Browsing by Author "Mehdian, Hossein"

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    ItemOpen Access
    An Analysis of the Incidence and Outcomes of Major Versus Minor Neurological Decline After Complex Adult Spinal Deformity Surgery: A Subanalysis of Scoli-RISK-1 Study.
    (Spine, 2018-07) Kato, So; Fehlings, Michael G; Lewis, Stephen J; Lenke, Lawrence G; Shaffrey, Christopher I; Cheung, Kenneth MC; Carreon, Leah Y; Dekutoski, Mark B; Schwab, Frank J; Boachie-Adjei, Oheneba; Kebaish, Khaled M; Ames, Christopher P; Qiu, Yong; Matsuyama, Yukihiro; Dahl, Benny T; Mehdian, Hossein; Pellisé, Ferran; Berven, Sigurd H

    Study design

    A subanalysis from a prospective, multicenter, international cohort study in 15 sites (Scoli-RISK-1).

    Objective

    To report detailed information regarding the severity of neurological decline related to complex adult spine deformity (ASD) surgery and to examine outcomes based on severity.

    Summary of background data

    Postoperative neurological decline after ASD surgeries can occur due to nerve root(s) or spinal cord dysfunction. The impact of decline and the pattern of recovery may be related to the anatomic location and the severity of the injury.

    Methods

    An investigation of 272 prospectively enrolled complex ASD surgical patients with neurological status measured by American Spinal Injury Association Lower Extremity Motor Scores (LEMS) was undertaken. Postoperative neurological decline was categorized into "major" (≥5 points loss) versus "minor" (<5 points loss) deficits. Timing and extent of recovery in LEMS were investigated for each group.

    Results

    Among the 265 patients with LEMS available at discharge, 61 patients (23%) had neurological decline, with 20 (33%) experiencing major decline. Of note, 90% of the patients with major decline had deficits in three or more myotomes. Full recovery was seen in 24% at 6 weeks and increased to 65% at 6 months. However, 34% continued to experience some neurological decline at 24 months, with 6% demonstrating no improvement. Of 41 patients (67%) with minor decline, 73% had deficits in one or two myotomes. Full recovery was seen in 49% at 6 weeks and increased to 70% at 6 months. Of note, 26% had persistence of some neurological deficit at 24 months, with 18% demonstrating no recovery.

    Conclusion

    In patients undergoing complex ASD correction, a rate of postoperative neurological decline of 23% was noted with 33% of these being "major." Although most patients showed substantial recovery by 6 months, approximately one-third continued to experience neurological dysfunction.

    Level of evidence

    2.
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    ItemOpen Access
    Are Higher Global Alignment and Proportion Scores Associated With Increased Risks of Mechanical Complications After Adult Spinal Deformity Surgery? An External Validation.
    (Clinical orthopaedics and related research, 2021-02) Kwan, Kenny Yat Hong; Lenke, Lawrence G; Shaffrey, Christopher I; Carreon, Leah Y; Dahl, Benny T; Fehlings, Michael G; Ames, Christopher P; Boachie-Adjei, Oheneba; Dekutoski, Mark B; Kebaish, Khaled M; Lewis, Stephen J; Matsuyama, Yukihiro; Mehdian, Hossein; Qiu, Yong; Schwab, Frank J; Cheung, Kenneth Man Chee; AO Spine Knowledge Forum Deformity

    Background

    The Global Alignment and Proportion (GAP) score, based on pelvic incidence-based proportional parameters, was recently developed to predict mechanical complications after surgery for spinal deformities in adults. However, this score has not been validated in an independent external dataset.

    Questions/purposes

    After adult spinal deformity surgery, is a higher GAP score associated with (1) an increased risk of mechanical complications, defined as rod fractures, implant-related complications, proximal or distal junctional kyphosis or failure; (2) a higher likelihood of undergoing revision surgery to treat a mechanical complication; and (3) is a lower (more proportioned) GAP score category associated with better validated outcomes scores using the Oswestry Disability Index (ODI), Scoliosis Research Society-22 (SRS-22) and the Short Form-36 questionnaires?

    Methods

    A total of 272 patients who had undergone corrective surgeries for complex spinal deformities were enrolled in the Scoli-RISK-1 prospective trial. Patients were included in this secondary analysis if they fulfilled the original inclusion criteria by Yilgor et al. From the original 272 patients, 14% (39) did not satisfy the radiographic inclusion criteria, the GAP score could not be calculated in 14% (37), and 24% (64) did not have radiographic assessment at postoperative 2 years, leaving 59% (159) for analysis in this review of data from the original trial. A total of 159 patients were included in this study,with a mean age of 58 ± 14 years at the time of surgery. Most patients were female (72%, 115 of 159), the mean number of levels involved in surgery was 12 ± 4, and three-column osteotomy was performed in 76% (120 of 159) of patients. The GAP score was calculated using parameters from early postoperative radiographs (between 3 and 12 weeks) including pelvic incidence, sacral slope, lumbar lordosis, lower arc lordosis and global tilt, which were independently obtained from a computer software based on centralized patient radiographs. The GAP score was categorized as proportional (scores of 0 to 2), moderately disproportional (scores of 3 to 6), or severely disproportional (scores higher than 7 to 13). Receiver operating characteristic area under curve (AUC) was used to assess associations between GAP score and risk of mechanical complications and risk of revision surgery. An AUC of 0.5 to 0.7 was classified as "no or low associative power", 0.7 to 0.9 as "moderate" and greater than 0.9 as "high". We analyzed differences in validated outcome scores between the GAP categories using Wilcoxon rank sum test.

    Results

    At a minimum of 2 years' follow-up, a higher GAP score was not associated with increased risks of mechanical complications (AUC = 0.60 [95% CI 0.50 to 0.70]). A higher GAP score was not associated with a higher likelihood of undergoing a revision surgery to treat a mechanical complication (AUC = 0.66 [95% 0.53 to 0.78]). However, a moderately disproportioned GAP score category was associated with better SF-36 physical component summary score (36 ± 10 versus 40 ± 11; p = 0.047), better SF-36 mental component summary score (46 ± 13 versus 51 ± 12; p = 0.01), better SRS-22 total score (3.4 ± 0.8 versus 3.7 ± 0.7, p = 0.02) and better ODI score (35 ± 21 versus 25 ± 20; p = 0.003) than severely disproportioned GAP score category.

    Conclusion

    Based on the findings of this external validation study, we found that alignment targets based on the GAP score alone were not associated with increased risks of mechanical complications and mechanical revisions in patients with complex adult spinal disorders. Parameters not included in the original GAP score needed to be considered to reduce the likelihood of mechanical complications.

    Level of evidence

    Level III, diagnostic study.
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    ItemOpen Access
    External Validation of the Adult Spinal Deformity (ASD) Frailty Index (ASD-FI) in the Scoli-RISK-1 Patient Database.
    (Spine, 2018-10) Miller, Emily K; Lenke, Lawrence G; Neuman, Brian J; Sciubba, Daniel M; Kebaish, Khaled M; Smith, Justin S; Qiu, Yong; Dahl, Benny T; Pellisé, Ferran; Matsuyama, Yukihiro; Carreon, Leah Y; Fehlings, Michael G; Cheung, Kenneth M; Lewis, Stephen; Dekutoski, Mark B; Schwab, Frank J; Boachie-Adjei, Oheneba; Mehdian, Hossein; Bess, Shay; Shaffrey, Christopher I; Ames, Christopher P; AOSpine Knowledge Forum Deformity, the International Spine Study Group

    Study design

    Analysis of a prospective multicenter database.

    Objective

    To assess the ability of the recently created Adult Spinal Deformity (ASD) Frailty Index (ASD-FI) to predict odds of major complications and length of hospital stay for patients who had more severe preoperative deformity and underwent more invasive ASD surgery compared with patients in the database used to create the index.

    Summary of background data

    Accurate preoperative estimates of risk are necessary given the high complication rates currently associated with ASD surgery.

    Methods

    Patients were enrolled by participating institutions in Europe, Asia, and North America from 2009 to 2011. ASD-FI scores were used to classify 267 patients as not frail (NF) (<0.3), frail (0.3-0. 5), or severely frail (SF) (>0.5). Multivariable logistic regression, adjusted for preoperative and surgical covariates such as operative time and blood loss, was performed to determine the relationship between ASD-FI category and incidence of major complications, overall incidence of complications, and length of hospital stay.

    Results

    The mean ASD-FI score was 0.3 (range, 0-0.7). We categorized 105 patients as NF, 103 as frail, and 59 as SF. The adjusted odds of developing a major complication were higher for SF patients (odds ratio = 4.4; 95% CI 2.0, 9.9) compared with NF patients. After adjusting for covariates, length of hospital stay for SF patients increased by 19% (95% CI 1.4%, 39%) compared with NF patients. The odds of developing a major complication or having increased length of stay were similar between frail and NF patients.

    Conclusion

    Greater patient frailty, as measured by the ASD-FI, is associated with a longer hospital stay and greater risk of major complications among patients who have severe preoperative deformity and undergo invasive surgical procedures.

    Level of evidence

    2.
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    ItemOpen Access
    Impact of New Motor Deficit on HRQOL After Adult Spinal Deformity Surgery: Subanalysis From Scoli Risk 1 Prospective Study.
    (Spine, 2021-04) Saigal, Rajiv; Lau, Darryl; Berven, Sigurd H; Carreon, Leah; Dekutoski, Mark B; Kebaish, Khaled M; Qiu, Yong; Matsuyama, Yukihiro; Kelly, Michael; Dahl, Benny T; Mehdian, Hossein; Pellisé, Ferran; Lewis, Stephen J; Cheung, Kenneth MC; Shaffrey, Christopher I; Fehlings, Michael G; Lenke, Lawrence G; Ames, Christopher P; AOSpine Knowledge Forum Deformity

    Study design

    International, multicenter, prospective, longitudinal observational cohort.

    Objective

    To assess how new motor deficits affect patient reported quality of life scores after adult deformity surgery.

    Summary of background data

    Adult spinal deformity surgery is associated with high morbidity, including risk of new postoperative motor deficit. It is unclear what effect new motor deficit has on Health-related Quality of Life scores (HRQOL) scores.

    Methods

    Adult spinal deformity patients were enrolled prospectively at 15 sites worldwide. Other inclusion criteria included major Cobb more than 80°, C7-L2 curve apex, and any patient undergoing three column osteotomy. American Spinal Injury Association (ASIA) scores and standard HRQOL scores were recorded pre-op, 6 weeks, 6 months, and 2 years.

    Results

    Two hundred seventy two complex adult spinal deformity (ASD) patients enrolled. HRQOL scores were worse for patients with lower extremity motor score (LEMS). Mean HRQOL changes at 6 weeks and 2 years compared with pre-op for patients with motor worsening were: ODI (+12.4 at 6 weeks and -4.7 at 2 years), SF-36v2 physical (-4.5 at 6 weeks and +2.3 at 2 years), SRS-22r (0.0 at 6 weeks and +0.4 at 2 years). Mean HRQOL changes for motor-neutral patients were: ODI (+0.6 at 6 weeks and -12.1 at 2 years), SF-36v2 physical (-1.6 at 6 weeks and +5.9 at 2 years), and SRS-22r (+0.4 at 6 weeks and +0.7 at 2 years). For patients with LEMS improvement, mean HRQOL changes were: ODI (-0.6 at 6 weeks and -16.3 at 2 years), SF-36v2 physical (+1.0 at 6 weeks and +7.0 at 2 years), and SRS-22r (+0.5 at 6 weeks and +0.9 at 2 years).

    Conclusion

    In the subgroup of deformity patients who developed a new motor deficit, total HRQOLs and HRQOL changes were negatively impacted. Patients with more than 2 points of LEMS worsening had the worst changes, but still showed overall HRQOL improvement at 6 months and 2 years compared with pre-op baseline.Level of Evidence: 3.
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    ItemOpen Access
    Incidence and risk factors of postoperative neurologic decline after complex adult spinal deformity surgery: results of the Scoli-RISK-1 study.
    (The spine journal : official journal of the North American Spine Society, 2018-10) Fehlings, Michael G; Kato, So; Lenke, Lawrence G; Nakashima, Hiroaki; Nagoshi, Narihito; Shaffrey, Christopher I; Cheung, Kenneth MC; Carreon, Leah; Dekutoski, Mark B; Schwab, Frank J; Boachie-Adjei, Oheneba; Kebaish, Khaled M; Ames, Christopher P; Qiu, Yong; Matsuyama, Yukihiro; Dahl, Benny T; Mehdian, Hossein; Pellisé-Urquiza, Ferran; Lewis, Stephen J; Berven, Sigurd H

    Background context

    Significant variability in neurologic outcomes after surgical correction for adult spinal deformity (ASD) has been reported. Risk factors for decline in neurologic motor outcomes are poorly understood.

    Purpose

    The objective of the present investigation was to identify the risk factors for postoperative neurologic motor decline in patients undergoing complex ASD surgery.

    Study design/setting

    This is a prospective international multicenter cohort study.

    Patient sample

    From September 2011 to October 2012, 272 patients undergoing complex ASD surgery were prospectively enrolled in a multicenter, international cohort study in 15 sites.

    Outcome measures

    Neurologic decline was defined as any postoperative deterioration in American Spinal Injury Association lower extremity motor score (LEMS) compared with preoperative status.

    Methods

    To identify risk factors, 10 candidate variables were selected for univariable analysis from the dataset based on clinical relevance, and a multivariable logistic regression analysis was used with backward stepwise selection.

    Results

    Complete datasets on 265 patients were available for analysis and 61 (23%) patients showed a decline in LEMS at discharge. Univariable analysis showed that the key factors associated with postoperative neurologic deterioration included older age, lumbar-level osteotomy, three-column osteotomy, and larger blood loss. Multivariable analysis revealed that older age (odds ratio [OR]=1.5 per 10 years, 95% confidence interval [CI] 1.1-2.1, p=.005), larger coronal deformity angular ratio [DAR] (OR=1.1 per 1 unit, 95% CI 1.0-1.2, p=.037), and lumbar osteotomy (OR=3.3, 95% CI 1.2-9.2, p=.022) were the three major predictors of neurologic decline.

    Conclusions

    Twenty-three percent of patients undergoing complex ASD surgery experienced a postoperative neurologic decline. Age, coronal DAR, and lumbar osteotomy were identified as the key contributing factors.
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    ItemOpen Access
    Lower Extremity Motor Function Following Complex Adult Spinal Deformity Surgery: Two-Year Follow-up in the Scoli-RISK-1 Prospective, Multicenter, International Study.
    (The Journal of bone and joint surgery. American volume, 2018-04) Lenke, Lawrence G; Shaffrey, Christopher I; Carreon, Leah Y; Cheung, Kenneth MC; Dahl, Benny T; Fehlings, Michael G; Ames, Christopher P; Boachie-Adjei, Oheneba; Dekutoski, Mark B; Kebaish, Khaled M; Lewis, Stephen J; Matsuyama, Yukihiro; Mehdian, Hossein; Pellisé, Ferran; Qiu, Yong; Schwab, Frank J; AO Spine International and SRS Scoli-RISK-1 Study Group
    BACKGROUND:The reported neurologic complication rate following surgery for complex adult spinal deformity (ASD) is variable due to several factors. Most series have been retrospective with heterogeneous patient populations and use of nonuniform neurologic assessments. The aim of this study was to prospectively document lower extremity motor function by means of the American Spinal Injury Association (ASIA) lower extremity motor score (LEMS) before and through 2 years after surgical correction of complex ASD. METHODS:The Scoli-RISK-1 study enrolled 272 patients with ASD, from 15 centers, who had undergone primary or revision surgery for a major Cobb angle of ≥80°, corrective osteotomy for congenital spinal deformity or as a revision procedure for any type of deformity, and/or a complex 3-column osteotomy. RESULTS:One of 272 patients lacked preoperative data and was excluded from the analysis, and 62 (22.9%) of the remaining 271 patients, who were included, lacked a 2-year postoperative assessment. Patients with no preoperative motor impairment (normal LEMS group; n = 203) had a small but significant decline from the mean preoperative LEMS value (50) to that at 2 years postoperatively (49.66 [95% confidence interval = 49.46 to 49.85]; p = 0.002). Patients who did have a motor deficit preoperatively (n = 68; mean LEMS, 43.79) had significant LEMS improvement at 6 months (47.21, p < 0.001) and 2 years (46.12, p = 0.003) postoperatively. The overall percentage of patients (in both groups combined) who had a postoperative LEMS decline, compared with the preoperative value, was 23.0% at discharge, 17.1% at 6 weeks, 9.9% at 6 months, and 10.0% at 2 years. CONCLUSIONS:The percentage of patients who had a LEMS decline (compared with the preoperative score) after undergoing complex spinal reconstructive surgery for ASD was 23.0% at discharge, which improved to 10.0% at 2 years postoperatively. These rates are higher than previously reported, which we concluded was due to the prospective, strict nature of the LEMS testing of patients with these challenging deformities. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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    ItemOpen Access
    Neurologic Outcomes of Complex Adult Spinal Deformity Surgery: Results of the Prospective, Multicenter Scoli-RISK-1 Study.
    (Spine, 2016-02) Lenke, Lawrence G; Fehlings, Michael G; Shaffrey, Christopher I; Cheung, Kenneth MC; Carreon, Leah; Dekutoski, Mark B; Schwab, Frank J; Boachie-Adjei, Oheneba; Kebaish, Khaled M; Ames, Christopher P; Qiu, Yong; Matsuyama, Yukihiro; Dahl, Benny T; Mehdian, Hossein; Pellisé-Urquiza, Ferran; Lewis, Stephen J; Berven, Sigurd H

    Study design

    Prospective, multicenter, international observational study.

    Objective

    To evaluate motor neurologic outcomes in patients undergoing surgery for complex adult spinal deformity (ASD).

    Summary of background data

    The neurologic outcomes after surgical correction for ASD have been reported with significant variability and have not been measured as a primary endpoint in any prospective, multicenter, observational study.

    Methods

    The primary outcome measure was the change in American Spinal Injury Association (ASIA) Lower Extremity Motor Scores (LEMS) obtained preoperatively, and at hospital discharge, 6 weeks and 6 months postoperatively.

    Results

    A total of 273 patients with complex ASD underwent surgery at 15 sites worldwide. One patient was excluded for lack of preoperative LEMS. The remaining 272 patients were divided into two groups: normal preoperative LEMS (=50) (Preop NML, N = 204, 75%) and abnormal preoperative LEMS (<50) (Preop ABNML, N = 68, 25%). At hospital discharge, 22.18% of patients showed a decline in LEMS compared with 12.78% who showed an improvement. At 6 weeks, there was a significant change compared with discharge: 17.91% patients showed a decline in LEMS and 16.42% showed an improvement. At 6 months, 10.82% patients showed a decline in preoperative LEMS, 20.52% improvement, and 68.66% maintenance. This was a significant change compared with 6 weeks and at discharge.

    Conclusion

    Although complex ASD surgery can restore neurologic function in patients with a preoperative neurologic deficit, a significant portion of patients with ASD experienced postoperative decline in LEMS. Measures that can anticipate and reduce the risk of postoperative neurologic complications are warranted.

    Level of evidence

    3.
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    ItemOpen Access
    Non-neurologic adverse events after complex adult spinal deformity surgery: results from the prospective, multicenter Scoli-RISK-1 study.
    (European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2019-01) Kwan, Kenny Yat Hong; Bow, Cora; Samartzis, Dino; Lenke, Lawrence G; Shaffrey, Christopher I; Carreon, Leah Y; Dahl, Benny T; Fehlings, Michael G; Ames, Christopher P; Boachie-Adjei, Oheneba; Dekutoski, Mark B; Kebaish, Khaled M; Lewis, Stephen J; Matsuyama, Yukihiro; Mehdian, Hossein; Pellisé, Ferran; Qiu, Yong; Schwab, Frank J; Cheung, Kenneth Man Chee

    Purpose

    Accurate information regarding the expected complications of complex adult spinal deformity (ASD) is important for shared decision making and informed consent. The purpose of the present study was to investigate the rate and types of non-neurologic adverse events after complex ASD surgeries, and to identify risk factors that affect their occurrence.

    Methods

    The details and occurrence of all non-neurologic adverse events were reviewed in a prospective cohort of 272 patients after complex ASD surgical correction in a mulitcentre database of the Scoli-RISK-1 study with a planned follow-up of 2 years. Logistic regression analyses were used to identify potential risk factors for non-neurologic adverse events.

    Results

    Of the 272 patients, 184 experienced a total of 515 non-neurologic adverse events for an incidence of 67.6%. 121 (44.5%) patients suffered from more than one adverse event. The most frequent non-neurologic adverse events were surgically related (27.6%), of which implant failure and dural tear were most common. In the unadjusted analyses, significant factors for non-neurologic adverse events were age, previous spine surgery performed, number of documented non-neurologic comorbidities and ASA grade. On multivariable logistic regression analysis, previous spine surgery was the only independent risk factor for non-neurologic adverse events.

    Conclusions

    The incidence of non-neurologic adverse events for patients undergoing corrective surgeries for ASD was 67.6%. Previous spinal surgery was the only independent risk factor predicting the occurrence of non-neurologic adverse events. These findings complement the earlier report of neurologic complications after ASD surgeries from the Scoli-RISK-1 study. These slides can be retrieved under Electronic Supplementary Material.
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    ItemOpen Access
    Predictors of Health-Related Quality-of-Life After Complex Adult Spinal Deformity Surgery: A Scoli-RISK-1 Secondary Analysis.
    (Spine deformity, 2017-03) Carreon, Leah Y; Glassman, Steven D; Shaffrey, Christopher I; Fehlings, Michael G; Dahl, Benny; Ames, Christopher P; Matsuyama, Yukihiro; Qiu, Yong; Mehdian, Hossein; Cheung, Kenneth MC; Schwab, Frank J; Pellisé, Ferran; Kebaish, Khaled M; Lenke, Lawrence G

    Study design

    Longitudinal cohort.

    Objectives

    To identify variables that predict 2-year Short Form-36 Physical Composite Summary Score (SF-36PCS) and the Scoliosis Research Society-22R (SRS22-R) Total score after surgery for complex adult spinal deformity.

    Summary of background data

    Increasingly, treatment effectiveness is assessed by the extent to which the procedure improves a patient's health-related quality of life (HRQOL). This is especially true in patients with complex adult spinal deformity.

    Methods

    The data set from the Scoli-Risk-1 study was queried for patients with complete 2-year SF-36 and SRS-22R. Regression analysis was performed to determine predictors of 2-year SF-36PCS and SRS-22R Total scores. Factors included were sex, age, smoking status, body mass index, American Society of Anesthesiologists (ASA) grade, Lower Extremity Motor Score improvement, indication for surgery, preoperative and 2-year maximum coronal Cobb angles, number of prior spine surgeries, number of three-column osteotomies, number of surgical levels, number of surgical stages, lowest instrumented level, presence and type of neurologic complication, and number of reported serious adverse events.

    Results

    Of 272 cases enrolled, 206 (76%) cases were included in this analysis, 143 (69%) females, and mean age of 57.69 years. Factors that were significantly associated with of 2-year SF-36PCS were age (p < .001), ASA grade (p < .001), maximum preoperative Cobb angle (p = .007), number of three-column osteotomies (p = .049) and type of neurologic complication (p = .068). Factors predictive of 2-year SRS-22R Total scores were maximum preoperative Cobb angle (p = .001) and the number of serious adverse events (p = .071).

    Conclusions

    Factors predictive of lower 2-year HRQOLs after surgery for complex adult spinal deformity were older age, higher ASA grade, larger preoperative Cobb angle, larger numbers of three-column osteotomies, and the occurrence of both neurologic and nonneurologic complications. Most of these factors are beyond the control of surgeons. Still, surgeons should medically optimize a patient prior to surgery to minimize the risk of complications and offer the best chance of improving a patient's quality of life.

    Level of evidence

    Level II. Prospective cohort.
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    ItemOpen Access
    Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study.
    (Spine, 2012-05) Schwab, Frank; Ungar, Benjamin; Blondel, Benjamin; Buchowski, Jacob; Coe, Jeffrey; Deinlein, Donald; DeWald, Christopher; Mehdian, Hossein; Shaffrey, Christopher; Tribus, Clifford; Lafage, Virginie

    Study design

    Inter- and intra-rater variability study.

    Objective

    On the basis of a Scoliosis Research Society effort, this study seeks to determine whether the new adult spinal deformity (ASD) classification system is clear and reliable.

    Summary of background data

    A classification of adult ASD can serve several purposes, including consistent characterization of a clinical entity, a basis for comparing different treatments, and recommended treatments. Although pediatric scoliosis classifications are well established, an ASD classification is still being developed. A previous classification developed by Schwab et al has met with clinical relevance but did not include pelvic parameters, which have shown substantial correlation with health-related quality of life measures in recent studies.

    Methods

    Initiated by the Scoliosis Research Society Adult Deformity Committee, this study revised a previously published classification to include pelvic parameters. Modifier cutoffs were determined using health-related quality of life analysis from a multicenter database of adult deformity patients. Nine readers graded 21 premarked cases twice each, approximately 1 week apart. Inter- and intra-rater variability and agreement were determined for curve type and each modifier separately. Fleiss' kappa was used for reliability measures, with values of 0.00 to 0.20 considered slight, 0.21 to 0.40 fair, 0.41 to 0.60 moderate, 0.61 to 0.80 substantial, and 0.81 to 1.00 almost perfect agreement.

    Results

    Inter-rater kappa for curve type was 0.80 and 0.87 for the 2 readings, respectively, with modifier kappas of 0.75 and 0.86, 0.97 and 0.98, and 0.96 and 0.96 for pelvic incidence minus lumbar lordosis (PI-LL), pelvic tilt (PT), and sagittal vertical axis (SVA), respectively. By the second reading, curve type was identified by all readers consistently in 66.7%, PI-LL in 71.4%, PT in 95.2%, and SVA in 90.5% of cases. Intra-rater kappa averaged 0.94 for curve type, 0.88 for PI-LL, 0.97 for PT, and 0.97 for SVA across all readers.

    Conclusion

    Data from this study show that there is excellent inter- and intra-rater reliability and inter-rater agreement for curve type and each modifier. The high degree of reliability demonstrates that applying the classification system is easy and consistent.
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    ItemOpen Access
    Spinal cord injury in high-risk complex adult spinal deformity surgery: review of incidence and outcomes from the Scoli-RISK-1 study
    (Spinal Cord Series and Cases, 2024) Jiang, Fan; Joshi, Hetshree; Badhiwala, Jetan H; Wilson, Jamie RF; Lenke, Lawrence G; Shaffrey, Christopher I; Cheung, Kenneth MC; Carreon, Leah Y; Dekutoski, Mark B; Schwab, Frank J; Boachie-Adjei, Oheneba; Kebaish, Khaled M; Ames, Christopher P; Berven, Sigurd H; Qiu, Yong; Matsuyama, Yukihiro; Dahl, Benny T; Mehdian, Hossein; Pellisé, Ferran; Lewis, Stephen J; Fehlings, Michael G
    Abstract Study design Clinical case series. Objective To describe the cause, treatment and outcome of 6 cases of perioperative spinal cord injury (SCI) in high-risk adult deformity surgery. Setting Adult spinal deformity patients were enrolled in the multi-center Scoli-RISK-1 cohort study. Methods A total of 272 patients who underwent complex adult deformity surgery were enrolled in the prospective, multi-center Scoli-RISK-1 cohort study. Clinical follow up data were available up to a maximum of 2 years after index surgery. Cases of perioperative SCI were identified and an extensive case review was performed. Results Six individuals with SCI were identified from the Scoli-RISK-1 database (2.2%). Two cases occurred intraoperatively and four cases occurred postoperatively. The first case was an incomplete SCI due to a direct intraoperative insult and was treated postoperatively with Riluzole. The second SCI case was caused by a compression injury due to overcorrection of the deformity. Three cases of incomplete SCI occurred; one case of postoperative hematoma, one case of proximal junctional kyphosis (PJK) and one case of adjacent segment disc herniation. All cases of post-operative incomplete SCI were managed with revision decompression and resulted in excellent clinical recovery. One case of incomplete SCI resulted from infection and PJK. The patient’s treatment was complicated by a delay in revision and the patient suffered persistent neurological deficits up to six weeks following the onset of SCI. Conclusion Despite the low incidence in high-risk adult deformity surgeries, perioperative SCI can result in devastating consequences. Thus, appropriate postoperative care, follow up and timely management of SCI are essential.
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    The Effect of Tobacco Smoking on Adverse Events Following Adult Complex Deformity Surgery: Analysis of 270 Patients From the Prospective, Multicenter Scoli-RISK-1 Study.
    (Spine, 2020-01) Wilson, Jamie RF; Jiang, Fan; Badhiwala, Jetan H; Shaffrey, Christopher I; Carreon, Leah Y; Cheung, Kenneth MC; Dahl, Benny T; Ames, Christopher P; Boachie-Adjei, Oheneba; Dekutoski, Mark B; Lewis, Stephen J; Matsuyama, Yukihiro; Mehdian, Hossein; Pellisé, Ferran; Qiu, Yong; Schwab, Frank J; Lenke, Lawrence G; Fehlings, Michael G

    Study design

    Post-hoc analysis of a prospective, multicenter cohort study.

    Objective

    To analyze the impact of smoking on rates of postoperative adverse events (AEs) in patients undergoing high-risk adult spine deformity surgery.

    Summary of background data

    Smoking is a known predictor of medical complications after adult deformity surgery, but the effect on complications, implant failure and other AEs has not been adequately described in prospective studies.

    Methods

    Twenty-six patients with a history of current smoking were identified out of the 272 patients enrolled in the SCOLI-RISK-1 study who underwent complex adult spinal deformity surgery at 15 centers, with 2-year follow-up. The outcomes and incidence of AEs in these patients were compared to the nonsmoking cohort (n = 244) using univariate analysis, with additional multivariate regression to adjust for the effect of patient demographics, complexity of surgery, and other confounders.

    Results

    The number of levels and complexity of surgery in both cohorts were comparable. In the univariate analysis, the rates of implant failure were almost double (odds ratio 2.28 [0.75-6.18]) in smoking group (n = 7; 26.9%)) that observed in the nonsmoking group (n = 34; 13.9%), but this was not statistically significant (P = 0.088). Surgery-related excessive bleeding (>4 L) was significantly higher in the smoking group (n = 5 vs. n = 9; 19.2% vs. 3.7%; OR 6.22[1.48 - 22.75]; P = 0.006). Wound infection rates and respiratory complications were similar in both groups. In the multivariate analysis, the smoking group demonstrated a higher incidence of any surgery-related AEs over 2 years (n = 13 vs. n = 95; 50.0% vs. 38.9%; OR 2.12 [0.88-5.09]) (P = 0.094).

    Conclusion

    In this secondary analysis of patients from the SCOLI-RISK-1 study, a history of smoking significantly increased the risk of excessive intraoperative bleeding and nonsignificantly increased the rate of implant failure or surgery-related AEs over 2 years. The authors therefore advocate a smoking cessation program in patients undergoing complex adult spine deformity surgery.

    Level of evidence

    2.
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    ItemOpen Access
    Unilateral versus bilateral lower extremity motor deficit following complex adult spinal deformity surgery: is there a difference in recovery up to 2-year follow-up?
    (The spine journal : official journal of the North American Spine Society, 2019-03) Tuchman, Alexander; Lenke, Lawrence G; Cerpa, Meghan; Fehlings, Michael G; Lewis, Stephen J; Shaffrey, Christopher I; Cheung, Kenneth MC; Carreon, Leah Yacat; Dekutoski, Mark B; Schwab, Frank J; Boachie-Adjei, Oheneba; Kebaish, Khaled; Ames, Christopher P; Qiu, Yong; Matsuyama, Yukihiro; Dahl, Benny T; Mehdian, Hossein; Pellisé, Ferran; Berven, Sigurd H

    Background context

    Scoli-RISK-1 is a multicenter prospective cohort designed to study neurologic outcomes following complex adult spinal deformity (ASD). The effect of unilateral versus bilateral postoperative motor deficits on the likelihood of long-term recovery has not been previously studied in this population.

    Purpose

    To evaluate whether bilateral postoperative neurologic deficits have a worse recovery than unilateral deficits.

    Study design

    Secondary analysis of a prospective, multicenter, international cohort study.

    Methods

    In a cohort of 272 patients, neurologic decline was defined as deterioration of the American Spinal Injury Association Lower Extremity Motor Scores (LEMS) following surgery. Patients with lower extremity neurologic decline were grouped into unilateral and bilateral cohorts. Differences in demographics, surgical variables, and patient outcome measures between the two cohorts were analyzed.

    Results

    A total of 265 patients had LEMS completed at discharge. Unilateral decline was seen in 32 patients (12%), while 29 (11%) had bilateral symptoms. At 2 years, there was no significant difference in either median LEMS (unilateral 50.0, interquartile range [IQR] 47.5-50.0; bilateral 50.0, IQR 48.0-50.0, p=.939) or change in LEMS from baseline (unilateral 0.0, IQR -1.0 to 0.0; bilateral 0.0, IQR -1.0 to 0.0, p=.920). In both groups, approximately two-thirds of patients saw recovery to at least their preoperative baseline by 2 years postoperatively (unilateral n=15, 63%; bilateral n=14, 67%). The mean Scoliosis Research Society-22R (SRS-22R) score at 2 years was 3.7±0.6 versus 3.2±0.6 (p=.009) for unilateral and bilateral groups, respectively.

    Conclusions

    The prognosis for neurologic recovery of new motor deficits following complex adult spinal deformity is similar with both unilateral and bilateral weaknesses. Despite similar rates of neurologic recovery, patient reported outcomes for those with bilateral motor decline measured by SRS-22R are worse at 2 years after surgery.