Hyperbaric Oxygen Treatment of Keratitis Following Facial Hyaluronic Acid Injection.

Background: With the increasing popularity of facial filler injections, growing numbers of complications have been reported. Case Report: We present the case of a 60-year-old female with vision changes and keratitis following hyaluronic acid (HA) facial filler injections who completely recovered following hyperbaric oxygen treatment (HBOT). Conclusion: Using HBOT to successfully treat ocular ischemia has been reported, but to our knowledge, our case is the first report of successful HBOT use for ocular ischemia and keratitis following cosmetic facial HA injection.

Classifying Complications: Assessing Adult Spinal Deformity 2-Year Surgical Outcomes.

STUDY DESIGN: Retrospective review of prospective database. OBJECTIVE: Complication rates for adult spinal deformity (ASD) surgery vary widely because there is no accepted system for categorization. Our objective was to identify the impact of complication occurrence, minor-major complication, and Clavien-Dindo complication classification (Cc) on clinical variables and patient-reported outcomes. METHODS: Complications in surgical ASD patients with complete baseline and 2-year data were considered intraoperatively, perioperatively (<6 weeks), and postoperatively (>6 weeks). Primary outcome measures were complication timing and severity according to 3 scales: complication presence (yes/no), minor-major, and Cc score. Secondary outcomes were surgical outcomes (estimated blood loss [EBL], length of stay [LOS], reoperation) and health-related quality of life (HRQL) scores. Univariate analyses determined complication presence, type, and Cc grade impact on operative variables and on HRQL scores. RESULTS: Of 167 patients, 30.5% (n = 51) had intraoperative, 48.5% (n = 81) had perioperative, and 58.7% (n = 98) had postoperative complications. Major intraoperative complications were associated with increased EBL (P < .001) and LOS (P = .0092). Postoperative complication presence and major postoperative complication were associated with reoperation (P < .001). At 2 years, major perioperative complications were associated with worse ODI, SF-36, and SRS activity and appearance scores (P < .02). Increasing perioperative Cc score and postoperative complication presence were the best predictors of worse HRQL outcomes (P < .05). CONCLUSION: The Cc Scale was most useful in predicting changes in patient outcomes; at 2 years, patients with raised perioperative Cc scores and postoperative complications saw reduced HRQL improvement. Intraoperative and perioperative complications were associated with worse short-term surgical and inpatient outcomes.

Arm Pain Versus Neck Pain: A Novel Ratio as a Predictor of Post-Operative Clinical Outcomes in Cervical Radiculopathy Patients.

BACKGROUND: Informed patient selection and counseling is key in improving surgical outcomes. Understanding the impact that certain baseline variables can have on postoperative outcomes is essential in optimizing treatment for certain symptoms, such as radiculopathy from cervical spine pathologies. The aim was to identify baseline characteristics that were related to improved or worsened postoperative outcomes for patients undergoing surgery for cervical spine radiculopathic pain. METHODS: Retrospective review of prospectively collected data. Patient Sample: Surgical cervical spine patients with a diagnosis classification of "degenerative." Diagnoses included in the "degenerative" category were those that caused radiculopathy: cervical disc herniation, cervical stenosis, and cervical spondylosis without myelopathy. Baseline variables considered as predictors were: (1) age, (2) body mass index (BMI), (3) gender, (4) history of cervical spine surgery, (5) baseline Neck Disability Index (NDI) score, (6) baseline SF-36 Physical Component Summary (PCS) scores, (7) baseline SF-36 Mental Component Summary (MCS) scores, (8) Visual Analog Scale (VAS) Arm score, and (9) VAS Neck. Outcome Measures: Improvement in NDI (≥50%), VAS Arm/Neck (≥50%), SF-36 PCS/MCS (≥10%) scores at 2-years postoperative. An arm-to-neck ratio (ANR) was also generated from baseline VAS scores. Univariate and multivariate analyses evaluated predictors for 2-year postoperative outcome improvements, controlling for surgical complications and technique. RESULTS: Three hundred ninety-eight patients were included. Patients with ANR ≤ 1 (n = 214) were less likely to reach improvements in 2-year NDI (30.0% vs 39.2%, P = .050) and SF-36 PCS (42.4% vs 53.5%, P = .025). Multivariate analysis for neck disability revealed higher baseline SF-36 PCS (odds ratio [OR] 1.053) and MCS (OR 1.028) were associated with over 50% improvements. Higher baseline NDI were reduced odds of postoperative neck pain improvement (OR 0.958). Arm pain greater than neck pain at baseline was associated with both increased odds of postoperative arm pain improvement (OR 1.707) and SF36 PCS improvement (OR 1.495). CONCLUSIONS: This study identified specific symptom locations and health-related quality of life (HRQL) scores, which were associated with postoperative pain and disability improvement. In particular, baseline arm pain greater than neck pain was determined to have the greatest impact on whether patients met at least 50% improvement in their upper body pain score. These findings are important for clinicians to optimize patient outcomes through effective preoperative counseling.

Trends in Nonoperative Treatment Modalities Prior to Cervical Surgery and Impact on Patient-Derived Outcomes: Two-Year Analysis of 1522 Patients From the Prospective Spine Treatment Outcome Study.

BACKGROUND: Effects of nonoperative treatments on surgical outcomes for patients who failed conservative management for cervical spine pathologies remain unknown. The objective is to describe conservative modality use in patients indicated for surgery for degenerative cervical spine conditions and its impact on perioperative outcomes. METHODS: The current study comprises a retrospective review of a prospective multicenter database. A total of 1522 patients with 1- to 2-level degenerative cervical pathology who were undergoing surgical intervention were included. Outcome measures used were health-related quality-of-life scores, length of hospitalization, estimated blood loss, length of surgery, and return-to-work status at 2 weeks, 6 months, 1 year, and 2 years postoperatively. Patients were grouped by diagnosis (radiculopathy vs. myelopathy), then divided based on epidural injection(s), physical therapy (PT), or opioid use prior to enrollment. Univariate t-tests and χ2 tests were performed to determine differences between groups and impact on outcomes. RESULTS: Among 1319 radiculopathy patients, 25.7% received preoperative epidural injections, 35.3% received PT, and 35.5% received opioids. Radiculopathy patients who received epidurals and PT had higher 1-year postoperative return-to-work rates (P < .05). Radiculopathy patients without preoperative PT had longer hospitalization times, whereas those who received PT had higher 36-Item Short Form Health Survey (SF-36) physical functioning and physical component scores, lower 2-year visual analog scale (VAS) neck/arm pain scores, and higher 2-year return-to-work incidence (P < .05). Of myelopathy patients (n = 203), 14.8% received epidural injections, 25.1% received opioids, and 41.5% received PT. Myelopathy patients with preoperative PT had worse VAS arm pain scores 2 years postoperatively (P < .05). Patients receiving opioids were younger and had greater baseline-2-year Neck Disability Index improvement (P < .05). CONCLUSIONS: Radiculopathy patients receiving epidurals returned to work after 1 year more frequently. PT was associated with shorter hospitalizations, greater SF-36 bodily pain norm and physical component score improvements, and increased return-to-work rates after 1 and 2 years. No statistically significant nonoperative treatment was associated with return-to-work rate in myelopathy patients. CLINICAL RELEVANCE: These findings suggest certain preoperative conservative treatment modalities are associated with improved outcomes in radiculopathy patients.

Patient Outcomes Following Micropulse Transscleral Cyclophotocoagulation: Intermediate-term Results.

PURPOSE: To report the safety and efficacy outcomes following micropulse transscleral cyclophotocoagulation (MPTSCPC) procedure in patients with uncontrolled glaucoma. MATERIALS AND METHODS: Longitudinal retrospective cohort, multicenter study. Patients with different types of glaucoma who underwent MPTSCPC with P3 probe between July 2015 and May 2017. Patients were treated by different glaucoma specialists from 5 different locations (Tulane Study Group). Data on preoperative characteristics, surgical procedure(s) performed, and postoperative outcomes were collected and analyzed. Statistical analysis using logistic regression and Kaplan-Meier analysis was performed with Stata software. Intraoperative and postoperative complications, intraocular pressure, visual acuity, need for incisional glaucoma surgery, need for repeat micropulse, and number of topical medications were studied. RESULTS: One hundred ninety-seven eyes from 161 patients were included. Median follow-up was 12 months [interquartile range (IQR), 6 to 14]. Glaucoma diagnosis included 141 primary open-angle glaucoma (POAG), 8 neovascular glaucoma, and 12 others. The total success rate was 71%. Two percent (4 patients) developed postoperative cystoid macular edema. Preoperative mean intraocular pressure (SD) was 22±9 and 16±6 mm Hg at last follow-up (P<0.001). Median preoperative logMAR visual acuity (IQR) was 0.4 (0.2 to 1.0) and 0.3 (0.2 to 1.0) at last follow-up (P=0.65, Wilcoxon signed-rank test). Median number (IQR) of topical medications was 3 (1 to 4) preoperative and 2 (1 to 3) at last follow-up (P<0.001). Kaplan-Meier analysis indicated 90% of patients free from repeat MPTSCPC at 12 months. Multivariable logistic regression identified 3 significant independent predictors of total success: diagnosis (P=0.011) (POAG), previous glaucoma surgery (P=0.003), and other concurrent procedures (P=0.013). CONCLUSIONS: Our large longitudinal cohort study has provided evidence that MPTSCPC is a safe and generally effective option in the treatment of POAG up to 12 months.

Development of New-Onset Cervical Deformity in Nonoperative Adult Spinal Deformity Patients With 2-Year Follow-Up.

PURPOSE: Evaluate the presence of new-onset cervical deformity (CD) in nonoperative adult spinal deformity (ASD) patients with extended follow-up, with consideration for predictors, prevalence, and impact on patient-reported outcomes. METHODS: Retrospective review of a prospective nonoperative ASD cohort. New onset CD patients at 1- (CD-1Y) and 2-year (CD-2Y) follow-up were defined as displaying baseline cervical alignment. Univariate analyses determined differences in radiographic parameters and outcome scores of CD and maintained-cervical-alignment patients. Multivariate binary logistic regression models determined new-onset CD predictors. RESULTS: A total of 143 patients were included (mean age 54 years, mean body mass index 25.6 kg/m2, 86% female). Cervical deformity rate was 38.5% at baseline. New-onset CD incidence at 1- and 2-year follow-up was 30.0% and 41.7%, respectively. Global sagittal profile comparison of CD-1Y/CD-2Y versus maintained cervical alignment cases revealed no differences (P > .05) at any interval. Baseline C2-C7 sagittal vertical axis (SVA) was associated with increased new-onset CD risk at 1 (odds ratio [OR] 1.14, P = .025) and 2 years (OR 1.04, P = .032); prior spine surgical history was associated with CD risk at 1-year follow-up (OR 6.75, P = .047); baseline C2 slope was associated with increased CD risk at 2-year follow-up (OR 1.12, P = .041). CD development did not significantly impact health-related quality of life (P > .05). CONCLUSIONS: Cervical deformity can manifest in nonoperative ASD patients: 30.0% at 1-year follow-up, and 41.7% at 2-year follow-up. Progressive CD manifested independently of thoracolumbar profile changes. Increased baseline C2-C7 SVA, C2 slope, and prior surgical history increased new-onset CD odds at 1 and 2 years.

Predictors of Hospital Length of Stay and 30-Day Readmission in Cervical Spondylotic Myelopathy Patients: An Analysis of 3057 Patients Using the ACS-NSQIP Database.

BACKGROUND: Hospital length of stay (LOS), 30-day readmission rate, and other metrics are increasingly being used to evaluate quality of surgical care. The factors most relevant to cervical spondylotic myelopathy (CSM) are not yet established. OBJECTIVE: To identify perioperative factors associated with extended LOS and 30-day readmission following elective surgery for CSM. METHODS: Surgical CSM patients at institutions represented by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) during 2010-2012 were included. Patients with fracture, 9 or more levels fused, or cancer were excluded. Extended LOS was defined as 75th percentile of the cohort. Univariate analysis and multivariate logistic regression identified predictors for extended LOS, 30-day readmission, and reoperation. Linear regression modeling was used to evaluate variables. RESULTS: Three thousand fifty-seven surgical CSM cases were isolated. Age (odds ratio [OR], 1.496), diabetes (OR, 1.691), American Society of Anesthesiologists (ASA) class (OR, 2.081), posterior surgical approach (OR, 2.695), and operative time (OR, 1.008) were all positive predictors (P < 0.05) for extended LOS (≥4 days). Thirty-two percent of the cohort (976 patients) had 30-day readmission data. Among these, 915 patients were not readmitted (93.8%), while 61 (6.2%) were readmitted. Diabetes (OR, 1.460) and ASA class (OR, 2.539) were significant positive predictors for hospital readmission. Age (OR, 0.918) was a negative predictor of re-operation in readmitted patients, and pulmonary comorbidities (OR, 4.584) were a positive predictor (P < 0.05). CONCLUSIONS: Patients with diabetes and higher ASA class were at increased risk for extended LOS and readmission within 30-days. Patients with increased operative time have greater risk for extended LOS. Preoperative pulmonary comorbidities increased reoperation risk, whereas increased age reduced the risk. Attention to these factors may benefit CSM patients.

Adult Spinal Deformity: National Trends in the Presentation, Treatment, and Perioperative Outcomes From 2003 to 2010.

STUDY DESIGN: Retrospective review of a prospective database. OBJECTIVES: To investigate adult spinal deformity (ASD) surgery outcome trends on a nationwide scale using the Nationwide Inpatient Sample (NIS) from 2003 to 2010. METHODS: ASD patients ≥25 years from 2003 to 2010 in the NIS undergoing anterior, posterior, or combined surgical approaches were included. Fractures, 9+ levels fused, or any cancer were excluded. Patient demographics, hospital data, and procedure-related complications were evaluated. Yearly trends were analyzed using univariate analysis and linear regression modeling. RESULTS: Of 10,966 discharges, 1,952 were anterior, 6,524 were posterior, and 1,106 were combined. The total surgical ASD volume increased by 112.5% (p = .029), and both the average patient age (p < .001) and number of patients >65 years old significantly increased from 2003 to 2010 (p = .009). Anterior approach case volume decreased by 13.7% (p = .019), whereas that of combined increased by 22.7% (p = .047). Posterior case volume increased by 38.9% from 2003 to 2010, though insignificantly (p = .084). Total hospital charges for all approaches increased over the interval (p < .001). Total length of stay for all approaches decreased over the time interval (p < .005). Although the overall morbidity for all approaches increased by 22.7% (p < .001), mortality did not change (p = .817). The most common morbidities in 2003 were hemorrhagic anemia, accidental cut, puncture, perforation, or laceration during a procedure, and device-related complications, which persisted in 2010 with the exception of increased acute respiratory distress syndrome and pulmonary-related complications. CONCLUSIONS: For ASD surgery from 2003 to 2010, the volume of anterior approaches decreased, whereas posterior procedures did not change, and combined approaches increased. Total hospital charges increased for all considered procedures, length of hospital stay decreased, whereas operative patients were increasingly elderly, and more procedures were observed for patients >65 years old. For all approaches, morbidity increased whereas mortality did not change. Future study is required to develop methods to reduce morbidity and costs, thereby optimizing patient outcomes.

Diabetes as an Independent Predictor for Extended Length of Hospital Stay and Increased Adverse Post-Operative Events in Patients Treated Surgically for Cervical Spondylotic Myelopathy.

BACKGROUND: Diabetes as an independent driver of peri-operative outcomes, and whether its severity impacts indications is conflicted in the research. The purpose of this study is to evaluate diabetes as a predictor for postoperative outcomes in cervical spondylotic myelopathy (CSM) patients. METHODS: A retrospective review was performed of patients treated surgically for CSM (ICD-9 721.1) from 2010-2012 in the prospectively-collected American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Outcome measures were length of stay, and the presence of complications. Diabetic patients were stratified based on whether or not their diabetes was insulin- or non-insulin-dependent. RESULTS: A total of 5,904 surgical CSM patients were included, 1101 (19%) had diabetes. 722 (65%) were non-insulin-dependent diabetics, and 381 (35%) were insulin-dependent diabetics. Diabetes was found to be an independent predictor of extended LOS (OR: 1.878[2.262-1.559], p<0.001) as well as of developing a complication (OR: 1.666[2.217-1.253], p<0.001) after controlling for associated variables like BMI. Type of diabetes (insulin- vs. non-insulin-dependent) showed little significant difference between the groups (p>0.05), however, patients with insulin-dependent diabetes were associated with an increased incidence of wound complications (p=0.027); severity of diabetes was not associated with any other individual complications. CONCLUSIONS: Type and severity of diabetes is not a predictor for complication. Diabetes is associated with extended LOS and peri-operative morbidity. Level of evidence: Class 2b. Clinical relevance: Our findings support the view of many spine surgeons, who believe that diabetes has a negative impact on the outcome of surgery for CSM. Our findings support those cohort studies that found an association between diabetes and worst post-operative outcomes following surgical treatment of CSM. These findings lend support to the importance of monitoring preoperative serum glucose levels, as prevention of peri-operative hyperglycemia has been linked to improved postoperative outcomes in spine, joint and colon surgery.

A novel index for quantifying the risk of early complications for patients undergoing cervical spine surgeries.

OBJECTIVE It is becoming increasingly necessary for surgeons to provide evidence supporting cost-effectiveness of surgical treatment for cervical spine pathology. Anticipating surgical risk is critical in accurately evaluating the risk/benefit balance of such treatment. Determining the risk and cost-effectiveness of surgery, complications, revision procedures, and mortality rates are the most significant limitations. The purpose of this study was to determine independent risk factors for medical complications (MCs), surgical complications (SCs), revisions, and mortality rates following surgery for patients with cervical spine pathology. The most relevant risk factors were used to structure an index that will help quantify risk and anticipate failure for such procedures. METHODS The authors of this study performed a retrospective review of the National Inpatient Sample (NIS) database for patients treated surgically for cervical spine pathology between 2001 and 2010. Multivariate models were performed to calculate the odds ratio (OR) of the independent risk factors that led to MCs and repeated for SCs, revisions, and mortality. The models controlled for age (< and > 65 years old), sex, race, revision status (except for revision analysis), surgical approach, number of levels fused/re-fused (2-3, 4-8, ≥ 9), and osteotomy utilization. ORs were weighted based on their predictive category: 2 times for revision surgery predictors and 4 times for mortality predictors. Fifty points were distributed among the predictors based on their cumulative OR to establish a risk index. RESULTS Discharges for 362,989 patients with cervical spine pathology were identified. The mean age was 52.65 years, and 49.47% of patients were women. Independent risk factors included medical comorbidities, surgical parameters, and demographic factors. Medical comorbidities included the following: pulmonary circulation disorder, coagulopathy, metastatic cancer, renal failure, congestive heart failure, alcohol abuse, neurological disorder, nonmetastatic cancer, liver disease, rheumatoid arthritis/collagen vascular diseases, and chronic blood loss/anemia. Surgical parameters included posterior approach to fusion/re-fusion, ≥ 9 levels fused/re-fused, corpectomy, 4-8 levels fused/re-fused, and osteotomy; demographic variables included age ≥ 65 years. These factors increased the risk of at least 1 of MC, SC, revision, or mortality (risk of death). A total of 50 points were distributed among the factors based on the cumulative risk ratio of every factor in proportion to the total risk ratios. CONCLUSIONS This study proposed an index to quantify the potential risk of morbidity and mortality prior to surgical intervention for patients with cervical spine pathology. This index may be useful for surgeons in patient counseling efforts as well as for health insurance companies and future socioeconomics studies in assessing surgical risks and benefits for patients undergoing surgical treatment of the cervical spine.

Two-Year Results of the Prospective Spine Treatment Outcomes Study: An Analysis of Complication Rates, Predictors of Their Development, and Effect on Patient Derived Outcomes at 2 Years for Surgical Management of Cervical Spondylotic Myelopathy.

OBJECTIVES: To investigate the baseline patient characteristics, nonoperative modalities, surgical procedures, and complications rates of surgical cervical spondylotic myelopathy (CSM) patients. To evaluate risk factors for developing complications and compare the changes in health-related quality of life (HRQOL) from baseline to 2 years postoperatively. METHODS: A retrospective review was performed on a prospectively collected database of CSM patients. Baseline patient demographic data, comorbidities, clinical information, nonoperative treatment modalities, surgical procedures, and complication rates were collected. HRQOL outcomes were assessed using the Short Form 36 (SF-36) Physical Score Component (PCS) and Mental Score Component (MCS) and the Neck Disability Index (NDI) at baseline and 2 years postoperatively. Statistical analyses included paired-sample t tests and multivariate logistic regression controlling for age, sex, and body mass index (BMI). RESULTS: A total of 203 surgical CSM patients were identified (43% female). Average age was 57.7 years and average BMI was 29.6 kg/m2. Before surgical intervention, patients underwent various nonoperative treatment modalities, most commonly nonsteroidal anti-inflammatory drugs (34%), analgesics (32%), and physical therapy (26%). The overall rate of complications was 7.4%. Complications included cerebrospinal fluid leak (2.5%), postoperative radiculopathy (1.0%), and excessive bleeding (1.0%). A previous history of cervical spine surgery was the sole significant risk factor for developing a complication (odds ratio, 9.22; P = 0.034). Average HRQOL scores improved significantly from baseline to 2 years postsurgery. CONCLUSIONS: The overall complication rate was 7.4% for the cohort. Baseline clinical information, comorbidities, use of nonoperative treatment modalities, and procedure type were not significantly associated with an increased risk of complications. Previous cervical spine surgery increased the risk of complications by 9-fold. The patients showed significantly improved SF-36 PCS, SF-36 MCS, and NDI scores at 2 years after surgery.

Cervical spondylotic myelopathy: National trends in the treatment and peri-operative outcomes over 10years.

BACKGROUND: Recent studies show increases in cervical spine surgery prevalence and cervical spondylotic myelopathy (CSM) diagnoses in the US. However, few studies have examined outcomes for CSM surgical management, particularly on a nationwide scale. OBJECTIVE: Evaluate national trends from 2001 to 2010 for CSM patient surgical approach, postoperative outcomes, and hospital characteristics. METHODS: A retrospective nationwide database analysis provided by the Nationwide Inpatient Sample (NIS) including CSM patients aged 25+ who underwent anterior and/or posterior cervical fusion or laminoplasty from 2001 to 2010. Patients with fractures, 9+ levels fused, or any cancer were excluded. Measures included demographics, hospital data, and procedure-related complications. Yearly trends were analyzed using linear regression modeling. RESULTS: 54,348 discharge cases were identified. ACDF, posterior only, and combined anterior/posterior approach volumes significantly increased from 2001 to 2010 (98.62%, 303.07%, and 576.19%; respectively, p<0.05). However, laminoplasty volume remained unchanged (p>0.05). Total charges for ACDF, posterior only, combined anterior/posterior, and laminoplasty approaches all significantly increased (138.72%, 176.74%, 182.48%, and 144.85%, respectively; p<0.05). For all procedures, overall mortality significantly decreased by 45.34% (p=0.001) and overall morbidity increased by 33.82% (p=0.0002). For all procedures except ACDF, which saw a significantly decrease by 8.75% (p<0.0001), length of hospital stay was unchanged. CONCLUSIONS: For CSM patients between 2001 and 2010, combined surgical approach increased sixfold, posterior only approach increased threefold, and ACDF doubled; laminoplasties without fusion volume remained the same. Mortality decreased whereas morbidity and total charges increased. Length of stay decreased only for ACDF approach. This study provides clinically useful data to direct future research, improving patient outcomes.

Bone morphogenetic protein in adult spinal deformity surgery: a meta-analysis.

INTRODUCTION: Since its introduction BMP has been utilized in populations with higher rates of malunion, such as adult spinal deformity (ASD) patients. Contradictory conclusions exist in spinal literature regarding the safety and efficacy of the use of BMP in this setting. Previous studies, however, did not distinguish deformity cases from spondylolisthesis or stenosis. The purpose of this study is to evaluate the safety and efficacy of BMP use in spinal fusion surgery for ASD. METHODS: 166 papers were screened after database search. 40 full texts were assessed for eligibility. Five studies were included for meta-analysis. Three were comparative studies between a BMP and non-BMP group, and the other was used to supplement dose-effect analysis. RESULTS: The current meta-analysis found increased odds of developing radiculitis or neurological complications (OR = 2.18, 95% CI, p = 0.02, i 2 = 0), but no other significant relationship between complications commonly attributed to BMP use (tumorigenesis, infections, seroma formation, or osteolysis) and BMP use. BMP patients had decreased rates of pseudarthrosis (OR = 0.23, 95% CI, p = 0.002, i 2 = 0). There was an average dose of 8.75 mg/level in the 417 patients studied, lower than the advised dosage of 12 mg/level. CONCLUSIONS: The current literature shows BMP to be a safe and effective grafting technique in the treatment of ASD. Spine surgeons may currently be using sub-optimal doses of BMP. The benefit of increasing the rate of fusion must be weighed against the increased risk of radiculitis and neurologic complications in this patient population.

Novel Index to Quantify the Risk of Surgery in the Setting of Adult Spinal Deformity: A Study on 10,912 Patients From the Nationwide Inpatient Sample.

STUDY DESIGN: Retrospective review of the Nationwide Inpatient Sample from 2001 to 2010, a prospectively collected national database. OBJECTIVE: Structure an index to quantify adult spinal deformity (ASD) surgical risk based on risk factors for medical complications, surgical complications, revisions (R), mortality (M) rates, and length of hospital stay. SUMMARY OF BACKGROUND DATA: Evidence supporting ASD surgery cost-effectiveness and anticipating surgical risk is critical to evaluate the risk/benefit balance of such treatment for patients. MATERIALS AND METHODS: Discharges ages 25+, 4+ levels fused, diagnoses specific for scoliosis, and refusions. Five multivariate models determined independent risk factors that increased the risk of ≥1 for medical complications, surgical complications, R, M, and length of hospital stay. Models controlled for age, sex, race, revision status, surgical approach, levels fused, and osteotomy utilization. Odds ratios (ORs) were weighted using Nationwide Inpatient Sample weight files and based on their predictive category: 2 times for revision predictors and 4 times for mortality predictors. Predictors with OR≥1.5 were considered clinically relevant. Fifty points were distributed among the predictors based on their accumulative OR to establish a risk index. RESULTS: A total of 10,912 ASD discharges were identified (mean age: 62 y; 73% females; 14% revision cases). The structured risk index incorporated the following factors based on accumulative ORs: pulmonary circulation disorder (42.05), drug abuse (21.86), congestive heart failure (15.25), neurological disorder (17.31), alcohol abuse (13.24), renal failure (11.64), age>65 (12.28), coagulopathy (11.65), level +9 (6.7), revision (3.35), and osteotomy (3). These risk factors were scored: 14, 7, 5, 5, 4, 4, 4, 4, 2, 1, 1, respectively. Three risk thresholds were proposed: mild (0-10), moderate (10-20), severe >20/50 points. CONCLUSIONS: This study proposes an index to quantify the possible risk of morbidity before ASD surgery that will help patients, health insurance companies, and socioeconomic studies in assessing surgical risk/benefits. LEVEL OF EVIDENCE: Level III.

Variability Over Time of Preoperative Sagittal Alignment Parameters: Radiographic and Clinical Considerations.

STUDY DESIGN: Retrospective review. OBJECTIVE: To evaluate preoperative variability in radiographic sagittal parameters in adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA: In ASD surgical planning, deformity magnitude is determined from preoperative radiographs. There are no studies evaluating the clinical relevance and timing to repeat radiographs during interval clinic visits and timing to repeat radiograph for preoperative planning. METHODS: A total of 139 patients with ASD with minimum two preoperative full-body spine x-rays were included. Cervical, thoracic, lumbar, pelvic, and hip/knee sagittal alignment parameters were analyzed using dedicated spine measurement software. Patients were grouped by time intervals between x-rays: A: 8 weeks or lesser, B: 10 to 20 weeks, and C: 21 weeks or more. Changes in sagittal parameters were correlated to age and deformity magnitude (T1 pelvic angle or pelvic tilt [PT] >20°). RESULTS: The cohort had mean age 59 years, mean body mass index 27, 30% men, 95 patients with no prior spine surgery, and 44 patients at minimum 9 months since prior spine surgery. There were 25 patients in group A, 38 in B, and 71 in C. All radiographic measures showed good time-based consistency at intervals less than 21 weeks (groups A and B). Group C had significant increases in PT (1.5°) and hip extension (2.1°) (P < 0.05). These changes were greater in group C patients with previous surgery (PT 3.7°; P < 0.006, hip extension 3.2°; P < 0.025). Greater interval changes in parameters were also associated with higher magnitudes of deformity and younger patient ages. CONCLUSION: All sagittal radiographic parameters were statistically consistent at intervals of less than 21 weeks. In patients with more than 21 weeks between interval x-rays, change in PT was greater than the standard error of measurement for patients with prior surgery or severe deformity. Consideration should be made to obtain new x-rays for patients with ASD when the interval between clinical visits exceeds 5 months. LEVEL OF EVIDENCE: 4.

Predictive Model for Cervical Alignment and Malalignment Following Surgical Correction of Adult Spinal Deformity.

STUDY DESIGN: Retrospective review of prospective multicenter database. OBJECTIVE: Use predictive modeling to identify patient characteristics, radiographic, and surgical variables that predict reaching an outcome threshold of suboptimal cervical alignment after adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Cervical deformity (CD) after ASD correction has been defined with the following criteria: T1S-CL>20°, C2-C7 SVA>40 mm, and/or C2-C7 kyphosis >10°. While studies have analyzed CD predictors, few have defined and identified predictors of optimal cervical alignment after thoracolumbar surgery. METHODS: Inclusion criteria were surgical ASD patients with baseline and 2-year follow-up. Postoperative cervical alignment (CA) and malalignment (nonCA) at 2 years was defined with the following radiographic criteria: 0°≤T1S-CL≤20°, 0 mm≤C2-C7 SVA≤40 mm, or C2-C7 lordosis >0°. Three thresholds classifying malalignment were defined: (T1) missing 1 criterion, (T2) missing 2 criteria, (T3) missing 3 criteria. Multivariable logistic stepwise regression models with bootstrap resampling procedure were performed for demographic, surgical, and radiographic variables. The model was validated with receiver operative characteristic and area under the curve. RESULTS: Two hundred twenty-five surgical ASD patients were included. At 2 years 208 patients (92.4%) were grouped as CA in T3, while 17 (7.6%) were nonCA. Patients were similar in age (CA: 56.10 vs. nonCA: 55.78 years, P = 0.150), BMI (CA: 26.93 vs. nonCA: 26.94 kg/m, P = 0.716), and sex (CA: 76.5% vs. nonCA: 87.0%, P = 0.194). The final predictive model included C2 slope, C2-T3 CL, T1S-CL, C2-C7 CL, Pelvic Tilt, C2-S1 SVA, PI-LL, and Smith-Peterson osteotomies number. In this model (area under the curve 89.22% [97.49-80.96%]), the following variables were identified as predictors of nonCA: increased Smith-Peterson osteotomies use (OR: 1.336, P = 0.017), and C2-T3 angle (OR: 1.048, P = 0.005). CONCLUSION: This study created a statistical model that predicts poor 2-year postoperative cervical malalignment in ASD patients. T3 (patients not meeting all three alignment criteria) was the most effective threshold for modeling nonCA, and included increased baseline C2-T3 angle and increased Smith-Peterson osteotomies during index. LEVEL OF EVIDENCE: 3.

"Reverse Bohlman" technique for the treatment of high grade spondylolisthesis in an adult population.

BACKGROUND/AIMS: Surgical techniques for effective high-grade spondylolisthesis (HGS) remain controversial. This study aims to evaluate radiographic/clinical outcomes in HGS patients treated using modified "Reverse Bohlman" (RB) technique. METHODS: Review of consecutive HGS patients undergoing RB at a single university-center from 2006 to 2013. Clinical, surgical, radiographic parameters collected. RESULTS: Six patients identified: five with L5-S1 HGS with L4-L5 instability and one had an L4-5 isthmic spondylolisthesis and grade 1 L5-S1 isthmic spondylolisthesis. Two interbody graft failures and one L5-S1 pseudoarthrosis. Postoperative improvement of anterolisthesis (62.3% vs. 49.6%, p = 0.003), slip angle (10 vs. 5°, p = 0.005), and lumbar lordosis (49 vs. 57.5°, p = 0.049). CONCLUSIONS: RB technique for HGS recommended when addressing adjacent level instability/slip.

Hospital Readmission Within 2 Years Following Adult Thoracolumbar Spinal Deformity Surgery: Prevalence, Predictors, and Effect on Patient-derived Outcome Measures.

STUDY DESIGN: A retrospective review of prospective multicenter database. OBJECTIVE: The aim of this study was to identify factors influencing readmission, reoperation, and the impact on health-related quality of life outcomes (HRQoLs) in adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Many ASD patients experience complications requiring readmission. It is important to identify baseline/operative factors leading to rehospitalizations and reoperation, which may impact outcomes. INCLUSION CRITERIA: ASD surgical patients (age >18 yrs, major coronal Cobb ≥20°, sagittal vertical axis ≥5 cm, pelvic tilt ≥25°, and/or thoracic kyphosis >60°) with complete baseline, 1-, and 2-year follow-up. Patients were grouped on the basis of readmission occurrence (yes/no) and type [medical (no reoperation) vs. surgical (revision surgery)]. Readmissions caused by infections requiring surgical treatment (e.g., deep infections) were considered reoperations. Univariate and multivariate analyses determined readmission and reoperation predictors. Repeated measures mixed models evaluated readmission impact on HRQoLs at 1 and 2 years. RESULTS: Three hundred thirty-four patients were included: 76 (22.8%) readmissions, involving 65 (85.5% of 76) reoperations (surgical readmission) and 11 (14.5% of 76) medical readmissions. The most common surgical readmission indication (n = 65) was implant complications (36.9%; rod breakage n = 13); the most common medical readmission indication was infection (36.4%, n = 4), treated with antibiotics. Noninfectious medical readmission (n = 7) included pleural effusion, deep vein thrombosis (DVT), intraoperative blood loss, neurologic, and unspecified. Readmission predictors: increased number of major peri-operative complications [odds ratio (OR) 5.13, P = 0.014], infection presence (OR 25.02, P = 0.001), implant complications (OR 6.12, P < 0.001), and radiographic complications (DJK, proximal junctional kyphosis, pseudoarthrosis, sagittal/coronal imbalance) (OR 16.94, P < 0.001). HRQoL analysis revealed overall improvement of the full cohort (P < 0.01), though the 76 readmitted improved less overall and at each time point P < 0.001) except in 6-week MCS (P = 0.14). CONCLUSION: Major peri-operative, implant, radiographic, and infection complications during index were associated with increased readmission odds. Implant complications most frequently caused surgical readmissions. Readmitted patients improved in outcome scores, although less compared with the nonreadmitted cohort, yet displayed reduced 6-week SF-36 Mental Component Summary. LEVEL OF EVIDENCE: 3.

The Impact of Advanced Age on Peri-Operative Outcomes in the Surgical Treatment of Cervical Spondylotic Myelopathy: A Nationwide Study Between 2001 and 2010.

STUDY DESIGN: Retrospective multicenter database review. OBJECTIVE: The aim of this study was to evaluate national postoperative outcomes and hospital characteristics trends from 2001 to 2010 for advanced age CSM patients. SUMMARY OF BACKGROUND DATA: Recent studies show increases in US cervical spine surgeries and CSM diagnoses. However, few have compared national outcomes for elderly and younger CSM patients. METHODS: A Nationwide Inpatient Sample (NIS) analysis from 2001 to 2010, including CSM patients 25+ who underwent anterior and/or posterior cervical fusion or laminoplasty. Fractures, 9+ levels fused, or any cancers were excluded. Measures included demographics, outcomes, and hospital-related data for 25 to 64 versus 65+ and 65 to 75 versus 76+ age groups. Univariate and logistic regression modeling evaluated procedure-related complications risk in 65+ and 76+ age groups (OR[95% CI]). RESULTS: Discharges for 35,319 patients in the age range of 25 to 64 years and 19,097 at the age 65+ years were identified. Average comorbidity indices for patients at 65+ years were higher compared to the 25 to 64 years age group (0.79 vs. 0.0.44, P < 0.0001), as was the total complications rate (11.39% vs. 5.93%, P < 0.0001) and charges ($57,449.94 vs. $49,951.11, P < 0.0001). Hospital course for aged 65+ patients was longer (4.76 vs. 3.26 days, P < 0.0001). Mortality risk was higher in the 65+ cohort (3.38[2.93-3.91]), adjusted for covariates. 65+ patients had increased risk of all complications except device-related, for which they had decreased risk (0.61[0.56-0.67]). Patients 76+ years displayed increased hospital charges ($59,197.60 vs. $56,601.44, P < 0.001) and courses (5.77 vs. 4.28 days, P < 0.001) compared to those in the age group 65 to 75 years. These same patients presented with increased Deyo scores (0.83 vs. 0.77, P < 0.001), had increased total complications rate (13.87% vs. 10.20%, P < 0.001), and displayed increased risk for postoperative shock (6.34 [11.16-3.60], P < 0.001), digestive system (1.92 [2.40-1.54], P < 0.001), and wound dehiscence (1.71 [2.56-1.15], P < 0.001). CONCLUSION: Patients aged 65+ years undergoing CSM surgical management have a higher mortality risk, more procedure-related complications, higher comorbidity burden, longer hospital course, and higher charges. This study provides clinically useful data for surgeons to educate patients and to improve outcomes.

Predicting Extended Length of Hospital Stay in an Adult Spinal Deformity Surgical Population.

STUDY DESIGN: A retrospective review of a prospective multicenter database. OBJECTIVE: The aim of this study was to identify variables associated with extended length of stay (ExtLOS) and this impact on health-related quality of life (HRQoL) scores in adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA: ASD surgery is complex and associated with complications including extLOS. Although variables contributing to extLOS have been considered, specific complications and pre-disposing factors among ASD surgical patients remain to be investigated. INCLUSION CRITERIA: ASD surgical patients (age >18 years, scoliosis ≥20°, sagittal vertical axis ≥5 cm, pelvic tilt ≥25°, and/or thoracic kyphosis >60°) with complete demographic, radiographic, and HRQoL data at baseline, 6 weeks, and 2 years postoperative. ExtLOS was based on 75th percentile (≥9 days). Univariate and multivariate analyses identified predictors and evaluated effects on outcomes. Repeated-measures mixed models analyzed impact of ExtLOS on HRQoL [Oswestry Disability Index; Short Form-36 physical component summary/mental component summary; SRS22r Activity (AC), Pain (P), Appearance (AP), Satisfaction (S), Mental (M) and Total (T)]. RESULTS: Three hundred eighty patients met inclusion criteria: 105 (27.6%) had extLOS (≥9 days) and 275 (72.4%) did not. Average LOS was 8 days (range: 1-30 days). Age [odds ratio (OR) 1.04], no. of levels fused (OR 1.12), no. of infections (OR 2.29), no. of neurologic complications (OR 2.51), Charlson Comorbidity Index Score (CCI) predicted ExtLOS (OR 3.92), and no. of intraop complications predicted ExtLOS (OR 3.56). ExtLOS patients had more intracardiopulmonary (pleural effusion: 1.9% vs. 0%) and operative complications (dural tear: 13.3% vs. 5.1%; excessive blood loss: 18% vs. 5.8%) (P < 0.022). At 2 years, both groups of patients experienced an overall improvement in all HRQoL scores (P < 0.001). ExtLOS patients had significantly less overall improvement in all HRQoLs (P < 0.01) except for MCS (P = 0.17) and SRS M (P = 0.08). CONCLUSION: Extended LOS of ASD patients is affected by comorbidities (higher CCI) and number of intraoperative, but not peri-operative, complications. All patients improved overall in HRQoL scores, but extended LOS patients improved less overall at 2 years in comparison. LEVEL OF EVIDENCE: 3.