Health-related quality of life measures in adult spinal deformity: can we replace the SRS-22 with PROMIS?

PURPOSE: To determine the validity and responsiveness of PROMIS metrics versus the SRS-22r questionnaire in adult spinal deformity (ASD). METHODS: Surgical ASD patients undergoing ≥ 4 levels fused with complete baseline PROMIS and SRS-22r data were included. Internal consistency (Cronbach's alpha) and test-retest reliability [intraclass correlation coefficient (ICC)] were compared. Cronbach's alpha and ICC values ≥ 0.70 were predefined as satisfactory. Convergent validity was evaluated via Spearman's correlations. Responsiveness was assessed via paired samples t tests with Cohen's d to assess measure of effect (baseline to 3 months). RESULTS: One hundred and ten pts are included. Mean baseline SRS-22r score was 2.62 ± 0.67 (domains = Function: 2.6, Pain: 2.5, Self-image: 2.2, Mental Health: 3.0). Mean PROMIS domains = Physical Function (PF): 12.4, Pain Intensity (PI): 91.7, Pain Interference (Int): 55.9. Cronbach's alpha, and ICC were not satisfactory for any SRS-22 and PROMIS domains. PROMIS-Int reliability was low for all SRS-22 domains (0.037-0.225). Convergent validity demonstrated strong correlation via Spearman's rho between PROMIS-PI and overall SRS-22r (- 0.61), SRS-22 Function (- 0.781), and SRS-22 Pain (- 0.735). PROMIS-PF had strong correlation with SRS-22 Function (0.643), while PROMIS-Int had moderate correlation with SRS-22 Pain (- 0.507). Effect size via Cohen's d showed that PROMIS had superior responsiveness across all domains except for self-image. CONCLUSIONS: PROMIS is a valid measure compared to SRS-22r in terms of convergent validity, and has greater measure of effect in terms of responsiveness, but failed in reliability and internal consistency. Surgeons should consider the lack of reliability and internal consistency (despite validity and responsiveness) of the PROMIS to SRS-22r before replacing the traditional questionnaire with the computer-adaptive testing.

Upper extremity injuries in the victims of intimate partner violence.

OBJECTIVES: To recognize most common patterns of upper extremity (UE) injuries in victims of Intimate Partner Violence (IPV). METHODS: Radiological review of 308 patients who reported physical IPV at our institution from January 2013 to June 2018, identified 55 patients with 88 unique UE injuries. Demographic data and injury patterns and associations were collected from the electronic medical records. RESULTS: The cohort included 49 females and 6 males (age 19-63, mean 38). At the time of injury, IPV was reported in 15/88 (17%) and IPV screening was documented for 22/88 (25%) injuries. There were 46 fractures, 8 dislocations or subluxations, and 34 isolated soft tissue injuries, most commonly involving the hand (56/88). Fractures most commonly involved the fingers (21/46, 46%) and the 5th digit (8/27, 30%). Medial UE fractures (5th digit, 4th digit) constituted 44% of hand and finger fractures (12/27) and 26% of all fractures (12/46). Comminuted and displaced fractures were rare (8/46, 17%). Head and face injuries were the most common concomitant injuries (9/22, 41%) and subsequent injuries (21/61, 35%). Of 12 patients with recurrent UE injuries, 6 had recurrent injuries of the same hand. Five of 6 non-acute fractures (83%) were of the hand. CONCLUSIONS: Hand and finger injuries are the most common UE injuries in patients with IPV, with finger being the most common site and medial hand the most common region of fracture. Repeated injuries involving the same site and a combination of medial hand and head or face injuries could indicate IPV. KEY POINTS: • Upper extremity injuries in victims of intimate partner violence are most commonly seen in the hand and fingers. • Fingers are the most common site of fracture and the medial hand is the most common region of fracture in the upper extremity in victims of intimate partner violence. • In intimate partner violence victims with upper extremity injuries, concomitant injuries and subsequent injuries are most commonly seen in the head and neck region.

Imaging patterns of lower extremity injuries in victims of intimate partner violence (IPV).

PURPOSE: To describe the pattern and distribution of lower extremity injuries in victims of intimate partner violence (IPV). MATERIALS AND METHODS: A retrospective radiological review of 688 patients reporting IPV to our institution's violence intervention and prevention program between January 2013 and June 2018 identified 88 patients with 154 lower extremity injuries. All lower extremity injuries visible on radiological studies were analyzed. Concomitant, recurrent, and associated injuries were also collected, in addition to the demographic data. RESULTS: The injuries consisted of 103 fractures, 46 soft tissue injuries, and 5 dislocations. The foot was the most common site of injury representing 39% (60/154) of total injuries, 48% (49/103) of fractures, 17% (8/46) of soft tissue injuries, and 3 dislocations. The ankle was the second most common site of injury representing 30% (47/154) of total injuries, 20% (21/103) of fractures, and 57% (26/46) of soft tissue injuries. Recurrent injuries of the lower extremity were seen in 30% (26/88) of victims who had 74 recurrent injuries. The most common sites of recurrent injury were the foot and ankle, representing 72% (53/74) of recurrent injuries. CONCLUSION: Recurrent injuries of the foot and ankle, synchronous craniofacial injuries, and upper extremity injuries in young women (<35 years) should prompt radiologists to consider IPV.

Intimate Partner Violence: A Primer for Radiologists to Make the "Invisible" Visible.

Intimate partner violence (IPV) is the physical, sexual, or emotional violence between current or former partners. It is a major public health issue that affects nearly one out of four women. Nonetheless, IPV is greatly underdiagnosed. Imaging has played a significant role in identifying cases of nonaccidental trauma in children, and similarly, it has the potential to enable the identification of injuries resulting from IPV. Radiologists have early access to the radiologic history of such victims and may be the first to diagnose IPV on the basis of the distribution and imaging appearance of the patient's currrent and past injuries. Radiologists must be familiar with the imaging findings that are suggestive of injuries resulting from IPV. Special attention should be given to cases in which there are multiple visits for injury care; coexistent fractures at different stages of healing, which may help differentiate injuries related to IPV from those caused by a stranger; and injuries in defensive locations and target areas such as the face and upper extremities. The authors provide an overview of current methods for diagnosing IPV and define the role of the radiologist in cases of IPV. They also describe a successful diagnostic imaging-based approach for helping to identify IPV, with a specific focus on the associated imaging findings and mechanisms of injuries. In addition, current needs and future perspectives for improving the diagnosis of this hidden epidemic are identified. This information is intended to raise awareness among radiologists, with the ultimate goal of improving the diagnosis of IPV and thus reducing the devastating effects on victims' lives. ©RSNA, 2020.

Costs of Surgery in Adult Spinal Deformity: Do Higher Cost Surgeries Lead to Better Outcomes?

STUDY DESIGN: This was a retrospective study. OBJECTIVE: To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny. MATERIALS AND METHODS: ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes. RESULTS: Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m 2 ), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4°), and pelvic tilt (HC: 25.3 vs. LC: 22.4°). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P =0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P =0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P =0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria. CONCLUSIONS: Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity. LEVEL OF EVIDENCE: 3.

Patient-Centered Outcomes Following Prone Lateral Single-Position Approach to Same-Day Circumferential Spine Surgery.

STUDY DESIGN: Retrospective study. OBJECTIVE: Evaluate surgical characteristics and postoperative 2-year results of the PL approach to spinal fusion. SUMMARY OF BACKGROUND DATA: Prone-lateral(PL) single positioning has recently gained popularity in spine surgery due to lower blood loss and operative time but has yet to be examined for other notable outcomes, including realignment and patient-reported measures. MATERIALS AND METHODS: We included circumferential spine fusion patients with a minimum one-year follow-up. Patients were stratified into groups based on undergoing PL approach versus same-day staged (Staged). Mean comparison tests identified differences in baseline parameters. Multivariable logistic regression, controlling for age, levels fused, and Charlson Comorbidity Index were used to determine the influence of the approach on complication rates, radiographic and patient-reported outcomes up to two years. RESULTS: One hundred twenty-two patients were included of which 72(59%) were same-day staged and 50(41%) were PL. PL patients were older with lower body mass index (both P <0.05). Patients undergoing PL procedures had lower estimated blood loss and operative time (both P <0.001), along with fewer osteotomies (63% vs. 91%, P <0.001). This translated to a shorter length of stay (3.8 d vs. 4.9, P =0.041). PL procedures demonstrated better correction in both PT (4.0 vs. -0.2, P =0.033 and pelvic incidence and lumbar lordosis (-3.7 vs. 3.1, P =0.012). PL procedures were more likely to improve in GAP relative pelvic version (OR: 2.3, [1.5-8.8]; P =0.003]. PL patients suffered lesser complications during the perioperative period and greater improvement in NRS-Back (-6.0 vs. -3.3, P =0.031), with less reoperations (0.0% vs. 4.8%, P =0.040) by two years. CONCLUSIONS: Patients undergoing PL single-position procedures received less invasive procedures with better correction of pelvic compensation, as well as earlier discharge. The prone lateral cohort also demonstrated greater clinical improvement and a lower rate of reoperations by two years following spinal corrective surgery. LEVEL OF EVIDENCE: Level-III.

Outcomes and survival analysis of adult cervical deformity patients with 10-year follow-up.

BACKGROUND: Previous studies have demonstrated that adult cervical deformity patients may be at increased risk of death in conjunction with increased frailty or a weakened physiologic state. However, such studies have often been limited by follow-up duration, and longer-term studies are needed to better assess temporal changes in ACD patients and associated mortality risk. PURPOSE: To assess if patients with decreased comorbidities and physiologic burden will be at lessened risk of death for a greater length of time after undergoing adult cervical deformity surgery. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: Two hundred ninety ACD patients. OUTCOME MEASURES: Morbidity and mortality data. METHODS: Operative ACD patients ≥18 years with pre-(BL) and 10-year (10Y) data were included. Patients were stratified as expired versus living, as well as temporally grouped by Expiration prior to 5Y or between 5Y and 10Y. Group differences were assessed via means comparison analysis. Backstep logistic regression identified mortality predictors. Kaplan-Meier analysis assessed survivorship of expired patients. Log rank analysis determined differences in survival distribution groups. RESULTS: Sixty-six total patients were included (60.97±10.19 years, 48% female, 28.03±7.28 kg/m2). Within 10Y, 12 (18.2% of ACD cohort) expired. At baseline, patients were comparable in age, gender, BMI, and CCI total on average (all p>.05). Furthermore, patients were comparable in BL HRQLs (all p>.05). However, patients who expired between 5Y and 10Y demonstrated higher BL EQ5D and mJOA scores than their earlier expired counterparts at 2Y (p<.021). Furthermore, patients who presented with no CCI markers at BL were significantly more likely to survive until the 5Y-10Y follow-up window. Surgically, the only differences observed between patients who survived until 5Y was in undergoing osteotomy, with longer survival seen in those who did not require it (p=.003). Logistic regression revealed independent predictors of death prior to 5Y to be increased BMI, increased frailty, and increased levels fused (model p<.001). KM analysis found that by Passias et al frailty, not frail patients had mean survival time of 170.56 weeks, versus 158.00 in frail patients (p=.949). CONCLUSIONS: Our study demonstrates that long-term survival after cervical deformity surgery may be predicted by baseline surgical factors. By optimizing BMI, frailty status, and minimizing fusion length when appropriate, surgeons may be able to further assist ACD patients in increasing their survivability postoperatively.

Lower Hounsfield Units at the Planned Lowest Instrumented Vertebra is an Independent Risk Factor for Complications Following Adult Cervical Deformity Surgery.

BACKGROUND: The association of Hounsfield units (HU) and junctional pathologies in adult cervical deformity (ACD) surgery has not been elucidated. OBJECTIVE: Assess if the bone mineral density of the LIV, as assessed by HUs, is prognostic for the risk of complications after ACD surgery. STUDY DESIGN/SETTING: Retrospective cohort study. METHODS: HUs were measured on preoperative CT scans. Means comparison test assessed differences in HUs based on the occurrence of complications, linear regression assessed the correlation of HUs with risk factors, and multivariable logistic regression followed by a conditional inference tree derived a threshold for HUs based on the increased likelihood of developing a complication. RESULTS: In all, 107 ACD patients were included. Thirty-one patients (29.0%) developed a complication (18.7% perioperative), with 20.6% developing DJK and 11.2% developing DJF. There was a significant correlation between lower LIVs and lower HUs (r=0.351, P=0.01), as well as age and HUs at the LIV. Age did not correlate with change in the DJK angle (P>0.2). HUs were lower at the LIV for patients who developed a complication and an LIV threshold of 190 HUs was predictive of complications (OR: 4.2, [1.2-7.6]; P=0.009). CONCLUSIONS: Low bone mineral density at the lowest instrumented vertebra, as assessed by a threshold lower than 190 Hounsfield units, may be a crucial risk factor for the development of complications after cervical deformity surgery. Preoperative CT scans should be routinely considered in at-risk patients to mitigate this modifiable risk factor during surgical planning. LEVEL OF EVIDENCE: Level-III.

The Impact of Lumbopelvic Realignment Versus Prevention Strategies at the Upper-instrumented Vertebra on the Rates of Junctional Failure Following Adult Spinal Deformity Surgery.

STUDY DESIGN/SETTING: Retrospective. OBJECTIVE: Evaluate the surgical technique that has the greatest influence on the rate of junctional failure following ASD surgery. SUMMARY OF BACKGROUND DATA: Differing presentations of adult spinal deformity(ASD) may influence the extent of surgical intervention and the use of prophylaxis at the base or the summit of a fusion construct to influence junctional failure rates. MATERIALS AND METHODS: ASD patients with two-year(2Y) data and at least 5-level fusion to the pelvis were included. Patients were divided based on UIV: [Longer Construct: T1-T4; Shorter Construct: T8-T12]. Parameters assessed included matching in age-adjusted PI-LL or PT, aligning in GAP-relative pelvic version or Lordosis Distribution Index. After assessing all lumbopelvic radiographic parameters, the combination of realigning the two parameters with the greatest minimizing effect of PJF constituted a good base. Good s was defined as having: (1) prophylaxis at UIV (tethers, hooks, cement), (2) no lordotic change(under-contouring) greater than 10° of the UIV, (3) preoperative UIV inclination angle<30°. Multivariable regression analysis assessed the effects of junction characteristics and radiographic correction individually and collectively on the development of PJK and PJF in differing construct lengths, adjusting for confounders. RESULTS: In all, 261 patients were included. The cohort had lower odds of PJK(OR: 0.5,[0.2-0.9]; P =0.044) and PJF was less likely (OR: 0.1,[0.0-0.7]; P =0.014) in the presence of a good summit. Normalizing pelvic compensation had the greatest radiographic effect on preventing PJF overall (OR: 0.6,[0.3-1.0]; P =0.044). In shorter constructs, realignment had a greater effect on decreasing the odds of PJF(OR: 0.2,[0.02-0.9]; P =0.036). With longer constructs, a good summit lowered the likelihood of PJK(OR: 0.3,[0.1-0.9]; P =0.027). A good base led to zero occurrences of PJF. In patients with severe frailty/osteoporosis, a good summit lowered the incidence of PJK(OR: 0.4,[0.2-0.9]; P =0.041) and PJF (OR: 0.1,[0.01-0.99]; P =0.049). CONCLUSION: To mitigate junctional failure, our study demonstrated the utility of individualizing surgical approaches to emphasize an optimal basal construct. Achievement of tailored goals at the cranial end of the surgical construct may be equally important, especially for higher-risk patients with longer fusions. LEVEL OF EVIDENCE: 3.

Comparison of multilevel low-grade techniques versus three-column osteotomies in adult spinal deformity surgery: does harmonious correction matter?

OBJECTIVE: Recent debate has arisen between whether to use a three-column osteotomy (3CO) or multilevel low-grade (MLG) techniques to treat severe sagittal malalignment in adult spinal deformity (ASD) surgery. The goal of this study was to compare the outcomes of 3CO and MLG techniques performed in corrective surgeries for ASD. METHODS: ASD patients who had a baseline PI-LL > 30° and 2-year follow-up data were included. Patients underwent either 3CO or MLG (thoracolumbar posterior column osteotomies at ≥ 3 levels or anterior lumbar interbody fusion at ≥ 3 levels with no 3CO). The segmental utility ratio was used to assess relative segmental correction (segmental correction divided by overall correction in lordosis divided by the number of thoracolumbar interventions [interbody fusion, thoracolumbar posterior column osteotomies, and 3CO]). The paired t-test was used to assess lordotic distribution by differences in lordosis between adjacent lumbar disc spaces (e.g., L1-2 to L2-3). Multivariate analysis, controlling for age, sex, BMI, osteoporosis, baseline pelvic incidence, and T1 pelvic angle, was used to evaluate the complication rates and radiographic and patient-reported outcomes between the groups. RESULTS: A total of 93 patients were included, 53% of whom underwent MLG and 47% of whom underwent 3CO. The MLG group had a lower BMI (p < 0.05). MLG patients received fewer previous fusions than 3CO patients (31% vs 80%, p < 0.001). MLG patients had 24% less blood loss but a 22% longer operative time (565 vs 419 minutes, p = 0.008). Using adjusted analysis, the 3CO group had greater segmental and relative correction at each level (segmental utility ratio mean 69% for 3CO vs 23% for MLG, p < 0.001). However, the 3CO group had lordotic differences between two adjacent lumbar disc pairs (range -0.5° to 9.0°, p = 0.009), while MLG was more harmonious (range 2.2°-6.5°, p > 0.4). MLG patients were more likely to undergo realignment to age-adjusted standards (OR 5.6, 95% CI 1.2-46.4; p = 0.033). MLG patients were less likely to develop neurological complications or undergo reoperation (OR 0.4, 95% CI 0.1-0.9; p = 0.041). Adjusted analysis revealed that MLG patients more often met a substantial clinical benefit in the Oswestry Disability Index score (OR 5.3, 95% CI 1.1-26.8; p = 0.043). CONCLUSIONS: MLG techniques showed better utility in lumbar distribution and age-adjusted global correction while minimizing neurological complications and reoperation rates by 2 years postoperatively. In selected instances, these techniques may offer the spine deformity surgeon a safer alternative when correcting severe adult spinal deformity.

Factors Influencing Maintenance of Alignment and Functional Improvement Following Adult Spinal Deformity Surgery: A 3-Year Outcome Analysis.

STUDY DESIGN: This was a retrospective review. OBJECTIVE: To assess the factors contributing to durability of surgical results following adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND: Factors contributing to the long-term sustainability of ASD correction are currently undefined. MATERIALS AND METHODS: Operative ASD patients with preoperatively (baseline) and 3-year postoperatively radiographic/health-related quality of life data were included. At 1 and 3 years postoperatively, a favorable outcome was defined as meeting at least three of four criteria: (1) no proximal junctional failure or mechanical failure with reoperation, (2) best clinical outcome (BCO) for Scoliosis Research Society (SRS) (≥4.5) or Oswestry Disability Index (ODI) (<15), (3) improving in at least one SRS-Schwab modifier, and (4) not worsening in any SRS-Schwab modifier. A robust surgical result was defined as having a favorable outcome at both 1 and 3 years. Predictors of robust outcomes were identified using multivariable regression analysis with conditional inference tree for continuous variables. RESULTS: We included 157 ASD patients in this analysis. At 1 year postoperatively, 62 patients (39.5%) met the BCO definition for ODI and 33 (21.0%) met the BCO for SRS. At 3 years, 58 patients (36.9%) had BCO for ODI and 29 (18.5%) for SRS. Ninety-five patients (60.5%) were identified as having a favorable outcome at 1 year postoperatively. At 3 years, 85 patients (54.1%) had a favorable outcome. Seventy-eight patients (49.7%) met criteria for a durable surgical result. Multivariable adjusted analysis identified the following independent predictors of surgical durability: surgical invasiveness >65, being fused to S1/pelvis, baseline to 6-week pelvic incidence and lumbar lordosis difference >13.9°, and having a proportional Global Alignment and Proportion score at 6 weeks. CONCLUSIONS: Nearly 50% of the ASD cohort demonstrated good surgical durability, with favorable radiographic alignment and functional status maintained up to 3 years. Surgical durability was more likely in patients whose reconstruction was fused to the pelvis and addressed lumbopelvic mismatch with adequate surgical invasiveness to achieve full alignment correction.

Patient-specific Cervical Deformity Corrections With Consideration of Associated Risk: Establishment of Risk Benefit Thresholds for Invasiveness Based on Deformity and Frailty Severity.

STUDY DESIGN/SETTING: This was a retrospective cohort study. BACKGROUND: Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty. OBJECTIVE: The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity. METHODS: This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely. RESULTS: A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P =0.002], and invasiveness increased with deformity severity ( P <0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P =0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P =0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P =0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group. CONCLUSIONS: Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes.

The Importance of Incorporating Proportional Alignment in Adult Cervical Deformity Corrections Relative to Regional and Global Alignment: Steps Toward Development of a Cervical-Specific Score.

STUDY DESIGN/SETTING: Retrospective single-center study. BACKGROUND: The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD). PURPOSE: Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD. METHODS: Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years. RESULTS: One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF. CONCLUSION: The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement.

Efficacy of Varying Surgical Approaches on Achieving Optimal Alignment in Adult Spinal Deformity Surgery.

BACKGROUND: The Roussouly, SRS-Schwab, and Global Alignment and Proportion (GAP) classifications define alignment by spinal shape and deformity severity. The efficacy of different surgical approaches and techniques to successfully achieve these goals is not well understood. PURPOSE: Identify the impact of surgical approach and/or technique on meeting complex realignment goals in adult spinal deformity (ASD) corrective surgery. STUDY DESIGN/SETTING: Retrospective study. MATERIALS AND METHODS: Included patients with ASD fused to pelvis with 2-year data. Patients were categorized by: (1) Roussouly: matching current and theoretical spinal shapes, (2) improving in SRS-Schwab modifiers (0, +, ++), and (3) improving GAP proportionality by 2 years. Analysis of covariance and multivariable logistic regression analyses controlling for age, levels fused, baseline deformity, and 3-column osteotomy usage compared the effect of different surgical approaches, interbody, and osteotomy use on meeting realignment goals. RESULTS: A total of 693 patients with ASD were included. By surgical approach, 65.7% were posterior-only and 34.3% underwent anterior-posterior approach with 76% receiving an osteotomy (21.8% 3-column osteotomy). By 2 years, 34% matched Roussouly, 58% improved in GAP, 45% in SRS-Schwab pelvic tilt (PT), 62% sagittal vertical axis, and 70% pelvic incidence-lumbar lordosis. Combined approaches were most effective for improvement in PT [odds ratio (OR): 1.7 (1.1-2.5)] and GAP [OR: 2.2 (1.5-3.2)]. Specifically, anterior lumbar interbody fusion (ALIF) below L3 demonstrated higher rates of improvement versus TLIFs in Roussouly [OR: 1.7 (1.1-2.5)] and GAP [OR: 1.9 (1.3-2.7)]. Patients undergoing pedicle subtraction osteotomy at L3 or L4 were more likely to improve in PT [OR: 2.0 (1.0-5.2)] and pelvic incidence-lumbar lordosis [OR: 3.8 (1.4-9.8)]. Clinically, patients undergoing the combined approach demonstrated higher rates of meeting SCB in Oswestry Disability Index by 2 years while minimizing rates of proximal junctional failure, most often with an ALIF at L5-S1 [Oswestry Disability Index-SCB: OR: 1.4 (1.1-2.0); proximal junctional failure: OR: 0.4 (0.2-0.8)]. CONCLUSIONS: Among patients undergoing ASD realignment, optimal lumbar shape and proportion can be achieved more often with a combined approach. Although TLIFs, incorporating a 3-column osteotomy, at L3 and L4 can restore lordosis and normalize pelvic compensation, ALIFs at L5-S1 were most likely to achieve complex realignment goals with an added clinical benefit and mitigation of junctional failure.

Enabling Technologies and the Development of Single Position Lateral Spine Surgery.

Technological advances have paved the way for surgical innovation in spine surgery. These advances have allowed for the creation of more accurate and less invasive surgical techniques. Spine surgeons play a critical role in the integration of new technology into the surgical workflow with the goal of improving safety, efficiency, and clinical outcomes. Navigation and robotic techniques are emerging technologies that have begun to revolutionize spine surgery. One particular advancement these technologies have recently enabled is single position prone lateral surgery. This review provides a history and brief overview of the different applications of new technologies in spine surgery. It will also discuss their enablement of single position prone lateral surgery in order to more critically evaluate their utilization.

Surgical costs in adult cervical Deformity: Do higher cost surgeries lead to better Outcomes?

BACKGROUND: As our focus on delivering cost effective healthcare increases, interventions like cervical deformity surgery, which are associated with high resource utilization, have received greater scrutiny. The purpose of this study was to assess relationship between surgical costs, deformity correction, and patient reported outcomes in ACD surgery. METHODS: ACD Patients ≥ 18 years with baseline (BL) and 2-year (2Y) data were included. Cost of surgery was calculated by applying average Medicare reimbursement rates by CPT code to surgical details of each patient in the cohort. CPT codes for corpectomy, ACDF, osteotomy, decompression, levels fused, and instrumentation were considered in the analysis. Costs of complications and reoperations were intentionally excluded from the cost analysis. Patients were ranked into two groups by surgical cost: lowest cost (LC) and highest cost (HC). ANCOVA assessed differences in outcomes while accounting for covariates as appropriate. RESULTS: 113 met inclusion criteria. While mean age, frailty, BMI and gender composition were similar between cost groups, mean CCI was significantly higher in the HC group compared to that of the LC group (p=.014). At baseline, LC and HC groups had similar HRQLs and radiographic deformity (all p >.05). Logistic regression accounting for baseline age, deformity and CCI found that HC patients had significantly lower odds of undergoing reoperation within 2-years (OR: 0.309, 95 % CI: 0.193 - 0.493, p <.001). Furthermore, logistic regression accounting for baseline age, deformity and CCI found odds of DJF were significantly lower for those in the HC group (OR: 0.163, 95 % CI: 0.083 - 0.323, p <.001). At 2-years, logistic regression accounting for age and baseline TS-CL found HC patients still had significantly higher odds of reaching a "0″ TS-CL modifier at 2-years (OR: 3.353, 95 % CI: 1.081 - 10.402, p=.036). Logistic regression accounting for age and baseline NDI score found HC patients had significantly higher odds of reaching MCID in NDI at 2-years (OR: 4.477, 95 % CI: 1.507 - 13.297, p=.007). A similar logistic regression accounting for age and baseline mJOA score found odds of reaching MCID in mJOA significantly higher for high-cost patients (OR: 2.942, 95 % CI: 1.101 - 7.864, p=.031). CONCLUSIONS: While patient presentation influences surgical planning and costs, this study attempted to control for such variations to assess impact of surgical costs on outcomes. Despite continued scrutiny over healthcare costs, we found that more costly surgical interventions can produce superior radiographic alignment as well as patient reported outcomes for patients with cervical deformity.

A Hierarchical Approach to Realignment Strategies in Adult Cervical Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Construct an individualized cervical realignment strategy based on patient parameters at the presentation that results in superior 2-year health-related quality of life metrics and decreased rates of junctional failure and reoperation following adult cervical deformity surgery. SUMMARY OF BACKGROUND DATA: Research has previously focused on adult cervical deformity realignment thresholds for maximizing clinical outcomes while minimizing complications. However, realignment strategies may differ based on patient presentation and clinical characteristics. METHODS: We included adult cervical deformity patients with 2-year data. The optimal outcome was defined as meeting good clinical outcomes without distal junctional failure or reoperation. Radiographic parameters assessed included C2 Slope, C2-C7, McGregor's slope, TS-CL, cSVA, T1 slope, and preoperative lowest-instrumented vertebra (LIV) inclination angle. Conditional inference trees were used to establish thresholds for each parameter based on achieving the optimal outcome. Analysis of Covariance and multivariable logistic regression analysis, controlling for age, comorbidities, baseline deformity and disability, and surgical factors, assessed outcome rates for the hierarchical approach within each deformity group. RESULTS: One hundred twenty-seven patients were included. After correction, there was a significant difference in meeting the optimal outcome when correcting the C2 slope below 10 degrees (85% vs. 34%, P <0.001), along with lower rates of distal junctional failure (DJF) (7% vs. 42%, P <0.001). Next, after isolating patients below the C2 slope threshold, the selection of LIV with an inclination between 0 and 40 degrees demonstrated lower rates of distal junctional kyphosis and higher odds of meeting optimal outcome(OR: 4.2, P =0.011). The best third step was the correction of cSVA below 35 mm. This hierarchical approach (11% of the cohort) led to significantly lower rates of DJF (0% vs. 15%, P <0.007), reoperation (8% vs. 28%, P <0.001), and higher rates of meeting optimal outcome (93% vs. 36%, P <0.001) when controlling for age, comorbidities, and baseline deformity and disability. CONCLUSION: Our results indicate that the correction of C2 slope should be prioritized during cervical deformity surgery, with the selection of a stable LIV and correction of cervical SVA below the idealized threshold. Among the numerous radiographic parameters considered during preoperative planning for cervical deformity correction, our determinations help surgeons prioritize those realignment strategies that maximize the health-related quality of life outcomes and minimize complications. LEVEL OF EVIDENCE: Level-III.

Predictors of reoperation for spinal disorders in Chiari malformation patients with prior surgical decompression.

Background: Chiari malformation (CM) is a cluster of related developmental anomalies of the posterior fossa ranging from asymptomatic to fatal. Cranial and spinal decompression can help alleviate symptoms of increased cerebrospinal fluid pressure and correct spinal deformity. As surgical intervention for CM increases in frequency, understanding predictors of reoperation may help optimize neurosurgical planning. Materials and Methods: This was a retrospective analysis of the prospectively collected Healthcare Cost and Utilization Project's California State Inpatient Database years 2004-2011. Chiari malformation Types 1-4 (queried with ICD-9 CM codes) with associated spinal pathologies undergoing stand-alone spinal decompression (queried with ICD-9 CM procedure codes) were included. Cranial decompressions were excluded. Results: One thousand four hundred and forty-six patients (29.28 years, 55.6% of females) were included. Fifty-eight patients (4.01%) required reoperation (67 reoperations). Patients aged 40-50 years had the most reoperations (11); however, patients aged 15-20 years had a significantly higher reoperation rate than all other groups (15.5% vs. 8.2%, P = 0.048). Female gender was significantly associated with reoperation (67.2% vs. 55.6%, P = 0.006). Medical comorbidities associated with reoperation included chronic lung disease (19% vs. 6.9%, P < 0.001), iron deficiency anemia (10.3% vs. 4.1%, P = 0.024), and renal failure (3.4% vs. 0.9%, P = 0.05). Associated significant cluster anomalies included spina bifida (48.3% vs. 34.8%, P = 0.035), tethered cord syndrome (6.9% vs. 2.1%, P = 0.015), syringomyelia (12.1% vs. 5.9%, P = 0.054), hydrocephalus (37.9% vs. 17.7%, P < 0.001), scoliosis (13.8% vs. 6.4%, P = 0.028), and ventricular septal defect (6.9% vs. 2.3%, P = 0.026). Conclusions: Multiple medical and CM-specific comorbidities were associated with reoperation. Addressing them, where possible, may aid in improving CM surgery outcomes.

Crossing the Bridge From Degeneration to Deformity: When Does Sagittal Correction Impact Outcomes in Adult Spinal Deformity Surgery?

BACKGROUND: Patients with less severe adult spinal deformity (ASD) undergo surgical correction and often achieve good clinical outcomes. However, it is not well understood how much clinical improvement is due to sagittal correction rather than treatment of the spondylotic process. PURPOSE: Determine baseline thresholds in radiographic parameters that, when exceeded, may result in substantive clinical improvement from surgical correction. STUDY DESIGN: Retrospective. MATERIALS AND METHODS: ASD patients with BL and two-year data were included. Parameters assessed: sagittal vertical axis, pelvic incidence-lumbar lordosis mismatch, pelvic tilt, T1 pelvic angle, L1 pelvic angle, L4-S1 lordosis, C2-C7 sagittal vertical axis, C2-T3, C2 slope. Outcomes: Good Outcome (GO) at two years: [meeting either: (1) Substantial Clinical Benefit for Oswestry Disability Index (change >18.8), or (2) Oswestry Disability Index <15 and Scoliosis Research Society Total>4.5]. Binary logistic regression assessed each parameter to determine if correction was more likely needed to achieve GO. Conditional inference tree run machine learning analysis generated baseline thresholds for each parameter, above which, correction was necessary to achieve GO. RESULTS: We included 431 ASD patients. There were 223 (50%) that achieved a GO by two years. Binary logistic regression analysis demonstrated, with increasing baseline severity in deformity, sagittal correction was more often seen in those achieving GO for each parameter(all P <0.001). Of patients with baseline T1 pelvic angle above the threshold, 95% required correction to meet GO (95% vs. 54%, P <0.001). A baseline pelvic incidence-lumbar lordosis >10° (74% of patients meeting GO) needed correction to achieve GO (odds ratio: 2.6, 95% confidence interval: 1.4-4.8). A baseline C2 slope >15° also necessitated correction to obtain clinical success (odds ratio: 7.7, 95% confidence interval: 3.7-15.7). CONCLUSIONS: Our study highlighted point may be present at which sagittal correction has an outsized influence on clinical improvement, reflecting the line where deformity becomes a significant contributor to disability. These new thresholds give us insight into which patients may be more suitable for sagittal correction, as opposed to intervention for the spondylotic process only, leading to a more efficient utility of surgical intervention for ASD.

Impact of Frailty on the Development of Proximal Junctional Failure: Does Frailty Supersede Achieving Optimal Realignment?

BACKGROUND: Patients undergoing surgery for adult spinal deformity (ASD) are often elderly, frail, and at elevated risk of adverse events perioperatively, with proximal junctional failure (PJF) occurring relatively frequently. Currently, the specific role of frailty in potentiating this outcome is poorly defined. PURPOSE: To determine if the benefits of optimal realignment in ASD, with respect to the development of PJF, can be offset by increasing frailty. STUDY DESIGN: Retrospective cohort. MATERIALS AND METHODS: Operative ASD patients (scoliosis >20°, SVA>5 cm, pelvic tilt>25°, or TK>60°) fused to the pelvis or below with available baseline and 2-year (2Y) radiographic and HRQL data were included. The Miller Frailty Index (FI) was used to stratify patients into 2 categories: Not Frail (FI <3) and Frail (>3). Proximal Junctional Failure (PJF) was defined using the Lafage criteria. "Matched" and "unmatched" refers to ideal age-adjusted alignment postoperatively. Multivariable regression determined the impact of frailty on the development of PJF. RESULTS: Two hundred eighty-four ASD patients met inclusion criteria [62.2yrs±9.9, 81%F, BMI: 27.5 kg/m 2 ±5.3, ASD-FI: 3.4±1.5, Charlson Comorbidity Index (CCI): 1.7±1.6]. Forty-three percent of patients were characterized as Not Frail (NF) and 57% were characterized as Frail (F). PJF development was lower in the NF group compared with the F group (7% vs . 18%; P =0.002). F patients had 3.2 × higher risk of PJF development compared to NF patients (OR: 3.2, 95% CI: 1.3-7.3, P =0.009). Controlling for baseline factors, F unmatched patients had a higher degree of PJF (OR: 1.4, 95% CI:1.02-1.8, P =0.03); however, with prophylaxis, there was no increased risk. Adjusted analysis shows F patients, when matched postoperatively in PI-LL, had no significantly higher risk of PJF. CONCLUSIONS: An increasingly frail state is significantly associated with the development of PJF after corrective surgery for ASD. Optimal realignment may mitigate the impact of frailty on eventual PJF. Prophylaxis should be considered in frail patients who do not reach ideal alignment goals.