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PURPOSE: To assess impact of baseline disability on HRQL outcomes. METHODS: CD patients with baseline (BL) and 2 year (2Y) data included, and ranked into quartiles by baseline NDI, from lowest/best score (Q1) to highest/worst score (Q4). Means comparison tests analyzed differences between quartiles. ANCOVA and logistic regressions assessed differences in outcomes while accounting for covariates (BL deformity, comorbidities, HRQLs, surgical details and complications). RESULTS: One hundred and sixteen patients met inclusion (Age:60.97 ± 10.45 years, BMI: 28.73 ± 7.59 kg/m2, CCI: 0.94 ± 1.31). The cohort mean cSVA was 38.54 ± 19.43 mm and TS-CL: 37.34 ± 19.73. Mean BL NDI by quartile was: Q1: 25.04 ± 8.19, Q2: 41.61 ± 2.77, Q3: 53.31 ± 4.32, and Q4: 69.52 ± 8.35. Q2 demonstrated greatest improvement in NRS Neck at 2Y (-3.93), compared to Q3 (-1.61, p = .032) and Q4 (-1.41, p = .015). Q2 demonstrated greater improvement in NRS Back (-1.71), compared to Q4 (+ 0.84, p = .010). Q2 met MCID in NRS Neck at the highest rates (69.9%), especially compared to Q4 (30.3%), p = .039. Q2 had the greatest improvement in EQ-5D (+ 0.082), compared to Q1 (+ 0.073), Q3 (+ 0.022), and Q4 (+ 0.014), p = .034. Q2 also had the greatest mJOA improvement (+ 1.517), p = .042. CONCLUSIONS: Patients in Q2, with mean BL NDI of 42, consistently demonstrated the greatest improvement in HRQLs whereas those in Q4, (NDI 70), saw the least. BL NDI between 39 and 44 may represent a disability "Sweet Spot," within which operative intervention maximizes patient-reported outcomes. Furthermore, delaying intervention until patients are severely disabled, beyond an NDI of 61, may limit the benefits of surgery.
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Vértebras Cervicales , Calidad de Vida , Humanos , Femenino , Persona de Mediana Edad , Masculino , Vértebras Cervicales/cirugía , Anciano , Evaluación de la Discapacidad , Resultado del TratamientoRESUMEN
Background: Adult spinal deformity (ASD) patients with concurrent sacroiliac joint (SIJ) pain are susceptible to worse postoperative outcomes. There is scarce literature on the impact of ASD realignment surgery on SIJ pain. Methods: Patients undergoing ASD realignment surgery were included and stratified by the presence of SIJ pain at the baseline (SIJP+) or SIJ pain absence (SIJP-). Mean comparison tests via ANOVA were used to assess baseline differences between both cohorts. Multivariable regression analyses analyzed factors associated with SIJ pain resolution/persistence, factoring in BMI, frailty, disability, and deformity. Results: A total of 464 patients were included, with 30.8% forming the SIJP+ cohort. At the baseline (BL), SIJP+ had worse disability scores, more severe deformity, higher BMI, higher frailty scores, and an increased magnitude of lower limb compensation. SIJP+ patients had higher mechanical complication (14.7 vs. 8.2%, p = 0.024) and reoperation rates (32.4 vs. 20.2%, p = 0.011) at 2 years. SIJP+ patients who subsequently underwent SI fusion achieved disability score outcomes similar to those of their SIJ- counterparts. Multivariable regression analysis revealed that SIJP+ patients who were aligned in the GAP lordosis distribution index were more likely to report symptom resolution at six weeks (OR 1.56, 95% CI: 1.02-2.37, p = 0.039), 1 year (OR 3.21, 2.49-5.33), and 2 years (OR 3.43, 2.41-7.12). SIJP- patients who did not report symptom resolution by 1 year and 2 years were more likely to demonstrate PI-LL > 5° (OR 1.36, 1.07-2.39, p = 0.045) and SVA > 20 mm (OR 1.62, 1.24-1.71 p = 0.017). Conclusions: SIJ pain in ASD patients may result in worsened pain and disability at presentation. Symptom resolution may be achieved in affected patients by adequate postoperative lumbar lordosis restoration.
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BACKGROUND AND OBJECTIVES: For patients with surgical adult spinal deformity (ASD), our understanding of alignment has evolved, especially in the last 20 years. Determination of optimal restoration of alignment and spinal shape has been increasingly studied, yet the assessment of how these alignment schematics have incrementally added benefit to outcomes remains to be evaluated. METHODS: Patients with ASD with baseline and 2-year were included, classified by 4 alignment measures: Scoliosis Research Society (SRS)-Schwab, Age-Adjusted, Roussouly, and Global Alignment and Proportion (GAP). The incremental benefits of alignment schemas were assessed in chronological order as our understanding of optimal alignment progressed. Alignment was considered improved from baseline based on SRS-Schwab 0 or decrease in severity, Age-Adjusted ideal match, Roussouly current (based on sacral slope) matching theoretical (pelvic incidence-based), and decrease in proportion. Patients separated into 4 first improving in SRS-Schwab at 2-year, second Schwab improvement and matching Age-Adjusted, third two prior with Roussouly, and fourth improvement in all four. Comparison was accomplished with means comparison tests and χ2 analyses. RESULTS: Sevenhundredthirty-two. patients met inclusion. SRS-Schwab BL: pelvic incidence-lumbar lordosis mismatch (++:32.9%), sagittal vertical axis (++: 23%), pelvic tilt (++:24.6%). 640 (87.4%) met criteria for first, 517 (70.6%) second, 176 (24%) third, and 55 (7.5%) fourth. The addition of Roussouly (third) resulted in lower rates of mechanical complications and proximal junctional kyphosis (48.3%) and higher rates of meeting minimal clinically important difference (MCID) for physical component summary and SRS-Mental (P < .05) compared with the second. Fourth compared with the third had higher rates of MCID for ODI (44.2% vs third: 28.3%, P = .011) and SRS-Appearance (70.6% vs 44.8%, P < .001). Mechanical complications and proximal junctional kyphosis were lower with the addition of Roussouly (P = .024), while the addition of GAP had higher rates of meeting MCID for SRS-22 Appearance (P = .002) and Oswestry Disability Index (P = .085). CONCLUSION: Our evaluation of the incremental benefit that alignment schemas have provided in ASD corrective surgery suggests that the addition of Roussouly provided the greatest reduction in mechanical complications, while the incorporation of GAP provided the most significant improvement in patient-reported outcomes.
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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.
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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.
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STUDY DESIGN: Retrospective cohort. OBJECTIVE: To investigate the impact of evolving Enhanced Recovery After Surgery (ERAS) protocols on outcomes after cervical deformity (CD) surgery. BACKGROUND: ERAS can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, there remains a paucity of literature assessing how developments have impacted outcomes after adult CD surgery. METHODS: Patients with operative CD 18 years or older with pre-baseline and 2 years (2Y) postoperative data, who underwent ERAS protocols, were stratified by increasing implantation of ERAS components: (1) early (multimodal pain program), (2) intermediate (early protocol + paraspinal blocks, early ambulation), and (3) late (early/intermediate protocols + comprehensive prehabilitation). Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through Bonferroni-adjusted means comparison analysis. RESULTS: A total of 131 patients were included (59.4 ± 11.7 y, 45% females, 28.8 ± 6.0 kg/m 2 ). Of these patients, 38.9% were considered "early," 36.6% were "intermediate," and 24.4% were "late." Perioperatively, rates of intraoperative complications were lower in the late group ( P = 0.036). Postoperatively, discharge disposition differed significantly between cohorts, with late patients more likely to be discharged to home versus early or intermediate cohorts [χ 2 (2) = 37.973, P < 0.001]. In terms of postoperative disability recovery, intermediate and late patients demonstrated incrementally improved 6 W modified Japanese Orthopedic Association scores ( P = 0.004), and late patients maintained significantly higher mean Euro-QOL 5-Dimension Questionnaire and modified Japanese Orthopedic Association scores by 1 year ( P < 0.001, P = 0.026). By 2Y, cohorts demonstrated incrementally increasing SWAL-QOL scores (all domains P < 0.028) domain scores versus early or intermediate cohorts. By 2Y, incrementally decreasing reoperation was observed in early versus intermediate versus late cohorts ( P = 0.034). CONCLUSIONS: The present study demonstrates that patients enrolled in an evolving ERAS program demonstrate incremental improvement in preoperative optimization and candidate selection, greater likelihood of discharge to home, decreased postoperative disability and dysphasia burden, and decreased likelihood of intraoperative complications and reoperation rates.
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Vértebras Cervicales , Recuperación Mejorada Después de la Cirugía , Humanos , Femenino , Persona de Mediana Edad , Masculino , Vértebras Cervicales/cirugía , Resultado del Tratamiento , Adulto , Anciano , Estudios RetrospectivosRESUMEN
OBJECTIVE: To assess the financial impact of Enhanced Recovery After Surgery (ERAS) protocols and cost-effectiveness in cervical deformity corrective surgery. STUDY DESIGN: Retrospective review of prospective CD database. BACKGROUND: Enhanced Recovery After Surgery (ERAS) can help accelerate patient recovery and assist hospitals in maximizing the incentives of bundled payment models while maintaining high-quality patient care. However, the economic benefit of ERAS protocols, nor the heterogeneous components that make up such protocols, has not been established. METHODS: Operative CD patients ≥18 y with complete pre-(BL) and up to 2-year(2Y) postop radiographic/HRQL data were stratified by enrollment in Standard-of-Care ERAS beginning in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, perioperative factors, and complication rates were assessed through means comparison analysis. Costs were calculated using PearlDiver database estimates from Medicare pay scales. QALY was calculated using NDI mapped to SF6D using validated methodology with a 3% discount rate to account for a residual decline in life expectancy. RESULTS: In all, 127 patients were included (59.07±11.16 y, 54% female, 29.08±6.43 kg/m 2 ) in the analysis. Of these patients, 54 (20.0%) received the ERAS protocol. Per cost analysis, ERAS+ patients reported a lower mean total 2Y cost of 35049 USD compared with ERAS- patients at 37553 ( P <0.001). Furthermore, ERAS+ patients demonstrated lower cost of reoperation by 2Y ( P <0.001). Controlling for age, surgical invasiveness, and deformity per BL TS-CL, ERAS+ patients below 70 years old were significantly more likely to achieve a cost-effective outcome by 2Y compared with their ERAS- counterparts (OR: 1.011 [1.001-1.999, P =0.048]. CONCLUSIONS: Patients undergoing ERAS protocols experience improved cost-effectiveness and reduced total cost by 2Y post-operatively. Due to the potential economic benefit of ERAS for patients incorporation of ERAS into practice for eligible patients should be considered.
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Análisis Costo-Beneficio , Recuperación Mejorada Después de la Cirugía , Humanos , Femenino , Masculino , Persona de Mediana Edad , Vértebras Cervicales/cirugía , Anciano , Adulto , Resultado del Tratamiento , Años de Vida Ajustados por Calidad de Vida , Estudios RetrospectivosRESUMEN
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 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 2-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: 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) at 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 6 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 6 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 years, F: 6.7±0.511 years, SF: 5.8±0.757 years; 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: III.
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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.
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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.
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Lordosis , Vértebras Lumbares , Osteotomía , Fusión Vertebral , Humanos , Osteotomía/métodos , Femenino , Masculino , Persona de Mediana Edad , Fusión Vertebral/métodos , Vértebras Lumbares/cirugía , Resultado del Tratamiento , Lordosis/cirugía , Vértebras Torácicas/cirugía , Adulto , Anciano , Estudios Retrospectivos , Estudios de Seguimiento , Curvaturas de la Columna Vertebral/cirugía , Curvaturas de la Columna Vertebral/diagnóstico por imagen , Complicaciones Posoperatorias/etiologíaRESUMEN
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.
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Ejercicio Preoperatorio , Humanos , Femenino , Persona de Mediana Edad , Masculino , Resultado del Tratamiento , Vértebras Cervicales/cirugía , Anciano , Calidad de Vida , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Periodo Posoperatorio , Curvaturas de la Columna Vertebral/cirugía , AdultoRESUMEN
Cervical spine deformity surgery has significantly evolved over recent decades. There has been substantial work performed, which has furthered the true understanding of alignment and advancements in surgical technique and instrumentation. Concomitantly, understanding of cervical spine pathology and the contributing drivers have also improved, which have influenced the development of classification systems for cervical spine deformity and the development of treatment-guiding algorithms. This article aims to provide a synopsis of the current knowledge surrounding cervical spine deformity to date, with particular focus on preoperative expected alignment targets, perioperative optimization, and the whole operative strategy.
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Algoritmos , Vértebras Cervicales , Adulto , Humanos , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugía , Vértebras Cervicales/patología , Columna Vertebral/cirugíaRESUMEN
OBJECTIVE: The objective was to determine the degree of regional decompensation to pelvic tilt (PT) normalization after complex adult spinal deformity (ASD) surgery. METHODS: Operative ASD patients with 1 year of PT measurements were included. Patients with normalized PT at baseline were excluded. Predicted PT was compared to actual PT, tested for change from baseline, and then compared against age-adjusted, Scoliosis Research Society-Schwab, and global alignment and proportion (GAP) scores. Lower-extremity (LE) parameters included the cranial-hip-sacrum angle, cranial-knee-sacrum angle, and cranial-ankle-sacrum angle. LE compensation was set as the 1-year upper tertile compared with intraoperative baseline. Univariate analyses were used to compare normalized and nonnormalized data against alignment outcomes. Multivariable logistic regression analyses were used to develop a model consisting of significant predictors for normalization related to regional compensation. RESULTS: In total, 156 patients met the inclusion criteria (mean ± SD age 64.6 ± 9.1 years, BMI 27.9 ± 5.6 kg/m2, Charlson Comorbidity Index 1.9 ± 1.6). Patients with normalized PT were more likely to have overcorrected pelvic incidence minus lumbar lordosis and sagittal vertical axis at 6 weeks (p < 0.05). GAP score at 6 weeks was greater for patients with nonnormalized PT (0.6 vs 1.3, p = 0.08). At baseline, 58.5% of patients had compensation in the thoracic and cervical regions. Postoperatively, compensation was maintained by 42% with no change after matching in age-adjusted or GAP score. The patients with nonnormalized PT had increased rates of thoracic and cervical compensation (p < 0.05). Compensation in thoracic kyphosis differed between patients with normalized PT at 6 weeks and those with normalized PT at 1 year (69% vs 35%, p < 0.05). Those who compensated had increased rates of implant complications by 1 year (OR [95% CI] 2.08 [1.32-6.56], p < 0.05). Cervical compensation was maintained at 6 weeks and 1 year (56% vs 43%, p = 0.12), with no difference in implant complications (OR 1.31 [95% CI -2.34 to 1.03], p = 0.09). For the lower extremities at baseline, 61% were compensating. Matching age-adjusted alignment did not eliminate compensation at any joint (all p > 0.05). Patients with nonnormalized PT had higher rates of LE compensation across joints (all p < 0.01). Overall, patients with normalized PT at 1 year had the greatest odds of resolving LE compensation (OR 9.6, p < 0.001). Patients with normalized PT at 1 year had lower rates of implant failure (8.9% vs 19.5%, p < 0.05), rod breakage (1.3% vs 13.8%, p < 0.05), and pseudarthrosis (0% vs 4.6%, p < 0.05) compared with patients with nonnormalized PT. The complication rate was significantly lower for patients with normalized PT at 1 year (56.7% vs 66.1%, p = 0.02), despite comparable health-related quality of life scores. CONCLUSIONS: Patients with PT normalization had greater rates of resolution in thoracic and LE compensation, leading to lower rates of complications by 1 year. Thus, consideration of both the lower extremities and thoracic regions in surgical planning is vital to preventing adverse outcomes and maintaining pelvic alignment.
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Lordosis , Escoliosis , Adulto , Humanos , Persona de Mediana Edad , Anciano , Calidad de Vida , Estudios de Seguimiento , Lordosis/diagnóstico por imagen , Lordosis/cirugía , Escoliosis/cirugía , Complicaciones Posoperatorias/epidemiología , Extremidad Inferior/cirugía , Estudios RetrospectivosRESUMEN
STUDY DESIGN: Retrospective study. OBJECTIVE: Evaluate surgical characteristics and postoperative 2-year results of the PL approach to spinal fusion. SUMMARY OF BACKGROUND DATA: Prone-lateral(PL) single positioning has recently gained popularity in spine surgery due to lower blood loss and operative time but has yet to be examined for other notable outcomes, including realignment and patient-reported measures. MATERIALS AND METHODS: We included circumferential spine fusion patients with a minimum one-year follow-up. Patients were stratified into groups based on undergoing PL approach versus same-day staged (Staged). Mean comparison tests identified differences in baseline parameters. Multivariable logistic regression, controlling for age, levels fused, and Charlson Comorbidity Index were used to determine the influence of the approach on complication rates, radiographic and patient-reported outcomes up to two years. RESULTS: One hundred twenty-two patients were included of which 72(59%) were same-day staged and 50(41%) were PL. PL patients were older with lower body mass index (both P <0.05). Patients undergoing PL procedures had lower estimated blood loss and operative time (both P <0.001), along with fewer osteotomies (63% vs. 91%, P <0.001). This translated to a shorter length of stay (3.8 d vs. 4.9, P =0.041). PL procedures demonstrated better correction in both PT (4.0 vs. -0.2, P =0.033 and pelvic incidence and lumbar lordosis (-3.7 vs. 3.1, P =0.012). PL procedures were more likely to improve in GAP relative pelvic version (OR: 2.3, [1.5-8.8]; P =0.003]. PL patients suffered lesser complications during the perioperative period and greater improvement in NRS-Back (-6.0 vs. -3.3, P =0.031), with less reoperations (0.0% vs. 4.8%, P =0.040) by two years. CONCLUSIONS: Patients undergoing PL single-position procedures received less invasive procedures with better correction of pelvic compensation, as well as earlier discharge. The prone lateral cohort also demonstrated greater clinical improvement and a lower rate of reoperations by two years following spinal corrective surgery. LEVEL OF EVIDENCE: Level-III.
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Complicaciones Posoperatorias , Fusión Vertebral , Humanos , Estudios Retrospectivos , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Columna Vertebral/cirugía , Fusión Vertebral/métodos , Atención Dirigida al PacienteRESUMEN
STUDY DESIGN/SETTING: Retrospective. OBJECTIVE: Evaluate the surgical technique that has the greatest influence on the rate of junctional failure following ASD surgery. SUMMARY OF BACKGROUND DATA: Differing presentations of adult spinal deformity(ASD) may influence the extent of surgical intervention and the use of prophylaxis at the base or the summit of a fusion construct to influence junctional failure rates. MATERIALS AND METHODS: ASD patients with two-year(2Y) data and at least 5-level fusion to the pelvis were included. Patients were divided based on UIV: [Longer Construct: T1-T4; Shorter Construct: T8-T12]. Parameters assessed included matching in age-adjusted PI-LL or PT, aligning in GAP-relative pelvic version or Lordosis Distribution Index. After assessing all lumbopelvic radiographic parameters, the combination of realigning the two parameters with the greatest minimizing effect of PJF constituted a good base. Good s was defined as having: (1) prophylaxis at UIV (tethers, hooks, cement), (2) no lordotic change(under-contouring) greater than 10° of the UIV, (3) preoperative UIV inclination angle<30°. Multivariable regression analysis assessed the effects of junction characteristics and radiographic correction individually and collectively on the development of PJK and PJF in differing construct lengths, adjusting for confounders. RESULTS: In all, 261 patients were included. The cohort had lower odds of PJK(OR: 0.5,[0.2-0.9]; P =0.044) and PJF was less likely (OR: 0.1,[0.0-0.7]; P =0.014) in the presence of a good summit. Normalizing pelvic compensation had the greatest radiographic effect on preventing PJF overall (OR: 0.6,[0.3-1.0]; P =0.044). In shorter constructs, realignment had a greater effect on decreasing the odds of PJF(OR: 0.2,[0.02-0.9]; P =0.036). With longer constructs, a good summit lowered the likelihood of PJK(OR: 0.3,[0.1-0.9]; P =0.027). A good base led to zero occurrences of PJF. In patients with severe frailty/osteoporosis, a good summit lowered the incidence of PJK(OR: 0.4,[0.2-0.9]; P =0.041) and PJF (OR: 0.1,[0.01-0.99]; P =0.049). CONCLUSION: To mitigate junctional failure, our study demonstrated the utility of individualizing surgical approaches to emphasize an optimal basal construct. Achievement of tailored goals at the cranial end of the surgical construct may be equally important, especially for higher-risk patients with longer fusions. LEVEL OF EVIDENCE: 3.
Asunto(s)
Cifosis , Lordosis , Adulto , Humanos , Cifosis/cirugía , Estudios Retrospectivos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Columna Vertebral/cirugía , Lordosis/diagnóstico por imagen , Lordosis/prevención & control , Lordosis/cirugíaRESUMEN
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.
Asunto(s)
Cifosis , Lordosis , Adulto , Humanos , Lordosis/diagnóstico por imagen , Lordosis/cirugía , Estudios Retrospectivos , Cifosis/cirugía , Cuello , Vértebras Cervicales/diagnóstico por imagen , Vértebras Cervicales/cirugíaRESUMEN
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.
Asunto(s)
Fragilidad , Adulto , Humanos , Femenino , Masculino , Estudios de Seguimiento , Estudios Retrospectivos , Pacientes , Estimación de Kaplan-MeierRESUMEN
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.
Asunto(s)
Calidad de Vida , Escoliosis , Adulto , Humanos , Estudios Retrospectivos , Escoliosis/cirugía , Dolor , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
STUDY DESIGN: A retrospective cohort review. OBJECTIVE: To develop a scoring system for predicting increased risk of postoperative complications in adult spinal deformity (ASD) surgery based on baseline nutritional and metabolic factors. BACKGROUND: Endocrine and metabolic conditions have been shown to adversely influence patient outcomes and may increase the likelihood of postoperative complications. The impact of these conditions has not been effectively evaluated in patients undergoing ASD surgery. MATERIALS AND METHODS: ASD patients 18 years or above with baseline and two-year data were included. An internally cross-validated weighted equation using preoperative laboratory and comorbidity data correlating to increased perioperative complications was developed via Poisson regression. Body mass index (BMI) categorization (normal, over/underweight, and obese) and diabetes classification (normal, prediabetic, and diabetic) were used per the Centers for Disease Control and Prevention and the American Diabetes Associates parameters. A novel ASD-specific nutritional and metabolic burden score (ASD-NMBS) was calculated via Beta-Sullivan adjustment, and Conditional Inference Tree determined the score threshold for experiencing ≥1 complication. Cohorts were stratified into low-risk and high-risk groups for comparison. Logistic regression assessed correlations between increasing burden score and complications. RESULTS: Two hundred one ASD patients were included (mean age: 58.60±15.4, sex: 48% female, BMI: 29.95±14.31, Charlson Comorbidity Index: 3.75±2.40). Significant factors were determined to be age (+1/yr), hypertension (+18), peripheral vascular disease (+37), smoking status (+21), anemia (+1), VitD hydroxyl (+1/ng/mL), BMI (+13/cat), and diabetes (+4/cat) (model: P <0.001, area under the curve: 92.9%). Conditional Inference Tree determined scores above 175 correlated with ≥1 post-op complication ( P <0.001). Furthermore, HIGH patients reported higher rates of postoperative cardiac complications ( P =0.045) and were more likely to require reoperation ( P =0.024) compared with low patients. CONCLUSIONS: The development of a validated novel nutritional and metabolic burden score (ASD-NMBS) demonstrated that patients with higher scores are at greater risk of increased postoperative complications and course. As such, surgeons should consider the reduction of nutritional and metabolic burden preoperatively to enhance outcomes and reduce complications in ASD patients.
Asunto(s)
Diabetes Mellitus , Calidad de Vida , Adulto , Humanos , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Reoperación/efectos adversos , Diabetes Mellitus/epidemiologíaRESUMEN
STUDY DESIGN: This was a retrospective study. OBJECTIVE: To assess the impact of surgical costs on patient-reported outcomes in adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: With increased focus on delivering cost-effective health care, interventions with high-resource utilization, such as ASD surgery, have received greater scrutiny. MATERIALS AND METHODS: ASD patients aged 18 years and older with BL and 2-year data were included. Surgical costs were calculated using the 2021 average Medicare reimbursement by Current Procedural Terminology code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes. RESULTS: Four hundred twenty-one patients met inclusion (60.7 yr, 81.8% female, Charlson Comorbidity Index: 1.6, 27.1 kg/m 2 ), 139 LC and 127 HC patients. After propensity score matching, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline health-related quality of life. Matched groups had similar baseline sagittal vertical axis (HC: 59.0 vs. LC: 56.7 mm), pelvic incidence and lumbar lordosis (HC: 13.1 vs. LC: 13.4°), and pelvic tilt (HC: 25.3 vs. LC: 22.4°). Rates of complications were not significantly different between the cost groups. Compared with the LC group, by 2 years, HC patients had higher odds of reaching substantial clinical benefit in Oswestry Disability Index [odds ratio (OR): 2.356 (1.220, 4.551), P =0.011], in Scoliosis Research Society-Total [OR: 2.988 (1.515, 5.895), P =0.002], and in Numerical Rating Scale Back [OR: 2.739 (1.105, 6.788), P =0.030]. Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria. CONCLUSIONS: Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient-reported outcomes compared with LC patients. Although cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of reintervention, particularly with more severe baseline deformity. LEVEL OF EVIDENCE: 3.