Radiographic Outcomes of Adult Spinal Deformity Correction: A Critical Analysis of Variability and Failures Across Deformity Patterns

STUDY DESIGN

Multicenter, prospective, consecutive, surgical case series from the International Spine Study Group.

OBJECTIVES

To evaluate the effectiveness of surgical treatment in restoring spinopelvic (SP) alignment.

SUMMARY OF BACKGROUND DATA

Pain and disability in the setting of adult spinal deformity have been correlated with global coronal alignment (GCA), sagittal vertical axis (SVA), pelvic incidence/lumbar lordosis mismatch (PI-LL), and pelvic tilt (PT). One of the main goals of surgery for adult spinal deformity is to correct these parameters to restore harmonious SP alignment.

METHODS

Inclusion criteria were operative patients (age greater than 18 years) with baseline (BL) and 1-year full-length X-rays. Thoracic and thoracolumbar Cobb angle and previous mentioned parameters were calculated. Each parameter at BL and 1 year was categorized as either pathological or normal. Pathologic limits were: Cobb greater than 30°, GCA greater than 40 mm, SVA greater than 40 mm, PI-LL greater than 10°, and PT greater than 20°. According to thresholds, corrected or worsened alignment groups of patients were identified and overall radiographic effectiveness of procedure was evaluated by combining the results from the coronal and sagittal planes.

RESULTS

A total of 161 patients (age, 55 ± 15 years) were included. At BL, 80% of patients had a Cobb angle greater than 30°, 25% had a GCA greater than 40 mm, and 42% to 58% had a pathological sagittal parameter of PI-LL, SVA, and/or PT. Sagittal deformity was corrected in about 50% of cases for patients with pathological SVA or PI-LL, whereas PT was most commonly worsened (24%) and least often corrected (24%). Only 23% of patients experienced complete radiographic correction of the deformity.

CONCLUSIONS

The frequency of inadequate SP correction was high. Pelvic tilt was the parameter least likely to be well corrected. The high rate of SP alignment failure emphasizes the need for better preoperative planning and intraoperative imaging.

Clinical improvement through nonoperative treatment of adult spinal deformity: who is likely to benefit?

Object

The goal of this study was to determine the outcome and risk factors in patients with adult spinal deformity (ASD) who elected to receive nonoperative care.

Methods

In this retrospective study the authors reviewed a nonoperative branch of the International Spine Study Group database, derived from 10 sites across the US. Specific inclusion criteria included nonoperative treatment for ASD and the availability of Scoliosis Research Society (SRS)-22 scores and radiographic data at baseline (BL) and at 1-year (1Y) follow-up. Health-related quality of life measures were assessed using the SRS-22 and radiographic data. Changes in SRS-22 scores were evaluated by domain and expressed in number of minimum clinically important differences (MCIDs) gained or lost; BL and 1Y scores were also compared with age- and sex-matched normative references.

Results

One hundred eighty-nine patients (mean age 53 years, 86% female) met inclusion criteria. Pain was the domain with the largest offset for 43% of patients, followed by the Appearance (23%), Activity (18%), and Mental (15%) domains. On average, patients improved 0.3 MCID in Pain over 1Y, without changes in Activity or Appearance. Baseline scores significantly impacted 1Y outcomes, with up to 85% of patients in the mildest category of deformity being classified as < 1 MCID of normative reference at 1Y, versus 0% of patients with the most severe initial deformity. Baseline radiographic parameters did not correlate with outcome.

Conclusions

Patients who received nonoperative care are significantly more disabled than age- and sex-matched normative references. The likelihood for a patient to reach SRS scores similar to the normative reference at 1Y decreases with increased BL disability. Nonoperative treatment is a viable option for certain patients with ASD, and up to 24% of patients demonstrated significant improvement over 1Y with nonoperative care.

The SRS-Schwab adult spinal deformity classification: assessment and clinical correlations based on a prospective operative and nonoperative cohort

BACKGROUND

The SRS-Schwab classification of adult spinal deformity (ASD) is a validated system that provides a common language for the complex pathology of ASD. Classification reliability has been reported; however, correlation with treatment has not been assessed.

OBJECTIVE

To assess the clinical relevance of the SRS-Schwab classification based on correlations with health-related quality of life (HRQOL) measures and the decision to pursue operative vs nonoperative treatment.

METHODS

Prospective analysis of consecutive ASD patients (18 years of age and older) collected through a multicenter group. The SRS-Schwab classification includes a curve type descriptor and 3 sagittal spinopelvic modifiers (sagittal vertical axis, pelvic tilt, pelvic incidence/lumbar lordosis mismatch). Differences in demographics, HRQOL (Oswestry Disability Index, SRS-22, Short Form-36), and classification between operative and nonoperative patients were evaluated.

RESULTS

A total of 527 patients (mean age, 52.9 years; range, 18.4-85.1 years) met inclusion criteria. Significant differences in HRQOL were identified based on SRS-Schwab curve type, with thoracolumbar and primary sagittal deformities associated with greater disability and poorer health status than thoracic or double curve deformities. Operative patients had significantly poorer grades for each of the sagittal spinopelvic modifiers, and progressively higher grades were associated with significantly poorer HRQOL (P < .05). Patients with worse sagittal spinopelvic modifier grades were significantly more likely to require major osteotomies, iliac fixation, and decompression (P ≤ .009).

CONCLUSION

The SRS-Schwab classification provides a validated language to describe and categorize ASD. This study demonstrates that the SRS-Schwab classification reflects severity of disease state based on multiple measures of HRQOL and significantly correlates with the important decision of whether to pursue operative or nonoperative treatment.

Prevalence of human papillomavirus among oesophageal squamous cell carcinoma cases: systematic review and meta-analysis

Background:

Oncogenic human papillomavirus (HPV) has been hypothesised as a risk factor for oesophageal squamous cell carcinoma (OSCC), but aetiological research has been limited by the varying methodology used for establishing HPV prevalence. The aims of this systematic review and meta-analysis were to estimate the prevalence of HPV DNA detected in OSCC tumours and the influence of study characteristics.

Methods:

Study-level estimates of overall and type-specific HPV prevalence were meta-analysed to obtain random-effects summary estimates.

Results:

This analysis included 124 studies with a total of 13 832 OSCC cases. The average HPV prevalence (95% confidence interval) among OSCC cases was 0.277 (0.234, 0.320) by polymerase chain reaction; 0.243 (0.159, 0.326) by in situ hybridisation; 0.304 (0.185, 0.423) by immunohistochemistry; 0.322 (0.154, 0.490) by L1 serology; and 0.176 (0.061, 0.292) by Southern/slot/dot blot. The highest HPV prevalence was found in Africa and Asia, notably among Chinese studies from provinces with high OSCC incidence rates.

Conclusions:

Future research should focus on quantifying HPV in OSCC cases using strict quality control measures, as well as determining the association between HPV and OSCC incidence by conducting large, population-based case–control studies. Such studies will provide a richer understanding of the role of HPV in OSCC aetiology.

Impact of age on the likelihood of reaching a minimum clinically important difference in 374 three-column spinal osteotomies

Object

Spinal osteotomies for adult spinal deformity correction may include resection of all 3 spinal columns (pedicle subtraction osteotomy [PSO] and vertebral column resection [VCR]). The relationship between patient age and health-related quality of life (HRQOL) outcomes for patients undergoing major spinal deformity correction via PSO or VCR has not been well characterized. The goal of this study was to characterize that relationship.

Methods

This study was a retrospective review of 374 patients who had undergone a 3-column osteotomy (299 PSOs and 75 VCRs) and were part of a prospectively collected, multicenter adult spinal deformity database. The consecutively enrolled patients were drawn from 11 sites across the United States. Health-related QOL outcomes, according to the visual analog scale (VAS), Oswestry Disability Index (ODI), 36-Item Short-Form Health Survey (SF-36, physical component score [PCS] and mental component score), and Scoliosis Research Society-22 questionnaire (SRS), were evaluated preoperatively and 1 and 2 years postoperatively. Differences and correlations between patient age and HRQOL outcomes were investigated. Age groupings included young (age ≤ 45 years), middle aged (age 46–64 years), and elderly (age ≥ 65 years).

Results

In patients who had undergone PSO, age significantly correlated (Spearman's correlation coefficient) with the 2-year ODI (ρ = 0.24, p = 0.0450), 2-year SRS function score (ρ = 0.30, p = 0.0123), and 2-year SRS total score (ρ = 0.30, p = 0.0133). Among all patients (PSO+VCR), the preoperative PCS and ODI in the young group were significantly higher and lower, respectively, than those in the elderly. Among the PSO patients, the elderly group had much greater improvement than the young group in the 1- and 2-year PCS, 2-year ODI, and 2-year SRS function and total scores. Among the VCR patients, the young age group had much greater improvement than the elderly in the 1-year SRS pain score, 1-year PCS, 2-year PCS, and 2-year ODI. There was no significant difference among all the age groups as regards the likelihood of reaching a minimum clinically important difference (MCID) within each of the HRQOL outcomes (p > 0.05 for all). Among the PSO patients, the elderly group was significantly more likely than the young to reach an MCID for the 1-year PCS (61% vs 21%, p = 0.0077) and the 2-year PCS (67% vs 17%, p = 0.0054), SRS pain score (57% vs 20%, p = 0.0457), and SRS function score (62% vs 20%, p = 0.0250). Among the VCR patients, the young group was significantly more likely than the elderly patients to reach an MCID for the 1-year (100% vs 20%, p = 0.0036) and 2-year (100% vs 0%, p = 0.0027) PCS scores and 1-year (60% vs 0%, p = 0.0173) and 2-year (70% vs 0%, p = 0.0433) SRS pain scores.

Conclusions

The PSO and VCR are not equivalent surgeries in terms of HRQOL outcomes and patient age. Among patients who underwent PSO, the elderly group started with more preoperative disability than the younger patients but had greater improvements in HRQOL outcomes and was more likely to reach an MCID at 1 and 2 years after treatment. Among those who underwent VCR, all had similar preoperative disabilities, but the younger patients had greater improvements in HRQOL outcomes and were more likely to reach an MCID at 1 and 2 years after treatment.

Likelihood of reaching minimal clinically important difference in adult spinal deformity: a comparison of operative and nonoperative treatment

BACKGROUND

Few studies have examined threshold improvements in health-related quality of life (HRQOL) by measuring minimal clinically important differences (MCIDs) in treatment of adult spinal deformity. We hypothesized that patients undergoing operative treatment would be more likely to achieve MCID threshold improvement compared with those receiving nonoperative care, although a subset of nonoperative patients may still reach threshold.

METHODS

We analyzed a multicenter, prospective, consecutive case series of 464 patients: 225 nonoperative and 239 operative. To be included in the study, patients had to have adult spinal deformity, be older than 18 years, and have both baseline and 1-year follow-up HRQOL measures (Oswestry Disability Index [ODI], Short Form-36 [SF-36] health survey, and Scoliosis Research Society-22 [SRS-22] questionnaire). We compared the percentages of patients achieving established MCID thresholds between operative and nonoperative groups using risk ratios (RR) with a 95% confidence interval (CI).

RESULTS

Compared to nonoperative patients, surgical patients demonstrated significant mean improvement (P<0.01) and were more likely to achieve threshold MCID improvement across all HRQOL scores (ODI RR = 7.37 [CI 4.45, 12.21], SF-36 physical component score RR = 2.96 [CI 2.11, 4.15], SRS Activity RR = 3.16 [CI 2.32, 4.31]). Furthermore, operative patients were more likely to reach threshold MCID improvement in 2 or more HRQOL measures simultaneously and were less likely to deteriorate.

CONCLUSION

Patients in both the operative and nonoperative treatment groups demonstrated improvement in at least one HRQOL measure at 1 year. However, surgical treatment was more likely to result in threshold improvement and more likely to lead to simultaneous improvement across multiple measures of ODI, SF-36, and SRS-22. Although a subset of nonoperative patients achieved threshold improvement, nonoperative patients were significantly less likely to improve in multiple HRQOL measures and more likely to sustain MCID deterioration or no change.

Mild diabetes is not a contraindication for surgical decompression in cervical spondylotic myelopathy: results of the AOSpine North America multicenter prospective study (CSM)

BACKGROUND CONTEXT

Cervical spondylotic myelopathy (CSM) is a chronic spinal cord disease and can lead to progressive or stepwise neurologic decline. Several factors may influence this process, including extent of spinal cord compression, duration of symptoms, and medical comorbidities. Diabetes is a systemic disease that can impact multiple organ systems, including the central and peripheral nervous systems. There has been little information regarding the effect of diabetes on patients with coexistent CSM.

PURPOSE

To provide empirical data regarding the effect of diabetes on treatment outcomes in patients who underwent surgical decompression for coexistent CSM.

STUDY DESIGN/SETTING

Large prospective multicenter cohort study of patients with and without diabetes who underwent decompressive surgery for CSM.

PATIENT SAMPLE

Two hundred thirty-six patients without and 42 patients with diabetes were enrolled. Of these, 37 were mild cases and five were moderate cases. Four required insulin. There were no severe cases associated with end-organ damage.

OUTCOME MEASURES

Self-report measures include Neck Disability Index and version 2 of 36-Item Short Form Health Survey (SF-36v2), and functional measures include modified Japanese Orthopedic Association (mJOA) score and Nurick grade.

METHODS

We compared presurgery symptoms and treatment outcomes between patients with and without diabetes using univariate and multivariate models, adjusting for demographics and comorbidities.

RESULTS

Diabetic patients were older, less likely to smoke, and more likely to be on social security disability insurance. Patients with diabetes presented with a worse Nurick grade, but there were no differences in mJOA and SF-36v2 at presentation. Overall, there was a significant improvement in all outcome parameters at 12 and 24 months. There was no difference in the level of improvement between the patients with and without diabetes, except in the SF-36v2 Physical Functioning, in which diabetic patients experienced significantly less improvement. There were no differences in surgical complication rates between diabetic patients and nondiabetic patients.

CONCLUSIONS

Except for a worse Nurick grade, diabetes does not seem to affect severity of symptoms at presentation for surgery. More importantly, with the exception of the SF-36v2 Physical Functioning scores, outcomes of surgical treatment are similar in patients with diabetes and without diabetes. Surgical decompression is effective and should be offered to patients with diabetes who have symptomatic CSM and are appropriate surgical candidates.

Prevalence and incidence of cervical intra-epithelial neoplasia among female sex workers in Korogocho, Kenya

SETTING

Sex Workers Outreach Programme Clinic, Korogocho, Nairobi, Kenya.

OBJECTIVE

In a cohort of sex workers, to determine 1) the prevalence of cervical intra-epithelial neoplasia (CIN) and its association with human immunodeficiency virus-1 (HIV-1) infection, and 2) the incidence rate of CIN during the 3-year follow-up from December 2009 to December 2012.

DESIGN

Prospective nested cohort study.

RESULTS

Of the 350 women enrolled, the median age was 29 years (range 18-49); 84 (24%) were HIV-1-infected. At enrollment, 54 (15%) had an abnormal cytology, 39 (11%) had low-grade intra-epithelial lesions (LSIL) and 15 (4%) high-grade intraepithelial lesions (HSIL). HIV-1-infected women were 2.7 times (95%CI 1.7-4.4) more likely to have CIN than non-HIV-1-infected women. Among HIV-1-infected women, the prevalence of LSIL and HSIL was 2.5 times (95%CI 1.2-5.1) and seven times (95%CI 2.3-23.3) greater than among non-HIV-infected women. During the follow-up period, 39 (11%) women had incident CIN (6.6/100 person years [py]), with no difference by HIV status, i.e., respectively 7.9/100 py and 6.3/100 py in HIV-1-infected and non-HIV-1-infected women.

CONCLUSION

The prevalence and incidence of CIN among HIV-1-infected sex workers was high; early, regular screening and follow-up of this life-threatening condition is therefore recommended.

Does smoking have an impact on fusion rate in single-level anterior cervical discectomy and fusion with allograft and rigid plate fixation?

Object

Although smoking has been shown to negatively affect fusion rates in patients undergoing multilevel fusions of the cervical and lumbar spine, the effect of smoking on fusion rates in patients undergoing single-level anterior cervical discectomy and fusion (ACDF) with allograft and plate fixation has yet to be thoroughly investigated. The objective of the present study was to address the effect of smoking on fusion rates in patients undergoing a 1-level ACDF with allograft and a locked anterior cervical plate.

Methods

This study is composed of patients from the control groups of 5 separate studies evaluating the use of an anterior cervical disc replacement to treat cervical radiculopathy. For each of the 5 studies the control group consisted of patients who underwent a 1-level ACDF with allograft and a locked cervical plate. The authors of the present study reviewed data obtained in a total of 573 patients; 156 patients were smokers and 417 were nonsmokers. A minimum follow-up period of 24 months was required for inclusion in this study. Fusion status was assessed by independent observers using lateral, neutral, and flexion/extension radiographs.

Results

An overall fusion rate of 91.4% was achieved in all 573 patients. A solid fusion was shown in 382 patients (91.6%) who were nonsmokers. Among patients who were smokers, 142 (91.0%) had radiographic evidence of a solid fusion. A 2-tailed Fisher exact test revealed a p value of 0.867, indicating no difference in the union rates between smokers and nonsmokers.

Conclusions

The authors found no statistically significant difference in fusion status between smokers and nonsmokers who underwent a single-level ACDF with allograft and a locked anterior cervical plate. Although the authors do not promote tobacco use, it appears that the use of allograft with a locked cervical plate in single-level ACDF among smokers produces similar fusion rates as it does in their nonsmoking counterparts.

The efficacy of lumbar discectomy and single-level fusion for spondylolisthesis: results from the NeuroPoint-SD registry

Object

There is significant practice variation and considerable uncertainty among payers and other major stakeholders as to whether many surgical treatments are effective in actual US spine practice. The aim of this study was to establish a multicenter cooperative research group and demonstrate the feasibility of developing a registry to assess the efficacy of common lumbar spinal procedures using prospectively collected patient-reported outcome measures.

Methods

An observational prospective cohort study was conducted at 13 US academic and community sites. Unselected patients undergoing lumbar discectomy or single-level fusion for spondylolisthesis were included. Patients completed the 36-item Short-Form Survey Instrument (SF-36), Oswestry Disability Index (ODI), and visual analog scale (VAS) questionnaires preoperatively and at 1, 3, 6, and 12 months postoperatively. Power analysis estimated a sample size of 160 patients: 125 patients with lumbar disc herniation, and 35 with lumbar spondylolisthesis. All patient data were entered into a secure Internet-based data management platform.

Results

Of 249 patients screened, there were 198 enrolled over 1 year. The median age of the patients was 45.0 years (49% female) for lumbar discectomy (n = 148), and 58.0 years (58% female) for lumbar spondylolisthesis (n = 50). At 30 days, 12 complications (6.1% of study population) were identified. Ten patients (6.8%) with disc herniation and 1 (2%) with spondylolisthesis required reoperation. The overall follow-up rate for the collection of patient-reported outcome data over 1 year was 88.3%. At 30 days, both lumbar discectomy and single-level fusion procedures were associated with significant improvements in ODI, VAS, and SF-36 scores (p ≤ 0.0002), which persisted over the 1-year follow-up period (p < 0.0001). By the 1-year follow-up evaluation, more than 80% of patients in each cohort who were working preoperatively had returned to work.

Conclusions

It is feasible to build a national spine registry for the collection of high-quality prospective data to demonstrate the effectiveness of spinal procedures in actual practice. Clinical trial registration no.: 01220921 (ClinicalTrials.gov).

Nonoperative management of cervical myelopathy: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To conduct a systematic review investigating the evidence of (1) efficacy, effectiveness, and safety of nonoperative treatment of patients with cervical myelopathy; (2) whether the severity of myelopathy affects outcomes of nonoperative treatment; and (3) whether specific activities or minor injuries are associated with neurological deterioration in patients with myelopathy or asymptomatic stenosis being treated nonoperatively.

SUMMARY OF BACKGROUND DATA

Little is known about the appropriate role of nonoperative treatment in the management of cervical myelopathy, which is typically considered a surgical disorder.

METHODS

A systematic search was conducted in PubMed and the Cochrane Collaboration Library for articles published between January 1, 1956, and November 20, 2012. We included all articles that compared nonoperative treatments or observation with surgery for patients with cervical myelopathy or asymptomatic cervical cord compression to determine their effects on clinical outcomes, including myelopathy scales (Japanese Orthopaedic Association, Nurick), general health scores (36-Item Short Form Health Survey), and pain (neck and arm). Nonoperative treatments included physical therapy, medications, injections, orthoses, and traction. We also searched for articles evaluating the effect of specific activities or minor trauma in neurological outcomes. Case reports and studies with less than 10 patients in the exposure group were excluded.

RESULTS

Of 54 citations identified from our search, 5 studies reported in 6 articles met inclusion criteria. In 1 randomized controlled study, there was low evidence that nonoperative treatment may yield equivalent or better outcomes than surgery in those with mild myelopathy. For moderate to severe myelopathy, nonoperative treatment had inferior outcomes versus surgery in 2 cohort studies, despite the fact that surgically treated patients were worse at baseline. There was insufficient evidence to determine whether specific activities or minor trauma is a risk factor for neurological deterioration in those with myelopathy or asymptomatic cord compression.

CONCLUSION

There is a paucity of evidence for nonoperative treatment of cervical myelopathy, and further studies are needed to determine its role more definitively. In particular, for the patient with milder degrees of myelopathy, randomized studies comparing nonoperative with surgical treatment would be particularly helpful, as would trials comparing specific types of nonoperative treatments with the natural history of myelopathy. EVIDENCE-BASED CLINICAL RECOMMENDATIONS:

RECOMMENDATION 1

Because myelopathy is known to be a typically progressive disorder and there is little evidence that nonoperative treatment halts or reverses its progression, we recommend not routinely prescribing nonoperative treatment as the primary modality in patients with moderate to severe myelopathy.

OVERALL STRENGTH OF EVIDENCE

Low.

STRENGTH OF RECOMMENDATION

Strong.

RECOMMENDATION 2

If there is a role for nonoperative treatment as a primary treatment modality, it may be in the patient with mild myelopathy. However, it is not clear which specific forms of nonoperative treatment provide any benefit compared with the natural history. If nonoperative treatment is selected, we suggest care be taken to observe for neurological deterioration.

OVERALL STRENGTH OF EVIDENCE

Low.

STRENGTH OF RECOMMENDATION

Weak.

RECOMMENDATION 3

In those with asymptomatic spondylotic cord compression but no clinical myelopathy, the available literature neither supports nor refutes the notion that minor trauma is a risk factor for neurological deterioration. We suggest that patients should be counseled about this uncertainty.

OVERALL STRENGTH OF EVIDENCE

Low.

STRENGTH OF RECOMMENDATION

Weak. Recommendation 4: In those with a clinical diagnosis of cervical spondylotic myelopathy but no ossification of the posterior longitudinal ligament, the available studies did not specifically address the issue of neurological deterioration secondary to minor trauma. However, in those with underlying ossification of the posterior longitudinal ligament, trauma may be more likely to cause worsening of existing myelopathy or even initiate symptoms in those who were previously asymptomatic. We suggest that patients should be counseled about these possibilities.

OVERALL STRENGTH OF EVIDENCE

Low.

STRENGTH OF RECOMMENDATION

Weak.

Reoperation rates and impact on outcome in a large, prospective, multicenter, adult spinal deformity database

Object

Complications and reoperation for surgery to correct adult spinal deformity are not infrequent, and many studies have analyzed the rates and factors that influence the likelihood of reoperation. However, there is a need for more comprehensive analyses of reoperation in adult spinal deformity surgery from a global standpoint, particularly focusing on the 1st year following operation and considering radiographic parameters and the effects of reoperation on health-related quality of life (HRQOL). This study attempts to determine the prevalence of reoperation following surgery for adult spinal deformity, assess the indications for these reoperations, evaluate for a relation between specific radiographic parameters and the need for reoperation, and determine the potential impact of reoperation on HRQOL measures.

Methods

A retrospective review was conducted of a prospective, multicenter, adult spinal deformity database collected through the International Spine Study Group. Data collected included age, body mass index, sex, date of surgery, information regarding complications, reoperation dates, length of stay, and operation time. The radiographic parameters assessed were total number of levels instrumented, total number of interbody fusions, C-7 sagittal vertical axis, uppermost instrumented vertebra (UIV) location, and presence of 3-column osteotomies. The HRQOL assessment included Oswestry Disability Index (ODI), 36-Item Short Form Health Survey physical component and mental component summary, and SRS-22 scores. Smoking history, Charlson Comorbidity Index scores, and American Society of Anesthesiologists Physical Status classification grades were also collected and assessed for correlation with risk of early reoperation. Various statistical tests were performed for evaluation of specific factors listed above, and the level of significance was set at p < 0.05.

Results

Fifty-nine (17%) of a total of 352 patients required reoperation. Forty-four (12.5%) of the reoperations occurred within 1 year after the initial surgery, including 17 reoperations (5%) within 30 days.

Two hundred sixty-eight patients had a minimum of 1 year of follow-up. Fifty-three (20%) of these patients had a 3-column osteotomy, and 10 (19%) of these 53 required reoperation within 1 year of the initial procedure. However, 3-column osteotomy was not predictive of reoperation within 1 year, p = 0.5476). There were no significant differences between groups with regard to the distribution of UIV, and UIV did not have a significant effect on reoperation rates. Patients needing reoperation within 1 year had worse ODI and SRS-22 scores measured at 1-year follow-up than patients not requiring operation.

Conclusions

Analysis of data from a large multicenter adult spinal deformity database shows an overall 17% reoperation rate, with a 19% reoperation rate for patients treated with 3-column osteotomy and a 16% reoperation rate for patients not treated with 3-column osteotomy. The most common indications for reoperation included instrumentation complications and radiographic failure. Reoperation significantly affected HRQOL outcomes at 1-year follow-up. The need for reoperation may be minimized by carefully considering spinal alignment, termination of fixation, and type of surgical procedure (presence of osteotomy). Precautions should be taken to avoid malposition or instrumentation (rod) failure.

Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study

BACKGROUND

Cervical spondylotic myelopathy is the leading cause of spinal cord dysfunction worldwide. The objective of this study was to evaluate the impact of surgical decompression on functional, quality-of-life, and disability outcomes at one year after surgery in a large cohort of patients with this condition.

METHODS

Adult patients with symptomatic cervical spondylotic myelopathy and magnetic resonance imaging evidence of spinal cord compression were enrolled at twelve North American centers from 2005 to 2007. At enrollment, the myelopathy was categorized as mild (modified Japanese Orthopaedic Association [mJOA] score ≥ 15), moderate (mJOA = 12 to 14), or severe (mJOA < 12). Patients were followed prospectively for one year, at which point the outcomes of interest included the mJOA score, Nurick grade, Neck Disability Index (NDI), and Short Form-36 version 2 (SF-36v2). All outcomes at one year were compared with the preoperative values with use of univariate paired statistics. Outcomes were also compared among the severity classes with use of one-way analysis of variance. Finally, a multivariate analysis that adjusted for baseline differences among the severity groups was performed. Treatment-related complication data were collected and the overall complication rate was calculated.

RESULTS

Eighty-five (30.6%) of the 278 enrolled patients had mild cervical spondylotic myelopathy, 110 (39.6%) had moderate disease, and 83 (29.9%) had severe disease preoperatively. One-year follow-up data were available for 222 (85.4%) of 260 patients. There was a significant improvement from baseline to one year postoperatively (p < 0.05) in the mJOA score, Nurick grade, NDI score, and all SF-36v2 health dimensions (including the mental and physical health composite scores) except general health. With the exception of the change in the mJOA, the degree of improvement did not depend on the severity of the preoperative symptoms. These results remained unchanged after adjusting for relevant confounders in the multivariate analysis. Fifty-two patients experienced complications (prevalence, 18.7%), with no significant differences among the severity groups.

CONCLUSIONS

Surgical decompression for the treatment of cervical spondylotic myelopathy was associated with improvement in functional, disability-related, and quality-of-life outcomes at one year of follow-up for all disease severity categories. Furthermore, complication rates observed in the study were commensurate with those in previously reported cervical spondylotic myelopathy series.

Operative and nonoperative treatment approaches for lumbar degenerative disc disease have similar long-term clinical outcomes among patients with positive discography

OBJECTIVE

It remains unclear whether fusion for lumbar degenerative disc disease with positive discography produces better outcomes compared with nonoperative treatment. The aim of this study was to compare outcomes of patients with discography-concordant lumbar degenerative disc disease electing for fusion versus nonoperative treatment.

METHODS

We retrospectively reviewed consecutive patients with back pain and concordant lumbar discogram who were offered fusion. Follow-up questionnaires included pain score, Oswestry disability index, short form-12, and satisfaction scale. Patients were stratified based on whether they elected for fusion or nonoperative treatment.

RESULTS

Overall follow-up was 48% (96/200). Patients lacking follow-up were slightly older (P = 0.021) and less likely to be smokers (P = 0.013). Between patients with and without follow-up, there were no significant differences in pain score at initial visit, body mass index, or gender (P ≥ 0.40). The 96 patients for whom follow-up was obtained included 53 in the operative and 43 in the nonoperative groups. At baseline, there were no significant differences between these groups based on age, pain score, body mass index, smoking, or gender (P ≥ 0.25). Mean follow-up was 63 months for operative and 58 months for nonoperative patients (P = 0.20). The mean pain score at last follow-up improved significantly for operative and nonoperative patients (P < 0.001). At follow-up, operative and nonoperative groups did not differ significantly with regard to pain scores, Oswestry disability index, short form-12, or satisfaction scale.

CONCLUSIONS

Comparison of long-term outcomes for patients with back pain and concordant discography did not demonstrate a significant difference in outcome measures of pain, health status, satisfaction, or disability based on whether the patient elected for fusion or nonoperative treatment.

A standardized nomenclature for cervical spine soft-tissue release and osteotomy for deformity correction

Object

Cervical spine osteotomies are powerful techniques to correct rigid cervical spine deformity. Many variations exist, however, and there is no current standardized system with which to describe and classify cervical osteotomies. This complicates the ability to compare outcomes across procedures and studies. The authors' objective was to establish a universal nomenclature for cervical spine osteotomies to provide a common language among spine surgeons.

Methods

A proposed nomenclature with 7 anatomical grades of increasing extent of bone/soft tissue resection and destabilization was designed. The highest grade of resection is termed the major osteotomy, and an approach modifier is used to denote the surgical approach(es), including anterior (A), posterior (P), anterior-posterior (AP), posterior-anterior (PA), anterior-posterior-anterior (APA), and posterior-anterior-posterior (PAP). For cases in which multiple grades of osteotomies were performed, the highest grade is termed the major osteotomy, and lower-grade osteotomies are termed minor osteotomies. The nomenclature was evaluated by 11 reviewers through 25 different radiographic clinical cases. The review was performed twice, separated by a minimum 1-week interval. Reliability was assessed using Fleiss kappa coefficients.

Results

The average intrarater reliability was classified as “almost perfect agreement” for the major osteotomy (0.89 [range 0.60–1.00]) and approach modifier (0.99 [0.95–1.00]); it was classified as “moderate agreement” for the minor osteotomy (0.73 [range 0.41–1.00]). The average interrater reliability for the 2 readings was the following: major osteotomy, 0.87 (“almost perfect agreement”); approach modifier, 0.99 (“almost perfect agreement”); and minor osteotomy, 0.55 (“moderate agreement”). Analysis of only major osteotomy plus approach modifier yielded a classification that was “almost perfect” with an average intrarater reliability of 0.90 (0.63–1.00) and an interrater reliability of 0.88 and 0.86 for the two reviews.

Conclusions

The proposed cervical spine osteotomy nomenclature provides the surgeon with a simple, standard description of the various cervical osteotomies. The reliability analysis demonstrated that this system is consistent and directly applicable. Future work will evaluate the relationship between this system and health-related quality of life metrics.

Failure of lumbopelvic fixation after long construct fusions in patients with adult spinal deformity: clinical and radiographic risk factors: clinical article

OBJECT

Lumbopelvic fixation provides biomechanical support to the base of the long constructs used for adult spinal deformity. However, the failure rate of the lumbopelvic fixation and its risk factors are not well known. The authors' objective was to report the failure rate and risk factors for lumbopelvic fixation in long instrumented spinal fusion constructs performed for adult spinal deformity.

METHODS

This retrospective review included 190 patients with adult spinal deformity who had long construct instrumentation (> 6 levels) with iliac screws. Patients' clinical and radiographic data were analyzed. The patients were divided into 2 groups: a failure group and a nonfailure group. A minimum 2-year follow-up was required for inclusion in the nonfailure group. In the failure group, all patients were included in the study regardless of whether the failure occurred before or after 2 years. In both groups, the patients who needed a revision for causes other than lumbopelvic fixation (for example, proximal junctional kyphosis) were also excluded. Failures were defined as major and minor. Major failures included rod breakage between L-4 and S-1, failure of S-1 screws (breakage, halo formation, or pullout), and prominent iliac screws requiring removal. Minor failures included rod breakage between S-1 and iliac screws and failure of iliac screws. Minor failures did not require revision surgery. Multiple clinical and radiographic values were compared between major failures and nonfailures.

RESULTS

Of 190 patients, 67 patients met inclusion criteria and were enrolled in the study. The overall failure rate was 34.3%; 8 patients had major failure (11.9%) and 15 had minor failure (22.4%). Major failure occurred at a statistically significant greater rate in patients who had undergone previous lumbar surgery, had greater pelvic incidence, and had poor restoration of lumbar lordosis and/or sagittal balance (that is, undercorrection). Patients with a greater number of comorbidities and preoperative coronal imbalance showed trends toward an increase in major failures, although these trends did not reach statistical significance. Age, sex, body mass index, smoking history, number of fusion segments, fusion grade, and several other radiographic values were not shown to be associated with an increased risk of major failure. Seventy percent of patients in the major failure group had anterior column support (anterior lumbar interbody fusion or transforaminal lumbar interbody fusion) while 80% of the nonfailure group had anterior column support.

CONCLUSIONS

The incidence of overall failure was 34.3%, and the incidence of clinically significant major failure of lumbopelvic fixation after long construct fusion for adult spinal deformity was 11.9%. Risk factors for major failures are a large pelvic incidence, revision surgery, and failure to restore lumbar lordosis and sagittal balance. Surgeons treating adult spinal deformity who use lumbopelvic fixation should pay special attention to restoring optimal sagittal alignment to prevent lumbopelvic fixation failure.

Dysphagia following combined anterior-posterior cervical spine surgeries

OBJECT

This study was undertaken to evaluate the incidence of and risk factors associated with the development of dysphagia following same-day combined anterior-posterior cervical spine surgeries.

METHODS

The records of 30 consecutive patients who underwent same-day combined anterior-posterior cervical spine surgery were reviewed. The presence of dysphagia was assessed by a formalized screening protocol using history/clinical presentation and a bedside swallowing test, followed by formal evaluation by speech and language pathologists and/or fiberoptic endoscopic evaluation of swallowing/modified barium swallow when necessary. Age, sex, previous cervical surgeries, diagnoses, duration of procedure, specific vertebral levels and number of levels operated on, degree of sagittal curve correction, use of anterior plate, estimated blood loss, use of recombinant human bone morphogenetic protein-2 (rhBMP-2), and length of hospital stay following procedures were analyzed.

RESULTS

In the immediate postoperative period, 13 patients (43.3%) developed dysphagia. Outpatient follow-up data were available for 11 patients with dysphagia, and within this subset, all cases of dysphagia resolved subjectively within 12 months following surgery. The mean numbers of anterior levels surgically treated in patients with and without dysphagia were 5.1 and 4.0, respectively (p = 0.004). All patients (100%) with dysphagia had an anterior procedure that extended above C-4, compared with 58.8% of patients without dysphagia (p = 0.010). Patients with dysphagia had significantly greater mean correction of C2-7 lordosis than patients without dysphagia (p = 0.020). The postoperative sagittal occiput-C2 angle and the change in this angle were not significantly associated with the occurrence of dysphagia (p = 0.530 and p = 0.711, respectively). Patients with postoperative dysphagia had significantly longer hospital stays than those who did not develop dysphagia (p = 0.004). No other significant difference between the dysphagia and no-dysphagia groups was identified; differences with respect to history of previous anterior cervical surgery (p = 0.141), use of an anterior plate (p = 0.613), and mean length of anterior cervical operative time (p = 0.541) were not significant.

CONCLUSIONS

The incidence of dysphagia following combined anterior-posterior cervical surgery in this study was comparable to that of previous reports. The risk factors for dysphagia that were identified in this study were increased number of anterior levels exposed, anterior surgery that extended above C-4, and increased surgical correction of C2-7 lordosis.

Sexual function in older adults following thoracolumbar to pelvic instrumentation for spinal deformity

Object

Sexual function is an often-overlooked aspect of health-related quality of life among older adults treated for spinal deformity. The authors' objective was to assess sexual function among older adults following thoracolumbar fusion with pelvic fixation for spinal deformity.

Methods

This was a retrospective review of consecutive older adults (≥50 years) treated with posterior thoracolumbar instrumentation (including pelvic fixation) for spinal deformity and with a minimum 18-month follow-up. Patients completed the Changes in Sexual Function Questionnaire-14 (CSFQ-14), Oswestry Disability Index (ODI), and 12-Item Short-Form Health Survey (SF-12).

Results

Sixty-two patients (45 women and 17 men) with a mean age of 70 years (range 50–83 years) met the inclusion criteria. Eight women did not complete all questionnaires and were excluded from the subanalysis. The mean number of instrumented levels was 9.8 (range 6–18), and the mean follow-up was 36 months (range 19–69 months). Based on the CSFQ-14, 13 patients (24%) had normal sexual function, and 8 (15%), 10 (19%), and 23 (42%) had mild, moderate, and severe dysfunction, respectively. Thirty-nine percent of patients reporting severe sexual dysfunction did not have available partners—23% because of a partner's death and 16% because of a partner's illness)—or had significant medical comorbidities of their own (48%). Thirty-nine percent of assessed patients had either no or only mild sexual dysfunction. Patients with minimal or mild disability tended to have no or mild sexual dysfunction.

Conclusions

The authors of this study assessed sexual function in older adults following surgical correction of spinal deformity that included posterior instrumented fusion and iliac bolts. Nearly 40% of assessed patients had either no or only mild sexual dysfunction, suggesting that despite an older age and extensive spinopelvic instrumentation, it remains very possible to maintain or achieve satisfactory sexual function.