Focused versus conventional radiotherapy in spinal oncology: is there any difference in fusion rates and pseudoarthrosis?

INTRODUCTION: Radiotherapy is considered standard of care for adjuvant peri-operative treatment of many spinal tumors, including those with instrumented fusion. Unfortunately, radiation treatment has been linked to increased risk of pseudoarthrosis. Newer focused radiotherapy strategies with enhanced conformality could offer improved fusion rates for these patients, but this has not been confirmed. METHODS: We performed a retrospective analysis of patients at three tertiary care academic institutions with primary and secondary spinal malignancies that underwent resection, instrumented fusion, and peri-operative radiotherapy. Two board certified neuro-radiologists used the Lenke fusion score to grade fusion status at 6 and 12-months after surgery. Secondary outcomes included clinical pseudoarthrosis, wound complications, the effect of radiation timing and radiobiological dose delivered, the use of photons versus protons, tumor type, tumor location, and use of autograft on fusion outcomes. RESULTS: After review of 1252 spinal tumor patients, there were 60 patients with at least 6 months follow-up that were included in our analyses. Twenty-five of these patients received focused radiotherapy, 20 patients received conventional radiotherapy, and 15 patients were treated with protons. There was no significant difference between the groups for covariates such as smoking status, obesity, diabetes, intraoperative use of autograft, and use of peri-operative chemotherapy. There was a significantly higher rate of fusion for patients treated with focused radiotherapy compared to those treated with conventional radiotherapy at 6-months (64.0% versus 30.0%, Odds ratio: 4.15, p = 0.036) and 12-months (80.0% versus 42.1%, OR: 5.50, p = 0.022). There was a significantly higher rate of clinical pseudoarthrosis in the conventional radiotherapy cohort compared to patients in the focused radiotherapy cohort (19.1% versus 0%, p = 0.037). There was no difference in fusion outcomes for any of the secondary outcomes except for use of autograft. The use of intra-operative autograft was associated with an improved fusion at 12-months (66.7% versus 37.5%, OR: 3.33, p = 0.043). CONCLUSION: Focused radiotherapy may be associated with an improved rate of fusion and clinical pseudoarthrosis when compared to conventional radiation delivery strategies in patients with spinal tumors. Use of autograft at the time of surgery may be associated with improved 12-month fusion rates. Further large-scale prospective and randomized controlled studies are needed to better stratify the effects of radiation delivery modality in these patients.

Cranial and spinal oligodendrogliomatosis: a case report and review of the literature.

INTRODUCTION: Oligodendrogliomatosis is a rarely reported entity in literature associated with poor prognosis in terms of length and quality of life. In this paper, we describe oligodendrogliomatosis in a 15-year-old male who initially presented with altered mental status due to diabetic ketoacidosis. CLINICAL PRESENTATION: He was refractory to temozolomide initially but demonstrated disease regression with radiotherapy (XRT). More recently, he has had disease recurrence, which was stabilized with temozolomide therapy for a period of time. CONCLUSION: Contrary to most reports in literature, our patient has had excellent quality of life since his initial diagnosis and continues to carry good prognosis. In addition to oligodendrogliomatosis, our patient also developed multiple intracranial cavernomas secondary to radiation therapy, which have remained stable and asymptomatic.

Venous thromboembolism in high grade glioma among surgical patients: results from a single center over a 10 year period.

Patients with high-grade glioma are at elevated risk of venous thromboembolism (VTE). The relationship between VTE and survival in glioma patients remains unclear, as does the optimal protocol for chemoprophylaxis. The purpose of this study was to assessthe incidence of and risk factors associated with VTE in patients with high-grade glioma, and the correlation between VTE and survival in this population. Furthermore, we sought to define a protocol for perioperative DVT prophylaxis. This was a retrospective review of patients who underwent craniotomy for resection of high-grade glioma (WHO grade III or IV) at Northwestern University between 1999 and 2010. A total of 336 patients met inclusion criteria. 53 patients developed postoperative VTE (15.7 %). Median survival was 12.0 months and was not significantly different between VTE(+) and VTE(-) patients. Demographics and surgical factors were not significantly correlated with VTE development. Prior history of VTE was highly predictive of postoperative VTE (OR 7.1, p < .01), as was seizure (OR 2.4, p = .005). Increased duration of postoperative ICU stay was also a risk factor for VTE (p = .025). 25 patients in our study received prophylactic anticoagulation(pAC) with either heparin or enoxaparin. Early initiation of pAC was associated with decreased incidence of VTE (p = .042). There were no hemorrhagic complications in patients receiving pAC. VTE is a common complication in high-grade glioma patients. Early initiation of anticoagulation is safe and may decrease the risk of VTE. We recommend initiation of chemoprophylaxis on postoperative day 1 in patients without contraindication.

Early Extrusion of an Anterior Odontoid Screw: A Case Report.

Odontoid fractures in the elderly typically require surgical intervention due to poor adaptability to conservative treatment. Anterior screw fixation, despite its high fusion rates under specific conditions, may lead to complications such as screw extrusion, as demonstrated in the case discussed, necessitating subsequent posterior cervical fusion. This study aimed to describe early extrusion of an anterior odontoid screw and the importance of caution and thorough postoperative assessment in elderly patients undergoing anterior screw fixation for odontoid fracture. A 73-year-old female patient with a history of ground-level fall and subsequent cervical pain was diagnosed with an odontoid type II fracture and underwent odontoid screw placement in June 2023. However, in August, follow-up imaging revealed screw displacement and a fracture of the posterior arch of the C1 vertebral, which was initially overlooked. After seeking a second opinion, a new surgical approach was decided, involving removal and replacement of the odontoid screw, posterior and posterolateral C1-C2 spinal instrumentation, arthrodesis, and fusion with the use of morselized allograft. The patient was discharged on postoperative day 3 with mild cervical pain, wearing a soft collar, and neurologically intact. Given the current literature, odontoid screw extrusion rates are still small but can come with enormous potential complications. Also, the present case is a reminder to always double-check preoperative imaging and recognize early failure/malpositioning of hardware.

Postoperative Outcomes for Spinal Fusion Procedures in Pediatric Patients with Anemia: A Retrospective and Multivariate Analysis.

BACKGROUND: Preoperative anemia is known to be associated with perioperative complications in many surgical interventions. Here, we examine the effects of preoperative anemia on peri-operative complications and postoperative outcomes in pediatric patients undergoing spinal fusion. METHODS: Retrospective analysis was conducted using the American College of Surgeons Pediatric National Surgery Quality Improvement Program Database between 2012-2020. Current Procedural Terminology codes 22800, 22,802, 22,804, 22,840, 22,842, 22,843, and 22,844 were included to represent all primary spinal fusion procedures performed. Patients without preoperative hematocrit (HCT) levels were excluded. Classification of anemia was determined via age- and sex-adjusted HCT levels. Patient demographics, preoperative comorbidities and risk factors, and 30-day postoperative outcomes were compared between the 2 cohorts using univariate analysis. Multivariate logistic regressions were performed to determine if anemia severity was independently associated with worse postoperative outcomes. RESULTS: A total of 30,243 pediatric patients were included in this study, with 26,621 not having preoperative anemia and 3622 having preoperative anemia. Pediatric patients with anemia have increased length of stay (LOS) (6.7 ± 9.6 vs. 5 ± 6, P < 0.001), 30-day unplanned reoperation rate (4% vs. 2.8%, P < 0.001), and total blood transfused (489.9 ± 497.8 vs. 423.4 ± 452.6, P < 0.001). Multivariate analysis supported anemia and degree of its severity as an independent predictor of increased length of stay (LOS), reoperation rate, and postoperative complications. CONCLUSIONS: Preoperative anemia leads to worse outcomes in pediatric spinal fusion procedures. Utilizing HCT recordings could be factored into the equation for optimal patient selection and prevention of post-operative complications.

Optimal Implant Sizing Using Machine Learning Is Associated With Increased Range of Motion After Cervical Disk Arthroplasty.

BACKGROUND AND OBJECTIVES: Cervical disk arthroplasty (CDA) offers the advantage of motion preservation in the treatment of focal cervical pathology. At present, implant sizing is performed using subjective tactile feedback and imaging of trial cages. This study aims to construct interpretable machine learning (IML) models to accurately predict postoperative range of motion (ROM) and identify the optimal implant sizes that maximize ROM in patients undergoing CDA. METHODS: Adult patients who underwent CDA for single-level disease from 2012 to 2020 were identified. Patient demographics, comorbidities, and outcomes were collected, including symptoms, examination findings, subsidence, and reoperation. Affected disk height, healthy rostral disk height, and implant height were collected at sequential time points. Linear regression and IML models, including bagged regression tree, bagged multivariate adaptive regression spline, and k-nearest neighbors, were used to predict ROM change. Model performance was assessed by calculating the root mean square error (RMSE) between predicted and actual changes in ROM in the validation cohort. Variable importance was assessed using RMSE loss. Area under the curve analyses were performed to identify the ideal implant size cutoffs in predicting improved ROM. RESULTS: Forty-seven patients were included. The average RMSE between predicted and actual ROM was 7.6° (range: 5.8-10.1) in the k-nearest neighbors model, 7.8° (range: 6.5-10.0) in the bagged regression tree model, 7.8° (range: 6.2-10.0) in the bagged multivariate adaptive regression spline model, and 15.8° (range: 14.3-17.5°) in a linear regression model. In the highest-performing IML model, graft size was the most important predictor with RMSE loss of 6.2, followed by age (RMSE loss = 5.9) and preoperative caudal disk height (RMSE loss = 5.8). Implant size at 110% of the normal adjacent disk height was the optimal cutoff associated with improved ROM. CONCLUSION: IML models can reliably predict change in ROM after CDA within an average of 7.6 degrees of error. Implants sized comparably with the healthy adjacent disk may maximize ROM.

Frailty as a Predictor of Postoperative Morbidity and Mortality in Patients Aged 80 Years and Older Undergoing Instrumented Fusion.

BACKGROUND AND OBJECTIVES: Degenerative spine disease is a leading cause of disability, with increasing prevalence in the older patients. While age has been identified as an independent predictor of outcomes, its predictive value is limited for similar older patients. Here, we aimed to determine the most predictive frailty score of adverse events in patients aged 80 and older undergoing instrumented lumbar fusion. METHODS: We proceeded with a multisite (3 tertiary academic centers) retrospective review including patients undergoing instrumented fusion aged 80 and older from January 2010 to present. A composite end point encompassing 30-day return to operating room, readmission, and mortality was created. We estimated the area under the receiver operating characteristic curve for frailty scores (Modified Frailty Index-5 [MFI-5], Modified Frailty Index-11 [MFI-11], and Charlson Comorbidity Index [CCI]) in relation to that composite score. In addition, we estimated the association between each score and the composite end point by means of logistic regression. RESULTS: A total of 153 patients with an average age of 85 years at the time of surgery were included. We observed a 30-day readmission rate of 11.1%, reoperation of 3.9%, and mortality of 0.6%. The overall rate of the composite end point at 30 days was 25 (15.1%). The AUC for MFI-5 was 0.597 (0.501-0.693), for MFI-11 was 0.620 (0.518-0.723), and for CCI was 0.564 (0.453-0.675). The association between the scores and composite end point did not reach statistical significance for MFI-5 (odds ratio [OR] = 1.45 [0.98-2.15], P = .061) and CCI (OR = 1.13 [0.97-1.31], P = .113) but was statistically significant for MFI-11 (OR = 1.46 [1.07-2.00], P = .018). CONCLUSION: This is the largest study comparing frailty index scores in octogenarians undergoing instrumented lumbar fusion. Our findings suggest that while MFI-11 score correlated with adverse events, the predictive ability of existing scores remains limited, highlighting the need for better approaches to identify select patients at age extremes.

The Predictors of Incidental Durotomy in Patients Undergoing Pedicle Subtraction Osteotomy for the Correction of Adult Spinal Deformity.

Background: Pedicle subtraction osteotomy (PSO) is a powerful tool for sagittal plane correction in patients with rigid adult spinal deformity (ASD); however, it is associated with high intraoperative blood loss and the increased risk of durotomy. The objective of the present study was to identify intraoperative techniques and baseline patient factors capable of predicting intraoperative durotomy. Methods: A tri-institutional database was retrospectively queried for all patients who underwent PSO for ASD. Data on baseline comorbidities, surgical history, surgeon characteristics and intraoperative maneuvers were gathered. PSO aggressiveness was defined as conventional (Schwab 3 PSO) or an extended PSO (Schwab type 4). The primary outcome of the study was the occurrence of durotomy intraoperatively. Univariable analyses were performed with Mann-Whitney U tests, Chi-squared analyses, and Fisher's exact tests. Statistical significance was defined by p < 0.05. Results: One hundred and sixteen patients were identified (mean age 61.9 ± 12.6 yr; 44.8% male), of whom 51 (44.0%) experienced intraoperative durotomy. There were no significant differences in baseline comorbidities between those who did and did not experience durotomy, with the exception that baseline weight and body mass index were higher in patients who did not suffer durotomy. Prior surgery (OR 2.73; 95% CI [1.13, 6.58]; p = 0.03) and, more specifically, prior decompression at the PSO level (OR 4.23; 95% CI [1.92, 9.34]; p < 0.001) was predictive of durotomy. A comparison of surgeon training showed no statistically significant difference in durotomy rate between fellowship and non-fellowship trained surgeons, or between orthopedic surgeons and neurosurgeons. The PSO level, PSO aggressiveness, the presence of stenosis at the PSO level, nor the surgical instrument used predicted the odds of durotomy occurrence. Those experiencing durotomy had similar hospitalization durations, rates of reoperation and rates of nonroutine discharge. Conclusions: In this large multisite series, a history of prior decompression at the PSO level was associated with a four-fold increase in intraoperative durotomy risk. Notably the use of extended (versus) standard PSO, surgical technique, nor baseline patient characteristics predicted durotomy. Durotomies occurred in 44% of patients and may prolong operative times. Additional prospective investigations are merited.

Management of ossification of the posterior longitudinal ligament of the thoracic spine.

The management of thoracic ossification of the posterior longitudinal ligament has been studied by many spinal surgeons. Indications for operative intervention include progressive radiculopathy, myelopathy, and neurological deterioration. The ideal surgery for decompression remains highly debatable as various methods of surgical treatment of ossification of the posterior longitudinal ligament have been devised. Although numerous modifications to the 3 main approaches have been identified (anterior, posterior, or lateral), the indication for each depends on the nature of compression, the morphology of the lesion, the level of the compression, the structural alignment of the spine, and the neurological status of the patient. The authors discuss treatment techniques for thoracic ossification of the posterior longitudinal ligament, cite case examples from a single institution, and review the literature.

Surgical management of cervical ossification of the posterior longitudinal ligament: natural history and the role of surgical decompression and stabilization.

OBJECT: Ossification of the posterior longitudinal ligament (OPLL) is a complex multifactorial disease process combining both metabolic and biomechanical factors. The role for surgical intervention and choice of anterior or posterior approach is controversial. The object of this study was to review the literature and present a single-institution experience with surgical intervention for OPLL. METHODS: The authors performed a retrospective review of their institutional experience with surgical intervention for cervical OPLL. They also reviewed the English-language literature regarding the epidemiology, pathophysiology, natural history, and surgical intervention for OPLL. RESULTS: Review of the literature suggests an improved benefit for anterior decompression and stabilization or posterior decompression and stabilization compared with posterior decompression via laminectomy or laminoplasty. Both anterior and posterior approaches are safe and effective means of decompression of cervical stenosis in the setting of OPLL. CONCLUSIONS: Anterior cervical decompression and reconstruction is a safe and appropriate treatment for cervical spondylitic myelopathy in the setting of OPLL. For patients with maintained cervical lordosis, posterior cervical decompression and stabilization is advocated. The use of laminectomy or laminoplasty is indicated in patients with preserved cervical lordosis and less than 60% of the spinal canal occupied by calcified ligament in a "hill-shaped" contour.

Pediatric Extramedullary Epidural Spinal Teratomas: A Case Report and Review of the Literature.

BACKGROUND: Teratomas in the pediatric population are most commonly found in the sacrococcygeal region. Pediatric intraspinal teratomas, however, are an exceedingly rare central nervous system (CNS) neoplasm. The clinical presentation of these intraspinal neoplasms can vary significantly and thus can be difficult to identify in infants less than one year of age where verbal expression and motor development are still lacking. Case Description. A 7-month-old, previously healthy male presented with a thoracic scoliosis and an asymptomatic right midupper thoracic spinal prominence present since birth. MRI revealed an extensive heterogenous mass in the right epidural space from T5-T6 and the right paravertebral space, resulting in severe spinal stenosis. Outcome. Complete resection of the tumor, including a three-level neurotomy, was achieved by posterior decompression/laminectomy. The final tumor was consistent with a mature teratoma. The surgical resection was performed without any immediate complications. CONCLUSIONS: Extramedullary epidural teratomas are exceptionally rare tumors in the pediatric population. Clinical presentation can be ambiguous, particularly in an infant. MRI was useful in suggesting a teratoma as a potential diagnosis and for postoperative surveillance for recurrence. However, histopathological analysis remains the gold standard for definitive diagnosis. Surgical resection is the mainstay of treatment, especially in the setting of cord compression and progressive loss of motor function. Close follow-up is crucial to monitor for progressive spinal deformity or recurrence.

Use of Temporary Rod and Intraoperative Neuroimaging for Correction of Adolescent Idiopathic Scoliosis: 2-Dimensional Operative Video.

Adolescent idiopathic scoliosis (AIS) is an abnormal lateral curvature of the spine that arises during the pubescent growth spurt. AIS mainly affects females in the age group of 10 to 16 yr, with a prevalence of about 1% to 3% in the at-risk population.1 Treatment options vary depending on disease presentation and severity. Mild curvature mainly requires periodic observation for disease progression, whereas more moderate curvature can necessitate bracing or corrective surgery.2 Here, we present the use of a temporary rod and neuroimaging for the correction of Lenke type 1 spinal curvature in an AIS patient. An inferior facetectomy is performed, and a Lenke probe is used for entry into the pedicle and vertebral body. The channel is sounded before and after tapping to check for adequate walls prior to insertion of the pedicle screw. The ARTIS pheno is brought into the field, which uses fluoroscopy to create a 3-dimensional (3D) representation of the instrumentation within the spine. A temporary rod is placed in the concavity, and a combination of corrective techniques, including a rod roll, apical translation, and reduction, is performed to bring up the concavity, derotate the spine, and translate the spine. The permanent rod is then placed in the convexity, and compression is performed to bring down the scapular prominence. The temporary rod is then removed, and a final rod is placed to complete the 3D correction. The patient consented to the procedure, and an informed written consent was obtained from the patient to use her photographs and video recordings for publication.

Metal Hypersensitivity After Spinal Instrumentation: When to Suspect and How to Treat.

BACKGROUND: Metal hypersensitivity is a rare complication after spinal implant placement but is related to significant clinical challenges including implant failure and poor wound healing. The incidence is likely underreported secondary to challenges with diagnosis and retreatment options. CASE DESCRIPTION: We present the case of a 41-year-old woman with metal hypersensitivity 6 years status post anterior lumbar interbody fusion after a previously failed revision procedure who presented with low back pain and abdominal pain with food intolerance. Diagnostics revealed presacral fluid collection, which was negative for infection. A detailed workup ruled out other possible differential diagnoses and confirmed hypersensitivity to nickel. Intraoperatively, the interbody was loose but difficult to remove secondary to scar tissue. Ultimately, it was successfully replaced with a polyetheretherketone interbody, which did not contain nickel. CONCLUSIONS: Metal hypersensitivity is likely an underreported complication in spine literature that is associated with poor outcomes. Further research to create evidence-based guidelines on diagnosis and retreatment options will facilitate diagnosis, reduce time to revision surgery, and ultimately decrease patient suffering.

Use of Pheno Room, Augmented Reality, and 3-Rod Technique for 3-Dimensional Correction of Adolescent Idiopathic Scoliosis.

This is a surgical video that showcases the surgical repair of a young male patient with idiopathic scoliosis in a hybrid operating room with the utilization of a new imaging modality Advanced Radar Target Identification System (ARTIS) PHENO (Siemens Medical Solutions, Pennsylvania, USA) and augmented reality (Video 1). A 17-year-old male patient with idiopathic scoliosis underwent scoliosis repair in a hybrid operating room with segment reality surgical planning. The use of augmented reality helped in visualization of proper screw trajectory, and the use of ARTIS PHENO helped in identification of correct screw placement and rod fixation. Intraoperative use of new imaging modalities as augmented reality imaging and ARTIS PHENO can decrease surgical complication and time.

Surgical correction of proximal junctional kyphosis.

This 3D video showcases the surgical techniques for patients with proximal junctional kyphosis. The surgical repair for patients with proximal junctional kyphosis is an individualized approach depending on patient history and imaging with adequate surgical measurements. This video will shed light on two cases with proximal junctional kyphosis and the method taken for their repair. The first case is of an 11-year-old female known to have osteogenesis imperfecta and status post T5-L3 posterior spinal fusion with segmental instrumentation. The patient underwent change of older instruments and scoliosis repair, with full correction on postoperative x-ray. The second patient is a 16-year-old male known to have cerebral palsy and kyphoscoliosis status post spinal fusion. The patient underwent scoliosis repair surgery with replacement of old instrumentation and scoliosis correction. The video can be found here: https://youtu.be/f5iLwqbU26Q.

Postoperative Restrictions After Anterior Cervical Discectomy and Fusion.

No scientific evidence on restrictions for patients following an anterior cervical discectomy and fusion (ACDF) is available. The goal of this study is to assess the practice and patterns of restrictions after single-level and multilevel ACDF at an academic institution. We submitted two questionnaires, for restrictions after single-level and multilevel ACDF, to 18 spine surgeons at our institution. Questions included length of time in practice, use of cervical collar, postoperative restrictions and practices. We received 10 complete responses. Four (40%) of the respondents were in practice for less than 5 years; 3 (30%) 5 or more years, but less than 10; 1 (10%) 10 or more years, but less than 20; 2 (20%) 20 or more years. Only two (20%) surgeons recommend a cervical collar after a single-level ACDF, while seven (70%) do so after a multilevel ACDF, for an average of 9.1 weeks and standard deviation (SD) of 2.8. Nine surgeons (90%) reported providing lifting restrictions after a single-level and multilevel ACDF, with a mean of 10 kg and SD of 2.5 in both cases. 5 (50%) give driving restrictions after a single-level ACDF, eight (80%) do so after a multilevel. eight (80%) recommend physical therapy after both single-level and multilevel ACDF. three (30%) obtain a CT to confirm fusion at one year. Only two (20%) recommend a bone stimulator. Significant variability exists among surgeons in regards to restrictions following ACDF, but some areas of consensus emerged: 90% of respondents give lifting restrictions, with a mean of 10 kg, 80% recommend physical therapy for a range of motion and muscle strengthening.

Spontaneous resolution of ruptured intracranial pial arteriovenous fistula following spinal surgery.

Pial arteriovenous fistulae (AVFs) are rare vascular abnormalities that are distinct from arteriovenous malformations and dural AVFs. These vascular lesions have been linked with trauma, ischemic syndromes, venous thrombotic diseases, and intracranial surgical procedures. In this report we describe a case of an intracranial ruptured pial AVF immediately following uneventful spinal surgery in an elderly patient with subsequent spontaneous resolution. He was a previous heavy smoker with a 60-pack-year history and alcohol abuse. His examination was positive for morbid obesity and mild weakness of the anterior tibialis and gastrocnemius muscles bilaterally. He underwent uneventful spinal surgery, suffering a generalized seizure shortly after extubation. Imaging studies demonstrated acute subarachnoid hemorrhage and cerebral angiography identified a pial AVF. He was stabilized medically and follow-up angiography demonstrated spontaneous resolution of the pial AVF. This case highlights a rare vascular malformation with rupture following uneventful spinal surgery.

Hemicraniectomy for Ischemic and Hemorrhagic Stroke: Facts and Controversies.

Malignant large artery stroke is associated with high mortality of 70% to 80% with best medical management. Decompressive craniectomy (DC) is a highly effective tool in reducing mortality. Convincing evidence has accumulated from several randomized trials, in addition to multiple retrospective studies, that demonstrate not only survival benefit but also improved functional outcome with DC in appropriately selected patients. This article explores in detail the evidence for DC, nuances regarding patient selection, and applicability of DC for supratentorial intracerebral hemorrhage and posterior fossa ischemic and hemorrhagic stroke.

Cranial Center of Mass Compared to C7 Plumb Line Alignment in Adult Spinal Deformity.

OBJECTIVE: To report the cranial center of mass (CCOM) progression in surgically treated patients for adult spinal deformity (ASD). The C7 plumb line/sagittal vertical axis (SVA) has important relationships with patient-reported outcomes; however, this has not yet been defined for CCOM. METHODS: Patients with consecutive ASD who were undergoing surgery greater than 5 levels of fusion between 2007 and 2012 and had radiographic, clinical, and outcomes data spanning ≥2 years were analyzed, retrospectively. Radiographic parameters were obtained preoperatively and at 6 weeks, 1 year, and 2 years postoperatively. Statistical analysis included descriptives (measures of central tendency, dispersion, frequencies), independent Student t tests, χ(2) square, Pearson correlation, and Kaplan-Meyer curve. RESULTS: Fifty-eight patients (10 male, 48 female) with a mean age of 60.5 years (range, 27-81 years) were reviewed. The mean preoperative SVA was 7.40 cm (SD = 5.51; 37/58 [63.8%] malalignment), and mean CCOM was 10.0 cm (SD = 6.58; 47/58 [81%] malalignment). Six-week postoperative SVA and CCOM was -0.17 cm (SD = 3.3) and 2.5 cm (SD = 4.11), respectively. SVA malalignment was 12.7% and CCOM malalignment was 38.2% at 6 weeks postop. Six week (absolute), 6-week change, and patient number at 6 weeks who were CCOM malaligned was significant compared with SVA (P = 0.003, P < 0.001, P < 0.001, respectively). SRS appearance worsened as preoperative SVA and CCOM increased (P < 0.05), and 2-year SRS appearance and mental health was worsened as 2-year SVA and CCOM increased (P < 0.05). SVA malalignment was 8 and 10 at 1 and 2 years, respectively, and CCOM malalignment was 24 and 32, respectively. Kaplan-Meier curve demonstrates persistent malalignment of CCOM at 6 weeks if not corrected. CONCLUSION: CCOM alignment restoration is an important parameter in ASD, and malalignment is consistent over time.