Anterior vertebral body tethering for idiopathic scoliosis: how well does the tether hold up?

PURPOSE: Durability of outcomes following vertebral body tethering (VBT) is a concern and may be impacted by tether breakage (TB), which has been unstudied in a large cohort. We characterized TB rates and their impact on clinical outcomes in the largest single-surgeon series to date. METHODS: Inclusion criteria were VBT patients with AIS, major Cobb angle ≤ 75°, and minimum 2-year follow-up (FU). TBs were identified on 1- and 2-year FU X-rays. TB rates between single-cord and double-cord tethers were evaluated using two-proportion z test. Curve correction rates and SRS-22 scores between patients with and without TB at 2 years were evaluated using Mann-Whitney U test. RESULTS: 69 patients were included. By 2-year FU, 18 (27%) had experienced TB. TB primarily occurred in major (70%) versus minor curves and thoracolumbar tethers (75%) versus thoracic. TB rates between thoracolumbar single (32%) and double-cord tethers (30%) were not significantly different (p = 0.88). Mean major curve correction at 2-year FU was lower (p = 0.02) in patients with major curve TB (48° to 24°, 50%) versus those without (53°-21°, 60%). 2 patients (3%) required reoperation, 1 due to foraminal encroachment from a screw tip and 1 for curve progression with TB. CONCLUSION: TB rate was 27% at 2 years following VBT. Broken major curve tethers are associated with minor loss of correction that may not be clinically significant. TB rates are higher for thoracolumbar curvatures and double cords may not be protective against TB. Further study of long-term TB rates is imperative. LEVEL OF EVIDENCE: IV.

Obesity Does Not Affect Patient-Reported Outcomes following Patellofemoral Arthroplasty.

Patellofemoral arthroplasty (PFA) has garnered attention in recent years as an effective alternative to total knee arthroplasty for patients with symptomatic, isolated patellofemoral joint arthritis. Obesity has previously been identified as a risk factor for revision surgery, but its effect on patient-reported outcome measures (PROMs) has not been evaluated. A retrospective review of a consecutive series of PFA surgeries was conducted at a single, specialized orthopedics center in a major urban center. Patients were dichotomized by body mass index (BMI) as obese (O, BMI >30) or nonobese (NO, BMI: 18.5-25). Demographic, surgical information, and PROMs were collected and analyzed accordingly. Seventy-six patients (41 nonobese, 35 obese) were identified. Patients who were obese presented with significantly worse preoperative PROMs regarding knee-specific quality of life, physical function, and MH or mental health (knee injury and osteoarthritis outcome score quality of life [KOOS QoL], NO: 26.2, O: 14.7, p = 0.019; KOOS PF, NO: 38.2, O: 50.5, p = 0.002; Veterans Rand-12 mental health [VR-12 MH], NO: 54.2, O: 47.0, p = 0.033). No significant difference was seen in improvement in knee function scores between patients who were obese or nonobese (KOOS QoL, NO: 39.5, O: 40.6, p = 0.898; KOOS PS [physical function], NO: -17.8, O: -17.3, p = 0.945). Additionally, no difference in the rate of PFA revision was observed and there were no postoperative complications reported. Obese patients with isolated PFA can expect the same improvement in function as nonobese patients following patellofemoral joint arthroplasty. This paper underscores the priority of patient selection in PFA and challenges the notion that surgeons should exclude patients from receiving a PFA on the basis of obesity.

The Ankle-Pelvic Angle (APA) and Global Lower Extremity Angle (GLA): Summary Measurements of Pelvic and Lower Extremity Compensation.

BACKGROUND: Adult sagittal spinal deformity (SSD) leads to the recruitment of compensatory mechanisms to maintain standing balance. After regional spinal compensation is exhausted, lower extremity compensation is recruited. Knee flexion, ankle flexion, and sacrofemoral angle increase to drive pelvic shift posterior and increase pelvic tilt. We aim to describe 2 summary angles termed ankle-pelvic angle (APA) and global lower extremity angle (GLA) that incorporate all aspects of lower extremity and pelvic compensation in a comprehensive measurement that can simplify radiographic analysis. METHODS: Full-body sagittal stereotactic radiographs were retrospectively collected and digitally analyzed. Spinal and lower extremity alignment were quantified with existing measures. Two angles-APA and GLA-were drawn as geometrically complementary angles to T1-pelvic angle (TPA) and global sagittal axis (GSA), respectively. Regression analysis was used to represent the predictive relationship between TPA and APA and between GSA and GLA. RESULTS: A total of 518 propensity score-matched patient records were available for analysis. Patients with lower extremity compensation had higher APA (21.83° versus 19.47°, P = .007) and GLA (6.03° versus 1.19°, P < .001) than those without compensation. APA and GLA demonstrated strong correlation with TPA (r = 0.81) and GSA (r = 0.77), respectively. Furthermore, the change between preoperative and postoperative values were strongly correlative between ΔAPA and ΔTPA (r = 0.71) and between ΔGLA and ΔGSA (r = 0.77). APA above 20.6° and GLA above 3.6° were indicative of lower extremity compensation. Patients with increased GLA values had significantly higher Oswestry Disability Index scores (48.67 versus 41.04, P = .005). CONCLUSIONS: TPA and GSA are measures of global spinal alignment and APA and GLA, respectively, and are geometrically complementary angles that vary proportionately to SSD and balance the body. APA and GLA increase in SSD patients with lower extremity compensation and decrease with corrective surgery. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: APA and GLA offer a concise and simple method of communicating pelvic and lower extremity compensation.

Age and Gender Confound PROMIS Scores in Spine Patients With Back and Neck Pain.

STUDY DESIGN: This was a single-center retrospective review. OBJECTIVES: To explore how age and gender affect PROMIS scores compared with traditional health-related quality of life (HRQL) in spine patients. METHODS: Patients presenting with a primary complaint of back pain (BP) or neck pain (NP) were included. Legacy HRQLs were Oswestry Disability Index (ODI), Neck Disability Index (NDI), and Visual Analogue Scale (VAS). PROMIS Physical Function (PF), Pain Intensity (Int), and Pain Interference (Inf) were also administered to patients in a clinical setting. Patients were grouped by chief complaint, age (18-44, 45-64, 65+ years) and gender. Two parallel analyses were conducted to identify the effects of age and gender on patient-reported outcomes. Age groups were compared after propensity-score matching by VAS-pain and gender. Separately, genders were compared after propensity-score matching by age and VAS-pain. RESULTS: A total of 484 BP and 128 NP patients were matched into gender cohorts (n = 201 in each BP group, 46 in each NP group). Among BP patients, female patients demonstrated worse disability by ODI (44.15 vs 38.45, P = .005); PROMIS-PF did not differ by gender. Among NP patients, neither legacy HRQLs nor PROMIS differed by gender when controlling for NP and age. BP and NP patients were matched into age cohorts (n = 135 in each BP group and n = 14 in each BP group). Among BP patients, ANOVA revealed differences between groups when controlling for BP and gender: ODI (P < .001), PROMIS-PF (P = .018), PROMIS-Int (P < .001) PROMIS-Inf (P < .001). Among NP patients, matched age groups differed significantly in terms of NDI (P = .032) and PROMIS-PF (P = .022) but not PROMIS-Int or PROMIS-Inf. CONCLUSIONS: Age and gender confound traditional HRQLs as well as PROMIS domains. However, PROMIS offers age and gender-specific scores, which traditional HRQLs lack.

Patellofemoral Arthroplasty Surgical Technique: Lateral or Medial Parapatellar Approach.

BACKGROUND: Patellofemoral arthroplasty (PFA) is an emerging treatment for patients with isolated patellofemoral compartment osteoarthritis. The medial parapatellar approach is the standard arthrotomy but has been shown in total knee arthroplasty to damage the patellar blood supply and increase postoperative patellar instability. The lateral parapatellar approach is an alternative that may reduce the risk of these outcomes. The purpose of this study is to compare the radiographic measures of patellar tracking and patient-reported outcomes of the medial and lateral parapatellar approaches in PFA. METHODS: Between 2012 and 2019, a retrospective review was performed of 136 knees undergoing PFA at a single institution. Patients were separated by preoperative congruence angle and then surgical approach into 3 cohorts. Preoperative and postoperative patellar tilt and congruence angle were measured. Preoperative and minimum 6-month postoperative patient-reported outcomes scores were collected. RESULTS: There were no significant differences in the mean postoperative congruence angle and postoperative patient-reported outcomes among the 3 cohorts. Mean postoperative patellar tilt was normalized only in the abnormal congruence angle/lateral approach group to 2.80° (standard error, 1.85). CONCLUSION: Congruence angle was improved regardless of surgical approach. Patellar tilt was normalized only for the lateral approach in patients with abnormal preoperative congruence angle. There were no significant differences in preoperative and postoperative scores between groups except for preoperative 12-item Short Form Mental Health Survey scores. This study supports that the lateral approach offers improved postoperative patellar tilt compared to a medial approach for PFA while achieving similar patient-reported outcomes.

The Importance of C2 Slope, a Singular Marker of Cervical Deformity, Correlates With Patient-reported Outcomes.

STUDY DESIGN: Retrospective review of a prospectively collected database. OBJECTIVE: To define a simplified singular measure of cervical deformity (CD), C2 slope (C2S), which correlates with postoperative outcomes. SUMMARY OF BACKGROUND DATA: Sagittal malalignment of the cervical spine, defined by the cervical sagittal vertical axis (cSVA) has been associated with poor outcomes following surgical correction of the deformity. There has been a proliferation of parameters to describe CD. This added complexity can lead to confusion in classifying, treating, and assessing outcomes of CD surgery. METHODS: A prospective database of CD patients was analyzed. Inclusion criteria were cervical kyphosis>10°, cervical scoliosis>10°, cSVA>4 cm, or chin-brow vertical angle >25°. Patients were categorized into two groups and compared based on whether the apex of the deformity was in the cervical (C) or the cervicothoracic (CT) region. Radiographic parameters were correlated to C2S, T1 slope (T1S) and 1-year health-related quality-of-life outcomes as measured by the EuroQol 5 Dimension questionnaire (EQ5D), modified Japanese Orthopedic Association Scale, numeric rating scale for neck pain, and the Neck Disability Index (NDI). RESULTS: One hundred four CD patients (C = 74, CT = 30; mean age 61 yr, 56% women, 42% revisions) were included. CT patients had higher baseline cSVA and T1S (P < 0.05). C2S correlated with T1 slope minus cervical lordosis (TS-CL) (r = 0.98, P < 0.001) and C0-C2 angle, cSVA, CL, T1S (r = 0.37-0.65, P < 0.001). Correlation of cSVA with C0-C2 was weaker (r = 0.48, P < 0.001). At 1-year postoperatively, higher C2S correlated with worse EQ-5D (r = 0.28, P = 0.02); in CT patients, higher C2S correlated with worse NDI, modified Japanese Orthopedic Association Scale, numeric rating scale for neck pain, and EQ5D (all r > 0.5, P≤0.05). Using linear regression, moderate disability by EQ5D corresponded to C2S of 20°(r = 0.08). For CT patients, C2S = 17° corresponded to moderate disability by NDI (r = 0.4), and C2S = 20° by EQ5D (r = 0.25). CONCLUSION: C2S correlated with upper-cervical and subaxial alignment. C2S correlated strongly with TS-CL (R = 0.98, P < 0.001) because C2S is a mathematical approximation of TS-CL. C2S is a useful marker of CD, linking the occipitocervical and cervico-thoracic spine. C2S defines the presence of a mismatch between cervical lordosis and thoracolumbar alignment. Worse 1-year postoperative C2 slope correlated with worse health outcomes. LEVEL OF EVIDENCE: 3.

Should Sagittal Spinal Alignment Targets for Adult Spinal Deformity Correction Depend on Pelvic Incidence and Age?

STUDY DESIGN: Retrospective analysis. OBJECTIVE: Determine whether deformity corrections should vary by pelvic incidence (PI). SUMMARY OF BACKGROUND DATA: Alignment targets for deformity correction have been reported for various radiographic parameters. The T1 pelvic-angle (TPA) has gained in applications for adult spinal deformity (ASD) surgical-planning since it directly measures spinal alignment separate from pelvic- and lower-extremity compensation. Recent studies have demonstrated that ASD corrections should be age specific. METHODS: A prospective database of consecutive ASD patients was analyzed in conjunction with a normative spine database. Clinical measures of disability included the Oswestry Disability Index (ODI) and Short Form 36 Survey (SF-36) Physical Component Score (PCS). Baseline relationships between TPA, age, PI, and ODI/SF-36 PCS scores were analyzed in the ASD and asymptomatic patients. Linear regression modeling was used to determine alignment targets based on PI and age-specific normative SF-36-PCS values. RESULTS: Nine hundred three ASD patients (mean 53.7 yr) and 111 normative subjects (mean 50.7 yr) were included. Patients were subanalyzed by PI: low, medium, high (<40, 40-75, >75); and age: elderly (>65 yr, n = 375), middle age (45-65 yr, n = 387), and young (18-45 yr, n = 141). TPA and SRS-Schwab parameters correlated with age and PI in ASD and normative subjects (r = 0.42, P < 0.0001). ODI correlated with PCS (r = 0.71, P < 0.0001). Linear regression analysis using age-normative SF-36-PCS values demonstrated that ideal spinopelvic alignment is less strict with increasing PI and age. CONCLUSION: Targets for ASD correction should vary by age and PI. This is demonstrated in both asymptomatic and ASD subjects. Using age-normative SF-36 PCS values, alignment targets are described for different age and PI categories. High-PI patients do not require as rigorous realignments to attain age-specific normative levels of health status. As such, sagittal spinal alignment targets increase with increasing age as well as PI. LEVEL OF EVIDENCE: 3.

Klippel-Feil: A constellation of diagnoses, a contemporary presentation, and recent national trends.

BACKGROUND: Klippel-Feil syndrome (KFS) includes craniocervical anomalies, low posterior hairline, and brevicollis, with limited cervical range of motion; however, there remains no consensus on inheritance pattern. This study defines incidence, characterizes concurrent diagnoses, and examines trends in the presentation and management of KFS. METHODS: This was a retrospective review of the Kid's Inpatient Database (KID) for KFSpatients aged 0-20 years from 2003 to 2012. Incidence was established using KID-supplied year and hospital-trend weights. Demographics and secondary diagnoses associated with KFS were evaluated. Comorbidities, anomalies, and procedure type trends from 2003 to 2012 were assessed for likelihood to increase among the years studied using ANOVA tests. RESULTS: Eight hundred and fifty-eight KFS diagnoses (age: 9.49 years; 51.1% females) and 475 patients with congenital fusion (CF) (age: 8.33 years; 50.3% females) were analyzed. We identified an incidence rate of 1/21,587 discharges. Only 6.36% of KFS patients were diagnosed with Sprengel's deformity; 1.44% with congenital fusion. About 19.1% of KFS patients presented with another spinal abnormality and 34.0% presented with another neuromuscular anomaly. About 36.51% of KFS patients were diagnosed with a nonspinal or nonmusculoskeletal anomaly, with the most prevalent anomalies being of cardiac origin (12.95%). About 7.34% of KFS patients underwent anterior fusions, whereas 6.64% of KFS patients underwent posterior fusions. The average number of levels operated on was 4.99 with 8.28% receiving decompressions. Interbody devices were used in 2.45% of cases. The rate of fusions with <3 levels (7.46%) was comparable to that of 3 levels or greater (7.81%). CONCLUSIONS: KFS patients were more likely to have other spinal abnormalities (19.1%) and nonnervous system abnormalities (13.63%). Compared to congenital fusions, KFS patients were more likely to have congenital abnormalities such as Sprengel's deformity. KFS patients are increasingly being treated with spinal fusion. LEVEL OF EVIDENCE: III.

Congenital Etiology Is an Independent Risk Factor for Complications in Adolescents Undergoing Corrective Scoliosis Surgery: Comparison of In-hospital Comorbidities Using Nationwide KID's Inpatient Database.

BACKGROUND: Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS. METHODS: A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above. Univariate analysis described differences in demographics, comorbidities, intraoperative complications, and clinical values between groups. Binary logistic regression controlling for age, sex, race, and invasiveness predicted complications risk in CS (odds ratios; 95% confidence interval). RESULTS: In total, 25,131 patients included (IS, n=22443; CS, n=2688). For patients under age 10, CS patients underwent 1 level shorter fusions (P<0.001), had fewer comorbidities (P<0.001), and sustained similar complication incidence. In the 10 and over age analysis, CS patients similarly had shorter fusions, but greater comorbidities, and significantly more complications (odds ratio, 1.6; confidence interval, 1.4-1.8). CONCLUSIONS: CS patients have higher in-hospital complication rates. With more comorbidities, these patients have increased risk of sustaining procedure-related complications such as shock, infection, and Adult Respiratory Distress Syndrome. These data help to counsel patients and their families before spinal fusion. LEVEL OF EVIDENCE: Level III-retrospective review of a prospectively collected database.

Suboptimal Age-Adjusted Lumbo-Pelvic Mismatch Predicts Negative Cervical-Thoracic Compensation in Obese Patients.

BACKGROUND: Given the paucity of literature regarding compensatory mechanisms used by obese patients with sagittal malalignment, it is necessary to gain a better understanding of the effects of obesity on compensation after comparing the degree of malalignment to age-adjusted ideals. This study aims to compare baseline alignment of obese and nonobese patients using age-adjusted spino-pelvic alignment parameters, describing associated spinal changes. METHODS: Patients ≥ 18 years with full-body stereoradiographs were propensity-score matched for sex, baseline pelvic incidence (PI), and categorized as nonobese (body mass index < 30kg/m2) or obese (body mass index ≥ 30). Age-adjusted ideals were calculated for sagittal vertical axis, spino-pelvic mismatch (PI-LL), pelvic tilt, and T1 pelvic angle using established formulas. Patients were stratified as meeting alignment ideals, being above ideal, or being below. Spinal alignment parameters included C0-C2, C2-C7, C2-T3, cervical thoracic pelvic angle, cervical sagittal vertical axis SVA, thoracic kyphosis, T1 pelvic angle, T1 slope, sagittal vertical axis, lumbar lordosis (LL), PI, PI-LL, pelvic tilt. Lower-extremity parameters included sacrofemoral angle, knee flexion (KA), ankle flexion (AA), pelvic shift (PS), and global sagittal angle (GSA). Independent t tests compared parameters between cohorts. RESULTS: Included: 800 obese, 800 nonobese patients. Both groups recruited lower-extremity compensation: sacrofemoral angle (P = .004), KA, AA, PS, GSA (all P < .001). Obese patients meeting age-adjusted PI-LL had greater lower-extremity compensation than nonobese patients: lower sacrofemoral angle (P = .002), higher KA (P = .008), PS (P = .002), and GSA (P = .02). Obese patients with PI-LL mismatch higher than age-adjusted ideal recruited greater lower-extremity compensation than nonobese patients: higher KA, AA, PS, GSA (all P < .001). Obese patients showed compensation through the cervical spine: increased C0-C2, C2-C7, C2-T3, and cervical sagittal vertical axis (all P < .001), high T1 pelvic angle (P < .001), cervical thoracic pelvic angle (P = .03), and T1 slope (P < .001), with increased thoracic kyphosis (P = .015) and decreased LL (P < .001) compared to nonobese patients with PI-LL larger than age-adjusted ideal. CONCLUSIONS: Regardless of malalignment severity, obese patients recruited lower-limb compensation more than nonobese patients. Obese patients with PI-LL mismatch larger than age-adjusted ideal also develop upper-cervical and cervicothoracic compensation for malalignment. LEVEL OF EVIDENCE: III. CLINICAL RELEVANCE: Clinical evaluation should extend to the cervical spine in obese patients not meeting age-adjusted sagittal alignment ideals.

McGregor's slope and slope of line of sight: two surrogate markers for Chin-Brow vertical angle in the setting of cervical spine pathology.

BACKGROUND CONTEXT: Chin-Brow Vertical Angle (CBVA) is not routinely measured on radiographs even though it is a strong assessor of horizontal gaze. STUDY DESIGN: Retrospective cohort study of patients with full-body stereoradiographs and a primary cervical diagnosis at the time of presentation. PURPOSE: Assess the utility of McGregor's Slope (McGS) and Slope of Line of Sight (SLS) as surrogate markers for the CBVA in cervical spine pathology. METHODS: A retrospective review of patients with full-body stereoradiographs was performed. Patients were ≥18 years of age with a primary cervical diagnosis. Analysis of CBVA, McGS, and SLS was conducted as markers of horizontal gaze. Sagittal alignment was characterized by: pelvic tilt (PT), pelvic incidence minus lumbar lordosis (PI-LL), T1-pelvic angle (TPA), sagittal vertical axis (SVA), T2-T12 thoracic kyphosis, C2-C7 SVA (cSVA), C2-C7 Cervical lordosis, T1-Slope minus Cervical Lordosis (TS-CL), and C2-Slope (C2S). A subgroup analysis was performed in patients with cervical deformity. Independent sample t tests and paired t tests compared radiographic alignment. Pearson correlations characterized linear relationships. Linear regression analysis identified relationships between the parameters. RESULTS: In all, 329 patients were identified with primary cervical spine diagnoses. Chin-Brow Vertical Angle was visible in 171 patients (52.0%), McGS in 281 (85.4%), and SLS in 259 (78.7%). Of the 171 patients with visible CBVA, the mean CBVA was 2.30±7.7, mean McGS was 5.02±8.1, and mean SLS was -1.588±2.03. Chin-Brow Vertical Angle strongly correlated with McGS (r=0.83) and SLS (r=0.89) with p<.001. McGregor's Slope positively correlated with SLS (r=0.89, p=.001). CONCLUSIONS: This study demonstrates that McGS and SLS serve as strong, positive correlates for CBVA. The reported mean differences between these measurements provide a useful conversion, broadening CBVA's use as a radiographic assessment of horizontal gaze.

Preoperative Patient-Reported Outcomes and Clinical Characteristics as Predictors of 90-Day Cost/Utilization and Complications.

BACKGROUND: With the advent of mandatory bundle payments for total joint arthroplasty (TJA), assessing patients' risk for increased 90-day complications and resource utilization is crucial. This study assesses the degree to which preoperative patient-reported outcomes predict 90-day complications, episode costs, and utilization in TJA patients. METHODS: All TJA cases in 2017 at 2 high-volume hospitals were queried. Preoperative HOOS/KOOS JR (Hip Injury and Osteoarthritis Outcome Score/Knee Injury and Osteoarthritis Outcome Score) and Veterans RAND 12-item health survey (VR-12) were administered to patients preoperatively via e-collection platform. For patients enrolled in the Medicare bundle, cost data were extracted from claims. Bivariate and multivariate regression analyses were performed. RESULTS: In total, 2108 patients underwent TJA in 2017; 1182 (56%) were missing patient-reported outcome data and were excluded. The final study population included 926 patients, 199 (21%) of which had available cost data. Patients with high bundle costs tended to be older, suffer from vascular disease and anemia, and have higher Charlson scores (P < .05 for all). These patients also had lower baseline VR-12 Physical Component Summary Score (PCS; 24 vs 30, P ≤ .001) and higher rates of extended length of stay, skilled nursing facility discharge, 90-day complications, and 90-day readmission (P ≤ .04 for all). In multivariate analysis, higher baseline VR-12 PCS was protective against extended length of stay, skilled nursing facility discharge, >75th percentile bundle cost, and 90-day bundle cost exceeding target bundle price (P < .01 for all). Baseline VR-12 Mental Component Summary Score and HOOS/KOOS JR were not predictive of complications or bundle cost. CONCLUSION: Low baseline VR-12 PCS is predictive of high 90-day bundle costs. Baseline HOOS/KOOS JR scores were not predictive of utilization or cost. Neither VR-12 nor HOOS/KOOS JR was predictive of 90-day readmission or complications.

Patient satisfaction reporting for patellofemoral arthroplasty is significantly lacking: a systematic review.

Background: Patellofemoral Arthroplasty (PFA) has been shown to be successful in restoring knee function and quality of life in patients with the isolated patellofemoral disease. Patient satisfaction has been suggested as an indicator of the quality of elective orthopedic operations, although there remains no standardized method to collect and evaluate satisfaction. The present study offers a systematic review of the available literature concerning patient satisfaction following PFA to assess common methodologies for reporting patient satisfaction. Methods: A query of the Medline database produced 116 articles that were reviewed for inclusion in the review. The following inclusion criteria were used to identify suitable articles: English language, clinical outcomes study related to PFA, and patient-reported satisfaction as an outcome measure. Results: Seven studies met inclusion criteria and were eligible for review. The highest level of evidence was level-III. The study publication dates ranged from 2009 to 2016, with six published in 2015 & 2016. In total, 320 PFAs were performed on 267 patients. Four articles reported the proportion of included patients who had previous knee surgeries (range: 20-60%). Three studies used ordinal scales to rate patient satisfaction. Four studies (57.1%) reported the numeric proportion of patients satisfied following PFA, which ranged from 76% to 96.5%. Two studies used Visual Analog Scale methods. For these two studies, one of them reported the mean satisfaction score as 7.5/10, and the other reported a median of 90/100. Conclusions: The available literature on patient satisfaction after PFA was found to be limited, with low-quality evidence and variable methodology.

Patient-Reported Outcomes Measurement Information System instruments: outperforming traditional quality of life measures in patients with back and neck pain.

OBJECTIVE The Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular due to computer adaptive testing methodology. This study aims to validate the association between PROMIS and legacy outcome metrics and compare PROMIS to legacy metrics in terms of ceiling and floor effects and questionnaire burden. METHODS A retrospective review of an outcomes database was performed at a single institution from December 2016 to April 2017. Inclusion criteria were age > 18 years and a chief complaint of back pain or neck pain. The PROMIS computer adaptive testing Pain Interference, Physical Function (PF), and Pain Intensity domains; Oswestry Disability Index (ODI); Neck Disability Index (NDI); and visual analog scale (VAS) back, VAS leg, VAS neck, and VAS arm were completed in random order. PROMIS was compared to legacy metrics in terms of the average number of questions needed to complete each questionnaire and the score distributions in the lower and higher bounds of scores. RESULTS A total of 494 patients with back pain and 130 patients with neck pain were included. For back pain, ODI showed a strong correlation with PROMIS-PF (R = −0.749, p < 0.001), Pain Intensity (R = 0.709, p < 0.001), and Pain Interference (R = 0.790, p < 0.001) domains. Additionally, the PROMIS Pain Intensity domain correlated to both VAS back and neck pain (R = 0.642, p < 0.001 for both). PROMIS-PF took significantly fewer questions to complete compared to the ODI (4.123 vs 9.906, p < 0.001). When assessing for instrument sensitivity, neither survey presented a significant ceiling and floor effect in the back pain population (ODI: 0.40% and 2.63%; PROMIS-PF: 0.60% and 1.41%). In the neck pain cohort, NDI showed a strong correlation with PROMIS-PF (R = 0.771, p < 0.001). Additionally, PROMIS Pain Intensity correlated to VAS neck (R = 0.642, p < 0.001). The mean number of questions required to complete the questionnaire was much lower for PROMIS-PF compared to NDI (4.417 vs 10, p < 0.001). There were no significant differences found in terms of ceiling and floor effects for neck complaints (NDI: 2.3% and 6.92%; PROMIS-PF: 0.00% and 5.38%) or back complaints (ODI: 0.40% and 2.63%; PROMIS-PF: 1.41% and 0.60%). CONCLUSIONS PROMIS correlates strongly with traditional disability measures in patients with back pain and neck pain. For both back and neck pain, the PROMIS-PF required patients to answer significantly fewer questions to achieve similar granularity. There were no significant differences in ceiling and floor effects for NDI or ODI when compared with the PROMIS-PF instrument.

Traumatic Fracture of the Pediatric Cervical Spine: Etiology, Epidemiology, Concurrent Injuries, and an Analysis of Perioperative Outcomes Using the Kids' Inpatient Database.

BACKGROUND: The study aimed to characterize trends in incidence, etiology, fracture types, surgical procedures, complications, and concurrent injuries associated with traumatic pediatric cervical fracture using a nationwide database. METHODS: The Kids' Inpatient Database (KID) was queried. Trauma cases from 2003 to 2012 were identified, and cervical fracture patients were isolated. Demographics, etiologies, fracture levels, procedures, complications, and concurrent injuries were assessed. The t-tests elucidated significance for continuous variables, and χ2 for categoric values. Logistic regressions identified predictors of spinal cord injury (SCI), surgery, any complication, and mortality. Level of significance was P < .05. RESULTS: A total of 11 196 fracture patients were isolated (age, 16.63 years; male, 65.7%; white, 65.4%; adolescent, 55.4%). Incidence significantly increased since 2003 (2003 vs 2012, 2.39% vs 3.12%, respectively), as did Charlson Comorbidity Index (CCI; 2003 vs 2012, 0.2012 vs 0.4408, respectively). Most common etiology was motor vehicle accidents (50.5%). Infants and children frequently fractured at C2 (closed: 43.1%, 32.9%); adolescents and young adults frequently fractured at C7 (closed: 23.9%, 26.5%). Upper cervical SCI was less common (5.8%) than lower cervical SCI (10.9%). Lower cervical unspecified-SCI, anterior cord syndrome, and other specified SCIs significantly decreased since 2003. Complications were common (acute respiratory distress syndrome, 7.8%; anemia, 6.7%; shock, 3.0%; and mortality, 4.2%), with bowel complications, cauda equina, anemia, and shock rates significantly increasing since 2003. Concurrent injuries were common (15.2% ribs; 14.4% skull; 7.1% pelvis) and have significantly increased since 2003. Predictors of SCI included sports injury and CCI. Predictors of surgery included falls, sports injuries, CCI, length of stay, and SCI. CCI, SCIs, and concurrent injuries were predictors of any complication and mortality, all (P < .001). CONCLUSIONS: Since 2003, incidence, complications, concurrent injuries, and fusions have increased. CCI, SCI, falls, and sports injuries were significant predictors of surgical intervention. Decreased mortality and SCI rates may indicate improving emergency medical services and management guidelines. LEVEL OF EVIDENCE: III. CLINICAL RELEVANCE: Clinicians should be aware of increased case complexity in the onset of added perioperative complications and concurrent injuries. Cervical fractures resultant of sports injuries should be scrutinized for concurrent SCIs.

Use of Gabapentin in Posterior Spinal Fusion is Associated With Decreased Postoperative Pain and Opioid Use in Children and Adolescents.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study was to examine associations of gabapentin use with inpatient postoperative daily pain scores and opioid use in children undergoing PSF for AIS. SUMMARY OF BACKGROUND DATA: Gabapentin use in posterior spinal fusion (PSF) postoperative pain management for adolescent idiopathic scoliosis (AIS) is increasingly common in order to decrease opioid use and improve pain control, though there is conflicting data on dosing and effectiveness to support this practice in real world settings. METHODS: Retrospective cohort study of children aged 10 to 21 years undergoing PSF for AIS between January 2013 and June 2016 at an urban academic tertiary care center. Adjuvant gabapentin exposure was defined as at least 15 mg/kg/d by postoperative day (POD) 1 with an initial loading dose of 10 mg/kg on day of surgery. Primary outcomes were daily postoperative mean pain score and opioid use [morphine milligram equivalents/kg/day(mme/kg/d)]. Secondary outcomes were short and long-term complications. RESULTS: Among 129 subjects (mean age, 14.6 y, 74% female, mean coronal cobb, 55.2 degrees), 24 (19%) received gabapentin. Unadjusted GABA exposure was associated with significantly lower opioid use on POD1 and 2 (49% and 31%mme/kg/d, respectively) and lower pain scores (14%) on POD2. Adjusting for preexisting back pain, preoperative coronal Cobb angle, and site, GABA use was associated with significantly lower mean pain scores on POD1 through POD3 (-0.68, P=0.01; -0.86, P=0.002; -0.63, P=0.04). Gabapentin use was also associated with decreased opioid use on POD1 and POD2 (-0.39mme/kg/d, P<0.001; -0.27, P=0.02). There was no difference in complications by gabapentin exposure. CONCLUSIONS: Addition of gabapentin as adjuvant therapy for adolescent PSF, beginning on day of surgery, is associated with improved pain scores and decreased opioid use in the first 48 to 72 hours postoperatively. LEVEL OF EVIDENCE: This is a retrospective cohort study, classified as Level III under "Therapeutic Studies Investigating the Results of a Treatment."

Measurement of Spinopelvic Angles on Prone Intraoperative Long-Cassette Lateral Radiographs Predicts Postoperative Standing Global Alignment in Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective review from a single institution. OBJECTIVES: To evaluate intraoperative T1-pelvic angle (TPA), T4PA, and T9PA as predictors of postoperative global alignment after adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Malalignment following adult spinal surgery is associated with disability and correlates with health-related quality of life. Preoperative planning and intraoperative verification are crucial for optimal postoperative outcomes. Currently, only pelvic incidence minus lumbar lordosis (PI-LL) mismatch has been used to assess intraoperative correction. METHODS: Patients undergoing ≥4-level spinal fusion with full-length pre-, intra-, and first postoperative calibrated radiographs were included from a single institution. Alignment measurements were obtained for sagittal vertical axis (SVA), PI-LL, TPA, T4PA, and T9PA. The whole cohort was divided into upper thoracic (UT: UIV > T7) and lower thoracic fusions (LT: UIV < T7). Change was assessed between phases, and a subanalysis was included for UT and LT groups to compare alignment changes for differing extent of proximal fusion in the sagittal plane. RESULTS: Eighty patients (mean 63.4 years, 70% female, mean levels fused 11.9) underwent significant ASD correction (ΔPI-LL = 22.1°; ΔTPA = 13.8°). For all, intraoperative TPA, T4PA, and T9PA correlated with postoperative SVA (range, r = 0.41-0.59), whereas intraoperative PI-LL correlated less (r = 0.38). For UT (n = 49), all spinopelvic angles and LL were similar intraoperative to postoperatively (p > .09). For LT (n = 31), intraoperative and postoperative T9PA and LL were similar (p > .10) but TPA and T4PA differed (p < .02). For UT, all intraoperative and postoperative spinopelvic angles strongly correlated (r = 0.8-0.9). For LT, intraoperative to postoperative T9PA strongly correlated (r = 0.83) and TPA, T4PA, and LL correlated moderately (r = 0.65-0.70). LT trended toward more reciprocal kyphosis postoperatively (8.1° vs. 2.6°; p = .059). CONCLUSIONS: Intraoperative measurements of TPA, T4PA, and T9PA correlated better with postoperative global alignment than PI-LL, demonstrating their utility in confirming alignment goals. When comparing intraoperative to postoperative films, only T9PA was similar in LT whereas all spinopelvic angles were similar in UT. Reciprocal kyphosis in unfused segments of LT fusions may account for difference in TPA and T4PA from intraoperative to postoperative films. LEVEL OF EVIDENCE: Level III.

Comparison of Patient Reported Outcome Measurement Information System With Neck Disability Index and Visual Analog Scale in Patients With Neck Pain.

STUDY DESIGN: A retrospective analysis of a patient-reported outcomes database from a single institution from December 2016 to April 2017. OBJECTIVE: To validate the association of Patient Reported Outcome Measurement Information System (PROMIS) with Neck Disability Index (NDI) in patients with neck pain and examine each instruments ability to capture concomitant arm pain and concomitant back pain. SUMMARY OF BACKGROUND DATA: PROMIS has been increasingly utilized and its computer adapted testing methodology improves assessment of pain and disability. However, literature is lacking regarding how these instruments perform in neck pain patients with concomitant arm pain or back pain. METHODS: Inclusion criteria were age >18 years and a primary complaint of neck pain. The NDI; Visual Analog Scale (VAS) back, neck, arm, and leg; and PROMIS physical function, pain intensity, and pain interference questionnaires were administered. Propensity score matching was performed to compare patients with high and low back and arm pain by controlling for neck pain. Bivariate correlations and independent samples t tests were performed to assess linear relationships and compare back and arm pain groups with PROMIS. RESULTS: Approximately, 130 patients were included. NDI correlated strongly to PROMIS physical function (r = -0.771, P < 0.001), pain intensity (r = 0.605, P < 0.001), and pain interference (r = 0.786, P < 0.001). VAS neck and arm pain also correlated to the PROMIS pain intensity instrument (VAS neck: r = 0.642, P < 0.001; VAS arm: r = 0.376, P < 0.001).After matching for neck pain, the high and low back pain groups each included 32 patients. There were significant differences in PROMIS physical function when high and low back pain groups were compared (39.07 vs. 43.68, P = 0.031). No significant difference was found for any outcome metric for high and low arm pain groups. CONCLUSION: PROMIS instruments are capable of characterizing pain and disability in patients with neck pain and are sensitive to disability in regions adjacent to the neck. LEVEL OF EVIDENCE: 3.

Trends in Treatment of Scheuermann Kyphosis: A Study of 1,070 Cases From 2003 to 2012.

STUDY DESIGN: Retrospective review of KID Inpatient Database (KID) from 2003, 2006, 2009, and 2012. OBJECTIVES: The aim of this study was to evaluate the impact of advances in spinal surgery on patient outcomes in the treatment of Scheuermann kyphosis (SK). SUMMARY OF BACKGROUND DATA: SK is one of the most common causes of back pain in adolescents. Trends in diagnoses and surgical treatment and approach to SK have not been well described. METHODS: SK patients aged 0-20 years in KID were identified by ICD-9 code 732.0. KID-supplied year- and hospital-trend weights were used to establish prevalence. Patient demographics, surgical details, and outcomes were analyzed with analysis of variance. RESULTS: A total of 1,070 SK patients were identified (33.2% female), with increasing incidence of SK diagnosed from 2003 to 2012 (3.6-7.5 per 100,000, p < .001). The average age of operative patients was 16.1±2.0 years and did not change (16.27-16.06 years, p = .905). The surgical rate has not changed over time (72.8%-72.8%, p = .909). Overall, 96.3% of operative patients underwent fusion, with 82.2% of cases spanning ≥4 levels; in addition, 8.6% underwent an anterior-only surgery, 74.6% posterior-only, and 13.6% combined approach. From 2003 to 2012, rates of posterior-only surgeries increased (62.4%-84.4%, p < .001) whereas the rate of combined-approach surgeries decreased (37.6%-8.8%, p < .001). Overall complication rates for SK surgeries have decreased (2003: 20.9%; 2012: 11.9%, p = .029). Concurrently, the rate of ≥4-level fusions has increased (43.5%-89.6%, p < .001), as well as the use of Smith-Peterson (7.8%-23.6%, p < .001) and three-column osteotomies (0.0%-2.7%, p = .011). In subanalysis comparing posterior to combined approaches, complication rates were significantly different (posterior: 9.88%, combined: 19.46%, p = .005). Patients undergoing a combined approach have a longer length of stay (LOS) than patients undergoing a posterior-only approach (7.8 vs. 5.6 days, p < .001). CONCLUSIONS: Despite unchanged demographics and operative rates in SK, there has been a shift from combined to isolated posterior approaches, with a concurrent increase in levels treated. A combined approach was associated with increased complication rates, LOS, and total charges compared to isolated approaches. Awareness of these inherent differences is important for surgical decision making and patient education. LEVELS OF EVIDENCE: Level III.

The Influence of Body Mass Index on Achieving Age-Adjusted Alignment Goals in Adult Spinal Deformity Corrective Surgery with Full-Body Analysis at 1 Year.

BACKGROUND: The impact of obesity on global spinopelvic alignment is poorly understood. This study investigated the effect of body mass index on achieving alignment targets and compensation mechanisms after corrective surgery for adult spinal deformity (ASD). METHODS: Retrospective review of a single-center database. Inclusion: patients ≥18 years with full-body stereographic images (baseline and 1 year) and who met ASD criteria (sagittal vertical axis [SVA] >5 cm, pelvic incidence minus lumbar lordosis [PI-LL] >10°, coronal curvature >20° or pelvic tilt >20°). Patients were stratified by age (<40, 40-65, and ≥65 years) and body mass index (<25, 25-30, and >30). Postoperative alignment was compared with age-adjusted ideal values. Prevalence of patients who matched ideals and unmatched (undercorrected/overcorrected) was assessed. Health-related quality of life (HRQL) scores, alignment, and compensatory mechanisms were compared across cohorts using analysis of variance and temporally with paired t tests. RESULTS: A total of 116 patients were included (average age, 62 years; 66% female). After corrective surgery, obese and overweight patients had more residual malalignment (worse PI-LL, T1 pelvic angle, pelvic tilt, and SVA) compared with normal patients (P < 0.05). In addition, obese and overweight patients recruited more pelvic shift (obese, 62.36; overweight, 49.80; normal, 31.50) and had a higher global sagittal angle (obese, 6.51; overweight, 6.35; normal, 3.40) (P < 0.05). Obese and overweight patients showed lower overcorrection rates and higher undercorrection rates (P < 0.05). Obese patients showed worse postoperative HRQL scores (Scoliosis Research Society 22 Questionnaire, Oswestry Disability Index, visual analog scale-leg) than did overweight and normal patients (P < 0.05). Obese and overweight patients who matched age-adjusted alignment targets for SVA or PI-LL showed no HRQL improvements (P > 0.05). CONCLUSIONS: After surgery, obese patients were undercorrected, showed more residual malalignment, recruited more pelvic shift, and had a greater global sagittal angle and worse HRQL scores. The benefits from age-adjusted alignment targets seem to be less substantial for obese and overweight patients.