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

The Impact of Unplanned Reoperation Following Adult Spinal Deformity Surgery: A Prospective Longitudinal Cohort Study with 5-Year Follow-up

BACKGROUND

The long-term impact of reoperations following adult spinal deformity (ASD) surgery is still poorly understood. Our aim was to identify the relationship between unplanned reoperation and health-related quality of life (HRQoL) gain at 2 and 5 years of follow-up.

METHODS

We included patients enrolled in a prospective ASD database who underwent surgery ≥5 years prior to the start of the study and who had 2 years of follow-up data. Adverse events (AEs) leading to an unplanned reoperation, the time of reoperation occurrence, invasiveness (blood loss, surgical time, hospital stay), and AE resolution were assessed. HRQoL was measured with use of the Oswestry Disability Index, Scoliosis Research Society-22, and Short Form-36. Linear models controlling for baseline data and index surgery characteristics were utilized to assess the relationships between HRQoL gain at 2 and 5-year follow-up and the number and invasiveness of reoperations. The association between 5-year HRQoL gain and the time of occurrence of the unplanned reoperation and that between 5-year HRQoL gain and AE resolution were also investigated.

RESULTS

Of 361 eligible patients, 316 (87.5%) with 2-year follow-up data met the inclusion criteria and 258 (71.5%) had 5-year follow-up data. At the 2-year follow-up, 96 patients (30.4%) had a total of 165 unplanned reoperations (1.72 per patient). At the 5-year follow-up, 73 patients (28.3%) had a total of 117 unplanned reoperations (1.60 per patient). The most common cause of reoperations was mechanical complications (64.9%), followed by surgical site infections (15.7%). At the 5-year follow-up, the AE that led to reoperation was resolved in 67 patients (91.8%). Reoperation invasiveness was not associated with 5-year HRQoL scores. The number of reoperations was associated with lesser HRQoL gain at 5 years for all HRQoL measures. The mean associated reduction in HRQoL gain per unplanned reoperation was 41% (range, 19% to 66%). Reoperations resulting in no resolution of the AE or resolution with sequelae had a greater impact on 5-year follow-up HRQoL scores than reoperations resulting in resolution of the AE.

CONCLUSIONS

A postoperative, unplanned reoperation following ASD surgery was associated with lesser gain in HRQoL at 5 years of follow-up. The association did not diminish over time and was affected by the number, but not the magnitude, of reoperations. Resolution of the associated AE reduced the impact of the unplanned reoperation.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Impact of Controlled Versus Uncontrolled mFI-5 Frailty on Perioperative Complications After Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

We substratified the mFI-5 frailty index to reflect controlled and uncontrolled conditions and assess their relationship to perioperative complications.

SUMMARY OF BACKGROUND DATA

Risk assessment before adult spinal deformity (ASD) surgery is critical because the surgery is highly invasive with a high complication rate. Although frailty is associated with risk of surgical complications, current frailty measures do not differentiate between controlled and uncontrolled conditions.

METHODS

Frailty was calculated using the mFI-5 index for 170 ASD patients with fusion of ≥5 levels. Uncontrolled frailty was defined as blood pressure >140/90 mm Hg, HbA1C >7% or postprandial glucose >180 mg/dL, or recent chronic obstructive pulmonary disease (COPD) exacerbation, while on medication. Patients were divided into nonfrailty, controlled frailty, and uncontrolled frailty cohorts. The primary outcome measure was perioperative major and wound complications. Bivariate analysis was performed. Multivariable analysis assessed the relationship between frailty and perioperative complications.

RESULTS

The cohorts included 97 nonfrail, 54 controlled frail, and 19 uncontrolled frail patients. Compared with nonfrail patients, patients with uncontrolled frailty were more likely to have age older than 60 years (84% vs. 24%), hyperlipidemia (42% vs. 20%), and Oswestry Disability Index (ODI) score >42 (84% vs. 52%) (P<0.05 for all). Controlled frailty was associated with those older than 60 years (41% vs. 24%) and hyperlipidemia (52% vs. 20%) (P<0.05 for all). On multivariable regression analysis controlling for hyperlipidemia, functional independence, motor weakness, ODI>42, and age older than 60 years, patients with uncontrolled frailty had greater odds of major complications (OR 4.24, P=0.03) and wound complications (OR 9.47, P=0.046) compared with nonfrail patients. Controlled frailty was not associated with increased risk of perioperative complications (P>0.05 for all).

CONCLUSIONS

Although patients with uncontrolled frailty had higher risk of perioperative complications compared with nonfrail patients, patients with controlled frailty did not, suggesting the importance of controlling modifiable risk factors before surgery.

LEVEL OF EVIDENCE

3.

AM-PAC Mobility Score <13 Predicts Development of Ileus Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus.

SUMMARY OF BACKGROUND DATA

Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition.

METHODS

Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables.

RESULTS

Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P<0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P<0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus (P=0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus.

CONCLUSIONS

In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management.

LEVEL OF EVIDENCE

Level-III.

Estimating the Cost of Spinopelvic Complications After Adult Spinal Deformity Surgery

Objective

Reoperations for spinopelvic failure after adult spinal deformity (ASD) surgery are common. We sought to determine the added costs of ASD surgery attributable to reoperations for spinopelvic construct failures.

Methods

We constructed a Markov process model to calculate the expected discounted 5-year costs of spinopelvic construct failures after ASD surgery. The Nationwide Inpatient Sample (NIS) was queried to estimate the number of ASD surgeries. Model inputs were based on literature review and expert opinion. ASD surgery was defined as thoracolumbar fusion of 4 or more levels with pelvic fixation. The following pelvic fixation failures were included: 1) rod fracture or pseudarthrosis from L4-S1, 2) iliac screw failure or set plug dislodgment, 3) iliac screw prominence, and 4) sacroiliac (SI) joint pain. The number of patients undergoing ASD surgery annually in the US was determined using a commercial claims database.

Results

The net present value 5-year cost per patient for spinopelvic complications was $35,265, equal to 29% of index surgery costs. Given an estimated 27,580 cases annually in the US, the additional cost to address spinopelvic complications reach nearly $1 billion over 5-years. A sensitivity analysis showed that these costs were most sensitive to the rate of rod fracture/pseudarthrosis, iliac screw prominence, and reoperation.

Conclusion

A conservative estimate of the cost of spinopelvic failures after ASD surgery is substantial, nearly $1 billion over 5-years. We propose a method of capturing spinopelvic fixation failures for use in future clinical studies and cost analyses.

Modified frailty index independently predicts morbidity in patients undergoing 3-column osteotomy

PURPOSE

Adult Spinal Deformity (ASD) includes a spectrum of spinal conditions that can be associated with significant pain and loss of function. While 3-column osteotomies have been the procedures of choice for ASD patients, there is also a substantial risk for complications. The prognostic value of the modified 5-item frailty index (mFI-5) for these procedures has not yet been studied. The goal of this study is to evaluate the association of mFI-5 with 30-day morbidity, readmission, and reoperation following a 3-column osteotomy.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried to identify patients undergoing 3-Column Osteotomy procedures from 2011-2019. Multivariate modeling was utilized to assess mFI-5 and other demographic, comorbidity, laboratory, and perioperative variables as independent predictors of morbidity, readmission, and reoperation.

RESULTS

N = 971. Multivariate analysis revealed that mFI-5 = 1 (OR = 1.62, p = 0.015) and mFI-5 ≥ 2 (OR = 2.17, p = 0.004) were significant independent predictors of morbidity. mFI-5 ≥ 2 was a significant independent predictor of readmission (OR = 2.16, p = 0.022) while mFI-5 = 1 was not a significant predictor of readmission (p = 0.053). Frailty did not predict reoperation.

CONCLUSION

Frailty as defined by mFI-5 strongly and independently predicted increased odds of postoperative morbidity for patients undergoing 3-column osteotomy as surgical intervention for ASD. Only mFI-5 ≥ 2 was a significant independent predictor of readmission, while frailty did not predict reoperation. Other variables independently predicted increased and decreased odds of postoperative morbidity, readmission, and reoperation.

LEVEL OF EVIDENCE

III.

Is lower screw density associated with mechanical complications in adult spinal deformity surgery?

PURPOSE

To assess the impact of screw density on: (1) rod fracture/pseudarthrosis, (2) proximal/distal junctional kyphosis/failure (PJK/DJK/PJF), and (3) deformity correction judged by sagittal vertical axis (SVA) and T1-pelvic angle (T1PA).

METHODS

A single-center, retrospective cohort study of patients undergoing adult spinal deformity (ASD) surgery from 2013 to 2017 was undertaken. Screw density was calculated by dividing the number of screws placed by the total instrumented levels. Screw density was then dichotomized at our calculated mean density to ≥ 1.65 and < 1.65. Outcomes consisted of mechanical complications and the amount of correction obtained.

RESULTS

145 patients underwent ASD surgery with 2-year follow-up. Mean screw density (range) was 1.6 ± 0.3 (1.00-2.00). The most common levels with missing screws were L2 (n = 59, 40.7%), L3 (n = 57, 39.3%) and L1 (n = 51, 35.2%), located mainly along the concavity in 113(80.0%) patients and apices in 98 (67.6%) patients. Rod fracture/pseudarthrosis: 23/32 (71.8%) patients with rod fracture and 35/46 (76.0%) with pseudarthrosis had missing screws within two levels of the rod fracture/pseudarthrosis. Logistic regression showed no significant association between screw density and rod fracture/pseudarthrosis.

PJK/F

15/47 (31.9%) patients with PJK and 9/30 (30.0%) with PJF had missing screws within three levels of the upper instrumented vertebra (UIV). Logistic regression showed no significant association between screws density and PJK/F. Correction obtained: linear regression failed to show any significant association between screw density and SVA or T1PA correction.

CONCLUSION

These findings showed that no significant association was found between screw density and mechanical complications or the amount of correction obtained, though approximately 3 out of 4 patients with rod fracture/pseudarthrosis had missing screws at or within two levels of the pathology. The prevention of mechanical complications is likely multifactorial and subject to both patient's characteristics and surgical techniques.

LEVEL OF EVIDENCE

III.

Decompression Alone in the Setting of Adult Degenerative Lumbar Scoliosis and Stenosis: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.OBJECTIVESSurgical decompression alone for patients with neurogenic leg pain in the setting of degenerative lumbar scoliosis (DLS) and stenosis is commonly performed, however, there is no summary of evidence for outcomes.

METHODS

A systematic search of English language medical literature databases was performed for studies describing outcomes of decompression alone in DLS, defined as Cobb angle >10˚, and 2-year minimum follow-up. Three outcomes were examined: 1) Cobb angle progression, 2) reoperation rate, and 3) ODI and overall satisfaction. Data were pooled and weighted averages were calculated to summarize available evidence.

RESULTS

Across 15 studies included in the final analysis, 586 patients were examined. Average preoperative and postoperative Cobb angles were 17.6˚ (Range: 12.7 - 25˚) and 18.0 (range 14.1 - 25˚), respectively. Average change in Cobb angle was an increase of 1.8˚. Overall rate of reoperation ranged from 3 to 33% with an average of 9.7%. Average ODI before surgery, after surgery, and change in scores were 56.4%, 27.2%, and an improvement of 29% respectively. Average from 8 studies that reported patient satisfaction was 71.2%.

CONCLUSIONS

Current literature on decompression alone in the setting of DLS is sparse and is not high quality, limited to patients with small magnitude of lumbar coronal Cobb angle, and heterogenous in the type of procedure performed. Based on available evidence, select patients with DLS who undergo decompression alone had minimal progression of Cobb angle, relatively low reoperation rate, and favorable patient-reported outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The postoperative course of mechanical complications in adult spinal deformity surgery

PURPOSE

(a) Describe the time course of each mechanical complication, and (b) compare radiographic measurements and preoperative patient-reported outcome measures (PROMs) among each mechanical complication type.

METHODS

A single-institution case-control study was undertaken of patients undergoing adult spinal deformity (ASD) surgery from 2009-2017. Exposure variables included patient demographics, operative variables, radiographic measurements, and preoperative PROMs, including Oswestry Disability Index (ODI), Numeric Rating Scale Back/Leg-pain scores (NRS-Back/Leg), and EuroQol-5D (EQ-5D). The primary outcomes were occurrence of a mechanical complication and time to complication. Due to overlapping occurrence, rod fracture and pseudarthrosis were grouped into one composite category.

RESULTS

145 patients underwent ASD surgery and were followed for at least 2 years. 30/47 (63.8%) patients with proximal junctional kyphosis (PJK) required reoperation, whereas 27/31 (87.1%) patients with pseudarthrosis/rod fracture required reoperation (63.8% vs. 87.1%, Χ² = -0.23, 95% CI -0.41, -0.05, p = 0.023). Cox regression showed no significant difference in time to reoperation between PJK and rod fracture/pseudarthrosis (HR = 0.97, 95% CI 0.85-1.11, p = 0.686). Distal junctional kyphosis (DJK) (N = 3; 2 reoperation) and implant failures (N = 4; 0 reoperations) were rare. Patients with PJK had significantly lower Hounsfield Units preoperatively compared to those with pseudarthrosis/rod fracture (138.2 ± 43.8 vs. 160.3 ± 41.0, mean difference (MD) =  -22.1, 95% CI -41.8, -2.4, p = 0.028), more prior fusions (51.1% vs. 25.8%, Χ² = 0.253, 95% CI 0.41, 0.46, p = 0.026), fewer instrumented vertebrae (9.2 ± 2.6 vs. 10.7 ± 2.5, MD =  -1.5, 95% CI -2.7, -0.31, p = 0.013), and higher postoperative thoracic kyphosis (TK) (46.3 ± 12.7 vs. 34.9 ± 10.6, MD = 11.4, 95% CI 5.9, 16.9, p < 0.001). Higher postoperative C7 sagittal vertical axis (SVA) did not achieve a significant difference (80.7 ± 72.1 vs. 51.9 ± 57.3, MD = 28.8, 95% CI -1.9, 59.5, p = 0.066). No differences were seen in preoperative PROMs.

CONCLUSION

Patients with pseudarthrosis/rod fracture had a higher reoperation rate compared to those with PJK with similar time to reoperation. Moreover, patients with PJK had higher postoperative TK, lower Hounsfield Units, more prior fusions, and fewer instrumented levels compared to those with pseudarthrosis/rod fracture. The results of this single-institution study suggest that even though mechanical complications are often analyzed as a single group, important differences may exist between them.

LEVEL OF EVIDENCE

III.

Systematic review and meta-analysis for the impact of rod materials and sizes in the surgical treatment of adult spine deformity

PURPOSE

To assess clinical and safety outcomes associated with different rod materials and diameters in adult spinal deformity (ASD) surgery.

METHODS

A systematic literature review and meta-analysis evaluated ASD surgery using pedicle screw fixation systems with rods of different materials and sizes. Postoperative outcomes (i.e., Cobb, sagittal vertical axis, and pelvic tilt angle) and complications (i.e., pseudarthrosis and rod breakage) were assessed. Random effects models (REMs) pooled data for outcomes reported in ≥ 2 studies.

RESULTS

Among 50 studies evaluating ASD surgery using pedicle screw fixation systems, 17 described rod material/diameter. Postoperative outcomes did not statistically differ between cobalt-chromium (CoCr) vs. titanium (Ti) rods (n = 2 studies; mean [95% confidence interval (CI)] sagittal vertical axis angle: CoCr 37.00° [18.58°-55.42°] and Ti 32.58° [24.62°-40.54°]; mean [95% CI] pelvic tilt angle: CoCr 26.20° [22.87°-29.53°] and Ti 20.15° [18.0°-22.31°]). The pooled proportion (95% CI) of pseudarthrosis was 15% (7-22%) for CoCr and 12% (- 8-32%) for stainless steel (SS) (n = 2 studies each; Chi2 = 0.07, p = 0.79). The pooled proportion (95% CI) of broken rods was 12% (1-22%) for Ti (n = 3 studies) and 10% (2-19) for CoCr (n = 1 study). Among 6.0-6.35 mm rods, the pooled (95% CI) postoperative Cobb angle (n = 2) was 12.01° (9.75°-14.28°), sagittal vertical axis angle (n = 4) was 35.32° (30.02°-40.62°), and pelvic tilt angle was 21.11° (18.35°-23.86°).

CONCLUSIONS

For ASD patients undergoing posterior fixation and fusion, there are no statistically significant differences in postoperative outcomes or complications among rods of varying materials and diameters. Benchmark postsurgical outcomes and complication rates by rod material and diameter are provided.

LEVEL OF EVIDENCE

III.

Failure in Adult Spinal Deformity Surgery: A Comprehensive Review of Current Rates, Mechanisms, and Prevention Strategies

STUDY DESIGN

Literature review.

OBJECTIVE

The aim of this review is to summarize recent literature on adult spinal deformity (ASD) treatment failure as well as prevention strategies for these failure modes.

SUMMARY OF BACKGROUND DATA

There is substantial evidence that ASD surgery can provide significant clinical benefits to patients. The volume of ASD surgery is increasing, and significantly more complex procedures are being performed, especially in the aging population with multiple comorbidities. Although there is potential for significant improvements in pain and disability with ASD surgery, these procedures continue to be associated with major complications and even outright failure.

METHODS

A systematic search of the PubMed database was performed for articles relevant to failure after ASD surgery. Institutional review board approval was not needed.

RESULTS

Failure and the potential need for revision surgery generally fall into 1 of 4 well-defined phenotypes: clinical failure, radiographic failure, the need for reoperation, and lack of cost-effectiveness. Revision surgery rates remain relatively high, challenging the overall cost-effectiveness of these procedures.

CONCLUSION

By consolidating the key evidence regarding failure, further research and innovation may be stimulated with the goal of significantly improving the safety and cost-effectiveness of ASD surgery.

Incidence and risk factors for early and late reoperation following lumbar fusion surgery

STUDY DESIGN

Retrospective cohort study.

PURPOSE

The aim of our study was to determine the rates and indications of reoperations following primary lumbar fusion, as well as the independent risk factors for early and late reoperation.

METHODS

We retrospectively reviewed patients who underwent lumbar fusion surgery between January 2017 and March 2020. All patients were followed up for more than 2 years. Characteristics, laboratory tests, primary diagnosis and surgery-related variables were compared among the early reoperation (< 3 months), the late reoperation (> 3 months) and the non-reoperation groups. Multivariable logistic regression analysis was used to identify independent risk factors for early and late reoperations.

RESULTS

Of 821 patients included in our studies, 34 patients underwent early reoperation, and 36 patients underwent late reoperation. The cumulative reoperation rate was about 4.1% (95% CI 3.8-4.5%) at 3 months, 6.2% (95% CI 5.9-6.5%) at 1 year and 8.2% (95% CI 8.0-8.5%) at 3 years. Multivariable analysis indicated that osteoporosis (odds ratio [OR] 3.6, 95% CI 1.2-10.5, p = 0.02) and diabetes (OR 2.1, 95% CI 1.1-4.5, p = 0.04) were independently associated with early reoperation and multilevel fusion (OR 2.4, 95% CI 1.1-5.4, p = 0.03) was independently associated with late reoperation.

CONCLUSIONS

The most common reasons for early reoperation and late operation were surgical site infection and adjacent segment diseases, respectively. Osteoporosis and diabetes were independent risk factors for early reoperation, and multilevel fusion was independent risk factor for late reoperation. Surgeons should pay more attention to these patients, and future studies should consider the effects of follow-up periods on results.

Surgeons' risk perception in ASD surgery: The value of objective risk assessment on decision making and patient counselling

BACKGROUND

Surgeons often rely on their intuition, experience and published data for surgical decision making and informed consent. Literature provides average values that do not allow for individualized assessments. Accurate validated machine learning (ML) risk calculators for adult spinal deformity (ASD) patients, based on 10 year multicentric prospective data, are currently available. The objective of this study is to assess surgeon ASD risk perception and compare it to validated risk calculator estimates.

METHODS

Nine ASD complete (demographics, HRQL, radiology, surgical plan) preoperative cases were distributed online to 100 surgeons from 22 countries. Surgeons were asked to determine the risk of major complications and reoperations at 72 h, 90 d and 2 years postop, using a 0-100% risk scale. The same preoperative parameters circulated to surgeons were used to obtain ML risk calculator estimates. Concordance between surgeons' responses was analyzed using intraclass correlation coefficients (ICC) (poor < 0.5/excellent > 0.85). Distance between surgeons' and risk calculator predictions was assessed using the mean index of agreement (MIA) (poor < 0.5/excellent > 0.85).

RESULTS

Thirty-nine surgeons (74.4% with > 10 years' experience), from 12 countries answered the survey. Surgeons' risk perception concordance was very low and heterogeneous. ICC ranged from 0.104 (reintervention risk at 72 h) to 0.316 (reintervention risk at 2 years). Distance between calculator and surgeon prediction was very large. MIA ranged from 0.122 to 0.416. Surgeons tended to overestimate the risk of major complications and reintervention in the first 72 h and underestimated the same risks at 2 years postop.

CONCLUSIONS

This study shows that expert surgeon ASD risk perception is heterogeneous and highly discordant. Available validated ML ASD risk calculators can enable surgeons to provide more accurate and objective prognosis to adjust patient expectations, in real time, at the point of care.

Impact of radiologic variables on item responses of ODI, SRS22 and SF-36. in adult spinal deformity patients: differential item functioning (DIF) analysis results from a multi-center database

PURPOSE

To determine if responses given to each question of the Scoliosis Research Society-22 (SRS22), Oswestry disability index (ODI) and Short Form-36 (SF-36) questionnaires are influenced by the radiological parameters.

METHODS

Patients enrolled in a multi-centre prospectively collected adult spinal deformity database who had complete SRS22, ODI and SF-36 data at baseline and at one-year follow-up were analysed. The presence of a differential item function of each question within each score in relation to radiological parameters was analysed using a mixed Rasch model with the radiological threshold value(s) determined.

RESULTS

Of those patients analysed (n = 1745; 1406 female, average age 51.0 ± 19.8 years), 944 were surgically and 801 were non-surgically treated. For the SRS22, questions (Q) 3, 5 and 18 were sensitive to almost all radiological parameters and the overall score was found sensitive to the Cobb angle. For the ODI, Q3, 6, 9 and 10 were not sensitive to any radiologic parameters whereas Q4 and 5 were sensitive to most. In contrast, only 3 of the SF-36 items were sensitive to radiological parameters.

CONCLUSIONS

78% of the SRS-22, 60% of the ODI and 8% of the questions in the SF-36 are sensitive to radiological parameters. Sagittal imbalance is independently associated with a poor overall outcome, but affects mental status and function more than pain and self-image. The assembly of questions responsive to radiological parameters may be useful in establishing a connection between changes in radiologic parameters and HRQL.

Trends in Intraoperative Assessment of Spinal Alignment: A Survey of Spine Surgeons in the United States

STUDY DESIGN

Survey.

OBJECTIVES

To characterize national practices of and shortcomings surrounding intraoperative assessments of spinal alignment.

METHODS

Spine surgeons in the US were surveyed to analyze their experience with assessing spinal alignment intraoperatively.

RESULTS

108 US spine surgeons from 77 surgical centers with an average of 19.2 + 8.8 years of surgical experience completed the survey. To assess alignment intraoperatively, 84% (91/108) use C-arm or spot radiographs, 40% (43/108) use full-length radiographs, and 20% utilize the T-bar (22/108). 88% of respondents' surgical centers (93/106) possessed a navigation camera and 63% of respondents (68/108) report using surgical navigation for 40% of their deformity cases on average. Reported deterrents for using current technology to assess alignment were workflow interruption (54%, 58/108), expense (33%, 36/108), and added radiation exposure (26%, 28/108). 87% of respondents (82/94) reported a need for improvement in current capabilities of making intraoperative assessments of spinal alignment.

CONCLUSIONS

Corrective surgery for spinal deformity is a complex procedure that requires a high level of expertise to perform safely. The majority of surveyed surgeons primarily rely on radiographs for intraoperative assessments of alignment. Despite the majority of surveyed surgical practices possessing navigation cameras, they are utilized only for a minority of spinal deformity cases. With the majority of surveyed surgeons reporting a need for improvement in technology to assess spinal alignment intraoperatively, 3 of the top design considerations should include workflow interruption, expense, and radiation exposure.

Quality metrics in adult spinal deformity surgery over the last decade: a combined analysis of the largest prospective multicenter data sets

OBJECTIVE

The reported rate of complications and cost of adult spinal deformity (ASD) surgery, associated with an exponential increase in the number of surgeries, cause alarm among healthcare payers and providers worldwide. The authors conjointly analyzed the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and health-related quality of life [HRQOL] outcomes) since 2010.

METHODS

This is an observational prospective longitudinal cohort study. Patients underwent surgery between January 2010 and December 2016, with > 2 years of follow-up data. Demographic, surgical, radiological, and HRQOL (i.e., Oswestry Disability Index, SF-36, Scoliosis Research Society-22r) data obtained preoperatively and at 3, 6, 12, and 24 months after surgery were evaluated. Trends and changes in indicators were analyzed using local regression (i.e., locally estimated scatterplot smoothing [LOESS]) and adjusted odds ratio (OR).

RESULTS

Of the 2286 patients included in the 2 registries, 1520 underwent surgery between 2010 and 2016. A total of 1151 (75.7%) patients who were treated surgically at 23 centers in 5 countries met inclusion criteria. Patient recruitment increased progressively (2010-2011 vs 2015-2016: OR 1.64, p < 0.01), whereas baseline clinical characteristics (age, American Society of Anesthesiologists class, HRQOL scores, sagittal deformity) did not change. Since 2010 there has been a sustained reduction in major and minor postoperative complications observed at 90 days (major: OR 0.59; minor: OR 0.65; p < 0.01); at 1 year (major: OR 0.52; minor: 0.75; p < 0.01); and at 2 years of follow-up (major: OR 0.4; minor: 0.80; p < 0.01) as well as in the 2-year reintervention rate (OR 0.41, p < 0.01). Simultaneously, there has been a slight improvement in the correction of sagittal deformity (i.e., pelvic incidence-lumbar lordosis mismatch: OR 1.11, p = 0.19) and a greater gain in quality of life (i.e., Oswestry Disability Index 26% vs 40%, p = 0.02; Scoliosis Research Society-22r, self-image domain OR 1.16, p = 0.13), and these are associated with a progressive reduction of surgical aggressiveness (number of fused segments: OR 0.81, p < 0.01; percent pelvic fixation: OR 0.66, p < 0.01; percent 3-column osteotomies: OR 0.63, p < 0.01).

CONCLUSIONS

The best available data show a robust global improvement in quality metrics in ASD surgery over the last decade. Surgical complications and reoperations have been reduced by half, while improvement in disability increased and correction rates were maintained, in patients with similar baseline characteristics.

Complications of adult spinal deformity surgery: A literature review

Purpose:

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

Methods:

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

Results:

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

Discussion:

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

Conclusion:

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

The Scoli-RISK 1 results of lower extremity motor function 5 years after complex adult spinal deformity surgery

INTRODUCTION

Neurologic complications after complex adult spinal deformity (ASD) surgery are important, yet outcomes are heterogeneously reported, and long-term follow-up of actual lower extremity motor function is unknown.

OBJECTIVE

To prospectively evaluate lower extremity motor function scores (LEMS) before and at 5 years after surgical correction of complex ASD.

DESIGN

Retrospective analysis of a prospective, multicenter, international observational study.

METHODS

The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers around the world. Inclusion criteria were Cobb angle of > 80°, corrective osteotomy for congenital or revision deformity and/or 3-column osteotomy. Among patients with 5-year follow-up, comparisons of LEMS to baseline and within each follow-up period were made via documented neurologic exams on each patient.

RESULTS

Seventy-seven (28.3%) patients had 5-year follow-up. Among these 77 patients with 5-year follow-up, rates of postoperative LEMS deterioration were: 14.3% hospital discharge, 10.7% at 6 weeks, 6.5% at 6 months, 9.5% at 2 years and 9.3% at 5 years postoperative. During the 2-5 year window, while mean LEMS did not change significantly (-0.5, p = 0.442), eight (11.1%) patients deteriorated (of which 3 were ≥ 4 motor points), and six (8.3%) patients improved (of which 2 were ≥ 4 points). Of the 14 neurologic complications, four (28.6%) were surgery-related, three of which required reoperation. While mean LEMS were not impacted in patients with a major surgery-related complication, mean LEMS were significantly lower in patients with neurologic surgery-related complications at discharge (p = 0.041) and 6 months (p = 0.008) between the two groups as well as the change from baseline to 5 years (p = 0.041).

CONCLUSIONS

In 77 patients undergoing complex ASD surgery with 5-year follow-up, while mean LEMS did not change from 2 to 5 years, subtle neurologic changes occurred in approximately 1 in 5 patients (11.1% deteriorated; 8.3% improved). Major surgery-related complication did not result in decreased LEMS; however, those with neurologic surgery-related complications continued to have decreased lower extremity motor function at 5 years postoperative. These results underscore the importance of long-term follow-up to 5 years, using individual motor scores rather than group averages, and comparing outcomes to both baseline and last follow-up.

A BMP/Activin A Chimera Induces Posterolateral Spine Fusion in Nonhuman Primates at Lower Concentrations Than BMP-2

BACKGROUND

Supraphysiologic bone morphogenetic protein (BMP)-2 concentrations are required to induce spinal fusion. In this study, a BMP-2/BMP-6/activin A chimera (BV-265), optimized for BMP receptor binding, delivered in a recombinant human collagen:CDHA [calcium-deficient hydroxyapatite] porous composite matrix (CM) or bovine collagen:CDHA granule porous composite matrix (PCM), engineered for optimal BV-265 retention and guided tissue repair, was compared with BMP-2 delivered in a bovine absorbable collagen sponge (ACS) wrapped around a MASTERGRAFT Matrix (MM) ceramic-collagen rod (ACS:MM) in a nonhuman primate noninstrumented posterolateral fusion (PLF) model.

METHODS

In vivo retention of 125I-labeled-BV-265/CM or PCM was compared with 125I-labeled-BMP-2/ACS or BMP-2/buffer in a rat muscle pouch model using scintigraphy. Noninstrumented PLF was performed by implanting CM, BV-265/CM, BV-265/PCM, or BMP-2/ACS:MM across L3-L4 and L5-L6 or L3-L4-L5 decorticated transverse processes in 26 monkeys. Computed tomography (CT) images were acquired at 0, 4, 8, 12, and 24 weeks after surgery, where applicable. Manual palpation, μCT (microcomputed tomography) or nCT (nanocomputed tomography), and histological analysis were performed following euthanasia.

RESULTS

Retention of 125I-labeled-BV-265/CM was greater than BV-265/PCM, followed by BMP-2/ACS and BMP-2/buffer. The CM, 0.43 mg/cm3 BMP-2/ACS:MM, and 0.05 mg/cm3 BV-265/CM failed to generate PLFs. The 0.15-mg/cm3 BV-265/CM or 0.075-mg/cm3 BV-265/PCM combinations were partially effective. The 0.25-mg/cm3 BV-265/CM and 0.15 and 0.3-mg/cm3 BV-265/PCM combinations generated successful 2-level PLFs at 12 and 24 weeks.

CONCLUSIONS

BV-265/CM or PCM can induce fusion in a challenging nonhuman primate noninstrumented PLF model at substantially lower concentrations than BMP-2/ACS:MM.

CLINICAL RELEVANCE

BV-265/CM and PCM represent potential alternatives to induce PLF in humans at substantially lower concentrations than BMP-2/ACS:MM.

Association of Duration of Preoperative Opioid Use with Reoperation After One-level Anterior Cervical Discectomy and Fusion in Nonmyelopathic Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to determine that rates of preoperative opioid use in patients undergoing single-level anterior discectomy and fusion (ACDF) without myelopathy and determine the association with reoperations over 5 years.

SUMMARY OF BACKGROUND DATA

Preoperative opioid use before cervical spine surgery has been linked to worse postoperative outcomes. However, no studies have determined the association of duration and type of opioid used with reoperations after ACDF.

METHODS

Patients undergoing single-level ACDF without myelopathy between 2007 and 2016 with at least 5-year follow-up were identified in one private insurance administrative database. Preoperative opiate use was divided into acute (within 3 months), subacute (acute use and use between 3 and 6 months), and chronic (subacute use and use before 6 months) and by the opiate medication prescribed (tramadol, oxycodone, and hydrocodone). Postoperative rates of additional cervical spine surgery were determined at 5 years and multivariate logistic regression was used to determine the association of preoperative opiates with additional surgery.

RESULTS

Of 445 patients undergoing single-level ACDF without myelopathy, 66.3% were taking opioid medications before surgery. The most commonly used preoperative opioid was hydrocodone (50.3% acute use, 24.7% chronic use). Opioid-naïve patients had a 5-year reoperation rate of 4.7%, compared to 25.0%, 15.5%, and 23.3% with chronic preoperative use of tramadol, hydrocodone, and oxycodone. In multivariate analysis, controlling for age, sex, and Charlson Comorbidity Index, chronic use of hydrocodone (odds ratio [OR] = 2.08, P = 0.05), oxycodone (OR = 4.46, P < 0.01), and tramadol (OR = 4.01, P = 0.01) were all associated with increased reoperations. However, acute use of hydrocodone, oxycodone, and tramadol was not associated with reoperations (P > 0.05).

CONCLUSION

Both subacute and chronic use of common lower-dose opioid medications is associated with increased reoperations after single-level ACDF in nonmyelopathic patients. This information is critical when counseling patients preoperatively and developing preoperative opioid cessation programs.Level of Evidence: 3.

Lowest Instrumented Vertebra Selection to S1 or Ilium Versus L4 or L5 in Adult Spinal Deformity: Factors for Consideration in 349 Patients With a Mean 46-Month Follow-Up

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare the outcomes of patients with adult spinal deformity (ASD) following spinal fusion with the lowest instrumented vertebra (LIV) at L4/L5 versus S1/ilium.

METHODS

A multicenter ASD database was evaluated. Patients were categorized into 2 groups based on LIV levels-groups L (fusion to L4/L5) and S (fusion to S1/ilium). Both groups were propensity matched by age and preoperative radiographic alignments. Patient demographics, operative details, radiographic parameters, revision rates, and health-related quality of life (HRQOL) scores were compared.

RESULTS

Overall, 349 patients had complete data, with a mean follow-up of 46 months. Patients in group S (n = 311) were older and had larger sagittal and coronal plane deformities than those in group L (n = 38). After matching, 28 patients were allocated to each group with similar demographic, radiographic, and clinical parameters. Sagittal alignment restoration at postoperative week 6 was significantly better in group S than in group L, but it was similar in both groups at the 2-year follow-up. Fusion to S1/ilium involved a longer operating time, higher PJK rates, and greater PJK angles than that to L4/L5. There were no significant differences in the complication and revision rates between the groups. Both groups showed significant improvements in HRQOL scores.

CONCLUSIONS

Fusion to S1/ilium had better sagittal alignment restoration at postoperative week 6 and involved higher PJK rates and greater PJK angles than that to L4/L5. The clinical outcomes and rates of revision surgery and complications were similar between the groups.

Sagittal alignment changes and postoperative complications following surgery for adult spinal deformity in patients with Parkinson's disease: a multi-institutional retrospective cohort study

Background

Parkinson’s disease (PD) has been found to increase the risk of postoperative complications in patients with adult spinal deformity (ASD). However, few studies have investigated this by directly comparing patients with PD and those without PD.

Methods

In this multicenter retrospective cohort study, we reviewed all surgically treated ASD patients with at least 2 years of follow-up. Among them, 27 had PD (PD+ group). Clinical data were collected on early and late postoperative complications as well as any revision surgery. Radiographic parameters were evaluated before and immediately after surgery and at final follow-up, including sagittal vertical axis (SVA), thoracic kyphosis, lumbar lordosis, sacral slope, and pelvic tilt. We compared the surgical outcomes and radiographic parameters of PD patients with those of non-PD patients.

Results

For early complications, the PD+ group demonstrated a higher rate of delirium than the PD− group. In terms of late complications, the rate of non-union was significantly higher in the PD+ group. Rates of rod failure and revision surgery due to mechanical complications also tended to be higher, but not significantly, in the PD+ group (p = 0.17, p = 0.13, respectively). SVA at final follow-up and loss of correction in SVA were significantly higher in the PD+ group.

Conclusion

Extra attention should be paid to perioperative complications, especially delirium, in PD patients undergoing surgery for ASD. Furthermore, loss of correction and rate of non-union were greater in these patients.

Use of Higher-strength Opioids has a Dose-Dependent Association With Reoperations After Lumbar Decompression and Interbody Fusion Surgery

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The aim of this study was to identify an association between preoperative opioid use and reoperations rates.

SUMMARY OF BACKGROUND DATA

Chronic opioid use is a public health crisis in the United States and has been linked to worse outcomes after lumbar spine surgery. However, no studies have identified an association between preoperative opioid use and reoperations rates.

METHODS

A retrospective cohort study was conducted using patients from one private insurance database who underwent primary lumbar decompression/discectomy (LDD) or posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Preoperative use of five specific opioid medications (tramadol, hydromorphone, oxycodone, hydromorphone, and extended-release oxycodone) was categorized as acute (within 3 months), subacute (acute use and use between 3 and 6 months), or chronic (subacute use and use before 6 months). Multivariate regression, controlling for multilevel surgery, age, sex, and Charlson Comorbidity Index, was used to determine the association of each medication on reoperations within 5 years.

RESULTS

A total of 11,551 patients undergoing LDD and 3291 patients undergoing PLIF/TLIF without previous lumbar spine surgery were identified. In the LDD group, opioid-naïve patients had a 5-year reoperation rate of 2.8%, compared with 25.0% and 8.0 with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of oxycodone was associated with increased reoperations (odds ratios [OR] = 1.4, 2.0, and 2.3, for acute, subacute, and chronic use; P < 0.01). Chronic use of hydromorphone was also associated with increased reoperations (OR = 7.5, P < 0.01).In the PLIF/TLIF group, opioid-naïve patients had a 5-year reoperation rate of 11.3%, compared with 66.7% and 16.8% with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of hydromorphone was associated with increased reoperations (OR = 2.9, 4.0, and 14.0, for acute, subacute, and chronic use; P < 0.05).

CONCLUSION

Preoperative use of the higher-potency opioid medications is associated with increased reoperations after LDD and PLIF/TLIF in a dose-dependent manner. Surgeons should use this data for preoperative opioid cessation counseling and individualized risk stratification.Level of Evidence: 3.

Adult spine deformity surgery in elderly patients: are outcomes worse in patients 75 years and older?

STUDY DESIGN

Retrospective study of a prospectively collected database at one center.

OBJECTIVES

Assess the outcomes and complications of adult spinal deformity (ASD) surgery in patients that are 75 years and older compared with patients of 65-75 years of age. With increasing amounts of ASD surgery being performed on elderly patients, it is important to assess how age plays a factor in corrective reconstruction surgery.

METHODS

Inclusion criteria for the study were all patients ≥ 65 years of age that underwent thoracolumbar deformity correction involving ≥ four levels at a single institution by two surgeons. Patients were divided based on age into 65-74.9 or ≥ 75 groups. Radiographic parameters were measured preoperatively, postoperatively, and at 2 years. The Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI) were collected preoperatively, at 1 year, and 2 years. Comorbidities included were based around the Charlson Comorbidity Index (CCI) and compared to the incidence of complications and need for further surgery.

RESULTS

Both age groups had improvements in their radiographic parameters postoperatively which was maintained at 2 years. Comparing the different age groups with similar comorbidity burden in regard to complications and need for additional surgery yielded no statistically significant difference between groups. Both groups had comparable decreases in NRS and increases in ODI at 2 years.

CONCLUSIONS

Analysis of our study population indicates that there is no difference between the outcomes and complications of deformity surgery in patients 75 years and older when compared to a younger elderly population. It also does not appear that a ≥ 3 comorbidity burden has a significant impact on the complications or need for additional surgery in our elderly spinal deformity surgery population.

LEVEL OF EVIDENCE

Level IV.

Medical optimization of modifiable risk factors before thoracolumbar three-column osteotomies: an analysis of 195 patients

PURPOSE

To determine the rate of preoperative modifiable laboratory abnormalities (both major and minor) and the association with early postoperative medical and surgical complications.

METHODS

All patients undergoing thoracolumbar three-column osteotomy between 2013 and 2016 with preoperative laboratory data were identified. Potential preoperative modifiable laboratory abnormalities (major and minor) were assessed including hyponatremia (sodium < 130 and < 135 mEq/L), anemia (hematocrit < 25% and < 30%), renal insufficiency (creatinine ≥ 1.8 and ≥ 1.2 mg/dL), coagulopathy (INR ≥ 1.8 and ≥ 1.2), and hypoalbuminemia (albumin < 2.5 and < 3.5 g/dL). Multivariate logistic regression was used to determine associations with 30-day complications after controlling for possible confounding factors.

RESULTS

A total of 195 patients were identified. The rates of major and minor preoperative laboratory abnormalities were 7.7% and 31.3%, respectively. The rates of serious medical, minor medical, and surgical complications over 30-days were 6.7%, 21.5%, and 10.3%, respectively. In multivariate analysis the presence of major preoperative laboratory abnormalities had a significant association with serious medical complications (odds ratio [OR] 77.8, P < 0.001), and minor medical complications (OR 13.3, P < 0.001), but not surgical complications (P = 0.243). The presence of minor preoperative laboratory abnormalities had a significant association with serious medical complications (OR 10.4, P = 0.041) and minor medical complications (OR 2.4, P = 0.045), but not surgical complications (P = 0.490).

CONCLUSIONS

While major laboratory abnormalities had a strong association with complications, even minor modifiable laboratory abnormalities had a significant association with both serious and minor medical complications.

Three-level lumbar Ponte osteotomies with less invasive pelvic fixation improve spinal balance, quality of life and decrease disability in adult and elderly women with moderate adult spinal deformity

PURPOSE

To report on quality of life and radiological changes of Ponte osteotomies (POs) with long fixation for primary and revision surgery, in elderly women with adult spinal deformity (ASD).

METHODS

Sixty-seven (67) women, aged 69 ± 7 years, received 3 POs, spinopelvic fixation plus TLIFs. Forty-nine (73%) patients received primary and 18 (27%) revision surgery. Survivorship analysis was made for unplanned revision surgery for broken rods (BR); proximal junction failure (PJF); and deep wound infection (DWI). ODI and SF-36 were used for disability (ODI) and quality of life (SF-36) evaluation.

RESULTS

In total, 201 lumbar POs were made and 9.55 ± 3 levels fused. All patients were available 49 ± 11 months postoperatively. Postoperatively, SVA, CSVL, PI-LL, scoliosis, PT and T9-spinopelvic inclination were reduced, while LL and SS were increased significantly. At the final visit, PI-LL ≤ 10° was achieved in 26 (39.4%) patients; ≤ 15° in 51 (76%) patients, while all 67 patients showed a PI-LL ≤ 20°. Unplanned reoperation was performed in 11 (16.4%) patients: for BR in 5 (7.5%); for PJF in 3 (4.5%) and for DWI in 3 (4.5%) patients, respectively. With end point the reoperation for any reason the survival ± SE was 67.8% ± 0.1; for PJF 89.6 ± 0.065; and for BR 76% ± 0.1 in the final evaluation. There was no difference in survival between the primary and revision surgery groups (P = 0.568). ODI and SF-36 scores were improved postoperatively.

CONCLUSIONS

Three-segment lumbar POs offered and maintained sufficient improvement of lumbar lordosis along with restoration of the sagittal and coronal spinal alignment, improvement of quality of life and disability of female adult and elderly population after primary and revision surgery for ASD.

The Effect of Parity on Age-Related Degenerative Changes in Sagittal Balance

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Evaluate the effects of parity (number of births) on measures of sagittal posture in elderly women. The long-term objective of this study is to identify and mitigate factors contributing to age-related postural deformity in older adults.

SUMMARY OF BACKGROUND DATA

Adult spinal deformity is a prevalent condition that often requires costly surgical management. Females are disproportionately represented in spinal deformity surgical cases with up to 90% of patients being women. The potential contributions of pregnancy on postural degeneration have only begun to be acknowledged and require further study.

METHODS

Two hundred eight women with standing lateral radiographs were selected from the TwinsUK register. Parity information was extracted from questionnaires. Sagittal balance measurements (thoracic kyphosis, lumbar lordosis [LL], pelvic incidence [PI]) were collected and PI-LL mismatch was calculated. One-way analysis of variance tests were done between three separate age categories for measures of sagittal balance and parity and stepwise multivariate regression was done for PI-LL.

RESULTS

Both age and PI-LL mismatch significantly differed between parity categories. PI-LL was on average 7.0° ± 2.5° greater in multiparous (3+ births) subjects than in nulliparous subjects (P < 0.01). Parity did not have an independent relationship with lumbar disc degeneration, lumbar bone mineral density, or any of the individual sagittal balance parameters (P > 0.05 for all), except for PI-LL. From a subanalysis of the effect of parity on sagittal alignment within twin pairs, we found that within pair differences in parity associate with within pair differences in thoracic kyphosis.

CONCLUSION

This study established correlations between measures of spinal curvature in older women and parity for the first time. Longitudinal research is required to establish a causative relationship.

LEVEL OF EVIDENCE

4.

The Role of Potentially Modifiable Factors in a Standard Work Protocol to Decrease Complications in Adult Spinal Deformity Surgery: A Systematic Review, Part 1

STUDY DESIGN

Structured Literature Review.

OBJECTIVES

We sought to evaluate the peer-reviewed literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

Lean Methodology uses Standard Work to improve efficiency and decrease waste and error. ASD is known to have a high surgical complication rate. Several patient and surgical potentially modifiable factors have been suggested to affect complications, including preoperative hemoglobin, bone density, body mass index (BMI), age-appropriate realignment, preoperative albumin/prealbumin, and smoking status. We sought to evaluate the literature for evidence supporting these factors to include in a Standard Work protocol to decrease complications.

METHODS

Each of these six factors was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). A comprehensive literature search was then performed. The authors reviewed abstracts and analyzed data from included studies. From 456 initial citations with abstract, 173 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 93 included studies.

RESULTS

We found fair evidence supporting a low preoperative hemoglobin level associated with increased transfusion rates and decreased BMD and increased BMI associated with increased complication rates. Fair evidence supported low albumin/prealbumin associated with increased complications. There was fair evidence associating smoking exposure to increased reoperations, but conflicting evidence associating it with increased complications. There was no evidence in the literature evaluating age-appropriate realignment and complications.

CONCLUSION

Preoperative hemoglobin, bone density, body mass index, preoperative albumin/prealbumin, and smoking status all are potentially modifiable risk factors that are associated with increased complications in the adult spine surgery population. Developing a Standard Work Protocol for patient evaluation and optimization should include these factors.

LEVEL OF EVIDENCE

Level II.

Spinal Fusion in Parkinson's Disease Patients: A Propensity Score-Matched Analysis With Minimum 2-Year Surveillance

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To compare outcomes and complication rates between patients with and without Parkinson's disease (PD) patients undergoing surgery for adult spinal deformity (ASD).

SUMMARY OF BACKGROUND DATA

There is limited literature evaluating the impact of PD on long-term outcomes after thoracolumbar fusion surgery for ASD.

METHODS

Patients admitted from 2009 to 2011 with diagnoses of ASD who underwent any thoracolumbar fusion procedure with a minimum 2-year follow-up surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. A 1:1 propensity score-match by age, Deyo score, and number of fused vertebral levels was conducted before comparing surgical outcomes of patients with ASD with and without PD. Univariate analysis compared demographics, complications, and subsequent revision. Multivariate binary stepwise logistic regression models identified independent predictors of these outcomes (covariates: age, sex, Deyo Index score, and PD diagnosis).

RESULTS

A total of 576 propensity score-matched patients were identified (PD: n = 288; no-PD: n = 288), with a mean age of 69.7 years (PD) and 70.2 years (no-PD). Each cohort had comparable distributions of age, sex, race, insurance provider, Deyo score, and number of levels fused (all P > 0.05). Patients with PD incurred higher total charges across ASD surgery-related visits ($187,807 vs. $126,610, P < 0.001), yet rates of medical complications (35.8% PD vs. 34.0% no-PD, P = 0.662) and revision surgery (12.2% vs. 10.8%, P > 0.05) were comparable. Postoperative mortality rates were comparable between PD and no-PD cohorts (2.8% vs. 1.4%, P = 0.243). Logistic regression identified nine-level or higher spinal fusion as a significant predictor for an increase in total complications (odds ratio = 5.64); PD was not associated with increased odds of any adverse outcomes.

CONCLUSION

Aside from higher hospital charges incurred, patients with PD experienced comparable overall complication and revision rates to a propensity score-matched patient cohort without PD from the general population undergoing thoracolumbar fusion surgery. These results can support management of concerns and postoperative expectations in this patient cohort.

LEVEL OF EVIDENCE

3.

Neurologic Comorbidities Predict Proximal Junctional Failure in Adult Spinal Deformity

STUDY DESIGN

Retrospective case-control matched cohort from a single institution.

OBJECTIVE

To examine the contribution of nonmechanical factors to the incidence of proximal junctional failure (PJF) after adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

Multiple studies have reported on the prevalence of PJF following surgery for ASD. However, little is known about the contribution of nonmechanical factors to the incidence of PJF.

METHODS

We identified a consecutive series of ASD patients who required revision surgery for PJF between 2013 and 2015. A matched cohort of ASD patients who did not develop PJF after surgical correction was identified based on age, gender, preoperative deformity type, number of fusion levels, and the lower instrumented vertebra level. We compared medical and surgical histories in the matched cohorts, with particular attention to the prevalence of preoperative neurologic comorbidities that might affect standing balance. Preoperative, immediate postoperative, and follow-up radiographs were reviewed to document specific characteristics of mechanical failure that resulted in PJF and required revision surgery.

RESULTS

Twenty-eight cases of PJF requiring revision surgery were identified. The prevalence rates of preoperative neurologic comorbidities in PJF cohort were significantly higher than in non-PJF cohort (75% vs. 32%, p < .001). Neurologic comorbidities included prior stroke (4), metabolic encephalopathy (2), Parkinson disease (1), seizure disorder (1), cervical and thoracic myelopathy (7), diabetic neuropathy (4), and other neuropathy (4). The mean preoperative sagittal vertical axis in PJF cohort was more positive compared with the non-PJF cohort (144 mm vs. 65 mm, p = .009) There were no significant differences in immediate postoperative or follow-up radiographic parameters between cohorts.

CONCLUSIONS

In this study, risk factors identified for the development of PJF included nonmechanical neurologic comorbidities, emphasizing the need to look beyond radiographic alignment in order to reduce the incidence of PJF.

LEVEL OF EVIDENCE

Level 3.

Readmissions, Length of Stay, and Mortality After Primary Surgery for Adult Spinal Deformity: A 10-Year Danish Nationwide Cohort Study

STUDY DESIGN

Cohort study.

OBJECTIVE

To report outcome after primary surgery for adult spinal deformity (ASD), and assess risk factors for extended length of stay (extLOS) and readmission within 90 days.

SUMMARY OF BACKGROUND DATA

Complications after ASD surgery have been reported in 20% to 50% of patients. A few studies have focused on detailed information concerning postoperative morbidity.

METHODS

Patients >18 years undergoing primary instrumented surgery for ASD in Denmark in the period 2006 to 2016 were included. Patients were identified in the Danish National Patient Registry (DNPR) using procedure codes for instrumented spine surgery combined with diagnosis of spinal deformity. Information on length of stay (LOS), readmissions, and mortality were retrieved from the DNPR. Medical records were reviewed for causes of extLOS (LOS >10 days) and readmission within 90 days after surgery. Charlson Comorbidity Index (CCI) was calculated for all patients based on DNPR.

RESULTS

We included 892 patients. Median LOS was 8 days (interquartile range, IQR, 7-11). A total of 175 (28.0%) patients had extLOS; 81% because of "medically" related complications. Most common medically related reason (>50%) for extLOS was pain/mobilization difficulties. The 90-days readmission risk was 13.8%; 74.5% of readmissions were "medically" related, primarily opioid related side effects (18.2%), and pain/mobilization issues (15.2%); 25.5% of readmissions were "surgically" related and 16.7% of patients required revision surgery. Ninety-days mortality was 0.9%. Age groups 61 to 70 years, >70 years, CCI score 1 to 2 and CCI score ≥3 were associated with increased risk of extLOS (odds ratio, OR = 1.79, 2.01, 1.81, and 2.49, respectively). Age group >70 years and CCI score 1 to 2 were associated with increased risk of readmission (OR = 2.21 and 1.83).

CONCLUSION

Increasing age and comorbidity were associated with increased risk extLOS and readmission. Pain/mobilization difficulties were the most common postoperative complications. A future focus on early mobilization and pain management may improve outcome of ASD patients.

LEVEL OF EVIDENCE

3.

Outcomes of decompression and fusion for treatment of spinal infection

OBJECTIVE

Spine infection including vertebral osteomyelitis, discitis, paraspinal musculoskeletal infection, and spinal abscess refractory to medical management poses significant challenges to the treating physician. Surgical management is often required in patients suffering neurological deficits or spinal deformity with significant pain. To date, best practices have not been elucidated for the optimization of health outcomes and resource utilization in the setting of surgical intervention for spinal infection. The authors conducted the present study to assess the magnitude of reoperation rates in both fusion and nonfusion groups as well as overall health resource utilization following surgical decompression for spine infection.

METHODS

The authors performed an analysis using MarketScan (2001–2015) to identify health outcomes and healthcare utilization metrics of spine infection following surgical intervention with decompression alone or combined with fusion. Adult patients underwent surgical management for primary or secondary spinal infection and were followed up for at least 12 months postoperatively. Assessed outcomes included reoperation, healthcare utilization and payment at the index hospitalization and within 12 months after discharge, postoperative complications, and infection recurrence.

RESULTS

A total of 2662 patients in the database were eligible for inclusion in this study. Rehospitalization for infection was observed in 3.99% of patients who had undergone fusion and in 11.25% of those treated with decompression alone. Reoperation was needed in 12.7% of the patients without fusion and 8.16% of those with fusion. Complications within 30 days were more common in the nonfusion group (24.64%) than in the fusion group (16.49%). Overall postoperative payments after 12 months totaled $33,137 for the nonfusion group and $23,426 for the fusion group.

CONCLUSIONS

In this large cohort study with a 12-month follow-up, the recurrence of infection, reoperation rates, and complications were higher in patients treated with decompression alone than in those treated with decompression plus fusion. These findings along with imaging characteristics, disease severity, extent of bony resection, and the presence of instability may help surgeons decide whether to include fusion at the time of initial surgery. Further studies that control for selection bias in appropriately matched cohorts are necessary to determine the additive benefits of fusion in spinal infection management.

Major Complications at Two Years After Surgery Impact SRS Scores for Adolescent Idiopathic Scoliosis Patients

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To determine whether adolescent idiopathic scoliosis (AIS) patients with active complications at two-year follow-up demonstrate lower Scoliosis Research Society (SRS-22) questionnaire scores.

SUMMARY OF BACKGROUND DATA

There is limited evidence as to whether the SRS-22 is sensitive to complications in postoperative AIS patients.

METHODS

Surgical patients with SRS-22 scores completed at two-year follow-up were included. Five groups were created: no complication, minor complication resolved by 2 years, major complication resolved by 2 years, minor complication active, and major complication active at 2 years. Likelihood of reaching a minimal clinically important difference (MCID) for pain (0.20) and self-image (0.98) was evaluated.

RESULTS

1,481 patients were identified. Major complications active at two years existed in 2.2% of patients. These patients had the lowest score in all domains and total scores (p < .05). If a minor complication was active, scores were impacted for pain, self-image, satisfaction, and total (p < .05). No differences were found between no complication and resolved complications. Patients with active major complications were more likely to have a pain score that worsened from pre- to two years reaching MCID (52%) compared to the other four groups (range 18%-29%, odds ratio [OR] 3.6, p < .001). They also had a nonsignificant decreased rate of improvement of self-image score at an MCID level (42% vs. range 51%-66%, OR 0.56, p = .10).

CONCLUSIONS

When timing is considered, the SRS-22 demonstrates the ability to discriminate between patients with and without a complication. Active experience of a major complication impacted SRS-22 scores, in particular, the rate of worsening scores for pain, self-image, function, and total score.

LEVEL OF EVIDENCE

Level III.

Stopping at Sacrum Versus Nonsacral Vertebra in Long Fusion Surgery for Adult Spinal Deformity: Meta-Analysis of Revision with Minimum 2-Year Follow-Up

OBJECTIVE

A pooled comparison was conducted on a revision to the sacrum (S) versus a nonsacral (NS) surgical strategy in adult spinal deformity (ASD).

METHODS

Strictly following the PRISMA 2009 guidelines, the MEDLINE, EMBASE, and Cochrane Library databases were used to search for studies published in English up to March 2018 that addressed the S versus NS surgical approach for a long fusion to treat ASD. Data on total revisions and revision reasons were extracted from the included studies and were pooled analyzed.

RESULTS

Eight retrospective studies with a total of 1846 ASD patients (528 S and 1318 NS) were included. The total revision rate was 11.38% (S: 17.80% and NS: 8.80%), and implant failure, pseudarthrosis, adjacent segment degeneration, and proximal junctional kyphosis (PJK) were common reasons for revision. The pooled results indicated that the NS group had decreased incident rates of total revision (95% confidence interval [CI] 1.20-2.32, P = 0.002; I2 = 0%) and pseudarthrosis (95% CI 2.16-15.44, P = 0.0005; I2 = 0%) compared with the S group. No significant differences were observed in implant failure (95% CI 0.86-3.90, P = 0.12; I2 = 0%), adjacent segment degeneration (95% CI 0.08-1.25, P = 0.10; I2 = 0%), and PJK (95% CI 0.54-6.88, P = 0.35; I2 = 0%) between the 2 groups.

CONCLUSIONS

Revision in ASD patients is a serious problem with a total rate of 11.38%, and implant failure, pseudarthrosis, adjacent segment degeneration, and PJK are common reasons for revision. Stopping at the sacrum vertebra in long fusion surgery on ASD patients seems to increase the incidence rates of total revision and pseudarthrosis.

Long-term clinical and radiographic outcomes and patient satisfaction after adult spinal deformity correction

Background and Aims:

Adult spinal deformity surgery has increased with the aging population and modern surgical approaches, although it has high complication and reoperation rates. The permanence of radiographic correction, mechanical complications, predictive factors for poor patient-reported outcomes, and patient satisfaction were analyzed.

Material and Methods:

A total of 79 adult patients were retrospectively analyzed at baseline and 1–9 years after adult spinal deformity correction between 2007 and 2016. Patient-reported outcomes (Oswestry Disability Index, visual analog scale, and Scoliosis Research Society–30 scores), changes in radiographic alignment, indications for reoperation, predictors of poor outcomes according to the Oswestry Disability Index and Scoliosis Research Society–30 scores, and patient satisfaction with management were studied.

Results:

Oswestry Disability Index and visual analog scale scores (p = 0.001), radiographic correction of thoracic kyphosis, lumbar lordosis, and pelvic retroversion (p ⩽ 0.001) and sagittal vertical axis (p = 0.043) were significantly better at 4–5 years of follow-up than at baseline. The risk for the first reoperation owing to mechanical failure of instrumentation or bone was highest within the first year, at 13.9% (95% confidence interval = 8.0%–23.7%), and 29.8% (95% confidence interval = 19.4%–43.9%) at the 5-year follow-up. Oswestry Disability Index and Scoliosis Research Society–30 total scores had a good correlation (r = −0.78; 95% CI = −0.86 to –0.68; p < 0.001). Satisfaction with management was correlated with patient-reported outcomes. Male sex and depression (p = 0.021 and 0.018, respectively) predicted poor outcomes according to the Oswestry Disability Index and/or Scoliosis Research Society–30 score.

Conclusion:

The achieved significant radiographic correction was maintained 5 years postoperatively. Despite reoperations, patient satisfaction and clinical outcomes were good. Depression and male sex predicted poor clinical outcomes.

Prevalence and Indications for Unplanned Reoperations Following Index Surgery in the Adult Symptomatic Lumbar Scoliosis NIH-Sponsored Clinical Trial

STUDY DESIGN

Longitudinal cohort.

OBJECTIVE

To report on the prevalence and indications for unplanned reoperations following index surgery in the Adult Symptomatic Lumbar Scoliosis NIH-sponsored Clinical Trial.

SUMMARY OF BACKGROUND DATA

Reoperation following adult spinal deformity surgery exposes the patient to additional surgical risk, increases the cost of care, and decreases the potential cost-effectiveness of the intervention. Accurate data regarding the prevalence and indication for reoperation will facilitate future efforts to minimize risk.

METHODS

A total of 153 patients underwent adult spinal deformity surgery as part of the observational, randomized, or crossover groups and were eligible for two-year follow-up. Reoperations were meticulously tracked as part of the National Institutes of Health (NIH)-mandated serious adverse event (SAE) reporting. The primary indication for reoperation was obtained from the treating surgeon's operative report.

RESULTS

Thirty-two patients had one reoperation, two patients underwent two reoperations, and three patients underwent three reoperations. A total of 45 reoperations were performed in 37 patients. Eleven patients (7%) underwent reoperation within 90 days of the index surgery: two for superficial wound dehiscence, three for radiculopathy with screw removal, and six for acute proximal junctional failure (PJF). Four patients underwent reoperation for PJF more than 90 days from index surgery. Twenty-six patients underwent 28 reoperations for rod fracture/pseudoarthrosis.

CONCLUSION

In a consecutive series of adult spinal deformity surgery patients with meticulous follow-up, 24% of patients required an unplanned reoperation. The most common indication for reoperation was rod fracture/pseudoarthrosis, which occurred from 9 months to 3.7 years following the index surgery and accounted for 62% (28/45) of the reoperations. The second most common indication for reoperation was PJF, which occurred from 1 month to 1.6 years following index surgery and accounted for 22% (10/45) of the reoperations. As these complications will likely increase with longer follow-up, efforts to lower the rates of these complications are warranted.

LEVEL OF EVIDENCE

Level II.

Does Reoperation Risk Vary for Different Types of Pediatric Scoliosis?

STUDY DESIGN

Retrospective cohort study of spine fusion surgery utilizing the New York State Inpatient Database.

OBJECTIVE

The objective was to determine whether there were differences in reoperation rates among pediatric scoliosis associated with various etiologies compared with idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

The incidence of postoperative complications and reoperations is known to vary among patients with diverse scoliosis pathologies. As these are heterogeneous conditions and often with rare occurrence, it is difficult to compare them in a single study. We aimed to assess reoperation events after fusion for several etiologies of pediatric scoliosis.

METHODS

The 2008 to 2011 New York State Inpatient Database was queried using International Classification of Diseases (ICD-9-CM) codes for patients with in-hospital stays including a spine arthrodesis for scoliosis. All approaches, all fusion lengths, and ages 10 to 21 were included. Patient identifiers and linkage variables were used to identify revisits. The relative risk of reoperation was calculated for several rare conditions associated with scoliosis.

RESULTS

Two thousand three hundred fifty-six pediatric scoliosis fusion surgeries were identified in 2008 in the state of New York. The 1- and 4-year reoperation rate for idiopathic scoliosis was 0.9% and 1.6%, respectively. For nonidiopathic scoliosis, the 1- and 4-year rates were 4.2% and 20.4%, respectively. Of the nonidiopathic scoliosis subtypes, congenital scoliosis (4.7% risk at 1 y, 41.6% at 4 y), the neuromuscular disease arthrogryposis (7.3% risk at 1 y, 28.6% at 4 y), and syndrome neurofibromatosis (9.1% at 1 y, 32.3% at 4 y) showed the highest risk for reoperation. Length of stay and hospital charges were higher for reoperations.

CONCLUSIONS

Using a large administrative database, we identified neuromuscular, syndromic, and congenital forms of scoliosis that have the highest relative risk for a reoperation within 1 year. At-risk populations should be identified and resources allocated and preventative measures instituted accordingly to prevent these costly events.

LEVEL OF EVIDENCE

Level III.

Anterior Lumbar Fusion: Differences in Patient Selection and Surgical Outcomes Between Neurosurgeons and Orthopaedic Surgeons

OBJECTIVE

Anterior lumbar fusion (ALF) is performed by both neurosurgeons and orthopaedic surgeons. The aim of this study was to determine differences between the 2 surgical subspecialties in terms of patient selection and postoperative outcomes after ALF.

METHODS

A retrospective cohort study of adult patients undergoing ALF in the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2014 was performed. Univariate analyses were performed to identify differences in baseline patient demographics, comorbidities, operative characteristics, and 30-day postoperative outcomes between neurosurgery and orthopaedic surgery patients. Multivariate logistic regression analysis was used to determine whether surgical subspecialty was an independent risk factor for postoperative complications.

RESULTS

The study included 3182 patients, with 1629 (51.2%) neurosurgery patients and 1553 (48.8%) orthopaedic surgery patients. A greater proportion of neurosurgery patients were >65 years old, were being treated with preoperative steroids, had cardiac or pulmonary comorbidities, and had an American Society of Anesthesiologists classification III or higher. ALF procedures performed by neurosurgeons more frequently involved use of intervertebral devices and bone graft. On multivariate logistic regression analysis, ALF procedures performed by neurosurgeons were independently associated with a higher risk of reoperation (odds ratio = 1.61; 95% confidence interval, 1.02-2.56; P = 0.042) and urinary tract infection (odds ratio = 1.94; 95% confidence interval, 1.02-3.68; P = 0.043).

CONCLUSIONS

In addition to differences in baseline patient demographics and comorbidities and operative characteristics, ALF performed by neurosurgeons had a higher risk of 30-day reoperation and urinary tract infection compared with ALF performed by orthopaedic surgeons.

Risk Factors for 30-Day Readmissions and Reoperations After 3-Column Osteotomy for Spinal Deformity

STUDY DESIGN

Retrospective study of a prospectively collected database.

OBJECTIVE

To investigate the rate and risk factors for 30-day readmissions and reoperations after 3-column osteotomy (3CO).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database (2012-2014) was reviewed. Inclusion criteria were adult patients who underwent 3CO. The rate of 30-day readmission/reoperation was examined, and the association between patient/operative characteristics and outcome was investigated via multivariate analysis.

RESULTS

There were 299 patients who underwent a 3CO for spinal deformity. The rate of 30-day readmission and reoperation was 11.0% and 8.4%, respectively; 7.7% of readmissions were related to the primary procedure and 3.3% were unrelated. The most common unique cause for readmission was wound infection in 27.2% of cases. Among reoperations, the most common unique indications were wound infection (20.0%) and implant-related complications (20.0%). On multivariate analysis, obesity (odds ratio [OR] = 2.96; 95% CI = 1.06-8.25; P = .038), chronic obstructive pulmonary disease (OR = 20.8; 95% CI = 3.49-123.5; P = .001), and fusion of 13 or more spinal levels were independent predictors of readmission (OR = 4.86; 95% CI = 1.21-19.5; P = .025). On the other hand, independent predictors of reoperation included chronic obstructive pulmonary disease (OR = 6.33; 95% CI = 1.16-34.5; P = .033) and chronic steroid use (OR = 6.69; 95% CI = 1.61-27.7; P = .009).

CONCLUSION

Wound complications and short-term implant-related complications are important causes of readmission and/or reoperation after 3CO. Preoperative factors such as obesity, chronic lung disease, chronic steroid use, and long-segment fusion procedures may significantly increase the risk of 30-day morbidity following high-grade osteotomies.

Age Stratification of 30-Day Postoperative Outcomes Following Excisional Laminectomy for Extradural Cervical and Thoracic Tumors

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate age as an independent predictive factor for perioperative morbidity and mortality in patients undergoing surgical decompression for metastatic cervical and thoracic spinal tumors using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2014.

METHODS

We identified 1673 adult patients undergoing excisional laminectomy of cervical and thoracic extradural tumors. Patients were stratified into quartiles based on age, with Q1 including patients aged 18 to 49 years, Q2 including patients aged 50 to 60 years, Q3 including patients aged 61 to 69 years, and Q4 including patients ≥70 years. Univariate and multivariate regression analyses were performed to examine the association between age and 30-day perioperative morbidity and mortality.

RESULTS

Age was an independent risk factor for 30-day venous thromboembolism (VTE) and reoperation. Patients in Q3 for age had nearly a 4 times increased risk of VTE than patients in Q1 (odds ratio [OR] 3.97; 95% CI 1.91-8.25; P < .001). However, there was no significant difference in VTE between patients in Q4 and Q1 (P = .069). Patients in Q2 (OR 1.99; 95% CI 1.06-3.74; P = .032) and Q4 (OR 2.18; 95% CI 1.06-4.52; P = .036) for age had a 2 times increased risk of reoperation compared with patients in Q1.

CONCLUSIONS

Age was an independent predictive factor for perioperative VTE and reoperation, but there was no clear age-dependent relationship between increasing age and the risk of these perioperative complications.

Incidence and predictors of all-cause mortality within one year after adult spinal deformity surgery

Background

Surgery for adult spinal deformity (ASD) can significantly improve quality of life but is associated with significant risk of morbidity. Among the most devastating potential complications after these operations is death. The current study aims to report the incidence, preoperative factors, and postoperative complications associated with all-cause mortality within 1 year following ASD surgery.

Methods

Adults who underwent thoracolumbar spinal deformity correction between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Demographic characteristics were extracted. The primary outcome was death within 1 year of ASD surgery. Propensity score matching was used to control for confounding factors, followed by univariate/multivariable logistic regression to predict the odds of death within 1 year of ASD surgery.

Results

A total of 6,158 patients underwent ASD surgery and 61 (0.99%) died within one year of surgery. Preoperative factors: controlling for age, gender, American Society of Anesthesiologists (ASA) score and postoperative complications, four independent risk factors were associated with all-cause mortality within 1 year of ASD surgery: increased age (OR =1.03; 95% CI, 1.01-1.06; P=0.012), ASA score (OR =4.32; 95% CI, 2.68-6.94; P<0.001), cancer history (OR =7.91; 95% CI, 4.23-14.78; P<0.001) and unintentional weight loss (OR =4.65; 95% CI, 1.68-12.89; P=0.003). Postoperative complications: using propensity score matching and multivariable logistic regression, three independent risk factors were associated with all-cause mortality within 1 year of ASD surgery: pneumonia (OR =4.00; 95% CI, 1.68-9.53), deep venous thrombosis (DVT) (OR =3.12; 95% CI, 1.20-8.10) and unplanned intubation (OR =3.13; 95% CI, 1.15-8.50).

Discussion

Death after elective ASD surgery is a devastating yet uncommon event with an incidence of 1%. Preoperative factors of age, ASA score, cancer history, and unexpected weight loss, along with postoperative complications of pneumonia, DVT, and unplanned intubation were independently associated with all-cause mortality within 1 year of ASD surgery. Interestingly, the potentially more severe complications of sepsis, PE, and MI did not independently predict death.

Impact of early unanticipated revision surgery on health-related quality of life after adult spinal deformity surgery

BACKGROUND CONTEXT

Revision surgery represents a major event for patients undergoing adult spinal deformity (ASD) surgery. Previous reports suggest that ASD surgery has minimal or no impact on health-related-quality of life (HRQOL) outcomes.

PURPOSE

The present study aims to investigate the impact of early reoperations within the first year on HRQOL and on the likelihood of reaching the minimally clinically important difference (MCID) after ASD surgery.

DESIGN

This is a retrospective analysis of prospectively collected data from consecutive surgically treated adult deformity surgery patients included in a multicenter, international database.

PATIENT SAMPLE

The present study included 280 patients from a multicenter international prospective database.

OUTCOME MEASURE

Oswestry Disability Index (ODI), Short Form-36 (SF-36), Scoliosis Research Society-22 (SRS-22), MCID were evaluated in this work.

METHODS

Consecutive surgical patients with ASD recruited prospectively in six different centers from four countries with a minimum 2-year follow-up were stratified into two groups: R (revision surgery within the first year) and NR (no revision). Health-related-quality of life (ODI, SF-36, SRS-22) was assessed and compared at 6-month, 1-year, and 2-year follow-up stages. Statistical analysis included chi-square tests, Student t tests, and linear mixed models.

RESULTS

Forty-three patients (R Group) received 46 revision surgeries. Nineteen patients (41.3%) had implant-related complications, 9 patients (19.6%) had deep surgical site infections, 9 patients (19.6%) had proximal junctional kyphosis, 3 patients (6.5%) had hematoma, and 6 patients (13%) had other complications. Baseline characteristics differed between groups. At 6 months, all HRQOL scores improved in both groups, except in the SF-36 Mental Component Summary and SRS-22 mental health domain in the R Group. At 1 year, ODI and SRS-22 improvement was significantly greater in the NR Group, exceeding the reported MCID. At the 2-year follow-up, ODI, SRS-22, SF-36 MCS, and SF-36 PCS improvement was similar in both groups. However, postoperative change was only above the MCID for SF-36 PCS, ODI, and SRS-22 in the NR Group.

CONCLUSIONS

Early unanticipated revision surgery has a negative impact on mental health at 6 months and reduces the chances of reaching an MCID improvement in SRS-22, SF-36 PCS, and ODI at the 2-year follow-up.