Browsing by Author "Lafage, Renaud"

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    ItemOpen 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 Group

    Study 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.
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    ItemOpen Access
    A comparative analysis of the prevalence and characteristics of cervical malalignment in adults presenting with thoracolumbar spine deformity based on variations in treatment approach over 2 years.
    (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, 2016-08) Jalai, Cyrus M; Passias, Peter G; Lafage, Virginie; Smith, Justin S; Lafage, Renaud; Poorman, Gregory W; Diebo, Bassel; Liabaud, Barthélemy; Neuman, Brian J; Scheer, Justin K; Shaffrey, Christopher I; Bess, Shay; Schwab, Frank; Ames, Christopher P; International Spine Study Group (ISSG)

    Purpose

    Characteristics specific to cervical deformity (CD) concomitant with adult thoracolumbar deformity (TLD) remains uncertain, particularly regarding treatment. This study identifies cervical malalignment prevalence following surgical and conservative TLD treatment through 2 years.

    Methods

    Retrospective analysis of a prospective, multicenter adult spinal deformity (ASD) database. CD was defined in operative and non-operative ASD patients according to the following criteria: T1 Slope minus Cervical Lordosis (T1S-CL) ≥20°, C2-C7 Cervical Sagittal Vertical Axis (cSVA) ≥40 mm, C2-C7 kyphosis >10°. Differences in rates, demographics, health-related quality of life (HRQoL) scores for Oswestry Disability Index (ODI) and Scoliosis Research Society Questionnaire (SRS-22r), and radiographic variables were assessed between treatment groups (Op vs. Non-Op) and follow-up periods (baseline, 1-year, 2-year).

    Results

    Three hundred and nineteen (200 Op, 199 Non-Op) ASD patients were analyzed. Op patients' CD rates at 1 and 2 years were 78.9, and 63.0 %, respectively. Non-Op CD rates were 21.1 and 37.0 % at 1 and 2 years, respectively. T1S-CL mismatch and cSVA malalignment characterized Op CD at 1 and 2 years (p < 0.05). Op and Non-Op CD groups had similar cervical/global alignment at 1 year (p > 0.05 for all), but at 2 years, Op CD patients had worse thoracic kyphosis (TK), T1S-CL, CL, cSVA, C2-T3 SVA, and global SVA compared to Non-Ops (p < 0.05). Op CD patients had worse ODI, and SRS Activity at 1 and 2 years post-operative (p < 0.05), but had greater 2-year SRS Satisfaction scores (p = 0.019).

    Conclusions

    In the first study to compare cervical malalignment at extended follow-up between ASD treatments, CD rates rose overall through 2 years. TLD surgery, resulting in higher CD rates characterized by T1S-CL and cSVA malalignment, produced poorer HRQoL. This information can aid in treatment method decision-making when cervical deformity is present concomitant with TLD.
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    ItemOpen Access
    A Comparison of Three Different Positioning Techniques on Surgical Corrections and Postoperative Alignment in Cervical Spinal Deformity (CD) Surgery.
    (Spine, 2021-05) Morse, Kyle W; Lafage, Renaud; Passias, Peter; Ames, Christopher P; Hart, Robert; Shaffrey, Christopher I; Mundis, Gregory; Protopsaltis, Themistocles; Gupta, Munish; Klineberg, Eric; Burton, Doug; Lafage, Virginie; Kim, Han Jo; International Spine Study Group

    Study design

    Retrospective review of a prospective multicenter cervical deformity database.

    Objective

    To examine the differences in sagittal alignment correction between three positioning methods in cervical spinal deformity surgery (CD).

    Summary of background data

    Surgical correction for CD is technically demanding and various techniques are utilized to achieve sagittal alignment objectives. The effect of different patient positioning techniques on sagittal alignment correction following CD remains unknown.

    Methods

    Patients with sagittal deformity who underwent a posterior approach (with and without anterior approach) with an upper instrumented vertebra of C6 or above. Patients with Grade 5, 6, or 7 osteotomies were excluded. Positioning groups were Mayfield skull clamp, bivector traction, and halo ring. Preoperative lower surgical sagittal curve (C2-C7), C2-C7 sagittal vertical axis (cSVA), cervical scoliosis, T1 slope minus cervical lordosis (TS-CL), T1 slope (T1S), chin-brow vertebral angle (CBVA), C2-T3 curve, and C2-T3 SVA was assessed and compared with postoperative radiographs. Segmental changes were analyzed using the Fergusson method.

    Results

    Eighty patients (58% female) with a mean age of 60.6 ± 10.5 years (range, 31-83) were included. The mean postoperative C2-C7 lordosis was 7.8° ± 14 and C2-C7 SVA was 34.1 mm ± 15. There were overall significant changes in cervical alignment across the entire cohort, with improvements in T1 slope (P < 0.001), C2-C7 (P < 0.001), TS-CL (P < 0.001), and cSVA (P = 0.006). There were no differences postoperatively of any radiographic parameter between positioning groups (P > 0.05). The majority of segmental lordotic correction was achieved at C4-5-6 (mean 6.9° ± 11). Additionally, patients who had bivector traction applied had had significantly more segmental correction at C7-T1-T2 compared with Mayfield and halo traction (4.2° vs. 0.3° vs. -1.7° respectively, P < 0.027).

    Conclusion

    Postoperative cervical sagittal correction or alignment was not affected by patient position. The majority of segmental correction occurred at C4-5-6 across all positioning methods, while bivector traction had the largest corrective ability at the cervicothoracic junction.Level of Evidence: 4.
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    ItemOpen Access
    A New Piece of the Puzzle to Understand Cervical Sagittal Alignment: Utilizing a Novel Angle δ to Describe the Relationship among T1 Vertebral Body Slope, Cervical Lordosis, and Cervical Sagittal Alignment.
    (Neurosurgery, 2020-03) Goldschmidt, Ezequiel; Angriman, Federico; Agarwal, Nitin; Trevisan, Marcos; Zhou, James; Chen, Katherine; Gerszten, Peter C; Kanter, Adam S; Okonkwo, David O; Passias, Peter; Scheer, Justin; Protopsaltis, Themistocles; Lafage, Virginie; Lafage, Renaud; Schwab, Frank; Bess, Shay; Ames, Christopher; Smith, Justin S; Shaffrey, Christopher I; Miller, Emily; Jain, Amit; Neuman, Brian; Sciubba, Daniel M; Burton, Douglas; Hamilton, D Kojo; International Spine Study Group (ISSG)
    Cervical alignment has become increasingly important in the planning of spine surgery. A relationship between the slope of T1 (T1S), the cervical lordosis (CL), and the overall cervical sagittal vertical axis (cSVA) has previously been demonstrated, but the exact nature of this relationship is poorly understood. In this study, we derive theoretical and empirical equations to better understand how T1S and CL affect cSVA. The first equation was developed on a theoretical basis using inherent trigonometric relationships of the cervical spine. By treating the cervical spine as the arc of a circumference, and by taking into account the cervical height (CH), the geometric relationship between theT1S, CL, and cSVA was described via a trigonometric identity utilizing a novel angle δ subtended by the CH and cSVA (δ = T1S-CL/2). The second equation was developed on an empiric basis by performing a multiple linear regression on data obtained from a retrospective review of a large multicenter deformity database. The theoretical equation determined that the value of cSVA could be expressed as: $cSVA\ = \ CH*{\rm{tan}}( {\pi /180*( {T1S - CL/2} )} )$. The empirical equation determined that value of cSVA could be expressed as: $cSVA=({1.1*T1} )\ - ( {0.43*CL} ) + 6.69$. In both, the sagittal alignment of the head over the shoulders is directly proportional to the T1S and inversely proportional to CL/2. These 2 equations may allow surgeons to better understand how the CL compensates for the T1S, to accurately predict the postoperative cSVA, and to customize cervical interbody grafts by taking into consideration each individual patient's specific cervical spine parameters.
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    ItemOpen Access
    A Novel Tool for Deformity Surgery Planning: Determining the Magnitude of Lordotic Correction Required to Achieve a Desired Sagittal Vertical Axis.
    (World neurosurgery, 2017-08) Goldschmidt, Ezequiel; Angriman, Federico; Agarwal, Nitin; Zhou, James; Chen, Katherine; Tempel, Zachary J; Gerszten, Peter C; Kanter, Adam S; Okonkwo, David O; Passias, Peter; Scheer, Justin; Protopsaltis, Themistocles; Lafage, Virginie; Lafage, Renaud; Schwab, Frank; Bess, Shay; Ames, Christopher; Smith, Justin S; Shaffrey, Christopher I; Miller, Emily; Jain, Amit; Neuman, Brian; Sciubba, Daniel M; Burton, Douglas; Hamilton, D Kojo; International Spine Study Group

    Objective

    We sought to create a model capable of predicting the magnitude of pelvic incidence-lumbar lordosis (PI-LL) correction necessary to achieve a desired change in sagittal vertical axis (SVA).

    Methods

    A retrospective review was conducted of a prospectively maintained multicenter adult spinal deformity database collected by the International Spine Study Group between 2009 and 2014. The independent variable of interest was the degree of correction achieved in the PI-LL mismatch 6 weeks after surgery. Primary outcome was the change in global sagittal alignment 6 weeks and 1 year after surgery. We used a linear mixed-effects model to determine the extent to which corrections in the PI-LL relationship affected postoperative changes in SVA.

    Results

    A total of 1053 adult patients were identified. Of these patients, 590 were managed surgically. Eighty-seven surgically managed patients were excluded because of incomplete or missing PI-LL measurements on follow-up; the remaining 503 patients were selected for inclusion. For each degree of improvement in the PI-LL mismatch at 6 weeks, the SVA decreased by 2.18 mm (95% confidence interval, -2.56, -1.79; P < 0.01) and 1.67 mm (95% confidence interval, -2.07, -1.27; P < 0.01) at 6 weeks and 12 months, respectively. A high SVA measurement (>50 mm) 1 year after surgery was negatively associated with health-related quality of life as measured by the Scoliosis Research Society 22 outcomes assessment.

    Conclusions

    We describe a novel model that shows how surgical correction of the PI-LL relationship affects postoperative changes in SVA. This model may enable surgeons to determine preoperatively the amount of LL necessary to achieve a desired change in SVA.
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    ItemOpen Access
    A Risk-Benefit Analysis of Increasing Surgical Invasiveness Relative to Frailty Status in Adult Spinal Deformity Surgery.
    (Spine, 2021-08) Passias, Peter G; Brown, Avery E; Bortz, Cole; Pierce, Katherine; Alas, Haddy; Ahmad, Waleed; Passfall, Lara; Kummer, Nicholas; Krol, Oscar; Lafage, Renaud; Lafage, Virginie; Burton, Douglas; Hart, Robert; Anand, Neel; Mundis, Gregory; Neuman, Brian; Line, Breton; Shaffrey, Christopher; Klineberg, Eric; Smith, Justin; Ames, Christopher; Schwab, Frank J; Bess, Shay; International Spine Study Group

    Study design

    Retrospective review of a prospectively enrolled multicenter Adult Spinal Deformity (ASD) database.

    Objective

    Investigate invasiveness and outcomes of ASD surgery by frailty state.

    Summary of background data

    The ASD Invasiveness Index incorporates deformity-specific components to assess correction magnitude. Intersections of invasiveness, surgical outcomes, and frailty state are understudied.

    Methods

    ASD patients with baseline and 3-year (3Y) data were included. Logistic regression analyzed the relationship between increasing invasiveness and major complications or reoperations and meeting minimal clinically important differences (MCID) for health-related quality-of-life measures at 3Y. Decision tree analysis assessed invasiveness risk-benefit cutoff points, above which experiencing complications or reoperations and not reaching MCID were higher. Significance was set to P < 0.05.

    Results

    Overall, 195 of 322 patients were included. Baseline demographics: age 59.9 ± 14.4, 75% female, BMI 27.8 ± 6.2, mean Charlson Comorbidity Index: 1.7 ± 1.7. Surgical information: 61% osteotomy, 52% decompression, 11.0 ± 4.1 levels fused. There were 98 not frail (NF), 65 frail (F), and 30 severely frail (SF) patients. Relationships were found between increasing invasiveness and experiencing a major complication or reoperation for the entire cohort and by frailty group (all P < 0.05). Defining a favorable outcome as no major complications or reoperation and meeting MCID in any health-related quality of life at 3Y established an invasiveness cutoff of 63.9. Patients below this threshold were 1.8[1.38-2.35] (P < 0.001) times more likely to achieve favorable outcome. For NF patients, the cutoff was 79.3 (2.11[1.39-3.20] (P < 0.001), 111 for F (2.62 [1.70-4.06] (P < 0.001), and 53.3 for SF (2.35[0.78-7.13] (P = 0.13).

    Conclusion

    Increasing invasiveness is associated with increased odds of major complications and reoperations. Risk-benefit cutoffs for successful outcomes were 79.3 for NF, 111 for F, and 53.3 for SF patients. Above these, increasing invasiveness has increasing risk of major complications or reoperations and not meeting MCID at 3Y.Level of Evidence: 3.
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    ItemOpen Access
    Achievement and Maintenance of Optimal Alignment After Adult Spinal Deformity Corrective Surgery: A 5-Year Outcome Analysis.
    (World neurosurgery, 2023-12) Mir, Jamshaid M; Galetta, Matthew S; Tretiakov, Peter; Dave, Pooja; Lafage, Virginie; Lafage, Renaud; Schoenfeld, Andrew J; Passias, Peter G

    Objective

    We sought to assess factors contributing to optimal radiographic outcomes.

    Methods

    Operative adult spinal deformity (ASD) patients with baseline and 5-year (5Y) data were included. Optimal alignment (O) was defined as improving in at least 1 Scoliosis Research Society-Schwab modifier without worsening in any Scoliosis Research Society-Schwab modifier. A robust outcome was defined as having optimal alignment 2 years (2Y) post operation that was maintained at 5Y. Predictors of robust outcomes were identified using multivariate regression analysis, with a conditional inference tree for continuous variables.

    Results

    Two-hundred and ninety-seven ASD patients met inclusion criteria. Most patients (77.4%) met O at 6W, which decreased to 54.2% at 2Y. The majority of patients (89.4%) that met O at 2Y went on to meet radiographic durability at 5Y (48.5% of total cohort). Rates of junctional failure were higher in O2+5- compared with O2+5- (P = 0.013), with reoperation rates of 17.2% due to loss of alignment. Multivariable regression identified the following independent predictors of optimal alignment at 5Y in those that had O at 2Y: inadequate correction of pelvic tilt and overcorrection of the difference between pelvic incidence and lumbar lordosis (P < 0.05). Increased age, body mass index, and invasiveness were the most significant nonradiographic predictors for not achieving 5Y durability (P < 0.05).

    Conclusions

    The durability of optimal alignment after ASD corrective surgery was seen in about half of the patients at 5Y. While the majority of patients at 2Y maintained their radiographic outcomes at 5Y, major contributors to loss of alignment included junctional failure and adjacent region compensation, with only a minority of patients losing correction through the existing construct. The reoperation rate for loss of alignment was 17.2%. Loss of alignment requiring reoperation had a detrimental effect on 5Y clinical outcomes.
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    ItemOpen Access
    Adult Cervical Deformity Patients Have Higher Baseline Frailty, Disability, and Comorbidities Compared With Complex Adult Thoracolumbar Deformity Patients: A Comparative Cohort Study of 616 Patients.
    (Global spine journal, 2023-11) Smith, Justin S; Kelly, Michael P; Buell, Thomas J; Ben-Israel, David; Diebo, Bassel; Scheer, Justin K; Line, Breton; Lafage, Virginie; Lafage, Renaud; Klineberg, Eric; Kim, Han Jo; Passias, Peter; Gum, Jeffrey L; Kebaish, Khal; Mullin, Jeffrey P; Eastlack, Robert; Daniels, Alan; Soroceanu, Alex; Mundis, Gregory; Hostin, Richard; Protopsaltis, Themistocles S; Hamilton, D Kojo; Gupta, Munish; Lewis, Stephen J; Schwab, Frank J; Lenke, Lawrence G; Shaffrey, Christopher I; Burton, Douglas; Ames, Christopher P; Bess, Shay; International Spine Study Group

    Study design

    Multicenter comparative cohort.

    Objective

    Studies have shown markedly higher rates of complications and all-cause mortality following surgery for adult cervical deformity (ACD) compared with adult thoracolumbar deformity (ATLD), though the reasons for these differences remain unclear. Our objectives were to compare baseline frailty, disability, and comorbidities between ACD and complex ATLD patients undergoing surgery.

    Methods

    Two multicenter prospective adult spinal deformity registries were queried, one ATLD and one ACD. Baseline clinical and frailty measures were compared between the cohorts.

    Results

    616 patients were identified (107 ACD and 509 ATLD). These groups had similar mean age (64.6 vs 60.8 years, respectively, P = .07). ACD patients were less likely to be women (51.9% vs 69.5%, P < .001) and had greater Charlson Comorbidity Index (1.5 vs .9, P < .001) and ASA grade (2.7 vs 2.4, P < .001). ACD patients had worse VR-12 Physical Component Score (PCS, 25.7 vs 29.9, P < .001) and PROMIS Physical Function Score (33.3 vs 35.3, P = .031). All frailty measures were significantly worse for ACD patients, including hand dynamometer (44.6 vs 55.6 lbs, P < .001), CSHA Clinical Frailty Score (CFS, 4.0 vs 3.2, P < .001), and Edmonton Frailty Scale (EFS, 5.15 vs 3.21, P < .001). Greater proportions of ACD patients were frail (22.9% vs 5.7%) or vulnerable (15.6% vs 10.9%) based on EFS (P < .001).

    Conclusions

    Compared with ATLD patients, ACD patients had worse baseline characteristics on all measures assessed (comorbidities/disability/frailty). These differences may help account for greater risk of complications and all-cause mortality previously observed in ACD patients and facilitate strategies for better preoperative optimization.
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    ItemOpen 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.
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    ItemOpen Access
    After 9 Years of 3-Column Osteotomies, Are We Doing Better? Performance Curve Analysis of 573 Surgeries With 2-Year Follow-up.
    (Neurosurgery, 2018-07) Diebo, Bassel G; Lafage, Virginie; Varghese, Jeffrey J; Gupta, Munish; Kim, Han Jo; Ames, Christopher; Kebaish, Khaled; Shaffrey, Christopher; Hostin, Richard; Obeid, Ibrahim; Burton, Doug; Hart, Robert A; Lafage, Renaud; Schwab, Frank J; International Spine Study Group (ISSG) of Denver, Colorado

    Background

    In spinal deformity treatment, the increased utilization of 3-column (3CO) osteotomies reflects greater comfort and better training among surgeons. This study aims to evaluate the longitudinal performance and adverse events (complications or revisions) for a multicenter group following a decade of 3CO.

    Objective

    To investigate if performance of 3CO surgeries improves with years of practice.

    Methods

    Patients who underwent 3CO for spinal deformity with intra/postoperative and revision data collected up to 2 yr were included. Patients were chronologically divided into 4 even groups. Demographics, baseline deformity/correction, and surgical metrics were compared using Student t-test. Postoperative and revision rates were compared using Chi-square analysis.

    Results

    Five hundred seventy-three patients were stratified into: G1 (n = 143, 2004-2008), G2 (n = 142, 2008-2009), G3 (n = 144, 2009-2010), G4 (n = 144 2010-2013). The most recent patients were more disabled by Oswestry disability index (G4 = 49.2 vs G1 = 38.3, P = .001), and received a larger osteotomy resection (G4 = 26° vs G1 = 20°, P = .011) than the earliest group. There was a decrease in revision rate (45%, 35%, 33%, 30%, P = .039), notably in revisions for pseudarthrosis (16.7% G1 vs 6.9% G4, P = .007). Major complication rates also decreased (57%, 50%, 46%, 39%, P = .023) as did excessive blood loss (>4 L, 27.2 vs 16.7%, P = .023) and bladder/bowel deficit (4.2% vs 0.7% P = .002). Successful outcomes (no complications or revision) significantly increased (P = .001).

    Conclusion

    Over 9 yr, 3COs are being performed on an increasingly disabled population while gaining a greater correction at the osteotomy site. Revisions and complication rate decreased while success rate improved during the 2-yr follow-up period.
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    ItemOpen 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.
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    Alterations in Magnitude and Shape of Thoracic Kyphosis Following Surgical Correction for Adult Spinal Deformity.
    (Global spine journal, 2023-11) Lafage, Renaud; Song, Junho; Diebo, Bassel; Daniels, Alan H; Passias, Peter G; Ames, Christopher P; Bess, Shay; Eastlack, Robert; Gupta, Munish C; Hostin, Richard; Kebaish, Khaled; Kim, Han Jo; Klineberg, Eric; Mundis, Gregory M; Smith, Justin S; Shaffrey, Christopher; Schwab, Frank; Lafage, Virginie; Burton, Douglas; International Spine Study Group

    Study design

    Retrospective review of prospective multicenter data.

    Objectives

    This study aimed to investigate the shape of TK before and after fusion in ASD patients treated with long fusion.

    Methods

    ASD patients undergoing posterior spinal fusions including at least T5 to L1 without prior fusion extending to the thoracic spine were included. Patients were categorized based on the preoperative T1-T12 kyphosis into: Hypo-TK (if < 30°), Normal-TK, and Hyper-TK (if > 70°). Regional kyphosis at T10-L1 (Distal), T5-T10 (Middle), and T1-T5 (Proximal) and their relative contributions to total kyphosis were compared between groups, and the pre-to postoperative changes were investigated using paired t test.

    Results

    In total, 329 patients were included in this analysis (mean age: 57 ± 16 years, 79.6% female). Preoperative T1-T12 TK for the entire cohort was 40.9 ± 2° (32% Hypo-TK, 11% Hyper-TK, 57% Normal-TK). The Hypo-TK group had the smallest distal TK (5.9 vs 17.1 & 26.0), and middle TK (8.0 vs 25.3 & 45.4), but the percentage of contribution to total kyphosis was not significantly different (Distal: 24.1% vs 34.1% vs 32.8%; Middle: 46.6% vs 53.9% vs 56.8%, all P > .1). Postoperatively, T1-12 TK increased significantly (40.9 ± 2.0° vs 57.8 ± 17.6°). Each group had a decrease in distal kyphosis (Hypo-TK 2.6 ± 10.4°; Normal-TK 8.9 ± 11.5°; Hyper-TK 14.9 ± 12°, all P < .05). The middle kyphosis significantly decreased for Hyper-TK (11.8 ± 12.4) and increased for both Normal-TK and Hypo-TK (3.8 ± 11° and 14.2 ± 11°). Proximal TK increased significantly for all groups by 14-18°. Deterioration from Normal-TK to Hyper-TK postoperatively was associated with lower rate of patient satisfaction (59.6% vs 77.3%, P = .032).

    Conclusions

    Posterior spinal fusion for ASD alters the magnitude and shape of thoracic kyphosis. While 60% of patients had a normal TK at baseline, 30% of those patients developed iatrogenic hyperkyphosis postoperatively. Patients with baseline hypokyphosis were more likely to be corrected to normal TK than hyperkyphotic patients. Future research should investigate TK restoration in ASD and its impact on clinical outcomes and complications.
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    ItemOpen Access
    An Economic Analysis of Early and Late Complications After Adult Spinal Deformity Correction.
    (Global spine journal, 2024-04) Williamson, Tyler K; Owusu-Sarpong, Stephane; Imbo, Bailey; Krol, Oscar; Tretiakov, Peter; Joujon-Roche, Rachel; Ahmad, Salman; Bennett-Caso, Claudia; Schoenfeld, Andrew J; Lebovic, Jordan; Vira, Shaleen; Diebo, Bassel; Lafage, Renaud; Lafage, Virginie; Passias, Peter G

    Study design/setting

    Retrospective cohort.

    Objective

    Adult spinal deformity (ASD) corrective surgery is often a highly invasive procedure portending patients to both immediate and long-term complications. Therefore, we sought to compare the economic impact of certain complications before and after 2 years.

    Methods

    ASD patients with minimum 3-year data included. Complication groups were defined as follows: any complication, major, medical, mechanical, radiographic, and reoperation. Complications stratified by occurrence before or after 2 years postoperatively. Published methods converted ODI to SF-6D to QALYs. Cost was calculated using CMS.gov definitions. Marginalized means for utility gained and cost-per-QALY were calculated via ANCOVA controlling for significant confounders.

    Results

    244 patients included. Before 2Y, complication rates: 76% ≥1 complication, 18% major, 26% required reoperation. After 2Y, complication rates: 32% ≥1 complication, 4% major, 2.5% required reoperation. Major complications after 2 years had worse cost-utility (.320 vs .441, P = .1). Patients suffering mechanical complications accrued the highest overall cost ($130,482.22), followed by infection and PJF for complications before 2 years. Patients suffering a mechanical complication after 2 years had lower cost-utility ($109,197.71 vs $130,482.22, P = .041). Patients developing PJF after 2 years accrued a better cost-utility ($77,227.84 vs $96,873.57; P = .038), compared to PJF before 2 years.

    Conclusion

    Mechanical complications had the single greatest impact on cost-utility after adult spinal deformity surgery, but less so after 2 years. Understanding the cost-utility of specific interventions at certain timepoints may mitigate economic burden and prophylactic efforts should strategically be made against early mechanical complications.
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    ItemOpen Access
    Analysis of Successful Versus Failed Radiographic Outcomes After Cervical Deformity Surgery.
    (Spine, 2018-07) Protopsaltis, Themistocles S; Ramchandran, Subaraman; Hamilton, D Kojo; Sciubba, Daniel; Passias, Peter G; Lafage, Virginie; Lafage, Renaud; Smith, Justin S; Hart, Robert A; Gupta, Munish; Burton, Douglas; Bess, Shay; Shaffrey, Christopher; Ames, Christopher P; International Spine Study Group (ISSG)

    Study design

    Prospective multicenter cohort study with consecutive enrollment.

    Objective

    To evaluate preoperative alignment and surgical factors associated with suboptimal early postoperative radiographic outcomes after surgery for cervical deformity.

    Summary of background data

    Recent studies have demonstrated correlation between cervical sagittal alignment and patient-reported outcomes. Few studies have explored cervical deformity correction prospectively, and the factors that result in successful versus failed cervical alignment corrections remain unclear.

    Methods

    Patients with adult cervical deformity (ACD) included with either cervical kyphosis more than 10°, C2-C7 sagittal vertical axis (cSVA) of more than 4 cm, or chin-brow vertical angle of more than 25°. Patients were categorized into failed outcomes group if cSVA of more than 4 cm or T1 slope and cervical lordosis (TS-CL) of more than 20° at 6 months postoperatively.

    Results

    A total of 71 patients with ACD (mean age 62 yr, 56% women, 41% revisions) were included. Fourty-five had primary cervical deformities and 26 at the cervico-thoracic junction. Thirty-three (46.4%) had failed radiographic outcomes by cSVA and 46 (64.7%) by TS-CL. Failure to restore cSVA was associated with worse preoperative C2 pelvic tilt angle (CPT: 64.4° vs. 47.8°, P = 0.01), worse postoperative C2 slope (35.0° vs. 23.8°, P = 0.004), TS-CL (35.2° vs. 24.9°, P = 0.01), CPT (47.9° vs. 28.2°, P < 0.001), "+" Schwab modifiers (P = 0.007), revision surgery (P = 0.05), and failure to address the secondary, thoracolumbar driver of the deformity (P = 0.02). Failure to correct TS-CL was associated with worse preoperative cervical kyphosis (10.4° vs. -2.1°, P = 0.03), CPT (52.6° vs. 39.1°, P = 0.04), worse postoperative C2 slope (30.2° vs. 13.3°, P < 0.001), cervical lordosis (-3.6° vs. -15.1°, P = 0.01), and CPT (37.7° vs. 24.0°, P < 0.001). Multivariate analysis revealed postoperative distal junctional kyphosis associated with suboptimal outcomes by cSVA (odds ratio 0.06, confidence interval 0.01-0.4, P = 0.004) and TS-CL (odds ratio 0.15, confidence interval 0.02-0.97, P = 0.05).

    Conclusion

    Factors associated with failure to correct the cSVA included revision surgery, worse preoperative CPT, and concurrent thoracolumbar deformity. Failure to correct the TS-CL mismatch was associated with worse preoperative cervical kyphosis and CPT. Occurrence of early postoperative distal junctional kyphosis significantly affects postoperative radiographic outcomes.

    Level of evidence

    3.
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    ItemOpen Access
    Analysis of tranexamic acid usage in adult spinal deformity patients with relative contraindications: does it increase the risk of complications?
    (JOURNAL OF NEUROSURGERY-SPINE, 2024) Mullin, Jeffrey P; Soliman, Mohamed AR; Smith, Justin S; Kelly, Michael P; Buell, Thomas J; Diebo, Bassel; Scheer, Justin K; Line, Breton; Lafage, Virginie; Lafage, Renaud; Klineberg, Eric; Kim, Han Jo; Passias, Peter G; Gum, Jeffrey L; Kebaish, Khaled; Eastlack, Robert K; Daniels, Alan H; Soroceanu, Alex; Mundis, Gregory; Hostin, Richard; Protopsaltis, Themistocles S; Hamilton, D Kojo; Gupta, Munish C; Lewis, Stephen J; Schwab, Frank J; Lenke, Lawrence G; Shaffrey, Christopher I; Bess, Shay; Ames, Christopher P; Burton, Douglas
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    Analysis of tranexamic acid usage in adult spinal deformity patients with relative contraindications: does it increase the risk of complications?
    (Journal of neurosurgery. Spine, 2024-03) Mullin, Jeffrey P; Soliman, Mohamed AR; Smith, Justin S; Kelly, Michael P; Buell, Thomas J; Diebo, Bassel; Scheer, Justin K; Line, Breton; Lafage, Virginie; Lafage, Renaud; Klineberg, Eric; Kim, Han Jo; Passias, Peter G; Gum, Jeffrey L; Kebaish, Khaled; Eastlack, Robert K; Daniels, Alan H; Soroceanu, Alex; Mundis, Gregory; Hostin, Richard; Protopsaltis, Themistocles S; Hamilton, D Kojo; Gupta, Munish C; Lewis, Stephen J; Schwab, Frank J; Lenke, Lawrence G; Shaffrey, Christopher I; Bess, Shay; Ames, Christopher P; Burton, Douglas

    Objective

    Complex spinal deformity surgeries may involve significant blood loss. The use of antifibrinolytic agents such as tranexamic acid (TXA) has been proven to reduce perioperative blood loss. However, for patients with a history of thromboembolic events, there is concern of increased risk when TXA is used during these surgeries. This study aimed to assess whether TXA use in patients undergoing complex spinal deformity correction surgeries increases the risk of thromboembolic complications based on preexisting thromboembolic risk factors.

    Methods

    Data were analyzed for adult patients who received TXA during surgical correction for spinal deformity at 21 North American centers between August 2018 and October 2022. Patients with preexisting thromboembolic events and other risk factors (history of deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, peripheral vascular disease, or cancer) were identified. Thromboembolic complication rates were assessed during the postoperative 90 days. Univariate and multivariate analyses were performed to assess thromboembolic outcomes in high-risk and low-risk patients who received intravenous TXA.

    Results

    Among 411 consecutive patients who underwent complex spinal deformity surgery and received TXA intraoperatively, 130 (31.6%) were considered high-risk patients. There was no significant difference in thromboembolic complications between patients with and those without preexisting thromboembolic risk factors in univariate analysis (high-risk group vs low-risk group: 8.5% vs 2.8%, p = 0.45). Specifically, there were no significant differences between groups regarding the 90-day postoperative rates of DVT (high-risk group vs low-risk group: 1.5% vs 1.4%, p = 0.98), PE (2.3% vs 1.8%, p = 0.71), acute MI (1.5% vs 0%, p = 0.19), or stroke (0.8% vs 1.1%, p > 0.99). On multivariate analysis, high-risk status was not a significant independent predictor for any of the thromboembolic complications.

    Conclusions

    Administration of intravenous TXA during the correction procedure did not change rates of thromboembolic events, acute MI, or stroke in this cohort of adult spinal deformity surgery patients.
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    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.
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    Are the Arbeitsgemeinschaft Für Osteosynthesefragen (AO) Principles for Long Bone Fractures Applicable to 3-Column Osteotomy to Reduce Rod Fracture Rates?
    (Clinical spine surgery, 2022-06) Virk, Sohrab; Lafage, Renaud; Bess, Shay; Shaffrey, Christopher; Kim, Han J; Ames, Christopher; Burton, Doug; Gupta, Munish; Smith, Justin S; Eastlack, Robert; Klineberg, Eric; Mundis, Gregory; Schwab, Frank; Lafage, Virginie; International Spine Study Group

    Objective

    The aim was to determine whether applying Arbeitsgemeinschaft für Osteosynthesefragen (AO) principles for external fixation of long bone fracture to patients with a 3-column osteotomy (3CO) would be associated with reduced rod fracture (RF) rates.

    Summary of background data

    AO dictate principles to follow when fixating long bone fractures: (1) decrease bone-rod distance; (2) increase the number of connecting rods; (3) increase the diameter of rods; (4) increase the working length of screws; (5) use multiaxial fixation. We hypothesized that applying these principles to patients undergoing a 3CO reduces the rate of RF.

    Methods

    Patients were categorized as having RF versus no rod fracture (non-RF). Details on location and type of instrumentation were collected. Dedicated software was used to calculate the distance between osteotomy site and adjacent pedicle screws, angle between screws and the distance between the osteotomy site and rod. Classic sagittal spinopelvic parameters were evaluated.

    Results

    The study included 170 patients (34=RF, 136=non-RF). There was no difference in age (P=0.224), sagittal vertical axis correction (P=0.287), or lumbar lordosis correction (P=0.36). There was no difference in number of screws cephalad (P=0.62) or caudal (P=0.31) to 3CO site. There was a lower rate of RF for patients with >2 rods versus 2 rods (P<0.001). Patients with multiplanar rod fixation had a lower rod fracture rate (P=0.01). For patients with only 2 rods (N=68), the non-RF cohort had adjacent screws that trended to have less angulation to each other (P=0.06) and adjacent screws that had a larger working length (P=0.03).

    Conclusions

    A portion of AO principles can be applied to 3CO to reduce RF rates. Placing more rods around a 3CO site, placing rods in multiple planes, and placing adjacent screws with a larger working length around the 3CO site is associated with lower RF rates.
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    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 Group

    Background

    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.
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    ItemOpen 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 I

    Objective

    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.