Browsing by Subject "Adult spinal deformity"
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Item Open Access Defining modern iatrogenic flatback syndrome: examination of segmental lordosis in short lumbar fusion patients undergoing thoracolumbar deformity correction(European Spine Journal, 2024-01-01) Diebo, Bassel G; Singh, Manjot; Balmaceno-Criss, Mariah; Daher, Mohammad; Lenke, Lawrence G; Ames, Christopher P; Burton, Douglas C; Lewis, Stephen M; Klineberg, Eric O; Lafage, Renaud; Eastlack, Robert K; Gupta, Munish C; Mundis, Gregory M; Gum, Jeffrey L; Hamilton, Kojo D; Hostin, Richard; Passias, Peter G; Protopsaltis, Themistocles S; Kebaish, Khaled M; Kim, Han Jo; Shaffrey, Christopher I; Line, Breton G; Mummaneni, Praveen V; Nunley, Pierce D; Smith, Justin S; Turner, Jay; Schwab, Frank J; Uribe, Juan S; Bess, Shay; Lafage, Virginie; Daniels, Alan H; International Spine Study Group (ISSG)Purpose: Understanding the mechanism and extent of preoperative deformity in revision procedures may provide data to prevent future failures in lumbar spinal fusion patients. Methods: ASD patients without prior spine surgery (PRIMARY) and with prior short (SHORT) and long (LONG) fusions were included. SHORT patients were stratified into modes of failure: implant, junctional, malalignment, and neurologic. Baseline demographics, spinopelvic alignment, offset from alignment targets, and patient-reported outcome measures (PROMs) were compared across PRIMARY and SHORT cohorts. Segmental lordosis analyses, assessing under-, match, or over-correction to segmental and global lordosis targets, were performed by SRS-Schwab coronal curve type and construct length. Results: Among 785 patients, 430 (55%) were PRIMARY and 355 (45%) were revisions. Revision procedures included 181 (23%) LONG and 174 (22%) SHORT corrections. SHORT modes of failure included 27% implant, 40% junctional, 73% malalignment, and/or 28% neurologic. SHORT patients were older, frailer, and had worse baseline deformity (PT, PI-LL, SVA) and PROMs (NRS, ODI, VR-12, SRS-22) compared to primary patients (p < 0.001). Segmental lordosis analysis identified 93%, 88%, and 62% undercorrected patients at LL, L1-L4, and L4-S1, respectively. SHORT patients more often underwent 3-column osteotomies (30% vs. 12%, p < 0.001) and had higher ISSG Surgical Invasiveness Score (87.8 vs. 78.3, p = 0.006). Conclusions: Nearly half of adult spinal deformity surgeries were revision fusions. Revision short fusions were associated with sagittal malalignment, often due to undercorrection of segmental lordosis goals, and frequently required more invasive procedures. Further initiatives to optimize alignment in lumbar fusions are needed to avoid costly and invasive deformity corrections. Level of evidence: IV: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.Item Open Access Evaluating the impact of multiple sclerosis on 2 year postoperative outcomes following long fusion for adult spinal deformity: a propensity score-matched analysis.(Spine deformity, 2024-09) Shah, Neil V; Kong, Ryan; Ikwuazom, Chibuokem P; Beyer, George A; Tiburzi, Hallie A; Segreto, Frank A; Alam, Juhayer S; Wolfert, Adam J; Alsoof, Daniel; Lafage, Renaud; Passias, Peter G; Schwab, Frank J; Daniels, Alan H; Lafage, Virginie; Paulino, Carl B; Diebo, Bassel GStudy design
Retrospective cohort study.Purpose
The impact of neuromuscular disorders such as multiple sclerosis (MS) on outcomes following long segment fusion is underreported. This study evaluates the impact of MS on two-year (2Y) postoperative complications and revisions following ≥ 4-level fusion for adult spinal deformity (ASD).Methods
Patients undergoing ≥ 4-level fusion for ASD were identified from a statewide database. Patients with a baseline diagnosis of MS were also identified. Patients with infectious/traumatic/neoplastic indications were excluded. Subjects were 1:1 propensity score-matched (MS to no-MS) based on age, sex and race and compared for rates of 2Y postoperative complications and reoperations. Logistic regression models were utilized to determine risk factors for adverse outcomes at 2Y.Results
86 patients were included overall (n = 43 per group). Age, sex, and race were comparable between groups (p > 0.05). MS patients incurred higher charges for their surgical visit ($125,906 vs. $84,006, p = 0.007) with similar LOS (8.1 vs. 5.3 days, p > 0.05). MS patients experienced comparable rates of overall medical complications (30.1% vs. 25.6%) and surgical complications (34.9% vs. 30.2%); p > 0.05. MS patients had similar rates of 2Y revisions (16.3% vs. 9.3%, p = 0.333). MS was not associated with medical, surgical, or overall complications or revisions at minimum 2Y follow-up.Conclusion
Patients with MS experienced similar postoperative course compared to those without MS following ≥ 4-level fusion for ASD. This data supports the findings of multiple previously published case series' that long segment fusions for ASD can be performed relatively safely in patients with MS.Item Open Access Intraoperative fluid management in adult spinal deformity surgery: variation analysis and association with outcomes(Spine Deformity, 2024-01-01) Cetik, Riza M; Gum, Jeffrey L; Lafage, Renaud; Smith, Justin S; Bess, Shay; Mullin, Jeffrey P; Kelly, Michael P; Diebo, Bassel G; Buell, Thomas J; Scheer, Justin K; Line, Breton G; Lafage, Virginie; Klineberg, Eric O; Kim, Han Jo; Passias, Peter G; Kebaish, Khaled M; Eastlack, Robert K; Daniels, Alan H; Soroceanu, Alex; Mundis, Gregory M; Hostin, Richard A; Protopsaltis, Themistocles S; Hamilton, D Kojo; Hart, Robert A; Gupta, Munish C; Lewis, Stephen J; Schwab, Frank J; Lenke, Lawrence G; Shaffrey, Christopher I; Ames, Christopher P; Burton, Douglas C; International Spine Study GroupPurpose: To evaluate the variability in intraoperative fluid management during adult spinal deformity (ASD) surgery, and analyze the association with complications, intensive care unit (ICU) requirement, and length of hospital stay (LOS). Methods: Multicenter comparative cohort study. Patients ≥ 18 years old and with ASD were included. Intraoperative intravenous (IV) fluid data were collected including: crystalloids, colloids, crystalloid/colloid ratio (C/C), total IV fluid (tIVF, ml), normalized total IV fluid (nIVF, ml/kg/h), input/output ratio (IOR), input–output difference (IOD), and normalized input–output difference (nIOD, ml/kg/h). Data from different centers were compared for variability analysis, and fluid parameters were analyzed for possible associations with the outcomes. Results: Seven hundred ninety-eight patients with a median age of 65.2 were included. Among different surgical centers, tIVF, nIVF, and C/C showed significant variation (p < 0.001 for each) with differences of 4.8-fold, 3.7-fold, and 4.9-fold, respectively. Two hundred ninety-two (36.6%) patients experienced at least one in-hospital complication, and ninety-two (11.5%) were IV fluid related. Univariate analysis showed significant relations for: LOS and tIVF (ρ = 0.221, p < 0.001), IOD (ρ = 0.115, p = 0.001) and IOR (ρ = −0.138, p < 0.001); IV fluid-related complications and tIVF (p = 0.049); ICU stay and tIVF, nIVF, IOD and nIOD (p < 0.001 each); extended ICU stay and tIVF (p < 0.001), nIVF (p = 0.010) and IOD (p < 0.001). Multivariate analysis controlling for confounders showed significant relations for: LOS and tIVF (p < 0.001) and nIVF (p = 0.003); ICU stay and IOR (p = 0.002), extended ICU stay and tIVF (p = 0.004). Conclusion: Significant variability and lack of standardization in intraoperative IV fluid management exists between different surgical centers. Excessive fluid administration was found to be correlated with negative outcomes. Level of evidence: III.Item Open Access Mechanisms of lumbar spine “flattening” in adult spinal deformity: defining changes in shape that occur relative to a normative population(European Spine Journal, 2024-01-01) Lafage, Renaud; Mota, Frank; Khalifé, Marc; Protopsaltis, Themistocles; Passias, Peter G; Kim, Han-Jo; Line, Breton; Elysée, Jonathan; Mundis, Gregory; Shaffrey, Christopher I; Ames, Christopher P; Klineberg, Eric O; Gupta, Munish C; Burton, Douglas C; Lenke, Lawrence G; Bess, Shay; Smith, Justin S; Schwab, Frank J; Lafage, Virginie; ISSGPurpose: Previous work comparing ASD to a normative population demonstrated that a large proportion of lumbar lordosis is lost proximally (L1-L4). The current study expands on these findings by collectively investigating regional angles and spinal contours. Methods: 119 asymptomatic volunteers with full-body free-standing radiographs were used to identify age-and-PI models of each Vertebra Pelvic Angle (VPA) from L5 to T10. These formulas were then applied to a cohort of primary surgical ASD patients without coronal malalignment. Loss of lumbar lordosis (LL) was defined as the offset between age-and-PI normative value and pre-operative alignment. Spine shapes defined by VPAs were compared and analyzed using paired t-tests. Results: 362 ASD patients were identified (age = 64.4 ± 13, 57.1% females). Compared to their age-and-PI normative values, patients demonstrated a significant loss in LL of 17 ± 19° in the following distribution: 14.1% had “No loss” (mean = 0.1 ± 2.3), 22.9% with 10°-loss (mean = 9.9 ± 2.9), 22.1% with 20°-loss (mean = 20.0 ± 2.8), and 29.3% with 30°-loss (mean = 33.8 ± 6.0). “No loss” patients’ spine was slightly posterior to the normative shape from L4 to T10 (VPA difference of 2°), while superimposed on the normative one from S1 to L2 and became anterior at L1 in the “10°-loss” group. As LL loss increased, ASD and normative shapes offset extended caudally to L3 for the “20°-loss” group and L4 for the “30°-loss” group. Conclusion: As LL loss increases, the difference between ASD and normative shapes first occurs proximally and then progresses incrementally caudally. Understanding spinal contour and LL loss location may be key to achieving sustainable correction by identifying optimal and personalized postoperative shapes.Item Open Access Proximal Lumbar Anterior Column Realignment for Iatrogenic Sagittal Plane Adult Spinal Deformity Correction: A Retrospective Case Series.(World neurosurgery, 2024-11) Frerich, Jason M; Dibble, Christopher F; Park, Christine; Bergin, Stephen M; Goodwin, C Rory; Abd-El-Barr, Muhammad M; Shaffrey, Christopher I; Than, Khoi DBackground
Anterior column realignment (ACR) is a powerful minimally invasive surgery technique to restore sagittal alignment in adult spinal deformity (ASD). This can accomplish similar segmental lordosis restoration as 3-column osteotomy with less blood loss and comparable complication rates. ACR can be performed at adjacent disease segments in the proximal lumbar spine in revision cases. However, two thirds of physiologic lordosis occurs between L4-S1, and concerns remain about altered lumbar morphology. We evaluated patients who underwent proximal lumbar ACR for iatrogenic flatback deformity.Methods
A total of 19 consecutive patients who underwent L1-2 or L2-3 ACR were retrospectively analyzed. All patients were treated with lateral minimally invasive surgery interbody technique, followed by posterior reconstruction with Smith-Peterson osteotomy. Preoperative and postoperative radiographic and clinical outcomes were obtained.Results
Mean follow-up was 19 months. All but 1 patient had a history of prior lumbar or lumbo-sacral fusion. Sagittal vertical axis and pelvic incidence-lumbar lordosis decreased from 11.9 cm to 6.1 cm (P < 0.0001) and 34.2° to 12.8° (P < 0.0001). Segmental lordosis increased from -2.7° to 21.9° (P < 0.0001). Proximal lumbar lordosis increased from -0.4° to 22.6° (P < 0.0001), and lordosis distribution index decreased from 79.5% to 48.9% (P < 0.0001). Mean Oswestry Disability Index and numeric pain rating scale back pain scores decreased from 58.0 to 36.2 (P = 0.0041) and 7.9 to 3.4 (P < 0.0001), respectively. Patient-Reported Outcomes Measurement Information System Physical and Mental Health T-scores increased from 34.1 to 43.3 (P = 0.0049) and 40.4 to 45.0 (P = 0.0993), respectively. Major complication rate was 15.8%. One patient required revision for mechanical failure. There were no permanent neurological or vascular injuries.Conclusions
Proximal lumbar ACR plus Smith-Peterson osteotomy can achieve sagittal correction with low major complication rates in patients with ASD and prior distal fusion. Differentially increasing proximal lumbar lordosis and lowering lumbar distribution index did not have deleterious effects on radiographic or clinical outcomes. Further work is needed to understand the effect of proximal ACR in the surgical management of ASD.Item Open Access Thoracolumbar fusions for adult lumbar deformity show superior QALY gain and lower costs compared with upper thoracic fusions(Spine Deformity, 2024-01-01) Kim, Andrew H; Hostin, Richard A; Yeramaneni, Samrat; Gum, Jeffrey L; Nayak, Pratibha; Line, Breton G; Bess, Shay; Passias, Peter G; Hamilton, D Kojo; Gupta, Munish C; Smith, Justin S; Lafage, Renaud; Diebo, Bassel G; Lafage, Virginie; Klineberg, Eric O; Daniels, Alan H; Protopsaltis, Themistocles S; Schwab, Frank J; Shaffrey, Christopher I; Ames, Christopher P; Burton, Douglas C; Kebaish, Khaled M; International Spine Study GroupPurpose: Adult spinal deformity (ASD) patients with sagittal plane deformity (N) or structural lumbar/thoraco-lumbar (TL) curves can be treated with fusions stopping at the TL junction or extending to the upper thoracic (UT) spine. This study evaluates the impact on cost/cumulative quality-adjusted life year (QALY) in patients treated with TL vs UT fusion. Methods: ASD patients with > 4-level fusion and 2-year follow-up were included. Index and total episode-of-care costs were estimated using average itemized direct costs obtained from hospital records. Cumulative QALY gained were calculated from preoperative to 2-year postoperative change in Short Form Six-Dimension (SF-6D) scores. The TL and UT groups comprised patients with upper instrumented vertebrae (UIV) at T9-T12 and T2-T5, respectively. Results: Of 566 patients with type N or L curves, mean age was 63.2 ± 12.1 years, 72% were female and 93% Caucasians. Patients in the TL group had better sagittal vertical axis (7.3 ± 6.9 vs. 9.2 ± 8.1 cm, p = 0.01), lower surgical invasiveness (− 30; p < 0.001), and shorter OR time (− 35 min; p = 0.01). Index and total costs were 20% lower in the TL than in the UT group (p < 0.001). Cost/QALY was 65% lower (492,174.6 vs. 963,391.4), and 2-year QALY gain was 40% higher, in the TL than UT group (0.15 vs. 0.10; p = 0.02). Multivariate model showed TL fusions had lower total cost (p = 0.001) and higher QALY gain (p = 0.03) than UT fusions. Conclusion: In Schwab type N or L curves, TL fusions showed lower 2-year cost and improved QALY gain without increased reoperation rates or length of stay than UT fusions. Level of evidence: III.Item Open Access Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty.(The spine journal : official journal of the North American Spine Society, 2023-05) McDonald, Christopher L; Berreta, Rodrigo A Saad; Alsoof, Daniel; Homer, Alex; Molino, Janine; Ames, Christopher P; Shaffrey, Christopher I; Hamilton, D Kojo; Diebo, Bassel G; Kuris, Eren O; Hart, Robert A; Daniels, Alan HBackground context
Surgery to correct adult spinal deformity (ASD) is performed by both neurological surgeons and orthopedic surgeons. Despite well-documented high costs and complication rates following ASD surgery, there is a dearth of research investigating trends in treatment according to surgeon subspeciality.Purpose
The purpose of this investigation was to perform an analysis of surgical trends, costs and complications of ASD operations by physician specialty using a large, nationwide sample.Study design/setting
Retrospective cohort study using an administrative claims database.Patient sample
A total of 12,929 patients were identified with ASD that underwent deformity surgery performed by neurological or orthopedic surgeons.Outcome measures
The primary outcome was surgical case volume by surgeon specialty. Secondary outcomes included costs, medical complications, surgical complications, and reoperation rates (30-day, 1-year, 5-year, and total).Methods
The PearlDiver Mariner database was queried to identify patients who underwent ASD correction from 2010 to 2019. The cohort was stratified to identify patients who were treated by either orthopedic or neurological surgeons. Surgical volume, baseline characteristics, and surgical techniques were examined between cohorts. Multivariable logistic regression was employed to assess the cost, rate of reoperation and complication according to each subspecialty while controlling for number of levels fused, rate of pelvic fixation, age, gender, region and Charlson Comorbidity Index (CCI). Alpha was set to 0.05 and a Bonferroni correction for multiple comparisons was utilized to set the significance threshold at p ≤.000521.Results
A total of 12,929 ASD patients underwent deformity surgery performed by neurological or orthopedic surgeons. Orthopedic surgeons performed most deformity procedures accounting for 64.57% (8,866/12,929) of all ASD operations, while the proportion treated by neurological surgeons increased 44.2% over the decade (2010: 24.39% vs. 2019: 35.16%; p<.0005). Neurological surgeons more frequently operated on older patients (60.52 vs. 55.18 years, p<.0005) with more medical comorbidities (CCI scores: 2.01 vs. 1.47, p<.0005). Neurological surgeons also performed higher rates of arthrodesis between one and six levels (OR: 1.86, p<.0005), three column osteotomies (OR: 1.35, p<.0005) and navigated or robotic procedures (OR: 3.30, p<.0005). Procedures performed by orthopedic surgeons had significantly lower average costs as compared to neurological surgeons (Orthopedic Surgeons: $17,971.66 vs. Neurological Surgeons: $22,322.64, p=.253). Adjusted logistic regression controlling for number of levels fused, pelvic fixation, age, sex, region, and comorbidities revealed that patients within neurosurgical care had similar odds of complications to orthopaedic surgery.Conclusions
This investigation of over 12,000 ASD patients demonstrates orthopedic surgeons continue to perform the majority of ASD correction surgery, although neurological surgeons are performing an increasingly larger percentage over time with a 44% increase in the proportion of surgeries performed in the decade. In this cohort, neurological surgeons more frequently operated on older and more comorbid patients, utilizing shorter-segment fixation with greater use of navigation and robotic assistance.