Browsing by Author "Lebovic, Jordan"

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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
    Costs of Surgery in Adult Spinal Deformity: Do Higher Cost Surgeries Lead to Better Outcomes?
    (Spine, 2024-02) Joujon-Roche, Rachel; Dave, Pooja; Tretiakov, Peter; Mcfarland, Kimberly; Mir, Jamshaid; Williamson, Tyler K; Imbo, Bailey; Krol, Oscar; Lebovic, Jordan; Schoenfeld, Andrew J; Vira, Shaleen; Lafage, Renaud; Lafage, Virginie; Passias, Peter G

    Study design

    This was a retrospective study.

    Objective

    To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).

    Summary of background data

    With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.

    Materials and methods

    ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.

    Results

    Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m 2 ), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4°), and pelvic tilt (HC: 25.3 vs. LC: 22.4°). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P =0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P =0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P =0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.

    Conclusions

    Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.

    Level of evidence

    3.
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    ItemOpen Access
    Efficacy of Varying Surgical Approaches on Achieving Optimal Alignment in Adult Spinal Deformity Surgery.
    (Spine, 2023-07) Passias, Peter G; Ahmad, Waleed; Williamson, Tyler K; Lebovic, Jordan; Kebaish, Khaled; Lafage, Renaud; Lafage, Virginie; Line, Breton; Schoenfeld, Andrew J; Diebo, Bassel G; Klineberg, Eric O; Kim, Han Jo; Ames, Christopher P; Daniels, Alan H; Smith, Justin S; Shaffrey, Christopher I; Burton, Douglas C; Hart, Robert A; Bess, Shay; Schwab, Frank J; Gupta, Munish C; International Spine Study Group

    Background

    The Roussouly, SRS-Schwab, and GAP classifications define alignment by spinal shape and deformity severity. The efficacy of different surgical approaches and techniques to successfully achieve these goals is not well understood.

    Purpose

    Identify the impact of surgical approach and/or technique on meeting complex realignment goals in adult spinal deformity(ASD) corrective-surgery.

    Study design/setting

    Retrospective.

    Methods

    Included: ASD patients fused to pelvis with two-year(2Y) data. Patients were categorized by: 1)Roussouly: matching current and theoretical spinal shapes; 2)improving in SRS-Schwab modifiers(0, +, ++); 3)improving GAP Proportionality by 2Y. ANCOVA and multivariable logistic regression analyses controlling for age, levels fused, baseline deformity, and three-column osteotomy usage compared the effect of different surgical approaches, interbody and osteotomy use on meeting realignment goals.

    Results

    693 ASD patients were included. By surgical approach, 65.7% were posterior-only and 34.3% underwent anterior-posterior(AP) approach with 76% receiving an osteotomy(21.8% 3CO). By 2Y, 34% matched Roussouly, 58% improved in GAP, 45% in SRS-Schwab PT, 62% SVA, and 70% PI-LL. Combined approaches were most effective for improvement in PT(OR: 1.7,[1.1-2.5]) and GAP(OR: 2.2,[1.5-3.2]). Specifically, ALIFs below L3 demonstrated higher rates of improvement versus TLIFs in Roussouly(OR: 1.7, [1.1-2.5]) and GAP(OR: 1.9, [1.3-2.7]). Patients undergoing PSO at L3 or L4 were more likely to improve in PT(OR: 2.0,[1.0-5.2]) and PI-LL(OR: 3.8[1.4-9.8]). Clinically, patients undergoing combined approach demonstrated higher rates of meeting SCB in ODI by 2Y while minimizing rates of PJF, most often with an ALIF at L5-S1(ODI-SCB: OR: 1.4,[1.1-2.0];PJF: OR: 0.4,[0.2-0.8]).

    Conclusions

    Among patients undergoing ASD realignment, optimal lumbar shape and proportion can be achieved more often with a combined approach. While TLIFs incorporating a three-column osteotomy at L3 and L4 can restore lordosis and normalize pelvic compensation, ALIFs at L5-S1 were most likely to achieve complex realignment goals with an added clinical benefit and mitigation of junctional failure.
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    ItemOpen Access
    Impact of Frailty on the Development of Proximal Junctional Failure: Does Frailty Supersede Achieving Optimal Realignment?
    (Spine, 2023-10) Krol, Oscar; McFarland, Kimberly; Owusu-Sarpong, Stephane; Sagoo, Navraj; Williamson, Tyler; Joujon-Roche, Rachel; Tretiakov, Peter; Imbo, Bailey; Dave, Pooja; Mir, Jamshaid; Lebovic, Jordan; Onafowokan, Oluwatobi O; Schoenfeld, Andrew J; De la Garza Ramos, Rafael; Janjua, Muhammad Burhan; Sciubba, Daniel M; Diebo, Bassel G; Vira, Shaleen; Smith, Justin S; Lafage, Virginie; Lafage, Renaud; Passias, Peter G

    Background

    Patients undergoing surgery for adult spinal deformity (ASD) are often elderly, frail, and at elevated risk of adverse events perioperatively, with proximal junctional failure (PJF) occurring relatively frequently. Currently, the specific role of frailty in potentiating this outcome is poorly defined.

    Purpose

    To determine if the benefits of optimal realignment in ASD, with respect to the development of PJF, can be offset by increasing frailty.

    Study design

    Retrospective cohort.

    Materials and methods

    Operative ASD patients (scoliosis >20°, SVA>5 cm, pelvic tilt>25°, or TK>60°) fused to the pelvis or below with available baseline and 2-year (2Y) radiographic and HRQL data were included. The Miller Frailty Index (FI) was used to stratify patients into 2 categories: Not Frail (FI <3) and Frail (>3). Proximal Junctional Failure (PJF) was defined using the Lafage criteria. "Matched" and "unmatched" refers to ideal age-adjusted alignment postoperatively. Multivariable regression determined the impact of frailty on the development of PJF.

    Results

    Two hundred eighty-four ASD patients met inclusion criteria [62.2yrs±9.9, 81%F, BMI: 27.5 kg/m 2 ±5.3, ASD-FI: 3.4±1.5, Charlson Comorbidity Index (CCI): 1.7±1.6]. Forty-three percent of patients were characterized as Not Frail (NF) and 57% were characterized as Frail (F). PJF development was lower in the NF group compared with the F group (7% vs . 18%; P =0.002). F patients had 3.2 × higher risk of PJF development compared to NF patients (OR: 3.2, 95% CI: 1.3-7.3, P =0.009). Controlling for baseline factors, F unmatched patients had a higher degree of PJF (OR: 1.4, 95% CI:1.02-1.8, P =0.03); however, with prophylaxis, there was no increased risk. Adjusted analysis shows F patients, when matched postoperatively in PI-LL, had no significantly higher risk of PJF.

    Conclusions

    An increasingly frail state is significantly associated with the development of PJF after corrective surgery for ASD. Optimal realignment may mitigate the impact of frailty on eventual PJF. Prophylaxis should be considered in frail patients who do not reach ideal alignment goals.
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    ItemOpen Access
    Natural history of adult spinal deformity: how do patients with suboptimal surgical outcomes fare relative to nonoperative counterparts?
    (Journal of neurosurgery. Spine, 2023-07) Passias, Peter G; Joujon-Roche, Rachel; Mir, Jamshaid M; Williamson, Tyler K; Tretiakov, Peter S; Imbo, Bailey; Krol, Oscar; Passfall, Lara; Ahmad, Salman; Lebovic, Jordan; Owusu-Sarpong, Stephane; Lanre-Amos, Tomi; Protopsaltis, Themistocles; Lafage, Renaud; Lafage, Virginie; Park, Paul; Chou, Dean; Mummaneni, Praveen V; Fu, Kai-Ming G; Than, Khoi D; Smith, Justin S; Janjua, M Burhan; Schoenfeld, Andrew J; Diebo, Bassel G; Vira, Shaleen

    Objective

    Management of adult spinal deformity (ASD) has increasingly favored operative intervention; however, the incidence of complications and reoperations is high, and patients may fail to achieve idealized postsurgical results. This study compared health-related quality of life (HRQOL) metrics between patients with suboptimal surgical outcomes and those who underwent nonoperative management as a proxy for the natural history (NH) of ASD.

    Methods

    ASD patients with 2-year data were included. Patients who were offered surgery but declined were considered nonoperative (i.e., NH) patients. Operative patients with suboptimal outcome (SOp)-defined as any reoperation, major complication, or ≥ 2 severe Scoliosis Research Society (SRS)-Schwab modifiers at follow-up-were selected for comparison. Propensity score matching (PSM) on the basis of baseline age, deformity, SRS-22 Total, and Charlson Comorbidity Index score was used to match the groups. ANCOVA and stepwise logistic regression analysis were used to assess outcomes between groups at 2 years.

    Results

    In total, 441 patients were included (267 SOp and 174 NH patients). After PSM, 142 patients remained (71 SOp 71 and 71 NH patients). At baseline, the SOp and NH groups had similar demographic characteristics, HRQOL, and deformity (all p > 0.05). At 2 years, ANCOVA determined that NH patients had worse deformity as measured with sagittal vertical axis (36.7 mm vs 21.3 mm, p = 0.025), mismatch between pelvic incidence and lumbar lordosis (11.9° vs 2.9°, p < 0.001), and pelvic tilt (PT) (23.1° vs 20.7°, p = 0.019). The adjusted regression analysis found that SOp patients had higher odds of reaching the minimal clinically important differences in Oswestry Disability Index score (OR [95% CI] 4.5 [1.7-11.5], p = 0.002), SRS-22 Activity (OR [95% CI] 3.2 [1.5-6.8], p = 0.002), SRS-22 Pain (OR [95% CI] 2.8 [1.4-5.9], p = 0.005), and SRS-22 Total (OR [95% CI] 11.0 [3.5-34.4], p < 0.001).

    Conclusions

    Operative patients with SOp still experience greater improvements in deformity and HRQOL relative to the progressive radiographic and functional deterioration associated with the NH of ASD. The NH of nonoperative management should be accounted for when weighing the risks and benefits of operative intervention for ASD.
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    ItemOpen Access
    Outcomes and survival analysis of adult cervical deformity patients with 10-year follow-up.
    (The spine journal : official journal of the North American Spine Society, 2024-03) Passias, Peter G; Tretiakov, Peter S; Das, Ankita; Thomas, Zach; Krol, Oscar; Joujon-Roche, Rachel; Williamson, Tyler; Imbo, Bailey; Owusu-Sarpong, Stephane; Lebovic, Jordan; Diebo, Bassel; Vira, Shaleen; Lafage, Virginie; Schoenfeld, Andrew J

    Background

    Previous studies have demonstrated that adult cervical deformity patients may be at increased risk of death in conjunction with increased frailty or a weakened physiologic state. However, such studies have often been limited by follow-up duration, and longer-term studies are needed to better assess temporal changes in ACD patients and associated mortality risk.

    Purpose

    To assess if patients with decreased comorbidities and physiologic burden will be at lessened risk of death for a greater length of time after undergoing adult cervical deformity surgery.

    Study design/setting

    Retrospective review.

    Patient sample

    Two hundred ninety ACD patients.

    Outcome measures

    Morbidity and mortality data.

    Methods

    Operative ACD patients ≥18 years with pre-(BL) and 10-year (10Y) data were included. Patients were stratified as expired versus living, as well as temporally grouped by Expiration prior to 5Y or between 5Y and 10Y. Group differences were assessed via means comparison analysis. Backstep logistic regression identified mortality predictors. Kaplan-Meier analysis assessed survivorship of expired patients. Log rank analysis determined differences in survival distribution groups.

    Results

    Sixty-six total patients were included (60.97±10.19 years, 48% female, 28.03±7.28 kg/m2). Within 10Y, 12 (18.2% of ACD cohort) expired. At baseline, patients were comparable in age, gender, BMI, and CCI total on average (all p>.05). Furthermore, patients were comparable in BL HRQLs (all p>.05). However, patients who expired between 5Y and 10Y demonstrated higher BL EQ5D and mJOA scores than their earlier expired counterparts at 2Y (p<.021). Furthermore, patients who presented with no CCI markers at BL were significantly more likely to survive until the 5Y-10Y follow-up window. Surgically, the only differences observed between patients who survived until 5Y was in undergoing osteotomy, with longer survival seen in those who did not require it (p=.003). Logistic regression revealed independent predictors of death prior to 5Y to be increased BMI, increased frailty, and increased levels fused (model p<.001). KM analysis found that by Passias et al frailty, not frail patients had mean survival time of 170.56 weeks, versus 158.00 in frail patients (p=.949).

    Conclusions

    Our study demonstrates that long-term survival after cervical deformity surgery may be predicted by baseline surgical factors. By optimizing BMI, frailty status, and minimizing fusion length when appropriate, surgeons may be able to further assist ACD patients in increasing their survivability postoperatively.
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    ItemOpen Access
    Patient-specific Cervical Deformity Corrections With Consideration of Associated Risk: Establishment of Risk Benefit Thresholds for Invasiveness Based on Deformity and Frailty Severity.
    (Clinical spine surgery, 2023-10) Passias, Peter G; Pierce, Katherine E; Williamson, Tyler K; Lebovic, Jordan; Schoenfeld, Andrew J; Lafage, Renaud; Lafage, Virginie; Gum, Jeffrey L; Eastlack, Robert; Kim, Han Jo; Klineberg, Eric O; Daniels, Alan H; Protopsaltis, Themistocles S; Mundis, Gregory M; Scheer, Justin K; Park, Paul; Chou, Dean; Line, Breton; Hart, Robert A; Burton, Douglas C; Bess, Shay; Schwab, Frank J; Shaffrey, Christopher I; Smith, Justin S; Ames, Christopher P; International Spine Study Group

    Study design/setting

    This was a retrospective cohort study.

    Background

    Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty.

    Objective

    The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity.

    Methods

    This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely.

    Results

    A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P=0.002], and invasiveness increased with deformity severity (P<0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P=0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P=0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P=0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group.

    Conclusions

    Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes.
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    ItemOpen Access
    Predictors of reoperation for spinal disorders in Chiari malformation patients with prior surgical decompression.
    (Journal of craniovertebral junction & spine, 2023-10) Onafowokan, Oluwatobi O; Das, Ankita; Mir, Jamshaid M; Alas, Haddy; Williamson, Tyler K; Mcfarland, Kimberly; Varghese, Jeffrey; Naessig, Sara; Imbo, Bailey; Passfall, Lara; Krol, Oscar; Tretiakov, Peter; Joujon-Roche, Rachel; Dave, Pooja; Moattari, Kevin; Owusu-Sarpong, Stephane; Lebovic, Jordan; Vira, Shaleen; Diebo, Bassel; Lafage, Virginie; Passias, Peter Gust

    Background

    Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning.

    Materials and methods

    This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004-2011. Chiari malformation Types 1-4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded.

    Results

    One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40-50 years had the most reoperations (11); however, patients aged 15-20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026).

    Conclusions

    Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes.
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    ItemOpen Access
    Should pelvic incidence influence realignment strategy? A detailed analysis in adult spinal deformity.
    (Journal of neurosurgery. Spine, 2024-11) Williamson, Tyler K; Onafowokan, Oluwatobi O; Schoenfeld, Andrew J; Owusu-Sarpong, Stephane; Lebovic, Jordan; Mir, Jamshaid; Das, Ankita; Lorentz, Nathan; Galetta, Matthew; Jankowski, Pawel P; Lafage, Renaud; Lafage, Virginie; Passias, Peter G

    Objective

    The purpose of this study was to assess how various realignment strategies affect mechanical failure and clinical outcomes in pelvic incidence (PI)-stratified cohorts following adult spinal deformity (ASD) surgery.

    Methods

    Median and interquartile range statistics were calculated for demographics and surgical details. Further statistical analysis was used to define subsets within PI generating significantly different rates of mechanical failure. These subsets of PI were further analyzed as subcohorts for the outcomes and effects of realignment within each subcohort. Multivariate logistic regression analysis controlling for baseline frailty and lumbar lordosis (LL; L1-S1) analyzed the association of age-adjusted realignment and Global Alignment and Proportion (GAP) strategies with the incidence of mechanical failure and clinical improvement within PI-stratified groups.

    Results

    A parabolic relationship between PI and mechanical failure was noted, whereas patients with either < 51° (n = 174, 39.1% of cohort) or > 63° (n = 114, 25.6% of cohort) of PI generated higher rates of mechanical failure (18.0% and 20.0%, respectively) and lower rates of good outcome (80.3% and 77.6%, respectively) than those with moderate PI (51°-63°). Patients with lower PI more often met good outcome criteria when undercorrected in age-adjusted PI-LL mismatch and sagittal age-adjusted score, and those not meeting good outcome criteria were more likely to deteriorate in GAP relative LL from first to final follow-up (OR 13.4, 95% CI 1.3-139.2). In those with moderate PI, patients were more likely to meet good outcome when aligned on the GAP lordosis distribution index (LDI; OR 1.7, 95% CI 0.9-3.3). Patients with higher PI meeting good outcome were more likely to be overcorrected in sagittal vertical axis (OR 2.4, 95% CI 1.1-5.2) at first follow-up and less likely to be undercorrected in T1 pelvic angle (OR 0.4, 95% CI 0.2-0.9) by final follow-up. When assessing GAP alignment, patients were more likely to meet good outcome when aligned on GAP LDI (OR 3.5, 95% CI 1.4-8.9).

    Conclusions

    There was a parabolic relationship between PI and both mechanical failure and clinical improvement following deformity correction in this study. Understanding the associations between this fixed parameter and poor outcomes can aid the surgeon in strategical planning when seeking to realign ASD.
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    ItemOpen Access
    Surgical costs in adult cervical Deformity: Do higher cost surgeries lead to better Outcomes?
    (Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 2023-07) Joujon-Roche, Rachel; Dave, Pooja; Tretiakov, Peter; Mcfarland, Kimberly; Mir, Jamshaid; Williamson, Tyler K; Imbo, Bailey; Krol, Oscar; Lebovic, Jordan; Schoenfeld, Andrew J; Vira, Shaleen; Passias, Peter G

    Background

    As our focus on delivering cost effective healthcare increases, interventions like cervical deformity surgery, which are associated with high resource utilization, have received greater scrutiny. The purpose of this study was to assess relationship between surgical costs, deformity correction, and patient reported outcomes in ACD surgery.

    Methods

    ACD Patients ≥ 18 years with baseline (BL) and 2-year (2Y) data were included. Cost of surgery was calculated by applying average Medicare reimbursement rates by CPT code to surgical details of each patient in the cohort. CPT codes for corpectomy, ACDF, osteotomy, decompression, levels fused, and instrumentation were considered in the analysis. Costs of complications and reoperations were intentionally excluded from the cost analysis. Patients were ranked into two groups by surgical cost: lowest cost (LC) and highest cost (HC). ANCOVA assessed differences in outcomes while accounting for covariates as appropriate.

    Results

    113 met inclusion criteria. While mean age, frailty, BMI and gender composition were similar between cost groups, mean CCI was significantly higher in the HC group compared to that of the LC group (p=.014). At baseline, LC and HC groups had similar HRQLs and radiographic deformity (all p >.05). Logistic regression accounting for baseline age, deformity and CCI found that HC patients had significantly lower odds of undergoing reoperation within 2-years (OR: 0.309, 95 % CI: 0.193 - 0.493, p <.001). Furthermore, logistic regression accounting for baseline age, deformity and CCI found odds of DJF were significantly lower for those in the HC group (OR: 0.163, 95 % CI: 0.083 - 0.323, p <.001). At 2-years, logistic regression accounting for age and baseline TS-CL found HC patients still had significantly higher odds of reaching a "0″ TS-CL modifier at 2-years (OR: 3.353, 95 % CI: 1.081 - 10.402, p=.036). Logistic regression accounting for age and baseline NDI score found HC patients had significantly higher odds of reaching MCID in NDI at 2-years (OR: 4.477, 95 % CI: 1.507 - 13.297, p=.007). A similar logistic regression accounting for age and baseline mJOA score found odds of reaching MCID in mJOA significantly higher for high-cost patients (OR: 2.942, 95 % CI: 1.101 - 7.864, p=.031).

    Conclusions

    While patient presentation influences surgical planning and costs, this study attempted to control for such variations to assess impact of surgical costs on outcomes. Despite continued scrutiny over healthcare costs, we found that more costly surgical interventions can produce superior radiographic alignment as well as patient reported outcomes for patients with cervical deformity.
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    ItemOpen Access
    The Additional Economic Burden of Frailty in Adult Cervical Deformity Patients Undergoing Surgical Intervention.
    (Spine, 2022-10) Passias, Peter G; Kummer, Nicholas A; Williamson, Tyler K; Ahmad, Waleed; Lebovic, Jordan; Lafage, Virginie; Lafage, Renaud; Kim, Han Jo; Daniels, Alan H; Gum, Jeffrey L; Diebo, Bassel G; Gupta, Munish C; Soroceanu, Alexandra; Scheer, Justin K; Hamilton, D Kojo; Klineberg, Eric O; Line, Breton; Schoenfeld, Andrew J; Hart, Robert A; Burton, Douglas C; Eastlack, Robert K; Mundis, Gregory M; Mummaneni, Praveen; Chou, Dean; Park, Paul; Schwab, Frank J; Shaffrey, Christopher I; Bess, Shay; Ames, Christopher P; Smith, Justin S; International Spine Study Group

    Summary of background data

    The influence of frailty on economic burden following corrective surgery for the adult cervical deformity (CD) is understudied and may provide valuable insights for preoperative planning.

    Objective

    To assess the influence of baseline frailty status on the economic burden of CD surgery.

    Study design

    Retrospective cohort.

    Materials and methods

    CD patients with frailty scores and baseline and two-year Neck Disability Index data were included. Frailty score was categorized patients by modified CD frailty index into not frail (NF) and frail (F). Analysis of covariance was used to estimate marginal means adjusting for age, sex, surgical approach, and baseline sacral slope, T1 slope minus cervical lordosis, C2-C7 angle, C2-C7 sagittal vertical axis. Costs were derived from PearlDiver registry data. Reimbursement consisted of a standardized estimate using regression analysis of Medicare payscales for services within a 30-day window including length of stay and death. This data is representative of the national average Medicare cost differentiated by complication/comorbidity outcome, surgical approach, and revision status. Cost per quality-adjusted life-year (QALY) at two years was calculated for NF and F patients.

    Results

    There were 126 patients included. There were 68 NF patients and 58 classified as F. Frailty groups did not differ by overall complications, instance of distal junctional kyphosis, or reoperations (all P >0.05). These groups had similar rates of radiographic and clinical improvement by two years. NF and F had similar overall cost ($36,731.03 vs. $37,356.75, P =0.793), resulting in equivocal costs per QALYs for both patients at two years ($90,113.79 vs. $80,866.66, P =0.097).

    Conclusion

    F and NF patients experienced similar complication rates and upfront costs, with equivocal utility gained, leading to comparative cost-effectiveness with NF patients based on cost per QALYs at two years. Surgical correction for CD is an economical healthcare investment for F patients when accounting for anticipated utility gained and cost-effectiveness following the procedure.

    Level of evidence

    III.
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    ItemOpen Access
    The Impact of Lumbopelvic Realignment Versus Prevention Strategies at the Upper-instrumented Vertebra on the Rates of Junctional Failure Following Adult Spinal Deformity Surgery.
    (Spine, 2024-03) Passias, Peter G; Williamson, Tyler K; Joujon-Roche, Rachel; Krol, Oscar; Tretiakov, Peter; Imbo, Bailey; Schoenfeld, Andrew J; Owusu-Sarpong, Stephane; Lebovic, Jordan; Mir, Jamshaid; Dave, Pooja; McFarland, Kimberly; Vira, Shaleen; Diebo, Bassel G; Park, Paul; Chou, Dean; Smith, Justin S; Lafage, Renaud; Lafage, Virginie

    Study design/setting

    Retrospective.

    Objective

    Evaluate the surgical technique that has the greatest influence on the rate of junctional failure following ASD surgery.

    Summary of background data

    Differing presentations of adult spinal deformity(ASD) may influence the extent of surgical intervention and the use of prophylaxis at the base or the summit of a fusion construct to influence junctional failure rates.

    Materials and methods

    ASD patients with two-year(2Y) data and at least 5-level fusion to the pelvis were included. Patients were divided based on UIV: [Longer Construct: T1-T4; Shorter Construct: T8-T12]. Parameters assessed included matching in age-adjusted PI-LL or PT, aligning in GAP-relative pelvic version or Lordosis Distribution Index. After assessing all lumbopelvic radiographic parameters, the combination of realigning the two parameters with the greatest minimizing effect of PJF constituted a good base. Good s was defined as having: (1) prophylaxis at UIV (tethers, hooks, cement), (2) no lordotic change(under-contouring) greater than 10° of the UIV, (3) preoperative UIV inclination angle<30°. Multivariable regression analysis assessed the effects of junction characteristics and radiographic correction individually and collectively on the development of PJK and PJF in differing construct lengths, adjusting for confounders.

    Results

    In all, 261 patients were included. The cohort had lower odds of PJK(OR: 0.5,[0.2-0.9]; P =0.044) and PJF was less likely (OR: 0.1,[0.0-0.7]; P =0.014) in the presence of a good summit. Normalizing pelvic compensation had the greatest radiographic effect on preventing PJF overall (OR: 0.6,[0.3-1.0]; P =0.044). In shorter constructs, realignment had a greater effect on decreasing the odds of PJF(OR: 0.2,[0.02-0.9]; P =0.036). With longer constructs, a good summit lowered the likelihood of PJK(OR: 0.3,[0.1-0.9]; P =0.027). A good base led to zero occurrences of PJF. In patients with severe frailty/osteoporosis, a good summit lowered the incidence of PJK(OR: 0.4,[0.2-0.9]; P =0.041) and PJF (OR: 0.1,[0.01-0.99]; P =0.049).

    Conclusion

    To mitigate junctional failure, our study demonstrated the utility of individualizing surgical approaches to emphasize an optimal basal construct. Achievement of tailored goals at the cranial end of the surgical construct may be equally important, especially for higher-risk patients with longer fusions.

    Level of evidence

    3.