Abnormal Postoperative PROMIS Scores are Associated With Patient Satisfaction in Adult Spinal Deformity and Degenerative Spine Patients

STUDY DESIGN

Retrospective review.

OBJECTIVES

To evaluate (1) patient satisfaction after adult spine surgery; (2) associations between the number of abnormal PROMIS domain scores and postoperative satisfaction; and (3) associations between the normalization of a patient's worst preoperative PROMIS domain score and postoperative satisfaction.

SUMMARY OF BACKGROUND DATA

Although "legacy" patient-reported outcome measures correlate with patient satisfaction after adult spine surgery, it is unclear whether PROMIS scores do.

MATERIALS AND METHODS

We included 1119 patients treated operatively for degenerative spine disease (DSD) or adult spinal deformity (ASD) from 2014 to 2019 at our tertiary hospital who completed questionnaires preoperatively and at ≥1 postoperative time points up to two years. Postoperative satisfaction was measured in ASD patients using items 21 and 22 from the SRS 22-revised questionnaire and in DSD patients using the NASS Patient Satisfaction Index. The "Worst" preoperative PROMIS domain was that with the greatest clinically negative deviation from the mean. "Normalization" was a postoperative score within 1 SD of the general population mean. Multivariate logistic regression identified factors associated with satisfaction.

RESULTS

Satisfaction was reported by 88% of DSD and 86% of ASD patients at initial postoperative follow-up; this proportion did not change during the first year after surgery. We observed an inverse relationship between postoperative satisfaction and the number of abnormal PROMIS domains at all postoperative time points beyond 6 weeks. Only among ASD patients was normalization of the worst preoperative PROMIS domain associated with greater odds of satisfaction at all time points up to one year.

CONCLUSION

The proportion of DSD and ASD patients satisfied postoperatively did not change from six weeks to 1 year. Normalizing the worst preoperative PROMIS domain and minimizing the number of abnormal postoperative PROMIS scores may reduce the number of dissatisfied patients. PROMIS data can guide perioperative patient management to improve satisfaction.

LEVEL OF EVIDENCE

Level-3.

Impact of Self-Reported Loss of Balance and Gait Disturbance on Outcomes following Adult Spinal Deformity Surgery

Background: The objective of this study was to evaluate if imbalance influences complication rates, radiological outcomes, and patient-reported outcomes (PROMs) following adult spinal deformity (ASD) surgery. Methods: ASD patients with baseline and 2-year radiographic and PROMs were included. Patients were grouped according to whether they answered yes or no to a recent history of pre-operative loss of balance. The groups were propensity-matched by age, pelvic incidence-lumbar lordosis (PI-LL), and surgical invasiveness score. Results: In total, 212 patients were examined (106 in each group). Patients with gait imbalance had worse baseline PROM measures, including Oswestry disability index (45.2 vs. 36.6), SF-36 mental component score (44 vs. 51.8), and SF-36 physical component score (p < 0.001 for all). After 2 years, patients with gait imbalance had less pelvic tilt correction (-1.2 vs. -3.6°, p = 0.039) for a comparable PI-LL correction (-11.9 vs. -15.1°, p = 0.144). Gait imbalance patients had higher rates of radiographic proximal junctional kyphosis (PJK) (26.4% vs. 14.2%) and implant-related complications (47.2% vs. 34.0%). After controlling for age, baseline sagittal parameters, PI-LL correction, and comorbidities, patients with imbalance had 2.2-times-increased odds of PJK after 2 years. Conclusions: Patients with a self-reported loss of balance/unsteady gait have significantly worse PROMs and higher risk of PJK.

Predictors of pelvic tilt normalization: a multicenter study on the impact of regional and lower-extremity compensation on pelvic alignment after complex adult spinal deformity surgery

OBJECTIVE

The objective was to determine the degree of regional decompensation to pelvic tilt (PT) normalization after complex adult spinal deformity (ASD) surgery.

METHODS

Operative ASD patients with 1 year of PT measurements were included. Patients with normalized PT at baseline were excluded. Predicted PT was compared to actual PT, tested for change from baseline, and then compared against age-adjusted, Scoliosis Research Society-Schwab, and global alignment and proportion (GAP) scores. Lower-extremity (LE) parameters included the cranial-hip-sacrum angle, cranial-knee-sacrum angle, and cranial-ankle-sacrum angle. LE compensation was set as the 1-year upper tertile compared with intraoperative baseline. Univariate analyses were used to compare normalized and nonnormalized data against alignment outcomes. Multivariable logistic regression analyses were used to develop a model consisting of significant predictors for normalization related to regional compensation.

RESULTS

In total, 156 patients met the inclusion criteria (mean ± SD age 64.6 ± 9.1 years, BMI 27.9 ± 5.6 kg/m2, Charlson Comorbidity Index 1.9 ± 1.6). Patients with normalized PT were more likely to have overcorrected pelvic incidence minus lumbar lordosis and sagittal vertical axis at 6 weeks (p < 0.05). GAP score at 6 weeks was greater for patients with nonnormalized PT (0.6 vs 1.3, p = 0.08). At baseline, 58.5% of patients had compensation in the thoracic and cervical regions. Postoperatively, compensation was maintained by 42% with no change after matching in age-adjusted or GAP score. The patients with nonnormalized PT had increased rates of thoracic and cervical compensation (p < 0.05). Compensation in thoracic kyphosis differed between patients with normalized PT at 6 weeks and those with normalized PT at 1 year (69% vs 35%, p < 0.05). Those who compensated had increased rates of implant complications by 1 year (OR [95% CI] 2.08 [1.32-6.56], p < 0.05). Cervical compensation was maintained at 6 weeks and 1 year (56% vs 43%, p = 0.12), with no difference in implant complications (OR 1.31 [95% CI -2.34 to 1.03], p = 0.09). For the lower extremities at baseline, 61% were compensating. Matching age-adjusted alignment did not eliminate compensation at any joint (all p > 0.05). Patients with nonnormalized PT had higher rates of LE compensation across joints (all p < 0.01). Overall, patients with normalized PT at 1 year had the greatest odds of resolving LE compensation (OR 9.6, p < 0.001). Patients with normalized PT at 1 year had lower rates of implant failure (8.9% vs 19.5%, p < 0.05), rod breakage (1.3% vs 13.8%, p < 0.05), and pseudarthrosis (0% vs 4.6%, p < 0.05) compared with patients with nonnormalized PT. The complication rate was significantly lower for patients with normalized PT at 1 year (56.7% vs 66.1%, p = 0.02), despite comparable health-related quality of life scores.

CONCLUSIONS

Patients with PT normalization had greater rates of resolution in thoracic and LE compensation, leading to lower rates of complications by 1 year. Thus, consideration of both the lower extremities and thoracic regions in surgical planning is vital to preventing adverse outcomes and maintaining pelvic alignment.

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.

Factors Associated with the Maintenance of Cost-Effectiveness at 5 Years in Adult Spinal Deformity Corrective Surgery

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To evaluate factors associated with the long-term durability of cost-effectiveness (CE) in ASD patients.

BACKGROUND

A substantial increase in costs associated with the surgical treatment for adult spinal deformity (ASD) has given precedence to scrutinize the value and utility it provides.

METHODS

We included 327 operative ASD patients with 5-year (5 Y) follow-up. Published methods were used to determine costs based on CMS.gov definitions and were based on the average DRG reimbursement rates. Utility was calculated using quality-adjusted life-years (QALY) utilizing the Oswestry Disability Index (ODI) converted to Short-Form Six-Dimension (SF-6D), with a 3% discount applied for its decline with life expectancy. The CE threshold of $150,000 was used for primary analysis.

RESULTS

Major and minor complication rates were 11% and 47% respectively, with 26% undergoing reoperation by 5 Y. The mean cost associated with surgery was $91,095±$47,003, with a utility gain of 0.091±0.086 at 1Y, QALY gained at 2 Y of 0.171±0.183, and at 5 Y of 0.42±0.43. The cost per QALY at 2 Y was $414,885, which decreased to $142,058 at 5 Y.With the threshold of $150,000 for CE, 19% met CE at 2 Y and 56% at 5 Y. In those in which revision was avoided, 87% met cumulative CE till life expectancy. Controlling analysis depicted higher baseline CCI and pelvic tilt (PT) to be the strongest predictors for not maintaining durable CE to 5 Y (CCI OR: 1.821 [1.159-2.862], P=0.009) (PT OR: 1.079 [1.007-1.155], P=0.030).

CONCLUSIONS

Most patients achieved cost-effectiveness after four years postoperatively, with 56% meeting at five years postoperatively. When revision was avoided, 87% of patients met cumulative cost-effectiveness till life expectancy. Mechanical complications were predictive of failure to achieve cost-effectiveness at 2 Y, while comorbidity burden and medical complications were at 5 Y.

Stronger association of objective physical metrics with baseline patient-reported outcome measures than preoperative standing sagittal parameters for adult spinal deformity patients

OBJECTIVE

Sagittal alignment measured on standing radiography remains a fundamental component of surgical planning for adult spinal deformity (ASD). However, the relationship between classic sagittal alignment parameters and objective metrics, such as walking time (WT) and grip strength (GS), remains unknown. The objective of this work was to determine if ASD patients with worse baseline sagittal malalignment have worse objective physical metrics and if those metrics have a stronger relationship to patient-reported outcome metrics (PROMs) than standing alignment.

METHODS

The authors conducted a retrospective review of a multicenter ASD cohort. ASD patients underwent baseline testing with the timed up-and-go 6-m walk test (seconds) and for GS (pounds). Baseline PROMs were surveyed, including Oswestry Disability Index (ODI), Patient-Reported Outcomes Measurement Information System (PROMIS), Scoliosis Research Society (SRS)-22r, and Veterans RAND 12 (VR-12) scores. Standard spinopelvic measurements were obtained (sagittal vertical axis [SVA], pelvic tilt [PT], and mismatch between pelvic incidence and lumbar lordosis [PI-LL], and SRS-Schwab ASD classification). Univariate and multivariable linear regression modeling was performed to interrogate associations between objective physical metrics, sagittal parameters, and PROMs.

RESULTS

In total, 494 patients were included, with mean ± SD age 61 ± 14 years, and 68% were female. Average WT was 11.2 ± 6.1 seconds and average GS was 56.6 ± 24.9 lbs. With increasing PT, PI-LL, and SVA quartiles, WT significantly increased (p < 0.05). SRS-Schwab type N patients demonstrated a significantly longer average WT (12.5 ± 6.2 seconds), and type T patients had a significantly shorter WT time (7.9 ± 2.7 seconds, p = 0.03). With increasing PT quartiles, GS significantly decreased (p < 0.05). SRS-Schwab type T patients had a significantly higher average GS (68.8 ± 27.8 lbs), and type L patients had a significantly lower average GS (51.6 ± 20.4 lbs, p = 0.03). In the frailty-adjusted multivariable linear regression analyses, WT was more strongly associated with PROMs than sagittal parameters. GS was more strongly associated with ODI and PROMIS Physical Function scores.

CONCLUSIONS

The authors observed that increasing baseline sagittal malalignment is associated with slower WT, and possibly weaker GS, in ASD patients. WT has a stronger relationship to PROMs than standing alignment parameters. Objective physical metrics likely offer added value to standard spinopelvic measurements in ASD evaluation and surgical planning.

The Case for Operative Efficiency in Adult Spinal Deformity Surgery: Impact of Operative Time on Complications, Length of Stay, Alignment, Fusion Rates, and Patient-Reported Outcomes

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To analyze the impact of operative room (OR) time in adult spinal deformity (ASD) surgery on patient outcomes.

BACKGROUND

It is currently unknown if OR time in ASD patients matched for deformity severity and surgical invasiveness is associated with patient outcomes.

MATERIALS AND METHODS

ASD patients with baseline and two-year postoperative radiographic and patient-reported outcome measures (PROM) data, undergoing a posterior-only approach for long fusion (>L1-Ilium) were included. Patients were grouped into short OR time (<40th percentile: <359 min) and long OR time (>60th percentile: >421 min). Groups were matched by age, baseline deformity severity, and surgical invasiveness. Demographics, radiographic, PROM data, fusion rate, and complications were compared between groups at baseline and two years follow-up.

RESULTS

In total, 270 patients were included for analysis: the mean OR time was 286 minutes in the short OR group versus 510 minutes in the long OR group ( P <0.001). Age, gender, percent of revision cases, surgical invasiveness, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt were comparable between groups ( P >0.05). Short OR had a slightly lower body mass index than the short OR group ( P <0.001) and decompression was more prevalent in the long OR time ( P =0.042). Patients in the long group had greater hospital length of stay ( P =0.02); blood loss ( P <0.001); proportion requiring intensive care unit ( P =0.003); higher minor complication rate ( P =0.001); with no significant differences for major complications or revision procedures ( P >0.5). Both groups had comparable radiographic fusion rates ( P =0.152) and achieved improvement in sagittal alignment measures, Oswestry disability index, and Short Form-36 ( P <0.001).

CONCLUSION

Shorter OR time for ASD correction is associated with a lower minor complication rate, a lower estimated blood loss, fewer intensive care unit admissions, and a shorter hospital length of stay without sacrificing alignment correction or PROMs. Maximizing operative efficiency by minimizing OR time in ASD surgery has the potential to benefit patients, surgeons, and hospital systems.

Inflation-adjusted medicare physician reimbursement for adult spinal deformity surgery substantially declined from 2002 to 2020

PURPOSE

Physician fees for orthopaedic surgeons by the Centers for Medicare and Medicaid Services (CMS) are increasingly scrutinized. The present retrospective review aims to assess whether adult spinal deformity (ASD) surgeries are properly valued for Medicare reimbursement.

METHODS

Current Procedural Terminology (CPT) codes related to posterior fusion of spinal deformity of ≤ 6, 7-12, and ≥ 13 vertebral levels, as well as additional arthrodesis and osteotomy levels, were assessed for (1) Compound annual growth rate (CAGR) from 2002 to 2020, calculated using physician fee data from the CMS Physician Fee Schedule Look-Up Tool; and (2) work relative value units (RVUs) per operative minute, using data from the National Surgical Quality Improvement Program.

RESULTS

From 2002 to 2020, all CPT codes for ASD surgery had negative inflation-adjusted CAGRs (range, - 18.49% to - 27.66%). Mean physician fees for spinal fusion declined by 26.02% (CAGR, - 1.66%) in ≤ 6-level fusion, 27.91% (CAGR, - 1.80%) in 7- to 12-level fusion, and 28.25% (CAGR, - 1.83%) ≥ 13-level fusion. Fees for both 7-12 (P < 0.00001) and ≥ 13 levels (P < 0.00001) declined more than those for fusion of ≤ 6 vertebral levels. RVU per minute was lower for 7- to 12-level and ≥ 13-level (P < 0.00001 for both) ASD surgeries than for ≤ 6-level.

CONCLUSIONS

Reimbursement for ASD surgery declined overall. CAGR for fusions of ≥ 7 levels were lower than those for fusions of ≤ 6 levels. For 2012-2018, ≥ 7-level fusions had lower RVU per minute than ≤ 6-level fusions. Revaluation of Medicare reimbursement for longer-level ASD surgeries may be warranted.

LEVEL OF EVIDENCE

III.

Impact of Hip and Knee Osteoarthritis on Full Body Sagittal Alignment and Compensation for Sagittal Spinal Deformity

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To investigate the effect of lower extremity osteoarthritis on sagittal alignment and compensatory mechanisms in adult spinal deformity (ASD).

BACKGROUND

Spine, hip, and knee pathologies often overlap in ASD patients. Limited data exists on how lower extremity osteoarthritis impacts sagittal alignment and compensatory mechanisms in ASD.

METHODS

527 pre-operative ASD patients with full body radiographs were included. Patients were grouped by Kellgren-Lawrence grade of bilateral hips and knees and stratified by quartile of T1-Pelvic Angle (T1PA) severity into low-, mid-, high-, and severe-T1PA. Full body alignment and compensation were compared across quartiles. Regression analysis examined the incremental impact of hip and knee osteoarthritis severity on compensation.

RESULTS

The mean T1PA for low-, mid-, high-, and severe-T1PA groups was 7.3°, 19.5°, 27.8°, 41.6°, respectively. Mid-T1PA patients with severe hip osteoarthritis had an increased sagittal vertical axis and global sagittal alignment (P<0.001). Increasing hip osteoarthritis severity resulted in decreased pelvic tilt (P=0.001) and sacrofemoral angle (P<0.001), but increased knee flexion (P=0.012). Regression analysis revealed with increasing T1PA, pelvic tilt correlated inversely with hip osteoarthritis and positively with knee osteoarthritis (r2=0.812). Hip osteoarthritis decreased compensation via sacrofemoral angle (β-coefficient=-0.206). Knee and hip osteoarthritis contributed to greater knee flexion (β-coefficients=0.215, 0.101; respectively). For pelvic shift, only hip osteoarthritis significantly contributed to the model (β-coefficient=0.100).

CONCLUSIONS

For the same magnitude of spinal deformity, increased hip osteoarthritis severity was associated with worse truncal and full body alignment with posterior translation of the pelvis. Patients with severe hip and knee osteoarthritis exhibited decreased hip extension and pelvic tilt, but increased knee flexion. This examines sagittal alignment and compensation in ASD patients with hip and knee arthritis and may help delineate whether hip and knee flexion is due to spinal deformity compensation or lower extremity osteoarthritis.

Are insufficient corrections a major factor in distal junctional kyphosis? A simulated analysis of cervical deformity correction using in-construct measurements

OBJECTIVE

The present study utilized recently developed in-construct measurements in simulations of cervical deformity surgery in order to assess undercorrection and predict distal junctional kyphosis (DJK).

METHODS

A retrospective review of a database of operative cervical deformity patients was analyzed for severe DJK and mild DJK. C2-lower instrumented vertebra (LIV) sagittal angle (SA) was measured postoperatively, and the correction was simulated in the preoperative radiograph in order to match the C2-LIV by using the planning software. Linear regression analysis that used C2 pelvic angle (CPA) and pelvic tilt (PT) determined the simulated PT that matched the virtual CPA. Linear regression analysis was used to determine the C2-T1 SA, C2-T4 SA, and C2-T10 SA that corresponded to DJK of 20° and cervical sagittal vertical axis (cSVA) of 40 mm.

RESULTS

Sixty-nine cervical deformity patients were included. Severe and mild DJK occurred in 11 (16%) and 22 (32%) patients, respectively; 3 (4%) required DJK revision. Simulated corrections demonstrated that severe and mild DJK patients had worse alignment compared to non-DJK patients in terms of cSVA (42.5 mm vs 33.0 mm vs 23.4 mm, p < 0.001) and C2-LIV SVA (68.9 mm vs 57.3 mm vs 36.8 mm, p < 0.001). Linear regression revealed the relationships between in-construct measures (C2-T1 SA, C2-T4 SA, and C2-T10 SA), cSVA, and change in DJK (all R > 0.57, p < 0.001). A cSVA of 40 mm corresponded to C2-T4 SA of 10.4° and C2-T10 SA of 28.0°. A DJK angle change of 10° corresponded to C2-T4 SA of 5.8° and C2-T10 SA of 20.1°.

CONCLUSIONS

Simulated cervical deformity corrections demonstrated that severe DJK patients have insufficient corrections compared to patients without DJK. In-construct measures assess sagittal alignment within the fusion separate from DJK and subjacent compensation. They can be useful as intraoperative tools to gauge the adequacy of cervical deformity correction.

Persistent Lower Extremity Compensation for Sagittal Imbalance After Surgical Correction of Complex Adult Spinal Deformity: A Radiographic Analysis of Early Impact

BACKGROUND AND OBJECTIVES

Achieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The objective is to analyze lower extremity compensation after complex ASD surgery, its effect on outcomes, and whether correction can alleviate these mechanisms.

METHODS

We included patients with complex ASD with 6-week data. LE parameters were as follows: sacrofemoral angle, knee flexion angle, and ankle flexion angle. Each parameter was ranked, and upper tertile was deemed compensation. Patients compensating and not compensating postoperatively were propensity score matched for body mass index, frailty, and T1 pelvic angle. Linear regression assessed correlation between LE parameters and baseline deformity, demographics, and surgical details. Multivariate analysis controlling for baseline deformity and history of total knee/hip arthroplasty evaluated outcomes.

RESULTS

Two hundred and ten patients (age: 61.3 ± 14.1 years, body mass index: 27.4 ± 5.8 kg/m2, Charlson Comorbidity Index: 1.1 ± 1.6, 72% female, 22% previous total joint arthroplasty, 24% osteoporosis, levels fused: 13.1 ± 3.8) were included. At baseline, 59% were compensating in LE: 32% at hips, 39% knees, and 36% ankles. After correction, 61% were compensating at least one joint. Patients undercorrected postoperatively were less likely to relieve LE compensation (odds ratio: 0.2, P = .037). Patients compensating in LE were more often undercorrected in age-adjusted pelvic tilt, pelvic incidence, lumbar lordosis, and T1 pelvic angle and disproportioned in Global Alignment and Proportion (P < .05). Patients matched in sagittal age-adjusted score at 6 weeks but compensating in LE were more likely to develop proximal junctional kyphosis (odds ratio: 4.1, P = .009) and proximal junctional failure (8% vs 0%, P = .035) than those sagittal age-adjusted score-matched and not compensating in LE.

CONCLUSION

Perioperative lower extremity compensation was a product of undercorrecting complex ASD. Even in age-adjusted realignment, compensation was associated with global undercorrection and junctional failure. Consideration of lower extremities during planning is vital to avoid adverse outcomes in perioperative course after complex ASD surgery.

Predicting major complications and discharge disposition after adult spinal deformity surgery

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.

Lumbar Lordosis Redistribution and Segmental Correction in Adult Spinal Deformity (ASD): Does it Matter?

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVE

Evaluate the impact of correcting to normative segmental lordosis values on post-operative outcomes.

BACKGROUND

Restoring lumbar lordosis magnitude is crucial in adult spinal deformity surgery, but the optimal location and segmental distribution remains unclear.

METHODS

Patients were grouped based on offset to normative segmental lordosis values, extracted from recent publications. Matched patients were within 10% of the cohort's mean offset, less than or over 10% were under- and over-corrected. Surgical technique, PROMs, and surgical complications were compared across groups at baseline and 2-year.

RESULTS

510 patients with an average age of 64.6, mean CCI 2.08, and average follow-up of 25 months. L4-5 was least likely to be matched (19.1%), while L4-S1 was the most likely (24.3%). More patients were overcorrected at proximal levels (T10-L2; Undercorrected, U: 32.2% vs. Matched, M: 21.7% vs. Overcorrected, O: 46.1%) and undercorrected at distal levels (L4-S1: U: 39.0% vs. M: 24.3% vs. O: 36.8%). Postoperative ODI was comparable across correction groups at all spinal levels except at L4-S1 and T10-L2/L4-S1, where overcorrected patients and matched were better than undercorrected (U: 32.1 vs. M: 25.4 vs. O: 26.5, P=0.005; U: 36.2 vs. M: 24.2 vs. O: 26.8, P=0.001; respectively). Patients overcorrected at T10-L2 experienced higher rates of proximal junctional failure (PJF) (U: 16.0% vs. M: 15.6% vs. O: 32.8%, P<0.001) and had greater posterior inclination of the upper instrumented vertebra (UIV) (U: -9.2±9.4° vs. M: -9.6±9.1° vs. O: -12.2±10.0°, P<0.001), whereas undercorrection at these levels led to higher rates of revision for implant failure (U: 14.2% vs. M: 7.3% vs. O: 6.4%, P=0.025).

CONCLUSIONS

Patients undergoing fusion for adult spinal deformity suffer higher rates of PJF with overcorrection and increased rates of implant failure with undercorrection based on normative segmental lordosis.

LEVEL OF EVIDENCE

IV.

Bone Mineral Density T-Score is an Independent Predictor of Major Blood Loss in Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

The purpose of this study was to determine the effect of low bone mineral density (BMD), as assessed by preoperative Dual-energy X-ray Absorptiometry (DEXA) scans, on intraoperative blood loss following adult spinal deformity (ASD) surgery.

METHODS

Patients who received spinal fusion for ASD (>5 levels fused) at a single academic center from 2010-2018 were included in this study. The lowest preoperative T-score was recorded for patients who had preoperative DEXA scans within a year of surgery. Patients with liver/kidney disease or on prescription anticoagulant medication were excluded. Major blood loss was a binary variable defined as above or below the 90th percentile of our cohort. Binomial regression was performed controlling for age, number of vertebrae fused, 3-column osteotomy, primary vs. revision surgery, preoperative platelet count, and if the patient was taking medication for osteoporosis.

RESULTS

91 patients were identified in the cohort. Mean age was 63 ± 11.6 years, 81% female. 56 (62%) of cases included revision of previous instrumentation. Patients had a mean SVA of 9.6 ± 8.6 cm and median of 9 vertebrae fused (range 5-22). The average T-score was -1.2 ± 1.0. Each point lower T-score was associated with significantly higher odds of major blood loss (OR 2.5, 95% CI 1.0 - 5.9) when controlling for age, number of vertebrae fused, 3-column osteotomy, preoperative platelet count and primary vs. revision surgery.

CONCLUSIONS

Preoperative T-score is independently associated with increased odds of major blood loss in ASD surgery.

Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery

STUDY DESIGN/SETTING

Retrospective cohort study.

OBJECTIVE

Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery.

METHODS

ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility.

RESULTS

By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001).

CONCLUSIONS

The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions.Level of evidence: III.

The impact of baseline cervical malalignment on the development of proximal junctional kyphosis following surgical correction of thoracolumbar adult spinal deformity

OBJECTIVE

The objective of this study was to identify the effect of baseline cervical deformity (CD) on proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in patients with adult spinal deformity (ASD).

METHODS

This study was a retrospective analysis of a prospectively collected, multicenter database comprising ASD patients enrolled at 13 participating centers from 2009 to 2018. Included were ASD patients aged > 18 years with concurrent CD (C2-7 kyphosis < -15°, T1S minus cervical lordosis > 35°, C2-7 sagittal vertical axis > 4 cm, chin-brow vertical angle > 25°, McGregor's slope > 20°, or C2-T1 kyphosis > 15° across any three vertebrae) who underwent surgery. Patients were grouped according to four deformity classification schemes: Ames and Passias CD modifiers, sagittal morphotypes as described by Kim et al., and the head versus trunk balance system proposed by Mizutani et al. Mean comparison tests and multivariable binary logistic regression analyses were performed to assess the impact of these deformity classifications on PJK and PJF rates up to 3 years following surgery.

RESULTS

A total of 712 patients with concurrent ASD and CD met the inclusion criteria (mean age 61.7 years, 71% female, mean BMI 28.2 kg/m2, and mean Charlson Comorbidity Index 1.90) and underwent surgery (mean number of levels fused 10.1, mean estimated blood loss 1542 mL, and mean operative time 365 minutes; 70% underwent osteotomy). By approach, 59% of the patients underwent a posterior-only approach and 41% underwent a combined approach. Overall, 277 patients (39.1%) had PJK by 1 year postoperatively, and an additional 189 patients (26.7%) developed PJK by 3 years postoperatively. Overall, 65 patients (9.2%) had PJF by 3 years postoperatively. Patients classified as having a cervicothoracic deformity morphotype had higher rates of early PJK than flat neck deformity and cervicothoracic deformity patients (p = 0.020). Compared with the head-balanced patients, trunk-balanced patients had higher rates of PJK and PJF (both p < 0.05). Examining Ames modifier severity showed that patients with moderate and severe deformity by the horizontal gaze modifier had higher rates of PJK (p < 0.001).

CONCLUSIONS

In patients with concurrent cervical and thoracolumbar deformities undergoing isolated thoracolumbar correction, the use of CD classifications allows for preoperative assessment of the potential for PJK and PJF that may aid in determining the correction of extending fusion levels.

Height Gain Following Correction of Adult Spinal Deformity

BACKGROUND

Height gain following a surgical procedure for patients with adult spinal deformity (ASD) is incompletely understood, and it is unknown if height gain correlates with patient-reported outcome measures (PROMs).

METHODS

This was a retrospective cohort study of patients undergoing ASD surgery. Patients with baseline, 6-week, and subanalysis of 1-year postoperative full-body radiographic and PROM data were examined. Correlation analysis examined relationships between vertical height differences and PROMs. Regression analysis was utilized to preoperatively estimate T1-S1 and S1-ankle height changes.

RESULTS

This study included 198 patients (mean age, 57 years; 69% female); 147 patients (74%) gained height. Patients with height loss, compared with those who gained height, experienced greater increases in thoracolumbar kyphosis (2.81° compared with -7.37°; p < 0.001) and thoracic kyphosis (12.96° compared with 4.42°; p = 0.003). For patients with height gain, sagittal and coronal alignment improved from baseline to postoperatively: 25° to 21° for pelvic tilt (PT), 14° to 3° for pelvic incidence - lumbar lordosis (PI-LL), and 60 mm to 17 mm for sagittal vertical axis (SVA) (all p < 0.001). The full-body mean height gain was 7.6 cm, distributed as follows: sella turcica-C2, 2.9 mm; C2-T1, 2.8 mm; T1-S1 (trunk gain), 3.8 cm; and S1-ankle (lower-extremity gain), 3.3 cm (p < 0.001). T1-S1 height gain correlated with the thoracic Cobb angle correction and the maximum Cobb angle correction (p = 0.002). S1-ankle height gain correlated with the corrections in PT, PI-LL, and SVA (p < 0.001). T1-ankle height gain correlated with the corrections in PT (p < 0.001) and SVA (p = 0.03). Trunk height gain correlated with improved Scoliosis Research Society (SRS-22r) Appearance scores (r = 0.20; p = 0.02). Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores correlated with S1-ankle height gain (r = -0.19; p = 0.03) and C2-T1 height gain (r = -0.18; p = 0.04). A 1° correction in a thoracic scoliosis Cobb angle corresponded to a 0.2-mm height gain, and a 1° correction in a thoracolumbar scoliosis Cobb angle resulted in a 0.25-mm height gain. A 1° improvement in PI-LL resulted in a 0.2-mm height gain.

CONCLUSIONS

Most patients undergoing ASD surgery experienced height gain following deformity correction, with a mean full-body height gain of 7.6 cm. Height gain can be estimated preoperatively with predictive ratios, and height gain was correlated with improvements in reported SRS-22r appearance and PROMIS scores.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

The ISSG-AO Complication Intervention Score, but Not Major/Minor Designation, is Correlated With Length of Stay Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

The International Spine Study Group-AO (ISSG-AO) Adult Spinal Deformity (ASD) Complication Classification System was developed to improve classification, reporting, and study of complications among patients undergoing ASD surgery. The ISSG-AO system classifies interventions to address complications by level of invasiveness: grade zero (none); grade 1, mild (e.g., medication change); grade 2, moderate (e.g., ICU admission); grade 3, severe (e.g., reoperation related to surgery of interest). To evaluate the efficacy of the ISSG-AO ASD Complication Classification System, we aimed to compare correlations between postoperative length of stay (LOS) and complication severity as classified by the ISSG-AO ASD and traditional major/minor complication classification systems.

METHODS

Patients age ≥18 in a multicenter ASD database who sustained in-hospital complications were identified. Complications were classified with the major/minor and ISSG-AO systems and correlated with LOS using an ensemble-based machine learning algorithm (conditional random forest) and a generalized linear mixed model.

RESULTS

490 patients at 19 sites were included. 64.9% of complications were major, and 35.1% were minor. By ISSG-AO classification, 20.4%, 66.1%, 6.7%, and 6.7% were grades 0-3, respectively. ISSG-AO complication grading demonstrated significant correlation with LOS, whereas major/minor complication classification demonstrated inverse correlation with LOS. In conditional random forest analysis, ISSG-AO classification had the greatest relative importance when assessing correlations across multiple variables with LOS.

CONCLUSIONS

The ISSG-AO system may help identify specific complications associated with prolonged LOS. Targeted interventions to avoid or reduce these complications may improve ASD surgical quality and resource utilization.

Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery

BACKGROUND

While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications.

OBJECTIVE

Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers.

STUDY DESIGN/SETTING

Retrospective cohort study of a prospectively collected multicenter database.

METHODS

ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility.

RESULTS

A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, p = 0.021) and major mechanical complications (12% vs. 22%, p = 0.002), and less reoperations (23% vs. 33%, p = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both p < 0.001) at two years.

CONCLUSIONS

Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success.

Spinopelvic sagittal compensation in adult cervical deformity

OBJECTIVE

The objective of this study was to evaluate spinopelvic sagittal alignment and spinal compensatory changes in adult cervical kyphotic deformity.

METHODS

A database composed of 13 US spine centers was retrospectively reviewed for adult patients who underwent cervical reconstruction with radiographic evidence of cervical kyphotic deformity: C2-7 sagittal vertical axis > 4 cm, chin-brow vertical angle > 25°, or cervical kyphosis (T1 slope [T1S] cervical lordosis [CL] > 15°) (n = 129). Sagittal parameters were evaluated preoperatively and in the early postoperative window (6 weeks to 6 months postoperatively) and compared with asymptomatic control patients. Adult cervical deformity patients were further stratified by degree of cervical kyphosis (severe kyphosis, C2-T3 Cobb angle ≤ -30°; moderate kyphosis, ≤ 0°; and minimal kyphosis, > 0°) and severity of sagittal malalignment (severe malalignment, sagittal vertical axis T3-S1 ≤ -60 mm; moderate malalignment, ≤ 20 mm; and minimal malalignment > 20 mm).

RESULTS

Compared with asymptomatic control patients, cervical deformity was associated with increased C0-2 lordosis (32.9° vs 23.6°), T1S (33.5° vs 28.0°), thoracolumbar junction kyphosis (T10-L2 Cobb angle -7.0° vs -1.7°), and pelvic tilt (PT) (19.7° vs 15.9°) (p < 0.01). Cervicothoracic kyphosis was correlated with C0-2 lordosis (R = -0.57, p < 0.01) and lumbar lordosis (LL) (R = -0.20, p = 0.03). Cervical reconstruction resulted in decreased C0-2 lordosis, increased T1S, and increased thoracic and thoracolumbar junction kyphosis (p < 0.01). Patients with severe cervical kyphosis (n = 34) had greater C0-2 lordosis (p < 0.01) and postoperative reduction of C0-2 lordosis (p = 0.02) but no difference in PT. Severe cervical kyphosis was also associated with a greater increase in thoracic and thoracolumbar junction kyphosis postoperatively (p = 0.01). Patients with severe sagittal malalignment (n = 52) had decreased PT (p = 0.01) and increased LL (p < 0.01), as well as a greater postoperative reduction in LL (p < 0.01).

CONCLUSIONS

Adult cervical deformity is associated with upper cervical hyperlordotic compensation and thoracic hypokyphosis. In the setting of increased kyphotic deformity and sagittal malalignment, thoracolumbar junction kyphosis and lumbar hyperlordosis develop to restore normal center of gravity. There was no consistent compensatory pelvic retroversion or anteversion among the adult cervical deformity patients in this cohort.

Predicting 30-day mortality after surgery for metastatic disease of the spine: the H2-FAILS score

PURPOSE

Scoring systems for metastatic spine disease focus on predicting long- to medium-term mortality or a combination of perioperative morbidity and mortality. However, accurate prediction of perioperative mortality alone may be the most important factor when considering surgical intervention. We aimed to develop and evaluate a new tool, the H2-FAILS score, to predict 30-day mortality after surgery for metastatic spine disease.

METHODS

Using the National Surgical Quality Improvement Program database, we identified 1195 adults who underwent surgery for metastatic spine disease from 2010 to 2018. Incidence of 30-day mortality was 8.7% (n = 104). Independent predictors of 30-day mortality were used to derive the H2-FAILS score. H2-FAILS is an acronym for: Heart failure (2 points), Functional dependence, Albumin deficiency, International normalized ratio elevation, Leukocytosis, and Smoking (1 point each). Discrimination was assessed using area under the receiver operating characteristic curve (AUC). The H2-FAILS score was compared with the American Society of Anesthesiologists Physical Status Classification (ASA Class), the 5-item modified Frailty Index (mFI-5), and the New England Spinal Metastasis Score (NESMS). Internal validation was performed using bootstrapping. Alpha = 0.05.

RESULTS

Predicted 30-day mortality was 1.8% for an H2-FAILS score of 0 and 78% for a score of 6. AUC of the H2-FAILS was 0.77 (95% confidence interval: 0.72-0.81), which was higher than the mFI-5 (AUC 0.58, p < 0.001), ASA Class (AUC 0.63, p < 0.001), and NESMS (AUC 0.70, p = 0.004). Internal validation showed an optimism-corrected AUC of 0.76.

CONCLUSIONS

The H2-FAILS score accurately predicts 30-day mortality after surgery for spinal metastasis.

LEVEL OF EVIDENCE

Prognostic level III.

Sarcopenia as a Risk Factor for Complications Following Pedicle Subtraction Osteotomy

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The objective was to determine if sarcopenia is an independent risk factor for complications in adult spinal deformity (ASD) patients undergoing pedicle subtraction osteotomy (PSO) and define categories of complication risk by sarcopenia severity.

SUMMARY OF BACKGROUND DATA

Sarcopenia is linked to morbidity and mortality in several orthopedic procedures. Data concerning sarcopenia in ASD surgery is limited, particularly with respect to complex techniques performed such as PSO. With the high surgical burden of PSOs, appropriate patient selection is critical for minimizing complications.

METHODS

We identified 73 ASD patients with lumbar CT/MRI scans who underwent PSO with spinal fusion ≥5 levels at a tertiary care center from 2005 to 2014. Sarcopenia was assessed by the psoas-lumbar vertebral index (PLVI). Using stratum-specific likelihood ratio analysis, patients were separated into 3 sarcopenia groups by complication risk. The primary outcome measure was any 2-year complication. Secondary outcome measures included intraoperative blood loss and length of stay.

RESULTS

The mean PLVI was 0.84±0.28, with 47% of patients having complications. Patients with a complication had a 27% lower PLVI on average than those without complications (0.76 vs. 0.91, P=0.021). Stratum-specific likelihood ratio analysis produced 3 complication categories: 32% complication rate for PLVI ≥ 0.81; 61% for PLVI 0.60-0.80; and 69% for PLVI < 0.60. Relative to patients with PLVI ≥ 0.81, those with PLVI 0.60-0.80 and PLVI < 0.60 had 3.2× and 4.3× greater odds of developing a complication (P<0.05). For individual complications, patients with PLVI < 1.0 had a significantly higher risk of proximal junctional kyphosis (34% vs. 0%, P=0.022), while patients with PLVI < 0.8 had a significantly higher risk of wound infection (12% vs. 0%, P=0.028) and dural tear (14% vs. 0%, P=0.019). There were no significant associations between sarcopenia, intraoperative blood loss, and length of stay.

CONCLUSIONS

The increasing severity of sarcopenia is associated with a significantly and incrementally increased risk of complications following ASD surgery that require PSO.

LEVEL OF EVIDENCE

Level III.

Pain Self-Efficacy (PSEQ) score of <22 is associated with daily opioid use, back pain, disability, and PROMIS scores in patients presenting for spine surgery

BACKGROUND CONTEXT

Pain self-efficacy, or the belief that one can carry out activities despite pain, has been shown to be associated with back and neck pain severity. However, the literature correlating psychosocial factors to opioid use, barriers to proper opioid use, and Patient-Reported Outcome Measurement Information System (PROMIS) scores is sparse.

PURPOSE

The primary aim of this study was to determine whether pain self-efficacy is associated with daily opioid use in patients presenting for spine surgery. The secondary aim was to determine whether there exists a threshold self-efficacy score that is predictive of daily preoperative opioid use and subsequently to correlate this threshold score with opioid beliefs, disability, resilience, patient activation, and PROMIS scores.

PATIENT SAMPLE

Five hundred seventy-eight elective spine surgery patients (286 females; mean age of 55 years) from a single institution were included in this study.

STUDY DESIGN/SETTING

Retrospective review of prospectively collected data.

OUTCOME MEASURES

PROMIS scores, daily opioid use, opioid beliefs, disability, patient activation, resilience.

METHODS

Elective spine surgery patients at a single institution completed questionnaires preoperatively. Pain self-efficacy was measured by the Pain Self-Efficacy Questionnaire (PSEQ). Threshold linear regression with Bayesian information criteria was utilized to identify the optimal threshold associated with daily opioid use. Multivariable analysis controlled for age, sex, education, income, and Oswestry Disability Index (ODI) and PROMIS-29, version 2 scores.

RESULTS

Of 578 patients, 100 (17.3%) reported daily opioid use. Threshold regression identified a PSEQ cutoff score of <22 as predictive of daily opioid use. On multivariable logistic regression, patients with a PSEQ score <22 had two times greater odds of being daily opioid users than those with a score ≥22. Further, PSEQ <22 was associated with lower patient activation; increased leg and back pain; higher ODI; higher PROMIS pain, fatigue, depression, and sleep scores; and lower PROMIS physical function and social satisfaction scores (p<.05 for all).

CONCLUSIONS

In patients presenting for elective spine surgery, a PSEQ score of <22 is associated with twice the odds of reporting daily opioid use. Further, this threshold is associated with greater pain, disability, fatigue, and depression. A PSEQ score <22 can identify patients at high risk for daily opioid use and can guide targeted rehabilitation to optimize postoperative quality of life.

Distal junctional kyphosis in adult cervical deformity patients: where does it occur?

PURPOSE

To evaluate the impact of the lowest instrumented vertebra (LIV) on Distal Junctional kyphosis (DJK) incidence in adult cervical deformity (ACD) surgery.

METHODS

Prospectively collected data from ACD patients undergoing posterior or anterior-posterior reconstruction at 13 US sites was reviewed up to 2-years postoperatively (n = 140). Data was stratified into five groups by level of LIV: C6-C7, T1-T2, T3-Apex, Apex-T10, and T11-L2. DJK was defined as a kyphotic increase > 10° in Cobb angle from LIV to LIV-1. Analysis included DJK-free survival, covariate-controlled cox regression, and DJK incidence at 1-year follow-up.

RESULTS

25/27 cases of DJK developed within 1-year post-op. In patients with a minimum follow-up of 1-year (n = 102), the incidence of DJK by level of LIV was: C6-7 (3/12, 25.00%), T1-T2 (3/29, 10.34%), T3-Apex (7/41, 17.07%), Apex-T10 (8/11, 72.73%), and T11-L2 (4/8, 50.00%) (p < 0.001). DJK incidence was significantly lower in the T1-T2 LIV group (adjusted residual = -2.13), and significantly higher in the Apex-T10 LIV group (adjusted residual = 3.91). In covariate-controlled regression using the T11-L2 LIV group as reference, LIV selected at the T1-T2 level (HR = 0.054, p = 0.008) or T3-Apex level (HR = 0.081, p = 0.010) was associated with significantly lower risk of DJK. However, there was no difference in DJK risk when LIV was selected at the C6-C7 level (HR = 0.239, p = 0.214).

CONCLUSION

DJK risk is lower when the LIV is at the upper thoracic segment than the lower cervical segment. DJK incidence is highest with LIV level in the lower thoracic or thoracolumbar junction.

Patient and procedural risk factors for decline in lower-extremity motor scores following adult spinal deformity surgery

OBJECTIVE

The purpose of this study was to discern factors that differentiate patients who experience postoperative lower-extremity motor function decline in the early postoperative period.

METHODS

Adult spinal deformity (ASD) patients who were enrolled in a multicenter, observational, and prospectively collected study from 2018 to 2021 at 18 spinal deformity centers in North America were queried. Eligible participants met at least one of the following radiographic and/or procedural inclusion criteria: pelvic incidence minus lumbar lordosis (PI-LL) ≥ 25°, T1 pelvic angle (T1PA) ≥ 30°, sagittal vertical axis (SVA) ≥ 15 cm, thoracic scoliosis ≥ 70°, thoracolumbar scoliosis ≥ 50°, global coronal malalignment ≥ 7 cm, 3-column osteotomy, spinal fusion ≥ 12 levels, and/or age ≥ 65 years with ≥ 7 levels of instrumentation. Patients with an inflammatory or autoimmune disease and those who were incarcerated or pregnant were excluded, as were non-English speakers. Only patients with baseline and 6-week postoperative lower-extremity motor score (LEMS) were analyzed. Patient information, including demographic data, operative data, patient-reported outcomes, and radiographic parameters, were collected. Univariate and multivariable logistic regression models were built to quantify the degree to which a patient's postoperative LEMS decline was related to demographic and clinical characteristics.

RESULTS

In total, 205 patients (mean age 61.5 years, mean total instrumented levels 12.6, 67.3% female, 54.2% primary cases, 79.5% with pelvic fixation) were evaluated. Of these 205 patients, 32 (15.5%) experienced LEMS decline in the perioperative period. These patients were older (p = 0.0014) and had greater BMI (p = 0.0176), higher frailty scores (p = 0.047), longer operating room times (p = 0.033), and greater estimated blood loss (p < 0.0001), and they were more frequently observed to have intraoperative neurophysiological monitoring (IONM) changes (p = 0.018). The deteriorated cohort had greater C7SVA at baseline (p = 0.0028) but were comparable in terms of all other radiographic parameters. No radiographic differences were seen between the groups at the 6-week visit; however, the deteriorated cohort experienced greater change in PI-LL (p < 0.0001), lumbar lordosis (p = 0.0461), C7SVA (p = 0.0004), and T1PA (p < 0.0001). Multivariate logistic regression demonstrated that the presence of IONM changes and each degree of negative change in T1PA conferred 3.71 (95% CI 1.01-13.42) and 1.09 (1.01-1.19) greater odds of postoperative LEMS deterioration, respectively.

CONCLUSIONS

In this study, 15.6% of ASD patients incurred LEMS decline in the perioperative period. The magnitude of change in global sagittal alignment, specifically T1PA, was the strongest independent predictor of LEMS decline, which has implications for surgical planning, patient counseling, and clinical research.

Can unsupervised cluster analysis identify patterns of complex adult spinal deformity with distinct perioperative outcomes?

OBJECTIVE

The objective of this study was to use an unsupervised cluster approach to identify patterns of operative adult spinal deformity (ASD) and compare the perioperative outcomes of these groups.

METHODS

A multicenter data set included patients with complex surgical ASD, including those with severe deformities, significant surgical complexity, or advanced age who underwent a multilevel fusion. An unsupervised cluster analysis allowing for 10% outliers was used to identify different deformity patterns. The perioperative outcomes of these clusters were then compared using ANOVA, Kruskal-Wallis, and chi-square tests, with p values < 0.05 considered significant.

RESULTS

Two hundred eighty-six patients were classified into four clusters of deformity patterns: hyper-thoracic kyphosis (hyper-TK), severe coronal, severe sagittal, and moderate sagittal. Hyper-TK patients had the lowest disability (mean Oswestry Disability Index [ODI] 32.9 ± 17.1) and pain scores (median numeric rating scale [NRS] back score 6, leg score 1). The severe coronal cluster had moderate functional impairment (mean physical component score 34.4 ± 12.3) and pain (median NRS back score 7, leg score 4) scores. The severe sagittal cluster had the highest levels of disability (mean ODI 49.3 ± 15.6) and low appearance scores (mean 2.3 ± 0.7). The moderate cluster (mean 68.8 ± 7.8 years) had the highest pain interference subscores on the Patient-Reported Outcomes Measurement Information System (mean 65.2 ± 5.8). Overall 30-day adverse events were equivalent among the four groups. Fusion to the pelvis was most common in the moderate sagittal (89.4%) and severe sagittal (97.5%) clusters. The severe coronal cluster had more osteotomies per case (median 11, IQR 6.5-14) and a higher rate of 30-day implant-related complications (5.5%). The severe sagittal and hyper-TK clusters had more three-column osteotomies (43% and 32.3%, respectively). Hyper-TK patients had shorter hospital stays.

CONCLUSIONS

This cohort of patients with complex ASD surgeries contained four natural clusters of deformity, each with distinct perioperative outcomes.

Social Media Presence Is Associated With Diversity and Application Volume for Orthopedic Surgery Residency Programs

The purpose of this study was to assess the association between social media presence (Twitter and Instagram), diversity in orthopedic surgery residency programs, and the number of applications received by a program. Data from Twitter and Instagram for 179 orthopedic residency programs accredited by the Accreditation Council for Graduate Medical Education were collected, including the presence of a social media account, date of first post, number of posts, and number of followers. Residency program data were collected from the Association of American Medical Colleges Residency Explorer Tool and included percentage of Whiteresidents, percentage of male residents, residency ranking, and number of applications submitted during the 2019 application cycle. Bivariate and multivariable analyses were performed with adjustment for program ranking. Of 179 residency programs, 34.6% (n=62) had Twitter, and 16.7% (n=30) had Instagram. Overall, 39.7% (n=71) had a social media presence, defined as having at least one of the two forms of social media. Programs with social media presences had higher average rankings (48.1 vs 99.6 rank, P<.001). After adjusting for program ranking, social media presence was associated with increased applications during the 2019 application cycle (odds ratio [OR]=2.76, P=.010). Social media presence was associated with increased odds of gender diversity (OR=3.07, P=.047) and racial diversity (OR=2.21, P=.041). Individually, Twitter presence was associated with increased odds of gender (OR=4.81, P=.018) and racial diversity (OR=4.00, P=.021), but Instagram was not (P>.05). Social media presence is associated with more residency program applications and increased resident diversity. Social media can be used to highlight inclusivity measures and related opportunities. [Orthopedics. 2023;46(1):47-53.].

Return to work after adult spinal deformity surgery

PURPOSE

To determine the proportions of patients returning to work at various points after adult spinal deformity (ASD) surgery and the associations between surgical invasiveness and time to return to work.

METHODS

Using a multicenter database of patients treated surgically for ASD from 2008 to 2015, we identified 188 patients (mean age 51 ± 15 years) who self-reported as employed preoperatively and had 2-year follow-up. Per the ASD-Surgical and Radiographical Invasiveness Index (ASD-SR), 118 patients (63%) underwent high-invasiveness (HI) surgery (ASD-SR ≥ 100) and 70 (37%) had low-invasiveness (LI) surgery (ASD-SR < 100). Patients who self-reported ≥ 75% normal level of work/school activity were considered to be working full time. Chi-squared and Fisher exact tests were used to compare categorical variables (α = .05).

RESULTS

Preoperatively, 69% of employed patients worked full time. Postoperatively, 15% of employed patients were full time at 6 weeks, 70% at 6 months, 83% at 1 year, and 84% at 2 years. Percentage of employed patients working full time at 2 years was greater than preoperatively (p < .001); percentage of patients returning to full time at 6 weeks was lower in the HI (5%) than in the LI group (19%) (p = .03), a difference not significant at later points.

CONCLUSIONS

Most adults returned to full-time work after ASD surgery. A smaller percentage of patients in the HI group than in the LI group returned to full-time work at 6 weeks. Patients employed full time preoperatively will likely return to full-time employment after ASD surgery.

LEVEL OF EVIDENCE

III.

Preoperative patient activation predicts minimum clinically important difference for PROMIS pain and physical function in patients undergoing elective spine surgery

BACKGROUND CONTEXT

Patient activation is a patient's willingness to take independent actions to manage their own health care.

PURPOSE

The goal of this study is to determine whether preoperative patient activation measure (PAM) predicts minimum clinically important difference (MCID) for Patient-Reported Outcomes Measurement Information System (PROMIS) pain, physical function, depression, and anxiety for patients undergoing elective spine surgery.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

A single-institution, academic database of patients undergoing elective spine surgery.

OUTCOME MEASURE

MCID at 1-year follow-up for PROMIS pain, physical function, depression and anxiety.

METHODS

We retrospectively reviewed a single-institution, academic database of patients undergoing elective spine surgery. Preoperative patient activation was evaluated using the PAM-13 survey, which was used to stratify patients into four activation stages. Primary outcome variable was achieving MCID at 1-year follow-up for PROMIS pain and physical function. Multivariable logistic regression analysis was used to determine impact of patient activation on PROMIS pain and the physical function.

RESULTS

Of the 430 patients, 220 (51%) were female with a mean age of 58.2±16.8. Preoperatively, 34 (8%) were in activation stage 1, 45 (10%) in stage 2, 98 (23%) in stage 3, and 253 (59%) in stage 4. At 1-year follow up, 248 (58%) achieved MCID for PROMIS physical function, 256 (60%) achieved MCID for PROMIS pain, 151 (35.28%) achieved MCID for PROMIS depression, and 197 (46%) achieved MCID for PROMIS anxiety. For PROMIS physical function, when compared to patients at stage 1 activation, patients at stage 2 (aOR:3.49, 95% CI:1.27, 9.59), stage 3 (aOR:3.54, 95% CI:1.40, 8.98) and stage 4 (aOR:7.88, 95% CI:3.29, 18.9) were more likely to achieve MCID. For PROMIS pain, when compared against patients at stage 1, patients at stage 3 (aOR:2.82, 95% CI:1.18, 6.76) and stage 4 (aOR:5.44, 95% CI:2.41, 12.3) were more likely to achieve MCID. For PROMIS depression, when compared against patients at stage 1, patients at stage 4 were more likely to achieve MCID (Adjusted Odds Ratio (aOR):2.59, 95% CI:1.08-6.19). For PROMIS anxiety, when compared against patients at stage 1, stage 3 (Adjusted Odds Ratio (aOR):3.21, 95% CI:1.20-8.57), and stage 4 (aOR:5.56, 95% CI:2.20-14.01) were more likely to achieve MCID.

CONCLUSION

Patients at higher stages of activation were more likely to achieve MCID for PROMIS pain, physical function, depression, and anxiety at 1-year follow-up. Routine preoperative assessment of patient activation may help identify patients at risk of poor outcomes.

Changes in health-related quality of life measures associated with degree of proximal junctional kyphosis

PURPOSE

To explore the changes in health-related quality of life parameters observed in patients experiencing varying degrees of proximal junctional kyphosis following corrective adult spinal deformity fusions.

METHODS

Inclusion: adult spinal deformity patients > 18 y/o, undergoing spinal fusion. PJK: ≥ 10° measure of the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the UIV + 2. Severe PJK: > 28° PJK. Mild PJK: ≥ 10^oand ≤ 28°. ANOVA, followed by ANCOVA, compared the change in HRQoLs between time points (BL, 1Y, 2Y) among PJK groups. Correlation-related change in PJK and change in HRQoL for mild and severe groups.

RESULTS

969 patients (age: 64.5 y/o,75% F, posterior levels fused:12.3) were studied. 59% no PJK, 32% mild PJK, 9% severe PJK. No differences in HRQoLs were seen between no PJK and PJK groups at baseline, one year, and 2 years. Adjusted analysis revealed Severe PJK patients improved less in SRS-22 Satisfaction (NoPJK: 1.6, MildPJK: 1.6, SeverePJK: 1.0; p = 0.022) scores at 2 years. Linear regression analysis only found clinical improvement in SRS-22 Satisfaction to correlate with the change of the PJK angle by 2 years (R = 0.176, P = 0.008). No other HRQoL metric correlated with either the incidence of PJK or the change in the PJK angle by one or 2 years.

CONCLUSIONS

These results maintain that patients presenting with and without proximal junctional kyphosis report similar health-related qualities of life following corrective adult spinal deformity surgery, and SRS-22 Satisfaction may be a clinical correlate to the degree of PJK. Rather than proving proximal junctional kyphosis to have a minimal clinical impact overall on HRQoL metrics, these data suggest that future analysis of this phenomenon requires different assessments.

LEVEL OF EVIDENCE

Level of evidence: III.

Preoperative characteristics are associated with increased likelihood of low early postoperative mobility after adult spinal deformity surgery

BACKGROUND CONTEXT

Low early postoperative mobility (LEPOM) has been shown to be associated with increased length of hospital stay, complication rates, and likelihood of nonhome discharge. However, few studies have examined preoperative characteristics associated with LEPOM in adult spinal deformity (ASD) patients.

PURPOSE

To investigate which preoperative patient characteristics may be associated with LEPOM after ASD surgery.

DESIGN

Retrospective review.

PATIENT SAMPLE

Included were 86 ASD patients with fusion of ≥5 levels for whom immediate-postoperative AM-PAC Basic Mobility Inpatient Short Form (6-Clicks) scores had been obtained.

OUTCOME MEASURES

The primary outcome of this study was the likelihood of LEPOM, defined as an AM-PAC score ≤15, which is associated with inability to stand for more than 1 minute.

METHODS

Significant cutoffs for preoperative characteristics associated with LEPOM were determined via threshold linear regression. Multivariable logistic regression was used to assess the impact of preoperative characteristics on the likelihood of LEPOM.

RESULTS

LEPOM was recorded in 38 patients (44.2%). Threshold regression identified the following cutoffs to be associated with LEPOM: preoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores of ≥68 for Pain, <28.3 for Physical Function, and ≥63.4 for Anxiety; preoperative Oswestry disability index (ODI) score of ≥60; and body mass index (BMI) of ≥35.2. On multivariate analysis, preoperative PROMIS scores of ≥68 for Pain (odds ratio [OR] 5.3, confidence interval [CI] 1.2-22.8, p=.03), <28.3 for Physical Function (OR 10.1, CI 1.8-58.2, p=.01), and ≥63.4 for Anxiety (OR 4.7, CI 1.1-20.8, p=.04); preoperative ODI score ≥60 (OR 38.8, CI 4.0-373.6, p=.002); BMI ≥35.2 (OR 14.2, CI 1.3-160.0, p=.03), and male sex (OR 5.4, CI 1.2-23.7, p=.03) were associated with increased odds of LEPOM.

CONCLUSIONS

Preoperative PROMIS Pain, Physical Function, and Anxiety scores; ODI score; BMI; and male sex were associated with LEPOM. Several of these characteristics are modifiable risk factors and thus may be candidates for optimization before surgery.

LEVEL OF EVIDENCE

III.

AM-PAC mobility scores predict non-home discharge following adult spinal deformity surgery

BACKGROUND CONTEXT

Adult spinal deformity (ASD) surgery requires an extended recovery period and often non-routine discharge. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility Inpatient Short Form (6-Clicks) is a prediction tool, validated for other orthopedic procedures, to assess a patient's ability to mobilize after surgery.

PURPOSE

To assess the thresholds of AM-PAC scores that determine non-home discharge disposition in patients who have undergone ASD surgery.

STUDY DESIGN

Retrospective review PATIENT SAMPLE: Ninety consecutive ASD patients with ≥5 levels fused who underwent surgery from 2015 to 2018, with postoperative AM-PAC scores measured before discharge, were included.

OUTCOME MEASURES

Non-home discharge disposition METHODS: Patients with routine home discharge were compared to those with non-home discharge. Bivariate analysis was first conducted to compare these groups by preoperative demographics, comorbidities, radiographic alignment, surgical characteristics, HRQOLs, and AM-PAC measurements. Threshold linear regression with Bayesian information criteria was utilized to identify the optimal cutoffs for AM-PAC scores associated with increased likelihood of non-home discharge. Finally, multivariable analysis controlling for age, sex, comorbidities, levels fused, perioperative complication, and home support was conducted to assess each threshold.

RESULTS

Thirty-six (40%) of 90 patients analyzed had non-home discharge. On bivariate analysis, first AM-PAC score (13.5 vs. 17), last AM-PAC score (17 vs. 20), and AM-PAC change per day (+.387 vs. +1) were all significantly associated with non-home discharge. Threshold regression identified that cutoffs of ≤15 for first AM-PAC score, <17 for last AM-PAC score, and <+0.625 for daily AM-PAC change were associated with non-home discharge. On multivariable analysis, first AM-PAC score ≤15 (odds ratio [OR] 11.28; confidence interval [CI] 2.96-42.99; p<.001), last AM-PAC score <17 (OR 33.57; CI 5.85-192.82; p<.001), and AM-PAC change per day <+0.625 (OR 6.24; CI 2.01-19.43; p<.001) were all associated with increased odds of non-home discharge.

CONCLUSIONS

First AM-PAC score of 15 or less can help predict non-home discharge. A goal of daily AM-PAC increases of 0.625 points toward a final AM-PAC score of 17 can aid in achieving home discharge. The early AM-PAC mobility threshold of ≤15 may help prepare for non-home discharge, while AM-PAC daily changes per day <0.625 and final AM-PAC <17 may provide goals for mobility improvement during the early postoperative period in order to prevent non-home discharge.

Preoperative duration of pain is associated with chronic opioid use after adult spinal deformity surgery

PURPOSE

Few studies have explored the association between preoperative patient-reported measures and chronic opioid use following adult spinal deformity (ASD) surgery. We sought to explore the association between preoperative duration of pain, as well as other patient-reported factors, and chronic opioid use after ASD surgery.

METHODS

We retrospectively reviewed our U.S. academic tertiary care hospital's database of ASD patients. We included patients 18 years or older who underwent arthrodesis of four or more spinal levels from January 2008 to February 2018, with 2-year follow-up. The primary outcome variable was chronic opioid use, defined as opioid use at both 1 and 2 years postoperatively. We analyzed patient characteristics; duration of preoperative pain (<4 years or ≥4 years); radiculopathy; preoperative Scoliosis Research Society-22r (SRS-22r) score; Oswestry Disability Index (ODI) value; and surgical characteristics.

RESULTS

Of 119 patients who met the inclusion criteria, 93 (78%) were women, and mean ± standard deviation age was 59 ± 13. Sixty patients (50%) reported preoperative opioid use, and 35 (29%) reported chronic opioid use. Preoperative opioid use was associated with higher odds of chronic use (adjusted odds ratio, 5.9; 95% confidence interval 1.6-21), as was preoperative pain duration of ≥4 years (adjusted odds ratio, 3.3; 95% confidence interval 1.1-9.8). Patient characteristics, surgical variables, ODI value, and SRS-22r score were not significantly associated with chronic postoperative opioid use.

CONCLUSION

Preoperative opioid use and duration of pain of ≥4 years were associated with higher odds of chronic opioid use after ASD surgery.

LEVEL OF EVIDENCE

III.

Summary of the FDA virtual public workshop on spinal device clinical review held on September 17, 2021

The mission of Food and Drug Administration (FDA)'s Center for Devices and Radiological Health is to protect and promote public health. It assures that patients and providers have timely and continued access to safe, effective, and high-quality medical devices and safe radiation-emitting products by providing meaningful and timely information about the products we regulate and the decisions we make. On September 17, 2021, an FDA workshop was held to provide information to stakeholders, including members of the spine community, device manufacturers, regulatory affairs professionals, clinicians, patients, and the general public regarding FDA regulations, guidance and regulatory pathways related to spinal device clinical review. It was not intended to communicate any new policies, processes, or interpretations regarding medical device marketing authorizations. This workshop consisted of individual presentations, group discussions, question and answer sessions, and audience surveys. Information-sharing included discussions related to patient-reported outcomes, clinician-reported outcomes, observer-reported outcomes, and performance outcomes. Discussions involving external subject matter experts covered topics related to spinal device clinical studies including definition of a target population, enrollment criteria, strategies for inclusion of under-represented patient groups, reporting of adverse event and secondary surgical procedures, clinical study endpoints, and clinical outcome assessments. A meeting transcript and webcast workshop link are currently posted on the FDA website. Important related issues and challenges were discussed, and an exciting range of new ideas and concepts were shared which hold promise to advance regulatory science, patient care and future innovation related to spinal devices.

Sacral-Alar-Iliac (SAI) Fixation in Children With Spine Deformity: Minimum 10-Year Follow-Up

INTRODUCTION

Sacral-alar-iliac (SAI) screws are utilized to achieve pelvic fixation in spine deformity patients. The primary purpose of this study is to investigate the long-term outcomes of pediatric patients with scoliosis treated with posterior spinal fusion and SAI fixation at 10-year clinical and radiographic follow-up.

METHODS

We reviewed the clinical and radiographic records of patients aged 18 years or below treated for scoliosis with posterior spinal fusion using SAI fixation. Pelvic obliquity and the major coronal curve were determined at the preoperative visit and 6-week, 1-year, 5-year, and 10-year postoperative visits. SAI screw-specific data collected included screw dimensions, rate of screw revision, pain at the SAI screw sites, presence of lucency >2 mm around the screw, screw loosening or breaking, and deep surgical site infections.

RESULTS

Ninety-seven of 151 patients (75%) were included. The average age at index surgery was 13.5±3.1 years, and the most common diagnosis was cerebral palsy (67%). The mean duration of follow-up was 11±3 years. The mean pelvic obliquity measured 20±8.0 degrees preoperatively, and 8.7±4.0 degrees at the 10-year follow-up. There were no significant difference in pelvic obliquity when comparing the 10-year follow-up visit with the 6-week postoperative follow-up. Average screw dimensions were 8.4×68.8 mm. By the 10-year follow-up, 4 patients (4%) had at least 1 SAI screw-related complication. Of these patients, 2 (2%) had pain at 1 SAI screw, 4 (4%) had lucency around the screw, and 3 (3%) had broken or loose screws. Two (2%) required SAI screw revision because of late deep wound infection, and underwent exchange with a longer screw. There were no intrapelvic protrusions, vascular, or neurological complications.

CONCLUSIONS

SAI screws are a safe and effective method for pelvic fixation in children with spinal deformity. The outcomes at ≥10 years are satisfactory, with low rates of long-term complications and excellent postoperative correction and subsequent maintenance of coronal curvature and pelvic obliquity over time.

LEVEL OF EVIDENCE

Level IV.

Prevalence of Osteoporosis Treatment and Its Effect on Post-Operative Complications, Revision Surgery and Costs After Multi-Level Spinal Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To study the prevalence of pre-operative osteoporosis treatment, and its effect on risk of ORC, revision surgery and costs in osteoporotic patients undergoing ≥3-level spinal fusion for degenerative pathology.

METHODS

Patients and procedures of interest were included using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding. Our outcome measures were ORC at 1-year post-operatively and included instrumentation complications, pathological fracture, and revision surgery. Kaplan-Meier survival curves and Cox proportional hazards analysis was done to study the effect of osteoporosis treatment on risk of ORC.

RESULTS

We included a total of 849 patients with documented osteoporosis undergoing ≥3-level spinal fusion. White (85.6%), female (82.7%), and 60-79 years of age (79.9%) was the most common demographic. Of entire cohort, 121(14.3%) were on osteoporosis treatment prior to spinal fusion. Of treated patients, 52/121 (43.0%) had continued prescriptions at 1 year post-operatively. Treated patients and not-treated patients had 1-year ORC incidence of 9.1% and 15.0%, respectively. The average 1-year reimbursement/patient for managing ORC was $3,053 (treated) and $21,147 (not-treated). On adjusted cox analysis, pre-operative osteoporosis treatment was associated with a lower risk of ORC (HR: 0.53, 95% CI: 0.28-0.99, p = 0.04).

CONCLUSIONS

Pre-operative osteoporosis treatment is associated with lower risk of ORC and revision surgery at 1-year after ≥3-level spinal fusion. There is a low incidence of osteoporosis treatment prior to spinal fusion, and subsequently a low rate of treatment continuation after surgery. These findings highlight the need for heightened awareness, patient education and management of osteoporosis before elective multi-level spinal fusion.

Growing Racial Disparities in the Utilization of Adult Spinal Deformity Surgery: An Analysis of Trends From 2004 to 2014

STUDY DESIGN

Retrospective.

OBJECTIVE

The purpose of this study was to assess trends in utilization rates of adult spinal deformity (ASD) surgery, as well as perioperative surgical metrics between Black and White patients undergoing operative treatment for ASD in the United States.

SUMMARY OF BACKGROUND DATA

Racial disparities in access to care, complications, and surgical selection have been shown to exist in the field of spine surgery. However, there is a paucity of data concerning racial disparities in the management of ASD patients.

METHODS

Adult patients undergoing ASD surgery from 2004 to 2014 were identified in the nationwide inpatient sample (NIS). Utilization rates, major complications rates, and length of stay (LOS) for Black patients and White patients were trended over time. Utilization rates were reported per 1,000,000 people and determined using annual census data among subpopulations stratified by race. All reported complication rates and prolonged hospital stay rates are adjusted for Elixhauser Comorbidity Index, income quartile by zip code, and insurance payer status.

RESULTS

From 2004 to 2014, ASD utilization for Black patients increased from 24.0 to 50.9 per 1,000,000 people, whereas ASD utilization for White patients increased from 29.9 to 73.1 per 1,000,000 people, indicating a significant increase in racial disparities in ASD utilization (P-trend < 0.001). There were no significant differences in complication rates or rates of prolonged hospital stay between Black and White patients across the time period studied (P > 0.05 for both).

CONCLUSION

Although Black and White patients undergoing ASD surgery do not differ significantly in terms of postoperative complications and length of hospital stay, there is a growing disparity in utilization of ASD surgery between White and Black patients from 2004 to 2014 in the United States. There is need for continued focus on identifying ways to reduce racial disparities in surgical selection and perioperative management in spine deformity surgery.Level of Evidence: 3.

Low-Density Pedicle Screw Constructs Are Associated with Lower Incidence of Proximal Junctional Failure in Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Determine whether screws per level and rod material/diameter are associated with incidence of proximal junctional kyphosis (PJF).

SUMMARY OF BACKGROUND DATA

PJF is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF.

METHODS

Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing primary fusion of more than or equal to five levels with lower instrumented vertebrae (LIV) at the sacro-pelvis were included. Screws per level fused was analyzed with a cutoff of 1.8 (determined by receiver operating characteristic curve (ROC) analysis). Multivariable logistic regression was utilized, controlling for age, body mass index (BMI), 6-week postoperative change from baseline in lumbar lordosis, number of posterior levels fused, sex, Charlson comorbidity index, approach, osteotomy, upper instrumented vertebra (UIV), osteoporosis, preoperative TPA, and pedicle screw at the UIV (as opposed to hook, wire, etc.).

RESULTS

In total, 504 patients were included. PJF occurred in 12.7%. The mean screws per level was 1.7, and 56.8% of patients had less than 1.8 screws per level. No differences were observed between low versus high screw density groups for T1-pelvic angle or magnitude of lordosis correction (both P > 0.15). PJF occurred in 17.0% versus 9.4% of patients with more than or equal to 1.8 versus less than 1.8 screws per level, respectively (P < 0.05). In multivariable analysis, patients with less than 1.8 screws per level exhibited lower odds of PJF (odds ratio (OR) 0.48, P < 0.05), and a continuous variable for screw density was significantly associated with PJF (OR 3.87 per 0.5 screws per level, P < 0.05). Rod material and diameter were not significantly associated with PJF (both P > 0.1).

CONCLUSION

Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with less than 1.8 screws per level. This finding may be related to construct rigidity. Residual confounding by other patient and surgeon-specific characteristics may exist. Further biomechanical and clinical studies exploring this relationship are warranted.Level of Evidence: 3.

Worsening pain and quality of life for spine surgery patients during the COVID-19 pandemic: Roles of psychological distress and patient activation

•

Psychological distress compounds negative effects of COVID-19 on pain and HRQoL.

•

Patient activation is protective from COVID-19 effects on pain and HRQoL.

•

Providers should screen for psychological distress and patient activation.

•

Enhanced patient supports to manage pain are needed for at-risk patients.

•

Enhanced patient supports to maintain HRQoL are needed for at-risk patients.

Background

Public health measures during the COVID-19 pandemic have disrupted access to basic resources (income, food, housing, healthcare). The effects may impact patients differently based on socioeconomic status (SES), pre-existing psychological distress, and patient activation (knowledge, skills, and motivation to manage healthcare). We examined changes in access to basic resources and in pain and health-related quality of life (HRQoL) during the pandemic and determined how pre-existing psychological distress and patient activation are associated with exacerbation or mitigation of effects on pain and HRQoL.

Methods

This cross-sectional study assessed 431 patients in a longitudinal-outcomes registry who underwent or scheduled spine surgery at our institution and were surveyed about COVID-19 effects on accessing basic resources. We assessed pain (numeric rating scale) and HRQoL (PROMIS 29-Item Profile). Information on preoperative SES, psychological distress, patient activation, pain, and HRQoL was collected previously. We compared access to basic resources by SES. We compared changes from pre-COVID-19 to COVID-19 assessments of pain and HRQoL and proportions of patients reporting worsened pain and HRQoL stratified by psychological distress. We analyzed associations between patient activation and negative effects on HRQoL using multivariable linear regression. Alpha=0.05.

Results

Respondents reported minor disruptions in accessing basic resources (no difference by SES) but significant worsening of back (p=.027) and leg pain (p=.013) and HRQoL (physical function, fatigue, p<0.001; satisfaction with participation in social roles, p=0.048) during COVID-19. Psychological distress was associated with clinically relevant worsening of back, pain, leg pain, and physical function all, (p<0.05). High patient activation was associated with less impairment of physical function (p=0.03).

Conclusion

Patients with pre-existing psychological distress experienced greater worsening of pain and HRQoL. High patient activation appeared to mitigate worsening of physical function. Providers should screen for psychological distress and patient activation and enhance supports to manage pain and maintain HRQoL in at-risk patients.

Level of Evidence: III

Best Practice Guidelines for Assessment and Management of Osteoporosis in Adult Patients Undergoing Elective Spinal Reconstruction

STUDY DESIGN

Expert consensus study.

OBJECTIVE

This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to elective spinal reconstruction.

SUMMARY OF BACKGROUND DATA

Currently, no guidelines exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. Untreated osteoporosis in spine reconstruction surgery is associated with higher complications and worse outcomes.

METHODS

A multidisciplinary panel with 18 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Surveys and discussions regarding the current literature were held according to Delphi method until a final set of guidelines was created with over 70% consensus.

RESULTS

Panelists agreed that bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic glucocorticoid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units of the vertebrae can be useful in identifying poor bone health. In the absence of contraindications, anabolic agents are considered first line therapy due to their bone building properties as compared with antiresorptive medications. Medications should be administered preoperatively for at least 2 months and postoperatively for minimum 8 months.

CONCLUSION

Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also established guidelines on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population.Level of Evidence: 5.

Increasing Cost Efficiency in Adult Spinal Deformity Surgery: Identifying Predictors of Lower Total Costs

STUDY DESIGN

Retrospective study of a prospective multicenter database.

OBJECTIVE

The purpose of this study was to identify predictors of lower total surgery costs at 3 years for adult spinal deformity (ASD) patients.

SUMMARY OF BACKGROUND DATA

ASD surgery involves complex deformity correction.

METHODS

Inclusion criteria: surgical ASD (scoliosis ≥20°, sagittal vertical axis [SVA] ≥5 cm, pelvic tilt ≥25°, or thoracic kyphosis ≥60°) patients >18 years. Total costs for surgery were calculated using the PearlDiver database. Cost per quality-adjusted life year was assessed. A Conditional Variable Importance Table used nonreplacement sampling set of 20,000 Conditional Inference trees to identify top factors associated with lower cost surgery for low (LSVA), moderate (MSVA), and high (HSVA) SRS Schwab SVA grades.

RESULTS

Three hundred sixtee of 322 ASD patients met inclusion criteria. At 3-year follow up, the potential cost of ASD surgery ranged from $57,606.88 to $116,312.54. The average costs of surgery at 3 years was found to be $72,947.87, with no significant difference in costs between deformity groups (P > 0.05). There were 152 LSVA patients, 53 MSVA patients, and 111 HSVA patients. For all patients, the top predictors of lower costs were frailty scores <0.19, baseline (BL) SRS Activity >1.5, BL Oswestry Disability Index <50 (all P < 0.05). For LSVA patients, no history of osteoporosis, SRS Activity scores >1.5, age <64, were the top predictors of lower costs (all P < 0.05). Among MSVA patients, ASD invasiveness scores <94.16, no past history of cancer, and frailty scores <0.3 trended toward lower total costs (P = 0.071, P = 0.210). For HSVA, no history of smoking and body mass index <27.8 trended toward lower costs (both P = 0.060).

CONCLUSION

ASD surgery has the potential for improved cost efficiency, as costs ranged from $57,606.88 to $116,312.54. Predictors of lower costs included higher BL SRS activity, decreased frailty, and not having depression. Additionally, predictors of lower costs were identified for different BL deformity profiles, allowing for the optimization of cost efficiency for all patients.Level of Evidence: 3.

Mental Health Associated With Postoperative Satisfaction in Lumbar Degenerative Surgery Patients

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To assess the association between preoperative and postoperative mental health status with postoperative satisfaction in lumbar degenerative surgery patients.

SUMMARY OF BACKGROUND DATA

Poor preoperative mental health has been shown to negatively affect postoperative satisfaction among spine surgery patients, but there is limited evidence on the impact of postoperative mental health on satisfaction.

MATERIALS AND METHODS

Adult patients undergoing surgery for lumbar degenerative conditions at a single institution were included. Mental health was assessed preoperatively and 12 months postoperatively using Patient-Reported Outcomes Measurement Information System Depression and Anxiety scores. Satisfaction was assessed 12 months postoperatively using North American Spine Society Patient Satisfaction Index. The authors evaluated associations between mental health and satisfaction with univariate and multivariable logistic regression to adjust for confounders. Preoperative depression/anxiety level was corrected for postoperative depression/anxiety level, and vice versa. Statistical significance was assessed at α=0.05.

RESULTS

A total of 183 patients (47% male individuals; avg. age, 62 y) were included. Depression was present in 27% preoperatively and 29% postoperatively, and anxiety in 50% preoperatively and 31% postoperatively. Ninteen percent reported postoperative dissatisfaction using the North American Spine Society Patient Satisfaction Index. Univariate analysis identified race, family income, relationship status, current smoking status, change in pain interference, and change in physical function as potential confounders. In adjusted analysis, odds of dissatisfaction were increased in those with mild postoperative depression (adjusted odds ratio=6.1; 95% confidence interval, 1.2-32; P=0.03) and moderate or severe postoperative depression (adjusted odds ratio=7.5; 95% confidence interval, 1.3-52; P=0.03). Preoperative and postoperative anxiety and preoperative depression were not associated with postoperative satisfaction.

CONCLUSIONS

Following lumbar degenerative surgery, patients with postoperative depression, irrespective of preoperative depression status, have significantly higher odds of dissatisfaction. These results emphasize the importance of postoperative screening and treatment of depression in spine patients with dissatisfaction.

LEVEL OF EVIDENCE

Level III-nonrandomized cohort study.

Operative Treatment of Severe Scoliosis in Symptomatic Adults: Multicenter Assessment of Outcomes and Complications With Minimum 2-Year Follow-up

BACKGROUND

Few reports focus on adults with severe scoliosis.

OBJECTIVE

To report surgical outcomes and complications for adults with severe scoliosis.

METHODS

A multicenter, retrospective review was performed on operatively treated adults with severe scoliosis (minimum coronal Cobb: thoracic [TH] ≥ 75°, thoracolumbar [TL] ≥ 50°, lumbar [L] ≥ 50°).

RESULTS

Of 178 consecutive patients, 146 (82%; TH = 8, TL = 88, L = 50) achieved minimum 2-yr follow-up (mean age = 53.9 ± 13.2 yr, 92% women). Operative details included posterior-only (58%), 3-column osteotomy (14%), iliac fixation (72%), and mean posterior fusion = 13.2 ± 3.7 levels. Global coronal alignment (3.8 to 2.8 cm, P = .001) and maximum coronal Cobb improved significantly (P ≤.020): TH (84º to 57º; correction = 32%), TL (67º to 35º; correction = 48%), L (61º to 29º; correction = 53%). Sagittal alignment improved significantly (P < .001), most notably for L: C7-sagittal vertical axis 6.7 to 2.5 cm, pelvic incidence-lumbar lordosis mismatch 18º to 3º. Health-related quality-of-life (HRQL) improved significantly (P < .001), most notably for L: Oswestry Disability Index (44.4 ± 20.5 to 26.1 ± 18.3), Short Form-36 Physical Component Summary (30.2 ± 10.8 to 39.9 ± 9.8), and Scoliosis Research Society-22r Total (2.9 ± 0.7 to 3.8 ± 0.7). Minimal clinically important difference and substantial clinical benefit thresholds were achieved in 36% to 75% and 29% to 51%, respectively. Ninety-four (64%) patients had ≥1 complication (total = 191, 92 minor/99 major, most common = rod fracture [13.0%]). Fifty-seven reoperations were performed in 37 (25.3%) patients, with most common indications deep wound infection (11) and rod fracture (10).

CONCLUSION

Although results demonstrated high rates of complications, operative treatment of adults with severe scoliosis was associated with significant improvements in mean HRQL outcome measures for the study cohort at minimum 2-yr follow-up.

COVID-19 Significantly Impacted Hospital Length of Stay and Discharge Patterns for Adult Spinal Deformity Patients

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.

Preoperative Hyponatremia is an Independent Risk Factor for Prolonged Hospital Stay Following Anterior Cervical Discectomy and Fusion

OBJECTIVE

To determine the effects of preoperative hyponatremia on short-term postoperative complications and healthcare utilization (length of stay, readmissions) following anterior cervical fusion and discectomy (ACDF).

METHODS

Patients who underwent ACDF were identified in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Patients who had revision surgery, trauma, vertebral malignancy, or infection were excluded. Eunatremia was defined as sodium (Na) level between 135 and 145 mEq/L, whereas hyponatremia was defined as Na < 135 mEq/L. Preoperatively hyponatremic patients were matched 1:1 with eunatremic patients using propensity-score matching based upon age, gender, American Society of Anesthesiology (ASA) score, and baseline comorbidities. Minor adverse events included superficial infection, dehiscence, urinary tract infection, pneumonia, and renal insufficiency or failure. Serious adverse events included deep wound infection, reintubation, pulmonary embolism, cerebrovascular accident, cardiac arrest, deep vein thrombosis, sepsis, return to operating room, and death within 30 days. Complications were analyzed using bivariate and logistic analysis with significance set at p<0.05.

RESULTS

Of the 9,094 patients undergoing ACDF, 3.64% (331 patients) were preoperatively hyponatremic. Preoperative hyponatremia was an independent risk factor for postoperative pneumonia following ACDF (OR=4.47; p=0.020) as well as extended length of hospital stay greater than one standard deviation above the mean (OR=1.71; p=0.042). Preoperative hyponatremia was an independent risk factor for having a serious adverse event (OR=2.40; p=0.005), as well as any adverse event (OR=2.44; p=0.009).

CONCLUSION

Preoperative hyponatremia is an independent risk factor for pneumonia and prolonged length of stay following ACDF.

Global coronal decompensation and adult spinal deformity surgery: comparison of upper-thoracic versus lower-thoracic proximal fixation for long fusions

OBJECTIVE

Deterioration of global coronal alignment (GCA) may be associated with worse outcomes after adult spinal deformity (ASD) surgery. The impact of fusion length and upper instrumented vertebra (UIV) selection on patients with this complication is unclear. The authors' objective was to compare outcomes between long sacropelvic fusion with upper-thoracic (UT) UIV and those with lower-thoracic (LT) UIV in patients with worsening GCA ≥ 1 cm.

METHODS

This was a retrospective analysis of a prospective multicenter database of consecutive ASD patients. Index operations involved instrumented fusion from sacropelvis to thoracic spine. Global coronal deterioration was defined as worsening GCA ≥ 1 cm from preoperation to 2-year follow-up.

RESULTS

Of 875 potentially eligible patients, 560 (64%) had complete 2-year follow-up data, of which 144 (25.7%) demonstrated worse GCA at 2-year postoperative follow-up (35.4% of UT patients vs 64.6% of LT patients). At baseline, UT patients were younger (61.6 ± 9.9 vs 64.5 ± 8.6 years, p = 0.008), a greater percentage of UT patients had osteoporosis (35.3% vs 16.1%, p = 0.009), and UT patients had worse scoliosis (51.9° ± 22.5° vs 32.5° ± 16.3°, p < 0.001). Index operations were comparable, except UT patients had longer fusions (16.4 ± 0.9 vs 9.7 ± 1.2 levels, p < 0.001) and operative duration (8.6 ± 3.2 vs 7.6 ± 3.0 hours, p = 0.023). At 2-year follow-up, global coronal deterioration averaged 2.7 ± 1.4 cm (1.9 to 4.6 cm, p < 0.001), scoliosis improved (39.3° ± 20.8° to 18.0° ± 14.8°, p < 0.001), and sagittal spinopelvic alignment improved significantly in all patients. UT patients maintained smaller positive C7 sagittal vertical axis (2.7 ± 5.7 vs 4.7 ± 5.7 cm, p = 0.014). Postoperative 2-year health-related quality of life (HRQL) significantly improved from baseline for all patients. HRQL comparisons demonstrated that UT patients had worse Scoliosis Research Society-22r (SRS-22r) Activity (3.2 ± 1.0 vs 3.6 ± 0.8, p = 0.040) and SRS-22r Satisfaction (3.9 ± 1.1 vs 4.3 ± 0.8, p = 0.021) scores. Also, fewer UT patients improved by ≥ 1 minimal clinically important difference in numerical rating scale scores for leg pain (41.3% vs 62.7%, p = 0.020). Comparable percentages of UT and LT patients had complications (208 total, including 53 reoperations, 77 major complications, and 78 minor complications), but the percentage of reoperated patients was higher among UT patients (35.3% vs 18.3%, p = 0.023). UT patients had higher reoperation rates of rod fracture (13.7% vs 2.2%, p = 0.006) and pseudarthrosis (7.8% vs 1.1%, p = 0.006) but not proximal junctional kyphosis (9.8% vs 8.6%, p = 0.810).

CONCLUSIONS

In ASD patients with worse 2-year GCA after long sacropelvic fusion, UT UIV was associated with worse 2-year HRQL compared with LT UIV. This may suggest that residual global coronal malalignment is clinically less tolerated in ASD patients with longer fusion to the proximal thoracic spine. These results may inform operative planning and improve patient counseling.

Multicenter assessment of outcomes and complications associated with transforaminal versus anterior lumbar interbody fusion for fractional curve correction

OBJECTIVE

Few studies have compared fractional curve correction after long fusion between transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) for adult symptomatic thoracolumbar/lumbar scoliosis (ASLS). The objective of this study was to compare fractional correction, health-related quality of life (HRQL), and complications associated with L4-S1 TLIF versus those of ALIF as an operative treatment of ASLS.

METHODS

The authors retrospectively analyzed a prospective multicenter adult spinal deformity database. Inclusion required a fractional curve ≥ 10°, a thoracolumbar/lumbar curve ≥ 30°, index TLIF or ALIF performed at L4-5 and/or L5-S1, and a minimum 2-year follow-up. TLIF and ALIF patients were propensity matched according to the number and type of interbody fusion at L4-S1.

RESULTS

Of 135 potentially eligible consecutive patients, 106 (78.5%) achieved the minimum 2-year follow-up (mean ± SD age 60.6 ± 9.3 years, 85% women, 44.3% underwent TLIF, and 55.7% underwent ALIF). Index operations had mean ± SD 12.2 ± 3.6 posterior levels, 86.6% of patients underwent iliac fixation, 67.0% underwent TLIF/ALIF at L4-5, and 84.0% underwent TLIF/ALIF at L5-S1. Compared with TLIF patients, ALIF patients had greater cage height (10.9 ± 2.1 mm for TLIF patients vs 14.5 ± 3.0 mm for ALIF patients, p = 0.001) and lordosis (6.3° ± 1.6° for TLIF patients vs 17.0° ± 9.9° for ALIF patients, p = 0.001) and longer operative duration (6.7 ± 1.5 hours for TLIF patients vs 8.9 ± 2.5 hours for ALIF patients, p < 0.001). In all patients, final alignment improved significantly in terms of the fractional curve (20.2° ± 7.0° to 6.9° ± 5.2°), maximum coronal Cobb angle (55.0° ± 14.8° to 23.9° ± 14.3°), C7 sagittal vertical axis (5.1 ± 6.2 cm to 2.3 ± 5.4 cm), pelvic tilt (24.6° ± 8.1° to 22.7° ± 9.5°), and lumbar lordosis (32.3° ± 18.8° to 51.4° ± 14.1°) (all p < 0.05). Matched analysis demonstrated comparable fractional correction (-13.6° ± 6.7° for TLIF patients vs -13.6° ± 8.1° for ALIF patients, p = 0.982). In all patients, final HRQL improved significantly in terms of Oswestry Disability Index (ODI) score (42.4 ± 16.3 to 24.2 ± 19.9), physical component summary (PCS) score of the 36-item Short-Form Health Survey (32.6 ± 9.3 to 41.3 ± 11.7), and Scoliosis Research Society-22r score (2.9 ± 0.6 to 3.7 ± 0.7) (all p < 0.05). Matched analysis demonstrated worse ODI (30.9 ± 21.1 for TLIF patients vs 17.9 ± 17.1 for ALIF patients, p = 0.017) and PCS (38.3 ± 12.0 for TLIF patients vs 45.3 ± 10.1 for ALIF patients, p = 0.020) scores for TLIF patients at the last follow-up (despite no differences in these parameters at baseline). The rates of total complications were similar (76.6% for TLIF patients vs 71.2% for ALIF patients, p = 0.530), but significantly more TLIF patients had rod fracture (28.6% of TLIF patients vs 7.1% of ALIF patients, p = 0.036). Multiple regression analysis demonstrated that a 1-mm increase in L4-5 TLIF cage height led to a 2.2° reduction in L4 coronal tilt (p = 0.011), and a 1° increase in L5-S1 ALIF cage lordosis led to a 0.4° increase in L5-S1 segmental lordosis (p = 0.045).

CONCLUSIONS

Operative treatment of ASLS with L4-S1 TLIF versus ALIF demonstrated comparable mean fractional curve correction (66.7% vs 64.8%), despite use of significantly larger, more lordotic ALIF cages. TLIF cage height had a significant impact on leveling L4 coronal tilt, whereas ALIF cage lordosis had a significant impact on restoration of lumbosacral lordosis. The advantages of TLIF may include reduced operative duration and hospitalization; however, associated HRQL was inferior and more rod fractures were detected in the TLIF patients included in this study.

Persistent sleep disturbance after spine surgery is associated with failure to achieve meaningful improvements in pain and health-related quality of life

BACKGROUND CONTEXT

Little is known about the effects of sleep disturbance (SD) on clinical outcomes after spine surgery.

PURPOSE

To determine the (1) prevalence of SD among patients presenting for spine surgery at an academic medical center; (2) correlations between SD and health-related quality of life (HRQoL) scores; and (3) associations between postoperative SD resolution and short-term HRQoL.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

We included 508 adults undergoing spine surgery at 1 academic center between December 2014 and January 2018.

OUTCOME MEASURES

Participants completed the Oswestry Disability Index (ODI) or Neck Disability Index (NDI) and Patient Reported Outcome Measurement System (PROMIS-29) questionnaire preoperatively, during the immediate postoperative period (6-12 weeks), and at 6, 12, and 24 months after surgery.

METHODS

Using preoperative PROMIS SD scores, we grouped participants as having no sleep disturbance (score <55), mild disturbance (score, 55-60), moderate disturbance (score 60-70), or severe disturbance (score, 70). For the final analysis, we collapsed these categories into no/mild and moderate/severe. Pearson correlation tests were used to assess correlations between SD and HRQoL measures. Regression analysis (adjusting for age, sex, comorbidities, current opioid use, and occurrence of complications) was used to estimate the effect of postoperative resolved or continuing SD on HRQoL scores and the likelihood of achieving clinically meaningful improvements in HRQoL. Alpha = 0.05.

RESULTS

Preoperative SD was reported by 127 participants (25%). SD was significantly correlated with worse ODI and/or NDI values and worse scores in all PROMIS health domains (all, p<.001). At the immediate postoperative assessment, SD had resolved in 80 of 127 participants (63%). Compared with participants who reported no preoperative SD, those with ongoing SD were significantly less likely to achieve clinically meaningful improvements in Pain Interference (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.28, 0.84), Physical Function (OR, 0.32; 95% CI, 0.13, 0.82), and Satisfaction with Participation in Social Roles (OR, 0.57; 95% CI, 0.37, 0.80).

CONCLUSION

One-quarter of spine surgery patients reported preoperative SD of at least moderate severity. Poor preoperative sleep quality and ongoing postoperative sleep disturbance were significantly associated with worse scores on several HRQoL measures. These results highlight the importance of addressing patients' sleep disturbance both before and after surgery.

Defining a Surgical Invasiveness Threshold for Increased Risk of a Major Complication Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

The aim of this study was to define a surgical invasiveness threshold that predicts major complications after adult spinal deformity (ASD) surgery; use this threshold to categorize patients into quartiles by invasiveness; and determine the odds of major complications by quartile.

SUMMARY OF BACKGROUND DATA

Understanding the relationship between surgical invasiveness and major complications is important for estimating the likelihood of major complications after ASD surgery.

METHODS

Using a multicenter database, we identified 574 ASD patients (more than 5 levels fused; mean age, 60 ± 15 years) with minimum 2-year follow-up. Invasiveness was calculated as the ASD Surgical and Radiographic (ASD-SR) score. Youden index was used to identify the invasiveness score cut-off associated with optimal sensitivity and specificity for predicting major complications. Resulting high- and low-invasiveness groups were divided in half to create quartiles. Odds of developing a major complication were analyzed for each quartile using logistic regression (alpha = 0.05).

RESULTS

The ASD-SR cutoff score that maximally predicted major complications was 90 points. ASD-SR quartiles were 0 to 65 (Q1), 66 to 89 (Q2), 90 to 119 (Q3), and ≥120 (Q4). Risk of a major complication was 17% in Q1, 21% in Q2, 35% in Q3, and 33% in Q4 (P < 0.001). Comparisons of adjacent quartiles showed an increase in the odds of a major complication from Q2 to Q3 (odds ratio [OR] 1.8; 95% confidence interval [CI]: 1.0-3.0), but not from Q1 to Q2 or from Q3 to Q4. Patients with ASD-SR scores ≥90 were 1.9 times as likely to have a major complication than patients with scores <90 (OR 1.9, 95% CI 1.3-2.9). Mean ASD-SR scores above and below 90 points were 121 ± 25 and 63 ± 17, respectively.

CONCLUSION

The odds of major complications after ASD surgery are significantly greater when the procedure has an ASD-SR score ≥90. ASD-SR score can be used to counsel patients regarding these increased odds.Level of Evidence: 3.