Validity of the global alignment proportion (GAP) score in predicting mechanical complications after adult spinal deformity surgery in elderly patients

Comparison of Surgical Burden, Radiographic and Clinical Outcomes According to the Severity of Baseline Sagittal Imbalance in Adult Spinal Deformity Patients

OBJECTIVE

To determine the clinical impact of the baseline sagittal imbalance severity in patients with adult spinal deformity (ASD).

METHODS

We retrospectively reviewed patients who underwent ≥ 5-level fusion including the pelvis, for ASD with a ≥ 2-year follow-up. Using the Scoliosis Research Society-Schwab classification system, patients were classified into 3 groups according to the severity of the preoperative sagittal imbalance: mild, moderate, and severe. Postoperative clinical and radiographic results were compared among the 3 groups.

RESULTS

A total of 259 patients were finally included. There were 42, 62, and 155 patients in the mild, moderate, and severe groups, respectively. The perioperative surgical burden was greatest in the severe group. Postoperatively, this group also showed the largest pelvic incidence minus lumbar lordosis mismatch, suggesting a tendency towards undercorrection. No statistically significant differences were observed in proximal junctional kyphosis, proximal junctional failure, or rod fractures among the groups. Visual analogue scale for back pain and Scoliosis Research Society-22 scores were similar across groups. However, severe group's last follow-up Oswestry Disability Index (ODI) scores significantly lower than those of the severe group.

CONCLUSION

Patients with severe sagittal imbalance were treated with more invasive surgical methods along with increased the perioperative surgical burden. All patients exhibited significant radiological and clinical improvements after surgery. However, regarding ODI, the severe group demonstrated slightly worse clinical outcomes than the other groups, probably due to relatively higher proportion of undercorrection. Therefore, more rigorous correction is necessary to achieve optimal sagittal alignment specifically in patients with severe baseline sagittal imbalance.

Assessing the predictive power of the GAP score on mechanical complications: a comprehensive systematic review and meta-analysis

PURPOSE

The prevention of mechanical complications (MC) is a major concern in adult spinal deformity (ASD) correction surgery; thus, the global alignment and proportion (GAP) score was developed to assess MC risk. Numerous studies have clarified the validity of the GAP score, but their contradictory results have prevented researchers from reaching compelling conclusions. This study aimed to analyze the predictive power of the GAP score on MC via a meta-analysis.

METHODS

A total of 1,617 patients were included in the meta-analysis. Studies relevant to the GAP score and MC were identified in PubMed, EMBASE, and Cochrane CENTRAL and screened according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The GAP score categories of the patients and their MC/revision surgery status were collected. The data collected for the meta-analysis of odds ratios (OR) included the number of patients in the GAP score subgroups and their MC/revision surgery status. To calculate the OR, three GAP score subgroups were combined into two groups; hence, the analysis was conducted twice (gap proportioned [GAP-P] and higher groups, and gap severely disproportioned [GAP-SD] and lower groups).

RESULTS

Eleven studies were collected; of them, revision surgery data were available for seven. The proportion of MC in the studies was 27.7-60.6%, while that of revision surgery was 11.7-34.9%. In the meta-analysis of the GAP-P and higher score groups, the difference in MC ratio was significant (OR = 2.83; 95% confidence interval [CI] = 1.20-6.67; P = 0.02), whereas that for revision surgery was not. For the GAP-SD and lower score groups, the GAP-SD group had significantly higher proportions of both MC (OR = 2.65; 95% CI = 1.57-4.45; P < 0.001) and revision surgery (OR = 2.27; 95% CI = 1.33-3.88; P = 0.003). Publication bias was significant only in the latter MC analysis.

CONCLUSION

The GAP score offers predictive value for the risk of mechanical complications.

Can Pelvic Incidence Change After Lumbo-Pelvic Fixation for Adult Spine Deformity, and Would the Change be Affected by the Type of Pelvic Fixation?

STUDY DESIGN

Retrospective review.

OBJECTIVE

To assess the change in pelvic incidence (PI) after lumbo-pelvic fixation and the differential impact of the type of pelvic fixation: S2-alar-iliac screws (S2AI) versus Iliac screws (IS) on postoperative PI.

SUMMARY OF BACKGROUND DATA

Recent studies suggest that changes occur to the previously assumed fixed PI after spino-pelvic fixation.

METHODS

Adult spine deformity (ASD) patients who underwent spino-pelvic fixation with≥4 levels of fusion were included. Preoperative and postoperative PI, lumbar lordosis (LL), thoracic kyphosis, pelvic tilt, sacral slope, PI-LL mismatch, and the Sagittal Vertical Axis (SVA) were analyzed on EOS imaging. A significant PI change was established at≥6°. Patients were categorized based on the type of pelvic fixation (S2AI vs. IS).

RESULTS

One-hundred-forty-nine patients were included. Of these, 77(52%) had a>6° change in their PI postoperatively. In patients with high preoperative PI (>60°), 62% had a significant PI change compared with 33% of patients with normal PI (40°-60°) and 53% in patients with low PI (<40°; P =0.01). PI was likely to decrease in patients with high baseline PI (>60°) and to increase in patients with low baseline PI (<40°). Patients with a significant PI change had a higher PI-LL. Patients in the S2AI group (n=99) and those in the IS group (n=50) were comparable at baseline. In the S2AI group, 50 (51%) patients had>6° change in their PI compared with 27(54%) patients in the IS group( P =0.65). In both groups, patients with high preoperative PI were more prone to significant postoperative changes ( P =0.02 in IS, P =0.01 in S2AI).

CONCLUSION

PI changed significantly in 50% of patients postoperatively, especially in those with high/low preoperative PI and those with severe baseline sagittal imbalance. This occurs similarly in patients with S2AI and those with IS screws. Surgeons should keep in mind these anticipated changes while planning ideal LL, as this impacts postoperative PI-LL mismatch.

LEVEL OF EVIDENCE

4.

Analysis of Mechanical Failure Using the GAP Score After Surgery With Lateral and Posterior Fusion for Adult Spinal Deformity

STUDY DESIGN

A retrospective observational study.

OBJECTIVE

The purpose of this study was to evaluate the Global Alignment and Proportion (GAP) score and mechanical failure (MF) following corrective fusion surgery with planned 2-stage surgery using lateral lumbar interbody fusion in patients with adult spinal deformity (ASD).

METHODS

Fifty-four patients (2 men, 52 females, aged 70.3 years) were included. MF, proximal junctional failure (PJF), and rod breakage (RB) occurred in 46.3% (25/54), 22.2% (12/54), and 29.6% (16/54) of patients, respectively. The immediate postoperative GAP scores were compared between patients with MF and without MF (MF+ and MF-, respectively). GAP scores in groups with and without PJF or RB were also compared.

RESULTS

Patients were grouped according to the GAP score for spinopelvic alignment: 23 (42.6%) as proportioned, 22 (40.7%) as moderately disproportioned, and 9 (16.7%) as severely disproportioned. The pre- and postoperative spinopelvic parameters did not differ significantly between the MF- and MF+ groups except pelvic incidence. Postoperatively, the mean pelvic incidence-lumbar lordosis changed to <10° in both groups. The GAP score and 3 categories of GAP scores did not differ significantly between the PJF- and PJF+ groups or between the RB+ and RB- groups.

CONCLUSION

Multiple factors can cause PJF and RB, and the patient's background may affect the ability to use the GAP score to predict MF. Further research may be needed in the future using modified GAP scores with additional factors in ASD patients.

Comparison of complications, revisions, spinopelvic parameters, and health-related quality of life after posterior spinal fusion using multiple-rod constructs or two-rod constructs for adult spinal deformity: a systematic review and meta-analysis

BACKGROUND

The incidence of mechanical complications is high in patients undergoing posterior spinal fusion (PSF) for adult spinal deformity (ASD), especially for cases with severe sagittal malalignment or a prior spinal fusion requiring three-column osteotomy (3-CO) or spinopelvic fixation (SPF). The purpose of this systematic review and meta-analysis was to compare the complications, revisions, radiographic spinopelvic parameters, health-related quality of life (HRQoL), and surgical data of PSF using multiple-rod constructs to those of two-rod constructs for the treatment of ASD.

METHODS

A comprehensive literature search was performed for relevant studies in PubMed, EMBASE, Web of Science, and the Cochrane Library. Complications, revisions, spinopelvic parameters, HRQoL, and surgical date were compared between patients with ASD who underwent PSF using multiple-rod constructs (multi-rod group) and two-rod constructs (two-rod group).

RESULTS

Ten studies, comprising 797 patients with ASD (399 in the multi-rod group and 398 in the two-rod group), were included. All these studies were retrospective cohort studies. There were no significant differences in the surgical, wound-related, and systemic complications between the groups. In the multi-rod group, we noted a significantly lower incidence of rod fracture (RR, 0.43; 95% CI 0.33 to 0.57, P < 0.01), pseudoarthrosis (RR, 0.38; 95% CI 0.28 to 0.53, P < 0.01), and revisions (RR, 0.44; 95% CI 0.33 to 0.58, P < 0.01); a superior restoration of PI-LL (WMD, 3.96; 95% CI 1.03 to 6.88, P < 0.01) and SVA (WMD, 31.53; 95% CI 21.16 to 41.90, P < 0.01); a better improvement of ODI score (WMD, 6.82; 95% CI 2.33 to 11.31, P < 0.01), SRS-22 total score (WMD, 0.44; 95% CI 0.06 to 0.83, P = 0.02), and VAS-BP score (WMD, 1.02; 95% CI 0.31 to 1.73, P < 0.01).

CONCLUSION

Compared with the two-rod constructs, PSF using multiple-rod constructs was associated with a lower incidence of mechanical complications, a lower revision rate, a superior restoration of sagittal alignment, and a better improvement of HRQoL, without increasing surgical invasiveness. Multiple-rod constructs should be routinely considered to for ASD patients, especially for cases with severe sagittal malalignment or a prior spinal fusion requiring 3-CO or SPF.

A Validation Study of Four Preoperative Surgical Planning Tools for Adult Spinal Deformity Surgery in Proximal Junctional Kyphosis and Clinical Outcomes

BACKGROUND

Four guidelines have been suggested for optimal correction in adult spinal deformity surgery: Scoliosis Research Society (SRS)-Schwab classification, age-adjusted sagittal alignment goals, Global Alignment and Proportion (GAP) score, and the Roussouly algorithm. Whether these goals provide benefit in both proximal junctional kyphosis (PJK) reduction and clinical outcome improvement remains unclear.

OBJECTIVE

To validate 4 preoperative surgical planning tools in PJK development and clinical outcomes.

METHODS

We retrospectively reviewed patients who underwent ≥5-segment fusion including the sacrum for adult spinal deformity with a follow-up of ≥2-year. PJK development and clinical outcomes were compared among the groups separately using 4 surgical guidelines: SRS-Schwab pelvic incidence (PI)-lumbar lordosis (LL) modifier (Group 0, +, ++), age-adjusted PI-LL goal (undercorrection, matched correction, and overcorrection), GAP score (proportioned, moderately disproportioned, and severely disproportioned groups), and the Roussouly algorithm (restored and nonrestored groups).

RESULTS

A total of 189 patients were included in this study. The mean age was 68.3 years, and there were 162 women (85.7%). There were no differences in the rate of PJK development and clinical outcomes among SRS-Schwab PI-LL modifier and GAP score groups. With the age-adjusted PI-LL goal, PJK developed significantly less frequently in the matched group compared with the under- and overcorrection groups. Clinical outcomes were significantly better in the matched group compared with the under- and overcorrection groups. With the Roussouly algorithm, PJK developed significantly less frequently in the restored group than in the nonrestored group. However, there were no differences in clinical outcomes between the 2 Roussouly groups.

CONCLUSION

Correction according to the age-adjusted PI-LL goal and the restored Roussouly type was associated with reduced PJK development. However, differences in clinical outcomes were only observed in the age-adjusted PI-LL groups.

Should Global Realignment Be Tailored to Frailty Status for Patients Undergoing Surgical Intervention for Adult Spinal Deformity?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes.

SUMMARY OF BACKGROUND DATA

The Global Alignment and Proportion (GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to the development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications.

MATERIALS AND METHODS

We included 412 surgical ASD patients with two-year follow-up. Frailty was quantified using the modified Adult Spinal Deformity Frailty Index (mASD-FI). Outcomes: proximal junctional kyphosis and proximal junctional failure (PJF), major mechanical complications, and "Best Clinical Outcome" (BCO), defined as Oswestry Disability Index<15 and Scoliosis Research Society 22-item Questionnaire Total>4.5. Logistic regression analysis established a six-week score based on GAP score, frailty, and Oswestry Disability Index US Norms. Logistic regression followed by conditional inference tree analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty-modified GAP score.

RESULTS

Baseline frailty categories: 57% not frail, 30% frail, 14% severely frail. Overall, 39 of patients developed proximal junctional kyphosis, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The mASD-FI demonstrated a correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at two years (all P <0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score (FAR Score)=0.49×mASD-FI+0.38×GAP Score. Thresholds for the FAR score (0-13): proportioned: <3.5, moderately disproportioned: 3.5-7.5, severely disproportioned: >7.5. Multivariable logistic regression assessing FAR score demonstrated associations with mechanical complications, reoperation, and meeting BCO by two years (all P <0.05), whereas the original GAP score was only significant for reoperation.

CONCLUSION

This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity.

LEVEL OF EVIDENCE

III.

Sagittal realignment: surgical restoration of the global alignment and proportion score parameters: a subgroup analysis. What are the consequences of failing to realign?

INTRODUCTION

The Global Alignment and Proportion (GAP) score incorporates three domains directly modified with surgery (relative pelvic version-RPV, relative lumbar lordosis-RLL, lumbar distribution index-LDI) and one indirectly restored (relative spinopelvic alignment-RSA). We analyzed our surgical realignment performance and the consequences of domain-specific realignment failure on mechanical complications and PROMs.

MATERIALS AND METHODS

From an adult spinal deformity prospective multicenter database, we selected patients: fused to pelvis, upper instrumented vertebra at or above L1, and 2 years of follow-up. Descriptive, univariate and multivariate analyses were employed.

RESULTS

The sample included 333 patients. RLL-6w showed the highest success rate (58.3% aligned), but 16.5% of patients were classified in the "Severe hypolordosis" and "Hyperlordosis" subgroups. RPV-6w was the most challenging to realign, with 51.6% moderate or severe retroversion. Regarding RSA-6w, 21.9% had severe positive malalignment. Correct alignment of RPV-6w (p = 0.025) and RSA-6w (p = 0.002) proved to be protective factors against the development of mechanical complications. Severe pelvic retroversion (p = 0.026) and severe positive malalignment (p = 0.007) were risk factors for mechanical complications. RSA-6w "Severe positive malalignment" was associated with less improvement in PROMs: ∆ODI (8.83 vs 17.2; p = 0.011), ∆SRS-22 total (0.54 vs 0.87; p = 0.007), and ∆SF-36PCS (3.47 vs 7.76; p = 0.04); MCID for ODI (37.0 vs 55.5%; p = 0.023), and SRS-22 (40.8 vs 60.1%; p = 0.015); and PASS for ODI (17.6 vs 31.7%; p = 0.047).

CONCLUSIONS

RPV was the most underperformed modifiable parameter. Severe pelvic retroversion and severe positive malalignment influenced the occurrence of mechanical complications. Severe positive malalignment affected PROMs improvement.

Mechanical complications and reoperations after adult spinal deformity surgery: a clinical analysis with the GAP score

PURPOSE

Adult spinal deformity (ASD) surgery is prone to postoperative complications, leading to high reoperation rates. The global alignment and proportion (GAP) score is a novel method to predict mechanical complications (MC) based on the optimal parameters related to individual pelvic incidence. The aim of this study was to determine the cut-off point and the predictive value of the GAP score for those MCs that require reoperation. A secondary aim was to investigate the cumulative incidence of MCs requiring reoperation during a long follow-up period.

METHODS

In total, 144 ASD patients were operated at our institution due to marked symptomatic spinal deformity between 2008 and 2020. The cut-off point and the predictive value of the GAP score for the MCs that required reoperation and the cumulative incidence of reoperated MCs after index surgery were determined.

RESULTS

A total of 142 patients were included in the analysis. The risk for having an MC that required reoperation was significantly lower when the postoperative GAP score was < 5 (HR = 3.55, 95% CI: 1.40-9.02). The discriminative power of the GAP score to predict MCs that require reoperation was good with an AUC of 0.70 (95% CI: 0.58-0.81). The cumulative incidence of reoperated MCs was 18%.

CONCLUSION

The GAP score was associated with the risk for MCs that require reoperation. The best predictive value for surgically treated MC was with the GAP score [Formula: see text] 5. The cumulative incidence of the reoperated MCs was 18%.

Association between sagittal alignment and loads at the adjacent segment in the fused spine: a combined clinical and musculoskeletal modeling study of 205 patients with adult spinal deformity

PURPOSE

Sagittal malalignment is a risk factor for mechanical complications after surgery for adult spinal deformity (ASD). Spinal loads, modulated by sagittal alignment, may explain this relationship. The aims of this study were to investigate the relationships between: (1) postoperative changes in loads at the proximal segment and realignment, and (2) absolute postoperative loads and postoperative alignment measures.

METHODS

A previously validated musculoskeletal model of the whole spine was applied to study a clinical sample of 205 patients with ASD. Based on clinical and radiographic data, pre-and postoperative patient-specific alignments were simulated to predict loads at the proximal segment adjacent to the spinal fusion.

RESULTS

Weak-to-moderate associations were found between pre-to-postop changes in lumbar lordosis, LL (r =  - 0.23, r =  - 0.43; p < 0.001), global tilt, GT (r = 0.26, r = 0.38; p < 0.001) and the Global Alignment and Proportion score, GAP (r = 0.26, r = 0.37; p < 0.001), and changes in compressive and shear forces at the proximal segment. GAP score parameters, thoracic kyphosis measurements and the slope of upper instrumented vertebra were associated with changes in shear. In patients with T10-pelvis fusion, moderate-to-strong associations were found between postoperative sagittal alignment measures and compressive and shear loads, with GT showing the strongest correlations (r = 0.75, r = 0.73, p < 0.001).

CONCLUSIONS

Spinal loads were estimated for patient-specific full spinal alignment profiles in a large cohort of patients with ASD pre-and postoperatively. Loads on the proximal segments were greater in association with sagittal malalignment and malorientation of proximal vertebra. Future work should explore whether they provide a causative mechanism explaining the associated risk of proximal junction complications.

The Effects of Global Alignment and Proportionality Scores on Postoperative Outcomes After Adult Spinal Deformity Correction

BACKGROUND

Recent studies have suggested achieving global alignment and proportionality (GAP) alignment may influence mechanical complications after adult spinal deformity (ASD) surgery.

OBJECTIVE

To investigate the association between the GAP score and mechanical complications after ASD surgery.

METHODS

Patients with ASD with at least 5-level fusion to pelvis and minimum 2-year data were included. Multivariate analysis was used to find an association between proportioned (P), GAP-moderately disproportioned, and severely disproportioned (GAP-SD) states and mechanical complications (inclusive of proximal junctional kyphosis [PJK], proximal junctional failure [PJF], and implant-related complications [IC]). Severe sagittal deformity was defined by a "++" in the Scoliosis Research Society (SRS)-Schwab criteria for sagittal vertebral axis or pelvic incidence and lumbar lordosis.

RESULTS

Two hundred ninety patients with ASD were included. Controlling for age, Charlson comorbidity index, invasiveness and baseline deformity, and multivariate analysis showed no association of GAP-moderately disproportioned patients with proximal junctional kyphosis, PJF, or IC, while GAP-SD patients showed association with IC (odds ratio [OR]: 1.7, [1.1-3.3]; P = .043). Aligning in GAP-relative pelvic version led to lower likelihood of all 3 mechanical complications (all P < .04). In patients with severe sagittal deformity, GAP-SD was predictive of IC (OR: 2.1, [1.1-4.7]; P = .047), and in patients 70 years and older, GAP-SD was also predictive of PJF development (OR: 2.5, [1.1-14.9]; P = .045), while improving in GAP led to lower likelihood of PJF (OR: 0.2, [0.02-0.8]; P = .023).

CONCLUSION

Severely disproportioned in GAP is associated with development of any IC and junctional failure specifically in older patients and those with severe baseline deformity. Therefore, incorporation of patient-specific factors into realignment goals may better strengthen the utility of this novel tool.

GAP score potential in predicting post-operative spinal mechanical complications: a systematic review of the literature

PURPOSE

In 2017, the GAP score was proposed as a tool to reduce mechanical complications (MC) in adult spinal deformity (ASD) surgery: the reported MC rate for the GAP proportioned category was only 6%, which is clearly lower to the MC rate reported in the literature. The aim of this study is to analyse if the most recent literature confirms the promising results of the original article.

MATERIALS AND METHODS

Using the PRISMA flow chart, we reviewed the literature to analyse GAP score capacity in predicting MC occurrence. We included articles clearly reporting ASD surgery MC stratified by GAP categories and the score's overall capacity to predict MC using the area under the curve (AUC). The quality of the included studies was evaluated using GRADE and MINORS systems.

RESULTS

Eleven retrospective articles (1,517 patients in total) were included. The MC distribution per GAP category was as follows: GAP-P, 32.8%; GAP-MD, 42.3%; GAP-SD, 55.4%. No statistically significant difference was observed between the different categories using the Kruskal-Wallis test (p = 0.08) and the two-by-two Pearson-Chi square test (P Vs MD, p = 0.300; P Vs SD, p = 0.275; MD Vs SD, p = 0.137). The global AUC was 0.68 ± 0.2 (moderate accuracy). The included studies were of poor quality according to the GRADE system and had a high risk of bias based on the MINORS criteria.

CONCLUSION

The actual literature does not corroborate the excellent results reported by the original GAP score article. Further prospective studies, possibly stratified by type of MC and type of surgery, are necessary to validate this score.

Relationship Between Hounsfield Units of Upper Instrumented Vertebrae, Proximal Junctional Failure, and Global Alignment and Proportion Score in Female Patients with Adult Spinal Deformity

STUDY DESIGN

This was a retrospective observational study.

OBJECTIVES

The purpose of this study was to evaluate bone mineral density using Hounsfield unit (HU) values at the upper instrumented vertebrae (UIV), UIV+1, and UIV+2 and to investigate the association with proximal junctional failure (PJF) in female patients with adult spinal deformity (ASD). We also evaluated the relationship between the global alignment and proportion (GAP) score and the HU value of patients after ASD surgery.

METHODS

Fifty-two patients (52 females, mean age =70.2 years) who underwent multiple-level lateral lumbar interbody fusion combined with posterior instrumentation for ASD were included. The patients were divided into 2 groups, PJF and non-PJF. The demographics, surgical characteristics, and radiographic parameters were compared. Vertebral HU values at UIV, UIV+1, and UIV+2 using preoperative computed tomography scans and immediate postoperative GAP scores were also compared.

RESULTS

PJF was found in 13 of 52 patients (25.0%). Preoperative and postoperative thoracic kyphosis was large in PJF patients. Based on the total GAP score, there was no significant difference among the categories of GAP scores (P = 0.514). The statistically significant difference in mean HU values (116.6 ± 28.1 vs. 141.8 ± 41.8, P = 0.049) between the two groups at UIV. Further correlation analysis showed that the mean HU values in UIV and UIV+1 showed a significantly negative correlation coefficient with the total GAP score.

CONCLUSIONS

Our study suggests that preoperative HU values at UIV may affect the development of PJF for female ASD patients. HU evaluation by preoperative computed tomography may help reduce the incidence of PJF.

Complications of adult spinal deformity surgery: A literature review

Purpose:

Adult spinal deformity incidence increases accordingly as the population ages. Even though surgery is the best option for the treatment, the complications due to surgery are pretty challenging. This study aims to review the complication rates of adult spinal deformity surgery.

Methods:

A literature review of the last decade was performed searching for the query “Adult spine deformity and complication.” This search yielded 2781 results, where 79 articles were chosen to investigate the complications of adult spinal deformity surgery. In addition, the demographic data, surgical interventions, and complications were extracted from the publications.

Results:

A total of 26,207 patients were analyzed, and 9138 complications were found (34.5%). Implant failure, including screw loosening, breakage, distal and proximal junctional kyphosis, were the most common complications. The neurologic complications were about 10.8%, and the infection rate was 3.6%. Cardiac and pulmonary complications were about 4.8%.

Discussion:

Age, body mass index, smoking, osteoporosis, and other comorbidities are the significant risk factors affecting adult spinal deformity surgery. Presurgical planning and preoperative risk factor assessment must be done to avoid complications. Furthermore, intra and postoperative complications affect the patients’ quality of life and length of stay, and hospital readmissions. Revision surgery also increases the risk of complications.

Conclusion:

Good patient evaluation before surgery and careful planning of the surgery are essential in avoiding complications of adult spinal deformity.

Health insurance policy on surgical treatment of adult spinal deformity

Background: Recent burgeoning research on adult spinal deformity (ASD) has unveiled the benefits of surgical treatment and how to gain the benefits although these have only been around for 10 years.Current Concepts: During the last decade, the significance of pelvic incidence in the global spinal sagittal alignment and introductions of the Scoliosis Research Society-Schwab classification for ASD have been the guidelines of surgical treatment for ASD and the milestones for promising surgical results. However, one of the unsolved problems for the surgical treatment of ASD is the proximal junctional kyphosis, for which multifactorial causative factors have been suggested. Recent studies have focused on dynamic natures in patients with ASD during daily activities, which might be a clue for both prevention of proximal junctional kyphosis and a better level of surgical results. Even though a recent remarkable advancement for surgical treatment for ASD is present, the national guideline for reimbursement is still following the surgical indication for lumbar degenerative kyphosis published in 1988.Discussion and Conclusion: A significant gap exists between the national reimbursement guideline and generally held surgical indication for ASD surgery. Consequently, this huge gap raises trouble in both patients and surgeons. The patients with ASD cannot take an appropriate surgery for ASD, while the spine surgeons experience unreasonable adjustment of the cost by the Health Insurance Review and Assessment Service.