Browsing by Author "Smith, Justin"
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Item Open Access A Risk-Benefit Analysis of Increasing Surgical Invasiveness Relative to Frailty Status in Adult Spinal Deformity Surgery.(Spine, 2021-08) Passias, Peter G; Brown, Avery E; Bortz, Cole; Pierce, Katherine; Alas, Haddy; Ahmad, Waleed; Passfall, Lara; Kummer, Nicholas; Krol, Oscar; Lafage, Renaud; Lafage, Virginie; Burton, Douglas; Hart, Robert; Anand, Neel; Mundis, Gregory; Neuman, Brian; Line, Breton; Shaffrey, Christopher; Klineberg, Eric; Smith, Justin; Ames, Christopher; Schwab, Frank J; Bess, Shay; International Spine Study GroupStudy design
Retrospective review of a prospectively enrolled multicenter Adult Spinal Deformity (ASD) database.Objective
Investigate invasiveness and outcomes of ASD surgery by frailty state.Summary of background data
The ASD Invasiveness Index incorporates deformity-specific components to assess correction magnitude. Intersections of invasiveness, surgical outcomes, and frailty state are understudied.Methods
ASD patients with baseline and 3-year (3Y) data were included. Logistic regression analyzed the relationship between increasing invasiveness and major complications or reoperations and meeting minimal clinically important differences (MCID) for health-related quality-of-life measures at 3Y. Decision tree analysis assessed invasiveness risk-benefit cutoff points, above which experiencing complications or reoperations and not reaching MCID were higher. Significance was set to P < 0.05.Results
Overall, 195 of 322 patients were included. Baseline demographics: age 59.9 ± 14.4, 75% female, BMI 27.8 ± 6.2, mean Charlson Comorbidity Index: 1.7 ± 1.7. Surgical information: 61% osteotomy, 52% decompression, 11.0 ± 4.1 levels fused. There were 98 not frail (NF), 65 frail (F), and 30 severely frail (SF) patients. Relationships were found between increasing invasiveness and experiencing a major complication or reoperation for the entire cohort and by frailty group (all P < 0.05). Defining a favorable outcome as no major complications or reoperation and meeting MCID in any health-related quality of life at 3Y established an invasiveness cutoff of 63.9. Patients below this threshold were 1.8[1.38-2.35] (P < 0.001) times more likely to achieve favorable outcome. For NF patients, the cutoff was 79.3 (2.11[1.39-3.20] (P < 0.001), 111 for F (2.62 [1.70-4.06] (P < 0.001), and 53.3 for SF (2.35[0.78-7.13] (P = 0.13).Conclusion
Increasing invasiveness is associated with increased odds of major complications and reoperations. Risk-benefit cutoffs for successful outcomes were 79.3 for NF, 111 for F, and 53.3 for SF patients. Above these, increasing invasiveness has increasing risk of major complications or reoperations and not meeting MCID at 3Y.Level of Evidence: 3.Item Open Access Cervical sagittal deformity develops after PJK in adult thoracolumbar deformity correction: radiographic analysis utilizing a novel global sagittal angular parameter, the CTPA.(European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2017-04) Protopsaltis, Themistocles; Bronsard, Nicolas; Soroceanu, Alex; Henry, Jensen K; Lafage, Renaud; Smith, Justin; Klineberg, Eric; Mundis, Gregory; Kim, Han Jo; Hostin, Richard; Hart, Robert; Shaffrey, Christopher; Bess, Shay; Ames, Christopher; International Spine Study GroupPurpose
To describe reciprocal changes in cervical alignment after adult spinal deformity (ASD) correction and subsequent development of proximal junctional kyphosis (PJK). This study also investigated these changes using two novel global sagittal angular parameters, cervical-thoracic pelvic angle (CTPA) and the T1 pelvic angle (TPA).Methods
Multicenter, retrospective consecutive case series of ASD patients undergoing thoracolumbar three-column osteotomy (3CO) with fusion to the pelvis. Radiographs were analyzed at baseline and 1 year post-operatively. Patients were substratified into upper thoracic (UT; UIV T6 and above) and lower thoracic (LT; UIV below T6). PJK was defined by >10° angle between UIV and UIV + 2 and >10° change in the angle from baseline to post-op.Results
PJK developed in 29 % (78 of 267) of patients. CTPA was linearly correlated with cervical plumbline (CPL) as a measure of cervical sagittal alignment (R = 0.826, p < 0.001). PJK patients had significantly greater post-operative CTPA and SVA than patients without PJK (NPJK) (p = 0.042; p = 0.021). For UT (n = 141) but not LT (n = 136), PJK patients at 1 year had larger CTPA (4.9° vs. 3.7°, p = 0.015) and CPL (5.1 vs. 3.8 cm, p = 0.022) than NPJK patients, despite similar corrections in PT and PI-LL.Conclusions
The prevalence of PJK was 29 % at 1 year follow-up. CTPA, which correlates with CPL as a global analog of cervical sagittal balance, and TPA describe relative proportions of cervical and thoracolumbar deformities. Patients who develop PJK in the upper thoracic spine after thoracolumbar 3CO also develop concomitant cervical sagittal deformity, with increases in CPL and CTPA.Item Open Access Cervical Versus Thoracolumbar Spinal Deformities: A Comparison of Baseline Quality-of-Life Burden.(Clinical spine surgery, 2018-12) Passias, Peter G; Poorman, Gregory W; Lafage, Virginie; Smith, Justin; Ames, Christopher; Schwab, Frank; Shaffrey, Chris; Segreto, Frank A; Horn, Samantha R; Bortz, Cole A; Varlotta, Christopher G; Hockley, Aaron; Wang, Charles; Daniels, Alan; Neuman, Brian; Hart, Robert; Burton, Douglas; Javidan, Yashar; Line, Breton; LaFage, Renaud; Bess, Shay; Sciubba, Daniel; ISSGStudy design
Retrospective analysis of 2 prospectively collected multicenter databases, one for cervical deformity (CD) and the other for general adult spinal deformity.Objective
To investigate the relative quality-of-life and disability burden in patients with uncompensated cervical, thoracolumbar, or cervical and thoracolumbar deformities.Summary of background data
The relative quality-of-life burden of cervical and thoracolumbar deformities have never been compared with each other. This may have significant implications when deciding on the appropriate treatment intervention for patients with combined thoracolumbar and cervical deformities.Methods
When defining CD C2-C7 sagittal vertical axis (SVA)>4 cm was used while a C7-S1 SVA>5 cm was used to defined thoracolumbar deformity. Patients with both SVA criteria were defined as "combined." Primary analysis compared patients in the different groups by demographic, comorbidity data, and quality-of-life scores [EuroQOL 5 dimensions questionnaire (EQ-5D)] using t tests. Secondary analysis matched deformity groups with propensity scores matching based on baseline EQ-5D scores. Differences in disease-specific metrics [the Oswestry Disability Index, Neck Disability Index, modified Japanese Orthopaedic Association questionnaire (mJOA)] were analyzed using analysis of variance tests and post hoc analysis.Results
In total, 212 patients were included in our analysis. Patients with CD only had less neurological deficits (mJOA: 14.6) and better EQ-5D (0.746) scores compared with patients with combined deformities (11.9, 0.716), all P<0.05. Regarding propensity score-matched deformity cohorts, 99 patients were matched with similar quality-of-life burden, 33 per deformity cohort. CD only patients had fewer comorbidities (1.03 vs. 2.12 vs. 2.70; P<0.001), whereas patients with combined deformity had more baseline neurological impairment compared with CD only patients (mJOA: 12.00 vs. 14.25; P=0.050).Conclusions
Combined deformity patients were associated with the lowest quality-of-life and highest disability. Furthermore, regarding deformity cohorts matched by similar baseline quality-of-life status (EQ-5D), patients with combined deformities were associated with significantly worse neurological impairments. This finding implies that quality of life may not be a direct reflection of a patient's disability status, especially in patients with combined cervical and thoracolumbar deformities.Level of evidence
Level III.Item Open Access Changes in thoracic kyphosis negatively impact sagittal alignment after lumbar pedicle subtraction osteotomy: a comprehensive radiographic analysis.(Spine, 2012-02) Lafage, Virginie; Ames, Christopher; Schwab, Frank; Klineberg, Eric; Akbarnia, Behrooz; Smith, Justin; Boachie-Adjei, Oheneba; Burton, Douglas; Hart, Robert; Hostin, Richard; Shaffrey, Christopher; Wood, Kirkham; Bess, Shay; International Spine Study GroupStudy design
Consecutive, multicenter retrospective review.Objective
To evaluate if change in thoracic kyphosis (TK) has a positive or negative impact on spinopelvic alignment after lumbar pedicle subtraction osteotomy (PSO) with short fusions.Summary of background data
In the setting of sagittal malalignment, the effect of large vertebral resections can now be anticipated in long fusions, but their impact on unfused segments (reciprocal changes [RC]) remains poorly understood.Methods
A total of 34 adult patients (mean age = 54 years; SD = 12) who underwent lumbar PSO with upper instrumented vertebra below T10 were included. Radiographic analysis included pre- and postassessment of TK, lumbar lordosis (LL), sagittal vertical axis (SVA), T1 spinopelvic inclination (T1SPI), pelvic tilt (PT), and pelvic incidence (PI). Final SVA and PT were analyzed to determine successful realignment. RC in the thoracic spine was designated favorable or unfavorable on the basis of impact on final SVA and PT.Results
Mean PSO resection was 26°. LL increased from 20° to 49° (P < 0.001). SVA improved from 14 to 4 cm (P < 0.001), and PT improved from 33° to 25° (P < 0.001). Mean increase in TK was 13° (P = 0.002) but was unchanged in 11 patients. Five patients had a favorable RC, and 18 patients had an unfavorable RC. Unfavorable RC was attributed to junctional failure in 6 of 18 patients. Significant differences in the unfavorable RC group included age and greater preoperative PT, PI, SVA, and T1SPI.Conclusion
Significant postoperative alignment changes can occur through unfused thoracic spinal segments after lumbar PSO. Unfavorable RC may limit optimal correction and lead to clinical failures. Risk factors for unfavorable thoracic RC include older patients, larger preoperative PI and PT, and worse preoperative T1SPI and are not simply due to junctional failure. Care should be taken with selective lumbar fusion and PSO in older patients and in those with severe preoperative spinopelvic parameters.Item Open Access Comparing Quality of Life in Cervical Spondylotic Myelopathy with Other Chronic Debilitating Diseases Using the Short Form Survey 36-Health Survey.(World neurosurgery, 2017-10) Oh, Taemin; Lafage, Renaud; Lafage, Virginie; Protopsaltis, Themistocles; Challier, Vincent; Shaffrey, Christopher; Kim, Han Jo; Arnold, Paul; Chapman, Jens; Schwab, Frank; Massicotte, Eric; Yoon, Tim; Bess, Shay; Fehlings, Michael; Smith, Justin; Ames, ChristopherBackground
Although cervical spondylotic myelopathy (CSM) can be devastating, its relative impact on general health remains unclear. Patient responses to the Short Form Survey 36-Health Survey (SF-36) Physical Component Summary (PCS)/Mental Component Summary (MCS) were compared between CSM and other diseases to evaluate their respective impacts on quality of life. The objective of this study was to compare SF-36 PCS/MCS scores in CSM with population and disease-specific norms.Methods
Retrospective analysis of a prospective, multicenter AOSpine North American CSM Study database. Inclusion criteria were symptomatic disease, age older than 18 years, cord compression on magnetic resonance imaging or computed tomography myelography, and baseline SF-36 values. SF-36 PCS/MCS scores in CSM were compared with national normative values and disease-specific norms using Student t test. Analysis of variance was used to assess differences across age groups and offsets from age-matched controls. Threshold for significance was P < 0.05.Results
There were 285 patients who met the inclusion criteria. The mean age was 56.6 ± 12.0 years, with male predominance (60%). SF-36 scores revealed significant baseline disability (PCS: 34.5 ± 9.8; MCS: 41.5 ± 14.4). Although there were no differences across age groups, when compared with age-matched normative data, younger patients had a larger PCS offset than older patients. CSM caused worse physical disability than most diseases except heart failure. Only back pain/sciatica induced worse mental disability.Conclusions
CSM affects quality of life to an extent greater than diabetes or cancer. Although mean impact of CSM does not vary with age, younger patients suffer from greater differences in baseline function. This study highlights the impact of myelopathy on patient function, particularly among younger age groups, and suggests that CSM merits a similar caliber of healthy policy attention as more well-studied diseases.Item Open Access Cost-utility analysis of cervical deformity surgeries using 1-year outcome.(The spine journal : official journal of the North American Spine Society, 2018-09) Poorman, Gregory W; Passias, Peter G; Qureshi, Rabia; Hassanzadeh, Hamid; Horn, Samantha; Bortz, Cole; Segreto, Frank; Jain, Amit; Kelly, Michael; Hostin, Richard; Ames, Christopher; Smith, Justin; LaFage, Virginie; Burton, Douglas; Bess, Shay; Shaffrey, Chris; Schwab, Frank; Gupta, MunishBackground context
Cost-utility analysis, a special case of cost-effectiveness analysis, estimates the ratio between the cost of an intervention to the benefit it produces in number of quality-adjusted life years. Cervical deformity correction has not been evaluated in terms of cost-utility and in the context of value-based health care. Our objective, therefore, was to determine the cost-utility ratio of cervical deformity correction.Study design
This is a retrospective review of a prospective, multicenter cervical deformity database. Patients with 1-year follow-up after surgical correction for cervical deformity were included. Cervical deformity was defined as the presence of at least one of the following: kyphosis (C2-C7 Cobb angle >10°), cervical scoliosis (coronal Cobb angle >10°), positive cervical sagittal malalignment (C2-C7 sagittal vertical axis >4 cm or T1-C6 >10°), or horizontal gaze impairment (chin-brow vertical angle >25°). Quality-adjusted life years were calculated by both EuroQol 5D (EQ5D) quality of life and Neck Disability Index (NDI) mapped to short form six dimensions (SF6D) index. Costs were assigned using Medicare 1-year average reimbursement for: 9+ level posterior fusions (PF), 4-8 level PF, 4-8 level PF with anterior fusion (AF), 2-3 level PF with AF, 4-8 level AF, and 4-8 level posterior refusion. Reoperations and deaths were added to cost and subtracted from utility, respectively. Quality-adjusted life year per dollar spent was calculated using standardized methodology at 1-year time point and subsequent time points relying on maintenance of 1-year utility.Results
Eighty-four patients (average age: 61.2 years, 60% female, body mass index [BMI]: 30.1) were analyzed after cervical deformity correction (average levels fused: 7.2, osteotomy used: 50%). Costs associated with index procedures were 9+ level PF ($76,617), 4-8 level PF ($40,596), 4-8 level PF with AF ($67,098), 4-8 level AF ($31,392), and 4-8 level posterior refusion ($35,371). Average 1-year reimbursement of surgery was $55,097 at 1 year with eight revisions and three deaths accounted for. Cost per quality-adjusted life year (QALY) gained to 1-year follow-up was $646,958 by EQ5D and $477,316 by NDI SF6D. If 1-year benefit is sustained, upper threshold of cost-effectiveness is reached 3-4.5 years after intervention.Conclusions
Medicare 1-year average reimbursement compared with 1-year QALYdescribed $646,958 by EQ5D and $477,316 by NDI SF6D. Cervical deformity surgeries reach accepted cost-effectiveness thresholds when benefit is sustained 3-4.5 years. Longer follow-up is needed for a more definitive cost-analysis, but these data are an important first step in justifying cost-utility ratio for cervical deformity correction.Item Open Access Defining Spino-Pelvic Alignment Thresholds: Should Operative Goals in Adult Spinal Deformity Surgery Account for Age?(Spine, 2016-01) Lafage, Renaud; Schwab, Frank; Challier, Vincent; Henry, Jensen K; Gum, Jeffrey; Smith, Justin; Hostin, Richard; Shaffrey, Christopher; Kim, Han J; Ames, Christopher; Scheer, Justin; Klineberg, Eric; Bess, Shay; Burton, Douglas; Lafage, Virginie; International Spine Study GroupStudy design
Retrospective review of prospective, multicenter database.Objective
The aim of the study was to determine age-specific spino-pelvic parameters, to extrapolate age-specific Oswestry Disability Index (ODI) values from published Short Form (SF)-36 Physical Component Score (PCS) data, and to propose age-specific realignment thresholds for adult spinal deformity (ASD).Summary of background data
The Scoliosis Research Society-Schwab classification offers a framework for defining alignment in patients with ASD. Although age-specific changes in spinal alignment and patient-reported outcomes have been established in the literature, their relationship in the setting of ASD operative realignment has not been reported.Methods
ASD patients who received operative or nonoperative treatment were consecutively enrolled. Patients were stratified by age, consistent with published US-normative values (Norms) of the SF-36 PCS (<35, 35-44, 45-54, 55-64, 65-74, >75 y old). At baseline, relationships between between radiographic spino-pelvic parameters (lumbar-pelvic mismatch [PI-LL], pelvic tilt [PT], sagittal vertical axis [SVA], and T1 pelvic angle [TPA]), age, and PCS were established using linear regression analysis; normative PCS values were then used to establish age-specific targets. Correlation analysis with ODI and PCS was used to determine age-specific ideal alignment.Results
Baseline analysis included 773 patients (53.7 y old, 54% operative, 83% female). There was a strong correlation between ODI and PCS (r = 0.814, P < 0.001), allowing for the extrapolation of US-normative ODI by age group. Linear regression analysis (all with r > 0.510, P < 0.001) combined with US-normative PCS values demonstrated that ideal spino-pelvic values increased with age, ranging from PT = 10.9 degrees, PI-LL = -10.5 degrees, and SVA = 4.1 mm for patients under 35 years to PT = 28.5 degrees, PI-LL = 16.7 degrees, and SVA = 78.1 mm for patients over 75 years. Clinically, older patients had greater compensation, more degenerative loss of lordosis, and were more pitched forward.Conclusion
This study demonstrated that sagittal spino-pelvic alignment varies with age. Thus, operative realignment targets should account for age, with younger patients requiring more rigorous alignment objectives.Item Open Access Determinants of Patient Satisfaction 2 Years After Spinal Deformity Surgery: A Latent Class Analysis.(Spine, 2019-01) Yang, Jingyan; Lafage, Virginie; Lafage, Renaud; Smith, Justin; Klineberg, Eric O; Shaffrey, Christopher I; Mundis, Gregory; Hostin, Richard; Burton, Douglas; Ames, Christopher P; Bess, Shay; Kim, Han Jo; Schwab, Frank; International Spine Study Group (ISSG)Study design
Retrospective review of prospective multicenter database.Objective
To investigate the determinants of patient satisfaction with respect to changes in functional limitations 2 years after spinal deformity surgery.Summary of background data
For operatively treated adult spine deformity (ASD), patient satisfaction has become an important component of evaluating quality of care.Methods
A total of 430 operative patients with ASD with 2-year follow-up were analyzed. Patient satisfaction was assessed using the Scoliosis Research Society 22-item. Latent class analysis was performed to assign individuals to classes based on the changes in pre- and 2-year postoperative functions, assessed using the Oswestry Disability Index (ODI). An ordered logistic regression was conducted to assess the association of class membership and satisfaction.Results
Latent class analysis identified four classes. The worsened-condition class (WC: 1.4%) consisted of patients who were likely to experience worsened function, particularly in lifting and pain intensity. The remained-same class (RS: 13.0%) included patients who remained the same, because the majority reported approximately no change in walking, standing, and sitting. The mild-improved class (mild-I: 40.2%) included patients with mildly enhanced conditions, specifically, in standing, social life, and employment. The most-improved class (most-I: 45.3%) included patients with great improvement after surgery mainly in standing, followed by social life and employment. The odds of being satisfied were significantly increased by 3.91- (P < 0.001) and 16.99-fold (P < 0.001), comparing patients in mild-I and most-I to the RS/WC class, respectively, after controlling for confounders.Conclusion
Improvement in standing, social life, and employment are the most important determinants of patient satisfaction postsurgery. Reduced pain intensity and enhanced walking ability also help to elevate patient satisfaction. However, lifting, personal care, sitting, sleeping, and travelling may be of less importance. Examining the heterogeneity of patient-reported outcome in patients with ASD allows the identification of classes with different patient characteristics and satisfaction, and thus, help to guide tailored provision of care.Level of evidence
4.Item Open Access Effect of Obesity on Radiographic Alignment and Short-Term Complications After Surgical Treatment of Adult Cervical Deformity.(World neurosurgery, 2019-05) Passias, Peter G; Poorman, Gregory W; Horn, Samantha R; Jalai, Cyrus M; Bortz, Cole; Segreto, Frank; Diebo, Bassel M; Daniels, Alan; Hamilton, D Kojo; Sciubba, Daniel; Smith, Justin; Neuman, Brian; Shaffrey, Christopher I; LaFage, Virginie; LaFage, Renaud; Schwab, Frank; Bess, Shay; Ames, Christopher; Hart, Robert; Soroceanu, Alexandra; Mundis, Gregory; Eastlack, Robert; International Spine Study GroupObjective
We investigated the 30-day complication incidence and 1-year radiographic correction in obese patients undergoing surgical treatment of cervical deformity.Methods
The patients were stratified according to World Health Organization's definition for obesity: obese, patients with a body mass index of ≥30 kg/m2; and nonobese, patients with a body mass index of <30 kg/m2. The patients had undergone surgery for the treatment of cervical deformity. The patient baseline demographic, comorbidity, and radiographic data were compared between the 2 groups at baseline and 1 year postoperatively. The 30-day complication incidence was stratified according to complication severity (any, major, or minor), and type (cardiopulmonary, dysphagia, infection, neurological, and operative). Binary logistic regression models were used to assess the effect of obesity on developing those complications, with adjustment for patient age and levels fused.Results
A total of 124 patients were included, 53 obese and 71 nonobese patients. The 2 groups had a similar T1 slope minus cervical lordosis (obese, 37.2° vs. nonobese, 36.9°; P = 0.932) and a similar C2-C7 (-5.9° vs. -7.3°; P = 0.718) and C2-C7 (50.1 mm vs. 44.1 mm; P = 0.184) sagittal vertical axis. At the 1-year follow-up examination, the T1 pelvic angle (1.0° vs. -3.1°; P = 0.021) and C2-S1 sagittal vertical axis (-5.9 mm vs. -35.0 mm; P = 0.036) were different, and the T1 spinopelvic inclination (-1.0° vs. -2.9°; P = 0.123) was similar. The obese patients had a greater risk of overall short-term complications (odds ratio, 2.5; 95% confidence interval, 1.1-6.1) and infectious complications (odds ratio, 5.0; 95% confidence interval, 1.0-25.6).Conclusions
Obese patients had a 5 times greater odds of developing infections after surgery for adult cervical deformity. Obese patients also showed significantly greater pelvic anteversion after cervical correction.Item Open 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 GroupPurpose
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.Item Open Access Frequency and Acceptability of Adverse Events After Anterior Cervical Discectomy and Fusion: A Survey Study From the Cervical Spine Research Society.(Clinical spine surgery, 2018-06) Wilson, Jefferson R; Radcliff, Kris; Schroeder, Gregory; Booth, Madison; Lucasti, Christopher; Fehlings, Michael; Ahmad, Nassr; Vaccaro, Alexander; Arnold, Paul; Sciubba, Daniel; Ching, Alex; Smith, Justin; Shaffrey, Christopher; Singh, Kern; Darden, Bruce; Daffner, Scott; Cheng, Ivan; Ghogawala, Zoher; Ludwig, Steven; Buchowski, Jacob; Brodke, Darrel; Wang, Jeffrey; Lehman, Ronald A; Hilibrand, Alan; Yoon, Tim; Grauer, Jonathan; Dailey, Andrew; Steinmetz, Michael; Harrop, James SPURPOSE:Anterior cervical discectomy and fusion has a low but well-established profile of adverse events. The goal of this study was to gauge surgeon opinion regarding the frequency and acceptability of these events. METHODS:A 2-page survey was distributed to attendees at the 2015 Cervical Spine Research Society (CSRS) meeting. Respondents were asked to categorize 18 anterior cervical discectomy and fusion-related adverse events as either: "common and acceptable," "uncommon and acceptable," "uncommon and sometimes acceptable," or "uncommon and unacceptable." Results were compiled to generate the relative frequency of these responses for each complication. Responses for each complication event were also compared between respondents based on practice location (US vs. non-US), primary specialty (orthopedics vs. neurosurgery) and years in practice. RESULTS:Of 150 surveys distributed, 115 responses were received (76.7% response rate), with the majority of respondents found to be US-based (71.3%) orthopedic surgeons (82.6%). Wrong level surgery, esophageal injury, retained drain, and spinal cord injury were considered by most to be unacceptable and uncommon complications. Dysphagia and adjacent segment disease occurred most often, but were deemed acceptable complications. Although surgeon experience and primary specialty had little impact on responses, practice location was found to significantly influence responses for 12 of 18 complications, with non-US surgeons found to categorize events more toward the uncommon and unacceptable end of the spectrum as compared with US surgeons. CONCLUSIONS:These results serve to aid communication and transparency within the field of spine surgery, and will help to inform future quality improvement and best practice initiatives.Item Open Access Impact of magnitude and percentage of global sagittal plane correction on health-related quality of life at 2-years follow-up.(Neurosurgery, 2012-08) Blondel, Benjamin; Schwab, Frank; Ungar, Benjamin; Smith, Justin; Bridwell, Keith; Glassman, Steven; Shaffrey, Christopher; Farcy, Jean-Pierre; Lafage, VirginieBackground
Sagittal plane malalignment has been established as the main radiographic driver of disability in adult spinal deformity (ASD).Objective
To evaluate the amount of sagittal correction needed for a patient to perceive improvement (minimal clinically important difference, MCID) in health-related quality of life (HRQOL) scores.Methods
This was a multicenter, retrospective analysis of prospectively consecutively enrolled ASD patients. Inclusion criterion was a sagittal vertical axis (SVA) >80 mm. Demographic, radiographic, and HRQOL preoperative and 2-year postsurgery data were collected. Surgical treatment was categorized based on SVA correction: <60 mm, 60 mm to 120 mm, and >120 mm. Changes in parameters were analyzed using paired t test, 1-way analysis of variance, and χ2 test.Results
Seventy-six patients (preoperative SVA = 140 mm) were analyzed; each subgroup revealed significant HRQOL improvements following surgery. Compared with the <60 mm correction group, the likelihood of reaching MCID was significantly improved for the >120 mm group (Oswestry Disability Index) but not for the 60 mm to 120 mm group. A significantly greater likelihood of reaching MCID thresholds was observed for corrections above 66% of preoperative SVA.Conclusion
Best HRQOL outcomes for ASD patients with severe sagittal plane deformity were obtained with a correction >120 mm for SVA and at least 66% of correction. Although lesser amounts of SVA correction yielded clinical improvement, the rate of MCID threshold improvement was not significantly different for mild or modest corrections. These results underline the need for complete sagittal plane deformity correction if high rates of HRQOL benefit are sought for patients with marked sagittal plane deformity.Item Open Access Increasing Cost Efficiency in Adult Spinal Deformity Surgery: Identifying Predictors of Lower Total Costs.(Spine, 2022-01) Passias, Peter G; Brown, Avery E; Bortz, Cole; Alas, Haddy; Pierce, Katherine; Ahmad, Waleed; Naessig, Sara; Lafage, Renaud; Lafage, Virginie; Hassanzadeh, Hamid; Labaran, Lawal A; Ames, Christopher; Burton, Douglas C; Gum, Jeffrey; Hart, Robert; Hostin, Richard; Kebaish, Khaled M; Neuman, Brian J; Bess, Shay; Line, Breton; Shaffrey, Christopher; Smith, Justin; Schwab, Frank; Klineberg, Eric; International Spine Study GroupStudy design
Retrospective study of a prospective multicenter database.Objective
The purpose of this study was to identify predictors of lower total surgery costs at 3 years for adult spinal deformity (ASD) patients.Summary of background data
ASD surgery involves complex deformity correction.Methods
Inclusion criteria: surgical ASD (scoliosis ≥20°, sagittal vertical axis [SVA] ≥5 cm, pelvic tilt ≥25°, or thoracic kyphosis ≥60°) patients >18 years. Total costs for surgery were calculated using the PearlDiver database. Cost per quality-adjusted life year was assessed. A Conditional Variable Importance Table used nonreplacement sampling set of 20,000 Conditional Inference trees to identify top factors associated with lower cost surgery for low (LSVA), moderate (MSVA), and high (HSVA) SRS Schwab SVA grades.Results
Three hundred sixtee of 322 ASD patients met inclusion criteria. At 3-year follow up, the potential cost of ASD surgery ranged from $57,606.88 to $116,312.54. The average costs of surgery at 3 years was found to be $72,947.87, with no significant difference in costs between deformity groups (P > 0.05). There were 152 LSVA patients, 53 MSVA patients, and 111 HSVA patients. For all patients, the top predictors of lower costs were frailty scores <0.19, baseline (BL) SRS Activity >1.5, BL Oswestry Disability Index <50 (all P < 0.05). For LSVA patients, no history of osteoporosis, SRS Activity scores >1.5, age <64, were the top predictors of lower costs (all P < 0.05). Among MSVA patients, ASD invasiveness scores <94.16, no past history of cancer, and frailty scores <0.3 trended toward lower total costs (P = 0.071, P = 0.210). For HSVA, no history of smoking and body mass index <27.8 trended toward lower costs (both P = 0.060).Conclusion
ASD surgery has the potential for improved cost efficiency, as costs ranged from $57,606.88 to $116,312.54. Predictors of lower costs included higher BL SRS activity, decreased frailty, and not having depression. Additionally, predictors of lower costs were identified for different BL deformity profiles, allowing for the optimization of cost efficiency for all patients.Level of Evidence: 3.Item Open Access Intraoperative alignment goals for distinctive sagittal morphotypes of severe cervical deformity to achieve optimal improvements in health-related quality of life measures.(The spine journal : official journal of the North American Spine Society, 2020-03-21) Virk, Sohrab; Passias, Peter; Lafage, Renaud; Klineberg, Eric; Mundis, Gregory; Protopsaltis, Themistocles; Shaffrey, Christopher; Bess, Shay; Burton, Doug; Hart, Robert; Kim, Han Jo; Ames, Christopher; Schwab, Frank; Smith, Justin; Lafage, Virginie; International Spine Study GroupBACKGROUND CONTEXT:Patients with severe cervical deformity (CD) often have profound deficits in numerous activities of daily living. The association between health status and post-operative radiographic goals is difficult to quantify. PURPOSE:We aimed to investigate the radiographic characteristics of patients who achieved optimal health related quality of life scores following surgery for CD. STUDY DESIGN:We performed a retrospective review of a prospectively collected database of patients with spinal deformity. PATIENT SAMPLE:One hundred and fifty-three patients with cervical deformity OUTCOME MEASURES: Common health-related quality of life scores (HRQOLs) measurements were taken for patients treated operatively for cervical deformity including neck disability index (NDI), modified Japanese Orthopaedic Association scale (mJOA) for myelopathy and numeric rating scale for neck pain (NRS-neck), METHODS: Surgical patients with severe (can you define severe?) CD were isolated based upon a previously presented discriminant analysis which outlined a combination of preoperative cervical sagittal vertical axis (cSVA), T1 slope, maximum focal kyphosis in extension, C2 slope in extension, and number of kyphotic levels in extension. Those with available preoperative and 1-year postoperative HRQL data were included. Based on a previous study, patients were grouped into 3 distinct sagittal morphotypes of CD: focal deformity (FD), flatneck (FN=large TS-CL and lack of compensation), or cervicothoracic (CT). Post-operative outcomes were defined as "good" if a patient had ≥2 of the 3 following criteria (1) NDI <20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Within each distinct deformity group, patients with good outcomes were compared to those with poor outcomes (i.e. not meeting the criteria for good) for differences in demographics, HRQL scores, and alignment, via Chi-squared or student's t-tests. RESULTS:Overall, 83 of 153 patients met the criteria of severe CD and 40 patients had complete 1-year follow-up of clinical/radiographic data. Patient breakdown by deformity pattern was: CT (N=13), FN (N=17), and FD (N=17), with 7 patients meeting criteria for both FD and FN deformities. Within the FD cohort, maximal focal kyphosis (i.e. kyphosis at one level) was better corrected in patients with a "good" outcome (p = 0.03). In the FN cohort, patients with "good" outcomes presented pre-operatively with worse horizontal gaze (McGregor Slope 21° vs 6°, p=0.061) and cSVA (72mm vs 60mm, p=0.030). "Good" outcome FN patients showed significantly greater postop correction of horizontal gaze (-25° vs -5°, p = 0.031). In the CT cohort, patients with "good" outcomes had superior global alignment both pre- (SVA: -17mm vs 108mm, p <0.001) and post-operatively (50mm vs 145mm, p=0.001). CT patients with "good" outcomes also had better postop cervical alignment (cSVA 35mm vs 49mm, p=0.030), and less kyphotic segments during extension (p=0.011). In the FD cohort, there were no differences between "good" and "poor" outcomes patients in preoperative alignment; however, "good" outcome patients showed superior changes in postoperative focal kyphosis (-2° vs 5°, p=0.030). Within all three deformity pattern categories, there were no differences between "good" and "poor" outcome patients with respect to demographics or surgical parameters (levels fused, surgical approach, decompression, osteotomy, all p>0.050). CONCLUSIONS:The results of this study show each CD patient's unique deformity must be carefully examined in order to determine the appropriate alignment goals to achieve optimal HRQOLs. In particular, the recognition of the sagittal morphotype can help assist surgeons to aim for specific alignment goals for CT, FN and FD. Distinct deformity specific intra-operative goals include obtaining proper sagittal global/cervical alignment for cervicothoracic patients, correcting maximal focal kyphosis in focal deformity patients, and correcting horizontal gaze for flatneck patients.Item Open Access Novel Angular Measures of Cervical Deformity Account for Upper Cervical Compensation and Sagittal Alignment.(Clinical spine surgery, 2017-08) Protopsaltis, Themistocles S; Lafage, Renaud; Vira, Shaleen; Sciubba, Daniel; Soroceanu, Alex; Hamilton, Kojo; Smith, Justin; Passias, Peter G; Mundis, Gregory; Hart, Robert; Schwab, Frank; Klineberg, Eric; Shaffrey, Christopher; Lafage, Virginie; Ames, Christopher; International Spine Study GroupStudy design
This is a retrospective review of a prospective multicenter database.Objective
This study introduces 2 new cervical alignment measures accounting for both cervical deformity (CD) and upper cervical compensation.Summary of background data
Current descriptions of CD like the C2-C7 sagittal vertical axis (cSVA) do not account for compensatory mechanisms such as C0-C2 lordosis and pelvic tilt, which makes surgical planning difficult. The craniocervical angle (CCA) combines the slope of McGregor's line and the inclination from C7 to the hard palate. The C2-pelvic tilt (CPT) combines C2 tilt and pelvic tilt. Like the T1 pelvic angle, CPT is less affected by lower extremity and pelvic compensation.Methods
Novel and existing CD measures were correlated in 781 patients from a thoracolumbar deformity (TLD) database and 61 patients from a prospective CD database. CD patients were subanalyzed by region of deformity driver: cervical or cervico-thoracic junction. TLD patients were substratified according to whether or not they had CD as well, where CD was defined as cSVA>4 cm or T1 slope minus cervical lordosis mismatch (TS-CL) >20.Results
TLD cohort: mean cSVA was 31.7±17.8 mm. Subanalysis of TLD patients with CD versus no-CD demonstrated significant differences in CCA (56.2 vs. 60.6, P<0.001) and CPT (32.6 vs. 19.3, P<0.001). CCA and CPT correlated with cSVA (r=-0.488/r=0.418, P<0.001) and C0-C2 lordosis (r=-0.630/r=0.289,P<0.001). CD cohort: mean cSVA was 47.3±32.2 mm. CCA and CPT correlated with cSVA (r=-0.811/r=0.657, P<0.001) and C0-C2 lordosis (r=-0.656/r=0.610, P<0.001). CD cohort subanalysis indicated that CT patients were significantly more deformed by cSVA (71.3 vs 24.0 mm, P<0.001), CCA (47.1 vs 59.1 degrees, P<0.001), and CPT (63.3 vs 43.8 degrees, P=0.002). Using linear regression analysis, cSVA of 4 cm corresponded to CCA of 53.2 degrees (r=0.5) and CPT of 48.5 degrees (r=0.4).Conclusions
CCA and CPT account for both cervical sagittal alignment and upper cervical compensation and can be utilized in assessment of cervical alignment.Item Open Access Postoperative cervical deformity in 215 thoracolumbar patients with adult spinal deformity: prevalence, risk factors, and impact on patient-reported outcome and satisfaction at 2-year follow-up.(Spine, 2015-03) Passias, Peter G; Soroceanu, Alex; Smith, Justin; Boniello, Anthony; Yang, Sun; Scheer, Justin K; Schwab, Frank; Shaffrey, Christopher; Kim, Han Jo; Protopsaltis, Themistocles; Mundis, Gregory; Gupta, Munish; Klineberg, Eric; Lafage, Virginie; Ames, Christopher; International Spine Study GroupStudy design
Retrospective review of prospective multicenter database.Objective
Quantify the incidence of new onset cervical deformity (CD) after adult spinal deformity surgery of the thoracolumbar spine, identify predictors of development, and determine the impact on outcomes.Summary of background data
High prevalence of residual CD has been identified after surgical treatment of adult spinal deformity. Development of new onset CD is less understood and its clinical impact unclear.Methods
A total of 215 patients with complete 2-year follow-up and full-length radiographs met inclusion criteria. CD was defined by T1 slope minus Cervical Lordosis (CL) more than 20°, C2-C7 sagittal vertical axis more than 40 mm, or C2-C7 kyphosis more than 10°. Univariate analysis was performed using t tests or tests of proportion. Multivariate logistic regression was used to determine independent predictors of new onset CD. The impact of CD on health-related quality of life and satisfaction was measured using repeated measures mixed models or logistic regression as appropriate, accounting for potential confounders.Results
The overall rate of CD at 2 years after surgery was 63%. Univariate analysis revealed that patients who developed new onset CD postoperatively had higher incidence of diabetes (7.35% vs. 1.28%, P = 0.05), increased preoperative C2-C7 sagittal vertical axis (P = 0.04) and C2 slope (P = 0.038), and smaller diameter rods used at surgery (P = 0.032). Independent predictors of new onset CD at 2 years included: diabetes (odds ratio, 10.49; P = 0.046) and increased preoperative T1 slope minus cervical lordosis (odds ratio, 1.08/º; P = 0.022). Ending instrumentation below T4 was a negative predictor (odds ratio, 0.31; P = 0.019). Patients with and without CD experienced improvements in 2-year 36-Item Short Form Health Survey (P = 0.0001), Oswestry Disability Index (P = 0.0001), and Scoliosis Research Society (P = 0.0001). Rates and overall improvement were similar. CD was not associated with decreased satisfaction (P = 0.28).Conclusion
A total of 47.7% of patients without preoperative CD developed new onset postoperative CD after thoracolumbar surgery. Independent predictors of new onset CD at 2 years included diabetes, higher preoperative T1 slope minus cervical lordosis, and ending instrumentation above T4. Significant improvements in health-related quality of life scores occurred despite the development of postoperative CD.Level of evidence
2.Item Open Access Predictive model for distal junctional kyphosis after cervical deformity surgery.(The spine journal : official journal of the North American Spine Society, 2018-12) Passias, Peter G; Vasquez-Montes, Dennis; Poorman, Gregory W; Protopsaltis, Themistocles; Horn, Samantha R; Bortz, Cole A; Segreto, Frank; Diebo, Bassel; Ames, Chris; Smith, Justin; LaFage, Virginie; LaFage, Renaud; Klineberg, Eric; Shaffrey, Chris; Bess, Shay; Schwab, Frank; ISSGBackground context
Distal junctional kyphosis (DJK) is a primary concern of surgeons correcting cervical deformity. Identifying patients and procedures at higher risk of developing this condition is paramount in improving patient selection and care.Purpose
The present study aimed to develop a risk index for DJK development in the first year after surgery.Study design/setting
This is a retrospective review of a prospective multicenter cervical deformity database.Patient sample
Patients over the age of 18 meeting one of the following deformities were included in the study: cervical kyphosis (C2-7 Cobb angle>10°), cervical scoliosis (coronal Cobb angle>10°), positive cervical sagittal imbalance (C2-C7 sagittal vertical axis (SVA)>4 cm or T1-C6>10°), or horizontal gaze impairment (chin-brow vertical angle>25°).Outcome measures
Development of DJK at any time before 1 year.Methods
Distal junctional kyphosis was defined by both clinical diagnosis (by enrolling surgeon) and post hoc identification of development of an angle<-10° from the end of fusion construct to the second distal vertebra, as well as a change in this angle by <-10° from baseline. Conditional Inference Decision Trees were used to identify factors predictive of DJK incidence and the cut-off points at which they have an effect. A conditional Variable-Importance table was constructed based on a non-replacement sampling set of 2,000 Conditional Inference Trees. Twelve influencing factors were found; binary logistic regression for each variable at significant cutoffs indicated their effect size.Results
Statistical analysis included 101 surgical patients (average age: 60.1 years, 58.3% female, body mass index: 30.2) undergoing long cervical deformity correction (mean levels fused: 7.1, osteotomy used: 49.5%, approach: 46.5% posterior, 17.8% anterior, 35.7% combined). In 2 years after surgery, 6% of patients were diagnosed with clinical DJK; however, 23.8% of patients met radiographic definition for DJK. Patients with neurologic symptoms were at risk of DJK (odds ratio [OR]: 3.71, confidence interval [CI]: 0.11-0.63). However, no significant relationship was found between osteoporosis, age, and ambulatory status with DJK incidence. Baseline radiographic malalignments were the most numerous and strong predictors for DJK: (1) C2-T1 tilt>5.33 (OR: 6.94, CI: 2.99-16.14); (2) kyphosis<-50.6° (OR: 5.89, CI: 0.07-0.43); (3) C2-C7 lordosis<-12° (OR: 5.7, CI: 0.08-0.41); (4) T1 slope minus cervical lordosis>36.4 (OR: 5.6, CI: 2.28-13.57); (5) C2-C7 SVA>56.3° (OR: 5.4, CI: 2.20-13.23); and (6) C4_Tilt>56.7 (OR: 5.0, CI: 1.90-13.1). Clinically, combined approaches (OR: 2.67, CI: 1.21-5.89) and usage of Smith-Petersen osteotomy (OR: 2.55, CI: 1.02-6.34) were the most important predictors of DJK.Conclusions
In a surgical cohort of patients with cervical deformity, we found a 23.8% incidence of DJK. Different procedures and patient malalignment predicted incidence of DJK up to 1 year. Preoperative T1 slope-cervical lordosis, cervical kyphosis, SVA, and cervical lordosis all strongly predicted DJK at specific cut-off points. Knowledge of these factors will potentially help direct future study and strategy aimed at minimizing this potentially dramatic occurrence.Item Open Access Predictors of Revision Surgical Procedure Excluding Wound Complications in Adult Spinal Deformity and Impact on Patient-Reported Outcomes and Satisfaction: A Two-Year Follow-up.(The Journal of bone and joint surgery. American volume, 2016-04) Passias, Peter G; Soroceanu, Alexandra; Yang, Sun; Schwab, Frank; Ames, Christopher; Boniello, Anthony; Smith, Justin; Shaffrey, Christopher; Boachie-Adjei, Oheneba; Mundis, Gregory; Burton, Douglas; Klineberg, Eric; Hart, Robert; Hamilton, D Kojo; Sciubba, Daniel M; Bess, Shay; Lafage, VirginieBackground
The surgical procedure to treat adult spinal deformity is challenging, with high rates of complications, including revision procedures performed to repair instrumentation failure or unplanned surgical complications. This study quantifies the incidence of, identifies predictors for, and determines health-related quality-of-life changes associated with revision procedures to treat adult spinal deformity.Methods
We analyzed a multicenter database of patients who underwent a surgical procedure for adult spinal deformity, which was defined as having an age of eighteen years or older and scoliosis of ≥20°, sagittal vertical axis of ≥5 cm, pelvic tilt of ≥25°, and/or thoracic kyphosis of >60°. We focused on demographic, radiographic, health-related quality-of-life, and operative data at the two-year follow-up. Patients with primary infections were excluded. Predictive and confounding variables for revisions were identified using univariate analysis and multivariate logistic regression modeling.Results
Two hundred and forty-three patients were included in this study; of these patients, forty (16.5%) underwent a revision surgical procedure (15% of these at six weeks, 38% between six weeks and one year, and 48% between one and two years). Screw or cage-related implant complications were the most common indications for revision, followed by proximal junctional kyphosis and rod failure. Positive predictors for a revision surgical procedure included total body mass, with an odds ratio of 1.33 (95% confidence interval, 1.04 to 1.70) per 10-kg increase, and preoperative sagittal vertical axis, with an odds ratio of 1.15 (95% confidence interval, 1.04 to 1.28) per 2-cm increase. Factors associated with lower risk of revision included use of bone morphogenetic protein-2 (BMP-2) (odds ratio, 0.16 [95% confidence interval, 0.05 to 0.47]) and greater diameter rods (odds ratio, 0.51 [95% confidence interval, 0.29 to 0.89]). Body mass index, although initially considered a potential predictor for a revision surgical procedure, was not significantly different between primary and revision cohorts on univariate analysis and was therefore not input into the multivariate model. All patients improved in two-year health-related quality-of-life scores; revision subjects had lower overall improvement (Scoliosis Research Society [SRS] score; p = 0.016) from baseline. Revision status did not predict two-year patient satisfaction (p = 0.726), as measured by the SRS Satisfaction domain (SRS-22r).Conclusions
Patients with greater preoperative sagittal vertical axis and high total body mass are at a higher risk for a revision surgical procedure following procedures to treat adult spinal deformity. Larger diameter rods and BMP-2 were associated with decreased revision odds. Revisions did not impact patient satisfaction at two years.Level of evidence
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.Item Open Access Reciprocal changes in cervical spine alignment after corrective thoracolumbar deformity surgery.(European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 2014-03) Ha, Yoon; Schwab, Frank; Lafage, Virginie; Mundis, Gregory; Shaffrey, Christopher; Smith, Justin; Bess, Shay; Ames, ChristopherPurpose
To identify changes in cervical alignment parameters following surgical correction of thoracolumbar deformity and then assess the preoperative parameters which induce changes in cervical alignment following corrective thoracolumbar deformity surgery.Methods
A retrospective study of 49 patients treated for thoracolumbar deformity with preoperative planning of an acceptably aligned coronal and sagittal plane in each case. We compared cervical spine parameters in two distinct low [preoperative C7 sagittal vertical axis (SVA) ≤ 6 cm] and high (preoperative C7 SVA ≥ 9 cm) C7 SVA groups. Multilinear regression analysis was performed and revealed the relationship between postoperative cervical lordosis and preoperative spinopelvic parameters and surgical plans.Results
In the lower C7 SVA group, cervical lordosis was significantly increased after thoracic/lumbar deformity correction (p < 0.01). In contrast, the high C7 SVA group showed decreased cervical lordosis postoperatively (p < 0.01). Multilinear regression analysis demonstrated the preoperative parameters (preoperative C2-7 angle, T1 slope, surgical plan for PT and C7 SVA), which determine the postoperative cervical lordosis.Conclusion
In spinal deformity procedures, preoperative spinal alignment parameters, and surgical plans could affect postoperative cervical spine alignment.Item Open Access Recurrent Proximal Junctional Kyphosis: Incidence, Risk Factors, Revision Rates, and Outcomes at 2-Year Minimum Follow-up.(Spine, 2020-01) Kim, Han Jo; Wang, Shan-Jin; Lafage, Renaud; Iyer, Sravisht; Shaffrey, Christopher; Mundis, Gregory; Hostin, Richard; Burton, Douglas; Ames, Christopher; Klineberg, Eric; Gupta, Munish; Smith, Justin; Schwab, Frank; Lafage, Virginie; International Spine Study GroupStudy design
Retrospective comparative cohort study.Objective
Assess the incidence, risk factors, and outcomes of recurrent proximal junctional kyphosis (r-PJK) in PJK revision patients.Summary of background data
Several studies have identified the incidence and risk factors for PJK after primary surgery. However, few studies have reported on PJK recurrence after revision for PJK.Methods
A multicenter database of patients who underwent PJK revision surgery with minimum 2-year follow-up was analyzed. Demographic, operative, and radiographic outcomes were compared in patients with r-PJK and patients without recurrence no-Proximal Junctional Kyphosis (n-PJK). Postoperative Scoliosis Research Society-22r, Short Form-36, and Oswestry Disability Index were compared. Preoperative and most recent spinopelvic, cervical, and cervicothoracic radiographic parameters were compared. Univariate and multivariate analyses were used to determine r-PJK risk factors. A predictive model was formulated based on our logistic regression analysis.Results
A total of 70 patients met the inclusion criteria with an average follow-up of 21.8 months. The mean age was 66.3 ± 9.4 and 80% of patients were women. Before revision, patients had a proximal junctional angle angle of -31.7° ± 15.9°. The rate of recurrent PJK was 44.3%. Logistic regression showed that pre-revision thoracic pelvic angle (odds ratio [OR]: 1.060 95% confidence interval [CI] 1.002; 1.121; P = 0.042) and prerevision C2-T3 sagittal vertical axis (SVA; OR: 1.040 95% CI [1.007; 1.073] P = 0.016) were independent predictors of r-PJK. Classification with these parameters yielded an accuracy of 72.7%, precision of 80.6%, and recall of 73.5%. When examining correction, or change in alignment with revision surgery, we found that change in SVA (OR: 0.981 95% CI [0.968; 0.994] P = 0.005) was the only predictor of r-PJK with accuracy of 66.7%, precision of 74.2%, and recall of 69.7%.Conclusion
Patients after PJK revision surgery had a recurrence rate of 44%. Logistic regression based on the prerevision variables showed that prerevision thoracic pelvic angle and prerevision C2-T3 SVA were independent predictors of r-PJK.Level of evidence
4.