the same revision strategy. Future analysis should look at the effect of correcting focal deformity alone vs correcting focal deformity and underlying malalignment simultaneously on recurrent PJK rate.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | - Shay Bess
- Denver International Spine Center, Presbyterian St Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | | | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | - Gregory Mundis
- Department Of Orthopedics, Scripps Clinic, San Diego, CA, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
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16
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Passias PG, Ahmad W, Tretiakov PS, Lafage R, Lafage V, Schoenfeld AJ, Line B, Daniels A, Mir JM, Gupta M, Mundis G, Eastlack R, Nunley P, Hamilton DK, Hostin R, Hart R, Burton DC, Shaffrey C, Schwab F, Ames C, Smith JS, Bess S, Klineberg EO. Critical Analysis of Radiographic and Patient Reported Outcomes Following Anterior/Posterior Staged vs. Same Day Surgery in Patients Undergoing Identical Corrective Surgery for Adult Spinal Deformity. Spine (Phila Pa 1976) 2023:00007632-990000000-00415. [PMID: 37450674 DOI: 10.1097/brs.0000000000004774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
STUDYDESIGN Retrospective cohort study of a prospectively collected multi-center adult spinal deformity (ASD) database. OBJECTIVE To compare staged procedures to same-day interventions and identify the optimal time interval between staged surgeries for treatment of ASD. BACKGROUND Surgical intervention for ASD is invasive and complex procedure that surgeons often elect to perform on different days (staging). Yet, there remains a paucity of literature on the timing and effects of the interval between stages. METHODS ASD patients with two-year (2Y) data undergoing an anterior/posterior (A/P) fusion to the ilium were included. Propensity score matching (PSM) was performed for number of levels fused, number of interbody devices, surgical approaches, number of osteotomies/three-column osteotomy (3CO), frailty, Oswestry Disability Index (ODI), Charlson Comorbidity Index (CCI), revisions, sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), and UIV to create balanced cohorts of Same-Day and Staged surgical patients. Staged patients were stratified by intervening time-period between surgeries, using quartiles. RESULTS 176 PSM patients were included. Median interval between A/P staged procedures was 3 days. Staged patients had greater operative time and lower ICU stays postop (P<0.05). At 2Y, staged compared to same day showed a greater improvement in T1 slope - cervical lordosis (TS-CL), C2 sacral slope (C2SS), and SRS-Schwab SVA (P<0.05). Staged patients had higher rates of minimal clinically-important difference (MCID) for 1Y SRS-Appearance and 2Y physical component summary (PCS) scores. Assessing different intervals of staging, patients at the 75th percentile interval showed greater improvement in 1Y SRS Pain and Total postop as well as SRS Activity, Pain, Satisfaction, and Total scores (P<0.05) compared to patients in lower quartiles. Compared to the 25th percentile, patients reaching the 50th percentile interval were associated with increased odds of improvement in Global Alignment and Proportion (GAP) score proportionality (9.3[1.6-53.2], P=0.01). CONCLUSIONS This investigation is among the first to compare multicenter staged and same day surgery anterior/posterior adult spinal deformity patients fused to ilium using propensity-matching. Staged procedures resulted in significant improvement radiographically, reduced ICU admissions, and superior patient reported outcomes compared to same day procedures. An interval of at least three days between staged procedures is associated with superior outcomes in terms of GAP score proportionality.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Waleed Ahmad
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Peter S Tretiakov
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Alan Daniels
- Department of Orthopedics, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Jamshaid M Mir
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, New York, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
| | - Gregory Mundis
- Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, CA
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Pierce Nunley
- Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, LA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | | | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
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17
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Bess S, Line B, Ames C, Burton D, Mundis G, Eastlack R, Hart R, Gupta M, Klineberg E, Kim HJ, Hostin R, Kebaish K, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Would You Do It Again? Discrepancies Between Patient and Surgeon Perceptions Following Adult Spine Deformity Surgery. Spine J 2023:S1529-9430(23)00191-2. [PMID: 37149153 DOI: 10.1016/j.spinee.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Adult spinal deformity (ASD) surgery can improve patient pain and physical function but is associated with high complication rates and long postoperative recovery. Accordingly, if given a choice, patients may indicate they would not undergo ASD surgery again. PURPOSE Evaluate surgically treated ASD patients to assess if given the option 1) would surgically treated ASD patients choose to undergo the same ASD surgery again, 2) would the treating surgeon perform the same ASD surgery again and if not why, 3) evaluate for consensus and/or discrepancies between patient and surgeon opinions for willingness to perform/receive the same surgery, and 4) evaluate for associations with willingness to undergo or not undergo the same surgery again and patient demographics, patient reported outcomes, and postoperative complications. STUDY DESIGN Retrospective review of a prospective ASD study. PATIENT SAMPLE Surgically treated ASD patients enrolled into a multicenter prospective study. OUTCOME MEASURES Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form-36v2 questionnaire (SF-36) physical component summary (PCS) and mental component summary (MCS), Oswestry Disability Index (ODI), numeric pain rating for back pain (NRS back) and leg pain (NRS leg), minimal clinically important difference (MCID) for SRS-22r domains and ODI, intraoperative and postoperative complications, surgeon and patient satisfaction with surgery. METHODS Surgically treated ASD patients prospectively enrolled into a multicenter study were asked at minimum two year postoperative, if, based upon their hospital and surgical experiences and surgical recovery experiences, would the patient undergo the same surgery again. Treating surgeons were then matched to their corresponding patients, blinded to the patients' preoperative and postoperative patient reported outcome measures, and interviewed and asked if 1) the surgeon believed that the corresponding patient would undergo the surgery again, 2) if the surgeon believed the corresponding patient was improved by the surgery and 3) if the surgeon would perform the same surgery on the corresponding patient again, and if not why. ASD patients were divided into those indicating they would (YES), would not (NO) or were unsure (UNSURE) if they would have same surgery again. Agreement between patient and surgeon willingness to receive/perform the same surgery was assessed and correlations between patient willingness for same surgery, postoperative complications, spine deformity correction, patient reported outcomes (PROs). RESULTS 580 of 961 ASD patients eligible for study were evaluated. YES (n=472) had similar surgical procedures performed, similar duration of hospital and ICU stay, similar spine deformity correction and similar postoperative spinal alignment as NO (n=29; p>0.05). UNSURE (n=79) had greater preoperative depression and opioid use rates, UNSURE and NO had more postoperative complications requiring surgery, and UNSURE and NO had fewer percentages of patients reaching postoperative MCID for SRS-22r domains and MCID for ODI than YES (p<0.05). Comparison of patient willingness to receive the same surgery vs. surgeon perceptions on patient's willingness to receive the same surgery demonstrated surgeons accurately identified YES (91.1%) but poorly identified NO (13.8%; p<0.05). CONCLUSIONS If given a choice, 18.6% of surgically treated ASD patients indicated they were unsure or would not undergo the surgery again. ASD patients indicating they were unsure or would not undergo ASD surgery again had greater preoperative depression, greater preoperative opioid use, worse postoperative PROs, fewer patients reaching MCID, more complications requiring surgery, and greater postoperative opioid use. Additionally, patients that indicated they would not have the same surgery again were poorly identified by their treating surgeons compared to patients indicating they would be willing to receive the same surgery again. More research is needed to understand patient expectations and improve patient experiences following ASD surgery.
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Affiliation(s)
- Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO.
| | - Breton Line
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Christopher Ames
- University of California San Francisco School of Medicine, Department of Neurosurgery, San Francisco CA
| | - Douglas Burton
- University of Kansas School of Medicine, Department of Orthopedic Surgery, Kansas City KS
| | | | | | | | - Munish Gupta
- Washington University School of Medicine, Department of Orthopedic Surgery, St. Louis MO
| | - Eric Klineberg
- University of California Davis School of Medicine, Department of Orthopedic Surgery, Sacramento CA
| | - Han Jo Kim
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York NY
| | | | - Khaled Kebaish
- Johns Hopkins University School of Medicine, Department of Orthopedic Surgery, Baltimore, MD
| | - Virgine Lafage
- Lenox Hill Hospital, Department of Orthopedic Surgery, New York NY
| | - Renaud Lafage
- Lenox Hill Hospital, Department of Orthopedic Surgery, New York NY
| | - Frank Schwab
- Lenox Hill Hospital, Department of Orthopedic Surgery, New York, NY
| | | | - Justin S Smith
- University of Virginia School of Medicine, Department of Neurosurgery, Charlottesville VA
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18
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Lovecchio F, Lafage R, Line B, Bess S, Shaffrey C, Kim HJ, Ames C, Burton D, Gupta M, Smith JS, Eastlack R, Klineberg E, Mundis G, Schwab F, Lafage V. Optimizing the Definition of Proximal Junctional Kyphosis: A Sensitivity Analysis. Spine (Phila Pa 1976) 2023; 48:414-420. [PMID: 36728798 DOI: 10.1097/brs.0000000000004564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/27/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Diagnostic binary threshold analysis. OBJECTIVE (1) Perform a sensitivity analysis demonstrating the test performance metrics for any combination of proximal junctional angle (PJA) magnitude and change; (2) Propose a new proximal junctional kyphosis (PJK) criteria. SUMMARY OF BACKGROUND DATA Previous definitions of PJK have been arbitrarily selected and then tested through retrospective case series, often showing little correlation with clinical outcomes. MATERIALS AND METHODS Surgically treated adult spinal deformity patients (≥4 levels fused) enrolled into a prospective, multicenter database were evaluated at a minimum 2-year follow-up for proximal junctional failure (PJF). Using PJF as the outcome of interest, test performance metrics including sensitivity, positive predictive value, and F1 metrics (harmonic mean of precision and recall) were calculated for all combinations of PJA magnitude and change using different combinations of perijunctional vertebrae. The combination with the highest F1 score was selected as the new PJK criteria. Performance metrics of previous PJK definitions and the new PJK definition were compared. RESULTS Of the total, 669 patients were reviewed. PJF rate was 10%. Overall, the highest F1 scores were achieved when the upper instrumented vertebrae -1 (UIV-1)/UIV+2 angle was measured. For lower thoracic cases, out of all the PJA and magnitude/change combinations tested, a UIV-1/UIV+2 magnitude of -28° and a change of -20° was associated with the highest F1 score. For upper thoracic cases, a UIV-1/UIV+2 magnitude of -30° and a change of -24° were associated with the highest F1 score. Using PJF as the outcome, patients meeting this new criterion (11.5%) at 6 weeks had the lowest survival rate (74.7%) at 2 years postoperative, compared with Glattes (84.4%) and Bridwell (77.4%). CONCLUSIONS Out of all possible PJA magnitude and change combinations, without stratifying by upper thoracic versus lower thoracic fusions, a magnitude of ≤-28° and a change of ≤-22° provide the best test performance metrics for predicting PJF.
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Affiliation(s)
- Francis Lovecchio
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Breton Line
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | | | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Christopher Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
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19
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Smith JS, Elias E, Sursal T, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias P, Nasser Z, Gum JL, Eastlack R, Daniels A, Mundis G, Hostin R, Protopsaltis TS, Soroceanu A, Hamilton DK, Kelly MP, Lewis SJ, Gupta M, Schwab FJ, Burton D, Ames CP, Lenke LG, Shaffrey CI, Bess S. How Good Are Surgeons at Achieving Their Preoperative Goal Sagittal Alignment Following Adult Deformity Surgery? Global Spine J 2023:21925682231161304. [PMID: 36821516 DOI: 10.1177/21925682231161304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
STUDY DESIGN Multicenter, prospective cohort. OBJECTIVES Malalignment following adult spine deformity (ASD) surgery can impact outcomes and increase mechanical complications. We assess whether preoperative goals for sagittal alignment following ASD surgery are achieved. METHODS ASD patients were prospectively enrolled based on 3 criteria: deformity severity (PI-LL ≥25°, TPA ≥30°, SVA ≥15 cm, TCobb≥70° or TLCobb≥50°), procedure complexity (≥12 levels fused, 3-CO or ACR) and/or age (>65 and ≥7 levels fused). The surgeon documented sagittal alignment goals prior to surgery. Goals were compared with achieved alignment on first follow-up standing radiographs. RESULTS The 266 enrolled patients had a mean age of 61.0 years (SD = 14.6) and 68% were women. Mean instrumented levels was 13.6 (SD = 3.8), and 23.2% had a 3-CO. Mean (SD) offsets (achieved-goal) were: SVA = -8.5 mm (45.6 mm), PI-LL = -4.6° (14.6°), TK = 7.2° (14.7°), reflecting tendencies to undercorrect SVA and PI-LL and increase TK. Goals were achieved for SVA, PI-LL, and TK in 74.4%, 71.4%, and 68.8% of patients, respectively, and was achieved for all 3 parameters in 37.2% of patients. Three factors were independently associated with achievement of all 3 alignment goals: use of PACs/equivalent for surgical planning (P < .001), lower baseline GCA (P = .009), and surgery not including a 3-CO (P = .037). CONCLUSIONS Surgeons failed to achieve goal alignment of each sagittal parameter in ∼25-30% of ASD patients. Goal alignment for all 3 parameters was only achieved in 37.2% of patients. Those at greatest risk were patients with more severe deformity. Advancements are needed to enable more consistent translation of preoperative alignment goals to the operating room.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Elias Elias
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, USA
| | - Tolga Sursal
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Breton Line
- Department of Orthopedic Surgery, Presbyterian St Lukes Medical Center, Denver, CO, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | - Zeina Nasser
- Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | - Jeffrey L Gum
- Department of Orthopedic Surgery, Leatherman Spine Center, Louisville, KY, USA
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | - Alan Daniels
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX, USA
| | | | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, AB, Canada
| | | | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Stephen J Lewis
- Department of Surgery, Division of Orthopedic Surgery, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO, USA
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Shay Bess
- Department of Orthopedic Surgery, Presbyterian St Lukes Medical Center, Denver, CO, USA
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20
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Elias E, Bess S, Line BG, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias P, Nasser Z, Gum JL, Kebaish K, Eastlack R, Daniels AH, Mundis G, Hostin R, Protopsaltis TS, Soroceanu A, Hamilton DK, Kelly MP, Gupta M, Hart R, Schwab FJ, Burton D, Ames CP, Shaffrey CI, Smith JS. Operative treatment outcomes for adult cervical deformity: a prospective multicenter assessment with mean 3-year follow-up. J Neurosurg Spine 2022; 37:855-864. [PMID: 35901674 DOI: 10.3171/2022.6.spine22422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adult cervical deformity (ACD) has high complication rates due to surgical complexity and patient frailty. Very few studies have focused on longer-term outcomes of operative ACD treatment. The objective of this study was to assess minimum 2-year outcomes and complications of ACD surgery. METHODS A multicenter, prospective observational study was performed at 13 centers across the United States to evaluate surgical outcomes for ACD. Demographics, complications, radiographic parameters, and patient-reported outcome measures (PROMs; Neck Disability Index, modified Japanese Orthopaedic Association, EuroQol-5D [EQ-5D], and numeric rating scale [NRS] for neck and back pain) were evaluated, and analyses focused on patients with ≥ 2-year follow-up. RESULTS Of 169 patients with ACD who were eligible for the study, 102 (60.4%) had a minimum 2-year follow-up (mean 3.4 years, range 2-8.1 years). The mean age at surgery was 62 years (SD 11 years). Surgical approaches included anterior-only (22.8%), posterior-only (39.6%), and combined (37.6%). PROMs significantly improved from baseline to last follow-up, including Neck Disability Index (from 47.3 to 33.0) and modified Japanese Orthopaedic Association score (from 12.0 to 12.8; for patients with baseline score ≤ 14), neck pain NRS (from 6.8 to 3.8), back pain NRS (from 5.5 to 4.8), EQ-5D score (from 0.74 to 0.78), and EQ-5D visual analog scale score (from 59.5 to 66.6) (all p ≤ 0.04). More than half of the patients (n = 58, 56.9%) had at least one complication, with the most common complications including dysphagia, distal junctional kyphosis, instrumentation failure, and cardiopulmonary events. The patients who did not achieve 2-year follow-up (n = 67) were similar to study patients based on baseline demographics, comorbidities, and PROMs. Over the course of follow-up, 23 of the total 169 enrolled patients were reported to have died. Notably, these represent all-cause mortalities during the course of follow-up. CONCLUSIONS This multicenter, prospective analysis demonstrates that operative treatment for ACD provides significant improvement of health-related quality of life at a mean 3.4-year follow-up, despite high complication rates and a high rate of all-cause mortality that is reflective of the overall frailty of this patient population. To the authors' knowledge, this study represents the largest and most comprehensive prospective effort to date designed to assess the intermediate-term outcomes and complications of operative treatment for ACD.
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Affiliation(s)
- Elias Elias
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Shay Bess
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Breton G Line
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Virginie Lafage
- 3Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Renaud Lafage
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric Klineberg
- 5Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Han Jo Kim
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter Passias
- 6Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Zeina Nasser
- 7Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | | | - Khaled Kebaish
- 9Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Alan H Daniels
- 11Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | | | - Richard Hostin
- 12Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | | | - Alex Soroceanu
- 13Department of Orthopedic Surgery, University of Calgary, Alberta, Canada
| | - D Kojo Hamilton
- 14Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Michael P Kelly
- 15Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Munish Gupta
- 16Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Robert Hart
- 17Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Frank J Schwab
- 3Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Douglas Burton
- 18Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher P Ames
- 19Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Christopher I Shaffrey
- 20Departments of Neurosurgery and Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Justin S Smith
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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21
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Passias PG, Krol O, Moattari K, Williamson TK, Lafage V, Lafage R, Kim HJ, Daniels A, Diebo B, Protopsaltis T, Mundis G, Kebaish K, Soroceanu A, Scheer J, Hamilton DK, Klineberg E, Schoenfeld AJ, Vira S, Line B, Hart R, Burton DC, Schwab FA, Shaffrey C, Bess S, Smith JS, Ames CP. Evolution of Adult Cervical Deformity Surgery Clinical and Radiographic Outcomes Based on a Multicenter Prospective Study: Are Behaviors and Outcomes Changing With Experience? Spine (Phila Pa 1976) 2022; 47:1574-1582. [PMID: 35797645 DOI: 10.1097/brs.0000000000004419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/02/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Assess changes in outcomes and surgical approaches for adult cervical deformity surgery over time. SUMMARY OF BACKGROUND DATA As the population ages and the prevalence of cervical deformity increases, corrective surgery has been increasingly seen as a viable treatment. Dramatic surgical advancements and expansion of knowledge on this procedure have transpired over the years, but the impact on cervical deformity surgery is unknown. MATERIALS AND METHODS Adult cervical deformity patients (18 yrs and above) with complete baseline and up to the two-year health-related quality of life and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were grouped into early (2013-2014) and late (2015-2017) by date of surgery. Univariate and multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical outcomes over time. RESULTS A total of 119 cervical deformity patients met the inclusion criteria. Early group consisted of 72 patients, and late group consisted of 47. The late group had a higher Charlson Comorbidity Index (1.3 vs. 0.72), more cerebrovascular disease (6% vs. 0%, both P <0.05), and no difference in age, frailty, deformity, or cervical rigidity. Controlling for baseline deformity and age, late group underwent fewer three-column osteotomies [odds ratio (OR)=0.18, 95% confidence interval (CI): 0.06-0.76, P =0.014]. At the last follow-up, late group had less patients with: a moderate/high Ames horizontal modifier (71.7% vs. 88.2%), and overcorrection in pelvic tilt (4.3% vs. 18.1%, both P <0.05). Controlling for baseline deformity, age, levels fused, and three-column osteotomies, late group experienced fewer adverse events (OR=0.15, 95% CI: 0.28-0.8, P =0.03), and neurological complications (OR=0.1, 95% CI: 0.012-0.87, P =0.03). CONCLUSION Despite a population with greater comorbidity and associated risk, outcomes remained consistent between early and later time periods, indicating general improvements in care. The later cohort demonstrated fewer three-column osteotomies, less suboptimal realignments, and concomitant reductions in adverse events and neurological complications. This may suggest a greater facility with less invasive techniques.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Kevin Moattari
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, NY, NY
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Alan Daniels
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Bassel Diebo
- Deparment of Orthopedic Surgery, SUNY Downstate, New York, NY
| | - Themistocles Protopsaltis
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alexandra Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Justin Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Shaleen Vira
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, TX
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Frank A Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, NY, NY
| | | | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
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22
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Lafage R, Smith JS, Fong AM, Sheikh Alshabab B, Protopsaltis T, Klineberg EO, Mundis G, Passias PG, Gupta M, Shaffrey CI, Kim HJ, Bess S, Schwab F, Ames CP, Lafage V. Proximal and distal reciprocal changes following cervical deformity malalignment correction. J Neurosurg Spine 2022; 37:599-606. [PMID: 35523249 DOI: 10.3171/2022.2.spine211316] [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: 10/11/2021] [Accepted: 02/22/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hyperextension of C0-2 is a debilitating compensatory mechanism used to maintain horizontal gaze, analogous to high pelvic tilt in the lumbopelvic complex to maintain an upright posture. This study aims to investigate the impact of cervical deformity (CD) correction on this hyperextension. The authors hypothesize that correction of cervical sagittal malalignment allows for relaxation of C0-2 hyperextension and improved clinical outcomes. METHODS A retrospective review was conducted of a multicenter database of patients with CD undergoing spinal realignment and fusion caudal to C2 and cephalad to the pelvis. Range of motion (ROM) and reserve of extension (ROE) were calculated across C2-7 and C0-2. The association between C2-7 correction and change in C0-2 ROE was investigated while controlling for horizontal gaze, followed by stratification into ΔC2-7 percentiles. RESULTS Sixty-five patients were included (mean age 61.8 ± 9.6 years, 68% female). At baseline, patients had cervical kyphosis (C2-7, -11.7° ± 18.2°; T1 slope-cervical lordosis mismatch, 38.6° ± 18.6°), negative global alignment (sagittal vertical axis [SVA] -12.8 ± 71.2 mm), and hyperlordosis at C0-2 (mean 33.2° ± 11.8°). The mean ROM was 25.7° ± 17.7° and 21.3° ± 9.9° at C2-7 and C0-2, respectively, with an ROE of approximately 9° for each segment. Limited C0-2 ROM and ROE correlated with the Neck Disability Index (r = -0.371 and -0.394, p < 0.01). The mean number of levels fused was 7.0 ± 3.1 (24.6% anterior, 43.1% posterior), with 87.7% undergoing at least an osteotomy. At 1 year, mean C2-7 increased to 5.5° ± 13.4°, SVA became neutral (11.5 ± 54.8 mm), C0-2 hyperlordosis decreased to 27.8° ± 11.7°, and thoracic kyphosis (TK) increased to -49.4° ± 18.1° (all p < 0.001). Concurrently, mean C0-2 ROM increased to 27.6° ± 8.1° and C2-7 ROM decreased significantly to 9.0° ± 12.3° without a change in ROE. Controlling for horizontal gaze, change in C2-7 lordosis significantly correlated with increased TK (r = -0.617, p < 0.001), decreased C0-2 (r = -0.747, p < 0.001), and increased C0-2 ROE (r = 0.550, p = 0.002). CONCLUSIONS CD correction can significantly impact cephalad and caudal compensation in the upper cervical and thoracic spine. Restoration of cervical alignment resulted in increased C0-2 ROE and TK and was also associated with improved clinical outcome.
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Affiliation(s)
- Renaud Lafage
- 1Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- 2Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Alex Moy Fong
- 1Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Basel Sheikh Alshabab
- 3Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
| | | | - Eric O Klineberg
- 5Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | | | - Peter G Passias
- 4Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Munish Gupta
- 7Department of Orthopaedics, Washington University, St. Louis, Missouri
| | | | - Han Jo Kim
- 1Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- 9Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado; and
| | - Frank Schwab
- 3Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
| | - Christopher P Ames
- 10Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Virginie Lafage
- 3Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
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Elias E, Bess S, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias PG, Nasser Z, Gum JL, Kebaish K, Eastlack R, Daniels AH, Mundis G, Hostin R, Protopsaltis TS, Soroceanu A, Hamilton DK, Kelly MP, Gupta M, Hart R, Schwab FJ, Burton D, Ames CP, Shaffrey CI, Smith JS. Outcomes of operative treatment for adult spinal deformity: a prospective multicenter assessment with mean 4-year follow-up. J Neurosurg Spine 2022; 37:607-616. [PMID: 35535835 DOI: 10.3171/2022.3.spine2295] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The current literature has primarily focused on the 2-year outcomes of operative adult spinal deformity (ASD) treatment. Longer term durability is important given the invasiveness, complications, and costs of these procedures. The aim of this study was to assess minimum 3-year outcomes and complications of ASD surgery. METHODS Operatively treated ASD patients were assessed at baseline, follow-up, and through mailings. Patient-reported outcome measures (PROMs) included scores on the Oswestry Disability Index (ODI), Scoliosis Research Society-22r (SRS-22r) questionnaire, mental component summary (MCS) and physical component summary (PCS) of the SF-36, and numeric rating scale (NRS) for back and leg pain. Complications were classified as perioperative (≤ 90 days), delayed (90 days to 2 years), and long term (≥ 2 years). Analyses focused on patients with minimum 3-year follow-up. RESULTS Of 569 patients, 427 (75%) with minimum 3-year follow-up (mean ± SD [range] 4.1 ± 1.1 [3.0-9.6] years) had a mean age of 60.8 years and 75% were women. Operative treatment included a posterior approach for 426 patients (99%), with a mean ± SD 12 ± 4 fusion levels. Anterior lumbar interbody fusion was performed in 35 (8%) patients, and 89 (21%) underwent 3-column osteotomy. All PROMs improved significantly from baseline to last follow-up, including scores on ODI (45.4 to 30.5), PCS (31.0 to 38.5), MCS (45.3 to 50.6), SRS-22r total (2.7 to 3.6), SRS-22r activity (2.8 to 3.5), SRS-22r pain (2.3 to 3.4), SRS-22r appearance (2.4 to 3.5), SRS-22r mental (3.4 to 3.7), SRS-22r satisfaction (2.7 to 4.1), NRS for back pain (7.1 to 3.8), and NRS for leg pain (4.8 to 3.0) (all p < 0.001). Degradations in some outcome measures were observed between the 2-year and last follow-up evaluations, but the magnitudes of these degradations were modest and arguably not clinically significant. Overall, 277 (65%) patients had at least 1 complication, including 185 (43%) perioperative, 118 (27%) delayed, and 56 (13%) long term. Notably, the 142 patients who did not achieve 3-year follow-up were similar to the study patients in terms of demographic characteristics, deformities, and baseline PROMs and had similar rates and types of complications. CONCLUSIONS This prospective multicenter analysis demonstrated that operative ASD treatment provided significant improvement of health-related quality of life at minimum 3-year follow-up (mean 4.1 years), suggesting that the benefits of surgery for ASD remain durable at longer follow-up. These findings should prove useful for counseling, cost-effectiveness assessments, and efforts to improve the safety of care.
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Affiliation(s)
- Elias Elias
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Shay Bess
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Breton Line
- 2Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Virginie Lafage
- 3Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Renaud Lafage
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric Klineberg
- 5Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Han Jo Kim
- 4Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter G Passias
- 6Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Zeina Nasser
- 7Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon
| | | | - Khal Kebaish
- 9Department of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Alan H Daniels
- 11Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | | | - Richard Hostin
- 12Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | | | - Alex Soroceanu
- 13Department of Orthopedic Surgery, University of Calgary, Alberta, Canada
| | - D Kojo Hamilton
- 14Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael P Kelly
- 15Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Munish Gupta
- 16Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Robert Hart
- 17Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Frank J Schwab
- 3Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Douglas Burton
- 18Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher P Ames
- 19Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Christopher I Shaffrey
- 20Departments of Neurosurgery and Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Justin S Smith
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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Lafage R, Virk S, Elysee J, Passias P, Ames C, Hart R, Shaffrey C, Mundis G, Protopsaltis T, Gupta M, Klineberg E, Burton D, Schwab F, Lafage V. Radiographic Characteristics of Cervical Deformity (CD) Using a Discriminant Analysis: The Value of Extension Radiographs. Clin Spine Surg 2022; 35:E504-E509. [PMID: 35249971 DOI: 10.1097/bsd.0000000000001297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective review of a prospectively collected database. OBJECTIVE The aim of this study was to delineate radiographic parameters that distinguish severe cervical spine deformity (CSD). SUMMARY OF BACKGROUND DATA Our objective was to define parameters that distinguish severe CSD using a consensus approach combined with discriminant analysis as no system currently exists in the literature. METHODS Twelve CSD surgeons reviewed preoperative x-rays from a CSD database. A consensus was reached for categorizing patients into a severe cervical deformity (sCD), non-severe cervical deformity (non-sCD), or an indeterminate cohort. Radiographic parameters were found including classic cervical and spinopelvic parameters in neutral/flexion/extension alignment. To perform our discriminant analysis, we selected for parameters that had a significant difference between the sCD and non-sCD groups using the Student t test. A discriminant function analysis was used to determine which variables discriminate between the sCD versus non-sCD. A stepwise analysis was performed to build a model of parameters to delineate sCD. RESULTS A total of 146 patients with cervical deformity were reviewed (60.5±10.5 y; body mass index: 29.8 kg/m2; 61.3% female). There were 83 (56.8%) classified as sCD and 51 (34.9%) as non-sCD. The comparison analysis led to 16 radiographic parameters that were different between cohorts, and 5 parameters discriminated sCD and non-sCD. These parameters were cervical sagittal vertical axis, T1 slope, maximum focal kyphosis in extension, C2 slope in extension, and number of kyphotic levels in extension. The canonical coefficient of correlation was 0.689, demonstrating a strong association between our model and cervical deformity classification. The accuracy of classification was 87.0%, and cross-validation was 85.2% successful. CONCLUSIONS More than one third of a series of CSD patients were not considered to have a sCD. Analysis of an initial 17 parameters showed that a subset of 5 parameters can discriminate between sCD versus non-sCD with 85% accuracy. Our study demonstrates that flexion/extension images are critical for defining severe CD.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York
| | - Sohrab Virk
- Department of Orthopedic Surgery, Northwell Health, Great Neck
| | - Jonathan Elysee
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York
| | - Peter Passias
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Christopher Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Robert Hart
- Department of Orthopedic Surgery, CA Swedish Neuroscience Institute, Seattle, WA
| | | | | | | | - Munish Gupta
- Department of Orthopedics, Washington University School of Medicine, St. Louis, MO
| | - Eric Klineberg
- Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, CA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Frank Schwab
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York
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Virk S, Lafage R, Bess S, Shaffrey C, Kim HJ, Ames C, Burton D, Gupta M, Smith JS, Eastlack R, Klineberg E, Mundis G, Schwab F, Lafage V. Are the Arbeitsgemeinschaft Für Osteosynthesefragen (AO) Principles for Long Bone Fractures Applicable to 3-Column Osteotomy to Reduce Rod Fracture Rates? Clin Spine Surg 2022; 35:E429-E437. [PMID: 34966036 DOI: 10.1097/bsd.0000000000001289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 11/17/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim was to determine whether applying Arbeitsgemeinschaft für Osteosynthesefragen (AO) principles for external fixation of long bone fracture to patients with a 3-column osteotomy (3CO) would be associated with reduced rod fracture (RF) rates. SUMMARY OF BACKGROUND DATA AO dictate principles to follow when fixating long bone fractures: (1) decrease bone-rod distance; (2) increase the number of connecting rods; (3) increase the diameter of rods; (4) increase the working length of screws; (5) use multiaxial fixation. We hypothesized that applying these principles to patients undergoing a 3CO reduces the rate of RF. METHODS Patients were categorized as having RF versus no rod fracture (non-RF). Details on location and type of instrumentation were collected. Dedicated software was used to calculate the distance between osteotomy site and adjacent pedicle screws, angle between screws and the distance between the osteotomy site and rod. Classic sagittal spinopelvic parameters were evaluated. RESULTS The study included 170 patients (34=RF, 136=non-RF). There was no difference in age (P=0.224), sagittal vertical axis correction (P=0.287), or lumbar lordosis correction (P=0.36). There was no difference in number of screws cephalad (P=0.62) or caudal (P=0.31) to 3CO site. There was a lower rate of RF for patients with >2 rods versus 2 rods (P<0.001). Patients with multiplanar rod fixation had a lower rod fracture rate (P=0.01). For patients with only 2 rods (N=68), the non-RF cohort had adjacent screws that trended to have less angulation to each other (P=0.06) and adjacent screws that had a larger working length (P=0.03). CONCLUSIONS A portion of AO principles can be applied to 3CO to reduce RF rates. Placing more rods around a 3CO site, placing rods in multiple planes, and placing adjacent screws with a larger working length around the 3CO site is associated with lower RF rates.
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Affiliation(s)
- Sohrab Virk
- Department of Orthopedic Surgery, North well Health, Great Neck
| | | | - Shay Bess
- Rocky Mountain Scoliosis and Spine Center, Denver, CO
| | | | - Han J Kim
- Hospital for Special Surgery, New York, NY
| | - Christopher Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Doug Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Munish Gupta
- Department of Orthopedics, Washington University School of Medicine, St. Louis, MO
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento
| | - Gregory Mundis
- Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, CA
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Passias PG, Poorman GW, Vasquez-Montes D, Kummer N, Mundis G, Anand N, Horn SR, Segreto FA, Passfall L, Krol O, Diebo B, Burton D, Buckland A, Gerling M, Soroceanu A, Eastlack R, Kojo Hamilton D, Hart R, Schwab F, Lafage V, Shaffrey C, Sciubba D, Bess S, Ames C, Klineberg E. Predictive Analytics for Determining Extended Operative Time in Corrective Adult Spinal Deformity Surgery. Int J Spine Surg 2022; 16:291-299. [PMID: 35444038 PMCID: PMC9930651 DOI: 10.14444/8174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND More sophisticated surgical techniques for correcting adult spinal deformity (ASD) have increased operative times, adding to physiologic stress on patients and increased complication incidence. This study aims to determine factors associated with operative time using a statistical learning algorithm. METHODS Retrospective review of a prospective multicenter database containing 837 patients undergoing long spinal fusions for ASD. Conditional inference decision trees identified factors associated with skin-to-skin operative time and cutoff points at which factors have a global effect. A conditional variable-importance table was constructed based on a nonreplacement sampling set of 2000 conditional inference trees. Means comparison for the top 15 variables at their respective significant cutoffs indicated effect sizes. RESULTS Included: 544 surgical ASD patients (mean age: 58.0 years; fusion length 11.3 levels; operative time: 378 minutes). The strongest predictor for operative time was institution/surgeon. Center/surgeons, grouped by decision tree hierarchy, a and b were, on average, 2 hours faster than center/surgeons c-f, who were 43 minutes faster than centers g-j, all P < 0.001. The next most important predictors were, in order, approach (combined vs posterior increases time by 139 minutes, P < 0.001), levels fused (<4 vs 5-9 increased time by 68 minutes, P < 0.050; 5-9 vs < 10 increased time by 47 minutes, P < 0.001), age (age <50 years increases time by 57 minutes, P < 0.001), and patient frailty (score <1.54 increases time by 65 minutes, P < 0.001). Surgical techniques, such as three-column osteotomies (35 minutes), interbody device (45 minutes), and decompression (48 minutes), also increased operative time. Both minor and major complications correlated with <66 minutes of increased operative time. Increased operative time also correlated with increased hospital length of stay (LOS), increased estimated intraoperative blood loss (EBL), and inferior 2-year Oswestry Disability Index (ODI) scores. CONCLUSIONS Procedure location and specific surgeon are the most important factors determining operative time, accounting for operative time increases <2 hours. Surgical approach and number of levels fused were also associated with longer operative times, respectively. Extended operative time correlated with longer LOS, higher EBL, and inferior 2-y ODI outcomes. CLINICAL RELEVANCE We further identified the poor outcomes associated with extended operative time during surgical correction of ASD, and attributed the useful predictors of time spent in the operating room, including site, surgeon, surgical approach, and the number of levels fused. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Peter G. Passias
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Gregory W. Poorman
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Dennis Vasquez-Montes
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Nicholas Kummer
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Gregory Mundis
- Department of Orthopaedics, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - Neel Anand
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Samantha R. Horn
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Frank A. Segreto
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Lara Passfall
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Oscar Krol
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Bassel Diebo
- Department of Orthopaedics, SUNY Downstate Medical Center, New York, NY, USA
| | - Doug Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Aaron Buckland
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Michael Gerling
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York, NY, USA
| | - Alex Soroceanu
- Department of Orthopaedics, University of Calgary, Calgary, AB, Canada
| | - Robert Eastlack
- Department of Orthopaedics, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - D. Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert Hart
- Department of Orthopaedics, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Frank Schwab
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | | | - Daniel Sciubba
- Department of Neurologic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
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Line B, Bess S, Gum JL, Hostin R, Kebaish K, Ames C, Burton D, Mundis G, Eastlack R, Gupta M, Klineberg E, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Opioid use prior to surgery is associated with worse preoperative and postoperative patient reported quality of life and decreased surgical cost effectiveness for symptomatic adult spine deformity; A matched cohort analysis. North American Spine Society Journal (NASSJ) 2022; 9:100096. [PMID: 35141660 PMCID: PMC8819939 DOI: 10.1016/j.xnsj.2021.100096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/07/2021] [Accepted: 12/07/2021] [Indexed: 11/06/2022]
Abstract
Multi-center, matched analysis of surgically treated SASD patients demonstrated preoperative opioid users reported greater pain, worse physical function, worse self-image preoperatively and at minimum 2-years postoperative and reported lower treatment satisfaction compared to opioid nonusers (p<0.05). Preoperative opioid users had longer ICU (40.8 vs 21.4 hours) and hospital stay (10.5 vs 8.0 days) than nonusers following SASD surgery, respectively (p<0.05). Preoperative opioid users demonstrated worse one and two-year postoperative cost/QALY following SASD surgery than nonusers (p<0.05). Preoperative opioid users reported greater opioid use at two-years following SASD surgery than preoperative nonusers (41.2% vs. 12.9%; odds ratio=4.5; 95% confidence interval=2.7-8.3; p<0.05).
Background Preoperative opioid is associated with poor postoperative outcomes for several surgical specialties, including neurosurgical, orthopedic, and general surgery. Patients with symptomatic adult spinal deformity (SASD) are among the highest patient populations reporting opioid use prior to surgery. Surgery for SASD has been demonstrated to improve patient reported quality of life, however, little medical economic data exists evaluating impact of preoperative opioid use upon surgical cost-effectiveness for SASD. The purpose of this study was to evaluate the impact that preoperative opioid use has upon SASD surgery including duration of intensive care unit (ICU) and hospital stay, postoperative complications, patient reported outcome measures (PROMs), and surgical cost-effectiveness using a propensity score matched analysis model. Methods Surgically treated SASD patients enrolled into a prospective multi-center SASD study were assessed for preoperative opioid use, and divided into two cohorts; preoperative opioid users (OPIOID) and preoperative opioid non-users (NON). Propensity score matching (PSM) was used to control for patient age, medical comorbidities, spine deformity type and magnitude, and surgical procedures for OPIOID vs NON. Preoperative and minimum 2-year postoperative PROMs, duration of ICU and hospital stay, postoperative complications, and opioid use at one and two years postoperative were compared for OPIOID vs NON. Preoperative, one year, and minimum two-year postoperative SF6D values were calculated, and one- and two-year postoperative QALYs were calculated using SF6D change from baseline. Hospital costs at the time of index surgery were calculated and cost/QALY compared at one and two years postop for OPIOID vs NON. Results 261/357 patients (mean follow-up 3.3 years) eligible for study were evaluated. Following the PSM control, OPIOID (n=97) had similar preoperative demographics, smoking and depression history, spine deformity magnitude, and surgery performed as NON (n=164; p>0.05). Preoperatively, OPIOID reported greater NRS back pain (7.7 vs 6.7) and leg pain (5.2 vs 3.9), worse ODI (50.8 vs 36.9), worse SF-36 PCS (28.8 vs 35.6), and worse SRS-22r self-image (2.3 vs 2.5) than NON, respectively (p<0.05). OPIOID had longer ICU (41.2 vs 21.4 hours) and hospital stay (10.6 vs 8.0 days) than NON, respectively (p<0.05). At last postoperative follow up, OPIOID reported greater NRS back pain (4.1 vs 2.3) and leg pain (2.9 vs 1.7), worse ODI (32.4 vs 19.4), worse SF-36 PCS (37.4 vs 47.0), worse SRS-22r self-image (3.5 vs 4.0), and lower SRS-22r treatment satisfaction score (2.5 vs 4.5) than NON, respectively (p<0.05). At last follow-up postoperative Cost/QALY was higher for OPIOID ($44,558.31) vs NON ($34,304.36; p<0.05). At last follow up OPIOID reported greater postoperative opioid usage than NON [41.2% vs. 12.9%, respectively; odds ratio =4.7 (95% CI=2.6-8.7; p<0.05)]. Conclusions Prospective, multi-center, matched analysis demonstrated SASD patients using opioids prior to SASD surgery reported worse preoperative and postoperative quality of life, had longer ICU and hospital stay, had less cost effectiveness of SASD surgery. Preoperative opioid users also reported lower treatment satisfaction, and reported greater postoperative opioid use than non-users. These data should be used to council patients on the negative impact preoperative opioid use can have on SASD surgery.
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Durand WM, Babu JM, Hamilton DK, Passias PG, Kim HJ, Protopsaltis T, Lafage V, Lafage R, Smith JS, Shaffrey C, Gupta M, Kelly MP, Klineberg EO, Schwab F, Gum JL, Mundis G, Eastlack R, Kebaish K, Soroceanu A, Hostin RA, Burton D, Bess S, Ames C, Hart RA, Daniels AH. Adult Spinal Deformity Surgery Is Associated with Increased Productivity and Decreased Absenteeism From Work and School. Spine (Phila Pa 1976) 2022; 47:287-294. [PMID: 34738986 DOI: 10.1097/brs.0000000000004271] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE We hypothesized that adult spinal deformity (ASD) surgery would be associated with improved work- and school-related productivity, as well as decreased rates of absenteeism. SUMMARY OF BACKGROUND DATA ASD patients experience markedly decreased health-related quality of life along many dimensions. METHODS Only patients eligible for 2-year follow-up were included, and those with a history of previous spinal fusion were excluded. The primary outcome measures in this study were Scoliosis Research Society-22r score (SRS-22r) questions 9 and 17. A repeated measures mixed linear regression was used to analyze responses over time among patients managed operatively (OP) versus nonoperatively (NON-OP). RESULTS In total, 1188 patients were analyzed. 66.6% were managed operatively. At baseline, the mean percentage of activity at work/school was 56.4% (standard deviation [SD] 35.4%), and the mean days off from work/school over the past 90 days was 1.6 (SD 1.8). Patients undergoing ASD surgery exhibited an 18.1% absolute increase in work/school productivity at 2-year follow-up versus baseline (P < 0.0001), while no significant change was observed for the nonoperative cohort (P > 0.5). Similarly, the OP cohort experienced 1.1 fewer absent days over the past 90 days at 2 years versus baseline (P < 0.0001), while the NON-OP cohort showed no such difference (P > 0.3). These differences were largely preserved after stratifying by baseline employment status, age group, sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), and deformity curve type. CONCLUSION ASD patients managed operatively exhibited an average increase in work/school productivity of 18.1% and decreased absenteeism of 1.1 per 90 days at 2-year follow-up, while patients managed nonoperatively did not exhibit change from baseline. Given the age distribution of patients in this study, these findings should be interpreted as pertaining primarily to obligations at work or within the home. Further study of the direct and indirect economic benefits of ASD surgery to patients is warranted.Level of Evidence: 3.
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Affiliation(s)
| | - Jacob M Babu
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Peter G Passias
- Langone Medical Center, New York University, New York City, NY
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | | | | | | | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA
| | | | - Munish Gupta
- Washington University in St Louis, St. Louis, MO
| | | | - Eric O Klineberg
- UC Davis Medical Center, University of California, Sacramento, CA
| | | | | | | | | | - Khaled Kebaish
- Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Doug Burton
- University of Kansas Medical Center, Kansas City, KS
| | - Shay Bess
- Denver International Spine Center, Denver, CO
| | | | - Robert A Hart
- Swedish Medical Center, Swedish Neuroscience Institute, Seattle, WA
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Daniels AH, Durand WM, Steinbaum AJ, Lafage R, Hamilton DK, Passias PG, Kim HJ, Protopsaltis T, Lafage V, Smith JS, Shaffrey C, Gupta M, Klineberg EO, Schwab F, Gum JL, Mundis G, Eastlack R, Kebaish K, Soroceanu A, Hostin RA, Burton D, Bess S, Ames C, Hart RA. Examination of Adult Spinal Deformity Patients Undergoing Surgery with Implanted Spinal Cord Stimulators and Intrathecal Pumps. Spine (Phila Pa 1976) 2022; 47:227-233. [PMID: 34310536 DOI: 10.1097/brs.0000000000004176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of a prospectively collected multi-center database of adult spinal deformity (ASD) patients. OBJECTIVE We hypothesized that patients undergoing ASD surgery with and without previous spinal cord stimulators (SCS)/ intrathecal medication pumps (ITP) would exhibit increased complication rates but comparable improvement in health-related quality of life. SUMMARY OF BACKGROUND DATA ASD patients sometimes seek pain management with SCS or ITP before spinal deformity correction. Few studies have examined outcomes in this patient population. METHODS Patients undergoing ASD surgery and eligible for 2-year follow-up were included. Preoperative radiographs were reviewed for the presence of SCS/ITP. Outcomes included complications, Oswestry Disability Index (ODI), Short Form-36 Mental Component Score, and SRS-22r. Propensity score matching was utilized. RESULTS In total, of 1034 eligible ASD patients, a propensity score-matched cohort of 60 patients (30 with SCS/ITP, 30 controls) was developed. SCS/ITP were removed intraoperatively in most patients (56.7%, n = 17). The overall complication rate was 80.0% versus 76.7% for SCS/ITP versus control (P > 0.2), with similarly nonsignificant differences for intraoperative and infection complications (all P > 0.2). ODI was significantly higher among patients with SCS/ITP at baseline (59.2 vs. 47.6, P = 0.0057) and at 2-year follow-up (44.4 vs. 27.7, P = 0.0295). The magnitude of improvement, however, did not significantly differ (P = 0.45). Similar results were observed for SRS-22r pain domain. Satisfaction did not differ between groups at either baseline or follow-up (P > 0.2). No significant difference was observed in the proportion of patients with SCS/ITP versus control reaching minimal clinically important difference in ODI (47.6% vs. 60.9%, P = 0.38). Narcotic usage was more common among patients with SCS/ITP at both baseline and follow-up (P < 0.05). CONCLUSION ASD patients undergoing surgery with SCS/ITP exhibited worse preoperative and postoperative ODI and SRS-22r pain domain; however, the mean improvement in outcome scores was not significantly different from patients without stimulators or pumps. No significant differences in complications were observed between patients with versus without SCS/ITP.Level of Evidence: 3.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School, Brown University, Providence, RI
| | - Wesley M Durand
- Warren Alpert Medical School, Brown University, Providence, RI
| | | | | | | | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | | | | | - Justin S Smith
- University of Virginia Health System, Charlottes-ville, VA
| | | | | | | | | | | | | | | | | | - Alex Soroceanu
- University of Calgary Spine Program, University of Calgary, Alberta, Canada
| | - Richard A Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Doug Burton
- University of Kansas Hospital, Kansas City, KS
| | - Shay Bess
- Denver International Spine Center, Denver, CO
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Lafage R, Smith JS, Elysee J, Passias P, Bess S, Klineberg E, Kim HJ, Shaffrey C, Burton D, Hostin R, Mundis G, Ames C, Schwab F, Lafage V. Sagittal age-adjusted score (SAAS) for adult spinal deformity (ASD) more effectively predicts surgical outcomes and proximal junctional kyphosis than previous classifications. Spine Deform 2022; 10:121-131. [PMID: 34460094 DOI: 10.1007/s43390-021-00397-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/06/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Several methodologies have been proposed to determine ideal ASD sagittal spinopelvic alignment (SRS-Schwab classification) global alignment and proportion (GAP) score, patient age-adjusted alignment). A recent study revealed the ability and limitations of these methodologies to predict PJK. The aim of the study was to develop a new approach, inspired by SRS classification, GAP score, and age-alignment to improve the evaluation of the sagittal plane. METHOD A multi-center ASD database was retrospectively evaluated for surgically treated ASD patients with complete fusion of the lumbar spine, and minimum 2 year follow-up. The Sagittal age-adjusted score (SAAS) methodology was created by assigning numerical values to the difference between each patient's postoperative sagittal alignment and ideal alignment defined by previously reported age generational norms for PI-LL, PT, and TPA. Postoperative HRQOL and PJK severity between each SAAS categories were evaluated. RESULTS 409 of 667 (61.3%) patients meeting inclusion criteria were evaluated. At 2 year SAAS score showed that 27.0% of the patients were under-corrected, 51.7% over-corrected, and 21.3% matched their age-adjusted target. SAAS score increased as PJK worsened (from SAAS = 0.2 for no-PJK, to 4.0 for PJF, p < 0.001). Post-operatively, HRQOL differences between SAAS groups included ODI, SRS pain, and SRS total. CONCLUSION Inspired by SRS classification, the concept of the GAP score, and age-adjusted alignment targets, the results demonstrated significant association with PJK and patient reported outcomes. With a lower rate of failure and better HRQOL, the SAAS seems to represent a "sweet spot" to optimize HRQOL while mitigating the risk of mechanical complications.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA.
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Sacramento, Davis, CA, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | | | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas, KS, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | | | - Christopher Ames
- Department of Neurological Surgery, School of Medicine, University of California, San Francisco, CA, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA
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Lafage R, Smith JS, Sheikh Alshabab B, Ames C, Passias PG, Shaffrey CI, Mundis G, Protopsaltis T, Gupta M, Klineberg E, Kim HJ, Bess S, Schwab F, Lafage V. When can we expect global sagittal alignment to reach a stable value following cervical deformity surgery? J Neurosurg Spine 2021; 36:616-623. [PMID: 34740177 DOI: 10.3171/2021.7.spine21306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical deformity (CD) is a complex condition with a clear impact on patient quality of life, which can be improved with surgical treatment. Previous study following thoracolumbar surgery demonstrated a spontaneous and maintained improvement in cervical alignment following lumbar pedicle subtraction osteotomy (PSO). In this study the authors aimed to investigate the complementary questions of whether cervical alignment induces a change in global alignment and whether this change stabilizes over time. METHODS To analyze spontaneous changes, this study included only patients with at least 5 levels remaining unfused following surgery. After data were obtained for the entire cohort, repeated-measures analyses were conducted between preoperative baseline and 3-month and 1-year follow-ups with a post hoc analysis and Bonferroni correction. A subanalysis of patients with 2-year follow-up was performed. RESULTS One-year follow-up data were available for 121 of 168 patients (72%), and 89 patients had at least 5 levels remaining unfused following surgery. Preoperatively there was a moderate anterior cervical alignment (C2-7, -7.7° [kyphosis]; T1 slope minus cervical lordosis, 37.1°; cervical sagittal vertebral axis [cSVA], 37 mm) combined with a posterior global alignment (SVA, -8 mm) with lumbar hyperextension (pelvic incidence [PI] minus lumbar lordosis [LL] mismatch [PI-LL], -0.6°). Patients underwent a significant correction of the cervical alignment (median ΔC2-7, 13.6°). Simultaneously, PI-LL, T1 pelvic angle (TPA), and SVA increased significantly (all p < 0.05) between baseline and 3-month and 1-year follow-ups. Post hoc analysis demonstrated that all of the changes occurred between baseline and 3 months. Subanalysis of patients with complete 2-year follow-up demonstrated similar results, with stable postoperative thoracolumbar alignment achieved at 3 months. CONCLUSIONS Correction of cervical malalignment can have a significant impact on thoracolumbar regional and global alignment. Peak relaxation of compensatory mechanisms is achieved by the 3-month follow-up and tends to remain stable. Subanalysis with 2-year data further supports this finding. These findings can help to identify when the results of cervical surgery on global alignment can be best evaluated.
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Kim HJ, Virk S, Elysee J, Ames C, Passias P, Shaffrey C, Mundis G, Protopsaltis T, Gupta M, Klineberg E, Hart R, Smith JS, Bess S, Schwab F, Lafage R, Lafage V. Surgical Strategy for the Management of Cervical Deformity Is Based on Type of Cervical Deformity. J Clin Med 2021; 10:jcm10214826. [PMID: 34768346 PMCID: PMC8584313 DOI: 10.3390/jcm10214826] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives: Cervical deformity morphotypes based on type and location of deformity have previously been described. This study aimed to examine the surgical strategies implemented to treat these deformity types and identify if differences in treatment strategies impact surgical outcomes. Our hypothesis was that surgical strategies will differ based on different morphologies of cervical deformity. Methods: Adult patients enrolled in a prospective cervical deformity database were classified into four deformity types (Flatneck (FN), Focal kyphosis (FK), Cervicothoracic kyphosis (CTK) and Coronal (C)), as previously described. We analyzed group differences in demographics, preoperative symptoms, health-related quality of life scores (HRQOLs), and surgical strategies were evaluated, and postop radiographic and HROQLs at 1+ year follow up were compared. Results: 90/109 eligible patients (mean age 63.3 ± 9.2, 64% female, CCI 1.01 ± 1.36) were evaluated. Group distributions included FN = 33%, FK = 29%, CTK = 29%, and C = 9%. Significant differences were noted in the surgical approaches for the four types of deformities, with FN and FK having a high number of anterior/posterior (APSF) approaches, while CTK and C had more posterior only (PSF) approaches. For FN and FK, PSF was utilized more in cases with prior anterior surgery (70% vs. 25%). For FN group, PSF resulted in inferior neck disability index compared to those receiving APSF suggesting APSF is superior for FN types. CTK types had more three-column osteotomies (3CO) (p < 0.01) and longer fusions with the LIV below T7 (p < 0.01). There were no differences in the UIV between all deformity types (p = 0.19). All four types of deformities had significant improvement in NRS neck pain post-op (p < 0.05) with their respective surgical strategies. Conclusions: The four types of cervical deformities had different surgical strategies to achieve improvements in HRQOLs. FN and FK types were more often treated with APSF surgery, while types CTK and C were more likely to undergo PSF. CTK deformities had the highest number of 3COs. This information may provide guidelines for the successful management of cervical deformities.
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Affiliation(s)
- Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
- Correspondence:
| | - Sohrab Virk
- Department of Orthopedics, Northwell Health, Great Neck, New York, NY 11021, USA;
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
| | - Christopher Ames
- Department of Neurosurgery, University of San Francisco School of Medicine, San Francisco, CA 94143, USA;
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY 10016, USA; (P.P.); (T.P.)
| | - Christopher Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27708, USA;
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic Medical Group, La Jolla, CA 92037, USA;
| | | | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO 63010, USA;
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California Davis, Davis, CA 95616, USA;
| | - Robert Hart
- Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, OR 97239, USA;
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA 22904, USA;
| | - Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children at Presbyterian St. Luke’s, Denver, CO 80218, USA;
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY 10021, USA; (J.E.); (F.S.); (R.L.); (V.L.)
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Passias PG, Brown AE, Bortz C, Pierce K, Alas H, Ahmad W, Passfall L, Kummer N, Krol O, Lafage R, Lafage V, Burton D, Hart R, Anand N, Mundis G, Neuman B, Line B, Shaffrey C, Klineberg E, Smith J, Ames C, Schwab FJ, Bess S. A Risk-Benefit Analysis of Increasing Surgical Invasiveness Relative to Frailty Status in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2021; 46:1087-1096. [PMID: 33534520 DOI: 10.1097/brs.0000000000003977] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively enrolled multicenter Adult Spinal Deformity (ASD) database. OBJECTIVE Investigate invasiveness and outcomes of ASD surgery by frailty state. SUMMARY OF BACKGROUND DATA The ASD Invasiveness Index incorporates deformity-specific components to assess correction magnitude. Intersections of invasiveness, surgical outcomes, and frailty state are understudied. METHODS ASD patients with baseline and 3-year (3Y) data were included. Logistic regression analyzed the relationship between increasing invasiveness and major complications or reoperations and meeting minimal clinically important differences (MCID) for health-related quality-of-life measures at 3Y. Decision tree analysis assessed invasiveness risk-benefit cutoff points, above which experiencing complications or reoperations and not reaching MCID were higher. Significance was set to P < 0.05. RESULTS Overall, 195 of 322 patients were included. Baseline demographics: age 59.9 ± 14.4, 75% female, BMI 27.8 ± 6.2, mean Charlson Comorbidity Index: 1.7 ± 1.7. Surgical information: 61% osteotomy, 52% decompression, 11.0 ± 4.1 levels fused. There were 98 not frail (NF), 65 frail (F), and 30 severely frail (SF) patients. Relationships were found between increasing invasiveness and experiencing a major complication or reoperation for the entire cohort and by frailty group (all P < 0.05). Defining a favorable outcome as no major complications or reoperation and meeting MCID in any health-related quality of life at 3Y established an invasiveness cutoff of 63.9. Patients below this threshold were 1.8[1.38-2.35] (P < 0.001) times more likely to achieve favorable outcome. For NF patients, the cutoff was 79.3 (2.11[1.39-3.20] (P < 0.001), 111 for F (2.62 [1.70-4.06] (P < 0.001), and 53.3 for SF (2.35[0.78-7.13] (P = 0.13). CONCLUSION Increasing invasiveness is associated with increased odds of major complications and reoperations. Risk-benefit cutoffs for successful outcomes were 79.3 for NF, 111 for F, and 53.3 for SF patients. Above these, increasing invasiveness has increasing risk of major complications or reoperations and not meeting MCID at 3Y.Level of Evidence: 3.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Avery E Brown
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Cole Bortz
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Katherine Pierce
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Haddy Alas
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Waleed Ahmad
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Lara Passfall
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Nicholas Kummer
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, CA
| | | | - Brian Neuman
- Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Christopher Shaffrey
- Department of Orthopedics and Neurosurgery, Duke University Medical Center, Durham, NC
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Justin Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
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Plais N, Bao H, Lafage R, Kim HJ, Gupta M, Smith JS, Shaffrey C, Mundis G, Burton D, Ames C, Klineberg E, Bess S, Hostin RA, Schwab F, Lafage V. Fractional Curve in Adult Spinal Deformity: Is it a Driver of or a Compensation for Coronal Malalignment? Clin Spine Surg 2021; 34:E276-E281. [PMID: 38011511 DOI: 10.1097/bsd.0000000000001151] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 12/22/2020] [Indexed: 10/21/2022]
Abstract
STUDY DESIGN This was a retrospective review of the multicenter adult spine deformity database. OBJECTIVE The objective of this study was to investigate the role of the fractional curve (FC) on global coronal malalignment. SUMMARY OF BACKGROUND DATA Despite being very common, the role of the coronal FC as either a driver or compensation for global coronal malalignment is not well documented. MATERIALS AND METHODS Patients with the following characteristics were extracted from a prospective multicenter database: lumbar/thoracolumbar (TL) major coronal curve >15 degrees, apex at T11-L3, lower end vertebra at L3 or L4, above 45 years old, and FC >5 degrees. In addition to the classic radiographic parameters, baseline analysis included Cobb angle, pelvic obliquity (PO), fractional ratio (fractional Cobb/main Cobb), the sum of PO and FC, as well as the coronal Qiu classification. Curves distribution (TL vs. FC) were compared across the 3 Qui types, and the role of the FC was investigated. RESULTS A total of 404 patients (63 y old, 83.3% female) were included: 43 patients were classified as type B, 120 as type C, and 241 were coronally balanced (type A). Compared with the balanced patients, type C patients had similar major TL Cobb angles but significantly larger fractional Cobb angles (17.5 vs. 22.3 degrees, P<0.001). By opposition, type B patients had significantly larger major TL Cobb angles (49 vs. 41 degrees, P=0.001) but smaller fractional Cobb angles (P<0.001). PO>5 degrees in the same direction as FC was more common in type B patients (20%) than in type C patients (7.5%), which suggests the preferential role of pelvic compensation. CONCLUSIONS Our findings challenge the idea that FC is only a compensatory curve below a main lumbar or TL curve. In type B patients, FC acts as a compensation mechanism but fails to maintain coronal alignment despite the presence of PO. In type C patients, however, the lumbosacral FC acts as a primary driver of coronal malalignment. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Nicolas Plais
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
- San Cecilio University Hospital in Granada, Granada, Spain
| | - Hongda Bao
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
- Nanjing Drum Tower Hospital, Nanjing University, Nanjing, Jiangsu Province, China
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | | | - Gregory Mundis
- San Diego Spine Foundation, San Diego
- Scripps Clinic, La Jolla, CA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco, San Francisco
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA
| | - Shay Bess
- Presbyterian/St. Luke's Medical Center & Rocky Mountain Hospital for Children, Denver, CO
| | | | - Frank Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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Durand WM, Lafage R, Hamilton DK, Passias PG, Kim HJ, Protopsaltis T, Lafage V, Smith JS, Shaffrey C, Gupta M, Kelly MP, Klineberg EO, Schwab F, Gum JL, Mundis G, Eastlack R, Kebaish K, Soroceanu A, Hostin RA, Burton D, Bess S, Ames C, Hart RA, Daniels AH. Artificial intelligence clustering of adult spinal deformity sagittal plane morphology predicts surgical characteristics, alignment, and outcomes. Eur Spine J 2021; 30:2157-2166. [PMID: 33856551 DOI: 10.1007/s00586-021-06799-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/12/2020] [Accepted: 02/24/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE AI algorithms have shown promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics-this study sought to complement these efforts by analyzing images of sagittal anatomical spinopelvic landmarks. We hypothesized that an AI algorithm would cluster preoperative lateral radiographs into groups with distinct morphology. METHODS This was a retrospective review of a multicenter, prospectively collected database of adult spinal deformity. A total of 915 patients with adult spinal deformity and preoperative lateral radiographs were included. A 2 × 3, self-organizing map-a form of artificial neural network frequently employed in unsupervised classification tasks-was developed. The mean spine shape was plotted for each of the six clusters. Alignment, surgical characteristics, and outcomes were compared. RESULTS Qualitatively, clusters C and D exhibited only mild sagittal plane deformity. Clusters B, E, and F, however, exhibited marked positive sagittal balance and loss of lumbar lordosis. Cluster A had mixed characteristics, likely representing compensated deformity. Patients in clusters B, E, and F disproportionately underwent 3-CO. PJK and PJF were particularly prevalent among clusters A and E. Among clusters B and F, patients who experienced PJK had significantly greater positive sagittal balance than those who did not. CONCLUSIONS This study clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology and association with sagittal alignment parameters, baseline HRQOL, and surgical characteristics. The relationship between SVA and PJK differed by cluster. This study represents significant progress toward incorporation of computer vision into clinically relevant classification systems in adult spinal deformity. LEVEL OF EVIDENCE IV Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.
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Affiliation(s)
- Wesley M Durand
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Alpert Medical School, Providence, Rhode Island, 1 Kettle Point Avenue, East Providence, RI, 02914, USA
| | | | - D Kojo Hamilton
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter G Passias
- Langone Medical Center, New York University, New York City, NY, USA
| | - Han Jo Kim
- Hospital for Special Surgery, Newyork city, NY, USA
| | | | | | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA, USA
| | | | | | | | - Eric O Klineberg
- University of California, UC Davis Medical Center, Sacramento, CA, USA
| | - Frank Schwab
- Hospital for Special Surgery, Newyork city, NY, USA
| | | | | | | | - Khaled Kebaish
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Doug Burton
- Medical Center, University of Kansas, Kansas City, KS, USA
| | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | | | - Robert A Hart
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Alpert Medical School, Providence, Rhode Island, 1 Kettle Point Avenue, East Providence, RI, 02914, USA.
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Lafage R, Ang B, Schwab F, Kim HJ, Smith JS, Shaffrey C, Burton D, Ames C, Mundis G, Hostin R, Bess S, Klineberg E, Passias P, Lafage V. Depression Symptoms Are Associated with Poor Functional Status Among Operative Spinal Deformity Patients. Spine (Phila Pa 1976) 2021; 46:447-456. [PMID: 33337685 DOI: 10.1097/brs.0000000000003886] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospective multicenter database. OBJECTIVE The aim of this study was to investigate how preoperative mental status affects preoperative and postoperative disability and health scores in adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA The relationship between health-related quality of life (HRQOL) and depression has previously been documented. However, the influence of depression on clinical outcomes among ASD patients is not well understood. METHODS ASD patients with minimum 2-year follow-up were stratified based on preoperative mental health measured by Short Form 36 (SF-36) mental component score (MCS). Patients with MCS in the 25th and 75th percentile of the cohort were designated as having low and high MCS, respectively. After matching by preoperative demographics and deformity, pre- and post-HRQOL were compared between the two groups. Further analysis was performed to identify individualized questions on the SF-36 that could potentially screen for patients with low MCS. RESULTS Five hundred thirteen patients were assessed (58.4 years' old, 79% women, mean MCS 45.5). Thresholds for low and high MCS cohorts were 35.0 and 57.3, respectively. After matching by preoperative alignment, low MCS patients had worse Oswestry Disability Index (ODI) (52.3 ± 17.0 vs. 35.7 ± 14.6, P < 0.001) and Scoliosis Research Society-22R scores for all domains (all P < 0.001) compared to high MCS patients. Similar results were maintained at 2-year postop, with low MCS patients having a worse ODI (35.2 ± 20.2 vs. 19.7 ± 18.6, P < 0.001) and MCS (42.4 ± 13.5 vs. 58.6 ± 7.1, P < 0.001). Despite similar preoperative Physical Component Score (PCS), low MCS patients were less likely to reach MCID for PCS (46.1% vs. 70.6%, P < 0.01) and had a lower satisfaction at 2-year follow-up (3.88 ± 1.07 vs. 4.39 ± 0.94, P < 0.001). Questions 5a, 9d, and 9f on the SF-36 were found to be independent predictors of low MCS. CONCLUSION ASD patients with low MCS are more likely to experience functional limitations before and after surgery and are less likely to be satisfied postoperatively, even when similar clinical goals are achieved. Incorporating psychological factors may assist in decision making.Level of Evidence: 3.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Bryan Ang
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | | | - Douglas Burton
- Department of Orthopedics, University of Kansas Medical Center, Kansas City, KS
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA
| | | | - Richard Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
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Lafage R, Beyer G, Schwab F, Klineberg E, Burton D, Bess S, Kim HJ, Smith J, Ames C, Hostin R, Khalife M, Shaffrey C, Mundis G, Lafage V. Risk Factor Analysis for Proximal Junctional Kyphosis After Adult Spinal Deformity Surgery: A New Simple Scoring System to Identify High-Risk Patients. Global Spine J 2020; 10:863-870. [PMID: 32905727 PMCID: PMC7485080 DOI: 10.1177/2192568219882350] [Citation(s) in RCA: 14] [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: 01/29/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Develop a simple scoring system to estimate proximal junctional kyphosis (PJK) risk. METHODS A total of 417 adult spinal deformity (ASD) patients (80% females, 57.8 years) with 2-year follow-up were included. PJK was defined as a >10° kyphotic angle between the upper-most instrumented vertebra (UIV) and the vertebrae 2 levels above the UIV (UIV+2). Based on a previous literature review, the following point score was attributed to parameters likely to impact PJK development: age >55 years (1 point), fusion to S1/ilium (1 point), UIV in the upper thoracic spine (UIV-UT: 1 point), UIV in the lower thoracic region (UIV-LT: 2 points), flattening of the thoracic kyphosis (TK) relative to the lumbar lordosis (LL; ie, ▵LL - ▵TK) greater than 10° (1 point). RESULTS At 2 years, the overall PJK rate was 43%. The odds ratios for each risk factor were the following: age >55 years (2.52), fusion to S1/ilium (5.17), UIV-UT (6.63), UIV-LT (8.24), and ▵LL - ▵TK >10° (1.59). Analysis by risk factor revealed a significant impact on PJK (no PJK vs PJK): age >55 years (28% vs 51%, P < .001), LIV S1/ilium (16.3% vs 51.4%, P < .001), UIV in lower thoracic spine (12.0% vs 38.7% vs 52.9%, P < .001), and a >10° surgical reduction in TK relative to LL increase (40.0% vs 51.5%, P < .001). The PJK rate by point score was as follows: 1 = 17%, 2 = 29%, 3 = 40%, 4 = 53%, and 5 = 69%. CONCLUSION A pragmatic scoring system was developed that is tied to the increasing risk of PJK. These findings are helpful for surgical planning and preoperative counseling.
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Affiliation(s)
- Renaud Lafage
- Hospital for Special Surgery, New York, NY, USA,Renaud Lafage, Spine Service, Hospital for Special Surgery, 525 E 71st Street, Belaire 4E, New York, NY 10021, USA.
| | - George Beyer
- Hospital for Special Surgery, New York, NY, USA,SUNY Downstate Medical Center, Brooklyn, NY, USA
| | | | | | - Douglas Burton
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | - Justin Smith
- University of Virginia Medical Center, Charlottesville, VA, USA
| | - Christopher Ames
- San Francisco Medical Center, University of California, San Francisco, CA, USA
| | | | - Marc Khalife
- Hopital Europeen Georges Pompidou, Paris, France
| | | | - Gregory Mundis
- San Diego Center for Spinal Disorders, La Jolla, CA, USA
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Virk S, Passias P, Lafage R, Klineberg E, Mundis G, Protopsaltis T, Shaffrey C, Bess S, Burton D, Hart R, Kim HJ, Ames C, Schwab F, Smith J, Lafage V. Intraoperative alignment goals for distinctive sagittal morphotypes of severe cervical deformity to achieve optimal improvements in health-related quality of life measures. Spine J 2020; 20:1267-1275. [PMID: 32209421 DOI: 10.1016/j.spinee.2020.03.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patients with severe cervical deformity (CD) often have profound deficits in numerous activities of daily living. The association between health status and postoperative radiographic goals is difficult to quantify. PURPOSE We aimed to investigate the radiographic characteristics of patients who achieved optimal health related quality of life scores following surgery for CD. STUDY DESIGN We performed a retrospective review of a prospectively collected database of patients with spinal deformity. PATIENT SAMPLE One hundred and fifty-three patients with cervical deformity OUTCOME MEASURES: Common health-related quality of life scores (HRQOLs) measurements were taken for patients treated operatively for cervical deformity including neck disability index (NDI), modified Japanese Orthopaedic Association scale (mJOA) for myelopathy and numeric rating scale for neck pain (NRS-neck), METHODS: Surgical patients with severe CD were isolated based upon a previously presented discriminant analysis which outlined a combination of preoperative cervical sagittal vertical axis (cSVA), T1 slope, maximum focal kyphosis in extension, C2 slope in extension, and number of kyphotic levels in extension. Those with available preoperative and 1-year postoperative HRQL data were included. Based on a previous study, patients were grouped into three distinct sagittal morphotypes of CD: focal deformity (FD), flat neck (FN = large TS-CL and lack of compensation), or cervicothoracic (CT). Postoperative outcomes were defined as "good" if a patient had ≥2 of the three following criteria (1) NDI <20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Within each distinct deformity group, patients with good outcomes were compared to those with poor outcomes (ie, not meeting the criteria for good) for differences in demographics, HRQOL scores, and alignment, via Chi-squared or student's t tests. RESULTS Overall, 83 of 153 patients met the criteria of severe CD and 40 patients had complete 1-year follow-up of clinical/radiographic data. Patient breakdown by deformity pattern was: CT (N=13), FN (N=17), and FD (N=17), with 7 patients meeting criteria for both FD and FN deformities. Within the FD cohort, maximal focal kyphosis (ie, kyphosis at one level) was better corrected in patients with a "good" outcome (p=.03). In the FN cohort, patients with "good" outcomes presented preoperatively with worse horizontal gaze (McGregor Slope 21° vs. 6°, p=.061) and cSVA (72 mm vs. 60 mm, p=.030). "Good" outcome FN patients showed significantly greater postop correction of horizontal gaze (-25° vs. -5°, p=.031). In the CT cohort, patients with "good" outcomes had superior global alignment both pre- (SVA: -17 mm vs. 108 mm, p<.001) and postoperatively (50 mm vs. 145 mm, p=.001). CT patients with "good" outcomes also had better postop cervical alignment (cSVA 35 mm vs. 49 mm, p=.030), and less kyphotic segments during extension (p=.011). In the FD cohort, there were no differences between "good" and "poor" outcomes patients in preoperative alignment; however, "good" outcome patients showed superior changes in postoperative focal kyphosis (-2° vs. 5°, p=.030). Within all three deformity pattern categories, there were no differences between "good" and "poor" outcome patients with respect to demographics or surgical parameters (levels fused, surgical approach, decompression, osteotomy, all p>.050). CONCLUSIONS The results of this study show each CD patient's unique deformity must be carefully examined in order to determine the appropriate alignment goals to achieve optimal HRQOLs. In particular, the recognition of the sagittal morphotype can help assist surgeons to aim for specific alignment goals for CT, FN and FD. Distinct deformity specific intra-operative goals include obtaining proper sagittal global/cervical alignment for cervicothoracic patients, correcting maximal focal kyphosis in focal deformity patients, and correcting horizontal gaze for flatneck patients.
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Affiliation(s)
- Sohrab Virk
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Renaud Lafage
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA
| | - Gregory Mundis
- Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | | | | | - Shay Bess
- Rocky Mountain Scoliosis and Spine Center, Denver, CO, USA
| | - Doug Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Oregon Health Sciences University, Portland, OR, USA
| | - Han Jo Kim
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA
| | - Christopher Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Frank Schwab
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA
| | - Justin Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Virginie Lafage
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA.
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Plais N, Bao H, Lafage R, Gupta M, Smith JS, Shaffrey C, Mundis G, Burton D, Ames C, Klineberg E, Bess S, Schwab F, Lafage V. The clinical impact of global coronal malalignment is underestimated in adult patients with thoracolumbar scoliosis. Spine Deform 2020; 8:105-113. [PMID: 31981146 DOI: 10.1007/s43390-020-00046-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 05/11/2019] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective review of multicenter adult spine deformity (ASD) database. OBJECTIVES A recent publication demonstrated that the laterality of the coronal offset is a key parameter that directly impacts postoperative outcomes. The objective of this study is to analyze the relationship between global coronal malalignment (GCM) and functional outcomes in a North American population of ASD patients with no history of previous surgery. The clinical impact of GCM in patients with ASD remains controversial. METHODS Primary patients were drawn from a multicenter database of ASD patients and categorized with the Qiu classification: Type A = GCM < 3 cm; Type B = GCM > 3 cm toward the concave side of the curve; and Type C = GCM > 3 cm toward the convex side. In addition to the classic radiographic parameter, the coronal truncal inclination was investigated in regard to the pelvic obliquity. Clinical outcomes, radiographic parameters, and demographics were compared across the three Qiu Types using analysis of variance. The analysis was repeated after propensity matching of the three types by age and sagittal alignment (PI-LL mismatch, pelvic tilt, and sagittal vertical axis). RESULTS 576 ASD patients (mean age 58.8 years) were included. Type B patients had significantly worse functional scores (Oswestry Disability Index, 36-item Short Form Survey physical component summary, and Scoliosis Research Society-22) and a more severe coronal deformity in terms of maximum Cobb angle, global coronal deformity angle, and coronal malalignment; they were also older (65.4 vs. 58.8 years, p = 0.004) and displayed more severe sagittal malalignment. Similar findings were observed after propensity matching. CONCLUSIONS This study is the first to establish an association between functional outcomes and the severity of the coronal plane deformity in the setting of a specific coronal curve pattern in patients without previous surgery. Coronal malalignment significantly affects the health status of patients when the offset is greater than 3 cm in the direction of curve concavity. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Nicolas Plais
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
- Hospital Universitario San Cecilio, Granada, Spain.
| | - Hongda Bao
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- Nanjing Drum Tower Hospital, Nanjing University, 321 Zhongshan Rd, Gulou Qu, Nanjing Shi, 210008, Jiangsu Sheng, China
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, P.O. Box 800212, Charlottesville, VA, USA
| | - Christopher Shaffrey
- Department of Neurosurgery, University of Virginia, P.O. Box 800212, Charlottesville, VA, USA
| | - Gregory Mundis
- San Diego Spine Foundation, 6190 Cornerstone Ct. Suite 212, San Diego, CA, 92121, USA
- Scripps Clinic, 10666 N Torrey Pines Rd, La Jolla, CA, 92036, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, One Shields Avenue, Davis, CA, 95616, USA
| | - Shay Bess
- Presbyterian/St. Luke's Medical Center and Rocky Mountain Hospital for Children, 2055 High Street, Suite 130, Denver, CO, 80205, USA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Kim HJ, Virk S, Elysee J, Passias P, Ames C, Shaffrey CI, Mundis G, Protopsaltis T, Gupta M, Klineberg E, Smith JS, Burton D, Schwab F, Lafage V, Lafage R. The morphology of cervical deformities: a two-step cluster analysis to identify cervical deformity patterns. J Neurosurg Spine 2019; 32:353-359. [PMID: 31731275 DOI: 10.3171/2019.9.spine19730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/10/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical deformity (CD) is difficult to define due to the high variability in normal cervical alignment based on postural- and thoracolumbar-driven changes to cervical alignment. The purpose of this study was to identify whether patterns of sagittal deformity could be established based on neutral and dynamic alignment, as shown on radiographs. METHODS This study is a retrospective review of a prospective, multicenter database of CD patients who underwent surgery from 2013 to 2015. Their radiographs were reviewed by 12 individuals using a consensus-based method to identify severe sagittal CD. Radiographic parameters correlating with health-related quality of life were introduced in a two-step cluster analysis (a combination of hierarchical cluster and k-means cluster) to identify patterns of sagittal deformity. A comparison of lateral and lateral extension radiographs between clusters was performed using an ANOVA in a post hoc analysis. RESULTS Overall, 75 patients were identified as having severe CD due to sagittal malalignment, and they formed the basis of this study. Their mean age was 64 years, their body mass index was 29 kg/m2, and 66% were female. There were significant correlations between focal alignment/flexibility of maximum kyphosis, cervical lordosis, and thoracic slope minus cervical lordosis (TS-CL) flexibility (r = 0.27, 0.31, and -0.36, respectively). Cluster analysis revealed 3 distinct groups based on alignment and flexibility. Group 1 (a pattern involving a flat neck with lack of compensation) had a large TS-CL mismatch despite flexibility in cervical lordosis; group 2 (a pattern involving focal deformity) had focal kyphosis between 2 adjacent levels but no large regional cervical kyphosis under the setting of a low T1 slope (T1S); and group 3 (a pattern involving a cervicothoracic deformity) had a very large T1S with a compensatory hyperlordosis of the cervical spine. CONCLUSIONS Three distinct patterns of CD were identified in this cohort: flat neck, focal deformity, and cervicothoracic deformity. One key element to understanding the difference between these groups was the alignment seen on extension radiographs. This information is a first step in developing a classification system that can guide the surgical treatment for CD and the choice of fusion level.
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Affiliation(s)
- Han Jo Kim
- 1Department of Orthopedics, Hospital for Special Surgery, New York
| | - Sohrab Virk
- 1Department of Orthopedics, Hospital for Special Surgery, New York
| | - Jonathan Elysee
- 1Department of Orthopedics, Hospital for Special Surgery, New York
| | - Peter Passias
- 2Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Christopher Ames
- 3Department of Neurological Surgery, UCSF School of Medicine, San Francisco, California
| | | | - Gregory Mundis
- 5San Diego Center for Spinal Disorders, La Jolla, California
| | | | - Munish Gupta
- 6Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Eric Klineberg
- 7Department of Orthopaedic Surgery, UC Davis Health, Sacramento, California
| | - Justin S Smith
- 8Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Douglas Burton
- 9Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Frank Schwab
- 1Department of Orthopedics, Hospital for Special Surgery, New York
| | - Virginie Lafage
- 1Department of Orthopedics, Hospital for Special Surgery, New York
| | - Renaud Lafage
- 1Department of Orthopedics, Hospital for Special Surgery, New York
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Chou D, Mundis G, Wang M, Fu KM, Shaffrey C, Okonkwo D, Kanter A, Eastlack R, Nguyen S, Deviren V, Uribe J, Fessler R, Nunley P, Anand N, Park P, Mummaneni P. Minimally Invasive Surgery for Mild-to-Moderate Adult Spinal Deformities: Impact on Intensive Care Unit and Hospital Stay. World Neurosurg 2019; 127:e649-e655. [PMID: 30947010 DOI: 10.1016/j.wneu.2019.03.237] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 03/21/2019] [Accepted: 03/22/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare circumferential minimally invasive (cMIS) versus open surgeries for mild-to-moderate adult spinal deformity (ASD) with regard to intensive care unit (ICU) and hospital lengths of stay (LOS). METHODS A retrospective review of 2 multicenter ASD databases with 426 ASD (sagittal vertical axis <6 cm) surgery patients with 4 or more fusion levels and 2-year follow-up was conducted. ICU stay, LOS, and estimated blood loss (EBL) were compared between open and cMIS surgeries. RESULTS Propensity matching resulted in 88 patients (44 cMIS, 44 open). cMIS were older (61 vs. 53 years, P = 0.005). Mean levels fused were 6.5 in cMIS and 7.1 in open (P = 0.368). Preoperative lordosis was higher in open than in cMIS (42.7° vs. 40.9°, P = 0.016), and preoperative visual analog score back pain was greater in open than in cMIS (7 vs. 6.2, P = 0.033). Preoperative and postoperative spinopelvic parameters and coronal Cobb angles were not different. EBL was 534 cc in cMIS and 1211 cc in open (P < 0.001). Transfusions were less in cMIS (27.3% vs. 70.5%, P < 0.001). ICU stay was 0.6 days for cMIS and 1.2 days for open (P = 0.009). Hospital LOS was 7.9 days for cMIS versus 9.6 for open (P = 0.804). CONCLUSIONS For patients with mild-to-moderate ASD, cMIS surgery had a significantly lower EBL and shorter ICU stay. Major and minor complication rates were lower in cMIS patients than open patients. Overall LOS was shorter in cMIS patients, but did not reach statistical significance.
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Affiliation(s)
- Dean Chou
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA.
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, California, USA
| | - Michael Wang
- Department of Neurousrgery, University of Miami, Coral Gables, Florida, USA
| | - Kai-Ming Fu
- Department of Neurosurgery, Weill Cornell Medical College, New York, New York, USA
| | | | - David Okonkwo
- Department of Neurosurgery, University of Pittsburgh, Pittsburg, Pennsylvania, USA
| | - Adam Kanter
- Department of Neurosurgery, University of Pittsburgh, Pittsburg, Pennsylvania, USA
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, California, USA
| | - Stacie Nguyen
- Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Juan Uribe
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Richard Fessler
- Department of Neurosurgery, Rush University, Chicago, Illinois, USA
| | - Pierce Nunley
- Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Louisiana, USA
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars Sinai Hospital, Los Angeles, California, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Praveen Mummaneni
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
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Passias PG, Poorman GW, Horn SR, Jalai CM, Bortz C, Segreto F, Diebo BM, Daniels A, Hamilton DK, Sciubba D, Smith J, Neuman B, Shaffrey CI, LaFage V, LaFage R, Schwab F, Bess S, Ames C, Hart R, Soroceanu A, Mundis G, Eastlack R. Effect of Obesity on Radiographic Alignment and Short-Term Complications After Surgical Treatment of Adult Cervical Deformity. World Neurosurg 2019; 125:e1082-e1088. [PMID: 30790725 DOI: 10.1016/j.wneu.2019.01.248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We investigated the 30-day complication incidence and 1-year radiographic correction in obese patients undergoing surgical treatment of cervical deformity. METHODS The patients were stratified according to World Health Organization's definition for obesity: obese, patients with a body mass index of ≥30 kg/m2; and nonobese, patients with a body mass index of <30 kg/m2. The patients had undergone surgery for the treatment of cervical deformity. The patient baseline demographic, comorbidity, and radiographic data were compared between the 2 groups at baseline and 1 year postoperatively. The 30-day complication incidence was stratified according to complication severity (any, major, or minor), and type (cardiopulmonary, dysphagia, infection, neurological, and operative). Binary logistic regression models were used to assess the effect of obesity on developing those complications, with adjustment for patient age and levels fused. RESULTS A total of 124 patients were included, 53 obese and 71 nonobese patients. The 2 groups had a similar T1 slope minus cervical lordosis (obese, 37.2° vs. nonobese, 36.9°; P = 0.932) and a similar C2-C7 (-5.9° vs. -7.3°; P = 0.718) and C2-C7 (50.1 mm vs. 44.1 mm; P = 0.184) sagittal vertical axis. At the 1-year follow-up examination, the T1 pelvic angle (1.0° vs. -3.1°; P = 0.021) and C2-S1 sagittal vertical axis (-5.9 mm vs. -35.0 mm; P = 0.036) were different, and the T1 spinopelvic inclination (-1.0° vs. -2.9°; P = 0.123) was similar. The obese patients had a greater risk of overall short-term complications (odds ratio, 2.5; 95% confidence interval, 1.1-6.1) and infectious complications (odds ratio, 5.0; 95% confidence interval, 1.0-25.6). CONCLUSIONS Obese patients had a 5 times greater odds of developing infections after surgery for adult cervical deformity. Obese patients also showed significantly greater pelvic anteversion after cervical correction.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York, USA.
| | - Gregory W Poorman
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Samantha R Horn
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Cyrus M Jalai
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Cole Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Frank Segreto
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Bassel M Diebo
- Deparment of Orthopedic Surgery, SUNY Downstate Medical School, Brooklyn, New York, USA
| | - Alan Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Daniel Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Justin Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Brian Neuman
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Virginie LaFage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Renaud LaFage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine, Denver, Colorado, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Alexandra Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Mundis
- San Diego Center for Spinal Disorders, La Jolla, California, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
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Guzman JZ, Larson AN, Sanders JO, Newton PO, Berven S, Mundis G, Dimar JR, Albert TJ, Sethi RK, Shah SA. New Paradigms in the Continuum of Spine Care: From Newborns to Elderly Patients. Instr Course Lect 2019; 68:289-304. [PMID: 32032060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The evaluation and management of spinal disorders is complex and constantly evolving. Back pain and spinal deformity are substantial contributors to hospital and outpatient physician visits even for young patients. With new insights into the etiology, clinical presentation, and evaluation, children can be more accurately diagnosed and treated. Patients with adolescent idiopathic scoliosis may undergo selective fusion to preserve motion segments, and in some cases, vertebral body tethering or other growth-modification techniques may provide correction with motion preservation in this rapidly changing specialty. The understanding of spinopelvic parameters (pelvic incidence, pelvic tilt, sacral slope) and sagittal balance as they relate to clinical health status has provided surgeons with valuable guidance when managing pediatric and adult spinal deformity. An evidence-based approach to the management of spinal disorders across the continuum of ages has the goal of improving the value of care through optimization of outcomes and limitation of costs and complications. There are new paradigms in the management of spinal disorders and evidence-based approaches to the evaluation and management of patients across the ages.
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Chou D, Mummaneni P, Anand N, Nunley P, La Marca F, Fu KM, Fessler R, Park P, Wang M, Than K, Nguyen S, Uribe J, Zavatsky J, Deviren V, Kanter A, Okonkwo D, Eastlack R, Mundis G. Treatment of the Fractional Curve of Adult Scoliosis With Circumferential Minimally Invasive Surgery Versus Traditional, Open Surgery: An Analysis of Surgical Outcomes. Global Spine J 2018; 8:827-833. [PMID: 30560035 PMCID: PMC6293429 DOI: 10.1177/2192568218775069] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
STUDY DESIGN Retrospective, multicenter review of adult scoliosis patients with minimum 2-year follow-up. OBJECTIVE Because the fractional curve (FC) of adult scoliosis can cause radiculopathy, we evaluated patients treated with either circumferential minimally invasive surgery (cMIS) or open surgery. METHODS A multicenter retrospective adult deformity review was performed. Patients included: age >18 years with FC >10°, ≥3 levels of instrumentation, 2-year follow-up, and one of the following: coronal Cobb angle (CCA) > 20°, pelvic incidence and lumbar lordosis (PI-LL) > 10°, pelvic tilt (PT) > 20°, and sagittal vertical axis (SVA) > 5 cm. RESULTS The FC was treated in 118 patients, 79 open and 39 cMIS. The FCs had similar coronal Cobb angles preoperative (17° cMIS, 19.6° open) and postoperative (7° cMIS, 8.1° open), but open had more levels treated (12.1 vs 5.7). cMIS patients had greater reduction in VAS leg (6.4 to 1.8) than open (4.3 to 2.5). With propensity matching 40 patients for levels treated (cMIS: 6.6 levels, N = 20; open: 7.3 levels, N = 20), both groups had similar FC correction (18° in both preoperative, 6.9° in cMIS and 8.5° postoperative). Open had more posterior decompressions (80% vs 22.2%, P < .001). Both groups had similar preoperative (Visual Analogue Scale [VAS] leg 6.1 cMIS and 5.4 open) and postoperative (VAS leg 1.6 cMIS and 3.1 open) leg pain. All cMIS patients had interbody grafts; 35% of open did. There was no difference in change of primary CCA, PI-LL, LL, Oswestry Disability Index, or VAS Back. CONCLUSION Patients' FCs treated with cMIS had comparable reduction of leg pain compared with those treated with open surgery, despite significantly fewer cMIS patients undergoing direct decompression.
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Affiliation(s)
- Dean Chou
- University of California San Francisco, CA, USA,Dean Chou, University of California San
Francisco, 505 Parnassus Ave, Box 0112, San Francisco, CA 94143, USA.
| | | | - Neel Anand
- Cedars Sinai Hospital, Los Angeles, CA, USA
| | | | | | - Kai-Ming Fu
- Weill Cornell Medical College, New York, NY, USA
| | | | - Paul Park
- University of Michigan, Detroit, MI, USA
| | | | - Khoi Than
- Oregon Health Sciences University, Portland, OR, USA
| | - Stacie Nguyen
- San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | - Juan Uribe
- Barrow Neurological Institute, Phoenix, AZ, USA
| | | | | | - Adam Kanter
- University of Pittsburgh, Pittsburgh, PA, USA
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Protopsaltis T, Terran J, Soroceanu A, Moses MJ, Bronsard N, Smith J, Klineberg E, Mundis G, Kim HJ, Hostin R, Hart R, Shaffrey C, Bess S, Ames C, Schwab F, Lafage V. T1 Slope Minus Cervical Lordosis (TS-CL), the Cervical Answer to PI-LL, Defines Cervical Sagittal Deformity in Patients Undergoing Thoracolumbar Osteotomy. Int J Spine Surg 2018; 12:362-370. [PMID: 30276093 PMCID: PMC6159736 DOI: 10.14444/5042] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Cervical kyphosis and C2-C7 plumb line (CPL) are established descriptors of cervical sagittal deformity (CSD). Reciprocal changes in these parameters have been demonstrated in thoracolumbar deformity correction. The purpose of this study was to investigate the development of CSD, using T1 slope minus cervical lordosis (TS-CL) to define CSD and to correlate TS-CL and a novel global sagittal parameter, cervical-thoracic pelvic angle (CTPA), with CPL. METHODS A multicenter, retrospective analysis of patients with thoracolumbar deformity undergoing three-column osteotomy was performed. Preoperative and postoperative cervical parameters were investigated. Linear regression for postoperative values resulted in a CPL of 4 cm corresponding to a TS-CL threshold of 17°. Patients were classified based on postoperative TS-CL into uncompensated (TS-CL > 17°) or compensated cohorts (TS-CL < 17°); the two were compared using an unpaired t test. Logistic regression modeling was used to determine predictors of postoperative CSD. RESULTS A total of 223 patients with thoracolumbar deformity (mean age, 57.56 years) were identified. CTPA correlated with CPL (preoperative r = .85, postoperative r = .69). TS-CL correlated with CTPA (preoperative r = .52, postoperative r = .37) and CPL (preoperative r = .52; postoperative r = .37). CSD had greater preoperative CPL (P < .001) and CTPA (P < .001). The compensated cohort had a decrease in TS-CL (from 10.2 to 8.0) with sagittal vertical axis (SVA) correction, whereas the uncompensated had an increase in TS-CL (from 22.3 to 26.8) with all P < .001. Reciprocal change was demonstrated in the compensated group given that CL decreased with SVA correction (r = .39), but there was no such correlation in the uncompensated. Positive predictors of postoperative CSD included baseline TS-CL > 17° (P = .007), longer fusion (P = .033), and baseline CTPA (P = .029). CONCLUSIONS TS-CL and CTPA correlated significantly with established sagittal balance measures. Whereas reciprocal change in cervical and thoracolumbar alignment was demonstrated in the compensated cohort, the uncompensated population had progression of their cervical deformities after three-column osteotomy. CLINICAL RELEVANCE The balance between TS-CL mirrors the relationship between pelvic incidence minus lumbar lordosis in defining deformities of their respective spinal regions.
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Affiliation(s)
| | - Jamie Terran
- New York University School of Medicine, Department of Orthopedic Surgery, New York, New York
| | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Moses
- New York University School of Medicine, Department of Orthopedic Surgery, New York, New York
| | - Nicolas Bronsard
- Department of Orthopaedic, Trauma, and Spine Surgery, Institut Universitaire de l'appareil Locomoteur et du Sport, Hôpital Pasteur 2, Centre Hospitalier Universaire de Nice, Nice, France
| | - Justin Smith
- University of Virginia School of Medicine, Department of Neurosurgery, Charlottesville, Virginia
| | - Eric Klineberg
- University of California Davis, Department of Orthopedic Surgery, Sacramento, California
| | - Gregory Mundis
- San Diego Center for Spinal Disorders, La Jolla, California
| | - Han Jo Kim
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, New York
| | | | - Robert Hart
- University of Oregon Health Sciences Center, Department of Orthopedic Surgery, Portland, Oregon
| | - Christopher Shaffrey
- University of Virginia School of Medicine, Department of Neurosurgery, Charlottesville, Virginia
| | - Shay Bess
- Rocky Mountain Hospital for Children, Presbyterian/St Luke's Medical Center, Denver, Colorado
| | - Christopher Ames
- University of California San Francisco, Department of Neurosurgery, San Francisco, California
| | - Frank Schwab
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, New York
| | - Virginie Lafage
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, New York
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Challier V, Henry JK, Liu S, Ames C, Kebaish K, Obeid I, Hostin R, Gupta M, Boachie-Adjei O, Smith JS, Mundis G, Bess S, Schwab F, Lafage V. Complication Rates and Maintenance of Correction After 3-Column Osteotomy in the Elderly: Report of 55 Patients With 2-Year Follow-up. Neurosurgery 2017; 83:973-980. [DOI: 10.1093/neuros/nyx580] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 11/07/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Vincent Challier
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
- Pellegrin Hospital, Bord-eaux, France
| | - Jensen K Henry
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Shian Liu
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Christopher Ames
- Department of Neurosu-rgery, University of California San Fran-cisco, San Francisco, California
| | - Khaled Kebaish
- Depart-ment of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Ibrahim Obeid
- Department of Orthopaedic Surgery, Bordeaux University Hospital, Bordeaux, France
| | | | - Munish Gupta
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, California
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Gregory Mundis
- San Diego Center for Spinal Disorders, La Jolla, California
| | - Shay Bess
- Rocky Mountain Hospital for Children, Denver, Colorado
| | - Frank Schwab
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Virginie Lafage
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
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47
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Ailon T, Smith JS, Shaffrey CI, Kim HJ, Mundis G, Gupta M, Klineberg E, Schwab F, Lafage V, Lafage R, Passias P, Protopsaltis T, Neuman B, Daniels A, Scheer JK, Soroceanu A, Hart R, Hostin R, Burton D, Deviren V, Albert TJ, Riew KD, Bess S, Ames CP. Outcomes of Operative Treatment for Adult Cervical Deformity: A Prospective Multicenter Assessment With 1-Year Follow-up. Neurosurgery 2017; 83:1031-1039. [DOI: 10.1093/neuros/nyx574] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/31/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tamir Ailon
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Gregory Mundis
- Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St Louis, Missouri
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Frank Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | - Brian Neuman
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Alan Daniels
- Department of Orthopaedic Surgery, Brown University Alpert Medical School, Providence, Rhode Island
| | - Justin K Scheer
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Alex Soroceanu
- Department of Orthopaedics, University of Calgary, Calgary, Alberta, Canada
| | - Robert Hart
- Swedish Neuroscience Institute, Seattle, Washington
| | - Rick Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, Kansas
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Todd J Albert
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - K Daniel Riew
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Nabizadeh N, Yaszay B, McClung A, Skaggs D, Thompson G, Boachie-Adjei O, Sponseller P, Shah SA, Sanders JO, Pawelek J, Mundis G, Akbarnia B. Paper #36: Multi-level Congenital Deformities in Early Onset Scoliosis: Radiographic and Clinical Outcomes in Growth Friendly Graduates. Spine Deform 2017; 5:458. [PMID: 31997174 DOI: 10.1016/j.jspd.2017.09.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Treatment of complex congenital scoliosis with growth friendly instrumentation led to only modest correction of major curves, residual imbalance, minimal gain in spine and thoracic height and a high incidence of complications. It is unknown whether this treatment improves upon the natural history or early fusion.
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Hosseini P, Eghbali A, Pawelek J, Heskett K, Mundis G, Akbarnia B. Paper #37: A high degree of variability exists in how "safety and efficacy" is defined and reported in growing rod surgery for early-onset scoliosis: A systematic review. Spine Deform 2017; 5:459. [PMID: 31997173 DOI: 10.1016/j.jspd.2017.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Established criteria for reporting safety and efficacy have not yet been defined in growing rod surgery for early-onset scoliosis. A systematic literature review revealed a high degree of variability in how authors stratified complications and patient outcomes as a means to define safety and efficacy for this challenging patient population.
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50
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McClung A, Mundis G, Pawelek J, Garg S, Yaszay B, Boachie-Adjei O, Sanders JO, Sponseller P, Pérez-Grueso FJS, Lavelle W, Emans J, Johnston C, Akbarnia B. Paper #19: Utilization and Reliability of Intraoperative Neuromonitoring in Vertebral Column Resections for Severe Early-Onset Scoliosis. Spine Deform 2017; 5:448-449. [PMID: 31997191 DOI: 10.1016/j.jspd.2017.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Use of IOM in treating EOS with a VCR was found to be effective in 100% of the patients; despite 7/33 having a preop neuro deficit. 12/33 with an IOM change, with 42% having a post-op deficit.
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