Browsing by Author "Ramachandran, Subaraman"
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Item Open Access Assessment of Surgical Treatment Strategies for Moderate to Severe Cervical Spinal Deformity Reveals Marked Variation in Approaches, Osteotomies, and Fusion Levels.(World neurosurgery, 2016-07) Smith, Justin S; Klineberg, Eric; Shaffrey, Christopher I; Lafage, Virginie; Schwab, Frank J; Protopsaltis, Themistocles; Scheer, Justin K; Ailon, Tamir; Ramachandran, Subaraman; Daniels, Alan; Mundis, Gregory; Gupta, Munish; Hostin, Richard; Deviren, Vedat; Eastlack, Robert; Passias, Peter; Hamilton, D Kojo; Hart, Robert; Burton, Douglas C; Bess, Shay; Ames, Christopher P; International Spine Study GroupObjective
Although previous reports suggest that surgery can improve the pain and disability of cervical spinal deformity (CSD), techniques are not standardized. Our objective was to assess for consensus on recommended surgical plans for CSD treatment.Methods
Eighteen CSD cases were assembled, including a clinical vignette, cervical imaging (radiography, computed tomography/magnetic resonance imaging), and full-length standing radiography. Fourteen deformity surgeons (10 orthopedic, 4 neurosurgery) were queried regarding recommended surgical plans.Results
There was marked variation in treatment plans across all deformity types. Even for the least complex deformities (moderate midcervical apex kyphosis), there was lack of agreement on approach (50% combined anterior-posterior, 25% anterior only, 25% posterior only), number of anterior (range, 2-6) and posterior (range, 4-16) fusion levels, and types of osteotomies. As the kyphosis apex moved caudally (cervical-thoracic junction/upper thoracic spine) and for cases with chin-on-chest kyphosis, >80% of surgeons agreed on a posterior-only approach and >70% recommended a pedicle subtraction osteotomy or vertebral column resection, but the range in number of anterior (4-8) and posterior (4-27) fusion levels was exceptionally broad. Cases of cervical/cervical-thoracic scoliosis had the least agreement for approach (48% posterior only, 33% combined anterior-posterior, 17% anterior-posterior-anterior or posterior-anterior-posterior, 2% anterior only) and had broad variation in the number of anterior (2-5) and posterior (6-19) fusion levels, and recommended osteotomies (41% pedicle subtraction osteotomy/vertebral column resection).Conclusions
Among a panel of deformity surgeons, there was marked lack of consensus on recommended surgical approach, osteotomies, and fusion levels for CSD. Further study is warranted to assess whether specific surgical treatment approaches are associated with better outcomes.Item Open Access The Relationship Between Improvements in Myelopathy and Sagittal Realignment in Cervical Deformity Surgery Outcomes.(Spine, 2018-08) Passias, Peter Gust; Horn, Samantha R; Bortz, Cole A; Ramachandran, Subaraman; Burton, Douglas C; Protopsaltis, Themistocles; Lafage, Renaud; Lafage, Virginie; Diebo, Bassel G; Poorman, Gregory W; Segreto, Frank A; Smith, Justin S; Ames, Christopher; Shaffrey, Christopher I; Kim, Han Jo; Neuman, Brian; Daniels, Alan H; Soroceanu, Alexandra; Klineberg, Eric; International Spine Study Group (ISSG)Study design
Retrospective review.Objective
Determine whether alignment or myelopathy improvement drives patient outcomes after cervical deformity (CD) corrective surgery.Summary of background data
CD correction involves radiographic malalignment correction and procedures to improve motor function and pain. It is unknown whether alignment or myelopathy improvement drives patient outcomes.Methods
Inclusion: Patients with CD with baseline/1-year radiographic and outcome scores. Cervical alignment improvement was defined by improvement in Ames CD modifiers. modified Japanese Orthopaedic Association (mJOA) improvement was defined as mild [15-17], moderate [12-14], severe [<12]. Patient groups included those who only improved in alignment, those who only improved in mJOA, those who improved in both, and those who did not improve. Changes in quality-of-life scores (neck disability index [NDI], EuroQuol-5 dimensions [EQ-5D], mJOA) were evaluated between groups.Results
A total of 70 patients (62 yr, 51% F) were included. Overall preoperative mJOA score was 13.04 ± 2.35. At baseline, 21 (30%) patients had mild myelopathy, 33 (47%) moderate, and 16 (23%) severe. Out of 70 patients 30 (44%) improved in mJOA and 13 (18.6%) met 1-year mJOA minimal clinically important difference. Distribution of improvement groups: 16/70 (23%) alignment-only improvement, 13 (19%) myelopathy-only improvement, 18 (26%) alignment and myelopathy improvement, and 23 (33%) no improvement. EQ-5D improved in 11 of 16 (69%) alignment-only patients, 11 of 18 (61%) myelopathy/alignment improvement, 13 of 13 (100%) myelopathy-only, and 10 of 23 (44%) no myelopathy/alignment improvement. There were no differences in decompression, baseline alignment, mJOA, EQ-5D, or NDI between groups. Patients who improved only in myelopathy showed significant differences in baseline-1Y EQ-5D (baseline: 0.74, 1 yr:0.83, P < 0.001). One-year C2-S1 sagittal vertical axis (SVA; mJOA r = -0.424, P = 0.002; EQ-5D r = -0.261, P = 0.050; NDI r = 0.321, P = 0.015) and C7-S1 SVA (mJOA r = -0.494, P < 0.001; EQ-5D r = -0.284, P = 0.031; NDI r = 0.334, P = 0.010) were correlated with improvement in health-related qualities of life.Conclusion
After CD-corrective surgery, improvements in myelopathy symptoms and functional score were associated with superior 1-year patient-reported outcomes. Although there were no relationships between cervical-specific sagittal parameters and patient outcomes, global parameters of C2-S1 SVA and C7-S1 SVA showed significant correlations with overall 1-year mJOA, EQ-5D, and NDI. These results highlight myelopathy improvement as a key driver of patient-reported outcomes, and confirm the importance of sagittal alignment in patients with CD.Level of evidence
3.