Browsing by Author "Eastlack, Robert K"
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Item Open Access Analysis of tranexamic acid usage in adult spinal deformity patients with relative contraindications: does it increase the risk of complications?(Journal of neurosurgery. Spine, 2024-03) Mullin, Jeffrey P; Soliman, Mohamed AR; Smith, Justin S; Kelly, Michael P; Buell, Thomas J; Diebo, Bassel; Scheer, Justin K; Line, Breton; Lafage, Virginie; Lafage, Renaud; Klineberg, Eric; Kim, Han Jo; Passias, Peter G; Gum, Jeffrey L; Kebaish, Khaled; Eastlack, Robert K; Daniels, Alan H; Soroceanu, Alex; Mundis, Gregory; Hostin, Richard; Protopsaltis, Themistocles S; Hamilton, D Kojo; Gupta, Munish C; Lewis, Stephen J; Schwab, Frank J; Lenke, Lawrence G; Shaffrey, Christopher I; Bess, Shay; Ames, Christopher P; Burton, DouglasObjective
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.Item Open Access Analysis of tranexamic acid usage in adult spinal deformity patients with relative contraindications: does it increase the risk of complications?(JOURNAL OF NEUROSURGERY-SPINE, 2024) Mullin, Jeffrey P; Soliman, Mohamed AR; Smith, Justin S; Kelly, Michael P; Buell, Thomas J; Diebo, Bassel; Scheer, Justin K; Line, Breton; Lafage, Virginie; Lafage, Renaud; Klineberg, Eric; Kim, Han Jo; Passias, Peter G; Gum, Jeffrey L; Kebaish, Khaled; Eastlack, Robert K; Daniels, Alan H; Soroceanu, Alex; Mundis, Gregory; Hostin, Richard; Protopsaltis, Themistocles S; Hamilton, D Kojo; Gupta, Munish C; Lewis, Stephen J; Schwab, Frank J; Lenke, Lawrence G; Shaffrey, Christopher I; Bess, Shay; Ames, Christopher P; Burton, DouglasItem Open Access Appropriate Risk Stratification and Accounting for Age-Adjusted Reciprocal Changes in the Thoracolumbar Spine Reduces the Incidence and Magnitude of Distal Junctional Kyphosis in Cervical Deformity Surgery.(Spine, 2021-11) Passias, Peter G; Bortz, Cole; Pierce, Katherine E; Kummer, Nicholas A; Lafage, Renaud; Diebo, Bassel G; Line, Breton G; Lafage, Virginie; Burton, Douglas C; Klineberg, Eric O; Kim, Han Jo; Daniels, Alan H; Mundis, Gregory M; Protopsaltis, Themistocles S; Eastlack, Robert K; Sciubba, Daniel M; Bess, Shay; Schwab, Frank J; Shaffrey, Christopher I; Smith, Justin S; Ames, Christopher P; International Spine Study Group (ISSG)Study design
Retrospective cohort study of a prospective cervical deformity (CD) database.Objective
Identify factors associated with distal junctional kyphosis (DJK); assess differences across DJK types.Summary of background data
DJK may develop as compensation for mal-correction of sagittal deformity in the thoracic curve. There is limited understanding of DJK drivers, especially for different DJK types.Methods
Included: patients with pre- and postoperative clinical/radiographic data. Excluded: patients with previous fusion to L5 or below. DJK was defined per surgeon note or DJK angle (kyphosis from LIV to LIV-2)<-10°, and pre- to postoperative change in DJK angle by<-10°. Age-specific target LL-TK alignment was calculated as published. Offset from target LL-TK was correlated to DJK magnitude and inclination. DJK types: severe (DJK<-20°), progressive (DJK increase>4.4°), symptomatic (reoperation or published disability thresholds of NDI ≥ 24 or mJOA≤14). Random forest identified factors associated with DJK. Means comparison tests assessed differences.Results
Included: 136 CD patients (61 ± 10 yr, 61%F). DJK rate was 30%. Postop offset from ideal LL-TK correlated with greater DJK angle (r = 0.428) and inclination of the distal end of the fusion construct (r = 0.244, both P < 0.02). Seven of the top 15 factors associated with DJK were radiographic, four surgical, and four clinical. Breakdown by type: severe (22%), progressive (24%), symptomatic (61%). Symptomatic had more posterior osteotomies than asymptomatic (P = 0.018). Severe had worse NDI and upper-cervical deformity (CL, C2 slope, C0-C2), as well as more posterior osteotomies than nonsevere (all P < 0.01). Progressive had greater malalignment both globally and in the cervical spine (all P < 0.03) than static. Each type had varying associated factors.Conclusion
Offset from age-specific alignment is associated with greater DJK and more anterior distal construct inclination, suggesting DJK may develop due to inappropriate realignment. Preoperative clinical and radiographic factors are associated with symptomatic and progressive DJK, suggesting the need for preoperative risk stratification.Level of Evidence: 3.Item Open Access Are insufficient corrections a major factor in distal junctional kyphosis? A simulated analysis of cervical deformity correction using in-construct measurements.(Journal of neurosurgery. Spine, 2024-05) Ani, Fares; Sissman, Ethan; Woo, Dainn; Soroceanu, Alex; Mundis, Gregory; Eastlack, Robert K; Smith, Justin S; Hamilton, D Kojo; Kim, Han Jo; Daniels, Alan H; Klineberg, Eric O; Neuman, Brian; Sciubba, Daniel M; Gupta, Munish C; Kebaish, Khaled M; Passias, Peter G; Hart, Robert A; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Ames, Christopher P; Protopsaltis, Themistocles SObjective
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.Item Open Access Are Minimally Invasive Spine Surgeons or Classical Open Spine Surgeons More Consistent with Their Treatment of Adult Spinal Deformity?(World neurosurgery, 2022-09) Uribe, Juan S; Koffie, Robert M; Wang, Michael Y; Mundis, Gregory M; Kanter, Adam S; Eastlack, Robert K; Anand, Neel; Park, Paul; Smith, Justin S; Burton, Douglas C; Chou, Dean; Kelly, Michael P; Kim, Han Jo; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lenke, Lawrence G; Mummaneni, Praveen VObjective
Spine surgeons have a heuristic sense of how to surgically restore alignment and address adult spinal deformity (ASD) symptoms, but consensus on the extent of treatment remains unclear. We sought to determine the variability of surgical approaches in treating ASD.Methods
Sixteen spine surgeons were surveyed on treatment approaches in 10 select ASD cases. We repeated the survey with the same surgeons 4 weeks later, with cases ordered differently. We examined the variability in length of construct, use of interbody spacers, osteotomies, and pelvic fixation frequency.Results
Treatment approaches for each case varied by surgeon, with some surgeons opting for long fusion constructs in cases for which others offered no surgery. There was no consensus among surgeons on the number of levels fused, interbody spacer use, or anterior/posterior osteotomies. Intersurgeon and intrasurgeon variability was 48% (kappa = 0.31) and 59% (kappa = 0.44) for surgeons performing minimally invasive surgery (MIS) versus 37% (kappa = 0.21) and 47% (kappa = 0.30) for those performing open surgery. In the second-round survey, 8 of 15 (53%) surgeons substantially changed the construct length, number of interbody spacers, and osteotomies in at least half the cases they previously reviewed. Surgeons performing MIS versus open surgery were less likely to extend constructs to the pelvis (42.5% vs. 67.5%; P = 0.02), but construct length was not correlated with whether a surgeon performed MIS or open surgery.Conclusions
Spinal deformity surgeons lack consensus on the optimal surgical approach for treating ASD. Classifying surgeons as performing MIS or open surgery does not mitigate this variability.Item Open Access Are we improving in the optimization of surgery for high-risk adult cervical spine deformity patients over time?(Journal of neurosurgery. Spine, 2023-07) Passias, Peter G; Tretiakov, Peter S; Smith, Justin S; Lafage, Renaud; Diebo, Bassel; Scheer, Justin K; Eastlack, Robert K; Daniels, Alan H; Klineberg, Eric O; Khabeish, Khaled M; Mundis, Gregory M; Turner, Jay D; Gupta, Munish C; Kim, Han Jo; Schwab, Frank; Bess, Shay; Lafage, Virginie; Ames, Christopher P; Shaffrey, Christopher IObjective
The aim of this study was to investigate whether surgery for high-risk patients is being optimized over time and if poor outcomes are being minimized.Methods
Patients who underwent surgery for cervical deformity (CD) and were ≥ 18 years with baseline and 2-year data were stratified by year of surgery from 2013 to 2018. The cohort was divided into two groups based on when the surgery was performed. Patients in the early cohort underwent surgery between 2013 and 2015 and those in the recent cohort underwent surgery between 2016 and 2018. High-risk patients met at least 2 of the following criteria: 1) baseline C2-7 Cobb angle > 15°, mismatch between T1 slope and cervical lordosis ≥ 35°, C2-7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°; 2) age ≥ 70 years; 3) severe baseline frailty (Miller index); 4) Charlson Comorbidity Index (CCI) ≥ 1 SD above the mean; 5) three-column osteotomy as treatment; and 6) fusion > 10 levels or > 7 levels for elderly patients. The mean comparison analysis assessed differences between groups. Stepwise multivariable linear regression described associations between increasing year of surgery and complications.Results
Eighty-two CD patients met high-risk criteria (mean age 62.11 ± 10.87 years, 63.7% female, mean BMI 29.70 ± 8.16 kg/m2, and mean CCI 1.07 ± 1.45). The proportion of high-risk patients increased with time, with 41.8% of patients in the early cohort classified as high risk compared with 47.6% of patients in the recent cohort (p > 0.05). Recent high-risk patients were more likely to be female (p = 0.008), have a lower BMI (p = 0.038), and have a higher baseline CCI (p = 0.013). Surgically, high-risk patients in the recent cohort were more likely to undergo low-grade osteotomy (p = 0.003). By postoperative complications, recent high-risk patients were less likely to experience any postoperative adverse events overall (p = 0.020) or complications such as dysphagia (p = 0.045) at 2 years. Regression analysis revealed increasing year of surgery to be correlated with decreasing minor complication rates (p = 0.030), as well as lowered rates of distal junctional kyphosis by 2 years (p = 0.048).Conclusions
Over time, high-risk CD patients have an increase in frequency and comorbidity rates but have demonstrated improved postoperative outcomes. These findings suggest that spine surgeons have improved over time in optimizing selection and reducing potential adverse events in high-risk patients.Item Open Access 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.(Journal of neurosurgery. Spine, 2023-06) Tretiakov, Peter S; Lafage, Renaud; Smith, Justin S; Line, Breton G; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey; Protopsaltis, Themistocles; Hamilton, D Kojo; Soroceanu, Alex; Scheer, Justin K; Eastlack, Robert K; Mundis, Gregory; Nunley, Pierce D; Klineberg, Eric O; Kebaish, Khaled; Lewis, Stephen; Lenke, Lawrence; Hostin, Richard; Gupta, Munish C; Ames, Christopher P; Hart, Robert A; Burton, Douglas; Shaffrey, Christopher I; Schwab, Frank; Bess, Shay; Kim, Han Jo; Lafage, Virginie; Passias, Peter GObjective
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.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 presentation and treatment of patients with cervical deformity secondary to thoracolumbar proximal junctional kyphosis are distinct despite achieving similar outcomes: Analysis of 123 prospective CD cases.(Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 2018-10) Passias, Peter G; Horn, Samantha R; Poorman, Gregory W; Daniels, Alan H; Hamilton, D Kojo; Kim, Han Jo; Diebo, Bassel G; Steinmetz, Leah; Bortz, Cole A; Segreto, Frank A; Sciubba, Daniel M; Smith, Justin S; Neuman, Brian J; Shaffrey, Christopher I; Lafage, Renaud; Lafage, Virginie; Ames, Christopher; Hart, Robert; Mundis, Gregory; Eastlack, Robert K; Schwab, Frank J; International Spine Study Group (ISSG)CD development secondary to PJK was recently documented in adult spinal deformity patients after surgical correction for thoracolumbar ASD. This study analyzes surgical management of patients with CD secondary to proximal junctional kyphosis (PJK) versus patients with primary CD. Retrospective review of multicenter cervical deformity (CD) database. CD defined as at least one of the following: C2-C7 coronal Cobb > 10°, cervical lordosis (CL) > 10°, cervical sagittal vertical axis (cSVA) > 4cm, CBVA > 25°. Patients were grouped into those with PJK (UIV +2 < -10°) prior to cervical surgery versus who don't (Non-PJK). Independent t-tests and chi-squared tests compared radiographic, clinical, and surgical metrics between PJK and non-PJK groups. Of 123 eligible CD patients, 26(21.1%) had radiographic PJK prior to cervical surgery. PJK patients had significantly greater T2-T12 thoracic kyphosis (-58.8° vs -45.0°, p = 0.002), cSVA (49.1 mm vs 38.9 mm, p = 0.020), T1 Slope (42.6° vs 28.4°, p < 0.001), TS-CL (44.1° vs 35.6°, p = 0.048), C2-T3 SVA (98.8 mm vs 75.8 mm, p = 0.015), C2 Slope (45.4° vs 36.0°, p = 0.043), and CTPA (6.4° vs 4.6°, p = 0.005). Comparing their surgeries, the PJK group had significantly more levels fused (10.7 vs 7.4, p = 0.01). There was significantly greater blood loss in PJK patients (1158 ± 1063vs 738 ± 793 cc, p = 0.028); operative time, surgical approach, and BMP-2 use were similar (all p > 0.05). PJK patients experienced higher rates of complications 30 and 90 days post-operatively (23.1% vs. 5.2%, p = 0.004; 30.8% vs. 19.6%, p = 0.026), and more instrumentation failure 30 days postoperatively (7.8% vs. 1.0%, p = 0.004). Patients with cervical deformity secondary to PJK had worse baseline CD, despite no differences in HRQL or demographics. Surgical correction of CD associated with PJK required more invasive surgery and had higher complication rates than non-PJK patients, despite achieving similar clinical outcomes.Item Open Access Comparison of Complications and Clinical and Radiographic Outcomes Between Nonobese and Obese Patients with Adult Spinal Deformity Undergoing Minimally Invasive Surgery.(World neurosurgery, 2016-03) Park, Paul; Wang, Michael Y; Nguyen, Stacie; Mundis, Gregory M; La Marca, Frank; Uribe, Juan S; Anand, Neel; Okonkwo, David O; Kanter, Adam S; Fessler, Richard; Eastlack, Robert K; Chou, Dean; Deviren, Vedat; Nunley, Pierce D; Shaffrey, Christopher I; Mummaneni, Praveen V; International Spine Study GroupObjective
Obesity can be associated with increased complications and potentially worse outcomes. We aimed to evaluate the impact of obesity on complications and outcomes in patients with adult spinal deformity (ASD) who underwent minimally invasive surgery (MIS).Methods
A multicenter database of patients with ASD treated via MIS was queried. Of 190 patients in the database, 77 fit the inclusion criteria of 3 or more spinal levels treated minimally invasively. Patients were divided by body mass index (BMI) <30 (nonobese; n = 59) and BMI ≥ 30 (obese; n = 18).Results
Mean BMI was 24.6 nonobese and 35.0 obese (P < 0.001). There were mean 3.8 interbody fusions nonobese and 4.7 obese (P = 0.065). Levels treated posteriorly averaged 5.8 nonobese and 5.9 obese (P = 0.502). Mean follow-up was 34.4 months nonobese and 35.3 months obese (P = 0.976). Baseline radiographic parameters were similar between groups. Postoperatively, SVA averaged 83.9 mm obese and 20.4 mm nonobese (P = 0.002). Postoperative lumbar lordosis-pelvic incidence mismatch averaged 17.9° obese and 9.9° nonobese (P = 0.028). Both groups had improvement in Oswestry Disability Index (ODI) scores with no difference in postoperative ODI scores between groups (P = 0.090). Similarly, both groups had decreased VAS scores for back and leg pain with no difference between groups postoperatively. Twenty (33.9%) nonobese patients versus 7 (38.9%) obese patients had complications (P = 0.452).Conclusions
Our results suggest that obesity does not negatively impact complication rate or clinical outcomes in patients with ASD treated via MIS approaches.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 Comparison of two minimally invasive surgery strategies to treat adult spinal deformity.(Journal of neurosurgery. Spine, 2015-04) Park, Paul; Wang, Michael Y; Lafage, Virginie; Nguyen, Stacie; Ziewacz, John; Okonkwo, David O; Uribe, Juan S; Eastlack, Robert K; Anand, Neel; Haque, Raqeeb; Fessler, Richard G; Kanter, Adam S; Deviren, Vedat; La Marca, Frank; Smith, Justin S; Shaffrey, Christopher I; Mundis, Gregory M; Mummaneni, Praveen V; International Spine Study GroupObject
Minimally invasive surgery (MIS) techniques are becoming a more common means of treating adult spinal deformity (ASD). The aim of this study was to compare the hybrid (HYB) surgical approach, involving minimally invasive lateral interbody fusion with open posterior instrumented fusion, to the circumferential MIS (cMIS) approach to treat ASD.Methods
The authors performed a retrospective, multicenter study utilizing data collected in 105 patients with ASD who were treated via MIS techniques. Criteria for inclusion were age older than 45 years, coronal Cobb angle greater than 20°, and a minimum of 1 year of follow-up. Patients were stratified into 2 groups: HYB (n = 62) and cMIS (n = 43).Results
The mean age was 60.7 years in the HYB group and 61.0 years in the cMIS group (p = 0.910). A mean of 3.6 interbody fusions were performed in the HYB group compared with a mean of 4.0 interbody fusions in the cMIS group (p = 0.086). Posterior fusion involved a mean of 6.9 levels in the HYB group and a mean of 5.1 levels in the cMIS group (p = 0.003). The mean follow-up was 31.3 months for the HYB group and 38.3 months for the cMIS group. The mean Oswestry Disability Index (ODI) score improved by 30.6 and 25.7, and the mean visual analog scale (VAS) scores for back/leg pain improved by 2.4/2.5 and 3.8/4.2 for the HYB and cMIS groups, respectively. There was no significant difference between groups with regard to ODI or VAS scores. For the HYB group, the lumbar coronal Cobb angle decreased by 13.5°, lumbar lordosis (LL) increased by 8.2°, sagittal vertical axis (SVA) decreased by 2.2 mm, and LL-pelvic incidence (LL-PI) mismatch decreased by 8.6°. For the cMIS group, the lumbar coronal Cobb angle decreased by 10.3°, LL improved by 3.0°, SVA increased by 2.1 mm, and LL-PI decreased by 2.2°. There were no significant differences in these radiographic parameters between groups. The complication rate, however, was higher in the HYB group (55%) than in the cMIS group (33%) (p = 0.024).Conclusions
Both HYB and cMIS approaches resulted in clinical improvement, as evidenced by decreased ODI and VAS pain scores. While there was no significant difference in degree of radiographic correction between groups, the HYB group had greater absolute improvement in degree of lumbar coronal Cobb angle correction, increased LL, decreased SVA, and decreased LL-PI. The complication rate, however, was higher with the HYB approach than with the cMIS approach.Item Open Access Determining the best vertebra for measuring pelvic incidence and spinopelvic parameters in adult spinal deformity patients with transitional anatomy.(Journal of neurosurgery. Spine, 2023-10) Ani, Fares; Protopsaltis, Themistocles S; Parekh, Yesha; Odeh, Khalid; Lafage, Renaud; Smith, Justin S; Eastlack, Robert K; Lenke, Lawrence; Schwab, Frank; Mundis, Gregory M; Gupta, Munish C; Klineberg, Eric O; Lafage, Virginie; Hart, Robert; Burton, Douglas; Ames, Christopher P; Shaffrey, Christopher I; Bess, ShayObjective
The aim of this study was to determine if spinal deformity patients with L5 sacralization should have pelvic incidence (PI) and other spinopelvic parameters measured from the L5 or S1 endplate.Methods
This study was a multicenter retrospective comparative cohort study comprising a large database of adult spinal deformity (ASD) patients and a database of asymptomatic individuals. Linear regression modeling was used to determine normative T1 pelvic angle (TPA) and PI - lumbar lordosis (LL) mismatch (PI-LL) based on PI and age in a database of asymptomatic subjects. In an ASD database, patients with radiographic evidence of L5 sacralization had the PI, LL, and TPA measured from the superior endplate of S1 and then also from L5. The differences in TPA and PI-LL from normative were calculated in the sacralization cohort relative to L5 and S1 and correlated to the Oswestry Disability Index (ODI). Patients were grouped based on the Scoliosis Research Society (SRS)-Schwab PI-LL modifier (0, +, or ++) using the L5 PI-LL and S1 PI-LL. Baseline ODI and SF-36 Physical Component Summary (PCS) scores were compared across and within groups.Results
Among 1179 ASD patients, 276 (23.4%) had transitional anatomy, 176 with sacralized L5 (14.9%) and 100 (8.48%) with lumbarization of S1. The 176 patients with sacralized L5 were analyzed. When measured using the L5 superior endplate, pelvic parameters were significantly smaller than those measured relative to S1 (PI: 24.5° ± 11.0° vs 55.7° ± 12.0°, p = 0.001;TPA: 11.2° ± 12.0° vs 20.3° ± 12.5°, p = 0.001; and PI-LL: 0.67° ± 21.1° vs 11.4° ± 20.8°, p = 0.001). When measured from S1, 76 (43%), 45 (25.6%), and 55 (31.3%) patients had SRS-Schwab PI-LL modifiers of 0, +, and ++, respectively, compared with 124 (70.5%), 22 (12.5%), and 30 (17.0%), respectively, when measured from L5. There were significant differences in ODI and PCS scores as the SRS-Schwab grade increased regardless of L5 or S1 measurement. The L5 group had lower PCS functional scores for SRS-Schwab modifiers 0 and ++ relative to same grades in the S1 group. Offset from normative TPA (0.5° ± 11.1° vs 9.6° ± 10.8°, p = 0.001) and PI-LL (4.5° ± 20.4° vs 15.2° ± 19.3°, p = 0.001) were smaller when measuring from L5. Moreover, S1 measurements were more correlated with health status by ODI (TPA offset from normative: S1, R = 0.326 vs L5, R = 0.285; PI-LL offset from normative: S1, R = 0.318 vs L5, R = 0.274).Conclusions
Measuring the PI and spinopelvic parameters at L5 in sacralized anatomy results in underestimating spinal deformity and is less correlated with health-related quality of life. Surgeons may consider measuring PI and spinopelvic parameters relative to S1 rather than at L5 in patients with a sacralized L5.Item Open Access Development of a Novel Cervical Deformity Surgical Invasiveness Index.(Spine, 2020-01) Passias, Peter G; Horn, Samantha R; Soroceanu, Alexandra; Oh, Cheongeun; Ailon, Tamir; Neuman, Brian J; Lafage, Virginie; Lafage, Renaud; Smith, Justin S; Line, Breton; Bortz, Cole A; Segreto, Frank A; Brown, Avery; Alas, Haddy; Pierce, Katherine E; Eastlack, Robert K; Sciubba, Daniel M; Protopsaltis, Themistocles S; Klineberg, Eric O; Burton, Douglas C; Hart, Robert A; Schwab, Frank J; Bess, Shay; Shaffrey, Christopher I; Ames, Christopher P; International Spine Study GroupSTUDY DESIGN:Retrospective review. OBJECTIVE:The aim of this study was to develop a novel surgical invasiveness index for cervical deformity (CD) surgery that incorporates CD-specific parameters. SUMMARY OF BACKGROUND DATA:There has been a surgical invasiveness index for general spine surgery and adult spinal deformity, but a CD index has not been developed. METHODS:CD was defined as at least one of the following: C2-C7 Cobb >10°, cervical lordosis (CL) >10°, cervical sagittal vertical axis (cSVA) >4 cm, chin brow vertical angle >25°. Consensus from experienced spine and neurosurgeons selected weightings for each variable that went into the invasiveness index. Binary logistic regression predicted high operative time (>338 minutes), estimated blood loss (EBL) (>600 mL), or length of stay (LOS) >5 days) based on the median values of operative time, EBL, and LOS. Multivariable regression modeling was utilized to construct a final model incorporating the strongest combination of factors to predict operative time, LOS, and EBL. RESULTS:Eighty-five CD patients were included (61 years, 66% females). The variables in the newly developed CD invasiveness index with their corresponding weightings were: history of previous cervical surgery (3), anterior cervical discectomy and fusion (2/level), corpectomy (4/level), levels fused (1/level), implants (1/level), posterior decompression (2/level), Smith-Peterson osteotomy (2/level), three-column osteotomy (8/level), fusion to upper cervical spine (2), absolute change in T1 slope minus cervical lordosis, cSVA, T4-T12 thoracic kyphosis (TK), and sagittal vertical axis (SVA) from baseline to 1-year. The newly developed CD-specific invasiveness index strongly predicted long LOS (R = 0.310, P < 0.001), high EBL (R = 0.170, P = 0.011), and extended operative time (R = 0.207, P = 0.031). A second analysis used multivariable regression modeling to determine which combination of factors in the newly developed index were the strongest determinants of operative time, LOS, and EBL. The final predictive model included: number of corpectomies, levels fused, decompression, combined approach, and absolute changes in SVA, cSVA, and TK. This model predicted EBL (R = 0.26), operative time (R = 0.12), and LOS (R = 0.13). CONCLUSION:Extended LOS, operative time, and high blood loss were strongly predicted by the newly developed CD invasiveness index, incorporating surgical factors and radiographic parameters clinically relevant for patients undergoing CD corrective surgery. LEVEL OF EVIDENCE:4.Item Open Access Does Achieving Global Spinal Alignment Lead to Higher Patient Satisfaction and Lower Disability in Adult Spinal Deformity?(Spine, 2021-08) Sheikh Alshabab, Basel; Gupta, Munish C; Lafage, Renaud; Bess, Shay; Shaffrey, Christopher; Kim, Han Jo; Ames, Christopher P; Burton, Douglas C; Smith, Justin S; Eastlack, Robert K; Klineberg, Eric O; Mundis, Gregory M; Schwab, Frank J; Lafage, Virginie; International Spine Study Group (ISSG)Study design
Multicenter retrospective review of prospective database.Objective
The aim of this study was to investigate potential associations between postoperative alignment and satisfaction.Summary of background data
Achieving high satisfaction is the main goal of any treatment, including adult spinal deformity (ASD) surgery. Despite being one of the key elements, literature is sparse regarding postoperative factors influencing patient satisfaction.Methods
ASD patients with 2-year follow-up were retrospectively reviewed. Patients without revision after the index procedure were stratified according to deformity type: sagittal (T1 pelvic angle >22°), coronal (C7 plumb line [C7PL] >5 cm or MaxCobb >50°), or mixed. Bivariate correlation between satisfaction and postoperative data was conducted on the entire cohort as well as by type of preoperative deformity. Multivariate regression controlling for pre-op alignment and demographic information was used to identify independent predictors of 2Y satisfaction.Results
A total of 509 patients were included in the analysis (58.7 ± 14.8, 80% females). The quality of life significantly improved between pre- and 2-year (ΔOswestry Disability Index [ODI]: 17.6, p < 0.001). At 2 years, SRS22 satisfaction was 4.27 ± 0.89 (median 4.5). Significant associations were found between satisfaction and disability (ODI, r = -0.50) and global coronal (C7PL r = -0.15) and sagittal (sagittal vertical axis [SVA], r = -0.10) alignment (all p < 0.01) but not with the coronal clavicle angle. Stratification by preoperative deformity revealed significant associations between satisfaction and SVA for sagittal deformity only, C7PL and MaxCobb for coronal only, and C7PL for combined deformity. In the multivariate analysis controlling for demographic and pre-op deformity, 2-year ODI and 2-year C7PL were independent predictors of satisfaction. Multilinear regression demonstrated 2-year SVA, pre-op ODI and patient's age were the independent predictors 2-year ODI.Conclusion
The ability to restore global alignment depends on the severity of the preoperative deformity as well as the correction of the main aspect of the deformity. Achieving global coronal and sagittal alignment is an independent predictor of both satisfaction and disability at 2 years post-op. Patients who continue to be disabled are also not satisfied.Level of Evidence: 3.Item Open Access Expectations of clinical improvement following corrective surgery for adult cervical deformity based on functional disability at presentation.(Spine deformity, 2024-07) Passias, Peter G; Onafowokan, Oluwatobi O; Joujon-Roche, Rachel; Smith, Justin; Tretiakov, Peter; Buell, Thomas; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey L; Hamiltion, D Kojo; Soroceanu, Alex; Scheer, Justin; Eastlack, Robert K; Fessler, Richard G; Klineberg, Eric O; Kim, Han Jo; Burton, Douglas C; Schwab, Frank J; Bess, Shay; Lafage, Virginie; Shaffrey, Christopher I; Ames, Christopher; International Spine Study GroupPurpose
To assess impact of baseline disability on HRQL outcomes.Methods
CD patients with baseline (BL) and 2 year (2Y) data included, and ranked into quartiles by baseline NDI, from lowest/best score (Q1) to highest/worst score (Q4). Means comparison tests analyzed differences between quartiles. ANCOVA and logistic regressions assessed differences in outcomes while accounting for covariates (BL deformity, comorbidities, HRQLs, surgical details and complications).Results
One hundred and sixteen patients met inclusion (Age:60.97 ± 10.45 years, BMI: 28.73 ± 7.59 kg/m2, CCI: 0.94 ± 1.31). The cohort mean cSVA was 38.54 ± 19.43 mm and TS-CL: 37.34 ± 19.73. Mean BL NDI by quartile was: Q1: 25.04 ± 8.19, Q2: 41.61 ± 2.77, Q3: 53.31 ± 4.32, and Q4: 69.52 ± 8.35. Q2 demonstrated greatest improvement in NRS Neck at 2Y (-3.93), compared to Q3 (-1.61, p = .032) and Q4 (-1.41, p = .015). Q2 demonstrated greater improvement in NRS Back (-1.71), compared to Q4 (+ 0.84, p = .010). Q2 met MCID in NRS Neck at the highest rates (69.9%), especially compared to Q4 (30.3%), p = .039. Q2 had the greatest improvement in EQ-5D (+ 0.082), compared to Q1 (+ 0.073), Q3 (+ 0.022), and Q4 (+ 0.014), p = .034. Q2 also had the greatest mJOA improvement (+ 1.517), p = .042.Conclusions
Patients in Q2, with mean BL NDI of 42, consistently demonstrated the greatest improvement in HRQLs whereas those in Q4, (NDI 70), saw the least. BL NDI between 39 and 44 may represent a disability "Sweet Spot," within which operative intervention maximizes patient-reported outcomes. Furthermore, delaying intervention until patients are severely disabled, beyond an NDI of 61, may limit the benefits of surgery.Item Open Access Factors affecting approach selection for minimally invasive versus open surgery in the treatment of adult spinal deformity: analysis of a prospective, nonrandomized multicenter study.(Journal of neurosurgery. Spine, 2020-06) Park, Paul; Than, Khoi D; Mummaneni, Praveen V; Nunley, Pierce D; Eastlack, Robert K; Uribe, Juan S; Wang, Michael Y; Le, Vivian; Fessler, Richard G; Okonkwo, David O; Kanter, Adam S; Anand, Neel; Chou, Dean; Fu, Kai-Ming G; Haddad, Alexander F; Shaffrey, Christopher I; Mundis, Gregory M; International Spine Study GroupObjective
Surgical decision-making and planning is a key factor in optimizing outcomes in adult spinal deformity (ASD). Minimally invasive spinal (MIS) strategies for ASD have been increasingly used as an option to decrease postoperative morbidity. This study analyzes factors involved in the selection of either a traditional open approach or a minimally invasive approach to treat ASD in a prospective, nonrandomized multicenter trial. All centers had at least 5 years of experience in minimally invasive techniques for ASD.Methods
The study enrolled 268 patients, of whom 120 underwent open surgery and 148 underwent MIS surgery. Inclusion criteria included age ≥ 18 years, and at least one of the following criteria: coronal curve (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, or thoracic kyphosis (TK) > 60°. Surgical approach selection was made at the discretion of the operating surgeon. Preoperative significant differences were included in a multivariate logistic regression analysis to determine odds ratios (ORs) for approach selection.Results
Significant preoperative differences (p < 0.05) between open and MIS groups were noted for age (61.9 vs 66.7 years), numerical rating scale (NRS) back pain score (7.8 vs 7), CC (36° vs 26.1°), PT (26.4° vs 23°), T1 pelvic angle (TPA; 25.8° vs 21.7°), and pelvic incidence-lumbar lordosis (PI-LL; 19.6° vs 14.9°). No significant differences in BMI (29 vs 28.5 kg/m2), NRS leg pain score (5.2 vs 5.7), Oswestry Disability Index (48.4 vs 47.2), Scoliosis Research Society 22-item questionnaire score (2.7 vs 2.8), PI (58.3° vs 57.1°), LL (38.9° vs 42.3°), or SVA (73.8 mm vs 60.3 mm) were found. Multivariate analysis found that age (OR 1.05, p = 0.002), VAS back pain score (OR 1.21, p = 0.016), CC (OR 1.03, p < 0.001), decompression (OR 4.35, p < 0.001), and TPA (OR 1.09, p = 0.023) were significant factors in approach selection.Conclusions
Increasing age was the primary driver for selecting MIS surgery. Conversely, increasingly severe deformities and the need for open decompression were the main factors influencing the selection of traditional open surgery. As experience with MIS surgery continues to accumulate, future longitudinal evaluation will reveal if more experience, use of specialized treatment algorithms, refinement of techniques, and technology will expand surgeon adoption of MIS techniques for adult spinal deformity.Item Open Access Factors Associated with the Maintenance of Cost-Effectiveness at 5 Years in Adult Spinal Deformity Corrective Surgery.(Spine, 2024-03) Passias, Peter G; Mir, Jamshaid M; Dave, Pooja; Smith, Justin S; Lafage, Renaud; Gum, Jeffrey; Line, Breton G; Diebo, Bassel; Daniels, Alan H; Hamilton, David Kojo; Buell, Thomas J; Scheer, Justin K; Eastlack, Robert K; Mullin, Jeffrey P; Mundis, Gregory M; Hosogane, Naobumi; Yagi, Mitsuru; Schoenfeld, Andrew J; Uribe, Juan S; Anand, Neel; Mummaneni, Praveen V; Chou, Dean; Klineberg, Eric O; Kebaish, Khaled M; Lewis, Stephen J; Gupta, Munish C; Kim, Han Jo; Hart, Robert A; Lenke, Lawrence G; Ames, Christopher P; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Hostin, Richard A; Bess, Shay; Burton, Douglas C; International Spine Study GroupStudy design
Retrospective cohort.Objective
To evaluate factors associated with the long-term durability of cost-effectiveness (CE) in ASD patients.Background
A substantial increase in costs associated with the surgical treatment for adult spinal deformity (ASD) has given precedence to scrutinize the value and utility it provides.Methods
We included 327 operative ASD patients with 5-year (5 Y) follow-up. Published methods were used to determine costs based on CMS.gov definitions and were based on the average DRG reimbursement rates. Utility was calculated using quality-adjusted life-years (QALY) utilizing the Oswestry Disability Index (ODI) converted to Short-Form Six-Dimension (SF-6D), with a 3% discount applied for its decline with life expectancy. The CE threshold of $150,000 was used for primary analysis.Results
Major and minor complication rates were 11% and 47% respectively, with 26% undergoing reoperation by 5 Y. The mean cost associated with surgery was $91,095±$47,003, with a utility gain of 0.091±0.086 at 1Y, QALY gained at 2 Y of 0.171±0.183, and at 5 Y of 0.42±0.43. The cost per QALY at 2 Y was $414,885, which decreased to $142,058 at 5 Y.With the threshold of $150,000 for CE, 19% met CE at 2 Y and 56% at 5 Y. In those in which revision was avoided, 87% met cumulative CE till life expectancy. Controlling analysis depicted higher baseline CCI and pelvic tilt (PT) to be the strongest predictors for not maintaining durable CE to 5 Y (CCI OR: 1.821 [1.159-2.862], P=0.009) (PT OR: 1.079 [1.007-1.155], P=0.030).Conclusions
Most patients achieved cost-effectiveness after four years postoperatively, with 56% meeting at five years postoperatively. When revision was avoided, 87% of patients met cumulative cost-effectiveness till life expectancy. Mechanical complications were predictive of failure to achieve cost-effectiveness at 2 Y, while comorbidity burden and medical complications were at 5 Y.Item Open Access Global coronal decompensation and adult spinal deformity surgery: comparison of upper-thoracic versus lower-thoracic proximal fixation for long fusions.(Journal of neurosurgery. Spine, 2021-08) Buell, Thomas J; Shaffrey, Christopher I; Kim, Han Jo; Klineberg, Eric O; Lafage, Virginie; Lafage, Renaud; Protopsaltis, Themistocles S; Passias, Peter G; Mundis, Gregory M; Eastlack, Robert K; Deviren, Vedat; Kelly, Michael P; Daniels, Alan H; Gum, Jeffrey L; Soroceanu, Alex; Hamilton, D Kojo; Gupta, Munish C; Burton, Douglas C; Hostin, Richard A; Kebaish, Khaled M; Hart, Robert A; Schwab, Frank J; Bess, Shay; Ames, Christopher P; Smith, Justin S; International Spine Study Group (ISSG)Objective
Deterioration of global coronal alignment (GCA) may be associated with worse outcomes after adult spinal deformity (ASD) surgery. The impact of fusion length and upper instrumented vertebra (UIV) selection on patients with this complication is unclear. The authors' objective was to compare outcomes between long sacropelvic fusion with upper-thoracic (UT) UIV and those with lower-thoracic (LT) UIV in patients with worsening GCA ≥ 1 cm.Methods
This was a retrospective analysis of a prospective multicenter database of consecutive ASD patients. Index operations involved instrumented fusion from sacropelvis to thoracic spine. Global coronal deterioration was defined as worsening GCA ≥ 1 cm from preoperation to 2-year follow-up.Results
Of 875 potentially eligible patients, 560 (64%) had complete 2-year follow-up data, of which 144 (25.7%) demonstrated worse GCA at 2-year postoperative follow-up (35.4% of UT patients vs 64.6% of LT patients). At baseline, UT patients were younger (61.6 ± 9.9 vs 64.5 ± 8.6 years, p = 0.008), a greater percentage of UT patients had osteoporosis (35.3% vs 16.1%, p = 0.009), and UT patients had worse scoliosis (51.9° ± 22.5° vs 32.5° ± 16.3°, p < 0.001). Index operations were comparable, except UT patients had longer fusions (16.4 ± 0.9 vs 9.7 ± 1.2 levels, p < 0.001) and operative duration (8.6 ± 3.2 vs 7.6 ± 3.0 hours, p = 0.023). At 2-year follow-up, global coronal deterioration averaged 2.7 ± 1.4 cm (1.9 to 4.6 cm, p < 0.001), scoliosis improved (39.3° ± 20.8° to 18.0° ± 14.8°, p < 0.001), and sagittal spinopelvic alignment improved significantly in all patients. UT patients maintained smaller positive C7 sagittal vertical axis (2.7 ± 5.7 vs 4.7 ± 5.7 cm, p = 0.014). Postoperative 2-year health-related quality of life (HRQL) significantly improved from baseline for all patients. HRQL comparisons demonstrated that UT patients had worse Scoliosis Research Society-22r (SRS-22r) Activity (3.2 ± 1.0 vs 3.6 ± 0.8, p = 0.040) and SRS-22r Satisfaction (3.9 ± 1.1 vs 4.3 ± 0.8, p = 0.021) scores. Also, fewer UT patients improved by ≥ 1 minimal clinically important difference in numerical rating scale scores for leg pain (41.3% vs 62.7%, p = 0.020). Comparable percentages of UT and LT patients had complications (208 total, including 53 reoperations, 77 major complications, and 78 minor complications), but the percentage of reoperated patients was higher among UT patients (35.3% vs 18.3%, p = 0.023). UT patients had higher reoperation rates of rod fracture (13.7% vs 2.2%, p = 0.006) and pseudarthrosis (7.8% vs 1.1%, p = 0.006) but not proximal junctional kyphosis (9.8% vs 8.6%, p = 0.810).Conclusions
In ASD patients with worse 2-year GCA after long sacropelvic fusion, UT UIV was associated with worse 2-year HRQL compared with LT UIV. This may suggest that residual global coronal malalignment is clinically less tolerated in ASD patients with longer fusion to the proximal thoracic spine. These results may inform operative planning and improve patient counseling.Item Open Access Height Gain Following Correction of Adult Spinal Deformity.(The Journal of bone and joint surgery. American volume, 2023-07) Diebo, Bassel G; Tataryn, Zachary; Alsoof, Daniel; Lafage, Renaud; Hart, Robert A; Passias, Peter G; Ames, Christopher P; Scheer, Justin K; Scheer, Justin K; Lewis, Stephen J; Shaffrey, Christopher I; Burton, Douglas C; Deviren, Vedat; Line, Breton G; Soroceanu, Alex; Hamilton, D Kojo; Klineberg, Eric O; Mundis, Gregory M; Kim, Han Jo; Gum, Jeffrey L; Smith, Justin S; Uribe, Juan S; Kelly, Michael P; Kebaish, Khaled M; Gupta, Munish C; Nunley, Pierce D; Eastlack, Robert K; Hostin, Richard; Protopsaltis, Themistocles S; Lenke, Lawrence G; Schwab, Frank J; Bess, Shay; Lafage, Virginie; Daniels, Alan H; the International Spine Study GroupBackground
Height gain following a surgical procedure for patients with adult spinal deformity (ASD) is incompletely understood, and it is unknown if height gain correlates with patient-reported outcome measures (PROMs).Methods
This was a retrospective cohort study of patients undergoing ASD surgery. Patients with baseline, 6-week, and subanalysis of 1-year postoperative full-body radiographic and PROM data were examined. Correlation analysis examined relationships between vertical height differences and PROMs. Regression analysis was utilized to preoperatively estimate T1-S1 and S1-ankle height changes.Results
This study included 198 patients (mean age, 57 years; 69% female); 147 patients (74%) gained height. Patients with height loss, compared with those who gained height, experienced greater increases in thoracolumbar kyphosis (2.81° compared with -7.37°; p < 0.001) and thoracic kyphosis (12.96° compared with 4.42°; p = 0.003). For patients with height gain, sagittal and coronal alignment improved from baseline to postoperatively: 25° to 21° for pelvic tilt (PT), 14° to 3° for pelvic incidence - lumbar lordosis (PI-LL), and 60 mm to 17 mm for sagittal vertical axis (SVA) (all p < 0.001). The full-body mean height gain was 7.6 cm, distributed as follows: sella turcica-C2, 2.9 mm; C2-T1, 2.8 mm; T1-S1 (trunk gain), 3.8 cm; and S1-ankle (lower-extremity gain), 3.3 cm (p < 0.001). T1-S1 height gain correlated with the thoracic Cobb angle correction and the maximum Cobb angle correction (p = 0.002). S1-ankle height gain correlated with the corrections in PT, PI-LL, and SVA (p < 0.001). T1-ankle height gain correlated with the corrections in PT (p < 0.001) and SVA (p = 0.03). Trunk height gain correlated with improved Scoliosis Research Society (SRS-22r) Appearance scores (r = 0.20; p = 0.02). Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores correlated with S1-ankle height gain (r = -0.19; p = 0.03) and C2-T1 height gain (r = -0.18; p = 0.04). A 1° correction in a thoracic scoliosis Cobb angle corresponded to a 0.2-mm height gain, and a 1° correction in a thoracolumbar scoliosis Cobb angle resulted in a 0.25-mm height gain. A 1° improvement in PI-LL resulted in a 0.2-mm height gain.Conclusions
Most patients undergoing ASD surgery experienced height gain following deformity correction, with a mean full-body height gain of 7.6 cm. Height gain can be estimated preoperatively with predictive ratios, and height gain was correlated with improvements in reported SRS-22r appearance and PROMIS scores.Level of evidence
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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