Browsing by Author "Eastlack, RK"
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Item Open Access Evolving concepts in pelvic fixation in adult spinal deformity surgery(Seminars in Spine Surgery, 2023-01-01) Turner, JD; Schupper, AJ; Mummaneni, PV; Uribe, JS; Eastlack, RK; Mundis, GM; Passias, PG; DiDomenico, JD; Harrison Farber, S; Soliman, MAR; Shaffrey, CI; Klineberg, EO; Daniels, AH; Buell, TJ; Burton, DC; Gum, JL; Lenke, LG; Bess, S; Mullin, JPLong-segment adult spinal deformity (ASD) constructs carry a high risk of mechanical complications. Pelvic fixation was introduced to improve distal construct mechanics and has since become the standard for long constructs spanning the lumbosacral junction. Pelvic fixation strategies have evolved substantially over the years. Numerous techniques now use a variety of entry points, screw trajectories, and construct configurations. We review the various strategies for pelvic fixation in ASD in a systematic review of the literature and update the techniques employed in the International Spine Study Group Complex Adult Deformity Surgery database.Item Open Access Preoperative dysphonia and dysphagia improve following cervical deformity surgery(Spine Journal, 2024-09-01) Soroceanu, A; Gum, JL; Protopsaltis, TS; Hamilton, DK; Passias, PG; Lafage, R; Smith, JS; Kebaish, KM; Eastlack, RK; Klineberg, EO; Gupta, MC; Lafage, V; Schwab, FJ; Shaffrey, CI; Bess, S; Burton, DC; Ames, CPBACKGROUND CONTEXT: Twenty-five percent of adult cervical deformity patients undergoing deformity correction have impairment due to a voice problem prior to surgery. Prior work has shown that these patients tend to be more frail and more likely to report preoperative dysphagia. We hypothesized that these patients could be at increased risk of post operative dysphonia and dysphagia. PURPOSE: The purpose of this study was to quantify how patients with preoperative dysphonia differ from their counterparts in terms postoperative dysphagia, dysphonia and HRQOL 6 weeks post surgery. STUDY DESIGN/SETTING: Retrospective analysis of a prospective multicenter cervical deformity database. PATIENT SAMPLE: Adult cervical deformity patients with preop dysphonia undergoing deformity correction. OUTCOME MEASURES: Voice handicap index-10 (VHI-10). METHODS: Retrospective analysis of a prospective multicenter cervical deformity database. The voice handicap index-10 (VHI-10) was used to assess patient's perception of impairment due to problems with their voice prior to surgery. A score ≥11 was considered indicative of dysphonia. Patients were divided into two groups: normalVHI group (VHI-10 score <11) and highVHI group (VHI score ≥11). The two groups were compared in terms of baseline demographics, alignment, surgical metrics, and 6-week dysphagia (measured on the EAT-10 questionnaire), and post operative outcomes. T-tests and chi2 tests were performed, as appropriate. The significance level was p<0.05. RESULTS: There were 74 ACD patients included: NormalVHI (n=58, average VHI score 2.77) and HighVHI (n=16, average VHI score 16.37). The groups were similar in terms of baseline demographics and preoperative alignment. There was no statistically significant difference in terms of surgical metrics between the two groups (revision surgery p=0.21, anterior approach p=0.92, use of osteotomies p=0.71, and OR time p=0.15). The two groups had a similar rate of in hospital adverse events (12.2% vs 7.7%, p=0.64), and similar improvements on the NDI, mJOA, and NRS neck and arm pain. HighVHI patients showed significant improvement on the VHI score 6 weeks post-surgery (11.18 vs 16.37, p=0.01). The HighVHI group also showed postoperative improvement on the EAT-10 questionnaire, compared to NormalVHI patients (-3.68 vs 4.03, p=0.003). CONCLUSIONS: Twenty-five percent of adult cervical deformity patients undergoing deformity correction have impairment due to a voice problem prior to surgery. Contrary to our initial hypothesis, these patients exhibited improvement in dysphonia and dysphagia scores 6 weeks post surgery, with 81% reporting improvement in symptoms of dysphonia, and 69% reporting improvement in symptoms of oropharyngeal dysphagia. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Quantifying the importance of upper cervical extension reserve in adult cervical deformity surgery and its impact on baseline presentation and outcomes(Spine Journal, 2024-09-01) Passias, PG; Mir, J; Smith, JS; Lafage, V; Lafage, R; Diebo, BG; Daniels, AH; Onafowokan, O; Line, B; Eastlack, RK; Mundis, GM; Kebaish, KM; Soroceanu, A; Scheer, JK; Kelly, MP; Protopsaltis, TS; Kim, HJ; Hostin, RA; Gupta, MC; Riew, KD; Burton, DC; Schwab, FJ; Bess, S; Shaffrey, CI; Ames, CPBACKGROUND CONTEXT: Hyperextension of the upper cervical spine is a prominent compensatory mechanism to maintain horizontal gaze and balance in adult cervical deformity (ACD) patients, akin to pelvic tilt in spinal deformity. The relaxation of ER and its impact on postoperative outcomes is not well understood. PURPOSE: To evaluate upper cervical ER impact on postoperative disability and outcomes. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Adult cervical deformity. OUTCOME MEASURES: ER, HRQLs. METHODS: ACD patients undergoing subaxial cervical fusion with 2Y data were included. Upper cervical extension reserve (ER) was defined as: C0-C2 sagittal Cobb angle between neutral and extension. Relaxation of ER was defined as the ER normative mean in those that met the ideal in all Passias ACD modifiers. Outcomes were defined as "good" if meeting ≥2 of the three: (1) NDI <20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Controlled analysis was conducted with ANCOVA and multivariable logistic regressions. Conditional inference tree (CIT) analysis determined thresholds. RESULTS: A total of 108 ACD patients met inclusion. (Age 61.4 ± 12.3, 61% F, BMI 29.4 ± 7.5 kg/m2, mCD-FI .24 ±.12, CCI 0.97 ± 1.30). Radiographic alignment is depicted in Table 1. Preoperative C0-C2 ER was 8.7 ±9.0 ±, and at the last follow-up was 10.3 ± 11.1. ER in those meeting all ideal CD modifiers at 2Y was 12.9 ± 9.0. Preoperatively 29% had adequate ER, while 59.7% had improvement in ER postoperatively, with 50% of patients achieving adequate ER at 2Y. Higher ER significantly correlated with lower cervical deformity (p<.05). Preoperatively, greater ER was predictive of lower preoperative disability, with worse baseline mobility, pain, and anxiety (EQ5D) (B = -6.1, -2.9, -2.9 respectively; R2 =0.212, p<.001). Improvement of ER depicted a higher rate of MCID for NDI (64% vs 39%, p=.008), and meeting good clinical outcomes (72% vs 54%, p=.04). Controlling for baseline deformity and demographic factors found resolution of inadequate ER to have 7x higher likelihood of meeting MCID for NDI (6.941 [1.378-34.961], p=.019) and 4x higher odds of achieving good outcomes (4.022 [1.017-15.900], p=.047). Isolating those with inadequate preoperative ER, found postoperative resolution having 5x odds of good outcomes (p<.05). In those with inadequate ER at baseline, the preoperative C2-C7 of <-18 and TS-CL of >59 for TS-CL was predictive of ER resolution (p<.05). In those with preoperative C2-C7 >-18, a T1PA of >13 was predictive of postoperative return of ER (p<.05). Independently TS-CL of >59, was significant for predicting ER return postoperatively, highlighting its compensatory role for proximal spinal deformities (all p<.05). Surgical correction of C2-C7 by >16 from baseline was found to be predictive of ER return. CONCLUSIONS: Increased preoperative utilization of the extension reserve in the upper cervical spine in cervical deformity was associated with worse baseline regional and global alignment while impacting health-related measures. The majority of patients had relaxation of extension reserve postoperatively, however, in those who didn't, there was a decreased likelihood of achieving good outcomes. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Redefining Clinically Significant Blood Loss in Complex Adult Spine Deformity Surgery(Spine, 2024-01-01) Daher, M; Xu, A; Singh, M; Lafage, R; Line, BG; Lenke, LG; Ames, CP; Burton, DC; Lewis, SM; Eastlack, RK; Gupta, MC; Mundis, GM; Gum, JL; Hamilton, KD; Hostin, R; Lafage, V; Passias, PG; Protopsaltis, TS; Kebaish, KM; Schwab, FJ; Shaffrey, CI; Smith, JS; Bess, S; Klineberg, EO; Diebo, BG; Daniels, AHStudy Design. Retrospective analysis of prospectively-collected data Objective. This study aims to define clinically relevant blood loss in adult spinal deformity (ASD) surgery. Background. Current definitions of excessive blood loss following spine surgery are highly variable and may be suboptimal in predicting adverse events (AE). Methods. Adults undergoing complex ASD surgery were included. Estimated blood loss (EBL) was extracted for investigation, and estimated blood volume loss (EBVL) was calculated by dividing EBL by the preoperative blood volume utilizing Nadler's formula. LASSO regression was performed to identify five variables from demographic and peri-operative parameters. Logistic regression was subsequently performed to generate a receiver operating characteristics (ROC) curve and estimate an optimal threshold for EBL and EBVL. Finally, the proportion of patients with AE plotted against EBL and EBVL to confirm the identified thresholds. Results. In total 552 patients were included with a mean age of 60.7±15.1 years, 68% females, mean CCI was 1.0±1.6, and 22% experienced AEs. LASSO regression identified ASA score, baseline hypertension, preoperative albumin, and use of intra-operative crystalloids as the top predictors of an AE, in addition to EBL/EBVL. Logistic regression resulted in ROC curve which was used to identify a cut-off of 2.3 liters of EBL and 42% for EBVL. Patients exceeding these thresholds had AE rates of 36% (odds-ratio: 2.1, 95% CI [1.2-3.6]) and 31% (odds-ratio: 1.7, 95% CI [1.1-2.8]), compared to 21% for those below the thresholds of EBL and EBVL, respectively. Conclusion. In complex ASD surgery, intraoperative EBL of 2.3 liters and an EBVL of 42% are associated with clinically-significant AEs. These thresholds may be useful in guiding preoperative-patient-counseling, healthcare system quality initiatives, and clinical perioperative bloodloss management strategies in patients undergoing complex spine surgery. Additionally, similar methodology could be performed in other specialties to establish procedure-specific clinically-relevant bloodloss thresholds.Item Open Access “Selection, planning and execution of minimally invasive surgery in adult spinal deformity correction”(Seminars in Spine Surgery, 2023-01-01) Alan, N; Uribe, JS; Turner, JD; Park, P; Anand, N; Eastlack, RK; Okonkwo, DO; Le, VP; Nunley, P; Mundis, GM; Passias, PG; Chou, D; Kanter, AS; Fu, KMG; Wang, MY; Fessler, RG; Shaffrey, CI; Bess, S; Mummaneni, PVMinimally invasive surgery (MIS) for correction of adult spinal deformity was developed to address the high rate of medical and surgical complications rate in open surgical treatment of increasingly aging and frail patient population. In the past decade, MIS group within the International Spine Study Group (ISSG) has been in the forefront of the application of MIS techniques to fulfill the well-established principles of ASD surgery. These efforts have resulted in landmark studies. Here, we review these studies that encompass all aspects of MIS surgical treatment of ASD including patient selection with Minimally Invasive Spinal Deformity Surgery (MISDEF) and MISDEF-2 algorithms, surgical planning with anterior column realignment classification and the Minimally Invasive Interbody Selection Algorithm (MIISA), and surgical execution with Spinal Deformity Complexity Checklist (SDCC). We will highlight that with careful selection, diligent planning and meticulous execution the MIS techniques can treat patients with ASD, abiding to correction principles and radiographic parameters.Item Open Access Severe hip and knee osteoarthritis worsens patient-reported disability in adult spinal deformity patients(Spine Journal, 2024-09-01) Balmaceno-Criss, M; Singh, M; Xu, A; Daher, M; Lafage, R; Lewis, SJ; Klineberg, EO; Eastlack, RK; Gupta, MC; Mundis, GM; Gum, JL; Hamilton, DK; Hostin, RA; Passias, PG; Protopsaltis, TS; Kebaish, KM; Kim, HJ; Shaffrey, CI; Smith, JS; Line, B; Lenke, LG; Ames, CP; Burton, DC; Bess, S; Schwab, FJ; Lafage, V; Diebo, BG; Daniels, AHBACKGROUND CONTEXT: The complex interplay between lower extremity osteoarthritis and sagittal alignment in adult spinal deformity patients is of growing clinical interest. PURPOSE: To quantify the sequential effects of lower extremity OA on PROMs in ASD patients. STUDY DESIGN/SETTING: Retrospective review of prospectively collected data. PATIENT SAMPLE: ASD patients with no prior history of thoracolumbar surgery, and available baseline PROMs and standing radiographs were included. OUTCOME MEASURES: Baseline demographics, spinopelvic alignment, and PROMs. METHODS: Included patients with PROMs, standing xrays, no prior thoracolumbar surgery, and bilateral Kellgren-Lawrence (KL) hip/knee grade at baseline. Patients grouped into Spine (KL <3 BL hips & knees), Spine-Hip (KL>3 BL hips, KL <3 BL knees), Spine-Knee (KL>3 BL knees, KL>3 BL hips), Spine-Hip-Knee (KL>3 BL hips & knees). Baseline demographics, spinopelvic alignment, and PROMs were compared. Multivariate regression with forward stepwise selection predicted PROMs with variables (demographic, radiographic, OA severity) with significant association identified on Pearson correlation RESULTS: Included 160 patients: 56 Spine, 32 Spine-Knee, 20 Spine-Hip, and 52 Spine-Hip-Knee. Spine-Hip-Knee patients were older (Spine=62.2, Spine-Knee=61.2, Spine-Hip=59.1, Spine-Hip-Knee=68.5; p<.001) but similar in sex, comorbidities, and frailty; p>.05. Spine-Hip-Knee patients had higher SVA (50.0,30.6,60.5,83.5), T1PA (25.2,20.4,20.3,27.8), GSA (3.7,2.3,4.3,7.5), and KA (0.0,2.1,2.9,10.5); p<.005. SRS total and VR12 PCS scores were similar but VR12-2b climbing stairs (1.73,1.91,1.55,1.40, p=.014) and SRS-8 back pain at rest (2.29,2.84,1.95,2.71, p=.012) were lower in Spine-Hip-Knee and Spine-Hip, respectively. ODI (42.75,35.88,50.30,44.59, p=.040) and ODI Pain (2.88,1.84,2.90,2.46, p=0.019) were higher in Spine-Hip patients; ODI lifting was higher in hip OA patients but not significant (2.95,2.69,3.45,3.35, p>.05). In multivariate analyses, KOA changed the prediction of ODI pain from R2 0.052 to 0.086 and SRS-8 from R2 0.077 to 0.147. HOA changed the prediction of VR12-2b from R2 0.113 to 0.140 and ODI Lifting from R2 0.175 to 0.202. Frailty impacted PROMs across all models (p<.001) and GSA changed ODI, ODI pain, and VR12-2b models (p<.05). CONCLUSIONS: Severe hip and knee OA worsen patient-reported disability and physical function in ASD patients. These results quantify the impact of lower limb arthritis on patient reported outcomes, and highlight the need for integrated assessment and management of both spinal alignment and joint health in patients. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access The cervical lordosis distribution index and its consideration of upper cervical region and morphology(Spine Journal, 2024-09-01) Williamson, TK; Passias, PG; Smith, JS; Lafage, R; Line, B; Diebo, BG; Daniels, AH; Gum, JL; Protopsaltis, TS; Hamilton, DK; Soroceanu, A; Eastlack, RK; Mundis, GM; Bess, S; Schwab, FJ; Shaffrey, CI; Lafage, V; Burton, DCBACKGROUND CONTEXT: The cervical lordosis distribution in relation to its apex has not been characterized, nor has the impact of morphologic differences and upper cervical segments. PURPOSE: The goal of this study is assess whether tailored correction of cervical deformity by incorporating the cervical apex into a distribution index (CLDI) improves clinical outcomes while lowering rates of junctional failure. STUDY DESIGN/SETTING: Retrospective review of a prospectively-collected cohort; Multiple academic centers. PATIENT SAMPLE: A total of 84 patients met radiographic criteria for adult cervical deformity and at least 2-year follow-up. OUTCOME MEASURES: Optimal outcome is defined as meeting Virk et al Good Clinical Outcome (GCO): [Meeting 2 of 3: 1) NDI<20 or meeting MCID, 2) mJOA>=14, 3) NRS-Neck<=5 or improved by >2 points] and no occurrence of distal junctional failure (DJF). METHODS: C2-T2 lordosis was divided into cranial (C2-to-apex) and caudal (apex-to-T2) arches. A cervical lordosis distribution index (CLDI) was developed by dividing the cranial lordotic arch (C2 to apex) by the total segment (C2-T2) and multiplying by 100. Cross-tabulations developed categories for CLDI producing the highest chi-square values for achieving Optimal Outcome at two years and outcomes were assessed by multivariable analysis controlling for significant confounders. Patients stratified by Ames et al deformity classification then assessed against thresholds. Patients were further divided into those meeting thresholds with upper cervical compensation (defined by C0-C2 angle, C0 slope, McGregor's Slope [MGS]) vs without compensation. Multivariate regression analysis controlling for T1 slope assessed differences in classification and impact of upper cervical region. RESULTS: Cervical apex distribution postoperatively was: 1% C3, 42% C4, 30% C5, 27% C6. Mean cervical LDI was 117±138. Mean cranial lordosis was 23.2±12.5°. Using cross-tabulations, CLDI between 70 and 90 was defined as ‘Aligned’. Chi-square test revealed significant differences among CLDI categories for DJK, DJF, Good Clinical Outcome, and Optimal Outcome (all p<.05). Patients aligned in CLDI were less likely to develop DJK (OR: 0.1, [<0.1-0.9]), more like to achieve GCO (OR: 3.9, [1.2-13.2]) and Optimal Outcome (OR: 7.9, [2.1-29.3]) at two years. Patients aligned in CLDI developed DJF at a rate of 0%. Those meeting this CLDI threshold were more likely to be classified into primarily cervical deformity by Ames criteria (OR: 1.9, [3.2-10.6], p<.05). CONCLUSIONS: The cervical lordosis distribution index, classified through the cranial segment, takes each unique cervical apex into account and tailors correction to the patient in order to better achieve good clinical outcomes. While differences based on morphology exists, upper cervical region functions as a reserve in all deformity types. Consideration of regional and global factors allows for a comprehensive assessment and individualization of realignment surgery. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Who are super-utilizers in adult spine deformity surgery and how can surgeons identify them preoperatively?(Spine Journal, 2024-09-01) Nayak, P; Hostin, RA; Staub, BN; Gum, JL; Line, B; Bess, S; Lenke, LG; Lafage, R; Smith, JS; Mullin, JP; Kelly, MP; Diebo, BG; Buell, TJ; Scheer, JK; Lafage, V; Klineberg, EO; Kim, HJ; Passias, PG; Kebaish, KM; Eastlack, RK; Daniels, AH; Soroceanu, A; Mundis, GM; Protopsaltis, TS; Hamilton, DK; Gupta, MC; Schwab, FJ; Shaffrey, CI; Ames, CP; Burton, DCBACKGROUND CONTEXT: A relatively small percentage of patients are responsible for a disproportional amount of resource utilization in adult ASD surgery and contribute to significantly elevating the average cost across the surgically treated patients. These patients are called super-utilizers (SU). Modest reduction in the frequency of these super-utilization episodes has the potential to significantly improve the value of ASD surgery. PURPOSE: The goal of this study was to determine which, if any, baseline patient, radiographic, and/or surgical factors are the most important drivers of this disproportional increased resource utilization. We hypothesize that baseline patient factors predicts super-utilizers (SU) in adult spinal deformity surgery (ASD) more than surgical or deformity factors. STUDY DESIGN/SETTING: Retrospective Review of a prospective, multicenter registry. PATIENT SAMPLE: A total of 1299 index operative ASD patients eligible for 2-yr follow-up. OUTCOME MEASURES: Predictors of SU vs Non-SU in ASD. METHODS: A prospective multicenter consecutive series of ASD patients was reviewed. Inclusion criteria was diagnosis of ASD (scoliosis≥20°, C7-SVA≥5cm, PT≥25°, or TK≥60°), >4 level posterior fusion, and minimum 2-year follow-up. Index and total episode of care (EOC) cost in 2022 dollars were calculated using average itemized direct costs obtained from the administrative hospital records for all events in the inpatient EOC. Patients with total 2-year EOC cost greater than 90th percentile were considered SU. Multivariate generalized linear models were used to identify the most significant predictors of SU. RESULTS: A total of 1299 patients were eligible for 2-yr follow-up with mean age 60.0+14.1 years, 76% female, and 93% caucasians. SU patients are marginally older (+2.6 yrs; p=0.03), depressed (34.2% vs 25.8%; p=0.03) and tend to have higher propensity for fraility (p=0.003), comorbidities (0.01), reoperation rates (54.8% vs 17.0%; p<0.001), and LOS (+3 days; p<0.0001) compared to non-SU. While degree of sagittal deformity (Schwab sagittal modifiers, all p>0.05) and proportion of 3-column osteotomies (p>0.05) were similar between the groups, SU patients have higher surgical invasiveness score (+28; p<0.001), more vertebrae fused (+3; p<0.0001); more interbody fusions (80% vs 55%; p<0.0001), more BMP use (87.3% vs 69.4%; p=0.0002); longer OR time (+91 mins; p<0.0001), increased blood loss (+700 mL; p<0.0001), and longer length of stay (+3 days; p<0.0001). Index and EOC cost were 49% (p<0.0001) and 62% (p<0.0001) higher respectively in SU. While cost/QALY was 3-times higher in SU compared to non-SU. Multivariate analysis identified Schwab modifier SVA, surgical invasiveness, OR time, blood loss, BMP use, and LOS as strong predictors of SU (all p<0.01). CONCLUSIONS: Surgical invasiveness score greater than 118, being in OR for more than 7.6 hrs, blood loss more than 700 ml, utilizing BMP, and LOS more than 11 days were strong predictors of being a SU. Patients with SVA grade of + and ++ were less likely to be a SU compared to SVA grade 0. Procedural and resource utilization factors were strong predictors of being a SU compared to patient factors. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.