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Passias PG, Williamson TK, Mir JM, Lebovic JA, Dave P, Tretiakov PS, Joujon-Roche R, Imbo B, Krol O, Owusu-Sarpong S, Vira S, Schoenfeld AJ, Daniels AH, Diebo BG, Lafage R, Lafage V. Comparison of multilevel low-grade techniques versus three-column osteotomies in adult spinal deformity surgery: does harmonious correction matter? J Neurosurg Spine 2024:1-7. [PMID: 38489818 DOI: 10.3171/2024.1.spine23802] [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: 07/26/2023] [Accepted: 01/08/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Recent debate has arisen between whether to use a three-column osteotomy (3CO) or multilevel low-grade (MLG) techniques to treat severe sagittal malalignment in adult spinal deformity (ASD) surgery. The goal of this study was to compare the outcomes of 3CO and MLG techniques performed in corrective surgeries for ASD. METHODS ASD patients who had a baseline PI-LL > 30° and 2-year follow-up data were included. Patients underwent either 3CO or MLG (thoracolumbar posterior column osteotomies at ≥ 3 levels or anterior lumbar interbody fusion at ≥ 3 levels with no 3CO). The segmental utility ratio was used to assess relative segmental correction (segmental correction divided by overall correction in lordosis divided by the number of thoracolumbar interventions [interbody fusion, thoracolumbar posterior column osteotomies, and 3CO]). The paired t-test was used to assess lordotic distribution by differences in lordosis between adjacent lumbar disc spaces (e.g., L1-2 to L2-3). Multivariate analysis, controlling for age, sex, BMI, osteoporosis, baseline pelvic incidence, and T1 pelvic angle, was used to evaluate the complication rates and radiographic and patient-reported outcomes between the groups. RESULTS A total of 93 patients were included, 53% of whom underwent MLG and 47% of whom underwent 3CO. The MLG group had a lower BMI (p < 0.05). MLG patients received fewer previous fusions than 3CO patients (31% vs 80%, p < 0.001). MLG patients had 24% less blood loss but a 22% longer operative time (565 vs 419 minutes, p = 0.008). Using adjusted analysis, the 3CO group had greater segmental and relative correction at each level (segmental utility ratio mean 69% for 3CO vs 23% for MLG, p < 0.001). However, the 3CO group had lordotic differences between two adjacent lumbar disc pairs (range -0.5° to 9.0°, p = 0.009), while MLG was more harmonious (range 2.2°-6.5°, p > 0.4). MLG patients were more likely to undergo realignment to age-adjusted standards (OR 5.6, 95% CI 1.2-46.4; p = 0.033). MLG patients were less likely to develop neurological complications or undergo reoperation (OR 0.4, 95% CI 0.1-0.9; p = 0.041). Adjusted analysis revealed that MLG patients more often met a substantial clinical benefit in the Oswestry Disability Index score (OR 5.3, 95% CI 1.1-26.8; p = 0.043). CONCLUSIONS MLG techniques showed better utility in lumbar distribution and age-adjusted global correction while minimizing neurological complications and reoperation rates by 2 years postoperatively. In selected instances, these techniques may offer the spine deformity surgeon a safer alternative when correcting severe adult spinal deformity.
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Affiliation(s)
- Peter G Passias
- 1Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Tyler K Williamson
- 1Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
- 2Department of Orthopaedic Surgery, University of Texas Health San Antonio, Texas
| | - Jamshaid M Mir
- 1Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Jordan A Lebovic
- 3Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York
| | - Pooja Dave
- 1Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Peter S Tretiakov
- 1Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Rachel Joujon-Roche
- 1Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Bailey Imbo
- 1Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Oscar Krol
- 1Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | | | - Shaleen Vira
- 4Department of Orthopaedic Surgery, Banner University/University of Arizona Medical Center, Phoenix, Arizona
| | - Andrew J Schoenfeld
- 5Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical Center, Boston, Massachusetts
| | - Alan H Daniels
- 6Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University Medical Center, Providence, Rhode Island; and
| | - Bassel G Diebo
- 6Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University Medical Center, Providence, Rhode Island; and
| | - Renaud Lafage
- 7Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Virginie Lafage
- 7Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
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Passias PG, Williamson TK, Mir JM, Smith JS, Lafage V, Lafage R, Line B, Daniels AH, Gum JL, Schoenfeld AJ, Hamilton DK, Soroceanu A, Scheer JK, Eastlack R, Mundis GM, Diebo B, Kebaish KM, Hostin RA, Gupta MC, Kim HJ, Klineberg EO, Ames CP, Hart RA, Burton DC, Schwab FJ, Shaffrey CI, Bess S. Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery. J Clin Med 2023; 12:5565. [PMID: 37685633 PMCID: PMC10488913 DOI: 10.3390/jcm12175565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications. OBJECTIVE Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers. STUDY DESIGN/SETTING Retrospective cohort study of a prospectively collected multicenter database. METHODS ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility. RESULTS A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, p = 0.021) and major mechanical complications (12% vs. 22%, p = 0.002), and less reoperations (23% vs. 33%, p = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both p < 0.001) at two years. CONCLUSIONS Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.
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Affiliation(s)
- Peter G. Passias
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, NY 10003, USA
| | - Tyler K. Williamson
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, NY 10003, USA
| | - Jamshaid M. Mir
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, NY 10003, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22904, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY 10021, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO 80205, USA
| | - Alan H. Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USA
| | - Jeffrey L. Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY 40202, USA
| | - Andrew J. Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women’s Center for Surgery and Public Health, Boston, MA 02120, USA
| | - David Kojo Hamilton
- Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Justin K. Scheer
- Department of Neurosurgery, University of California, San Francisco, CA 94143, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA 92037, USA
| | - Gregory M. Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA 92037, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USA
| | - Khaled M. Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD 21205, USA
| | - Richard A. Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX 75243, USA
| | - Munish C. Gupta
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI 02912, USA
| | - Han Jo Kim
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY 10021, USA
| | - Eric O. Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA 95819, USA
| | - Christopher P. Ames
- Department of Neurosurgery, University of California, San Francisco, CA 94143, USA
| | - Robert A. Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA 98122, USA
| | - Douglas C. Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Frank J. Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY 10075, USA
| | - Christopher I. Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO 80205, USA
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