Browsing by Author "Williamson, Tyler K"
Now showing 1 - 20 of 28
- Results Per Page
- Sort Options
Item Open Access Adult cervical spine deformity: a state-of-the-art review.(Spine Deform, 2023-09-30) Jackson-Fowl, Brendan; Hockley, Aaron; Naessig, Sara; Ahmad, Waleed; Pierce, Katherine; Smith, Justin S; Ames, Christopher; Shaffrey, Christopher; Bennett-Caso, Claudia; Williamson, Tyler K; McFarland, Kimberly; Passias, Peter GAdult cervical deformity is a structural malalignment of the cervical spine that may present with variety of significant symptomatology for patients. There are clear and substantial negative impacts of cervical spine deformity, including the increased burden of pain, limited mobility and functionality, and interference with patients' ability to work and perform everyday tasks. Primary cervical deformities develop as the result of a multitude of different etiologies, changing the normal mechanics and structure of the cervical region. In particular, degeneration of the cervical spine, inflammatory arthritides and neuromuscular changes are significant players in the development of disease. Additionally, cervical deformities, sometimes iatrogenically, may present secondary to malalignment or correction of the thoracic, lumbar or sacropelvic spine. Previously, classification systems were developed to help quantify disease burden and influence management of thoracic and lumbar spine deformities. Following up on these works and based on the relationship between the cervical and distal spine, Ames-ISSG developed a framework for a standardized tool for characterizing and quantifying cervical spine deformities. When surgical intervention is required to correct a cervical deformity, there are advantages and disadvantages to both anterior and posterior approaches. A stepwise approach may minimize the drawbacks of either an anterior or posterior approach alone, and patients should have a surgical plan tailored specifically to their cervical deformity based upon symptomatic and radiographic indications. This state-of-the-art review is based upon a comprehensive overview of literature seeking to highlight the normal cervical spine, etiologies of cervical deformity, current classification systems, and key surgical techniques.Item Open Access An Economic Analysis of Early and Late Complications After Adult Spinal Deformity Correction.(Global spine journal, 2024-04) Williamson, Tyler K; Owusu-Sarpong, Stephane; Imbo, Bailey; Krol, Oscar; Tretiakov, Peter; Joujon-Roche, Rachel; Ahmad, Salman; Bennett-Caso, Claudia; Schoenfeld, Andrew J; Lebovic, Jordan; Vira, Shaleen; Diebo, Bassel; Lafage, Renaud; Lafage, Virginie; Passias, Peter GStudy design/setting
Retrospective cohort.Objective
Adult spinal deformity (ASD) corrective surgery is often a highly invasive procedure portending patients to both immediate and long-term complications. Therefore, we sought to compare the economic impact of certain complications before and after 2 years.Methods
ASD patients with minimum 3-year data included. Complication groups were defined as follows: any complication, major, medical, mechanical, radiographic, and reoperation. Complications stratified by occurrence before or after 2 years postoperatively. Published methods converted ODI to SF-6D to QALYs. Cost was calculated using CMS.gov definitions. Marginalized means for utility gained and cost-per-QALY were calculated via ANCOVA controlling for significant confounders.Results
244 patients included. Before 2Y, complication rates: 76% ≥1 complication, 18% major, 26% required reoperation. After 2Y, complication rates: 32% ≥1 complication, 4% major, 2.5% required reoperation. Major complications after 2 years had worse cost-utility (.320 vs .441, P = .1). Patients suffering mechanical complications accrued the highest overall cost ($130,482.22), followed by infection and PJF for complications before 2 years. Patients suffering a mechanical complication after 2 years had lower cost-utility ($109,197.71 vs $130,482.22, P = .041). Patients developing PJF after 2 years accrued a better cost-utility ($77,227.84 vs $96,873.57; P = .038), compared to PJF before 2 years.Conclusion
Mechanical complications had the single greatest impact on cost-utility after adult spinal deformity surgery, but less so after 2 years. Understanding the cost-utility of specific interventions at certain timepoints may mitigate economic burden and prophylactic efforts should strategically be made against early mechanical complications.Item Open Access Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery.(Journal of clinical medicine, 2023-08) Passias, Peter G; Williamson, Tyler K; Mir, Jamshaid M; Smith, Justin S; Lafage, Virginie; Lafage, Renaud; Line, Breton; Daniels, Alan H; Gum, Jeffrey L; Schoenfeld, Andrew J; Hamilton, David Kojo; Soroceanu, Alex; Scheer, Justin K; Eastlack, Robert; Mundis, Gregory M; Diebo, Bassel; Kebaish, Khaled M; Hostin, Richard A; Gupta, Munish C; Kim, Han Jo; Klineberg, Eric O; Ames, Christopher P; Hart, Robert A; Burton, Douglas C; Schwab, Frank J; Shaffrey, Christopher I; Bess, Shay; On Behalf Of The International Spine Study GroupBackground
While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications.Objective
Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers.Study design/setting
Retrospective cohort study of a prospectively collected multicenter database.Methods
ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility.Results
A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, p = 0.021) and major mechanical complications (12% vs. 22%, p = 0.002), and less reoperations (23% vs. 33%, p = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both p < 0.001) at two years.Conclusions
Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.Item Open Access Changes in health-related quality of life measures associated with degree of proximal junctional kyphosis.(Spine deformity, 2023-05) Passias, Peter G; Frangella, Nicholas J; Williamson, Tyler K; Moattari, Kevin A; Lafage, Renaud; Lafage, Virginie; Smith, Justin S; Kebaish, Khaled M; Burton, Douglas C; Hart, Robert A; Ames, Christopher P; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; International Spine Study GroupPurpose
To explore the changes in health-related quality of life parameters observed in patients experiencing varying degrees of proximal junctional kyphosis following corrective adult spinal deformity fusions.Methods
Inclusion: adult spinal deformity patients > 18 y/o, undergoing spinal fusion. PJK: ≥ 10° measure of the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the UIV + 2. Severe PJK: > 28° PJK. Mild PJK: ≥ 10oand ≤ 28°. ANOVA, followed by ANCOVA, compared the change in HRQoLs between time points (BL, 1Y, 2Y) among PJK groups. Correlation-related change in PJK and change in HRQoL for mild and severe groups.Results
969 patients (age: 64.5 y/o,75% F, posterior levels fused:12.3) were studied. 59% no PJK, 32% mild PJK, 9% severe PJK. No differences in HRQoLs were seen between no PJK and PJK groups at baseline, one year, and 2 years. Adjusted analysis revealed Severe PJK patients improved less in SRS-22 Satisfaction (NoPJK: 1.6, MildPJK: 1.6, SeverePJK: 1.0; p = 0.022) scores at 2 years. Linear regression analysis only found clinical improvement in SRS-22 Satisfaction to correlate with the change of the PJK angle by 2 years (R = 0.176, P = 0.008). No other HRQoL metric correlated with either the incidence of PJK or the change in the PJK angle by one or 2 years.Conclusions
These results maintain that patients presenting with and without proximal junctional kyphosis report similar health-related qualities of life following corrective adult spinal deformity surgery, and SRS-22 Satisfaction may be a clinical correlate to the degree of PJK. Rather than proving proximal junctional kyphosis to have a minimal clinical impact overall on HRQoL metrics, these data suggest that future analysis of this phenomenon requires different assessments.Level of evidence
Level of evidence: III.Item Open Access Compensation from mild and severe cases of early proximal junctional kyphosis may manifest as progressive cervical deformity at two year follow-up.(Spine deformity, 2023-12) Passias, Peter G; Naessig, Sara; Williamson, Tyler K; Lafage, Renaud; Lafage, Virginie; Smith, Justin S; Gupta, Munish C; Klineberg, Eric; Burton, Douglas C; Ames, Christopher; Bess, Shay; Shaffrey, Christopher; Schwab, Frank J; International Spine Study Group (ISSG)Background
Postoperative reciprocal changes (RC) in the cervical spine associated with varying factors of proximal junctional kyphosis (PJK) following fusions of the thoracopelvic spine are poorly understood.Purpose
Explore reciprocal changes in the cervical spine associated with varying factors (severity, progression, patient age) of PJK in patients undergoing adult spinal deformity (ASD) correction.Patients and methods
Retrospective review of a multicenter ASD database.Inclusion
ASD patients > 18 y/o, undergoing fusions from the thoracic spine (UIV: T6-T12) to the pelvis with two-year radiographic data. ASD was defined as: Coronal Cobb angle ≥ 20°, Sagittal Vertical Axis ≥ 5 cm, Pelvic Tilt ≥ 25°, and/or Thoracic Kyphosis ≥ 60°. PJK was defined as a ≥ 10° measure of the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the UIV + 2. Patients were grouped by mild (M; 10°-20°) and severe (S; > 20°) PJK at one year. Propensity Score Matching (PSM) controlled for CCI, age, PI and UIV. Unpaired and paired t test analyses determined difference between RC parameters and change between time points. Pearson bi-variate correlations analyzed associations between RC parameters (T4-T12, TS-CL, cSVA, C2-Slope, and T1-Slope) and PJK descriptors.Results
284 ASD patients (UIV: T6: 1.1%; T7: 0.7%; T8: 4.6%; T9: 9.9%; T10: 58.8%; T11: 19.4%; T12: 5.6%) were studied. PJK analysis consisted of 182 patients (Mild = 91 and Severe = 91). Significant difference between M and S groups were observed in T4-T12 Δ1Y(- 16.8 v - 22.8, P = 0.001), TS-CLΔ1Y(- 0.6 v 2.8, P = 0.037), cSVAΔ1Y(- 1.8 v 1.9, P = 0.032), and C2 slopeΔ1Y(- 1.6 v 2.3, P = 0.022). By two years post-op, all changes in cervical alignment parameters were similar between mild and severe groups. Correlation between age and cSVAΔ1Y(R = 0.153, P = 0.034) was found. Incidence of severe PJK was found to correlate with TS-CLΔ1Y(R = 0.142, P = 0.049), cSVAΔ1Y(R = 0.171, P = 0.018), C2SΔ1Y(R = 0.148, P = 0.040), and T1SΔ2Y(R = 0.256, P = 0.003).Conclusions
Compensation within the cervical spine differed between individuals with mild and severe PJK at one year postoperatively. However, similar levels of pathologic change in cervical alignment parameters were seen by two years, highlighting the progression of cervical compensation due to mild PJK over time. These findings provide greater evidence for the development of cervical deformity in individuals presenting with proximal junctional kyphosis.Item Open Access Contemporary utilization of three-column osteotomy techniques in a prospective complex spinal deformity multicenter database: implications on full-body alignment and perioperative course.(Spine deformity, 2024-06) Williamson, Tyler K; Mir, Jamshaid M; Smith, Justin S; Lafage, Virginie; Lafage, Renaud; Line, Breton; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey L; Hamilton, D Kojo; Scheer, Justin K; Eastlack, Robert; Demetriades, Andreas K; Kebaish, Khaled M; Lewis, Stephen; Lenke, Lawrence G; Hostin, Richard A; Gupta, Munish C; Kim, Han Jo; Ames, Christopher P; Burton, Douglas C; Shaffrey, Christopher I; Klineberg, Eric O; Bess, Shay; Passias, Peter G; International Spine Study GroupBackground
Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described.Study design/setting
This is a retrospective study on a prospectively enrolled, complex ASD database.Purpose
This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications.Methods
Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70 mm) or C7-PL > 70 mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO.Results
648 patients were included (Mean age 61 ± 14.6 years, BMI 27.55 ± 5.8 kg/m2, levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6-10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500 mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3-21; G4-24; G5-27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086).Conclusion
Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes.Item Open Access Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery.(Global Spine J, 2023-12-11) Passias, Peter G; Williamson, Tyler K; Kummer, Nicholas A; Pellisé, Ferran; Lafage, Virginie; Lafage, Renaud; Serra-Burriel, Miguel; Smith, Justin S; Line, Breton; Vira, Shaleen; Gum, Jeffrey L; Haddad, Sleiman; Sánchez Pérez-Grueso, Francisco Javier; Schoenfeld, Andrew J; Daniels, Alan H; Chou, Dean; Klineberg, Eric O; Gupta, Munish C; Kebaish, Khaled M; Kelly, Michael P; Hart, Robert A; Burton, Douglas C; Kleinstück, Frank; Obeid, Ibrahim; Shaffrey, Christopher I; Alanay, Ahmet; Ames, Christopher P; Schwab, Frank J; Hostin, Richard A; Bess, Shay; International Spine Study GroupSTUDY DESIGN/SETTING: Retrospective cohort study. OBJECTIVE: Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery. METHODS: ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility. RESULTS: By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001). CONCLUSIONS: The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions.Level of evidence: III.Item Open Access Costs of Surgery in Adult Spinal Deformity: Do Higher Cost Surgeries Lead to Better Outcomes?(Spine, 2024-02) Joujon-Roche, Rachel; Dave, Pooja; Tretiakov, Peter; Mcfarland, Kimberly; Mir, Jamshaid; Williamson, Tyler K; Imbo, Bailey; Krol, Oscar; Lebovic, Jordan; Schoenfeld, Andrew J; Vira, Shaleen; Lafage, Renaud; Lafage, Virginie; Passias, Peter GStudy design
This was a retrospective study.Objective
To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD).Summary of background data
With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny.Materials and methods
ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes.Results
Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m 2 ), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4°), and pelvic tilt (HC: 25.3 vs. LC: 22.4°). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P =0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P =0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P =0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria.Conclusions
Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity.Level of evidence
3.Item Open Access Efficacy of Varying Surgical Approaches on Achieving Optimal Alignment in Adult Spinal Deformity Surgery.(Spine, 2023-07) Passias, Peter G; Ahmad, Waleed; Williamson, Tyler K; Lebovic, Jordan; Kebaish, Khaled; Lafage, Renaud; Lafage, Virginie; Line, Breton; Schoenfeld, Andrew J; Diebo, Bassel G; Klineberg, Eric O; Kim, Han Jo; Ames, Christopher P; Daniels, Alan H; Smith, Justin S; Shaffrey, Christopher I; Burton, Douglas C; Hart, Robert A; Bess, Shay; Schwab, Frank J; Gupta, Munish C; International Spine Study GroupBackground
The Roussouly, SRS-Schwab, and GAP classifications define alignment by spinal shape and deformity severity. The efficacy of different surgical approaches and techniques to successfully achieve these goals is not well understood.Purpose
Identify the impact of surgical approach and/or technique on meeting complex realignment goals in adult spinal deformity(ASD) corrective-surgery.Study design/setting
Retrospective.Methods
Included: ASD patients fused to pelvis with two-year(2Y) data. Patients were categorized by: 1)Roussouly: matching current and theoretical spinal shapes; 2)improving in SRS-Schwab modifiers(0, +, ++); 3)improving GAP Proportionality by 2Y. ANCOVA and multivariable logistic regression analyses controlling for age, levels fused, baseline deformity, and three-column osteotomy usage compared the effect of different surgical approaches, interbody and osteotomy use on meeting realignment goals.Results
693 ASD patients were included. By surgical approach, 65.7% were posterior-only and 34.3% underwent anterior-posterior(AP) approach with 76% receiving an osteotomy(21.8% 3CO). By 2Y, 34% matched Roussouly, 58% improved in GAP, 45% in SRS-Schwab PT, 62% SVA, and 70% PI-LL. Combined approaches were most effective for improvement in PT(OR: 1.7,[1.1-2.5]) and GAP(OR: 2.2,[1.5-3.2]). Specifically, ALIFs below L3 demonstrated higher rates of improvement versus TLIFs in Roussouly(OR: 1.7, [1.1-2.5]) and GAP(OR: 1.9, [1.3-2.7]). Patients undergoing PSO at L3 or L4 were more likely to improve in PT(OR: 2.0,[1.0-5.2]) and PI-LL(OR: 3.8[1.4-9.8]). Clinically, patients undergoing combined approach demonstrated higher rates of meeting SCB in ODI by 2Y while minimizing rates of PJF, most often with an ALIF at L5-S1(ODI-SCB: OR: 1.4,[1.1-2.0];PJF: OR: 0.4,[0.2-0.8]).Conclusions
Among patients undergoing ASD realignment, optimal lumbar shape and proportion can be achieved more often with a combined approach. While TLIFs incorporating a three-column osteotomy at L3 and L4 can restore lordosis and normalize pelvic compensation, ALIFs at L5-S1 were most likely to achieve complex realignment goals with an added clinical benefit and mitigation of junctional failure.Item Unknown Evolution of Adult Cervical Deformity Surgery Clinical and Radiographic Outcomes Based on a Multicenter Prospective Study: Are Behaviors and Outcomes Changing With Experience?(Spine, 2022-11) Passias, Peter G; Krol, Oscar; Moattari, Kevin; Williamson, Tyler K; Lafage, Virginie; Lafage, Renaud; Kim, Han Jo; Daniels, Alan; Diebo, Bassel; Protopsaltis, Themistocles; Mundis, Gregory; Kebaish, Khaled; Soroceanu, Alexandra; Scheer, Justin; Hamilton, D Kojo; Klineberg, Eric; Schoenfeld, Andrew J; Vira, Shaleen; Line, Breton; Hart, Robert; Burton, Douglas C; Schwab, Frank A; Shaffrey, Christopher; Bess, Shay; Smith, Justin S; Ames, Christopher P; International Spine Study GroupStudy design
Retrospective cohort study.Objective
Assess changes in outcomes and surgical approaches for adult cervical deformity surgery over time.Summary of background data
As the population ages and the prevalence of cervical deformity increases, corrective surgery has been increasingly seen as a viable treatment. Dramatic surgical advancements and expansion of knowledge on this procedure have transpired over the years, but the impact on cervical deformity surgery is unknown.Materials and methods
Adult cervical deformity patients (18 yrs and above) with complete baseline and up to the two-year health-related quality of life and radiographic data were included. Descriptive analysis included demographics, radiographic, and surgical details. Patients were grouped into early (2013-2014) and late (2015-2017) by date of surgery. Univariate and multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical outcomes over time.Results
A total of 119 cervical deformity patients met the inclusion criteria. Early group consisted of 72 patients, and late group consisted of 47. The late group had a higher Charlson Comorbidity Index (1.3 vs. 0.72), more cerebrovascular disease (6% vs. 0%, both P <0.05), and no difference in age, frailty, deformity, or cervical rigidity. Controlling for baseline deformity and age, late group underwent fewer three-column osteotomies [odds ratio (OR)=0.18, 95% confidence interval (CI): 0.06-0.76, P =0.014]. At the last follow-up, late group had less patients with: a moderate/high Ames horizontal modifier (71.7% vs. 88.2%), and overcorrection in pelvic tilt (4.3% vs. 18.1%, both P <0.05). Controlling for baseline deformity, age, levels fused, and three-column osteotomies, late group experienced fewer adverse events (OR=0.15, 95% CI: 0.28-0.8, P =0.03), and neurological complications (OR=0.1, 95% CI: 0.012-0.87, P =0.03).Conclusion
Despite a population with greater comorbidity and associated risk, outcomes remained consistent between early and later time periods, indicating general improvements in care. The later cohort demonstrated fewer three-column osteotomies, less suboptimal realignments, and concomitant reductions in adverse events and neurological complications. This may suggest a greater facility with less invasive techniques.Item Unknown Highest Achievable Outcomes for Patients Undergoing Cervical Deformity Corrective Surgery by Frailty.(Neurosurgery, 2022-11) Passias, Peter G; Kummer, Nicholas; Williamson, Tyler K; Williamson, Tyler K; Moattari, Kevin; Lafage, Virginie; Lafage, Renaud; Kim, Han Jo; Daniels, Alan H; Gum, Jeffrey L; Diebo, Bassel G; Protopsaltis, Themistocles S; Mundis, Gregory M; Eastlack, Robert K; Soroceanu, Alexandra; Scheer, Justin K; Hamilton, D Kojo; Klineberg, Eric O; Line, Breton; Hart, Robert A; Burton, Douglas C; Mummaneni, Praveen; Chou, Dean; Park, Paul; Schwab, Frank J; Shaffrey, Christopher I; Bess, Shay; Ames, Christopher P; Smith, Justin S; International Spine Study GroupBackground
Frailty is influential in determining operative outcomes, including complications, in patients with cervical deformity (CD).Objective
To assess whether frailty status limits the highest achievable outcomes of patients with CD.Methods
Adult patients with CD with 2-year (2Y) data included. Frailty stratification: not frail (NF) <0.2, frail (F) 0.2 to 0.4, and severely frail (SF) >0.4. Analysis of covariance established estimated marginal means based on age, invasiveness, and baseline deformity, for improvement, deterioration, or maintenance in Neck Disability Index (NDI), Modified Japanese Orthopaedic Association (mJOA), and Numerical Rating Scale Neck Pain.Results
One hundred twenty-six patients with CD included 29 NF, 83 F, and 14 SF. The NF group had the highest rates of deterioration and lowest rates of improvement in cervical Sagittal Vertical Axis and horizontal gaze modifiers. Two-year improvements in NDI by frailty: NF: -11.2, F: -16.9, and SF: -14.6 ( P = .524). The top quartile of NF patients also had the lowest 1-year (1Y) NDI (7.0) compared with F (11.0) and SF (40.5). Between 1Y and 2Y, 7.9% of patients deteriorated in NDI, 71.1% maintained, and 21.1% improved. Between 1Y and 2Y, SF had the highest rate of improvement (42%), while NF had the highest rate of deterioration (18.5%).Conclusion
Although frail patients improved more often by 1Y, SF patients achieve most of their clinical improvement between 1 and 2Y. Frailty is associated with factors such as osteoporosis, poor alignment, neurological status, sarcopenia, and other medical comorbidities. Similarly, clinical outcomes can be affected by many factors (fusion status, number of pain generators within treated levels, integrity of soft tissues and bone, and deformity correction). Although accounting for such factors will ultimately determine whether frailty alone is an independent risk factor, these preliminary findings may suggest that frailty status affects the clinical outcomes and improvement after CD surgery.Item Unknown Impact of congestive heart failure on patients undergoing lumbar spine fusion for adult spine deformity.(Journal of craniovertebral junction & spine, 2024-01) Onafowokan, Oluwatobi O; Ahmad, Waleed; McFarland, Kimberly; Williamson, Tyler K; Tretiakov, Peter; Mir, Jamshaid M; Das, Ankita; Bell, Joshua; Naessig, Sara; Vira, Shaleen; Lafage, Virginie; Paulino, Carl; Diebo, Bassel; Schoenfeld, Andrew; Hassanzadeh, Hamid; Jankowski, Pawel P; Hockley, Aaron; Passias, Peter GustBackground
With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks.Purpose
The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients.Study design/setting
This was a retrospective cohort study of the PearlDiver database.Patient sample
We enrolled 670,526 patients undergoing spine fusion surgery.Outcome measures
Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs.Methods
Patients undergoing elective spine fusion surgery were isolated and stratified by preoperative HF with preserved ejection fraction (P-EF) or reduced ejection fraction (R-EF) (International Classification of Diseases-9: 428.32 [chronic diastolic HF] and 428.22 [chronic systolic HF]). Means comparison tests (Chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, comorbidities, procedural characteristics, LOS, 30-day and 90-day complication outcomes, and total hospital charges between those diagnosed with P-EF and those not R-EF. Binary logistic regression assessed the odds of complication associated with HF, controlling for levels fused (odds ratio [OR] [95% confidence interval]). Statistical significance was set at P < 0.05.Results
Totally 670,526 elective spine fusion patients were included. Four thousand and seventy-seven were diagnosed with P-EF and 2758 R-EF. Overall, P-EF patients presented with higher rates of morbid obesity, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension (all P < 0.001). In relation to No-HF, P-EF patients had higher rates of 30-day major complications including pulmonary embolism, pneumonia, cerebrovascular accident (CVA), myocardial infarctions (MI), sepsis, and death (all P < 0.001). Furthermore, P-EF was associated significantly with increased odds of pneumonia (OR: 2.07 [1.64-2.56], P < 0.001) and sepsis (OR: 2.09 [1.62-2.66], P < 0.001). Relative to No-HF, R-EF was associated with significantly higher odds of MI (OR: 3.66 [2.34-5.47]), CVA (OR: 2.70 [1.67-4.15]), and pneumonia (OR: 1.85 [1.40-2.40]) (all P < 0.001) postoperative within 30 days. Adjusting for prior history of MI, CAD, and the presence of a pacemaker R-EF was a significant predictor of an MI 30 days postoperatively (OR: 2.2 [1.14-4.32], P = 0.021). Further adjusting for history of CABG or stent placement, R-EF was associated with higher odds of CVA (OR: 2.11 [1.09-4.19], P = 0.028) and MI (OR: 2.27 [1.20-4.43], P = 0.013).Conclusions
When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF.Item Unknown Natural history of adult spinal deformity: how do patients with suboptimal surgical outcomes fare relative to nonoperative counterparts?(Journal of neurosurgery. Spine, 2023-07) Passias, Peter G; Joujon-Roche, Rachel; Mir, Jamshaid M; Williamson, Tyler K; Tretiakov, Peter S; Imbo, Bailey; Krol, Oscar; Passfall, Lara; Ahmad, Salman; Lebovic, Jordan; Owusu-Sarpong, Stephane; Lanre-Amos, Tomi; Protopsaltis, Themistocles; Lafage, Renaud; Lafage, Virginie; Park, Paul; Chou, Dean; Mummaneni, Praveen V; Fu, Kai-Ming G; Than, Khoi D; Smith, Justin S; Janjua, M Burhan; Schoenfeld, Andrew J; Diebo, Bassel G; Vira, ShaleenObjective
Management of adult spinal deformity (ASD) has increasingly favored operative intervention; however, the incidence of complications and reoperations is high, and patients may fail to achieve idealized postsurgical results. This study compared health-related quality of life (HRQOL) metrics between patients with suboptimal surgical outcomes and those who underwent nonoperative management as a proxy for the natural history (NH) of ASD.Methods
ASD patients with 2-year data were included. Patients who were offered surgery but declined were considered nonoperative (i.e., NH) patients. Operative patients with suboptimal outcome (SOp)-defined as any reoperation, major complication, or ≥ 2 severe Scoliosis Research Society (SRS)-Schwab modifiers at follow-up-were selected for comparison. Propensity score matching (PSM) on the basis of baseline age, deformity, SRS-22 Total, and Charlson Comorbidity Index score was used to match the groups. ANCOVA and stepwise logistic regression analysis were used to assess outcomes between groups at 2 years.Results
In total, 441 patients were included (267 SOp and 174 NH patients). After PSM, 142 patients remained (71 SOp 71 and 71 NH patients). At baseline, the SOp and NH groups had similar demographic characteristics, HRQOL, and deformity (all p > 0.05). At 2 years, ANCOVA determined that NH patients had worse deformity as measured with sagittal vertical axis (36.7 mm vs 21.3 mm, p = 0.025), mismatch between pelvic incidence and lumbar lordosis (11.9° vs 2.9°, p < 0.001), and pelvic tilt (PT) (23.1° vs 20.7°, p = 0.019). The adjusted regression analysis found that SOp patients had higher odds of reaching the minimal clinically important differences in Oswestry Disability Index score (OR [95% CI] 4.5 [1.7-11.5], p = 0.002), SRS-22 Activity (OR [95% CI] 3.2 [1.5-6.8], p = 0.002), SRS-22 Pain (OR [95% CI] 2.8 [1.4-5.9], p = 0.005), and SRS-22 Total (OR [95% CI] 11.0 [3.5-34.4], p < 0.001).Conclusions
Operative patients with SOp still experience greater improvements in deformity and HRQOL relative to the progressive radiographic and functional deterioration associated with the NH of ASD. The NH of nonoperative management should be accounted for when weighing the risks and benefits of operative intervention for ASD.Item Unknown Patient-specific Cervical Deformity Corrections With Consideration of Associated Risk: Establishment of Risk Benefit Thresholds for Invasiveness Based on Deformity and Frailty Severity.(Clinical spine surgery, 2023-10) Passias, Peter G; Pierce, Katherine E; Williamson, Tyler K; Lebovic, Jordan; Schoenfeld, Andrew J; Lafage, Renaud; Lafage, Virginie; Gum, Jeffrey L; Eastlack, Robert; Kim, Han Jo; Klineberg, Eric O; Daniels, Alan H; Protopsaltis, Themistocles S; Mundis, Gregory M; Scheer, Justin K; Park, Paul; Chou, Dean; Line, Breton; Hart, Robert A; Burton, Douglas C; Bess, Shay; Schwab, Frank J; Shaffrey, Christopher I; Smith, Justin S; Ames, Christopher P; International Spine Study GroupStudy design/setting
This was a retrospective cohort study.Background
Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty.Objective
The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity.Methods
This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely.Results
A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P=0.002], and invasiveness increased with deformity severity (P<0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P=0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P=0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P=0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group.Conclusions
Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes.Item Unknown Pelvic Nonresponse Following Treatment of Adult Spinal Deformity: Influence of Realignment Strategies on Occurrence.(Spine, 2023-05) Passias, Peter G; Pierce, Katherine E; Williamson, Tyler K; Krol, Oscar; Lafage, Renaud; Lafage, Virginie; Schoenfeld, Andrew J; Protopsaltis, Themistocles S; Vira, Shaleen; Line, Breton; Diebo, Bassel G; Ames, Christopher P; Kim, Han Jo; Smith, Justin S; Chou, Dean; Daniels, Alan H; Gum, Jeffrey L; Shaffrey, Christopher I; Burton, Douglas C; Kelly, Michael P; Klineberg, Eric O; Hart, Robert A; Bess, Shay; Schwab, Frank J; Gupta, Munish C; International Spine Study GroupPurpose
Despite adequate correction, the pelvis may fail to readjust, deemed pelvic nonresponse (PNR). To assess alignment outcomes [PNR, proximal junctional kyphosis (PJK), postoperative cervical deformity (CD)] following adult spinal deformity (ASD) surgery utilizing different realignment strategies.Materials and methods
ASD patients with two-year data were included. PNR defined as undercorrected in age-adjusted pelvic tilt (PT) at six weeks and maintained at two years. Patients classified by alignment utilities: (a) improvement in Scoliosis Research Society-Schwab sagittal vertical axis, (b) matching in age-adjusted pelvic incidence-lumbar lordosis, (c) matching in Roussouly, (d) aligning Global Alignment and Proportionality (GAP) score. Multivariable regression analyses, controlling for age, baseline deformity, and surgical factors, assessed rates of PNR, PJK, and CD development following realignment.Results
A total of 686 patients met the inclusion criteria. Rates of postoperative PJK and CD were not significant in the PNR group (both P >0.15). PNR patients less often met substantial clinical benefit in Oswestry Disability Index by two years [odds ratio: 0.6 (0.4-0.98)]. Patients overcorrected in age-adjusted pelvic incidence-lumbar lordosis, matching Roussouly, or proportioned in GAP at six weeks had lower rates of PNR (all P <0.001). Incremental addition of classifications led to 0% occurrence of PNR, PJK, and CD. Stratifying by baseline PT severity, Low and moderate deformity demonstrated the least incidence of PNR (7.7%) when proportioning in GAP at six weeks, while severe PT benefited most from matching in Roussouly (all P <0.05).Conclusions
Following ASD corrective surgery, 24.9% of patients showed residual pelvic malalignment. This occurrence was often accompanied by undercorrection of lumbopelvic mismatch and less improvement of pain. However, overcorrection in any strategy incurred higher rates of PJK. We recommend surgeons identify a middle ground using one, or more, of the available classifications to inform correction goals in this regard.Level of evidence
III.Item Unknown Persistent Lower Extremity Compensation for Sagittal Imbalance After Surgical Correction of Complex Adult Spinal Deformity: A Radiographic Analysis of Early Impact.(Operative neurosurgery (Hagerstown, Md.), 2024-02) Williamson, Tyler K; Williamson, Tyler K; Dave, Pooja; Mir, Jamshaid M; Smith, Justin S; Lafage, Renaud; Line, Breton; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey L; Protopsaltis, Themistocles S; Hamilton, D Kojo; Soroceanu, Alex; Scheer, Justin K; Eastlack, Robert; Kelly, Michael P; Nunley, Pierce; Kebaish, Khaled M; Lewis, Stephen; Lenke, Lawrence G; Hostin, Richard A; Gupta, Munish C; Kim, Han Jo; Ames, Christopher P; Hart, Robert A; Burton, Douglas C; Shaffrey, Christopher I; Klineberg, Eric O; Schwab, Frank J; Lafage, Virginie; Chou, Dean; Fu, Kai-Ming; Bess, Shay; Passias, Peter G; International Spine Study GroupAchieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The objective is to analyze lower extremity compensation after complex ASD surgery, its effect on outcomes, and whether correction can alleviate these mechanisms. We included patients with complex ASD with 6-week data. LE parameters were as follows: sacrofemoral angle, knee flexion angle, and ankle flexion angle. Each parameter was ranked, and upper tertile was deemed compensation. Patients compensating and not compensating postoperatively were propensity score matched for body mass index, frailty, and T1 pelvic angle. Linear regression assessed correlation between LE parameters and baseline deformity, demographics, and surgical details. Multivariate analysis controlling for baseline deformity and history of total knee/hip arthroplasty evaluated outcomes. Two hundred and ten patients (age: 61.3 ± 14.1 years, body mass index: 27.4 ± 5.8 kg/m2, Charlson Comorbidity Index: 1.1 ± 1.6, 72% female, 22% previous total joint arthroplasty, 24% osteoporosis, levels fused: 13.1 ± 3.8) were included. At baseline, 59% were compensating in LE: 32% at hips, 39% knees, and 36% ankles. After correction, 61% were compensating at least one joint. Patients undercorrected postoperatively were less likely to relieve LE compensation (odds ratio: 0.2, P = .037). Patients compensating in LE were more often undercorrected in age-adjusted pelvic tilt, pelvic incidence, lumbar lordosis, and T1 pelvic angle and disproportioned in Global Alignment and Proportion (P < .05). Patients matched in sagittal age-adjusted score at 6 weeks but compensating in LE were more likely to develop proximal junctional kyphosis (odds ratio: 4.1, P = .009) and proximal junctional failure (8% vs 0%, P = .035) than those sagittal age-adjusted score-matched and not compensating in LE. Perioperative lower extremity compensation was a product of undercorrecting complex ASD. Even in age-adjusted realignment, compensation was associated with global undercorrection and junctional failure. Consideration of lower extremities during planning is vital to avoid adverse outcomes in perioperative course after complex ASD surgery.Item Unknown Predictors of reoperation for spinal disorders in Chiari malformation patients with prior surgical decompression.(Journal of craniovertebral junction & spine, 2023-10) Onafowokan, Oluwatobi O; Das, Ankita; Mir, Jamshaid M; Alas, Haddy; Williamson, Tyler K; Mcfarland, Kimberly; Varghese, Jeffrey; Naessig, Sara; Imbo, Bailey; Passfall, Lara; Krol, Oscar; Tretiakov, Peter; Joujon-Roche, Rachel; Dave, Pooja; Moattari, Kevin; Owusu-Sarpong, Stephane; Lebovic, Jordan; Vira, Shaleen; Diebo, Bassel; Lafage, Virginie; Passias, Peter GustBackground
Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning.Materials and methods
This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004-2011. Chiari malformation Types 1-4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded.Results
One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40-50 years had the most reoperations (11); however, patients aged 15-20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026).Conclusions
Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes.Item Unknown Proximal Junctional Kyphosis and Failure Prophylaxis Improves Cost Efficacy, While Maintaining Optimal Alignment, in Adult Spinal Deformity Surgery.(Neurosurgery, 2025-04) Passias, Peter G; Krol, Oscar; Williamson, Tyler K; Bennett-Caso, Claudia; Smith, Justin S; Diebo, Bassel; Lafage, Virginie; Lafage, Renaud; Line, Breton; Daniels, Alan H; Gum, Jeffrey L; Protopsaltis, Themistocles S; Hamilton, D Kojo; Soroceanu, Alex; Scheer, Justin K; Eastlack, Robert; Mundis, Gregory M; Kebaish, Khaled M; Hostin, Richard A; Gupta, Munish C; Kim, Han Jo; Klineberg, Eric O; Ames, Christopher P; Hart, Robert A; Burton, Douglas C; Schwab, Frank J; Shaffrey, Christopher I; Bess, Shay; International Spine Study GroupBackground and objectives
To investigate the cost-effectiveness and impact of prophylactic techniques on the development of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in the context of postoperative alignment.Methods
Adult spinal deformity patients with fusion to pelvis and 2-year data were included. Patients receiving PJK prophylaxis (hook, tether, cement, minimally-invasive surgery approach) were compared to those who did not. These cohorts were further stratified into "Matched" and "Unmatched" groups based on achievement of age-adjusted alignment criteria. Costs were calculated using the Diagnosis-Related Group costs accounting for PJK prophylaxis, postoperative complications, outpatient health care encounters, revisions, and medical-related readmissions. Quality-adjusted life years were calculated using Short Form-36 converted to Short-Form Six-Dimension (SF-6D) and used an annual 3% discount rate. Multivariate analysis controlling for age, sex, levels fused, and baseline deformity severity assessed outcomes of developing PJK/PJF if matched and/or with use of PJK prophylaxis.Results
A total of 738 adult spinal deformity patients met inclusion criteria (age: 63.9 ± 9.9, body mass index: 28.5 ± 5.7, Charlson comorbidity index: 2.0 ± 1.7). Multivariate analysis revealed patients corrected to age-adjusted criteria postoperatively had lower rates of developing PJK or PJF (odds ratio [OR]: 0.4, [0.2-0.8]; P = .011) with the use of prophylaxis. Among those unmatched in T1 pelvic angle, pelvic incidence lumbar lordosis mismatch, and pelvic tilt, prophylaxis reduced the likelihood of developing PJK (OR: 0.5, [0.3-0.9]; P = .023) and PJF (OR: 0.1, [0.03-0.5]; P = .004). Analysis of covariance analysis revealed patients matched in age-adjusted alignment had better cost-utility at 2 years compared with those without prophylaxis ($361 539.25 vs $419 919.43; P < .001). Patients unmatched in age-adjusted criteria also generated better cost ($88 348.61 vs $101 318.07; P = .005) and cost-utility ($450 190.80 vs $564 108.86; P < .001) with use of prophylaxis.Conclusion
Despite additional surgical cost, the optimization of radiographic realignment in conjunction with prophylaxis of the proximal junction appeared to be a more cost-effective strategy, primarily because of the minimization of reoperations secondary to mechanical failure. Even among those not achieving optimal alignment, junctional prophylactic measures were shown to improve cost efficiency.Item Unknown Should Global Realignment Be Tailored to Frailty Status for Patients Undergoing Surgical Intervention for Adult Spinal Deformity?(Spine, 2023-07) Passias, Peter G; Williamson, Tyler K; Krol, Oscar; Tretiakov, Peter S; Joujon-Roche, Rachel; Imbo, Bailey; Ahmad, Salman; Bennett-Caso, Claudia; Owusu-Sarpong, Stephane; Lebovic, Jordan B; Robertson, Djani; Vira, Shaleen; Dhillon, Ekamjeet; Schoenfeld, Andrew J; Janjua, Muhammad B; Raman, Tina; Protopsaltis, Themistocles S; Maglaras, Constance; O'Connell, Brooke; Daniels, Alan H; Paulino, Carl; Diebo, Bassel G; Smith, Justin S; Schwab, Frank J; Lafage, Renaud; Lafage, VirginieStudy design
Retrospective cohort study.Objective
Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes.Summary of background data
The Global Alignment and Proportion (GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to the development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications.Materials and methods
We included 412 surgical ASD patients with two-year follow-up. Frailty was quantified using the modified Adult Spinal Deformity Frailty Index (mASD-FI). Outcomes: proximal junctional kyphosis and proximal junctional failure (PJF), major mechanical complications, and "Best Clinical Outcome" (BCO), defined as Oswestry Disability Index<15 and Scoliosis Research Society 22-item Questionnaire Total>4.5. Logistic regression analysis established a six-week score based on GAP score, frailty, and Oswestry Disability Index US Norms. Logistic regression followed by conditional inference tree analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty-modified GAP score.Results
Baseline frailty categories: 57% not frail, 30% frail, 14% severely frail. Overall, 39 of patients developed proximal junctional kyphosis, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The mASD-FI demonstrated a correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at two years (all P <0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score (FAR Score)=0.49×mASD-FI+0.38×GAP Score. Thresholds for the FAR score (0-13): proportioned: <3.5, moderately disproportioned: 3.5-7.5, severely disproportioned: >7.5. Multivariable logistic regression assessing FAR score demonstrated associations with mechanical complications, reoperation, and meeting BCO by two years (all P <0.05), whereas the original GAP score was only significant for reoperation.Conclusion
This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity.Level of evidence
III.Item Unknown Should pelvic incidence influence realignment strategy? A detailed analysis in adult spinal deformity.(Journal of neurosurgery. Spine, 2024-11) Williamson, Tyler K; Onafowokan, Oluwatobi O; Schoenfeld, Andrew J; Owusu-Sarpong, Stephane; Lebovic, Jordan; Mir, Jamshaid; Das, Ankita; Lorentz, Nathan; Galetta, Matthew; Jankowski, Pawel P; Lafage, Renaud; Lafage, Virginie; Passias, Peter GObjective
The purpose of this study was to assess how various realignment strategies affect mechanical failure and clinical outcomes in pelvic incidence (PI)-stratified cohorts following adult spinal deformity (ASD) surgery.Methods
Median and interquartile range statistics were calculated for demographics and surgical details. Further statistical analysis was used to define subsets within PI generating significantly different rates of mechanical failure. These subsets of PI were further analyzed as subcohorts for the outcomes and effects of realignment within each subcohort. Multivariate logistic regression analysis controlling for baseline frailty and lumbar lordosis (LL; L1-S1) analyzed the association of age-adjusted realignment and Global Alignment and Proportion (GAP) strategies with the incidence of mechanical failure and clinical improvement within PI-stratified groups.Results
A parabolic relationship between PI and mechanical failure was noted, whereas patients with either < 51° (n = 174, 39.1% of cohort) or > 63° (n = 114, 25.6% of cohort) of PI generated higher rates of mechanical failure (18.0% and 20.0%, respectively) and lower rates of good outcome (80.3% and 77.6%, respectively) than those with moderate PI (51°-63°). Patients with lower PI more often met good outcome criteria when undercorrected in age-adjusted PI-LL mismatch and sagittal age-adjusted score, and those not meeting good outcome criteria were more likely to deteriorate in GAP relative LL from first to final follow-up (OR 13.4, 95% CI 1.3-139.2). In those with moderate PI, patients were more likely to meet good outcome when aligned on the GAP lordosis distribution index (LDI; OR 1.7, 95% CI 0.9-3.3). Patients with higher PI meeting good outcome were more likely to be overcorrected in sagittal vertical axis (OR 2.4, 95% CI 1.1-5.2) at first follow-up and less likely to be undercorrected in T1 pelvic angle (OR 0.4, 95% CI 0.2-0.9) by final follow-up. When assessing GAP alignment, patients were more likely to meet good outcome when aligned on GAP LDI (OR 3.5, 95% CI 1.4-8.9).Conclusions
There was a parabolic relationship between PI and both mechanical failure and clinical improvement following deformity correction in this study. Understanding the associations between this fixed parameter and poor outcomes can aid the surgeon in strategical planning when seeking to realign ASD.