Browsing by Author "Gum, Jeffrey L"
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Item Open Access A Multicenter Study of the Presentation, Treatment, and Outcomes of Cervical Dural Tears.(Global spine journal, 2017-04) O'Neill, Kevin R; Fehlings, Michael G; Mroz, Thomas E; Smith, Zachary A; Hsu, Wellington K; Kanter, Adam S; Steinmetz, Michael P; Arnold, Paul M; Mummaneni, Praveen V; Chou, Dean; Nassr, Ahmad; Qureshi, Sheeraz A; Cho, Samuel K; Baird, Evan O; Smith, Justin S; Shaffrey, Christopher; Tannoury, Chadi A; Tannoury, Tony; Gokaslan, Ziya L; Gum, Jeffrey L; Hart, Robert A; Isaacs, Robert E; Sasso, Rick C; Bumpass, David B; Bydon, Mohamad; Corriveau, Mark; De Giacomo, Anthony F; Derakhshan, Adeeb; Jobse, Bruce C; Lubelski, Daniel; Lee, Sungho; Massicotte, Eric M; Pace, Jonathan R; Smith, Gabriel A; Than, Khoi D; Riew, K DanielStudy design
Retrospective multicenter case series study.Objective
Because cervical dural tears are rare, most surgeons have limited experience with this complication. A multicenter study was performed to better understand the presentation, treatment, and outcomes following cervical dural tears.Methods
Multiple surgeons from 23 institutions retrospectively identified 21 rare complications that occurred between 2005 and 2011, including unintentional cervical dural tears. Demographic data and surgical history were obtained. Clinical outcomes following surgery were assessed, and any reoperations were recorded. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA), Nurick classification (NuC), and Short-Form 36 (SF36) scores were recorded at baseline and final follow-up at certain centers. All data were collected, collated, and analyzed by a private research organization.Results
There were 109 cases of cervical dural tears among 18 463 surgeries performed. In 101 cases (93%) there was no clinical sequelae following successful dural tear repair. There were statistical improvements (P < .05) in mJOA and NuC scores, but not NDI or SF36 scores. No specific baseline or operative factors were found to be associated with the occurrence of dural tears. In most cases, no further postoperative treatments of the dural tear were required, while there were 13 patients (12%) that required subsequent treatment of cerebrospinal fluid drainage. Analysis of those requiring further treatments did not identify an optimum treatment strategy for cervical dural tears.Conclusions
In this multicenter study, we report our findings on the largest reported series (n = 109) of cervical dural tears. In a vast majority of cases, no subsequent interventions were required and no clinical sequelae were observed.Item Open Access Adult Cervical Deformity Patients Have Higher Baseline Frailty, Disability, and Comorbidities Compared With Complex Adult Thoracolumbar Deformity Patients: A Comparative Cohort Study of 616 Patients.(Global spine journal, 2023-11) Smith, Justin S; Kelly, Michael P; Buell, Thomas J; Ben-Israel, David; Diebo, Bassel; Scheer, Justin K; Line, Breton; Lafage, Virginie; Lafage, Renaud; Klineberg, Eric; Kim, Han Jo; Passias, Peter; Gum, Jeffrey L; Kebaish, Khal; Mullin, Jeffrey P; Eastlack, Robert; Daniels, Alan; Soroceanu, Alex; Mundis, Gregory; Hostin, Richard; Protopsaltis, Themistocles S; Hamilton, D Kojo; Gupta, Munish; Lewis, Stephen J; Schwab, Frank J; Lenke, Lawrence G; Shaffrey, Christopher I; Burton, Douglas; Ames, Christopher P; Bess, Shay; International Spine Study GroupStudy design
Multicenter comparative cohort.Objective
Studies have shown markedly higher rates of complications and all-cause mortality following surgery for adult cervical deformity (ACD) compared with adult thoracolumbar deformity (ATLD), though the reasons for these differences remain unclear. Our objectives were to compare baseline frailty, disability, and comorbidities between ACD and complex ATLD patients undergoing surgery.Methods
Two multicenter prospective adult spinal deformity registries were queried, one ATLD and one ACD. Baseline clinical and frailty measures were compared between the cohorts.Results
616 patients were identified (107 ACD and 509 ATLD). These groups had similar mean age (64.6 vs 60.8 years, respectively, P = .07). ACD patients were less likely to be women (51.9% vs 69.5%, P < .001) and had greater Charlson Comorbidity Index (1.5 vs .9, P < .001) and ASA grade (2.7 vs 2.4, P < .001). ACD patients had worse VR-12 Physical Component Score (PCS, 25.7 vs 29.9, P < .001) and PROMIS Physical Function Score (33.3 vs 35.3, P = .031). All frailty measures were significantly worse for ACD patients, including hand dynamometer (44.6 vs 55.6 lbs, P < .001), CSHA Clinical Frailty Score (CFS, 4.0 vs 3.2, P < .001), and Edmonton Frailty Scale (EFS, 5.15 vs 3.21, P < .001). Greater proportions of ACD patients were frail (22.9% vs 5.7%) or vulnerable (15.6% vs 10.9%) based on EFS (P < .001).Conclusions
Compared with ATLD patients, ACD patients had worse baseline characteristics on all measures assessed (comorbidities/disability/frailty). These differences may help account for greater risk of complications and all-cause mortality previously observed in ACD patients and facilitate strategies for better preoperative optimization.Item Open Access Adult Spinal Deformity Surgery Is Associated with Increased Productivity and Decreased Absenteeism From Work and School.(Spine, 2022-02) Durand, Wesley M; Babu, Jacob M; Hamilton, David K; Passias, Peter G; Kim, Han Jo; Protopsaltis, Themistocles; Lafage, Virginie; Lafage, Renaud; Smith, Justin S; Shaffrey, Christopher; Gupta, Munish; Kelly, Michael P; Klineberg, Eric O; Schwab, Frank; Gum, Jeffrey L; Mundis, Gregory; Eastlack, Robert; Kebaish, Khaled; Soroceanu, Alex; Hostin, Richard A; Burton, Doug; Bess, Shay; Ames, Christopher; Hart, Robert A; Daniels, Alan H; International Spine Study Group (ISSG)Study design
Retrospective cohort study.Objective
We hypothesized that adult spinal deformity (ASD) surgery would be associated with improved work- and school-related productivity, as well as decreased rates of absenteeism.Summary of background data
ASD patients experience markedly decreased health-related quality of life along many dimensions.Methods
Only patients eligible for 2-year follow-up were included, and those with a history of previous spinal fusion were excluded. The primary outcome measures in this study were Scoliosis Research Society-22r score (SRS-22r) questions 9 and 17. A repeated measures mixed linear regression was used to analyze responses over time among patients managed operatively (OP) versus nonoperatively (NON-OP).Results
In total, 1188 patients were analyzed. 66.6% were managed operatively. At baseline, the mean percentage of activity at work/school was 56.4% (standard deviation [SD] 35.4%), and the mean days off from work/school over the past 90 days was 1.6 (SD 1.8). Patients undergoing ASD surgery exhibited an 18.1% absolute increase in work/school productivity at 2-year follow-up versus baseline (P < 0.0001), while no significant change was observed for the nonoperative cohort (P > 0.5). Similarly, the OP cohort experienced 1.1 fewer absent days over the past 90 days at 2 years versus baseline (P < 0.0001), while the NON-OP cohort showed no such difference (P > 0.3). These differences were largely preserved after stratifying by baseline employment status, age group, sagittal vertical axis (SVA), pelvic incidence minus lumbar lordosis (PI-LL), and deformity curve type.Conclusion
ASD patients managed operatively exhibited an average increase in work/school productivity of 18.1% and decreased absenteeism of 1.1 per 90 days at 2-year follow-up, while patients managed nonoperatively did not exhibit change from baseline. Given the age distribution of patients in this study, these findings should be interpreted as pertaining primarily to obligations at work or within the home. Further study of the direct and indirect economic benefits of ASD surgery to patients is warranted.Level of Evidence: 3.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 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 Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery.(Journal of clinical medicine, 2023-08) Passias, Peter G; Williamson, Tyler K; Mir, Jamshaid M; Smith, Justin S; Lafage, Virginie; Lafage, Renaud; Line, Breton; Daniels, Alan H; Gum, Jeffrey L; Schoenfeld, Andrew J; Hamilton, David Kojo; Soroceanu, Alex; Scheer, Justin K; Eastlack, Robert; Mundis, Gregory M; Diebo, Bassel; Kebaish, Khaled M; Hostin, Richard A; Gupta, Munish C; Kim, Han Jo; Klineberg, Eric O; Ames, Christopher P; Hart, Robert A; Burton, Douglas C; Schwab, Frank J; Shaffrey, Christopher I; Bess, Shay; On Behalf Of The International Spine Study GroupBackground
While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications.Objective
Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers.Study design/setting
Retrospective cohort study of a prospectively collected multicenter database.Methods
ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility.Results
A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, p = 0.021) and major mechanical complications (12% vs. 22%, p = 0.002), and less reoperations (23% vs. 33%, p = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both p < 0.001) at two years.Conclusions
Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.Item Open Access Artificial intelligence clustering of adult spinal deformity sagittal plane morphology predicts surgical characteristics, alignment, and outcomes.(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, 2021-08) Durand, Wesley M; Lafage, Renaud; Hamilton, D Kojo; Passias, Peter G; Kim, Han Jo; Protopsaltis, Themistocles; Lafage, Virginie; Smith, Justin S; Shaffrey, Christopher; Gupta, Munish; Kelly, Michael P; Klineberg, Eric O; Schwab, Frank; Gum, Jeffrey L; Mundis, Gregory; Eastlack, Robert; Kebaish, Khaled; Soroceanu, Alex; Hostin, Richard A; Burton, Doug; Bess, Shay; Ames, Christopher; Hart, Robert A; Daniels, Alan H; International Spine Study Group (ISSG)Purpose
AI algorithms have shown promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics-this study sought to complement these efforts by analyzing images of sagittal anatomical spinopelvic landmarks. We hypothesized that an AI algorithm would cluster preoperative lateral radiographs into groups with distinct morphology.Methods
This was a retrospective review of a multicenter, prospectively collected database of adult spinal deformity. A total of 915 patients with adult spinal deformity and preoperative lateral radiographs were included. A 2 × 3, self-organizing map-a form of artificial neural network frequently employed in unsupervised classification tasks-was developed. The mean spine shape was plotted for each of the six clusters. Alignment, surgical characteristics, and outcomes were compared.Results
Qualitatively, clusters C and D exhibited only mild sagittal plane deformity. Clusters B, E, and F, however, exhibited marked positive sagittal balance and loss of lumbar lordosis. Cluster A had mixed characteristics, likely representing compensated deformity. Patients in clusters B, E, and F disproportionately underwent 3-CO. PJK and PJF were particularly prevalent among clusters A and E. Among clusters B and F, patients who experienced PJK had significantly greater positive sagittal balance than those who did not.Conclusions
This study clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology and association with sagittal alignment parameters, baseline HRQOL, and surgical characteristics. The relationship between SVA and PJK differed by cluster. This study represents significant progress toward incorporation of computer vision into clinically relevant classification systems in adult spinal deformity.Level of evidence iv
Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.Item Open Access Canadian Spine Society: 23rd Annual Scientific Conference, Wednesday, March 1 - Saturday, March 4, Fairmont Le Château Frontenac, Québec, Que., Canada.(Can J Surg, 2023) Birk, Manjot; Sidhu, Kara; Filezio, Marina Rosa; Singh, Vishwajeet; Ferri-de-Barros, Fabio; Chan, Vivien; Shumilak, Geoffrey; Nataraj, Andrew; Langston, Holly; Yee, Nicholas J; Iorio, Carlo; Shkumat, Nicholas; Rocos, Brett; Ertl-Wagner, Birgit; Lebel, David; Camp, Mark W; Dimentberg, Evan; Saran, Neil; Laflamme, Melissa; Ouellet, Jean A; Wenghofer, Jessica; Livock, Holly; Beaton, Luke; Tice, Andrew; Smit, Kevin; Graham, Ryan; Duarte, Matias Pereira; Roy-Beaudry, Marjolaine; Turgeon, Isabelle; Joncas, Julie; Mac-Thiong, Jean-Marc; Labelle, Hubert; Barchi, Soraya; Parent, Stefan; Gholamian, Tara; Livock, Holly; Tice, Andrew; Smit, Kevin; Yoon, Samuel; Zulfiqar, Amna; Rocos, Brett; Murphy, Anne; Bath, Natasha; Moll, Stanley; Sorbara, Julia; Lebel, David; Camp, Mark W; Nallet, Jérémie Arthur; Rocos, Brett; Lebel, David Eduard; Zeller, Reinhard; Dermott, Jennifer A; Kim, Dorothy J; Anthony, Alison; Zeller, Reinhard; Lebel, David E; Wang, Zhi; Shen, Jesse; Kamel, Youssef; Liu, Jia; Shedid, Daniel; Al-Shakfa, Fidaa; Yuh, Sung-Joo; Boubez, Ghassan; Rizkallah, Maroun; Rizkallah, Maroun; Shen, Jesse; Boubez, Ghassan; Kamel, Youssef; Liu, Jia; Shedid, Daniel; Al-Shakfa, Fidaa; Lavoie, Frederic; Yug, Sung-Joo; Wang, Zhi; Alavi, Fatemeh; Nielsen, Christopher; Rampersaud, Raja; Lewis, Stephen; Cheung, Angela M; Cadieux, Chloe; Fernandes, Renan; Brzozowski, Pawel; Zdero, Radovan; Bailey, Chris; Rasoulinejad, Parham; Cherry, Ahmed; Manoharan, Ragavan; Xu, Mark; Srikandarajah, Nisaharan; Iorio, Carlo; Raj, Aditya; Nielsen, Christopher; Rampersaud, Raja; Lewis, Stephen; Beange, Kristen; Graham, Ryan; Livock, Holly; Smit, Kevin; Manoharan, Ragavan; Cherry, Ahmed; Srikandarajah, Nisaharan; Raj, Aditya; Xu, Mark; Iorio, Carlo; Nielsen, Christopher J; Rampersaud, Y Raja; Lewis, Stephen J; Nasrabadi, Ali Asghar Mohammadi; Moammer, Gemah; Phee, John Mc; Walker, Taryn; Urquhart, Jennifer C; Glennie, R Andrew; Rampersaud, Y Raja; Fisher, Charles G; Bailey, Chris S; Herrington, Brandon J; Fernandes, Renan R; Urquhart, Jennifer C; Rasoulinejad, Parham; Siddiqi, Fawaz; Bailey, Christopher S; Urquhart, Jennifer; Fernandes, Renan R; Glennie, R Andrew; Rampersaud, Y Raja; Fisher, Charles G; Bailey, Chris S; Yang, Michael MH; Riva-Cambrin, Jay; Cunningham, Jonathan; Casha, Steven; Cadieux, Chloe N; Urquhart, Jennifer; Fernandes, Renan; Glennie, Andrew; Fisher, Charles; Rampersaud, Raja; Xu, Mark; Manoharan, Ragavan; Cherry, Ahmed; Raj, Aditya; Srikandarajah, Nish; Iorio, Carlo; Nielsen, Christopher; Lewis, Stephen; Rampersaud, Raja; Cherry, Ahmed; Raj, Aditya; McIntosh, Greg; Manoharan, Ragavan; Murray, Jean-Christophe; Nielsen, Christopher; Xu, Mark; Srikandarajah, Nisaharan; Iorio, Carlo; Perruccio, Anthony; Canizares, Mayilee; Rampersaud, Raja; El-Mughayyar, Dana; Bigney, Erin; Richardson, Eden; Manson, Neil; Abraham, Edward; Attabib, Najmedden; Small, Chris; Kolyvas, George; LeRoux, Andre; Outcomes, Canadian Spine; Investigators, Research Network; Hebert, Jeff; Baisamy, Victor; Rizkallah, Maroun; Shen, Jesse; Cresson, Thierry; Vazquez, Carlos; Wang, Zhi; Boubez, Ghassan; Lung, Tiffany; Canizares, Mayilee; Perruccio, Anthony; Rampersaud, Raja; Crawford, Eric J; Ravinsky, Robert A; Perruccio, Anthony V; Rampersaud, Y Raja; Coyte, Peter C; Bond, Michael; Street, John; Fisher, Charles; Charest-Morin, Raphaele; Sutherland, Jason M; Bartolozzi, Arthur R; Barzilai, Ori; Chou, Dean; Laufer, Ilya; Verlaan, Jorrit-Jan; Sahgal, Arjun; Rhines, Laurence D; Scuibba, Daniel M; Lazary, Aron; Weber, Michael H; Schuster, James M; Boriani, Stefano; Bettegowda, Chetan; Arnold, Paul M; Clarke, Michelle J; Fehlings, Michael G; Reynolds, Jeremy J; Gokaslan, Ziya L; Fisher, Charles G; Dea, Nicolas; Versteeg, Anne L; Charest-Morin, Raphaele; Laufer, Ilya; Teixeira, William; Barzilai, Ori; Gasbarrini, Alessandro; Fehlings, Michael G; Chou, Dean; Johnson, Michael G; Gokaslan, Ziya L; Dea, Nicolas; Verlaan, Jorrit-Jan; Goldschlager, Tony; Shin, John H; O'Toole, John E; Sciubba, Daniel M; Bettegowda, Chetan; Clarke, Michelle J; Weber, Michael H; Mesfin, Addisu; Kawahara, Norio; Goodwin, Rory; Disch, Alexander; Lazary, Aron; Boriani, Stefano; Sahgal, Arjun; Rhines, Laurence; Fisher, Charles G; Versteeg, Anne L; Gal, Roxanne; Reich, Leilani; Tsang, Angela; Aludino, Allan; Sahgal, Arjun; Verlaan, Jorrit-Jan; Fisher, Charles G; Verkooijen, Lenny; Rizkallah, Maroun; Wang, Zhi; Yuh, Sung-Joo; Shedid, Daniel; Shen, Jesse; Al-Shakfa, Fidaa; Belguendouz, Céline; AlKafi, Rayan; Boubez, Ghassan; MacLean, Mark A; Georgiopoulos, Miltiadis; Charest-Morin, Raphaele; Germscheid, Niccole; Goodwin, C Rory; Weber, Michael; International, Ao Spine; Rizkallah, Maroun; Boubez, Ghassan; Zhang, Hao; Al-Shakfa, Fidaa; Brindamour, Pamela; Boule, Danielle; Shen, Jesse; Shedid, Daniel; Yuh, Sung-Joo; Wang, Zhi; Correale, Marcia Rebecca; Soever, Leslie Jayne; Rampersaud, Raja; Malic, Claudia Cristina; Dubreuil, Melanie; Duke, Kate; Kingwell, Stephen P; Lin, Zihan; MacLean, Mark A; Julien, Lisa C; Patriquin, Glenn; LeBlanc, Jason; Green, Ryan; Alant, Jacob; Barry, Sean; Glennie, R Andrew; Oxney, William; Christie, Sean D; Sarraj, Mohamed; Alqahtani, Abdullah; Thornley, Patrick; Koziarz, Frank; Bailey, Christopher S; Freire-Archer, Millaray; Bhanot, Kunal; Kachur, Edward; Bhandari, Mohit; Oitment, Colby; Malhotra, Armaan K; Balas, Michael; Jaja, Blessing NR; Harrington, Erin M; Hofereiter, Johann; Jaffe, Rachael H; He, Yingshi; Byrne, James P; Wilson, Jefferson R; Witiw, Christopher D; Brittain, Kennedy CM; Christie, Sean; Pillai, Saranyan; Dvorak, Marcel F; Evaniew, Nathan; Chen, Melody; Waheed, Zeina; Rotem-Kohavi, Naama; Fallah, Nader; Noonan, Vanessa K; Fisher, Charles G; Charest-Morin, Raphaële; Dea, Nicolas; Ailon, Tamir; Street, John; Kwon, Brian K; Sandarage, Ryan V; Galuta, Ahmad; Ghinda, Diana; Kwan, Jason CS; TsaI, Eve C; Hachem, Laureen D; Hong, James; Velumian, Alexander; Mothe, Andrea J; Tator, Charles H; Fehlings, Michael G; Shakil, Husain; Jaja, Blessing NR; Zhang, Peng; Jaffe, Rachael; Malhotra, Armaan K; Wilson, Jefferson R; Witiw, Christopher D; Rotem-Kohavi, Naama; Dvorak, Marcel F; Dea, Nicolas; Evaniew, Nathan; Chen, Melody; Waheed, Zeina; Xu, Jijie; Fallah, Nader; Noonan, Vanessa; Kwon, Brian; Dandurand, Charlotte; Muijs, Sander; Dvorak, Marcel; Schnake, Klaus; Cumhur; Ouml Ner; Greene, Ryan; Furlong, Bradley; Smith-Forrester, Jenna; Swab, Michelle; Christie, Sean D; Hall, Amanda; Leck, Erika; Marshall, Emily; Christie, Sean; Dvorak, Marcel F; Cumhur, F; Ouml Ner; Vaccaro, Alexander R; Benneker, Lorin M; Rajasekaran, Shanmuganathan; El-Sharkawi, Mohammad; Popescu, Eugen Cezar; Tee, Jin Wee; Paquet, Jerome; France, John C; Allen, Richard; Lavelle, William F; Hirschfeld, Miguel; Pneumaticos, Spyros; Dandurand, Charlotte; Cumhur; Ouml Ner; Muijs, Sander; Schnake, Klaus; Dvorak, Marcel; Fernandes, Renan Rodrigues; Thornley, Patrick; Urquhart, Jennifer; Kelly, Sean; Alenezi, Nasser; Alahmari, Abdulmajeed; Siddiqi, Fawaz; Singh, Supriya; Rasoulinejad, Parham; Bailey, Christopher; Evaniew, Nathan; Burger, Lukas D; Dea, Nicolas; Cadotte, David W; McIntosh, Greg; Jacobs, Bradley; St-Laurent-Lebeux, Loïc; Bourassa-Moreau, Étienne; Sarraj, Mohamed; Majeed, Meerab; Guha, Daipayan; Pahuta, Markian; Laflamme, Mathieu; McIntosh, Greg; Dea, Nicolas; Bak, Alex B; Alvi, Mohammed A; Moghaddamjou, Ali; Fehlings, Michael G; Silva, Yan Gabriel Morais David; Goulet, Julien; McIntosh, Greg; Bedard, Sonia; Pimenta, Newton; Blanchard, Jocelyn; Couture, Jerome; LaRue, Bernard; Investigators, Csorn; Adams, Tyler; Cunningham, Erin; El-Mughayyar, Dana; Bigney, Erin; Vandewint, Amanda; Manson, Niel; Abraham, Edward; Small, Chris; Attabib, Najmedden; Richardson, Eden; Hebert, Jeffery; Bond, Michael; Street, John; Fisher, Charles; Charest-Morin, Raphaele; Sutherland, Jason M; Hillier, Troy; Bailey, Chris S; Fisher, Charles; Rampersaud, Raja; Koto, Prosper; Glennie, R Andrew; Soroceanu, Alex; Nicholls, Fred; Thomas, Ken; Evaniew, Nathan; Lewkonia, Peter; Bouchard, Jacques; Jacobs, Brad; Ben-Israel, David; Crawford, Eric J; Fisher, Charles; Dea, Nicolas; Spackman, Eldon; Rampersaud, Raja; Thomas, Kenneth C; Srikandarajah, Nisaharan; Murray, Jean-Christophe; Nielsen, Christopher; Manoharan, Ragavan; Cherry, Ahmed; Raj, Aditiya; Xu, Mark; Iorio, Carlo; Bailey, Chris; Dea, Nicolas; Fisher, Charles; Hall, Hamilton; Manson, Neil; Thomas, Kenneth; Canizares, Mayilee; Rampersaud, Yoga Raja; Urquhart, Jennifer; Fernandes, Renan R; Glennie, R Andrew; Rampersaud, Y Raja; Fisher, Charles G; Bailey, Chris; Yang, Michael MH; Far, Rena; Sajobi, Tolulope; Riva-Cambrin, Jay; Casha, Steven; Bond, Michael; Street, John; Fisher, Charles; Charest-Morin, Raphaele; Sutherland, Jason M; Silva, Yan; Pimenta, Newton Godoy; LaRue, Bernard; Bedard, Sonia; Oviedo, Sonia Cheng; Goulet, Julien; Couture, Jerome; Blanchard, Jocelyn; McDonald, James; Al-Jahdali, Fares; Urquhart, Jennifer; Alahmari, Abdulmajeed; Rampersaud, Raja; Fisher, Charles; Bailey, Chris; Glennie, Andrew; Evaniew, Nathan; Coyle, Matthew; Rampersaud, Y Raja; Bailey, Christopher S; Jacobs, W Bradley; Cadotte, David W; Thomas, Kenneth C; Attabib, Najmedden; Paquet, Jérôme; Nataraj, Andrew; Christie, Sean D; Weber, Michael H; Phan, Philippe; Charest-Morin, Raphaële; Fisher, Charles G; Hall, Hamilton; McIntosh, Greg; Dea, Nicolas; Malhotra, Armaan K; Davis, Aileen M; He, Yingshi; Harrington, Erin M; Jaja, Blessing NR; Zhu, Mary P; Shakil, Husain; Dea, Nicolas; Jacobs, W Bradley; Cadotte, David W; Paquet, Jérôme; Weber, Michael H; Phan, Philippe; Christie, Sean D; Nataraj, Andrew; Bailey, Christopher S; Johnson, Michael G; Fisher, Charles G; Manson, Neil; Rampersaud, Y Raja; Thomas, Kenneth C; Hall, Hamilton; Fehlings, Michael G; Ahn, Henry; Ginsberg, Howard J; Witiw, Christopher D; Wilson, Jefferson R; Althagafi, Alwalaa; McIntosh, Greg; Charest-Morin, Raphaële; Rizzuto, Michael A; Ailon, Tamir; Dea, Nicolas; Evaniew, Nathan; Jacobs, Bradley W; Paquet, Jerome; Rampersaud, Raja; Hall, Hamilton; Bailey, Christopher S; Weber, Michael; Johnson, Michael G; Nataraj, Andrew; Attabib, Najmedden; Cadotte, David W; Manson, Neil; Stratton, Alexandra; Christie, Sean D; Thomas, Kenneth C; Wilson, Jefferson R; Fisher, Charles G; Charest-Morin, Raphaele; Bak, Alex B; Alvi, Mohammed A; Moghaddamjou, Ali; Fehlings, Michael G; Bak, Alex B; Alvi, Mohammed A; Moghaddamjou, Ali; Fehlings, Michael G; Soroceanu, Alex; Nicholls, Fred; Thomas, Ken; Evaniew, Nathan; Salo, Paul; Bouchard, Jacques; Jacobs, Brad; Dandurand, Charlotte; Laghaei, Pedram Farimani; Ailon, Tamir; Charest-Morin, Raphaele; Dea, Nicolas; Dvorak, Marcel; Fisher, Charles; Kwon, Brian K; Paquette, Scott; Street, John; Soroceanu, Alex; Nicholls, Fred; Thomas, Ken; Evaniew, Nathan; Bouchard, Jacques; Salo, Paul; Jacobs, Brad; Varshney, Vishal P; Sahjpaul, Ramesh; Paquette, Scott; Osborn, Jill; Bak, Alex B; Moghaddamjou, Ali; Fehlings, Michael G; Leck, Erika; Marshall, Emily; Christie, Sean; Elkaim, Lior M; Lasry, Oliver J; Raj, Aditya; Murray, Jean-Christophe; Cherry, Ahmed; McIntosh, Greg; Nielsen, Christopher; Srikandarajah, Nisaharan; Manoharan, Ragavan; Iorio, Carlo; Xu, Mark; Perruccio, Anthony; Canizares, Mayilee; Rampersaud, Yoga Raja; Stratton, Alexandra; Tierney, Sarah; Wai, Eugene K; Phan, Philippe; Kingwell, Stephen; Magnan, Marie-Claude; Soroceanu, Alex; Nicholls, Fred; Thomas, Ken; Evaniew, Nathan; Salo, Paul; Bouchard, Jacques; Jacobs, Brad; Spanninga, Barend; Hoelen, Thomáy-Claire A; Johnson, Scott; Arts, Jacobus JC; Bailey, Chris S; Urquhart, Jennifer C; Glennie, R Andrew; Rampersaud, Y Raja; Fisher, Charles G; Levett, Jordan J; Elkaim, Lior M; Alotaibi, Naif M; Weber, Michael H; Dea, Nicolas; Abd-El-Barr, Muhammad M; Cherry, Ahmed; Yee, Albert; Jaber, Nadia; Fehlings, Michael; Cunningham, Erin; Adams, Tyler; El-Mughayyar, Dana; Bigney, Erin; Vandewint, Amanda; Manson, Neil; Abraham, Edward; Small, Chris; Attabib, Najmedden; Richardson, Eden; Hebert, Jeffery; Werier, Joel; Smit, Kevin; Villeneuve, James; Sachs, Adam; Abdelbary, Hesham; Al-Mosuli, Yusra Kassim; Rakhra, Kawan; Phan, Philippe; Nagata, Kosei; Gum, Jeffrey L; Brown, Morgan E; Daniels, Christy L; Carreon, Leah Y; Bonello, John-Peter; Koucheki, Robert; Abbas, Aazad; Lex, Johnathan; Nucci, Nicholas; Whyne, Cari; Larouche, Jeremie; Ahn, Henry; Finkelstein, Joel; Lewis, Stephen; Toor, Jay; Lee, Nathan J; Orosz, Lindsay D; Gum, Jeffrey L; Poulter, Gregory T; Jazini, Ehsan; Haines, Colin M; Good, Christopher R; Lehman, Ronald A; Crawford, Eric J; Ravinsky, Robert A; Perruccio, Anthony V; Coyte, Peter C; Rampersaud, Y Raja; Freire-Archer, Millaray; Sarraj, Mohamed; AlShaalan, Fawaz; Koziarz, Alex; Thornley, Patrick; Alnemari, Haitham; Oitment, Colby; Bharadwaj, Lalita; El-Mughayyar, Dana; Bigney, Erin; Manson, Neil; Abraham, Edward; Small, Chris; Attabib, Najmedden; Richardson, Eden; Kearney, Jill; Kundap, Uday; Investigators, Csorn; Hebert, Jeffrey; Elkaim, Lior M; Levett, Jordan J; Niazi, Farbod; Bokhari, Rakan; Alotaibi, Naif M; Lasry, Oliver J; Bissonnette, Vincent; Yen, David; Muddaluru, Varun S; Gandhi, Pranjan; Mastrolonardo, Alexander; Guha, Daipayan; Pahuta, Markian A; Christie, Sean D; Vandertuin, Trevor; Ritcey, Gillian; Rainham, Daniel; Alhawsawi, Mamdoh; Mumtaz, Rohail; Abdelnour, Mark; Qumquji, Feras; Soroceanu, Alex; Swamy, Ganesh; Thomas, Kenneth; Wai, Eugene; Phan, Philippe; Bhatt, Fenil R; Orosz, Lindsay D; Yamout, Tarek; Good, Christopher R; Schuler, Thomas C; Nguyen, Tiffany; Jazini, Ehsan; Haines, Colin M; Oppermann, Marcelo; Gupta, Shaurya; Ramjist, Joel; Oppermann, Priscila Santos; Yang, Victor XD; Levett, Jordan J; Elkaim, Lior M; Niazi, Farbod; Weber, Michael H; Ioro-Morin, Christian; Bonizzato, Marco; Weil, Alexander G; Oppermann, Marcelo; Ramjist, Joel; Gupta, Shaurya; Oppermann, Priscila S; Yang, Victor XD; Jung, Youngkyung; Muddalaru, Varun; Gandhi, Pranjan; Guha, Daipayan; Koucheki, Robert; Bonello, John-Peter; Abbas, Aazad; Lex, Johnathan R; Nucci, Nicholas; Whyne, Cari; Yee, Albert; Ahn, Henry; Finkelstein, Joel; Larouche, Jeremie; Lewis, Stephen; Toor, Jay; Dhawan, Alaina; Dhawan, Jillian; Sharma, Ajay N; Azzam, Daniel B; Cherry, Ahmed; Fehlings, Michael G; Orosz, Lindsay D; Lee, Nathan J; Yamout, Tarek; Gum, Jeffrey L; Lehman, Ronald A; Poulter, Gregory T; Haines, Colin M; Jazini, Ehsan; Good, Christopher R; Ridha, Barzany B; Persad, Amit; Fourney, Daryl; Byers, Elizabeth; Gallagher, Michelle; Sugar, James; Brown, Justin L; Wang, Zhi; Shen, Jesse; Boubez, Ghassan; Al-Shakfa, Fidaa; Yuh, Sung-Joo; Shedid, Daniel; Rizkallah, Maroun; Singh, Manmohan; Singh, Pankaj Kumar; Lawrence, Peyton Lloyd; Dell, Shevaughn; Goodluck-Tyndall, Ronette; Wade, Kevin; Morgan, Mark; Bruce, Carl; Silva, Yan Gabriel Morais David; Pimenta, Newton; LaRue, Bernard; Aldakhil, Salman; Blanchard, Jocelyn; Couture, Jerome; Goulet, Julien; Bednar, Drew A; Raj, Ruheksh; Urquhart, Jennifer; Bailey, Chris; Christie, Sean D; Greene, Ryan; Chaves, Jennyfer Paulla Galdino; Zarrabian, Mohammed; Sigurdson, Leif; Manoharan, Ragavan; Cherry, Ahmed; Iorio, Carlo; Srikandarajah, Nisaharan; Xu, Mark; Raj, Aditya; Nielsen, Christopher J; Rampersaud, Yoga Raja; Lewis, Stephen JItem Open Access Cell Saver for Adult Spinal Deformity Surgery Reduces Cost.(Spine deformity, 2017-07) Gum, Jeffrey L; Carreon, Leah Yacat; Kelly, Michael P; Hostin, Richard; Robinson, Chessie; Burton, Douglas C; Polly, David W; Shaffrey, Christopher I; LaFage, Virginie; Schwab, Frank J; Ames, Christopher P; Kim, Han Jo; Smith, Justin S; Bess, R Shay; International Spine Study GroupStudy design
Retrospective cohort.Objectives
To determine if the use of cell saver reduces overall blood costs in adult spinal deformity (ASD) surgery.Summary of background data
Recent studies have questioned the clinical value of cell saver during spine procedures.Methods
ASD patients enrolled in a prospective, multicenter surgical database who had complete preoperative and surgical data were identified. Patients were stratified into (1) cell saver available during surgery, but no intraoperative autologous infusion (No Infusion group), or (2) cell saver available and received autologous infusion (Infusion group).Results
There were 427 patients in the Infusion group and 153 in the No infusion group. Patients in both groups had similar demographics. Mean autologous infusion volume was 698 mL. The Infusion group had a higher percentage of EBL relative to the estimated blood volume (42.2%) than the No Infusion group (19.6%, p < .000). Allogeneic transfusion was more common in the Infusion group (255/427, 60%) than the No Infusion group (67/153, 44%, p = .001). The number of allogeneic blood units transfused was also higher in the Infusion group (2.4) than the No Infusion group (1.7, p = .009). Total blood costs ranged from $396 to $2,146 in the No Infusion group and from $1,262 to $5,088 in the Infusion group. If the cost of cell saver blood was transformed into costs of allogeneic blood, total blood costs for the Infusion group would range from $840 to $5,418. Thus, cell saver use yielded a mean cost savings ranging from $330 to $422 (allogeneic blood averted). Linear regression showed that after an EBL of 614 mL, cell saver becomes cost-efficient.Conclusion
Compared to transfusing allogeneic blood, cell saver autologous infusion did not reduce the proportion or the volume of allogeneic transfusion for patients undergoing surgery for adult spinal deformity. The use of cell saver becomes cost-efficient above an EBL of 614 mL, producing a cost savings of $330 to $422.Level of evidence
Level III.Item Open Access Comparison of Structural Disease Burden to Health-related Quality of Life Scores in 264 Adult Spinal Deformity Patients With 2-Year Follow-up: Novel Insights into Drivers of Disability.(Clinical spine surgery, 2017-03) Bakhsheshian, Joshua; Scheer, Justin K; Gum, Jeffrey L; Horner, Lance; Hostin, Richard; Lafage, Virginie; Bess, Shay; Protopsaltis, Themistocles S; Burton, Douglas C; Keefe, Malla; Hart, Robert A; Mundis, Gregory M; Shaffrey, Christopher I; Schwab, Frank; Smith, Justin S; Ames, Christopher P; International Spine Study Group (ISSG)Study design
This is a review of a prospective multicenter database.Objective
To investigate the relationship between preoperative disability and sagittal deformity in patients with high Oswestry Disability Index (ODI) and no sagittal malalignment, or low ODI and high sagittal malalignment.Summary of background data
The relationship between ODI and sagittal malalignment varies between each adult spinal deformity (ASD) patient.Methods
A prospective multicenter database of 365 patients with ASD undergoing surgical reconstruction was analyzed. Inclusion criteria entailed: age 18 years or above and the presence of spinal deformity as defined by a coronal Cobb angle≥20 degrees, sagittal vertical axis (SVA)≥5 cm, pelvic tilt (PT) angle≥25 degrees, or thoracic kyphosis≥60 degrees. Radiographic and health-related quality of life (HRQOL) variables were examined and compared, preoperatively and at 2-year postoperative follow-up. Group 1 (low disability high sagittal-LDHS) consisted of ODI<40 and SVA≥5 cm or PT≥25 degrees or pelvic incidence-lumbar lordosis≥11 degrees and group 2 (high disability low sagittal-HDLS) consisted of ODI>40 and SVA<5 cm and PT<25 degrees and pelvic incidence-lumbar lordosis<11 degrees.Results
Of 264 patients with follow-up, 58 (22.0%) patients were included in LDHS and 30 (11.4%) were included in HDLS. Both groups had similar demographics and preoperative coronal angles. HDLS had worse baseline HRQOL for all measures (P<0.05) except leg and back pain. HDLS had a higher rate of self-reported leg weakness, arthritis, depression and neurological disorder. Both groups had similar 2-year improvements in HRQOL (P>0.05), except only HDLS had a significant Scoliosis Research Society Mental improvement and a significantly higher rate of reaching minimal clinically important differences in Scoliosis Research Society Mental scores (P<0.05).Conclusions
There is an association of worse baseline HRQOL measures, weakness, arthritis, and mental disease in HDLS. Furthermore, HDLS patients demonstrated similar improvements to LDHS. However, HDLS had greater improvements in the mental domains, perhaps indicating the responsiveness of the mental disability to surgical treatment.Level of evidence
Level III.Item Open Access Contemporary utilization of three-column osteotomy techniques in a prospective complex spinal deformity multicenter database: implications on full-body alignment and perioperative course.(Spine deformity, 2024-06) Williamson, Tyler K; Mir, Jamshaid M; Smith, Justin S; Lafage, Virginie; Lafage, Renaud; Line, Breton; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey L; Hamilton, D Kojo; Scheer, Justin K; Eastlack, Robert; Demetriades, Andreas K; Kebaish, Khaled M; Lewis, Stephen; Lenke, Lawrence G; Hostin, Richard A; Gupta, Munish C; Kim, Han Jo; Ames, Christopher P; Burton, Douglas C; Shaffrey, Christopher I; Klineberg, Eric O; Bess, Shay; Passias, Peter G; International Spine Study GroupBackground
Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described.Study design/setting
This is a retrospective study on a prospectively enrolled, complex ASD database.Purpose
This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications.Methods
Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70 mm) or C7-PL > 70 mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO.Results
648 patients were included (Mean age 61 ± 14.6 years, BMI 27.55 ± 5.8 kg/m2, levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6-10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500 mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3-21; G4-24; G5-27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086).Conclusion
Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes.Item Open Access Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery.(Global Spine J, 2023-12-11) Passias, Peter G; Williamson, Tyler K; Kummer, Nicholas A; Pellisé, Ferran; Lafage, Virginie; Lafage, Renaud; Serra-Burriel, Miguel; Smith, Justin S; Line, Breton; Vira, Shaleen; Gum, Jeffrey L; Haddad, Sleiman; Sánchez Pérez-Grueso, Francisco Javier; Schoenfeld, Andrew J; Daniels, Alan H; Chou, Dean; Klineberg, Eric O; Gupta, Munish C; Kebaish, Khaled M; Kelly, Michael P; Hart, Robert A; Burton, Douglas C; Kleinstück, Frank; Obeid, Ibrahim; Shaffrey, Christopher I; Alanay, Ahmet; Ames, Christopher P; Schwab, Frank J; Hostin, Richard A; Bess, Shay; International Spine Study GroupSTUDY DESIGN/SETTING: Retrospective cohort study. OBJECTIVE: Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery. METHODS: ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility. RESULTS: By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001). CONCLUSIONS: The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions.Level of evidence: III.Item Open Access Cost-effectiveness of Surgical Treatment of Adult Spinal Deformity: Comparison of Posterior-only versus Antero-posterior Approach.(The spine journal : official journal of the North American Spine Society, 2020-04-11) Ogura, Yoji; Gum, Jeffrey L; Hostin, Richard A; Robinson, Chessie; Ames, Christopher P; Glassman, Steven D; Burton, Douglas C; Bess, R Shay; Shaffrey, Christopher I; Smith, Justin S; Yeramaneni, Samrat; Lafage, Virginie F; Protopsaltis, Themistocles; Passias, Peter G; Schwab, Frank J; Carreon, Leah Y; International Spine Study Group (ISSG)BACKGROUND CONTEXT:Considerable debate exists regarding the optimal surgical approach for adult spinal deformity (ASD). It remains unclear which approach, posterior-only or combined anterior-posterior (AP), is more cost-effective. Our goal is to determine the 2-year cost per quality-adjusted life year (QALY) for each approach. PURPOSE:To compare the 2-year cost-effectiveness of surgical treatment for ASD between the posterior-only approach and combined AP approach. STUDY DESIGN:Retrospective economic analysis of a prospective, multicenter database PATIENT SAMPLE: From a prospective, multicenter surgical database of ASD, patients undergoing 5 or more level fusions through a posterior-only or AP approach were identified and compared. METHODS:QALYs gained were determined using baseline, 1-year, and 2-year post-operative Short Form 6D. Cost was calculated from actual, direct hospital costs including any subsequent readmission or revision. Cost-effectiveness was determined using cost/QALY gained. RESULTS:The AP approach showed significantly higher index cost than the posterior-only approach ($84,329 vs $64,281). This margin decreased at 2-year follow-up with total costs of $89,824 and $73,904, respectively. QALYs gained at two years were similar with 0.21 and 0.17 in the posterior-only and the AP approaches, respectively. The cost/QALY at two years after surgery was significantly higher in the AP approach ($525,080) than in the posterior-only approach ($351,086). CONCLUSIONS:We assessed 2-year cost-effectiveness for the surgical treatment through posterior-only and AP approaches. The posterior-only approach is less expensive both for the index surgery and at 2-year follow-up. The QALY gained at 2-years was similar between the two approaches. Thus, posterior-only approach was more cost-effective than the AP approach under our study parameters. However, both approaches were not cost-effective at 2-year follow-up.Item Open Access Cost-Utility Analysis of rhBMP-2 Use in Adult Spinal Deformity Surgery.(Spine, 2020-07) Jain, Amit; Yeramaneni, Samrat; Kebaish, Khaled M; Raad, Micheal; Gum, Jeffrey L; Klineberg, Eric O; Hassanzadeh, Hamid; Kelly, Michael P; Passias, Peter G; Ames, Christopher P; Smith, Justin S; Shaffrey, Christopher I; Bess, Shay; Lafage, Virginie; Glassman, Steve; Carreon, Leah Y; Hostin, Richard A; International Spine Study GroupStudy design
Economic modeling of data from a multicenter, prospective registry.Objective
The aim of this study was to analyze the cost utility of recombinant human bone morphogenetic protein-2 (BMP) in adult spinal deformity (ASD) surgery.Summary of background data
ASD surgery is expensive and presents risk of major complications. BMP is frequently used off-label to reduce the risk of pseudarthrosis.Methods
Of 522 ASD patients with fusion of five or more spinal levels, 367 (70%) had at least 2-year follow-up. Total direct cost was calculated by adding direct costs of the index surgery and any subsequent reoperations or readmissions. Cumulative quality-adjusted life years (QALYs) gained were calculated from the change in preoperative to final follow-up SF-6D health utility score. A decision-analysis model comparing BMP versus no-BMP was developed with pseudarthrosis as the primary outcome. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates (Alpha = 0.05).Results
BMP was used in the index surgery for 267 patients (73%). The mean (±standard deviation) direct cost of BMP for the index surgery was $14,000 ± $6400. Forty patients (11%) underwent revision surgery for symptomatic pseudarthrosis (BMP group, 8.6%; no-BMP group, 17%; P = 0.022). The mean 2-year direct cost was significantly higher for patients with pseudarthrosis ($138,000 ± $17,000) than for patients without pseudarthrosis ($61,000 ± $25,000) (P < 0.001). Simulation analysis revealed that BMP was associated with positive incremental utility in 67% of patients and considered favorable at a willingness-to-pay threshold of $150,000/QALY in >52% of patients.Conclusion
BMP use was associated with reduction in revisions for symptomatic pseudarthrosis in ASD surgery. Cost-utility analysis suggests that BMP use may be favored in ASD surgery; however, this determination requires further research.Level of evidence
2.Item Open Access Defining a Surgical Invasiveness Threshold for Increased Risk of a Major Complication Following Adult Spinal Deformity Surgery.(Spine, 2021-07) Neuman, Brian J; Harris, Andrew B; Klineberg, Eric O; Hostin, Richard A; Protopsaltis, Themistocles S; Passias, Peter G; Gum, Jeffrey L; Hart, Robert A; Kelly, Michael P; Daniels, Alan H; Ames, Christopher P; Shaffrey, Christopher I; Kebaish, Khaled M; and the International Spine Study GroupStudy design
Retrospective review.Objectives
The aim of this study was to define a surgical invasiveness threshold that predicts major complications after adult spinal deformity (ASD) surgery; use this threshold to categorize patients into quartiles by invasiveness; and determine the odds of major complications by quartile.Summary of background data
Understanding the relationship between surgical invasiveness and major complications is important for estimating the likelihood of major complications after ASD surgery.Methods
Using a multicenter database, we identified 574 ASD patients (more than 5 levels fused; mean age, 60 ± 15 years) with minimum 2-year follow-up. Invasiveness was calculated as the ASD Surgical and Radiographic (ASD-SR) score. Youden index was used to identify the invasiveness score cut-off associated with optimal sensitivity and specificity for predicting major complications. Resulting high- and low-invasiveness groups were divided in half to create quartiles. Odds of developing a major complication were analyzed for each quartile using logistic regression (alpha = 0.05).Results
The ASD-SR cutoff score that maximally predicted major complications was 90 points. ASD-SR quartiles were 0 to 65 (Q1), 66 to 89 (Q2), 90 to 119 (Q3), and ≥120 (Q4). Risk of a major complication was 17% in Q1, 21% in Q2, 35% in Q3, and 33% in Q4 (P < 0.001). Comparisons of adjacent quartiles showed an increase in the odds of a major complication from Q2 to Q3 (odds ratio [OR] 1.8; 95% confidence interval [CI]: 1.0-3.0), but not from Q1 to Q2 or from Q3 to Q4. Patients with ASD-SR scores ≥90 were 1.9 times as likely to have a major complication than patients with scores <90 (OR 1.9, 95% CI 1.3-2.9). Mean ASD-SR scores above and below 90 points were 121 ± 25 and 63 ± 17, respectively.Conclusion
The odds of major complications after ASD surgery are significantly greater when the procedure has an ASD-SR score ≥90. ASD-SR score can be used to counsel patients regarding these increased odds.Level of Evidence: 3.Item Open Access Development and validation of risk stratification models for adult spinal deformity surgery.(Journal of neurosurgery. Spine, 2019-06) Pellisé, Ferran; Serra-Burriel, Miquel; Smith, Justin S; Haddad, Sleiman; Kelly, Michael P; Vila-Casademunt, Alba; Sánchez Pérez-Grueso, Francisco Javier; Bess, Shay; Gum, Jeffrey L; Burton, Douglas C; Acaroğlu, Emre; Kleinstück, Frank; Lafage, Virginie; Obeid, Ibrahim; Schwab, Frank; Shaffrey, Christopher I; Alanay, Ahmet; Ames, Christopher; International Spine Study Group; European Spine Study GroupOBJECTIVE:Adult spinal deformity (ASD) surgery has a high rate of major complications (MCs). Public information about adverse outcomes is currently limited to registry average estimates. The object of this study was to assess the incidence of adverse events after ASD surgery, and to develop and validate a prognostic tool for the time-to-event risk of MC, hospital readmission (RA), and unplanned reoperation (RO). METHODS:Two models per outcome, created with a random survival forest algorithm, were trained in an 80% random split and tested in the remaining 20%. Two independent prospective multicenter ASD databases, originating from the European continent and the United States, were queried, merged, and analyzed. ASD patients surgically treated by 57 surgeons at 23 sites in 5 countries in the period from 2008 to 2016 were included in the analysis. RESULTS:The final sample consisted of 1612 ASD patients: mean (standard deviation) age 56.7 (17.4) years, 76.6% women, 10.4 (4.3) fused vertebral levels, 55.1% of patients with pelvic fixation, 2047.9 observation-years. Kaplan-Meier estimates showed that 12.1% of patients had at least one MC at 10 days after surgery; 21.5%, at 90 days; and 36%, at 2 years. Discrimination, measured as the concordance statistic, was up to 71.7% (95% CI 68%-75%) in the development sample for the postoperative complications model. Surgical invasiveness, age, magnitude of deformity, and frailty were the strongest predictors of MCs. Individual cumulative risk estimates at 2 years ranged from 3.9% to 74.1% for MCs, from 3.17% to 44.2% for RAs, and from 2.67% to 51.9% for ROs. CONCLUSIONS:The creation of accurate prognostic models for the occurrence and timing of MCs, RAs, and ROs following ASD surgery is possible. The presented variability in patient risk profiles alongside the discrimination and calibration of the models highlights the potential benefits of obtaining time-to-event risk estimates for patients and clinicians.Item Open Access Development of Deployable Predictive Models for Minimal Clinically Important Difference Achievement Across the Commonly Used Health-related Quality of Life Instruments in Adult Spinal Deformity Surgery.(Spine, 2019-08) Ames, Christopher P; Smith, Justin S; Pellisé, Ferran; Kelly, Michael P; Gum, Jeffrey L; Alanay, Ahmet; Acaroğlu, Emre; Pérez-Grueso, Francisco Javier Sánchez; Kleinstück, Frank S; Obeid, Ibrahim; Vila-Casademunt, Alba; Burton, Douglas C; Lafage, Virginie; Schwab, Frank J; Shaffrey, Christopher I; Bess, Shay; Serra-Burriel, Miquel; European Spine Study Group, International Spine Study GroupStudy design
Retrospective analysis of prospectively-collected, multicenter adult spinal deformity (ASD) databases.Objective
To predict the likelihood of reaching minimum clinically important differences in patient-reported outcomes after ASD surgery.Summary of background data
ASD surgeries are costly procedures that do not always provide the desired benefit. In some series only 50% of patients achieve minimum clinically important differences in patient-reported outcomes (PROs). Predictive modeling may be useful in shared-decision making and surgical planning processes. The goal of this study was to model the probability of achieving minimum clinically important differences change in PROs at 1 and 2 years after surgery.Methods
Two prospective observational ASD cohorts were queried. Patients with Scoliosis Research Society-22, Oswestry Disability Index , and Short Form-36 data at preoperative baseline and at 1 and 2 years after surgery were included. Seventy-five variables were used in the training of the models including demographics, baseline PROs, and modifiable surgical parameters. Eight predictive algorithms were trained at four-time horizons: preoperative or postoperative baseline to 1 year and preoperative or postoperative baseline to 2 years. External validation was accomplished via an 80%/20% random split. Five-fold cross validation within the training sample was performed. Precision was measured as the mean average error (MAE) and R values.Results
Five hundred seventy patients were included in the analysis. Models with the lowest MAE were selected; R values ranged from 20% to 45% and MAE ranged from 8% to 15% depending upon the predicted outcome. Patients with worse preoperative baseline PROs achieved the greatest mean improvements. Surgeon and site were not important components of the models, explaining little variance in the predicted 1- and 2-year PROs.Conclusion
We present an accurate and consistent way of predicting the probability for achieving clinically relevant improvement after ASD surgery in the largest-to-date prospective operative multicenter cohort with 2-year follow-up. This study has significant clinical implications for shared decision making, surgical planning, and postoperative counseling.Level of evidence
4.Item Open Access Development of predictive models for all individual questions of SRS-22R after adult spinal deformity surgery: a step toward individualized medicine.(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, 2019-09) Ames, Christopher P; Smith, Justin S; Pellisé, Ferran; Kelly, Michael; Gum, Jeffrey L; Alanay, Ahmet; Acaroğlu, Emre; Pérez-Grueso, Francisco Javier Sánchez; Kleinstück, Frank S; Obeid, Ibrahim; Vila-Casademunt, Alba; Shaffrey, Christopher I; Burton, Douglas C; Lafage, Virginie; Schwab, Frank J; Shaffrey, Christopher I; Bess, Shay; Serra-Burriel, Miquel; European Spine Study Group; International Spine Study GroupPurpose
Health-related quality of life (HRQL) instruments are essential in value-driven health care, but patients often have more specific, personal priorities when seeking surgical care. The Scoliosis Research Society-22R (SRS-22R), an HRQL instrument for spinal deformity, provides summary scores spanning several health domains, but these may be difficult for patients to utilize in planning their specific care goals. Our objective was to create preoperative predictive models for responses to individual SRS-22R questions at 1 and 2 years after adult spinal deformity (ASD) surgery to facilitate precision surgical care.Methods
Two prospective observational cohorts were queried for ASD patients with SRS-22R data at baseline and 1 and 2 years after surgery. In total, 150 covariates were used in training machine learning models, including demographics, surgical data and perioperative complications. Validation was accomplished via an 80%/20% data split for training and testing, respectively. Goodness of fit was measured using area under receiver operating characteristic (AUROC) curves.Results
In total, 561 patients met inclusion criteria. The AUROC ranged from 56.5 to 86.9%, reflecting successful fits for most questions. SRS-22R questions regarding pain, disability and social and labor function were the most accurately predicted. Models were less sensitive to questions regarding general satisfaction, depression/anxiety and appearance.Conclusions
To the best of our knowledge, this is the first study to explicitly model the prediction of individual answers to the SRS-22R questionnaire at 1 and 2 years after deformity surgery. The ability to predict individual question responses may prove useful in preoperative counseling in the age of individualized medicine. These slides can be retrieved under Electronic Supplementary Material.Item Open Access Durability of Satisfactory Functional Outcomes Following Surgical Adult Spinal Deformity Correction: A 3-Year Survivorship Analysis.(Operative neurosurgery (Hagerstown, Md.), 2020-02) Passias, Peter G; Bortz, Cole A; Lafage, Virginie; Lafage, Renaud; Smith, Justin S; Line, Breton; Eastlack, Robert; Gupta, Munish C; Hostin, Richard A; Horn, Samantha R; Segreto, Frank A; Egers, Max; Sciubba, Daniel M; Gum, Jeffrey L; Kebaish, Khaled M; Klineberg, Eric O; Burton, Douglas C; Schwab, Frank J; Shaffrey, Christopher I; Ames, Christopher P; Bess, ShayBackground
Despite reports showing positive long-term functional outcomes following adult spinal deformity (ASD)-corrective surgery, it is unclear which factors affect the durability of these outcomes.Objective
To assess durability of functional gains following ASD-corrective surgery; determine predictors for postoperative loss of functionality.Methods
Surgical ASD patients > 18 yr with 3-yr Oswestry Disability Index (ODI) follow-up, and 1-yr postoperative (1Y) ODI scores reaching substantial clinical benefit (SCB) threshold (SCB < 31.3 points). Patients were grouped: those sustaining ODI at SCB threshold beyond 1Y (sustained functionality) and those not (functional decline). Kaplan-Meier survival analysis determined postoperative durability of functionality. Multivariate Cox regression assessed the relationship between patient/surgical factors and functional decline, accounting for age, sex, and levels fused.Results
All 166 included patients showed baseline to 1Y functional improvement (mean ODI: 35.3 ± 16.5-13.6 ± 9.2, P < .001). Durability of satisfactory functional outcomes following the 1Y postoperative interval was 88.6% at 2-yr postoperative, and 71.1% at 3-yr postoperative (3Y). Those sustaining functionality after 1Y had lower baseline C2-S1 sagittal vertical axis (SVA) and T1 slope (both P < .05), and lower 1Y thoracic kyphosis (P = .035). From 1Y to 3Y, patients who sustained functionality showed smaller changes in alignment: pelvic incidence minus lumbar lordosis, SVA, T1 slope minus cervical lordosis, and C2-C7 SVA (all P < .05). Those sustaining functionality beyond 1Y were also younger, less frail at 1Y, and had lower rates of baseline osteoporosis, hypertension, and lung disease (all P < .05). Lung disease (Hazard Ratio:4.8 [1.4-16.4]), 1Y frailty (HR:1.4 [1.1-1.9]), and posterior approach (HR:2.6 [1.2-5.8]) were associated with more rapid decline.Conclusion
Seventy-one percent of ASD patients maintained satisfactory functional outcomes by 3Y. Of those who failed to sustain functionality, the largest functional decline occurred 3-yr postoperatively. Frailty, preoperative comorbidities, and surgical approach affected durability of functional gains following surgery.Item Open Access Economic burden of nonoperative treatment of adult spinal deformity.(J Neurosurg Spine, 2023-12-01) Passias, Peter G; Ahmad, Waleed; Dave, Pooja; Lafage, Renaud; Lafage, Virginie; Mir, Jamshaid; Klineberg, Eric O; Kabeish, Khaled M; Gum, Jeffrey L; Line, Breton G; Hart, Robert; Burton, Douglas; Smith, Justin S; Ames, Christopher P; Shaffrey, Christopher I; Schwab, Frank; Hostin, Richard; Buell, Thomas; Hamilton, D Kojo; Bess, ShayOBJECTIVE: The purpose of this study was to investigate the cost utility of nonoperative treatment for adult spinal deformity (ASD). METHODS: Nonoperatively and operatively treated patients who met database criteria for ASD and in whom complete radiographic and health-related quality of life data at baseline and at 2 years were available were included. A cost analysis was completed on the PearlDiver database assessing the average cost of nonoperative treatment prior to surgical intervention based on previously published treatments (NSAIDs, narcotics, muscle relaxants, epidural steroid injections, physical therapy, and chiropractor). Utility data were calculated using the Oswestry Disability Index (ODI) converted to SF-6D with published conversion methods. Quality-adjusted life years (QALYs) used a 3% discount rate to account for residual decline in life expectancy (78.7 years). Minor and major comorbidities and complications were assessed according to the CMS.gov manual's definitions. Successful nonoperative treatment was defined as a gain in the minimum clinically importance difference (MCID) in both ODI and Scoliosis Research Society (SRS)-pain scores, and failure was defined as a loss in MCID or conversion to operative treatment. Patients with baseline ODI ≤ 20 and continued ODI of ≤ 20 at 2 years were considered nonoperative successful maintenance. The average utilization of nonoperative treatment and cost were applied to the ASD cohort. RESULTS: A total of 824 patients were included (mean age 58.24 years, 81% female, mean body mass index 27.2 kg/m2). Overall, 75.5% of patients were in the operative and 24.5% were in the nonoperative cohort. At baseline patients in the operative cohort were significantly older, had a greater body mass index, increased pelvic tilt, and increased pelvic incidence-lumbar lordosis mismatch (all p < 0.05). With respect to deformity, patients in the operative group had higher rates of severe (i.e., ++) sagittal deformity according to SRS-Schwab modifiers for pelvic tilt, sagittal vertical axis, and pelvic incidence-lumbar lordosis mismatch (p < 0.05). At 2 years, patients in the operative cohort showed significantly increased rates of a gain in MCID for physical component summary of SF-36, ODI, and SRS-activity, SRS-pain, SRS-appearance, and SRS-mental scores. Cost analysis showed the average cost of nonoperative treatment 2 years prior to surgical intervention to be $2041. Overall, at 2 years patients in the nonoperative cohort had again in ODI of 0.36, did not show a gain in QALYs, and nonoperative treatment was determined to be cost-ineffective. However, a subset of patients in this cohort underwent successful maintenance treatment and had a decrease in ODI of 1.1 and a gain in utility of 0.006 at 2 years. If utility gained for this cohort was sustained to full life expectancy, patients' cost per QALY was $18,934 compared to a cost per QALY gained of $70,690.79 for posterior-only and $48,273.49 for combined approach in patients in the operative cohort. CONCLUSIONS: Patients with ASD undergoing operative treatment at baseline had greater sagittal deformity and greater improvement in health-related quality of life postoperatively compared to patients treated nonoperatively. Additionally, patients in the nonoperative cohort overall had an increase in ODI and did not show improvement in utility gained. Patients in the nonoperative cohort who had low disability and sagittal deformity underwent successful maintenance and cost-effective treatment.