The Conceptualization and Derivation of the Cervical Lordosis Distribution Index.

SUMMARY OF BACKGROUND DATA: Yilgor et al developed the lumbar Lordosis Distribution Index to individualize the pelvic mismatch to each patient's pelvic incidence. The cervical lordosis distribution in relation to its apex has not been characterized. OBJECTIVE: Tailor correction of cervical deformity by incorporating the cervical apex into a distribution index(CLDI) to maximize clinical outcomes while lowering rates of junctional failure. STUDY DESIGN/SETTING: Retrospective cohort. METHODS: CD patients with complete 2Y data were included. Optimal outcome is defined by no DJF, and meeting Virk et al Good Clinical Outcome Criteria:[Meeting 2 of 3: 1)an NDI<20 or meeting MCID, 2)mJOA>=14, 3)an NRS-Neck<=5 or improved by 2 or more points]. C2-T2 lordosis was divided into cranial (C2 to apex) and caudal (apex to T2) arches postoperatively. A cervical lordosis distribution index(CLDI) was developed by dividing the cranial lordotic arch(C2 to apex) by the total segment(C2-T2) and multiplying by 100. Cross-tabulations developed categories for CLDI producing the highest chi-square values for achieving Optimal Outcome at two years and outcomes were assessed by multivariable analysis controlling for significant confounders. RESULTS: 84 CD patients were included. Cervical apex distribution postoperatively was: 1% C3, 42% C4, 30% C5, 27% C6. Mean cervical LDI was 117±138. Mean cranial lordosis was 23.2±12.5°. Using cross-tabulations, a CLDI between 70 and 90 was defined as 'Aligned'. Chi-square test revealed significant differences among CLDI categories for DJK, DJF, Good Clinical Outcome, and Optimal Outcome(all P<0.05). Patients aligned in CLDI were less likely to develop DJK(OR: 0.1, [0.01-0.88]), more like to achieve GCO (OR: 3.9, [1.2-13.2]) and Optimal Outcome (OR: 7.9, [2.1-29.3] at two years. Patients aligned in CLDI developed DJF at a rate of 0%. CONCLUSION: The cervical lordosis distribution index, classified through the cranial segment, takes each unique cervical apex into account and tailors correction to the patient in order to better achieve good clinical outcomes and minimize catastrophic complications following cervical deformity surgery. LEVEL OF EVIDENCE: III.

Should pelvic incidence influence realignment strategy? A detailed analysis in adult spinal deformity.

OBJECTIVE: The purpose of this study was to assess how various realignment strategies affect mechanical failure and clinical outcomes in pelvic incidence (PI)-stratified cohorts following adult spinal deformity (ASD) surgery. METHODS: Median and interquartile range statistics were calculated for demographics and surgical details. Further statistical analysis was used to define subsets within PI generating significantly different rates of mechanical failure. These subsets of PI were further analyzed as subcohorts for the outcomes and effects of realignment within each subcohort. Multivariate logistic regression analysis controlling for baseline frailty and lumbar lordosis (LL; L1-S1) analyzed the association of age-adjusted realignment and Global Alignment and Proportion (GAP) strategies with the incidence of mechanical failure and clinical improvement within PI-stratified groups. RESULTS: A parabolic relationship between PI and mechanical failure was noted, whereas patients with either < 51° (n = 174, 39.1% of cohort) or > 63° (n = 114, 25.6% of cohort) of PI generated higher rates of mechanical failure (18.0% and 20.0%, respectively) and lower rates of good outcome (80.3% and 77.6%, respectively) than those with moderate PI (51°-63°). Patients with lower PI more often met good outcome criteria when undercorrected in age-adjusted PI-LL mismatch and sagittal age-adjusted score, and those not meeting good outcome criteria were more likely to deteriorate in GAP relative LL from first to final follow-up (OR 13.4, 95% CI 1.3-139.2). In those with moderate PI, patients were more likely to meet good outcome when aligned on the GAP lordosis distribution index (LDI; OR 1.7, 95% CI 0.9-3.3). Patients with higher PI meeting good outcome were more likely to be overcorrected in sagittal vertical axis (OR 2.4, 95% CI 1.1-5.2) at first follow-up and less likely to be undercorrected in T1 pelvic angle (OR 0.4, 95% CI 0.2-0.9) by final follow-up. When assessing GAP alignment, patients were more likely to meet good outcome when aligned on GAP LDI (OR 3.5, 95% CI 1.4-8.9). CONCLUSIONS: There was a parabolic relationship between PI and both mechanical failure and clinical improvement following deformity correction in this study. Understanding the associations between this fixed parameter and poor outcomes can aid the surgeon in strategical planning when seeking to realign ASD.

Developing a risk score to inform the use of rhBMP-2 in adult spinal deformity surgery.

BACKGROUND: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has not shown superior benefit overall in cost-effectiveness during adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTING: Retrospective PURPOSE: Generate a risk score for pseudarthrosis to inform the utilization of rhBMP-2, balancing costs against quality of life and complications. METHODS: ASD patients with 3-year data were included. Quality of life gained was calculated from ODI to SF-6D and translated to quality-adjusted life years (QALYs). Cost was calculated using the PearlDiver database and CMS definitions for complications and comorbidities. Established weights were generated for predictive variables via logistic regression to yield a predictive risk score for pseudarthrosis that accounted for frailty, diabetes, depression, ASA grade, thoracolumbar kyphosis and three-column osteotomy use. Risk score categories, established via conditional inference tree (CIT)-derived thresholds were tested for cost-utility of rhBMP-2 usage, controlling for age, prior fusion, and baseline deformity and disability. RESULTS: 64% of ASD patients received rhBMP-2 (308/481). There were 17 (3.5%) patients that developed pseudarthrosis. rhBMP-2 use overall did not lower pseudarthrosis rates (OR: 0.5, [0.2-1.3]). Pseudarthrosis rates for each risk category were: No Risk (NoR) 0%; Low-Risk (LowR) 1.6%; Moderate Risk (ModR) 9.3%; High-Risk (HighR) 24.3%. Patients receiving rhBMP-2 had similar QALYs overall to those that did not (0.163 vs. 0.171, p = .65). rhBMP-2 usage had worse cost-utility in the LowR cohort (p < .001). In ModR patients, rhBMP-2 usage had equivocal cost-utility ($53,398 vs. $61,581, p = .232). In the HighR cohort, the cost-utility was reduced via rhBMP-2 usage ($98,328 vs. $211,091, p < .001). CONCLUSION: Our study shows rhBMP-2 demonstrates effective cost-utility for individuals at high risk for developing pseudarthrosis. The generated score can aid spine surgeons in the assessment of risk and enhance justification for the strategic use of rhBMP-2 in the appropriate clinical contexts. LEVEL OF EVIDENCE: III.

Aspirin in prevention of venous thromboembolism following hip fracture surgery: A systematic review and meta-analysis.

Background: Many orthopaedic surgeons routinely prescribe aspirin (ASA) as prophylaxis for venous thromboembolism (VTE) following hip fracture surgery (HFS). The purpose of this study is to assess the effectiveness of aspirin to other agents in preventing VTE and mortality following hip fracture surgery. Methods: Following PRISMA guidelines, we performed a search for HFS studies from 1998 to 2023 reporting comparisons between aspirin and other chemoprophylaxis methods for VTE (DVT - deep vein thrombosis; PE - pulmonary embolism). SPSS Meta-analysis function was used to calculate Mean Effect Size Estimate (MESE) and 95 % Confidence Intervals for each outcome. Reverse Fragility Index (RFI) and Fragility Quotient (FQ) were calculated for each study. Results: Of the 847 articles screened, 4 studies with 5 comparisons met the search criteria to be included for analysis. A total of 1194 participants were included in these studies. There was a decreased risk of mortality seen with use of aspirin compared to other agents (MESE = 0.86, 95 % CI: [0.07-1.66]; p=.03). There was no increased risk of DVT or PE with use of aspirin (both p>.4). The overall RFI and FQ for all 19 outcomes were 12 (IQR: 6.5-15) and 0.080 (IQR: 0.027-0.110), respectively. Ten studies (52.6 %) reported a loss-to-follow-up (LTF) greater than the overall RFI. Conclusions: Aspirin demonstrates similar protective effects on prevention of VTE compared to other agents and may have significant protective effects on overall mortality following surgical intervention for hip fractures. However, the current evidence concerning its use in this arena is less than robust, with more than half of the studied outcomes considered statistically fragile.

Re-Purposing the Ordering of Routine Laboratory Tests in Hospitalized Medical Patients (RePORT): protocol for a multicenter stepped-wedge cluster randomised trial to evaluate the impact of a multicomponent intervention bundle to reduce laboratory test over-utilization.

BACKGROUND: Laboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada. METHODS: We have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2-3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes. DISCUSSION: The study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work. TRIAL REGISTRATION: This study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic. CLINICALTRIALS: gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1.

Osteopathic Students Have Decreased Match Rates in Orthopaedic Surgery Compared with Allopathic Students.

Introduction: Orthopaedic surgery continues to be one of the most competitive specialties to match into as a medical student, particularly for osteopathic medical students. Therefore, in this study, we sought to examine the prevalence of osteopathic students (DO) matching into orthopaedic surgery at traditional Accreditation Council for Graduate Medical Education (ACGME) accredited programs (former allopathic residency programs) in recent years. Methods: A retrospective review of National Residency Match Program annual reports and Association of American Medical Colleges's Electronic Residency Application Service Statistic reports were performed to determine the number of applications and match rates among osteopathic (DO) and allopathic (MD) medical students into orthopaedic surgery from 2019 to 2023. Data on the degree type of current residents at all ACGME-accredited residency programs were identified. Results: During the analyzed study period of 2019 to 2023, there were 3,473 (74.5%) allopathic students and 571 (59.9%) osteopathic students who successfully matched into orthopaedic surgery. This match rate for allopathic students was 74.5% compared with 59.9% for osteopathic students. Of the 3,506 medical students who hold postgraduate orthopaedic surgery positions at former allopathic programs over the past 5 years, only 58 (1.7%) hold an osteopathic degree. Of the 560 medical students who hold postgraduate orthopaedic surgery positions at former osteopathic programs over the past 5 years, 47 (8.4%) hold an allopathic degree. The match rate of allopathic students at former osteopathic programs is significantly higher than the match rate of osteopathic students at former allopathic programs. Conclusions: Osteopathic students continue to match into orthopaedic surgery at lower rates than their allopathic counterparts. In addition, there remains a consistent and low number of osteopathic students matching into former allopathic programs. Allopathic students also have a higher likelihood of matching into former osteopathic programs when compared with osteopathic students matching into previous allopathic orthopaedic surgery programs.

Contemporary utilization of three-column osteotomy techniques in a prospective complex spinal deformity multicenter database: implications on full-body alignment and perioperative course.

BACKGROUND: Research has focused on the increased correction from a three-column osteotomy (3CO) during adult spinal deformity (ASD) surgery. However, an in-depth analysis on the performance of a 3CO in a cohort of complex spinal deformity cases has not been described. STUDY DESIGN/SETTING: This is a retrospective study on a prospectively enrolled, complex ASD database. PURPOSE: This study aimed to determine if three-column osteotomies demonstrate superior benefit in correction of complex sagittal deformity at the cost of increased perioperative complications. METHODS: Surgical complex adult spinal deformity patients were included and grouped into thoracolumbar 3COs compared to those who did not have a 3CO (No 3CO) (remaining cohort). Rigid deformity was defined as ΔLL less than 33% from standing to supine. Severe deformity was defined as global (SVA > 70 mm) or C7-PL > 70 mm, or lumbopelvic (PI-LL > 30°). Means comparison tests assessed correction by 3CO grade/location. Multivariate analysis controlling for baseline deformity evaluated outcomes up to six weeks compared to No 3CO. RESULTS: 648 patients were included (Mean age 61 ± 14.6 years, BMI 27.55 ± 5.8 kg/m2, levels fused: 12.6 ± 3.8). 126 underwent 3CO, a 20% higher usage than historical cohorts. 3COs were older, frail, and more likely to undergo revision (OR 5.2, 95% CI [2.6-10.6]; p < .001). 3COs were more likely to present with both severe global/lumbopelvic deformity (OR 4), 62.4% being rigid. 3COs had greater use of secondary rods (OR 4st) and incurred 4 times greater risk for: massive blood loss (> 3500 mL), longer LOS, SICU admission, perioperative wound and spine-related complications, and neurologic complications when performed below L3. 3COs had similar HRQL benefit, but higher perioperative opioid use. Mean segmental correction increased by grade (G3-21; G4-24; G5-27) and was 4 × greater than low-grade osteotomies, especially below L3 (OR 12). 3COs achieved 2 × greater spinopelvic correction. Higher grades properly distributed lordosis 50% of the time except L5. Pelvic compensation and non-response were relieved more often with increasing grade, with greater correction in all lower extremity parameters (p < .01). Due to the increased rate of complications, 3COs trended toward higher perioperative cost ($42,806 vs. $40,046, p = .086). CONCLUSION: Three-column osteotomy usage in contemporary complex spinal deformities is generally limited to more disabled individuals undergoing the most severe sagittal and coronal realignment procedures. While there is an increased perioperative cost and prolongation of length of stay with usage, these techniques represent the most powerful realignment techniques available with a dramatic impact on normalization at operative levels and reciprocal changes.

Is It Possible for Patients with Early Distal Junctional Kyphosis following Adult Cervical Deformity Corrective Surgery to Achieve Similar Outcomes to Their Unaffected Counterparts? An Analysis of Recovery Kinetics.

Background: Distal junctional kyphosis (DJK) is a concerning complication for surgeons performing cervical deformity (CD) surgery. Patients sustaining such complications may demonstrate worse recovery profiles compared to their unaffected peers. Methods: DJK was defined as a >10° change in kyphosis between LIV and LIV-2, and a >10° index angle. CD patients were grouped according to the development of DJK by 3M vs. no DJK development. Means comparison tests and regression analyses used to analyze differences between groups and arelevant associations. Results: A total of 113 patients were included (17 DJK, 96 non-DJK). DJK patients were more sagittally malaligned preop, and underwent more osteotomies and combined approaches. Postop, DJK patients experienced more dysphagia (17.7% vs. 4.2%; p = 0.034). DJK patients remained more malaligned in cSVA through the 2-year follow-up. DJK patients exhibited worse patient-reported outcomes from 3M to 1Y, but these differences subsided when following patients through to 2Y; they also exhibited worse NDI (65.3 vs. 35.3) and EQ5D (0.68 vs. 0.79) scores at 1Y (both p < 0.05), but these differences had subsided by 2Y. Conclusions: Despite patients exhibiting similar preoperative health-related quality of life metrics, patients who developed early DJK exhibited worse postoperative neck disability following the development of their DJK. These differences subsided by the 2-year follow-up, highlighting the prolonged but eventually successful course of many DJK patients after CD surgery.

PTCOG Gastrointestinal Subcommittee Lower Gastrointestinal Tract Malignancies Consensus Statement.

Purpose: Radiotherapy delivery in the definitive management of lower gastrointestinal (LGI) tract malignancies is associated with substantial risk of acute and late gastrointestinal (GI), genitourinary, dermatologic, and hematologic toxicities. Advanced radiation therapy techniques such as proton beam therapy (PBT) offer optimal dosimetric sparing of critical organs at risk, achieving a more favorable therapeutic ratio compared with photon therapy. Materials and Methods: The international Particle Therapy Cooperative Group GI Subcommittee conducted a systematic literature review, from which consensus recommendations were developed on the application of PBT for LGI malignancies. Results: Eleven recommendations on clinical indications for which PBT should be considered are presented with supporting literature, and each recommendation was assessed for level of evidence and strength of recommendation. Detailed technical guidelines pertaining to simulation, treatment planning and delivery, and image guidance are also provided. Conclusion: PBT may be of significant value in select patients with LGI malignancies. Additional clinical data are needed to further elucidate the potential benefits of PBT for patients with anal cancer and rectal cancer.

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.

Highest Achievable Outcomes for Adult Spinal Deformity Corrective Surgery: Does Frailty Severity Exert a Ceiling Effect?

STUDY DESIGN: Retrospective single-center study. OBJECTIVE: To assess the influence of frailty on optimal outcome following ASD corrective surgery. SUMMARY OF BACKGROUND DATA: Frailty is a determining factor in outcomes after ASD surgery and may exert a ceiling effect on the best possible outcome. METHODS: ASD patients with frailty measures, baseline, and 2-year ODI included. Frailty was classified as Not Frail (NF), Frail (F) and Severely Frail (SF) based on the modified Frailty Index, then stratified into quartiles based on two-year ODI improvement (most improved designated "Highest"). Logistic regression analyzed relationships between frailty and ODI score and improvement, maintenance, or deterioration. A Kaplan-Meier survival curve was used to analyze differences in time to complication or reoperation. RESULTS: A total of 393 ASD patients were isolated (55.2% NF, 31.0% F, and 13.7% SF), then classified as 12.5% NF-Highest, 17.8% F-Highest, and 3.1% SF-Highest. The SF group had the highest rate of deterioration (16.7%, P =0.025) in the second postoperative year, but the groups were similar in improvement (NF: 10.1%, F: 11.5%, SF: 9.3%, P =0.886). Improvement of SF patients was greatest at six months (ΔODI of -22.6±18.0, P <0.001), but NF and F patients reached maximal ODI at 2 years (ΔODI of -15.7±17.9 and -20.5±18.4, respectively). SF patients initially showed the greatest improvement in ODI (NF: -4.8±19.0, F: -12.4±19.3, SF: -22.6±18.0 at six months, P <0.001). A Kaplan-Meier survival curve showed a trend of less time to major complication or reoperation by 2 years with increasing frailty (NF: 7.5±0.381 yr, F: 6.7±0.511 yr, SF: 5.8±0.757 yr; P =0.113). CONCLUSIONS: Increasing frailty had a negative effect on maximal improvement, where severely frail patients exhibited a parabolic effect with greater initial improvement due to higher baseline disability, but reached a ceiling effect with less overall maximal improvement. Severe frailty may exert a ceiling effect on improvement and impair maintenance of improvement following surgery. LEVEL OF EVIDENCE: Level III.

Impact of congestive heart failure on patients undergoing lumbar spine fusion for adult spine deformity.

Background: With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks. Purpose: The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients. Study Design/Setting: This was a retrospective cohort study of the PearlDiver database. Patient Sample: We enrolled 670,526 patients undergoing spine fusion surgery. Outcome Measures: Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs. Methods: Patients undergoing elective spine fusion surgery were isolated and stratified by preoperative HF with preserved ejection fraction (P-EF) or reduced ejection fraction (R-EF) (International Classification of Diseases-9: 428.32 [chronic diastolic HF] and 428.22 [chronic systolic HF]). Means comparison tests (Chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, comorbidities, procedural characteristics, LOS, 30-day and 90-day complication outcomes, and total hospital charges between those diagnosed with P-EF and those not R-EF. Binary logistic regression assessed the odds of complication associated with HF, controlling for levels fused (odds ratio [OR] [95% confidence interval]). Statistical significance was set at P < 0.05. Results: Totally 670,526 elective spine fusion patients were included. Four thousand and seventy-seven were diagnosed with P-EF and 2758 R-EF. Overall, P-EF patients presented with higher rates of morbid obesity, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension (all P < 0.001). In relation to No-HF, P-EF patients had higher rates of 30-day major complications including pulmonary embolism, pneumonia, cerebrovascular accident (CVA), myocardial infarctions (MI), sepsis, and death (all P < 0.001). Furthermore, P-EF was associated significantly with increased odds of pneumonia (OR: 2.07 [1.64-2.56], P < 0.001) and sepsis (OR: 2.09 [1.62-2.66], P < 0.001). Relative to No-HF, R-EF was associated with significantly higher odds of MI (OR: 3.66 [2.34-5.47]), CVA (OR: 2.70 [1.67-4.15]), and pneumonia (OR: 1.85 [1.40-2.40]) (all P < 0.001) postoperative within 30 days. Adjusting for prior history of MI, CAD, and the presence of a pacemaker R-EF was a significant predictor of an MI 30 days postoperatively (OR: 2.2 [1.14-4.32], P = 0.021). Further adjusting for history of CABG or stent placement, R-EF was associated with higher odds of CVA (OR: 2.11 [1.09-4.19], P = 0.028) and MI (OR: 2.27 [1.20-4.43], P = 0.013). Conclusions: When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF.

The Impact of Peri-operative Enhanced Recovery After Surgery Protocols on Outcomes Following Adult Cervical Deformity Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To assess the impact of Enhanced recovery after surgery (ERAS) protocols on peri-operative course in adult cervical deformity (ACD) corrective surgery. METHODS: Patients ≥18 yrs with complete pre-(BL) and up to 2-year (2Y) radiographic and clinical outcome data were stratified by enrollment in an ERAS protocol that commenced in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, peri-operative factors and complication rates were assessed via means comparison analysis. Logistic regression analysed differences while controlling for baseline disability and deformity. RESULTS: We included 220 patients (average age 58.1 ± 11.9 years, 48% female). 20% were treated using the ERAS protocol (ERAS+). Disability was similar between both groups at baseline. When controlling for baseline disability and myelopathy, ERAS- patients were more likely to utilize opioids than ERAS+ (OR 1.79, 95% CI: 1.45-2.50, P = .016). Peri-operatively, ERAS+ had significantly lower operative time (P < .021), lower EBL (583.48 vs 246.51, P < .001), and required significantly lower doses of propofol intra-operatively than ERAS- patients (P = .020). ERAS+ patients also reported lower mean LOS overall (4.33 vs 5.84, P = .393), and were more likely to be discharged directly to home (χ2(1) = 4.974, P = .028). ERAS+ patients were less likely to require steroids after surgery (P = .045), were less likely to develop neuromuscular complications overall (P = .025), and less likely experience venous complications or be diagnosed with venous disease post-operatively (P = .025). CONCLUSIONS: Enhanced recovery after surgery programs in ACD surgery demonstrate significant benefit in terms of peri-operative outcomes for patients.

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.

Assessing the effects of prehabilitation protocols on post-operative outcomes in adult cervical deformity surgery: does early optimization lead to optimal clinical outcomes?

PURPOSE: To investigate the effect of a prehabilitation program on peri- and post-operative outcomes in adult cervical deformity (CD) surgery. METHODS: Operative CD patients ≥ 18 years with complete baseline (BL) and 2-year (2Y) data were stratified by enrollment in a prehabilitation program beginning in 2019. Patients were stratified as having undergone prehabilitation (Prehab+) or not (Prehab-). Differences in pre and post-op factors were assessed via means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay-scales. RESULTS: 115 patients were included (age: 61 years, 70% female, BMI: 28 kg/m2). Of these patients, 57 (49%) were classified as Prehab+. At baseline, groups were comparable in age, gender, BMI, CCI, and frailty. Surgically, Prehab+ were able to undergo longer procedures (p = 0.017) with equivalent EBL (p = 0.627), and shorter SICU stay (p < 0.001). Post-operatively, Prehab+ patients reported greater reduction in pain scores and greater improvement in quality of life metrics at both 1Y and 2Y than Prehab- patients (all p < 0.05). Prehab+ patients reported significantly less complications overall, as well as less need for reoperation (all p < 0.05). CONCLUSION: Introducing prehabilitation protocols in adult cervical deformity surgery may aid in improving patient physiological status, enabling patients to undergo longer surgeries with lessened risk of peri- and post-operative complications.

Top 50 most impactful publications on massive rotator cuff tears.

Background: Bibliometric analysis is a useful tool for measuring the scholarly impact of a topic and its more and less heavily studied aspects. The purpose of this study is to use bibliometric analysis to comprehensively analyze the 50 articles with the highest citation indices in studies evaluating the treatment and outcomes of massive rotator cuff tears (mRCTs). Methods: This cross-sectional study identified articles within the Scopus database published through December 2022. Keywords used were "massive rotator cuff tear." Articles were sorted in chronological order. The year published and number of citations were recorded. A citation index (CI) was calculated for each article by dividing the number of citations by number of years published [1 citation/1 year published (2021) = CI of 1]. Of these, the 50 articles with the highest CIs were carried forward for evaluation. Frequencies and distributions were assessed for data of each variable collected. Results: These search methods produced 625 articles regarding mRCT research (ranging from January 1986 to December 2022). Four of the top 10 most impactful articles were published in the 2010s. The level of evidence (LOE) published with the greatest frequency was level of evidence 4 (41%). The journal Arthroscopy published the highest number within the top 50 (26%) followed by the Journal of Bone and Joint Surgery and the American Journal of Sports Medicine (20% each). Clinical studies composed 88% of the top 50. Case series (38%) predominated, while systematic reviews (20%) and randomized control trials (8%) were less prevalent. The majority of studies concentrated on the clinical outcomes of certain interventions (62%), mainly comparing multiple interventions. Conclusion: Despite the relatively high prevalence of mRCTs (40% of all tears), this topic comprises only a small proportion of all rotator cuff research. This analysis has identified gaps within and limitations of the findings concerning mRCTs for researchers to propose research questions targeting understudied topics and influence the future treatment and outcomes of this clinically difficult diagnosis.

Persistent Lower Extremity Compensation for Sagittal Imbalance After Surgical Correction of Complex Adult Spinal Deformity: A Radiographic Analysis of Early Impact.

BACKGROUND AND OBJECTIVES: Achieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The objective is to analyze lower extremity compensation after complex ASD surgery, its effect on outcomes, and whether correction can alleviate these mechanisms. METHODS: We included patients with complex ASD with 6-week data. LE parameters were as follows: sacrofemoral angle, knee flexion angle, and ankle flexion angle. Each parameter was ranked, and upper tertile was deemed compensation. Patients compensating and not compensating postoperatively were propensity score matched for body mass index, frailty, and T1 pelvic angle. Linear regression assessed correlation between LE parameters and baseline deformity, demographics, and surgical details. Multivariate analysis controlling for baseline deformity and history of total knee/hip arthroplasty evaluated outcomes. RESULTS: Two hundred and ten patients (age: 61.3 ± 14.1 years, body mass index: 27.4 ± 5.8 kg/m2, Charlson Comorbidity Index: 1.1 ± 1.6, 72% female, 22% previous total joint arthroplasty, 24% osteoporosis, levels fused: 13.1 ± 3.8) were included. At baseline, 59% were compensating in LE: 32% at hips, 39% knees, and 36% ankles. After correction, 61% were compensating at least one joint. Patients undercorrected postoperatively were less likely to relieve LE compensation (odds ratio: 0.2, P = .037). Patients compensating in LE were more often undercorrected in age-adjusted pelvic tilt, pelvic incidence, lumbar lordosis, and T1 pelvic angle and disproportioned in Global Alignment and Proportion (P < .05). Patients matched in sagittal age-adjusted score at 6 weeks but compensating in LE were more likely to develop proximal junctional kyphosis (odds ratio: 4.1, P = .009) and proximal junctional failure (8% vs 0%, P = .035) than those sagittal age-adjusted score-matched and not compensating in LE. CONCLUSION: Perioperative lower extremity compensation was a product of undercorrecting complex ASD. Even in age-adjusted realignment, compensation was associated with global undercorrection and junctional failure. Consideration of lower extremities during planning is vital to avoid adverse outcomes in perioperative course after complex ASD surgery.

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.

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.

Can Baseline Disability Predict Outcomes in Adult Spinal Deformity Surgery?

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: To assess if there is a threshold of baseline disability beyond which the patient-reported outcomes after surgical correction of adult spinal deformity (ASD) are adversely impacted. BACKGROUND: Patient-reported outcomes vary after correction of adult spinal deformity, even when patients are optimally realigned. There is a paucity of literature examining the impact of baseline disability on patient-reported outcomes in ASD. METHODS: Patients with baseline (BL) and two-year data were included. Disability was ranked according to BL Oswestry Disability Index (ODI) into quintiles: Q1 (lowest ODI score) to Q5 (highest ODI score). Adjusted logistic regression analyses evaluated the likelihood of reaching ≥1 MCID in Scoliosis Research Society Outcomes Questionnaire (SRS-22) Pain, SRS-22 Activity, and Short Form-36 physical component summary at two years across disability groups Q1-Q4 with respect to Q5. Sensitivity tests were performed, excluding patients with any "0" Schwab modifiers at BL. RESULTS: Compared with patients in Q5, the odds of reaching MCID in SRS-22 Pain at 2Y were significantly higher for those in Q1 (OR: 3.771), Q2 (OR: 3.006), and Q3 (OR: 2.897), all P <0.021. Similarly, compared with patients in Q5, the odds of reaching MCID in SRS-22 Activity at two years were significantly higher for those in Q2 (OR: 3.454) and Q3 (OR: 2.801), both P <0.02. Lastly, compared with patients in Q5, odds of reaching MCID in Short Form-36 physical component summary at two years were significantly higher for patients in Q1 (OR: 5.350), Q2 (OR: 4.795), and Q3 (OR: 6.229), all P <0.004. CONCLUSIONS: This study found that patients presenting with moderate disability at BL (ODI<40) consistently surpassed health-related quality of life outcomes as compared with those presenting with greater levels of disability. We propose that a baseline ODI of 40 represents a disability threshold within which operative inte rvention maximizes patient-reported outcomes. Furthermore, delaying the intervention until patients progress to severe disability may limit the benefits of surgical correction in ASD patients. LEVEL OF EVIDENCE: 3.