Browsing by Author "Okonkwo, David"
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Item Open Access Benchmark Values for Construct Survival and Complications by Type of ASD Surgery.(Spine, 2024-04) Bass, Robert Daniel; Lafage, Renaud; Smith, Justin S; Ames, Christopher; Bess, Shay; Eastlack, Robert; Gupta, Munish; Hostin, Richard; Kebaish, Khaled; Kim, Han Jo; Klineberg, Eric; Mundis, Gregory; Okonkwo, David; Shaffrey, Christopher; Schwab, Frank; Lafage, Virginie; Burton, Douglas; International Spine Study GroupObjective
Provide benchmarks for the rates of complications by type of surgery performed.Study design
Prospective multicenter database.Background
We have previously examined overall construct survival and complication rates for ASD surgery. However, the relationship between type of surgery and construct survival warrants more detailed assessment.Methods
Eight surgical scenarios were defined based on the levels treated, previous fusion status (primary [P] vs. revision [R]), and 3-column osteotomy use [3CO]: Short Lumbar fusion, LT-Pelvis with 5-12 levels treated (P, R or 3CO), UT-Pelvis with 13 levels treated (P, R or 3CO), and Thoracic to Lumbar fusion without pelvic fixation, representing 92.4% of the case in the cohort. Complication rates for each type were calculated and Kaplan Meier curves with multivariate Cox regression analysis was used to evaluate the effect of the case characteristics on construct survival rate, while controlling for patient profile.Results
1073 of 1494 patients eligible for 2-year follow-up (71.8%) were captured. Survival curves for major complications (with or without reoperation), while controlling for demographics differed significantly among surgical types (P<0.001). Fusion procedures short of the pelvis had the best survival rate, while UT-Pelvis with 3CO had the worst survival rate. Longer fusions and more invasive operations were associated with lower 2-year complication-free survival, however there were no significant associations between type of surgery and renal, cardiac, infection, wound, gastrointestinal, pulmonary, implant malposition or neurologic complications (all P>0.5).Conclusion
This study suggests that there is an inherent increased risk of complication for some types of ASD surgery independent of patient profile. The results of this paper can be used to produce a surgery-adjusted benchmark for ASD surgery with regard to complications and survival. Such a tool can have very impactful applications for surgical decision making and more informed patient counseling.Item Open Access Does MIS Surgery Allow for Shorter Constructs in the Surgical Treatment of Adult Spinal Deformity?(Neurosurgery, 2017-03) Uribe, Juan S; Beckman, Joshua; Mummaneni, Praveen V; Okonkwo, David; Nunley, Pierce; Wang, Michael Y; Mundis, Gregory M; Park, Paul; Eastlack, Robert; Anand, Neel; Kanter, Adam; Lamarca, Frank; Fessler, Richard; Shaffrey, Chris I; Lafage, Virginie; Chou, Dean; Deviren, Vedat; MIS-ISSG GroupBackground
The length of construct can potentially influence perioperative risks in adult spinal deformity (ASD) surgery. A head-to-head comparison between open and minimally invasive surgery (MIS) techniques for treatment of ASD has yet to be performed.Objective
To examine the impact of MIS approaches on construct length and clinical outcomes in comparison to traditional open approaches when treating similar ASD profiles.Methods
Two multicenter databases for ASD, 1 involving MIS procedures and the other open procedures, were propensity matched for clinical and radiographic parameters in this observational study. Inclusion criteria were ASD and minimum 2-year follow-up. Independent t -test and chi-square test were used to evaluate and compare outcomes.Results
A total of 1215 patients were identified, with 84 patients matched in each group. Statistical significance was found for mean levels fused (4.8 for circumferential MIS [cMIS] and 10.1 for open), mean interbody fusion levels (3.6 cMIS and 2.4 open), blood loss (estimated blood loss 488 mL cMIS and 1762 mL open), and hospital length of stay (6.7 days cMIS and 9.7 days open). There was no significant difference in preoperative radiographic parameters or postoperative clinical outcomes (Owestry Disability Index and visual analog scale) between groups. There was a significant difference in postoperative lumbar lordosis (43.3° cMIS and 49.8° open) and pelvic incidence-lumbar lordosis correction (10.6° cMIS and 5.2° open) in the open group. There was no significant difference in reoperation rate between the 2 groups.Conclusion
MIS techniques for ASD may reduce construct length, reoperation rates, blood loss, and length of stay without affecting clinical and radiographic outcomes when compared to a similar group of patients treated with open techniques.Item Open Access Is There a Patient Profile That Characterizes a Patient With Adult Spinal Deformity as a Candidate for Minimally Invasive Surgery?(Global spine journal, 2017-10) Eastlack, Robert K; Mundis, Gregory M; Wang, Michael; Mummaneni, Praveen V; Uribe, Juan; Okonkwo, David; Akbarnia, Behrooz A; Anand, Neel; Kanter, Adam; Park, Paul; Lafage, Virginie; Shaffrey, Christopher; Fessler, Richard; Deviren, Vedat; International Spine Study GroupRetrospective review.The goal of this study was to evaluate the baseline characteristics of patients chosen to undergo traditional open versus minimally invasive surgery (MIS) for adult spinal deformity (ASD).A multicenter review of 2 databases including ASD patients treated with surgery. Inclusion criteria were age >45 years, Cobb angle minimum of 20°, and minimum 2-year follow-up. Preoperative radiographic parameters and disability outcome measures were reviewed.A total of 350 patients were identified: 173 OPEN patients and 177 MIS. OPEN patients were significantly younger than MIS patients (61.5 years vs 63.74 years, P = .013). The OPEN group had significantly more females (87% vs 76%, P = .006), but both groups had similar body mass index. Preoperative lumbar Cobb was significantly higher for the OPEN group (34.2°) than for the MIS group (26.0°, P < .001). The mean preoperative Oswestry Disability Index was significantly higher in the MIS group (44.8 in OPEN patients and 49.8 in MIS patients, P < .011). The preoperative Numerical Rating Scale value for back pain was 7.2 in the OPEN group and 6.8 in the MIS group preoperatively, P = .100.Patients chosen for MIS for ASD are slightly older and have smaller coronal deformities than those chosen for open techniques, but they did not have a substantially lesser degree of sagittal malalignment. MIS surgery was most frequently utilized for patients with an sagittal vertical axis under 6 cm and a baseline pelvic incidence and lumbar lordosis mismatch under 30°.Item Open Access Minimally Invasive Spinal Deformity Surgery: Analysis of Patients Who Fail to Reach Minimal Clinically Important Difference.(World neurosurgery, 2020-02-12) Wang, Michael Y; Uribe, Juan; Mummaneni, Praveen V; Tran, Stacie; Brusko, G Damian; Park, Paul; Nunley, Pierce; Kanter, Adam; Okonkwo, David; Anand, Neel; Chou, Dean; Shaffrey, Christopher I; Fu, Kai-Ming; Mundis, Gregory M; Eastlack, Robert; Minimally Invasive Surgery-International Spine Study GroupBACKGROUND:It is well known that clinical improvements following surgical intervention are variable. While all surgeons strive to maximize reliability and degree of improvement, certain patients will fail to achieve meaningful gains. We aim to analyze patients who failed to reach minimal clinically important difference (MCID) in an effort to improve outcomes for minimally invasive deformity surgery. METHODS:Data were collected on a multicenter registry of minimally invasive surgery adult spinal deformity surgeries. Patient inclusion criteria were age ≥18 years, coronal Cobb ≥20 degrees, pelvic incidence-lumbar lordosis ≥10 degrees, or a sagittal vertical axis >5 cm. All patients had minimum 2 years' follow-up (N = 222). MCID was defined as 12.8 or more points of improvement in the Oswestry Disability Index. Up to 2 different etiologies for failure were allowed per patient. RESULTS:We identified 78 cases (35%) where the patient failed to achieve MCID at long-term follow-up. A total of 82 identifiable causes were seen in these patients with 14 patients having multiple causes. In 6 patients, the etiology was unclear. The causes were subclassified as neurologic, medical, structural, under treatment, degenerative progression, traumatic, idiopathic, and floor effects. In 71% of cases, an identifiable cause was related to the spine, whereas in 35% the cause was not related to the spine. CONCLUSIONS:Definable causes of failed MIS ASD surgery are often identifiable and similar to open surgery. In some cases the cause is treatable and structural. However, it is also common to see failure due to pathologies unrelated to the index surgery.Item Open Access Minimally Invasive Surgery for Mild-to-Moderate Adult Spinal Deformities: Impact on Intensive Care Unit and Hospital Stay.(World neurosurgery, 2019-07) Chou, Dean; Mundis, Gregory; Wang, Michael; Fu, Kai-Ming; Shaffrey, Christopher; Okonkwo, David; Kanter, Adam; Eastlack, Robert; Nguyen, Stacie; Deviren, Vedat; Uribe, Juan; Fessler, Richard; Nunley, Pierce; Anand, Neel; Park, Paul; Mummaneni, Praveen; International Spine Study GroupObjective
To compare circumferential minimally invasive (cMIS) versus open surgeries for mild-to-moderate adult spinal deformity (ASD) with regard to intensive care unit (ICU) and hospital lengths of stay (LOS).Methods
A retrospective review of 2 multicenter ASD databases with 426 ASD (sagittal vertical axis <6 cm) surgery patients with 4 or more fusion levels and 2-year follow-up was conducted. ICU stay, LOS, and estimated blood loss (EBL) were compared between open and cMIS surgeries.Results
Propensity matching resulted in 88 patients (44 cMIS, 44 open). cMIS were older (61 vs. 53 years, P = 0.005). Mean levels fused were 6.5 in cMIS and 7.1 in open (P = 0.368). Preoperative lordosis was higher in open than in cMIS (42.7° vs. 40.9°, P = 0.016), and preoperative visual analog score back pain was greater in open than in cMIS (7 vs. 6.2, P = 0.033). Preoperative and postoperative spinopelvic parameters and coronal Cobb angles were not different. EBL was 534 cc in cMIS and 1211 cc in open (P < 0.001). Transfusions were less in cMIS (27.3% vs. 70.5%, P < 0.001). ICU stay was 0.6 days for cMIS and 1.2 days for open (P = 0.009). Hospital LOS was 7.9 days for cMIS versus 9.6 for open (P = 0.804).Conclusions
For patients with mild-to-moderate ASD, cMIS surgery had a significantly lower EBL and shorter ICU stay. Major and minor complication rates were lower in cMIS patients than open patients. Overall LOS was shorter in cMIS patients, but did not reach statistical significance.Item Open Access Re-operation After Long-Segment Fusions for Adult Spinal Deformity: The Impact of Extending the Construct Below the Lumbar Spine.(Neurosurgery, 2018-02) Witiw, Christopher D; Fessler, Richard G; Nguyen, Stacie; Mummaneni, Praveen; Anand, Neel; Blaskiewicz, Donald; Uribe, Juan; Wang, Michael Y; Kanter, Adam S; Okonkwo, David; Park, Paul; Deviren, Vedat; Akbarnia, Behrooz A; Eastlack, Robert K; Shaffrey, Christopher; Mundis, Gregory MBackground
Deciding where to end a long-segment fusion for adult spinal deformity (ASD) may be a challenge, particularly in the absence of an abnormality at L5/S1. Some suggest prophylactic extension of the construct to the sacrum and/or ilium (S/I) to protect against distal junctional failure, while others support terminating in the lower lumbar spine to preserve motion.Objective
To compare the risk of re-operation after long-segment fusions for ASD that ends at L4 or L5 (L4/5) vs S/I.Methods
A multicenter database of patients treated for ASD by circumferential minimally invasive surgery or hybrid surgical technique was screened for individuals with long fusions (≥4 vertebral levels) ending at L4 or below and with at least 2 yr of follow-up. Multivariate regression modeling was used to compare surgical morbidity between the L4/5 and S/I groups, and Cox proportional hazard modeling was used to compare risk of re-operation.Results
There were 45 subjects with fusion to L4/5 and 71 to S/I. Over a 32-mo median follow-up, 41 re-operations were performed; 6 were for distal junctional failure. In those with normal or mild degeneration at L5/S1, fusion to S/I afforded no significant change in re-operative risk (hazard ratio = 1.18 [95% confidence interval: 0.53-2.62], P = .682). In those undergoing circumferential minimally invasive surgery correction, fusion to S/I was associated with significantly greater blood loss (499.6 cc, P < .001) and surgical time (97.5 min, P = .04).Conclusion
In the setting of a normal or mildly degenerated L5/S1 disc space, fusion to the sacrum/ilium did not significantly change the risk of requiring a re-operation after a long-segment fusion for ASD.