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Balmaceno-Criss M, Lafage R, Alsoof D, Daher M, Hamilton DK, Smith JS, Eastlack RK, Fessler RG, Gum JL, Gupta MC, Hostin R, Kebaish KM, Klineberg EO, Lewis SJ, Line BG, Nunley PD, Mundis GM, Passias PG, Protopsaltis TS, Buell T, Scheer JK, Mullin JP, Soroceanu A, Ames CP, Lenke LG, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Burton DC, Diebo BG, Daniels AH. Impact of Hip and Knee Osteoarthritis on Full Body Sagittal Alignment and Compensation for Sagittal Spinal Deformity. Spine (Phila Pa 1976) 2024; 49:743-751. [PMID: 38375611 DOI: 10.1097/brs.0000000000004957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/26/2024] [Indexed: 02/21/2024]
Abstract
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. PATIENTS AND METHODS In total, 527 preoperative 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°, and 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 that with increasing T1PA, pelvic tilt correlated inversely with hip osteoarthritis and positively with knee osteoarthritis ( r2 =0.812). Hip osteoarthritis decreased compensation through 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.
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Affiliation(s)
- Mariah Balmaceno-Criss
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell, New York, NY
| | - Daniel Alsoof
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Mohammad Daher
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - David Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA
| | | | - Richard G Fessler
- Department of Neurological Surgery, Rush University Medical School, Chicago, IL
| | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | | | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of Texas Health, Houston, TX
| | - Stephen J Lewis
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Canada
| | | | | | | | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | | | - Thomas Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, CA
| | | | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, Canada
| | | | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Shay Bess
- Denver International Spine Center, Denver, CO
| | | | - Frank J Schwab
- Department of Orthopedic Surgery, Northwell, New York, NY
| | | | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Bassel G Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
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2
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Mohanty S, Hassan FM, Lenke LG, Lewerenz E, Passias PG, Klineberg EO, Lafage V, Smith JS, Hamilton DK, Gum JL, Lafage R, Mullin J, Diebo B, Buell TJ, Kim HJ, Kebaish K, Eastlack R, Daniels AH, Mundis G, Hostin R, Protopsaltis TS, Hart RA, Gupta M, Schwab FJ, Shaffrey CI, Ames CP, Burton D, Bess S. Machine learning clustering of adult spinal deformity patients identifies four prognostic phenotypes: a multicenter prospective cohort analysis with single surgeon external validation. Spine J 2024; 24:1095-1108. [PMID: 38365004 DOI: 10.1016/j.spinee.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/11/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND CONTEXT Among adult spinal deformity (ASD) patients, heterogeneity in patient pathology, surgical expectations, baseline impairments, and frailty complicates comparisons in clinical outcomes and research. This study aims to qualitatively segment ASD patients using machine learning-based clustering on a large, multicenter, prospectively gathered ASD cohort. PURPOSE To qualitatively segment adult spinal deformity patients using machine learning-based clustering on a large, multicenter, prospectively gathered cohort. STUDY DESIGN/SETTING Machine learning algorithm using patients from a prospective multicenter study and a validation cohort from a retrospective single center, single surgeon cohort with complete 2-year follow up. PATIENT SAMPLE About 805 ASD patients; 563 patients from a prospective multicenter study and 242 from a single center to be used as a validation cohort. OUTCOME MEASURES To validate and extend the Ames-ISSG/ESSG classification using machine learning-based clustering analysis on a large, complex, multicenter, prospectively gathered ASD cohort. METHODS We analyzed a training cohort of 563 ASD patients from a prospective multicenter study and a validation cohort of 242 ASD patients from a retrospective single center/surgeon cohort with complete two-year patient-reported outcomes (PROs) and clinical/radiographic follow-up. Using k-means clustering, a machine learning algorithm, we clustered patients based on baseline PROs, Edmonton frailty, age, surgical history, and overall health. Baseline differences in clusters identified using the training cohort were assessed using Chi-Squared and ANOVA with pairwise comparisons. To evaluate the classification system's ability to discern postoperative trajectories, a second machine learning algorithm assigned the single-center/surgeon patients to the same 4 clusters, and we compared the clusters' two-year PROs and clinical outcomes. RESULTS K-means clustering revealed four distinct phenotypes from the multicenter training cohort based on age, frailty, and mental health: Old/Frail/Content (OFC, 27.7%), Old/Frail/Distressed (OFD, 33.2%), Old/Resilient/Content (ORC, 27.2%), and Young/Resilient/Content (YRC, 11.9%). OFC and OFD clusters had the highest frailty scores (OFC: 3.76, OFD: 4.72) and a higher proportion of patients with prior thoracolumbar fusion (OFC: 47.4%, OFD: 49.2%). ORC and YRC clusters exhibited lower frailty scores and fewest patients with prior thoracolumbar procedures (ORC: 2.10, 36.6%; YRC: 0.84, 19.4%). OFC had 69.9% of patients with global sagittal deformity and the highest T1PA (29.0), while YRC had 70.2% exhibiting coronal deformity, the highest mean coronal Cobb Angle (54.0), and the lowest T1PA (11.9). OFD and ORC had similar alignment phenotypes with intermediate values for Coronal Cobb Angle (OFD: 33.7; ORC: 40.0) and T1PA (OFD: 24.9; ORC: 24.6) between OFC (worst sagittal alignment) and YRC (worst coronal alignment). In the single surgeon validation cohort, the OFC cluster experienced the greatest increase in SRS Function scores (1.34 points, 95%CI 1.01-1.67) compared to OFD (0.5 points, 95%CI 0.245-0.755), ORC (0.7 points, 95%CI 0.415-0.985), and YRC (0.24 points, 95%CI -0.024-0.504) clusters. OFD cluster patients improved the least over 2 years. Multivariable Cox regression analysis demonstrated that the OFD cohort had significantly worse reoperation outcomes compared to other clusters (HR: 3.303, 95%CI: 1.085-8.390). CONCLUSION Machine-learning clustering found four different ASD patient qualitative phenotypes, defined by their age, frailty, physical functioning, and mental health upon presentation, which primarily determines their ability to improve their PROs following surgery. This reaffirms that these qualitative measures must be assessed in addition to the radiographic variables when counseling ASD patients regarding their expected surgical outcomes.
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Affiliation(s)
- Sarthak Mohanty
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | - Fthimnir M Hassan
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA.
| | - Lawrence G Lenke
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | - Erik Lewerenz
- Department of Orthopaedics, Columbia University Medical Center, New York, NY, USA
| | - Peter G Passias
- Department of Orthopaedic Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health Lenox Hill, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Northwell Health Lenox Hill, New York, NY, USA
| | - Jeffrey Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, University Orthopedics, Providence, RI, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Khalid Kebaish
- Department of Orthopaedic Surgery, John Hopkins Medical Institute, Baltimore, MD, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, University Orthopedics, Providence, RI, USA
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis and Spine Institute, Dallas, TX, USA
| | | | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Northwell Health Lenox Hill, New York, NY, USA
| | | | - Christopher P Ames
- Department of Neurosurgery, University of California San Francisco Spine Center, San Francisco, CA, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
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Jalali O, Smith JS, Bess S, Hostin R, Lafage R, Lafage V, Shaffrey CI, Ames CP, Lenke LG, Kelly MP. Validation of the Oswestry Disability Index in Adult Spinal Deformity. Spine (Phila Pa 1976) 2024; 49:682-688. [PMID: 38356276 DOI: 10.1097/brs.0000000000004960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/03/2024] [Indexed: 02/16/2024]
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE To examine the validity of the Oswestry Disability Index (ODI) in patients with adult spinal deformity (ASD) treated with surgery. BACKGROUND The ODI is a patient-reported outcome measure of low back pain and disability. Although nearly ubiquitous in ASD research, the measure has not been validated in this patient population. PATIENTS AND METHODS A registry of patients with ASD was queried for baseline and 1-year PROM data, including the ODI, the Scoliosis Research Society-22r (SRS-22r), and the Patient Reported Outcomes Measurement Information System-Pain Interference (PI) and Physical Function (PF) CATs. Internal reliability was assessed with Cronbach alpha, where values ≥0.7 are considered reliable. Validity was assessed with Spearman correlation coefficients calculated for the ODI against validated Patient-Reported Outcomes Measurement Information System (PROMIS)-PI and PF, and legacy measures SRS-Pain and SRS-Activity. Responsiveness to change was measured with the adjusted effect size. RESULTS A total of 325 patients were enrolled, with 208 completing baseline and 1-year patient-reported outcome measures. The majority (149, 72%) were females and White (193, 93%), median Charlson Comorbidity Index 0 (interquartile range: 0-2). The majority of cases included sagittal plane deformity [mean T1PA: 24.2° (13.9)]. Cronbach alpha showed excellent internal reliability (baseline = 0.89, 1 yr = 0.90). ODI was valid, with strong correlations between PROMIS-PI, PROMIS-PF, SRS-Pain, and SRS-Activity at baseline and 1-year follow-up. All measures were responsive to change, with the ODI showing greater responsiveness than PROMIS-PI, PROMIS-PF, and SRS-Activity. CONCLUSIONS The ODI is a valid measure of disability as measured by pain and function in patients with ASD. It is responsive to change in a manner not different from validated PROMIS-CAT or the SRS-22r legacy measure. It is multidimensional, however, as it assesses both pain and function simultaneously. It does not measure disability related to self-image and may not account for all disease-related disability in patients with ASD.
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Affiliation(s)
- Omid Jalali
- Department of Orthopaedic Surgery, University of California, San Diego, San Diego, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | | | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA
| | | | - Michael P Kelly
- Department of Orthopaedic Surgery, University of California, San Diego, San Diego, CA
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4
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Lafage R, Kim HJ, Eastlack RK, Daniels AH, Diebo BG, Mundis G, Khalifé M, Smith JS, Bess SR, Shaffrey CI, Ames CP, Burton DC, Gupta MC, Klineberg EO, Schwab FJ, Lafage V. Revision Strategy for Proximal Junctional Failure: Combined Effect of Proximal Extension and Focal Correction. Global Spine J 2024:21925682241254805. [PMID: 38736317 DOI: 10.1177/21925682241254805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
STUDY DESIGN Retrospective review of a prospectively-collected multicenter database. OBJECTIVES The objective of this study was to determine optimal strategies in terms of focal angular correction and length of proximal extension during revision for PJF. METHODS 134 patients requiring proximal extension for PJF were analyzed in this study. The correlation between amount of proximal junctional angle (PJA) reduction and recurrence of proximal junctional kyphosis (PJK) and/or PJF was investigated. Following stratification by the degree of PJK correction and the numbers of levels extended proximally, rates of radiographic PJK (PJA >28° & ΔPJA >22°), and recurrent surgery for PJF were reported. RESULTS Before revision, mean PJA was 27.6° ± 14.6°. Mean number of levels extended was 6.0 ± 3.3. Average PJA reduction was 18.8° ± 18.9°. A correlation between the degree of PJA reduction and rate of recurrent PJK was observed (r = -.222). Recurrent radiographic PJK (0%) and clinical PJF (4.5%) were rare in patients undergoing extension ≥8 levels, regardless of angular correction. Patients with small reductions (<5°) and small extensions (<4 levels) experienced moderate rates of recurrent PJK (19.1%) and PJF (9.5%). Patients with large reductions (>30°) and extensions <8 levels had the highest rate of recurrent PJK (31.8%) and PJF (16.0%). CONCLUSION While the degree of focal PJK correction must be determined by the treating surgeon based upon clinical goals, recurrent PJK may be minimized by limiting reduction to <30°. If larger PJA correction is required, more extensive proximal fusion constructs may mitigate recurrent PJK/PJF rates.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Han-Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Robert K Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, University Orthopedics, Providence, RI, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, University Orthopedics, Providence, RI, USA
| | - Greg Mundis
- San Diego Spine Foundation, San Diego, CA, USA
| | - Marc Khalifé
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
- Department of Orthopedic Surgery, Hôpital Européen Georges Pompidou, Paris, France
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Shay R Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, CO, USA
| | | | - Christopher P Ames
- Department of Neurosurgery, University of California San Francisco Spine Center, San Francisco, CA, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | - Frank J Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
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5
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Bess S, Line BG, Nunley P, Ames C, Burton D, Mundis G, Eastlack R, Hart R, Gupta M, Klineberg E, Kim HJ, Kelly M, Hostin R, Kebaish K, Lafage V, Lafage R, Schwab F, Shaffrey C, Smith JS. Postoperative Discharge to Acute Rehabilitation or Skilled Nursing Facility Compared With Home Does Not Reduce Hospital Readmissions, Return to Surgery, or Improve Outcomes Following Adult Spine Deformity Surgery. Spine (Phila Pa 1976) 2024; 49:E117-E127. [PMID: 37694516 DOI: 10.1097/brs.0000000000004825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/01/2023] [Indexed: 09/12/2023]
Abstract
STUDY DESIGN Retrospective review of a prospective multicenter adult spinal deformity (ASD) study. OBJECTIVE The aim of this study was to evaluate 30-day readmissions, 90-day return to surgery, postoperative complications, and patient-reported outcomes (PROs) for matched ASD patients receiving nonhome discharge (NON), including acute rehabilitation (REHAB), and skilled nursing facility (SNF), or home (HOME) discharge following ASD surgery. SUMMARY OF BACKGROUND DATA Postoperative disposition following ASD surgery frequently involves nonhome discharge. Little data exists for longer term outcomes for ASD patients receiving nonhome discharge versus patients discharged to home. MATERIALS AND METHODS Surgically treated ASD patients prospectively enrolled into a multicenter study were assessed for NON or HOME disposition following hospital discharge. NON was further divided into REHAB or SNF. Propensity score matching was used to match for patient age, frailty, spine deformity, levels fused, and osteotomies performed at surgery. Thirty-day hospital readmissions, 90-day return to surgery, postoperative complications, and 1-year and minimum 2-year postoperative PROs were evaluated. RESULTS A total of 241 of 374 patients were eligible for the study. NON patients were identified and matched to HOME patients. Following matching, 158 patients remained for evaluation; NON and HOME had similar preoperative age, frailty, spine deformity magnitude, surgery performed, and duration of hospital stay ( P >0.05). Thirty-day readmissions, 90-day return to surgery, and postoperative complications were similar for NON versus HOME and similar for REHAB (N=64) versus SNF (N=42) versus HOME ( P >0.05). At 1-year and minimum 2-year follow-up, HOME demonstrated similar to better PRO scores including Oswestry Disability Index, Short-Form 36v2 questionnaire Mental Component Score and Physical Component Score, and Scoliosis Research Society scores versus NON, REHAB, and SNF ( P <0.05). CONCLUSIONS Acute needs must be considered following ASD surgery, however, matched analysis comparing 30-day hospital readmissions, 90-day return to surgery, postoperative complications, and PROs demonstrated minimal benefit for NON, REHAB, or SNF versus HOME at 1- and 2-year follow-up, questioning the risk and cost/benefits of routine use of nonhome discharge. LEVEL OF EVIDENCE Level III-prognostic.
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Affiliation(s)
- Shay Bess
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Breton G Line
- Denver International Spine Center, Rocky Mountain Hospital for Children and Presbyterian St. Luke's Medical Center, Denver, CO
| | - Pierce Nunley
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco School of Medicine, San Francisco, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas School of Medicine, Kansas City, KS
| | | | | | | | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California Davis School of Medicine, Sacramento, CA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Michael Kelly
- Department of Orthopedic Surgery, San Diego Children's Hospital, San Diego, CA
| | | | - Khaled Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Virgine Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | - Frank Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA
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Zhang S, Makoś MZ, Jadrich RB, Kraka E, Barros K, Nebgen BT, Tretiak S, Isayev O, Lubbers N, Messerly RA, Smith JS. Exploring the frontiers of condensed-phase chemistry with a general reactive machine learning potential. Nat Chem 2024; 16:727-734. [PMID: 38454071 PMCID: PMC11087274 DOI: 10.1038/s41557-023-01427-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 12/12/2023] [Indexed: 03/09/2024]
Abstract
Atomistic simulation has a broad range of applications from drug design to materials discovery. Machine learning interatomic potentials (MLIPs) have become an efficient alternative to computationally expensive ab initio simulations. For this reason, chemistry and materials science would greatly benefit from a general reactive MLIP, that is, an MLIP that is applicable to a broad range of reactive chemistry without the need for refitting. Here we develop a general reactive MLIP (ANI-1xnr) through automated sampling of condensed-phase reactions. ANI-1xnr is then applied to study five distinct systems: carbon solid-phase nucleation, graphene ring formation from acetylene, biofuel additives, combustion of methane and the spontaneous formation of glycine from early earth small molecules. In all studies, ANI-1xnr closely matches experiment (when available) and/or previous studies using traditional model chemistry methods. As such, ANI-1xnr proves to be a highly general reactive MLIP for C, H, N and O elements in the condensed phase, enabling high-throughput in silico reactive chemistry experimentation.
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Affiliation(s)
- Shuhao Zhang
- Department of Chemistry, Mellon College of Science, Carnegie Mellon University, Pittsburgh, PA, USA
- Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM, USA
| | - Małgorzata Z Makoś
- Computational and Theoretical Chemistry Group, Department of Chemistry, Southern Methodist University, Dallas, TX, USA
- Computer, Computational, and Statistical Sciences Division, Los Alamos National Laboratory, Los Alamos, NM, USA
| | - Ryan B Jadrich
- Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM, USA
- Center for Nonlinear Studies, Los Alamos National Laboratory, Los Alamos, NM, USA
| | - Elfi Kraka
- Computational and Theoretical Chemistry Group, Department of Chemistry, Southern Methodist University, Dallas, TX, USA
| | - Kipton Barros
- Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM, USA
- Center for Nonlinear Studies, Los Alamos National Laboratory, Los Alamos, NM, USA
| | - Benjamin T Nebgen
- Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM, USA
| | - Sergei Tretiak
- Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM, USA
- Center for Nonlinear Studies, Los Alamos National Laboratory, Los Alamos, NM, USA
| | - Olexandr Isayev
- Department of Chemistry, Mellon College of Science, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Nicholas Lubbers
- Computer, Computational, and Statistical Sciences Division, Los Alamos National Laboratory, Los Alamos, NM, USA.
| | - Richard A Messerly
- Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM, USA.
| | - Justin S Smith
- Theoretical Division, Los Alamos National Laboratory, Los Alamos, NM, USA.
- NVIDIA Corp., Santa Clara, CA, USA.
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7
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Passias PG, Pierce KE, Mir JM, Krol O, Lafage R, Lafage V, Line B, Uribe JS, Hostin R, Daniels A, Hart R, Burton D, Shaffrey C, Schwab F, Diebo BG, Ames CP, Smith JS, Schoenfeld AJ, Bess S, Klineberg EO. Development of a modified frailty index for adult spinal deformities independent of functional changes following surgical correction: a true baseline risk assessment tool. Spine Deform 2024; 12:811-817. [PMID: 38305990 DOI: 10.1007/s43390-023-00808-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 12/16/2023] [Indexed: 02/03/2024]
Abstract
PURPOSE To develop a simplified, modified frailty index for adult spinal deformity (ASD) patients dependent on objective clinical factors. METHODS ASD patients with baseline (BL) and 2-year (2Y) follow-up were included. Factors with the largest R2 value derived from multivariate forward stepwise regression were including in the modified ASD-FI (clin-ASD-FI). Factors included in the clin-ASD-FI were regressed against mortality, extended length of hospital stay (LOS, > 8 days), revisions, major complications and weights for the clin-ASD-FI were calculated via Beta/Sullivan. Total clin-ASD-FI score was created with a score from 0 to 1. Linear regression correlated clin-ASD-FI with ASD-FI scores and published cutoffs for the ASD-FI were used to create the new frailty cutoffs: not frail (NF: < 0.11), frail (F: 0.11-0.21) and severely frail (SF: > 0.21). Binary logistic regression assessed odds of complication or reop for frail patients. RESULTS Five hundred thirty-one ASD patients (59.5 yrs, 79.5% F) were included. The final model had a R2 of 0.681, and significant factors were: < 18.5 or > 30 BMI (weight: 0.0625 out of 1), cardiac disease (0.125), disability employment status (0.3125), diabetes mellitus (0.0625), hypertension (0.0625), osteoporosis (0.125), blood clot (0.1875), and bowel incontinence (0.0625). These factors calculated the score from 0 to 1, with a mean cohort score of 0.13 ± 0.14. Breakdown by clin-ASD-FI score: 51.8% NF, 28.1% F, 20.2% SF. Increasing frailty severity was associated with longer LOS (NF: 7.0, F: 8.3, SF: 9.2 days; P < 0.001). Frailty independently predicted occurrence of any complication (OR: 9.357 [2.20-39.76], P = 0.002) and reop (OR: 2.79 [0.662-11.72], P = 0.162). CONCLUSIONS Utilizing an existing ASD frailty index, we proposed a modified version eliminating the patient-reported components. This index is a true assessment of physiologic status, and represents a superior risk factor assessment compared to other tools for both primary and revision spinal deformity surgery as a result of its immutability with surgery, lack of subjectivity, and ease of use.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, Orthopaedic Hospital - NYU School of Medicine, New York Spine Institute, 301 East 17th St, New York, NY, 10003, USA.
| | - Katherine E Pierce
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, Orthopaedic Hospital - NYU School of Medicine, New York Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Jamshaid M Mir
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, Orthopaedic Hospital - NYU School of Medicine, New York Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Oscar Krol
- Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, Orthopaedic Hospital - NYU School of Medicine, New York Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA, USA
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8
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Ani F, Sissman E, Woo D, Soroceanu A, Mundis G, Eastlack RK, Smith JS, Hamilton DK, Kim HJ, Daniels AH, Klineberg EO, Neuman B, Sciubba DM, Gupta MC, Kebaish KM, Passias PG, Hart RA, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Ames CP, Protopsaltis TS. Are insufficient corrections a major factor in distal junctional kyphosis? A simulated analysis of cervical deformity correction using in-construct measurements. J Neurosurg Spine 2024; 40:622-629. [PMID: 38364226 DOI: 10.3171/2023.12.spine23481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 12/13/2023] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
- Fares Ani
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ethan Sissman
- 2Department of Orthopedic Surgery, Chaim Sheba Medical Center Hospital, Tel Aviv University, Tel Aviv, Israel
| | - Dainn Woo
- 3Department of Orthopedic Surgery, Penn Medicine, Philadelphia, Pennsylvania
| | - Alex Soroceanu
- 4Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Robert K Eastlack
- 6Department of Orthopaedic Surgery, Scripps Spine Center, La Jolla, California
| | - Justin S Smith
- 7Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - D Kojo Hamilton
- 8The Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Han Jo Kim
- 9Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Alan H Daniels
- 10Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Brian Neuman
- 12Department of Orthopaedics, Johns Hopkins University, Baltimore, Maryland
| | | | - Munish C Gupta
- 14Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Khaled M Kebaish
- 12Department of Orthopaedics, Johns Hopkins University, Baltimore, Maryland
| | - Peter G Passias
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Robert A Hart
- 15Swedish Neuroscience Institute, Seattle, Washington
| | - Shay Bess
- 16Denver International Spine Center, Denver, Colorado
| | - Christopher I Shaffrey
- 17Department of Orthopaedic Surgery, University of Virginia Medical Center, Charlottesville, Virginia; and
| | | | | | - Christopher P Ames
- 18Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, California
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9
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Kato S, Smith JS, Driesman D, Shaffrey CI, Lenke LG, Lewis SJ. Post-operative bracing following adult spine deformity surgery: Results from the AO Spine surveillance of post-operative management of patients with adult spine deformity. PLoS One 2024; 19:e0297541. [PMID: 38626050 PMCID: PMC11020681 DOI: 10.1371/journal.pone.0297541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/09/2024] [Indexed: 04/18/2024] Open
Abstract
STUDY DESIGN Cross-sectional international survey with a literature review. OBJECTIVES While some surgeons favor spine bracing after surgery for adult spine deformity (ASD) to help prevent mechanical failures, there is a lack of evidence. The objective of the present study was to better understand the current trend in the use of bracing following ASD surgery based on an international survey. METHODS An e-mail-based online survey was conducted among over 6000 international AO Spine members regarding the post-operative management of patients with ASD. The details of brace prescription, indications and influencing factors were solicited. Descriptive data were summarized based on different demographic groups and fusion levels for the responding surgeons who annually perform at least 10 long-segment fusions of >5 levels extending to the pelvis. RESULTS A total of 116 responses were received, including 71 surgeons (61%) who used post-operative bracing for >5 levels of long fusion. The most common reason for bracing was pain management (55%) and bone quality was the strongest influencing factor (69%). Asia-Pacific surgeons had the highest rate of bracing (88%), while North American surgeons had the lowest (45%). The most common type of brace used were TLSO for cases with an uppermost instrumented vertebra (UIV) in the low- or mid-thoracic spine and a cervical brace for UIV at T1-3. The majority (56%) used bracing for 6-12 weeks after surgery. CONCLUSIONS The present survey demonstrated significant interest in bracing following ASD surgery, however, there is substantial variability in post-operative bracing practice. A formal study on the role of bracing in ASD surgery is needed.
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Affiliation(s)
- So Kato
- Department of Orthopaedic Surgery, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Devin Driesman
- Department of Orthopaedic Surgery, Toronto Western Hospital, Schroeder Arthritis Institute, University of Toronto, Toronto, Ontario, Canada
| | - Christopher I. Shaffrey
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States of America
| | - Lawrence G. Lenke
- Department of Orthopedic Spine Surgery, The Spine Hospital, Columbia University Medical Center, New York, New York, United States of America
| | - Stephen J. Lewis
- Department of Orthopaedic Surgery, Toronto Western Hospital, Schroeder Arthritis Institute, University of Toronto, Toronto, Ontario, Canada
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10
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Bass RD, Lafage R, Smith JS, Ames C, Bess S, Eastlack R, Gupta M, Hostin R, Kebaish K, Kim HJ, Klineberg E, Mundis G, Okonkwo D, Shaffrey C, Schwab F, Lafage V, Burton D. Benchmark Values for Construct Survival and Complications by Type of ASD Surgery. Spine (Phila Pa 1976) 2024:00007632-990000000-00643. [PMID: 38616765 DOI: 10.1097/brs.0000000000005012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/24/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVE Provide benchmarks for the rates of complications by type of surgery performed. STUDY DESIGN Prospective multicenter database. BACKGROUND We have previously examined overall construct survival and complication rates for ASD surgery. However, the relationship between type of surgery and construct survival warrants more detailed assessment. METHODS Eight surgical scenarios were defined based on the levels treated, previous fusion status (primary [P] vs. revision [R]), and 3-column osteotomy use [3CO]: Short Lumbar fusion, LT-Pelvis with 5-12 levels treated (P, R or 3CO), UT-Pelvis with 13 levels treated (P, R or 3CO), and Thoracic to Lumbar fusion without pelvic fixation, representing 92.4% of the case in the cohort. Complication rates for each type were calculated and Kaplan Meier curves with multivariate Cox regression analysis was used to evaluate the effect of the case characteristics on construct survival rate, while controlling for patient profile. RESULTS 1073 of 1494 patients eligible for 2-year follow-up (71.8%) were captured. Survival curves for major complications (with or without reoperation), while controlling for demographics differed significantly among surgical types (P<0.001). Fusion procedures short of the pelvis had the best survival rate, while UT-Pelvis with 3CO had the worst survival rate. Longer fusions and more invasive operations were associated with lower 2-year complication-free survival, however there were no significant associations between type of surgery and renal, cardiac, infection, wound, gastrointestinal, pulmonary, implant malposition or neurologic complications (all P>0.5). CONCLUSION This study suggests that there is an inherent increased risk of complication for some types of ASD surgery independent of patient profile. The results of this paper can be used to produce a surgery-adjusted benchmark for ASD surgery with regard to complications and survival. Such a tool can have very impactful applications for surgical decision making and more informed patient counseling.
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Affiliation(s)
- R Daniel Bass
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
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11
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Diebo BG, Alsoof D, Lafage R, Daher M, Balmaceno-Criss M, Passias PG, Ames CP, Shaffrey CI, Burton DC, Deviren V, Line BG, Soroceanu A, Hamilton DK, Klineberg EO, Mundis GM, Kim HJ, Gum JL, Smith JS, Uribe JS, Kebaish KM, Gupta MC, Nunley PD, Eastlack RK, Hostin R, Protopsaltis TS, Lenke LG, Hart RA, Schwab FJ, Bess S, Lafage V, Daniels AH. Impact of Self-Reported Loss of Balance and Gait Disturbance on Outcomes following Adult Spinal Deformity Surgery. J Clin Med 2024; 13:2202. [PMID: 38673475 PMCID: PMC11051140 DOI: 10.3390/jcm13082202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
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.
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Affiliation(s)
- Bassel G. Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
| | - Daniel Alsoof
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY 10075, USA; (R.L.); (F.J.S.); (V.L.)
| | - Mohammad Daher
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
| | - Mariah Balmaceno-Criss
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
| | - Peter G. Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY 10016, USA; (P.G.P.); (T.S.P.)
| | - Christopher P. Ames
- Department of Neurosurgery, University of California, San Francisco, CA 94115, USA; (C.P.A.); (V.D.)
| | | | - Douglas C. Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd., Kansas City, KS 66160, USA;
| | - Vedat Deviren
- Department of Neurosurgery, University of California, San Francisco, CA 94115, USA; (C.P.A.); (V.D.)
| | - Breton G. Line
- Denver International Spine Center, Denver, CO 80218, USA; (B.G.L.); (S.B.)
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - David Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Eric O. Klineberg
- Department of Orthopaedic Surgery, University of California, 1 Shields Ave., Davis, CA 95616, USA;
| | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY 10021, USA;
| | | | - Justin S. Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA 22903, USA;
| | - Juan S. Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA;
| | - Khaled M. Kebaish
- Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Munish C. Gupta
- Department of Orthopedics, Washington University in St Louis, St. Louis, MO 63110, USA;
| | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, 4708 Alliance Blvd #800, Plano, TX 75093, USA;
| | | | - Lawrence G. Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY 10032, USA;
| | | | - Frank J. Schwab
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY 10075, USA; (R.L.); (F.J.S.); (V.L.)
| | - Shay Bess
- Denver International Spine Center, Denver, CO 80218, USA; (B.G.L.); (S.B.)
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY 10075, USA; (R.L.); (F.J.S.); (V.L.)
| | - Alan H. Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI 02914, USA; (B.G.D.); (D.A.); (M.D.); (M.B.-C.)
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12
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Passias PG, Onafowokan OO, Tretiakov P, Williamson T, Kummer N, Mir J, Das A, Krol O, Passfall L, Joujon-Roche R, Imbo B, Yee T, Sciubba D, Paulino CB, Schoenfeld AJ, Smith JS, Lafage R, Lafage V. Highest Achievable Outcomes for Adult Spinal Deformity Corrective Surgery: Does Frailty Severity Exert a Ceiling Effect? Spine (Phila Pa 1976) 2024:00007632-990000000-00633. [PMID: 38595092 DOI: 10.1097/brs.0000000000004981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/27/2024] [Indexed: 04/11/2024]
Abstract
STUDY DESIGN Retrospective Single-Center Study. OBJECTIVE To assess the influence of frailty on optimal outcome following ASD corrective surgery. SUMMARY OF BACKGROUND DATA Frailty is a determining factor in outcomes after ASD surgery and may exert a ceiling effect on best possible outcome. METHODS ASD patients with frailty measures, baseline and 2-year ODI included. Frailty was classified as Not Frail (NF), Frail (F) and Severely Frail (SF) based on the modified Frailty Index, then stratified into quartiles based on 2-year ODI improvement (most improved designated "Highest"). Logistic regression analyzed relationships between frailty and ODI score and improvement, maintenance, or deterioration. A Kaplan-Meier survival curve was used to analyze differences in time to complication or reoperation. RESULTS 393 ASD patients were isolated (55.2% NF, 31.0% F, and 13.7% SF), then classified as 12.5% NF-Highest, 17.8% F-Highest, and 3.1% SF-Highest. The SF-group had the highest rate of deterioration (16.7%, P=0.025) at the second postoperative year but the groups were similar in improvement (NF: 10.1%, F: 11.5%, SF: 9.3%, P=0.886). Improvement of SF patients was greatest at 6 months (ΔODI of -22.6±18.0, P<0.001) but NF and F patients reached maximal ODI at 2 years (ΔODI of -15.7±17.9 and -20.5±18.4, respectively). SF patients initially showed the greatest improvement in ODI (NF: -4.8±19.0, F: -12.4±19.3, SF: -22.6±18.0 at 6 months, P<0.001). A Kaplan-Meier survival curve showed a trend of less time to major complication or reoperation by 2 years with increasing frailty (NF: 7.5±0.381 years, F: 6.7±0.511 years, SF: 5.8±0.757 years; P=0.113). CONCLUSIONS Increasing frailty had a negative effect on maximal improvement, where severely frail patients exhibited a parabolic effect with greater initial improvement due to higher baseline disability, but reached a ceiling effect with less overall maximal improvement. Severe frailty may exert a ceiling effect on improvement and impair maintenance of improvement following surgery. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Oluwatobi O Onafowokan
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Peter Tretiakov
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Tyler Williamson
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Nicholas Kummer
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Jamshaid Mir
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Ankita Das
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Oscar Krol
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Lara Passfall
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Rachel Joujon-Roche
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Bailey Imbo
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, USA
| | - Timothy Yee
- Department of Neurosurgery, University of California San Francisco, CA, USA
| | - Daniel Sciubba
- Department of Neurosurgery, Northwell Health, New York, NY, USA
| | - Carl B Paulino
- Department of Orthopedic Surgery, SUNY Downstate-University Hospital of Brooklyn, New York, NY, USA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
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Dave P, Lafage R, Smith JS, Line BG, Tretiakov PS, Mir J, Diebo B, Daniels AH, Gum JL, Hamilton DK, Buell T, Than KD, Fu KM, Scheer JK, Eastlack R, Mullin JP, Mundis G, Hosogane N, Yagi M, Nunley P, Chou D, Mummaneni PV, Klineberg EO, Kebaish KM, Lewis S, Hostin RA, Gupta MC, Kim HJ, Ames CP, Hart RA, Lenke LG, Shaffrey CI, Bess S, Schwab FJ, Lafage V, Burton DC, Passias PG. 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. J Neurosurg Spine 2024; 40:505-512. [PMID: 38215449 DOI: 10.3171/2023.11.spine23766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/13/2023] [Indexed: 01/14/2024]
Abstract
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.
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Affiliation(s)
- Pooja Dave
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Renaud Lafage
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton G Line
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Peter S Tretiakov
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Jamshaid Mir
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
| | - Bassel Diebo
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Alan H Daniels
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Jeffrey L Gum
- 6Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - D Kojo Hamilton
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Thomas Buell
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Khoi D Than
- 8Departments of Neurosurgery and Orthopaedic Surgery, Spine Division, Duke University School of Medicine, Durham, North Carolina
| | - Kai-Ming Fu
- 9Department of Neurological Surgery, Weill Cornell Medicine Brain and Spine Center/NewYork-Presbyterian Lower Manhattan Hospital, New York, New York
| | - Justin K Scheer
- 10Department of Neurosurgery, Columbia University, New York, New York
| | - Robert Eastlack
- 11Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Jeffrey P Mullin
- 12Department of Neurosurgery at University at Buffalo Medical School, Buffalo, New York
| | - Gregory Mundis
- 11Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Naobumi Hosogane
- 13Division of Orthopaedic Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Mitsuru Yagi
- 14Department of Orthopedic surgery, Keio University School of Medicine, Shinjyuku, Tokyo, Japan
- 26Department of Orthopedic Surgery, International University of Health and Welfare School of Medicine, Chiba, Narita, Japan
| | - Pierce Nunley
- 15Spine Institute of Louisiana, Shreveport, Louisiana
| | - Dean Chou
- 10Department of Neurosurgery, Columbia University, New York, New York
| | - Praveen V Mummaneni
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Eric O Klineberg
- 17Department of Orthopedic Surgery, University of California Davis, Sacramento, California
| | - Khaled M Kebaish
- 18Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Stephen Lewis
- 19Department of Surgery, Division of Neurosurgery, University of Toronto, Ontario, Canada
| | - Richard A Hostin
- 20Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas
| | - Munish C Gupta
- 21Department of Orthopaedic Surgery, Washington University of St. Louis, Missouri
| | - Han Jo Kim
- 2Department of Orthopaedics, Hospital for Special Surgery, New York, New York
| | - Christopher P Ames
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert A Hart
- 22Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Lawrence G Lenke
- 23Department of Orthopaedic Surgery, Columbia College of Physicians and Surgeons, New York, New York
| | - Christopher I Shaffrey
- 8Departments of Neurosurgery and Orthopaedic Surgery, Spine Division, Duke University School of Medicine, Durham, North Carolina
| | - Shay Bess
- 4Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Frank J Schwab
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Virginie Lafage
- 24Northwell Health, Department of Orthopedic Surgery, Lenox Hill Hospital, New York, New York
| | - Douglas C Burton
- 25Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Peter G Passias
- 1Departments of Orthopaedic and Neurosurgery, Division of Spinal Surgery, NYU Langone Medical Center, NY Spine Institute, New York, New York
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Ani F, Ayres EW, Soroceanu A, Mundis GM, Smith JS, Gum JL, Daniels AH, Klineberg EO, Ames CP, Bess S, Shaffrey CI, Schwab FJ, Lafage V, Protopsaltis TS. Functional Alignment Within the Fusion in Adult Spinal Deformity (ASD) Improves Outcomes and Minimizes Mechanical Failures. Spine (Phila Pa 1976) 2024; 49:405-411. [PMID: 37698284 DOI: 10.1097/brs.0000000000004828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/03/2023] [Indexed: 09/13/2023]
Abstract
STUDY DESIGN Retrospective review of an adult deformity database. OBJECTIVE To identify pelvic incidence (PI) and age-appropriate physical function alignment targets using a component angle of T1-pelvic angle within the fusion to define correction and their relationship to proximal junctional kyphosis (PJK) and clinical outcomes. SUMMARY OF BACKGROUND DATA In preoperative planning, a patient's PI is often utilized to determine the alignment target. In a trend toward more patient-specific planning, age-specific alignment has been shown to reduce the risk of mechanical failures. PI and age have not been analyzed with respect to defining a functional alignment. METHODS A database of patients with operative adult spinal deformity was analyzed. Patients fused to the pelvis and upper-instrumented vertebrae above T11 were included. Alignment within the fusion correlated with clinical outcomes and PI. Short form 36-Physical Component Score (SF36-PCS) normative data and PI were used to compute functional alignment for each patient. Overcorrected, under-corrected, and functionally corrected groups were determined using T10-pelvic angle (T10PA). RESULTS In all, 1052 patients met the inclusion criteria. T10PA correlated with SF36-PCS and PI (R=0.601). At six weeks, 40.7% were functionally corrected, 39.4% were overcorrected, and 20.9% were under-corrected. The PJK incidence rate was 13.6%. Overcorrected patients had the highest PJK rate (18.1%) compared with functionally (11.3%) and under-corrected (9.5%) patients ( P <0.05). Overcorrected patients had a trend toward more PJK revisions. All groups improved in HRQL; however, under-corrected patients had the worst 1-year SF36-PCS offset relative to normative patients of equivalent age (-8.1) versus functional (-6.1) and overcorrected (-4.5), P <0.05. CONCLUSIONS T10PA was used to determine functional alignment, an alignment based on PI and age-appropriate physical function. Correcting patients to functional alignment produced improvements in clinical outcomes, with the lowest rates of PJK. This patient-specific approach to spinal alignment provides adult spinal deformity correction targets that can be used intraoperatively.
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Affiliation(s)
- Fares Ani
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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Passias PG, Williamson TK, Joujon-Roche R, Krol O, Tretiakov P, Imbo B, Schoenfeld AJ, Owusu-Sarpong S, Lebovic J, Mir J, Dave P, McFarland K, Vira S, Diebo BG, Park P, Chou D, Smith JS, Lafage R, Lafage V. The Impact of Lumbopelvic Realignment Versus Prevention Strategies at the Upper-instrumented Vertebra on the Rates of Junctional Failure Following Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2024; 49:E72-E78. [PMID: 37235802 DOI: 10.1097/brs.0000000000004732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/06/2023] [Indexed: 05/28/2023]
Abstract
STUDY DESIGN/SETTING Retrospective. OBJECTIVE Evaluate the surgical technique that has the greatest influence on the rate of junctional failure following ASD surgery. SUMMARY OF BACKGROUND DATA Differing presentations of adult spinal deformity(ASD) may influence the extent of surgical intervention and the use of prophylaxis at the base or the summit of a fusion construct to influence junctional failure rates. MATERIALS AND METHODS ASD patients with two-year(2Y) data and at least 5-level fusion to the pelvis were included. Patients were divided based on UIV: [Longer Construct: T1-T4; Shorter Construct: T8-T12]. Parameters assessed included matching in age-adjusted PI-LL or PT, aligning in GAP-relative pelvic version or Lordosis Distribution Index. After assessing all lumbopelvic radiographic parameters, the combination of realigning the two parameters with the greatest minimizing effect of PJF constituted a good base. Good s was defined as having: (1) prophylaxis at UIV (tethers, hooks, cement), (2) no lordotic change(under-contouring) greater than 10° of the UIV, (3) preoperative UIV inclination angle<30°. Multivariable regression analysis assessed the effects of junction characteristics and radiographic correction individually and collectively on the development of PJK and PJF in differing construct lengths, adjusting for confounders. RESULTS In all, 261 patients were included. The cohort had lower odds of PJK(OR: 0.5,[0.2-0.9]; P =0.044) and PJF was less likely (OR: 0.1,[0.0-0.7]; P =0.014) in the presence of a good summit. Normalizing pelvic compensation had the greatest radiographic effect on preventing PJF overall (OR: 0.6,[0.3-1.0]; P =0.044). In shorter constructs, realignment had a greater effect on decreasing the odds of PJF(OR: 0.2,[0.02-0.9]; P =0.036). With longer constructs, a good summit lowered the likelihood of PJK(OR: 0.3,[0.1-0.9]; P =0.027). A good base led to zero occurrences of PJF. In patients with severe frailty/osteoporosis, a good summit lowered the incidence of PJK(OR: 0.4,[0.2-0.9]; P =0.041) and PJF (OR: 0.1,[0.01-0.99]; P =0.049). CONCLUSION To mitigate junctional failure, our study demonstrated the utility of individualizing surgical approaches to emphasize an optimal basal construct. Achievement of tailored goals at the cranial end of the surgical construct may be equally important, especially for higher-risk patients with longer fusions. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Oscar Krol
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Peter Tretiakov
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Bailey Imbo
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical Center, Boston, MA
| | | | - Jordan Lebovic
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Jamshaid Mir
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Pooja Dave
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Kimberly McFarland
- Division of Spinal Surgery,/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY
| | - Shaleen Vira
- Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Paul Park
- Department of Neurosurgery, Semmes-Murphey Clinic, Memphis, TN
| | - Dean Chou
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
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16
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Passias PG, Mir JM, Dave P, Smith JS, Lafage R, Gum J, Line BG, Diebo B, Daniels AH, Hamilton DK, Buell TJ, Scheer JK, Eastlack RK, Mullin JP, Mundis GM, Hosogane N, Yagi M, Schoenfeld AJ, Uribe JS, Anand N, Mummaneni PV, Chou D, Klineberg EO, Kebaish KM, Lewis SJ, Gupta MC, Kim HJ, Hart RA, Lenke LG, Ames CP, Shaffrey CI, Schwab FJ, Lafage V, Hostin RA, Bess S, Burton DC. Factors Associated with the Maintenance of Cost-Effectiveness at 5 Years in Adult Spinal Deformity Corrective Surgery. Spine (Phila Pa 1976) 2024:00007632-990000000-00613. [PMID: 38462731 DOI: 10.1097/brs.0000000000004982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/07/2024] [Indexed: 03/12/2024]
Abstract
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.
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Affiliation(s)
- Peter G Passias
- Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center; New York Spine Institute, New York, NY, USA
| | - Jamshaid M Mir
- Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center; New York Spine Institute, New York, NY, USA
| | - Pooja Dave
- Division of Spine Surgery, Departments of Orthopedic and Neurological Surgery, NYU Langone Medical Center; New York Spine Institute, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Renaud Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - David Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Jeffrey P Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Gregory M Mundis
- Division of Orthopedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Naobumi Hosogane
- Department of Orthopedic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Mitsuru Yagi
- Department of Orthopedic Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Stephen J Lewis
- Division of Orthopedics, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, MO, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Robert A Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, The Och Spine Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher I Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Richard A Hostin
- Department of Orthopedic Surgery, Southwest Scoliosis Institute, Dallas, TX, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
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Reynolds BD, Nagel HG, Perry E, Whittaker CJ, Caruso KA, Annear MJ, Irving WM, McCarthy PM, Dion A, Yi JMS, Hall E, Smith JS. Ophthalmic findings associated with Australian tick paralysis (holocyclotoxicity) in hospitalized domestic dogs and cats. Vet Ophthalmol 2024. [PMID: 38468143 DOI: 10.1111/vop.13205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 02/21/2024] [Accepted: 02/24/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVE To describe ophthalmic findings in hospitalized canine and feline patients with tick paralysis (TP) and investigate possible predisposing factors. ANIMALS STUDIED Forty-seven dogs and 28 cats hospitalized with TP assessed with an ophthalmic examination performed by an ABVO resident. METHODS Dogs and cats were hospitalized with TP from October 2021 to January 2022 and had an ophthalmic examination performed by an ABVO resident. Patient signalment data, information regarding tick number and location, hospitalization duration, medications used, and patient paralysis grades were recorded. Statistical analysis was performed to correlate findings. RESULTS Corneal ulcers developed in up to 34.8% of dogs and up to 42.9% of cats hospitalized with TP. An absent palpebral reflex ipsilaterally increased the odds of a concurrent corneal ulcer being present by 14.7× in dogs and 20.1× in cats (p < .0001). Palpebral reflexes were absent in 38.3% of dogs and 35.7% of cats hospitalized with TP and were correlated with more severe gait paralysis (p = .01) and respiratory paralysis (p = .005) in dogs, and respiratory paralysis in cats (p = .041). STT-1 findings <10 mm/min were present in 27.7% of dogs and 57.1% of cats examined and were associated with increasing gait paralysis (p = .017) and respiratory paralysis (p = .007) in dogs, and increasing gait paralysis in cats (p = .017). CONCLUSIONS Simple corneal ulcers, loss of a complete palpebral reflex, and reduced STT-1 scores frequently occurred in dogs and cats hospitalized for TP. The frequency of these findings increased as the degree of patient paralysis increased.
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Affiliation(s)
- B D Reynolds
- Eye Clinic for Animals, Sydney, New South Wales, Australia
| | - H G Nagel
- Terrey Hills Animal Hospital, Sydney, New South Wales, Australia
| | - E Perry
- Northside Emergency Veterinary Service, Sydney, New South Wales, Australia
| | - C J Whittaker
- Eye Clinic for Animals, Sydney, New South Wales, Australia
| | - K A Caruso
- Eye Clinic for Animals, Sydney, New South Wales, Australia
| | - M J Annear
- Eye Clinic for Animals, Sydney, New South Wales, Australia
| | - W M Irving
- Eye Clinic for Animals, Sydney, New South Wales, Australia
| | - P M McCarthy
- Eye Clinic for Animals, Sydney, New South Wales, Australia
| | - A Dion
- Northside Emergency Veterinary Service, Sydney, New South Wales, Australia
| | - J M S Yi
- Northside Emergency Veterinary Service, Sydney, New South Wales, Australia
| | - E Hall
- University of Sydney, Sydney, New South Wales, Australia
| | - J S Smith
- Eye Clinic for Animals, Sydney, New South Wales, Australia
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18
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Azad TD, Schwab FJ, Lafage V, Soroceanu A, Eastlack RK, Lafage R, Kebaish KM, Hart RA, Diebo B, Kelly MP, Smith JS, Daniels AH, Hamilton DK, Gupta M, Klineberg EO, Protopsaltis TS, Passias PG, Bess S, Gum JL, Hostin R, Lewis SJ, Shaffrey CI, Burton D, Lenke LG, Ames CP, Scheer JK. Stronger association of objective physical metrics with baseline patient-reported outcome measures than preoperative standing sagittal parameters for adult spinal deformity patients. J Neurosurg Spine 2024:1-8. [PMID: 38457811 DOI: 10.3171/2024.1.spine231030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/03/2024] [Indexed: 03/10/2024]
Abstract
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.
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Affiliation(s)
- Tej D Azad
- 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Frank J Schwab
- 2Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Virginie Lafage
- 2Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Alex Soroceanu
- 3Department of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Robert K Eastlack
- 4Department of Orthopedic Surgery, Scripps Clinic, San Diego, California
| | - Renaud Lafage
- 2Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Khaled M Kebaish
- 5Department of Orthopedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Hart
- 6Department of Orthopedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Bassel Diebo
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Michael P Kelly
- 8Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Justin S Smith
- 9Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Alan H Daniels
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - D Kojo Hamilton
- 10Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Munish Gupta
- 11Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Eric O Klineberg
- 12Department of Orthopedic Surgery, University of Texas Health Houston, Houston, Texas
| | | | - Peter G Passias
- 13Department of Orthopedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | - Shay Bess
- 14Presbyterian St. Luke's Medical Center, Denver, Colorado
| | | | - Richard Hostin
- 16Department of Orthopedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | - Stephen J Lewis
- 17Department of Surgery, Division of Orthopedic Surgery, University of Toronto, and Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Douglas Burton
- 19Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Lawrence G Lenke
- 20Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York; and
| | - Christopher P Ames
- 21Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Justin K Scheer
- 21Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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19
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Mullin JP, Soliman MAR, Smith JS, Kelly MP, Buell TJ, Diebo B, Scheer JK, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias PG, Gum JL, Kebaish K, Eastlack RK, Daniels AH, Soroceanu A, Mundis G, Hostin R, Protopsaltis TS, Hamilton DK, Gupta MC, Lewis SJ, Schwab FJ, Lenke LG, Shaffrey CI, Bess S, Ames CP, Burton D. Analysis of tranexamic acid usage in adult spinal deformity patients with relative contraindications: does it increase the risk of complications? J Neurosurg Spine 2024:1-8. [PMID: 38457792 DOI: 10.3171/2024.1.spine231098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/08/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE Complex spinal deformity surgeries may involve significant blood loss. The use of antifibrinolytic agents such as tranexamic acid (TXA) has been proven to reduce perioperative blood loss. However, for patients with a history of thromboembolic events, there is concern of increased risk when TXA is used during these surgeries. This study aimed to assess whether TXA use in patients undergoing complex spinal deformity correction surgeries increases the risk of thromboembolic complications based on preexisting thromboembolic risk factors. METHODS Data were analyzed for adult patients who received TXA during surgical correction for spinal deformity at 21 North American centers between August 2018 and October 2022. Patients with preexisting thromboembolic events and other risk factors (history of deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, peripheral vascular disease, or cancer) were identified. Thromboembolic complication rates were assessed during the postoperative 90 days. Univariate and multivariate analyses were performed to assess thromboembolic outcomes in high-risk and low-risk patients who received intravenous TXA. RESULTS Among 411 consecutive patients who underwent complex spinal deformity surgery and received TXA intraoperatively, 130 (31.6%) were considered high-risk patients. There was no significant difference in thromboembolic complications between patients with and those without preexisting thromboembolic risk factors in univariate analysis (high-risk group vs low-risk group: 8.5% vs 2.8%, p = 0.45). Specifically, there were no significant differences between groups regarding the 90-day postoperative rates of DVT (high-risk group vs low-risk group: 1.5% vs 1.4%, p = 0.98), PE (2.3% vs 1.8%, p = 0.71), acute MI (1.5% vs 0%, p = 0.19), or stroke (0.8% vs 1.1%, p > 0.99). On multivariate analysis, high-risk status was not a significant independent predictor for any of the thromboembolic complications. CONCLUSIONS Administration of intravenous TXA during the correction procedure did not change rates of thromboembolic events, acute MI, or stroke in this cohort of adult spinal deformity surgery patients.
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Affiliation(s)
- Jeffrey P Mullin
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York
- 2Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, New York
| | - Mohamed A R Soliman
- 1Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences at University at Buffalo, Buffalo, New York
- 3Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Justin S Smith
- 4Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Michael P Kelly
- 5Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California
| | - Thomas J Buell
- 6Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bassel Diebo
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Justin K Scheer
- 8Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Breton Line
- 9Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Virginie Lafage
- 10Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Renaud Lafage
- 10Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Eric Klineberg
- 11Department of Orthopedic Surgery, University of Texas Health Houston, Houston, Texas
| | - Han Jo Kim
- 12Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Peter G Passias
- 13Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | - Khaled Kebaish
- 15Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Robert K Eastlack
- 16Department of Orthopedic Surgery, Scripps Clinic, San Diego, California
| | - Alan H Daniels
- 7Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Alex Soroceanu
- 17Department of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gregory Mundis
- 16Department of Orthopedic Surgery, Scripps Clinic, San Diego, California
| | - Richard Hostin
- 18Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | | | - D Kojo Hamilton
- 6Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Munish C Gupta
- 19Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Stephen J Lewis
- 20Department of Surgery, Division of Orthopedic Surgery, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Frank J Schwab
- 10Department of Orthopedic Surgery, Lennox Hill Hospital, New York, New York
| | - Lawrence G Lenke
- 21Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Christopher I Shaffrey
- 22Departments of Neurosurgery and Orthopedic Surgery, Spine Division, Duke University, Durham, North Carolina; and
| | - Shay Bess
- 9Presbyterian St. Luke's Medical Center, Denver, Colorado
| | - Christopher P Ames
- 8Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Douglas Burton
- 23Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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20
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Daniels AH, Daher M, Singh M, Balmaceno-Criss M, Lafage R, Diebo BG, Hamilton DK, Smith JS, Eastlack RK, Fessler RG, Gum JL, Gupta MC, Hostin R, Kebaish KM, Klineberg EO, Lewis SJ, Line BG, Nunley PD, Mundis GM, Passias PG, Protopsaltis TS, Buell T, Scheer JK, Mullin JP, Soroceanu A, Ames CP, Lenke LG, Bess S, Shaffrey CI, Burton DC, Lafage V, Schwab FJ. 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. Spine (Phila Pa 1976) 2024; 49:313-320. [PMID: 37942794 DOI: 10.1097/brs.0000000000004873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/25/2023] [Indexed: 11/10/2023]
Abstract
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.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Mohammad Daher
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Manjot Singh
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Mariah Balmaceno-Criss
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - Renaud Lafage
- Department of Orthopedic Surgery, Northwell, New York, NY
| | - Bassel G Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, East Providence, RI
| | - David K Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin S Smith
- University of Virginia Health System, Charlottesville, VA
| | | | - Richard G Fessler
- Department of Neurological Surgery, Rush University Medical School, Chicago, IL
| | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX
| | | | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA
| | - Stephen J Lewis
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Canada
| | | | | | | | - Peter G Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | | | - Thomas Buell
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, CA
| | | | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, Canada
| | | | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, The Spine Hospital at New York Presbyterian, New York, NY
| | - Shay Bess
- Denver International Spine Center, Denver, CO
| | | | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | | | - Frank J Schwab
- Department of Orthopedic Surgery, Northwell, New York, NY
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21
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Reynolds BD, Annear MJ, Caruso KA, Whittaker CJ, Irving WM, McCarthy PM, Smith JS. Feline distichiasis treated with cryoepilation: A retrospective study of 15 cats (27 eyes). Vet Ophthalmol 2024. [PMID: 38424032 DOI: 10.1111/vop.13202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 02/07/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVE To describe the clinical features of cats diagnosed with distichiasis and report on the outcomes following cryoepilation. ANIMALS STUDIED Fifteen cats (27 eyes). PROCEDURES Medical records of domestic cats with distichiasis that underwent a double freeze-thaw cycle with a -80°C cryoprobe applied to the palpebral conjunctiva, with hair then epilated were retrospectively studied. The patient signalment, distichiae locations, concurrent ocular diseases, recurrences, complications, and outcomes were recorded. RESULTS The mean (std dev) age at the time of diagnosis and treatment was 2.2 years (2.8 years). All (15/15) cats were of the domestic shorthair (DSH) breed. Concurrent ocular findings at the initial examination were observed in 17/27 (63%) eyes, with upper lateral eyelid hypoplasia the most prevalent, present in 9/27 (33.3%) eyes. Recurrence of distichiae occurred in 8/27 (29.6%) eyes. The clinical presentation in the instances of recurrence was judged as asymptomatic and not of a clinical concern in 3/27 (11.1%) eyes, with a second procedure deemed necessary to alleviate symptoms in 5/27 (18.5%) eyes. All eyes treated with a second procedure had no recurrence of distichiae or symptoms. Complications following cryoepilation occurred in 4/27 (14.8%) eyes, with two cats developing bilateral entropion post-procedure. CONCLUSIONS Treatment of distichiasis in cats utilizing cryoepilation was effective at alleviating symptoms, though some cats needed a second procedure. The development of post-procedural entropion was seen occasionally.
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Affiliation(s)
- B D Reynolds
- Eye Clinic for Animals, Artarmon, New South Wales, Australia
| | - M J Annear
- Eye Clinic for Animals, Artarmon, New South Wales, Australia
| | - K A Caruso
- Eye Clinic for Animals, Artarmon, New South Wales, Australia
| | - C J Whittaker
- Eye Clinic for Animals, Artarmon, New South Wales, Australia
| | - W M Irving
- Eye Clinic for Animals, Artarmon, New South Wales, Australia
| | - P M McCarthy
- Eye Clinic for Animals, Artarmon, New South Wales, Australia
| | - J S Smith
- Eye Clinic for Animals, Artarmon, New South Wales, Australia
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22
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Lafage R, Bass RD, Klineberg E, Smith JS, Bess S, Shaffrey C, Burton DC, Kim HJ, Eastlack R, Mundis G, Ames CP, Passias PG, Gupta M, Hostin R, Hamilton K, Schwab F, Lafage V. Complication Rates Following Adult Spinal Deformity Surgery: Evaluation of the Category of Complication and Chronology. Spine (Phila Pa 1976) 2024:00007632-990000000-00600. [PMID: 38375636 DOI: 10.1097/brs.0000000000004969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 02/12/2024] [Indexed: 02/21/2024]
Abstract
OBJECTIVE Provide benchmarks for the rates of complications by type and timing. STUDY DESIGN Prospective multicenter database. BACKGROUND Complication rates following adult spinal deformity (ASD) surgery have been previously reported. However, the interplay between timing and complication type warrants further analysis. METHODS The data for this study were sourced from a prospective, multicenter ASD database. Date and type of complication were collected and classified into three severity groups (minor, major, major leading to reoperation). Only complications occurring before the 2-year visit were retained for analysis. RESULTS Of the 1260 patients eligible for 2-year follow-up, 997 (79.1%) achieved 2-year follow-up. The overall complication rate was 67.4% (N=672). 247 patients (24.8%) experienced at least one complication on the day of surgery (including intra-operatively), 359 (36.0%) between post-op day 1 and 6 weeks post-op, 271 (27.2%) between 6 weeks and 1 one -year post-op, and finally 162 (16.3%) between 1 year and 2 years post-op. Using Kaplan-Meier survival analysis, the rate of remaining complication-free was estimated at different time points for different severities and types of complications. Stratification by type of complication demonstrated that most of the medical complications occurred within the first 60 days. Surgical complications presented over two distinct timeframes. Operative complications, incision-related complications, and infections occurred early (within 60 d), while implant-related and radiographic complications occurred at a constant rate over the 2-year follow-up period. Neurologic complications had the highest occurrence within the first 60 days but continued to increase up to the 2-year visit. CONCLUSION Only one-third of ASD patients remained complication-free by 2 years, and 2 out of 10 patients had a complication requiring a reoperation or revision. Estimation of timing and type of complication associated with surgical treatment may prove useful for more meaningful patient counseling and aid in assessing the cost-effectiveness of treatment.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - R Daniel Bass
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | | | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, CA
| | - Christopher P Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Peter G Passias
- Departments of Orthopedic Surgery, NYU Langone, New York, NY
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO
| | | | - Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
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23
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Reynolds BD, Perry E, Nagel HG, Whittaker CJ, Caruso KA, Annear MJ, Irving WM, McCarthy PM, Dion A, Yi JS, Hall E, Smith JS. Retrospective assessment of ophthalmic disease development in domestic dogs and cats when hospitalised with tick paralysis caused by Ixodes holocyclus. Aust Vet J 2024. [PMID: 38369322 DOI: 10.1111/avj.13325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/19/2023] [Accepted: 01/21/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To investigate the incidence and predisposing factors leading to the development of corneal ulcers and the loss of a palpebral reflex in hospitalised canine and feline patients with tick paralysis (TP). ANIMALS STUDIED A total of 102 dogs and 100 cats retrospectively were assessed from previously hospitalised patients. METHODS A retrospective cohort study was performed on 102 different canine and 100 different feline patients who were hospitalised for TP from October 2020-January 2022. Patient data were collected, and logistic regression was conducted to determine factors affecting the palpebral reflex and the development of corneal ulcers. RESULTS Corneal ulcers occurred in 23/102 (22.5%) dogs during hospitalisation and were strongly associated with an incomplete palpebral reflex ipsilaterally during hospitalisation (P < 0.001), hospitalisation ≥3 days (P = 0.004), mechanical ventilation ≥3 days (P = 0.015) or a tick location cranial to C1 (P = 0.003). An incomplete palpebral reflex during hospitalisation was observed in 29/102 (28.4%) dogs and was significantly associated with decreasing patient weight (P = 0.018), increasing days hospitalised (P = 0.001), having a tick found cranial to C1 (P = 0.004), highest recorded GP grade (P = 0.01), highest recorded RP grade (P = 0.005), use of amoxycillin-clavulanic acid during hospitalisation (P = 0.002) and use of piperacillin/tazobactam during hospitalisation (P = 0.003). There was a significant association between the loss of a complete palpebral reflex and mortality during hospitalisation in dogs (OR = 4.5, P = 0.029). Corneal ulcers occurred in 10/100 (10.0%) cats during hospitalisation, and was significantly more likely to occur to an eye if an incomplete palpebral reflex was observed ipsilaterally during hospitalisation (OR = 20.1, P < 0.0001) and with increasing patient age (P = 0.019). The absence of a complete palpebral reflex during hospitalisation was observed in 18/10 (18.0%) cats and was significantly associated with increasing days hospitalised (P = 0.034). There was no significant association between the loss of a complete palpebral reflex and mortality during hospitalisation in cats. CONCLUSIONS The frequency of corneal ulcers and loss of palpebral reflexes were significant in dogs and cats hospitalised by TP, with many factors contributing to the risk of these developing.
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Affiliation(s)
- B D Reynolds
- Eye Clinic for Animals, Sydney, New South Wales, 2064, Australia
| | - E Perry
- Northside Emergency Veterinary Service, Sydney, New South Wales, 2084, Australia
| | - H G Nagel
- Terrey Hills Animal Hospital, Sydney, New South Wales, 2084, Australia
| | - C J Whittaker
- Eye Clinic for Animals, Sydney, New South Wales, 2064, Australia
| | - K A Caruso
- Eye Clinic for Animals, Sydney, New South Wales, 2064, Australia
| | - M J Annear
- Eye Clinic for Animals, Sydney, New South Wales, 2064, Australia
| | - W M Irving
- Eye Clinic for Animals, Sydney, New South Wales, 2064, Australia
| | - P M McCarthy
- Eye Clinic for Animals, Sydney, New South Wales, 2064, Australia
| | - A Dion
- Northside Emergency Veterinary Service, Sydney, New South Wales, 2084, Australia
| | - Jm-S Yi
- Northside Emergency Veterinary Service, Sydney, New South Wales, 2084, Australia
| | - E Hall
- University of Sydney, Sydney, New South Wales, 2006, Australia
| | - J S Smith
- Eye Clinic for Animals, Sydney, New South Wales, 2064, Australia
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24
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Williamson TK, Dave P, Mir JM, Smith JS, Lafage R, Line B, Diebo BG, Daniels AH, Gum JL, Protopsaltis TS, Hamilton DK, Soroceanu A, Scheer JK, Eastlack R, Kelly MP, Nunley P, Kebaish KM, Lewis S, Lenke LG, Hostin RA, Gupta MC, Kim HJ, Ames CP, Hart RA, Burton DC, Shaffrey CI, Klineberg EO, Schwab FJ, Lafage V, Chou D, Fu KM, Bess S, Passias PG. Persistent Lower Extremity Compensation for Sagittal Imbalance After Surgical Correction of Complex Adult Spinal Deformity: A Radiographic Analysis of Early Impact. Oper Neurosurg (Hagerstown) 2024; 26:156-164. [PMID: 38227826 DOI: 10.1227/ons.0000000000000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/06/2023] [Indexed: 01/18/2024] Open
Abstract
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.
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Affiliation(s)
- Tyler K Williamson
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
| | - Pooja Dave
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
| | - Jamshaid M Mir
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, New York, USA
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky, USA
| | | | - D Kojo Hamilton
- Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA
| | - Pierce Nunley
- Spine Institute of Louisiana, Shreveport, Louisiana, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Stephen Lewis
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia College of Physicians and Surgeons, New York, New York, USA
| | - Richard A Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University of St Louis, St Louis, Missouri, USA
| | - Han Jo Kim
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher I Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, California, USA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medicine Brain and Spine Center, New York, New York, USA
| | - Shay Bess
- Department of Orthopaedics, Hospital for Special Surgery, New York, New York, USA
| | - Peter G Passias
- Departments of Orthopaedic and Neurological Surgery, NYU Langone Orthopaedic Hospital, New York Spine Institute, New York, New York, USA
- Rocky Mountain Scoliosis and Spine, Denver, Colorado, USA
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Passias PG, Pierce KE, Williamson TK, Lebovic J, Schoenfeld AJ, Lafage R, Lafage V, Gum JL, Eastlack R, Kim HJ, Klineberg EO, Daniels AH, Protopsaltis TS, Mundis GM, Scheer JK, Park P, Chou D, Line B, Hart RA, Burton DC, Bess S, Schwab FJ, Shaffrey CI, Smith JS, Ames CP. Patient-specific Cervical Deformity Corrections With Consideration of Associated Risk: Establishment of Risk Benefit Thresholds for Invasiveness Based on Deformity and Frailty Severity. Clin Spine Surg 2024; 37:E43-E51. [PMID: 37798829 DOI: 10.1097/bsd.0000000000001540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 08/10/2023] [Indexed: 10/07/2023]
Abstract
STUDY DESIGN/SETTING This was a retrospective cohort study. BACKGROUND Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty. OBJECTIVE The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity. METHODS This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely. RESULTS A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P =0.002], and invasiveness increased with deformity severity ( P <0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P =0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P =0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P =0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group. CONCLUSIONS Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Katherine E Pierce
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Tyler K Williamson
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Jordan Lebovic
- Division of Spinal Surgery/Department of Orthopaedic and Neurosurgery, NYU Langone Medical Center; NY Spine Institute, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY
| | - Robert Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California-Davis, Davis, CA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Justin K Scheer
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
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Lovecchio F, Lafage R, Kim HJ, Bess S, Ames C, Gupta M, Passias P, Klineberg E, Mundis G, Burton D, Smith JS, Shaffrey C, Schwab F, Lafage V. Revision-Free Loss of Sagittal Correction Greater Than Three Years After Adult Spinal Deformity Surgery: Who and Why? Spine (Phila Pa 1976) 2024; 49:157-164. [PMID: 37847773 DOI: 10.1097/brs.0000000000004852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/15/2022] [Indexed: 10/19/2023]
Abstract
STUDY DESIGN Multicenter retrospective cohort study. OBJECTIVE To investigate risk factors for loss of correction within the instrumented lumbar spine after adult spinal deformity surgery. SUMMARY OF BACKGROUND DATA The sustainability of adult spinal deformity surgery remains a health care challenge. Malalignment is a major reason for revision surgery. PATIENTS AND METHODS A total of 321 patients who underwent fusion of the lumbar spine (≥5 levels, LIV pelvis) with a revision-free follow-up of ≥3 years were identified. Patients were stratified by a change in pelvic incidence-lumbar lordosis from 6 weeks to 3 years postoperative as "maintained" versus "loss" >5°. Those with instrumentation failure (broken rod, screw pullout, etc .) were excluded before comparisons. Demographics, surgical data, and radiographic alignment were compared. Repeated measure analysis of variance was performed to evaluate the maintenance of the correction for L1-L4 and L4-S1. Multivariate logistic regression was conducted to identify independent surgical predictors of correction loss. RESULTS The cohort had a mean age of 64 years, a mean Body Mass Index of 28 kg/m 2 , and 80% females. Eighty-two patients (25.5%) lost >5° of pelvic incidence-lumbar lordosis correction (mean loss 10±5°). After the exclusion of patients with instrumentation failure, 52 losses were compared with 222 maintained. Demographics, osteotomies, 3CO, interbody fusion, use of bone morphogenetic protein, rod material, rod diameter, and fusion length were not significantly different. L1-S1 screw orientation angle was 1.3 ± 4.1 from early postoperative to 3 years ( P = 0.031), but not appreciably different at L4-S1 (-0.1 ± 2.9 P = 0.97). Lack of a supplemental rod (odds ratio: 4.0, P = 0.005) and fusion length (odds ratio 2.2, P = 0.004) were associated with loss of correction. CONCLUSIONS Approximately, a quarter of revision-free patients lose an average of 10° of their 6-week correction by 3 years. Lordosis is lost proximally through the instrumentation ( i.e. tulip/shank angle shifts and/or rod bending). The use of supplemental rods and avoiding sagittal overcorrection may help mitigate this loss.
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Affiliation(s)
- Francis Lovecchio
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Han Jo Kim
- Department of Spine Surgery, Hospital for Special Surgery, New York, NY
| | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center/Presbyterian St. Luke's Medical Center, Denver, CO
| | - Christopher Ames
- Department of Neurosurgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University School of Medicine, St Louis, IL
| | - Peter Passias
- Department of Orthopedic Surgery, NYU Hospital for Joint Diseases-Langone Medical Center, New York, NY
| | - Eric Klineberg
- Department of Orthopedic Surgery, The University of Texas Health Science Center of Houston, Houston, TX
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, La Jolla, CA
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Christopher Shaffrey
- Department of Neurosurgery and Orthopedic Surgery, University of Virginia Medical Center, Charlottesville, VA
| | - Frank Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
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27
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Diebo BG, Balmaceno-Criss M, Lafage R, Daher M, Singh M, Hamilton DK, Smith JS, Eastlack RK, Fessler R, Gum JL, Gupta MC, Hostin R, Kebaish KM, Lewis S, Line BG, Nunley PD, Mundis GM, Passias PG, Protopsaltis TS, Turner J, Buell T, Scheer JK, Mullin J, Soroceanu A, Ames CP, Bess S, Shaffrey CI, Lenke LG, Schwab FJ, Lafage V, Burton DC, Daniels AH. Lumbar Lordosis Redistribution and Segmental Correction in Adult Spinal Deformity (ASD): Does it Matter? Spine (Phila Pa 1976) 2024:00007632-990000000-00569. [PMID: 38270393 DOI: 10.1097/brs.0000000000004930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 01/01/2024] [Indexed: 01/26/2024]
Abstract
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.
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Affiliation(s)
- Bassel G Diebo
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mariah Balmaceno-Criss
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Mohammad Daher
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Manjot Singh
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Robert K Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | | | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, Kentucky
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, Missouri
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas
| | - Khaled M Kebaish
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen Lewis
- Department of Orthopedics, University of Toronto, Toronto, Canada
| | - Breton G Line
- Department of Spine Surgery, Denver International Spine Center, Denver, Colorado
| | | | - Gregory M Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | | | - Jay Turner
- Barrow Brain and Spine, Phoenix, Arizona
| | - Thomas Buell
- Department of Neurological Surgery, University of Pittsburgh
| | - Justin K Scheer
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Jeffery Mullin
- Department of Neurosurgery, University of Buffalo, Amherst, New York, New York
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Canada
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Denver, Colorado
| | | | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Passias PG, Passfall L, Moattari K, Krol O, Kummer NA, Tretiakov P, Williamson T, Joujon-Roche R, Imbo B, Burhan Janjua M, Jankowski P, Paulino C, Schwab FJ, Owusu-Sarpong S, Singh V, Ahmad S, Onafowokan T, Lebovic J, Tariq M, Saleh H, Vira S, Smith JS, Diebo B, Schoenfeld AJ. Factors Influencing Maintenance of Alignment and Functional Improvement Following Adult Spinal Deformity Surgery: A 3-Year Outcome Analysis. Spine (Phila Pa 1976) 2024; 49:90-96. [PMID: 37199423 DOI: 10.1097/brs.0000000000004717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/07/2022] [Indexed: 05/19/2023]
Abstract
STUDY DESIGN This was a retrospective review. OBJECTIVE To assess the factors contributing to durability of surgical results following adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND Factors contributing to the long-term sustainability of ASD correction are currently undefined. MATERIALS AND METHODS Operative ASD patients with preoperatively (baseline) and 3-year postoperatively radiographic/health-related quality of life data were included. At 1 and 3 years postoperatively, a favorable outcome was defined as meeting at least three of four criteria: (1) no proximal junctional failure or mechanical failure with reoperation, (2) best clinical outcome (BCO) for Scoliosis Research Society (SRS) (≥4.5) or Oswestry Disability Index (ODI) (<15), (3) improving in at least one SRS-Schwab modifier, and (4) not worsening in any SRS-Schwab modifier. A robust surgical result was defined as having a favorable outcome at both 1 and 3 years. Predictors of robust outcomes were identified using multivariable regression analysis with conditional inference tree for continuous variables. RESULTS We included 157 ASD patients in this analysis. At 1 year postoperatively, 62 patients (39.5%) met the BCO definition for ODI and 33 (21.0%) met the BCO for SRS. At 3 years, 58 patients (36.9%) had BCO for ODI and 29 (18.5%) for SRS. Ninety-five patients (60.5%) were identified as having a favorable outcome at 1 year postoperatively. At 3 years, 85 patients (54.1%) had a favorable outcome. Seventy-eight patients (49.7%) met criteria for a durable surgical result. Multivariable adjusted analysis identified the following independent predictors of surgical durability: surgical invasiveness >65, being fused to S1/pelvis, baseline to 6-week pelvic incidence and lumbar lordosis difference >13.9°, and having a proportional Global Alignment and Proportion score at 6 weeks. CONCLUSIONS Nearly 50% of the ASD cohort demonstrated good surgical durability, with favorable radiographic alignment and functional status maintained up to 3 years. Surgical durability was more likely in patients whose reconstruction was fused to the pelvis and addressed lumbopelvic mismatch with adequate surgical invasiveness to achieve full alignment correction.
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Affiliation(s)
- Peter G Passias
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Lara Passfall
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Kevin Moattari
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Oscar Krol
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Nicholas A Kummer
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Peter Tretiakov
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Tyler Williamson
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Rachel Joujon-Roche
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Bailey Imbo
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | | | - Pawel Jankowski
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Carl Paulino
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | | | - Vivek Singh
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Salman Ahmad
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Tobi Onafowokan
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Jordan Lebovic
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Muhammad Tariq
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Hesham Saleh
- Department of Neurological Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach
| | - Shaleen Vira
- Departments of Orthopaedic and Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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29
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Passias PG, Naessig S, Williamson TK, Lafage R, Lafage V, Smith JS, Gupta MC, Klineberg E, Burton DC, Ames C, Bess S, Shaffrey C, Schwab FJ. Compensation from mild and severe cases of early proximal junctional kyphosis may manifest as progressive cervical deformity at two year follow-up. Spine Deform 2024; 12:221-229. [PMID: 38041769 DOI: 10.1007/s43390-023-00763-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/29/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Postoperative reciprocal changes (RC) in the cervical spine associated with varying factors of proximal junctional kyphosis (PJK) following fusions of the thoracopelvic spine are poorly understood. PURPOSE Explore reciprocal changes in the cervical spine associated with varying factors (severity, progression, patient age) of PJK in patients undergoing adult spinal deformity (ASD) correction. PATIENTS AND METHODS Retrospective review of a multicenter ASD database. INCLUSION ASD patients > 18 y/o, undergoing fusions from the thoracic spine (UIV: T6-T12) to the pelvis with two-year radiographic data. ASD was defined as: Coronal Cobb angle ≥ 20°, Sagittal Vertical Axis ≥ 5 cm, Pelvic Tilt ≥ 25°, and/or Thoracic Kyphosis ≥ 60°. PJK was defined as a ≥ 10° measure of the sagittal Cobb angle between the inferior endplate of the UIV and the superior endplate of the UIV + 2. Patients were grouped by mild (M; 10°-20°) and severe (S; > 20°) PJK at one year. Propensity Score Matching (PSM) controlled for CCI, age, PI and UIV. Unpaired and paired t test analyses determined difference between RC parameters and change between time points. Pearson bi-variate correlations analyzed associations between RC parameters (T4-T12, TS-CL, cSVA, C2-Slope, and T1-Slope) and PJK descriptors. RESULTS 284 ASD patients (UIV: T6: 1.1%; T7: 0.7%; T8: 4.6%; T9: 9.9%; T10: 58.8%; T11: 19.4%; T12: 5.6%) were studied. PJK analysis consisted of 182 patients (Mild = 91 and Severe = 91). Significant difference between M and S groups were observed in T4-T12 Δ1Y(- 16.8 v - 22.8, P = 0.001), TS-CLΔ1Y(- 0.6 v 2.8, P = 0.037), cSVAΔ1Y(- 1.8 v 1.9, P = 0.032), and C2 slopeΔ1Y(- 1.6 v 2.3, P = 0.022). By two years post-op, all changes in cervical alignment parameters were similar between mild and severe groups. Correlation between age and cSVAΔ1Y(R = 0.153, P = 0.034) was found. Incidence of severe PJK was found to correlate with TS-CLΔ1Y(R = 0.142, P = 0.049), cSVAΔ1Y(R = 0.171, P = 0.018), C2SΔ1Y(R = 0.148, P = 0.040), and T1SΔ2Y(R = 0.256, P = 0.003). CONCLUSIONS Compensation within the cervical spine differed between individuals with mild and severe PJK at one year postoperatively. However, similar levels of pathologic change in cervical alignment parameters were seen by two years, highlighting the progression of cervical compensation due to mild PJK over time. These findings provide greater evidence for the development of cervical deformity in individuals presenting with proximal junctional kyphosis.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA.
| | - Sara Naessig
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA
| | - Tyler K Williamson
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | | | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine, Denver, CO, USA
| | | | - Frank J Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY, USA
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Passias PG, Ahmad W, Williamson TK, Lebovic J, Kebaish K, Lafage R, Lafage V, Line B, Schoenfeld AJ, Diebo BG, Klineberg EO, Kim HJ, Ames CP, Daniels AH, Smith JS, Shaffrey CI, Burton DC, Hart RA, Bess S, Schwab FJ, Gupta MC. Efficacy of Varying Surgical Approaches on Achieving Optimal Alignment in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976) 2024; 49:22-28. [PMID: 37493057 DOI: 10.1097/brs.0000000000004784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/21/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND The Roussouly, SRS-Schwab, and Global Alignment and Proportion (GAP) classifications define alignment by spinal shape and deformity severity. The efficacy of different surgical approaches and techniques to successfully achieve these goals is not well understood. PURPOSE Identify the impact of surgical approach and/or technique on meeting complex realignment goals in adult spinal deformity (ASD) corrective surgery. STUDY DESIGN/SETTING Retrospective study. MATERIALS AND METHODS Included patients with ASD fused to pelvis with 2-year data. Patients were categorized by: (1) Roussouly: matching current and theoretical spinal shapes, (2) improving in SRS-Schwab modifiers (0, +, ++), and (3) improving GAP proportionality by 2 years. Analysis of covariance and multivariable logistic regression analyses controlling for age, levels fused, baseline deformity, and 3-column osteotomy usage compared the effect of different surgical approaches, interbody, and osteotomy use on meeting realignment goals. RESULTS A total of 693 patients with ASD were included. By surgical approach, 65.7% were posterior-only and 34.3% underwent anterior-posterior approach with 76% receiving an osteotomy (21.8% 3-column osteotomy). By 2 years, 34% matched Roussouly, 58% improved in GAP, 45% in SRS-Schwab pelvic tilt (PT), 62% sagittal vertical axis, and 70% pelvic incidence-lumbar lordosis. Combined approaches were most effective for improvement in PT [odds ratio (OR): 1.7 (1.1-2.5)] and GAP [OR: 2.2 (1.5-3.2)]. Specifically, anterior lumbar interbody fusion (ALIF) below L3 demonstrated higher rates of improvement versus TLIFs in Roussouly [OR: 1.7 (1.1-2.5)] and GAP [OR: 1.9 (1.3-2.7)]. Patients undergoing pedicle subtraction osteotomy at L3 or L4 were more likely to improve in PT [OR: 2.0 (1.0-5.2)] and pelvic incidence-lumbar lordosis [OR: 3.8 (1.4-9.8)]. Clinically, patients undergoing the combined approach demonstrated higher rates of meeting SCB in Oswestry Disability Index by 2 years while minimizing rates of proximal junctional failure, most often with an ALIF at L5-S1 [Oswestry Disability Index-SCB: OR: 1.4 (1.1-2.0); proximal junctional failure: OR: 0.4 (0.2-0.8)]. CONCLUSIONS Among patients undergoing ASD realignment, optimal lumbar shape and proportion can be achieved more often with a combined approach. Although TLIFs, incorporating a 3-column osteotomy, at L3 and L4 can restore lordosis and normalize pelvic compensation, ALIFs at L5-S1 were most likely to achieve complex realignment goals with an added clinical benefit and mitigation of junctional failure.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital and New York Spine Institute, New York, NY
| | - Waleed Ahmad
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital and New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital and New York Spine Institute, New York, NY
| | - Jordan Lebovic
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
| | - Khaled Kebaish
- Department of Orthopedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Bassel G Diebo
- Department of Orthopedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Alan H Daniels
- Department of Orthopedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Christopher I Shaffrey
- Departments of Neurosurgery and Orthopedic Surgery, Spine Division, Duke University School of Medicine, Durham, NC
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Robert A Hart
- Department of Orthopedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Frank J Schwab
- Department of Orthopedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Munish C Gupta
- Department of Orthopedic Surgery, Washington University, St. Louis, MO
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McCarthy MH, Lafage R, Smith JS, Bess S, Ames CP, Klineberg EO, Kim HJ, Shaffrey CI, Burton DC, Mundis GM, Gupta MC, Schwab FJ, Lafage V. How Much Lumbar Lordosis does a Patient Need to Reach their Age-Adjusted Alignment Target? A Formulated Approach Predicting Successful Surgical Outcomes. Global Spine J 2024; 14:41-48. [PMID: 35442842 PMCID: PMC10676150 DOI: 10.1177/21925682221092003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Identify optimal lumbar lordosis in adult deformity correction to achieve age-adjusted targets and sustained alignment. METHODS Surgical adult spinal deformity patients reaching an age-adjusted ideal alignment at one year were identified. Multilinear regression analysis was used to identify the relationship between regional curvatures (LL and TK) that enabled achievement of a given global alignment (T1 pelvic angle, TPA) based on pelvic incidence (PI). RESULTS 347 patients out of 1048 available reached their age-adjusted TPA within 5° (60-year-old, 72% women, body mass index 29 ± 6.2). They had a significant improvement in all sagittal parameters (except PI) from pre-operative baseline to 1 year following surgery (P < .001). Multilinear regression predicting L1-S1 based on TK, TPA, and PI demonstrated excellent results (R2 = .85). Simplification of the coefficients of prediction combined with a conversion to an age-based formula led to the following: LL = PI - 0.3TK - 0.5Age + 10. Internal validation of the formula led to a mean error of -.4°, and an absolute error of 5.0°. Internal validation on patients with an age-adjusted alignment revealed similar accuracy across the entire age-adjusted TPA spectrum (ranges of LL errors: ME = .2° to 1.7°, AE = 4.0° to 5.3°). CONCLUSION This study provides a simple guideline to identify the amount of LL needed to reach a given alignment (i.e., age-adjusted target) based on PI and associated TK. Implementation of this predictive formula during pre-operative surgical planning may help to reduce unexpected sub-optimal post-operative alignment outcomes.
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Affiliation(s)
- Michael H. McCarthy
- Indiana Spine Group, Carmel, IN, USA; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | - Christopher P. Ames
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | - Eric O. Klineberg
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Han J. Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | | | - Douglas C. Burton
- Department of Orthopaedic Surgery, The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Manish C. Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | - Frank J. Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - International Spine Study Group (ISSG)
- Indiana Spine Group, Carmel, IN, USA; Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
- Denver International Spine Center, Denver, CO, USA
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, CA, USA
- Department of Orthopaedic Surgery, Duke University, Durham, NC, USA
- Department of Orthopaedic Surgery, The University of Kansas Medical Center, Kansas City, KS, USA
- San Diego Center for Spinal Disorders, La Jolla, CA, USA
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
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Jackson-Fowl B, Hockley A, Naessig S, Ahmad W, Pierce K, Smith JS, Ames C, Shaffrey C, Bennett-Caso C, Williamson TK, McFarland K, Passias PG. Adult cervical spine deformity: a state-of-the-art review. Spine Deform 2024; 12:3-23. [PMID: 37776420 DOI: 10.1007/s43390-023-00735-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 07/01/2023] [Indexed: 10/02/2023]
Abstract
Adult cervical deformity is a structural malalignment of the cervical spine that may present with variety of significant symptomatology for patients. There are clear and substantial negative impacts of cervical spine deformity, including the increased burden of pain, limited mobility and functionality, and interference with patients' ability to work and perform everyday tasks. Primary cervical deformities develop as the result of a multitude of different etiologies, changing the normal mechanics and structure of the cervical region. In particular, degeneration of the cervical spine, inflammatory arthritides and neuromuscular changes are significant players in the development of disease. Additionally, cervical deformities, sometimes iatrogenically, may present secondary to malalignment or correction of the thoracic, lumbar or sacropelvic spine. Previously, classification systems were developed to help quantify disease burden and influence management of thoracic and lumbar spine deformities. Following up on these works and based on the relationship between the cervical and distal spine, Ames-ISSG developed a framework for a standardized tool for characterizing and quantifying cervical spine deformities. When surgical intervention is required to correct a cervical deformity, there are advantages and disadvantages to both anterior and posterior approaches. A stepwise approach may minimize the drawbacks of either an anterior or posterior approach alone, and patients should have a surgical plan tailored specifically to their cervical deformity based upon symptomatic and radiographic indications. This state-of-the-art review is based upon a comprehensive overview of literature seeking to highlight the normal cervical spine, etiologies of cervical deformity, current classification systems, and key surgical techniques.
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Affiliation(s)
- Brendan Jackson-Fowl
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Aaron Hockley
- Department of Neurosurgery, University of Alberta, Edmonton, AB, USA
| | - Sara Naessig
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Waleed Ahmad
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Katherine Pierce
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Christopher Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Claudia Bennett-Caso
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Tyler K Williamson
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Kimberly McFarland
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA
| | - Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, 301 East 17th St, New York, NY, 10003, USA.
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Ani F, Protopsaltis TS, Parekh Y, Odeh K, Lafage R, Smith JS, Eastlack RK, Lenke L, Schwab F, Mundis GM, Gupta MC, Klineberg EO, Lafage V, Hart R, Burton D, Ames CP, Shaffrey CI, Bess S. Determining the best vertebra for measuring pelvic incidence and spinopelvic parameters in adult spinal deformity patients with transitional anatomy. J Neurosurg Spine 2024; 40:92-98. [PMID: 37862715 DOI: 10.3171/2023.8.spine23432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/08/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE The aim of this study was to determine if spinal deformity patients with L5 sacralization should have pelvic incidence (PI) and other spinopelvic parameters measured from the L5 or S1 endplate. METHODS This study was a multicenter retrospective comparative cohort study comprising a large database of adult spinal deformity (ASD) patients and a database of asymptomatic individuals. Linear regression modeling was used to determine normative T1 pelvic angle (TPA) and PI - lumbar lordosis (LL) mismatch (PI-LL) based on PI and age in a database of asymptomatic subjects. In an ASD database, patients with radiographic evidence of L5 sacralization had the PI, LL, and TPA measured from the superior endplate of S1 and then also from L5. The differences in TPA and PI-LL from normative were calculated in the sacralization cohort relative to L5 and S1 and correlated to the Oswestry Disability Index (ODI). Patients were grouped based on the Scoliosis Research Society (SRS)-Schwab PI-LL modifier (0, +, or ++) using the L5 PI-LL and S1 PI-LL. Baseline ODI and SF-36 Physical Component Summary (PCS) scores were compared across and within groups. RESULTS Among 1179 ASD patients, 276 (23.4%) had transitional anatomy, 176 with sacralized L5 (14.9%) and 100 (8.48%) with lumbarization of S1. The 176 patients with sacralized L5 were analyzed. When measured using the L5 superior endplate, pelvic parameters were significantly smaller than those measured relative to S1 (PI: 24.5° ± 11.0° vs 55.7° ± 12.0°, p = 0.001;TPA: 11.2° ± 12.0° vs 20.3° ± 12.5°, p = 0.001; and PI-LL: 0.67° ± 21.1° vs 11.4° ± 20.8°, p = 0.001). When measured from S1, 76 (43%), 45 (25.6%), and 55 (31.3%) patients had SRS-Schwab PI-LL modifiers of 0, +, and ++, respectively, compared with 124 (70.5%), 22 (12.5%), and 30 (17.0%), respectively, when measured from L5. There were significant differences in ODI and PCS scores as the SRS-Schwab grade increased regardless of L5 or S1 measurement. The L5 group had lower PCS functional scores for SRS-Schwab modifiers 0 and ++ relative to same grades in the S1 group. Offset from normative TPA (0.5° ± 11.1° vs 9.6° ± 10.8°, p = 0.001) and PI-LL (4.5° ± 20.4° vs 15.2° ± 19.3°, p = 0.001) were smaller when measuring from L5. Moreover, S1 measurements were more correlated with health status by ODI (TPA offset from normative: S1, R = 0.326 vs L5, R = 0.285; PI-LL offset from normative: S1, R = 0.318 vs L5, R = 0.274). CONCLUSIONS Measuring the PI and spinopelvic parameters at L5 in sacralized anatomy results in underestimating spinal deformity and is less correlated with health-related quality of life. Surgeons may consider measuring PI and spinopelvic parameters relative to S1 rather than at L5 in patients with a sacralized L5.
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Affiliation(s)
- Fares Ani
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | | | - Yesha Parekh
- 2Department of Orthopedic Surgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Khalid Odeh
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Renaud Lafage
- 3Department of Orthopedic Surgery, Lenox Hill, Northwell Health, New York, New York
| | - Justin S Smith
- 4Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert K Eastlack
- 5Department of Orthopedic Surgery, Scripps Memorial Hospital, La Jolla, California
| | - Lawrence Lenke
- 6Department of Orthopedic Surgery, Columbia University, New York, New York
| | - Frank Schwab
- 3Department of Orthopedic Surgery, Lenox Hill, Northwell Health, New York, New York
| | - Gregory M Mundis
- 5Department of Orthopedic Surgery, Scripps Memorial Hospital, La Jolla, California
| | - Munish C Gupta
- 7Department of Orthopedic Surgery, Washington University in St. Louis, Missouri
| | - Eric O Klineberg
- 8Department of Orthopedic Surgery, University of California, Davis, California
| | - Virginie Lafage
- 3Department of Orthopedic Surgery, Lenox Hill, Northwell Health, New York, New York
| | - Robert Hart
- 9Department of Orthopedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Douglas Burton
- 10Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher P Ames
- 11Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Shay Bess
- 13Department of Spine Surgery, Denver International Spine Center, Denver, Colorado
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Passias PG, Williamson TK, Kummer NA, Pellisé F, Lafage V, Lafage R, Serra-Burriel M, Smith JS, Line B, Vira S, Gum JL, Haddad S, Sánchez Pérez-Grueso FJ, Schoenfeld AJ, Daniels AH, Chou D, Klineberg EO, Gupta MC, Kebaish KM, Kelly MP, Hart RA, Burton DC, Kleinstück F, Obeid I, Shaffrey CI, Alanay A, Ames CP, Schwab FJ, Hostin RA, Bess S. Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery. Global Spine J 2023:21925682231212966. [PMID: 38081300 DOI: 10.1177/21925682231212966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
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.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, NY, NY, USA
| | - Tyler K Williamson
- Department of Orthopaedic Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Nicholas A Kummer
- Departments of Orthopedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, NY, NY, USA
| | - Ferran Pellisé
- Spine Surgery Unit, Vall d'Hebron Hospital, Barcelona, Spain
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, New York, NY, USA
| | - Renaud Lafage
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Miguel Serra-Burriel
- Center for Research in Health and Economics, Universitat Pompeu Fabra, Barcelona, Spain
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Breton Line
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Shaleen Vira
- Department of Orthopedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Sleiman Haddad
- Spine Surgery Unit, Vall d'Hebron Hospital, Barcelona, Spain
| | | | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California Davis, Sacramento, CA, USA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri, USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael P Kelly
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Robert A Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Frank Kleinstück
- Spine Center Division, Department of Orthopedics and Neurosurgery, Schulthess Klinik, Zürich, Switzerland
| | - Ibrahim Obeid
- Spine Surgery Unit, Bordeaux University Hospital, Bordeaux, France
| | - Christopher I Shaffrey
- Spine Division, Departments of Neurosurgery and Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acıbadem University, Istanbul, Turkey
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, New York, NY, USA
| | - Richard A Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
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Ye J, Gupta S, Farooqi AS, Yin T, Soroceanu A, Schwab FJ, Lafage V, Kelly MP, Kebaish K, Hostin R, Gum JL, Smith JS, Shaffrey CI, Scheer JK, Protopsaltis TS, Passias PG, Klineberg EO, Kim HJ, Hart RA, Hamilton DK, Ames CP, Gupta MC. Predictive role of global spinopelvic alignment and upper instrumented vertebra level in symptomatic proximal junctional kyphosis in adult spinal deformity. J Neurosurg Spine 2023; 39:774-784. [PMID: 37542446 DOI: 10.3171/2023.6.spine23383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/06/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVE The authors of this study sought to evaluate the predictive role of global sagittal alignment and upper instrumented vertebra (UIV) level in symptomatic proximal junctional kyphosis (PJK) among patients with adult spinal deformity (ASD). METHODS Data on ASD patients who had undergone fusion of ≥ 5 vertebrae from 2008 to 2018 and with a minimum follow-up of 1 year were obtained from a prospectively collected multicenter database and evaluated (n = 1312). Radiographs were obtained preoperatively and at 6 weeks, 6 months, 1 year, 2 years, and 3 years postoperatively. The 22-Item Scoliosis Research Society Patient Questionnaire Revised (SRS-22r) scores were collected preoperatively, 1 year postoperatively, and 2 years postoperatively. Symptomatic PJK was defined as a kyphotic increase > 20° in the Cobb angle from the UIV to the UIV+2. At 6 weeks postoperatively, sagittal parameters were evaluated and patients were categorized by global alignment and proportion (GAP) score/category and SRS-Schwab sagittal modifiers. Patients were stratified by UIV level: upper thoracic (UT) UIV ≥ T8 or lower thoracic (LT) UIV ≤ T9. RESULTS Patients who developed symptomatic PJK (n = 260) had worse 1-year postoperative SRS-22r mental health (3.70 vs 3.86) and total (3.56 vs 3.67) scores, as well as worse 2-year postoperative self-image (3.45 vs 3.65) and satisfaction (4.03 vs 4.22) scores (all p ≤ 0.04). In the whole study cohort, patients with PJK had less pelvic incidence-lumbar lordosis (PI-LL) mismatch (-0.24° vs 3.29°, p < 0.001) but no difference in their GAP score/category or SRS-Schwab sagittal modifiers compared with the patients without PJK. Regression showed a higher risk of PJK with a pelvic tilt (PT) grade ++ (OR 2.35) and less risk with a PI-LL grade ++ (OR 0.35; both p < 0.01). When specifically analyzing the LT UIV cohort, patients with PJK had a higher GAP score (5.66 vs 4.79), greater PT (23.02° vs 20.90°), and less PI-LL mismatch (1.61° vs 4.45°; all p ≤ 0.02). PJK patients were less likely to be proportioned postoperatively (17.6% vs 30.0%, p = 0.015), and regression demonstrated a greater PJK risk with severe disproportion (OR 1.98) and a PT grade ++ (OR 3.15) but less risk with a PI-LL grade ++ (OR 0.45; all p ≤ 0.01). When specifically evaluating the UT UIV cohort, the PJK patients had less PI-LL mismatch (-2.11° vs 1.45°) but no difference in their GAP score/category. Regression showed a greater PJK risk with a PT grade + (OR 1.58) and a decreased risk with a PI-LL grade ++ (OR 0.21; both p < 0.05). CONCLUSIONS Symptomatic PJK leads to worse patient-reported outcomes and is associated with less postoperative PI-LL mismatch and greater postoperative PT. A worse postoperative GAP score and disproportion are only predictive of symptomatic PJK in patients with an LT UIV.
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Affiliation(s)
- Jichao Ye
- 1Department of Orthopaedic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Sachin Gupta
- 2Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali S Farooqi
- 2Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tsung Yin
- 3Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Alex Soroceanu
- 4University of Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
| | - Frank J Schwab
- 5Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
| | - Virginie Lafage
- 5Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, New York
| | - Michael P Kelly
- 7Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Khaled Kebaish
- 8Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Richard Hostin
- 9Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Dallas, Texas
| | - Jeffrey L Gum
- 10Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, Kentucky
| | - Justin S Smith
- 11Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | | | - Justin K Scheer
- 13Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | | | - Peter G Passias
- 14Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Eric O Klineberg
- 15Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Han Jo Kim
- 6Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Robert A Hart
- 16Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington; and
| | - D Kojo Hamilton
- 17Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher P Ames
- 13Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Munish C Gupta
- 7Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
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Passias PG, Ahmad W, Dave P, Lafage R, Lafage V, Mir J, Klineberg EO, Kabeish KM, Gum JL, Line BG, Hart R, Burton D, Smith JS, Ames CP, Shaffrey CI, Schwab F, Hostin R, Buell T, Hamilton DK, Bess S. Economic burden of nonoperative treatment of adult spinal deformity. J Neurosurg Spine 2023; 39:751-756. [PMID: 37728175 DOI: 10.3171/2023.7.spine23195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/24/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate the cost utility of nonoperative treatment for adult spinal deformity (ASD). METHODS Nonoperatively and operatively treated patients who met database criteria for ASD and in whom complete radiographic and health-related quality of life data at baseline and at 2 years were available were included. A cost analysis was completed on the PearlDiver database assessing the average cost of nonoperative treatment prior to surgical intervention based on previously published treatments (NSAIDs, narcotics, muscle relaxants, epidural steroid injections, physical therapy, and chiropractor). Utility data were calculated using the Oswestry Disability Index (ODI) converted to SF-6D with published conversion methods. Quality-adjusted life years (QALYs) used a 3% discount rate to account for residual decline in life expectancy (78.7 years). Minor and major comorbidities and complications were assessed according to the CMS.gov manual's definitions. Successful nonoperative treatment was defined as a gain in the minimum clinically importance difference (MCID) in both ODI and Scoliosis Research Society (SRS)-pain scores, and failure was defined as a loss in MCID or conversion to operative treatment. Patients with baseline ODI ≤ 20 and continued ODI of ≤ 20 at 2 years were considered nonoperative successful maintenance. The average utilization of nonoperative treatment and cost were applied to the ASD cohort. RESULTS A total of 824 patients were included (mean age 58.24 years, 81% female, mean body mass index 27.2 kg/m2). Overall, 75.5% of patients were in the operative and 24.5% were in the nonoperative cohort. At baseline patients in the operative cohort were significantly older, had a greater body mass index, increased pelvic tilt, and increased pelvic incidence-lumbar lordosis mismatch (all p < 0.05). With respect to deformity, patients in the operative group had higher rates of severe (i.e., ++) sagittal deformity according to SRS-Schwab modifiers for pelvic tilt, sagittal vertical axis, and pelvic incidence-lumbar lordosis mismatch (p < 0.05). At 2 years, patients in the operative cohort showed significantly increased rates of a gain in MCID for physical component summary of SF-36, ODI, and SRS-activity, SRS-pain, SRS-appearance, and SRS-mental scores. Cost analysis showed the average cost of nonoperative treatment 2 years prior to surgical intervention to be $2041. Overall, at 2 years patients in the nonoperative cohort had again in ODI of 0.36, did not show a gain in QALYs, and nonoperative treatment was determined to be cost-ineffective. However, a subset of patients in this cohort underwent successful maintenance treatment and had a decrease in ODI of 1.1 and a gain in utility of 0.006 at 2 years. If utility gained for this cohort was sustained to full life expectancy, patients' cost per QALY was $18,934 compared to a cost per QALY gained of $70,690.79 for posterior-only and $48,273.49 for combined approach in patients in the operative cohort. CONCLUSIONS Patients with ASD undergoing operative treatment at baseline had greater sagittal deformity and greater improvement in health-related quality of life postoperatively compared to patients treated nonoperatively. Additionally, patients in the nonoperative cohort overall had an increase in ODI and did not show improvement in utility gained. Patients in the nonoperative cohort who had low disability and sagittal deformity underwent successful maintenance and cost-effective treatment.
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Affiliation(s)
- Peter G Passias
- 1Departments of Orthopaedic and Neurologic Surgery, Division of Spine, NYU Langone Medical Center; New York Spine Institute, New York, New York
| | - Waleed Ahmad
- 1Departments of Orthopaedic and Neurologic Surgery, Division of Spine, NYU Langone Medical Center; New York Spine Institute, New York, New York
| | - Pooja Dave
- 1Departments of Orthopaedic and Neurologic Surgery, Division of Spine, NYU Langone Medical Center; New York Spine Institute, New York, New York
| | - Renaud Lafage
- 2Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- 2Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Jamshaid Mir
- 1Departments of Orthopaedic and Neurologic Surgery, Division of Spine, NYU Langone Medical Center; New York Spine Institute, New York, New York
| | - Eric O Klineberg
- 3Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Khaled M Kabeish
- 4Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Jeffrey L Gum
- 5Norton Leatherman Spine Center, Louisville, Kentucky
| | - Breton G Line
- 6Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Robert Hart
- 7Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Douglas Burton
- 8Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Justin S Smith
- 9Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Christopher P Ames
- 8Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher I Shaffrey
- 10Department of Neurological Surgery, University of California, San Francisco, California
| | - Frank Schwab
- 2Department of Orthopedics, Hospital for Special Surgery, New York, New York
| | - Richard Hostin
- 11Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas; and
| | - Thomas Buell
- 12Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - D Kojo Hamilton
- 12Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shay Bess
- 6Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
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Protopsaltis TS, Ani F, Soroceanu A, Lafage R, Kim HJ, Balouch E, Norris Z, Smith JS, Daniels AH, Klineberg EO, Ames CP, Hart R, Bess S, Shaffrey CI, Schwab FJ, Lenke LG, Lafage V, Gupta MC. Clinical outcomes and proximal junctional failure in adult spinal deformity patients corrected to normative alignment versus functional alignment. J Neurosurg Spine 2023; 39:757-764. [PMID: 37503890 DOI: 10.3171/2023.5.spine221266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 05/19/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE The objective of this study was to explore the rate of proximal junctional failure (PJF) and functional outcomes of normative alignment goals compared with alignment targets based on age-appropriate physical function. METHODS Baseline relationships between age, pelvic incidence (PI), and a component of the T1 pelvic angle (TPA) within the fusion were analyzed in adult spinal deformity (ASD) patients and compared with those of asymptomatic patients. Linear regression modeling was used to determine alignment based on PI and age in asymptomatic patients (normative alignment), and in ASD patients, alignment corresponding to age-appropriate functional status (functional alignment). A cohort of 288 ASD patients was split into two groups based on whether the patient was closer to their normative or functional alignment goal at their 6-week postoperative radiographic follow-up. The rates of proximal junctional kyphosis (PJK) and PJF were determined for each cohort. RESULTS In the 288 ASD patients included in this pre- to postoperative analysis, there was no difference in baseline alignment or health-related quality of life (HRQOL) between the normative alignment and functional alignment groups. At 6 weeks, patients with normative alignment had a smaller TPA (4.45° vs 14.1°) and PI minus lumbar lordosis (-7.24° vs 7.4°) (both p < 0.0001) and higher PJK (40% vs 27.2%, p = 0.03) and PJF (17% vs 6.8%, p = 0.008) rates than patients with functional alignment. CONCLUSIONS Correction in ASD patients to normative alignment resulted in higher rates of PJK and PJF without improvements in HRQOL. Correction in ASD patients to functional alignment that mirrors the physical function of their age-matched asymptomatic peers is recommended.
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Affiliation(s)
| | - Fares Ani
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | | | - Renaud Lafage
- 3Department of Orthopedic Surgery, Northwell Health, New York, New York
| | - Han Jo Kim
- 4Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eaman Balouch
- 1Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Zoe Norris
- 5Department of Orthopedic Surgery, George Washington University, Washington, DC
| | - Justin S Smith
- 6Department of Neurological Surgery, University of Virginia Health, Charlottesville, Virginia
| | - Alan H Daniels
- 7Department of Orthopedic Surgery, Brown University, East Providence, Rhode Island
| | - Eric O Klineberg
- 8Department of Orthopedic Surgery, University of California, Davis, California
| | - Christopher P Ames
- 9Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert Hart
- 10Department of Orthopedic Surgery, Swedish Medical Center, Seattle, Washington
| | - Shay Bess
- 11Department of Spine Surgery, Denver International Spine Center, Denver, Colorado
| | | | - Frank J Schwab
- 3Department of Orthopedic Surgery, Northwell Health, New York, New York
| | - Lawrence G Lenke
- 13Department of Orthopedic Surgery, Columbia University, New York, New York; and
| | - Virginie Lafage
- 3Department of Orthopedic Surgery, Northwell Health, New York, New York
| | - Munish C Gupta
- 14Department of Orthopedic Surgery, Washington University in St. Louis, Missouri
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Passfall L, Imbo B, Lafage V, Lafage R, Smith JS, Line B, Schoenfeld AJ, Protopsaltis T, Daniels AH, Kebaish KM, Gum JL, Koller H, Hamilton DK, Hostin R, Gupta M, Anand N, Ames CP, Hart R, Burton D, Schwab FJ, Shaffrey CI, Klineberg EO, Kim HJ, Bess S, Passias PG. The impact of baseline cervical malalignment on the development of proximal junctional kyphosis following surgical correction of thoracolumbar adult spinal deformity. J Neurosurg Spine 2023; 39:742-750. [PMID: 37503903 DOI: 10.3171/2023.5.spine22752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 05/09/2023] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Lara Passfall
- 1Division of Spine Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York, New York
| | - Bailey Imbo
- 1Division of Spine Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York, New York
| | - Virginie Lafage
- 2Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Renaud Lafage
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- 4Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Breton Line
- 5Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Andrew J Schoenfeld
- 6Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, Massachusetts
| | | | - Alan H Daniels
- 8Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Khaled M Kebaish
- 9Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Jeffrey L Gum
- 10Norton Leatherman Spine Center, Louisville, Kentucky
| | - Heiko Koller
- 11Department of Neurosurgery, Technical University of Munich (TUM), Klinikum Rechts Der Isar, Munich, Germany
- 21Department for Traumatology and Sports Injuries, Paracelsus Medical University, Salzburg, Austria
| | - D Kojo Hamilton
- 12Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Richard Hostin
- 13Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas
| | - Munish Gupta
- 14Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Neel Anand
- 15Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, California
| | - Christopher P Ames
- 16Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert Hart
- 17Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Douglas Burton
- 18Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Frank J Schwab
- 2Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Christopher I Shaffrey
- 19Division of Spine Surgery, Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Eric O Klineberg
- 20Department of Orthopaedic Surgery, University of California, Davis, California; and
| | - Han Jo Kim
- 3Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- 5Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's, Rocky Mountain Hospital for Children, Denver, Colorado
| | - Peter G Passias
- 1Division of Spine Surgery, Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, New York Spine Institute, New York, New York
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Lafage R, Song J, Diebo B, Daniels AH, Passias PG, Ames CP, Bess S, Eastlack R, Gupta MC, Hostin R, Kebaish K, Kim HJ, Klineberg E, Mundis GM, Smith JS, Shaffrey C, Schwab F, Lafage V, Burton D. Alterations in Magnitude and Shape of Thoracic Kyphosis Following Surgical Correction for Adult Spinal Deformity. Global Spine J 2023:21925682231218003. [PMID: 38031967 DOI: 10.1177/21925682231218003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
STUDY DESIGN Retrospective review of prospective multicenter data. OBJECTIVES This study aimed to investigate the shape of TK before and after fusion in ASD patients treated with long fusion. METHODS ASD patients undergoing posterior spinal fusions including at least T5 to L1 without prior fusion extending to the thoracic spine were included. Patients were categorized based on the preoperative T1-T12 kyphosis into: Hypo-TK (if < 30°), Normal-TK, and Hyper-TK (if > 70°). Regional kyphosis at T10-L1 (Distal), T5-T10 (Middle), and T1-T5 (Proximal) and their relative contributions to total kyphosis were compared between groups, and the pre-to postoperative changes were investigated using paired t test. RESULTS In total, 329 patients were included in this analysis (mean age: 57 ± 16 years, 79.6% female). Preoperative T1-T12 TK for the entire cohort was 40.9 ± 2° (32% Hypo-TK, 11% Hyper-TK, 57% Normal-TK). The Hypo-TK group had the smallest distal TK (5.9 vs 17.1 & 26.0), and middle TK (8.0 vs 25.3 & 45.4), but the percentage of contribution to total kyphosis was not significantly different (Distal: 24.1% vs 34.1% vs 32.8%; Middle: 46.6% vs 53.9% vs 56.8%, all P > .1). Postoperatively, T1-12 TK increased significantly (40.9 ± 2.0° vs 57.8 ± 17.6°). Each group had a decrease in distal kyphosis (Hypo-TK 2.6 ± 10.4°; Normal-TK 8.9 ± 11.5°; Hyper-TK 14.9 ± 12°, all P < .05). The middle kyphosis significantly decreased for Hyper-TK (11.8 ± 12.4) and increased for both Normal-TK and Hypo-TK (3.8 ± 11° and 14.2 ± 11°). Proximal TK increased significantly for all groups by 14-18°. Deterioration from Normal-TK to Hyper-TK postoperatively was associated with lower rate of patient satisfaction (59.6% vs 77.3%, P = .032). CONCLUSIONS Posterior spinal fusion for ASD alters the magnitude and shape of thoracic kyphosis. While 60% of patients had a normal TK at baseline, 30% of those patients developed iatrogenic hyperkyphosis postoperatively. Patients with baseline hypokyphosis were more likely to be corrected to normal TK than hyperkyphotic patients. Future research should investigate TK restoration in ASD and its impact on clinical outcomes and complications.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Junho Song
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Christopher P Ames
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Shay Bess
- Denver International Spine Center, Denver, CO, USA
| | | | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | | | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY, USA
| | - Eric Klineberg
- Department of Orthopaedic surgery, University of Texas Health, Houston, TX
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Frank Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Douglas Burton
- Department of Orthopedic Surgery and Sports Medicine, University of Kansas Medical Center, Kansas, KS, USA
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Smith JS, Mundis GM, Osorio JA, Nicolau RJ, Temple-Wong M, Lafage R, Bess S, Ames CP. Analysis of Personalized Interbody Implants in the Surgical Treatment of Adult Spinal Deformity. Global Spine J 2023:21925682231216926. [PMID: 38124314 DOI: 10.1177/21925682231216926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
STUDY DESIGN Multicenter cohort. OBJECTIVES A report from the International Spine Study Group (ISSG) noted that surgeons failed to achieve alignment goals in nearly two-thirds of 266 complex adult deformity surgery (CADS) cases. We assess whether personalized interbody spacers are associated with improved rates of achieving goal alignment following adult spinal deformity (ASD) surgery. METHODS ASD patients were included if their surgery utilized 3D-printed personalized interbody spacer(s) and they met ISSG CADS inclusion criteria. Planned alignment was personalized by the surgeon during interbody planning. Planned vs achieved alignment was assessed and compared with the ISSG CADS series that used stock interbodies. RESULTS For 65 patients with personalized interbodies, 62% were women, mean age was 70.3 years (SD = 8.3), mean instrumented levels was 9.9 (SD = 4.1), and the mean number of personalized interbodies per patient was 2.2 (SD = .8). Segmental alignment was achieved close to plan for levels with personalized interbodies, with mean difference between goal and achieved as follows: intervertebral lordosis = .9° (SD = 5.2°), intervertebral coronal angle = .1° (SD = 4.7°), and posterior disc height = -0.1 mm (SD = 2.3 mm). Achieved pelvic incidence-to-lumbar lordosis mismatch (PI-LL) correlated significantly with goal PI-LL (r = .668, P < .001). Compared with the ISSG CADS cohort, utilization of personalized interbodies resulted in significant improvement in achieving PI-LL <5° of plan (P = .046) and showed a significant reduction in cases with PI-LL >15° of plan (P = .012). CONCLUSIONS This study supports use of personalized interbodies as a means of better achieving goal segmental sagittal and coronal alignment and significantly improving achievement of goal PI-LL compared with stock devices.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Gregory M Mundis
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, CA, USA
| | - Joseph A Osorio
- Department of Neurological Surgery, University of California, San Diego, San Diego, CA, USA
| | | | | | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Shay Bess
- Presbyterian St Lukes Medical Center, Denver, CO, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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Passias PG, Krol O, Williamson TK, Lafage V, Lafage R, Smith JS, Line B, Vira S, Lipa S, Daniels A, Diebo B, Schoenfeld A, Gum J, Kebaish K, Park P, Mundis G, Hostin R, Gupta MC, Eastlack R, Anand N, Ames C, Hart R, Burton D, Schwab FJ, Shaffrey C, Klineberg E, Bess S. The Benefit of Addressing Malalignment in Revision Surgery for Proximal Junctional Kyphosis Following ASD Surgery. Spine (Phila Pa 1976) 2023; 48:1581-1587. [PMID: 36083599 DOI: 10.1097/brs.0000000000004476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/23/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Understand the benefit of addressing malalignment in revision surgery for proximal junctional kyphosis (PJK). SUMMARY OF BACKGROUND DATA PJK is a common cause of revision surgery for adult spinal deformity patients. During a revision, surgeons may elect to perform a proximal extension of the fusion, or also correct the source of the lumbopelvic mismatch. MATERIALS AND METHODS Recurrent PJK following revision surgery was the primary outcome. Revision surgical strategy was the primary predictor (proximal extension of fusion alone compared with combined sagittal correction and proximal extension). Multivariable logistic regression determined rates of recurrent PJK between the two surgical groups with lumbopelvic surgical correction assessed through improving ideal alignment in one or more alignment criteria [Global Alignment and Proportionality (GAP), Roussouly-type, and Sagittal Age-Adjusted Score (SAAS)]. RESULTS A total of 151 patients underwent revision surgery for PJK. PJK occurred at a rate of 43.0%, and PJF at 12.6%. Patients proportioned in GAP postrevision had lower rates of recurrent PJK [23% vs. 42%; odds ratio (OR): 0.3, 95% confidence interval (CI): 0.1-0.8, P =0.024]. Following adjusted analysis, patients who were ideally aligned in one of three criteria (Matching in SAAS and/or Roussouly matched and/or achieved GAP proportionality) had lower rates of recurrent PJK (36% vs. 53%; OR: 0.4, 95% CI: 0.1-0.9, P =0.035) and recurrent PJF (OR: 0.1, 95% CI: 0.02-0.7, P =0.015). Patients ideally aligned in two of three criteria avoid any development of PJF (0% vs. 16%, P <0.001). CONCLUSIONS Following revision surgery for PJK, patients with persistent poor sagittal alignment showed increased rates of recurrent PJK compared with patients who had abnormal lumbopelvic alignment corrected during the revision. These findings suggest addressing the root cause of surgical failure in addition to proximal extension of the fusion may be beneficial.
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Affiliation(s)
- Peter G Passias
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Oscar Krol
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Tyler K Williamson
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Shaleen Vira
- Department of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, TX
| | - Shaina Lipa
- Department of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Alan Daniels
- Department of Orthopedics, Brown University, Warren Alpert Medical School, Providence, RI
| | - Bassel Diebo
- Department of Orthopedic Surgery, SUNY Downstate, New York, NY
| | - Andrew Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Center for Surgery and Public Health, Boston, MA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville, KY
| | - Khaled Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, MD
| | - Paul Park
- Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, TX
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO
| | - Robert Eastlack
- Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, CA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Lenox Hill, Northwell Health, New York, NY
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
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Smith JS, Kelly MP, Buell TJ, Ben-Israel D, Diebo B, Scheer JK, Line B, Lafage V, Lafage R, Klineberg E, Kim HJ, Passias P, Gum JL, Kebaish K, Mullin JP, Eastlack R, Daniels A, Soroceanu A, Mundis G, Hostin R, Protopsaltis TS, Hamilton DK, Gupta M, Lewis SJ, Schwab FJ, Lenke LG, Shaffrey CI, Burton D, Ames CP, Bess S. Adult Cervical Deformity Patients Have Higher Baseline Frailty, Disability, and Comorbidities Compared With Complex Adult Thoracolumbar Deformity Patients: A Comparative Cohort Study of 616 Patients. Global Spine J 2023:21925682231214059. [PMID: 37948666 DOI: 10.1177/21925682231214059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
STUDY DESIGN Multicenter comparative cohort. OBJECTIVE Studies have shown markedly higher rates of complications and all-cause mortality following surgery for adult cervical deformity (ACD) compared with adult thoracolumbar deformity (ATLD), though the reasons for these differences remain unclear. Our objectives were to compare baseline frailty, disability, and comorbidities between ACD and complex ATLD patients undergoing surgery. METHODS Two multicenter prospective adult spinal deformity registries were queried, one ATLD and one ACD. Baseline clinical and frailty measures were compared between the cohorts. RESULTS 616 patients were identified (107 ACD and 509 ATLD). These groups had similar mean age (64.6 vs 60.8 years, respectively, P = .07). ACD patients were less likely to be women (51.9% vs 69.5%, P < .001) and had greater Charlson Comorbidity Index (1.5 vs .9, P < .001) and ASA grade (2.7 vs 2.4, P < .001). ACD patients had worse VR-12 Physical Component Score (PCS, 25.7 vs 29.9, P < .001) and PROMIS Physical Function Score (33.3 vs 35.3, P = .031). All frailty measures were significantly worse for ACD patients, including hand dynamometer (44.6 vs 55.6 lbs, P < .001), CSHA Clinical Frailty Score (CFS, 4.0 vs 3.2, P < .001), and Edmonton Frailty Scale (EFS, 5.15 vs 3.21, P < .001). Greater proportions of ACD patients were frail (22.9% vs 5.7%) or vulnerable (15.6% vs 10.9%) based on EFS (P < .001). CONCLUSIONS Compared with ATLD patients, ACD patients had worse baseline characteristics on all measures assessed (comorbidities/disability/frailty). These differences may help account for greater risk of complications and all-cause mortality previously observed in ACD patients and facilitate strategies for better preoperative optimization.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Michael P Kelly
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - Thomas J Buell
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Ben-Israel
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Bassel Diebo
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Breton Line
- Presbyterian St Lukes Medical Center, Denver, CO, USA
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Eric Klineberg
- Department of Orthopedic Surgery, University of Texas Health Houston, Houston, TX, USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA
| | | | - Khal Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Robert Eastlack
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, USA
| | - Alan Daniels
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, AB, Canada
| | - Gregory Mundis
- Department of Orthopedic Surgery, Scripps Clinic, San Diego, USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, TX, USA
| | | | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO, USA
| | - Stephen J Lewis
- Department of Surgery, Division of Orthopedic Surgery, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lennox Hill Hospital, New York City, NY, USA
| | - Lawrence G Lenke
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | | | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KA, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Shay Bess
- Presbyterian St Lukes Medical Center, Denver, CO, USA
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Passias PG, Pierce KE, Dave P, Lafage R, Lafage V, Schoenfeld AJ, Line B, Uribe J, Hostin R, Daniels A, Hart R, Burton D, Kim HJ, Mundis GM, Eastlack R, Diebo BG, Gum JL, Shaffrey C, Schwab F, Ames CP, Smith JS, Bess S, Klineberg E, Gupta MC, Hamilton DK. When not to Operate in Spinal Deformity: Identifying Subsets of Patients With Simultaneous Clinical Deterioration, Major Complications, and Reoperation. Spine (Phila Pa 1976) 2023; 48:1481-1485. [PMID: 37470375 DOI: 10.1097/brs.0000000000004778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/15/2023] [Indexed: 07/21/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively enrolled adult spinal deformity (ASD) database. OBJECTIVE To investigate what patient factors elevate the risk of sub-optimal outcomes after deformity correction. BACKGROUND Currently, it is unknown what factors predict a poor outcome after adult spinal deformity surgery, which may require increased preoperative consideration and counseling. MATERIALS AND METHODS Patients >18 yrs undergoing surgery for ASD(scoliosis≥20°, SVA≥5 cm, PT≥25°, or TK≥60°). An unsatisfactory outcome was defined by the following categories met at two years: (1) clinical: deteriorating in ODI at two years follow-up (2) complications/reoperation: having a reoperation and major complication were deemed high risk for poor outcomes postoperatively (HR). Multivariate analyses assessed predictive factors of HR patients in adult spinal deformity patients. RESULTS In all, 633 adult spinal deformity (59.9 yrs, 79% F, 27.7 kg/m 2, CCI: 1.74) were included. Baseline severe Schwab modifier incidence (++): 39.2% pelvic incidence and lumbar lordosis, 28.8% sagittal vertical axis, 28.9% PT. Overall, 15.5% of patients deteriorated in ODI by two years, while 7.6% underwent reoperation and had a major complication. This categorized 11 (1.7%) as HR. HR were more comorbid in terms of arthritis (73%), heart disease (36%), and kidney disease (18%), P <0.001. Surgically, HR had greater EBL (4431ccs) and underwent more osteotomies (91%), specifically Ponte(36%) and Three Column Osteotomies(55%), which occurred more at L2(91%). HR underwent more PLIFs (45%) and had more blood transfusion units (2641ccs), all P <0.050. The multivariate regression determined a combination of a baseline Distress and Risk Assessment Method score in the 75th percentile, having arthritis and kidney disease, a baseline right lower extremity motor score ≤3, cSVA >65 mm, C2 slope >30.2°, CTPA >5.5° for an R2 value of 0.535 ( P <0.001). CONCLUSIONS When addressing adult spine deformities, poor outcomes tend to occur in severely comorbid patients with major baseline psychological distress scores, poor neurologic function, and concomitant cervical malalignment.
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Affiliation(s)
- Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Katherine E Pierce
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Pooja Dave
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute, New York, NY
| | - Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Virginie Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Juan Uribe
- Department of Neurosurgery, University of South Florida, Tampa, FL
| | - Richard Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Alan Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | | | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Jeffrey L Gum
- Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY
| | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Frank Schwab
- Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis, CA
| | - Munish C Gupta
- Department of Orthopaedic Surgery, Washington University of St Louis, St. Louis, MO
| | - D Kojo Hamilton
- Departments of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Passias PG, Tretiakov PS, Smith JS, Lafage R, Diebo B, Scheer JK, Eastlack RK, Daniels AH, Klineberg EO, Khabeish KM, Mundis GM, Turner JD, Gupta MC, Kim HJ, Schwab F, Bess S, Lafage V, Ames CP, Shaffrey CI. Are we improving in the optimization of surgery for high-risk adult cervical spine deformity patients over time? J Neurosurg Spine 2023; 39:628-635. [PMID: 37548546 DOI: 10.3171/2023.5.spine23457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/24/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE The aim of this study was to investigate whether surgery for high-risk patients is being optimized over time and if poor outcomes are being minimized. METHODS Patients who underwent surgery for cervical deformity (CD) and were ≥ 18 years with baseline and 2-year data were stratified by year of surgery from 2013 to 2018. The cohort was divided into two groups based on when the surgery was performed. Patients in the early cohort underwent surgery between 2013 and 2015 and those in the recent cohort underwent surgery between 2016 and 2018. High-risk patients met at least 2 of the following criteria: 1) baseline C2-7 Cobb angle > 15°, mismatch between T1 slope and cervical lordosis ≥ 35°, C2-7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°; 2) age ≥ 70 years; 3) severe baseline frailty (Miller index); 4) Charlson Comorbidity Index (CCI) ≥ 1 SD above the mean; 5) three-column osteotomy as treatment; and 6) fusion > 10 levels or > 7 levels for elderly patients. The mean comparison analysis assessed differences between groups. Stepwise multivariable linear regression described associations between increasing year of surgery and complications. RESULTS Eighty-two CD patients met high-risk criteria (mean age 62.11 ± 10.87 years, 63.7% female, mean BMI 29.70 ± 8.16 kg/m2, and mean CCI 1.07 ± 1.45). The proportion of high-risk patients increased with time, with 41.8% of patients in the early cohort classified as high risk compared with 47.6% of patients in the recent cohort (p > 0.05). Recent high-risk patients were more likely to be female (p = 0.008), have a lower BMI (p = 0.038), and have a higher baseline CCI (p = 0.013). Surgically, high-risk patients in the recent cohort were more likely to undergo low-grade osteotomy (p = 0.003). By postoperative complications, recent high-risk patients were less likely to experience any postoperative adverse events overall (p = 0.020) or complications such as dysphagia (p = 0.045) at 2 years. Regression analysis revealed increasing year of surgery to be correlated with decreasing minor complication rates (p = 0.030), as well as lowered rates of distal junctional kyphosis by 2 years (p = 0.048). CONCLUSIONS Over time, high-risk CD patients have an increase in frequency and comorbidity rates but have demonstrated improved postoperative outcomes. These findings suggest that spine surgeons have improved over time in optimizing selection and reducing potential adverse events in high-risk patients.
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Affiliation(s)
- Peter G Passias
- 1Departments of Orthopedic and Neurological Surgery, Division of Spine Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Peter S Tretiakov
- 1Departments of Orthopedic and Neurological Surgery, Division of Spine Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 2New York Spine Institute, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Renaud Lafage
- 4Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Bassel Diebo
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Justin K Scheer
- 6Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert K Eastlack
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Alan H Daniels
- 5Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Eric O Klineberg
- 8Department of Orthopaedic Surgery, University of California, Davis, California
| | - Khaled M Khabeish
- 9Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Gregory M Mundis
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Jay D Turner
- 10Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Munish C Gupta
- 11Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri
| | - Han Jo Kim
- 12Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Frank Schwab
- 4Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Shay Bess
- 13Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado; and
| | - Virginie Lafage
- 4Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Christopher P Ames
- 6Department of Neurological Surgery, University of California, San Francisco, California
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Baroncini A, Frechon P, Bourghli A, Smith JS, Larrieu D, Pellisé F, Pizones J, Kleinstueck F, Alanay A, Kieser D, Cawley DT, Boissiere L, Obeid I. Adherence to the Obeid coronal malalignment classification and a residual malalignment below 20 mm can improve surgical outcomes in adult spine deformity surgery. Eur Spine J 2023; 32:3673-3680. [PMID: 37393421 DOI: 10.1007/s00586-023-07831-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/17/2023] [Accepted: 06/17/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE Coronal balance is a major factor impacting the surgical outcomes in adult spinal deformity (ASD). The Obeid coronal malalignment (O-CM) classification has been proposed to improve the coronal alignment in ASD surgery. Aim of this study was to investigate whether a postoperative CM < 20 mm and adherence to the O-CM classification could improve surgical outcomes and decrease the rate of mechanical failure in a cohort of ASD patients. METHODS Multicenter retrospective analysis of prospectively collected data on all ASD patients who underwent surgical management and had a preoperative CM > 20 mm and a 2-year follow-up. Patients were divided in two groups according to whether or not surgery had been performed in adherence to the guidelines of the O-CM classification and according to whether or not the residual CM was < 20 mm. The outcomes of interest were radiographic data, rate of mechanical complications and Patient-Reported Outcome Measures. RESULTS At 2 years, adherence to the O-CM classification led to a lower rate of mechanical complications (40 vs. 60%). A coronal correction of the CM < 20 mm allowed for a significant improvement in SRS-22 and SF-36 scores and was associated with a 3.5 times greater odd of achieving the minimal clinical important difference for the SRS-22. CONCLUSION Adherence to the O-CM classification could reduce the risk of mechanic complications 2 years after ASD surgery. Patients with a residual CM < 20 mm showed better functional outcomes and a 3.5 times greater odd of achieving the MCID for the SRS-22 score.
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Affiliation(s)
- Alice Baroncini
- Department of Orthopaedics and Trauma Surgery, RWTH Uniklinik Aachen, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - Paul Frechon
- Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France
- Department of Neurosurgery, Caen University Hospital, Caen, France
| | - Anouar Bourghli
- Spine Surgery Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel Larrieu
- Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France
| | - Ferran Pellisé
- Spine Surgery Unit, Vall D'Hebron Hospital, Barcelona, Spain
| | - Javier Pizones
- Spine Surgery Unit, Hospital Universitario La Paz, Madrid, Spain
| | | | - Ahmet Alanay
- Spine Center, Acibadem University School of Medicine, Istanbul, Turkey
| | - David Kieser
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, Christchurch School of Medicine, University of Otago, Christchurch, New Zealand
| | - Derek T Cawley
- Department of Spine Surgery, Mater Private Hospital, Dublin, Ireland
| | - Louis Boissiere
- Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France
- ELSAN, Polyclinique Jean Villar, Brugge Cedex, France
| | - Ibrahim Obeid
- Spine Surgery Unit 1, Bordeaux University Pellegrin Hospital, Bordeaux, France
- ELSAN, Polyclinique Jean Villar, Brugge Cedex, France
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Krol O, McFarland K, Owusu-Sarpong S, Sagoo N, Williamson T, Joujon-Roche R, Tretiakov P, Imbo B, Dave P, Mir J, Lebovic J, Onafowokan OO, Schoenfeld AJ, De la Garza Ramos R, Janjua MB, Sciubba DM, Diebo BG, Vira S, Smith JS, Lafage V, Lafage R, Passias PG. Impact of Frailty on the Development of Proximal Junctional Failure: Does Frailty Supersede Achieving Optimal Realignment? Spine (Phila Pa 1976) 2023; 48:1348-1353. [PMID: 37199421 DOI: 10.1097/brs.0000000000004719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/31/2022] [Indexed: 05/19/2023]
Abstract
BACKGROUND Patients undergoing surgery for adult spinal deformity (ASD) are often elderly, frail, and at elevated risk of adverse events perioperatively, with proximal junctional failure (PJF) occurring relatively frequently. Currently, the specific role of frailty in potentiating this outcome is poorly defined. PURPOSE To determine if the benefits of optimal realignment in ASD, with respect to the development of PJF, can be offset by increasing frailty. STUDY DESIGN Retrospective cohort. MATERIALS AND METHODS Operative ASD patients (scoliosis >20°, SVA>5 cm, pelvic tilt>25°, or TK>60°) fused to the pelvis or below with available baseline and 2-year (2Y) radiographic and HRQL data were included. The Miller Frailty Index (FI) was used to stratify patients into 2 categories: Not Frail (FI <3) and Frail (>3). Proximal Junctional Failure (PJF) was defined using the Lafage criteria. "Matched" and "unmatched" refers to ideal age-adjusted alignment postoperatively. Multivariable regression determined the impact of frailty on the development of PJF. RESULTS Two hundred eighty-four ASD patients met inclusion criteria [62.2yrs±9.9, 81%F, BMI: 27.5 kg/m 2 ±5.3, ASD-FI: 3.4±1.5, Charlson Comorbidity Index (CCI): 1.7±1.6]. Forty-three percent of patients were characterized as Not Frail (NF) and 57% were characterized as Frail (F). PJF development was lower in the NF group compared with the F group (7% vs . 18%; P =0.002). F patients had 3.2 × higher risk of PJF development compared to NF patients (OR: 3.2, 95% CI: 1.3-7.3, P =0.009). Controlling for baseline factors, F unmatched patients had a higher degree of PJF (OR: 1.4, 95% CI:1.02-1.8, P =0.03); however, with prophylaxis, there was no increased risk. Adjusted analysis shows F patients, when matched postoperatively in PI-LL, had no significantly higher risk of PJF. CONCLUSIONS An increasingly frail state is significantly associated with the development of PJF after corrective surgery for ASD. Optimal realignment may mitigate the impact of frailty on eventual PJF. Prophylaxis should be considered in frail patients who do not reach ideal alignment goals.
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Affiliation(s)
- Oscar Krol
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Kimberly McFarland
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | | | - Navraj Sagoo
- Departments of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, TX
| | - Tyler Williamson
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Rachel Joujon-Roche
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Peter Tretiakov
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Bailey Imbo
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Pooja Dave
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Jamshaid Mir
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
| | - Jordan Lebovic
- Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, NY
| | - Oluwatobi O Onafowokan
- Exeter Spine Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital/Harvard Medical Center, Boston, MA
| | - Rafael De la Garza Ramos
- Departments of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, TX
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | | | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore MD
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, New York, NY
| | - Shaleen Vira
- Departments of Orthopaedic and Neurosurgery, UT Southwestern Medical Center, Dallas, TX
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, NY
| | - Peter G Passias
- Departments of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY
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Sursal T, Kim HJ, Sardi JP, Yen CP, Smith JS. Use of Tethers for Proximal Junctional Kyphosis Prophylaxis in Adult Spinal Deformity Surgery: A Review of Current Clinical Evidence. Int J Spine Surg 2023; 17:S26-S37. [PMID: 37673684 PMCID: PMC10626134 DOI: 10.14444/8515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Surgery for adult spinal deformity (ASD) often involves long-segment posterior instrumentation that introduces stress at the proximal junction that can result in proximal junctional kyphosis (PJK) or proximal junctional failure (PJF). Recently, the use of tethers at the proximal junction has been proposed as a means of buffering the transitional stresses and reducing the risk of PJK/PJF. Our objectives are to summarize the clinical literature on proximal junctional tethers for PJK/PJF prophylaxis. METHODS Articles published between 1 January 2000 and 10 November 2022 were identified via a PubMed search using combinations of the search terms "spine surgery," "ASD," "complication," "surgery," "PJK," "PJF," "tether," "sublaminar band," and "prophylaxis." No restrictions were placed on the number of patients, surgical indications, or surgical procedures. Relevant articles were reviewed and summarized. RESULTS Fifteen articles were identified, including 2 prospective cohorts (Level II), 10 retrospective cohorts (Level III), and 3 retrospective case series (Level IV). All studies were published between 2016 and 2022, and all focused on ASD patient populations. The mean age in each study ranged from 55 to 69 years, and most studies had a mean follow-up of at least 12 months (range, 5.5-45.4 months). Eleven studies used a polyethylene tether, 2 used soft sublaminar cables, and 2 used semitendinous allograft. The tether extended to the UIV+1 or UIV+2, passing either through or around the spinous processes, in 13 studies. In the remaining 2 studies, the tether was passed sublaminar at the UIV+1. Fourteen studies favored the use of tethers with regard to reduction of PJK/PJF rates, and one demonstrated similar rates of PJK between the tether and no-tether groups. CONCLUSIONS PJK/PJF remain major challenges in ASD surgery. Most early studies suggest that the use of tethers for ligamentous augmentation may help to mitigate the development of PJK/PJF. However, the multifactorial etiology of PJK/PJF makes it unlikely that any single technique will solve this complex problem. Further study is needed to address not only the effectiveness of junctional tethers but also to clarify whether there are optimal tether configurations, tether materials, and tether tension. LEVEL EVIDENCE 3.
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Affiliation(s)
- Tolga Sursal
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York City, NY, USA
| | - Juan Pablo Sardi
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Chun-Po Yen
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
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48
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Lafage R, Smith JS, Soroceanu A, Ames C, Passias P, Shaffrey C, Mundis G, Alshabab BS, Protopsaltis T, Klineberg E, Elysee J, Kim HJ, Bess S, Schwab F, Lafage V. Predicting Mechanical Failure Following Cervical Deformity Surgery: A Composite Score Integrating Age-Adjusted Cervical Alignment Targets. Global Spine J 2023; 13:2432-2438. [PMID: 35350922 PMCID: PMC10538337 DOI: 10.1177/21925682221086535] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Investigate a composite score to evaluate the relationship between alignment proportionality and risk of distal junctional kyphosis (DJK). METHODS 84 patients with minimum 1 year follow-up were included (age = 61.1 ± 10.3 years, 64.3% women). The Cervical Score was constructed using offsets from age-adjusted normative values for sagittal vertical axis (SVA), T1 Slope (TS), and TS minus cervical lordosis (CL). Individual points were assigned based on offset with age-adjusted alignment targets and summed to generate the Cervical Score. Rates of mechanical failure (DJK revision or severe DJK [DJK> 20° and ΔDJK> 10°]) were assessed overall and based on Cervical Score. Logistical regressions assessed associations between early radiographic alignment and 1-year failure rate. RESULTS Mechanical failure rate was 21.4% (N = 18), 10.7% requiring revision. By multivariate logistical regression: 3-month T1S (OR: .935), TS-CL (OR:0.882), and SVA (OR:1.015) were independent predictors of 1-year failure (all P < .05). Cervical Score ranged (-6 to 6), 37.8% of patients between -1 and 1, and 50.0% with 2 or higher. DJK patients had significantly higher Cervical Score (4.1 ± 1.3 vs .6 ± 2.2, P < .001). Patients with a score ≥3 were significantly more likely to develop a failure (71.4%) with OR of 38.55 (95%CI [7.73; 192.26]) and Nagelkerke r2 .524 (P < .001). CONCLUSION This study developed a composite alignment score predictive of mechanical failures in CD surgery. A score ≥3 at 3 months following surgery was associated with a marked increase in failure rate. The Cervical Score can be used to analyze sagittal alignment and help define realignment objectives to reduce mechanical failure.
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Affiliation(s)
- Renaud Lafage
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | | | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
| | - Peter Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
| | | | | | - Basel Sheikh Alshabab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
| | - Jonathan Elysee
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Han Jo Kim
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Frank Schwab
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
| | - On behalf of the International Spine Study Group (ISSG)
- Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
- Department of Surgery, University of Calgary, Calgary, AB, Canada
- Department of Neurological Surgery, University of California, San Francisco, School of Medicine, San Francisco, CA, USA
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
- Scripps Clinic, San Diego, CA, USA
- Department of Orthopaedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, CO, USA
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49
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Hostin RA, Yeramaneni S, Gum JL, Smith JS. Clinical and Economic Impact of Proximal Junctional Kyphosis on Pediatric and Adult Spinal Deformity Patients. Int J Spine Surg 2023; 17:S9-S17. [PMID: 37798077 PMCID: PMC10626147 DOI: 10.14444/8518] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
The common goal of pediatric and adult spinal reconstructive procedures is to minimize long-term risk of disability, pain, and mortality. A common complication that has proved particularly problematic in the adult spinal deformity population and that has been an area of increased research and clinical focus is proximal junctional kyphosis (PJK). The incidence of PJK ranges from 10%-40% based on criteria used to define the condition. Clinically, PJK complication is associated with increased pain, decreased self-image and Scoliosis Research Society scores, and severe neurological injuries affecting the patient's quality of life. Economically, direct costs of PJK complication-associated revision surgery ranges from $20,000 to $120,000, which places an enormous burden on patients, providers, and payers. To mitigate the risk of PJK occurrence postoperatively, it is paramount to develop consistent guidelines in defining and classifying PJK in addition to extensive preoperative planning and risk stratification that is patient specific. This article will provide an overview on the clinical and economic impact of PJK in pediatric and adult spine deformity patients with an emphasis on the role of patient factors and predictive analytics, challenges in developing a consistent PJK classification, and current treatment and prevention strategies.
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Affiliation(s)
- Richard A Hostin
- Department of Orthopedic Surgery, Medical City Dallas, Dallas, TX, USA
| | - Samrat Yeramaneni
- Department of Orthopedic Surgery, Medical City Dallas, Dallas, TX, USA
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia, VA, USA
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50
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Clohisy JCF, Smith JS, Kelly MP, Yanik EL, Baldus CR, Bess S, Shaffrey CI, Kim HJ, LaBore A, Pham V, Bridwell KH. Failure of nonoperative care in adult symptomatic lumbar scoliosis: incidence, timing, and risk factors for conversion from nonoperative to operative treatment. J Neurosurg Spine 2023; 39:498-508. [PMID: 37327144 PMCID: PMC10252148 DOI: 10.3171/2023.5.spine2326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/01/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE The Adult Symptomatic Lumbar Scoliosis (ASLS) study is a prospective multicenter trial with randomized and observational cohorts comparing operative and nonoperative treatment for ASLS. The objective of the present study was to perform a post hoc analysis of the ASLS trial to examine factors related to failure of nonoperative treatment in ASLS. METHODS Patients from the ASLS trial who initially received at least 6 months of nonoperative treatment were followed for up to 8 years after trial enrollment. Baseline patient-reported outcome measures (Scoliosis Research Society-22 [SRS-22] questionnaire and Oswestry Disability Index), radiographic data, and other clinical characteristics were compared between patients who did and did not convert to operative treatment during follow-up. The incidence of operative treatment was calculated and independent predictors of operative treatment were identified using multivariate regression. RESULTS Of 135 nonoperative patients, 42 (31%) crossed over to operative treatment after 6 months and 93 (69%) received only nonoperative treatment. In the observational cohort, 23 (22%) of 106 nonoperative patients crossed over to surgery. In the randomized cohort, 19 (66%) of 29 patients randomized to nonoperative treatment crossed over to surgery. The most impactful factors associated with crossover from nonoperative to operative treatment were enrollment in the randomized cohort and baseline SRS-22 subscore < 3.0 at the 2-year follow-up, closer to 3.4 at 8 years. In addition, baseline lumbar lordosis (LL) < 50° was associated with crossover to operative treatment. Each 1-point decrease in baseline SRS-22 subscore was associated with a 233% higher risk of conversion to surgery (hazard ratio [HR] 2.33, 95% confidence interval [CI] 1.14-4.76, p = 0.0212). Each 10° decrease in LL was associated with a 24% increased risk of conversion to operative treatment (HR 1.24, 95% CI 1.03-1.49, p = 0.0232). Enrollment in the randomized cohort was associated with a 337% higher probability of proceeding with operative treatment (HR 3.37, 95% CI 1.54-7.35, p = 0.0024). CONCLUSIONS Enrollment in the randomized cohort, a lower baseline SRS-22 subscore, and lower LL were associated with conversion from nonoperative treatment to surgery in patients (observational and randomized) who were initially managed nonoperatively in the ASLS trial.
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Affiliation(s)
- John C. F. Clohisy
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Justin S. Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Michael P. Kelly
- Department of Orthopedic Surgery, Rady Children’s Hospital, San Diego, California
| | - Elizabeth L. Yanik
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christine R. Baldus
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke’s/Rocky Mountain Hospital for Children, Denver, Colorado
| | | | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Adam LaBore
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Vy Pham
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Keith H. Bridwell
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
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