Browsing by Author "Smith, JS"

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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, CP
INTRODUCTION: 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.
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, CP
Object 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.
Open Access
Anaplastic extramedullary cervical ependymoma with leptomeningeal metastasis.
(Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 2015-12) Pomeraniec, IJ; Dallapiazza, RF; Sumner, HM; Lopes, MB; Shaffrey, CI; Smith, JS
We present a rare extramedullary ependymoma with diffuse spinal metastatic disease, and review the previous reports of extramedullary spinal ependymomas. Ependymomas are the most common intramedullary spinal cord tumor in adults. These tumors rarely present as extramedullary masses. We treated a 23-year-old man with a history of progressive neck, shoulder and arm pain, with sensory and motor symptoms in the C7 dermatome. MRI of the cervical spine demonstrated a ventral contrast-enhancing lesion with evidence of enhancement along the dura and spinal cord of the upper cervical spine, thoracic spine, and cauda equina. He underwent a tumor debulking procedure without complications. Following surgery, he received craniospinal radiation to treat the remaining tumor and diffuse leptomeningeal disease. The final pathology of the tumor revealed that is was a World Health Organization Grade III anaplastic ependymoma. At the 1 year follow-up, the patient had stable imaging and had returned to his preoperative functional status. Of the 19 reported patients with primary intradural, extramedullary spinal ependymomas, two had extradural components and seven had anaplastic grades. Only one tumor with an anaplastic grade resulted in metastatic disease, but without spinal recurrence. To our knowledge, this is the first report of an intradural, extramedullary spinal ependymoma with an anaplastic grade, presenting with concomitant diffuse, nodular leptomeningeal metastasis involving the upper cervical spine, thoracic spine, conus medullaris, and cauda equina. Similar to the treatment of intramedullary ependymomas with metastasis, this patient underwent an aggressive debulking procedure followed by radiation therapy to the entire neuroaxis.
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, C
OBJECT: 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.
Open Access
Clinically Significant Thromboembolic Disease in Adult Spinal Deformity Surgery: Incidence and Risk Factors in 737 Patients
(Global Spine Journal, 2018-05-01) Kim, HJ; Iyer, S; Diebo, BG; Kelly, MP; Sciubba, D; Schwab, F; Lafage, V; Mundis, GM; Shaffrey, CI; Smith, JS; Hart, R; Burton, D; Bess, S; Klineberg, EO
Study Design: Retrospective cohort study. Objectives: Describe the rate and risk factors for venous thromboembolic events (VTEs; defined as deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in adult spinal deformity (ASD) surgery. Methods: ASD patients with VTE were identified in a prospective, multicenter database. Complications, revision, and mortality rate were examined. Patient demographics, operative details, and radiographic and clinical outcomes were compared with a non-VTE group. Multivariate binary regression model was used to identify predictors of VTE. Results: A total of 737 patients were identified, 32 (4.3%) had VTE (DVT = 14; PE = 18). At baseline, VTE patients were less likely to be employed in jobs requiring physical labor (59.4% vs 79.7%, P <.01) and more likely to have osteoporosis (29% vs 15.1%, P =.037) and liver disease (6.5% vs 1.4%, P =.027). Patients with VTE had a larger preoperative sagittal vertical axis (SVA; 93 mm vs 55 mm, P <.01) and underwent larger SVA corrections. VTE was associated with a combined anterior/posterior approach (45% vs 25%, P =.028). VTE patients had a longer hospital stay (10 vs 7 days, P <.05) and higher mortality rate (6.3% vs 0.7%, P <.01). Multivariate analysis demonstrated osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE (r2 =.11, area under the curve = 0.74, P <.05). Conclusions: The incidence of VTE in ASD is 4.3% with a DVT rate of 1.9% and PE rate of 2.4%. Osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE. Patients with VTE had a higher mortality rate compared with non-VTE patients.
Open Access
Complications of surgical intervention in adult lumbar scoliosis
(Current Reviews in Musculoskeletal Medicine, 2016-09-01) Christiansen, PA; LaBagnara, M; Sure, DR; Shaffrey, CI; Smith, JS
If nonoperative measures are unsuccessful in managing the pain and disability of adult spinal deformities, surgical correction may provide the potential for significant improvement in a patient’s quality of life. However, these procedures have a relatively high risk of complications. Identifying patients that may benefit from surgical intervention requires a thorough understanding of potential complications and managing the risks of any individual patient. Complications do not necessarily result in poor outcomes, and good outcomes are not always complication free. Higher risk patients potentially have more to gain, even if they experience complications. With the rapidly expanding senior population and expanded capabilities to manage high-risk patients, it is helpful to consider the lessons provided by ever expanding databases of outcome measures to refine the surgical decision-making process.
Open Access
Dorsal thoracic arachnoid web and the "scalpel sign": a distinct clinical-radiologic entity.
(AJNR. American journal of neuroradiology, 2013-05) Reardon, MA; Raghavan, P; Carpenter-Bailey, K; Mukherjee, S; Smith, JS; Matsumoto, JA; Yen, C-P; Shaffrey, ME; Lee, RR; Shaffrey, CI; Wintermark, M
Arachnoid webs are intradural extramedullary bands of arachnoid tissue that can extend to the pial surface of the spinal cord, causing a focal dorsal indentation of the cord. These webs tend to occur in the upper thoracic spine and may produce a characteristic deformity of the cord that we term the "scalpel sign." We describe 14 patients whose imaging studies demonstrated the scalpel sign. Ten of 13 patients who underwent MR imaging demonstrated T2WI cord signal-intensity changes, and 7 of these patients also demonstrated syringomyelia adjacent to the level of indentation. Seven patients underwent surgery, with 5 demonstrating an arachnoid web as the cause of the dorsal indentation demonstrated on preoperative imaging. Although the webs themselves are rarely demonstrated on imaging, we propose that the scalpel sign is a reliable indicator of their presence and should prompt consideration of surgical lysis, which is potentially curative.
Open Access
Expanding lateral access spine surgery
(Neurosurgical Focus: Video, 2022-07-01) Snyder, LA; Erickson, M; Smith, JS; Mummaneni, PV
Open Access
Impact of obesity on complications, infection, and patient-reported outcomes in adult spinal deformity surgery
(Journal of Neurosurgery: Spine, 2015-11-01) Soroceanu, A; Burton, DC; Diebo, BG; Smith, JS; Hostin, R; Shaffrey, CI; Boachie-Adjei, O; Mundis, GM; Ames, C; Errico, TJ; Bess, S; Gupta, MC; Hart, RA; Schwab, FJ; Lafage, V
OBJECT: Adult spinal deformity (ASD) surgery is known for its high complication rate. This study examined the impact of obesity on complication rates, infection, and patient-reported outcomes in patients undergoing surgery for ASD. METHODS: This study was a retrospective review of a multicenter prospective database of patients with ASD who were treated surgically. Patients with available 2-year follow-up data were included. Obesity was defined as having a body mass index (BMI) ≥ 30 kg/m2. Data collected included complications (total, minor, major, implant-related, radiographic, infection, revision surgery, and neurological injury), estimated blood loss (EBL), operating room (OR) time, length of stay (LOS), and patient-reported questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], and Scoliosis Research Society [SRS]) at baseline and at 6 weeks, 1 year, and 2 years postoperatively. The impact of obesity was studied using multivariate modeling, accounting for confounders. RESULTS: Of 241 patients who satisfied inclusion criteria, 175 patients were nonobese and 66 were obese. Regression models showed that obese patients had a higher overall incidence of major complications (IRR 1.54, p = 0.02) and wound infections (odds ratio 4.88, p = 0.02). Obesity did not increase the number of minor complications (p = 0.62), radiographic complications (p = 0.62), neurological complications (p = 0.861), or need for revision surgery (p = 0.846). Obesity was not significantly correlated with OR time (p = 0.23), LOS (p = 0.9), or EBL (p = 0.98). Both groups experienced significant improvement over time, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001). CONCLUSIONS: This study revealed that obese patients have an increased risk of complications following ASD correction. Despite these increased complications, obese patients do benefit from surgical intervention; however, their improvement in health-related quality of life (HRQL) is less than that of nonobese patients.
Open Access
In response
(Spine, 2012-02-01) Williams, BJ; Smith, JS; Shaffrey, CI
Open Access
Introduction: Video Illustrations of Techniques and Strategies for Adult and Pediatric Spinal Deformity Surgery
(Neurosurgical Focus: Video, 2020-01-01) Smith, JS; Shaffrey, CI; Wang, M; Bydon, M; Lenke, L
Open Access
Mechanisms of lumbar spine “flattening” in adult spinal deformity: defining changes in shape that occur relative to a normative population
(European Spine Journal, 2024-01-01) Lafage, R; Mota, F; Khalifé, M; Protopsaltis, T; Passias, PG; Kim, HJ; Line, B; Elysée, J; Mundis, G; Shaffrey, CI; Ames, CP; Klineberg, EO; Gupta, MC; Burton, DC; Lenke, LG; Bess, S; Smith, JS; Schwab, FJ; Lafage, V
Purpose: Previous work comparing ASD to a normative population demonstrated that a large proportion of lumbar lordosis is lost proximally (L1-L4). The current study expands on these findings by collectively investigating regional angles and spinal contours. Methods: 119 asymptomatic volunteers with full-body free-standing radiographs were used to identify age-and-PI models of each Vertebra Pelvic Angle (VPA) from L5 to T10. These formulas were then applied to a cohort of primary surgical ASD patients without coronal malalignment. Loss of lumbar lordosis (LL) was defined as the offset between age-and-PI normative value and pre-operative alignment. Spine shapes defined by VPAs were compared and analyzed using paired t-tests. Results: 362 ASD patients were identified (age = 64.4 ± 13, 57.1% females). Compared to their age-and-PI normative values, patients demonstrated a significant loss in LL of 17 ± 19° in the following distribution: 14.1% had “No loss” (mean = 0.1 ± 2.3), 22.9% with 10°-loss (mean = 9.9 ± 2.9), 22.1% with 20°-loss (mean = 20.0 ± 2.8), and 29.3% with 30°-loss (mean = 33.8 ± 6.0). “No loss” patients’ spine was slightly posterior to the normative shape from L4 to T10 (VPA difference of 2°), while superimposed on the normative one from S1 to L2 and became anterior at L1 in the “10°-loss” group. As LL loss increased, ASD and normative shapes offset extended caudally to L3 for the “20°-loss” group and L4 for the “30°-loss” group. Conclusion: As LL loss increases, the difference between ASD and normative shapes first occurs proximally and then progresses incrementally caudally. Understanding spinal contour and LL loss location may be key to achieving sustainable correction by identifying optimal and personalized postoperative shapes.
Open Access
Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity
(Neurosurgery, 2016-09) Smith, JS; Lafage, V; Shaffrey, C
Open Access
Outcomes, Expectations, and Complications Overview for the Surgical Treatment of Adult and Pediatric Spinal Deformity
(Spine Deformity, 2012-09-01) Smith, JS; Kasliwal, MK; Crawford, A; Shaffrey, CI
The aim of this article was to summarize current literature on surgical treatment of pediatric and adult spinal deformity with regard to clinical outcomes and surgical complications. When surgery is considered for treatment of spinal deformity, it is important for both the physician and patient to appreciate the outcome objectives, have reasonable expectations, and understand the potential for adverse events. We conducted a comprehensive search of the English literature from the years 2000–2011 using Medline for articles related to the surgical treatment of spinal deformity, using selected terms. We reviewed abstracts and restricted them to those focused on surgical treatment of spinal deformity. We included clinical outcomes measures and overall complications rates, and reviewed corresponding manuscripts. For pediatric and adult spinal deformity, we identified 8 and 17 manuscripts, respectively, that included preoperative and postoperative assessments of outcomes measures. The vast majority of reported studies demonstrated that operative treatment has the potential to produce significant improvement of health-related quality of life. Surgical treatment of pediatric scoliosis, including idiopathic, neuromuscular, and congenital, had reported complication rates ranging from 4.4% to 15.4%, 17.9% to 48.1%, and 8.3% to 31%, respectively. Surgical treatment of adult scoliosis had reported overall complication rates ranging from 10.5% to 96%. The number of high-quality studies that provide assessment of the outcomes of surgery for pediatric and adult scoliosis remains limited; further study is needed. Available studies suggest that in selected patients, surgical treatment offers potential for improvement of health-related quality of life. The current literature also demonstrates the risks that accompany surgical procedures for the correction of spinal deformity. It is important that spinal deformity patients considering surgical treatment have appropriate expectations not only of the potential benefits it may offer, but also of the risks inherent to such procedures.
Open Access
Presentation and Outcomes After Medical and Surgical Treatment Versus Medical Treatment Alone of Spontaneous Infectious Spondylodiscitis: A Systematic Literature Review and Meta-Analysis
(Global Spine Journal, 2018-12-01) Taylor, DG; Buchholz, AL; Sure, DR; Buell, TJ; Nguyen, JH; Chen, CJ; Diamond, JM; Washburn, PA; Harrop, J; Shaffrey, CI; Smith, JS
Study Design: Systematic literature review. Objectives: The aims of this study were to (1) describe the clinical features, disabilities, and incidence of neurologic deficits of pyogenic spondylodiscitis prior to treatment and (2) compare the functional outcomes between patients who underwent medical treatment alone or in combination with surgery for pyogenic spondylodiscitis. Methods: A systematic literature review was performed using PubMed according to PRISMA guidelines. No year restriction was put in place. Statistical analysis of pooled data, when documented in the original report (ie, number of patients with desired variable and number of patients evaluated), was conducted to determine the most common presenting symptoms, incidence of pre- and postoperative neurologic deficits, associated comorbidities, infectious pathogens, approach for surgery when performed, and duration of hospitalization. Outcomes data, including return to work status, resolution of back pain, and functional recovery were also pooled among all studies and surgery-specific studies alone. Meta-analysis of studies with subgroup analysis of pain-free outcome in surgical and medical patients was performed. Results: Fifty of 1286 studies were included, comprising 4173 patients undergoing either medical treatment alone or in combination with surgery. Back pain was the most common presenting symptom, reported in 91% of patients. Neurologic deficit was noted in 31% of patients. Staphylococcus aureus was the most commonly reported pathogen, seen in 35% of reported cases. Decompression and fusion was the most commonly reported surgical procedure, performed in 80% of the surgically treated patients. Combined anterior-posterior procedures and staged surgeries were performed in 33% and 26% of surgeries, respectively. The meta-analysis comparing visual analog scale score at follow-up was superior among patients receiving surgery over medical treatment alone (mean difference −0.61, CI −0.90 to −0.25), while meta-analysis comparing freedom from pain in patients receiving medical treatment alone versus combined medical and surgical treatment demonstrated superior pain-free outcomes among surgical series (odds ratio 5.35, CI 2.27-12.60, P <.001), but was subject to heterogeneity among studies (I 2 = 56%, P =.13). Among all patients, freedom from pain was achieved in 79% of patients, and an excellent outcome was achieved in 73% of patients. Conclusion: Medical management remains first-line treatment of infectious pyogenic spondylodiscitis. Surgery may be indicated for progressive pain, persistent infection on imaging, deformity or neurologic deficits. If surgery is required, reported literature shows potential for significant pain reduction, improved neurologic function and a high number of patients returning to a normal functional/work status.
Open Access
Radiographic outcomes of adult spinal deformity correction: A critical analysis of variability and failures across deformity patterns
(Spine Deformity, 2014-01-01) Moal, B; Schwab, F; Ames, CP; Smith, JS; Ryan, D; Mummaneni, PV; Mundis, GM; Terran, JS; Klineberg, E; Hart, RA; Boachie-Adjei, O; Shaffrey, CI; Skalli, W; Lafage, V
Study Design Multicenter, prospective, consecutive, surgical case series from the International Spine Study Group. Objectives To evaluate the effectiveness of surgical treatment in restoring spinopelvic (SP) alignment. Summary of Background Data Pain and disability in the setting of adult spinal deformity have been correlated with global coronal alignment (GCA), sagittal vertical axis (SVA), pelvic incidence/lumbar lordosis mismatch (PI-LL), and pelvic tilt (PT). One of the main goals of surgery for adult spinal deformity is to correct these parameters to restore harmonious SP alignment. Methods Inclusion criteria were operative patients (age greater than 18 years) with baseline (BL) and 1-year full-length X-rays. Thoracic and thoracolumbar Cobb angle and previous mentioned parameters were calculated. Each parameter at BL and 1 year was categorized as either pathological or normal. Pathologic limits were: Cobb greater than 30°, GCA greater than 40 mm, SVA greater than 40 mm, PI-LL greater than 10°, and PT greater than 20°. According to thresholds, corrected or worsened alignment groups of patients were identified and overall radiographic effectiveness of procedure was evaluated by combining the results from the coronal and sagittal planes. Results A total of 161 patients (age, 55 ± 15 years) were included. At BL, 80% of patients had a Cobb angle greater than 30°, 25% had a GCA greater than 40 mm, and 42% to 58% had a pathological sagittal parameter of PI-LL, SVA, and/or PT. Sagittal deformity was corrected in about 50% of cases for patients with pathological SVA or PI-LL, whereas PT was most commonly worsened (24%) and least often corrected (24%). Only 23% of patients experienced complete radiographic correction of the deformity. Conclusions The frequency of inadequate SP correction was high. Pelvic tilt was the parameter least likely to be well corrected. The high rate of SP alignment failure emphasizes the need for better preoperative planning and intraoperative imaging. © 2014 Scoliosis Research Society.
Open Access
Spine surgery training: Is it time to consider categorical spine surgery residency?
(Spine Journal, 2015-07-01) Daniels, AH; Ames, CP; Garfin, SR; Shaffrey, CI; Riew, KD; Smith, JS; Anderson, PA; Hart, RA
Open Access
The Clinical Impact of Global Coronal Malalignment Is Underestimated in Adult Patients With Thoracolumbar Scoliosis
(Spine Deformity, 2019-01-01) Plais, N; Bao, H; Lafage, R; Gupta, M; Smith, JS; Shaffrey, C; Mundis, G; Burton, D; Ames, C; Klineberg, E; Bess, S; Schwab, F; Lafage, V
Study Design: Retrospective review of multicenter adult spine deformity (ASD) database. Objectives: A recent publication demonstrated that the laterality of the coronal offset is a key parameter that directly impacts postoperative outcomes. The objective of this study is to analyze the relationship between global coronal malalignment (GCM) and functional outcomes in a North American population of ASD patients with no history of previous surgery. Summary of Background Data: The clinical impact of GCM in patients with ASD remains controversial. Methods: Primary patients were drawn from a multicenter database of ASD patients and categorized with the Qiu classification: Type A = GCM <3 cm; Type B = GCM >3 cm toward the concave side of the curve; and Type C = GCM >3 cm toward the convex side. In addition to the classic radiographic parameter, the coronal truncal inclination was investigated in regard to the pelvic obliquity. Clinical outcomes, radiographic parameters, and demographics were compared across the three Qiu Types using analysis of variance. The analysis was repeated after propensity matching of the three types by age and sagittal alignment (PI-LL mismatch, pelvic tilt, and sagittal vertical axis). Results: 576 ASD patients (mean age 58.8 years) were included. Type B patients had significantly worse functional scores (Oswestry Disability Index, 36-item Short Form Survey physical component summary, and Scoliosis Research Society–22) and a more severe coronal deformity in terms of maximum Cobb angle, global coronal deformity angle, and coronal malalignment; they were also older (65.4 vs. 58.8 years, p = .004) and displayed more severe sagittal malalignment. Similar findings were observed after propensity matching. Conclusions: This study is the first to establish an association between functional outcomes and the severity of the coronal plane deformity in the setting of a specific coronal curve pattern in patients without previous surgery. Coronal malalignment significantly affects the health status of patients when the offset is greater than 3 cm in the direction of curve concavity. Level of Evidence: Level III.
Open Access
Thoracolumbar fusions for adult lumbar deformity show superior QALY gain and lower costs compared with upper thoracic fusions
(Spine Deformity, 2024-01-01) Kim, AH; Hostin, RA; Yeramaneni, S; Gum, JL; Nayak, P; Line, BG; Bess, S; Passias, PG; Hamilton, DK; Gupta, MC; Smith, JS; Lafage, R; Diebo, BG; Lafage, V; Klineberg, EO; Daniels, AH; Protopsaltis, TS; Schwab, FJ; Shaffrey, CI; Ames, CP; Burton, DC; Kebaish, KM
Purpose: Adult spinal deformity (ASD) patients with sagittal plane deformity (N) or structural lumbar/thoraco-lumbar (TL) curves can be treated with fusions stopping at the TL junction or extending to the upper thoracic (UT) spine. This study evaluates the impact on cost/cumulative quality-adjusted life year (QALY) in patients treated with TL vs UT fusion. Methods: ASD patients with > 4-level fusion and 2-year follow-up were included. Index and total episode-of-care costs were estimated using average itemized direct costs obtained from hospital records. Cumulative QALY gained were calculated from preoperative to 2-year postoperative change in Short Form Six-Dimension (SF-6D) scores. The TL and UT groups comprised patients with upper instrumented vertebrae (UIV) at T9-T12 and T2-T5, respectively. Results: Of 566 patients with type N or L curves, mean age was 63.2 ± 12.1 years, 72% were female and 93% Caucasians. Patients in the TL group had better sagittal vertical axis (7.3 ± 6.9 vs. 9.2 ± 8.1 cm, p = 0.01), lower surgical invasiveness (− 30; p < 0.001), and shorter OR time (− 35 min; p = 0.01). Index and total costs were 20% lower in the TL than in the UT group (p < 0.001). Cost/QALY was 65% lower (492,174.6 vs. 963,391.4), and 2-year QALY gain was 40% higher, in the TL than UT group (0.15 vs. 0.10; p = 0.02). Multivariate model showed TL fusions had lower total cost (p = 0.001) and higher QALY gain (p = 0.03) than UT fusions. Conclusion: In Schwab type N or L curves, TL fusions showed lower 2-year cost and improved QALY gain without increased reoperation rates or length of stay than UT fusions. Level of evidence: III.
Open Access
Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) as an adjunct for instrumented posterior arthrodesis in the occipital cervical region: An analysis of safety, efficacy and dosing
(Journal of Craniovertebral Junction and Spine, 2011-07-01) Hamilton, DK; Smith, JS; Reames, DL; Williams, BJ; Shaffrey, CI

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