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Chen JW, Chanbour H, Gupta R, Izah J, Vaughan WE, Abtahi AM, Zuckerman SL, Stephens BF. Adult versus adolescent idiopathic scoliosis surgery: a meta-analysis of clinical and radiographic outcomes. 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 2024; 33:1637-1643. [PMID: 38436875 DOI: 10.1007/s00586-024-08177-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 12/31/2023] [Accepted: 01/31/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION While the natural history of adolescent idiopathic scoliosis (AIS) and adult idiopathic scoliosis (AdIS) is well documented in the literature, the impact of age on postoperative outcomes remains an active area of research. We performed a systematic review and meta-analysis to compare patients undergoing surgery for AIS and AdIS with respect to: (1) postoperative Cobb correction, (2) perioperative variables, and (3) postoperative complications. METHODS A systematic literature search was performed in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. INCLUSION CRITERIA studies published between 2002 and 2022, retrospective, and comparing AIS vs. AdIS patients undergoing deformity surgery. The primary outcome was postoperative Cobb correction. Secondary outcomes included estimated blood loss (EBL), operative time, total instrumented levels, length of stay (LOS), and postoperative complications. Random-effects models were performed according to the method of DerSimonian and Laird. RESULTS Of 190 identified articles, 14 fit the inclusion criteria. A total of 1788 patients were included, 1275(71.3%) with AIS, and 513(28.7%) with AdIS. There was a significant age difference between AIS and AdIS (15.3 vs. 36.7 years, mean difference (MD) = 21.3 years, 95%CI = 14.3-28.4,p < 0.001). Mean postoperative Cobb percentage correction was reported in 5 articles and was significantly higher in AIS (68.4%) vs. AdIS (61.4%) (MD = -7.2, 95%CI = -11.6,-2.7,p = 0.001). EBL was not significantly different between AIS and AdIS (695.6 mL vs 817.7 mL,p = 0.204). Furthermore, no difference was found in operative time (MD = 37.9 min,95%CI = -10.7;86.6,p = 0.127), total instrumented level (MD = 0.88,95%CI = -0.7,2.4,p = 0.273), and LOS (MD = 0.5, 95%CI = -0.2;1.2, p = 0.188). Four articles reported postoperative complications in AIS vs AdIS, with no difference in neurological deficit, instrumentation-related complications, and medical complications. CONCLUSION AIS patients had better radiographic correction compared to AdIS. Though no difference was found in perioperative outcomes and complications, these findings emphasize the importance of counseling patients regarding the optimal timing of surgical correction.
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Affiliation(s)
- Jeffrey W Chen
- School of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rishabh Gupta
- School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Justine Izah
- School of Medicine, Meharry Medical College, Nashville, TN, USA
| | | | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, 1215 21st Ave S, South Tower, Suite #4200, Nashville, TN, 37232, USA.
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Li W, Zhang Y, Zhou X, Quan X, Chen B, Hou X, Xu Q, He W, Chen L, Liu X, Zhang Y, Xiang T, Li R, Liu Q, Wu SN, Wang K, Liu W, Zheng J, Luan H, Yu X, Chen A, Xu C, Luo T, Hu Z. Ensemble learning-assisted prediction of prolonged hospital length of stay after spine correction surgery: a multi-center cohort study. J Orthop Surg Res 2024; 19:112. [PMID: 38308336 PMCID: PMC10838003 DOI: 10.1186/s13018-024-04576-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/23/2024] [Indexed: 02/04/2024] Open
Abstract
PURPOSE This research aimed to develop a machine learning model to predict the potential risk of prolonged length of stay in hospital before operation, which can be used to strengthen patient management. METHODS Patients who underwent posterior spinal deformity surgery (PSDS) from eleven medical institutions in China between 2015 and 2022 were included. Detailed preoperative patient data, including demographics, medical history, comorbidities, preoperative laboratory results, and surgery details, were collected from their electronic medical records. The cohort was randomly divided into a training dataset and a validation dataset with a ratio of 70:30. Based on Boruta algorithm, nine different machine learning algorithms and a stack ensemble model were trained after hyperparameters tuning visualization and evaluated on the area under the receiver operating characteristic curve (AUROC), precision-recall curve, calibration, and decision curve analysis. Visualization of Shapley Additive exPlanations method finally contributed to explaining model prediction. RESULTS Of the 162 included patients, the K Nearest Neighbors algorithm performed the best in the validation group compared with other machine learning models (yielding an AUROC of 0.8191 and PRAUC of 0.6175). The top five contributing variables were the preoperative hemoglobin, height, body mass index, age, and preoperative white blood cells. A web-based calculator was further developed to improve the predictive model's clinical operability. CONCLUSIONS Our study established and validated a clinical predictive model for prolonged postoperative hospitalization duration in patients who underwent PSDS, which offered valuable prognostic information for preoperative planning and postoperative care for clinicians. Trial registration ClinicalTrials.gov identifier NCT05867732, retrospectively registered May 22, 2023, https://classic. CLINICALTRIALS gov/ct2/show/NCT05867732 .
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Affiliation(s)
- Wenle Li
- State Key Laboratory of Molecular Vaccinology and Molecular, Diagnostics and Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, China.
- Key Laboratory of Neurological Diseases, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China.
- Department of Spinal Surgery, Guangxi Medical University Affiliated Liuzhou People's Hospital, Liuzhou, China.
| | - Yusi Zhang
- Cancer Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Precision Medicine Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xin Zhou
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Xubin Quan
- Department of Spinal Surgery, Guangxi Medical University Affiliated Liuzhou People's Hospital, Liuzhou, China
| | - Binghao Chen
- Department of Spinal Surgery, Guangxi Medical University Affiliated Liuzhou People's Hospital, Liuzhou, China
| | - Xuewen Hou
- Department of Radiology, The First Dongguan Affiliated Hospital, Guangdong Medical University, Dongguan, China
| | - Qizhong Xu
- Department of Radiology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China
| | - Weiheng He
- Department of Radiology, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Liang Chen
- Department of Radiology, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
| | - Xiaozhu Liu
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Zhang
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
- Medical Data Science Academy, Chongqing Medical University, Chongqing, China
| | - Tianyu Xiang
- Information Center, The University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Runmin Li
- Department of Foot and Ankle Surgery, Honghui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Qiang Liu
- Department of Orthopedics, Xianyang Central Hospital, Xianyang, Shannxi, China
| | - Shi-Nan Wu
- Eye Institute of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China
| | - Kai Wang
- Key Laboratory of Neurological Diseases, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Wencai Liu
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, China
| | - Jialiang Zheng
- Cancer Research Center, School of Medicine, Xiamen University, Xiamen, China
| | - Haopeng Luan
- Department of Spine Surgery, The Six Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Xiaolin Yu
- Department of Orthopedics, Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Anfa Chen
- Department of Orthopedics, Jiangxi Province Hospital of Integrated Chinese and Western Medicine, Nanchang, China
| | - Chan Xu
- State Key Laboratory of Molecular Vaccinology and Molecular, Diagnostics and Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, China
| | - Tongqing Luo
- Department of Spinal Surgery, Guangxi Medical University Affiliated Liuzhou People's Hospital, Liuzhou, China.
| | - Zhaohui Hu
- Department of Spinal Surgery, Guangxi Medical University Affiliated Liuzhou People's Hospital, Liuzhou, China.
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Vadhera AS, Sachdev R, Andrade NS, Ren M, Zhang B, Kebaish KM, Cohen DB, Skolasky RL, Neuman BJ. Predicting major complications and discharge disposition after adult spinal deformity surgery. Spine J 2024; 24:325-329. [PMID: 37844627 DOI: 10.1016/j.spinee.2023.09.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/29/2023] [Accepted: 09/30/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND CONTEXT Several spine-specific comorbidity indices are available to help risk-stratify patients before they undergo invasive spine procedures. Studies of patients with adult spinal deformity (ASD) typically use the Charlson Comorbidity Index (CCI), which is not specific to spine patients. PURPOSE To compare the CCI with the Seattle Spine Score (SSS), the Adult Spinal Deformity-Comorbidity Score (ASD-CS), and the Modified 5-Item Frailty Index (mFI-5) and identify which tool more accurately predicted major perioperative complications and discharge disposition after ASD surgery. STUDY DESIGN/SETTING Retrospective review. PATIENT SAMPLE Patients with ASD who underwent spinal arthrodesis of at least four levels at a single institution. OUTCOME MEASURES Self-reported measures include SSS, ASD-CS, and mFI-5. Functional measures include the CCI. METHODS We retrospectively reviewed records of 164 patients with ASD who underwent spinal arthrodesis of ≥ four levels from January 2008 to February 2018 at our U.S. academic tertiary care center and who had available Oswestry Disability Index values. To assess the predictive ability of the comorbidity indices, we created five multivariable logistic regression models, with the presence of major complications and discharge disposition (home or inpatient rehabilitation) as the primary outcome variables. The base model used validated demographic and surgical factors that were predictors of complications and outcomes in those with ASD and within the broader spinal literature. The other four models used the base model along with one of the four indices. The predictive ability of each model was compared using goodness-of-fit testing, with higher pseudo-R2 values and lower Akaike information criteria (AIC) values indicating better model fit. RESULTS Thirty-one patients (19%) experienced major perioperative complications, and 68 (42%) were discharged to inpatient rehabilitation facilities (vs home). The model using the SSS had the highest pseudo-R2 value and lowest AIC value for both major complications and discharge disposition. The mFI-5 had a similar predictive ability. The models using the CCI and ASD-CS were weaker predictors. CONCLUSIONS Compared with the CCI and the ASD-CS, the SSS and the mFI-5 were strong predictors of major complications and discharge disposition after ASD surgery. These results suggest that the SSS and the mFI-5 are preferable to the CCI for clinical risk stratification and outcomes research in patients undergoing ASD surgery.
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Affiliation(s)
- Amar S Vadhera
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Rahul Sachdev
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Nicholas S Andrade
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Mark Ren
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Bo Zhang
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - David B Cohen
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Richard L Skolasky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287
| | - Brian J Neuman
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287.
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Bergin SM, Abd-El-Barr MM, Gottfried ON, Goodwin CR, Shaffrey CI, Than KD. Measuring Outcomes in Spinal Deformity Surgery. Neurosurg Clin N Am 2023; 34:689-696. [PMID: 37718115 DOI: 10.1016/j.nec.2023.06.013] [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] [Indexed: 09/02/2023]
Abstract
Outcome assessment in adult spinal deformity has evolved from radiographic analysis of curve correction to patient-centered perception of health-related quality-of-life. Oswestry Disability Index and the Scoliosis Research Society-22 Patient Questionnaire are the predominantly used patient-reported outcome (PRO) measurements for deformity surgery. Correction of sagittal alignment correlates with improved PRO. Functional outcomes and accelerometer measurements represent newer methods of measuring outcomes but have not yet been widely adopted or validated. Further adoption of a minimum set of core outcome domains will help facilitate international comparisons and benchmarking, and ultimately enhance value-based healthcare.
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Affiliation(s)
- Stephen M Bergin
- Department of Neurosurgery, Division of Spine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Muhammad M Abd-El-Barr
- Department of Neurosurgery, Division of Spine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Oren N Gottfried
- Department of Neurosurgery, Division of Spine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Division of Spine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Division of Spine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Khoi D Than
- Department of Neurosurgery, Division of Spine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA.
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Shen J, Nemani VM, Leveque JC, Sethi R. Personalized Medicine in Orthopaedic Surgery: The Case of Spine Surgery. J Am Acad Orthop Surg 2023; 31:901-907. [PMID: 37040614 DOI: 10.5435/jaaos-d-22-00789] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/01/2023] [Indexed: 04/13/2023] Open
Abstract
Personalized medicine has made a tremendous impact on patient care. Although initially, it revolutionized pharmaceutical development and targeted therapies in oncology, it has also made an important impact in orthopaedic surgery. The field of spine surgery highlights the effect of personalized medicine because the improved understanding of spinal pathologies and technological innovations has made personalized medicine a key component of patient care. There is evidence for several of these advancements to support their usage in improving patient care. Proper understanding of normative spinal alignment and surgical planning software has enabled surgeons to predict postoperative alignment accurately. Furthermore, 3D printing technologies have demonstrated the ability to improve pedicle screw placement accuracy compared with free-hand techniques. Patient-specific, precontoured rods have shown improved biomechanical properties, which reduces the risk of postoperative rod fractures. Moreover, approaches such as multidisciplinary evaluations tailored to specific patient needs have demonstrated the ability to decrease complications. Personalized medicine has shown the ability to improve care in all phases of surgical management, and several of these approaches are now readily available to orthopaedic surgeons.
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Affiliation(s)
- Jesse Shen
- From the Department of Orthopedic Surgery, Université de Montréal (Shen), the Virginia Mason Medical Center (Nemani, Leveque, and Sethi), University of Washington (Sethi)
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Passias PG, Williamson TK, Krol O, Tretiakov PS, Joujon-Roche R, Imbo B, Ahmad S, Bennett-Caso C, Owusu-Sarpong S, Lebovic JB, Robertson D, Vira S, Dhillon E, Schoenfeld AJ, Janjua MB, Raman T, Protopsaltis TS, Maglaras C, O'Connell B, Daniels AH, Paulino C, Diebo BG, Smith JS, Schwab FJ, Lafage R, Lafage V. Should Global Realignment Be Tailored to Frailty Status for Patients Undergoing Surgical Intervention for Adult Spinal Deformity? Spine (Phila Pa 1976) 2023; 48:930-936. [PMID: 36191091 DOI: 10.1097/brs.0000000000004501] [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: 06/30/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes. SUMMARY OF BACKGROUND DATA The Global Alignment and Proportion (GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to the development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications. MATERIALS AND METHODS We included 412 surgical ASD patients with two-year follow-up. Frailty was quantified using the modified Adult Spinal Deformity Frailty Index (mASD-FI). Outcomes: proximal junctional kyphosis and proximal junctional failure (PJF), major mechanical complications, and "Best Clinical Outcome" (BCO), defined as Oswestry Disability Index<15 and Scoliosis Research Society 22-item Questionnaire Total>4.5. Logistic regression analysis established a six-week score based on GAP score, frailty, and Oswestry Disability Index US Norms. Logistic regression followed by conditional inference tree analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty-modified GAP score. RESULTS Baseline frailty categories: 57% not frail, 30% frail, 14% severely frail. Overall, 39 of patients developed proximal junctional kyphosis, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The mASD-FI demonstrated a correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at two years (all P <0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score (FAR Score)=0.49×mASD-FI+0.38×GAP Score. Thresholds for the FAR score (0-13): proportioned: <3.5, moderately disproportioned: 3.5-7.5, severely disproportioned: >7.5. Multivariable logistic regression assessing FAR score demonstrated associations with mechanical complications, reoperation, and meeting BCO by two years (all P <0.05), whereas the original GAP score was only significant for reoperation. CONCLUSION This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Peter S Tretiakov
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Bailey Imbo
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Salman Ahmad
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Claudia Bennett-Caso
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | | | - Jordan B Lebovic
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Djani Robertson
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Shaleen Vira
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Ekamjeet Dhillon
- Department of Orthopaedic Surgery, University of Washington Medical Center, Seattle, WA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical Center, Boston, MA
| | - Muhammad B Janjua
- Department of Neurosurgery, Washington University of St Louis, St Louis, MO
| | - Tina Raman
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | | | - Constance Maglaras
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Brooke O'Connell
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine/Brown University, Providence, RI
| | - Carl Paulino
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
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Safaee MM, Lin J, Smith DL, Fury M, Scheer JK, Burke JF, Bravate C, Lambert D, Ames CP. Association of telomere length with risk of complications in adult spinal deformity surgery: a pilot study of 43 patients. J Neurosurg Spine 2023; 38:331-339. [PMID: 36461827 DOI: 10.3171/2022.10.spine22605] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/11/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE Risk stratification is a critical element of surgical planning. Early tools were fairly crude, while newer instruments incorporate disease-specific elements and markers of frailty. It is unknown if discrepancies between chronological and cellular age can guide surgical planning or treatment. Telomeres are DNA-protein complexes that serve an important role in protecting genomic DNA. Their shortening is a consequence of aging and environmental exposures, with well-established associations with diseases of aging and mortality. There are compelling data to suggest that telomere length can provide insight toward overall health. The authors sought to determine potential associations between telomere length and postoperative complications. METHODS Adults undergoing elective surgery for spinal deformity were prospectively enrolled. Telomere length was measured from preoperative whole blood using quantitative polymerase chain reaction and expressed as the ratio of telomere (T) to single-copy gene (S) abundance (T/S ratio), with higher T/S ratios indicating longer telomere length. Demographic and patient data included age, BMI, and results for the following rating scales: the Adult Spinal Deformity Frailty Index (ASD-FI), Oswestry Disability Index (ODI), Scoliosis Research Society-22r (SRS-22r), American Society of Anesthesiology (ASA) classification, and Charlson Comorbidity Index (CCI). Operative and postoperative complication data (medical or surgical within 90 days) were also collected. RESULTS Forty-three patients were enrolled, including 31 women (53%), with a mean age of 66 years and a mean BMI of 28.5. The mean number of levels fused was 11, with 21 (48.8%) combined anterior-posterior approaches. Twenty-two patients (51.2%) had a medical or surgical complication. Patients with a postoperative complication had a significantly lower T/S ratio (0.712 vs 0.813, p = 0.008), indicating shorter telomere length, despite a mild difference in age compared with patients without a postoperative complication (68 vs 63 years, p = 0.069). Patients with complications also had higher CCI scores than patients without complications (2.3 vs 3.8, p = 0.004). There were no significant differences in sex, BMI, ASD-FI score, ASA class, preoperative ODI and SRS-22r scores, number of levels fused, or use of three-column osteotomies. In a multivariate model including age, frailty, ASA class, use of an anterior-posterior approach, CCI score, and telomere length, the authors found that short telomere length was significantly associated with postoperative complications. Patients whose telomere length fell in the shortest quartile had the highest risk (OR 18.184, p = 0.030). CONCLUSIONS Short telomere length was associated with an increased risk of postoperative complications despite only a mild difference in chronological age. Increasing comorbidity scores also trended toward significance. Larger prospective studies are needed; however, these data provide a compelling impetus to investigate the role of biological aging as a component of surgical risk stratification.
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Affiliation(s)
- Michael M Safaee
- 1Department of Neurological Surgery, University of Southern California, Los Angeles; and
- 3Neurological Surgery, and
| | - Jue Lin
- Departments of2Biochemistry and Biophysics
| | | | | | | | | | | | | | - Christopher P Ames
- 3Neurological Surgery, and
- 4Orthopedic Surgery, University of California, San Francisco, California
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Risk factors of early complications after thoracic and lumbar spinal deformity surgery: a systematic review and meta-analysis. 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 2023; 32:899-913. [PMID: 36611078 DOI: 10.1007/s00586-022-07486-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/07/2022] [Accepted: 12/04/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE To determine risk factors increasing susceptibility to early complications (intraoperative and postoperative within 6 weeks) associated with surgery to correct thoracic and lumbar spinal deformity. METHODS We systematically searched the PubMed and EMBASE databases for studies published between January 1990 and September 2021. Observational studies evaluating predictors of early complications of thoracic and lumbar spinal deformity surgery were included. Pooled odds ratio (OR) or standardized mean difference (SMD) with 95% confidence intervals (CI) was calculated via the random effects model. RESULTS Fifty-two studies representing 102,432 patients met the inclusion criteria. Statistically significant patient-related risk factors for early complications included neurological comorbidity (OR = 3.45, 95% CI 1.83-6.50), non-ambulatory status (OR = 3.37, 95% CI 1.96-5.77), kidney disease (OR = 2.80, 95% CI 1.80-4.36), American Society of Anesthesiologists score > 2 (OR = 2.23, 95% CI 1.76-2.84), previous spine surgery (OR = 1.98, 95% CI 1.41-2.77), pulmonary comorbidity (OR = 1.94, 95% CI 1.21-3.09), osteoporosis (OR = 1.60, 95% CI 1.17-2.20), cardiovascular diseases (OR = 1.46, 95% CI 1.20-1.78), hypertension (OR = 1.37, 95% CI 1.23-1.52), diabetes mellitus (OR = 1.84, 95% CI 1.30-2.60), preoperative Cobb angle (SMD = 0.43, 95% CI 0.29, 0.57), number of comorbidities (SMD = 0.41, 95% CI 0.12, 0.70), and preoperative lumbar lordotic angle (SMD = - 0.20, 95% CI - 0.35, - 0.06). Statistically significant procedure-related factors were fusion extending to the sacrum or pelvis (OR = 2.53, 95% CI 1.53-4.16), use of osteotomy (OR = 1.60, 95% CI 1.12-2.29), longer operation duration (SMD = 0.72, 95% CI 0.05, 1.40), estimated blood loss (SMD = 0.46, 95% CI 0.07, 0.85), and number of levels fused (SMD = 0.37, 95% CI 0.03, 0.70). CONCLUSION These data may contribute to development of a systematic approach aimed at improving quality-of-life and reducing complications in high-risk patients.
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Quigley M, Apos E, Truong TA, Ahern S, Johnson MA. Comorbidity data collection across different spine registries: an evidence map. 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 2023; 32:753-777. [PMID: 36658363 DOI: 10.1007/s00586-023-07529-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/28/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Comorbidities are significant patient factors that contribute to outcomes after surgery. There is highly variable collection of this information across the literature. To help guide the systematic collection of best practice data, the Australian Spine Registry conducted an evidence map to investigate (i) what comorbidities are collected by spine registries, (ii) how they are collected and (iii) the compliance and completeness in collecting comorbidity data. METHOD A literature search was performed to identify published studies of adult spine registry data reporting comorbidities. In addition, targeted questionnaires were sent to existing global spine registries to identify the maximum number of relevant results to build the evidence map. RESULTS Thirty-six full-text studies met the inclusion criteria. There was substantial variation in the reporting of comorbidity data; 55% of studies reported comorbidity collection, but only 25% reported the data collection method and 20% reported use of a comorbidity index. The variation in the literature was confirmed with responses from 50% of the invited registries (7/14). Of seven, three use a recognised comorbidity index and the extent and methods of comorbidity collection varied by registry. CONCLUSION This evidence map identified variations in the methodology, data points and reporting of comorbidity collection in studies using spine registry data, with no consistent approach. A standardised set of comorbidities and data collection methods would encourage collaboration and data comparisons between patient cohorts and could facilitate improved patient outcomes following spine surgery by allowing data comparisons and predictive modelling of risk factors.
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Affiliation(s)
- Matthew Quigley
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Esther Apos
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia. .,Spine Society of Australia, 3-5 West Street, North Sydney, NSW, 2060, Australia.
| | - Trieu-Anh Truong
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Susannah Ahern
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Michael A Johnson
- Spine Society of Australia, 3-5 West Street, North Sydney, NSW, 2060, Australia
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Patient and Spine Surgeon Perceptions on Shared Decision-Making in the Treatment of Older Adults Undergoing Corrective Surgery for Adult Spinal Deformity. Spine (Phila Pa 1976) 2022; 47:730-736. [PMID: 34652306 DOI: 10.1097/brs.0000000000004257] [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] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective. OBJECTIVE To understand patients' and spine surgeons' perspectives about decision-making around surgery for adult spinal deformity. SUMMARY OF BACKGROUND DATA Surgery for correction of adult spinal deformity is often beneficial; however, in over 20% of older adults (≥ 65 yrs of age), outcomes from surgery are less desirable. MATERIALS AND METHODS We conducted semistructured, in-depth interviews with six patients and five spine surgeons. Two investigators independently coded the transcripts using constant comparative method, as well as an integrative, team-based approach to identify themes. RESULTS Patients themes: 1) patients felt surgery was their only choice because they were running out of time to undergo invasive procedures; 2) patients mentally committed to surgery prior to the initial encounter with their surgeon and contextualized the desired benefits while minimizing the potential risks; 3) patients felt that the current decision support tools were ineffective in preparing them for surgery; and 4) patients felt that pain management was the most difficult part of recovery from surgery. Surgeons themes: 1) surgeons varied substantially in their interpretations of shared decision-making; 2) surgeons did not consider patients' chronological age as a major contraindication to undergoing surgery; 3) there is a goal mismatch between patients and surgeons in the desired outcomes from surgery, where patients prioritize complete pain relief whereas surgeons prioritize concrete functional improvement; and 4) surgeons felt that patient expectations from surgery were often established prior to their initial surgery visit, and frequently required recalibration. CONCLUSION Older adult patients viewed the decision to have surgery as time-sensitive, whereas spine surgeons expressed the need for recalibrating patient expectations and balancing the risks and benefits when considering surgery. These findings highlight the need for improved understanding of both sides of shared decision-making which should involve the needs and priorities of older adults to help convey patient-specific risks and choice awareness. LEVEL OF EVIDENCE 3.
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Wang KY, McNeely EL, Dhanjani SA, Raad M, Puvanesarajah V, Neuman BJ, Cohen D, Khanna AJ, Kebaish F, Hassanzadeh H, Kebaish KM. COVID-19 Significantly Impacted Hospital Length of Stay and Discharge Patterns for Adult Spinal Deformity Patients. Spine (Phila Pa 1976) 2021; 46:1551-1556. [PMID: 34431833 PMCID: PMC8552912 DOI: 10.1097/brs.0000000000004204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/03/2021] [Accepted: 07/21/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE The primary aim was to compare length of stay (LOS) and discharge disposition of adult spinal deformity (ASD) patients undergoing surgery before and during the pandemic. Secondary aims were to compare the rates of 30-day complications, reoperations, readmissions, and unplanned emergency department (ED) visits. SUMMARY OF BACKGROUND DATA ASD patients often require extended LOS and non-routine discharge. Given resource limitations during the Coronavirus Disease 2019 (COVID-19) pandemic and caution regarding hospital stays, surgeons modified standard postoperative protocols to minimize patient exposure. METHODS We identified all patients who underwent elective thoracolumbar ASD surgery with more than or equal to five levels fusion at a tertiary care center during two distinct time intervals: July to December 2019 (Pre-COVID, N = 60) and July to December 2020 (During-COVID, N = 57). Outcome measures included LOS and discharge disposition (home vs. non-home), as well as 30-day major complications, reoperations, readmissions, and ED visits. Regression analyses controlled for demographic and surgical factors. RESULTS Patients who underwent ASD surgery during the pandemic were younger (61 vs. 67 yrs) and had longer fusion constructs (nine vs. eight levels) compared with before the pandemic (P < 0.05 for both). On bivariate analysis, patients undergoing surgery during the pandemic had shorter LOS (6 vs. 9 days) and were more likely to be discharged home (70% vs. 28%) (P < 0.05 for both). After controlling for age and levels fused on multivariable regression, patients who had surgery during the pandemic had shorter LOS (IRR = 0.83, P = 0.015) and greater odds of home discharge (odds ratios [OR] = 7.2, P < 0.001). Notably, there were no differences in major complications, reoperations, readmissions, or ED visits between the two groups. CONCLUSION During the COVID-19 pandemic, LOS for patients undergoing thoracolumbar ASD surgery decreased, and more patients were discharged home without adversely affecting complication or readmission rates. Lessons learned during the pandemic may help improve resource utilization without negatively influencing short-term outcomes.Level of Evidence: 3.
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Affiliation(s)
- Kevin Y Wang
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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