Browsing by Subject "Spinal Diseases"

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    ItemOpen Access
    A comparative analysis of the prevalence and characteristics of cervical malalignment in adults presenting with thoracolumbar spine deformity based on variations in treatment approach over 2 years.
    (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, 2016-08) Jalai, Cyrus M; Passias, Peter G; Lafage, Virginie; Smith, Justin S; Lafage, Renaud; Poorman, Gregory W; Diebo, Bassel; Liabaud, Barthélemy; Neuman, Brian J; Scheer, Justin K; Shaffrey, Christopher I; Bess, Shay; Schwab, Frank; Ames, Christopher P; International Spine Study Group (ISSG)

    Purpose

    Characteristics specific to cervical deformity (CD) concomitant with adult thoracolumbar deformity (TLD) remains uncertain, particularly regarding treatment. This study identifies cervical malalignment prevalence following surgical and conservative TLD treatment through 2 years.

    Methods

    Retrospective analysis of a prospective, multicenter adult spinal deformity (ASD) database. CD was defined in operative and non-operative ASD patients according to the following criteria: T1 Slope minus Cervical Lordosis (T1S-CL) ≥20°, C2-C7 Cervical Sagittal Vertical Axis (cSVA) ≥40 mm, C2-C7 kyphosis >10°. Differences in rates, demographics, health-related quality of life (HRQoL) scores for Oswestry Disability Index (ODI) and Scoliosis Research Society Questionnaire (SRS-22r), and radiographic variables were assessed between treatment groups (Op vs. Non-Op) and follow-up periods (baseline, 1-year, 2-year).

    Results

    Three hundred and nineteen (200 Op, 199 Non-Op) ASD patients were analyzed. Op patients' CD rates at 1 and 2 years were 78.9, and 63.0 %, respectively. Non-Op CD rates were 21.1 and 37.0 % at 1 and 2 years, respectively. T1S-CL mismatch and cSVA malalignment characterized Op CD at 1 and 2 years (p < 0.05). Op and Non-Op CD groups had similar cervical/global alignment at 1 year (p > 0.05 for all), but at 2 years, Op CD patients had worse thoracic kyphosis (TK), T1S-CL, CL, cSVA, C2-T3 SVA, and global SVA compared to Non-Ops (p < 0.05). Op CD patients had worse ODI, and SRS Activity at 1 and 2 years post-operative (p < 0.05), but had greater 2-year SRS Satisfaction scores (p = 0.019).

    Conclusions

    In the first study to compare cervical malalignment at extended follow-up between ASD treatments, CD rates rose overall through 2 years. TLD surgery, resulting in higher CD rates characterized by T1S-CL and cSVA malalignment, produced poorer HRQoL. This information can aid in treatment method decision-making when cervical deformity is present concomitant with TLD.
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    ItemOpen Access
    A survey-based study of wrong-level lumbar spine surgery: the scope of the problem and current practices in place to help avoid these errors.
    (World neurosurgery, 2013-03) Groff, Michael W; Heller, Joshua E; Potts, Eric A; Mummaneni, Praveen V; Shaffrey, Christopher I; Smith, Justin S

    Objective

    To understand better the scope of wrong-level lumbar spine surgery and current practices in place to help avoid such errors.

    Methods

    The Joint Section on Disorders of the Spine and Peripheral Nerves (Spine Section) developed a survey on single-level lumbar spine decompression surgery. Invitations to complete the Web-based survey were sent to all Spine Section members. Respondents were assured of confidentiality.

    Results

    There were 569 responses from 1045 requests (54%). Most surgeons either routinely (74%) or sometimes (11%) obtain preoperative imaging for incision planning. Most surgeons indicated that they obtained imaging after the incision was performed for localization either routinely before bone removal (73%) or most frequently before bone removal but occasionally after (16%). Almost 50% of reporting surgeons have performed wrong-level lumbar spine surgery at least once, and >10% have performed wrong-side lumbar spine surgery at least once. Nearly 20% of responding surgeons have been the subject of at least one malpractice case relating to these errors. Only 40% of respondents believed that the site marking/"time out" protocol of The Joint Commission on the Accreditation of Healthcare Organizations has led to a reduction in these errors.

    Conclusions

    There is substantial heterogeneity in approaches used to localize operative levels in the lumbar spine. Existing safety protocols may not be mitigating wrong-level surgery to the extent previously thought.
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    ItemOpen Access
    Adult Spinal Deformity Patients Recall Fewer Than 50% of the Risks Discussed in the Informed Consent Process Preoperatively and the Recall Rate Worsens Significantly in the Postoperative Period.
    (Spine, 2015-07) Saigal, Rajiv; Clark, Aaron J; Scheer, Justin K; Smith, Justin S; Bess, Shay; Mummaneni, Praveen V; McCarthy, Ian M; Hart, Robert A; Kebaish, Khaled M; Klineberg, Eric O; Deviren, Vedat; Schwab, Frank; Shaffrey, Christopher I; Ames, Christopher P

    Study design

    Recall of the informed consent process in patients undergoing adult spinal deformity surgery and their family members was investigated prospectively.

    Objective

    To quantify the percentage recall of the most common complications discussed during the informed consent process in adult spinal deformity surgery, assess for differences between patients and family members, and correlate with mental status.

    Summary of background data

    Given high rates of complications in adult spinal deformity surgery, it is critical to shared decision making that patients are adequately informed about risks and are able to recall preoperative discussion of possible complications to mitigate medical legal risk.

    Methods

    Patients undergoing adult spinal deformity surgery underwent an augmented informed consent process involving both verbal and video explanations. Recall of the 11 most common complications was scored. Mental status was assessed with the mini-mental status examination-brief version. Patients subjectively scored the informed consent process and video. After surgery, the recall test and mini-mental status examination-brief version were readministered at 5 additional time points: hospital discharge, 6 to 8 weeks, 3 months, 6 months, and 1 year postoperatively. Family members were assessed at the first 3 time points for comparison.

    Results

    Fifty-six patients enrolled. Despite ranking the consent process as important (median overall score: 10/10; video score: 9/10), median patient recall was only 45% immediately after discussion and video re-enforcement and subsequently declined to 18% at 6 to 8 weeks and 1 year postoperatively. Median family recall trended higher at 55% immediately and 36% at 6 to 8 weeks postoperatively. The perception of the severity of complications significantly differs between patient and surgeon. Mental status scores showed a transient, significant decrease from preoperation to discharge but were significantly higher at 1 year.

    Conclusion

    Despite being well-informed in an optimized informed consent process, patients cannot recall most surgical risks discussed and recall declines over time. Significant progress remains to improve informed consent retention.

    Level of evidence

    3.
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    ItemOpen Access
    After 9 Years of 3-Column Osteotomies, Are We Doing Better? Performance Curve Analysis of 573 Surgeries With 2-Year Follow-up.
    (Neurosurgery, 2018-07) Diebo, Bassel G; Lafage, Virginie; Varghese, Jeffrey J; Gupta, Munish; Kim, Han Jo; Ames, Christopher; Kebaish, Khaled; Shaffrey, Christopher; Hostin, Richard; Obeid, Ibrahim; Burton, Doug; Hart, Robert A; Lafage, Renaud; Schwab, Frank J; International Spine Study Group (ISSG) of Denver, Colorado

    Background

    In spinal deformity treatment, the increased utilization of 3-column (3CO) osteotomies reflects greater comfort and better training among surgeons. This study aims to evaluate the longitudinal performance and adverse events (complications or revisions) for a multicenter group following a decade of 3CO.

    Objective

    To investigate if performance of 3CO surgeries improves with years of practice.

    Methods

    Patients who underwent 3CO for spinal deformity with intra/postoperative and revision data collected up to 2 yr were included. Patients were chronologically divided into 4 even groups. Demographics, baseline deformity/correction, and surgical metrics were compared using Student t-test. Postoperative and revision rates were compared using Chi-square analysis.

    Results

    Five hundred seventy-three patients were stratified into: G1 (n = 143, 2004-2008), G2 (n = 142, 2008-2009), G3 (n = 144, 2009-2010), G4 (n = 144 2010-2013). The most recent patients were more disabled by Oswestry disability index (G4 = 49.2 vs G1 = 38.3, P = .001), and received a larger osteotomy resection (G4 = 26° vs G1 = 20°, P = .011) than the earliest group. There was a decrease in revision rate (45%, 35%, 33%, 30%, P = .039), notably in revisions for pseudarthrosis (16.7% G1 vs 6.9% G4, P = .007). Major complication rates also decreased (57%, 50%, 46%, 39%, P = .023) as did excessive blood loss (>4 L, 27.2 vs 16.7%, P = .023) and bladder/bowel deficit (4.2% vs 0.7% P = .002). Successful outcomes (no complications or revision) significantly increased (P = .001).

    Conclusion

    Over 9 yr, 3COs are being performed on an increasingly disabled population while gaining a greater correction at the osteotomy site. Revisions and complication rate decreased while success rate improved during the 2-yr follow-up period.
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    ItemOpen Access
    An analysis from the Quality Outcomes Database, Part 1. Disability, quality of life, and pain outcomes following lumbar spine surgery: predicting likely individual patient outcomes for shared decision-making.
    (Journal of neurosurgery. Spine, 2017-10) McGirt, Matthew J; Bydon, Mohamad; Archer, Kristin R; Devin, Clinton J; Chotai, Silky; Parker, Scott L; Nian, Hui; Harrell, Frank E; Speroff, Theodore; Dittus, Robert S; Philips, Sharon E; Shaffrey, Christopher I; Foley, Kevin T; Asher, Anthony L
    OBJECTIVE Quality and outcomes registry platforms lie at the center of many emerging evidence-driven reform models. Specifically, clinical registry data are progressively informing health care decision-making. In this analysis, the authors used data from a national prospective outcomes registry (the Quality Outcomes Database) to develop a predictive model for 12-month postoperative pain, disability, and quality of life (QOL) in patients undergoing elective lumbar spine surgery. METHODS Included in this analysis were 7618 patients who had completed 12 months of follow-up. The authors prospectively assessed baseline and 12-month patient-reported outcomes (PROs) via telephone interviews. The PROs assessed were those ascertained using the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for back pain (BP) and leg pain (LP). Variables analyzed for the predictive model included age, gender, body mass index, race, education level, history of prior surgery, smoking status, comorbid conditions, American Society of Anesthesiologists (ASA) score, symptom duration, indication for surgery, number of levels surgically treated, history of fusion surgery, surgical approach, receipt of workers' compensation, liability insurance, insurance status, and ambulatory ability. To create a predictive model, each 12-month PRO was treated as an ordinal dependent variable and a separate proportional-odds ordinal logistic regression model was fitted for each PRO. RESULTS There was a significant improvement in all PROs (p < 0.0001) at 12 months following lumbar spine surgery. The most important predictors of overall disability, QOL, and pain outcomes following lumbar spine surgery were employment status, baseline NRS-BP scores, psychological distress, baseline ODI scores, level of education, workers' compensation status, symptom duration, race, baseline NRS-LP scores, ASA score, age, predominant symptom, smoking status, and insurance status. The prediction discrimination of the 4 separate novel predictive models was good, with a c-index of 0.69 for ODI, 0.69 for EQ-5D, 0.67 for NRS-BP, and 0.64 for NRS-LP (i.e., good concordance between predicted outcomes and observed outcomes). CONCLUSIONS This study found that preoperative patient-specific factors derived from a prospective national outcomes registry significantly influence PRO measures of treatment effectiveness at 12 months after lumbar surgery. Novel predictive models constructed with these data hold the potential to improve surgical effectiveness and the overall value of spine surgery by optimizing patient selection and identifying important modifiable factors before a surgery even takes place. Furthermore, these models can advance patient-focused care when used as shared decision-making tools during preoperative patient counseling.
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    ItemOpen Access
    An Analysis of Public Interest in Elective Neurosurgical Procedures During the COVID-19 Pandemic Through Online Search Engine Trends.
    (World neurosurgery, 2021-04) Feng, Austin Y; Garcia, Cesar A; Jin, Michael C; Ho, Allen L; Li, Gordon; Grant, Gerald; Ratliff, John; Skirboll, Stephen L

    Objective

    In the wake of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) has recommended the temporary cessation of all elective surgeries. The effects on patients' interest of elective neurosurgical procedures are currently unexplored.

    Methods

    Using Google Trends, search terms of 7 different neurosurgical procedure categories (trauma, spine, tumor, movement disorder, epilepsy, endovascular, and miscellaneous) were assessed in terms of relative search volume (RSV) between January 2015 and September 2020. Analyses of search terms were performed for over the short term (February 18, 2020, to April 18, 2020), intermediate term (January 1, 2020, to May 31, 2020), and long term (January 2015 to September 2020). State-level interest during phase I reopening (April 28, 2020, to May 31, 2020) was also evaluated.

    Results

    In the short term, RSVs of 4 categories (epilepsy, movement disorder, spine, and tumor) were significantly lower in the post-CMS announcement period. In the intermediate term, RSVs of 5 categories (miscellaneous, epilepsy, movement disorder, spine, and tumor) were significantly lower in the post-CMS announcement period. In the long term, RSVs of nearly all categories (endovascular, epilepsy, miscellaneous, movement disorder, spine, and tumor) were significantly lower in the post-CMS announcement period. Only the movement disorder procedure category had significantly higher RSV in states that reopened early.

    Conclusions

    With the recommendation for cessation of elective surgeries, patient interests in overall elective neurosurgical procedures have dropped significantly. With gradual reopening, there has been a resurgence in some procedure types. Google Trends has proven to be a useful tracker of patient interest and may be used by neurosurgical departments to facilitate outreach strategies.
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    ItemOpen Access
    Classifications for adult spinal deformity and use of the Scoliosis Research Society-Schwab Adult Spinal Deformity Classification.
    (Neurosurgery clinics of North America, 2013-04) Bess, Shay; Schwab, Frank; Lafage, Virginie; Shaffrey, Christopher I; Ames, Christopher P
    Adult spinal deformity (ASD) is a complex disease state that pathologically alters standing upright posture and is associated with substantial pain and disability. This article provides an overview of classification systems for spinal deformity, clarifies the need to differentiate between pediatric and adult classifications, and provides an explanation on the use of the Scoliosis Research Society-Schwab Adult Spinal Deformity Classification (SRS-Schwab ASD Classification). This information allows surgeons, researchers, and health care providers to (1) identify sources of pain and disability in patients with ASD and (2) accurately use the SRSeSchwab ASD Classification to evaluate patients with ASD.
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    ItemOpen Access
    Clinical and radiographic evaluation of the adult spinal deformity patient.
    (Neurosurgery clinics of North America, 2013-04) Smith, Justin S; Shaffrey, Christopher I; Fu, Kai-Ming G; Scheer, Justin K; Bess, Shay; Lafage, Virginie; Schwab, Frank; Ames, Christopher P
    Among the prevalent forms of adult spinal deformity are residual adolescent idiopathic and degenerative scoliosis, kyphotic deformity, and spondylolisthesis. Clinical evaluation should include a thorough history, discussion of concerns, and a review of comorbidities. Physical examination should include assessment of the deformity and a neurologic examination. Imaging studies should include full-length standing posteroanterior and lateral spine radiographs, and measurement of pelvic parameters. Advanced imaging studies are frequently indicated to assess for neurologic compromise and for surgical planning. This article focuses on clinical and radiographic evaluation of spinal deformity in the adult population, particularly scoliosis and kyphotic deformities.
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    ItemOpen Access
    Comparison of patient and surgeon perceptions of adverse events after adult spinal deformity surgery.
    (Spine, 2013-04) Hart, Robert A; Cabalo, Adam; Bess, Shay; Akbarnia, Behrooz A; Boachie-Adjei, Oheneba; Burton, Douglas; Cunningham, Matthew E; Gupta, Munish; Hostin, Richard; Kebaish, Khaled; Klineberg, Eric; Mundis, Gregory; Shaffrey, Christopher; Smith, Justin S; Wood, Kirkham; International Spine Study Group

    Study design

    Survey based on complication scenarios.

    Objective

    To assess and compare perceived potential impacts of various perioperative adverse events by both surgeons and patients.

    Summary of background data

    Incidence of adverse events after adult spinal deformity surgery remains substantial. Patient-centered outcomes tools measuring the impact of these events have not been developed. An important first step is to assess the perceptions of surgeons and patients regarding the impact of these events on surgical outcome and quality of life.

    Methods

    Descriptions of 22 potential adverse events of surgery (heart attack, stroke, spinal cord injury, nerve root injury, cauda equina injury, blindness, dural tear, blood transfusion, deep vein thrombosis, pulmonary embolism, superficial infection, deep infection, lung failure, urinary tract infection, nonunion, adjacent segment disease, persistent deformity, implant failure, death, renal failure, gastrointestinal complications, and sexual dysfunction) were presented to 14 spinal surgeons and 16 adult patients with spinal deformity. Impact scores were assigned to each complication on the basis of perceptions of overall severity, satisfaction with surgery, and effect on quality of life. Impact scores were compared between surgeons and patients with a Wilcoxon/Kruskal-Wallis test.

    Results

    Mean impact scores varied from 0.9 (blood transfusion) to 10.0 (death) among surgeons and 2.3 (urinary tract infection) to 9.2 (stroke) among patients. Patients' scores were consistently higher (P < 0.05) than surgeons in all 3 categories for 6 potential adverse events: stroke, lung failure, heart attack, pulmonary embolism, dural tear, and blood transfusion. Three additional complications (renal failure, non-union, and deep vein thrombosis) were rated higher in 1 or 2 categories by patients.

    Conclusion

    There was substantial variation in how both surgeons and patients perceived impacts of various adverse events after spine surgery. Patients generally perceived the impact of adverse events to be greater than surgeons. Patient-centered descriptions of adverse events would provide a more complete description of surgical outcomes.
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    ItemOpen Access
    Complications and intercenter variability of three-column osteotomies for spinal deformity surgery: a retrospective review of 423 patients.
    (Neurosurgical focus, 2014-05) Bianco, Kristina; Norton, Robert; Schwab, Frank; Smith, Justin S; Klineberg, Eric; Obeid, Ibrahim; Mundis, Gregory; Shaffrey, Christopher I; Kebaish, Khaled; Hostin, Richard; Hart, Robert; Gupta, Munish C; Burton, Douglas; Ames, Christopher; Boachie-Adjei, Oheneba; Protopsaltis, Themistocles S; Lafage, Virginie; International Spine Study Group

    Object

    Three-column resection osteotomies (3COs) are commonly performed for sagittal deformity but have high rates of reported complications. Authors of this study aimed to examine the incidence of and intercenter variability in major intraoperative complications (IOCs), major postoperative complications (POCs) up to 6 weeks postsurgery, and overall complications (that is, both IOCs and POCs). They also aimed to investigate the incidence of and intercenter variability in blood loss during 3CO procedures.

    Methods

    The incidence of IOCs, POCs, and overall complications associated with 3COs were retrospectively determined for the study population and for each of 8 participating surgical centers. The incidence of major blood loss (MBL) over 4 L and the percentage of total blood volume lost were also determined for the study population and each surgical center. Complication rates and blood loss were compared between patients with one and those with two osteotomies, as well as between patients with one thoracic osteotomy (ThO) and those with one lumbar or sacral osteotomy (LSO). Risk factors for developing complications were determined.

    Results

    Retrospective review of prospectively acquired data for 423 consecutive patients who had undergone 3CO at 8 surgical centers was performed. The incidence of major IOCs, POCs, and overall complications was 7%, 39%, and 42%, respectively, for the study population overall. The most common IOC was spinal cord deficit (2.6%) and the most common POC was unplanned return to the operating room (19.4%). Patients with two osteotomies had more POCs (56% vs 38%, p = 0.04) than the patients with one osteotomy. Those with ThO had more IOCs (16% vs 6%, p = 0.03), POCs (58% vs 34%, p < 0.01), and overall complications (67% vs 37%, p < 0.01) than the patients with LSO. There was significant variation in the incidence of IOCs, POCs, and overall complications among the 8 sites (p < 0.01). The incidence of MBL was 24% for the study population, which varied significantly between sites (p < 0.01). Patients with MBL had a higher risk of IOCs, POCs, and overall complications (OR 2.15, 1.76, and 2.01, respectively). The average percentage of total blood volume lost was 55% for the study population, which also varied among sites (p < 0.01).

    Conclusions

    Given the complexity of 3COs for spinal deformity, it is important for spine surgeons to understand the risk factors and complication rates associated with these procedures. In this study, the overall incidence of major complications following 3CO procedures was 42%. Risks for developing complications included an older age (> 60 years), two osteotomies, ThO, and MBL.
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    ItemOpen Access
    Coronal realignment and reduction techniques and complication avoidance.
    (Neurosurgery clinics of North America, 2013-04) Fu, Kai-Ming G; Smith, Justin S; Shaffrey, Christopher I; Ames, Christopher P; Bess, Shay
    Scoliosis is a broad term encompassing multiple pathologies with different etiologies. Patients may range from the infant with congenital deformity, to the adolescent with idiopathic scoliosis, to the elderly patient with severe degenerative scoliosis. Treatment must be tailored to individual circumstances and the pathoanatomy of each deformity. Various coronal reduction techniques have been described and will be discussed within this article. While scoliosis is generally considered a deformity in the coronal plane, often deformity is present in the sagittal and axial planes also. Treatment of these deformities can require osteotomies or vertebral column resections, techniques further discussed in accompanying articles.
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    ItemOpen Access
    Correlation of higher preoperative American Society of Anesthesiology grade and increased morbidity and mortality rates in patients undergoing spine surgery.
    (Journal of neurosurgery. Spine, 2011-04) Fu, Kai-Ming G; Smith, Justin S; Polly, David W; Ames, Christopher P; Berven, Sigurd H; Perra, Joseph H; McCarthy, Richard E; Knapp, D Raymond; Shaffrey, Christopher I; Scoliosis Research Society Morbidity and Mortality Committee

    Object

    Patients with varied medical comorbidities often present with spinal pathology for which operative intervention is potentially indicated, but few studies have examined risk stratification in determining morbidity and mortality rates associated with the operative treatment of spinal disorders. This study provides an analysis of morbidity and mortality data associated with 22,857 cases reported in the multicenter, multisurgeon Scoliosis Research Society Morbidity and Mortality database stratified by American Society of Anesthesiologists (ASA) physical status classification, a commonly used system to describe preoperative physical status and to predict operative morbidity.

    Methods

    The Scoliosis Research Society Morbidity and Mortality database was queried for the year 2007, the year in which ASA data were collected. Inclusion criterion was a reported ASA grade. Cases were categorized by operation type and disease process. Details on the surgical approach and type of instrumentation were recorded. Major perioperative complications and deaths were evaluated. Two large subgroups--patients with adult degenerative lumbar disease and patients with major deformity--were also analyzed separately. Statistical analyses were performed with the chi-square test.

    Results

    The population studied comprised 22,857 patients. Spinal disease included degenerative disease (9409 cases), scoliosis (6782 cases), spondylolisthesis (2144 cases), trauma (1314 cases), kyphosis (831 cases), and other (2377 cases). The overall complication rate was 8.4%. Complication rates for ASA Grades 1 through 5 were 5.4%, 9.0%, 14.4%, 20.3%, and 50.0%, respectively (p = 0.001). In patients undergoing surgery for degenerative lumbar diseases and major adult deformity, similarly increasing rates of morbidity were found in higher-grade patients. The mortality rate was also higher in higher-grade patients. The incidence of major complications, including wound infections, hematomas, respiratory problems, and thromboembolic events, was also greater in patients with higher ASA grades.

    Conclusions

    Patients with higher ASA grades undergoing spinal surgery had significantly higher rates of morbidity than those with lower ASA grades. Given the common application of the ASA system to surgical patients, this grade may prove helpful for surgical decision making and preoperative counseling with regard to risks of morbidity and mortality.
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    ItemOpen Access
    Defining a Surgical Invasiveness Threshold for Increased Risk of a Major Complication Following Adult Spinal Deformity Surgery.
    (Spine, 2021-07) Neuman, Brian J; Harris, Andrew B; Klineberg, Eric O; Hostin, Richard A; Protopsaltis, Themistocles S; Passias, Peter G; Gum, Jeffrey L; Hart, Robert A; Kelly, Michael P; Daniels, Alan H; Ames, Christopher P; Shaffrey, Christopher I; Kebaish, Khaled M; and the International Spine Study Group

    Study design

    Retrospective review.

    Objectives

    The aim of this study was to define a surgical invasiveness threshold that predicts major complications after adult spinal deformity (ASD) surgery; use this threshold to categorize patients into quartiles by invasiveness; and determine the odds of major complications by quartile.

    Summary of background data

    Understanding the relationship between surgical invasiveness and major complications is important for estimating the likelihood of major complications after ASD surgery.

    Methods

    Using a multicenter database, we identified 574 ASD patients (more than 5 levels fused; mean age, 60 ± 15 years) with minimum 2-year follow-up. Invasiveness was calculated as the ASD Surgical and Radiographic (ASD-SR) score. Youden index was used to identify the invasiveness score cut-off associated with optimal sensitivity and specificity for predicting major complications. Resulting high- and low-invasiveness groups were divided in half to create quartiles. Odds of developing a major complication were analyzed for each quartile using logistic regression (alpha = 0.05).

    Results

    The ASD-SR cutoff score that maximally predicted major complications was 90 points. ASD-SR quartiles were 0 to 65 (Q1), 66 to 89 (Q2), 90 to 119 (Q3), and ≥120 (Q4). Risk of a major complication was 17% in Q1, 21% in Q2, 35% in Q3, and 33% in Q4 (P < 0.001). Comparisons of adjacent quartiles showed an increase in the odds of a major complication from Q2 to Q3 (odds ratio [OR] 1.8; 95% confidence interval [CI]: 1.0-3.0), but not from Q1 to Q2 or from Q3 to Q4. Patients with ASD-SR scores ≥90 were 1.9 times as likely to have a major complication than patients with scores <90 (OR 1.9, 95% CI 1.3-2.9). Mean ASD-SR scores above and below 90 points were 121 ± 25 and 63 ± 17, respectively.

    Conclusion

    The odds of major complications after ASD surgery are significantly greater when the procedure has an ASD-SR score ≥90. ASD-SR score can be used to counsel patients regarding these increased odds.Level of Evidence: 3.
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    ItemOpen Access
    Degenerative Spinal Deformity.
    (Neurosurgery, 2015-10) Ailon, Tamir; Smith, Justin S; Shaffrey, Christopher I; Lenke, Lawrence G; Brodke, Darrel; Harrop, James S; Fehlings, Michael; Ames, Christopher P
    Degenerative spinal deformity afflicts a significant portion of the elderly and is increasing in prevalence. Recent evidence has revealed sagittal plane malalignment to be a key driver of pain and disability in this population and has led to a significant shift toward a more evidence-based management paradigm. In this narrative review, we review the recent literature on the epidemiology, evaluation, management, and outcomes of degenerative adult spinal deformity (ASD). ASD is increasing in prevalence in North America due to an aging population and demographic shifts. It results from cumulative degenerative changes focused in the intervertebral discs and facet joints that occur asymmetrically to produce deformity. Deformity correction focuses on restoration of global alignment, especially in the sagittal plane, and decompression of the neural elements. General realignment goals have been established, including sagittal vertical axis <50 mm, pelvic tilt <22°, and lumbopelvic mismatch <±9°; however, these should be tailored to the patient. Operative management, in carefully selected patients, yields satisfactory outcomes that appear to be superior to nonoperative strategies. ASD is characterized by malalignment in the sagittal and/or coronal plane and, in adults, presents with pain and disability. Nonoperative management is recommended for patients with mild, nonprogressive symptoms; however, evidence of its efficacy is limited. Surgery aims to restore global spinal alignment, decompress neural elements, and achieve fusion with minimal complications. The surgical approach should balance the desired correction with the increased risk of more aggressive maneuvers. In well-selected patients, surgery yields excellent outcomes.
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    ItemOpen Access
    Does bone morphogenetic protein increase the incidence of perioperative complications in spinal fusion? A comparison of 55,862 cases of spinal fusion with and without bone morphogenetic protein.
    (Spine, 2011-09) Williams, Brian J; Smith, Justin S; Fu, Kai-Ming G; Hamilton, D Kojo; Polly, David W; Ames, Christopher P; Berven, Sigurd H; Perra, Joseph H; Knapp, Dennis R; McCarthy, Richard E; Shaffrey, Christopher I; Scoliosis Research Society Morbidity and Mortality Committee

    Study design

    Retrospective review of a multi-institutional, multisurgeon database.

    Objective

    Assess for associations between bone morphogenetic protein (BMP) use and rate of complications in spinal fusion.

    Summary of background data

    BMP is commonly used in spinal surgery to augment fusion; however, there is limited evidence demonstrating its associated complications.

    Methods

    We performed a retrospective analysis of all fusion cases submitted by members of the Scoliosis Research Society from 2004 to 2007. We stratified on the basis of the use of BMP and evaluated for complications and associated characteristics.

    Results

    A total of 55,862 cases of spinal fusion were identified with BMP used in 21% (11,933) of the cases. Excluding anterior cervical fusions, there were no significant differences between fusions with and without BMP with regard to overall complications (8.4% vs. 8.5%; P = 0.5), wound infections (2.4% vs. 2.4%; P = 0.8), or epidural hematomas/seromas (0.2% vs. 0.2%; P = 0.3). Anterior cervical fusions with BMP were associated with more overall complications (5.8% vs. 2.4%; P < 0.001) and more wound infections (2.1% vs. 0.4%; P < 0.001) than fusions without BMP. On multivariate analysis for thoracolumbar and posterior cervical fusions, BMP use was not a significant predictor of complications (P = 0.334; odds ratio = 1.039; 95% confidence interval = 0.961-1.124; covariates were BMP use, patient age, revision vs. primary surgery). Multivariate analysis for anterior cervical spinal fusion demonstrated that BMP use remained a significant predictor of complications (P < 0.001, odds ratio = 1.6; 95% confidence interval = 1.516-1.721), after adjusting for the effects of patient age and whether the surgery was a revision procedure.

    Conclusion

    BMP use with anterior cervical fusion was associated with an increased incidence of complications. Use of BMP was not associated with more complications in thoracolumbar and posterior cervical fusions.
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    ItemOpen Access
    Durability of Satisfactory Functional Outcomes Following Surgical Adult Spinal Deformity Correction: A 3-Year Survivorship Analysis.
    (Operative neurosurgery (Hagerstown, Md.), 2020-02) Passias, Peter G; Bortz, Cole A; Lafage, Virginie; Lafage, Renaud; Smith, Justin S; Line, Breton; Eastlack, Robert; Gupta, Munish C; Hostin, Richard A; Horn, Samantha R; Segreto, Frank A; Egers, Max; Sciubba, Daniel M; Gum, Jeffrey L; Kebaish, Khaled M; Klineberg, Eric O; Burton, Douglas C; Schwab, Frank J; Shaffrey, Christopher I; Ames, Christopher P; Bess, Shay

    Background

    Despite reports showing positive long-term functional outcomes following adult spinal deformity (ASD)-corrective surgery, it is unclear which factors affect the durability of these outcomes.

    Objective

    To assess durability of functional gains following ASD-corrective surgery; determine predictors for postoperative loss of functionality.

    Methods

    Surgical ASD patients > 18 yr with 3-yr Oswestry Disability Index (ODI) follow-up, and 1-yr postoperative (1Y) ODI scores reaching substantial clinical benefit (SCB) threshold (SCB < 31.3 points). Patients were grouped: those sustaining ODI at SCB threshold beyond 1Y (sustained functionality) and those not (functional decline). Kaplan-Meier survival analysis determined postoperative durability of functionality. Multivariate Cox regression assessed the relationship between patient/surgical factors and functional decline, accounting for age, sex, and levels fused.

    Results

    All 166 included patients showed baseline to 1Y functional improvement (mean ODI: 35.3 ± 16.5-13.6 ± 9.2, P < .001). Durability of satisfactory functional outcomes following the 1Y postoperative interval was 88.6% at 2-yr postoperative, and 71.1% at 3-yr postoperative (3Y). Those sustaining functionality after 1Y had lower baseline C2-S1 sagittal vertical axis (SVA) and T1 slope (both P < .05), and lower 1Y thoracic kyphosis (P = .035). From 1Y to 3Y, patients who sustained functionality showed smaller changes in alignment: pelvic incidence minus lumbar lordosis, SVA, T1 slope minus cervical lordosis, and C2-C7 SVA (all P < .05). Those sustaining functionality beyond 1Y were also younger, less frail at 1Y, and had lower rates of baseline osteoporosis, hypertension, and lung disease (all P < .05). Lung disease (Hazard Ratio:4.8 [1.4-16.4]), 1Y frailty (HR:1.4 [1.1-1.9]), and posterior approach (HR:2.6 [1.2-5.8]) were associated with more rapid decline.

    Conclusion

    Seventy-one percent of ASD patients maintained satisfactory functional outcomes by 3Y. Of those who failed to sustain functionality, the largest functional decline occurred 3-yr postoperatively. Frailty, preoperative comorbidities, and surgical approach affected durability of functional gains following surgery.
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    Early Patient-Reported Outcomes Predict 3-Year Outcomes in Operatively Treated Patients with Adult Spinal Deformity.
    (World neurosurgery, 2017-06) Jain, Amit; Kebaish, Khaled M; Sciubba, Daniel M; Hassanzadeh, Hamid; Scheer, Justin K; Neuman, Brian J; Lafage, Virginie; Bess, Shay; Protopsaltis, Themistocles S; Burton, Douglas C; Smith, Justin S; Shaffrey, Christopher I; Hostin, Richard A; Ames, Christopher P; International Spine Study Group

    Background

    For patients with adult spinal deformity (ASD), surgical treatment may improve their health-related quality of life. This study investigates when the greatest improvement in outcomes occurs and whether incremental improvements in patient-reported outcomes during the first postoperative year predict outcomes at 3 years.

    Methods

    Using a multicenter registry, we identified 84 adults with ASD treated surgically from 2008 to 2012 with complete 3-year follow-up. Pairwise t tests and multivariate regression were used for analysis. Significance was set at P < 0.01.

    Results

    Mean Oswestry Disability Index (ODI) and Scoliosis Research Society-22r total (SRS-22r) scores improved by 13 and 0.8 points, respectively, from preoperatively to 3 years (both P < 0.001). From preoperatively to 6 weeks postoperatively, ODI scores worsened by 5 points (P = 0.049) and SRS-22r scores improved by 0.3 points (P < 0.001). Between 6 weeks and 1 year, ODI and SRS-22r scores improved by 19 and 0.5 points, respectively (both P < 0.001). Incremental improvements during the first postoperative year predicted 3-year outcomes in ODI and SRS-22r scores (adjusted R2 = 0.52 and 0.42, respectively). There were no significant differences in the measured or predicted 3-year ODI (P = 0.991) or SRS-22r scores (P = 0.986).

    Conclusions

    In surgically treated patients with ASD, the greatest improvements in outcomes occurred between 6 weeks and 1 year postoperatively. A model with incremental improvements from baseline to 6 weeks and from 6 weeks to 1 year can be used to predict ODI and SRS-22r scores at 3 years.
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    Effect of Antifibrinolytic Therapy on Complications, Thromboembolic Events, Blood Product Utilization, and Fusion in Adult Spinal Deformity Surgery.
    (Spine, 2016-07) Soroceanu, Alex; Oren, Jonathan H; Smith, Justin S; Hostin, Richard; Shaffrey, Christopher I; Mundis, Gregory M; Ames, Christopher P; Burton, Douglas C; Bess, Shay; Gupta, Munish C; Deviren, Vedat; Schwab, Frank J; Lafage, Virginie; Errico, Thomas J

    Study design

    A multicenter, prospective, consecutive database of surgical patients with adult spinal deformity (ASD).

    Objective

    This study investigated the use of antifibrinolytic (AF) therapy in ASD surgery.

    Summary of background data

    AF therapy has been shown to be effective in preventing blood loss in some settings. Its effect on major and minor perioperative complications, blood product utilization, vascular events, and postoperative fusion in patients undergoing ASD surgery remains unclear.

    Methods

    All patients with data on AF use were included. Parameters of blood utilization included transfusion rates and units of packed red blood cells and fresh frozen plasma transfused. Thromboembolic events included stroke, deep vein thrombosis, and pulmonary embolus. Multivariate regression was used, accounting for confounders.

    Results

    Four hundred three patients were included. One hundred thirty-seven patients received aminocaproic acid (EACA), 81 received tranexamic acid (TXA), and 185 received no AFs. The use of AF was associated with a decrease in transfusion (EACA: odds ratio [OR] = 0.38, P = 0.043; TXA: OR = 0.31, P = 0.047), a decrease in the number of units of packed red blood cells transfused (EACA: incidence risk ratio [IRR] = 0.45, P = 0.0005; TXA: IRR = 0.7, P = 0.0005), and a decrease in the number of fresh frozen plasma transfused (EACA: IRR = 0.65, P = 0.003; TXA: IRR = 0.67, P = 0.006). AF use was associated with an increase in minor intraoperative complications (EACA: IRR = 2.15, P = 0.008; TXA: IRR = 2.12, P = 0.011). TXA use (but not EACA) was associated with a decrease in the incidence of major perioperative complications compared with no AF (IRR = 0.37, P = 0.019). There was no difference in the incidence of thromboembolic events.

    Conclusion

    TXA or EACA use was associated with increased minor intraoperative complications. TXA was associated with decreased major perioperative complications. AF was associated with decreased utilization of blood products without an increased rate of thromboembolic events. Given the nature of this study, transfusion threshold was not standardized. Future studies with rigid criteria for transfusion should be prospectively performed to better evaluate the impact of AF during ASD surgery.

    Level of evidence

    3.
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    Effect of Resident and Fellow Involvement in Adult Spinal Deformity Surgery.
    (World neurosurgery, 2019-02) Zuckerman, Scott L; Lim, Jaims; Lakomkin, Nikita; Than, Khoi D; Smith, Justin S; Shaffrey, Christopher I; Devin, Clinton J

    Background

    Adult spinal deformity (ASD) operations are complex and often require a multisurgeon team. Simultaneously, it is the responsibility of academic spine surgeons to train future complex spine surgeons. Our objective was to assess the effect of resident and fellow involvement (RFI) on ASD surgery in 4 areas: 1) perioperative outcomes, 2) length of stay (LOS), 3) discharge status, and 4) complications.

    Methods

    Adults undergoing thoracolumbar spinal deformity correction from 2008 to 2014 were identified in the National Surgical Quality Improvement Program database. Cases were divided into those with RFI and those with attendings only. Outcomes were operative time, transfusions, LOS, discharge status, and complications. Univariate and multivariable regression modeling was used. Covariates included preoperative comorbidities, specialty, and levels undergoing instrumentation.

    Results

    A total of 1471 patients underwent ASD surgery with RFI in 784 operations (53%). After multivariable regression modeling, RFI was independently associated with longer operations (β = 66.01 minutes; 95% confidence interval [CI], 35.82-96.19; P < 0.001), increased odds of transfusion (odds ratio, 2.80; 95% CI, 1.81-4.32; P < 0.001), longer hospital stay (β = 1.76 days; 95% CI, 0.18-3.34; P = 0.030), and discharge to an inpatient rehabilitation or a skilled nursing facility (odds ratio, 2.02; 95% CI, 1.34-3.05; P < 0.001). However, RFI was not associated with any increase in major or minor complications.

    Conclusion

    RFI in ASD surgery was associated with increased operative time, the need for additional transfusions, longer LOS, and nonhome discharge. However, no increase in major, minor, or severe complications occurred. These data support the continued training of future deformity and complex spine surgeons without fear of worsening complications; however, areas of improvement exist.
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    Experience with intrawound vancomycin powder for spinal deformity surgery.
    (Spine, 2014-01) Martin, Joel R; Adogwa, Owoicho; Brown, Christopher R; Bagley, Carlos A; Richardson, William J; Lad, Shivanand P; Kuchibhatla, Maragatha; Gottfried, Oren N

    Study design

    Retrospective cohort study.

    Objective

    To evaluate the ability of local vancomycin powder to prevent deep wound infection after thoracolumbar and lumbar spinal fusion for open deformity cases.

    Summary of background data

    Recent studies report that local delivery of vancomycin powder is associated with a decrease in spinal surgical site infection (SSI). This study compares deformity fusion cases before and after the routine application of spinal vancomycin powder.

    Methods

    Posterior spinal deformity surgical procedures by a single institution were reviewed from January 2011 to April 2013. Routine application of vancomycin powder started in April 2012. Inclusion criteria included adult patients who underwent posterior fusion for deformity pathologies, including spondylolisthesis, kyphosis, sagittal imbalance, and scoliosis. Each cohort's baseline characteristics including infection risk factors, operative data, and rates of wound infection were compared. Associations between infection and vancomycin powder, with and without propensity score adjustment for risk factors were determined using logistic regression.

    Results

    A total of 306 patients were included in the study. All measured baseline and operative variables were statistically similar between untreated (n = 150) and those who received vancomycin powder (n = 156). No significant change in deep wound infection rate was seen between the control (5.3%) and intervention group (5.1%, P = 0.936). Logistic regression with and without propensity score adjusted for risk factors demonstrated that the use of vancomycin powder did not impact the development of SSI (odds ratio [95% confidence interval]: 1.01 [0.36-2.79], P = 0.9910) and (odds ratio [95% confidence interval]: 0.87 [0.31-2.42], P = 0.7876), respectively.

    Conclusion

    The local application of powdered vancomycin was not associated with a significant difference in the rate of deep SSI after spinal deformity surgery, and other treatment modalities are necessary to limit infection for this high-risk group. This study is in contrary to prior studies, which have reported a decrease in SSI with vancomycin powder.

    Level of evidence

    2.