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The Impact of Lumbopelvic Realignment versus Prevention Strategies at the Upper-Instrumented Vertebra on Rates of Junctional Failure following Adult Spinal Deformity Surgery

Passias, Peter G; Williamson, Tyler K; Joujon-Roche, Rachel; Krol, Oscar; Tretiakov, Peter; Imbo, Bailey; Schoenfeld, Andrew J; Owusu-Sarpong, Stephane; Lebovic, Jordan; Mir, Jamshaid; Dave, Pooja; McFarland, Kimberly; Vira, Shaleen; Diebo, Bassel G; Park, Paul; Chou, Dean; Smith, Justin S; Lafage, Renaud; Lafage, Virginie
SUMMARY OF BACKGROUND DATA/BACKGROUND:Differing presentations of adult spinal deformity(ASD) may influence the extent of surgical intervention and use of prophylaxis at the base or the summit of a fusion construct to influence junctional failure rates. OBJECTIVE:Evaluate the surgical technique that has greatest influence on the rate of junctional failure following ASD surgery. STUDY DESIGN/SETTING/METHODS:Retrospective. METHODS:ASD patients with two-year(2Y) data and at least 5-level fusion to 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 Summit 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 effects of junction characteristics and radiographic correction individually and collectively on development of PJK and PJF in differing construct lengths, adjusting for confounders. RESULTS: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 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 likelihood of PJK(OR: 0.3,[0.1-0.9];P=0.027). Good Base led to zero occurrences of PJF. In patients with severe frailty/osteoporosis, a Good Summit lowered 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/CONCLUSIONS: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/METHODS:III.
PMID: 37235802
ISSN: 1528-1159
CID: 5508652

The Case for Operative Efficiency in Adult Spinal Deformity Surgery: Impact of Operative Time on Complications, Length of Stay, Alignment, Fusion Rates, and Patient-Reported Outcomes

Daniels, Alan H; Daher, Mohammad; Singh, Manjot; Balmaceno-Criss, Mariah; Lafage, Renaud; Diebo, Bassel G; Hamilton, David K; Smith, Justin S; Eastlack, Robert K; Fessler, Richard G; Gum, Jeffrey L; Gupta, Munish C; Hostin, Richard; Kebaish, Khaled M; Klineberg, Eric O; Lewis, Stephen J; Line, Breton G; Nunley, Pierce D; Mundis, Gregory M; Passias, Peter G; Protopsaltis, Themistocles S; Buell, Thomas; Scheer, Justin K; Mullin, Jeffrey P; Soroceanu, Alex; Ames, Christopher P; Lenke, Lawrence G; Bess, Shay; Shaffrey, Christopher I; Burton, Douglas C; Lafage, Virginie; Schwab, Frank J; ,
STUDY DESIGN/METHODS:Retrospective review of prospectively collected data. OBJECTIVE:To analyze the impact of operative room (OR) time in adult spinal deformity (ASD) surgery on patient outcomes. BACKGROUND:It is currently unknown if OR time in ASD patients matched for deformity severity and surgical invasiveness is associated with patient outcomes. MATERIALS AND METHODS/METHODS:ASD patients with baseline and two-year postoperative radiographic and patient-reported outcome measures (PROM) data, undergoing a posterior-only approach for long fusion (>L1-Ilium) were included. Patients were grouped into short OR time (<40th percentile: <359 min) and long OR time (>60th percentile: >421 min). Groups were matched by age, baseline deformity severity, and surgical invasiveness. Demographics, radiographic, PROM data, fusion rate, and complications were compared between groups at baseline and two years follow-up. RESULTS:In total, 270 patients were included for analysis: the mean OR time was 286 minutes in the short OR group versus 510 minutes in the long OR group ( P <0.001). Age, gender, percent of revision cases, surgical invasiveness, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt were comparable between groups ( P >0.05). Short OR had a slightly lower body mass index than the short OR group ( P <0.001) and decompression was more prevalent in the long OR time ( P =0.042). Patients in the long group had greater hospital length of stay ( P =0.02); blood loss ( P <0.001); proportion requiring intensive care unit ( P =0.003); higher minor complication rate ( P =0.001); with no significant differences for major complications or revision procedures ( P >0.5). Both groups had comparable radiographic fusion rates ( P =0.152) and achieved improvement in sagittal alignment measures, Oswestry disability index, and Short Form-36 ( P <0.001). CONCLUSION/CONCLUSIONS:Shorter OR time for ASD correction is associated with a lower minor complication rate, a lower estimated blood loss, fewer intensive care unit admissions, and a shorter hospital length of stay without sacrificing alignment correction or PROMs. Maximizing operative efficiency by minimizing OR time in ASD surgery has the potential to benefit patients, surgeons, and hospital systems.
PMID: 37942794
ISSN: 1528-1159
CID: 5633072

Combination radiofrequency ablation and vertebral cement augmentation for spinal metastatic tumors: A systematic review and meta-analysis of safety and treatment outcomes

Chen, Andrew L; Sagoo, Navraj S; Vannabouathong, Christopher; Reddy, Yashas; Deme, Sathvik; Patibandla, Sahiti; Passias, Peter G; Vira, Shaleen
BACKGROUND/UNASSIGNED:The treatment of spine metastases continues to pose a significant clinical challenge, requiring the integration of multiple therapeutic modalities to address the multifactorial aspects of this disease process. Radiofrequency ablation (RFA) and vertebral cement augmentation (VCA) are 2 less invasive modalities compared to open surgery that have emerged as promising strategies, offering the potential for both pain relief and preservation of vertebral stability. The utility of these approaches, however, remains uncertain and subject to ongoing investigation.This systematic review and meta-analysis evaluates the available evidence and synthesize the results of studies that have investigated the combination of RFA and VCA for the treatment of spinal metastases, with the goal of providing a comprehensive and up-to-date assessment of the efficacy and safety of this therapeutic approach. METHODS/UNASSIGNED:package. RESULTS/UNASSIGNED:In the 25 included studies, a total of 947 patients (females=53.9%) underwent RFA + VCA for spinal metastatic tumors. Out of 1,163 metastatic lesions, the majority were located in the lumbar region (585/1,163 [50.3%]) followed by thoracic (519/1,163 [44.6%]), sacrum (39/1,163 [3.4%]), and cervical (2/1,163 [0.2%]). 48/72 [66.7%] metastatic lesions expanded into the posterior elements. Preoperative pathologic vertebral fractures were identified in 115/176 [65.3%] patients. Between pre-procedure pain scores and postprocedure pain scores, average follow-up (FU) was 4.41±2.87 months. Pain scores improved significantly at a short-term FU (1-6 months), with a pooled mean difference (MD) from baseline of 4.82 (95% CI, 4.48-5.16). The overall local tumor progression (LTP) rate at short-term FU (1-6 months) was 5% (95% CI, 1%-8%), at mid-term FU (6-12 months) was 22% (95% CI, 0%-48%), and at long-term FU (>12 months) was 5% (95% CI, 0%-11%). The pooled incidence of total complications was 1% (95% CI, 0%-1%), the most frequent of which were transient radicular pain and asymptomatic cement extravasation. CONCLUSIONS/UNASSIGNED:The findings of this meta-analysis reveal that the implementation of RFA in conjunction with VCA for the treatment of spinal metastatic tumors resulted in a significant short-term reduction of pain, with minimal total complications. The LTP rate was additionally low. The clinical efficacy and safety of this technique are established, although further exploration of the long-term outcomes of RFA+VCA is warranted.
PMCID:10950794
PMID: 38510810
ISSN: 2666-5484
CID: 5640652

Outcomes and survival analysis of adult cervical deformity patients with ten-year follow-up

Passias, Peter G; Tretiakov, Peter S; Das, Ankita; Thomas, Zach; Krol, Oscar; Joujon-Roche, Rachel; Williamson, Tyler; Imbo, Bailey; Owusu-Sarpong, Stephane; Lebovic, Jordan; Diebo, Bassel; Vira, Shaleen; Lafage, Virginie; Schoenfeld, Andrew J
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/OBJECTIVE: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/METHODS:Retrospective review PATIENT SAMPLE: Two hundred and ninety ACD Patients OUTCOME MEASURES: Morbidity and mortality data. METHODS:). 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 post-operatively.
PMID: 37918570
ISSN: 1878-1632
CID: 5620392

Complication Rates Following Adult Spinal Deformity Surgery: Evaluation of the Category of Complication and Chronology

Lafage, Renaud; Bass, R Daniel; Klineberg, Eric; Smith, Justin S; Bess, Shay; Shaffrey, Christopher; Burton, Douglas C; Kim, Han Jo; Eastlack, Robert; Mundis, Gregory; Ames, Christopher P; Passias, Peter G; Gupta, Munish; Hostin, Richard; Hamilton, Kojo; Schwab, Frank; Lafage, Virginie; ,
OBJECTIVE:Provide benchmarks for the rates of complications by type and timing. STUDY DESIGN/METHODS:Prospective multicenter database. BACKGROUND:Complication rates following adult spinal deformity (ASD) surgery have been previously reported. However, the interplay between timing and complication type warrants further analysis. METHODS:The data for this study were sourced from a prospective, multicenter ASD database. Date and type of complication were collected and classified into three severity groups (minor, major, major leading to reoperation). Only complications occurring before the 2-year visit were retained for analysis. RESULTS:Of the 1260 patients eligible for 2-year follow-up, 997 (79.1%) achieved 2-year follow-up. The overall complication rate was 67.4% (N=672). 247 patients (24.8%) experienced at least one complication on the day of surgery (including intra-operatively), 359 (36.0%) between post-op day 1 and 6 weeks post-op, 271 (27.2%) between 6 weeks and 1 one -year post-op, and finally 162 (16.3%) between 1 year and 2 years post-op. Using Kaplan-Meier survival analysis, the rate of remaining complication-free was estimated at different time points for different severities and types of complications. Stratification by type of complication demonstrated that most of the medical complications occurred within the first 60 days. Surgical complications presented over two distinct timeframes. Operative complications, incision-related complications, and infections occurred early (within 60 d), while implant-related and radiographic complications occurred at a constant rate over the 2-year follow-up period. Neurologic complications had the highest occurrence within the first 60 days but continued to increase up to the 2-year visit. CONCLUSION/CONCLUSIONS:Only one-third of ASD patients remained complication-free by 2 years, and 2 out of 10 patients had a complication requiring a reoperation or revision. Estimation of timing and type of complication associated with surgical treatment may prove useful for more meaningful patient counseling and aid in assessing the cost-effectiveness of treatment.
PMID: 38375636
ISSN: 1528-1159
CID: 5634132

Impact of Hip and Knee Osteoarthritis on Full Body Sagittal Alignment and Compensation for Sagittal Spinal Deformity

Balmaceno-Criss, Mariah; Lafage, Renaud; Alsoof, Daniel; Daher, Mohammad; Hamilton, D Kojo; Smith, Justin S; Eastlack, Robert K; Fessler, Richard G; Gum, Jeffrey L; Gupta, Munish C; Hostin, Richard; Kebaish, Khaled M; Klineberg, Eric O; Lewis, Stephen J; Line, Breton G; Nunley, Pierce D; Mundis, Gregory M; Passias, Peter G; Protopsaltis, Themistocles S; Buell, Thomas; Scheer, Justin K; Mullin, Jeffrey P; Soroceanu, Alex; Ames, Christopher P; Lenke, Lawrence G; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Burton, Douglas C; Diebo, Bassel G; Daniels, Alan H; ,
STUDY DESIGN/METHODS:Retrospective review of prospectively collected data. OBJECTIVE:To investigate the effect of lower extremity osteoarthritis on sagittal alignment and compensatory mechanisms in adult spinal deformity (ASD). BACKGROUND:Spine, hip, and knee pathologies often overlap in ASD patients. Limited data exists on how lower extremity osteoarthritis impacts sagittal alignment and compensatory mechanisms in ASD. METHODS:527 pre-operative ASD patients with full body radiographs were included. Patients were grouped by Kellgren-Lawrence grade of bilateral hips and knees and stratified by quartile of T1-Pelvic Angle (T1PA) severity into low-, mid-, high-, and severe-T1PA. Full body alignment and compensation were compared across quartiles. Regression analysis examined the incremental impact of hip and knee osteoarthritis severity on compensation. RESULTS:The mean T1PA for low-, mid-, high-, and severe-T1PA groups was 7.3°, 19.5°, 27.8°, 41.6°, respectively. Mid-T1PA patients with severe hip osteoarthritis had an increased sagittal vertical axis and global sagittal alignment (P<0.001). Increasing hip osteoarthritis severity resulted in decreased pelvic tilt (P=0.001) and sacrofemoral angle (P<0.001), but increased knee flexion (P=0.012). Regression analysis revealed with increasing T1PA, pelvic tilt correlated inversely with hip osteoarthritis and positively with knee osteoarthritis (r2=0.812). Hip osteoarthritis decreased compensation via sacrofemoral angle (β-coefficient=-0.206). Knee and hip osteoarthritis contributed to greater knee flexion (β-coefficients=0.215, 0.101; respectively). For pelvic shift, only hip osteoarthritis significantly contributed to the model (β-coefficient=0.100). CONCLUSIONS:For the same magnitude of spinal deformity, increased hip osteoarthritis severity was associated with worse truncal and full body alignment with posterior translation of the pelvis. Patients with severe hip and knee osteoarthritis exhibited decreased hip extension and pelvic tilt, but increased knee flexion. This examines sagittal alignment and compensation in ASD patients with hip and knee arthritis and may help delineate whether hip and knee flexion is due to spinal deformity compensation or lower extremity osteoarthritis.
PMID: 38375611
ISSN: 1528-1159
CID: 5634122

What is the effect of preoperative depression on outcomes after minimally invasive surgery for adult spinal deformity? A prospective cohort analysis

Agarwal, Nitin; Letchuman, Vijay; Lavadi, Raj Swaroop; Le, Vivian P; Aabedi, Alexander A; Shabani, Saman; Chan, Andrew K; Park, Paul; Uribe, Juan S; Turner, Jay D; Eastlack, Robert K; Fessler, Richard G; Fu, Kai-Ming; Wang, Michael Y; Kanter, Adam S; Okonkwo, David O; Nunley, Pierce D; Anand, Neel; Mundis, Gregory M; Passias, Peter G; Bess, Shay; Shaffrey, Christopher I; Chou, Dean; Mummaneni, Praveen V
OBJECTIVE:Depression has been implicated with worse immediate postoperative outcomes in adult spinal deformity (ASD) correction, yet the specific impact of depression on those patients undergoing minimally invasive surgery (MIS) requires further clarity. This study aimed to evaluate the role of depression in the recovery of patients with ASD after undergoing MIS. METHODS:Patients who underwent MIS for ASD with a minimum postoperative follow-up of 1 year were included from a prospectively collected, multicenter registry. Two cohorts of patients were identified that consisted of either those affirming or denying depression on preoperative assessment. The patient-reported outcome measures (PROMs) compared included scores on the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back and leg pain, Scoliosis Research Society Outcomes Questionnaire (SRS-22), SF-36 physical component summary, SF-36 mental component summary (MCS), EQ-5D, and EQ-5D visual analog scale. RESULTS:Twenty-seven of 147 (18.4%) patients screened positive for preoperative depression. The nondepressed cohort had an average of 4.83 levels fused, and the depressed cohort had 5.56 levels fused per patient (p = 0.267). At 1-year follow-up, 10 patients still reported depression, representing a 63% decrease. Postoperatively, both cohorts demonstrated improvement in their PROMs; however, at 1-year follow-up, those without depression had statistically better outcomes based on the EQ-5D, MCS, and SRS-22 scores (p < 0.05). Patients with depression continued to experience higher NRS leg scores at 1-year follow-up (3.63 vs 2.22, p = 0.018). After controlling for covariates, the authors found that depression significantly impacted only 1-year follow-up MCS scores (β = 8.490, p < 0.05). CONCLUSIONS:Depressed and nondepressed patients reported similar improvements after MIS surgery, except MCS scores were more likely to improve in nondepressed patients.
PMID: 38364229
ISSN: 1547-5646
CID: 5636032

Are insufficient corrections a major factor in distal junctional kyphosis? A simulated analysis of cervical deformity correction using in-construct measurements

Ani, Fares; Sissman, Ethan; Woo, Dainn; Soroceanu, Alex; Mundis, Gregory; Eastlack, Robert K; Smith, Justin S; Hamilton, D Kojo; Kim, Han Jo; Daniels, Alan H; Klineberg, Eric O; Neuman, Brian; Sciubba, Daniel M; Gupta, Munish C; Kebaish, Khaled M; Passias, Peter G; Hart, Robert A; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Ames, Christopher P; Protopsaltis, Themistocles S
OBJECTIVE:The present study utilized recently developed in-construct measurements in simulations of cervical deformity surgery in order to assess undercorrection and predict distal junctional kyphosis (DJK). METHODS:A retrospective review of a database of operative cervical deformity patients was analyzed for severe DJK and mild DJK. C2-lower instrumented vertebra (LIV) sagittal angle (SA) was measured postoperatively, and the correction was simulated in the preoperative radiograph in order to match the C2-LIV by using the planning software. Linear regression analysis that used C2 pelvic angle (CPA) and pelvic tilt (PT) determined the simulated PT that matched the virtual CPA. Linear regression analysis was used to determine the C2-T1 SA, C2-T4 SA, and C2-T10 SA that corresponded to DJK of 20° and cervical sagittal vertical axis (cSVA) of 40 mm. RESULTS:Sixty-nine cervical deformity patients were included. Severe and mild DJK occurred in 11 (16%) and 22 (32%) patients, respectively; 3 (4%) required DJK revision. Simulated corrections demonstrated that severe and mild DJK patients had worse alignment compared to non-DJK patients in terms of cSVA (42.5 mm vs 33.0 mm vs 23.4 mm, p < 0.001) and C2-LIV SVA (68.9 mm vs 57.3 mm vs 36.8 mm, p < 0.001). Linear regression revealed the relationships between in-construct measures (C2-T1 SA, C2-T4 SA, and C2-T10 SA), cSVA, and change in DJK (all R > 0.57, p < 0.001). A cSVA of 40 mm corresponded to C2-T4 SA of 10.4° and C2-T10 SA of 28.0°. A DJK angle change of 10° corresponded to C2-T4 SA of 5.8° and C2-T10 SA of 20.1°. CONCLUSIONS:Simulated cervical deformity corrections demonstrated that severe DJK patients have insufficient corrections compared to patients without DJK. In-construct measures assess sagittal alignment within the fusion separate from DJK and subjacent compensation. They can be useful as intraoperative tools to gauge the adequacy of cervical deformity correction.
PMID: 38364226
ISSN: 1547-5646
CID: 5636022

Costs of Surgery in Adult Spinal Deformity: Do Higher Cost Surgeries Lead to Better Outcomes?

Joujon-Roche, Rachel; Dave, Pooja; Tretiakov, Peter; Mcfarland, Kimberly; Mir, Jamshaid; Williamson, Tyler K; Imbo, Bailey; Krol, Oscar; Lebovic, Jordan; Schoenfeld, Andrew J; Vira, Shaleen; Lafage, Renaud; Lafage, Virginie; Passias, Peter G
STUDY DESIGN/METHODS:Retrospective. OBJECTIVE:To assess impact of surgical costs on patient reported outcomes in ASD. SUMMARY OF BACKGROUND DATA/BACKGROUND:With increased focus on delivering cost effective healthcare, interventions with high resource utilization, such as adult spinal deformity (ASD) surgery, have received greater scrutiny. METHODS:ASD patients≥18 years with BL and 2Y data were included. Surgical costs were calculated using 2021 average Medicare reimbursement by CPT 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 (PSM) to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes. RESULTS:421 patients met inclusion (60.7 y, 81.8% female, CCI: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After PSM, 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 HRQLs. Matched groups had similar baseline SVA (HC: 59.0 vs. LC: 56.7 mm), PI-LL (HC: 13.1 vs. LC: 13.4°), and PT (HC: 25.3 vs. LC: 22.4°). Rates of complications were not significantly different between the cost groups. Compared to LC group, by 2Y HC patients had higher odds of reaching SCB in ODI (OR: 2.356, [1.220, 4.551], P=0.011), in SRS-Total (OR: 2.988, [1.515, 5.895], P=0.002), and in NRS 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 to LC patients. While cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of re-intervention, particularly with more severe baseline deformity. LEVEL OF EVIDENCE/METHODS:III.
PMID: 37163657
ISSN: 1528-1159
CID: 5509362

Machine learning clustering of adult spinal deformity patients identifies four prognostic phenotypes: a multicenter prospective cohort analysis with single surgeon external validation

Mohanty, Sarthak; Hassan, Fthimnir M; Lenke, Lawrence G; Lewerenz, Erik; Passias, Peter G; Klineberg, Eric O; Lafage, Virginie; Smith, Justin S; Hamilton, D Kojo; Gum, Jeffrey L; Lafage, Renaud; Mullin, Jeffrey; Diebo, Bassel; Buell, Thomas J; Kim, Han Jo; Kebaish, Khalid; Eastlack, Robert; Daniels, Alan H; Mundis, Gregory; Hostin, Richard; Protopsaltis, Themistocles S; Hart, Robert A; Gupta, Munish; Schwab, Frank J; Shaffrey, Christopher I; Ames, Christopher P; Burton, Douglas; Bess, Shay; ,
BACKGROUND CONTEXT/BACKGROUND:Among adult spinal deformity (ASD) patients, heterogeneity in patient pathology, surgical expectations, baseline impairments, and frailty complicates comparisons in clinical outcomes and research. This study aims to qualitatively segment ASD patients using machine learning-based clustering on a large, multicenter, prospectively gathered ASD cohort. PURPOSE/OBJECTIVE:To qualitatively segment adult spinal deformity patients using machine learning-based clustering on a large, multicenter, prospectively gathered cohort. STUDY DESIGN/SETTING/METHODS:Machine learning algorithm using patients from a prospective multicenter study and a validation cohort from a retrospective single center, single surgeon cohort with complete 2-year follow up. PATIENT SAMPLE/METHODS:About 805 ASD patients; 563 patients from a prospective multicenter study and 242 from a single center to be used as a validation cohort. OUTCOME MEASURES/METHODS:To validate and extend the Ames-ISSG/ESSG classification using machine learning-based clustering analysis on a large, complex, multicenter, prospectively gathered ASD cohort. METHODS:We analyzed a training cohort of 563 ASD patients from a prospective multicenter study and a validation cohort of 242 ASD patients from a retrospective single center/surgeon cohort with complete two-year patient-reported outcomes (PROs) and clinical/radiographic follow-up. Using k-means clustering, a machine learning algorithm, we clustered patients based on baseline PROs, Edmonton frailty, age, surgical history, and overall health. Baseline differences in clusters identified using the training cohort were assessed using Chi-Squared and ANOVA with pairwise comparisons. To evaluate the classification system's ability to discern postoperative trajectories, a second machine learning algorithm assigned the single-center/surgeon patients to the same 4 clusters, and we compared the clusters' two-year PROs and clinical outcomes. RESULTS:K-means clustering revealed four distinct phenotypes from the multicenter training cohort based on age, frailty, and mental health: Old/Frail/Content (OFC, 27.7%), Old/Frail/Distressed (OFD, 33.2%), Old/Resilient/Content (ORC, 27.2%), and Young/Resilient/Content (YRC, 11.9%). OFC and OFD clusters had the highest frailty scores (OFC: 3.76, OFD: 4.72) and a higher proportion of patients with prior thoracolumbar fusion (OFC: 47.4%, OFD: 49.2%). ORC and YRC clusters exhibited lower frailty scores and fewest patients with prior thoracolumbar procedures (ORC: 2.10, 36.6%; YRC: 0.84, 19.4%). OFC had 69.9% of patients with global sagittal deformity and the highest T1PA (29.0), while YRC had 70.2% exhibiting coronal deformity, the highest mean coronal Cobb Angle (54.0), and the lowest T1PA (11.9). OFD and ORC had similar alignment phenotypes with intermediate values for Coronal Cobb Angle (OFD: 33.7; ORC: 40.0) and T1PA (OFD: 24.9; ORC: 24.6) between OFC (worst sagittal alignment) and YRC (worst coronal alignment). In the single surgeon validation cohort, the OFC cluster experienced the greatest increase in SRS Function scores (1.34 points, 95%CI 1.01-1.67) compared to OFD (0.5 points, 95%CI 0.245-0.755), ORC (0.7 points, 95%CI 0.415-0.985), and YRC (0.24 points, 95%CI -0.024-0.504) clusters. OFD cluster patients improved the least over 2 years. Multivariable Cox regression analysis demonstrated that the OFD cohort had significantly worse reoperation outcomes compared to other clusters (HR: 3.303, 95%CI: 1.085-8.390). CONCLUSION/CONCLUSIONS:Machine-learning clustering found four different ASD patient qualitative phenotypes, defined by their age, frailty, physical functioning, and mental health upon presentation, which primarily determines their ability to improve their PROs following surgery. This reaffirms that these qualitative measures must be assessed in addition to the radiographic variables when counseling ASD patients regarding their expected surgical outcomes.
PMID: 38365004
ISSN: 1878-1632
CID: 5636072