Browsing by Author "Akbarnia, Behrooz A"
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Item Open Access Can a Minimal Clinically Important Difference Be Achieved in Elderly Patients with Adult Spinal Deformity Who Undergo Minimally Invasive Spinal Surgery?(World neurosurgery, 2016-02) Park, Paul; Okonkwo, David O; Nguyen, Stacie; Mundis, Gregory M; Than, Khoi D; Deviren, Vedat; La Marca, Frank; Fu, Kai-Ming; Wang, Michael Y; Uribe, Juan S; Anand, Neel; Fessler, Richard; Nunley, Pierce D; Chou, Dean; Kanter, Adam S; Shaffrey, Christopher I; Akbarnia, Behrooz A; Passias, Peter G; Eastlack, Robert K; Mummaneni, Praveen V; International Spine Study GroupBackground
Older age has been considered a relative contraindication to complex spinal procedures. Minimally invasive surgery (MIS) techniques to treat patients with adult spinal deformity (ASD) have emerged with the potential benefit of decreased approach-related morbidity.Objective
To determine whether a minimal clinically important difference (MCID) could be achieved in patients ages ≥ 65 years with ASD who underwent MIS.Methods
Multicenter database of patients who underwent MIS for ASD was queried. Outcome metrics assessed were Oswestry Disability Index (ODI) and visual analog scale (VAS) scores for back and leg pain. On the basis of published reports, MCID was defined as a positive change of 12.8 ODI, 1.2 VAS back pain, and 1.6 VAS leg pain.Results
Forty-two patients were identified. Mean age was 70.3 years; 31 (73.8%) were women. Preoperatively, mean coronal curve, pelvic tilt, pelvic incidence to lumbar lordosis mismatch, and sagittal vertical axis were 35°, 24.6°, 14.2°, and 4.7 cm, respectively. Postoperatively, mean coronal curve, pelvic tilt, pelvic incidence to lumbar lordosis, and sagittal vertical axis were 18°, 25.4°, 11.9°, and 4.9 cm, respectively. A mean of 5.0 levels was treated posteriorly, and a mean of 4.0 interbody fusions was performed. Mean ODI improved from 47.1 to 25.1. Mean VAS back and leg pain scores improved from 6.8 and 5.9 to 2.7 and 2.7, respectively. Mean follow-up was 32.1 months. For ODI, 64.3% of patients achieved MCID. For VAS back and leg pain, 82.9% and 72.2%, respectively, reached MCID.Conclusions
MCID represents the threshold at which patients feel a meaningful clinical improvement has occurred. Our study results suggest that the majority of elderly patients with modest ASD can achieve MCID with MIS.Item Open Access Clinical and radiographic parameters associated with best versus worst clinical outcomes in minimally invasive spinal deformity surgery.(Journal of neurosurgery. Spine, 2016-07) Than, Khoi D; Park, Paul; Fu, Kai-Ming; Nguyen, Stacie; Wang, Michael Y; Chou, Dean; Nunley, Pierce D; Anand, Neel; Fessler, Richard G; Shaffrey, Christopher I; Bess, Shay; Akbarnia, Behrooz A; Deviren, Vedat; Uribe, Juan S; La Marca, Frank; Kanter, Adam S; Okonkwo, David O; Mundis, Gregory M; Mummaneni, Praveen V; International Spine Study GroupOBJECTIVE Minimally invasive surgery (MIS) techniques are increasingly used to treat adult spinal deformity. However, standard minimally invasive spinal deformity techniques have a more limited ability to restore sagittal balance and match the pelvic incidence-lumbar lordosis (PI-LL) than traditional open surgery. This study sought to compare "best" versus "worst" outcomes of MIS to identify variables that may predispose patients to postoperative success. METHODS A retrospective review of minimally invasive spinal deformity surgery cases was performed to identify parameters in the 20% of patients who had the greatest improvement in Oswestry Disability Index (ODI) scores versus those in the 20% of patients who had the least improvement in ODI scores at 2 years' follow-up. RESULTS One hundred four patients met the inclusion criteria, and the top 20% of patients in terms of ODI improvement at 2 years (best group, 22 patients) were compared with the bottom 20% (worst group, 21 patients). There were no statistically significant differences in age, body mass index, pre- and postoperative Cobb angles, pelvic tilt, pelvic incidence, levels fused, operating room time, and blood loss between the best and worst groups. However, the mean preoperative ODI score was significantly higher (worse disability) at baseline in the group that had the greatest improvement in ODI score (58.2 vs 39.7, p < 0.001). There was no difference in preoperative PI-LL mismatch (12.8° best vs 19.5° worst, p = 0.298). The best group had significantly less postoperative sagittal vertical axis (SVA; 3.4 vs 6.9 cm, p = 0.043) and postoperative PI-LL mismatch (10.4° vs 19.4°, p = 0.027) than the worst group. The best group also had better postoperative visual analog scale back and leg pain scores (p = 0.001 and p = 0.046, respectively). CONCLUSIONS The authors recommend that spinal deformity surgeons using MIS techniques focus on correcting a patient's PI-LL mismatch to within 10° and restoring SVA to < 5 cm. Restoration of these parameters seems to impact which patients will attain the greatest degree of improvement in ODI outcomes, while the spines of patients who do the worst are not appropriately corrected and may be fused into a fixed sagittal plane deformity.Item Open Access Comparison of patient and surgeon perceptions of adverse events after adult spinal deformity surgery.(Spine, 2013-04) Hart, Robert A; Cabalo, Adam; Bess, Shay; Akbarnia, Behrooz A; Boachie-Adjei, Oheneba; Burton, Douglas; Cunningham, Matthew E; Gupta, Munish; Hostin, Richard; Kebaish, Khaled; Klineberg, Eric; Mundis, Gregory; Shaffrey, Christopher; Smith, Justin S; Wood, Kirkham; International Spine Study GroupStudy design
Survey based on complication scenarios.Objective
To assess and compare perceived potential impacts of various perioperative adverse events by both surgeons and patients.Summary of background data
Incidence of adverse events after adult spinal deformity surgery remains substantial. Patient-centered outcomes tools measuring the impact of these events have not been developed. An important first step is to assess the perceptions of surgeons and patients regarding the impact of these events on surgical outcome and quality of life.Methods
Descriptions of 22 potential adverse events of surgery (heart attack, stroke, spinal cord injury, nerve root injury, cauda equina injury, blindness, dural tear, blood transfusion, deep vein thrombosis, pulmonary embolism, superficial infection, deep infection, lung failure, urinary tract infection, nonunion, adjacent segment disease, persistent deformity, implant failure, death, renal failure, gastrointestinal complications, and sexual dysfunction) were presented to 14 spinal surgeons and 16 adult patients with spinal deformity. Impact scores were assigned to each complication on the basis of perceptions of overall severity, satisfaction with surgery, and effect on quality of life. Impact scores were compared between surgeons and patients with a Wilcoxon/Kruskal-Wallis test.Results
Mean impact scores varied from 0.9 (blood transfusion) to 10.0 (death) among surgeons and 2.3 (urinary tract infection) to 9.2 (stroke) among patients. Patients' scores were consistently higher (P < 0.05) than surgeons in all 3 categories for 6 potential adverse events: stroke, lung failure, heart attack, pulmonary embolism, dural tear, and blood transfusion. Three additional complications (renal failure, non-union, and deep vein thrombosis) were rated higher in 1 or 2 categories by patients.Conclusion
There was substantial variation in how both surgeons and patients perceived impacts of various adverse events after spine surgery. Patients generally perceived the impact of adverse events to be greater than surgeons. Patient-centered descriptions of adverse events would provide a more complete description of surgical outcomes.Item Open Access Comparison of radiographic results after minimally invasive, hybrid, and open surgery for adult spinal deformity: a multicenter study of 184 patients.(Neurosurgical focus, 2014-05) Haque, Raqeeb M; Mundis, Gregory M; Ahmed, Yousef; El Ahmadieh, Tarek Y; Wang, Michael Y; Mummaneni, Praveen V; Uribe, Juan S; Okonkwo, David O; Eastlack, Robert K; Anand, Neel; Kanter, Adam S; La Marca, Frank; Akbarnia, Behrooz A; Park, Paul; Park, Paul; Lafage, Virginie; Terran, Jamie S; Shaffrey, Christopher I; Klineberg, Eric; Deviren, Vedat; Fessler, Richard G; International Spine Study GroupObject
Various surgical approaches, including open, minimally invasive, and hybrid techniques, have gained momentum in the management of adult spinal deformity. However, few data exist on the radiographic outcomes of different surgical techniques. The objective of this study was to compare the radiographic and clinical outcomes of the surgical techniques used in the treatment of adult spinal deformity.Methods
The authors conducted a retrospective review of two adult spinal deformity patient databases, a prospective open surgery database and a retrospective minimally invasive surgery (MIS) and hybrid surgery database. The time frame of enrollment in this study was from 2007 to 2012. Spinal deformity patients were stratified into 3 surgery groups: MIS, hybrid surgery, and open surgery. The following pre- and postoperative radiographic parameters were assessed: lumbar major Cobb angle, lumbar lordosis, pelvic incidence minus lumbar lordosis (PI-LL), sagittal vertical axis, and pelvic tilt. Scores on the Oswestry Disability Index (ODI) and a visual analog scale (VAS) for both back and leg pain were also obtained from each patient.Results
Of the 234 patients with adult spinal deformity, 184 patients had pre- and postoperative radiographs and were thus included in the study (MIS, n = 42; hybrid, n = 33; open, n = 109). Patients were a mean of 61.7 years old and had a mean body mass index of 26.9 kg/m(2). Regarding radiographic outcomes, the MIS group maintained a significantly smaller mean lumbar Cobb angle (13.1°) after surgery compared with the open group (20.4°, p = 0.002), while the hybrid group had a significantly larger lumbar curve correction (26.6°) compared with the MIS group (18.8°, p = 0.045). The mean change in the PI-LL was larger for the hybrid group (20.6°) compared with the open (10.2°, p = 0.023) and MIS groups (5.5°, p = 0.003). The mean sagittal vertical axis correction was greater for the open group (25 mm) compared with the MIS group (≤ 1 mm, p = 0.008). Patients in the open group had a significantly larger postoperative thoracic kyphosis (41.45°) compared with the MIS patients (33.5°, p = 0.005). There were no significant differences between groups in terms of pre- and postoperative mean ODI and VAS scores at the 1-year follow-up. However, patients in the MIS group had much lower estimated blood loss and transfusion rates compared with patients in the hybrid or open groups (p < 0.001). Operating room time was significantly longer with the hybrid group compared with the MIS and open groups (p < 0.001). Major complications occurred in 14% of patients in the MIS group, 14% in the hybrid group, and 45% in the open group (p = 0.032).Conclusions
This study provides valuable baseline characteristics of radiographic parameters among 3 different surgical techniques used in the treatment of adult spinal deformity. Each technique has advantages, but much like any surgical technique, the positive and negative elements must be considered when tailoring a treatment to a patient. Minimally invasive surgical techniques can result in clinical outcomes at 1 year comparable to those obtained from hybrid and open surgical techniques.Item Open Access Does Minimally Invasive Percutaneous Posterior Instrumentation Reduce Risk of Proximal Junctional Kyphosis in Adult Spinal Deformity Surgery? A Propensity-Matched Cohort Analysis.(Neurosurgery, 2016-01) Mummaneni, Praveen V; Park, Paul; Fu, Kai-Ming; Wang, Michael Y; Nguyen, Stacie; Lafage, Virginie; Uribe, Juan S; Ziewacz, John; Terran, Jamie; Okonkwo, David O; Anand, Neel; Fessler, Richard; Kanter, Adam S; LaMarca, Frank; Deviren, Vedat; Bess, R Shay; Schwab, Frank J; Smith, Justin S; Akbarnia, Behrooz A; Mundis, Gregory M; Shaffrey, Christopher I; International Spine Study GroupBackground
Proximal junctional kyphosis (PJK) is a known complication after spinal deformity surgery. One potential cause is disruption of posterior muscular tension band during pedicle screw placement.Objective
To investigate the effect of minimally invasive surgery (MIS) on PJK.Methods
A multicenter database of patients who underwent deformity surgery was propensity matched for pelvic incidence (PI) to lumbar lordosis (LL) mismatch and change in LL. Radiographic PJK was defined as proximal junctional angle >10°. Sixty-eight patients made up the circumferential MIS (cMIS) group, and 68 were in the hybrid (HYB) surgery group (open screw placement).Results
Preoperatively, there was no difference in age, body mass index, PI-LL mismatch, or sagittal vertical axis. The mean number of levels treated posteriorly was 4.7 for cMIS and 8.2 for HYB (P < .001). Both had improved LL and PI-LL mismatch postoperatively. Sagittal vertical axis remained physiological for the cMIS and HYB groups. Oswestry Disability Index scores were significantly improved in both groups. Radiographic PJK developed in 31.3% of the cMIS and 52.9% of the HYB group (P = .01). Reoperation for PJK was 4.5% for the cMIS and 10.3% for the HYB group (P = .20). Subgroup analysis for patients undergoing similar levels of posterior instrumentation in the cMIS and HYB groups found a PJK rate of 48.1% and 53.8% (P = .68) and a reoperation rate of 11.1% and 19.2%, respectively (P = .41). Mean follow-up was 32.8 months.Conclusion
Overall rates of radiographic PJK and reoperation for PJK were not significantly decreased with MIS pedicle screw placement. However, a larger comparative study is needed to confirm that MIS pedicle screw placement does not affect PJK.Item Open Access Does recombinant human bone morphogenetic protein-2 use in adult spinal deformity increase complications and are complications associated with location of rhBMP-2 use? A prospective, multicenter study of 279 consecutive patients.(Spine, 2014-02) Bess, Shay; Line, Breton G; Lafage, Virginie; Schwab, Frank; Shaffrey, Christopher I; Hart, Robert A; Boachie-Adjei, Oheneba; Akbarnia, Behrooz A; Ames, Christopher P; Burton, Douglas C; Deverin, Vedat; Fu, Kai-Ming G; Gupta, Munish; Hostin, Richard; Kebaish, Khaled; Klineberg, Eric; Mundis, Gregory; O'Brien, Michael; Shelokov, Alexis; Smith, Justin S; International Spine Study Group ISSGStudy design
Multicenter, prospective analysis of consecutive patients with adult spinal deformity (ASD).Objective
Evaluate complications associated with recombinant human bone morphogenetic protein-2 (rhBMP-2) use in ASD.Summary of background data
Off-label rhBMP-2 use is common; however, underreporting of rhBMP-2 associated complications has been recently scrutinized.Methods
Patients with ASD consecutively enrolled into a prospective, multicenter database were evaluated for type and timing of acute perioperative complications.Inclusion criteria
age 18 years and older, ASD, spinal arthrodesis of more than 4 levels, and 3 or more months of follow-up. Patients were divided into those receiving rhBMP-2 (BMP) or no rhBMP-2 (NOBMP). BMP divided into location of use: posterior (PBMP), interbody (IBMP), and interbody + posterior spine (I + PBMP). Correlations between acute perioperative complications and rhBMP-2 use including total dose, dose/level, and location of use were evaluated.Results
A total of 279 patients (mean age: 57 yr; mean spinal levels fused: 12.0; and mean follow-up: 28.8 mo) met inclusion criteria. BMP (n = 172; average posterior dose = 2.5 mg/level, average interbody dose = 5 mg/level) had similar age, smoking history, previous spine surgery, total spinal levels fused, estimated blood loss, and duration of hospital stay as NOBMP (n = 107; P > 0.05). BMP had greater Charlson Comorbidity Index (1.9 vs. 1.2), greater scoliosis (43° vs. 38°), longer operative time (488.2 vs. 414.6 min), more osteotomies per patient (4.0 vs. 1.6), and greater percentage of anteroposterior fusion (APSF; 20.9% vs. 8.4%) than NOBMP, respectively (P < 0.05). BMP had more total complications per patient (1.4 vs. 0.6) and more minor complications per patient (0.9 vs. 0.2) than NOBMP, respectively (P < 0.05). NOBMP had more complications requiring surgery per patient than BMP (0.3 vs. 0.2; P < 0.05). Major, neurological, wound, and infectious complications were similar for NOBMP, BMP, PBMP, IBMP, and I + PBMP (P > 0.05). Multivariate analysis demonstrated small to nonexistent correlations between rhBMP-2 use and complications.Conclusion
RhBMP-2 use and location of rhBMP-2 use in ASD surgery, at reported doses, do not increase acute major, neurological, or wound complications. Research is needed for higher rhBMP-2 dosing and long-term follow-up.Level of evidence
2.Item Open Access Does vertebral level of pedicle subtraction osteotomy correlate with degree of spinopelvic parameter correction?(Journal of neurosurgery. Spine, 2011-02) Lafage, Virginie; Schwab, Frank; Vira, Shaleen; Hart, Robert; Burton, Douglas; Smith, Justin S; Boachie-Adjei, Oheneba; Shelokov, Alexis; Hostin, Richard; Shaffrey, Christopher I; Gupta, Munish; Akbarnia, Behrooz A; Bess, Shay; Farcy, Jean-PierreObject
Pedicle subtraction osteotomy (PSO) is a spinal realignment technique that may be used to correct sagittal spinal imbalance. Theoretically, the level and degree of resection via a PSO should impact the degree of sagittal plane correction in the setting of deformity. However, the quantitative effect of PSO level and focal angular change on postoperative spinopelvic parameters has not been well described. The purpose of this study is to analyze the relationship between the level/degree of PSO and changes in global sagittal balance and spinopelvic parameters.Methods
In this multicenter retrospective study, 70 patients (54 women and 16 men) underwent lumbar PSO surgery for spinal imbalance. Preoperative and postoperative free-standing sagittal radiographs were obtained and analyzed by regional curves (lumbar, thoracic, and thoracolumbar), pelvic parameters (pelvic incidence and pelvic tilt [PT]) and global balance (sagittal vertical axis [SVA] and T-1 spinopelvic inclination). Correlations between PSO parameters (level and degree of change in angle between the 2 adjacent vertebrae) and spinopelvic measurements were analyzed.Results
Pedicle subtraction osteotomy distribution by level and degree of correction was as follows: L-1 (6 patients, 24°), L-2 (15 patients, 24°), L-3 (29 patients, 25°), and L-4 (20 patients, 22°). There was no significant difference in the focal correction achieved by PSO by level. All patients demonstrated changes in preoperative to postoperative parameters including increased lumbar lordosis (from 20° to 49°, p < 0.001), increased thoracic kyphosis (from 30° to 38°, p < 0.001), decreased SVA and T-1 spinopelvic inclination (from 122 to 34 mm, p < 0.001 and from +3° to -4°, p < 0.001, respectively), and decreased PT (from 31° to 23°, p < 0.001). More caudal PSO was correlated with greater PT reduction (r = -0.410, p < 0.05). No correlation was found between SVA correction and PSO location. The PSO degree was correlated with change in thoracic kyphosis (r = -0.474, p < 0.001), lumbar lordosis (r = 0.667, p < 0.001), sacral slope (r = 0.426, p < 0.001), and PT (r = -0.358, p < 0.005).Conclusions
The degree of PSO resection correlates more with spinopelvic parameters (lumbar lordosis, thoracic kyphosis, PT, and sacral slope) than PSO level. More importantly, PSO level impacts postoperative PT correction but not SVA.Item Open Access Is There a Patient Profile That Characterizes a Patient With Adult Spinal Deformity as a Candidate for Minimally Invasive Surgery?(Global spine journal, 2017-10) Eastlack, Robert K; Mundis, Gregory M; Wang, Michael; Mummaneni, Praveen V; Uribe, Juan; Okonkwo, David; Akbarnia, Behrooz A; Anand, Neel; Kanter, Adam; Park, Paul; Lafage, Virginie; Shaffrey, Christopher; Fessler, Richard; Deviren, Vedat; International Spine Study GroupRetrospective review.The goal of this study was to evaluate the baseline characteristics of patients chosen to undergo traditional open versus minimally invasive surgery (MIS) for adult spinal deformity (ASD).A multicenter review of 2 databases including ASD patients treated with surgery. Inclusion criteria were age >45 years, Cobb angle minimum of 20°, and minimum 2-year follow-up. Preoperative radiographic parameters and disability outcome measures were reviewed.A total of 350 patients were identified: 173 OPEN patients and 177 MIS. OPEN patients were significantly younger than MIS patients (61.5 years vs 63.74 years, P = .013). The OPEN group had significantly more females (87% vs 76%, P = .006), but both groups had similar body mass index. Preoperative lumbar Cobb was significantly higher for the OPEN group (34.2°) than for the MIS group (26.0°, P < .001). The mean preoperative Oswestry Disability Index was significantly higher in the MIS group (44.8 in OPEN patients and 49.8 in MIS patients, P < .011). The preoperative Numerical Rating Scale value for back pain was 7.2 in the OPEN group and 6.8 in the MIS group preoperatively, P = .100.Patients chosen for MIS for ASD are slightly older and have smaller coronal deformities than those chosen for open techniques, but they did not have a substantially lesser degree of sagittal malalignment. MIS surgery was most frequently utilized for patients with an sagittal vertical axis under 6 cm and a baseline pelvic incidence and lumbar lordosis mismatch under 30°.Item Open Access Medical Complications After Adult Spinal Deformity Surgery: Incidence, Risk Factors, and Clinical Impact.(Spine, 2016-11) Soroceanu, Alex; Burton, Douglas C; Oren, Jonathan Haim; Smith, Justin S; Hostin, Richard; Shaffrey, Christopher I; Akbarnia, Behrooz A; Ames, Christopher P; Errico, Thomas J; Bess, Shay; Gupta, Munish C; Deviren, Vedat; Schwab, Frank J; Lafage, Virginie; International Spine Study GroupStudy design
Retrospective review of a prospective multicenter database evaluating surgical adult spinal deformity (ASD) patients.Objective
This study aims to identify risk factors for medical complications in ASD patients undergoing surgery.Summary of background data
ASD surgery is known for its high complication rate. This study examines baseline patient characteristics for predictors of medical complications in surgical ASD patients.Methods
Intra and perioperative medical complications were included. Medical complications were: infection, pneumonia, urinary tract infection, c-difficile, sepsis, stroke, delirium, deep venous thrombosis, pulmonary embolism, myocardial infarction, arrhythmia, congestive heart failure, pneumothorax, atelectasis, adult respiratory distress syndrome, bowel obstruction, ileus, and renal failure. Potential predictors were identified using univariate testing. Multivariate Poisson regression was used to determine independent predictors of medical complications. Health-related quality of life (HRQL) was measured using the Oswestry Disability Index and SF-36. Multivariate repeated measures mixed models were used to examine HRQL.Results
Four hundred forty-eight patients were included. The incidence of patients with at least one medical complication was 26.8%. Potential predictors included: age, BMI, anemia, arthritis, depression, cardiac history, hypertension, lung disease, history of PVD, Charlson Comorbidity Index, ASA, smoking, sex, and the number of years with spine problems. Independent predictors identified on multivariate logistic regression modeling included hypertension (IRR 2.43 P = 0.0001), smoking (IRR 2.49 P = 0.0001), and number of years with spine problems (IRR 1.23 P = 0.03). Despite medical complications, patients experienced significant improvements in HRQL, as measured by the SF-36 (P = 0.0001) and oswestry disability index (P = 0.0001). The rate of improvement and overall improvement compared with baseline were not statistically different than that of patients who did not experience medical complications.Conclusion
Risk factors for the development of postoperative medical complications after correction of ASD include smoking, hypertension, and duration of symptoms. Patients who have one or more of these risk factors should be identified and informed during informed consent of their increased risks. They should be optimized preoperatively, and followed closely during the postoperative period.Level of evidence
3.Item Open Access Multicenter validation of a formula predicting postoperative spinopelvic alignment.(Journal of neurosurgery. Spine, 2012-01) Lafage, Virginie; Bharucha, Neil J; Schwab, Frank; Hart, Robert A; Burton, Douglas; Boachie-Adjei, Oheneba; Smith, Justin S; Hostin, Richard; Shaffrey, Christopher; Gupta, Munish; Akbarnia, Behrooz A; Bess, ShayObject
Sagittal spinopelvic imbalance is a major contributor to pain and disability for patients with adult spinal deformity (ASD). Preoperative planning is essential for pedicle subtraction osteotomy (PSO) candidates; however, current methods are often inaccurate because no formula to date predicts both postoperative sagittal balance and pelvic alignment. The authors of this study aimed to evaluate the accuracy of 2 novel formulas in predicting postoperative spinopelvic alignment after PSO.Methods
This study is a multicenter retrospective consecutive PSO case series. Adults with spinal deformity (> 21 years old) who were treated with a single-level lumbar PSO for sagittal imbalance were evaluated. All patients underwent preoperative and a minimum of 6-month postoperative radiography. Two novel formulas were used to predict the postoperative spinopelvic alignment. The results predicted by the formulas were then compared with the actual postoperative radiographic values, and the formulas' ability to identify successful (sagittal vertical axis [SVA] ≤ 50 mm and pelvic tilt [PT] ≤ 25°) and unsuccessful (SVA > 50 mm or PT > 25°) outcomes was evaluated.Results
Ninety-nine patients met inclusion criteria. The median absolute error between the predicted and actual PT was 4.1° (interquartile range 2.0°-6.4°). The median absolute error between the predicted and actual SVA was 27 mm (interquartile range 11-47 mm). Forty-one of 54 patients with a formula that predicted a successful outcome had a successful outcome as shown by radiography (positive predictive value = 0.76). Forty-four of 45 patients with a formula that predicted an unsuccessful outcome had an unsuccessful outcome as shown by radiography (negative predictive value = 0.98).Conclusions
The spinopelvic alignment formulas were accurate when predicting unsuccessful outcomes but less reliable when predicting successful outcomes. The preoperative surgical plan should be altered if an unsuccessful result is predicted. However, even after obtaining a predicted successful outcome, surgeons should ensure that the predicted values are not too close to unsuccessful values and should identify other variables that may affect alignment. In the near future, it is anticipated that the use of these formulas will lead to better surgical planning and improved outcomes for patients with complex ASD.Item Open Access Outcomes and complications of extension of previous long fusion to the sacro-pelvis: is an anterior approach necessary?(World neurosurgery, 2013-01) Fu, Kai-Ming G; Smith, Justin S; Burton, Douglas C; Shaffrey, Christopher I; Boachie-Adjei, Oheneba; Carlson, Brandon; Schwab, Frank J; Lafage, Virginie; Hostin, Richard; Bess, Shay; Akbarnia, Behrooz A; Mundis, Greg; Klineberg, Eric; Gupta, Munish; International Spine Study GroupBackground
Patients with previous multilevel spinal fusion may require extension of the fusion to the sacro-pelvis. Our objective was to evaluate the outcomes and complications of these patients, stratified based on whether the revision was performed using a posterior-only spinal fusion (PSF) or combined anterior-posterior spinal fusion (APSF).Methods
A retrospective, multicenter evaluation of adults (>18 years old) with a history of prior spinal fusion for scoliosis (≥4 levels) terminating in the distal lumbar spine requiring extension of fusion to the sacro-pelvis (including iliac fixation in all cases), with minimum 2-year follow-up, was performed. Patients were stratified based on approach (APSF vs. PSF) and inclusion of pedicle subtraction osteotomy (PSO). The PSF group included patients treated with an anterior interbody fusion done through a posterior approach, whereas patients in the APSF group all had both anterior and posterior surgical approaches. Clinical outcomes were based on the Scoliosis Research Society (SRS-22) questionnaire.Results
Between 1995 and 2006, 45 patients (mean age = 49 years) met inclusion criteria, with a mean follow-up of 41.9 months (range 24 to 135 months). Demographic, preoperative, operative, and postoperative radiographic, SRS-22, and follow-up results were similar between APSF (n=30) and PSF (n=15) groups. The APSF group had more complications (13 of 30 vs. 3 of 15) and a greater number of pseudarthrosis (4 of 30 vs. 0 of 15) than the PSF group; however, these differences did not reach statistical significance. Patients treated with a PSO (n=13) had greater sagittal vertical axis correction (7.7 cm vs. 2.2 cm; P=.04) compared with patients not treated with a PSO (n=32). There were no differences in complication rates or follow-up SRS-22 scores based on whether a PSO was performed (P>.05).Conclusions
Among adults with previously treated scoliosis requiring extension to the sacro-pelvis, PSF produced radiographic fusion and clinical outcomes equivalent to APSF, whereas complication rates may be lower. PSO resulted in greater sagittal plane correction, without an increase in overall complication rates.Item Open Access Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity: A Prospective, Multicenter, Propensity-Matched Cohort Assessment With Minimum 2-Year Follow-up.(Neurosurgery, 2016-06) Smith, Justin S; Lafage, Virginie; Shaffrey, Christopher I; Schwab, Frank; Lafage, Renaud; Hostin, Richard; OʼBrien, Michael; Boachie-Adjei, Oheneba; Akbarnia, Behrooz A; Mundis, Gregory M; Errico, Thomas; Kim, Han Jo; Protopsaltis, Themistocles S; Hamilton, D Kojo; Scheer, Justin K; Sciubba, Daniel; Ailon, Tamir; Fu, Kai-Ming G; Kelly, Michael P; Zebala, Lukas; Line, Breton; Klineberg, Eric; Gupta, Munish; Deviren, Vedat; Hart, Robert; Burton, Doug; Bess, Shay; Ames, Christopher P; International Spine Study GroupBackground
High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed.Objective
To compare outcomes of operative and nonoperative treatment for ASD.Methods
This is a multicenter, prospective analysis of consecutive ASD patients opting for operative or nonoperative care. Inclusion criteria were age >18 years and ASD. Operative and nonoperative patients were propensity matched with the baseline Oswestry Disability Index, Scoliosis Research Society-22r, thoracolumbar/lumbar Cobb angle, pelvic incidence-to-lumbar lordosis mismatch (PI-LL), and leg pain score. Analyses were confined to patients with a minimum of 2 years of follow-up.Results
Two hundred eighty-six operative and 403 nonoperative patients met the criteria, with mean ages of 53 and 55 years, 2-year follow-up rates of 86% and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At baseline, operative patients had significantly worse health-related quality of life (HRQOL) based on all measures assessed (P < .001) and had worse deformity based on pelvic tilt, pelvic incidence-to-lumbar lordosis mismatch, and sagittal vertical axis (P ≤ .002). At the minimum 2-year follow-up, all HRQOL measures assessed significantly improved for operative patients (P < .001), but none improved significantly for nonoperative patients except for modest improvements in the Scoliosis Research Society-22r pain (P = .04) and satisfaction (P < .001) domains. On the basis of matched operative-nonoperative cohorts (97 in each group), operative patients had significantly better HRQOL at follow-up for all measures assessed (P < .001), except Short Form-36 mental component score (P = .06). At the minimum 2-year follow-up, 71.5% of operative patients had ≥1 complications.Conclusion
Operative treatment for ASD can provide significant improvement of HRQOL at a minimum 2-year follow-up. In contrast, nonoperative treatment on average maintains presenting levels of pain and disability.Abbreviations
ASD, adult spinal deformityHRQOL, health-related quality of lifeLL, lumbar lordosisMCID, minimal clinically important differenceNRS, numeric rating scaleODI, Oswestry Disability IndexPI, pelvic incidenceSF-36, Short Form-36SRS-22r, Scoliosis Research Society-22rSVA, sagittal vertical axis.Item Open Access Patients with adult spinal deformity treated operatively report greater baseline pain and disability than patients treated nonoperatively; however, deformities differ between age groups.(Spine, 2014-08) Fu, Kai-Ming G; Bess, Shay; Shaffrey, Christopher I; Smith, Justin S; Lafage, Virginie; Schwab, Frank; Burton, Douglas C; Akbarnia, Behrooz A; Ames, Christopher P; Boachie-Adjei, Oheneba; Deverin, Vedat; Hart, Robert A; Hostin, Richard; Klineberg, Eric; Gupta, Munish; Kebaish, Khaled; Mundis, Gregory; Mummaneni, Praveen V; International Spine Study GroupStudy design
Multicenter, prospective analysis of consecutive patients with adult spinal deformity (ASD).Objective
Identify age-related radiographical parameters associated with poor health-related quality of life (HRQOL) and treatment preferences for ASD.Summary of background data
Patients with ASD report discrepant severities of disability. Understanding age-associated differences for reported disability and treatment preferences may improve ASD evaluation and treatment.Methods
Baseline demographic, radiographical, and HRQOL values were evaluated in a multicenter, prospective cohort of consecutive patients with ASD.Inclusion criteria
ASD, age more than 18 years, and no prior spine surgery. Patients were grouped into those treated operatively (OP) or nonoperatively (NON) and stratified into 3 age groups: G1, 50 years or less; G2, 50 to 65 years; G3, 65 years or more. HRQOL measures included Scoliosis Research Society-22r questionnaire, Oswestry Disability Index, and Short Form-36 Health Survey.Results
Four hundred ninety-seven patients (OP = 156, NON = 341) with a mean age of 50.4 years met inclusion criteria. The OP group was older (53.3 vs. 49.0 yr), had larger scoliosis (49.3° vs. 43.3°), larger sagittal vertical axis (SVA, 33.2 vs. 13.7 mm), greater pelvic incidence-lumbar lordosis mismatch (6.6°vs. 3.1°), and worse HRQOL scores than the NON group, respectively (P < 0.05). Age stratification demonstrated worsening of SVA, spinopelvic alignment (SPA), and HRQOL scores with increasing age (P < 0.05). Age/treatment stratification demonstrated that younger OP had greater scoliosis than NON (G1OP = 49.9°vs. G1NON = 42.2°; G2OP = 56°vs. G2NON = 47.2°; P < 0.05) but similar SPA as NON. Older OP had similar scoliosis, but larger SVA than NON (G3OP = 100.6 vs. G3NON = 66.4 mm; P < 0.05). OP in all age groups reported worse HRQOL than NON (P < 0.05).Conclusion
Poor HRQOL uniformly determined operative treatment for ASD. Spinal deformities differed between age groups. Younger OP had larger scoliosis but similar SPA and SVA than NON. Older OP had similar scoliosis but worse SVA than NON. Age-associated differences for poor HRQOL must be considered when evaluating patients with ASD.Level of evidence
2.Item Open Access Peak Timing for Complications After Adult Spinal Deformity Surgery.(World neurosurgery, 2018-07) Daniels, Alan H; Bess, Shay; Line, Breton; Eltorai, Adam EM; Reid, Daniel BC; Lafage, Virginie; Akbarnia, Behrooz A; Ames, Christopher P; Boachie-Adjei, Oheneba; Burton, Douglas C; Deviren, Vedat; Kim, Han Jo; Hart, Robert A; Kebaish, Khaled M; Klineberg, Eric O; Gupta, Munish; Mundis, Gregory M; Hostin, Richard A; O'Brien, Michael; Schwab, Frank J; Shaffrey, Christopher I; Smith, Justin S; International Spine Study Group FoundationOverall complication rates for adult spinal deformity (ASD) surgery have been reported; however, little data exist on the peak timing associated with specific complications. This study quantifies the peak timing for multiple complication types in an ASD cohort at minimum 2-year follow-up.Multicenter, prospective analysis of all complications after ASD surgery in a consecutively enrolled cohort was performed. Inclusion criteria were ASD, age ≥18 years, spinal fusion ≥4 levels, and minimum 2-year follow-up. Complications included major and minor and specific complication types. Peak timing of specific complications was identified and described. Regression analysis was performed to assess correlation between patient/surgical factors and complication timing.There were 280 patients who met the inclusion criteria. Mean follow-up time was 2.9 years (range, 2-5 years). Of the patients, 209 (74.6%) had at least 1 complication, accounting for 529 total complications (258 minor and 271 major). Both major and minor complications peaked at <3 months. Infection and neurologic complications peaked at <3 months. Proximal junctional kyphosis had bimodal peaks at <3 and >24 months. Implant failure peaked at 12-24 and >24 months. There was a significant positive correlation between preoperative sagittal vertical axis and total complications at 6-12 months, major complications at 24 months, and reoperation. Body mass index was associated with total complications and implant failure at 12-24 and >24 months.The peak timing of specific complications after ASD surgery is identifiable. Understanding when these complications are likely to occur may improve patient counseling, early diagnosis, and prophylactic interventions and may help inform future reimbursement models.Item Open Access Radiographical spinopelvic parameters and disability in the setting of adult spinal deformity: a prospective multicenter analysis.(Spine, 2013-06) Schwab, Frank J; Blondel, Benjamin; Bess, Shay; Hostin, Richard; Shaffrey, Christopher I; Smith, Justin S; Boachie-Adjei, Oheneba; Burton, Douglas C; Akbarnia, Behrooz A; Mundis, Gregory M; Ames, Christopher P; Kebaish, Khaled; Hart, Robert A; Farcy, Jean-Pierre; Lafage, Virginie; International Spine Study Group (ISSG)Study design
Prospective multicenter study evaluating operative (OP) versus nonoperative (NONOP) treatment for adult spinal deformity (ASD).Objective
Evaluate correlations between spinopelvic parameters and health-related quality of life (HRQOL) scores in patients with ASD.Summary of background data
Sagittal spinal deformity is commonly defined by an increased sagittal vertical axis (SVA); however, SVA alone may underestimate the severity of the deformity. Spinopelvic parameters provide a more complete assessment of the sagittal plane but only limited data are available that correlate spinopelvic parameters with disability. METHODS.: Baseline demographic, radiographical, and HRQOL data were obtained for all patients enrolled in a multicenter consecutive database. Inclusion criteria were: age more than 18 years and radiographical diagnosis of ASD. Radiographical evaluation was conducted on the frontal and lateral planes and HRQOL questionnaires (Oswestry Disability Index [ODI], Scoliosis Research Society-22r and Short Form [SF]-12) were completed. Radiographical parameters demonstrating highest correlation with HRQOL values were evaluated to determine thresholds predictive of ODI more than 40.Results
Four hundred ninety-two consecutive patients with ASD (mean age, 51.9 yr) were enrolled. Patients from the OP group (n = 178) were older (55 vs. 50.1 yr, P < 0.05), had greater SVA (5.5 vs. 1.7 cm, P < 0.05), greater pelvic tilt (PT; 22° vs. 11°, P < 0.05), and greater pelvic incidence/lumbar lordosis PI/LL mismatch (PI-LL; 12.2 vs. 4.3; P < 0.05) than NONOP group (n = 314). OP group demonstrated greater disability on all HRQOL measures compared with NONOP group (ODI = 41.4 vs. 23.9, P < 0.05; Scoliosis Research Society score total = 2.9 vs. 3.5, P < 0.05). Pearson analysis demonstrated that among all parameters, PT, SVA, and PI-LL correlated most strongly with disability for both OP and NONOP groups (P < 0.001). Linear regression models demonstrated threshold radiographical spinopelvic parameters for ODI more than 40 to be: PT 22° or more (r = 0.38), SVA 47 mm or more (r = 0.47), PI - LL 11° or more (r = 0.45).Conclusion
ASD is a disabling condition. Prospective analysis of consecutively enrolled patients with ASD demonstrated that PT and PI-LL combined with SVA can predict patient disability and provide a guide for patient assessment for appropriate therapeutic decision making. Threshold values for severe disability (ODI > 40) included: PT 22° or more, SVA 47 mm or more, and PI - LL 11° or more.Item Open Access Re-operation After Long-Segment Fusions for Adult Spinal Deformity: The Impact of Extending the Construct Below the Lumbar Spine.(Neurosurgery, 2018-02) Witiw, Christopher D; Fessler, Richard G; Nguyen, Stacie; Mummaneni, Praveen; Anand, Neel; Blaskiewicz, Donald; Uribe, Juan; Wang, Michael Y; Kanter, Adam S; Okonkwo, David; Park, Paul; Deviren, Vedat; Akbarnia, Behrooz A; Eastlack, Robert K; Shaffrey, Christopher; Mundis, Gregory MBackground
Deciding where to end a long-segment fusion for adult spinal deformity (ASD) may be a challenge, particularly in the absence of an abnormality at L5/S1. Some suggest prophylactic extension of the construct to the sacrum and/or ilium (S/I) to protect against distal junctional failure, while others support terminating in the lower lumbar spine to preserve motion.Objective
To compare the risk of re-operation after long-segment fusions for ASD that ends at L4 or L5 (L4/5) vs S/I.Methods
A multicenter database of patients treated for ASD by circumferential minimally invasive surgery or hybrid surgical technique was screened for individuals with long fusions (≥4 vertebral levels) ending at L4 or below and with at least 2 yr of follow-up. Multivariate regression modeling was used to compare surgical morbidity between the L4/5 and S/I groups, and Cox proportional hazard modeling was used to compare risk of re-operation.Results
There were 45 subjects with fusion to L4/5 and 71 to S/I. Over a 32-mo median follow-up, 41 re-operations were performed; 6 were for distal junctional failure. In those with normal or mild degeneration at L5/S1, fusion to S/I afforded no significant change in re-operative risk (hazard ratio = 1.18 [95% confidence interval: 0.53-2.62], P = .682). In those undergoing circumferential minimally invasive surgery correction, fusion to S/I was associated with significantly greater blood loss (499.6 cc, P < .001) and surgical time (97.5 min, P = .04).Conclusion
In the setting of a normal or mildly degenerated L5/S1 disc space, fusion to the sacrum/ilium did not significantly change the risk of requiring a re-operation after a long-segment fusion for ASD.Item Open Access Reoperation rates in minimally invasive, hybrid and open surgical treatment for adult spinal deformity with minimum 2-year follow-up.(European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2016-08) Hamilton, D Kojo; Kanter, Adam S; Bolinger, Bryan D; Mundis, Gregory M; Nguyen, Stacie; Mummaneni, Praveen V; Anand, Neel; Fessler, Richard G; Passias, Peter G; Park, Paul; La Marca, Frank; Uribe, Juan S; Wang, Michael Y; Akbarnia, Behrooz A; Shaffrey, Christopher I; Okonkwo, David O; International Spine Study Group (ISSG)Introduction
Minimally invasive surgical (MIS) techniques are gaining popularity in the treatment of adult spinal deformity (ASD). The premise is that MIS techniques will lead to equivalent outcomes and a reduction in perioperative complications when compared with open techniques. Potential issues with MIS techniques are a limited capacity to correct lumbar lordosis, unknown long-term efficacy, and the potential need for revision surgery. This study compares reoperation rates and reasons for reoperation following MIS, hybrid, and open surgery for ASD through multicenter database analysis.Methods
We retrospectively analyzed a prospective multicenter ASD database comparing open and MIS correction techniques. Inclusion criteria were: age > 18 years with minimum 20° coronal lumbar Cobb angle, a minimum of three levels fused, and minimum 2-year follow-up. Patients were propensity matched for preoperative sagittal vertebral axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), and number of levels fused. We included 189 patients from three propensity-matched subgroups of 63 patients each: (1) MIS: lateral or transforaminal lumbar interbody fusion (LIF) and percutaneous pedicle instrumentation, (2) Hybrid: MIS LIF with open posterior segmental fixation (PSF), and (3) OPEN: open posterior fixation ± osteotomies.Results
With propensity matching, there were significant differences between groups in pre-op SVA or PI-LL (p > 0.05). The MIS group had significantly fewer levels fused (5.4) (0-14) than the OPEN group (7.4) (p = 0.002) (0-17). The rate of revision surgery was significantly different between the groups with a higher rate of revision (27 %) amongst the HYB group versus MIS = 11.1 %, and OPEN = 12.0 %. The most common reason for reoperation in the OPEN and HYB groups was a postoperative neurological deficit (7.9 and 11.1 %), respectively. The most common reason for reoperation in the MIS group was pseudoarthrosis (7.9 %).Conclusions
Reoperation rates were not statistically different among the MIS, and OPEN surgical groups, but differed significantly on multivariate analysis with HYB group. The incidence of reoperations was twice as high in the Hybrid group compared to OPEN and MIS.Item Open Access Sagittal realignment failures following pedicle subtraction osteotomy surgery: are we doing enough?: Clinical article.(Journal of neurosurgery. Spine, 2012-06) Schwab, Frank J; Patel, Ashish; Shaffrey, Christopher I; Smith, Justin S; Farcy, Jean-Pierre; Boachie-Adjei, Oheneba; Hostin, Richard A; Hart, Robert A; Akbarnia, Behrooz A; Burton, Douglas C; Bess, Shay; Lafage, VirginieObject
Pedicle subtraction osteotomy (PSO) is a surgical procedure that is frequently performed on patients with sagittal spinopelvic malalignment. Although it allows for substantial spinopelvic realignment, suboptimal realignment outcomes have been reported in up to 33% of patients. The authors' objective in the present study was to identify differences in radiographic profiles and surgical procedures between patients achieving successful versus failed spinopelvic realignment following PSO.Methods
This study is a multicenter retrospective consecutive PSO case series. The authors evaluated 99 cases involving patients who underwent PSO for sagittal spinopelvic malalignment. Because precise cutoffs of acceptable residual postoperative sagittal vertical axis (SVA) values have not been well defined, comparisons were focused between patient groups with a postoperative SVA that could be clearly considered either a success or a failure. Only cases in which the patients had a postoperative SVA of less than 50 mm (successful PSO realignment) or more than 100 mm (failed PSO realignment) were included in the analysis. Radiographic measures and PSO parameters were compared between successful and failed PSO realignments.Results
Seventy-nine patients met the inclusion criteria. Successful realignment was achieved in 61 patients (77%), while realignment failed in 18 (23%). Patients with failed realignment had larger preoperative SVA (mean 217.9 vs 106.7 mm, p < 0.01), larger pelvic tilt (mean 36.9° vs 30.7°, p < 0.01), larger pelvic incidence (mean 64.2° vs 53.7°, p < 0.01), and greater lumbar lordosis-pelvic incidence mismatch (-47.1° vs -30.9°, p < 0.01) compared with those in whom realignment was successful. Failed and successful realignments were similar regarding the vertebral level of the PSO, the median size of wedge resection 22.0° (interquartile range 16.5°-28.5°), and the numerical changes in pre- and postoperative spinopelvic parameters (p > 0.05).Conclusions
Patients with failed PSO realignments had significantly larger preoperative spinopelvic deformity than patients in whom realignment was successful. Despite their apparent need for greater correction, the patients in the failed realignment group only received the same amount of correction as those in the successfully realigned patients. A single-level standard PSO may not achieve optimal outcome in patients with high preoperative spinopelvic sagittal malalignment. Patients with large spinopelvic deformities should receive larger osteotomies or additional corrective procedures beyond PSOs to avoid undercorrection.