Recovery kinetics following spinal deformity correction: a comparison of isolated cervical, thoracolumbar, and combined deformity morphometries.

BACKGROUND CONTEXT: The postoperative recovery patterns of cervical deformity patients, thoracolumbar deformity patients, and patients with combined cervical and thoracolumbar deformities, all relative to one another, is not well understood. Clear objective benchmarks are needed to quantitatively define a "good" versus a "bad" postoperative recovery across multiple follow-up visits, varying deformity types, and guide expectations. PURPOSE: To objectively define and compare the complete 2-year postoperative recovery process among operative cervical only, thoracolumbar only, and combined deformity patients using area-under-the-curve (AUC) methodology. STUDY DESIGN/SETTING: Retrospective review of 2 prospective, multicenter adult cervical and spinal deformity databases. PATIENT SAMPLE: One hundred seventy spinal deformity patients. OUTCOME MEASURES: Common health-related quality of life (HRQOL) assessments across both databases included the EuroQol 5-Dimension Questionnaire and Numeric Rating Scale (NRS) back pain assessment. In order to compare disability improvements, the Neck Disability Index (NDI) and the Oswestry Disability Index (ODI) were merged into one outcome variable, the ODI-NDI. Both assessments are gauged on the same scale, with minimal question deviation. Sagittal Radiographic Alignment was also assessed at pre- and all postoperative time points. METHODS: Operative deformity patients >18 years old with baseline (BL) to 2-year HRQOLs were included. Patients were stratified by cervical only (C), thoracolumbar only (T), and combined deformities (CT). HRQOL and radiographic outcomes were compared within and between deformity groups. AUC normalization generated normalized HRQOL scores at BL and all follow-up intervals (6 weeks, 3 months, 1 year, and 2 year). Normalized scores were plotted against follow-up time interval. AUC was calculated for each follow-up interval, and total area was divided by cumulative follow-up length, determining overall, time-adjusted HRQOL recovery (Integrated Health State, IHS). Multiple linear regression models determined significant predictors of HRQOL discrepancies among deformity groups. RESULTS: One hundred seventy patients were included (27 C, 27 T, and 116 CT). Age, BMI, sex, smoking status, osteoporosis, depression, and BL HRQOL scores were similar among groups (p >. 05). T and CT patients had higher comorbidity severities (CCI: C 0.696, T 1.815, CT 1.699, p = .020). Posterior surgical approaches were most common (62.9%) followed by combined (28.8%) and anterior (6.5%). Standard HRQOL analysis found no significant differences among groups until 1-year follow-up, where C patients exhibited comparatively greater NRS back pain (4.88 vs. 3.65 vs. 3.28, p = .028). NRS Back pain differences between groups subsided by 2-years (p>.05). Despite C patients exhibiting significantly faster ODI-NDI minimal clinically important difference (MCID) achievement (33.3% vs. 0% vs. 23.0%, p < .001), all deformity groups exhibited similar ODI-NDI MCID achievement by 2-years (51.9% vs. 59.3% vs. 62.9%, p = 0.563). After HRQOL normalization, similar results were observed relative to the standard analysis (1-year NRS Back: C 1.17 vs. T 0.50 vs. CT 0.51, p < .001; 2-year NRS Back: 1.20 vs. 0.51 vs. 0.69, p = .060). C patients exhibited a worse NRS back normalized IHS (C 1.18 vs. T 0.58 vs. CT 0.63, p = .004), indicating C patients were in a greater state of postoperative back pain for a longer amount of time. Linear regression models determined postoperative distal junctional kyphosis (adjusted beta: 0.207, p = .039) and osteoporosis (adjusted beta: 0.269, p = .007) as the strongest predictors of a poor NRS back IHS (model summary: R2 = 0.177, p = .039). CONCLUSIONS: Despite C patients exhibiting a quicker rate of MCID disability (ODI-NDI) improvement, they exhibited a poorer overall recovery of back pain with worse NRS back scores compared with BL status and other deformity groups. Postoperative distal junctional kyphosis and osteoporosis were identified as primary drivers of a poor postoperative NRS back IHS. Utilization of the IHS, a single number adjusting for all postoperative HRQOL visits, in conjunction with predictive modelling may pose as an improved method of gauging the effect of surgical details and complications on a patient's entire recovery process.

Implementation of safe sleep practices in Massachusetts NICUs: a state-wide QI collaborative.

OBJECTIVE: To increase the use of safe sleep practices (SSP) among high-risk infants discharged from Massachusetts (MA) NICUs to 90% in 2 years. DESIGN/METHODS: The Neonatal Quality Improvement Collaborative of MA (NeoQIC) is a consortium of neonatal providers that provides infrastructure to lead and manage state-wide quality improvement initiatives. The safe sleep initiative was started in July 2015 with participation of all 10 MA level III NICUs. Based upon the project algorithm, infants are eligible for two sleep practices: SSP or NICU therapeutic positioning (NTP) depending on their gestational age, weight, and clinical illness. Compliance with SSP is defined as: (1) supine positioning, (2) in a flat crib with no incline, (3) without positioning devices, and (4) without soft objects. NTP comprised usual NICU care. Local improvement teams devise intervention strategies, perform weekly crib audits for all NICU infants, and submit data on overall compliance and compliance with each SSP component on a monthly basis to NeoQIC. RESULTS: From July 2015 to June 2017, 7261 cribs were audited. Statistical process control charts showed significant improvement in the primary outcome of interest, overall compliance with SSP, for all participating NICUs. Compliance increased from 47.7% at the start of the project to 75.5% by the end of year 1 and to 81.0% by June 2017. CONCLUSIONS: This state-wide collaborative has improved SSP compliance in all level III MA NICUs and demonstrated that on a state-wide level, SSPs can be routinely integrated into the care of high-risk infants.

Recovery following adult spinal deformity surgery: the effect of complications and reoperation in 149 patients with 2-year follow-up.

PURPOSE: To identify the effect of complications and reoperation on the recovery process following adult spinal deformity (ASD) surgery by examining health-related quality of life (HRQOL) measures over time via an integrated health state analysis (IHS). METHODS: A retrospective review of a multicenter, prospective ASD database was conducted. Complication number, type, and need for reoperation (REOP) or not (NOREOP) were recorded. Patients were stratified as having no complication (NOCOMP), any complication (COMP), only minor complications (MINOR) and any major complications (MAJOR). HRQOL measures included Oswestry Disability Index (ODI), Short Form-36 (SF-36), and Scoliosis Research Society-22 (SRS22) at baseline, 6 weeks, 1 and 2 years postoperatively. All HRQOL scores were normalized to each patient's baseline scores and an IHS was then calculated. RESULTS: 149 patients were included. COMP, MINOR, and MAJOR had significantly lower normalized SRS mental scores at 1 and 2 years than NOCOMP (p < 0.05). REOP had significantly worse normalized 1 and 2 year mental component score (MCS), SRS mental, and total score than NOCOMP (p < 0.05). COMP, MINOR, and MAJOR all had significantly lower SRS mental IHSs than NOCOMP (p < 0.05). REOP had significantly lower IHSs for MCS and SRS satisfaction than NOREOP (p < 0.05). REOP had a significantly lower MCS and SRS mental IHS than NOCOMP (p < 0.05). CONCLUSION: An IHS analysis suggests there was a significantly protracted mental recovery phase associated with patients that had at least one complication, as well as either a minor and major complication. The addition of a reoperation also adversely affected the mental recovery as well as overall satisfaction.

Postoperative Recovery After Adult Spinal Deformity Surgery: Comparative Analysis of Age in 149 Patients During 2-year Follow-up.

STUDY DESIGN: Retrospective review of a multicenter, prospective adult spinal deformity (ASD) database. OBJECTIVE: We hypothesized that increased age and increased preoperative disability would negatively impact both the length of time needed to achieve maximal recovery and the amount of functional improvement achieved. In order to gauge the recovery process, a normalization process was used to calculate an integrated health state (IHS) during the 2-year postoperative period. SUMMARY OF BACKGROUND DATA: Elderly patients with ASD generally have worse baseline health-related quality of life (HRQOL) measures than younger patients. Current methods of reporting outcomes are limited, perhaps diminishing the health impact of the entire postoperative recovery experience. METHODS: Inclusion criteria included 18 or more years and ASD. Patient groups: young (≤45 yr), middle (46-64), elderly (≥65) as well as by baseline Oswestry Disability Index (ODI) scores: MILD (0-30), MEDIUM (31-49), and HIGH (≥50). Collected HRQOL measures included ODI, Short Form-36(PCS/MCS), and Scoliosis Research Society-22 (SRS22) at baseline, 6 weeks, 1, and 2-year postoperative. All HRQOL measures were normalized to each patient's baseline scores. A 2-year IHS was calculated for each individual patient and the means were compared between groups. RESULTS: 149 patients were included (≤45:32, 46-64:67, ≥65:50). All groups significantly improved in all HRQOL at 2-year compared with baseline (P < 0.05) except for MCS, ODI, and SRS activity for the 45 or less group (P > 0.05). Normalized IHS HRQOL for young patients was worse than elderly for ODI, PCS, MCS, SRS activity, pain and total during the 2-year recovery period from index surgery. The MILD ODI group had significantly worse 2-year IHS values than the HIGH group for all HRQOL measured (P < 0.05) except SRS appearance and satisfaction (P > 0.05). CONCLUSION: Contrary to our hypothesis, an IHS analysis suggested that the recovery process was significantly better for elderly patients than young patients and better for patients with high baseline disability. LEVEL OF EVIDENCE: 3.