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Lovecchio F, Lafage R, Kim HJ, Bess S, Ames C, Gupta M, Passias P, Klineberg E, Mundis G, Burton D, Smith JS, Shaffrey C, Schwab F, Lafage V. Revision-Free Loss of Sagittal Correction Greater Than Three Years After Adult Spinal Deformity Surgery: Who and Why? Spine (Phila Pa 1976) 2024; 49:157-164. [PMID: 37847773 DOI: 10.1097/brs.0000000000004852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 10/19/2023]
Abstract
STUDY DESIGN Multicenter retrospective cohort study. OBJECTIVE To investigate risk factors for loss of correction within the instrumented lumbar spine after adult spinal deformity surgery. SUMMARY OF BACKGROUND DATA The sustainability of adult spinal deformity surgery remains a health care challenge. Malalignment is a major reason for revision surgery. PATIENTS AND METHODS A total of 321 patients who underwent fusion of the lumbar spine (≥5 levels, LIV pelvis) with a revision-free follow-up of ≥3 years were identified. Patients were stratified by a change in pelvic incidence-lumbar lordosis from 6 weeks to 3 years postoperative as "maintained" versus "loss" >5°. Those with instrumentation failure (broken rod, screw pullout, etc .) were excluded before comparisons. Demographics, surgical data, and radiographic alignment were compared. Repeated measure analysis of variance was performed to evaluate the maintenance of the correction for L1-L4 and L4-S1. Multivariate logistic regression was conducted to identify independent surgical predictors of correction loss. RESULTS The cohort had a mean age of 64 years, a mean Body Mass Index of 28 kg/m 2 , and 80% females. Eighty-two patients (25.5%) lost >5° of pelvic incidence-lumbar lordosis correction (mean loss 10±5°). After the exclusion of patients with instrumentation failure, 52 losses were compared with 222 maintained. Demographics, osteotomies, 3CO, interbody fusion, use of bone morphogenetic protein, rod material, rod diameter, and fusion length were not significantly different. L1-S1 screw orientation angle was 1.3 ± 4.1 from early postoperative to 3 years ( P = 0.031), but not appreciably different at L4-S1 (-0.1 ± 2.9 P = 0.97). Lack of a supplemental rod (odds ratio: 4.0, P = 0.005) and fusion length (odds ratio 2.2, P = 0.004) were associated with loss of correction. CONCLUSIONS Approximately, a quarter of revision-free patients lose an average of 10° of their 6-week correction by 3 years. Lordosis is lost proximally through the instrumentation ( i.e. tulip/shank angle shifts and/or rod bending). The use of supplemental rods and avoiding sagittal overcorrection may help mitigate this loss.
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Affiliation(s)
- Francis Lovecchio
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Han Jo Kim
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center/Presbyterian St. Luke's Medical Center, Denver, CO
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, IL
| | - Peter Passias
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Eric Klineberg
- Department of Orthopedic Surgery, The University of Texas Health Science Center of Houston, Houston, TX
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, La Jolla, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher Shaffrey
- Department of Neurosurgery and Orthopedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Frank Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
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Passias PG, Williamson TK, Pierce KE, Schoenfeld AJ, Krol O, Imbo B, Joujon-Roche R, Tretiakov P, Ahmad S, Bennett-Caso C, Mir J, Dave P, McFarland K, Owusu-Sarpong S, Lebovic JA, Janjua MB, de la Garza-Ramos R, Vira S, Diebo B, Koller H, Protopsaltis TS, Lafage R, Lafage V. The Importance of Incorporating Proportional Alignment in Adult Cervical Deformity Corrections Relative to Regional and Global Alignment: Steps Toward Development of a Cervical-Specific Score. Spine (Phila Pa 1976) 2024; 49:116-127. [PMID: 37796161 DOI: 10.1097/brs.0000000000004843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
STUDY DESIGN/SETTING Retrospective single-center study. BACKGROUND The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD). PURPOSE Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD. METHODS Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years. RESULTS One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF. CONCLUSION The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Andrew J Schoenfeld
- New York Spine Institute, New York, NY
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Oscar Krol
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Bailey Imbo
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Peter Tretiakov
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Salman Ahmad
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Claudia Bennett-Caso
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Jamshaid Mir
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Pooja Dave
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | - Kimberly McFarland
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY
- New York Spine Institute, New York, NY
| | | | - Jordan A Lebovic
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | | | - Rafael de la Garza-Ramos
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Shaleen Vira
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Heiko Koller
- International Center for Spinal Disorders and Deformity, Orthopedic Department II, Asklepios Clinics Bad Abbach, Bad Tölz, Germany
| | | | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
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Predicting the Magnitude of Distal Junctional Kyphosis Following Cervical Deformity Correction. Spine (Phila Pa 1976) 2023; 48:232-239. [PMID: 36149856 DOI: 10.1097/brs.0000000000004492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/08/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of a cervical deformity database. OBJECTIVE This study aimed to develop a model that can predict the postoperative distal junctional kyphosis angle (DJKA) using preoperative and postoperative radiographic measurements. SUMMARY OF BACKGROUND DATA Distal junctional kyphosis (DJK) is a complication following cervical deformity correction that can reduce of patient quality of life and functional status. Although researchers have identified the risk factors for DJK, no model has been proposed to predict the magnitude of DJK. MATERIALS AND METHODS The DJKA was defined as the Cobb angle from the lower instrumented vertebra (LIV) to LIV-2 with traditional DJK having a DJKA change >10°. Models were trained using 66.6% of the randomly selected patients and validated in the remaining 33.3%. Preoperative and postoperative radiographic parameters associated with DJK were identified and ranked using a conditional variable importance table. Linear regression models were developed using the factors most strongly associated with postoperative DJKA. RESULTS A total of 131 patients were included with a mean follow-up duration of 14±8 months. The mean postoperative DJKA was 14.6±14° and occurred in 35% of the patients. No significant differences between the training and validation cohort were observed. The variables most associated with postoperative DJK were: preoperative DJKA (DJKApre), postoperative C2-LIV, and change in cervical lordosis (∆CL). The model identified the following equation as predictive of DJKA: DJKA=9.365+(0.123×∆CL)-(0.315×∆C2-LIV)-(0.054×DJKApre). The predicted and actual postoperative DJKA values were highly correlated ( R =0.871, R2 =0.759, P <0.001). CONCLUSIONS The variables that most increased the DJKA were the preoperative DJKA, postoperative alignment within the construct, and change in cervical lordosis. Future studies can build upon the model developed to be applied in a clinical setting when planning for cervical deformity correction.
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Passias PG, Ahmad W, Oh C, Imbo B, Naessig S, Pierce K, Lafage V, Lafage R, Hamilton DK, Protopsaltis TS, Klineberg EO, Gum J, Schoenfeld AJ, Line B, Hart RA, Burton DC, Bess S, Schwab FJ, Smith JS, Shaffrey CI, Ames CP. Development of Risk Stratification Predictive Models for Cervical Deformity Surgery. Neurosurgery 2022; 91:928-935. [PMID: 36250700 DOI: 10.1227/neu.0000000000002136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 06/29/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As corrective surgery for cervical deformity (CD) increases, so does the rate of complications and reoperations. To minimize suboptimal postoperative outcomes, it is important to develop a tool that allows for proper preoperative risk stratification. OBJECTIVE To develop a prognostic utility for identification of risk factors that lead to the development of major complications and unplanned reoperations. METHODS CD patients age 18 years or older were stratified into 2 groups based on the postoperative occurrence of a revision and/or major complication. Multivariable logistic regressions identified characteristics that were associated with revision or major complication. Decision tree analysis established cutoffs for predictive variables. Models predicting both outcomes were quantified using area under the curve (AUC) and receiver operating curve characteristics. RESULTS A total of 109 patients with CD were included in this study. By 1 year postoperatively, 26 patients experienced a major complication and 17 patients underwent a revision. Predictive modeling incorporating preoperative and surgical factors identified development of a revision to include upper instrumented vertebrae > C5, lowermost instrumented vertebrae > T7, number of unfused lordotic cervical vertebrae > 1, baseline T1 slope > 25.3°, and number of vertebral levels in maximal kyphosis > 12 (AUC: 0.82). For developing a major complication, a model included a current smoking history, osteoporosis, upper instrumented vertebrae inclination angle < 0° or > 40°, anterior diskectomies > 3, and a posterior Smith Peterson osteotomy (AUC: 0.81). CONCLUSION Revisions were predicted using a predominance of radiographic parameters while the occurrence of major complications relied on baseline bone health, radiographic, and surgical characteristics.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Waleed Ahmad
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Cheongeun Oh
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Bailey Imbo
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Sara Naessig
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Katherine Pierce
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Themistocles S Protopsaltis
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, New York, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, California, USA
| | - Jeffrey Gum
- Department of Orthopedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Breton Line
- Denver International Spine Center, Denver, Colorado, USA
| | - Robert A Hart
- Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shay Bess
- Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | | | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Choi DY, Shin MH, Kim JT. Impact of C3 Involvement on Postoperative Kyphosis Following Cervical Laminoplasty: A Comparison Between High and Low T1 Slope. World Neurosurg 2022; 167:e1084-e1089. [PMID: 36087912 DOI: 10.1016/j.wneu.2022.08.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The goal of the present study was to investigate the impact of C3 involvement on the postoperative kyphosis following cervical laminoplasty in patients with high and low T1S. METHODS The data from ossification of the posterior longitudinal ligament patients who had undergone laminoplasty between January 2016 and December 2019 were retrospectively reviewed. Patients were divided into low-and high-T1S groups according to preoperative T1S, and the postoperative alignment change was compared between the groups. The relationships between postoperative cervical kyphosis and preoperative variables, including gender, C3 laminoplasty, T1S, cervical lordosis (CL), C2-7 Sagittal Vertical Axis, and T1S minus CL (T1S-CL) were investigated. RESULTS Eighty-six patients were divided into 2 groups above and below median preoperative T1S (23.70). There were thirty-three patients (38.3%) in low-T1S group and fifty-three patients (61.7%) in high-T1S group. Twenty-three patients (26.7%) were performed with C3 involved laminoplasty. C3 laminoplasty (odds ratio [OR], 9.67; 2.82-33.16; P = 0.000), high T1S (OR, 4.89; 1.54-15.49; P = 0.007), and mismatched T1S-CL (OR, 5.96; 1.83-19.43; P = 0.003) were significantly associated with postoperative kyphosis. In high-T1S group, the loss of CL was significant (P = 0.017) when C3 laminoplasty was performed, whereas, in low-T1S group, the C3 laminoplasty did not show the statistically significant difference. (P = 0.194). CONCLUSIONS C3 laminoplasty, mismatched T1S-CL, and high T1S were found to increase the risk of postoperative kyphosis following cervical laminoplasty. Patients with high T1 slope tended to exhibit a greater loss of CL when the laminoplasty was performed extending to C3 segment.
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Affiliation(s)
- Du-Yong Choi
- Departments of Neurosurgery, Incheon St Mary's Hospital, College of Medicine, The Catholic University, Incheon, Republic of Korea
| | - Myung-Hoon Shin
- Departments of Neurosurgery, Incheon St Mary's Hospital, College of Medicine, The Catholic University, Incheon, Republic of Korea.
| | - Jong-Tae Kim
- Departments of Neurosurgery, Incheon St Mary's Hospital, College of Medicine, The Catholic University, Incheon, Republic of Korea
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Passias PG, Kummer N, Williamson TK, Moattari K, Lafage V, Lafage R, Kim HJ, Daniels AH, Gum JL, Diebo BG, Protopsaltis TS, Mundis GM, Eastlack RK, Soroceanu A, Scheer JK, Hamilton DK, Klineberg EO, Line B, Hart RA, Burton DC, Mummaneni P, Chou D, Park P, Schwab FJ, Shaffrey CI, Bess S, Ames CP, Smith JS. Highest Achievable Outcomes for Patients Undergoing Cervical Deformity Corrective Surgery by Frailty. Neurosurgery 2022; 91:693-700. [PMID: 36084195 DOI: 10.1227/neu.0000000000002091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Frailty is influential in determining operative outcomes, including complications, in patients with cervical deformity (CD). OBJECTIVE To assess whether frailty status limits the highest achievable outcomes of patients with CD. METHODS Adult patients with CD with 2-year (2Y) data included. Frailty stratification: not frail (NF) <0.2, frail (F) 0.2 to 0.4, and severely frail (SF) >0.4. Analysis of covariance established estimated marginal means based on age, invasiveness, and baseline deformity, for improvement, deterioration, or maintenance in Neck Disability Index (NDI), Modified Japanese Orthopaedic Association (mJOA), and Numerical Rating Scale Neck Pain. RESULTS One hundred twenty-six patients with CD included 29 NF, 83 F, and 14 SF. The NF group had the highest rates of deterioration and lowest rates of improvement in cervical Sagittal Vertical Axis and horizontal gaze modifiers. Two-year improvements in NDI by frailty: NF: -11.2, F: -16.9, and SF: -14.6 (P = .524). The top quartile of NF patients also had the lowest 1-year (1Y) NDI (7.0) compared with F (11.0) and SF (40.5). Between 1Y and 2Y, 7.9% of patients deteriorated in NDI, 71.1% maintained, and 21.1% improved. Between 1Y and 2Y, SF had the highest rate of improvement (42%), while NF had the highest rate of deterioration (18.5%). CONCLUSION Although frail patients improved more often by 1Y, SF patients achieve most of their clinical improvement between 1 and 2Y. Frailty is associated with factors such as osteoporosis, poor alignment, neurological status, sarcopenia, and other medical comorbidities. Similarly, clinical outcomes can be affected by many factors (fusion status, number of pain generators within treated levels, integrity of soft tissues and bone, and deformity correction). Although accounting for such factors will ultimately determine whether frailty alone is an independent risk factor, these preliminary findings may suggest that frailty status affects the clinical outcomes and improvement after CD surgery.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Nicholas Kummer
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Tyler K Williamson
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Kevin Moattari
- Department of Orthopedic and Neurosurgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Themistocles S Protopsaltis
- Department of Orthopaedic Surgery, NYU Langone Orthopaedic Hospital, NYU Langone Health, New York, New York, USA
| | - Gregory M Mundis
- Division of Orthopaedic Surgery, Scripps Clinic Medical Group, La Jolla, California, USA
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, California, USA
| | - Alexandra Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - D Kojo Hamilton
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, UC Davis Health System, Sacramento, California, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's Medical Center/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Praveen Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Christopher I Shaffrey
- Division of Spine, Departments of Neurosurgery and Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's Medical Center/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Justin S Smith
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
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7
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Divi SN, Karamian BA, Canseco JA, Chang M, Toci GR, Goyal DKC, Nicholson KJ, Mujica VE, Bronson W, Kaye ID, Kurd MF, Woods BI, Radcliff KE, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. The Impact of Upper Cervical Spine Alignment on Patient-reported Outcome Measures in Anterior Cervical Decompression and Fusion. Clin Spine Surg 2022; 35:E539-E545. [PMID: 35302961 DOI: 10.1097/bsd.0000000000001310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE To determine the extent to which the upper cervical spine compensates for malalignment in the subaxial cervical spine, and how changes in upper cervical spine sagittal alignment affect patient-reported outcomes. SUMMARY OF BACKGROUND DATA Previous research has investigated the relationship between clinical outcomes and radiographic parameters in the subaxial cervical spine following anterior cervical discectomy and fusion (ACDF). However, limited research exists regarding the upper cervical spine (occiput to C2), which accounts for up to 40% of neck movement and has been hypothesized to compensate for subaxial dysfunction. MATERIALS AND METHODS Patients undergoing ACDF for cervical radiculopathy and/or myelopathy at a single center with minimum 1-year follow-up were included. Radiographic parameters including cervical sagittal vertical axis, C0 angle, C1 inclination angle, C2 slope, Occiput-C1 angle (Oc-C1 degrees), Oc-C2 degrees, Oc-C7 degrees, C1-C2 degrees, C1-C7 degrees, and C2-C7 degrees cervical lordosis (CL) were recorded preoperatively and postoperatively. Delta (Δ) values were calculated by subtracting preoperative values from postoperative values. Correlation analysis as well as multiple linear regression analysis was used to determine relationships between radiographic and clinical outcomes. Alpha was set at 0.05. RESULTS A total of 264 patients were included (mean follow-up 20 mo). C2 slope significantly decreased for patients after surgery (Δ=-0.8, P =0.02), as did parameters of regional cervical lordosis (Oc-C7 degrees, C1-C7 degrees, and C2-C7 degrees; P <0.001, <0.001, and 0.01, respectively). Weak to moderate associations were observed between postoperative CL and C1 inclination ( r =-0.24, P <0.001), Oc-C1 degrees ( r =0.59, P <0.001), and C1-C2 degrees ( r =-0.23, P <0.001). Increased preoperative C1-C2 degrees and Oc-C2 degrees inversely correlated with preoperative SF-12 Mental Composite Score (MCS-12) scores ( r =-0.16, P =0.01 and r =-0.13, P =0.04). Cervical sagittal vertical axis was found to have weak but significant associations with Short Form-12 (SF-12) Physical Composite Score (PCS-12) ( r =-0.13, P =0.03) and MCS-12 ( r =0.12, P =0.05). CONCLUSION No clinically significant relationship between upper cervical and subaxial cervical alignment was detected for patients undergoing ACDF for neurological symptoms. Upper cervical spine alignment was not found to be a significant predictor of patient-reported outcomes after ACDF. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Srikanth N Divi
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Lafage R, Smith JS, Sheikh Alshabab B, Ames C, Passias PG, Shaffrey CI, Mundis G, Protopsaltis T, Gupta M, Klineberg E, Kim HJ, Bess S, Schwab F, Lafage V. When can we expect global sagittal alignment to reach a stable value following cervical deformity surgery? J Neurosurg Spine 2021; 36:616-623. [PMID: 34740177 DOI: 10.3171/2021.7.spine21306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical deformity (CD) is a complex condition with a clear impact on patient quality of life, which can be improved with surgical treatment. Previous study following thoracolumbar surgery demonstrated a spontaneous and maintained improvement in cervical alignment following lumbar pedicle subtraction osteotomy (PSO). In this study the authors aimed to investigate the complementary questions of whether cervical alignment induces a change in global alignment and whether this change stabilizes over time. METHODS To analyze spontaneous changes, this study included only patients with at least 5 levels remaining unfused following surgery. After data were obtained for the entire cohort, repeated-measures analyses were conducted between preoperative baseline and 3-month and 1-year follow-ups with a post hoc analysis and Bonferroni correction. A subanalysis of patients with 2-year follow-up was performed. RESULTS One-year follow-up data were available for 121 of 168 patients (72%), and 89 patients had at least 5 levels remaining unfused following surgery. Preoperatively there was a moderate anterior cervical alignment (C2-7, -7.7° [kyphosis]; T1 slope minus cervical lordosis, 37.1°; cervical sagittal vertebral axis [cSVA], 37 mm) combined with a posterior global alignment (SVA, -8 mm) with lumbar hyperextension (pelvic incidence [PI] minus lumbar lordosis [LL] mismatch [PI-LL], -0.6°). Patients underwent a significant correction of the cervical alignment (median ΔC2-7, 13.6°). Simultaneously, PI-LL, T1 pelvic angle (TPA), and SVA increased significantly (all p < 0.05) between baseline and 3-month and 1-year follow-ups. Post hoc analysis demonstrated that all of the changes occurred between baseline and 3 months. Subanalysis of patients with complete 2-year follow-up demonstrated similar results, with stable postoperative thoracolumbar alignment achieved at 3 months. CONCLUSIONS Correction of cervical malalignment can have a significant impact on thoracolumbar regional and global alignment. Peak relaxation of compensatory mechanisms is achieved by the 3-month follow-up and tends to remain stable. Subanalysis with 2-year data further supports this finding. These findings can help to identify when the results of cervical surgery on global alignment can be best evaluated.
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Pierce KE, Passias PG, Brown AE, Bortz CA, Alas H, Lafage R, Krol O, Chou D, Burton DC, Line B, Klineberg E, Hart R, Gum J, Daniels A, Hamilton K, Bess S, Protopsaltis T, Shaffrey C, Schwab FA, Smith JS, Lafage V, Ames C. Prioritization of realignment associated with superior clinical outcomes for surgical cervical deformity patients. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:311-317. [PMID: 34729000 PMCID: PMC8501814 DOI: 10.4103/jcvjs.jcvjs_26_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/22/2021] [Indexed: 11/05/2022] Open
Abstract
Background: To optimize quality of life in patients with cervical deformity (CD), there may be alignment targets to be prioritized. Objective: To prioritize the cervical parameter targets for alignment. Methods: Included: CD patients (C2–C7 Cobb >10°°, C2–C7 lordosis [CL] >10°°, cSVA > 4 cm, or chin-brow vertical angle >25°°) with full baseline (BL) and 1-year (1Y) radiographic parameters and Neck Disability Index (NDI) scores; patients with cervical (C) or cervicothoracic (CT) Primary Driver Ames type. Patients with BL Ames classified as low CD for both parameters of cSVA (<4 cm) and T1 slope minus CL (TS-CL) (<15°°) were excluded. Patients assessed: Meeting Minimal Clinically Important Difference (MCID) for NDI (<−15 ΔNDI). Ratios of correction were found for regional parameters categorized by Primary Ames Driver (C or CT). Decision tree analysis assessed cut-offs for differences associated with meeting NDI MCID at 1Y. Results: Seventy-seven CD patients (62.1 years, 64%F, 28.8 kg/m2). 41.6% met MCID for NDI. A backward linear regression model including radiographic differences as predictors from BL to 1Y for meeting MCID for NDI demonstrated an R2= 0.820 (P = 0.032) included TS-CL, cSVA, MGS, C2SS, C2-T3 angle, C2-T3 sagittal vertical axis (SVA), CL. By primary Ames driver, 67.5% of patients were C, and 32.5% CT. Ratios of change in predictors for MCID NDI patients for C and CT were not significant between the two groups (P > 0.050). Decision tree analysis determined cut-offs for radiographic change, prioritizing in the following order: ≥42.5° C2-T3 angle, >35.4° CL, <−31.76° C2 slope, <−11.57 mm cSVA, <−2.16° MGS, >−30.8 mm C2-T3 SVA, and ≤−33.6° TS-CL. Conclusions: Certain ratios of correction of cervical parameters contribute to improving neck disability. Prioritizing these radiographic alignment parameters may help optimize patient-reported outcomes for patients undergoing CD surgery.
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Affiliation(s)
- Katherine E Pierce
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Peter Gust Passias
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Avery E Brown
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Cole A Bortz
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Haddy Alas
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Oscar Krol
- Department of Orthopaedic, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA.,Departments of Neurologic Surgery, New York Spine Institute, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Kojo Hamilton
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | | | - Christopher Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.,Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Frank A Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Passias PG, Alas H, Pierce KE, Galetta M, Krol O, Passfall L, Kummer N, Naessig S, Ahmad W, Diebo BG, Lafage R, Lafage V. The impact of the lower instrumented level on outcomes in cervical deformity surgery. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:306-310. [PMID: 34728999 PMCID: PMC8501812 DOI: 10.4103/jcvjs.jcvjs_23_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/07/2021] [Indexed: 11/24/2022] Open
Abstract
Background: The lower instrumented vertebrae (LIVs) in cervical deformity (CD) constructs may have varying effects on patient outcomes that are still poorly understood. Objective: The objective of the study is to compare outcomes in CD patients undergoing instrumented correction according to the relation of LIV with primary driver (PD). Methods: Patients who met radiographic criteria for CD were included in the study. Patients were stratified by PD of deformity: cervical (C) through AMES classification (TS-CL >20 or cervical sagittal vertical axis >40) and thoracic (T) through hyper/hypokyphosis (TK) from T4-T12 (60 < TK < 40). Patients were further stratified by LIV in relation to curve apex (above/below). Univariate and multivariate analyses identified group differences in postoperative health-related quality-of-life and distal junctional kyphosis (DJK) (>10° LIV and LIV + 2) rate up to 1 year. Results: Sixty-two patients were analyzed. Twenty-one patients had a C-PD and 41 had a T-PD by definition. 100% of C-PDs had LIVs below CL apex, while 9.2% of T-PDs had LIVs below (caudal) to TK apex and 90.8% had LIVs above TK apex. By 1 year, C patients trended lower Neck Disability Index (NDI) (21.9 vs. 29.0, P = 0.245), lower numeric rating scales neck pain (4.2 vs. 5.1, P = 0.358), and significantly higher EuroQol five-dimensional questionnaire Visual Analog Scale (69.2 vs. 52.4, P = 0.040). When T patients with LIVs below TK apex were excluded, remaining T patients with LIV above apex had significantly higher 1-year NDI than C patients (37.5 vs. 21.9, P = .05). T patients also trended higher rates of postoperative DJK than C (19.5% vs. 4.8%, P = 0.119). Conclusions: Stopping before apex was more common in patients with a primary thoracic driver (T) and associated with deleterious effects. Primary cervical driver (C) tended to have LIVs inclusive of CL apex with lower rates of DJK.
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Affiliation(s)
- Peter Gust Passias
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Haddy Alas
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Katherine E Pierce
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Matthew Galetta
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Oscar Krol
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Lara Passfall
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Nicholas Kummer
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Sara Naessig
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Waleed Ahmad
- Department of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Medical Center, NY Spine Institute, New York, NY, USA
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
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Passias PG, Bortz C, Pierce KE, Kummer NA, Lafage R, Diebo BG, Line BG, Lafage V, Burton DC, Klineberg EO, Kim HJ, Daniels AH, Mundis GM, Protopsaltis TS, Eastlack RK, Sciubba DM, Bess S, Schwab FJ, Shaffrey CI, Smith JS, Ames CP. Appropriate Risk Stratification and Accounting for Age-Adjusted Reciprocal Changes in the Thoracolumbar Spine Reduces the Incidence and Magnitude of Distal Junctional Kyphosis in Cervical Deformity Surgery. Spine (Phila Pa 1976) 2021; 46:1437-1447. [PMID: 33710114 DOI: 10.1097/brs.0000000000004033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of a prospective cervical deformity (CD) database. OBJECTIVE Identify factors associated with distal junctional kyphosis (DJK); assess differences across DJK types. SUMMARY OF BACKGROUND DATA DJK may develop as compensation for mal-correction of sagittal deformity in the thoracic curve. There is limited understanding of DJK drivers, especially for different DJK types. METHODS Included: patients with pre- and postoperative clinical/radiographic data. Excluded: patients with previous fusion to L5 or below. DJK was defined per surgeon note or DJK angle (kyphosis from LIV to LIV-2)<-10°, and pre- to postoperative change in DJK angle by<-10°. Age-specific target LL-TK alignment was calculated as published. Offset from target LL-TK was correlated to DJK magnitude and inclination. DJK types: severe (DJK<-20°), progressive (DJK increase>4.4°), symptomatic (reoperation or published disability thresholds of NDI ≥ 24 or mJOA≤14). Random forest identified factors associated with DJK. Means comparison tests assessed differences. RESULTS Included: 136 CD patients (61 ± 10 yr, 61%F). DJK rate was 30%. Postop offset from ideal LL-TK correlated with greater DJK angle (r = 0.428) and inclination of the distal end of the fusion construct (r = 0.244, both P < 0.02). Seven of the top 15 factors associated with DJK were radiographic, four surgical, and four clinical. Breakdown by type: severe (22%), progressive (24%), symptomatic (61%). Symptomatic had more posterior osteotomies than asymptomatic (P = 0.018). Severe had worse NDI and upper-cervical deformity (CL, C2 slope, C0-C2), as well as more posterior osteotomies than nonsevere (all P < 0.01). Progressive had greater malalignment both globally and in the cervical spine (all P < 0.03) than static. Each type had varying associated factors. CONCLUSION Offset from age-specific alignment is associated with greater DJK and more anterior distal construct inclination, suggesting DJK may develop due to inappropriate realignment. Preoperative clinical and radiographic factors are associated with symptomatic and progressive DJK, suggesting the need for preoperative risk stratification.Level of Evidence: 3.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Cole Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Katherine E Pierce
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Nicholas A Kummer
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Breton G Line
- Department of Orthopaedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, CO
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Davis, CA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | | | | | | | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shay Bess
- Department of Orthopaedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, CO
| | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
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12
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Pierce KE, Passias PG, Brown AE, Bortz CA, Alas H, Passfall L, Krol O, Kummer N, Lafage R, Chou D, Burton DC, Line B, Klineberg E, Hart R, Gum J, Daniels A, Hamilton K, Bess S, Protopsaltis T, Shaffrey C, Schwab FA, Smith JS, Lafage V, Ames C. Prioritization of Realignment Associated With Superior Clinical Outcomes for Cervical Deformity Patients. Neurospine 2021; 18:506-514. [PMID: 34610683 PMCID: PMC8497252 DOI: 10.14245/ns.2040540.270] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 06/15/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To prioritize the cervical parameter targets for alignment.
Methods Included: cervical deformity (CD) patients (C2–7 Cobb angle > 10°, cervical lordosis > 10°, cervical sagittal vertical axis [cSVA] > 4 cm, or chin-brow vertical angle > 25°) with full baseline (BL) and 1-year (1Y) radiographic parameters and Neck Disability Index (NDI) scores; patients with cervical [C] or cervicothoracic [CT] Primary Driver Ames type. Patients with BL Ames classified as low CD for both parameters of cSVA (< 4 cm) and T1 slope minus cervical lordosis (TS–CL) (< 15°) were excluded. Patients assessed: meeting minimum clinically important differences (MCID) for NDI (< -15 ΔNDI). Ratios of correction were found for regional parameters categorized by primary Ames driver (C or CT). Decision tree analysis assessed cutoffs for differences associated with meeting NDI MCID at 1Y.
Results Seventy-seven CD patients (mean age, 62.1 years; 64% female; body mass index, 28.8 kg/m2). Forty-one point six percent of patients met MCID for NDI. A backwards linear regression model including radiographic differences as predictors from BL to 1Y for meeting MCID for NDI demonstrated an R2 of 0.820 (p=0.032) included TS–CL, cSVA, McGregor’s slope (MGS), C2 sacral slope, C2–T3 angle, C2–T3 SVA, cervical lordosis. By primary Ames driver, 67.5% of patients were C, and 32.5% CT. Ratios of change in predictors for MCID NDI patients for C and CT were not significant between the 2 groups (p>0.050). Decision tree analysis determined cutoffs for radiographic change, prioritizing in the following order: ≥ 42.5° C2–T3 angle, > 35.4° cervical lordosis, < -31.76° C2 slope, < -11.57-mm cSVA, < -2.16° MGS, > -30.8-mm C2–T3 SVA, and ≤ -33.6° TS–CL.
Conclusion Certain ratios of correction of cervical parameters contribute to improving neck disability. Prioritizing these radiographic alignment parameters may help optimize patient-reported outcomes for patients undergoing CD surgery.
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Affiliation(s)
- Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Avery E Brown
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Cole A Bortz
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Haddy Alas
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Lara Passfall
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Oscar Krol
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Nicholas Kummer
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Breton Line
- Rocky Mountain Scoliosis and Spine, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | | | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Frank A Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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Passias PG, Pierce KE, Imbo B, Krol O, Passfall L, Tretiakov P, Moattari K, Williamson T, Joujon-Roche R, Passano B, Ahmad W, Naessig S, Diebo B. What are the major drivers of outcomes in cervical deformity surgery? JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:401-405. [PMID: 35068823 PMCID: PMC8740818 DOI: 10.4103/jcvjs.jcvjs_106_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background Context: Cervical deformity (CD) correction is becoming more challenging and complex. Understanding the factors that drive optimal outcomes has been understudied in CD corrective surgery. Purpose: The purpose of the study was to weight baseline (BL) factors on impact upon outcomes following CD surgery. Study Design Setting: This was a retrospective review of a single-center database. Patient Sample: The sample size of the study was 61 cervical patients. Outcome Measures: Two outcomes were measured: “Improved outcome (IO)”: (1) radiographic improvement: “nondeformed” Schwab pelvic tilt (PT)/sagittal vertical axis (SVA) and Ames cervical sagittal vertical axis (cSVA)/T1 Slope – cervical lordosis (TSCL); (2) clinical: MCID Euro-QOL 5 Dimension (EQ5D), Neck Disability Index (NDI), or improvement in modified Japanese Orthopedic Association (mJOA) scale modifier; and (3) complications/reoperation: no reoperation or major complications and “poor outcome” (PO): (1) radiographic deterioration: “moderate” or “severely” deformed Schwab SVA/PT and Ames cSVA/TS-CL; (2) clinical: not meeting MCID EQ5D and NDI worsening in mJOA modifier; and (3) complications/reoperation: reoperation or complications. Materials and Methods: CD patients included full BL and 1-year (1Y) radiographic measures and Health related quality of life (HRQLs) questionnaires. Patients who underwent a reoperation for infection were excluded. Patients were categorized by IO, PO, or not. Random forest assessed ratios of predictors for IO and PO. Categorical regression models predicted how BL regional deformity (Ames cSVA, TS-CL, and horizontal gaze), BL global deformity (Schwab PI-LL, SVA, and PT), regional/global change (BL to 1Y), BL disability (mJOA score), and BL pain/function impact outcomes. Results: Sixty-one patients were included in the study (55.8 years, 54.1% of females). Surgical approach included 18.3% anterior, 51.7% posterior, and 30% combined. The average number of levels fused for the cohort was 7.7. Mean operative time was 823 min, and estimated blood loss (EBL): 1037ccs. At 1Y, 24.6% had an IO and 9.8% had PO. Random forest analysis showed the top five individual factors associated with an IO: BL maximum kyphosis, maximum lordosis, C0–C2, L4 pelvic angle, and NSR back pain (80% radiographic, 20% clinical). Categorical IO regression model (R2 = 0.328, P = 0.007) showed low BL regional deformity (β = ‒0.082), low BL global deformity (β = ‒0.099), global improvement (β = ‒0.532), regional improvement (β = ‒0.230), low BL disability (β = ‒0.100), and low BL NDI (β = ‒0.024). Random forest demonstrated the top five individual BL factors associated with PO, 80% were radiographic: BL CL apex, DJK angle, cervical lordosis, T1 slope, and NSR neck pain. Categorical PO regression model (R2 = 0.306, P = 0.012) showed high BL regional deformity (β = ‒0.108), high BL global deformity (β = ‒0.255), global decline (β = ‒0.272), regional decline (β = 0.443), BL disability (β = −‒0.164), BL and severe NDI (>69) (β = ‒0.181). Conclusions: Categorical weight demonstrated radiographic as the strongest predictor of both improved (global alignment) and PO (regional deformity/deterioration). Radiographic factors carry the most weight in determining an improved or PO, and can be ultimately utilized in preoperative planning and surgical decision-making to optimize outcomes.
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Affiliation(s)
- Peter Gust Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Bailey Imbo
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Oscar Krol
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Lara Passfall
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Peter Tretiakov
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Kevin Moattari
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Tyler Williamson
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Rachel Joujon-Roche
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Brandon Passano
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Waleed Ahmad
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Sara Naessig
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY, USA
| | - Bassel Diebo
- Department of Orthopedics, SUNY Downstate, New York, NY, USA
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14
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Passias PG, Pierce KE, Passano B, Tariq MB, Ahmad S, Singh V, Owusu-Sarpong S, Krol O, Imbo B, Passfall L, Tretiakov P, Williamson T, Joujon-Roche R, Ahmad W, Naessig S, Diebo B. What are the major drivers of outcomes in cervical deformity surgery? JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:376-380. [PMID: 35068819 PMCID: PMC8740812 DOI: 10.4103/jcvjs.jcvjs_117_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/06/2021] [Indexed: 11/15/2022] Open
Abstract
Background Context: Cervical deformity (CD) correction is becoming more challenging and complex. Understanding the factors that drive optimal outcomes has been understudied in CD correction surgery. Purpose: The purpose of this study is to assess the factors associated with improved outcomes (IO) following CD surgery. Study Design Setting: Retrospective review of a single-center database. Patient Sample: Sixty-one patients with CD. Outcome Measures: The primary outcomes measured were radiographic and clinical “IO” or “poor outcome” (PO). Radiographic IO or PO was assessed utilizing Schwab pelvic tilt (PT)/sagittal vertical axis (SVA), and Ames cervical SVA (cSVA)/TS-CL. Clinical IO or PO was assessed using MCID EQ5D, Neck Disability Index (NDI), and/or improvement in Modified Japanese Orthopedic Association Scale (mJOA) modifier. The secondary outcomes assessed were complication and reoperation rates. Materials and Methods: CD patients with data available on baseline (BL) and 1-year (1Y) radiographic measures and health-related quality of life s were included in our study. Patients with reoperations for infection were excluded. Patients were categorized by IO, PO, or not. IO was defined as “nondeformed” radiographic measures as well as improved clinical outcomes. PO was defined as “moderate or severe deformed” radiographic measures as well as worsening clinical outcome measures. Random forest assessed ratios of predictors for IO and PO. The categorical regression models were utilized to predict BL regional deformity (Ames cSVA, TS-CL, horizontal gaze), BL global deformity (Schwab PI-LL, SVA, PT), regional/global change (BL to 1Y), BL disability (mJOA score), and BL pain/function impact outcomes. Results: Sixty-one patients met inclusion criteria for our study (mean age of 55.8 years with 54.1% female). The most common surgical approaches were as follows: 18.3% anterior, 51.7% posterior, and 30% combined. Average number of levels fused was 7.7. The mean operative time was 823 min and mean estimated blood loss was 1037 ml. At 1 year, 24.6% of patients were found to have an IO and 9.8% to have a PO. Random forest analysis showed the top 5 individual factors associated with an “IO” were: BL Maximum Kyphosis, Maximum Lordosis, C0-C2 Angle, L4-Pelvic Angle, and NSR Back Pain (80% radiographic, 20% clinical). Categorical IO regression model (R2 = 0.328, P = 0.007) found following factors to be significant: low BL regional deformity (β = ‒0.082), low BL global deformity (β = ‒0.099), global improve (β = 0.532), regional improve (β = 0.230), low BL disability (β = 0.100), and low BL NDI (β = 0.024). Random forest found the top 5 individual BL factors associated with “PO” (80% were radiographic): BL CL Apex, DJK angle, cervical lordosis, T1 slope, and NSR neck pain. Categorical PO regression model (R2 = 0.306, P = 0.012) found following factors to be significant: high BL regional deformity (β = ‒0.108), high BL global deformity (β = ‒0.255), global decline (β = 0.272), regional decline (β = 0.443), BL disability (β = ‒0.164), and BL severe NDI (>69) (β = 0.181). Conclusions: The categorical weight demonstrated radiographic as the strongest predictor of both improved (global alignment) and PO (regional deformity/deterioration). Radiographic factors carry the most weight in determining an improved or PO and can be ultimately utilized in preoperative planning and surgical decision-making to optimize the outcomes.
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Affiliation(s)
- Peter Gust Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Brandon Passano
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Muhammad B Tariq
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Salman Ahmad
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Vivek Singh
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Stephane Owusu-Sarpong
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Oscar Krol
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Bailey Imbo
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Lara Passfall
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Peter Tretiakov
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Tyler Williamson
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Rachel Joujon-Roche
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Waleed Ahmad
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Sara Naessig
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, USA
| | - Bassel Diebo
- Department of Orthopedics, SUNY Downstate, Brooklyn, NY, USA
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15
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Le HV, Wick JB, Lafage R, Mundis GM, Eastlack RK, Bess S, Burton DC, Ames CP, Smith JS, Passias PG, Gupta MC, Lafage V, Klineberg EO. Association of findings on preoperative extension lateral cervical radiography with osteotomy type, approach, and postoperative cervical alignment after cervical deformity surgery. J Neurosurg Spine 2021; 36:93-98. [PMID: 34479192 DOI: 10.3171/2021.3.spine202156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/10/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' objective was to determine whether preoperative lateral extension cervical spine radiography can be used to predict osteotomy type and postoperative alignment parameters after cervical spine deformity surgery. METHODS A total of 106 patients with cervical spine deformity were reviewed. Radiographic parameters on preoperative cervical neutral and extension lateral radiography were compared with 3-month postoperative radiographic alignment parameters. The parameters included T1 slope, C2 slope, C2-7 cervical lordosis, cervical sagittal vertical axis, and T1 slope minus cervical lordosis. Associations of radiographic parameters with osteotomy type and surgical approach were also assessed. RESULTS On extension lateral radiography, patients who underwent lower grade osteotomy had significantly lower T1 slope, T1 slope minus cervical lordosis, cervical sagittal vertical axis, and C2 slope. Patients who achieved more normal parameters on extension lateral radiography were more likely to undergo surgery via an anterior approach. Although baseline parameters were significantly different between neutral lateral and extension lateral radiographs, 3-month postoperative lateral and preoperative extension lateral radiographs were statistically similar for T1 slope minus cervical lordosis and C2 slope. CONCLUSIONS Radiographic parameters on preoperative extension lateral radiography were significantly associated with surgical approach and osteotomy grade and were similar to those on 3-month postoperative lateral radiography. These results demonstrated that extension lateral radiography is useful for preoperative planning and predicting postoperative alignment.
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Affiliation(s)
- Hai V Le
- 1Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California
| | - Joseph B Wick
- 1Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California
| | | | - Gregory M Mundis
- 3Department of Orthopedics, Scripps Clinic, La Jolla, California
| | | | - Shay Bess
- 4Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Douglas C Burton
- 5Department of Orthopaedic Surgery, University of Kansas School of Medicine, Kansas City, Kansas
| | - Christopher P Ames
- 6Department of Neurosurgery, University of California, San Francisco, California
| | - Justin S Smith
- 7Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Peter G Passias
- 8Department of Orthopedic Surgery, NYU Langone Health, New York, New York; and
| | - Munish C Gupta
- 9Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Eric O Klineberg
- 1Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California
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16
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Kim HJ, Yao YC, Bannwarth M, Smith JS, Klineberg EO, Mundis GM, Protopsaltis TS, Charles-Elysee J, Bess S, Shaffrey CI, Passias PG, Schwab FJ, Ames CP, Lafage V. Cervicothoracic Versus Proximal Thoracic Lower Instrumented Vertebra Have Comparable Radiographic and Clinical Outcomes in Adult Cervical Deformity. Global Spine J 2021; 13:1056-1063. [PMID: 34013765 DOI: 10.1177/21925682211017478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Comparative cohort study. OBJECTIVE Factors that influence the lower instrumented vertebra (LIV) selection in adult cervical deformity (ACD) are less reported, and outcomes in the cervicothoracic junction (CTJ) and proximal thoracic (PT) spine are unclear. METHODS A prospective ACD database was analyzed using the following inclusion criteria: LIV between C7 and T5, upper instrumented vertebra at C2, and at least a 1-year follow-up. Patients were divided into CTJ (LIV C7-T2) and PT groups (LIV T3-T5) based on LIV levels. Demographics, operative details, radiographic parameters, and the health-related quality of life (HRQOL) scores were compared. RESULTS Forty-six patients were included (mean age, 62 years), with 22 and 24 patients in the CTJ and PT groups, respectively. Demographics and surgical parameters were comparable between the groups. The PT group had a significantly higher preoperative C2-C7 sagittal vertical axis (cSVA) (46.9 mm vs 32.6 mm, P = 0.002) and T1 slope minus cervical lordosis (45.9° vs 36.0°, P = 0.042) than the CTJ group and was more likely treated with pedicle-subtraction osteotomy (33.3% vs 0%, P = 0.004). The PT group had a larger correction of cSVA (-7.7 vs 0.7 mm, P = 0.037) and reciprocal change of increased T4-T12 kyphosis (8.6° vs 0.0°, P = 0.001). Complications and reoperations were comparable. The HRQOL scores were not different preoperatively and at 1-year follow-up. CONCLUSIONS The selection of PT LIV in cervical deformities was more common in patients with larger baseline deformities, who were more likely to undergo pedicle-subtraction osteotomy. Despite this, the complications and HRQOL outcomes were comparable at 1-year follow-up.
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Affiliation(s)
- Han Jo Kim
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Yu-Cheng Yao
- Spine Service, Hospital for Special Surgery, New York, NY, USA.,Department of Orthopaedic, 46615Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mathieu Bannwarth
- Spine Service, Hospital for Special Surgery, New York, NY, USA.,Neurosurgery, University Hospital Reims, Reims, France
| | - Justin S Smith
- Department of Neurosurgery, 2358University of Virginia Health Sciences Center, Charlottesville, VA, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA, USA
| | | | | | | | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
| | | | - Peter G Passias
- Division of Spine Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, NY, USA
| | - Frank J Schwab
- Spine Service, Hospital for Special Surgery, New York, NY, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Virginie Lafage
- Spine Service, Hospital for Special Surgery, New York, NY, USA
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17
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Massaad E, Hadzipasic M, Kiapour A, Lak AM, Shankar G, Zaidi HA, Hershman SH, Shin JH. Association of Spinal Alignment Correction With Patient-Reported Outcomes in Adult Cervical Deformity: Review of the Literature. Neurospine 2021; 18:533-542. [PMID: 34015894 PMCID: PMC8497234 DOI: 10.14245/ns.2040656.328] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/07/2020] [Indexed: 11/19/2022] Open
Abstract
Objective Adult cervical deformity (ACD) is a debilitating spinal condition that causes significant pain, neurologic dysfunction, and functional impairment. Surgery is often performed to correct cervical alignment, but the optimal amount of correction required to improve patient-reported outcomes (PROs) are not yet well-defined. Methods A review of the literature was performed and Fisher's z-transformation (Zr) was used to pool the correlation coefficients between alignment parameters and PROs. The strength of correlation was defined according to the following: poor (0 < r ≤ 0.3), fair (0.3 < r ≤ 0.5), moderate (0.5 < r ≤ 0.8), and strong (0.8 < r ≤ 1). Results Increased C2-C7 SVA was fairly associated with increased Neck Disability Index (NDI) (pooled Zr = 0.31; 95% CI, -0.03, 0.58). Changes in TS-CL poorly correlated with NDI (pooled Zr = -0.04; 95% CI, -0.23-0.30). Increased C7-S1 was poorly associated with worse EQ-5D (pooled Zr = -0.22; 95% CI, -0.36, -0.06). Correction of horizontal gaze (CBVA) did not correlate with legacy metrics. mJOA correlated with C2-slope, C7-S1, and C2-S1. Conclusion Spinal alignment parameters variably correlated with improved HRQoL and myelopathy after corrective surgery for ACD. Further studies evaluating legacy PROs, PROMIS, and ACD specific instruments are needed for further validation.
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Affiliation(s)
- Elie Massaad
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Muhamed Hadzipasic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Kiapour
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Asad M Lak
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ganesh Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hasan A Zaidi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stuart H Hershman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John H. Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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18
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Divi SN, Bronson WH, Canseco JA, Chang M, Goyal DKC, Nicholson KJ, Mujica VE, Kaye ID, Kurd MF, Woods BI, Radcliff KE, Rihn JA, Anderson DG, Hilibrand AS, Kepler CK, Vaccaro AR, Schroeder GD. How do C2 tilt and C2 slope correlate with patient reported outcomes in patients after anterior cervical discectomy and fusion? Spine J 2021; 21:578-585. [PMID: 33197615 DOI: 10.1016/j.spinee.2020.10.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/28/2020] [Accepted: 10/31/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND/CONTEXT C2 tilt and C2 slope are quick and easy measurements to obtain on lateral radiographs and may be used to determine overall cervical sagittal alignment; however, the influence of these measurements on patient outcomes has not been well established in literature. PURPOSE To determine if C2 tilt and/or C2 slope predict patient outcomes better compared with conventional radiographic measures after an anterior cervical discectomy and fusion (ACDF). STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 249 patients who underwent 1 to 3 level ACDF to address radiculopathy and/or myelopathy at a single academic institution between 2011 and 2015 were identified. Patients with less than 1 year of follow-up were excluded. OUTCOME MEASURES Patient Reported Outcomes: Neck Disability Index (NDI), Physical Component Score-12 (PCS-12), and Mental Component Score (MCS-12), Visual Analog Score (VAS) Neck and Arm scores Cervical radiographic measurements: C2 tilt, C2 slope, C2-C7 lordosis, cervical SVA, T1 slope, T1 slope minus cervical lordosis (TS-CL), and C2-C7 ROM METHODS: Pearson correlation tests were performed to assess for significant associations between radiographic measurements and patient outcomes. Multiple linear regression models were developed adjusting for demographics and radiographic parameters to determine which factors were predictive of patient outcomes. RESULTS C2 tilt and TS-CL correlated with all postoperative physical outcome scores (NDI, PCS-12, VAS Neck and ARM; p<.05), however no association was seen between C2 slope and postoperative outcomes. After accounting for the presence of subaxial deformity, C2 tilt and TS-CL remained strongly correlated to patient outcome scores. With multiple linear regression, C2 tilt was a significant predictor for NDI, whereas TS-CL was a significant predictor for PCS-12, VAS Neck and VAS Arm. CONCLUSIONS C2 tilt significantly correlated with well-described conventional cervical parameters as well as postoperative physical outcomes measures, especially NDI, on multivariate analysis. C2 tilt may provide an easy and practical tool for predicting physical outcomes after ACDF.
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Affiliation(s)
- Srikanth N Divi
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA.
| | - Wesley H Bronson
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Michael Chang
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Dhruv K C Goyal
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Kristen J Nicholson
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Victor E Mujica
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Ian David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Mark F Kurd
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Kristen E Radcliff
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Jeffrey A Rihn
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - David Greg Anderson
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA
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Lafage R, Ang B, Schwab F, Kim HJ, Smith JS, Shaffrey C, Burton D, Ames C, Mundis G, Hostin R, Bess S, Klineberg E, Passias P, Lafage V. Depression Symptoms Are Associated with Poor Functional Status Among Operative Spinal Deformity Patients. Spine (Phila Pa 1976) 2021; 46:447-456. [PMID: 33337685 DOI: 10.1097/brs.0000000000003886] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of prospective multicenter database. OBJECTIVE The aim of this study was to investigate how preoperative mental status affects preoperative and postoperative disability and health scores in adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA The relationship between health-related quality of life (HRQOL) and depression has previously been documented. However, the influence of depression on clinical outcomes among ASD patients is not well understood. METHODS ASD patients with minimum 2-year follow-up were stratified based on preoperative mental health measured by Short Form 36 (SF-36) mental component score (MCS). Patients with MCS in the 25th and 75th percentile of the cohort were designated as having low and high MCS, respectively. After matching by preoperative demographics and deformity, pre- and post-HRQOL were compared between the two groups. Further analysis was performed to identify individualized questions on the SF-36 that could potentially screen for patients with low MCS. RESULTS Five hundred thirteen patients were assessed (58.4 years' old, 79% women, mean MCS 45.5). Thresholds for low and high MCS cohorts were 35.0 and 57.3, respectively. After matching by preoperative alignment, low MCS patients had worse Oswestry Disability Index (ODI) (52.3 ± 17.0 vs. 35.7 ± 14.6, P < 0.001) and Scoliosis Research Society-22R scores for all domains (all P < 0.001) compared to high MCS patients. Similar results were maintained at 2-year postop, with low MCS patients having a worse ODI (35.2 ± 20.2 vs. 19.7 ± 18.6, P < 0.001) and MCS (42.4 ± 13.5 vs. 58.6 ± 7.1, P < 0.001). Despite similar preoperative Physical Component Score (PCS), low MCS patients were less likely to reach MCID for PCS (46.1% vs. 70.6%, P < 0.01) and had a lower satisfaction at 2-year follow-up (3.88 ± 1.07 vs. 4.39 ± 0.94, P < 0.001). Questions 5a, 9d, and 9f on the SF-36 were found to be independent predictors of low MCS. CONCLUSION ASD patients with low MCS are more likely to experience functional limitations before and after surgery and are less likely to be satisfied postoperatively, even when similar clinical goals are achieved. Incorporating psychological factors may assist in decision making.Level of Evidence: 3.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Bryan Ang
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | | | - Douglas Burton
- Department of Orthopedics, University of Kansas Medical Center, Kansas City, KS
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA
| | | | - Richard Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
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20
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Passias PG, Horn SR, Lafage V, Lafage R, Smith JS, Line BG, Protopsaltis TS, Soroceanu A, Bortz C, Segreto FA, Ahmad W, Naessig S, Pierce KE, Brown AE, Alas H, Kim HJ, Daniels AH, Klineberg EO, Burton DC, Hart RA, Schwab FJ, Bess S, Shaffrey CI, Ames CP. Effect of age-adjusted alignment goals and distal inclination angle on the fate of distal junctional kyphosis in cervical deformity surgery. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:65-71. [PMID: 33850384 PMCID: PMC8035585 DOI: 10.4103/jcvjs.jcvjs_170_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022] Open
Abstract
Background: Age-adjusted alignment targets in the context of distal junctional kyphosis (DJK) development have yet to be investigated. Our aim was to assess age-adjusted alignment targets, reciprocal changes, and role of lowest instrumented level orientation in DJK development in cervical deformity (CD) patients. Methods: CD patients were evaluated based on lowest fused level: cervical (C7 or above), upper thoracic (UT: T1–T6), and lower thoracic (LT: T7–T12). Age-adjusted alignment targets were calculated using published formulas for sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), pelvic tilt (PT), T1 pelvic angle (TPA), and LL-thoracic kyphosis (TK). Outcome measures were cervical and global alignment parameters: Cervical SVA (cSVA), cervical lordosis, C2 slope, C2–T3 angle, C2–T3 SVA, TS-CL, PI-LL, PT, and SVA. Subanalysis matched baseline PI to assess age-adjusted alignment between DJK and non-DJK. Results: Seventy-six CD patients included. By 1Y, 20 patients developed DJK. Non-DJK patients had 27% cervical lowest instrumented vertebra (LIV), 68% UT, and 5% LT. DJK patients had 25% cervical, 50% UT, and 25% LT. There were no baseline or 1Y differences for PI, PI-LL, SVA, TPA, or PT for actual and age-adjusted targets. DJK patients had worse baseline cSVA and more severe 1Y cSVA, C2–T3 SVA, and C2 slope (P < 0.05). The distribution of over/under corrected patients and the offset between actual and ideal alignment for SVA, PT, TPA, PI-LL, and LL-TK were similar between DJK and non-DJK patients. DJK patients requiring reoperation had worse postoperative changes in all cervical parameters and trended toward larger offsets for global parameters. Conclusion: CD patients with severe baseline malalignment went on to develop postoperative DJK. Age-adjusted alignment targets did not capture differences in these populations, suggesting the need for cervical-specific goals.
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Affiliation(s)
- Peter Gust Passias
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Samantha R Horn
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Clinic, Denver, Colorado, USA
| | | | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Canada
| | - Cole Bortz
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Frank A Segreto
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Waleed Ahmad
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Sara Naessig
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Katherine E Pierce
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Avery E Brown
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Haddy Alas
- Department of Orthopaedics, NYU Medical Center-Orthopaedic Hospital, New York City, NY, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Denver, Colorado, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Cady-McCrea CI, Galgano MA. C2 quad-screws facilitate 4-rod fixation across the cervico-thoracic junction. Surg Neurol Int 2021; 12:40. [PMID: 33598356 PMCID: PMC7881508 DOI: 10.25259/sni_870_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/04/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Cervical spine deformity is a potentially devitalizing problem. Contemporary techniques for repair and reconstruction include fusion using rods of tapered diameter alone, or quadruple-rod constructs in which primary rods are joined to floating accessory rods by connectors. Here, we present how we utilized a quadruple-rod construct to perform five C2 to thoracic spine fusions. Methods: Our hospital electronic medical record revealed five patients who underwent the four rod C2-thoracic spine fixation. Patients ranged in age from 14-years-old to 78-years-old. The mean operative time was 715.8 min (range 549–987 min), and average estimated blood loss was 878 cc (range 40–1800 cc). Results: None of the five patients sustained any intraoperative complications, and none demonstrated progressive kyphotic deformity over the average follow-up interval of 8 months. Conclusion: We successfully treated five patients with degenerative or oncologic cervical pathology requiring fixation across the cervicothoracic junction utilizing a 4-rod C2-cervicothoracic fusion technique.
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Affiliation(s)
- Clarke I Cady-McCrea
- Department of Neurosurgery, Upstate Medical University, Syracuse, New York, United States
| | - Michael A Galgano
- Department of Neurosurgery, Upstate Medical University, Syracuse, New York, United States
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Virk S, Passias P, Lafage R, Klineberg E, Mundis G, Protopsaltis T, Shaffrey C, Bess S, Burton D, Hart R, Kim HJ, Ames C, Schwab F, Smith J, Lafage V. Intraoperative alignment goals for distinctive sagittal morphotypes of severe cervical deformity to achieve optimal improvements in health-related quality of life measures. Spine J 2020; 20:1267-1275. [PMID: 32209421 DOI: 10.1016/j.spinee.2020.03.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patients with severe cervical deformity (CD) often have profound deficits in numerous activities of daily living. The association between health status and postoperative radiographic goals is difficult to quantify. PURPOSE We aimed to investigate the radiographic characteristics of patients who achieved optimal health related quality of life scores following surgery for CD. STUDY DESIGN We performed a retrospective review of a prospectively collected database of patients with spinal deformity. PATIENT SAMPLE One hundred and fifty-three patients with cervical deformity OUTCOME MEASURES: Common health-related quality of life scores (HRQOLs) measurements were taken for patients treated operatively for cervical deformity including neck disability index (NDI), modified Japanese Orthopaedic Association scale (mJOA) for myelopathy and numeric rating scale for neck pain (NRS-neck), METHODS: Surgical patients with severe CD were isolated based upon a previously presented discriminant analysis which outlined a combination of preoperative cervical sagittal vertical axis (cSVA), T1 slope, maximum focal kyphosis in extension, C2 slope in extension, and number of kyphotic levels in extension. Those with available preoperative and 1-year postoperative HRQL data were included. Based on a previous study, patients were grouped into three distinct sagittal morphotypes of CD: focal deformity (FD), flat neck (FN = large TS-CL and lack of compensation), or cervicothoracic (CT). Postoperative outcomes were defined as "good" if a patient had ≥2 of the three following criteria (1) NDI <20 or meeting MCID, (2) mild myelopathy (mJOA≥14), and (3) NRS-Neck ≤5 or improved by ≥2 points from baseline. Within each distinct deformity group, patients with good outcomes were compared to those with poor outcomes (ie, not meeting the criteria for good) for differences in demographics, HRQOL scores, and alignment, via Chi-squared or student's t tests. RESULTS Overall, 83 of 153 patients met the criteria of severe CD and 40 patients had complete 1-year follow-up of clinical/radiographic data. Patient breakdown by deformity pattern was: CT (N=13), FN (N=17), and FD (N=17), with 7 patients meeting criteria for both FD and FN deformities. Within the FD cohort, maximal focal kyphosis (ie, kyphosis at one level) was better corrected in patients with a "good" outcome (p=.03). In the FN cohort, patients with "good" outcomes presented preoperatively with worse horizontal gaze (McGregor Slope 21° vs. 6°, p=.061) and cSVA (72 mm vs. 60 mm, p=.030). "Good" outcome FN patients showed significantly greater postop correction of horizontal gaze (-25° vs. -5°, p=.031). In the CT cohort, patients with "good" outcomes had superior global alignment both pre- (SVA: -17 mm vs. 108 mm, p<.001) and postoperatively (50 mm vs. 145 mm, p=.001). CT patients with "good" outcomes also had better postop cervical alignment (cSVA 35 mm vs. 49 mm, p=.030), and less kyphotic segments during extension (p=.011). In the FD cohort, there were no differences between "good" and "poor" outcomes patients in preoperative alignment; however, "good" outcome patients showed superior changes in postoperative focal kyphosis (-2° vs. 5°, p=.030). Within all three deformity pattern categories, there were no differences between "good" and "poor" outcome patients with respect to demographics or surgical parameters (levels fused, surgical approach, decompression, osteotomy, all p>.050). CONCLUSIONS The results of this study show each CD patient's unique deformity must be carefully examined in order to determine the appropriate alignment goals to achieve optimal HRQOLs. In particular, the recognition of the sagittal morphotype can help assist surgeons to aim for specific alignment goals for CT, FN and FD. Distinct deformity specific intra-operative goals include obtaining proper sagittal global/cervical alignment for cervicothoracic patients, correcting maximal focal kyphosis in focal deformity patients, and correcting horizontal gaze for flatneck patients.
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Affiliation(s)
- Sohrab Virk
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Renaud Lafage
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, CA
| | - Gregory Mundis
- Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, CA, USA
| | | | | | - Shay Bess
- Rocky Mountain Scoliosis and Spine Center, Denver, CO, USA
| | - Doug Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Oregon Health Sciences University, Portland, OR, USA
| | - Han Jo Kim
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA
| | - Christopher Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Frank Schwab
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA
| | - Justin Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Virginie Lafage
- Hospital for Special Surgery, Department of Orthopedic Surgery, New York, NY, USA.
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Patel PD, Arutyunyan G, Plusch K, Vaccaro A, Vaccaro AR. A review of cervical spine alignment in the normal and degenerative spine. JOURNAL OF SPINE SURGERY 2020; 6:106-123. [PMID: 32309650 DOI: 10.21037/jss.2020.01.10] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
With recent advancements in surgical spine technology and techniques, the importance of regional and global spine alignment has become an important factor in surgical planning. Our review aims to consolidate the current literature on cervical and global alignment parameters and its relationship to cervical symptomatology, quality of life (QOL), requirements for surgery, potential surgical complications and health-related quality of life (HRQOL) outcomes.
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Affiliation(s)
- Parthik D Patel
- Department of Orthopaedics, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Grigoriy Arutyunyan
- Department of Orthopaedics, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Kyle Plusch
- Department of Orthopaedics, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Alexander Vaccaro
- Department of Orthopaedics, Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedics, Rothman Orthopaedic Institute, Philadelphia, PA, USA
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Rao H, Huang Y, Lan Z, Xu Z, Li G, Xu W. Does Preoperative T1 Slope and Cervical Lordosis Mismatching Affect Surgical Outcomes After Laminoplasty in Patients with Cervical Spondylotic Myelopathy? World Neurosurg 2019; 130:e687-e693. [DOI: 10.1016/j.wneu.2019.06.193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
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Dru AB, Lockney DT, Vaziri S, Decker M, Polifka AJ, Fox WC, Hoh DJ. Cervical Spine Deformity Correction Techniques. Neurospine 2019; 16:470-482. [PMID: 31607079 PMCID: PMC6790735 DOI: 10.14245/ns.1938288.144] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/18/2019] [Indexed: 11/19/2022] Open
Abstract
Cervical kyphotic deformity can be a debilitating condition with symptoms ranging from mechanical neck pain, radiculopathy, and myelopathy to impaired swallowing and horizontal gaze. Surgical correction of cervical kyphosis has the potential to halt progression of neurological and clinical deterioration and even restore function. There are various operative approaches and deformity correction techniques. Choosing the optimal strategy is predicated on a fundamental understanding of spine biomechanics. Preoperative characterization of cervical malalignment, assessment of deformity rigidity, and defining postoperative clinical and radiographic objectives are paramount to formulating a surgical plan that balances clinical benefit with morbidity. This review of cervical deformity treatment provides an overview of the biomechanics of cervical kyphosis, radiographic classification, algorithm-based management, surgical techniques, and current surgical outcome studies.
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Affiliation(s)
- Alexander B Dru
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Dennis Timothy Lockney
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Sasha Vaziri
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Matthew Decker
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Adam J Polifka
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - W Christopher Fox
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Daniel J Hoh
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA
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Bortz CA, Passias PG, Segreto F, Horn SR, Lafage V, Smith JS, Line B, Mundis GM, Kebaish KM, Kelly MP, Protopsaltis T, Sciubba DM, Soroceanu A, Klineberg EO, Burton DC, Hart RA, Schwab FJ, Bess S, Shaffrey CI, Ames CP. Indicators for Nonroutine Discharge Following Cervical Deformity-Corrective Surgery: Radiographic, Surgical, and Patient-Related Factors. Neurosurgery 2019; 85:E509-E519. [DOI: 10.1093/neuros/nyz016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 01/29/2019] [Indexed: 11/14/2022] Open
Abstract
AbstractBACKGROUNDNonroutine discharge, including discharge to inpatient rehab and skilled nursing facilities, is associated with increased cost-of-care. Given the rising prevalence of cervical deformity (CD)-corrective surgery and the necessity of value-based healthcare, it is important to identify indicators for nonroutine discharge.OBJECTIVETo identify factors associated with nonroutine discharge after CD-corrective surgery using a statistical learning algorithm.METHODSA retrospective review of patients ≥18 yr with discharge and baseline (BL) radiographic data. Conditional inference decision trees identified factors associated with nonroutine discharge and cut-off points at which factors were significantly associated with discharge status. A conditional variable importance table used nonreplacement sampling set of 10 000 conditional inference trees to identify influential patient/surgical factors. The binary logistic regression indicated odds of nonroutine discharge for patients with influential factors at significant cut-off points.RESULTSOf 138 patients (61 yr, 63% female) undergoing surgery for CD (8 ± 5 levels; 49% posterior approach, 16% anterior, and 35% combined), 29% experienced nonroutine discharge. BL cervical/upper-cervical malalignment showed the strongest relationship with nonroutine discharge: C1 slope ≥ 14°, C2 slope ≥ 57°, TS-CL ≥ 57°. Patient-related factors associated with nonroutine discharge included BL gait impairment, age ≥ 59 yr and apex of CD primary driver ≥ C7. The only surgical factor associated with nonroutine discharge was fusion ≥ 8 levels. There was no relationship between nonhome discharge and reoperation within 6 mo or 1 yr (both P > .05) of index procedure. Despite no differences in BL EQ-5D (P = .946), nonroutine discharge patients had inferior 1-yr postoperative EQ-5D scores (P = .044).CONCLUSIONSevere preoperative cervical malalignment was strongly associated with nonroutine discharge following CD-corrective surgery. Age, deformity driver, and ≥ 8 level fusions were also associated with nonroutine discharge and should be taken into account to improve patient counseling and health care resource allocation.
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Affiliation(s)
- Cole A Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital New York, New York
| | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital New York, New York
| | - Frank Segreto
- Department of Orthopedics, NYU Langone Orthopedic Hospital New York, New York
| | - Samantha R Horn
- Department of Orthopedics, NYU Langone Orthopedic Hospital New York, New York
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton Line
- International Spine Study Group, Denver, Colorado
| | | | - Khaled M Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | | | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexandra Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, California
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine, Denver, Colorado
| | | | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California
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Koller H, Ames C, Mehdian H, Bartels R, Ferch R, Deriven V, Toyone H, Shaffrey C, Smith J, Hitzl W, Schröder J, Robinson Y. Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project. 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 2018; 28:324-344. [PMID: 30483961 DOI: 10.1007/s00586-018-5835-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/25/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND PURPOSE Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study. METHODS Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types A-D). RESULTS Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001). CONCLUSIONS Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.
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Affiliation(s)
- H Koller
- Spine and Scoliosis Center, Schön Klinik Vogtareuth, Krankenhausstrasse 20, 83569, Vogtareuth, Germany. .,Department for Trauma and Sports Injuries, Paracelsus Medical University, Salzburg, Austria.
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TO THE EDITOR. Spine (Phila Pa 1976) 2018; 43:E980-E981. [PMID: 30059483 DOI: 10.1097/brs.0000000000002727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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