Preoperative CT Angiography Informs Instrumentation in Anterior Spine Surgery for Idiopathic Scoliosis.

The objective of this study is to evaluate whether the artery of Adamkiewicz localization with preoperative CT angiography influences anterior spinal instrumentation. Methods: Children with idiopathic scoliosis who underwent anterior instrumentation and with a preoperative CT angiography were evaluated retrospectively. Data included curve type, artery of Adamkiewicz level/laterality, surgical approach laterality, number of instrumented levels and segmental vessels ligated, intraoperative neuromonitoring changes, and postoperative neural complications. Results: Thirty-nine girls and eight boys (mean age 12 years [6.7 to 16.8 years]) were analyzed. Instrumented curves indicate 28 thoracic, 14 thoracolumbar, and seven double major. The artery of Adamkiewicz: T6 (left-1), T8 (left-1), T9 (left-4/right-2), T10 (left-11/right-4), T11 (left-4/right-4), T12 (left-1/right-2), L1 (left-2/right-1), and L2 (left-3/right-2). Four had bilateral dominant segmentals, whereas in nine patients, none was identified. T10 (32%) and left side (57%) were most frequent. On average, 7.1 (4 to 11) segmentals were ligated per case (total 355). Dominant vessels were ipsilateral to/within instrumentation levels in 30%. Discussion: In children with idiopathic scoliosis who underwent anterior instrumentation, the artery of Adamkiewicz was identified on the left in >50% and at T10 in 32%. In one-third of the patients, the artery was within intended surgical levels and resulted in instrumentation modification.

Correlation Between Lumbopelvic and Sagittal Parameters and Health-Related Quality of Life in Adults With Lumbosacral Spondylolisthesis.

STUDY DESIGN: Secondary analysis of prospective, multicenter data. OBJECTIVE: To evaluate impact of sagittal parameters on health-related quality of life (HRQoL) in adults with lumbosacral spondylolisthesis. METHODS: Adults with unoperated lumbosacral spondylolisthesis were identified in the Spinal Deformity Study Group database. Pearson's correlations were calculated between SF-12 (Short Form-12)/Scoliosis Research Society-30 (SRS-30) scores and radiographic parameters (C7 sagittal vertical axis [SVA] deviation, T1 pelvic angle, pelvic tilt [PT], pelvic incidence, sacral slope, slip angle, Meyerding slip grade, Labelle classification). Main effects linear regression models measured association between individual health status measures and individual radiographic predictor variables. RESULTS: Forty-five patients were analyzed (male, 15; female, 30; average age 40.5 ± 18.7 years; 14 low-grade, 31 high-grade). For low-grade slips, SVA had strong negative correlations with SF-12 mental component score (MCS), SRS-30 appearance, mental, and satisfaction domains (r = -0.57, r = -0.60, r = -0.58, r = -0.53, respectively; P < .05). For high-grade slips, slip angle had a moderate negative correlation with SF-12 MCS (r = -0.36; P = .05) and SVA had strong negative correlations with SF-12 physical component score (PCS), SRS-30 appearance and activity domains (r = -0.48, r = -0.48, r = -0.45; P < .05) and a moderate negative correlation with SRS-30 total (r = -0.37; P < .05). T1 pelvic angle had a moderate negative correlation with SF-12 PCS and SRS-30 appearance (r = -0.37, r = -0.36; P ≤ .05). For every 1° increase in PT, there was a 0.04-point decrease in SRS appearance, 0.05-point decrease in SRS activity, 0.06-point decrease in SRS satisfaction, and 0.04-point decrease in SRS total score (P < .05). CONCLUSION: Lumbosacral spondylolisthesis in adults negatively affects HRQoL. Multiple radiographic sagittal parameters negatively affect HRQoLs for patients with low- and high-grade slips. Improvement of sagittal parameters is an important goal of surgery for adults with lumbosacral spondylolisthesis.

Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance.

OBJECTIVE Surgical treatment of adult spinal deformity (ASD) is an effective endeavor that can be accomplished using a variety of surgical strategies. Here, the authors assess and compare radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent a posterior spinal fixation (PSF)-only approach, a posterior approach combined with lateral lumbar interbody fusion (LLIF+PSF), or a posterior approach combined with anterior lumbar interbody fusion (ALIF+PSF). METHODS The medical records of consecutive adults who underwent thoracolumbar fusion for ASD between 2003 and 2013 at a single institution were reviewed. Included were patients who underwent instrumentation from the pelvis to L-1 or above, had a sagittal vertical axis (SVA) of < 10 cm, and underwent a minimum of 2 years' follow-up. Those who underwent a 3-column osteotomy were excluded. Three groups of patients were compared on the basis of the procedure performed, LLIF+PSF, ALIF+PSF, and PSF only. Perioperative spinal deformity parameters, complications, and HRQoL outcome scores (Oswestry Disability Index [ODI], Scoliosis Research Society 22-question Questionnaire [SRS-22], 36-Item Short Form Health Survey [SF-36], visual analog scale [VAS] for back/leg pain) from each group were assessed and compared with each other using ANOVA. The minimal clinically important differences used were -1.2 (VAS back pain), -1.6 (VAS leg pain), -15 (ODI), 0.587/0.375/0.8/0.42 (SRS-22 pain/function/self-image/mental health), and 5.2 (SF-36, physical component summary). RESULTS A total of 221 patients (58 LLIF, 91 ALIF, 72 PSF only) met the inclusion criteria. Average deformities consisted of a SVA of < 10 cm, a pelvic incidence-lumbar lordosis (LL) mismatch of > 10°, a pelvic tilt of > 20°, a lumbar Cobb angle of > 20°, and a thoracic Cobb angle of > 15°. Preoperative SVA, LL, pelvic incidence-LL mismatch, and lumbar and thoracic Cobb angles were similar among the groups. Patients in the PSF-only group had more comorbidities, those in the ALIF+PSF group were, on average, younger and had a lower body mass index than those in the LLIF+PSF group, and patients in the LLIF+PSF group had a significantly higher mean number of interbody fusion levels than those in the ALIF+PSF and PSF-only groups. At final follow-up, all radiographic parameters and the mean numbers of complications were similar among the groups. Patients in the LLIF+PSF group had proximal junctional kyphosis that required revision surgery significantly less often and fewer proximal junctional fractures and vertebral slips. All preoperative HRQoL scores were similar among the groups. After surgery, the LLIF+PSF group had a significantly lower ODI score, higher SRS-22 self-image/total scores, and greater achievement of the minimal clinically important difference for the SRS-22 pain score. CONCLUSIONS Satisfactory radiographic outcomes can be achieved similarly and adequately with these 3 surgical approaches for patients with ASD with mild to moderate sagittal deformity. Compared with patients treated with an ALIF+PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of proximal junctional kyphosis and mechanical failure at the upper instrumented vertebra and less back pain, less disability, and better SRS-22 scores.

Factors Associated With the Development of and Revision for Proximal Junctional Kyphosis in 440 Consecutive Adult Spinal Deformity Patients.

MINI: Proximal junctional kyphosis (PJK) is a common, yet incompletely understood, complication of surgery for adult spinal deformity. We analyzed 440 consecutive adult spinal deformity patients for trends in development of PJK and need for revision surgery. pelvic tilt and thoracic kyphosis were predictive for developing PJK, while radiographic evidence of proximal junctional failure was predictive for proceeding to revision. STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: The aim of this study was to examine which radiographic parameters and surgical strategies are most closely associated with proximal junctional kyphosis (PJK) after adult spinal deformity (ASD) surgery, the need for revision surgery for PJK, and whether these differ based on the upper instrumented vertebra (UIV). SUMMARY OF BACKGROUND DATA: Multiple parameters are considered when planning correction of ASD. Determining which of these factors contribute to the development of and need for revision surgery for PJK presents a challenging problem. METHODS: Consecutive patients undergoing long fusion to the pelvis with age >18 years, minimum 6-month follow-up, and adequate radiographs for analysis in a single institution between 2003 and 2011 were included. Along with chart review, measurement of proximal junctional angle (PJA), sagittal balance, and pelvic parameters was performed on preoperative, postoperative, and latest follow-up radiographs. Postoperative radiographs were also examined for signs of PJF. RESULTS: A total of 440 patients with a mean follow-up of 34 months met inclusion criteria, 159 of whom developed PJK (36%), with 65 requiring revision surgery (41%). Higher preoperative pelvic tilt (PT) (P = 0.018) and postoperative thoracic kyphosis (TK) (P ≤ 0.001) were predictive for development of PJK, whereas hooks at UIV were protective (odds ratio [OR] 0.049). In patients who developed PJK, revision was more frequent in younger patients (P = 0.005) with greater postoperative sagittal vertical axis and PJA (P = 0.029, P = 0.018). PJF with spondylolisthesis, fracture, or instrumentation failure at the UIV had the highest ORs for proceeding to a revision (5.1, 1.6, and 2.2, respectively). CONCLUSION: TK and PT are important indicators of overall rigidity and reference the ability of the spine to compensate for sagittal plane deformity. Special attention should be paid to these characteristics and to the choice of proximal instrumentation when attempting to prevent PJK. Prevention of radiographically evident PJF may hold the key to reducing the need for revision surgery. LEVEL OF EVIDENCE: 3.

Magnitude, Location, and Factors Related to Regional and Global Sagittal Alignment Change in Long Adult Deformity Constructs: Report of 183 Patients With 2-Year Follow-up.

STUDY DESIGN: This is a retrospective review of a prospective multicenter adult spinal deformity (ASD) database. OBJECTIVE: To quantify the location and magnitude of sagittal alignment changes within instrumented and noninstrumented spinal segments and to investigate the factors associated with these changes after surgery for ASD. SUMMARY OF BACKGROUND DATA: Spinal realignment is one of the major goals in ASD surgery and changes in the alignment are common following surgical correction. METHODS: Inclusion criteria: operative patients with age above 18, coronal Cobb angle ≥20 degrees, sagittal vertical axis (SVA) ≥5 cm, pelvic tilt ≥25 degrees, and/or thoracic kyphosis ≥60 degrees. EXCLUSION CRITERIA: revision surgery 6 weeks postoperatively. Standard sagittal radiographic spinal deformity parameters were evaluated. Changes in sagittal parameters between 6 weeks and 2 years postoperatively were assessed within and outside instrumented segments. Associations between changes in sagittal alignment and age, preoperative SVA, rod diameters, rod material, presence of 3-column osteotomy, and the use of interbody fusions were evaluated. Patients were also stratified by >5- and >10-degree changes in alignment. RESULTS: In total, 183 patients (male:29, female:154, average age: 56±14.8 y) met inclusion criteria. A total of 45(24.6%) patients had increase in pelvic tilt >5 degrees, 74(40.4%) had increase in pelvic incidence and lumbar lordosis (LL) >5 degrees, and 76 (41.5%) had increase in SVA >2 cm. Mean change of thoracic sagittal alignment was +8 degrees; 70 (60%) patients had increases of >5 degrees and 31 (27%) had increases of >10 degrees. Noninstrumented thoracic segments had significantly more increase than instrumented thoracic segments (P=0.02). Mean loss of LL was -6 degrees; 49(47%) patients had worsening >5 degrees and 13(13%) >10 degrees. Noninstrumented lumbar segments had significantly less loss of lordosis than instrumented segments (P<0.01). Risks for loss of LL were: age 65 years and above [odds ratio (OR) 9.4; 95% confidence interval (CI), 3.5-25.2; P<0.01], preoperative SVA>5 cm (OR, 2.4; 95% CI, 1.3-4.4; P<0.01), and lumbar interbody fusion (OR, 2.3; 95% CI, 1.2-4.2; P<0.01). Smaller rods (4.5 mm) were associated with a lower probability of worsening LL compared with 5.5-mm rods (OR, 0.15; 95% CI, 0.04-0.58; P<0.01) and 6.0-mm rods (OR, 0.36; 95% CI, 0.18-0.72; P<0.01). The presence of a 3-column osteotomy and rod material were not significant factors in alignment changes (P>0.05). CONCLUSIONS: After correction of ASD, increases in thoracic and decreases in lumbar alignment is common. Loss of thoracic sagittal alignment primarily occurs in noninstrumented thoracic segments, whereas instrumented lumbar levels in elderly patients ( above 65 y) with high preoperative SVA, interbody fusions, and larger rods have significantly higher rates of postoperative sagittal alignment changes in the lumbar spine.

National Trends in the Surgical Management of Adolescent Idiopathic Scoliosis: Analysis of a National Estimate of 60,108 Children From the National Inpatient Sample Over a 13-Year Time Period in the United States.

STUDY DESIGN: Analysis of Nationwide Inpatient Sample (NIS). OBJECTIVE: Evaluate evolution of operative treatment of adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Spinal surgery is one of the most rapidly evolving branches of surgery. Changes in AIS operations are incompletely defined. METHODS: Children (10-18 years) with ICD-9 diagnosis of idiopathic scoliosis who underwent thoracic and/or lumbar spinal fusion identified in the NIS (1998-2011) were analyzed. Population-based utilization rates were calculated from US Census data. Patient demographics, surgical approach, operative techniques, complications during hospitalization, hospital stay length, and charges were analyzed. RESULTS: 60,108 children (46,256 girls, 13,776 boys, 76 gender not specified; average age 14.1 years) were identified. Thoracic fusions were the majority. Number of operations increased over time. For thoracic fusions, posterior operations significantly increased, whereas anterior and anterior/posterior operations decreased significantly. Although anterior operations for lumbar fusions declined, this was not as steep as thoracic. Use of autogenous bone graft (including iliac crest) significantly increased, which mirrored significant decreases in alternative fusion agents. Thoracoplasty significantly decreased, whereas osteotomy significantly increased. The average complication rate was 3.7%. Rates of blood transfusions, infection, and neural injury did not differ significantly from 1998 to 2011. Device-related complications increased significantly over time. Average lengths of hospital stay decreased significantly, whereas average total hospital charges increased significantly. CONCLUSIONS: In a representative sample of the US population from 1998 to 2011, operative approaches and techniques for AIS significantly changed. Anterior procedure is rarely performed for thoracic curves; lumbar curves continue to be treated with anterior and posterior approaches. Osteotomy and autogenous bone graft increased, while thoracoplasty decreased. Overall complication rates remain stable, whereas hospital lengths of stays decreased and charges increased.

Spinal Realignment for Adult Deformity: Three-column Osteotomies Alter Total Hip Acetabular Component Positioning.

INTRODUCTION: A goal of adult spinal deformity surgery is correction of sagittal imbalance by increasing lumbar lordosis (LL), allowing a previously retroverted pelvis to normalize as evidenced by decreases in pelvic tilt (PT). Realignment of pelvic orientation may alter the position of preexisting total hip arthroplasties (THAs). METHODS: Twenty-seven patients with unilateral THA who underwent thoracolumbar fusions for adult spinal deformity from the pelvis to L1 or above were retrospectively reviewed (levels fused, 10.3 [range, 6 to 17]; age, 70 ± 9 years). Comparisons of preoperative and postoperative spinal deformity parameters, acetabular tilt (AT), and acetabular cup abduction angle (CAA) were performed, with subgroup analysis for those who had undergone three-column osteotomy and those who had not. RESULTS: Preoperative deformity was severe, with findings of a sagittal vertical axis >9 cm, PT >25°, and pelvic incidence-LL >20°. Postoperatively, AT decreased significantly (-7° ± 10°; P < 0.001), signifying relative acetabular retroversion. Comparing patients with three-column osteotomy versus those without, AT changes were greater in those with three-column osteotomy (11° ± 7° and -2 ± 10°, respectively; P = 0.024). AT was significantly correlated with changes of PT (r = 0.704; P < 0.001) and LL (r = -0.481; P = 0.011). AT decreased (ie, retroverted) 1° for every 3.23° of LL or 1.13° of PT correction. The coronal plane CAA did not change substantially. DISCUSSION: Spinal deformity correction, with techniques such as three-column osteotomy, result in significant THA acetabular component repositioning in the sagittal plane. Resultant decreased AT (ie, retroversion) theoretically may affect tribology, wear, and joint stability and warrants further investigation.

Anterior Versus Posterior Approaches for Odontoid Fracture Stabilization in Patients Older Than 65 Years: 30-day Morbidity and Mortality in a National Database.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To compare 30-day perioperative clinical outcomes of surgical odontoid stabilization by an anterior or posterior operative approach in elderly patients. SUMMARY OF BACKGROUND DATA: Surgical stabilization of odontoid fractures is superior to nonoperative management in geriatric patients. How elderly patients with odontoid fractures fare after anterior and posterior approaches, however, is not well defined. MATERIALS AND METHODS: Retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Elderly patients (≥65 y) with odontoid fractures who underwent odontoid stabilization through anterior or posterior approaches were identified by International Classification of Diseases 9th Revision/Common Procedure Terminology codes. Exclusion criteria included concomitant subaxial spine surgery, instrumentation noncontiguous with the atlantoaxial interval, and combined approaches. Baseline demographics and perioperative details were compared. Adverse events, mortality, reoperation, discharge, and readmission rates within 30 days of operation were compared using bivariate and multivariate generalized linear regressions. RESULTS: One hundred forty-one patients (male-81; female-60; average age: 77.8±6.5 y; anterior approach-48; posterior approach-93) were analyzed. Patients scheduled to have a posterior approach had significantly more nonunions preoperatively and higher body mass indices. Operative times for posterior surgeries were significantly longer. Age, comorbidities, functional dependence, time to surgery, and length of hospital stay were similar between groups. There were no significant differences in the relative risk (RR) of the composite outcome of "any adverse event" after adjusting for differences in baseline characteristics. Patients who underwent an anterior approach were more likely to have an unplanned hospital readmission (RR=8.95; 95% confidence interval, 2.21-36.29; P=0.002) and have significantly more revision operations (RR=19.51; 95% confidence interval, 2.49-152.62; P=0.005) than patients who had a posterior operation. CONCLUSIONS: An anterior approach for odontoid fracture stabilization in patients ≥65 years old were associated with shorter operative times and greater RRs of unplanned readmissions and revision operations within 30 days of surgery relative to a posterior approach.

Sexual function after cervical spine surgery: Independent predictors of functional impairment.

Sexual function (SF) is an important component of patient-focused health related quality of life (HRQoL), but it has not been well studied in spine surgery. This study aims to assess SF after cervical spine surgery and identify predictors of SF. This single-center retrospective study evaluates SF of adults who underwent cervical spine surgery 2007-2012. Predictor variables included demographics, medical/surgical history, operative information, HRQoL measures (Neck Disability Index, SF-12), validated SF surveys [Female Sexual Function Index (FSFI) and Brief Sexual Function Inventory (BSFI) for males], and a study-specific SF questionnaire. 59 patients (31M, 28F; mean age=56±8.4) had significantly lower SF scores compared to age-matched peers: average BSFI = 2.26±1.22 (vs. 06±0.74), average FSFI=13.05±11.42 (<26.55 indicating sexual dysfunction). In men, lower mental SF-12 and higher NDI, back pain, and number of operated levels were associated with lower BSFI scores (all p<0.05). In women, higher total number of medications and pain medications were associated with lower FSFI scores (both p<0.05). 46% of patients reported difficulty performing a sexual position after surgery that they had previously enjoyed. 39% of men had difficulty on top during intercourse, and 32% of participants reported difficulty performing oral sex. 39% of patients reported worse SF, while only 5% reported an improvement in postoperative SF. Men and women who underwent cervical spine surgery had lower SF scores than age-matched peers, likely attributable to general mental health, regional neck disability, back pain, and medications. A large portion of patients reported subjectively worsened SF after surgery.

Utility of multilevel lateral interbody fusion of the thoracolumbar coronal curve apex in adult deformity surgery in combination with open posterior instrumentation and L5-S1 interbody fusion: a case-matched evaluation of 32 patients.

OBJECTIVE The aim of this study was to evaluate the utility of supplementing long thoracolumbar posterior instrumented fusion (posterior spinal fusion, PSF) with lateral interbody fusion (LIF) of the lumbar/thoracolumbar coronal curve apex in adult spinal deformity (ASD). METHODS Two multicenter databases were evaluated. Adults who had undergone multilevel LIF of the coronal curve apex in addition to PSF with L5-S1 interbody fusion (LS+Apex group) were matched by number of posterior levels fused with patients who had undergone PSF with L5-S1 interbody fusion without LIF (LS-Only group). All patients had at least 2 years of follow-up. Percutaneous PSF and 3-column osteotomy (3CO) were excluded. Demographics, perioperative details, radiographic spinal deformity measurements, and HRQoL data were analyzed. RESULTS Thirty-two patients were matched (LS+Apex: 16; LS: 16) (6 men, 26 women; mean age 63 ± 10 years). Overall, the average values for measures of deformity were as follows: Cobb angle > 40°, sagittal vertical axis (SVA) > 6 cm, pelvic tilt (PT) > 25°, and mismatch between pelvic incidence (PI) and lumbar lordosis (LL) > 15°. There were no significant intergroup differences in preoperative radiographic parameters, although patients in the LS+Apex group had greater Cobb angles and less LL. Patients in the LS+Apex group had significantly more anterior levels fused (4.6 vs 1), longer operative times (859 vs 379 minutes), and longer length of stay (12 vs 7.5 days) (all p < 0.01). For patients in the LS+Apex group, Cobb angle, pelvic tilt (PT), lumbar lordosis (LL), PI-LL (lumbopelvic mismatch), Oswestry Disability Index (ODI) scores, and visual analog scale (VAS) scores for back and leg pain improved significantly (p < 0.05). For patients in the LS-Only group, there were significant improvements in Cobb angle, ODI score, and VAS scores for back and leg pain. The LS+Apex group had better correction of Cobb angles (56% vs 33%, p = 0.02), SVA (43% vs 5%, p = 0.46), LL (62% vs 13%, p = 0.35), and PI-LL (68% vs 33%, p = 0.32). Despite more LS+Apex patients having major complications (56% vs 13%; p = 0.02) and postoperative leg weakness (31% vs 6%, p = 0.07), there were no intergroup differences in 2-year outcomes. CONCLUSIONS Long open posterior instrumented fusion with or without multilevel LIF is used to treat a variety of coronal and sagittal adult thoracolumbar deformities. The addition of multilevel LIF to open PSF with L5-S1 interbody support in this small cohort was often used in more severe coronal and/or lumbopelvic sagittal deformities and offered better correction of major Cobb angles, lumbopelvic parameters, and SVA than posterior-only operations. As these advantages came at the expense of more major complications, more leg weakness, greater blood loss, and longer operative times and hospital stays without an improvement in 2-year outcomes, future investigations should aim to more clearly define deformities that warrant the addition of multilevel LIF to open PSF and L5-S1 interbody fusion.

Investigating the Universality of Preoperative Health-Related Quality of Life (HRQoL) for Surgically Treated Spinal Deformity in Young Adults: A Propensity Score-Matched Comparison Between African and US Populations.

STUDY DESIGN: Retrospective analysis of propensity score-matched (PSM) observational cohorts. OBJECTIVES: To evaluate and compare preoperative health-related quality of life (HRQoL) scores and radiographic measurements of young African and US adults with spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: Young ASD patients in the United States are motivated more to correct coronal and sagittal plane deformities than to alleviate pain. Motivations for surgical correction in young ASD patients in Africa have not been previously investigated. METHODS: Retrospective review of two large databases of African and US patients with ASD. African patients who underwent ASD surgery were PSM by age, gender, and pelvic tilt with US patients. Preoperative radiographic parameters and HRQoL scores (ODI, SRS-22r, back/leg pain) were compared between cohorts. Pearson correlations used to evaluate relationships between radiographic parameters and HRQoL scores. RESULTS: Fifty-four US patients (average age 22.9 ± 4.9 years; 0% African American) and 54 African patients (24.6 ± 7.2 years) met inclusion criteria. Compared to the United States, African patients had significantly lower body mass index (21.1 ± 3.3 vs. 24.6 ± 7.2) and more severe scoliosis, coronal malalignment, and sagittal malalignment (p < .05). Africans also had significantly better Oswestry Disability Index (12.8 vs. 17.7), worse Scoliosis Research Society questionnaire (SRS-22r)-Appearance (2.5 vs. 3.2), SRS-Function (3.3 vs. 3.9), and SRS-Total (3.2 vs. 3.5) scores than US patients (p < .05). SRS-Appearance scores correlated with Cobb angles of the upper thoracic (r = -0.321), thoracic (r = -0.277), and thoracolumbar (r = -0.300) curves for US patients. For African patients, global sagittal alignment and C7 inclination correlated with SRS-Appearance (r = -0.347, -0.346, respectively). CONCLUSIONS: Young African ASD patients have significantly more severe deformity, less disability, and worse SRS-22r scores preoperatively than a matched cohort of US patients. Spinal deformity and associated poor self-image appear to be the major drivers of surgical intervention in this cohort. Global malalignment in African patients is most closely correlated with appearance scores and should be surgically addressed accordingly. LEVEL OF EVIDENCE: Level III.

Prior Lumbar Spinal Arthrodesis Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty.

BACKGROUND: Degenerative hip disorders often coexist with degenerative changes of the lumbar spine. Limited data on this patient population suggest inferior functional improvement and pain relief after surgical management. The purpose of this study is to compare the rates of prosthetic-related complication after primary total hip arthroplasty (THA) in patients with and without prior lumbar spine arthrodesis (SA). METHODS: Medicare patients (n = 811,601) undergoing primary THA were identified and grouped by length of prior SA (no fusion, 1-2 levels fused [S-SAHA], and ≥3 levels fused [L-SAHA]). RESULTS: Compared with controls, patients with prior SA had significantly higher rates of complications including dislocation (control: 2.36%; S-SAHA: 4.26%; and L-SAHA: 7.51%), revision (control: 3.43%, S-SAHA: 5.55%, and L-SAHA: 7.77%), loosening (control: 1.33%, S-SAHA: 2.10%, and L-SAHA: 3.04%), and any prosthetic-related complication (control: 7.33%, S-SAHA: 11.15% [relative risk: 1.52], and L-SAHA: 14.16% [relative risk: 1.93]) within 24 months (P < .001). CONCLUSION: The interplay of coexisting degenerative hip and spine disease deserves further attention of both arthroplasty and spine surgeons.

Impact of preoperative depression on 2-year clinical outcomes following adult spinal deformity surgery: the importance of risk stratification based on type of psychological distress.

OBJECTIVE The objective of this study was to isolate whether the effect of a baseline clinical history of depression on outcome is independent of associated physical disability and to evaluate which mental health screening tool has the most utility in determining 2-year clinical outcomes after adult spinal deformity (ASD) surgery. METHODS Consecutively enrolled patients with ASD in a prospective, multicenter ASD database who underwent surgical intervention with a minimum 2-year follow-up were retrospectively reviewed. A subset of patients who completed the Distress and Risk Assessment Method (DRAM) was also analyzed. The effects of categorical baseline depression and DRAM classification on the Oswestry Disability Index (ODI), SF-36, and Scoliosis Research Society questionnaire (SRS-22r) were assessed using univariate and multivariate linear regression analyses. The probability of achieving ≥ 1 minimal clinically important difference (MCID) on the ODI based on the DRAM's Modified Somatic Perceptions Questionnaire (MSPQ) score was estimated. RESULTS Of 267 patients, 66 (24.7%) had self-reported preoperative depression. Patients with baseline depression had significantly more preoperative back pain, greater BMI and Charlson Comorbidity Indices, higher ODIs, and lower SRS-22r and SF-36 Physical/Mental Component Summary (PCS/MCS) scores compared with those without self-reported baseline depression. They also had more severe regional and global sagittal malalignment. After adjusting for these differences, preoperative depression did not impact 2-year ODI, PCS/MCS, or SRS-22r totals (p > 0.05). Compared with those in the "normal" DRAM category, "distressed somatics" (n = 11) had higher ODI (+23.5 points), lower PCS (-10.9), SRS-22r activity (-0.9), and SRS-22r total (-0.8) scores (p ≤ 0.01), while "distressed depressives" (n = 25) had lower PCS (-8.4) and SRS-22r total (-0.5) scores (p < 0.05). After adjusting for important covariates, each additional point on the baseline MSPQ was associated with a 0.8-point increase in 2-year ODI (p = 0.03). The probability of improving by at least 1 MCID in 2-year ODI ranged from 77% to 21% for MSPQ scores 0-20, respectively. CONCLUSIONS A baseline clinical history of depression does not correlate with worse 2-year outcomes after ASD surgery after adjusting for baseline differences in comorbidities, health-related quality of life, and spinal deformity severity. Conversely, DRAM improved risk stratification of patient subgroups predisposed to achieving suboptimal surgical outcomes. The DRAM's MSPQ was more predictive than MCS and SRS mental domain for 2-year outcomes and may be a valuable tool for surgical screening.

Costs and readmission rates for the resection of primary and metastatic spinal tumors: a comparative analysis of 181 patients.

OBJECTIVE Because the surgical strategies for primary and metastatic spinal tumors are different, the respective associated costs and morbidities associated with those treatments likely vary. This study compares the direct costs and 90-day readmission rates between the resection of extradural metastatic and primary spinal tumors. The factors associated with cost and readmission are identified. METHODS Adults (age 18 years or older) who underwent the resection of spinal tumors between 2008 and 2013 were included in the study. Patients with intradural tumors were excluded. The direct costs of index hospitalization and 90-day readmission hospitalization were evaluated. The direct costs were compared between patients who were treated surgically for primary and metastatic spinal tumors. The independent factors associated with costs and readmissions were identified using multivariate analysis. RESULTS A total of 181 patients with spinal tumors were included (63 primary and 118 metastatic tumors). Overall, the mean index hospital admission cost for the surgical management of spinal tumors was $52,083. There was no significant difference in the cost of hospitalization between primary ($55,801) and metastatic ($50,098) tumors (p = 0.426). The independent factors associated with higher cost were male sex (p = 0.032), preoperative inability to ambulate (p = 0.002), having more than 3 comorbidities (p = 0.037), undergoing corpectomy (p = 0.021), instrumentation greater than 7 levels (p < 0.001), combined anterior-posterior approach (p < 0.001), presence of a perioperative complication (p < 0.001), and longer hospital stay (p < 0.001). The perioperative complication rate was 21.0%. Of this cohort, 11.6% of patients were readmitted within 90 days, and the mean hospitalization cost of that readmission was $20,078. Readmission rates after surgical treatment for primary and metastatic tumors were similar (11.1% vs 11.9%, respectively) (p = 0.880). Prior hospital stay greater than 15 days (OR 6.62, p = 0.016) and diagnosis of lung metastasis (OR 52.99, p = 0.007) were independent predictors of readmission. CONCLUSIONS Primary and metastatic spinal tumors are comparable with regard to the direct costs of the index surgical hospitalization and readmission rate within 90 days. The factors independently associated with costs are related to preoperative health status, type and complexity of surgery, and postoperative course.

Adult Spinal Deformity Correction with Multi-level Anterior Column Releases: Description of a New Surgical Technique and Literature Review.

STUDY DESIGN: Case series. OBJECTIVE: To evaluate radiographic and clinical outcomes of adults with spinal deformity treated with multilevel anterior column releases (ACR). SUMMARY OF BACKGROUND DATA: Pedicle subtraction osteotomy can be used effectively to correct spinal deformity; however, it is not without complications. ACR is an attractive alternative minimally invasive technique for spinal deformity correction, although few clinical reports on its clinical effectiveness exist. METHODS: Adults with spinal deformity who underwent multilevel ACRs (≥2) followed by open posterior instrumentation with a minimum 1-year follow-up were retrospectively reviewed. Deformity radiographic data and clinical outcomes, including the Oswestry Disability Index (ODI) and the EuroQol-5D were analyzed. RESULTS: Eight patients [7 female, 1 male; mean age 65 y (49-79 y)] met inclusion criteria. The mean follow-up was 18.4 months (12-28 mo). The average number of levels treated with an ACR per patient was 2.4 (2-3). There were no anterior approach-related complications. The average number of levels instrumented posteriorly was 8.1 (3-15). Six patients underwent Schwab type 1 posterior osteotomies (partial facetectomies). After the first anterior stage, there was a significant increase in the lumbar lordosis and significant decreases in the sagittal vertical axis, pelvic tilt, and lumbopelvic mismatch (P<0.05). After the second stage there was no significant change in the sagittal vertical axis, lumbar lordosis, pelvic tilt, or lumbopelvic mismatch relative to the values obtained after ACR. There was significantly less disability postoperatively [ODI: 15 (0-30)] compared with preoperatively [ODI: 46 (16-80)] (P<0.01). There was significant improvement in general health after operation, as assessed by the EuroQol-5D utility scores [preop: 0.44 (0.21-0.82) vs. postop: 0.71 (0.60-0.80)] (P=0.01). Back and leg visual analog scale pain scores improved significantly postoperatively. CONCLUSIONS: A staged approach using multilevel ACRs with open posterior instrumentation has an acceptable complication profile and provides excellent restoration of sagittal and coronal balance and pelvic parameters in adults with spinal deformity.

Multilevel Corpectomy With Anterior Column Reconstruction and Plating for Subaxial Cervical Osteomyelitis.

STUDY DESIGN: A retrospective case series. OBJECTIVE: The aim of this study was to evaluate patients with cervical spine osteomyelitis who underwent multilevel (≥2) subaxial corpectomies and anterior column reconstruction and plating. SUMMARY OF BACKGROUND DATA: Neglected multilevel subaxial cervical osteomyelitis is a potentially dangerous disease. As it is rare, early radiographic and clinical outcomes after multilevel anterior corpectomy and reconstruction for subaxial cervical osteomyelitis are incompletely defined. METHODS: Adults who underwent multilevel corpectomy and anterior plating/reconstruction for subaxial cervical osteomyelitis at two institutions were reviewed. Analysis of patient demographics, operative details, and radiographic cervical alignment parameters [segmental kyphosis, cervical lordosis, C2-7 sagittal vertical axis (SVA)] was performed. RESULTS: Nineteen patients [15 males, four females; average age 48 years (20-81 yrs)] met inclusion criteria. The majority had pre-operative neurologic deficits or was immunosuppressed. All were treated with ≥6 weeks of intravenous antibiotics following operation. All had anterior plating/reconstruction with titanium cages (expandable-6; mesh-6) or structural bone graft (fibular allogaft-6; tricortical iliac crest-1). The average number of corpectomies was 2.4 (2-4). The average numbers of levels fused anteriorly was 4.4 (4-6) and posteriorly was 6.3 (4-9). The majority of patients (74%) was treated with an anterior/posterior approach. Average follow-up was 16 ±â€Š9 months. There was significant improvement in all cervical alignment parameters (segmental kyphosis, C2-7 SVA, cervical lordosis). No intraoperative complications occurred and no patient deteriorated neurologically postoperatively. Postoperative complications included anterior cage/graft dislodgement (n = 2), recurrent neck hematomas requiring revision (n = 1), epidural hematoma (n = 1), and wound infection (n = 1). Sixty percent of patients had persistent neurologic dysfunction at final follow-up. None required reoperation for recurrent infection or pseudarthrosis. CONCLUSION: Although overall prognosis and neurologic recovery are guarded in medically fragile patients with multilevel subaxial cervical osteomyelitis, reconstruction with multilevel (≥2) corpectomy and anterior reconstruction/plating results in excellent restoration of cervical alignment and low rates of recurrent infection and pseudarthrosis. LEVEL OF EVIDENCE: 4.

Economic Impact of Revision Surgery for Proximal Junctional Failure After Adult Spinal Deformity Surgery: A Cost Analysis of 57 Operations in a 10-year Experience at a Major Deformity Center.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To evaluate the economic impact of revision surgery for proximal junctional failures (PJF) after thoracolumbar fusions for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: PJF after fusions for ASD is a major cause of disability. Although clinical sequelae are described, PJF-revision operation costs are incompletely defined. METHODS: Consecutive adults who underwent thoracolumbar fusions for ASD (August, 2003 to January, 2013) were evaluated. Inclusion criteria include construct from pelvis to L2 or above and minimum 6 months follow-up after the index ASD operation. Direct costs (surgical supplies/implants, room/care, pharmacy, services) were identified from medical billing data and calculated for index ASD operations and subsequent surgeries for PJF. Not included in direct cost data were indirect costs, charges, surgeon fees, or revision operations for indications other than PJF (i.e., pseudarthrosis). Patients were compared based on the construct's upper-instrumented vertebra: upper thoracic (UT: T1-6) versus thoracolumbar junction (TLjxn: T9-L2). RESULTS: Of 501 patients, 382 met inclusion criteria. Fifty-one patients [UT:14; TLjxn: 40 at index; average follow-up 32.6 months (6-92 months)] had revisions for PJF, which summed to $3.2 million total direct cost. Average direct cost of index operations for the cohort ($68,294) was significantly greater than PJF-revisions ($55,547). Compared with TLjxn, UT had a significantly higher average cost for index operations ($79,860 vs. $65,868). However, PJF-revision cases were similar in average cost (UT:$60,103; TLjxn:$53,920; P = 0.09). Costs of PJF amounted to an additional 12.1% of the total index surgical cost in 382 patients. CONCLUSION: Revision operations for PJF after long thoracolumbar fusions for ASD are associated with an average direct cost of $55,547 per case. Revision costs for PJF are similar based on the index procedure's upper-instrumented vertebra level. At a major tertiary center over a 10-year period, PJF came at a very significant economic expense amounting to $3.2 million for 57 cases. LEVEL OF EVIDENCE: 3.

Anterior corpectomy via the mini-open, extreme lateral, transpsoas approach combined with short-segment posterior fixation for single-level traumatic lumbar burst fractures: analysis of health-related quality of life outcomes and patient satisfaction.

OBJECTIVE: The authors present clinical outcome data and satisfaction of patients who underwent minimally invasive vertebral body corpectomy and cage placement via a mini-open, extreme lateral, transpsoas approach and posterior short-segment instrumentation for lumbar burst fractures. METHODS: Patients with unstable lumbar burst fractures who underwent corpectomy and anterior column reconstruction via a mini-open, extreme lateral, transpsoas approach with short-segment posterior fixation were reviewed retrospectively. Demographic information, operative parameters, perioperative radiographic measurements, and complications were analyzed. Patient-reported outcome instruments (Oswestry Disability Index [ODI], 12-Item Short Form Health Survey [SF-12]) and an anterior scar-specific patient satisfaction questionnaire were recorded at the latest follow-up. RESULTS: Twelve patients (7 men, 5 women, average age 42 years, range 22-68 years) met the inclusion criteria. Lumbar corpectomies with anterior column support were performed (L-1, n = 8; L-2, n = 2; L-3, n = 2) and supplemented with short-segment posterior instrumentation (4 open, 8 percutaneous). Four patients had preoperative neurological deficits, all of which improved after surgery. No new neurological complications were noted. The anterior incision on average was 6.4 cm (range 5-8 cm) in length, caused mild pain and disability, and was aesthetically acceptable to the large majority of patients. Three patients required chest tube placement for pleural violation, and 1 patient required reoperation for cage subsidence/hardware failure. Average clinical follow-up was 38 months (range 16-68 months), and average radiographic follow-up was 37 months (range 6-68 months). Preoperative lumbar lordosis and focal lordosis were significantly improved/maintained after surgery. Patients were satisfied with their outcomes, had minimal/moderate disability (average ODI score 20, range 0-52), and had good physical (SF-12 physical component score 41.7% ± 10.4%) and mental health outcomes (SF-12 mental component score 50.2% ± 11.6%) after surgery. CONCLUSIONS: Anterior corpectomy and cage placement via a mini-open, extreme lateral, transpsoas approach supplemented by short-segment posterior instrumentation is a safe, effective alternative to conventional approaches in the treatment of single-level unstable burst fractures and is associated with excellent functional outcomes and patient satisfaction.

Surgical Consent of Children and Guardians for the Treatment of Adolescent Idiopathic Scoliosis is Incompletely Informed.

STUDY DESIGN: Prospective, multicenter cohort analysis. OBJECTIVE: Assess children and guardian's comprehension of surgical consent for adolescent idiopathic scoliosis (AIS) surgery and factors associated with their comprehension. SUMMARY OF BACKGROUND DATA: Informed consent is essential to the ethical practice of surgery. Little is known about how informed are children and guardians when consenting to operation for AIS. METHODS: Guardians and their children (10-18 yr) undergoing spinal fusion for AIS were prospectively evaluated at 4 institutions. Each child and guardian was asked to complete a questionnaire of the risks, benefits and expected results of operative treatment and a self-assessment of overall comprehension. A site-survey questionnaire regarding teaching methods, timing between teaching and consent, and healthcare provider involved in the consent process was also used. Significance was assessed using logistic regression examining factors associated with good (≥6 scores correct) and poor (<6 scores correct) comprehension. RESULTS: One hundred seventy six pairs of patient/guardian were enrolled. Fifty-seven patient/guardian questionnaires were discarded due to incompleteness. A greater percentage of guardians had good overall comprehension of the surgical consent (patients: 59.7%; guardian: 71.4%). Post-operative mobility (patient 31%; guardian 42%) was poorly understood. Surgical risks (i.e., neurologic injury, infection, hardware failure, future sequelae) were modestly understood (40-70% correct). Factors associated with better understanding were older patient age (>12 yr), guardian with a college degree, obtaining consent by the attending surgeon and at a separate preoperative visit than the time of teaching, the use of visual aids, and participation in a "peer-support group" preoperatively. There was a trend toward guardians' and patients' self-assessment of understanding mirroring their respective objective performances. DISCUSSION: Patients who undergo surgical intervention for AIS and their guardians understand approximately 60% of the surgical consent. The use of preoperative multimodal teaching techniques and "peer-support groups" may improve patient and guardian comprehension.

Safety and Efficacy of Reconstruction of Complex Cervical Spine Pathology Using Pedicle Screws Inserted with Stealth Navigation and 3D Image-Guided (O-Arm) Technology.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To determine safety and efficacy of cervical pedicle screw placement using O-Arm and Stealth Navigation in patients with cervicothoracic spinal deformities and revision subaxial cervical pathology. SUMMARY OF BACKGROUND DATA: Cervical pedicle screws are biomechanically advantageous to other posterior cervical fixation techniques; however, their use is limited by concerns for neurovascular injury. Few clinical reports exist on their placement safety and efficacy using modern navigation systems. METHODS: Adults who had cervical pedicle screws inserted using O-Arm and Stealth Navigation between November 2007 and January 2014 and with a minimum 1-year follow-up were retrospectively studied. Screw insertion safety, surgical complications, need for reoperation, and clinical outcomes [Neck Disability Index, EQ-5D, numeric pain rating scales] were evaluated. RESULTS: 21 patients (female-10; male-11; average age 63 yr [32-83 yr]) met inclusion criteria. Average follow-up was 29.8 months (12-81.6 mo). Reconstruction of C2 and the subaxial cervical spine included 8 primary operations for cervicothoracic kyphosis and 13 revision operations. 121 pedicle screws were placed (C2: 4, C3: 20, C4: 22, C5: 23, C6: 18, C7: 34) using Stealth Navigation. The average number of screws placed per case was 6 (1-12). Greater than 99% of screws were placed safely without neurovascular injury. 1 screw (0.8%) was noted postoperatively to critically breach the medial wall and was associated with an acute C5 nerve root palsy. 2 patients required revisions for postoperative iatrogenic foraminal stenosis and associated C8 radiculopathies. No vascular complications due to aberrant screw placement occurred. There were significant improvements (P < 0.05) in EQ-5D utility scores and neck and arm pain. Neck Disability Index scores decreased on average by 10 points (P = 0.12). CONCLUSION: Placement of cervical pedicle screws using O-Arm/Stealth Navigation in this series was a safe and effective method for posterior stabilization in cervicothoracic deformity and revision operations of the subaxial cervical spine. LEVEL OF EVIDENCE: 4.