Browsing by Author "Hockley, Aaron"

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    ItemOpen Access
    Adult cervical spine deformity: a state-of-the-art review.
    (Spine Deform, 2023-09-30) Jackson-Fowl, Brendan; Hockley, Aaron; Naessig, Sara; Ahmad, Waleed; Pierce, Katherine; Smith, Justin S; Ames, Christopher; Shaffrey, Christopher; Bennett-Caso, Claudia; Williamson, Tyler K; McFarland, Kimberly; Passias, Peter G
    Adult cervical deformity is a structural malalignment of the cervical spine that may present with variety of significant symptomatology for patients. There are clear and substantial negative impacts of cervical spine deformity, including the increased burden of pain, limited mobility and functionality, and interference with patients' ability to work and perform everyday tasks. Primary cervical deformities develop as the result of a multitude of different etiologies, changing the normal mechanics and structure of the cervical region. In particular, degeneration of the cervical spine, inflammatory arthritides and neuromuscular changes are significant players in the development of disease. Additionally, cervical deformities, sometimes iatrogenically, may present secondary to malalignment or correction of the thoracic, lumbar or sacropelvic spine. Previously, classification systems were developed to help quantify disease burden and influence management of thoracic and lumbar spine deformities. Following up on these works and based on the relationship between the cervical and distal spine, Ames-ISSG developed a framework for a standardized tool for characterizing and quantifying cervical spine deformities. When surgical intervention is required to correct a cervical deformity, there are advantages and disadvantages to both anterior and posterior approaches. A stepwise approach may minimize the drawbacks of either an anterior or posterior approach alone, and patients should have a surgical plan tailored specifically to their cervical deformity based upon symptomatic and radiographic indications. This state-of-the-art review is based upon a comprehensive overview of literature seeking to highlight the normal cervical spine, etiologies of cervical deformity, current classification systems, and key surgical techniques.
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    ItemOpen Access
    Assessing the Economic Benefits of Enhanced Recovery After Surgery (ERAS) Protocols in Adult Cervical Deformity Patients: Is the Initial Additive Cost of Protocols Offset by Clinical Gains?
    (Clinical spine surgery, 2024-05) Tretiakov, Peter S; Onafowokan, Oluwatobi O; Lorentz, Nathan; Galetta, Matthew; Mir, Jamshaid M; Das, Ankita; Dave, Pooja; Yee, Timothy; Buell, Thomas J; Jankowski, Pawel P; Eastlack, Robert; Hockley, Aaron; Schoenfeld, Andrew J; Passias, Peter G

    Objective

    To assess the financial impact of Enhanced Recovery After Surgery (ERAS) protocols and cost-effectiveness in cervical deformity corrective surgery.

    Study design

    Retrospective review of prospective CD database.

    Background

    Enhanced Recovery After Surgery (ERAS) can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, the economic benefit of ERAS protocols, nor the heterogeneous components that make up such protocols, has not been established.

    Methods

    Operative CD patients ≥18 y with complete pre-(BL) and up to 2-year(2Y) postop radiographic/HRQL data were stratified by enrollment in Standard-of-Care ERAS beginning in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay scales. QALY was calculated using NDI mapped to SF6D using validated methodology with a 3% discount rate to account for a residual decline in life expectancy.

    Results

    In all, 127 patients were included (59.07±11.16 y, 54% female, 29.08±6.43 kg/m 2 ) in the analysis. Of these patients, 54 (20.0%) received the ERAS protocol. Per cost analysis, ERAS+ patients reported a lower mean total 2Y cost of 35049 USD compared with ERAS- patients at 37553 ( P <0.001). Furthermore, ERAS+ patients demonstrated lower cost of reoperation by 2Y ( P <0.001). Controlling for age, surgical invasiveness, and deformity per BL TS-CL, ERAS+ patients below 70 years old were significantly more likely to achieve a cost-effective outcome by 2Y compared with their ERAS- counterparts (OR: 1.011 [1.001-1.999, P =0.048].

    Conclusions

    Patients undergoing ERAS protocols experience improved cost-effectiveness and reduced total cost by 2Y post-operatively. Due to the potential economic benefit of ERAS for patients incorporation of ERAS into practice for eligible patients should be considered.
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    ItemOpen Access
    Cervical Versus Thoracolumbar Spinal Deformities: A Comparison of Baseline Quality-of-Life Burden.
    (Clinical spine surgery, 2018-12) Passias, Peter G; Poorman, Gregory W; Lafage, Virginie; Smith, Justin; Ames, Christopher; Schwab, Frank; Shaffrey, Chris; Segreto, Frank A; Horn, Samantha R; Bortz, Cole A; Varlotta, Christopher G; Hockley, Aaron; Wang, Charles; Daniels, Alan; Neuman, Brian; Hart, Robert; Burton, Douglas; Javidan, Yashar; Line, Breton; LaFage, Renaud; Bess, Shay; Sciubba, Daniel; ISSG

    Study design

    Retrospective analysis of 2 prospectively collected multicenter databases, one for cervical deformity (CD) and the other for general adult spinal deformity.

    Objective

    To investigate the relative quality-of-life and disability burden in patients with uncompensated cervical, thoracolumbar, or cervical and thoracolumbar deformities.

    Summary of background data

    The relative quality-of-life burden of cervical and thoracolumbar deformities have never been compared with each other. This may have significant implications when deciding on the appropriate treatment intervention for patients with combined thoracolumbar and cervical deformities.

    Methods

    When defining CD C2-C7 sagittal vertical axis (SVA)>4 cm was used while a C7-S1 SVA>5 cm was used to defined thoracolumbar deformity. Patients with both SVA criteria were defined as "combined." Primary analysis compared patients in the different groups by demographic, comorbidity data, and quality-of-life scores [EuroQOL 5 dimensions questionnaire (EQ-5D)] using t tests. Secondary analysis matched deformity groups with propensity scores matching based on baseline EQ-5D scores. Differences in disease-specific metrics [the Oswestry Disability Index, Neck Disability Index, modified Japanese Orthopaedic Association questionnaire (mJOA)] were analyzed using analysis of variance tests and post hoc analysis.

    Results

    In total, 212 patients were included in our analysis. Patients with CD only had less neurological deficits (mJOA: 14.6) and better EQ-5D (0.746) scores compared with patients with combined deformities (11.9, 0.716), all P<0.05. Regarding propensity score-matched deformity cohorts, 99 patients were matched with similar quality-of-life burden, 33 per deformity cohort. CD only patients had fewer comorbidities (1.03 vs. 2.12 vs. 2.70; P<0.001), whereas patients with combined deformity had more baseline neurological impairment compared with CD only patients (mJOA: 12.00 vs. 14.25; P=0.050).

    Conclusions

    Combined deformity patients were associated with the lowest quality-of-life and highest disability. Furthermore, regarding deformity cohorts matched by similar baseline quality-of-life status (EQ-5D), patients with combined deformities were associated with significantly worse neurological impairments. This finding implies that quality of life may not be a direct reflection of a patient's disability status, especially in patients with combined cervical and thoracolumbar deformities.

    Level of evidence

    Level III.
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    ItemOpen Access
    Impact of congestive heart failure on patients undergoing lumbar spine fusion for adult spine deformity.
    (Journal of craniovertebral junction & spine, 2024-01) Onafowokan, Oluwatobi O; Ahmad, Waleed; McFarland, Kimberly; Williamson, Tyler K; Tretiakov, Peter; Mir, Jamshaid M; Das, Ankita; Bell, Joshua; Naessig, Sara; Vira, Shaleen; Lafage, Virginie; Paulino, Carl; Diebo, Bassel; Schoenfeld, Andrew; Hassanzadeh, Hamid; Jankowski, Pawel P; Hockley, Aaron; Passias, Peter Gust

    Background

    With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks.

    Purpose

    The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients.

    Study design/setting

    This was a retrospective cohort study of the PearlDiver database.

    Patient sample

    We enrolled 670,526 patients undergoing spine fusion surgery.

    Outcome measures

    Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs.

    Methods

    Patients undergoing elective spine fusion surgery were isolated and stratified by preoperative HF with preserved ejection fraction (P-EF) or reduced ejection fraction (R-EF) (International Classification of Diseases-9: 428.32 [chronic diastolic HF] and 428.22 [chronic systolic HF]). Means comparison tests (Chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, comorbidities, procedural characteristics, LOS, 30-day and 90-day complication outcomes, and total hospital charges between those diagnosed with P-EF and those not R-EF. Binary logistic regression assessed the odds of complication associated with HF, controlling for levels fused (odds ratio [OR] [95% confidence interval]). Statistical significance was set at P < 0.05.

    Results

    Totally 670,526 elective spine fusion patients were included. Four thousand and seventy-seven were diagnosed with P-EF and 2758 R-EF. Overall, P-EF patients presented with higher rates of morbid obesity, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension (all P < 0.001). In relation to No-HF, P-EF patients had higher rates of 30-day major complications including pulmonary embolism, pneumonia, cerebrovascular accident (CVA), myocardial infarctions (MI), sepsis, and death (all P < 0.001). Furthermore, P-EF was associated significantly with increased odds of pneumonia (OR: 2.07 [1.64-2.56], P < 0.001) and sepsis (OR: 2.09 [1.62-2.66], P < 0.001). Relative to No-HF, R-EF was associated with significantly higher odds of MI (OR: 3.66 [2.34-5.47]), CVA (OR: 2.70 [1.67-4.15]), and pneumonia (OR: 1.85 [1.40-2.40]) (all P < 0.001) postoperative within 30 days. Adjusting for prior history of MI, CAD, and the presence of a pacemaker R-EF was a significant predictor of an MI 30 days postoperatively (OR: 2.2 [1.14-4.32], P = 0.021). Further adjusting for history of CABG or stent placement, R-EF was associated with higher odds of CVA (OR: 2.11 [1.09-4.19], P = 0.028) and MI (OR: 2.27 [1.20-4.43], P = 0.013).

    Conclusions

    When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF.
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    ItemOpen Access
    The Evolution of Enhanced Recovery After Surgery: Assessing the Clinical Benefits of Developments Within Enhanced Recovery After Surgery Protocols in Adult Cervical Deformity Surgery.
    (Clinical spine surgery, 2024-05) Passias, Peter G; Tretiakov, Peter S; Onafowokan, Oluwatobi O; Galetta, Matthew; Lorentz, Nathan; Mir, Jamshaid M; Das, Ankita; Dave, Pooja; Lafage, Renaud; Yee, Timothy; Diebo, Bassel; Vira, Shaleen; Jankowski, Pawel P; Hockley, Aaron; Daniels, Alan; Schoenfeld, Andrew J; Mummaneni, Praveen; Paulino, Carl B; Lafage, Virginie

    Study design

    Retrospective cohort.

    Objective

    To investigate the impact of evolving Enhanced Recovery After Surgery (ERAS) protocols on outcomes after cervical deformity (CD) surgery.

    Background

    ERAS can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, there remains a paucity of literature assessing how developments have impacted outcomes after adult CD surgery.

    Methods

    Patients with operative CD 18 years or older with pre-baseline and 2 years (2Y) postoperative data, who underwent ERAS protocols, were stratified by increasing implantation of ERAS components: (1) early (multimodal pain program), (2) intermediate (early protocol + paraspinal blocks, early ambulation), and (3) late (early/intermediate protocols + comprehensive prehabilitation). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through Bonferroni-adjusted means comparison analysis.

    Results

    A total of 131 patients were included (59.4 ± 11.7 y, 45% females, 28.8 ± 6.0 kg/m 2 ). Of these patients, 38.9% were considered "early," 36.6% were "intermediate," and 24.4% were "late." Perioperatively, rates of intraoperative complications were lower in the late group ( P = 0.036). Postoperatively, discharge disposition differed significantly between cohorts, with late patients more likely to be discharged to home versus early or intermediate cohorts [χ 2 (2) = 37.973, P < 0.001]. In terms of postoperative disability recovery, intermediate and late patients demonstrated incrementally improved 6 W modified Japanese Orthopedic Association scores ( P = 0.004), and late patients maintained significantly higher mean Euro-QOL 5-Dimension Questionnaire and modified Japanese Orthopedic Association scores by 1 year ( P < 0.001, P = 0.026). By 2Y, cohorts demonstrated incrementally increasing SWAL-QOL scores (all domains P < 0.028) domain scores versus early or intermediate cohorts. By 2Y, incrementally decreasing reoperation was observed in early versus intermediate versus late cohorts ( P = 0.034).

    Conclusions

    The present study demonstrates that patients enrolled in an evolving ERAS program demonstrate incremental improvement in preoperative optimization and candidate selection, greater likelihood of discharge to home, decreased postoperative disability and dysphasia burden, and decreased likelihood of intraoperative complications and reoperation rates.
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    ItemOpen Access
    The Impact of Peri-operative Enhanced Recovery After Surgery Protocols on Outcomes Following Adult Cervical Deformity Surgery.
    (Global spine journal, 2024-04) Tretiakov, Peter S; Onafowokan, Oluwatobi O; Mir, Jamshaid M; Lorentz, Nathan; Galetta, Matthew; Das, Ankita; Shin, John; Sciubba, Daniel; Krol, Oscar; Joujon-Roche, Rachel; Williamson, Tyler; Imbo, Bailey; Yee, Timothy; Jankowski, Pawel P; Hockley, Aaron; Schoenfeld, Andrew J; Passias, Peter G

    Study design

    Retrospective cohort study.

    Objectives

    To assess the impact of Enhanced recovery after surgery (ERAS) protocols on peri-operative course in adult cervical deformity (ACD) corrective surgery.

    Methods

    Patients ≥18 yrs with complete pre-(BL) and up to 2-year (2Y) radiographic and clinical outcome data were stratified by enrollment in an ERAS protocol that commenced in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, peri-operative factors and complication rates were assessed via means comparison analysis. Logistic regression analysed differences while controlling for baseline disability and deformity.

    Results

    We included 220 patients (average age 58.1 ± 11.9 years, 48% female). 20% were treated using the ERAS protocol (ERAS+). Disability was similar between both groups at baseline. When controlling for baseline disability and myelopathy, ERAS- patients were more likely to utilize opioids than ERAS+ (OR 1.79, 95% CI: 1.45-2.50, P = .016). Peri-operatively, ERAS+ had significantly lower operative time (P < .021), lower EBL (583.48 vs 246.51, P < .001), and required significantly lower doses of propofol intra-operatively than ERAS- patients (P = .020). ERAS+ patients also reported lower mean LOS overall (4.33 vs 5.84, P = .393), and were more likely to be discharged directly to home (χ2(1) = 4.974, P = .028). ERAS+ patients were less likely to require steroids after surgery (P = .045), were less likely to develop neuromuscular complications overall (P = .025), and less likely experience venous complications or be diagnosed with venous disease post-operatively (P = .025).

    Conclusions

    Enhanced recovery after surgery programs in ACD surgery demonstrate significant benefit in terms of peri-operative outcomes for patients.