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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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Agarwal N, Letchuman V, Lavadi RS, Le VP, Aabedi AA, Shabani S, Chan AK, Park P, Uribe JS, Turner JD, Eastlack RK, Fessler RG, Fu KM, Wang MY, Kanter AS, Okonkwo DO, Nunley PD, Anand N, Mundis GM, Passias PG, Bess S, Shaffrey CI, Chou D, Mummaneni PV. What is the effect of preoperative depression on outcomes after minimally invasive surgery for adult spinal deformity? A prospective cohort analysis. J Neurosurg Spine 2024; 40:602-610. [PMID: 38364229 DOI: 10.3171/2023.12.spine221330] [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: 12/01/2022] [Accepted: 12/08/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Depression has been implicated with worse immediate postoperative outcomes in adult spinal deformity (ASD) correction, yet the specific impact of depression on those patients undergoing minimally invasive surgery (MIS) requires further clarity. This study aimed to evaluate the role of depression in the recovery of patients with ASD after undergoing MIS. METHODS Patients who underwent MIS for ASD with a minimum postoperative follow-up of 1 year were included from a prospectively collected, multicenter registry. Two cohorts of patients were identified that consisted of either those affirming or denying depression on preoperative assessment. The patient-reported outcome measures (PROMs) compared included scores on the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back and leg pain, Scoliosis Research Society Outcomes Questionnaire (SRS-22), SF-36 physical component summary, SF-36 mental component summary (MCS), EQ-5D, and EQ-5D visual analog scale. RESULTS Twenty-seven of 147 (18.4%) patients screened positive for preoperative depression. The nondepressed cohort had an average of 4.83 levels fused, and the depressed cohort had 5.56 levels fused per patient (p = 0.267). At 1-year follow-up, 10 patients still reported depression, representing a 63% decrease. Postoperatively, both cohorts demonstrated improvement in their PROMs; however, at 1-year follow-up, those without depression had statistically better outcomes based on the EQ-5D, MCS, and SRS-22 scores (p < 0.05). Patients with depression continued to experience higher NRS leg scores at 1-year follow-up (3.63 vs 2.22, p = 0.018). After controlling for covariates, the authors found that depression significantly impacted only 1-year follow-up MCS scores (β = 8.490, p < 0.05). CONCLUSIONS Depressed and nondepressed patients reported similar improvements after MIS surgery, except MCS scores were more likely to improve in nondepressed patients.
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Affiliation(s)
- Nitin Agarwal
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- 2Division of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- 3Neurological Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Vijay Letchuman
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Raj Swaroop Lavadi
- 1Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Vivian P Le
- 5Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Alexander A Aabedi
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Saman Shabani
- 6Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Andrew K Chan
- 5Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Paul Park
- 7Department of Neurosurgery, Semmes Murphey Clinic, Memphis, Tennessee
| | - Juan S Uribe
- 8Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D Turner
- 8Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert K Eastlack
- 9Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California
| | - Richard G Fessler
- 10Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kai-Ming Fu
- 11Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael Y Wang
- 12Department of Neurosurgery, University of Miami, Florida
| | - Adam S Kanter
- 13Division of Neurosurgery, Hoag Neurosciences Institute, Newport Beach, California
| | - David O Okonkwo
- 2Division of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Neel Anand
- 15Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Gregory M Mundis
- 9Department of Orthopedic Surgery, Scripps Clinic, La Jolla, California
| | - Peter G Passias
- 16Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - Shay Bess
- 17Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado; and
| | | | - Dean Chou
- 5Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York
| | - Praveen V Mummaneni
- 4Department of Neurological Surgery, University of California, San Francisco, California
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3
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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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4
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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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5
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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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6
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Beall DP, Amirdelfan K, Nunley PD, Phillips TR, Imaz Navarro LC, Spath A. Hydrogel Augmentation of the Lumbar Intervertebral Disc: An Early Feasibility Study of a Treatment for Discogenic Low Back Pain. J Vasc Interv Radiol 2024; 35:51-58.e1. [PMID: 37758022 DOI: 10.1016/j.jvir.2023.09.018] [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: 11/10/2022] [Revised: 09/12/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023] Open
Abstract
PURPOSE To assess the safety and effectiveness of intradiscal hydrogel in patients with chronic low back pain (CLBP) due to degenerative disc disease (DDD) refractory to conventional medical management. MATERIALS AND METHODS Twenty patients aged 22-69 years with numerical rating scale (NRS) pain of ≥4 were enrolled. All patients with CLBP resulting from DDD confirmed by imaging and discography received injections of hydrogel (Hydrafil Intervertebral Disc Augmentation; ReGelTec, Baltimore, Maryland) at 1 or 2 lumbar levels (29 levels treated) from August to December 2020. The primary safety end point was freedom from serious adverse events (SAEs). The primary performance end point was successful gel delivery into the desired disc. Patients were also assessed on the NRS as well as the Oswestry disability index (ODI). RESULTS Nineteen patients were followed up at a mean of 131 days, and 1 patient was lost to follow-up. Preliminary results showed significant reductions in median NRS back pain from 7 (range 4-10) to 1 (range 0-8) (P <.0001) and median ODI scores from 54 (range 22-58) to 2 (range 0-58) (P <.0001) at 6 months of follow-up. There were 5 SAEs, and 4 of the 2 were determined to be associated with treatment. CONCLUSIONS This early feasibility study showed that the hydrogel implant was safe with no persistently symptomatic SAEs, and demonstrated effectiveness with significant reduction in pain and improvement in function when used to treat painful DDD and CLBP.
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Affiliation(s)
- Douglas P Beall
- Comprehensive Specialty Care, Interventional Pain/Interventional Radiology, Edmond, Oklahoma
| | - Kasra Amirdelfan
- IPM Medical Group, Interventional Pain, Walnut Creek, California
| | - Pierce D Nunley
- Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Los Angeles
| | - Tyler R Phillips
- Comprehensive Specialty Care, Interventional Pain/Interventional Radiology, Edmond, Oklahoma.
| | | | - Alfonso Spath
- Interventional Radiology, Cediul Imagenes Diagnostics Y Terapeuticas, Barranquilla, Columbia
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Eastlack RK, Nunley PD, Poelstra KA, Vaccaro AR, Stone M, Miller LE, Legay P, Clin J, Agarwal A. Finite element analysis comparing a PEEK posterior fixation device versus pedicle screws for lumbar fusion. J Orthop Surg Res 2023; 18:855. [PMID: 37950318 PMCID: PMC10636999 DOI: 10.1186/s13018-023-04349-5] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Pedicle screw loosening and breakage are common causes of revision surgery after lumbar fusion. Thus, there remains a continued need for supplemental fixation options that offer immediate stability without the associated failure modes. This finite element analysis compared the biomechanical properties of a novel cortico-pedicular posterior fixation (CPPF) device with those of a conventional pedicle screw system (PSS). METHODS The CPPF device is a polyetheretherketone strap providing circumferential cortical fixation for lumbar fusion procedures via an arcuate tunnel. Using a validated finite element model, we compared the stability and load transfer characteristics of CPPF to intact conditions under a 415 N follower load and PSS conditions under a 222 N preload. Depending on the instrumented levels, two different interbody devices were used: a lateral lumbar interbody device at L4-5 or an anterior lumbar interbody device at L5-S1. Primary outcomes included range of motion of the functional spinal units and anterior load transfer, defined as the total load through the disk and interbody device after functional motion and follower load application. RESULTS Across all combinations of interbody devices and lumbar levels evaluated, CPPF consistently demonstrated significant reductions in flexion (ranging from 90 to 98%), extension (ranging from 88 to 94%), lateral bending (ranging from 75 to 80%), and torsion (ranging from 77 to 86%) compared to the intact spine. Stability provided by the CPPF device was comparable to PSS in all simulations (range of motion within 0.5 degrees for flexion-extension, 0.6 degrees for lateral bending, and 0.5 degrees for torsion). The total anterior load transfer was higher with CPPF versus PSS, with differences across all tested conditions ranging from 128 to 258 N during flexion, 89-323 N during extension, 135-377 N during lateral bending, 95-258 N during torsion, and 82-250 N during standing. CONCLUSION Under the modeled conditions, cortico-pedicular fixation for supplementing anterior or lateral interbody devices between L4 and S1 resulted in comparable stability based on range of motion measures and less anterior column stress shielding based on total anterior load transfer measures compared to PSS. Clinical studies are needed to confirm these finite element analysis findings.
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Affiliation(s)
- Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA, USA
| | | | - Kornelis A Poelstra
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marcus Stone
- Spine Institute of Louisiana, Shreveport, LA, USA
| | - Larry E Miller
- Miller Scientific, 3101 Browns Mill Road, Ste 6, #311, Johnson City, TN, 37604, USA.
| | | | | | - Aakash Agarwal
- Departments of Bioengineering and Orthopaedic Surgery, University of Toledo, Toledo, OH, USA
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Campbell PG, Nunley PD. The Lumbosacral Fractional Curve in Adult Degenerative Scoliosis. Neurosurg Clin N Am 2023; 34:537-544. [PMID: 37718100 DOI: 10.1016/j.nec.2023.06.001] [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] [Indexed: 09/19/2023]
Abstract
Spine surgeons are often faced with a profoundly difficult challenge in surgically treating adult degenerative scoliosis. Deformity correction surgery is complicated by the difficulty in offering extensive surgical corrections to the elderly, complication-prone population it commonly affects. As spine surgeons attempt to offer minimally invasive solutions to this disease process, the need for fusion of the fractional curve at L4, L5, and S1 may be discounted. A treatment strategy to identify, address, and treat the fractional curve with either open or minimally invasive techniques can lead to improved patient outcomes and decrease revision rates in this complicated pathologic process.
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Affiliation(s)
- Peter G Campbell
- Spine Institute of Louisiana, 1500 Line Avenue, Shreveport, LA 71101, USA.
| | - Pierce D Nunley
- Spine Institute of Louisiana, 1500 Line Avenue, Shreveport, LA 71101, USA
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9
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Diebo BG, Tataryn Z, Alsoof D, Lafage R, Hart RA, Passias PG, Ames CP, Scheer JK, Lewis SJ, Shaffrey CI, Burton DC, Deviren V, Line BG, Soroceanu A, Hamilton DK, Klineberg EO, Mundis GM, Kim HJ, Gum JL, Smith JS, Uribe JS, Kelly MP, Kebaish KM, Gupta MC, Nunley PD, Eastlack RK, Hostin R, Protopsaltis TS, Lenke LG, Schwab FJ, Bess S, Lafage V, Daniels AH. Height Gain Following Correction of Adult Spinal Deformity. J Bone Joint Surg Am 2023; 105:1410-1419. [PMID: 37478308 DOI: 10.2106/jbjs.23.00031] [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] [Indexed: 07/23/2023]
Abstract
BACKGROUND Height gain following a surgical procedure for patients with adult spinal deformity (ASD) is incompletely understood, and it is unknown if height gain correlates with patient-reported outcome measures (PROMs). METHODS This was a retrospective cohort study of patients undergoing ASD surgery. Patients with baseline, 6-week, and subanalysis of 1-year postoperative full-body radiographic and PROM data were examined. Correlation analysis examined relationships between vertical height differences and PROMs. Regression analysis was utilized to preoperatively estimate T1-S1 and S1-ankle height changes. RESULTS This study included 198 patients (mean age, 57 years; 69% female); 147 patients (74%) gained height. Patients with height loss, compared with those who gained height, experienced greater increases in thoracolumbar kyphosis (2.81° compared with -7.37°; p < 0.001) and thoracic kyphosis (12.96° compared with 4.42°; p = 0.003). For patients with height gain, sagittal and coronal alignment improved from baseline to postoperatively: 25° to 21° for pelvic tilt (PT), 14° to 3° for pelvic incidence - lumbar lordosis (PI-LL), and 60 mm to 17 mm for sagittal vertical axis (SVA) (all p < 0.001). The full-body mean height gain was 7.6 cm, distributed as follows: sella turcica-C2, 2.9 mm; C2-T1, 2.8 mm; T1-S1 (trunk gain), 3.8 cm; and S1-ankle (lower-extremity gain), 3.3 cm (p < 0.001). T1-S1 height gain correlated with the thoracic Cobb angle correction and the maximum Cobb angle correction (p = 0.002). S1-ankle height gain correlated with the corrections in PT, PI-LL, and SVA (p < 0.001). T1-ankle height gain correlated with the corrections in PT (p < 0.001) and SVA (p = 0.03). Trunk height gain correlated with improved Scoliosis Research Society (SRS-22r) Appearance scores (r = 0.20; p = 0.02). Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores correlated with S1-ankle height gain (r = -0.19; p = 0.03) and C2-T1 height gain (r = -0.18; p = 0.04). A 1° correction in a thoracic scoliosis Cobb angle corresponded to a 0.2-mm height gain, and a 1° correction in a thoracolumbar scoliosis Cobb angle resulted in a 0.25-mm height gain. A 1° improvement in PI-LL resulted in a 0.2-mm height gain. CONCLUSIONS Most patients undergoing ASD surgery experienced height gain following deformity correction, with a mean full-body height gain of 7.6 cm. Height gain can be estimated preoperatively with predictive ratios, and height gain was correlated with improvements in reported SRS-22r appearance and PROMIS scores. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bassel G Diebo
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Daniel Alsoof
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Renaud Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY
| | | | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | | | - Justin K Scheer
- University of California-San Francisco, San Francisco, California
| | - Stephen J Lewis
- Division of Orthopaedics, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Vedat Deviren
- University of California-San Francisco, San Francisco, California
| | - Breton G Line
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Alex Soroceanu
- Department of Orthopedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California-Davis, Davis, California
| | | | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, Kentucky
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael P Kelly
- Division of Orthopedics & Scoliosis at Rady Children's Hospital-San Diego, San Diego, California
| | - Khaled M Kebaish
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Institute, Dallas, Texas
| | | | - Lawrence G Lenke
- Department of Orthopaedic Surgery, The Och Spine Hospital/Columbia University Irving Medical Center, New York, NY
| | - Frank J Schwab
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY
| | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Virginie Lafage
- Department of Orthopedic Surgery, Lenox Hill Northwell, New York, NY
| | - Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Tretiakov PS, Lafage R, Smith JS, Line BG, Diebo BG, Daniels AH, Gum J, Protopsaltis T, Hamilton DK, Soroceanu A, Scheer JK, Eastlack RK, Mundis G, Nunley PD, Klineberg EO, Kebaish K, Lewis S, Lenke L, Hostin R, Gupta MC, Ames CP, Hart RA, Burton D, Shaffrey CI, Schwab F, Bess S, Kim HJ, Lafage V, Passias PG. Calibration of a comprehensive predictive model for the development of proximal junctional kyphosis and failure in adult spinal deformity patients with consideration of contemporary goals and techniques. J Neurosurg Spine 2023; 39:311-319. [PMID: 37310039 DOI: 10.3171/2023.4.spine221412] [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: 12/24/2022] [Accepted: 04/17/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE The objective of this study was to calibrate an updated predictive model incorporating novel clinical, radiographic, and prophylactic measures to assess the risk of proximal junctional kyphosis (PJK) and failure (PJF). METHODS Operative patients with adult spinal deformity (ASD) and baseline and 2-year postoperative data were included. PJK was defined as ≥ 10° in sagittal Cobb angle between the inferior uppermost instrumented vertebra (UIV) endplate and superior endplate of the UIV + 2 vertebrae. PJF was radiographically defined as a proximal junctional sagittal Cobb angle ≥ 15° with the presence of structural failure and/or mechanical instability, or PJK with reoperation. Backstep conditional binary supervised learning models assessed baseline demographic, clinical, and surgical information to predict the occurrence of PJK and PJF. Internal cross validation of the model was performed via a 70%/30% cohort split. Conditional inference tree analysis determined thresholds at an alpha level of 0.05. RESULTS Seven hundred seventy-nine patients with ASD (mean 59.87 ± 14.24 years, 78% female, mean BMI 27.78 ± 6.02 kg/m2, mean Charlson Comorbidity Index 1.74 ± 1.71) were included. PJK developed in 50.2% of patients, and 10.5% developed PJF by their last recorded visit. The six most significant demographic, radiographic, surgical, and postoperative predictors of PJK/PJF were baseline age ≥ 74 years, baseline sagittal age-adjusted score (SAAS) T1 pelvic angle modifier > 1, baseline SAAS pelvic tilt modifier > 0, levels fused > 10, nonuse of prophylaxis measures, and 6-week SAAS pelvic incidence minus lumbar lordosis modifier > 1 (all p < 0.015). Overall, the model was deemed significant (p < 0.001), and internally validated receiver operating characteristic analysis returned an area under the curve of 0.923, indicating robust model fit. CONCLUSIONS PJK and PJF remain critical concerns in ASD surgery, and efforts to reduce the occurrence of PJK and PJF have resulted in the development of novel prophylactic techniques and enhanced clinical and radiographic selection criteria. This study demonstrates a validated model incorporating such techniques that may allow for the prediction of clinically significant PJK and PJF, and thus assist in optimizing patient selection, enhancing intraoperative decision making, and reducing postoperative complications in ASD surgery.
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Affiliation(s)
- Peter S Tretiakov
- 1Department of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 8Department of Orthopaedic Surgery, New York Spine Institute, New York, New York
| | - Renaud Lafage
- 2Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Breton G Line
- 4Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Bassel G 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 Gum
- 6Norton Leatherman Spine Center, Louisville, Kentucky
| | - Themistocles Protopsaltis
- 1Department of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, New York
| | - D Kojo Hamilton
- 7Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alex Soroceanu
- 7Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Justin K Scheer
- 9Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert K Eastlack
- 10Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Gregory Mundis
- 10Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | | | - Eric O Klineberg
- 12Department of Orthopaedic Surgery, University of California, Davis, California
| | - Khaled Kebaish
- 13Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, Maryland
| | - Stephen Lewis
- 14Division of Orthopaedic Surgery, University of Toronto, Ontario, Canada
| | - Lawrence Lenke
- 15Department of Orthopaedic Surgery, Columbia University, New York, New York
| | - Richard Hostin
- 16Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas, Texas
| | - Munish C Gupta
- 17Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri
| | - Christopher P Ames
- 9Department of Neurological Surgery, University of California, San Francisco, California
| | - Robert A Hart
- 18Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Douglas Burton
- 19Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Christopher I Shaffrey
- 20Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina; and
| | - Frank Schwab
- 2Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Shay Bess
- 4Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Han Jo Kim
- 21Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- 2Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Peter G Passias
- 1Department of Orthopaedic and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, New York
- 8Department of Orthopaedic Surgery, New York Spine Institute, New York, New York
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Passias PG, Tretiakov PS, Nunley PD, Wang MY, Park P, Kanter AS, Okonkwo DO, Eastlack RK, Mundis GM, Chou D, Agarwal N, Fessler RG, Uribe JS, Anand N, Than KD, Brusko G, Fu KM, Turner JD, Le VP, Line BG, Ames CP, Smith JS, Shaffrey CI, Hart RA, Burton D, Lafage R, Lafage V, Schwab F, Bess S, Mummaneni PV. Incremental benefits of circumferential minimally invasive surgery for increasingly frail patients with adult spinal deformity. J Neurosurg Spine 2023:1-7. [PMID: 37086158 DOI: 10.3171/2023.2.spine221278] [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: 11/22/2022] [Accepted: 02/28/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVE Circumferential minimally invasive surgery (cMIS) may provide incremental benefits compared with open surgery for patients with increasing frailty status by decreasing peri- and postoperative complications. METHODS Operative patients with adult spinal deformity (ASD) ≥ 18 years old with baseline and 2-year postoperative data were assessed. With propensity score matching, patients who underwent cMIS (cMIS group) were matched with similar patients who underwent open surgery (open group) based on baseline BMI, C7-S1 sagittal vertical axis, pelvic incidence to lumbar lordosis mismatch, and S1 pelvic tilt. The Passias modified ASD frailty index (mASD-FI) was used to determine patient frailty stratification as not frail, frail, or severely frail. Baseline and postoperative factors were assessed using two-way analysis of covariance (ANCOVA) and multivariate ANCOVA while controlling for baseline age, Charlson Comorbidity Index (CCI) score, and number of levels fused. RESULTS After propensity score matching, 170 ASD patients (mean age 62.71 ± 13.64 years, 75.0% female, mean BMI 29.25 ± 6.60 kg/m2) were included, split evenly between the cMIS and open groups. Surgically, patients in the open group had higher numbers of posterior levels fused (p = 0.021) and were more likely to undergo three-column osteotomies (p > 0.05). Perioperatively, cMIS patients had lower intraoperative blood loss and decreased use of cell saver across frailty groups (with adjustment for baseline age, CCI score, and levels fused), as well as fewer perioperative complications (p < 0.001). Adjusted analysis also revealed that compared to open patients, increasingly frail patients in the cMIS group were also more likely to demonstrate greater improvement in 1- and 2-year postoperative scores for the Oswestry Disability Index, SRS-36 (total), EQ-5D and SF-36 (all p < 0.05). With regard to postoperative complications, increasingly frail patients in the cMIS group were also noted to experience significantly fewer complications overall (p = 0.036) and fewer major intraoperative complications (p = 0.039). The cMIS patients were also less likely to need a reoperation than their open group counterparts (p = 0.043). CONCLUSIONS Surgery performed with a cMIS technique may offer acceptable outcomes, with diminishment of perioperative complications and mitigation of catastrophic outcomes, in increasingly frail patients who may not be candidates for surgery using traditional open techniques. However, further studies should be performed to investigate the long-term impact of less optimal alignment in this population.
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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 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 Spine Institute, New York, New York
| | - Pierce D Nunley
- 2Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Michael Y Wang
- 3Department of Neurological Surgery, University of Miami, Florida
| | - Paul Park
- 4Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Adam S Kanter
- 5Department of Neurosurgery, Hoag Pickup Family Neurosciences Institute, Newport Beach, California
| | - David O Okonkwo
- 6Department of Neurological Surgery, Division of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert K Eastlack
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Gregory M Mundis
- 7Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Dean Chou
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Nitin Agarwal
- 6Department of Neurological Surgery, Division of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Richard G Fessler
- 9Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Juan S Uribe
- 10Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Neel Anand
- 11Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, California
| | - Khoi D Than
- 12Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - Gregory Brusko
- 3Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 13Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Jay D Turner
- 10Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Vivian P Le
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Breton G Line
- 14Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Christopher P Ames
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Justin S Smith
- 15Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | | | - Robert A Hart
- 16Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington
| | - Douglas Burton
- 17Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas; and
| | - Renaud Lafage
- 18Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Virginie Lafage
- 18Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Frank Schwab
- 18Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Shay Bess
- 14Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Praveen V Mummaneni
- 8Department of Neurological Surgery, University of California, San Francisco, California
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Nunley PD, Hisey M, Smith M, Stone MB. Cervical Disc Arthroplasty vs Anterior Cervical Discectomy and Fusion at 10 Years: Results From a Prospective, Randomized Clinical Trial at 3 Sites. Int J Spine Surg 2023; 17:230-240. [PMID: 37028803 PMCID: PMC10165661 DOI: 10.14444/8431] [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: 04/09/2023] Open
Abstract
BACKGROUND Over the past 20 years, multiple randomized controlled trials have shown cervical disc arthroplasty (CDA) to be safe and effective for treating 1- and 2-level degenerative disc disease (DDD). The purpose of this postmarket study is to compare 10-year outcomes between CDA and anterior cervical discectomy and fusion (ACDF) from a randomized study at 3 centers. METHODS This study was a continuation of a randomized, prospective, multicenter clinical trial comparing CDA with the Mobi-C cervical disc (Zimmer Biomet) vs ACDF. Following completion of the 7-year US Food and Drug Administration study, 10-year follow-up was obtained from consenting patients at 3 high-enrolling centers. The clinical and radiographic endpoints collected at 10 years included composite success, Neck Disability Index, neck and arm pain, short form-12, patient satisfaction, adjacent-segment pathology, major complications, and subsequent surgery. RESULTS A total of 155 patients were enrolled (105 CDA; 50 ACDF). Follow-up was obtained from 78.1% of patients eligible after 7 years. At 10 years, CDA demonstrated superiority to ACDF. Composite success was 62.4% in CDA and 22.2% in ACDF (P < 0.0001). The cumulative risk of subsequent surgery at 10 years was 7.2% vs 25.5% (P = .001), and the risk of adjacent-level surgery was 3.1% vs 20.5% (P = .0005) in CDA vs ACDF, respectively. The progression to radiographically significant adjacent-segment pathology at 10 years was lower in CDA vs ACDF (12.9% vs 39.3%; P = 0.006). At 10 years, patient-reported outcomes and change from baseline were generally better in CDA patients. A higher percentage of CDA patients reported they were "very satisfied" at 10 years (98.7% vs 88.9%; P = 0.05). CONCLUSIONS In this postmarket study, CDA was superior to ACDF for treating symptomatic cervical DDD. CDA was statistically superior to ACDF for clinical success, subsequent surgery, and neurologic success. Results through 10 years demonstrate that CDA continues to be a safe and effective surgical alternative to fusion. CLINICAL RELEVANCE The results of this study support the long-term safety and effectiveness of cervical disc arthroplasty with the Mobi-C. LEVEL OF EVIDENCE: 1
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Nunley PD, Eastlack RK, Miller LE, Poelstra KA, Cox JB, Shedden PM, Stone M. Metal-free Cortico-pedicular Device for Supplemental Fixation in Lumbar Interbody Fusion. World Neurosurg 2023; 174:4-10. [PMID: 36871655 DOI: 10.1016/j.wneu.2023.02.119] [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: 02/15/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE Pedicle screw fixation is a commonly utilized adjunct for lumbar interbody fusion, yet risks include screw malposition, pullout, loosening, neurovascular injury, and stress transfers leading to adjacent segment degeneration. This report describes the preclinical and initial clinical results of a minimally invasive, metal-free cortico-pedicular fixation device used for supplemental posterior fixation in lumbar interbody fusion. METHODS Safety of arcuate tunnel creation was evaluated in cadaveric lumbar (L1 to S1) specimens. A finite element analysis (FEA) study evaluated clinical stability of the device to pedicular screw-rod fixation at L4-L5. Preliminary clinical results were assessed by analysis of Manufacturer and User Facility Device Experience (MAUDE) database complications, and 6-month outcomes in 13 patients treated with the device. RESULTS Among 35 curved drill holes in 5 lumbar specimens, no breaches of the anterior cortex were identified. The mean minimum distance from the anterior surface of the hole to the spinal canal ranged from 5.1 mm at L1-L2 to 9.8 mm at L5-S1. In the FEA study, the PEEK strap provided comparable clinical stability and reduced anterior stress shielding compared to the conventional screw-rod construct. The MAUDE database identified one device fracture with no clinical sequelae among 227 procedures. Initial clinical experience showed a 53% decrease in pain severity (p=0.009), a 50% decrease in Oswestry Disability Index (p<0.001), and no device-related complications. CONCLUSIONS Cortico-pedicular fixation is a safe and reproducible procedure that may address limitations of pedicle screw fixation. Longer term clinical data in large clinical studies are recommended to confirm these promising early results.
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Affiliation(s)
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA, United States
| | | | - Kornelis A Poelstra
- The Robotic Spine Institute of Las Vegas at Nevada Spine Clinic, Las Vegas, NV, United States
| | - J Bridger Cox
- Neuroscience Specialists, Oklahoma City, OK, United States
| | - Peter M Shedden
- Greater Houston Neurosurgery Center, The Woodlands, TX, United States
| | - Marcus Stone
- Spine Institute of Louisiana, Shreveport, LA, United States
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Anand N, Mummaneni PV, Uribe JS, Turner J, Than KD, Chou D, Nunley PD, Wang MY, Fessler RG, Le V, Robinson J, Walker C, Kahwaty S, Khanderhoo B, Eastlack RK, Okonkwo DO, Kanter AS, Fu KMG, Mundis GM, Passias P, Park P. Spinal Deformity Complexity Checklist for Minimally Invasive Surgery: Expert Consensus from the Minimally Invasive International Spine Study Group. World Neurosurg 2023; 173:e472-e477. [PMID: 36841536 DOI: 10.1016/j.wneu.2023.02.082] [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: 01/06/2023] [Revised: 02/17/2023] [Accepted: 02/18/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND We developed a spinal deformity complexity checklist (SDCC) to assess the difficulty in performing a circumferential minimally invasive surgery (MIS) for adult spinal deformity. METHODS A modified Delphi method of panel experts was used to construct an SDCC checklist of radiographic and patient-related characteristics that could affect the complexity of surgery via MIS approaches. Ten surgeons with expertise in MIS deformity surgery were queried to develop and refine the SDCC with 3 radiographic categories (x-ray, magnetic resonance imaging, computed tomography) and 1 patient-related category. Within each category, characteristics affecting MIS complexity were identified by initial roundtable discussion. Second-round discussion determined which characteristics substantially impacted complexity the most. RESULTS Thirteen characteristics within the x-ray category were determined. Spinopelvic characteristics, endpoints of instrumentation, and prior hardware/fusion were associated with increased complexity. Vertebral body rotation-as reflected by the Nash-Moe grade-added significant complexity. Psoas anatomy and spinal stenosis added the most complexity for the 5 magnetic resonance imaging characteristics. There were 3 characteristics in the CT category with pre-exisiting fusion, being the variable most highly selected. Of the 5 patient-related characteristics, osteoporosis and BMI were found to most affect complexity. CONCLUSIONS The SDCC is a comprehensive list of pertinent radiographic and patient-related characteristics affecting complexity level for MIS deformity surgery. The value of the SDCC is that it allows rapid assessment of key factors when determining whether MIS surgery can be performed effectively and safely. Patients with scores of 4 in any characteristic should be considered challenging to treat with MIS; open surgery may be a better alternative.
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Affiliation(s)
- Neel Anand
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California-San Francisco, San Francisco, California, USA
| | - Juan S Uribe
- Barrow Neurologic Institute, Phoenix, Arizona, USA
| | - Jay Turner
- Barrow Neurologic Institute, Phoenix, Arizona, USA
| | - Khoi D Than
- Departments of Orthopaedic Surgery and Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Dean Chou
- Department of Neurosurgery, University of California-San Francisco, San Francisco, California, USA
| | | | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami, Florida, USA
| | - Richard G Fessler
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Vivian Le
- Department of Neurosurgery, University of California-San Francisco, San Francisco, California, USA
| | - Jerry Robinson
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Corey Walker
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sheila Kahwaty
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Babak Khanderhoo
- Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Robert K Eastlack
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kai-Ming G Fu
- Department of Neurosurgery, Cornell Medical Center, New York, New York, USA
| | - Gregory M Mundis
- Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California, USA
| | - Peter Passias
- Division of Spinal Surgery, Department of Orthopaedic and Neurological Surgery, NYU School of Medicine, New York Spine Institute, New York, New York, USA
| | - Paul Park
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA; Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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15
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Coric D, Guyer RD, Bae H, Nunley PD, Strenge KB, Peloza JH, Boltes MO, Ohnmeiss DD. Prospective, multicenter study of 2-level cervical arthroplasty with a PEEK-on-ceramic artificial disc. J Neurosurg Spine 2022; 37:357-367. [PMID: 35364570 DOI: 10.3171/2022.1.spine211264] [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: 12/15/2021] [Accepted: 01/31/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the safety and efficacy of a PEEK-on-ceramic cervical total disc replacement (cTDR) device for the treatment of 2-level cervical disc disease with radiculopathy and/or myelopathy. METHODS The study was a prospective, nonrandomized, historically controlled FDA investigational device exemption trial evaluating the Simplify Cervical Artificial Disc for use at 2 levels. The anterior cervical discectomy and fusion (ACDF) control group was derived from a propensity score-matched (using subclassification) cohort of patients who participated in an earlier prospective trial in which similar indications were used. The follow-up duration was 24 months. The primary outcome was a 4-point composite success classification. Other validated clinical and radiographic assessments were also evaluated. RESULTS The investigational group (n = 182) was compared with patients who underwent ACDF (n = 170) in a historical control group using propensity score analysis. The overall composite success rate was statistically significantly greater in the cTDR group compared with the ACDF group (86.7% vs 77.1%; p < 0.05). The mean Neck Disability Index scores improved significantly in both groups, with cTDR significantly lower at some follow-up points. At the 24-month follow-up, a minimum 15-point improvement in Neck Disability Index scores was achieved in 92.9% of the cTDR group and 83.5% of the ACDF group (p > 0.05). In both groups, neck and arm pain scores improved significantly (p < 0.05) by 6 weeks and improvement was maintained throughout follow-up. Segmental range of motion was maintained at both treated segments in the cTDR group. MRI performed in the cTDR group at 24 months postoperatively found minimal changes in facet joint degeneration. The rate of subsequent surgical intervention was 2.2% in the cTDR group and 8.8% in the ACDF group. CONCLUSIONS This study adds to the growing body of literature supporting cTDR for 2-level cervical disc disease with radiculopathy or myelopathy. cTDR showed a superior overall success rate compared to ACDF, while maintaining motion. These results support that the Simplify disc is a viable alternative to ACDF in appropriately selected patients with 2-level cervical spondylosis.
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Affiliation(s)
- Domagoj Coric
- 1Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
- 2Atrium Musculoskeletal Institute, Charlotte, North Carolina
| | - Richard D Guyer
- 3Center for Disc Replacement at Texas Back Institute, Plano, Texas
| | - Hyun Bae
- 4Cedars-Sinai, Los Angeles, California
| | | | | | | | - Margaret O Boltes
- 1Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Donna D Ohnmeiss
- 3Center for Disc Replacement at Texas Back Institute, Plano, Texas
- 8Texas Back Institute Research Foundation, Plano, Texas
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16
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Guyer RD, Coric D, Nunley PD, Ohnmeiss DD. Cervical Total Disk Replacement: Available Implant Size Matters. Clin Spine Surg 2022; 35:166-169. [PMID: 35344516 DOI: 10.1097/bsd.0000000000001314] [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: 01/24/2022] [Accepted: 03/01/2022] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This study was a post hoc analysis of data collected from 2 Food and Drug Administration (FDA) Investigational Device Exemption (IDE) trials. OBJECTIVE The purposes of this study were to: (1) measure disk space heights adjacent to the level to be treated with a total disk replacement (TDR); (2) analyze cervical disk space heights to be replaced with TDR; and (3) investigate the frequency of use of a smaller height TDR when available. SUMMARY OF BACKGROUND DATA Cervical TDR produces outcomes noninferior or superior to anterior cervical discectomy and fusion. While the restoration of the height of a collapsed, degenerated disk is a surgical goal, there are potential problems with overdistracting the segment with an implant. METHODS Disk heights were measured using radiographs from the 1-level Simplify Cervical Artificial Disk IDE trial, producing values for 259 levels adjacent to the treated level and 162 treated levels. The device is available in 4, 5, and 6 mm heights. The 4 mm height became available only after treatment was 13% complete in the single-level trial and was available for all of the 2-level trial. RESULTS Measurements of 259 adjacent levels found that 55.2% of disk spaces had a height of <4 mm. Among operated levels, 82.7% were <4 mm. When a 4 mm TDR was available, it was used in 38.4% of operated levels in the 1-level trial and 54.3% of levels in the 2-level trial. CONCLUSIONS Among nonoperated levels, 55.2% were of height <4 mm, suggesting that TDRs of greater heights may potentially overdistract the disk space. The 4 mm TDR was selected by surgeons in 49.4% of all implanted levels, suggesting a preference for smaller TDR height. Further investigation is warranted to determine if the lower height implants are related to clinical and/or radiographic outcomes. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Richard D Guyer
- Center for Disk Replacement at Texas Back Institute, Plano, TX
| | - Domagoj Coric
- Carolina Neurosurgery and Spine Associates, Charlotte, NC
| | | | - Donna D Ohnmeiss
- Center for Disk Replacement at Texas Back Institute, Plano, TX
- Texas Back Institute Research Foundation, Plano, TX
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Mundis GM, Godzik J, Park P, Fu KM, Tran S, Uribe JS, Wang MY, Than KD, Okonkwo DO, Kanter AS, Nunley PD, Anand N, Fessler RG, Chou D, Lafage R, Eastlack RK, _ _. Prospective multicenter study of minimally invasive surgery for the treatment of adult spinal deformity. J Neurosurg Spine 2022. [DOI: 10.3171/2021.8.spine21369] [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] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Traditional surgery for adult spinal deformity (ASD) is effective but may result in exposure-related morbidity. Minimally invasive surgery (MIS) can potentially minimize this morbidity; however, high-level evidence is lacking. This study presents the first prospective multicenter investigation of MIS approaches for ASD.
METHODS
A prospective multicenter study was conducted. Inclusion criteria were age ≥ 18 years, with at least one of the following radiographic criteria: coronal Cobb (CC) angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, and thoracic kyphosis > 60°. Additional inclusion criteria were circumferential MIS, including interbody fusion (transforaminal lumbar interbody fusion [TLIF], lateral lumbar interbody fusion [LLIF], or anterior lumbar interbody fusion [ALIF]) with percutaneous posterior fixation on a minimum of 4 intervertebral levels. Radiographic and clinical outcomes (visual analog scale [VAS], Oswestry Disability Index [ODI], and Scoliosis Research Society–22 [SRS-22]) were collected preoperatively and at 12 months postoperatively; preoperative and postoperative values were compared using paired Student t-tests.
RESULTS
Seventy-five patients with a minimum 1-year follow-up were identified (75 of 111; 67.6%). The mean ± SD age was 68.8 ± 9.0 years, and 48 patients (64%) were female. Patients underwent a mean of 6.7 ± 2.9 levels of fusion with LLIF (85%), ALIF (55%), and TLIF (9%); the mean estimated blood loss was 547.6 ± 567.2 mL, and the mean length of stay was 7.0 ± 3.7 days. Significant improvements were observed in ODI (−19 ± 12.9, p < 0.001), SRS-22 (0.8 ± 0.66, p < 0.001), VAS back (−4.3 ± 2.8, p < 0.001), and VAS leg (−3.0 ± 3.2, p < 0.001) scores. Significant decreases in SVA (−26.4 ± 53.6 mm; p < 0.001), pelvic incidence–lumbar lordosis (−11.3° ± 14.9°, p < 0.001), and CC angle (−12.1° ± 11.8°, p < 0.001) were also observed. Complications occurred in 39 patients (52%); 11 patients (15%) experienced major complications, and 16 patients (21%) required reoperation.
CONCLUSIONS
MIS approaches for ASD resulted in meaningful symptomatic improvement. The complication rates were similar to historic norms, with a fairly high reoperation rate at 1 year. Longer follow-up will be necessary to evaluate the durability of this approach in the treatment of ASD.
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Affiliation(s)
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kai-Ming Fu
- Department of Neurosurgery, Weill Cornell Medical College, New York, New York
| | - Stacie Tran
- San Diego Spine Foundation, Scripps Clinic, La Jolla, California
| | - Juan S. Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Michael Y. Wang
- Department of Neurosurgery, University of Miami, Coral Gables, Florida
| | - Khoi D. Than
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam S. Kanter
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Neel Anand
- Anand Spine Group, Los Angeles, California
| | - Richard G. Fessler
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, California; and
| | - Renaud Lafage
- Department of Orthopedics, Hospital of Special Surgery, New York, New York
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18
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Chi JH, Nunley PD, Huang KT, Krag MH, Bydon M, Lavoie S, Lu Y, Driver J, Stone MB. Two-Year Outcomes From a Prospective Multicenter Investigation Device Trial of a Novel Conformal Mesh Interbody Fusion Device. Int J Spine Surg 2022; 15:1103-1114. [PMID: 35078899 DOI: 10.14444/8169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/20/2022] Open
Abstract
BACKGROUND Interbody fusion is a widely utilized and accepted procedure to treat advanced debilitating lumbar degenerative disc disease (DDD). Increasingly, surgeons are seeking interbody devices that are large for stability and grafting purposes but can be inserted with less invasive techniques. To achieve these contrary objectives a novel, conformable mesh interbody fusion device was designed to be placed in the disc space through a small portal and filled with bone graft in situ to a large size. This design can reduce the risk of trauma to surrounding structures while creating a large graft footprint that intimately contours to the patient's own anatomy. The purpose of this Investigational Device Exempt (IDE) trial was to evaluate the perioperative and long-term results of this novel conformable mesh interbody fusion device. METHODS This investigation is a prospective, multicenter, single-arm, Food and Drug Administration and Institutional Review Board-approved IDE, performance goal trial. A total of 102 adults presenting with DDD at a single level between L2 and S1 and unresponsive to 6 months conservative care had instrumented lumbar interbody fusion. Validated assessment tools include 100 mm visual analog scale for pain, Oswestry Disability Index (ODI) for function, single question survey for patient satisfaction, and computed tomography (CT) scan for fusion. Patients were enrolled across 10 geographically distributed sites. Pain/ODI surveys, physical evaluations, and imaging were performed serially through 24 months. Specifically, CT was performed at 12 and, if not fused, 24 months. Independent radiologists assessed CTs for fusion. An independent committee adjudicated adverse events. Patients with complete data at 24 months were included in the analysis. RESULTS Ninety-six (96, 94% follow-up rate) patients (57.0 ± 12.0 years, 50.0% female, Body Mass Index 30.6 ± 4.9) reported average decreased low back pain from baseline of 45.0 ± 26.6 at 6 weeks and 51.4 ± 26.2 at 24 months. Right/left leg pain reduced by 28.9 ± 36.7/37.8±32.4 at 6 weeks and 30.5±33.0/40.3 34.6 at 24 months. Mean ODI improved 17.1 ± 18.7 from baseline to 6 weeks and 32.0 ± 18.5 by 24 months. At 24 months, 91.7% of patients rated their procedure as excellent/good. Fusion rates were 97.9% (94/96) at 12 months, and 99% (95/96) at 24 months. Mean operative time, estimated blood loss, and length of stay were 2.6 ± 0.9 hours, 137 ± 217 mL, and 2.3 ± 1.2 days, respectively. No device-related serious adverse events have occurred. CONCLUSIONS Clinically significant outcomes for pain, function, fusion, and device safety were demonstrated in this population. Substantial clinical improvements occur by 6 weeks postoperative and continue to improve to 24 months. The successful outcomes observed in this trial support use of this novel device in an instrumented lumbar interbody fusion. LEVEL OF EVIDENCE 3. CLINICAL RELEVANCE This reports substantiates that the preliminary 1-year findings published earlier for this investigation are confirmed and the fusion rates and that patient improvements reported are sustained through 2 years.
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Affiliation(s)
- John H Chi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School
| | | | - Kevin T Huang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School
| | - Martin H Krag
- Department of Orthopedic Surgery, University of Vermont Medical Center
| | | | | | - Yi Lu
- Spine Institute of Louisiana
| | - Joseph Driver
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School
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Chan AK, Eastlack RK, Fessler RG, Than KD, Chou D, Fu KM, Park P, Wang MY, Kanter AS, Okonkwo DO, Nunley PD, Anand N, Uribe JS, Mundis GM, Bess S, Shaffrey CI, Le VP, Mummaneni PV. Two- and three-year outcomes of minimally invasive and hybrid correction of adult spinal deformity. J Neurosurg Spine 2021; 36:595-608. [PMID: 34740175 DOI: 10.3171/2021.7.spine21138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous studies have demonstrated the short-term radiographic and clinical benefits of circumferential minimally invasive surgery (cMIS) and hybrid (i.e., minimally invasive anterior or lateral interbody fusion with an open posterior approach) techniques to correct adult spinal deformity (ASD). However, it is not known if these benefits are maintained over longer periods of time. This study evaluated the 2- and 3-year outcomes of cMIS and hybrid correction of ASD. METHODS A multicenter database was retrospectively reviewed for patients undergoing cMIS or hybrid surgery for ASD. Patients were ≥ 18 years of age and had one of the following: maximum coronal Cobb angle (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic incidence-lumbar lordosis mismatch (PI-LL) ≥ 10°, or pelvic tilt (PT) > 20°. Radiographic parameters were evaluated at the latest follow-up. Clinical outcomes were compared at 2- and 3-year time points and adjusted for age, preoperative CC, levels operated, levels with interbody fusion, presence of L5-S1 anterior lumbar interbody fusion, and upper and lower instrumented vertebral level. RESULTS Overall, 197 (108 cMIS, 89 hybrid) patients were included with 187 (99 cMIS, 88 hybrid) and 111 (60 cMIS, 51 hybrid) patients evaluated at 2 and 3 years, respectively. The mean (± SD) follow-up duration for cMIS (39.0 ± 13.3 months, range 22-74 months) and hybrid correction (39.9 ± 16.8 months, range 22-94 months) were similar for both cohorts. Hybrid procedures corrected the CC greater than the cMIS technique (adjusted p = 0.022). There were no significant differences in postoperative SVA, PI-LL, PT, and sacral slope (SS). At 2 years, cMIS had lower Oswestry Disability Index (ODI) scores (adjusted p < 0.001), greater ODI change as a percentage of baseline (adjusted p = 0.006), less visual analog scale (VAS) back pain (adjusted p = 0.006), and greater VAS back pain change as a percentage of baseline (adjusted p = 0.001) compared to hybrid techniques. These differences were no longer significant at 3 years. At 3 years, but not 2 years, VAS leg pain was lower for cMIS compared to hybrid techniques (adjusted p = 0.032). Those undergoing cMIS had fewer overall complications compared to hybrid techniques (adjusted p = 0.006), but a higher odds of pseudarthrosis (adjusted p = 0.039). CONCLUSIONS In this review of a multicenter database for patients undergoing cMIS and hybrid surgery for ASD, hybrid procedures were associated with a greater CC improvement compared to cMIS techniques. cMIS was associated with superior ODI and back pain at 2 years, but this difference was no longer evident at 3 years. However, cMIS was associated with superior leg pain at 3 years. There were fewer complications following cMIS, with the exception of pseudarthrosis.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Richard G Fessler
- 3Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Khoi D Than
- 4Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Kai-Ming Fu
- 5Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Paul Park
- 6Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Michael Y Wang
- 7Department of Neurosurgery, University of Miami, Florida
| | - Adam S Kanter
- 8Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David O Okonkwo
- 8Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Neel Anand
- 10Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Juan S Uribe
- 11Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | | | - Shay Bess
- 12Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | | | - Vivian P Le
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
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20
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Guyer RD, Coric D, Nunley PD, Sasso RC, Musacchio M, Bae HW, Peloza JH, Ohnmeiss DD. Single-Level Cervical Disc Replacement Using a PEEK-on-Ceramic Implant: Results of a Multicenter FDA IDE Trial With 24-Month Follow-up. Int J Spine Surg 2021; 15:633-644. [PMID: 34281951 DOI: 10.14444/8084] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 01/25/2023] Open
Abstract
BACKGROUND Many early cervical total disc replacements (TDRs) produced motion through a ball-and-socket action, with metal endplates articulating with a plastic core. Polyetheretherketone (PEEK) is used increasingly for spinal implants due to its mechanical properties and lack of artifacts on imaging. A TDR was designed with titanium-coated PEEK endplates and a ceramic core. The purpose of this study was to compare this TDR with anterior cervical discectomy and fusion (ACDF) to treat single-level cervical disc degeneration. METHODS This was a prospective, nonrandomized, historically controlled, multicenter US Food and Drug Administration (FDA) Investigational Device Exemption (IDE) trial. Patients received the PEEK-on-ceramic Simplify® Cervical Artificial Disc (n = 150). The historic control group included 117 propensity-matched ACDF patients from an earlier IDE trial. The primary outcome was a composite success classification at the 24-month follow-up. Outcome measures included the Neck Disability Index (NDI), neurological status, adverse events, subsequent surgery, a visual analog scale assessing neck and arm pain, and the Dysphagia Handicap Index. Radiographic assessment included flexion/extension range of motion and heterotopic ossification. Facet joints were assessed at 24 months using MRI. RESULTS The success rate was significantly greater in the TDR group vs the ACDF group (93.0% vs 73.6%; P < .001). Mean NDI, neck pain, and arm pain scores improved significantly in both groups at all follow-up points. Mean NDI scores in the TDR group were significantly lower than ACDF scores at all follow-up points. There were no significant differences in the rates of serious adverse events. The range of motion of the TDR level had increased significantly by 3 months and remained so throughout follow-up. Facet joint assessment by MRI in the TDR group showed little change from preoperation. CONCLUSIONS The TDR had an acceptable safety profile and a significantly greater composite success rate than ACDF. These results support that the PEEK-on-ceramic TDR is a viable alternative to ACDF for single-level symptomatic disc degeneration. CLINICAL RELEVANCE This study found that the PEEK-on-ceramic TDR is a viable treatment for symptoms related to cervical disc degeneration and offers similar or superior outcomes compared with fusion. LEVEL OF EVIDENCE 2.
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Affiliation(s)
- Richard D Guyer
- Center for Disc Replacement at Texas Back Institute, Plano, Texas
| | - Domagoj Coric
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | | | | | | | - Hyun W Bae
- The Spine Institute, Los Angeles, California
| | | | - Donna D Ohnmeiss
- Center for Disc Replacement at Texas Back Institute, Plano, Texas.,Texas Back Institute Research Foundation, Plano, Texas
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Mummaneni PV, Hussain I, Shaffrey CI, Eastlack RK, Mundis GM, Uribe JS, Fessler RG, Park P, Robinson L, Rivera J, Chou D, Kanter AS, Okonkwo DO, Nunley PD, Wang MY, Marca FL, Than KD, Fu KM. The minimally invasive interbody selection algorithm for spinal deformity. J Neurosurg Spine 2021:1-8. [PMID: 33711811 DOI: 10.3171/2020.9.spine20230] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 03/23/2020] [Accepted: 09/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Minimally invasive surgery (MIS) for spinal deformity uses interbody techniques for correction, indirect decompression, and arthrodesis. Selection criteria for choosing a particular interbody approach are lacking. The authors created the minimally invasive interbody selection algorithm (MIISA) to provide a framework for rational decision-making in MIS for deformity. METHODS A retrospective data set of circumferential MIS (cMIS) for adult spinal deformity (ASD) collected over a 5-year period was analyzed by level in the lumbar spine to identify surgeon preferences and evaluate segmental lordosis outcomes. These data were used to inform a Delphi session of minimally invasive deformity surgeons from which the algorithm was created. The algorithm leads to 1 of 4 interbody approaches: anterior lumbar interbody fusion (ALIF), anterior column release (ACR), lateral lumbar interbody fusion (LLIF), and transforaminal lumbar interbody fusion (TLIF). Preoperative and 2-year postoperative radiographic parameters and clinical outcomes were compared. RESULTS Eleven surgeons completed 100 cMISs for ASD with 338 interbody devices, with a minimum 2-year follow-up. The type of interbody approach used at each level from L1 to S1 was recorded. The MIISA was then created with substantial agreement. The surgeons generally preferred LLIF for L1-2 (91.7%), L2-3 (85.2%), and L3-4 (80.7%). ACR was most commonly performed at L3-4 (8.4%) and L2-3 (6.2%). At L4-5, LLIF (69.5%), TLIF (15.9%), and ALIF (9.8%) were most commonly utilized. TLIF and ALIF were the most selected approaches at L5-S1 (61.4% and 38.6%, respectively). Segmental lordosis at each level varied based on the approach, with greater increases reported using ALIF, especially at L4-5 (9.2°) and L5-S1 (5.3°). A substantial increase in lordosis was achieved with ACR at L2-3 (10.9°) and L3-4 (10.4°). Lateral interbody arthrodesis without the use of an ACR did not generally result in significant lordosis restoration. There were statistically significant improvements in lumbar lordosis (LL), pelvic incidence-LL mismatch, coronal Cobb angle, and Oswestry Disability Index at the 2-year follow-up. CONCLUSIONS The use of the MIISA provides consistent guidance for surgeons who plan to perform MIS for deformity. For L1-4, the surgeons preferred lateral approaches to TLIF and reserved ACR for patients who needed the greatest increase in segmental lordosis. For L4-5, the surgeons' order of preference was LLIF, TLIF, and ALIF, but TLIF failed to demonstrate any significant lordosis restoration. At L5-S1, the surgical team typically preferred an ALIF when segmental lordosis was desired and preferred a TLIF if preoperative segmental lordosis was adequate.
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Affiliation(s)
- Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Ibrahim Hussain
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Christopher I Shaffrey
- 3Departments of Neurological Surgery and Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Robert K Eastlack
- 4Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, California
| | - Gregory M Mundis
- 4Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, California
| | - Juan S Uribe
- 5Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Paul Park
- 7Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | | | | | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Adam S Kanter
- 10Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David O Okonkwo
- 10Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pierce D Nunley
- 11Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Michael Y Wang
- 2Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Frank La Marca
- 12Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan; and
| | - Khoi D Than
- 3Departments of Neurological Surgery and Orthopedic Surgery, Duke University, Durham, North Carolina
| | - Kai-Ming Fu
- 13Department of Neurological Surgery, Weill Cornell Medical College, New York, New York
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Loenen ACY, Noriega DC, Ruiz Wills C, Noailly J, Nunley PD, Kirchner R, Ito K, van Rietbergen B. Misaligned spinal rods can induce high internal forces consistent with those observed to cause screw pullout and disc degeneration. Spine J 2021; 21:528-537. [PMID: 33007470 DOI: 10.1016/j.spinee.2020.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Received: 06/09/2020] [Revised: 08/31/2020] [Accepted: 09/24/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Manual contouring of spinal rods is often required intraoperatively for proper alignment of the rods within the pedicle screw heads. Residual misalignments are frequently reduced by using dedicated reduction devices. The forces exerted by these devices, however, are uncontrolled and may lead to excessive reaction forces. As a consequence, screw pullout might be provoked and surrounding tissue may experience unfavorable biomechanical loads. The corresponding loads and induced tissue deformations are however not well identified. Additionally, whether the forced reduction alters the biomechanical behavior of the lumbar spine during physiological movements postoperatively, remains unexplored. PURPOSE To predict whether the reduction of misaligned posterior instrumentation might result in clinical complications directly after reduction and during a subsequent physiological flexion movement. STUDY DESIGN Finite element analysis. METHODS A patient-specific, total lumbar (L1-S1) spine finite element model was available from previous research. The model consists of poro-elastic intervertebral discs with Pfirrmann grade-dependent material parameters, with linear elastic bone tissue with stiffness values related to the local bone density, and with the seven major ligaments per spinal motion segment described as nonlinear materials. Titanium instrumentation was implemented in this model to simulate a L4, L5, and S1 posterolateral fusion. Next, coronal and sagittal misalignments of 6 mm each were introduced between the rod and the screw head at L4. These misalignments were computationally reduced and a physiological flexion movement of 15° was prescribed. Non-instrumented and well-aligned instrumented models were used as control groups. RESULTS Pulling forces up to 1.0 kN were required to correct the induced misalignments of 6 mm. These forces affected the posture of the total lumbar spine, as motion segments were predicted to rotate up to 3 degrees and rotations propagated proximally to and even affect the L1-2 level. The facet contact pressures in the corrected misaligned models were asymmetrical suggesting non-physiological joint loading in the misaligned models. In addition, the discs and vertebrae experienced abnormally high forces as a result of the correction procedure. These effects were more pronounced after a 15° flexion movement following forced reduction. CONCLUSIONS The results of this study indicate that the correction of misaligned posterior instrumentation can result in high forces at the screws consistent with those reported to cause screw pullout, and may cause high-tissue strains in adjacent and downstream spinal segments. CLINICAL SIGNIFICANCE Proper alignment of spinal posterior instrumentation may reduce clinical complications secondary to unfavorable biomechanics.
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Affiliation(s)
- Arjan C Y Loenen
- Department of Orthopaedic Surgery, Laboratory for Experimental Orthopaedics, CAPHRI, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - David C Noriega
- Spine-Unit, University Hospital of Valladolid, Valladolid, Spain
| | - Carlos Ruiz Wills
- Department of Information and Communication Technologies, Barcelona Centre for New Medical Technologies (BCN MedTech), Universitat Pompeu Fabra, Barcelona, Spain
| | - Jérôme Noailly
- Department of Information and Communication Technologies, Barcelona Centre for New Medical Technologies (BCN MedTech), Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Rainer Kirchner
- Department of Orthopaedic Surgery and Trauma Surgery, Clinics Husum and Niebüll, Husum, Germany
| | - Keita Ito
- Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Bert van Rietbergen
- Department of Orthopaedic Surgery, Laboratory for Experimental Orthopaedics, CAPHRI, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Biomedical Engineering, Orthopaedic Biomechanics, Eindhoven University of Technology, Eindhoven, the Netherlands.
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23
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Ferrara L, Ford W, Nunley PD, Boyan BD, Stone MB. Critical Evaluation of Biomechanical Principles and Radiographic Indicators for Fusion Assessment in a Novel Conformable Porous Mesh Implant. Int J Spine Surg 2020; 14:S108-S114. [DOI: 10.14444/7133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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24
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Ferrara LA, Nunley PD, Stone MB. Load Share Mapping for Traditional PEEK vs Novel Hybrid PEEK With Expandable Porous Mesh Intervertebral Devices. Int J Spine Surg 2020; 14:S115-S120. [DOI: 10.14444/7134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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25
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Nunley PD, Kerr EJ, Cavanaugh DA, Utter PA, Campbell PG, Wadhwa R, Frank KA, Marshall KE, Stone MB. Adjacent Segment Pathology After Treatment With Cervical Disc Arthroplasty or Anterior Cervical Discectomy and Fusion, Part 2: Clinical Results at 7-Year Follow-Up. Int J Spine Surg 2020; 14:278-285. [PMID: 32699748 DOI: 10.14444/7037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 12/12/2022] Open
Abstract
Background Adjacent segment pathology (ASP) following cervical disc arthroplasty (CDA) or anterior cervical discectomy and fusion (ACDF) is identified by imaging (RASP) or clinical symptoms (CASP). Clinical symptoms of CASP have been broadly defined, but subsequent adjacent-level surgeries are clear indicators of CASP. Current literature remains inconsistent in the incidence and potential predictors of CASP. Here, we will evaluate a robust data set for the incidence of CASP resulting in subsequent surgery, attempt to identify factors that might affect CASP, and analyze the association of CASP with patient-reported outcomes (PROS) and RASP. Methods Data were prospectively collected during a US Food and Drug Administration randomized, multicenter, investigational device exemption trial comparing CDA (Mobi-C, Zimmer Biomet, Westminster, CO) with ACDF. CASP was defined as any adjacent-level subsequent surgical intervention. Post hoc analyses were conducted on the incidence, time to CASP diagnosis, and relationship of CASP with patient demographics. Longitudinal retrospective case-control analysis was used to assess the correlation of CASP to PROs and radiographic adjacent segment pathology (RASP). Results Kaplan-Meier estimates indicated significantly lower probability of CASP over time for 1-level (P = .002) and 2-level (P = .008) CDA patients. Treatment with ACDF and younger age were associated with higher CASP risk. CDA was more effective than ACDF (70.5%; 95% CI = 45.1, 84.2; P < .0001) at preventing CASP. Case-control analysis indicated increased probability of CASP for patients with grade 3/4 RASP, but the difference was not statistically significant. When we pooled CASP patients, the median grade of RASP at the visit prior to surgery was 1, with only 6 patients presenting with grade 3/4 RASP. Conclusions Patients treated with CDA have a lower incidence of CASP than do patients treated with ACDF, although the mechanism remains unclear. CASP and RASP remain uncorrelated in this large data set, but other predictive variables such as treatment, age, and number of levels should be further investigated.
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Affiliation(s)
| | | | | | | | | | - Rishi Wadhwa
- Spine Institute of Louisiana, Shreveport, Louisiana
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26
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Nunley PD, Kerr EJ, Cavanaugh DA, Utter PA, Campbell PG, Wadhwa R, Frank KA, Marshall KE, Stone MB. Adjacent Segment Pathology After Treatment With Cervical Disc Arthroplasty or Anterior Cervical Discectomy and Fusion, Part 1: Radiographic Results at 7-Year Follow-Up. Int J Spine Surg 2020; 14:269-277. [PMID: 32699747 DOI: 10.14444/7036] [Citation(s) in RCA: 4] [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: 12/14/2022] Open
Abstract
Background Adjacent segment pathology (ASP) remains a concern following treatment with cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF). Radiographic ASP (RASP) is ASP identified on imaging, which may or may not include clinical symptoms. The risk factors for development of RASP and its clinical effects remain controversial. In part 1 of a 2-part publication we evaluate the incidence and predictors of RASP as well as determine whether any association exists between RASP and patient-reported outcomes (PROs). Methods Data were prospectively collected during a US Food and Drug Administration randomized, multicenter, investigational device exemption trial comparing CDA (Mobi-C; Zimmer Biomet, Westminster, CO) with ACDF. Multiple post hoc analyses were conducted on RASP as it related to demographics and patient outcomes. Kaplan-Meier estimates of time to Kellgren-Lawrence (K-L) grade 3/4 were calculated separately for all groups. Multivariate Cox proportional hazard models were used analyze whether RASP was associated with patient preoperative demographic characteristics and preoperative and postoperative radiographic characteristics. The association of RASP with PROs was analyzed using generalized estimating equations and matched, retrospective cohort analysis. Results The incidence of grade 3/4 RASP was lower for patients treated with CDA when initial treatment was at 1 level (27% vs 47%, P < .0001) and at 2 levels (14% vs 49%, P < .0001). Kaplan-Meier estimates indicated significantly lower probability of grade 3/4 RASP over time for patients receiving CDA (P < .001). Treatment with ACDF, treatment of 1 level, higher age, body mass index, higher preoperative physical components score, and a lower Cobb angle were associated with elevated risk of grade 3/4 RASP. CDA was shown to be more effective than ACDF (64.4%; 95% CI = 50.9, 74.2; P < .0001) at preventing RASP. Conclusions The incidence and risk of RASP is decreased when patients are treated with CDA compared with ACDF. Although the mechanism of CDA that generates this protective effect is not understood, PROs remain unaffected through 7 years despite changes in RASP.
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Affiliation(s)
| | | | | | | | | | - Rishi Wadhwa
- Spine Institute of Louisiana, Shreveport, Louisiana
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27
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Park P, Than KD, Mummaneni PV, Nunley PD, Eastlack RK, Uribe JS, Wang MY, Le V, Fessler RG, Okonkwo DO, Kanter AS, Anand N, Chou D, Fu KMG, Haddad AF, Shaffrey CI, Mundis GM. Factors affecting approach selection for minimally invasive versus open surgery in the treatment of adult spinal deformity: analysis of a prospective, nonrandomized multicenter study. J Neurosurg Spine 2020; 33:601-606. [PMID: 32559745 DOI: 10.3171/2020.4.spine20169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 02/07/2020] [Accepted: 04/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgical decision-making and planning is a key factor in optimizing outcomes in adult spinal deformity (ASD). Minimally invasive spinal (MIS) strategies for ASD have been increasingly used as an option to decrease postoperative morbidity. This study analyzes factors involved in the selection of either a traditional open approach or a minimally invasive approach to treat ASD in a prospective, nonrandomized multicenter trial. All centers had at least 5 years of experience in minimally invasive techniques for ASD. METHODS The study enrolled 268 patients, of whom 120 underwent open surgery and 148 underwent MIS surgery. Inclusion criteria included age ≥ 18 years, and at least one of the following criteria: coronal curve (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, or thoracic kyphosis (TK) > 60°. Surgical approach selection was made at the discretion of the operating surgeon. Preoperative significant differences were included in a multivariate logistic regression analysis to determine odds ratios (ORs) for approach selection. RESULTS Significant preoperative differences (p < 0.05) between open and MIS groups were noted for age (61.9 vs 66.7 years), numerical rating scale (NRS) back pain score (7.8 vs 7), CC (36° vs 26.1°), PT (26.4° vs 23°), T1 pelvic angle (TPA; 25.8° vs 21.7°), and pelvic incidence-lumbar lordosis (PI-LL; 19.6° vs 14.9°). No significant differences in BMI (29 vs 28.5 kg/m2), NRS leg pain score (5.2 vs 5.7), Oswestry Disability Index (48.4 vs 47.2), Scoliosis Research Society 22-item questionnaire score (2.7 vs 2.8), PI (58.3° vs 57.1°), LL (38.9° vs 42.3°), or SVA (73.8 mm vs 60.3 mm) were found. Multivariate analysis found that age (OR 1.05, p = 0.002), VAS back pain score (OR 1.21, p = 0.016), CC (OR 1.03, p < 0.001), decompression (OR 4.35, p < 0.001), and TPA (OR 1.09, p = 0.023) were significant factors in approach selection. CONCLUSIONS Increasing age was the primary driver for selecting MIS surgery. Conversely, increasingly severe deformities and the need for open decompression were the main factors influencing the selection of traditional open surgery. As experience with MIS surgery continues to accumulate, future longitudinal evaluation will reveal if more experience, use of specialized treatment algorithms, refinement of techniques, and technology will expand surgeon adoption of MIS techniques for adult spinal deformity.
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Affiliation(s)
- Paul Park
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Khoi D Than
- 2Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Praveen V Mummaneni
- 3Department of Neurosurgery, University of California, San Francisco, California
| | | | - Robert K Eastlack
- 5Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
| | - Juan S Uribe
- 6Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael Y Wang
- 7Department of Neurosurgery, University of Miami, Florida
| | - Vivian Le
- 3Department of Neurosurgery, University of California, San Francisco, California
| | - Richard G Fessler
- 8Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - David O Okonkwo
- 9Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam S Kanter
- 9Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Neel Anand
- 10Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Dean Chou
- 3Department of Neurosurgery, University of California, San Francisco, California
| | - Kai-Ming G Fu
- 11Department of Neurosurgery, Cornell Medical Center, New York, New York
| | - Alexander F Haddad
- 12School of Medicine, University of California, San Francisco, California; and
| | - Christopher I Shaffrey
- 13Departments of Orthopaedic Surgery and Neurosurgery, Duke University, Durham, North Carolina
| | - Gregory M Mundis
- 5Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, California
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28
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Mummaneni PV, Park P, Shaffrey CI, Wang MY, Uribe JS, Fessler RG, Chou D, Kanter AS, Okonkwo DO, Mundis GM, Eastlack RK, Nunley PD, Anand N, Virk MS, Lenke LG, Than KD, Robinson LC, Fu KM, _ _. The MISDEF2 algorithm: an updated algorithm for patient selection in minimally invasive deformity surgery. J Neurosurg Spine 2020; 32:221-228. [DOI: 10.3171/2019.7.spine181104] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 07/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVEMinimally invasive surgery (MIS) can be used as an alternative or adjunct to traditional open techniques for the treatment of patients with adult spinal deformity. Recent advances in MIS techniques, including advanced anterior approaches, have increased the range of candidates for MIS deformity surgery. The minimally invasive spinal deformity surgery (MISDEF2) algorithm was created to provide an updated framework for decision-making when considering MIS techniques in correction of adult spinal deformity.METHODSA modified algorithm was developed that incorporates a patient’s preoperative radiographic parameters and leads to one of 4 general plans ranging from basic to advanced MIS techniques to open deformity surgery with osteotomies. The authors surveyed 14 fellowship-trained spine surgeons experienced with spinal deformity surgery to validate the algorithm using a set of 24 cases to establish interobserver reliability. They then re-surveyed the same surgeons 2 months later with the same cases presented in a different sequence to establish intraobserver reliability. Responses were collected and analyzed. Correlation values were determined using SPSS software.RESULTSOver a 3-month period, 14 fellowship-trained deformity surgeons completed the surveys. Responses for MISDEF2 algorithm case review demonstrated an interobserver kappa of 0.85 for the first round of surveys and an interobserver kappa of 0.82 for the second round of surveys, consistent with substantial agreement. In at least 7 cases, there was perfect agreement between the reviewing surgeons. The mean intraobserver kappa for the 2 surveys was 0.8.CONCLUSIONSThe MISDEF2 algorithm was found to have substantial inter- and intraobserver agreement. The MISDEF2 algorithm incorporates recent advances in MIS surgery. The use of the MISDEF2 algorithm provides reliable guidance for surgeons who are considering either an MIS or an open approach for the treatment of patients with adult spinal deformity.
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Affiliation(s)
- Praveen V. Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Paul Park
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Christopher I. Shaffrey
- 3Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Juan S. Uribe
- 5Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
| | - Richard G. Fessler
- 6Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Adam S. Kanter
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | - Neel Anand
- 10Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael S. Virk
- 11Department of Neurosurgery, Cornell Medical Center, New York, New York
| | | | - Khoi D. Than
- 13Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Leslie C. Robinson
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Kai-Ming Fu
- 11Department of Neurosurgery, Cornell Medical Center, New York, New York
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29
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Horn SR, Passias PG, Oh C, Lafage V, Lafage R, Smith JS, Line B, Anand N, Segreto FA, Bortz CA, Scheer JK, Eastlack RK, Deviren V, Mummaneni PV, Daniels AH, Park P, Nunley PD, Kim HJ, Klineberg EO, Burton DC, Hart RA, Schwab FJ, Bess S, Shaffrey CI, Ames CP, _ _. Predicting the combined occurrence of poor clinical and radiographic outcomes following cervical deformity corrective surgery. J Neurosurg Spine 2020; 32:182-190. [DOI: 10.3171/2019.7.spine18651] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/09/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVECervical deformity (CD) correction is clinically challenging. There is a high risk of developing complications with these highly complex procedures. The aim of this study was to use baseline demographic, clinical, and surgical factors to predict a poor outcome following CD surgery.METHODSThe authors performed a retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: cervical kyphosis (C2–7 Cobb angle > 10°), cervical scoliosis (coronal Cobb angle > 10°), C2–7 sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical angle (CBVA) > 25°. Patients were categorized based on having an overall poor outcome or not. Health-related quality of life measures consisted of Neck Disability Index (NDI), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scale scores. A poor outcome was defined as having all 3 of the following categories met: 1) radiographic poor outcome: deterioration or severe radiographic malalignment 1 year postoperatively for cSVA or T1 slope–cervical lordosis mismatch (TS-CL); 2) clinical poor outcome: failing to meet the minimum clinically important difference (MCID) for NDI or having a severe mJOA Ames modifier; and 3) complications/reoperation poor outcome: major complication, death, or reoperation for a complication other than infection. Univariate logistic regression followed by multivariate regression models was performed, and internal validation was performed by calculating the area under the curve (AUC).RESULTSIn total, 89 patients with CD were included (mean age 61.9 years, female sex 65.2%, BMI 29.2 kg/m2). By 1 year postoperatively, 18 (20.2%) patients were characterized as having an overall poor outcome. For radiographic poor outcomes, patients’ conditions either deteriorated or remained severe for TS-CL (73% of patients), cSVA (8%), horizontal gaze (34%), and global SVA (28%). For clinical poor outcomes, 80% and 60% of patients did not reach MCID for EQ-5D and NDI, respectively, and 24% of patients had severe symptoms (mJOA score 0–11). For the complications/reoperation poor outcome, 28 patients experienced a major complication, 11 underwent a reoperation, and 1 had a complication-related death. Of patients with a poor clinical outcome, 75% had a poor radiographic outcome; 35% of poor radiographic and 37% of poor clinical outcome patients had a major complication. A poor outcome was predicted by the following combination of factors: osteoporosis, baseline neurological status, use of a transition rod, number of posterior decompressions, baseline pelvic tilt, T2–12 kyphosis, TS-CL, C2–T3 SVA, C2–T1 pelvic angle (C2 slope), global SVA, and number of levels in maximum thoracic kyphosis. The final model predicting a poor outcome (AUC 86%) included the following: osteoporosis (OR 5.9, 95% CI 0.9–39), worse baseline neurological status (OR 11.4, 95% CI 1.8–70.8), baseline pelvic tilt > 20° (OR 0.92, 95% CI 0.85–0.98), > 9 levels in maximum thoracic kyphosis (OR 2.01, 95% CI 1.1–4.1), preoperative C2–T3 SVA > 5.4 cm (OR 1.01, 95% CI 0.9–1.1), and global SVA > 4 cm (OR 3.2, 95% CI 0.09–10.3).CONCLUSIONSOf all CD patients in this study, 20.2% had a poor overall outcome, defined by deterioration in radiographic and clinical outcomes, and a major complication. Additionally, 75% of patients with a poor clinical outcome also had a poor radiographic outcome. A poor overall outcome was most strongly predicted by severe baseline neurological deficit, global SVA > 4 cm, and including more of the thoracic maximal kyphosis in the construct.
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Affiliation(s)
- Samantha R. Horn
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Peter G. Passias
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Cheongeun Oh
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Virginie Lafage
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Renaud Lafage
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Justin S. Smith
- 3Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Breton Line
- 4Denver International Spine Center, Presbyterian/St. Luke’s Medical Center and Rocky Mountain Hospital for Children, Denver, Colorado
| | - Neel Anand
- 5Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Frank A. Segreto
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Cole A. Bortz
- 1Department of Orthopaedics, NYU Langone Medical Center–Orthopaedic Hospital, New York, New York
| | - Justin K. Scheer
- 6Department of Neurosurgery, University of Illinois at Chicago, Illinois
| | - Robert K. Eastlack
- 7Department of Orthopaedic Surgery, Scripps Health, La Jolla, California
| | - Vedat Deviren
- 8Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Praveen V. Mummaneni
- 8Department of Orthopaedic Surgery, University of California, San Francisco, California
| | - Alan H. Daniels
- 9Department of Orthopaedic Surgery, Brown University Medical Center, Providence, Rhode Island
| | - Paul Park
- 10Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Pierce D. Nunley
- 11Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Han Jo Kim
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric O. Klineberg
- 12Department of Orthopedic Surgery, University of California Davis, Sacramento, California
| | - Douglas C. Burton
- 13Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Robert A. Hart
- 14Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, Washington; and
| | - Frank J. Schwab
- 2Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- 4Denver International Spine Center, Presbyterian/St. Luke’s Medical Center and Rocky Mountain Hospital for Children, Denver, Colorado
| | - Christopher I. Shaffrey
- 3Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher P. Ames
- 15Department of Neurological Surgery, University of California, San Francisco, California
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Campbell PG, Nunley PD, Cavanaugh D, Kerr E, Utter PA, Frank K, Stone M. Short-term outcomes of lateral lumbar interbody fusion without decompression for the treatment of symptomatic degenerative spondylolisthesis at L4-5. Neurosurg Focus 2019; 44:E6. [PMID: 29290128 DOI: 10.3171/2017.10.focus17566] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [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: 11/06/2022]
Abstract
OBJECTIVE Recently, authors have called into question the utility and complication index of the lateral lumbar interbody fusion procedure at the L4-5 level. Furthermore, the need for direct decompression has also been debated. Here, the authors report the clinical and radiographic outcomes of transpsoas lumbar interbody fusion, relying only on indirect decompression to treat patients with neurogenic claudication secondary to Grade 1 and 2 spondylolisthesis at the L4-5 level. METHODS The authors conducted a retrospective evaluation of 18 consecutive patients with Grade 1 or 2 spondylolisthesis from a prospectively maintained database. All patients underwent a transpsoas approach, followed by posterior percutaneous instrumentation without decompression. The Oswestry Disability Index (ODI) and SF-12 were administered during the clinical evaluations. Radiographic evaluation was also performed. The mean follow-up was 6.2 months. RESULTS Fifteen patients with Grade 1 and 3 patients with Grade 2 spondylolisthesis were identified and underwent fusion at a total of 20 levels. The mean operative time was 165 minutes for the combined anterior and posterior phases of the operation. The estimated blood loss was 113 ml. The most common cage width in the anteroposterior dimension was 22 mm (78%). Anterior thigh dysesthesia was identified on detailed sensory evaluation in 6 of 18 patients (33%); all patients experienced resolution within 6 months postoperatively. No patient had lasting sensory loss or motor deficit. The average ODI score improved 26 points by the 6-month follow-up. At the 6-month follow-up, the SF-12 mean Physical and Mental Component Summary scores improved by 11.9% and 9.6%, respectively. No patient required additional decompression postoperatively. CONCLUSIONS This study offers clinical results to establish lateral lumbar interbody fusion as an effective technique for the treatment of Grade 1 or 2 degenerative spondylolisthesis at L4-5. The use of this surgical approach provides a minimally invasive solution that offers excellent arthrodesis rates as well as favorable clinical and radiological outcomes, with low rates of postoperative complications. However, adhering to the techniques of transpsoas lateral surgery, such as minimal table break, an initial look-and-see approach to the psoas, clear identification of the plexus, minimal cranial caudal expansion of the retractor, mobilization of any traversing sensory nerves, and total psoas dilation times less than 20 minutes, ensures the lowest possible complication profile for both visceral and neural injuries even in the narrow safe zones when accessing the L4-5 disc space in patients with degenerative spondylolisthesis.
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Affiliation(s)
| | | | | | | | | | - Kelly Frank
- 3Clinical Research, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Marcus Stone
- 3Clinical Research, Spine Institute of Louisiana, Shreveport, Louisiana
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Eastlack R, Uribe JS, Fessler RG, Than KD, Tran S, Fu KMG, Park P, Wang MY, Kanter AS, Okonkwo DO, Nunley PD, Anand N, Mundis GM, Mummaneni PV, Chou D. Treatment of Adult Scoliosis Fractional Curve With Minimally Invasive Surgery: Anterior Versus Posterior Approach? Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Park P, Than KD, Nunley PD, Eastlack R, Uribe JS, Wang MY, Tran S, Fessler RG, Okonkwo DO, Kanter AS, Anand N, Chou D, Fu KMG, Mundis GM. Choosing Minimally Invasive Versus Open Surgery in the Treatment of Adult Spinal Deformity (ASD): Analysis of a Prospective, Nonrandomized Multi-Center Study. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lu Y, Wu K, Krag MH, Lavoie S, Bydon M, Nunley PD, Chi JH. SCOUT IDE Investigation: 1-Year Clinical Findings for a Conforming Porous Polymeric Lumbar Interbody Fusion Device. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kanter AS, Eastlack R, Uribe JS, Fessler RG, Than KD, Tran S, Chou D, Fu K, Park P, Wang MY, Okonkwo DO, Nunley PD, Anand NN, Mundis GM, Mummaneni PV. Does Anterior Column Realignment Result in Greater Morbidity than Lateral Lumbar Interbody Fusion Alone When Treating Adult Spinal Deformity? Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Than KD, Tran S, Chou D, Fu KMG, Park P, Fessler RG, Wang MY, Kanter AS, Okonkwo DO, Nunley PD, Anand N, Uribe JS, Eastlack R, Mundis GM, Mummaneni PV. Body Mass Index Greater Than 35 Is Associated With Increased Major and Radiographic Complications After Minimally Invasive Adult Spinal Deformity Surgery. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Wang MY, Tran S, Brusko GD, Eastlack R, Park P, Nunley PD, Kanter AS, Uribe JS, Anand N, Okonkwo DO, Than KD, Shaffrey CI, Lafage V, Mundis GM, Mummaneni PV. Less invasive spinal deformity surgery: the impact of the learning curve at tertiary spine care centers. J Neurosurg Spine 2019; 31:865-872. [PMID: 31443084 DOI: 10.3171/2019.6.spine19531] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 05/02/2019] [Accepted: 06/05/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The past decade has seen major advances in techniques for treating more complex spinal disorders using minimally invasive surgery (MIS). While appealing from the standpoint of patient perioperative outcomes, a major impediment to adoption has been the significant learning curve in utilizing MIS techniques. METHODS Data were retrospectively analyzed from a multicenter series of adult spinal deformity surgeries treated at eight tertiary spine care centers in the period from 2008 to 2015. All patients had undergone a less invasive or hybrid approach for a deformity correction satisfying the following inclusion criteria at baseline: coronal Cobb angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, or pelvic tilt > 20°. Analyzed data included baseline demographic details, severity of deformity, surgical metrics, clinical outcomes (numeric rating scale [NRS] score and Oswestry Disability Index [ODI]), radiographic outcomes, and complications. A minimum follow-up of 2 years was required for study inclusion. RESULTS Across the 8-year study period, among 222 patients, there was a trend toward treating increasingly morbid patients, with the mean age increasing from 50.7 to 62.4 years (p = 0.013) and the BMI increasing from 25.5 to 31.4 kg/m2 (p = 0.12). There was no statistical difference in the severity of coronal and sagittal deformity treated over the study period. With regard to radiographic changes following surgery, there was an increasing emphasis on sagittal correction and, conversely, less coronal correction. There was no statistically significant difference in clinical outcomes over the 8-year period, and meaningful improvements were seen in all years (ODI range of improvement: 15.0-26.9). Neither were there statistically significant differences in major complications; however, minor complications were seen less often as the surgeons gained experience (p = 0.064). Operative time was decreased on average by 47% over the 8-year period.Trends in surgical practice were seen as well. Total fusion construct length was unchanged until the last year when there was a marked decrease in conjunction with a decrease in interbody levels treated (p = 0.004) while obtaining a higher degree of sagittal correction, suggesting more selective but powerful interbody reduction methods as reflected by an increase in the lateral and anterior column resection techniques being utilized. CONCLUSIONS The use of minimally invasive methods for adult spinal deformity surgery has evolved over the past decade. Experienced surgeons are treating older and more morbid patients with similar outcomes. A reliance on selective, more powerful interbody approaches is increasing as well.
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Affiliation(s)
- Michael Y Wang
- 1Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Stacie Tran
- 2Department of Orthopedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California
| | - G Damian Brusko
- 1Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Robert Eastlack
- 3Department of Neurological Surgery, Scripps Clinic Torrey Pines, La Jolla, California
| | - Paul Park
- 4Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Pierce D Nunley
- 5Department of Orthopedic Surgery, Spine Institute of Louisiana, Shreveport, Louisiana
| | - Adam S Kanter
- 6Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Juan S Uribe
- 7Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Neel Anand
- 8Department of Orthopedic Surgery, Cedars-Sinai Hospital, Los Angeles, California
| | - David O Okonkwo
- 6Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Khoi D Than
- 9Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | | | - Virginie Lafage
- 11Spine Service, Hospital for Special Surgery, New York, New York
| | - Gregory M Mundis
- 12Department of Orthopedic Surgery, Scripps Clinic Torrey Pines, La Jolla, California; and
| | - Praveen V Mummaneni
- 13Department of Neurological Surgery, University of California, San Francisco, California
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Block JE, Lavelle WF, Nunley PD. Toward a cure for lumbar spinal stenosis: The potential of interspinous process decompression. Med Hypotheses 2019; 132:109357. [PMID: 31421414 DOI: 10.1016/j.mehy.2019.109357] [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] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/06/2019] [Accepted: 08/09/2019] [Indexed: 11/24/2022]
Abstract
There is a growing impetus to treat aging as a disease in the quest to significantly extend the human life span through cellular regeneration methods. This approach, while promising, overlooks the fact that the evolutionary adaptation to bipedalism puts the human body in a distinctively vulnerable biomechanical and functional position. Orthograde human posture places unusually-high axial compressive loads on the weight-bearing joints of the skeleton, resulting in arthritic deterioration with aging. The effects are particularly robust in the lumbar spine were age-related degeneration, most commonly lumbar spinal stenosis (LSS), is ubiquitous among the elderly. It is postulated that re-establishing a favorable mechanical environment via interventions that unload the affected spinal joint complex may mitigate and potentially reverse the structural damage that is the cardinal pathoanatomical feature of this disease. The hypothesis of this paper is that a minimally-invasive surgical procedure, interspinous process decompression (IPD), which utilizes a stand-alone intervertebral spacer, effectively unloads the diseased spinal motion segment providing a healthy micro-environment to reverse and repair age-related and genetic deterioration of the spinal motion segment. Several lines of supporting evidence are provided from long-term follow-up results of a randomized controlled trial of IPD safety and effectiveness of the Superion® device including clinical outcomes, reoperation rates, opioid analgesic usage and advanced imaging utilization. All of these outcomes show uniquely-favorable trends with time that imply that the benefits of IPD are structural. The compendium of evidence suggests that IPD offers both a durable palliative effect due to direct blocking of back extension and a disease-modifying effect due to unloading of the spinal joint complex.
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Affiliation(s)
- Jon E Block
- 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, United States.
| | - William F Lavelle
- Upstate Bone and Joint Center, East Syracuse, NY 13057, United States.
| | - Pierce D Nunley
- Spine Institute of Louisiana, Shreveport, LA 71101, United States.
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Segreto FA, Passias PG, Lafage R, Lafage V, Smith JS, Line BG, Mundis GM, Bortz CA, Stekas ND, Horn SR, Diebo BG, Brown AE, Ihejirika Y, Nunley PD, Daniels AH, Gupta MC, Gum JL, Hamilton DK, Klineberg EO, Burton DC, Hart RA, Schwab FJ, Bess S, Shaffrey CI, Ames CP. Incidence of Acute, Progressive, and Delayed Proximal Junctional Kyphosis Over an 8-Year Period in Adult Spinal Deformity Patients. Oper Neurosurg (Hagerstown) 2019; 18:75-82. [DOI: 10.1093/ons/opz128] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 01/09/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Proximal junctional kyphosis (PJK) is a common radiographic complication of adult spinal deformity (ASD) corrective surgery. Although previous literature has reported a 5 to 61% incidence of PJK, these studies are limited by small sample sizes and short-term follow-up.
OBJECTIVE
To assess the incidence of PJK utilizing a high-powered ASD database.
METHODS
Retrospective review of a prospective multicenter ASD database. Operative ASD patients > 18 yr old from 2009 to 2017 were included. PJK was defined as ≥ 10° for the sagittal Cobb angle between the inferior upper instrumented vertebra (UIV) endplate and the superior endplate of the UIV + 2. Chi-square analysis and post hoc testing assessed annual and overall incidence of acute (6-wk follow-up [f/u]), progressive (increase in degree of PJK from 6 wk to 1 yr), and delayed (1-yr, 2-yr, and 3-yr f/u) PJK development.
RESULTS
A total of 1005 patients were included (age: 59.3; 73.5% F; body mass index: 27.99). Overall PJK incidence was 69.4%. Overall incidence of acute PJK was 48.0%. Annual incidence of acute PJK has decreased from 53.7% in 2012 to 31.6% in 2017 (P = .038). Overall incidence of progressive PJK was 35.0%, with stable rates observed from 2009 to 2016 (P = .297). Overall incidence of 1-yr-delayed PJK was 9.3%. Annual incidence of 1-yr-delayed PJK has decreased from 9.2% in 2009 to 3.2% in 2016 (P < .001). Overall incidence of 2-yr-delayed PJK development was 4.3%. Annual incidence of 2-yr-delayed PJK has decreased from 7.3% in 2009 to 0.9% in 2015 (P < .05). Overall incidence of 3-yr-delayed PJK was 1.8%, with stable rates observed from 2009 to 2014 (P = .594).
CONCLUSION
Although progressive PJK has remained a challenge for physicians over time, significantly lower incidences of acute and delayed PJK in recent years may indicate improving operative decision-making and management strategies.
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Affiliation(s)
- Frank A Segreto
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York
| | - Peter G Passias
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Breton G Line
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Gregory M Mundis
- Department of Orthopedics, San Diego Center for Spinal Disorders, La Jolla, California
| | - Cole A Bortz
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York
| | - Nicholas D Stekas
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York
| | - Samantha R Horn
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York
| | - Bassel G Diebo
- Department of Orthopedic Surgery, State University of New York Downstate Medical Center, Brooklyn, New York, New York
| | - Avery E Brown
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York
| | - Yael Ihejirika
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, New York, New York
| | | | - Alan H Daniels
- Department of Orthopedics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Munish C Gupta
- Department of Orthopedic Surgery, University of California, Davis, Davis, California
| | - Jeffrey L Gum
- Norton Leatherman Spine Center, Louisville, Kentucky
| | - D Kojo Hamilton
- Department of Neurosurgery, University of Pittsburg School of Medicine, Pittsburgh, Pennsylvania
| | - Eric O Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Davis, California
| | - Douglas C Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Robert A Hart
- Department of Orthopedics, Swedish Neuroscience Institute, Seattle, Washington
| | - Frank J Schwab
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Shay Bess
- Department of Orthopedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Christopher I Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Badve SA, Kurra S, Nunley PD, Lavelle WF. The Mobi-C® cervical disc and other devices for two-level disc replacement: overview of its safety and efficacy. Expert Rev Med Devices 2019; 16:307-315. [PMID: 30907183 DOI: 10.1080/17434440.2019.1593137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 01/22/2023]
Abstract
INTRODUCTION Cervical disc arthroplasty (CDA) has become an acceptable alternative for anterior cervical discectomy and fusion (ACDF) for a significant patient population with cervical radiculopathy and/or myelopathy secondary to degenerative changes in the cervical spine. There are sufficient mid- and long-term data supporting performance and safety of one-level CDA. With the success of single-level cervical CDA, considerable interest exists about CDA use for multilevel cervical degenerative disc disease (DDD). This review analyzes the safety and efficacy of two-level CDA for treatment of symptomatic cervical DDD with focus on the Mobi-C® Cervical Disc. AREAS COVERED This review summarizes previously published articles in a literature search using keywords: 'two-level-anterior cervical arthrodesis; two-level anterior cervical decompression and fusion (ACDF); two-level cervical disc arthroplasty (CDA); two-level cervical total disc replacement; two-level symptomatic degenerative disc disease (DDD); Mobi-C® disc'. EXPERT OPINION Two-level CDA with the Mobi-C® device demonstrated equivalent, and in certain aspects, favorable outcomes compared to ACDF for treatment of symptomatic cervical 2-level degenerative disc disease (DDD) indicating a satisfactory safety and efficacy profile.
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Affiliation(s)
- Siddharth A Badve
- a Carolina Pines Regional Medical Center , Hartsville Orthopaedics & Sports Medicine , Hartsville , SC , USA
| | - Swamy Kurra
- b Department of Orthopedic Surgery , SUNY Upstate Medical University , Syracuse , NY , USA
| | | | - William F Lavelle
- b Department of Orthopedic Surgery , SUNY Upstate Medical University , Syracuse , NY , USA
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Than KD, Park P, Tran S, Mundis GM, Fu KM, Uribe JS, Okonkwo DO, Nunley PD, Fessler RG, Eastlack RK, Kanter A, Anand N, LaMarca F, Passias PG, Mummaneni PV. Analysis of Complications with Staged Surgery for Less Invasive Treatment of Adult Spinal Deformity. World Neurosurg 2019; 126:e1337-e1342. [PMID: 30898739 DOI: 10.1016/j.wneu.2019.03.090] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 02/05/2019] [Revised: 03/08/2019] [Accepted: 03/09/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Spinal deformity surgery is often invasive and lengthy. Staging surgery over separate operative days may reduce complications. Staging is often used in minimally invasive treatment of adult spinal deformity (ASD). OBJECTIVE To investigate the impact of staging on complication rates between hybrid (HYB; minimally invasive interbody with open posterior screw and rod fixation) and circumferential minimally invasive surgery (cMIS; minimally invasive interbody and screw/rod placement) procedures in patients with ASD. METHODS A multicenter database of patients with ASD was reviewed. Patients who underwent staging (at least 3 levels) and 2 years of follow-up were analyzed. A total of 99 patients underwent staging: 53 cMIS and 46 HYB surgeries. Propensity matching for levels fused resulted in 19 patients in each group. Intra- and perioperative complications were assessed. RESULTS Three HYB but no cMIS intraoperative complications occurred. More HYB patients had perioperative complications than cMIS patients. Neurologic complications were more frequent in HYB versus cMIS. Other complications did not differ significantly. Thirty-day reoperations were higher with cMIS than HYB, but there was no difference in reoperation rate at long-term follow-up. cMIS patients had greater improvement in the Oswestry Disability Index. There was no difference in complications between staged versus unstaged cMIS surgeries. CONCLUSIONS cMIS staged surgeries appear safer than HYB staged surgeries, and equally safe to cMIS unstaged surgeries. Perioperative complications were significantly higher for HYB staged surgeries. HYB surgeries may have better results when performed in a single setting, whereas cMIS surgeries can be performed in 1 or 2 stages depending on surgeon preference.
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Affiliation(s)
- Khoi D Than
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Stacie Tran
- San Diego Center for Spinal Disorders, La Jolla, California, USA
| | - Gregory M Mundis
- Division of Orthopaedic Surgery, Scripps Clinic Medical Group, La Jolla, California, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pierce D Nunley
- Department of Neurosurgery, Spine Institute of Louisiana, Shreveport, Louisiana, USA
| | - Richard G Fessler
- Department of Neurosurgery, Rush Medical College, Chicago, Illinois, USA
| | - Robert K Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic Medical Group, La Jolla, California, USA
| | - Adam Kanter
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Neel Anand
- Department of Orthopedics, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Frank LaMarca
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Peter G Passias
- Department of Orthopedic Surgery, New York Spine Institute, New York, New York, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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Park P, Fu KM, Eastlack RK, Tran S, Mundis GM, Uribe JS, Wang MY, Than KD, Okonkwo DO, Kanter AS, Nunley PD, Anand N, Fessler RG, Chou D, Oppenlander ME, Mummaneni PV. Is achieving optimal spinopelvic parameters necessary to obtain substantial clinical benefit? An analysis of patients who underwent circumferential minimally invasive surgery or hybrid surgery with open posterior instrumentation. J Neurosurg Spine 2019; 30:833-838. [PMID: 30797202 DOI: 10.3171/2018.11.spine181261] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 10/21/2018] [Accepted: 11/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It is now well accepted that spinopelvic parameters are correlated with clinical outcomes in adult spinal deformity (ASD). The purpose of this study was to determine whether obtaining optimal spinopelvic alignment was absolutely necessary to achieve a minimum clinically important difference (MCID) or substantial clinical benefit (SCB). METHODS A multicenter retrospective review of patients who underwent less-invasive surgery for ASD was conducted. Inclusion criteria were age ≥ 18 years and one of the following: coronal Cobb angle > 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 20°, or pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°. A total of 223 patients who were treated with circumferential minimally invasive surgery or hybrid surgery and had a minimum 2-year follow-up were identified. Based on optimal spinopelvic parameters (PI-LL mismatch ± 10° and SVA < 5 cm), patients were divided into aligned (AL) or malaligned (MAL) groups. The primary clinical outcome studied was the Oswestry Disability Index (ODI) score. RESULTS There were 74 patients in the AL group and 149 patients in the MAL group. Age and body mass index were similar between groups. Although the baseline SVA was similar, PI-LL mismatch (9.9° vs 17.7°, p = 0.002) and PT (19° vs 24.7°, p = 0.001) significantly differed between AL and MAL groups, respectively. As expected postoperatively, the AL and MAL groups differed significantly in PI-LL mismatch (-0.9° vs 13.1°, p < 0.001), PT (14° vs 25.5°, p = 0.001), and SVA (11.8 mm vs 48.3 mm, p < 0.001), respectively. Notably, there was no difference in the proportion of AL or MAL patients in whom an MCID (52.75% vs 61.1%, p > 0.05) or SCB (40.5% vs 46.3%, p > 0.05) was achieved for ODI score, respectively. Similarly, no differences in percentage of patients obtaining an MCID or SCB for visual analog scale back and leg pain score were observed. On multivariate analysis controlling for surgical and preoperative demographic differences, achieving optimal spinopelvic parameters was not associated with achieving an MCID (OR 0.645, 95% CI 0.31-1.33) or an SCB (OR 0.644, 95% CI 0.31-1.35) for ODI score. CONCLUSIONS Achieving optimal spinopelvic parameters was not a predictor for achieving an MCID or SCB. Since spinopelvic parameters are correlated with clinical outcomes, the authors' findings suggest that the presently accepted optimal spinopelvic parameters may require modification. Other factors, such as improvement in neurological symptoms and/or segmental instability, also likely impacted the clinical outcomes.
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Affiliation(s)
- Paul Park
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kai-Ming Fu
- 2Department of Neurosurgery, Cornell Medical Center, New York, New York
| | | | - Stacie Tran
- 4San Diego Center for Spinal Disorders, San Diego, California
| | | | | | - Michael Y Wang
- 6Department of Neurosurgery, University of Miami, Florida
| | - Khoi D Than
- 7Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - David O Okonkwo
- 8Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam S Kanter
- 8Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Neel Anand
- 10Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Richard G Fessler
- 11Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois; and
| | - Dean Chou
- 12Department of Neurosurgery, University of California, San Francisco, California
| | - Mark E Oppenlander
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Praveen V Mummaneni
- 12Department of Neurosurgery, University of California, San Francisco, California
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Nunley PD, Deer TR, Benyamin RM, Staats PS, Block JE. Interspinous process decompression is associated with a reduction in opioid analgesia in patients with lumbar spinal stenosis. J Pain Res 2018; 11:2943-2948. [PMID: 30538533 PMCID: PMC6251434 DOI: 10.2147/jpr.s182322] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Lumbar spinal stenosis (LSS) causes significant pain and functional impairment, and medical management has increasingly included the prescription of opioid-based analgesics. Interspinous process decompression (IPD) provides a minimally-invasive treatment option for LSS. Methods This study estimated the type, dosage, and duration of opioid medications through 5 years of follow-up after IPD with the Superion Indirect Decompression System (Vertiflex Inc., Carlsbad, CA USA). Data were obtained from the Superion-treatment arm of a randomized controlled noninferiority trial. The prevalence of subjects using opiates was determined at baseline through 60 months. Primary analysis included all 190 patients randomized to receive the Superion device. In a subgroup of 98 subjects, we determined opioid-medication prevalence among subjects with a history of opioid use. Results At baseline, almost 50% (94 of 190) of subjects were using opioid medication. Thereafter, there was a sharp decrease in opioid-medication prevalence from 25.2% (41 of 163) at 12 months to 13.3% (20 of 150) at 24 months to 7.5% (8 of 107) at 60 months. Between baseline and 5 years, there was an 85% decrease in the proportion of subjects using opioids. A similar pattern was also observed among subjects with a history of opiates prior to entering the trial. Conclusion Stand-alone IPD is associated with a marked decrease in the need for opioid medications to manage symptoms related to LSS. In light of the current opiate epidemic, such alternatives as IPD may provide effective pain relief in patients with LSS without the need for opioid therapy.
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Affiliation(s)
| | | | | | - Peter S Staats
- National Spine and Pain Centers, Rockville, MD 20852, USA
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Park P, Fu KM, Mummaneni PV, Uribe JS, Wang MY, Tran S, Kanter AS, Nunley PD, Okonkwo DO, Shaffrey CI, Mundis GM, Chou D, Eastlack R, Anand N, Than KD, Zavatsky JM, Fessler RG. The impact of age on surgical goals for spinopelvic alignment in minimally invasive surgery for adult spinal deformity. J Neurosurg Spine 2018; 29:560-564. [DOI: 10.3171/2018.4.spine171153] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 04/18/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAchieving appropriate spinopelvic alignment in deformity surgery has been correlated with improvement in pain and disability. Minimally invasive surgery (MIS) techniques have been used to treat adult spinal deformity (ASD); however, there is concern for inadequate sagittal plane correction. Because age can influence the degree of sagittal correction required, the purpose of this study was to analyze whether obtaining optimal spinopelvic alignment is required in the elderly to obtain clinical improvement.METHODSA multicenter database of ASD patients was queried. Inclusion criteria were age ≥ 18 years; an MIS component as part of the index procedure; at least one of the following: pelvic tilt (PT) > 20°, sagittal vertical axis (SVA) > 50 mm, pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°, or coronal curve > 20°; and minimum follow-up of 2 years. Patients were stratified into younger (< 65 years) and older (≥ 65 years) cohorts. Within each cohort, patients were categorized into aligned (AL) or mal-aligned (MAL) subgroups based on postoperative radiographic measurements. Mal-alignment was defined as a PI-LL > 10° or SVA > 50 mm. Pre- and postoperative radiographic and clinical outcomes were compared.RESULTSOf the 185 patients, 107 were in the younger cohort and 78 in the older cohort. Based on postoperative radiographs, 36 (33.6%) of the younger patients were in the AL subgroup and 71 (66.4%) were in the MAL subgroup. The older patients were divided into 2 subgroups based on alignment; there were 26 (33.3%) patients in the AL and 52 (66.7%) in the MAL subgroups. Overall, patients within both younger and older cohorts significantly improved with regard to postoperative visual analog scale (VAS) scores for back and leg pain and Oswestry Disability Index (ODI) scores. In the younger cohort, there were no significant differences in postoperative VAS back and leg pain scores between the AL and MAL subgroups. However, the postoperative ODI score of 37.9 in the MAL subgroup was significantly worse than the ODI score of 28.5 in the AL subgroup (p = 0.019). In the older cohort, there were no significant differences in postoperative VAS back and leg pain score or ODI between the AL and MAL subgroups.CONCLUSIONSMIS techniques did not achieve optimal spinopelvic alignment in most cases. However, age appears to impact the degree of sagittal correction required. In older patients, optimal spinopelvic alignment thresholds did not need to be achieved to obtain similar symptomatic improvement. Conversely, in younger patients stricter adherence to optimal spinopelvic alignment thresholds may be needed.https://thejns.org/doi/abs/10.3171/2018.4.SPINE171153
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Affiliation(s)
- Paul Park
- 1Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Kai-Ming Fu
- 2Department of Neurosurgery, Cornell Medical Center, New York, New York
| | - Praveen V Mummaneni
- 3Department of Neurosurgery, University of California, San Francisco, California
| | - Juan S Uribe
- 4Barrow Neurological Institute, Phoenix, Arizona
| | - Michael Y Wang
- 5Department of Neurosurgery, University of Miami, Florida
| | - Stacie Tran
- 6San Diego Center for Spinal Disorders, San Diego, California
| | - Adam S Kanter
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - David O Okonkwo
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher I Shaffrey
- 9Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Dean Chou
- 3Department of Neurosurgery, University of California, San Francisco, California
| | | | - Neel Anand
- 11Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, California
| | - Khoi D Than
- 12Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | | | - Richard G Fessler
- 14Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois
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Park P, Eastlack R, Fu KMG, Tran S, Mundis GM, Uribe JS, Wang MY, Than KD, Okonkwo DO, Kanter AS, Nunley PD, Anand N, Fessler RG, Chou D, Mummaneni PV. 166 Is Achieving Optimal Spinopelvic Parameters Necessary to Obtain Substantial Clinical Benefit. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nunley PD, Cavanaugh DA, Kerr EJ, Utter PA, Campbell PG, Frank KA, Marshall KE, Stone MB. Heterotopic Ossification After Cervical Total Disc Replacement at 7 Years-Prevalence, Progression, Clinical Implications, and Risk Factors. Int J Spine Surg 2018; 12:352-361. [PMID: 30276092 DOI: 10.14444/5041] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [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: 12/20/2022] Open
Abstract
Background Heterotopic ossification (HO) is a known risk following cervical total disc replacement (CTDR) surgery, but the cause and effect of HO are not well understood. Reported HO rates vary, and few studies are specifically designed to report HO. The effects on outcomes, and the risk factors for the development of HO have been hypothesized and reported in small-population, retrospective analyses, using univariate statistics. Methods Posthoc, multiple-phase analysis of radiographic, clinical, and demographic data for CTDR as it relates to HO was performed. HO was radiographically graded for 164 one-level and 225 two-level CTDR patients using the McAfee and Mehren system. Analysis was performed to correlate HO grades to clinical outcomes and to evaluate potential risk factors for the development of HO using demographics and baseline clinical measures. Results At 7 years, 1-level clinically relevant HO grades were 17.6% grade 3 and 11.1% grade 4. Two-level clinically relevant HO grades, evaluated using the highest patient grade, were 26.6% grade 3 and 10.8% grade 4. Interaction between HO and time revealed significance for neck disability index (NDI; P = .04) and Visual Analog Scale (VAS) neck pain (P = .02). When analyzed at each time point NDI was significant at 48-84 months and VAS neck at 60 months. For predictors 2 analyses were run; odds ratios indicated follow-up visit, male sex, and preoperative VAS neck pain are related to HO development, whereas hazard ratios indicated male sex, obesity, endplate coverage, levels treated, and preoperative VAS neck pain. Conclusions This is the largest study to report HO rates, and related outcomes and risk factors. To develop an accurate predictive model, further large-scale analyses need to be performed. Based on the results reported here, clinically relevant HO should be more accurately described as motion-restricting HO until a definitive link to outcomes has been established.
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Nunley PD, Mundis GM, Fessler RG, Park P, Zavatsky JM, Uribe JS, Eastlack RK, Chou D, Wang MY, Anand N, Frank KA, Stone MB, Kanter AS, Shaffrey CI, Mummaneni PV. Impact of case type, length of stay, institution type, and comorbidities on Medicare diagnosis-related group reimbursement for adult spinal deformity surgery. Neurosurg Focus 2018; 43:E11. [PMID: 29191102 DOI: 10.3171/2017.7.focus17278] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery. METHODS Medicare's Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion. RESULTS Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay. CONCLUSIONS Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.
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Affiliation(s)
| | - Gregory M Mundis
- San Diego Center for Spinal Disorders, San Diego, California.,Scripps Clinic, La Jolla, California
| | | | - Paul Park
- University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Dean Chou
- University of California, San Francisco, California
| | | | - Neel Anand
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Adam S Kanter
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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Campbell PG, Nunley PD. The Challenge of the Lumbosacral Fractional Curve in the Setting of Adult Degenerative Scoliosis. Neurosurg Clin N Am 2018; 29:467-474. [DOI: 10.1016/j.nec.2018.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Coric D, Guyer RD, Nunley PD, Musante D, Carmody C, Gordon C, Lauryssen C, Boltes MO, Ohnmeiss DD. Prospective, randomized multicenter study of cervical arthroplasty versus anterior cervical discectomy and fusion: 5-year results with a metal-on-metal artificial disc. J Neurosurg Spine 2018; 28:252-261. [DOI: 10.3171/2017.5.spine16824] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVESeven cervical total disc replacement (TDR) devices have received FDA approval since 2006. These devices represent a heterogeneous assortment of implants made from various biomaterials with different biomechanical properties. The majority of these devices are composed of metallic endplates with a polymer core. In this prospective, randomized multicenter study, the authors evaluate the safety and efficacy of a metal-on-metal (MoM) TDR (Kineflex|C) versus anterior cervical discectomy and fusion (ACDF) in the treatment of single-level spondylosis with radiculopathy through a long-term (5-year) follow-up.METHODSAn FDA-regulated investigational device exemption (IDE) pivotal trial was conducted at 21 centers across the United States. Standard validated outcome measures including the Neck Disability Index (NDI) and visual analog scale (VAS) for assessing pain were used. Patients were randomized to undergo TDR using the Kineflex|C cervical artificial disc or anterior cervical fusion using structural allograft and an anterior plate. Patients were evaluated preoperatively and at 6 weeks and 3, 6, 12, 24, 36, 48, and 60 months after surgery. Serum ion analysis was performed on a subset of patients randomized to receive the MoM TDR.RESULTSA total of 269 patients were enrolled and randomly assigned to undergo either TDR (136 patients) or ACDF (133 patients). There were no significant differences between the TDR and ACDF groups in terms of operative time, blood loss, or length of hospital stay. In both groups, the mean NDI scores improved significantly by 6 weeks after surgery and remained significantly improved throughout the 60-month follow-up (both p < 0.01). Similarly, VAS pain scores improved significantly by 6 weeks and remained significantly improved through the 60-month follow-up (both p < 0.01). There were no significant changes in outcomes between the 24- and 60-month follow-ups in either group. Range of motion in the TDR group decreased at 3 months but was significantly greater than the preoperative mean value at the 12- and 24-month follow-ups and remained significantly improved through the 60-month period. There were no significant differences between the 2 groups in terms of reoperation/revision surgery or device-/surgery-related adverse events. The serum ion analysis revealed cobalt and chromium levels significantly lower than the levels that merit monitoring.CONCLUSIONSCervical TDR with an MoM device is safe and efficacious at the 5-year follow-up. These results from a prospective randomized study support that Kineflex|C TDR as a viable alternative to ACDF in appropriately selected patients with cervical radiculopathy.Clinical trial registration no.: NCT00374413 (clinicaltrials.gov)
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Affiliation(s)
- Domagoj Coric
- 1Carolina Neurosurgery and Spine Associates, Charlotte
| | | | | | - David Musante
- 4Triangle Orthopedics Associates, Durham, North Carolina
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Badve SA, Nunley PD, Kurra S, Lavelle WF. Review of long-term outcomes of disc arthroplasty for symptomatic single level cervical degenerative disc disease. Expert Rev Med Devices 2018; 15:205-217. [DOI: 10.1080/17434440.2018.1433533] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Siddharth A. Badve
- Hartsville Orthopaedics & Sports Medicine, Carolina Pines Regional Medical Center, Hartsville, SC, USA
| | | | - Swamy Kurra
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - William F. Lavelle
- Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
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Nunley PD, Coric D, Frank KA, Stone MB. Cervical Disc Arthroplasty: Current Evidence and Real-World Application. Neurosurgery 2018; 83:1087-1106. [DOI: 10.1093/neuros/nyx579] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/07/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
| | - Domagoj Coric
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | | | - Marcus B Stone
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
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