Browsing by Author "Scheer, JK"
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Item Open Access 166 Predictive Modeling of Length of Hospital Stay Following Adult Spinal Deformity Correction: Analysis of 653 Patients With an Accuracy of 75% Within 2 Days(Neurosurgery, 2016-08-01) Scheer, JK; Ailon, TT; Smith, JS; Hart, R; Burton, DC; Bess, S; Neuman, BJ; Passias, PG; Miller, E; Shaffrey, CI; Schwab, F; Lafage, V; Klineberg, E; Ames, CPINTRODUCTION: The length of stay (LOS) following adult spinal deformity (ASD) surgery is a critical time period allowing for recovery to levels safe enough to return home or to rehabilitation. Thus, the goal is to minimize it for conserving hospital resources and third-party payer pressure. Factors related to LOS have not been studied nor has a predictive model been created. The goal of this study was to construct a preadmission predictive model based on patients' baseline variables and modifiable surgical parameters.Item Open Access Adult Spinal Deformity Surgeons Are Unable to Accurately Predict Postoperative Spinal Alignment Using Clinical Judgment Alone(Spine Deformity, 2016-07-01) Ailon, T; Scheer, JK; Lafage, V; Schwab, FJ; Klineberg, E; Sciubba, DM; Protopsaltis, TS; Zebala, L; Hostin, R; Obeid, I; Koski, T; Kelly, MP; Bess, S; Shaffrey, CI; Smith, JS; Ames, CPObject Adult spinal deformity (ASD) surgery seeks to reduce disability and improve quality of life through restoration of spinal alignment. In particular, correction of sagittal malalignment is correlated with patient outcome. Inadequate correction of sagittal deformity is not infrequent. The present study assessed surgeons' ability to accurately predict postoperative alignment. Methods Seventeen cases were presented with preoperative radiographic measurements, and a summary of the operation as performed by the treating physician. Surgeon training, practice characteristics, and use of surgical planning software was assessed. Participants predicted if the surgical plan would lead to adequate deformity correction and attempted to predict postoperative radiographic parameters including sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence to lumbar lordosis mismatch (PI-LL), thoracic kyphosis (TK). Results Seventeen surgeons participated: 71% within 0 to 10 years of practice; 88% devote >25% of their practice to deformity surgery. Surgeons accurately judged adequacy of the surgical plan to achieve correction to specific thresholds of SVA 69% ± 8%, PT 68% ± 9%, and PI-LL 68% ± 11% of the time. However, surgeons correctly predicted the actual postoperative radiographic parameters only 42% ± 6% of the time. They were more successful at predicting PT (61% ± 10%) than SVA (45% ± 8%), PI-LL (26% ± 11%), or TK change (35% ± 21%; p <.05). Improved performance correlated with greater focus on deformity but not number of years in practice or number of three-column osteotomies performed per year. Conclusion Surgeons failed to correctly predict the adequacy of the proposed surgical plan in approximately one third of presented cases. They were better at determining whether a surgical plan would achieve adequate correction than predicting specific postoperative alignment parameters. Pelvic tilt and SVA were predicted with the greatest accuracy.Item Open Access Assessment of impact of standing long-cassette radiographs on surgical planning for lumbar pathology: An international survey of spine surgeons(Journal of Neurosurgery: Spine, 2015-11-01) Maggio, D; Ailon, TT; Smith, JS; Shaffrey, CI; Lafage, V; Schwab, F; Haid, RW; Protopsaltis, T; Klineberg, E; Scheer, JK; Bess, S; Arnold, PM; Chapman, J; Fehlings, MG; Ames, COBJECT: The associations among global spinal alignment, patient-reported disability, and surgical outcomes have increasingly gained attention. The assessment of global spinal alignment requires standing long-cassette anteroposterior and lateral radiographs; however, spine surgeons routinely rely only on short-segment imaging when evaluating seemingly isolated lumbar pathology. This may prohibit adequate surgical planning and may predispose surgeons to not recognize associated pathology in the thoracic spine and sagittal spinopelvic malalignment. The authors used a case-based survey questionnaire to evaluate if including long-cassette radiographs led to changes to respondents' operative plans as compared with their chosen plan when cases contained standard imaging of the involved lumbar spine only. METHODS: A case-based survey was distributed to AOSpine International members that consisted of 15 cases of lumbar spine pathology and lumbar imaging only. The same 15 cases were then shuffled and presented a second time with additional long-cassette radiographs. Each case required participants to select a single operative plan with 5 choices ranging from least to most extensive. The cases included 5 "control" cases with normal global spinal alignment and 10 "test" cases with significant sagittal and/or coronal malalignment. Mean scores were determined for each question with higher scores representing more invasive and/or extensive operative plans. RESULTS: Of 712 spine surgeons who started the survey, 316 (44%) completed the entire series, including 68% of surgeons with spine fellowship training and representation from more than 40 countries. For test cases, but not for control cases, there were significantly higher average surgical invasiveness scores for cases presented with long-cassette radiographs (4.2) as compared with those cases with lumbar imaging only (3.4; p = 0.002). The addition of long-cassette radiographs resulted in 82.1% of respondents recommending instrumentation up to the thoracic spine, a 23.2% increase as compared with the same cases presented with lumbar imaging only (p = 0.008). CONCLUSIONS: This study demonstrates the importance of maintaining a low threshold for performing standing long-cassette imaging when assessing seemingly isolated lumbar pathology. Such imaging is necessary for the assessment of spinopelvic and global spinal alignment, which can be important in operative planning. Deformity, particularly positive sagittal malalignment, may go undetected unless one maintains a high index of suspicion and obtains long-cassette radiographs. It is recommended that spine surgeons recognize the prevalence and importance of such deformity when contemplating operative intervention.Item Open Access Quantifying the importance of upper cervical extension reserve in adult cervical deformity surgery and its impact on baseline presentation and outcomes(Spine Journal, 2024-09-01) Passias, PG; Mir, J; Smith, JS; Lafage, V; Lafage, R; Diebo, BG; Daniels, AH; Onafowokan, O; Line, B; Eastlack, RK; Mundis, GM; Kebaish, KM; Soroceanu, A; Scheer, JK; Kelly, MP; Protopsaltis, TS; Kim, HJ; Hostin, RA; Gupta, MC; Riew, KD; Burton, DC; Schwab, FJ; Bess, S; Shaffrey, CI; Ames, CPBACKGROUND CONTEXT: Hyperextension of the upper cervical spine is a prominent compensatory mechanism to maintain horizontal gaze and balance in adult cervical deformity (ACD) patients, akin to pelvic tilt in spinal deformity. The relaxation of ER and its impact on postoperative outcomes is not well understood. PURPOSE: To evaluate upper cervical ER impact on postoperative disability and outcomes. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Adult cervical deformity. OUTCOME MEASURES: ER, HRQLs. METHODS: ACD patients undergoing subaxial cervical fusion with 2Y data were included. Upper cervical extension reserve (ER) was defined as: C0-C2 sagittal Cobb angle between neutral and extension. Relaxation of ER was defined as the ER normative mean in those that met the ideal in all Passias ACD modifiers. Outcomes were defined as "good" if meeting ≥2 of the three: (1) NDI <20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Controlled analysis was conducted with ANCOVA and multivariable logistic regressions. Conditional inference tree (CIT) analysis determined thresholds. RESULTS: A total of 108 ACD patients met inclusion. (Age 61.4 ± 12.3, 61% F, BMI 29.4 ± 7.5 kg/m2, mCD-FI .24 ±.12, CCI 0.97 ± 1.30). Radiographic alignment is depicted in Table 1. Preoperative C0-C2 ER was 8.7 ±9.0 ±, and at the last follow-up was 10.3 ± 11.1. ER in those meeting all ideal CD modifiers at 2Y was 12.9 ± 9.0. Preoperatively 29% had adequate ER, while 59.7% had improvement in ER postoperatively, with 50% of patients achieving adequate ER at 2Y. Higher ER significantly correlated with lower cervical deformity (p<.05). Preoperatively, greater ER was predictive of lower preoperative disability, with worse baseline mobility, pain, and anxiety (EQ5D) (B = -6.1, -2.9, -2.9 respectively; R2 =0.212, p<.001). Improvement of ER depicted a higher rate of MCID for NDI (64% vs 39%, p=.008), and meeting good clinical outcomes (72% vs 54%, p=.04). Controlling for baseline deformity and demographic factors found resolution of inadequate ER to have 7x higher likelihood of meeting MCID for NDI (6.941 [1.378-34.961], p=.019) and 4x higher odds of achieving good outcomes (4.022 [1.017-15.900], p=.047). Isolating those with inadequate preoperative ER, found postoperative resolution having 5x odds of good outcomes (p<.05). In those with inadequate ER at baseline, the preoperative C2-C7 of <-18 and TS-CL of >59 for TS-CL was predictive of ER resolution (p<.05). In those with preoperative C2-C7 >-18, a T1PA of >13 was predictive of postoperative return of ER (p<.05). Independently TS-CL of >59, was significant for predicting ER return postoperatively, highlighting its compensatory role for proximal spinal deformities (all p<.05). Surgical correction of C2-C7 by >16 from baseline was found to be predictive of ER return. CONCLUSIONS: Increased preoperative utilization of the extension reserve in the upper cervical spine in cervical deformity was associated with worse baseline regional and global alignment while impacting health-related measures. The majority of patients had relaxation of extension reserve postoperatively, however, in those who didn't, there was a decreased likelihood of achieving good outcomes. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.Item Open Access Who are super-utilizers in adult spine deformity surgery and how can surgeons identify them preoperatively?(Spine Journal, 2024-09-01) Nayak, P; Hostin, RA; Staub, BN; Gum, JL; Line, B; Bess, S; Lenke, LG; Lafage, R; Smith, JS; Mullin, JP; Kelly, MP; Diebo, BG; Buell, TJ; Scheer, JK; Lafage, V; Klineberg, EO; Kim, HJ; Passias, PG; Kebaish, KM; Eastlack, RK; Daniels, AH; Soroceanu, A; Mundis, GM; Protopsaltis, TS; Hamilton, DK; Gupta, MC; Schwab, FJ; Shaffrey, CI; Ames, CP; Burton, DCBACKGROUND CONTEXT: A relatively small percentage of patients are responsible for a disproportional amount of resource utilization in adult ASD surgery and contribute to significantly elevating the average cost across the surgically treated patients. These patients are called super-utilizers (SU). Modest reduction in the frequency of these super-utilization episodes has the potential to significantly improve the value of ASD surgery. PURPOSE: The goal of this study was to determine which, if any, baseline patient, radiographic, and/or surgical factors are the most important drivers of this disproportional increased resource utilization. We hypothesize that baseline patient factors predicts super-utilizers (SU) in adult spinal deformity surgery (ASD) more than surgical or deformity factors. STUDY DESIGN/SETTING: Retrospective Review of a prospective, multicenter registry. PATIENT SAMPLE: A total of 1299 index operative ASD patients eligible for 2-yr follow-up. OUTCOME MEASURES: Predictors of SU vs Non-SU in ASD. METHODS: A prospective multicenter consecutive series of ASD patients was reviewed. Inclusion criteria was diagnosis of ASD (scoliosis≥20°, C7-SVA≥5cm, PT≥25°, or TK≥60°), >4 level posterior fusion, and minimum 2-year follow-up. Index and total episode of care (EOC) cost in 2022 dollars were calculated using average itemized direct costs obtained from the administrative hospital records for all events in the inpatient EOC. Patients with total 2-year EOC cost greater than 90th percentile were considered SU. Multivariate generalized linear models were used to identify the most significant predictors of SU. RESULTS: A total of 1299 patients were eligible for 2-yr follow-up with mean age 60.0+14.1 years, 76% female, and 93% caucasians. SU patients are marginally older (+2.6 yrs; p=0.03), depressed (34.2% vs 25.8%; p=0.03) and tend to have higher propensity for fraility (p=0.003), comorbidities (0.01), reoperation rates (54.8% vs 17.0%; p<0.001), and LOS (+3 days; p<0.0001) compared to non-SU. While degree of sagittal deformity (Schwab sagittal modifiers, all p>0.05) and proportion of 3-column osteotomies (p>0.05) were similar between the groups, SU patients have higher surgical invasiveness score (+28; p<0.001), more vertebrae fused (+3; p<0.0001); more interbody fusions (80% vs 55%; p<0.0001), more BMP use (87.3% vs 69.4%; p=0.0002); longer OR time (+91 mins; p<0.0001), increased blood loss (+700 mL; p<0.0001), and longer length of stay (+3 days; p<0.0001). Index and EOC cost were 49% (p<0.0001) and 62% (p<0.0001) higher respectively in SU. While cost/QALY was 3-times higher in SU compared to non-SU. Multivariate analysis identified Schwab modifier SVA, surgical invasiveness, OR time, blood loss, BMP use, and LOS as strong predictors of SU (all p<0.01). CONCLUSIONS: Surgical invasiveness score greater than 118, being in OR for more than 7.6 hrs, blood loss more than 700 ml, utilizing BMP, and LOS more than 11 days were strong predictors of being a SU. Patients with SVA grade of + and ++ were less likely to be a SU compared to SVA grade 0. Procedural and resource utilization factors were strong predictors of being a SU compared to patient factors. FDA Device/Drug Status: This abstract does not discuss or include any applicable devices or drugs.