Browsing by Author "Lorentz, Nathan"

Filter results by typing the first few letters
Now showing 1 - 7 of 7
  • Thumbnail Image
    ItemOpen Access
    Assessing the Economic Benefits of Enhanced Recovery After Surgery (ERAS) Protocols in Adult Cervical Deformity Patients: Is the Initial Additive Cost of Protocols Offset by Clinical Gains?
    (Clinical spine surgery, 2024-05) Tretiakov, Peter S; Onafowokan, Oluwatobi O; Lorentz, Nathan; Galetta, Matthew; Mir, Jamshaid M; Das, Ankita; Dave, Pooja; Yee, Timothy; Buell, Thomas J; Jankowski, Pawel P; Eastlack, Robert; Hockley, Aaron; Schoenfeld, Andrew J; Passias, Peter G

    Objective

    To assess the financial impact of Enhanced Recovery After Surgery (ERAS) protocols and cost-effectiveness in cervical deformity corrective surgery.

    Study design

    Retrospective review of prospective CD database.

    Background

    Enhanced Recovery After Surgery (ERAS) can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, the economic benefit of ERAS protocols, nor the heterogeneous components that make up such protocols, has not been established.

    Methods

    Operative CD patients ≥18 y with complete pre-(BL) and up to 2-year(2Y) postop radiographic/HRQL data were stratified by enrollment in Standard-of-Care ERAS beginning in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay scales. QALY was calculated using NDI mapped to SF6D using validated methodology with a 3% discount rate to account for a residual decline in life expectancy.

    Results

    In all, 127 patients were included (59.07±11.16 y, 54% female, 29.08±6.43 kg/m 2 ) in the analysis. Of these patients, 54 (20.0%) received the ERAS protocol. Per cost analysis, ERAS+ patients reported a lower mean total 2Y cost of 35049 USD compared with ERAS- patients at 37553 ( P <0.001). Furthermore, ERAS+ patients demonstrated lower cost of reoperation by 2Y ( P <0.001). Controlling for age, surgical invasiveness, and deformity per BL TS-CL, ERAS+ patients below 70 years old were significantly more likely to achieve a cost-effective outcome by 2Y compared with their ERAS- counterparts (OR: 1.011 [1.001-1.999, P =0.048].

    Conclusions

    Patients undergoing ERAS protocols experience improved cost-effectiveness and reduced total cost by 2Y post-operatively. Due to the potential economic benefit of ERAS for patients incorporation of ERAS into practice for eligible patients should be considered.
  • Thumbnail Image
    ItemOpen Access
    Assessing the Impact of Radiographic Realignment on Adult Spinal Deformity Patients with Sacroiliac Joint Pain at Presentation.
    (Journal of clinical medicine, 2024-06) Onafowokan, Oluwatobi O; Tretiakov, Peter; Lorentz, Nathan; Galetta, Matthew; Das, Ankita; Mir, Jamshaid; Roberts, Timothy; Passias, Peter G
    Background: Adult spinal deformity (ASD) patients with concurrent sacroiliac joint (SIJ) pain are susceptible to worse postoperative outcomes. There is scarce literature on the impact of ASD realignment surgery on SIJ pain. Methods: Patients undergoing ASD realignment surgery were included and stratified by the presence of SIJ pain at the baseline (SIJP+) or SIJ pain absence (SIJP-). Mean comparison tests via ANOVA were used to assess baseline differences between both cohorts. Multivariable regression analyses analyzed factors associated with SIJ pain resolution/persistence, factoring in BMI, frailty, disability, and deformity. Results: A total of 464 patients were included, with 30.8% forming the SIJP+ cohort. At the baseline (BL), SIJP+ had worse disability scores, more severe deformity, higher BMI, higher frailty scores, and an increased magnitude of lower limb compensation. SIJP+ patients had higher mechanical complication (14.7 vs. 8.2%, p = 0.024) and reoperation rates (32.4 vs. 20.2%, p = 0.011) at 2 years. SIJP+ patients who subsequently underwent SI fusion achieved disability score outcomes similar to those of their SIJ- counterparts. Multivariable regression analysis revealed that SIJP+ patients who were aligned in the GAP lordosis distribution index were more likely to report symptom resolution at six weeks (OR 1.56, 95% CI: 1.02-2.37, p = 0.039), 1 year (OR 3.21, 2.49-5.33), and 2 years (OR 3.43, 2.41-7.12). SIJP- patients who did not report symptom resolution by 1 year and 2 years were more likely to demonstrate PI-LL > 5° (OR 1.36, 1.07-2.39, p = 0.045) and SVA > 20 mm (OR 1.62, 1.24-1.71 p = 0.017). Conclusions: SIJ pain in ASD patients may result in worsened pain and disability at presentation. Symptom resolution may be achieved in affected patients by adequate postoperative lumbar lordosis restoration.
  • Thumbnail Image
    ItemOpen Access
    Is It Possible for Patients with Early Distal Junctional Kyphosis following Adult Cervical Deformity Corrective Surgery to Achieve Similar Outcomes to Their Unaffected Counterparts? An Analysis of Recovery Kinetics.
    (Journal of clinical medicine, 2024-05) Onafowokan, Oluwatobi O; Imbo, Bailey; Williamson, Tyler; Das, Ankita; Mir, Jamshaid M; Galetta, Matthew; Lorentz, Nathan; Passias, Peter G
    Background: Distal junctional kyphosis (DJK) is a concerning complication for surgeons performing cervical deformity (CD) surgery. Patients sustaining such complications may demonstrate worse recovery profiles compared to their unaffected peers. Methods: DJK was defined as a >10° change in kyphosis between LIV and LIV-2, and a >10° index angle. CD patients were grouped according to the development of DJK by 3M vs. no DJK development. Means comparison tests and regression analyses used to analyze differences between groups and arelevant associations. Results: A total of 113 patients were included (17 DJK, 96 non-DJK). DJK patients were more sagittally malaligned preop, and underwent more osteotomies and combined approaches. Postop, DJK patients experienced more dysphagia (17.7% vs. 4.2%; p = 0.034). DJK patients remained more malaligned in cSVA through the 2-year follow-up. DJK patients exhibited worse patient-reported outcomes from 3M to 1Y, but these differences subsided when following patients through to 2Y; they also exhibited worse NDI (65.3 vs. 35.3) and EQ5D (0.68 vs. 0.79) scores at 1Y (both p < 0.05), but these differences had subsided by 2Y. Conclusions: Despite patients exhibiting similar preoperative health-related quality of life metrics, patients who developed early DJK exhibited worse postoperative neck disability following the development of their DJK. These differences subsided by the 2-year follow-up, highlighting the prolonged but eventually successful course of many DJK patients after CD surgery.
  • Thumbnail Image
    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.
  • Thumbnail Image
    ItemOpen Access
    The Evolution of Enhanced Recovery After Surgery: Assessing the Clinical Benefits of Developments Within Enhanced Recovery After Surgery Protocols in Adult Cervical Deformity Surgery.
    (Clinical spine surgery, 2024-05) Passias, Peter G; Tretiakov, Peter S; Onafowokan, Oluwatobi O; Galetta, Matthew; Lorentz, Nathan; Mir, Jamshaid M; Das, Ankita; Dave, Pooja; Lafage, Renaud; Yee, Timothy; Diebo, Bassel; Vira, Shaleen; Jankowski, Pawel P; Hockley, Aaron; Daniels, Alan; Schoenfeld, Andrew J; Mummaneni, Praveen; Paulino, Carl B; Lafage, Virginie

    Study design

    Retrospective cohort.

    Objective

    To investigate the impact of evolving Enhanced Recovery After Surgery (ERAS) protocols on outcomes after cervical deformity (CD) surgery.

    Background

    ERAS can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, there remains a paucity of literature assessing how developments have impacted outcomes after adult CD surgery.

    Methods

    Patients with operative CD 18 years or older with pre-baseline and 2 years (2Y) postoperative data, who underwent ERAS protocols, were stratified by increasing implantation of ERAS components: (1) early (multimodal pain program), (2) intermediate (early protocol + paraspinal blocks, early ambulation), and (3) late (early/intermediate protocols + comprehensive prehabilitation). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through Bonferroni-adjusted means comparison analysis.

    Results

    A total of 131 patients were included (59.4 ± 11.7 y, 45% females, 28.8 ± 6.0 kg/m 2 ). Of these patients, 38.9% were considered "early," 36.6% were "intermediate," and 24.4% were "late." Perioperatively, rates of intraoperative complications were lower in the late group ( P = 0.036). Postoperatively, discharge disposition differed significantly between cohorts, with late patients more likely to be discharged to home versus early or intermediate cohorts [χ 2 (2) = 37.973, P < 0.001]. In terms of postoperative disability recovery, intermediate and late patients demonstrated incrementally improved 6 W modified Japanese Orthopedic Association scores ( P = 0.004), and late patients maintained significantly higher mean Euro-QOL 5-Dimension Questionnaire and modified Japanese Orthopedic Association scores by 1 year ( P < 0.001, P = 0.026). By 2Y, cohorts demonstrated incrementally increasing SWAL-QOL scores (all domains P < 0.028) domain scores versus early or intermediate cohorts. By 2Y, incrementally decreasing reoperation was observed in early versus intermediate versus late cohorts ( P = 0.034).

    Conclusions

    The present study demonstrates that patients enrolled in an evolving ERAS program demonstrate incremental improvement in preoperative optimization and candidate selection, greater likelihood of discharge to home, decreased postoperative disability and dysphasia burden, and decreased likelihood of intraoperative complications and reoperation rates.
  • Thumbnail Image
    ItemOpen Access
    The Impact of Peri-operative Enhanced Recovery After Surgery Protocols on Outcomes Following Adult Cervical Deformity Surgery.
    (Global spine journal, 2024-04) Tretiakov, Peter S; Onafowokan, Oluwatobi O; Mir, Jamshaid M; Lorentz, Nathan; Galetta, Matthew; Das, Ankita; Shin, John; Sciubba, Daniel; Krol, Oscar; Joujon-Roche, Rachel; Williamson, Tyler; Imbo, Bailey; Yee, Timothy; Jankowski, Pawel P; Hockley, Aaron; Schoenfeld, Andrew J; Passias, Peter G

    Study design

    Retrospective cohort study.

    Objectives

    To assess the impact of Enhanced recovery after surgery (ERAS) protocols on peri-operative course in adult cervical deformity (ACD) corrective surgery.

    Methods

    Patients ≥18 yrs with complete pre-(BL) and up to 2-year (2Y) radiographic and clinical outcome data were stratified by enrollment in an ERAS protocol that commenced in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, peri-operative factors and complication rates were assessed via means comparison analysis. Logistic regression analysed differences while controlling for baseline disability and deformity.

    Results

    We included 220 patients (average age 58.1 ± 11.9 years, 48% female). 20% were treated using the ERAS protocol (ERAS+). Disability was similar between both groups at baseline. When controlling for baseline disability and myelopathy, ERAS- patients were more likely to utilize opioids than ERAS+ (OR 1.79, 95% CI: 1.45-2.50, P = .016). Peri-operatively, ERAS+ had significantly lower operative time (P < .021), lower EBL (583.48 vs 246.51, P < .001), and required significantly lower doses of propofol intra-operatively than ERAS- patients (P = .020). ERAS+ patients also reported lower mean LOS overall (4.33 vs 5.84, P = .393), and were more likely to be discharged directly to home (χ2(1) = 4.974, P = .028). ERAS+ patients were less likely to require steroids after surgery (P = .045), were less likely to develop neuromuscular complications overall (P = .025), and less likely experience venous complications or be diagnosed with venous disease post-operatively (P = .025).

    Conclusions

    Enhanced recovery after surgery programs in ACD surgery demonstrate significant benefit in terms of peri-operative outcomes for patients.
  • Thumbnail Image
    ItemOpen Access
    Treatment of adult spine deformity: A retrospective comparison of bone morphogenic protein and bone marrow aspirate with bone allograft.
    (Acta neurochirurgica, 2024-11) Onafowokan, Oluwatobi O; Uzosike, Akachimere C; Sharma, Abhinav; Galetta, Matthew; Lorentz, Nathan; Montgomery, Samuel; Fisher, Max R; Yung, Anthony; Tahmasebpour, Paritash; Seo, Lauren; Roberts, Timothy; Lafage, Renaud; Smith, Justin; Jankowski, Pawel P; Sardar, Zeeshan M; Shaffrey, Christopher I; Lafage, Virginie; Schoenfeld, Andrew J; Passias, Peter G
    BACKGROUND  : The use of bone morphogenic protein (BMP-2) in adult spine deformity (ASD) surgery remains controversial more than two decades following its approval for clinical application in spine surgery. This study was performed to assess outcomes in patients undergoing ASD surgery with BMP application compared with a combination of bone marrow aspirate, cancellous bone chips and i-Factor.

    Methods

    This was a retrospective cohort study. ASD patients were stratified by use of intra-operative BMP (BMP +) or not (BMA + I) and surveyed for the development of complications and mechanical failure. Quality of life gained following the procedure was evaluated using quality-adjusted life years (QALYs). Cost was calculated using the PearlDiver database and CMS definitions. Multivariable analyses (ANCOVA) and logistic regression were used to adjust for confounding.

    Results

    512 patients were included (60% BMP +). At baseline, BMP + patients were older (62.5 vs 60.8 years, p < 0.010). Radiographic and quality-of-life metrics did not differ at follow up timepoints (all p > 0.05). BMP use was associated with higher supplemental rod use (OR: 7.0, 1.9 - 26.2, p = 0.004), greater number of levels fused (OR: 1.1, 1.03 - 1.17, p = 0.003) and greater neurological complications (OR: 5.0, 1.3 - 18.7, p = 0.017). Controlling for rod use and levels fused, BMP use was not associated with a lower risk of mechanical complications (OR 0.3, 95% CI: 0.2 - 3.0, p = 0.353), rod breakage (OR: 3.3, 0.6 - 18.7, p = 0.182) or implant failure (OR: 0.3, 0.04 - 1.51). At 2 years, the BMP + cohort exhibited higher overall costs ($108,062 vs $95,144, p = 0.002), comparable QALYs (0.163 vs 0.171, p = 0.65) and higher cost per QALY (p = 0.001) at two years.

    Conclusions

    In this analysis, BMP-2 application was not associated with superior outcomes when compared to a less costly biologic alternative (bone marrow aspirate + cancellous bone chips + i-Factor) following ASD surgery. The use of BMP-2 in ASD surgery appears to have reduced cost-efficacy at two years postoperatively.