Faculty Bibliography

INTRODUCTION:Informed decision making for operative treatment of the skeletally mature adolescent idiopathic scoliosis (AIS) patient meeting surgical indications requires a discussion of differences in operative morbidity in adult scoliosis versus AIS. This study evaluated differences in operative data and outcomes between AIS and adult scoliosis patients based on an estimated natural history of curve progression. METHODS:Twenty-eight adult scoliosis patients (43.7 ± 15.8 years; 93% F) were 1:2 matched with 56 (Risser 4/5) AIS patients (15.7 ± 2.1 years) based on gender and curve type as vetted by 5 surgeons' consensus in committee. Curve progression of 0.3°/year for the first 10 years following skeletal maturity and a 0.5°/year thereafter was assumed to estimate curve progression from AIS to adulthood for the adult counterpart. Operative data, complications, and quality of life (Scoliosis Research Society [SRS-22r] questionnaire) measures were evaluated, with a minimum 2-year follow-up. RESULTS:Postoperative major Cobb and percentage correction were similar between adult versus AIS, whereas operative time, percentage estimated blood loss (EBL; % total blood volume), length of hospital stay (LOS), and total spine levels fused were greater for adult patients (p < .05). No difference was found in EBL, operative time, or LOS when normalized by levels fused. Ten (36%) adult scoliosis patients were fused to the pelvis compared with none in AIS (p < .0001). Major complication rate was higher for adult versus AIS (25% vs. 5.4%; p < .05). Preoperative SRS-22r scores were worse for adult patients; however, they demonstrated greater improvement in SRS-22r than the AIS cohort at final follow-up. A higher percentage of adult patients reached the MCID in self-image domain than the AIS patients (92.3% vs. 61.8%; p = .0040). CONCLUSION:Treatment of the adult scoliosis patient who has undergone an estimated natural history of progression is characterized by greater levels fused, operative time, and higher complication rates than the AIS counterpart. Longer-term follow-up of AIS is needed to define the benefits of early intervention of relatively asymptomatic adolescent patients versus late treatment of symptomatic disease in the adult.

HYPOTHESIS/OBJECTIVE:The frequency of disc degeneration (DD) in the distal mobile segments will increase over time following surgery for adolescent idiopathic scoliosis (AIS). DESIGN/METHODS:Retrospective review of a prospective AIS registry. INTRODUCTION/BACKGROUND:Durability of surgical outcomes is essential for maintenance of quality of life as well as for family decision making and for assessment of the value of a healthcare intervention. We assessed DD, its risk factors, and association with health-related quality of life 10 years after AIS surgery. METHODS:test. CRS ≥3 was chosen to indicate significant DD. Association of CRS with SRS-22 outcome was evaluated by linear regression. RESULTS:=0.83, p=.0313), respectively. More than 50% of DD occurred at the second (35.5%) and third (20%) disc caudal to the LIV. LIV of L4 compared with more cephalad LIV had the highest risk of developing significant DD (27.3%; p=.0267). It was found that disc wedging subjacent to the LIV (≥5°) and LIV translation (≥2 cm) lead to a sixfold increase in significant DD (odds ratio=6.71 and 6.13, respectively). Severity of DD was not associated with the number of levels fused (p=.2131), the surgical approach (p=.8245), or the construct type (p=.2922). No significant association was established between 10-year CRS and SRS-22 scores. CONCLUSION/CONCLUSIONS:In the first study of its kind, we found that only 7.3% of patients had significant DD 10 years after surgical correction of AIS. Rates of DD increased over time. Our data provide evidence to support recommendations to save as many caudal motion segments as possible, to avoid fusing to L4, and maintain the LIV tilt angle below 5° and LIV translation less than 2 cm.

STUDY DESIGN/METHODS:Preoperative and two-year follow-up health-related quality of life (HRQOL) data were prospectively collected in 82 Scheuermann kyphosis (SK) and 995 adolescent idiopathic scoliosis (AIS) patients using the Scoliosis Research Society-22 patient questionnaire (SRS-22) outcomes instrument in a multicenter study. Visual analog scale (VAS) scores were also collected for the SK population. OBJECTIVES/OBJECTIVE:This study assessed changes in HRQOL prospectively and compared them to those occurring in AIS. SUMMARY OF BACKGROUND DATA/BACKGROUND:There has been limited evaluation of patient-reported HRQOL changes with operative management of SK. METHODS:Median SRS values for the SK and AIS cohorts were compared using a repeated measure of analysis of variance with age as a covariate and using a Mann-Whitney U nonparametric comparison. RESULTS:Kyphosis was corrected from 73.9° to 45.8° (p < .001); the major curve in AIS was corrected from 55.5 to 20.2 (p < .001). Preoperative and magnitude of radiographic correction, kyphosis apex and body mass index in SK were not correlated with baseline or change in HRQOL. SK SRS scores improved after surgery in all domains with the greatest change (2.8-4.4) in self-image (p < .001). Changes in SRS Pain, Activity, and Self-Image domains met the minimal clinically important difference. Baseline SK and AIS scores differed significantly in the Self-Image, Mental Health and Total Score domains, with SK having worse scores (p < .001). At two years postoperatively, the greatest improvements were made in Self-Image, along with Mental Health and Total Score, and the SK group achieved greater gains (p < .001). At two years postoperatively, the SK scores improved to reach equivalent values to the AIS scores. VAS scores improved from 3.69 to 1.51, and these changes were correlated with change in the Pain, Mental Health, and Total Score SRS domains (p < .001). CONCLUSIONS:Surgery for SK in the adolescent population results in significant improvements in HRQOL, which outpace those of the AIS population. LEVEL OF EVIDENCE/METHODS:Level II.

STUDY DESIGN: Retrospective cohort study of spine fusion surgery utilizing the New York State Inpatient Database. OBJECTIVE: The objective was to determine whether there were differences in reoperation rates among pediatric scoliosis associated with various etiologies compared with idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: The incidence of postoperative complications and reoperations is known to vary among patients with diverse scoliosis pathologies. As these are heterogeneous conditions and often with rare occurrence, it is difficult to compare them in a single study. We aimed to assess reoperation events after fusion for several etiologies of pediatric scoliosis. METHODS: The 2008 to 2011 New York State Inpatient Database was queried using International Classification of Diseases (ICD-9-CM) codes for patients with in-hospital stays including a spine arthrodesis for scoliosis. All approaches, all fusion lengths, and ages 10 to 21 were included. Patient identifiers and linkage variables were used to identify revisits. The relative risk of reoperation was calculated for several rare conditions associated with scoliosis. RESULTS: Two thousand three hundred fifty-six pediatric scoliosis fusion surgeries were identified in 2008 in the state of New York. The 1- and 4-year reoperation rate for idiopathic scoliosis was 0.9% and 1.6%, respectively. For nonidiopathic scoliosis, the 1- and 4-year rates were 4.2% and 20.4%, respectively. Of the nonidiopathic scoliosis subtypes, congenital scoliosis (4.7% risk at 1 y, 41.6% at 4 y), the neuromuscular disease arthrogryposis (7.3% risk at 1 y, 28.6% at 4 y), and syndrome neurofibromatosis (9.1% at 1 y, 32.3% at 4 y) showed the highest risk for reoperation. Length of stay and hospital charges were higher for reoperations. CONCLUSIONS: Using a large administrative database, we identified neuromuscular, syndromic, and congenital forms of scoliosis that have the highest relative risk for a reoperation within 1 year. At-risk populations should be identified and resources allocated and preventative measures instituted accordingly to prevent these costly events. LEVEL OF EVIDENCE: Level III.

STUDY DESIGN/METHODS:A retrospective review was conducted of 57 consecutive patients (26 female; mean age: 16.6 years) who underwent posterior or combined anterior-posterior spinal fusion for neuromuscular scoliosis (NMS) from 2006 and 2007. OBJECTIVES/OBJECTIVE:We aimed to assess which patient and surgical factors are predictive of increased blood loss and transfusion requirements during spinal fusion for NMS. BACKGROUND:Spinal fusion surgery in patients with NMS has been associated with significant intraoperative blood loss and transfusion requirements. Specific factors predictive of greater blood loss have not been delineated; recognizing these factors will assist predicting the need for blood products and antifibrinolytics. METHODS:Data gathered included demographic, operative (operative time, levels fused, estimated blood loss, cell saver transfused, IV fluids transfused, and units transfused), and laboratory parameters (hemoglobin, hematocrit, platelet count, prothrombin time, partial prothrombin time, and international normalized ratio). Multivariate linear regression was used to identify parameters associated with greater intraoperative blood loss and transfusion requirements. RESULTS:Eighty-three percent of patients underwent primary surgery with mean levels fused of 13.5. Regression analysis showed a statistically significant increase in blood loss with age (p = 0.00), operative time (p = 0.00), and postoperative platelets (p = 0.016). Each year of increasing age corresponded with an increase of 50 cc of estimated blood loss (EBL). Each additional hour of operative time was associated with an additional EBL of 147.7 cc. Each additional unit of postoperative platelets was associated with an EBL decrease of 2.8 cc. Units transfused increased with age (p = 0.00): each year of increasing age corresponded with an increase of 0.04 units of blood transfused. CONCLUSIONS:Patients with NMS remain a challenging group of patients to treat. We find that age, operative time, and postoperative platelets are predictive of increased blood loss while only age was related to greater transfused units. Our findings may predict the need for blood products and antifibrinolytic agents preoperatively in this heterogeneous population, especially as patients age.

STUDY DESIGN/METHODS:Retrospective analysis of a prospectively collected, national inpatient hospital database. OBJECTIVE:We aimed to investigate comorbid psychiatric disorders in the ASD population. We hypothesized that a high incidence of comorbid psychiatric disorders in ASD would negatively impact perioperative outcomes. SUMMARY OF BACKGROUND DATA/BACKGROUND:Adult spinal fusion (ASF) patients suffer from severe back pain and often depression. Psychiatric comorbidities in the adult spinal deformity (ASD) population are not well understood, despite the apparent psychological effects of spinal deformity-related self-image. METHODS:The Nationwide Inpatient Sample databases from 2001-2009 were queried for patients age ≥18 with in-hospital stays including a spine arthrodesis. Patients were divided into two groups: ASD (diagnosis of scoliosis, excluding neuromuscular & congenital) and all other ASF. Subjects were further stratified by presence of a comorbid psychiatric diagnosis. Differences between each surgical group in psychiatric frequency and complications were calculated using ANOVA, adjusted for operative complexity. A binary logistic regression analyzed the association between psychiatric diagnoses and likelihood of complications. RESULTS:3,366,352 ASF and 219,975 ASD patients were identified. The rate of comorbid psychiatric diagnoses in ASD was significantly higher (23.5%) compared to ASF patients (19.4%, p < 0.001). Complication rates were higher for ASD compared to ASF; patients without a psychiatric diagnosis had lower (or comparable) complication rates than psychiatric patients, across all disorder categories. Patients with psychotic disorders and dementia showed more complications than controls; patients with mood, anxiety and alcohol disorders showed fewer. CONCLUSIONS:Psychiatric comorbidities are more common in the adult spinal deformity population than in adult fusion patients. ASD and ASF patients with the most common psychiatric disorders (mood, anxiety and alcohol abuse) are not at increased risk for complications compared to controls. Those patients with psychotic disorders and dementia are at a significant risk for increased complications and surgeons should be aware of these specific risks. LEVEL OF EVIDENCE/METHODS:2.

STUDY DESIGN/METHODS:Consensus-building using the Delphi and nominal group technique. OBJECTIVE:To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. METHODS:The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. RESULTS:Participants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. CONCLUSION/CONCLUSIONS:We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. LEVEL OF EVIDENCE/METHODS:Level V.

STUDY DESIGN: A retrospective review of prospective data OBJECTIVE:: The purpose of this study was to compare operative and nonoperative patients with similar curve magnitudes to determine motivating factors associated with surgical correction in "smaller" curves. SUMMARY OF BACKGROUND DATA: Despite traditional treatment recommendations on major curve angle measurements, many patients with thoracolumbar/lumbar (TH/L) curves of smaller magnitudes are unhappy and desire correction. METHODS: A prospectively enrolled multicenter adolescent idiopathic scoliosis database was queried. Patients with major TH/L curves <50 degrees and low risk of progression (Risser 3, 4, and 5) were identified and grouped based on their treatment (operative vs. nonoperative). Preoperative demographic, radiographic, Scoliosis Research Society (SRS) outcome scores, and trunk shape values were compared. RESULTS: A total of 126 patients undergoing surgical intervention and 17 patients pursuing nonoperative treatment were analyzed. The average lumbar curve of the operative group was 43 degrees (range, 35 to 49 degrees) and for the nonoperative group was 39 degrees (range, 26 to 49 degrees). The operative group was significantly younger, had larger lumbar major curve angles, lower thoracic to lumbar curve ratio, increased TH/L apical translation, and greater trunk shift (P<0.05). Only lumbar curve (P=0.018, OR=1.19) and trunk shift (P=0.01, OR=3.22) remained significant predictors of surgery in a multivariate regression analysis. SRS scores were significantly lower in the operative group for pain, self-image, function, mental health, and total (P<0.05). When SRS total score was entered into the regression, it was the only significant predictor of surgical intervention (P=0.004, OR=0.03). CONCLUSIONS: Many patients with smaller lumbar curves have clinical deformities that are more consistent with larger curves. These smaller curves can produce similar coronal imbalance and trunk shift, with lower SRS domains that may drive patients to seek surgical treatment. What is unclear is the reason for this greater degree of imbalance in this select group of patients and whether the natural history is different for a more balanced TH/L curve. LEVEL OF EVIDENCE: Level II-Prognostic.

BACKGROUND CONTEXT: Current metrics to assess patients' health-related quality of life (HRQOL) may not reflect a true change in the patients' specific perception of what is most important to them. PURPOSE: This study aimed to describe the initial experience of a Patient Generated Index (PGI) in which patients create their own outcome domains. STUDY DESIGN: This is a single-center prospective study. PATIENT SAMPLE: Patients with adult spinal deformity (ASD) comprise the study sample. OUTCOME MEASURES: Oswestry Disability Index (ODI), Short Form-36 (SF-36 Physical Component Score [PCS] and Mental Component Score [MCS]), Scoliosis Research Society-22r (SRS-22r), and PGI. METHODS: Oswestry Disability Index, SF-36, SRS-22r, and PGI were administered preoperatively and postoperatively at 6 weeks, 3 months, 6 months, and 1 and 2 years. PGI correlations with ODI, SF-36, SRS total score, free-text frequency analysis of PGI exact response with text in ODI and SRS-22r questionnaires, and the responsiveness (effect size [ES]) of the HRQOL metrics were analyzed. No funding was used for this study and there are no conflicts of interest. RESULTS: A total of 59 patients with 209 clinical encounters produced 370 PGI written response topics that included affect or emotions, relationships, activities of daily life, personal care, work, and hobbies. Mean preoperative PGI score was 18.6+/-13.5 (0-71.7 out of 100 [best]), and mean scores significantly improved at every postoperative time point (p<.05). Preoperative PGI scores significantly correlated with preoperative ODI (r=-0.28, p=.03), MCS (r=0.48, p<.01), and SRS total (r=0.57, p<.01). Postoperative PGI scores correlated with all HRQOL measures (p<.0001): ODI (r=-0.65), PCS (r=0.50), MCS (r=0.55), and SRS total (r=0.63). PGI responses exactly matched ODI and SRS-22r text at 47.8% and 35.4%, respectively, and at 63.2% and 58.9%, respectively, for categories. Patient Generated Index ES at a minimum of 1-year follow-up was -2.39, indicating substantial responsiveness (|ES|>0.8). Effect sizes for ODI, SRS-22r total, SF-36 PCS, and SF-36 MCS were 2.16, -2.06, -2.05, and -0.80, respectively. CONCLUSIONS: The PGI is easy to administer and offers additional information about the patients' perspective not captured in standard HRQOL metrics. Patient Generated Index scores correlated with all of the standard HRQOL scores and were more responsive than ODI, SF-36, and SRS-22r, suggesting that the PGI may be a step closer to one HRQOL measure that better encompasses concerns and goals of the individual patients.