Browsing by Author "Lafage, V"
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Item Open Access 166 Predictive Modeling of Length of Hospital Stay Following Adult Spinal Deformity Correction: Analysis of 653 Patients With an Accuracy of 75% Within 2 Days(Neurosurgery, 2016-08-01) Scheer, JK; Ailon, TT; Smith, JS; Hart, R; Burton, DC; Bess, S; Neuman, BJ; Passias, PG; Miller, E; Shaffrey, CI; Schwab, F; Lafage, V; Klineberg, E; Ames, CPINTRODUCTION: The length of stay (LOS) following adult spinal deformity (ASD) surgery is a critical time period allowing for recovery to levels safe enough to return home or to rehabilitation. Thus, the goal is to minimize it for conserving hospital resources and third-party payer pressure. Factors related to LOS have not been studied nor has a predictive model been created. The goal of this study was to construct a preadmission predictive model based on patients' baseline variables and modifiable surgical parameters.Item Open Access Adult Spinal Deformity Surgeons Are Unable to Accurately Predict Postoperative Spinal Alignment Using Clinical Judgment Alone(Spine Deformity, 2016-07-01) Ailon, T; Scheer, JK; Lafage, V; Schwab, FJ; Klineberg, E; Sciubba, DM; Protopsaltis, TS; Zebala, L; Hostin, R; Obeid, I; Koski, T; Kelly, MP; Bess, S; Shaffrey, CI; Smith, JS; Ames, CPObject Adult spinal deformity (ASD) surgery seeks to reduce disability and improve quality of life through restoration of spinal alignment. In particular, correction of sagittal malalignment is correlated with patient outcome. Inadequate correction of sagittal deformity is not infrequent. The present study assessed surgeons' ability to accurately predict postoperative alignment. Methods Seventeen cases were presented with preoperative radiographic measurements, and a summary of the operation as performed by the treating physician. Surgeon training, practice characteristics, and use of surgical planning software was assessed. Participants predicted if the surgical plan would lead to adequate deformity correction and attempted to predict postoperative radiographic parameters including sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence to lumbar lordosis mismatch (PI-LL), thoracic kyphosis (TK). Results Seventeen surgeons participated: 71% within 0 to 10 years of practice; 88% devote >25% of their practice to deformity surgery. Surgeons accurately judged adequacy of the surgical plan to achieve correction to specific thresholds of SVA 69% ± 8%, PT 68% ± 9%, and PI-LL 68% ± 11% of the time. However, surgeons correctly predicted the actual postoperative radiographic parameters only 42% ± 6% of the time. They were more successful at predicting PT (61% ± 10%) than SVA (45% ± 8%), PI-LL (26% ± 11%), or TK change (35% ± 21%; p <.05). Improved performance correlated with greater focus on deformity but not number of years in practice or number of three-column osteotomies performed per year. Conclusion Surgeons failed to correctly predict the adequacy of the proposed surgical plan in approximately one third of presented cases. They were better at determining whether a surgical plan would achieve adequate correction than predicting specific postoperative alignment parameters. Pelvic tilt and SVA were predicted with the greatest accuracy.Item Open Access Area under the Curve: Analysis of Approach-Related Recovery Time in 165 Operative Cervical Spondylotic Myelopathy Patients with a 2-Year Follow-Up(Global Spine Journal, 2015-05-01) Challier, V; Smith, J; Shaffrey, C; Kim, HJ; Arnold, P; Liu, S; Scheer, J; Chapman, J; Protopsaltis, T; Lafage, V; Schwab, F; Massicotte, E; Yoon, ST; Fehlings, M; Ames, CIntroduction Much debate about postoperative outcomes regarding surgical approaches for cervical spondylotic myelopathy (CSM) exists in the literature with no clear evidence of superiority. We propose a novel method for assessing health-related quality of life (HRQOL) outcomes by taking into account each patient's baseline at postoperative time points and analyzing the “area under the curve” (AUC), a proxy for suffering time. Patients and Methods Post hoc analysis of a prospective, multicenter database of patients with CSM. A total of 165 patients met the following inclusion criteria: symptomatic CSM, age older than 18 years, and 2-year follow-up with modified Japanese Orthopaedic Association (mJOA) and neck disability index (NDI). The anterior approach group (AAG) ( n = 110) and posterior approach group (PAG) ( n = 55) were compared at baseline, 1 year, and 2 years for each HRQOL. This comparison was repeated with normalization, using the patient's baseline as the anchor, followed by an integration and comparison of AUC. Results and Conclusion: For the first time, AUC analysis was applied to evaluating patients with CSM. Nonnormalized HRQOLs demonstrated the AAG started higher and met better standards at all times points compared with the PAG. Normalized mJOA demonstrated the PAG actually did better at 2 years, whereas NDI suggested that the AAG did better, although this was not significant. AUC analysis further supported the superiority of the PAG, with statistical significance at 1 and 2 years' time points, suggesting that patients who undergo the posterior approach may suffer less in the first 2 years of their postoperative course.Item Open Access Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: An international survey of spine surgeons(Journal of Neurosurgery: Spine, 2015-11-01) Maggio, D; Ailon, TT; Smith, JS; Shaffrey, CI; Lafage, V; Schwab, F; Haid, RW; Protopsaltis, T; Klineberg, E; Scheer, JK; Bess, S; Arnold, PM; Chapman, J; Fehlings, MG; Ames, COBJECT: The associations among global spinal alignment, patient-reported disability, and surgical outcomes have increasingly gained attention. The assessment of global spinal alignment requires standing long-cassette anteroposterior and lateral radiographs; however, spine surgeons routinely rely only on short-segment imaging when evaluating seemingly isolated lumbar pathology. This may prohibit adequate surgical planning and may predispose surgeons to not recognize associated pathology in the thoracic spine and sagittal spinopelvic malalignment. The authors used a case-based survey questionnaire to evaluate if including long-cassette radiographs led to changes to respondents' operative plans as compared with their chosen plan when cases contained standard imaging of the involved lumbar spine only. METHODS: A case-based survey was distributed to AOSpine International members that consisted of 15 cases of lumbar spine pathology and lumbar imaging only. The same 15 cases were then shuffled and presented a second time with additional long-cassette radiographs. Each case required participants to select a single operative plan with 5 choices ranging from least to most extensive. The cases included 5 "control" cases with normal global spinal alignment and 10 "test" cases with significant sagittal and/or coronal malalignment. Mean scores were determined for each question with higher scores representing more invasive and/or extensive operative plans. RESULTS: Of 712 spine surgeons who started the survey, 316 (44%) completed the entire series, including 68% of surgeons with spine fellowship training and representation from more than 40 countries. For test cases, but not for control cases, there were significantly higher average surgical invasiveness scores for cases presented with long-cassette radiographs (4.2) as compared with those cases with lumbar imaging only (3.4; p = 0.002). The addition of long-cassette radiographs resulted in 82.1% of respondents recommending instrumentation up to the thoracic spine, a 23.2% increase as compared with the same cases presented with lumbar imaging only (p = 0.008). CONCLUSIONS: This study demonstrates the importance of maintaining a low threshold for performing standing long-cassette imaging when assessing seemingly isolated lumbar pathology. Such imaging is necessary for the assessment of spinopelvic and global spinal alignment, which can be important in operative planning. Deformity, particularly positive sagittal malalignment, may go undetected unless one maintains a high index of suspicion and obtains long-cassette radiographs. It is recommended that spine surgeons recognize the prevalence and importance of such deformity when contemplating operative intervention.Item Open Access Clinical Impact Correlation of a Delphi-Based Proximal Junctional Kyphosis Severity Scale and HRQOL(Global Spine Journal, 2015-05-01) Lau, D; Funao, H; Clark, A; Smith, J; Bess, S; Shaffrey, C; Schwab, F; Lafage, V; Deviren, V; Hart, R; Kebaish, K; Ames, CIntroduction Proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) are adverse outcomes following adult spinal surgery (ASD) surgery. There is a lack of consensus regarding which patients (pts) require revision surgery. The Hart ISSG PJK severity scale correlates with the need for revision surgery. This study evaluates the Hart International Spine Study Group (ISSG) PJK severity scale and health-related quality of life (HRQOL) measures in pts with PJK. Patients and Methods All ASD pts with PJK and/or PJF who eventually underwent revision surgery were identified from two large academic medical centers. Pts were retrospectively assigned scores based on the Hart ISSG PJK severity scale: neurological status, focal pain, instrumentation problem, kyphosis severity/PLC integrity, UIV/UIV + 1 fracture, and level of UIV. Scores range from 0 to 15. Pre-PJK revision HRQOL measures included: Oswestry disability index (ODI), short-form 36 (SF-36), and Scoliosis Research Society questionnaire (SRS30). Scores were subcategorized into 0 to 2, 3 to 5, 6 to 8, 9 to 11, and 12 to 15, and differences in HRQOL outcomes were determined with linear regression. Correlation was assessed with a Pearson correlation coefficient. Results A total of 54 cases were included, out of which 31.5% were male, and the mean age was 64.9 years. The Hart ISSG PJK severity scale scores ranged from 4 to 15, with the median being 8. PJK/PJF occurred in the upper thoracic spine in 24.1% of the cases. 54.8% had fractures and 77.8% had instrumentation issues. Overall, 55.6% had neurological deficits, with 16.7% having weakness and/or myelopathy. All pts had preoperative pain (median VAS 9/10). While statistical significance on linear regression was not seen, there were obvious trends that correlated with the Hart ISSG PJK severity scale. Higher Hart ISSG PJK severity scale scores were associated with higher ODI (p = 0.283, r = 0.350), lower SRS30 function (p = 0.821, r = −0.323), and lower SRS mental (p = 0.646, r = −0.592). Conclusion The Hart ISSG PJK severity scale has been shown to be predictive in the decision making of when patients require revision surgery. Based on the current study, it may also correlate with functional outcomes, specifically ODI and SRS30 components.Item Open Access Clinically Significant Thromboembolic Disease in Adult Spinal Deformity Surgery: Incidence and Risk Factors in 737 Patients(Global Spine Journal, 2018-05-01) Kim, HJ; Iyer, S; Diebo, BG; Kelly, MP; Sciubba, D; Schwab, F; Lafage, V; Mundis, GM; Shaffrey, CI; Smith, JS; Hart, R; Burton, D; Bess, S; Klineberg, EOStudy Design: Retrospective cohort study. Objectives: Describe the rate and risk factors for venous thromboembolic events (VTEs; defined as deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in adult spinal deformity (ASD) surgery. Methods: ASD patients with VTE were identified in a prospective, multicenter database. Complications, revision, and mortality rate were examined. Patient demographics, operative details, and radiographic and clinical outcomes were compared with a non-VTE group. Multivariate binary regression model was used to identify predictors of VTE. Results: A total of 737 patients were identified, 32 (4.3%) had VTE (DVT = 14; PE = 18). At baseline, VTE patients were less likely to be employed in jobs requiring physical labor (59.4% vs 79.7%, P <.01) and more likely to have osteoporosis (29% vs 15.1%, P =.037) and liver disease (6.5% vs 1.4%, P =.027). Patients with VTE had a larger preoperative sagittal vertical axis (SVA; 93 mm vs 55 mm, P <.01) and underwent larger SVA corrections. VTE was associated with a combined anterior/posterior approach (45% vs 25%, P =.028). VTE patients had a longer hospital stay (10 vs 7 days, P <.05) and higher mortality rate (6.3% vs 0.7%, P <.01). Multivariate analysis demonstrated osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE (r2 =.11, area under the curve = 0.74, P <.05). Conclusions: The incidence of VTE in ASD is 4.3% with a DVT rate of 1.9% and PE rate of 2.4%. Osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE. Patients with VTE had a higher mortality rate compared with non-VTE patients.Item Open Access Comparison of Best versus Worst Clinical Outcomes for Adult Spinal Deformity Surgery: A Prospective, Multicenter Assessment with Minimum 2-Year Follow-Up(Global Spine Journal, 2015-05-01) Smith, J; Shaffrey, C; Lafage, V; Schwab, F; Protopsaltis, T; Klineberg, E; Gupta, M; Hostin, R; Ming-Fu, K; Soroceanu, A; Hart, R; Burton, D; Bess, S; Ames, CIntroduction Adults with spinal deformity typically present with pain and disability. Our objective was to compare outcomes for op and nonop treatment for ASD based on a prospective, multicenter patient population. Patients and Methods This is a multicenter, prospective analysis of consecutive patients with ASD electing for op or non-op care at enrollment. Inclusion criteria are age < 18 years and ASD. Propensity scores were used to match an op and nonop patients based on baseline (BL) ODI, SRS22, maximum thoracolumbar/lumbar Cobb angle, pelvic incidence to lumbar lordosis mismatch (PI–LL), and leg pain numeric rating scale (NRS) score. Results A total of 689 patients met criteria, including 286 op and 403 non-op, with mean ages of 53 and 55 years, minimum 2-year follow-up rates of 86 and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At BL, compared with nonop, op patients had significantly worse HRQL based on ODI, SRS22, SF36, and leg and back pain NRS (p > 0.001) and had worse deformity based on pelvic tilt, PI–LL, and C7SVA (p > 0.002). Before reaching minimum 2-year follow-up, 38 non-op patients converted to op treatment and were analyzed in the op group. At minimum 2-year follow-up, all HRQL measures assessed significantly improved for op patients (p > 0.001), but none of these measures improved significantly for non-op patients (p < 0.11). Overall, 97 matched op–non-op pairs were identified based on propensity scores. At last follow-up, the 97 matched op patients had significant improvement in all HRQL measures assessed (p > 0.001), but the 97 matched non-op patients lacked significant improvement in any of the HRQL measures (p < 0.20). Paired op–non-op analysis demonstrated the op patients to have significantly better HRQL scores at follow-up for all measures assessed (p > 0.001), except SF36 MCS (p = 0.058). Overall minor and major complication rates for op patients were 53 and 40%, respectively. Conclusion Op treatment for ASD can provide significant improvement of HRQL measures at minimum 2-year follow-up. In contrast, non-op treatment appears to at best maintain presenting levels of pain and disability.Item Open Access Determining the utility of three-column osteotomies in revision surgery compared with primary surgeries in the thoracolumbar spine: a retrospective cohort study in the United States(Asian Spine Journal, 2024-01-01) Williamson, TK; Onafowokan, OO; Das, A; Mir, JM; Krol, O; Tretiakov, P; Joujon-Roche, R; Imbo, B; Ahmad, S; Owusu-Sarpong, S; Lebovic, J; Vira, S; Schoenfeld, AJ; Janjua, MB; Diebo, B; Lafage, R; Lafage, V; Passias, PGStudy Design: Retrospective cohort study. Purpose: To determine the incidence and success of three-column osteotomies (3COs) performed in primary and revision adult spine deformity (ASD) corrective surgeries. Overview of Literature: 3COs are often required to correct severe, rigid ASD presentations. However, controversy remains on the utility of 3COs, particularly in primary surgery. Methods: Patients ASD having 2-year data were included and divided into 3CO and non-3CO (remaining ASD cohort) groups. For the subanalysis, patients were stratified based on whether they were undergoing primary (P3CO) or revision (R3CO) surgery. Multivariate analysis controlling for age, Charlson comorbidity index, body mass index, baseline pelvic incidence–lumbar lordosis, and fused levels evaluated the complication rates and radiographic and patient-reported outcomes between the 3CO and non-3CO groups. Results: Of the 436 patients included, 20% had 3COs. 3COs were performed in 16% of P3COs and 51% of R3COs. Both 3CO groups had greater severity in deformity and disability at baseline; however, only R3COs improved more than non-3COs. Despite greater segmental correction, 3COs had much lower rates of aligning in the lumbar distribution index (LDI), higher mechanical complications, and more reoperations when performed below L3. When comparing P3COs and R3COs, baseline lumbopelvic and global alignments, as well as disability, were different. The R3CO group had greater clinical improvements and global correction (both p <0.04), although the P3CO group achieved alignment in LDI more often (odds ratio, 3.9; 95% confidence interval, 1.3–6.2; p =0.006). The P3CO group had more neurological complications (30% vs. 13%, p =0.042), whereas the R3CO tended to have higher mechanical complication rates (25% vs. 15%, p =0.2). Conclusions: 3COs showed greater improvements in realignment while failing to demonstrate the same clinical improvement as primaries without a 3CO. Overall, when suitably indicated, a 3CO offers superior utility for achieving optimal realignment across primary and revision surgeries for ASD correction.Item Open Access Impact of obesity on complications, infection, and patient-reported outcomes in adult spinal deformity surgery(Journal of Neurosurgery: Spine, 2015-11-01) Soroceanu, A; Burton, DC; Diebo, BG; Smith, JS; Hostin, R; Shaffrey, CI; Boachie-Adjei, O; Mundis, GM; Ames, C; Errico, TJ; Bess, S; Gupta, MC; Hart, RA; Schwab, FJ; Lafage, VOBJECT: Adult spinal deformity (ASD) surgery is known for its high complication rate. This study examined the impact of obesity on complication rates, infection, and patient-reported outcomes in patients undergoing surgery for ASD. METHODS: This study was a retrospective review of a multicenter prospective database of patients with ASD who were treated surgically. Patients with available 2-year follow-up data were included. Obesity was defined as having a body mass index (BMI) ≥ 30 kg/m2. Data collected included complications (total, minor, major, implant-related, radiographic, infection, revision surgery, and neurological injury), estimated blood loss (EBL), operating room (OR) time, length of stay (LOS), and patient-reported questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], and Scoliosis Research Society [SRS]) at baseline and at 6 weeks, 1 year, and 2 years postoperatively. The impact of obesity was studied using multivariate modeling, accounting for confounders. RESULTS: Of 241 patients who satisfied inclusion criteria, 175 patients were nonobese and 66 were obese. Regression models showed that obese patients had a higher overall incidence of major complications (IRR 1.54, p = 0.02) and wound infections (odds ratio 4.88, p = 0.02). Obesity did not increase the number of minor complications (p = 0.62), radiographic complications (p = 0.62), neurological complications (p = 0.861), or need for revision surgery (p = 0.846). Obesity was not significantly correlated with OR time (p = 0.23), LOS (p = 0.9), or EBL (p = 0.98). Both groups experienced significant improvement over time, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001). CONCLUSIONS: This study revealed that obese patients have an increased risk of complications following ASD correction. Despite these increased complications, obese patients do benefit from surgical intervention; however, their improvement in health-related quality of life (HRQL) is less than that of nonobese patients.Item Open Access Lowest Instrumented Vertebra Selection to S1 or Ilium Versus L4 or L5 in Adult Spinal Deformity: Factors for Consideration in 349 Patients With a Mean 46-Month Follow-Up(Global Spine Journal, 2023-05-01) Yao, YC; Kim, HJ; Bannwarth, M; Smith, J; Bess, S; Klineberg, E; Ames, CP; Shaffrey, CI; Burton, D; Gupta, M; Mundis, GM; Hostin, R; Schwab, F; Lafage, VStudy Design: Retrospective cohort study. Objective: To compare the outcomes of patients with adult spinal deformity (ASD) following spinal fusion with the lowest instrumented vertebra (LIV) at L4/L5 versus S1/ilium. Methods: A multicenter ASD database was evaluated. Patients were categorized into 2 groups based on LIV levels—groups L (fusion to L4/L5) and S (fusion to S1/ilium). Both groups were propensity matched by age and preoperative radiographic alignments. Patient demographics, operative details, radiographic parameters, revision rates, and health-related quality of life (HRQOL) scores were compared. Results: Overall, 349 patients had complete data, with a mean follow-up of 46 months. Patients in group S (n = 311) were older and had larger sagittal and coronal plane deformities than those in group L (n = 38). After matching, 28 patients were allocated to each group with similar demographic, radiographic, and clinical parameters. Sagittal alignment restoration at postoperative week 6 was significantly better in group S than in group L, but it was similar in both groups at the 2-year follow-up. Fusion to S1/ilium involved a longer operating time, higher PJK rates, and greater PJK angles than that to L4/L5. There were no significant differences in the complication and revision rates between the groups. Both groups showed significant improvements in HRQOL scores. Conclusions: Fusion to S1/ilium had better sagittal alignment restoration at postoperative week 6 and involved higher PJK rates and greater PJK angles than that to L4/L5. The clinical outcomes and rates of revision surgery and complications were similar between the groups.Item Open Access Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity(Neurosurgery, 2016-09) Smith, JS; Lafage, V; Shaffrey, CItem Open Access Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity (ASD): A Prospective, Multicenter Matched and Unmatched Cohort Assessment with Minimum 2-Year Follow-Up(Global Spine Journal, 2015-05-01) Smith, J; Lafage, V; Shaffrey, C; Schwab, F; Hostin, R; Boachie-Adjei, O; Akbarnia, B; Klineberg, E; Gupta, M; Deviren, V; Hart, R; Burton, D; Bess, S; Ames, CIntroduction Adults with spinal deformity typically present with pain and disability. Aim Our objective was to compare outcomes for operative (op) and nonoperative (nonop) treatment for ASD based on a prospective, multicenter patient population. Material and Methods This is a multicenter, prospective analysis of consecutive ASD patients electing for op or nonop care at enrollment. Inclusion criteria: age > 18 year and ASD. Propensity scores were used to match op and nonop patients based on baseline (BL) ODI, SRS22, maximum thoracolumbar/lumbar Cobb angle, pelvic incidence to lumbar lordosis mismatch (PI-LL), and leg pain numeric rating scale (NRS) score. Results A total of 689 patients met with the criteria, including 286 op and 403 nonop, with mean ages of 53 and 55 years, minimum 2-year follow-up rates of 86 and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At BL, compared with nonop, op patients had significantly worse HRQL based on ODI, SRS22, SF36, and leg and back pain NRS (p < 0.001) and had worse deformity based on pelvic tilt, PI-LL, and C7SVA (p ≤ 0.002). Before reaching minimum 2-year follow-up 38 nonop patients converted to op treatment and were analyzed in the op group. At minimum 2-year follow-up all HRQL measures assessed significantly improved for op patients (p < 0.001), but none of these measures improved significantly for nonop patients (p ≥ 0.11). Total 97 matched op–nonop pairs were identified based on propensity scores. At last follow-up the 97 matched op patients had significant improvement in all HRQL measures assessed (p < 0.001), but the 97 matched nonop patients lacked significant improvement in any of the HRQL measures (p ≥ 0.20). Paired op–nonop analysis demonstrated the op patients to have significantly better HRQL scores at follow-up for all measures assessed (p < 0.001), except SF36 MCS (p = 0.058). Overall minor and major complication rates for op patients were 53 and 40%, respectively. Conclusion Op treatment for ASD can provide significant improvement of HRQL measures at minimum 2-year follow-up. In contrast, nonop treatment appears to at best maintain presenting levels of pain and disability.Item Open Access Preoperative Cervical Hyperlordosis and C2–T3 Angle are Correlated to Increased Risk of Post-Op Sagittal Spinal Pelvic Malalignment in Adult Spinal Deformity Patients at 2-Year Follow-Up(Global Spine Journal, 2015-05-01) Passias, P; Yang, S; Soroceanu, A; Scheer, J; Schwab, F; Shaffrey, C; Kim, HJ; Protopsaltis, T; Mundis, G; Gupta, M; Klineberg, E; Lafage, V; Smith, J; Ames, CIntroduction Cervical deformity (CD) is prevalent among patients with adult spinal deformity (ASD). The effect of baseline cervical alignment and achieving optimal TL alignment in ASD surgery is unclear. This study assesses the relationship between preoperative cervical spinal parameters and global alignment following thoracolumbar ASD surgery at 2-year follow-up. Patients and Methods Using a multicenter prospective database of surgical patients with ASD, we included patients with 2-year follow-up and cervical X-rays. SRS-Schwab sagittal modifiers (PT, GA, and PI–LL) were assessed at 2-year postoperative as either normal (0) or abnormal (“ + ” or “ + +”). Patients were classified in the aligned group (AG) or maligned group (MG) if all the three sagittal modifiers were normal or abnormal, respectively. Patients were assessed for CD based on the following criteria: C2–C7 SVA > 4 cm, C2–C7 SVA < 4 cm, cervical kyphosis (CL > 0), cervical lordosis (CL < 0), any deformity (C2C7 SVA > 4 cm or CL > 0), and both CD (C2C7 SVA > 4 cm and CL > 0). Univariate testing was performed using t test or chi-square test, looking at the following pre-op parameters: CD, C2–C7 SVA, C2–T3 SVA, CL, T1S, T1S–CL, C2–T3 angle, LL, TK, PT, C7–S1 SVA, and PI–LL. Results A total of 184 patients met initial inclusion criteria with 70 in the AG and 34 in MG. Pre-op, patients in the MG had a higher cervical lordosis (11.7 vs. 4.9, p = 0.03), higher C2–T3 angle (13.59 vs. 4.9 p = 0.01), and higher PT ( p < 0.0001), higher SVA ( p < 0.0001), and higher PI–LL ( p < 0.0001) compared with the AG. Interestingly, the prevalence of CD at baseline was similar for both the groups: MG and AG. There was no statistically significant difference in the amount of improvement over 2 years on the ODI or the SF-36 PCS. Conclusion Patients with 2-year sagittal TL malalignment also have preoperative sagittal TL malalignment and concomitant cervical hyperlordosis as a compensatory mechanism to maintain horizontal gaze. Cervical radiographs suggestive of cervical hyperlordosis should be followed up with complete standing radiographs to asses for sagittal TL malalignment.Item Open Access Preoperative dysphonia and dysphagia improve following cervical deformity surgery(Spine Journal, 2024-09-01) Soroceanu, A; Gum, JL; Protopsaltis, TS; Hamilton, DK; Passias, PG; Lafage, R; Smith, JS; Kebaish, KM; Eastlack, RK; Klineberg, EO; Gupta, MC; Lafage, V; Schwab, FJ; Shaffrey, CI; Bess, S; Burton, DC; Ames, CPBACKGROUND CONTEXT: Twenty-five percent of adult cervical deformity patients undergoing deformity correction have impairment due to a voice problem prior to surgery. Prior work has shown that these patients tend to be more frail and more likely to report preoperative dysphagia. We hypothesized that these patients could be at increased risk of post operative dysphonia and dysphagia. PURPOSE: The purpose of this study was to quantify how patients with preoperative dysphonia differ from their counterparts in terms postoperative dysphagia, dysphonia and HRQOL 6 weeks post surgery. STUDY DESIGN/SETTING: Retrospective analysis of a prospective multicenter cervical deformity database. PATIENT SAMPLE: Adult cervical deformity patients with preop dysphonia undergoing deformity correction. OUTCOME MEASURES: Voice handicap index-10 (VHI-10). METHODS: Retrospective analysis of a prospective multicenter cervical deformity database. The voice handicap index-10 (VHI-10) was used to assess patient's perception of impairment due to problems with their voice prior to surgery. A score ≥11 was considered indicative of dysphonia. Patients were divided into two groups: normalVHI group (VHI-10 score <11) and highVHI group (VHI score ≥11). The two groups were compared in terms of baseline demographics, alignment, surgical metrics, and 6-week dysphagia (measured on the EAT-10 questionnaire), and post operative outcomes. T-tests and chi2 tests were performed, as appropriate. The significance level was p<0.05. RESULTS: There were 74 ACD patients included: NormalVHI (n=58, average VHI score 2.77) and HighVHI (n=16, average VHI score 16.37). The groups were similar in terms of baseline demographics and preoperative alignment. There was no statistically significant difference in terms of surgical metrics between the two groups (revision surgery p=0.21, anterior approach p=0.92, use of osteotomies p=0.71, and OR time p=0.15). The two groups had a similar rate of in hospital adverse events (12.2% vs 7.7%, p=0.64), and similar improvements on the NDI, mJOA, and NRS neck and arm pain. HighVHI patients showed significant improvement on the VHI score 6 weeks post-surgery (11.18 vs 16.37, p=0.01). The HighVHI group also showed postoperative improvement on the EAT-10 questionnaire, compared to NormalVHI patients (-3.68 vs 4.03, p=0.003). CONCLUSIONS: Twenty-five percent of adult cervical deformity patients undergoing deformity correction have impairment due to a voice problem prior to surgery. Contrary to our initial hypothesis, these patients exhibited improvement in dysphonia and dysphagia scores 6 weeks post surgery, with 81% reporting improvement in symptoms of dysphonia, and 69% reporting improvement in symptoms of oropharyngeal dysphagia. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Proximal junctional kyphosis and failure: How much can we attribute to known risk factors?(Spine Journal, 2024-09-01) Onafowokan, O; Jankowski, PP; Mir, J; Das, A; Hockley, A; Lorentz, N; Galetta, MS; Lebovic, J; Hamilton, DK; Diebo, BG; Daniels, AH; Anand, N; Pour, PT; Sciubba, DM; Ramos, RDLG; Shaffrey, CI; Lafage, R; Lafage, V; Schoenfeld, AJ; Passias, PGBACKGROUND CONTEXT: Despite advancements in the understanding of spinal alignment and in instrumentation for adult spine deformity (ASD) surgery, complications such as proximal junctional kyphosis and proximal junctional failure (PJK/PJF) continue to be a significant concern. PURPOSE: To assess the attributable risk of various reported contributors to development of PJK/PJF. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A total of 464 ASD patients. OUTCOME MEASURES: Odds ratios of PJK/F risk factors. METHODS: We included ASD patients with complete baseline (BL) and up to 2Y clinical, radiographic and HRQL data. Stratified according to development of PJK/PJF by 2 years. Means comparison analyses compared outcomes between groups. Backstep logistic regression assessed factors predictive of PJK/F development. RESULTS: There were 464 patients included (age: 59.8 ± 14.3 years, BMI: 26.9 ± 5.5 kg/m2, CCI: 1.65 ± 1.68). 80.5% of patients were female; 173 patients (37.3%) formed the PJK/F+ group, as at 2 years (173 PJK and 28 PJF patients). At BL, PJK/F+ patients were older (63.2 vs 57.9 years, p<0.001) and had worse deformity (PI-LL 20.3 vs 11.8, p<0.001). There were no differences between groups in baseline disability, demographic, frailty or comorbidity factors. Controlling for age and baseline deformity, PJK/F+ patients were more likely to develop mechanical complications (OR 2.1, 95% CI: 1.2-3.7, p=0.007). Use of PJK prophylaxis techniques did not have a significant effect on risk of developing PJK/F (p=0.307). Factors associated with increased risk of developing PJK/F were significant baseline deformity (OR 1.02, 95% CI: 1.01-1.03, p=0.026), peripheral vascular disease (OR 5.5, 1.3-23.6, p=0.023), undergoing an osteotomy (OR 1.7, 1.1-2.8, p=0.017) and age >60 (OR 1.1, 1.1-1.2, p=0.026) and hypertension (OR 2.01, 1.04-3.87, p=0.038). Diabetes was associated with lower odds for developing PJK/F+ (OR: 0.3, 95% CI: 0.1-0.8, p=0.018). CONCLUSIONS: Proximal junctional kyphosis/failure remains a significant postoperative concern in the ASD population. With currently known risk factors, we are still unable to fully quantify and predict a patient's total risk for developing postoperative PJK/F. Further work is needed to delineate contributing factors that are yet to be determined. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Quantifying the importance of upper cervical extension reserve in adult cervical deformity surgery and its impact on baseline presentation and outcomes(Spine Journal, 2024-09-01) Passias, PG; Mir, J; Smith, JS; Lafage, V; Lafage, R; Diebo, BG; Daniels, AH; Onafowokan, O; Line, B; Eastlack, RK; Mundis, GM; Kebaish, KM; Soroceanu, A; Scheer, JK; Kelly, MP; Protopsaltis, TS; Kim, HJ; Hostin, RA; Gupta, MC; Riew, KD; Burton, DC; Schwab, FJ; Bess, S; Shaffrey, CI; Ames, CPBACKGROUND CONTEXT: Hyperextension of the upper cervical spine is a prominent compensatory mechanism to maintain horizontal gaze and balance in adult cervical deformity (ACD) patients, akin to pelvic tilt in spinal deformity. The relaxation of ER and its impact on postoperative outcomes is not well understood. PURPOSE: To evaluate upper cervical ER impact on postoperative disability and outcomes. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Adult cervical deformity. OUTCOME MEASURES: ER, HRQLs. METHODS: ACD patients undergoing subaxial cervical fusion with 2Y data were included. Upper cervical extension reserve (ER) was defined as: C0-C2 sagittal Cobb angle between neutral and extension. Relaxation of ER was defined as the ER normative mean in those that met the ideal in all Passias ACD modifiers. Outcomes were defined as "good" if meeting ≥2 of the three: (1) NDI <20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Controlled analysis was conducted with ANCOVA and multivariable logistic regressions. Conditional inference tree (CIT) analysis determined thresholds. RESULTS: A total of 108 ACD patients met inclusion. (Age 61.4 ± 12.3, 61% F, BMI 29.4 ± 7.5 kg/m2, mCD-FI .24 ±.12, CCI 0.97 ± 1.30). Radiographic alignment is depicted in Table 1. Preoperative C0-C2 ER was 8.7 ±9.0 ±, and at the last follow-up was 10.3 ± 11.1. ER in those meeting all ideal CD modifiers at 2Y was 12.9 ± 9.0. Preoperatively 29% had adequate ER, while 59.7% had improvement in ER postoperatively, with 50% of patients achieving adequate ER at 2Y. Higher ER significantly correlated with lower cervical deformity (p<.05). Preoperatively, greater ER was predictive of lower preoperative disability, with worse baseline mobility, pain, and anxiety (EQ5D) (B = -6.1, -2.9, -2.9 respectively; R2 =0.212, p<.001). Improvement of ER depicted a higher rate of MCID for NDI (64% vs 39%, p=.008), and meeting good clinical outcomes (72% vs 54%, p=.04). Controlling for baseline deformity and demographic factors found resolution of inadequate ER to have 7x higher likelihood of meeting MCID for NDI (6.941 [1.378-34.961], p=.019) and 4x higher odds of achieving good outcomes (4.022 [1.017-15.900], p=.047). Isolating those with inadequate preoperative ER, found postoperative resolution having 5x odds of good outcomes (p<.05). In those with inadequate ER at baseline, the preoperative C2-C7 of <-18 and TS-CL of >59 for TS-CL was predictive of ER resolution (p<.05). In those with preoperative C2-C7 >-18, a T1PA of >13 was predictive of postoperative return of ER (p<.05). Independently TS-CL of >59, was significant for predicting ER return postoperatively, highlighting its compensatory role for proximal spinal deformities (all p<.05). Surgical correction of C2-C7 by >16 from baseline was found to be predictive of ER return. CONCLUSIONS: Increased preoperative utilization of the extension reserve in the upper cervical spine in cervical deformity was associated with worse baseline regional and global alignment while impacting health-related measures. The majority of patients had relaxation of extension reserve postoperatively, however, in those who didn't, there was a decreased likelihood of achieving good outcomes. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Radiographic outcomes of adult spinal deformity correction: A critical analysis of variability and failures across deformity patterns(Spine Deformity, 2014-01-01) Moal, B; Schwab, F; Ames, CP; Smith, JS; Ryan, D; Mummaneni, PV; Mundis, GM; Terran, JS; Klineberg, E; Hart, RA; Boachie-Adjei, O; Shaffrey, CI; Skalli, W; Lafage, VStudy Design Multicenter, prospective, consecutive, surgical case series from the International Spine Study Group. Objectives To evaluate the effectiveness of surgical treatment in restoring spinopelvic (SP) alignment. Summary of Background Data Pain and disability in the setting of adult spinal deformity have been correlated with global coronal alignment (GCA), sagittal vertical axis (SVA), pelvic incidence/lumbar lordosis mismatch (PI-LL), and pelvic tilt (PT). One of the main goals of surgery for adult spinal deformity is to correct these parameters to restore harmonious SP alignment. Methods Inclusion criteria were operative patients (age greater than 18 years) with baseline (BL) and 1-year full-length X-rays. Thoracic and thoracolumbar Cobb angle and previous mentioned parameters were calculated. Each parameter at BL and 1 year was categorized as either pathological or normal. Pathologic limits were: Cobb greater than 30°, GCA greater than 40 mm, SVA greater than 40 mm, PI-LL greater than 10°, and PT greater than 20°. According to thresholds, corrected or worsened alignment groups of patients were identified and overall radiographic effectiveness of procedure was evaluated by combining the results from the coronal and sagittal planes. Results A total of 161 patients (age, 55 ± 15 years) were included. At BL, 80% of patients had a Cobb angle greater than 30°, 25% had a GCA greater than 40 mm, and 42% to 58% had a pathological sagittal parameter of PI-LL, SVA, and/or PT. Sagittal deformity was corrected in about 50% of cases for patients with pathological SVA or PI-LL, whereas PT was most commonly worsened (24%) and least often corrected (24%). Only 23% of patients experienced complete radiographic correction of the deformity. Conclusions The frequency of inadequate SP correction was high. Pelvic tilt was the parameter least likely to be well corrected. The high rate of SP alignment failure emphasizes the need for better preoperative planning and intraoperative imaging. © 2014 Scoliosis Research Society.Item Open Access Redefining Clinically Significant Blood Loss in Complex Adult Spine Deformity Surgery(Spine, 2024-01-01) Daher, M; Xu, A; Singh, M; Lafage, R; Line, BG; Lenke, LG; Ames, CP; Burton, DC; Lewis, SM; Eastlack, RK; Gupta, MC; Mundis, GM; Gum, JL; Hamilton, KD; Hostin, R; Lafage, V; Passias, PG; Protopsaltis, TS; Kebaish, KM; Schwab, FJ; Shaffrey, CI; Smith, JS; Bess, S; Klineberg, EO; Diebo, BG; Daniels, AHStudy Design. Retrospective analysis of prospectively-collected data Objective. This study aims to define clinically relevant blood loss in adult spinal deformity (ASD) surgery. Background. Current definitions of excessive blood loss following spine surgery are highly variable and may be suboptimal in predicting adverse events (AE). Methods. Adults undergoing complex ASD surgery were included. Estimated blood loss (EBL) was extracted for investigation, and estimated blood volume loss (EBVL) was calculated by dividing EBL by the preoperative blood volume utilizing Nadler's formula. LASSO regression was performed to identify five variables from demographic and peri-operative parameters. Logistic regression was subsequently performed to generate a receiver operating characteristics (ROC) curve and estimate an optimal threshold for EBL and EBVL. Finally, the proportion of patients with AE plotted against EBL and EBVL to confirm the identified thresholds. Results. In total 552 patients were included with a mean age of 60.7±15.1 years, 68% females, mean CCI was 1.0±1.6, and 22% experienced AEs. LASSO regression identified ASA score, baseline hypertension, preoperative albumin, and use of intra-operative crystalloids as the top predictors of an AE, in addition to EBL/EBVL. Logistic regression resulted in ROC curve which was used to identify a cut-off of 2.3 liters of EBL and 42% for EBVL. Patients exceeding these thresholds had AE rates of 36% (odds-ratio: 2.1, 95% CI [1.2-3.6]) and 31% (odds-ratio: 1.7, 95% CI [1.1-2.8]), compared to 21% for those below the thresholds of EBL and EBVL, respectively. Conclusion. In complex ASD surgery, intraoperative EBL of 2.3 liters and an EBVL of 42% are associated with clinically-significant AEs. These thresholds may be useful in guiding preoperative-patient-counseling, healthcare system quality initiatives, and clinical perioperative bloodloss management strategies in patients undergoing complex spine surgery. Additionally, similar methodology could be performed in other specialties to establish procedure-specific clinically-relevant bloodloss thresholds.Item Open Access Sarcopenic obesity: an underrated phenomenon impacting adult spinal deformity intervention outcomes(Spine Journal, 2024-09-01) Das, A; Onafowokan, O; Mir, J; Lorentz, N; Lebovic, J; Daniels, AH; Buell, TJ; Hamilton, DK; Lafage, R; Jankowski, PP; Sardar, Z; Shaffrey, CI; Kim, HJ; Lafage, V; Passias, PGBACKGROUND CONTEXT: The amount and quality of tissue do not always positively correlate as is the case with sarcopenic obesity. As the population of elderly people with adult spinal deformity (ASD) continues to increase, sarcopenia (decreased muscle mass) and obesity continue to soar in prevalence, although sarcopenia is underacknowledged. PURPOSE: To determine how sarcopenic obesity may impact adult spinal deformity surgery outcomes and better characterize the health of important surrounding structural tissue that is key to alignment. STUDY DESIGN/SETTING: Retrospective cohort review of prospectively enrolled database. PATIENT SAMPLE: A total of 529 adult spinal deformity patients. OUTCOME MEASURES: radiographic parameters, mechanical complications, complications METHODS: Operative ASD patients with complete baseline (BL) and 2-year (2Y) baseline, radiographic, and health related quality of life (HRQL) data were included. Sarcopenia was defined based on the validated European Working Group of Sarcopenia in Older People (EWGOSOP2). Obesity was classified via traditional BMI categories. The cohort with sarcopenic obesity (SO) was compared to a cohort of patients without. Descriptive statistics, means comparison testing, and regression analyses were applied to identify differences and trends, including a subanalysis of those with SO vs each condition alone. RESULTS: A total of 529 patients met inclusion criteria (mean age: 60.2±14.3, mean BMI: 27.1±5.8, mean CCI 1.6±1.7, mean weighted mASD-FI: 6.5±4.9). In terms of surgical characteristics, mean operative time 414.1±175.3 minutes, mean EBL 1565.9±1387.2, mean levels fused 10.9 ±4.6). 311 patients (58.8%) registered a confirmed diagnosis of sarcopenia, while 100 patients (60.4%) were considered obese. Altogether, 206 (38.9%) of patients demonstrated aspects of SO. The SO cohort was significantly older (61.9 vs 59.1, p=0.032) with a significantly greater number of comorbidities and higher frailty score (p<.001, both). At baseline, patients with SO demonstrated significantly lower baseline lower extremity motor scores (p=.004). Radiographically, SO patients had greater pelvic tilt (25.2 vs 22.9, p=0.018), greater PI-LL (19.6 vs 12.6, p<.001), less lumbar lordosis (41.7 vs 36.3, p=0.004), greater vertebral pelvic angles (p<.01) at T1, T4, T9, L1 and L4, and greater GAP scores indicating higher disproportionality (p=0.032). In terms of complications, SO patients demonstrated considerably higher rates of cardiac complications (83.3% vs 16.7%, p=0.025) and surgical infection (66.7% vs 33.3%, p=0.025).The SO cohort also sustained a significantly greater rates of pseudarthrosis (64.3% vs 35.7%, p=0.049) and failure with reoperation (60.0% vs 40.0%, p=0.027), with a significantly higher rates instrumentation failure (50.7% vs 49.3%, p=0.045). From a prevention perspective, the use of PJK prophylaxis amongst those with SO showed lower rates of screw breakage (p=0.039) and mechanical complications (p=0.004) as opposed to SO patients who did not receive prophylaxis. SO was a positive predictor of instrumentation failure (OR 1.7, p=0.047) while obesity or sarcopenia were not significant predictors alone. SO patients also achieved age-adjusted match goals at a lower rate than non-SO patients (p<.001). Clinically, this manifested as greater back and leg NSR pain scores at every time point up to 2 years. CONCLUSIONS: Sarcopenic obesity appears to significantly hamper outcomes after ASD, and awareness of the patient's muscle quality could guide operative decision-making as well as serve as a valuable target for preoperative optimization through measures such as nutritional counseling and prehabilitation. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Selection of upper instrumented vertebra in adult spinal deformity: risk calculator and recommendations based on proximal junctional kyphosis(Spine Journal, 2024-09-01) Passias, PG; Mir, J; Das, A; Onafowokan, O; Galetta, M; Shaffrey, CI; Lafage, VBACKGROUND CONTEXT: The surgical correction of adult spinal deformity (ASD) presents a complex and multifaceted challenge, further intensified by the need for revision surgery. Determination of the upper instrumented vertebra can often be challenging. PURPOSE: To develop a UIV risk index score for patients undergoing ASD corrective surgery. STUDY DESIGN/SETTING: Retrospective cohort study of a prospectively collected single-center ASD database. PATIENT SAMPLE: ASD. OUTCOME MEASURES: PJK. METHODS: We included operative ASD patients with a minimum of a 2-year follow-up undergoing fusion from at least L1 and proximal to the sacrum. Patients without PJK were isolated to determine predictive thresholds based on patient and surgical factors. Variable importance was determined utilizing random forest analysis to determine the weighting of variables with multivariable logistic regression. Conditional inference tree (CIT) determined threshold values predictive of UIV level in those who didn't develop PJK. RESULTS: A total of 334 patients met inclusion. (Age 63±10, 77% F, BMI 27.6±5.1 kg/m2, frailty 3.5±1.5, CCI 1.9±1.7). The model for predicting PJK was significant for osteoporosis, LL, TK, TLPA, with posterior UIV and IBD UIV (p<.05). Table 1. Baseline UIV slope of >42.4 had a higher rate of PJK postoperatively (63% vs 27%, p<.001). Evaluating factor importance for the selection of UIV determined UIV slope to have the greatest weight, with T1PA, PJK prophylaxis, PI-LL, frailty, osteoporosis, and CCI following in those who didn't have PJK. For those with UIV slope <12.7, selection of upper thoracic UIV was contingent on T1PA being <7 (p=0.018). Patients with UIV slope >27 and T1PA >30 were likely to have UIV in the upper thoracic (T4 mean) in those who didn't develop PJK. Whereas, those with a UIV slope between 12.7 to 30 with T1PA >30 were less likely to develop PJK with a lower thoracic UIV (p<.001). CONCLUSIONS: The selection of UIV was strongly correlated to UIV slope and T1PA for avoidance of proximal junctional kyphosis. Frailty and lumbar lordosis were important contributors to the model for the selection of optimal UIV. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.