Browsing by Author "Kelly, MP"
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Item Open Access A comparative cohort study of surgical approaches for adult spinal deformity at a minimum 2-year follow-up(European Spine Journal, 2024-01-01) Kazarian, GS; Feuchtbaum, E; Bao, H; Soroceanu, A; Kelly, MP; Kebaish, KM; Shaffrey, CI; Burton, DC; Ames, CP; Mundis, GM; Bess, S; Klineberg, EO; Swamy, G; Schwab, FJ; Kim, HJStudy design: This study was a retrospective multi-center comparative cohort study. Materials and methods: A retrospective institutional database of operative adult spinal deformity patients was utilized. All fusions > 5 vertebral levels and including the sacrum/pelvis were eligible for inclusion. Revisions, 3 column osteotomies, and patients with < 2-year clinical follow-up were excluded. Patients were separated into 3 groups based on surgical approach: 1) posterior spinal fusion without interbody (PSF), 2) PSF with interbody (PSF-IB), and 3) anteroposterior (AP) fusion (anterior lumbar interbody fusion or lateral lumbar interbody fusion with posterior screw fixation). Intraoperative, radiographic, and clinical outcomes, as well as complications, were compared between groups with ANOVA and χ2 tests. Results: One-hundred and thirty-eight patients were included for study (PSF, n = 37; PSF-IB, n = 44; AP, n = 57). Intraoperatively, estimated blood loss was similar between groups (p = 0.171). However, the AP group had longer operative times (547.5 min) compared to PSF (385.1) and PSF-IB (370.7) (p < 0.001). Additionally, fusion length was shorter in PSF-IB (11.4) compared to AP (13.6) and PSF (12.9) (p = 0.004). There were no differences between the groups in terms of change in alignment from preoperative to 2 years postoperative. There were no differences in clinical outcomes. While postoperative complications were largely similar between groups, operative complications were higher in the AP group (31.6%) compared to the PSF (5.4%) and PSF-IB (9.1) groups (p < 0.001). Conclusion: While there were differences in intraoperative outcomes (operative time and fusion length), there were no differences in postoperative clinical or radiographic outcomes. AP fusion was associated with a higher rate of operative complications.Item Open Access Adult Spinal Deformity Surgeons Are Unable to Accurately Predict Postoperative Spinal Alignment Using Clinical Judgment Alone(Spine Deformity, 2016-07-01) Ailon, T; Scheer, JK; Lafage, V; Schwab, FJ; Klineberg, E; Sciubba, DM; Protopsaltis, TS; Zebala, L; Hostin, R; Obeid, I; Koski, T; Kelly, MP; Bess, S; Shaffrey, CI; Smith, JS; Ames, CPObject Adult spinal deformity (ASD) surgery seeks to reduce disability and improve quality of life through restoration of spinal alignment. In particular, correction of sagittal malalignment is correlated with patient outcome. Inadequate correction of sagittal deformity is not infrequent. The present study assessed surgeons' ability to accurately predict postoperative alignment. Methods Seventeen cases were presented with preoperative radiographic measurements, and a summary of the operation as performed by the treating physician. Surgeon training, practice characteristics, and use of surgical planning software was assessed. Participants predicted if the surgical plan would lead to adequate deformity correction and attempted to predict postoperative radiographic parameters including sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence to lumbar lordosis mismatch (PI-LL), thoracic kyphosis (TK). Results Seventeen surgeons participated: 71% within 0 to 10 years of practice; 88% devote >25% of their practice to deformity surgery. Surgeons accurately judged adequacy of the surgical plan to achieve correction to specific thresholds of SVA 69% ± 8%, PT 68% ± 9%, and PI-LL 68% ± 11% of the time. However, surgeons correctly predicted the actual postoperative radiographic parameters only 42% ± 6% of the time. They were more successful at predicting PT (61% ± 10%) than SVA (45% ± 8%), PI-LL (26% ± 11%), or TK change (35% ± 21%; p <.05). Improved performance correlated with greater focus on deformity but not number of years in practice or number of three-column osteotomies performed per year. Conclusion Surgeons failed to correctly predict the adequacy of the proposed surgical plan in approximately one third of presented cases. They were better at determining whether a surgical plan would achieve adequate correction than predicting specific postoperative alignment parameters. Pelvic tilt and SVA were predicted with the greatest accuracy.Item Open Access Clinically Significant Thromboembolic Disease in Adult Spinal Deformity Surgery: Incidence and Risk Factors in 737 Patients(Global Spine Journal, 2018-05-01) Kim, HJ; Iyer, S; Diebo, BG; Kelly, MP; Sciubba, D; Schwab, F; Lafage, V; Mundis, GM; Shaffrey, CI; Smith, JS; Hart, R; Burton, D; Bess, S; Klineberg, EOStudy Design: Retrospective cohort study. Objectives: Describe the rate and risk factors for venous thromboembolic events (VTEs; defined as deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in adult spinal deformity (ASD) surgery. Methods: ASD patients with VTE were identified in a prospective, multicenter database. Complications, revision, and mortality rate were examined. Patient demographics, operative details, and radiographic and clinical outcomes were compared with a non-VTE group. Multivariate binary regression model was used to identify predictors of VTE. Results: A total of 737 patients were identified, 32 (4.3%) had VTE (DVT = 14; PE = 18). At baseline, VTE patients were less likely to be employed in jobs requiring physical labor (59.4% vs 79.7%, P <.01) and more likely to have osteoporosis (29% vs 15.1%, P =.037) and liver disease (6.5% vs 1.4%, P =.027). Patients with VTE had a larger preoperative sagittal vertical axis (SVA; 93 mm vs 55 mm, P <.01) and underwent larger SVA corrections. VTE was associated with a combined anterior/posterior approach (45% vs 25%, P =.028). VTE patients had a longer hospital stay (10 vs 7 days, P <.05) and higher mortality rate (6.3% vs 0.7%, P <.01). Multivariate analysis demonstrated osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE (r2 =.11, area under the curve = 0.74, P <.05). Conclusions: The incidence of VTE in ASD is 4.3% with a DVT rate of 1.9% and PE rate of 2.4%. Osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE. Patients with VTE had a higher mortality rate compared with non-VTE patients.Item Open Access Intraoperative neuromonitoring has a poor correlation with postoperative neurological deficits in noncord level adult deformity surgery(Spine Journal, 2024-09-01) Sardar, Z; Swamy, G; Yoshida, G; Kelly, MP; Strantzas, S; Basu, S; Kwan, K; Smith, JS; Pellise, F; Gupta, MC; Jones, KE; Charalampidis, A; Rocos, B; Lewis, SJ; Lenke, LGBACKGROUND CONTEXT: Intraoperative neuromonitoring (IONM) is routinely used during spinal deformity surgery. While it is highly effective at detecting spinal cord level changes, the utility for surgery at a noncord level is less known. The purpose of this study is to evaluate rates of new neural deficits relative to IONM alerts in noncord-level spinal deformity surgery. PURPOSE: In noncord-level spinal deformity surgery, postop neural deficits are incompletely associated with IONM alerts. The purpose of this study was to assess the efficacy of neuromonitoring in detecting and preventing neurological deficits. STUDY DESIGN/SETTING: Prospective, international, multicenter cohort. PATIENT SAMPLE: A total of 197 adult patients undergoing spinal deformity surgery at a noncord level. OUTCOME MEASURES: IONM changes defined as loss of amplitude>50% in SSEP or MEP from baseline or sustained EMG activity lasting>10 seconds were recorded. Postoperative new neurological deficits were recorded. Other outcomes measured were baseline demographics, radiographic alignment parameters, events leading to and following IONM alerts. METHODS: Twenty international centers prospectively documented IONM (EMG, SSEP and MEP), demographics, radiographic findings, and surgical events of patients (10-80 years) undergoing spinal deformity surgery. Inclusion criteria: neurologically intact, spinal deformity correction with major Cobb>80° or involving any osteotomy. IONM change was defined as loss of amplitude>50% in SSEP or MEP from baseline or sustained EMG activity lasting>10 seconds. RESULTS: Of 197 patients, 22 (11.2%) had an IONM alert. More patients were undergoing revision surgery during an alert compared to those with no alert (40.9% vs 18.9%, p = 0.026). IONM alerts did not correlate with coronal cobb angle, deformity angular ratio, sagittal vertical axis, or coronal vertical axis. There were a total of 26 alerts in 22 patients - 4 patients (18.2%) had 2 IONM alerts, while the other 18 (81.8%) had 1 alert. MEPs were affected in 21 of 26 alerts (80.8%) and 15 (71.4%) of those were recovered. Isolated MEP changes were seen in 16 of 26 alerts (61.5%). SSEPs were affected in 8 of 26 alerts (30.8%). Isolated SSEP changes were seen in 3 (11.5%). Lastly, EMGs were affected in only 2 (7.7%) and were isolated. Five of 21 MEP alerts (23.8%) were bilateral, whereas 16 (76.2%) were unilateral. The most frequent event preceding an MEP change was an osteotomy in 6 (28.6%) of 21 patients. The most frequent nonsurgical event preceding an MEP alert was technical in 5 (23.8%), followed by systemic (low blood pressure/anemia) and anesthetic in 3 patients each (14.3%). Thirty-three of 197 patients (16.8%) developed a new postop neural deficit. Of these patients, 24 (72.7%) had no IONM alert. In the presence of an IONM alert 9 of 22 (40.9%) had a new neural deficit. IONM alert and development of new neural deficit had a crude negative predictive value (NPV) of 86.1%. CONCLUSIONS: In noncord-level spinal deformity surgery, IONM alerts occurred in 11.2% of patients, with osteotomy being the most frequent preceding surgical event. A new postop neural deficit was observed in 16.8% of all patients, and in 41% of patients with a IONM alert. A surprisingly high 73% of postop neural deficits occurred in patients who did not have an alert. This highlights the need for further refinement of IONM techniques and alert criteria for noncord-level surgery. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Quantifying the importance of upper cervical extension reserve in adult cervical deformity surgery and its impact on baseline presentation and outcomes(Spine Journal, 2024-09-01) Passias, PG; Mir, J; Smith, JS; Lafage, V; Lafage, R; Diebo, BG; Daniels, AH; Onafowokan, O; Line, B; Eastlack, RK; Mundis, GM; Kebaish, KM; Soroceanu, A; Scheer, JK; Kelly, MP; Protopsaltis, TS; Kim, HJ; Hostin, RA; Gupta, MC; Riew, KD; Burton, DC; Schwab, FJ; Bess, S; Shaffrey, CI; Ames, CPBACKGROUND CONTEXT: Hyperextension of the upper cervical spine is a prominent compensatory mechanism to maintain horizontal gaze and balance in adult cervical deformity (ACD) patients, akin to pelvic tilt in spinal deformity. The relaxation of ER and its impact on postoperative outcomes is not well understood. PURPOSE: To evaluate upper cervical ER impact on postoperative disability and outcomes. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Adult cervical deformity. OUTCOME MEASURES: ER, HRQLs. METHODS: ACD patients undergoing subaxial cervical fusion with 2Y data were included. Upper cervical extension reserve (ER) was defined as: C0-C2 sagittal Cobb angle between neutral and extension. Relaxation of ER was defined as the ER normative mean in those that met the ideal in all Passias ACD modifiers. Outcomes were defined as "good" if meeting ≥2 of the three: (1) NDI <20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Controlled analysis was conducted with ANCOVA and multivariable logistic regressions. Conditional inference tree (CIT) analysis determined thresholds. RESULTS: A total of 108 ACD patients met inclusion. (Age 61.4 ± 12.3, 61% F, BMI 29.4 ± 7.5 kg/m2, mCD-FI .24 ±.12, CCI 0.97 ± 1.30). Radiographic alignment is depicted in Table 1. Preoperative C0-C2 ER was 8.7 ±9.0 ±, and at the last follow-up was 10.3 ± 11.1. ER in those meeting all ideal CD modifiers at 2Y was 12.9 ± 9.0. Preoperatively 29% had adequate ER, while 59.7% had improvement in ER postoperatively, with 50% of patients achieving adequate ER at 2Y. Higher ER significantly correlated with lower cervical deformity (p<.05). Preoperatively, greater ER was predictive of lower preoperative disability, with worse baseline mobility, pain, and anxiety (EQ5D) (B = -6.1, -2.9, -2.9 respectively; R2 =0.212, p<.001). Improvement of ER depicted a higher rate of MCID for NDI (64% vs 39%, p=.008), and meeting good clinical outcomes (72% vs 54%, p=.04). Controlling for baseline deformity and demographic factors found resolution of inadequate ER to have 7x higher likelihood of meeting MCID for NDI (6.941 [1.378-34.961], p=.019) and 4x higher odds of achieving good outcomes (4.022 [1.017-15.900], p=.047). Isolating those with inadequate preoperative ER, found postoperative resolution having 5x odds of good outcomes (p<.05). In those with inadequate ER at baseline, the preoperative C2-C7 of <-18 and TS-CL of >59 for TS-CL was predictive of ER resolution (p<.05). In those with preoperative C2-C7 >-18, a T1PA of >13 was predictive of postoperative return of ER (p<.05). Independently TS-CL of >59, was significant for predicting ER return postoperatively, highlighting its compensatory role for proximal spinal deformities (all p<.05). Surgical correction of C2-C7 by >16 from baseline was found to be predictive of ER return. CONCLUSIONS: Increased preoperative utilization of the extension reserve in the upper cervical spine in cervical deformity was associated with worse baseline regional and global alignment while impacting health-related measures. The majority of patients had relaxation of extension reserve postoperatively, however, in those who didn't, there was a decreased likelihood of achieving good outcomes. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Rapid response during spinal deformity surgery can successfully save spinal cord function using intraoperative monitoring.(Spine Journal, 2024-09-01) Theologis, AA; Gupta, MC; Swamy, G; Yoshida, G; Kelly, MP; Strantzas, S; Basu, S; Kwan, K; Smith, JS; Pellise, F; Kato, S; Sardar, Z; Ames, CP; Jones, KE; Charalampidis, A; Rocos, B; Lenke, LG; Lewis, SJThis abstract contains content that is significantly similar to the authors' previously published abstract in the Global Spine Journal Rapid Fire. For access to the original publication, please visit the following DOI: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11086046/pdf/10.1177_21925682241239518.pdf.Item Open Access Three-dimensional evaluation of the dynamic interplay between pelvic anatomy, lower-limb compensation, and standing alignment in ASD(Spine Journal, 2024-09-01) Assi, A; Khalifé, M; Prince, G; Boutros, M; Karam, M; Ames, CP; Bess, S; Daniels, AH; Gupta, MC; Hostin, RA; Kelly, MP; Kim, HJ; Klineberg, EO; Lenke, LG; Nunley, PD; Passias, PG; Schwab, FJ; Shaffrey, CI; Smith, JS; Lafage, R; Diebo, BG; Lafage, VBACKGROUND CONTEXT: Previous studies have shown that lower limbs play a crucial role in compensating for sagittal spinal malalignment. However, these studies primarily focused on lower limb parameters in the sagittal plane, mainly knee flexion, leaving compensatory mechanisms that might happen in the coronal or axial planes unexplored. PURPOSE: This study aimed to investigate factors associated with lower-limb recruitment in adult spinal deformity (ASD) patients. STUDY DESIGN/SETTING: Retrospective study of prospectively collected data. PATIENT SAMPLE: ASD patients who underwent full-body biplanar X-rays and 3D reconstruction of lower limbs and pelvis. OUTCOME MEASURES: Association between morphological parameters and compensatory mechanisms METHODS: The study included ASD patients with moderate to severe sagittal plane deformities. Classic 2D parameters included pelvic shift (PSh), knee flexion (KA), sacro-femoral (SFA), and ankle dorsiflexion (AA) angles for the lower limbs, as well as TPA, PT, PI, and PI-LL mismatch. 3D reconstructions were used to assess acetabular parameters (abduction, coverage, and anteversion), pelvic depth (PD: distance between the pubic symphysis and the sacral endplate), and knee varus/valgus angle. After univariate analysis, multiple linear regressions were performed to investigate associations between spinal deformity and lower limb 2D/3D parameters with and without accounting for spinal alignment. RESULTS: A total of 146 subjects (67±10 years) were included with a mean PI-LL of 25.1±16.1°, TPA 37.4±10.6°, PT 27±9.1°, and PD of 85.9±16.2mm. Lower limbs compensation consisted of a PSh 38.4±43.7mm, KA 6.9±7.9°, and AA of 5.8±4.1°. Pelvic depth significantly correlated with PI (r=0.6, p<0.001), PT (r=0.3, p<0.001), and SFA (r=0.2, p=0.02). In multivariate analysis considering the full-body parameters, ankle dorsiflexion (AA) was associated with PT, PSh, and KA (all p<0.001) but not with spinal alignment and correlated with increased knee varus angulation (p=0.01). Similarly, KA correlated with PT, SFA, and AA (all p<0.001) but not with spinal alignment. Those associations remained significant in multivariate analysis considering only the lower-limbs parameters. In addition, patients with high pelvic depth (>100mm) had greater pelvic shift and PT than low ones (<70mm): 29.4+49.1mm versus 54.8±41.7mm and 23.7±9.3° versus 32.4±9.4°. Finally, increased PT was associated with higher PI (p<0.001) and more vertical acetabular abduction (57.4±3.9° for PT<15°, vs 60.7±4.2° for PT > 25°, p=0.009). CONCLUSIONS: There was 3D analysis of the lower extremities that revealed significant multiplanar interplay in the setting of spinal deformity. Pelvic morphology including antero-posterior depth is associated with greater compensatory abilities such as pelvic translation and retroversion. Greater PT compensation in the sagittal plane is associated with a more vertical acetabulum in the coronal plane. Knee and ankle flexion were indirectly correlated with spinal alignment as they contributed to higher PT and pelvic shift. Consequently, their assessment is valuable for understanding how patients compensate for malalignment but should not be a primary consideration in the correction strategy. The sagittal and coronal alignment of lower limbs cannot be separated, as an increase in ankle and knee flexion angles is associated with greater genu varum. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Who are super-utilizers in adult spine deformity surgery and how can surgeons identify them preoperatively?(Spine Journal, 2024-09-01) Nayak, P; Hostin, RA; Staub, BN; Gum, JL; Line, B; Bess, S; Lenke, LG; Lafage, R; Smith, JS; Mullin, JP; Kelly, MP; Diebo, BG; Buell, TJ; Scheer, JK; Lafage, V; Klineberg, EO; Kim, HJ; Passias, PG; Kebaish, KM; Eastlack, RK; Daniels, AH; Soroceanu, A; Mundis, GM; Protopsaltis, TS; Hamilton, DK; Gupta, MC; Schwab, FJ; Shaffrey, CI; Ames, CP; Burton, DCBACKGROUND CONTEXT: A relatively small percentage of patients are responsible for a disproportional amount of resource utilization in adult ASD surgery and contribute to significantly elevating the average cost across the surgically treated patients. These patients are called super-utilizers (SU). Modest reduction in the frequency of these super-utilization episodes has the potential to significantly improve the value of ASD surgery. PURPOSE: The goal of this study was to determine which, if any, baseline patient, radiographic, and/or surgical factors are the most important drivers of this disproportional increased resource utilization. We hypothesize that baseline patient factors predicts super-utilizers (SU) in adult spinal deformity surgery (ASD) more than surgical or deformity factors. STUDY DESIGN/SETTING: Retrospective Review of a prospective, multicenter registry. PATIENT SAMPLE: A total of 1299 index operative ASD patients eligible for 2-yr follow-up. OUTCOME MEASURES: Predictors of SU vs Non-SU in ASD. METHODS: A prospective multicenter consecutive series of ASD patients was reviewed. Inclusion criteria was diagnosis of ASD (scoliosis≥20°, C7-SVA≥5cm, PT≥25°, or TK≥60°), >4 level posterior fusion, and minimum 2-year follow-up. Index and total episode of care (EOC) cost in 2022 dollars were calculated using average itemized direct costs obtained from the administrative hospital records for all events in the inpatient EOC. Patients with total 2-year EOC cost greater than 90th percentile were considered SU. Multivariate generalized linear models were used to identify the most significant predictors of SU. RESULTS: A total of 1299 patients were eligible for 2-yr follow-up with mean age 60.0+14.1 years, 76% female, and 93% caucasians. SU patients are marginally older (+2.6 yrs; p=0.03), depressed (34.2% vs 25.8%; p=0.03) and tend to have higher propensity for fraility (p=0.003), comorbidities (0.01), reoperation rates (54.8% vs 17.0%; p<0.001), and LOS (+3 days; p<0.0001) compared to non-SU. While degree of sagittal deformity (Schwab sagittal modifiers, all p>0.05) and proportion of 3-column osteotomies (p>0.05) were similar between the groups, SU patients have higher surgical invasiveness score (+28; p<0.001), more vertebrae fused (+3; p<0.0001); more interbody fusions (80% vs 55%; p<0.0001), more BMP use (87.3% vs 69.4%; p=0.0002); longer OR time (+91 mins; p<0.0001), increased blood loss (+700 mL; p<0.0001), and longer length of stay (+3 days; p<0.0001). Index and EOC cost were 49% (p<0.0001) and 62% (p<0.0001) higher respectively in SU. While cost/QALY was 3-times higher in SU compared to non-SU. Multivariate analysis identified Schwab modifier SVA, surgical invasiveness, OR time, blood loss, BMP use, and LOS as strong predictors of SU (all p<0.01). CONCLUSIONS: Surgical invasiveness score greater than 118, being in OR for more than 7.6 hrs, blood loss more than 700 ml, utilizing BMP, and LOS more than 11 days were strong predictors of being a SU. Patients with SVA grade of + and ++ were less likely to be a SU compared to SVA grade 0. Procedural and resource utilization factors were strong predictors of being a SU compared to patient factors. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.