Browsing by Author "Onafowokan, Oluwatobi O"

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    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.
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    ItemOpen Access
    Assessing the effects of prehabilitation protocols on post-operative outcomes in adult cervical deformity surgery: does early optimization lead to optimal clinical outcomes?
    (Spine deformity, 2024-07) Jankowski, Pawel P; Tretiakov, Peter S; Onafowokan, Oluwatobi O; Das, Ankita; Imbo, Bailey; Krol, Oscar; Joujon-Roche, Rachel; Williamson, Tyler; Dave, Pooja; Mir, Jamshaid; Owusu-Sarpong, Stephane; Passias, Peter G

    Purpose

    To investigate the effect of a prehabilitation program on peri- and post-operative outcomes in adult cervical deformity (CD) surgery.

    Methods

    Operative CD patients ≥ 18 years with complete baseline (BL) and 2-year (2Y) data were stratified by enrollment in a prehabilitation program beginning in 2019. Patients were stratified as having undergone prehabilitation (Prehab+) or not (Prehab-). Differences in pre and post-op factors were assessed via means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay-scales.

    Results

    115 patients were included (age: 61 years, 70% female, BMI: 28 kg/m2). Of these patients, 57 (49%) were classified as Prehab+. At baseline, groups were comparable in age, gender, BMI, CCI, and frailty. Surgically, Prehab+ were able to undergo longer procedures (p = 0.017) with equivalent EBL (p = 0.627), and shorter SICU stay (p < 0.001). Post-operatively, Prehab+ patients reported greater reduction in pain scores and greater improvement in quality of life metrics at both 1Y and 2Y than Prehab- patients (all p < 0.05). Prehab+ patients reported significantly less complications overall, as well as less need for reoperation (all p < 0.05).

    Conclusion

    Introducing prehabilitation protocols in adult cervical deformity surgery may aid in improving patient physiological status, enabling patients to undergo longer surgeries with lessened risk of peri- and post-operative complications.
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    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.
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    ItemOpen Access
    Cause and Effect of Revisions in Adult Spinal Deformity Surgery: A Multicenter Study on Outcomes Based on Etiology.
    (The spine journal : official journal of the North American Spine Society, 2024-12) Passias, Peter G; Dave, Pooja; Smith, Justin S; Lafage, Renaud; Onafowokan, Oluwatobi O; Tretiakov, Peter; Mir, Jamshaid; Line, Breton; Diebo, Bassel; Daniels, Alan H; Gum, Jeffrey L; Eastlack, Robert; Hamilton, D Kojo; Chou, Dean; Klineberg, Eric O; Kebaish, Khaled M; Lewis, Stephen; Gupta, Munish C; Kim, Han Jo; Lenke, Lawrence G; Ames, Christopher P; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Bess, Shay; Hostin, Robert; Burton, Douglas C

    Background context

    While the treatment of adult spinal deformity (ASD) has increasingly favored surgical correction, the incidence of revision surgery remains high. Yet, little has been explored on the association between the etiology of reoperation and patient outcomes.

    Purpose

    To assess the impact of the etiology of revision surgery on postoperative outcomes.

    Study design/setting

    Retrospective cohort analysis.

    Patient sample

    891 ASD patients.

    Outcome measures

    Complications, radiographic parameters, disability metrics.

    Methods

    Operative ASD patients with at least 1 revision stratified by etiology (mechanical [Mech] -pseudoarthrosis, thoracic decompensation without junctional failure, x-ray malalignment, implant failure, implant malposition, PJK ± major malalignment; infection [Infx]-early vs late onset, major vs minor; wound [Wound]; SI pain [SI Pain]). Excluded multiple etiologies, and intraoperative or medical complications. Data from the immediate visit prior to the final revision was used as baseline (rBL). Follow-up based on visits best aligned to time points after final revision. Radiographic parameters SVA, PI-LL, and PT were used to assess alignment post-revision via ANOVA. Multivariate analysis controlling for relevant covariates assessed outcome differences after final revision surgery.

    Results

    891 MET INCLUSION (AGE: 60.40±14.17, 77% F, BMI: 27.97±5.87 KG/M2, CCI: : 1.80±1.73). Etiology groups were as follows: Mech: 432; Infx: 296; Wound: 65; SI Pain: 98. Surgically, Infx had lower rates of osteotomy, interbody fusion, and decompression (p<.05). Infx and SI Pain demonstrated similar correction in radiographics SVA, PI-LL, and PT (p>.05), whereas Mech had significantly less improvement by 2 years (p<.003) that improved by 5 years. Compared to without revision, the odds of MCID in ODI were 48.6% lower across groups (OR: 0.514 [.280, .945], p=.032). Indications of x-ray malalignment were 93.0% less likely to reach MCID (OR: 0.071, [.006, .866], p=.038). Similarly, implant failure negatively impacted rates of MCID (40% vs. 15.2%, p=.029). Those with PJK had 57% lower odds of MCID (33% vs 54%, OR: .43, [0.2, 0.9] p= 0.023), further negated by major malalignment (OR: 0.05, [.07, .97], p=.02). Indications of pseudarthrosis, thoracic decompensation, implant malposition were not significant. Major sepsis had lower rates of MCID compared to minor (6.4% vs. 21.2%), and early onset infection improved compared to late (OR: 1.43, [1.17, 2.98], p<.001). In the early follow-up period, the Mech group has significantly worse SRS Pain and Mental Health scores compared to other groups (1-year: Mech 1.56 vs Infx 0.83 vs SI Pain 0.72, p<0.001; 2-year: 1.88 vs 0.71 vs 0.76, p=0.034). Complication rates increased with the number of revisions and with mechanical indication (all p<.05). At 5 years, patient satisfaction was significantly more likely to improve compared to early follow-up (OR: 1.22, p=.011), along with improved pain score, in Mech group (0.89 vs 0.49 vs 0.56, p=.081).

    Conclusions

    This study focused on the impact of revision as it varies with etiology and time of occurrence postoperatively. Compared to other etiologies, revision surgery due to mechanical complications had less radiographic improvement and worsening patient-reported scores in the early postoperative period despite stabilization at 5 years. The depth of impact of mechanical complication, particularly with the addition of malalignment, merits greater focus during surgical planning.

    Level of evidence

    III.
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    ItemOpen Access
    Comparative Analysis of Outcomes in Adult Spinal Deformity Patients with Proximal Junctional Kyphosis or Failure Initially Fused to Upper Versus Lower Thoracic Spine.
    (Journal of clinical medicine, 2024-12) Onafowokan, Oluwatobi O; Lafage, Renaud; Tretiakov, Peter; Smith, Justin S; Line, Breton G; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey L; Protopsaltis, Themistocles S; Hamilton, David Kojo; Buell, Thomas; Soroceanu, Alex; Scheer, Justin; Eastlack, Robert K; Mullin, Jeffrey P; Mundis, Gregory; Hosogane, Naobumi; Yagi, Mitsuru; Anand, Neel; Okonkwo, David O; Wang, Michael Y; Klineberg, Eric O; Kebaish, Khaled M; Lewis, Stephen; Hostin, Richard; Gupta, Munish Chandra; Lenke, Lawrence G; Kim, Han Jo; Ames, Christopher P; Shaffrey, Christopher I; Bess, Shay; Schwab, Frank J; Lafage, Virginie; Burton, Douglas; Passias, Peter G; International Spine Study Group
    Background: Patients with proximal junctional kyphosis (PJK) or failure (PJF) may demonstrate disparate outcomes and recovery when fused to the upper (UT) versus lower (LT) thoracic spine. Few studies have distinguished the reoperation and recovery abilities of patients with PJK or PJF when fused to the upper (UT) versus lower (LT) thoracic spine. Methods: Adult spine deformity patients ≥ 18 yrs with preoperative and 5-year (5Y) data fused to the sacrum/pelvis were included. The rates of PJK, PJK revision, and radiographic PJF were compared between patients with upper instrumented vertebra (UIV) in the upper thoracic spine (UT; T1-T7) and lower thoracic spine (LT; T8-L1). Mean differences were assessed via analyses of covariance, factoring in any differences between cohorts at baseline and any use of PJF prophylaxis. Backstep logistic regressions assessed predictors of achieving Smith et al.'s Best Clinical Outcomes (BCOs) and complications, controlling for similar covariates. Results: A total of 232 ASD patients were included (64.2 ± 10.2 years, 78% female); 36.3% were UT and 63.7% were LT. Postoperatively, the rates of PJK for UT were lower than LT at 1Y (34.6 vs. 50.4%, p = 0.024), 2Y (29.5 vs. 49.6% (p = 0.003), and 5Y (48.7 vs. 62.8%, p = 0.048), with comparable rates of PJF. In total, 4.0% of UT patients underwent subsequent reoperation, compared to 13.0% of LT patients (p = 0.025). A total of 6.0% of patients had recurrent PJK, and 3.9% had recurrent PJF (both p > 0.05). After reoperation, UT patients reported higher rates of improvement in the minimum clinically important difference for ODI by 2Y (p = 0.007) and last follow-up (p < 0.001). While adjusted regression revealed that, for UT patients, the minimization of construct extension was predictive of achieving BCOs by last follow-up (model p < 0.001), no such relationship was identified in LT patients. Conclusions: Patients initially fused to the lower thoracic spine demonstrate an increased incidence of PJK and lower rates of disability improvement, but are at a lessened risk of neurologic complications if reoperation is required.
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    ItemOpen Access
    Despite a Multifactorial Etiology, Rates of Distal Junctional Kyphosis After Adult Cervical Deformity Corrective Surgery Can be Dramatically Diminished by Optimizing Age Specific Radiographic Improvement.
    (Global spine journal, 2024-11) Mir, Jamshaid M; Onafowokan, Oluwatobi O; Jankowski, Pawel P; Krol, Oscar; Williamson, Tyler; Das, Ankita; Thomas, Zach; Padon, Benjamin; Schoenfeld, Andrew J; Janjua, Muhammad Burhan; Passias, Peter G

    Study design

    Retrospective cohort study of a prospectively collected single-center database.

    Objective

    Distal Junctional Kyphosis (DJK) is one of the most common complications in adult cervical deformity (ACD) correction. The utility of radiographic alignment alone in predicting and minimizing DJK occurrence warrants further study. To investigate the impact of post-operative radiographic alignment on development of DJK in ACD patients.

    Methods

    ACD patients (≥18 yrs) with complete baseline (BL) and two-year (2Y) radiographic data were included. DJF was defined as DJK greater than 15° (Passias et al) or DJK with reop. Multivariable logistic regression (MVA) identified 3-month predictors of DJK. Conditional inference tree (CIT) machine learning analysis determined threshold cutoffs. Radiographic predictors were combined in a model to determine predictive value using area under the curve (AUC) methodology. "Match" refers to ideal age-adjusted alignment.

    Results

    140 cervical deformity patients met inclusion criteria (61.3 yrs, 67% F, BMI: 29 kg/m2, CCI: 0.96 ± 1.3). Surgically, 51.3% had osteotomies, 47.1% had a posterior approach, 34.5% combined approach, 18.5% anterior approach, with an average 7.6 ± 3.8 levels fused and EBL of 824 mL. Overall, 33 patients (23.6%) developed DJK, and 11 patients (9%) developed DJF. MVA controlling for age, and baseline deformity, followed by CIT found 3M cSVA <3.7 cm (OR: .2, 95% CI:.06-.6), and TK T4-T12 <50 (OR:.17, 95% CI:.05-.5, both P < .05) were significant predictors of a lower likelihood of DJK. Receiver operator curve AUC using age, T1S match, TS-CL match, LL-TK match, cSVA <3.7 cm, and T4-T12 <50 predicted DJK with an AUC of .91 for DJK by 2Y, and .88 for DJF by 2Y.

    Conclusion

    These findings suggest post-operative radiographic alignment is strongly associated with distal junctional kyphosis. When utilizing age-adjusted realignment in addition to newly developed thresholds, a suggested post-operative cSVA target of 3.7 cm and thoracic kyphosis less than 50, it is possible to substantially reduce the occurrence of distal junctional kyphosis and distal junctional failure.
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    ItemOpen Access
    Expectations of clinical improvement following corrective surgery for adult cervical deformity based on functional disability at presentation.
    (Spine deformity, 2024-07) Passias, Peter G; Onafowokan, Oluwatobi O; Joujon-Roche, Rachel; Smith, Justin; Tretiakov, Peter; Buell, Thomas; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey L; Hamiltion, D Kojo; Soroceanu, Alex; Scheer, Justin; Eastlack, Robert K; Fessler, Richard G; Klineberg, Eric O; Kim, Han Jo; Burton, Douglas C; Schwab, Frank J; Bess, Shay; Lafage, Virginie; Shaffrey, Christopher I; Ames, Christopher; International Spine Study Group

    Purpose

    To assess impact of baseline disability on HRQL outcomes.

    Methods

    CD patients with baseline (BL) and 2 year (2Y) data included, and ranked into quartiles by baseline NDI, from lowest/best score (Q1) to highest/worst score (Q4). Means comparison tests analyzed differences between quartiles. ANCOVA and logistic regressions assessed differences in outcomes while accounting for covariates (BL deformity, comorbidities, HRQLs, surgical details and complications).

    Results

    One hundred and sixteen patients met inclusion (Age:60.97 ± 10.45 years, BMI: 28.73 ± 7.59 kg/m2, CCI: 0.94 ± 1.31). The cohort mean cSVA was 38.54 ± 19.43 mm and TS-CL: 37.34 ± 19.73. Mean BL NDI by quartile was: Q1: 25.04 ± 8.19, Q2: 41.61 ± 2.77, Q3: 53.31 ± 4.32, and Q4: 69.52 ± 8.35. Q2 demonstrated greatest improvement in NRS Neck at 2Y (-3.93), compared to Q3 (-1.61, p = .032) and Q4 (-1.41, p = .015). Q2 demonstrated greater improvement in NRS Back (-1.71), compared to Q4 (+ 0.84, p = .010). Q2 met MCID in NRS Neck at the highest rates (69.9%), especially compared to Q4 (30.3%), p = .039. Q2 had the greatest improvement in EQ-5D (+ 0.082), compared to Q1 (+ 0.073), Q3 (+ 0.022), and Q4 (+ 0.014), p = .034. Q2 also had the greatest mJOA improvement (+ 1.517), p = .042.

    Conclusions

    Patients in Q2, with mean BL NDI of 42, consistently demonstrated the greatest improvement in HRQLs whereas those in Q4, (NDI 70), saw the least. BL NDI between 39 and 44 may represent a disability "Sweet Spot," within which operative intervention maximizes patient-reported outcomes. Furthermore, delaying intervention until patients are severely disabled, beyond an NDI of 61, may limit the benefits of surgery.
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    ItemOpen Access
    Frail patients require instrumentation of a more proximal vertebra for a successful outcome after surgery for adult spine deformity.
    (The bone & joint journal, 2024-11) Onafowokan, Oluwatobi O; Jankowski, Pawel P; Das, Ankita; Lafage, Renaud; Smith, Justin S; Shaffrey, Christopher I; Lafage, Virginie; Passias, Peter G

    Aims

    The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD).

    Methods

    Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes.

    Results

    A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m2 (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than 'not frail' patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV.

    Conclusion

    Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally.
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    ItemOpen Access
    Have We Made Advancements in Optimizing Surgical Outcomes and Enhancing Recovery for Patients With High-Risk Adult Spinal Deformity Over Time?
    (Oper Neurosurg (Hagerstown), 2024-11-04) Passias, Peter G; Passfall, Lara; Tretiakov, Peter S; Das, Ankita; Onafowokan, Oluwatobi O; Smith, Justin S; Lafage, Virginie; Lafage, Renaud; Line, Breton; Gum, Jeffrey; Kebaish, Khaled M; Than, Khoi D; Mundis, Gregory; Hostin, Richard; Gupta, Munish; Eastlack, Robert K; Chou, Dean; Forman, Alexa; Diebo, Bassel; Daniels, Alan H; Protopsaltis, Themistocles; Hamilton, D Kojo; Soroceanu, Alex; Pinteric, Raymarla; Mummaneni, Praveen; Kim, Han Jo; Anand, Neel; Ames, Christopher P; Hart, Robert; Burton, Douglas; Schwab, Frank J; Shaffrey, Christopher; Klineberg, Eric O; Bess, Shay; International Spine Study Group
    BACKGROUND AND OBJECTIVES: The spectrum of patients requiring adult spinal deformity (ASD) surgery is highly variable in baseline (BL) risk such as age, frailty, and deformity severity. Although improvements have been realized in ASD surgery over the past decade, it is unknown whether these carry over to high-risk patients. We aim to determine temporal differences in outcomes at 2 years after ASD surgery in patients stratified by BL risk. METHODS: Patients ≥18 years with complete pre- (BL) and 2-year (2Y) postoperative data from 2009 to 2018 were categorized as having undergone surgery from 2009 to 2013 [early] or from 2014 to 2018 [late]. High-risk [HR] patients met ≥2 of the criteria: (1) ++ BL pelvic incidence and lumbar lordosis or SVA by Scoliosis Research Society (SRS)-Schwab criteria, (2) elderly [≥70 years], (3) severe BL frailty, (4) high Charlson comorbidity index, (5) undergoing 3-column osteotomy, and (6) fusion of >12 levels, or >7 levels for elderly patients. Demographics, clinical outcomes, radiographic alignment targets, and complication rates were assessed by time period for high-risk patients. RESULTS: Of the 725 patients included, 52% (n = 377) were identified as HR. 47% (n = 338) had surgery pre-2014 [early], and 53% (n = 387) underwent surgery in 2014 or later [late]. There was a higher proportion of HR patients in Late group (56% vs 48%). Analysis by early/late status showed no significant differences in achieving improved radiographic alignment by SRS-Schwab, age-adjusted alignment goals, or global alignment and proportion proportionality by 2Y (all P > .05). Late/HR patients had significantly less poor clinical outcomes per SRS and Oswestry Disability Index (both P < .01). Late/HR patients had fewer complications (63% vs 74%, P = .025), reoperations (17% vs 30%, P = .002), and surgical infections (0.9% vs 4.3%, P = .031). Late/HR patients had lower rates of early proximal junctional kyphosis (10% vs 17%, P = .041) and proximal junctional failure (11% vs 22%, P = .003). CONCLUSION: Despite operating on more high-risk patients between 2014 and 2018, surgeons effectively reduced rates of complications, mechanical failures, and reoperations, while simultaneously improving health-related quality of life.
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    ItemOpen Access
    Highest Achievable Outcomes for Adult Spinal Deformity Corrective Surgery: Does Frailty Severity Exert a Ceiling Effect?
    (Spine, 2024-09) Passias, Peter G; Onafowokan, Oluwatobi O; Tretiakov, Peter; Williamson, Tyler; Kummer, Nicholas; Mir, Jamshaid; Das, Ankita; Krol, Oscar; Passfall, Lara; Joujon-Roche, Rachel; Imbo, Bailey; Yee, Timothy; Sciubba, Daniel; Paulino, Carl B; Schoenfeld, Andrew J; Smith, Justin S; Lafage, Renaud; Lafage, Virginie

    Study design

    Retrospective single-center study.

    Objective

    To assess the influence of frailty on optimal outcome following ASD corrective surgery.

    Summary of background data

    Frailty is a determining factor in outcomes after ASD surgery and may exert a ceiling effect on the best possible outcome.

    Methods

    ASD patients with frailty measures, baseline, and 2-year ODI included. Frailty was classified as Not Frail (NF), Frail (F) and Severely Frail (SF) based on the modified Frailty Index, then stratified into quartiles based on two-year ODI improvement (most improved designated "Highest"). Logistic regression analyzed relationships between frailty and ODI score and improvement, maintenance, or deterioration. A Kaplan-Meier survival curve was used to analyze differences in time to complication or reoperation.

    Results

    A total of 393 ASD patients were isolated (55.2% NF, 31.0% F, and 13.7% SF), then classified as 12.5% NF-Highest, 17.8% F-Highest, and 3.1% SF-Highest. The SF group had the highest rate of deterioration (16.7%, P =0.025) in the second postoperative year, but the groups were similar in improvement (NF: 10.1%, F: 11.5%, SF: 9.3%, P =0.886). Improvement of SF patients was greatest at six months (ΔODI of -22.6±18.0, P <0.001), but NF and F patients reached maximal ODI at 2 years (ΔODI of -15.7±17.9 and -20.5±18.4, respectively). SF patients initially showed the greatest improvement in ODI (NF: -4.8±19.0, F: -12.4±19.3, SF: -22.6±18.0 at six months, P <0.001). A Kaplan-Meier survival curve showed a trend of less time to major complication or reoperation by 2 years with increasing frailty (NF: 7.5±0.381 yr, F: 6.7±0.511 yr, SF: 5.8±0.757 yr; P =0.113).

    Conclusions

    Increasing frailty had a negative effect on maximal improvement, where severely frail patients exhibited a parabolic effect with greater initial improvement due to higher baseline disability, but reached a ceiling effect with less overall maximal improvement. Severe frailty may exert a ceiling effect on improvement and impair maintenance of improvement following surgery.

    Level of evidence

    Level III.
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    ItemOpen Access
    Impact of congestive heart failure on patients undergoing lumbar spine fusion for adult spine deformity.
    (Journal of craniovertebral junction & spine, 2024-01) Onafowokan, Oluwatobi O; Ahmad, Waleed; McFarland, Kimberly; Williamson, Tyler K; Tretiakov, Peter; Mir, Jamshaid M; Das, Ankita; Bell, Joshua; Naessig, Sara; Vira, Shaleen; Lafage, Virginie; Paulino, Carl; Diebo, Bassel; Schoenfeld, Andrew; Hassanzadeh, Hamid; Jankowski, Pawel P; Hockley, Aaron; Passias, Peter Gust

    Background

    With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks.

    Purpose

    The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients.

    Study design/setting

    This was a retrospective cohort study of the PearlDiver database.

    Patient sample

    We enrolled 670,526 patients undergoing spine fusion surgery.

    Outcome measures

    Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs.

    Methods

    Patients undergoing elective spine fusion surgery were isolated and stratified by preoperative HF with preserved ejection fraction (P-EF) or reduced ejection fraction (R-EF) (International Classification of Diseases-9: 428.32 [chronic diastolic HF] and 428.22 [chronic systolic HF]). Means comparison tests (Chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, comorbidities, procedural characteristics, LOS, 30-day and 90-day complication outcomes, and total hospital charges between those diagnosed with P-EF and those not R-EF. Binary logistic regression assessed the odds of complication associated with HF, controlling for levels fused (odds ratio [OR] [95% confidence interval]). Statistical significance was set at P < 0.05.

    Results

    Totally 670,526 elective spine fusion patients were included. Four thousand and seventy-seven were diagnosed with P-EF and 2758 R-EF. Overall, P-EF patients presented with higher rates of morbid obesity, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension (all P < 0.001). In relation to No-HF, P-EF patients had higher rates of 30-day major complications including pulmonary embolism, pneumonia, cerebrovascular accident (CVA), myocardial infarctions (MI), sepsis, and death (all P < 0.001). Furthermore, P-EF was associated significantly with increased odds of pneumonia (OR: 2.07 [1.64-2.56], P < 0.001) and sepsis (OR: 2.09 [1.62-2.66], P < 0.001). Relative to No-HF, R-EF was associated with significantly higher odds of MI (OR: 3.66 [2.34-5.47]), CVA (OR: 2.70 [1.67-4.15]), and pneumonia (OR: 1.85 [1.40-2.40]) (all P < 0.001) postoperative within 30 days. Adjusting for prior history of MI, CAD, and the presence of a pacemaker R-EF was a significant predictor of an MI 30 days postoperatively (OR: 2.2 [1.14-4.32], P = 0.021). Further adjusting for history of CABG or stent placement, R-EF was associated with higher odds of CVA (OR: 2.11 [1.09-4.19], P = 0.028) and MI (OR: 2.27 [1.20-4.43], P = 0.013).

    Conclusions

    When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF.
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    Impact of Enhanced Recovery After Surgery (ERAS) Protocols on Outcomes Up to Two Years After Adult Structural Spine Disorder Surgery
    (Spine, 2024-01-01) Yung, Anthony; Onafowokan, Oluwatobi O; Das, Ankita; Fisher, Max R; Cottrill, Ethan J; Prado, Isabel P; Ivasyk, Iryna; Wu, Caroline M; Tretiakov, Peter S; Lord, Elizbeth L; Jankowski, Pawel P; Orndorff, Douglas G; Schoenfeld, Andrew J; Shaffrey, Christopher I; Passias, Peter G
    Objective: We analyze the recovery pattern of Adult Structural Spine Disorder (ASD) patients who underwent corrective surgery with Enhanced Recovery After Surgery protocol (ERAS+), including physical and psychological prehabilitation components, compared to non-ERAS protocol (ERAS-) up to 2-years after surgery. Summary of Background Data: Spine surgery for ASD is often highly invasive, which can contribute to prolonged recovery. The trajectory of recovery may be accelerated by the application of enhanced recovery principles. Methods: Inclusion criteria were operative patients with ASD >18yrs with complete baseline, 90 days perioperative, and 2-year postoperative data. We assessed differences in baseline demographics, surgical details, baseline Health-Related Quality of Life (HRQL), and surgical outcomes between ERAS+ and ERAS- patients. Outcomes included adverse events, reoperations, and radiographic parameters such as sacral slope (SS), pelvic tilt (PT), pelvic incidence-lumbar lordosis (PI-LL) mismatch, sagittal vertical axis (SVA), lumbar lordosis (LL), T2–T12 kyphosis, and maximum Cobb angle. Additionally, HRQL measures included the PCS, ODI, NDI, EQ-5D, SRS-22r total and domain scores, NRS-Back, and NRS-Leg. We used multivariable logistic regression and ANCOVA to adjust for confounding. Results: 471 patients with ASD met inclusion criteria, with 59 designated ERAS+. Those individuals ERAS+ were older (64.1±13.0 vs 58.0±16.0;p=0.005), had a higher CCI, (2.4±1.8 vs 1.4±1.6;p<0.001), and exhibited a higher modified ASD frailty index (8.2±5.4vs6.3±4.9;p=0.019). Adjusted analysis demonstrated the ERAS+ cohort demonstrated lower likelihood of overall reoperations (OR:0.3; 95%CI:0.13-0.89), and a lower likelihood of overall adverse events (OR:0.4;CI95%:0.19-0.93). ERAS+ was more likely to achieve the MCID in the SRS-22r Total scores at 6 months(OR:3.1;CI95%:1.2-8.4), self-image domain at 6 months (OR:9.0;CI95%:1.6-50.0), in the pain domain at 6 months (OR:3.5;CI95%:1.01-11.9) and 1 year postoperatively (OR:2.6;CI95%:1.03-6.7), and in the SF-36’s physical component summary scores (PCS) at 1 year (OR:2.1;CI95%:1.05-4.2). No other statistically significant differences in HRQL were observed at the remaining time points (P > 0.05). Conclusion: Our work is the first to evaluate HRQL metrics and complication over two-years following ASD correction with ERAS. Despite presenting with more severe baseline frailty and higher comorbidity profiles, patients with ASD who underwent corrective surgery with an ERAS protocol experienced fewer short-term adverse events, and improved HRQL. We believe ERAS following ASD surgery leads to faster functional recovery, reduced postoperative deconditioning, and improved quality of life.
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    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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    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.
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    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
    Response to Letter to the Editor on "Critical Analysis of Radiographic and Patient Reported Outcome Following Anterior/Posterior Staged vs. Same Day Surgery in Patients Undergoing Identical Corrective Surgery for Adult Spinal Deformity".
    (Spine, 2024-09) Onafowokan, Oluwatobi O; Monas, Arie; Yung, Anthony; Fisher, Max R; Das, Ankita; Cottrill, Ethan J; Prado, Isabel P; Wu, Caroline M; Passias, Peter G
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    Response to Letter to the Editor on "Other Factors that Can Affect Wound Healing with Elective Lumbar Spine Surgery and Perioperative Nutritional Supplementation in Patients".
    (Spine, 2024-09) Yung, Anthony; Onafowokan, Oluwatobi O; Fisher, Max R; Das, Ankita; Cottrill, Ethan J; Prado, Isabel P; Wu, Caroline M; Passias, Peter G
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    Risk of spinal surgery among individuals who have been re-vascularized for coronary artery disease.
    (Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 2024-01) Passias, Peter G; Ahmad, Waleed; Kapadia, Bhaveen H; Krol, Oscar; Bell, Joshua; Kamalapathy, Pramod; Imbo, Bailey; Tretiakov, Peter; Williamson, Tyler; Onafowokan, Oluwatobi O; Das, Ankita; Joujon-Roche, Rachel; Moattari, Kevin; Passfall, Lara; Kummer, Nicholas; Vira, Shaleen; Lafage, Virginie; Diebo, Bassel; Schoenfeld, Andrew J; Hassanzadeh, Hamid

    Hypothesis

    Revascularization is a more effective intervention to reduce future postop complications.

    Methods

    Patients undergoing elective spine fusion surgery were isolated in the PearlDiver database. Patients were stratified by having previous history of vascular stenting (Stent), coronary artery bypass graft (CABG), and no previous heart procedure (No-HP). Means comparison tests (chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, and comorbidities. Binary logistic regression assessed the odds of 30-day and 90-day postoperative (postop) complications associated with each heart procedure (Odds Ratio [95 % confidence interval]). Statistical significance was set p < 0.05.

    Results

    731,173 elective spine fusion patients included. Overall, 8,401 pts underwent a CABG, 24,037 pts Stent, and 698,735 had No-HP prior to spine fusion surgery. Compared to Stent and No-HP patients, CABG patients had higher rates of morbid obesity, chronic kidney disease, and diabetes (p < 0.001 for all). Meanwhile, stent patients had higher rates of PVD, hypertension, and hyperlipidemia (all p < 0.001). 30-days post-op, CABG patients had significantly higher complication rates including pneumonia, CVA, MI, sepsis, and death compared to No-HP (all p < 0.001). Stent patients vs. No-HF had higher 30-day post-op complication rates including pneumonia, CVA, MI, sepsis, and death. Furthermore, adjusting for age, comorbidities, and sex Stent was significantly predictive of a MI 30-days post-op (OR: 1.90 [1.53-2.34], P < 0.001). Additionally, controlling for levels fused, stent patients compared to CABG patients had 1.99x greater odds of a MI within 30-days (OR: 1.99 [1.26-3.31], p = 0.005) and 2.02x odds within 90-days postop (OR: 2.2 [1.53-2.71, p < 0.001).

    Conclusion

    With regards to spine surgery, coronary artery bypass graft remains the gold standard for risk reduction. Stenting does not appear to minimize risk of experiencing a post-procedure cardiac event as dramatically as CABG.
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    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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    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.