Browsing by Author "Klineberg, Eric O"
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Item Open Access 1-Year Post-Operative Radiographic and Patient-Reported Outcomes following Cervical Deformity Correction are not Affected by a Short-Term Unplanned Return to the OR.(Spine, 2023-02) Fourman, Mitchell S; Lafage, Renaud; Ames, Christopher; Smith, Justin S; Passias, Peter G; Shaffrey, Christopher I; Mundis, Gregory; Protopsaltis, Themistocles; Gupta, Munish; Klineberg, Eric O; Bess, Shay; Lafage, Virginie; Kim, Han Jo; International Spine Study GroupStudy design
Retrospective analysis of a prospectively-collected multi-center database.Objective
Assess the radiographic and health-related quality of life (HRQoL) impact of a short term (<1 y) return to the OR after adult cervical spine deformity (ACSD) surgery.Summary of background data
Returns to the OR within a year of ACSD correction can be particularly devastating to these vulnerable hosts as they often involve compromise of the soft tissue envelope, neurologic deficits or hardware failure. This work sought to assess the impact of a short-term reoperation on 1-year radiographic and HRQoL outcomes.Methods
Patients operated on from 1/1/2013 to 1/1/2019 with at least 1-year of follow-up were included. The primary outcome was a short-term return to the OR. Variables of interest included patient demographics, Charlson Comorbidity Index (CCI), HRQoL measured with the Modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI) and EuroQuol-5D visual analogue scale (EQ-5D VAS) and radiographic outcomes, including T1-slope (TS), C2-C7 sagittal cobb angle (CL), TS-CL and cervical sagittal vertical axis (cSVA). Comparisons between those who did versus did not require a 1-year reoperation were performed using paired t-tests. A Kaplan Meier survival curve was used to estimate reoperation-free survival up to 2-years post-operatively.Results
A total of 121 patients were included in this work (age 61.9±10.1 y, BMI 28.4±6.9, CCI 1.0±1.4, 62.8% female). A 1-year unplanned return to the OR was required for 28 (23.1%) patients, of whom 19 followed-up for at least 1-year. Indications for a return to the OR were most commonly for neurologic complications (5%), infectious/wound complications (5.8%) and junctional failure (6.6%) No differences in demographics, comorbidities, pre-operative or 1-year post-operative HRQoL or radiographic outcomes were seen between operative groups.Conclusion
Reoperation <1 year after ACSD surgery did not influence 1-year radiographic outcomes or HRQoL.Item Open Access Adult Spinal Deformity Patients Recall Fewer Than 50% of the Risks Discussed in the Informed Consent Process Preoperatively and the Recall Rate Worsens Significantly in the Postoperative Period.(Spine, 2015-07) Saigal, Rajiv; Clark, Aaron J; Scheer, Justin K; Smith, Justin S; Bess, Shay; Mummaneni, Praveen V; McCarthy, Ian M; Hart, Robert A; Kebaish, Khaled M; Klineberg, Eric O; Deviren, Vedat; Schwab, Frank; Shaffrey, Christopher I; Ames, Christopher PStudy design
Recall of the informed consent process in patients undergoing adult spinal deformity surgery and their family members was investigated prospectively.Objective
To quantify the percentage recall of the most common complications discussed during the informed consent process in adult spinal deformity surgery, assess for differences between patients and family members, and correlate with mental status.Summary of background data
Given high rates of complications in adult spinal deformity surgery, it is critical to shared decision making that patients are adequately informed about risks and are able to recall preoperative discussion of possible complications to mitigate medical legal risk.Methods
Patients undergoing adult spinal deformity surgery underwent an augmented informed consent process involving both verbal and video explanations. Recall of the 11 most common complications was scored. Mental status was assessed with the mini-mental status examination-brief version. Patients subjectively scored the informed consent process and video. After surgery, the recall test and mini-mental status examination-brief version were readministered at 5 additional time points: hospital discharge, 6 to 8 weeks, 3 months, 6 months, and 1 year postoperatively. Family members were assessed at the first 3 time points for comparison.Results
Fifty-six patients enrolled. Despite ranking the consent process as important (median overall score: 10/10; video score: 9/10), median patient recall was only 45% immediately after discussion and video re-enforcement and subsequently declined to 18% at 6 to 8 weeks and 1 year postoperatively. Median family recall trended higher at 55% immediately and 36% at 6 to 8 weeks postoperatively. The perception of the severity of complications significantly differs between patient and surgeon. Mental status scores showed a transient, significant decrease from preoperation to discharge but were significantly higher at 1 year.Conclusion
Despite being well-informed in an optimized informed consent process, patients cannot recall most surgical risks discussed and recall declines over time. Significant progress remains to improve informed consent retention.Level of evidence
3.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 Alignment Targets, Curve Proportion and Mechanical Loading: Preliminary Analysis of an Ideal Shape Toward Reducing Proximal Junctional Kyphosis.(Global spine journal, 2022-07) Katsuura, Yoshihiro; Lafage, Renaud; Kim, Han Jo; Smith, Justin S; Line, Breton; Shaffrey, Christopher; Burton, Douglas C; Ames, Christopher P; Mundis, Gregory M; Hostin, Richard; Bess, Shay; Klineberg, Eric O; Passias, Peter G; Lafage, Virginie; International Spine Study Group (ISSG)Study design
Retrospective cohort study.Objective
Investigate risk factors for PJK including theoretical kyphosis, mechanical loading at the UIV and age adjusted offset alignment.Methods
373 ASD patients (62.7 yrs ± 9.9; 81%F) with 2-year follow up and UIV of at least L1 and LIV of sacrum were included. Images of patients without PJK, with PJK and with PJF were compared using standard spinopelvic parameters before and after the application of the validated virtual alignment method which corrects for the compensatory mechanisms of PJK. Age-adjusted offset, theoretical thoracic kyphosis and mechanical loading at the UIV were then calculated and compared between groups. A subanalysis was performed based on the location of the UIV (upper thoracic (UT) vs. Lower thoracic (LT)).Results
At 2-years 172 (46.1%) had PJK, and 21 (5.6%) developed PJF. As PJK severity increased, the post-operative global alignment became more posterior secondary to increased over-correction of PT, PI-LL, and SVA (all P < 0.005). Also, a larger under correction of the theoretical TK (flattening) and a smaller bending moment at the UIV (underloading of UIV) was found. Multivariate analysis demonstrated that PI-LL and bending moment offsets from normative values were independent predictors of PJK/PJF in UT group; PT and bending moment difference were independent predictors for LT group.Conclusions
Spinopelvic over correction, under correction of TK (flattening), and under loading of the UIV (decreased bending moment) were associated with PJK and PJF. These differences are often missed when compensation for PJK is not accounted for in post-operative radiographs.Item Open Access Appropriate Risk Stratification and Accounting for Age-Adjusted Reciprocal Changes in the Thoracolumbar Spine Reduces the Incidence and Magnitude of Distal Junctional Kyphosis in Cervical Deformity Surgery.(Spine, 2021-11) Passias, Peter G; Bortz, Cole; Pierce, Katherine E; Kummer, Nicholas A; Lafage, Renaud; Diebo, Bassel G; Line, Breton G; Lafage, Virginie; Burton, Douglas C; Klineberg, Eric O; Kim, Han Jo; Daniels, Alan H; Mundis, Gregory M; Protopsaltis, Themistocles S; Eastlack, Robert K; Sciubba, Daniel M; Bess, Shay; Schwab, Frank J; Shaffrey, Christopher I; Smith, Justin S; Ames, Christopher P; International Spine Study Group (ISSG)Study design
Retrospective cohort study of a prospective cervical deformity (CD) database.Objective
Identify factors associated with distal junctional kyphosis (DJK); assess differences across DJK types.Summary of background data
DJK may develop as compensation for mal-correction of sagittal deformity in the thoracic curve. There is limited understanding of DJK drivers, especially for different DJK types.Methods
Included: patients with pre- and postoperative clinical/radiographic data. Excluded: patients with previous fusion to L5 or below. DJK was defined per surgeon note or DJK angle (kyphosis from LIV to LIV-2)<-10°, and pre- to postoperative change in DJK angle by<-10°. Age-specific target LL-TK alignment was calculated as published. Offset from target LL-TK was correlated to DJK magnitude and inclination. DJK types: severe (DJK<-20°), progressive (DJK increase>4.4°), symptomatic (reoperation or published disability thresholds of NDI ≥ 24 or mJOA≤14). Random forest identified factors associated with DJK. Means comparison tests assessed differences.Results
Included: 136 CD patients (61 ± 10 yr, 61%F). DJK rate was 30%. Postop offset from ideal LL-TK correlated with greater DJK angle (r = 0.428) and inclination of the distal end of the fusion construct (r = 0.244, both P < 0.02). Seven of the top 15 factors associated with DJK were radiographic, four surgical, and four clinical. Breakdown by type: severe (22%), progressive (24%), symptomatic (61%). Symptomatic had more posterior osteotomies than asymptomatic (P = 0.018). Severe had worse NDI and upper-cervical deformity (CL, C2 slope, C0-C2), as well as more posterior osteotomies than nonsevere (all P < 0.01). Progressive had greater malalignment both globally and in the cervical spine (all P < 0.03) than static. Each type had varying associated factors.Conclusion
Offset from age-specific alignment is associated with greater DJK and more anterior distal construct inclination, suggesting DJK may develop due to inappropriate realignment. Preoperative clinical and radiographic factors are associated with symptomatic and progressive DJK, suggesting the need for preoperative risk stratification.Level of Evidence: 3.Item Open Access Are insufficient corrections a major factor in distal junctional kyphosis? A simulated analysis of cervical deformity correction using in-construct measurements.(Journal of neurosurgery. Spine, 2024-05) Ani, Fares; Sissman, Ethan; Woo, Dainn; Soroceanu, Alex; Mundis, Gregory; Eastlack, Robert K; Smith, Justin S; Hamilton, D Kojo; Kim, Han Jo; Daniels, Alan H; Klineberg, Eric O; Neuman, Brian; Sciubba, Daniel M; Gupta, Munish C; Kebaish, Khaled M; Passias, Peter G; Hart, Robert A; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Ames, Christopher P; Protopsaltis, Themistocles SObjective
The present study utilized recently developed in-construct measurements in simulations of cervical deformity surgery in order to assess undercorrection and predict distal junctional kyphosis (DJK).Methods
A retrospective review of a database of operative cervical deformity patients was analyzed for severe DJK and mild DJK. C2-lower instrumented vertebra (LIV) sagittal angle (SA) was measured postoperatively, and the correction was simulated in the preoperative radiograph in order to match the C2-LIV by using the planning software. Linear regression analysis that used C2 pelvic angle (CPA) and pelvic tilt (PT) determined the simulated PT that matched the virtual CPA. Linear regression analysis was used to determine the C2-T1 SA, C2-T4 SA, and C2-T10 SA that corresponded to DJK of 20° and cervical sagittal vertical axis (cSVA) of 40 mm.Results
Sixty-nine cervical deformity patients were included. Severe and mild DJK occurred in 11 (16%) and 22 (32%) patients, respectively; 3 (4%) required DJK revision. Simulated corrections demonstrated that severe and mild DJK patients had worse alignment compared to non-DJK patients in terms of cSVA (42.5 mm vs 33.0 mm vs 23.4 mm, p < 0.001) and C2-LIV SVA (68.9 mm vs 57.3 mm vs 36.8 mm, p < 0.001). Linear regression revealed the relationships between in-construct measures (C2-T1 SA, C2-T4 SA, and C2-T10 SA), cSVA, and change in DJK (all R > 0.57, p < 0.001). A cSVA of 40 mm corresponded to C2-T4 SA of 10.4° and C2-T10 SA of 28.0°. A DJK angle change of 10° corresponded to C2-T4 SA of 5.8° and C2-T10 SA of 20.1°.Conclusions
Simulated cervical deformity corrections demonstrated that severe DJK patients have insufficient corrections compared to patients without DJK. In-construct measures assess sagittal alignment within the fusion separate from DJK and subjacent compensation. They can be useful as intraoperative tools to gauge the adequacy of cervical deformity correction.Item Open Access Are 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 Are we improving in the optimization of surgery for high-risk adult cervical spine deformity patients over time?(Journal of neurosurgery. Spine, 2023-07) Passias, Peter G; Tretiakov, Peter S; Smith, Justin S; Lafage, Renaud; Diebo, Bassel; Scheer, Justin K; Eastlack, Robert K; Daniels, Alan H; Klineberg, Eric O; Khabeish, Khaled M; Mundis, Gregory M; Turner, Jay D; Gupta, Munish C; Kim, Han Jo; Schwab, Frank; Bess, Shay; Lafage, Virginie; Ames, Christopher P; Shaffrey, Christopher IObjective
The aim of this study was to investigate whether surgery for high-risk patients is being optimized over time and if poor outcomes are being minimized.Methods
Patients who underwent surgery for cervical deformity (CD) and were ≥ 18 years with baseline and 2-year data were stratified by year of surgery from 2013 to 2018. The cohort was divided into two groups based on when the surgery was performed. Patients in the early cohort underwent surgery between 2013 and 2015 and those in the recent cohort underwent surgery between 2016 and 2018. High-risk patients met at least 2 of the following criteria: 1) baseline C2-7 Cobb angle > 15°, mismatch between T1 slope and cervical lordosis ≥ 35°, C2-7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°; 2) age ≥ 70 years; 3) severe baseline frailty (Miller index); 4) Charlson Comorbidity Index (CCI) ≥ 1 SD above the mean; 5) three-column osteotomy as treatment; and 6) fusion > 10 levels or > 7 levels for elderly patients. The mean comparison analysis assessed differences between groups. Stepwise multivariable linear regression described associations between increasing year of surgery and complications.Results
Eighty-two CD patients met high-risk criteria (mean age 62.11 ± 10.87 years, 63.7% female, mean BMI 29.70 ± 8.16 kg/m2, and mean CCI 1.07 ± 1.45). The proportion of high-risk patients increased with time, with 41.8% of patients in the early cohort classified as high risk compared with 47.6% of patients in the recent cohort (p > 0.05). Recent high-risk patients were more likely to be female (p = 0.008), have a lower BMI (p = 0.038), and have a higher baseline CCI (p = 0.013). Surgically, high-risk patients in the recent cohort were more likely to undergo low-grade osteotomy (p = 0.003). By postoperative complications, recent high-risk patients were less likely to experience any postoperative adverse events overall (p = 0.020) or complications such as dysphagia (p = 0.045) at 2 years. Regression analysis revealed increasing year of surgery to be correlated with decreasing minor complication rates (p = 0.030), as well as lowered rates of distal junctional kyphosis by 2 years (p = 0.048).Conclusions
Over time, high-risk CD patients have an increase in frequency and comorbidity rates but have demonstrated improved postoperative outcomes. These findings suggest that spine surgeons have improved over time in optimizing selection and reducing potential adverse events in high-risk patients.Item Open Access 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 Assessing Abnormal Proximal Junctional Angles in Adult Spinal Deformity: A Normative Data Approach to Define Proximal Junctional Kyphosis.(Spine, 2024-10) Khalifé, Marc; Lafage, Renaud; Daniels, Alan H; Diebo, Bassel G; Elysée, Jonathan; Ames, Christopher P; Bess, Shay R; Burton, Douglas C; Eastlack, Robert K; Gupta, Munish C; Hostin, Richard A; Kebaish, Khaled; Kim, Han-Jo; Klineberg, Eric O; Mundis, Gregory; Okonkwo, David O; Gille, Olivier; Guigui, Pierre; Ferrero, Emmanuelle; Skalli, Wafa; Assi, Ayman; Vergari, Claudio; Shaffrey, Christopher I; Smith, Justin S; Schwab, Frank J; Lafage, Virginie; International Spine Study GroupStudy design
Multicentric retrospective study of prospectively collected data.Objective
Based on normative data from a cohort of asymptomatic volunteers, this study sought to determine the rate of abnormal values of proximal junctional angles (PJA) in adult spinal deformity (ASD) surgery patients, and compare it with PJK rate.Summary of background data
Proximal junctional kyphosis (PJK) definition does not take the vertebral level into account.Methods
This study included 721 healthy volunteers and 824 ASD surgery patients with 2-year postoperative follow-up. Normative values for each disc and vertebral body between T1 and T12 were analyzed, then normative values for PJA at each thoracic level were defined in the volunteer cohort as the mean±2 standard deviations. PJA abnormal values at the upper instrumented vertebra (UIV) were compared with Glattes' and Lovecchio's definitions for PJK in the ASD population at two years.Results
Mean age was 37.7±16.3 in the volunteer cohort, with 50.5% of females. Mean thoracic kyphosis (TK) was -50.9±10.8°. Corridors of normality included PJA greater than 20° between T3 and T12. Mean age was 60.5±14.0 years in the ASD cohort, with 77.2% of females. Mean baseline TK was -37.4±19.9°, with a significant increase after surgery (-15.6±15.3°, P<0.001). There was 46.2% of PJK according to Glattes' versus 8.7% according to Lovecchio's and 22.9% of kyphotic PJA compared to normative values (P<0.001).Conclusion
This study provides normative values for segmental and regional alignment of thoracic spine, used to describe abnormal values of PJA for each level. Using level-adjusted PJA values allows a more precise assessment of abnormal proximal angles and question the definition for PJK.Level of evidence
II.Item Open Access Assessment of a Novel Adult Cervical Deformity Frailty Index as a Component of Preoperative Risk Stratification.(World neurosurgery, 2018-01) Miller, Emily K; Ailon, Tamir; Neuman, Brian J; Klineberg, Eric O; Mundis, Gregory M; Sciubba, Daniel M; Kebaish, Khaled M; Lafage, Virginie; Scheer, Justin K; Smith, Justin S; Hamilton, D Kojo; Bess, Shay; Shaffrey, Christopher I; Ames, Christopher P; International Spine Study GroupTo determine the value of a novel adult cervical deformity frailty index (CD-FI) in preoperative risk stratification.We reviewed a prospective, multicenter database of adults with cervical spine deformity. We selected 40 variables to construct the CD-FI using a validated method. Patients were categorized as not frail (NF) (<0.2), frail (0.2-0.4), or severely frail (SF) (>0.4) according to CD-FI score. We performed multivariate logistic regression to determine the relationships between CD-FI score and incidence of complications, length of hospital stay, and discharge disposition.Of 61 patients enrolled from 2009 to 2015 with at least 1 year of follow-up, the mean CD-FI score was 0.26 (range 0.25-0.59). Seventeen patients were categorized as NF, 34 as frail, and 10 as SF. The incidence of major complications increased with greater frailty, with a gamma correlation coefficient of 0.25 (asymptotic standard error, 0.22). The odds of having a major complication were greater for frail patients (odds ratio 4.4; 95% confidence interval 0.6-32) and SF patients (odds ratio 43; 95% confidence interval 2.7-684) compared with NF patients. Greater frailty was associated with a greater incidence of medical complications and had a gamma correlation coefficient of 0.30 (asymptotic standard error, 0.26). Surgical complications, discharge disposition, and length of hospital stay did not correlate significantly with frailty.Greater frailty was associated with greater risk of major complications for patients undergoing cervical spine deformity surgery. The CD-FI may be used to improve the accuracy of preoperative risk stratification and allow for adequate patient counseling.Item Open Access Assessment of Adult Spinal Deformity Complication Timing and Impact on 2-Year Outcomes Using a Comprehensive Adult Spinal Deformity Classification System.(Spine, 2022-03) Wick, Joseph B; Le, Hai V; Lafage, Renaud; Gupta, Munish C; Hart, Robert A; Mundis, Gregory M; Bess, Shay; Burton, Douglas C; Ames, Christopher P; Smith, Justin S; Shaffrey, Christopher I; Schwab, Frank J; Passias, Peter G; Protopsaltis, Themistocles S; Lafage, Virginie; Klineberg, Eric O; International Spine Study GroupStudy design
Retrospective review of prospectively collected multicenter registry data.Objective
To identify rates and timing of postoperative complications in adult spinal deformity (ASD) patients, the impact of complication type and timing on health related quality of life (HRQoL) outcomes, and the impact of complication timing on readmission and reoperation rates. Better understanding of complication timing and impact on HRQoL may improve patient selection, preoperative counseling, and postoperative complication surveillance.Summary of background data
ASD is common and associated with significant disability. Surgical correction is often pursued, but is associated with high complication rates. The International Spine Study Group, AO Spinal Deformity Forum, and European Spine Study Group have developed a new complication classification system for ASD (ISSG-AO spine complications classification system).Methods
The ISSG-AO spine complications classification system was utilized to assess complications occurring over the 2-year postoperative time period amongst a multicenter, prospectively enrolled cohort of patients who underwent surgery for ASD. Kaplan-Meier survival curves were established for each complication type. Propensity score matching was performed to adjust for baseline disability and comorbidities. Associations between each complication type and HRQoL, and reoperation/readmission and complication timing, were assessed.Results
Of 584 patients meeting inclusion criteria, cardiopulmonary, gastrointestinal, infection, early adverse events, and operative complications contributed to a rapid initial decrease in complication-free survival. Implant-related, radiographic, and neurologic complications substantially decreased long-term complication-free survival. Only radiographic and implant-related complications were significantly associated with worse 2-year HRQoL outcomes. Need for readmission and/or reoperation was most frequent among those experiencing complications after postoperative day 90.Conclusion
Surgeons should recognize that long-term complications have a substantial negative impact on HRQoL, and should carefully monitor for implant-related and radiographic complications over long-term follow-up.Level of Evidence: 4.Item Open Access Calibration of a comprehensive predictive model for the development of proximal junctional kyphosis and failure in adult spinal deformity patients with consideration of contemporary goals and techniques.(Journal of neurosurgery. Spine, 2023-06) Tretiakov, Peter S; Lafage, Renaud; Smith, Justin S; Line, Breton G; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey; Protopsaltis, Themistocles; Hamilton, D Kojo; Soroceanu, Alex; Scheer, Justin K; Eastlack, Robert K; Mundis, Gregory; Nunley, Pierce D; Klineberg, Eric O; Kebaish, Khaled; Lewis, Stephen; Lenke, Lawrence; Hostin, Richard; Gupta, Munish C; Ames, Christopher P; Hart, Robert A; Burton, Douglas; Shaffrey, Christopher I; Schwab, Frank; Bess, Shay; Kim, Han Jo; Lafage, Virginie; Passias, Peter GObjective
The objective of this study was to calibrate an updated predictive model incorporating novel clinical, radiographic, and prophylactic measures to assess the risk of proximal junctional kyphosis (PJK) and failure (PJF).Methods
Operative patients with adult spinal deformity (ASD) and baseline and 2-year postoperative data were included. PJK was defined as ≥ 10° in sagittal Cobb angle between the inferior uppermost instrumented vertebra (UIV) endplate and superior endplate of the UIV + 2 vertebrae. PJF was radiographically defined as a proximal junctional sagittal Cobb angle ≥ 15° with the presence of structural failure and/or mechanical instability, or PJK with reoperation. Backstep conditional binary supervised learning models assessed baseline demographic, clinical, and surgical information to predict the occurrence of PJK and PJF. Internal cross validation of the model was performed via a 70%/30% cohort split. Conditional inference tree analysis determined thresholds at an alpha level of 0.05.Results
Seven hundred seventy-nine patients with ASD (mean 59.87 ± 14.24 years, 78% female, mean BMI 27.78 ± 6.02 kg/m2, mean Charlson Comorbidity Index 1.74 ± 1.71) were included. PJK developed in 50.2% of patients, and 10.5% developed PJF by their last recorded visit. The six most significant demographic, radiographic, surgical, and postoperative predictors of PJK/PJF were baseline age ≥ 74 years, baseline sagittal age-adjusted score (SAAS) T1 pelvic angle modifier > 1, baseline SAAS pelvic tilt modifier > 0, levels fused > 10, nonuse of prophylaxis measures, and 6-week SAAS pelvic incidence minus lumbar lordosis modifier > 1 (all p < 0.015). Overall, the model was deemed significant (p < 0.001), and internally validated receiver operating characteristic analysis returned an area under the curve of 0.923, indicating robust model fit.Conclusions
PJK and PJF remain critical concerns in ASD surgery, and efforts to reduce the occurrence of PJK and PJF have resulted in the development of novel prophylactic techniques and enhanced clinical and radiographic selection criteria. This study demonstrates a validated model incorporating such techniques that may allow for the prediction of clinically significant PJK and PJF, and thus assist in optimizing patient selection, enhancing intraoperative decision making, and reducing postoperative complications in ASD surgery.Item Open Access Can unsupervised cluster analysis identify patterns of complex adult spinal deformity with distinct perioperative outcomes?(Journal of neurosurgery. Spine, 2023-05) Lafage, Renaud; Fourman, Mitchell S; Smith, Justin S; Bess, Shay; Shaffrey, Christopher I; Kim, Han Jo; Kebaish, Khaled M; Burton, Douglas C; Hostin, Richard; Passias, Peter G; Protopsaltis, Themistocles S; Daniels, Alan H; Klineberg, Eric O; Gupta, Munish C; Kelly, Michael P; Lenke, Lawrence G; Schwab, Frank J; Lafage, Virginie; International Spine Study GroupObjective
The objective of this study was to use an unsupervised cluster approach to identify patterns of operative adult spinal deformity (ASD) and compare the perioperative outcomes of these groups.Methods
A multicenter data set included patients with complex surgical ASD, including those with severe deformities, significant surgical complexity, or advanced age who underwent a multilevel fusion. An unsupervised cluster analysis allowing for 10% outliers was used to identify different deformity patterns. The perioperative outcomes of these clusters were then compared using ANOVA, Kruskal-Wallis, and chi-square tests, with p values < 0.05 considered significant.Results
Two hundred eighty-six patients were classified into four clusters of deformity patterns: hyper-thoracic kyphosis (hyper-TK), severe coronal, severe sagittal, and moderate sagittal. Hyper-TK patients had the lowest disability (mean Oswestry Disability Index [ODI] 32.9 ± 17.1) and pain scores (median numeric rating scale [NRS] back score 6, leg score 1). The severe coronal cluster had moderate functional impairment (mean physical component score 34.4 ± 12.3) and pain (median NRS back score 7, leg score 4) scores. The severe sagittal cluster had the highest levels of disability (mean ODI 49.3 ± 15.6) and low appearance scores (mean 2.3 ± 0.7). The moderate cluster (mean 68.8 ± 7.8 years) had the highest pain interference subscores on the Patient-Reported Outcomes Measurement Information System (mean 65.2 ± 5.8). Overall 30-day adverse events were equivalent among the four groups. Fusion to the pelvis was most common in the moderate sagittal (89.4%) and severe sagittal (97.5%) clusters. The severe coronal cluster had more osteotomies per case (median 11, IQR 6.5-14) and a higher rate of 30-day implant-related complications (5.5%). The severe sagittal and hyper-TK clusters had more three-column osteotomies (43% and 32.3%, respectively). Hyper-TK patients had shorter hospital stays.Conclusions
This cohort of patients with complex ASD surgeries contained four natural clusters of deformity, each with distinct perioperative outcomes.Item Open Access Cause and Effect of Revisions in Adult Spinal Deformity Surgery: A Multicenter Study on Outcomes Based on Etiology.(The spine journal : official journal of the North American Spine Society, 2024-12) Passias, Peter G; Dave, Pooja; Smith, Justin S; Lafage, Renaud; Onafowokan, Oluwatobi O; Tretiakov, Peter; Mir, Jamshaid; Line, Breton; Diebo, Bassel; Daniels, Alan H; Gum, Jeffrey L; Eastlack, Robert; Hamilton, D Kojo; Chou, Dean; Klineberg, Eric O; Kebaish, Khaled M; Lewis, Stephen; Gupta, Munish C; Kim, Han Jo; Lenke, Lawrence G; Ames, Christopher P; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Bess, Shay; Hostin, Robert; Burton, Douglas CBackground context
While the treatment of adult spinal deformity (ASD) has increasingly favored surgical correction, the incidence of revision surgery remains high. Yet, little has been explored on the association between the etiology of reoperation and patient outcomes.Purpose
To assess the impact of the etiology of revision surgery on postoperative outcomes.Study design/setting
Retrospective cohort analysis.Patient sample
891 ASD patients.Outcome measures
Complications, radiographic parameters, disability metrics.Methods
Operative ASD patients with at least 1 revision stratified by etiology (mechanical [Mech] -pseudoarthrosis, thoracic decompensation without junctional failure, x-ray malalignment, implant failure, implant malposition, PJK ± major malalignment; infection [Infx]-early vs late onset, major vs minor; wound [Wound]; SI pain [SI Pain]). Excluded multiple etiologies, and intraoperative or medical complications. Data from the immediate visit prior to the final revision was used as baseline (rBL). Follow-up based on visits best aligned to time points after final revision. Radiographic parameters SVA, PI-LL, and PT were used to assess alignment post-revision via ANOVA. Multivariate analysis controlling for relevant covariates assessed outcome differences after final revision surgery.Results
891 MET INCLUSION (AGE: 60.40±14.17, 77% F, BMI: 27.97±5.87 KG/M2, CCI: : 1.80±1.73). Etiology groups were as follows: Mech: 432; Infx: 296; Wound: 65; SI Pain: 98. Surgically, Infx had lower rates of osteotomy, interbody fusion, and decompression (p<.05). Infx and SI Pain demonstrated similar correction in radiographics SVA, PI-LL, and PT (p>.05), whereas Mech had significantly less improvement by 2 years (p<.003) that improved by 5 years. Compared to without revision, the odds of MCID in ODI were 48.6% lower across groups (OR: 0.514 [.280, .945], p=.032). Indications of x-ray malalignment were 93.0% less likely to reach MCID (OR: 0.071, [.006, .866], p=.038). Similarly, implant failure negatively impacted rates of MCID (40% vs. 15.2%, p=.029). Those with PJK had 57% lower odds of MCID (33% vs 54%, OR: .43, [0.2, 0.9] p= 0.023), further negated by major malalignment (OR: 0.05, [.07, .97], p=.02). Indications of pseudarthrosis, thoracic decompensation, implant malposition were not significant. Major sepsis had lower rates of MCID compared to minor (6.4% vs. 21.2%), and early onset infection improved compared to late (OR: 1.43, [1.17, 2.98], p<.001). In the early follow-up period, the Mech group has significantly worse SRS Pain and Mental Health scores compared to other groups (1-year: Mech 1.56 vs Infx 0.83 vs SI Pain 0.72, p<0.001; 2-year: 1.88 vs 0.71 vs 0.76, p=0.034). Complication rates increased with the number of revisions and with mechanical indication (all p<.05). At 5 years, patient satisfaction was significantly more likely to improve compared to early follow-up (OR: 1.22, p=.011), along with improved pain score, in Mech group (0.89 vs 0.49 vs 0.56, p=.081).Conclusions
This study focused on the impact of revision as it varies with etiology and time of occurrence postoperatively. Compared to other etiologies, revision surgery due to mechanical complications had less radiographic improvement and worsening patient-reported scores in the early postoperative period despite stabilization at 5 years. The depth of impact of mechanical complication, particularly with the addition of malalignment, merits greater focus during surgical planning.Level of evidence
III.Item Open Access Cervical deformity patients with baseline hyperlordosis or hyperkyphosis differ in surgical treatment and radiographic outcomes(Journal of Craniovertebral Junction and Spine, 2022-07-01) Passias, Peter Gust; Alas, Haddy; Kummer, Nicholas; Tretiakov, Peter; Diebo, Bassel G; Lafage, Renaud; Ames, Christopher P; Line, Breton; Klineberg, Eric O; Burton, Douglas C; Uribe, Juan S; Kim, Han Jo; Daniels, Alan H; Bess, Shay; Protopsaltis, Themistocles; Mundis, Gregory M; Shaffrey, Christopher I; Schwab, Frank J; Smith, Justin S; Lafage, Virginie; International Spine Study GroupBackground: Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), although patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD corrective surgery with regard to HK and hyperlordosis (HL). Objective: The objective of the study is to evaluate patterns in treatment for CD patients with baseline (BL) HK and HL and understand how extreme curvature of the spine may influence surgical outcomes. Materials and Methods: Operative CD patients with BL and 1-year (1Y) radiographic data were included in the study. Patients were stratified based on BL C2-C7 lordosis (CL) angle: those >1 standard deviation (SD) from the mean (-6.96 ± 21.47°) were hyperlordotic (>14.51°) or hyperkyphotic (<-28.43°) depending on directionality. Patients within 1SD were considered control group. Results: 102 surgical CD patients (61 years, 65% F, 30 kg/m 2) with BL and 1Y radiographic data were included. 20 patients met definitions for HK and 21 patients met definitions for HL. No differences in demographics or disability were noted. HK had higher estimated blood loss (EBL) with anterior approaches than HL but similar EBL with posterior approach. Operative time did not differ between groups. Control, HL, and HK groups differed in BL TS-CL (36.6° vs. 22.5° vs. 60.7°, P < 0.001) and BL-SVA (10.8 vs. 7.0 vs. -47.8 mm, P = 0.001). HL patients had less discectomies, less corpectomies, and similar osteotomy rates to HK. HL had 3x revisions of HK and controls (28.6 vs. 10.0 vs. 9.2%, respectively, P = 0.046). At 1Y, HL patients had higher cSVA and trended higher SVA and SS than HK. In terms of BL-upper cervical alignment, HK patients had higher McGregor's slope (MGS) (16.1° vs. 3.3°, P = 0.002) and C0-C2 Cobb (43.3° vs. 26.9°, P < 0.001), however, postoperative differences in MGS and C0-C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary CT (38.1%), UT (23.8%), and C (14.3%) drivers. Conclusions: Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1-year postoperative, perhaps due to undercorrection compared to kyphotic etiologies.Item Open Access Cervical deformity patients with baseline hyperlordosis or hyperkyphosis differ in surgical treatment and radiographic outcomes(Journal of Craniovertebral Junction and Spine, 2021-07-01) Alas, Haddy; Passias, Peter Gust; Diebo, Bassel G; Brown, Avery E; Pierce, Katherine E; Bortz, Cole; Lafage, Renaud; Ames, Christopher P; Line, Breton; Klineberg, Eric O; Burton, Douglas C; Uribe, Juan S; Kim, Han Jo; Daniels, Alan H; Bess, Shay; Protopsaltis, Themistocles; Mundis, Gregory M; Shaffrey, Christopher I; Schwab, Frank J; Smith, Justin S; Lafage, VirginieIntroduction: Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), though patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD-corrective surgery with regards to HK and hyperlordosis (HL). Materials and Methods: Operative CD patients (C2-C7 Cobb >10°, cervical lordosis [CL] >10°, cervical sagittal vertical axis [cSVA] >4 cm, chin-brow vertical angle >25°) with baseline (BL) and 1Y radiographic data. Patients were stratified based on BL C2-7 lordosis (CL) angle: those >1 standard deviation (SD) from the mean (-6.96° ±21.47°) were hyperlordotic (>14.51°) or hyperkyphotic (≤28.43°) depending on directionality. Patients within 1 SD were considered the control group. Results: One hundred and two surgical CD pts (61 years, 65%F, 30 kg/m 2) with BL and 1Y radiographic data were included. Twenty pts met definitions for HK and 21 pts met definitions for HL. No differences in demographics or disability were noted. HK had higher estimated blood loss (EBL) with anterior approaches than HL but similar EBL with the posterior approach. Op-time did not differ between groups. Control, HL, and HK groups differed in BL TS-CL (36.6° vs. 22.5° vs. 60.7°, P < 0.001) and BL-sagittal vertical axis (SVA) (10.8 vs. 7.0 vs. -47.8 mm, P = 0.001). HL pts had less discectomies, less corpectomies, and similar osteotomy rates to HK. HL had × 3 revisions of HK and controls (28.6 vs. 10.0 vs. 9.2%, respectively, P = 0.046). At 1Y, HL pts had higher cSVA, and trended higher SVA and SS than HK. In terms of BL-upper cervical alignment, HK pts had higher McGregor's-slope (16.1° vs. -3.3°, P = 0.001) and C0-C2 Cobb (43.3° vs. 26.9°, P < 0.001), however postoperative differences in McGregor's slope and C0-C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary computed tomography (38.1%), upper thoracic (23.8%), and C (14.3%) drivers. Conclusions: Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1Y postoperative, perhaps due to undercorrection compared to kyphotic etiologies.Item Open Access Cervicothoracic Versus Proximal Thoracic Lower Instrumented Vertebra Have Comparable Radiographic and Clinical Outcomes in Adult Cervical Deformity.(Global spine journal, 2023-05) Kim, Han Jo; Yao, Yu-Cheng; Bannwarth, Mathieu; Smith, Justin S; Klineberg, Eric O; Mundis, Gregory M; Protopsaltis, Themistocles S; Charles-Elysee, Jonathan; Bess, Shay; Shaffrey, Christopher I; Passias, Peter G; Schwab, Frank J; Ames, Christopher P; Lafage, Virginie; International Spine Study Group (ISSG)Study design
Comparative cohort study.Objective
Factors that influence the lower instrumented vertebra (LIV) selection in adult cervical deformity (ACD) are less reported, and outcomes in the cervicothoracic junction (CTJ) and proximal thoracic (PT) spine are unclear.Methods
A prospective ACD database was analyzed using the following inclusion criteria: LIV between C7 and T5, upper instrumented vertebra at C2, and at least a 1-year follow-up. Patients were divided into CTJ (LIV C7-T2) and PT groups (LIV T3-T5) based on LIV levels. Demographics, operative details, radiographic parameters, and the health-related quality of life (HRQOL) scores were compared.Results
Forty-six patients were included (mean age, 62 years), with 22 and 24 patients in the CTJ and PT groups, respectively. Demographics and surgical parameters were comparable between the groups. The PT group had a significantly higher preoperative C2-C7 sagittal vertical axis (cSVA) (46.9 mm vs 32.6 mm, P = 0.002) and T1 slope minus cervical lordosis (45.9° vs 36.0°, P = 0.042) than the CTJ group and was more likely treated with pedicle-subtraction osteotomy (33.3% vs 0%, P = 0.004). The PT group had a larger correction of cSVA (-7.7 vs 0.7 mm, P = 0.037) and reciprocal change of increased T4-T12 kyphosis (8.6° vs 0.0°, P = 0.001). Complications and reoperations were comparable. The HRQOL scores were not different preoperatively and at 1-year follow-up.Conclusions
The selection of PT LIV in cervical deformities was more common in patients with larger baseline deformities, who were more likely to undergo pedicle-subtraction osteotomy. Despite this, the complications and HRQOL outcomes were comparable at 1-year follow-up.Item Open Access Clinical outcomes and proximal junctional failure in adult spinal deformity patients corrected to normative alignment versus functional alignment.(Journal of neurosurgery. Spine, 2023-07) Protopsaltis, Themistocles S; Ani, Fares; Soroceanu, Alexandra; Lafage, Renaud; Kim, Han Jo; Balouch, Eaman; Norris, Zoe; Smith, Justin S; Daniels, Alan H; Klineberg, Eric O; Ames, Christopher P; Hart, Robert; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lenke, Lawrence G; Lafage, Virginie; Gupta, Munish CObjective
The objective of this study was to explore the rate of proximal junctional failure (PJF) and functional outcomes of normative alignment goals compared with alignment targets based on age-appropriate physical function.Methods
Baseline relationships between age, pelvic incidence (PI), and a component of the T1 pelvic angle (TPA) within the fusion were analyzed in adult spinal deformity (ASD) patients and compared with those of asymptomatic patients. Linear regression modeling was used to determine alignment based on PI and age in asymptomatic patients (normative alignment), and in ASD patients, alignment corresponding to age-appropriate functional status (functional alignment). A cohort of 288 ASD patients was split into two groups based on whether the patient was closer to their normative or functional alignment goal at their 6-week postoperative radiographic follow-up. The rates of proximal junctional kyphosis (PJK) and PJF were determined for each cohort.Results
In the 288 ASD patients included in this pre- to postoperative analysis, there was no difference in baseline alignment or health-related quality of life (HRQOL) between the normative alignment and functional alignment groups. At 6 weeks, patients with normative alignment had a smaller TPA (4.45° vs 14.1°) and PI minus lumbar lordosis (-7.24° vs 7.4°) (both p < 0.0001) and higher PJK (40% vs 27.2%, p = 0.03) and PJF (17% vs 6.8%, p = 0.008) rates than patients with functional alignment.Conclusions
Correction in ASD patients to normative alignment resulted in higher rates of PJK and PJF without improvements in HRQOL. Correction in ASD patients to functional alignment that mirrors the physical function of their age-matched asymptomatic peers is recommended.Item Open Access Comparative Analysis of Outcomes in Adult Spinal Deformity Patients with Proximal Junctional Kyphosis or Failure Initially Fused to Upper Versus Lower Thoracic Spine.(Journal of clinical medicine, 2024-12) Onafowokan, Oluwatobi O; Lafage, Renaud; Tretiakov, Peter; Smith, Justin S; Line, Breton G; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey L; Protopsaltis, Themistocles S; Hamilton, David Kojo; Buell, Thomas; Soroceanu, Alex; Scheer, Justin; Eastlack, Robert K; Mullin, Jeffrey P; Mundis, Gregory; Hosogane, Naobumi; Yagi, Mitsuru; Anand, Neel; Okonkwo, David O; Wang, Michael Y; Klineberg, Eric O; Kebaish, Khaled M; Lewis, Stephen; Hostin, Richard; Gupta, Munish Chandra; Lenke, Lawrence G; Kim, Han Jo; Ames, Christopher P; Shaffrey, Christopher I; Bess, Shay; Schwab, Frank J; Lafage, Virginie; Burton, Douglas; Passias, Peter G; International Spine Study GroupBackground: Patients with proximal junctional kyphosis (PJK) or failure (PJF) may demonstrate disparate outcomes and recovery when fused to the upper (UT) versus lower (LT) thoracic spine. Few studies have distinguished the reoperation and recovery abilities of patients with PJK or PJF when fused to the upper (UT) versus lower (LT) thoracic spine. Methods: Adult spine deformity patients ≥ 18 yrs with preoperative and 5-year (5Y) data fused to the sacrum/pelvis were included. The rates of PJK, PJK revision, and radiographic PJF were compared between patients with upper instrumented vertebra (UIV) in the upper thoracic spine (UT; T1-T7) and lower thoracic spine (LT; T8-L1). Mean differences were assessed via analyses of covariance, factoring in any differences between cohorts at baseline and any use of PJF prophylaxis. Backstep logistic regressions assessed predictors of achieving Smith et al.'s Best Clinical Outcomes (BCOs) and complications, controlling for similar covariates. Results: A total of 232 ASD patients were included (64.2 ± 10.2 years, 78% female); 36.3% were UT and 63.7% were LT. Postoperatively, the rates of PJK for UT were lower than LT at 1Y (34.6 vs. 50.4%, p = 0.024), 2Y (29.5 vs. 49.6% (p = 0.003), and 5Y (48.7 vs. 62.8%, p = 0.048), with comparable rates of PJF. In total, 4.0% of UT patients underwent subsequent reoperation, compared to 13.0% of LT patients (p = 0.025). A total of 6.0% of patients had recurrent PJK, and 3.9% had recurrent PJF (both p > 0.05). After reoperation, UT patients reported higher rates of improvement in the minimum clinically important difference for ODI by 2Y (p = 0.007) and last follow-up (p < 0.001). While adjusted regression revealed that, for UT patients, the minimization of construct extension was predictive of achieving BCOs by last follow-up (model p < 0.001), no such relationship was identified in LT patients. Conclusions: Patients initially fused to the lower thoracic spine demonstrate an increased incidence of PJK and lower rates of disability improvement, but are at a lessened risk of neurologic complications if reoperation is required.