Faculty Bibliography

BACKGROUND:There is controversy as to whether fusions should have the upper instrumented vertebrae (UIV) end in the upper lumbar spine or cross the thoracolumbar junction. This study compares outcomes and reoperation rates for thoracolumbar fusions to the sacrum or pelvis with UIV in the lower thoracic versus lumbar spine to determine if there is an increased reoperation rate depending on UIV selection. METHODS:A retrospective review of prospectively collected data was conducted from a single-center database on adult patients with degeneration and deformity who underwent primary and revision fusions with a caudal level of S1 or ilium between 2012 and 2018. Fusions were classified as anterior, posterior, or combination approach. Revision fusions included patients who had spinal surgery at another institution prior to their revision surgery at the center. Patients were categorized into 1 of 3 groups based on UIV: T9-T11, upper lumbar region (L1-L2), and lower lumbar region (L3-L5). Inclusion criteria were age 18 years or older and at least 1 year of clinical follow-up. Patients were excluded from analysis if they had tumors, infections, or less than 1 year of follow-up after the index procedure. RESULTS:= .002) from the reoperation rates for the same diagnoses in the upper lumbar spine (4.6% and 1%) or lower lumbar spine (6.2% and 0%). A multivariate logistical regression model at 2-year follow up did not show a statistically significant difference between reoperation rates between the thoracic and upper lumbar spine UIV groups. CONCLUSION/CONCLUSIONS:Constructs with UIV in the thoracic spine suffer from higher rates of proximal junctional kyphosis and pseudoarthrosis, whereas those with UIV in the upper lumbar spine have higher rates of adjacent segment disease. Given this tradeoff, there is no certain recommendation on what UIV will result in a lower reoperation rate in thoracolumbar fusion constructs to the sacrum or pelvis. Surgeons must evaluate patient characteristics and risks to make the optimal decision.

Robotic-assisted adult deformity surgery has played a rapidly expanding role since its introduction. As robotic spine technologies improve, the potential to limit complications and morbidity is vast. The improvements in instrumentation accuracy combined with the ability to maintain that accuracy in multiple positions allow creative surgical approaches and techniques that can limit operative time, blood loss, and improve outcomes. In the years to come, robotic-assisted spine surgery and navigation will likely play an expanding role that continues to be defined. LEVEL OF EVIDENCE: 5, expert opinion.

STUDY DESIGN/METHODS:Retrospective cohort analysis. OBJECTIVE:To compare outcomes of plastic versus spine surgeon wound closure in revision 1 to 4 level thoracolumbar fusions. SUMMARY OF BACKGROUND DATA/BACKGROUND:Plastic surgeons perform layered musculocutaneous flap closures in high-risk spine patients such as revision posterior spinal fusion and complex deformity correction surgeries. Few studies have assessed outcomes of revision fusion performed with plastic surgical closures, particularly in nondeformity thoracolumbar spinal surgery. METHODS:A retrospective review of 1 to 4 level revision thoracolumbar fusion performed by Orthopedic or Neurosurgical spine surgeons. Patient charts were reviewed for demographics and perioperative outcomes. Patients were divided into two cohorts: wound closures performed by spine surgeons and those closed by plastic surgeons. Outcomes were analyzed before and after propensity score match for prior levels fused, iliac fixation, and levels fused at index surgery. Significance was set at P < 0.05. RESULTS:Three hundred fifty-seven (87.3%) spine surgeon (SS) and 52 (12.7%) plastic surgeon (PS) closures were identified. PS group had significantly higher number of levels fused at index (PS 2.7 ± 1.0 vs. SS 1.8 ± 0.9, P < 0.001) and at prior surgeries (PS 1.8 ± 1.2 vs. SS 1.0 ± 0.9, P < 0.001), and rate of iliac instrumentation (PS 17.3% vs. SS 2.8%, P < 0.001). Plastics closure was an independent risk factor for length of stay  > 5 days (odds ratio 2.3) and postoperative seroma formation (odds ratio 7.8). After propensity score match, PS had higher rates of seromas (PS 36.5% vs. SS 3.8%, P < 0.001). There were no differences between PS and SS groups in surgical outcomes, perioperative complication, surgical site infection, seroma requiring aspiration, or return to operating room at all time points until follow-up (P > 0.05 for all). CONCLUSION/CONCLUSIONS:Plastic spinal closure for 1 to 4 level revision posterior thoracolumbar fusions had no advantage in reducing wound complications over spine surgeon closure but increased postoperative seroma formation.Level of Evidence: 4.

BACKGROUND CONTEXT: Since circumferential adult spinal deformity (ASD) surgery can lead to high surgical burden for the patient, surgeons may elect to stage these procedures during the same hospitalization. As a result, there is a trend toward planning same-hospitalization staged ASD surgeries by performing an anterior lumbar interbody fusion (ALIF) prior to a subsequent staged posterior fusion. PURPOSE: The aim of this study was to determine optimal timing for staging (early vs delayed) thoracolumbar ASD surgery within the same hospitalization. STUDY DESIGN/SETTING: Retrospective review of a multicenter database. PATIENT SAMPLE: A total of 158 surgical ASD patients undergoing anterior and staged posterior spinal fusion >=5 levels. OUTCOME MEASURES: Our outcome measures were 90-day complication rates, postoperative alignment, and 2-year ODI.
METHOD(S): Using a prospective, multicenter database, we identified 158 surgical ASD patients undergoing first an anterior surgery followed by a staged posterior spinal fusion >=5 levels during the same hospitalization. Stratum-specific likelihood ratio (SSLR) analysis was performed to calculate a cutoff point beyond which 90-day complications were increased. The cutoff generated through SSLR were confirmed with multivariable logistic regression analysis controlling for age, gender, levels fused for each stage, preoperative alignment, three-column osteotomy, and Charlson Comorbidity Index. The outcome measures were 90-day complication rates, postoperative alignment, and 2-year ODI. Multivariable analyses were performed with logistic, Poisson and linear regressions where appropriate.
RESULT(S): Utilization of staged procedures increased 4x from 2008-2019, and the mean staging interval was 3 days (range 1-8). On SSLR analysis, patients were divided into two staging categories based on complication risk: early (<6 days, range 1-5, N=139) versus delayed (>= 6 day, range 6-8, N=19). On bivariate analysis, the delayed group had higher 90-day complication rates (68.4% vs 32.4%, p=0.002) and longer operative times (638 min vs 739 min, p=0.020) relative to the early group. Adjusting for covariates on multivariable analysis, patients with delayed staging had significantly greater odds of 90-day complications (OR=7.57, p=0.006), and longer total operative time (beta=119, p=0.035). With respect to specific complications, delayed staging carries increased odds of infection compared to early staging (OR=11.8 p=0.031). There were no significant differences in postoperative alignment or 2-year ODI between the groups (p>0.05 for all).
CONCLUSION(S): Compared to early staging (< 6 days) of ALIF and subsequent staged posterior fusion, delayed staging (>= 6 days) is associated with greater odds of 90-day complications, particularly infection. With the growing trend toward staged ASD surgeries, efforts should be made to shorten the interval between ALIF and subsequent posterior fusion. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Cervical alignment and cervical deformity surgery are complex topics. Recently, a score inspired by work on thoracolumbar alignment was developed for cervical alignment (cervical deformity score, CDS). While this score was designed to predict early mechanical failures, its association with patient reported outcomes (PROM) remains unclear. PURPOSE: Investigate the association between PROM, complications, and a newly described cervical deformity score. STUDY DESIGN/SETTING: Retrospective review of prospective multicenter database. PATIENT SAMPLE: A total of 102 adult cervical deformity (CD) patients with at least 1 year follow-up. OUTCOME MEASURES: NDI, neck pain, EQ5D, complication rates.
Method(s): CD patients with baseline and 1-year follow-up were included. Postoperative CDS was constructed using offset from age-adjusted values: SVA [(age -55)*2+25], T1 Slope [(age -55)/4 + 28.7], and TS minus CL [cst: between 26.5 and 14.5degree]. Points were assigned based on the offset from alignment targets and the CDS was the sum of the three individual scores. Association with patient-reported outcomes was investigated using Pearson's correlations. Comparison of CDS between patients with and without complication within 1-year was conducted. Logistical regression controlling for demographic and comorbidities was conducted to identify if CDS was an independent predictor of complications.
Result(s): A total of 102 patients met inclusion criteria (61.7yo+/-10, 66.7% F); 37.6% of them had a history of previous cervical surgery (16.7% previous ACDF, 11.7% previous posterior fusion). Preoperatively, they had elevated disability (NDI: 47.1+/-18.1), pain (NSR Neck: 6.6+/-2.5), myelopathy (mJOA: 13.6+/-2.7) and lower general health (EQ5D: 0.74+/-0.07). They also presented with an overall cervical kyphotic alignment (C2-C7: -6.3degree+/-20.9), a moderate cervical anterior alignment (cSVA: 39mm+/-20; TS-CL: 37.9degree+/-19.4) and a posterior global thoracolumbar alignment (SVA: -3mm+/-68). The median of number of levels fused was 7 [4-9], with 49% treated with a posterior approach and 30.4% with a combined approach; 83.2% received an osteotomy, 44.6% some posterior osteotomy, 16.8% grade 6 or 7. The mean operative time was 368min+/-208, median EBL was 525cc [200 1025], and LOS was 5 days [4 8]. At 1 year, patients improved significantly in terms of disability (NDI: 36.2+/-20.7, 60.8% reached MCID), pain (NSR: 4.1+/-2.9) and general health (EQ5D: 0.79+/-0.08) (all p<0.001). The cervical alignment significantly changed (C2-C7: 7.8+/-14.5m; cSVA: 34mm+/-15; TS-CL: 28.9degree+/-12.6 all p <0.002), with a 1-year CDS of 1.68+/-2.46 (prctl [0 3.25]). There was a significant association between increased CDS and increased disability (r=0.273), pain (r=0.336) and lower general health (r=-0.283). Patient with a lower disability level (NDI<20) had a significantly lower CDS (0.71+/-2.3 vs 2.16+/-2.4 p<0.004). Patients without any complications before 1 year had a lower CDS (0.78+/-2.33 vs 2.18+/-2.40 p=0.005), as did patients without major complications (1.36+/-2.27 vs 2.50+/-.78 p=0.037). Deeper analysis revealed significant differences in terms of CDS for patients experiencing cardiopulmonary, instrumentation and radiographic complications (p<0.05). Multivariate analysis, controlling for age and comorbidities, show 1-year CDS to be a significant predictor of complication (p=0.002, OR=1.409).
Conclusion(s): With better outcomes and lower complication rate, maintaining a proportionate alignment postoperatively can result in superior outcomes following CD surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: A previous study utilized normative alignment to determine overcorrections and predict mechanical complications in adult spinal deformity (ASD) surgery. Other studies have recommended alignment targets that optimize age-appropriate physical function. The difference in functional outcomes and mechanical complications between these prescribed alignment targets has not been explored. This study utilizes a component angle of the T1 pelvic angle (TPA) within the fusion to compare normative and age-pelvic incidence (PI) optimal alignment in terms of proximal junctional kyphosis (PJK), proximal junctional failure (PJF) and health related quality of life measures (HRQL). Using the component of TPA within the fusion, the T4-pelvic angle (T4PA), allows for the measurement spinopelvic alignment separate from that of the unfused thoracic spine and any PJK that may occur postoperatively. PURPOSE: To compare ASD patients corrected to normative alignment vs age-PI optimal alignment in terms of PJK/PJF and outcomes. STUDY DESIGN/SETTING: Retrospective analysis of a prospective multicenter ASD database and a database of asymptomatic subjects. PATIENT SAMPLE: This study included 1,916 ASD patients and 118 asymptomatic subjects for formula development; 288 ASD patients with 2-year X-ray and HRQL follow-up. OUTCOME MEASURES: SF36-PCS, ODI, SRS-22, NRS back/leg, PJK (change in UIV to UIV+2 >10degree), PJF (defined as severe PJK with change >21.6degree, or UIV olisthesis, or proximal junctional fracture).
METHOD(S): Baseline relationships between age, PI and T4PA, were analyzed in the ASD patients and compared to the asymptomatic subjects. Linear regression modeling was used to determine alignment based on PI and age in asymptomatic subjects (normative alignment), and in ASD patients, alignment corresponding to age-appropriate functional status (optimal alignment). ASD patients with UIV above T4 were grouped based on their corrections: normative vs optimal. Extreme over or under corrected patients were excluded (greater than or less than 2SD from mean postop T4PA). For each group, the rate of PJK and PJF were determined.
RESULT(S): In the multilinear regression analysis of the 119 asymptomatic subjects, T4PA correlated with age and PI, r=.713, p<.0001. 1916 ASD patients were included in the optimal formula development. In the 288 ASD patients included in the pre- to postop analysis (137 normative, 151 optimal), there was no difference in baseline alignment or HRQL between the groups. At 6 weeks, the normative aligned group had smaller T4PA (4.45 vs 14.1) and PI-LL (-7.24 vs 7.4), all p<.0001. Normative aligned patients had the higher PJK rate (40% vs 27.2%, p=.03) compared with optimal; and a higher PJF rate (17% vs 6.8%, p=.008). PJF patients had -1.2degreeof T4PA offset from normative alignment and -5.2degreeof offset from optimal alignment. By contrast, no PJF patients had 3.8degree of T4PA offset from normative alignment and -0.42degree of offset from optimal alignment. There was a trend toward worse 2-year SF36-PCS in patients who suffered PJF (37.7 vs 41.6, p=.09). Both the Normative and Optimal groups improved in outcomes from baseline to 2-year (p<.001) with no difference in 2-year HRQL.
CONCLUSION(S): Correcting ASD patients to normative alignment resulted in higher rates of PJK and PJF without improvements in HRQL. ASD patients should not be corrected to match the alignment of their asymptomatic unfused peers, rather they should be realigned optimally to match age-appropriate physical function. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Robot-guided lumbar instrumented fusion (RGLF) has the potential to improve safety and accuracy of pedicle screw placement. However, there are pitfalls in adopting this new technology and, as in adopting any new OR technology, there may be early complications. Optimizing workflow by avoiding interbody placement prior to pedicle screws placement (interbody-first workflow, IFW) and using caution in patients with poor bone quality (L1 Hounsfield units [HU] under 148) may improve outcomes. PURPOSE: To determine risk factors for robot-related complications and suggest optimal OR workflow. STUDY DESIGN/SETTING: Single-center retrospective study. PATIENT SAMPLE: A total of 344 RGLF cases from 2018 to 2021. OUTCOME MEASURES: L1 and UIV HU, levels fused, L5-S1 inclusion, interbody placed first workflow (IFW), hyperlordotic interbody, robot registration method, robot registration failure, intraoperative robot mechanical failures and pedicle screw malpositioning.
METHOD(S): Retrospective analysis of RGLFs at a single institution. Univariate analysis with t-tests, Mann-Whitney U tests, or chi-squared analysis assessed demographics, L1 and UIV HU, levels fused, L5-S1 inclusion, IFW, hyperlordotic cage, and robot registration method as risk factors for robot registration failure, intraoperative robot mechanical failures, and pedicle screw malpositioning. Multivariate logistic regression of risk factors approaching or achieving significance was conducted. A receiver operating characteristic (ROC) curve was created to determine a threshold for independent risk factors.
RESULT(S): A total of 344 RGLFs were included. In registered vs registration failure cases, smoking (12.73% vs 28.57%; p=0.041), L1HU (139.81+/-46.86 vs 177.16+/-55.74; p=0.009), L5-S1 inclusion (50.00% vs 80.95%; p=0.006), and IFW (58.07% vs 85.71%; p=0.014) were significant risk factors on univariate analysis. On multivariate analysis, smoking (p=0.003), L1HU (p=0.006), and L5-S1 inclusion (p=0.022) were independent risk factors and IFW approached significance (p=0.099) for risk of registration failure. In successful vs all robot failures cases, age (55.72+/-13.38 vs 59.92+/-11.38 years; p=0.046), female gender (48.70% vs 69.44%; p=0.018), levels fused (1.37+/-0.63 vs 1.67+/-0.76; p=0.010), L5-S1 inclusion (50.00% vs 69.44%; p=0.027), and IFW (57.47% vs 77.78%; p=0.012) were significant risk factors on univariate analysis. On multivariate analysis, female gender (p=0.047) and L5-S1 inclusion (p=0.049) were independent risk factors and IFW approached significance (p=0.055) for risk of mechanical failure. In successful vs pedicle screw malpositioned cases, IFW was a significant independent risk factor for pedicle screw malpositioning on multivariate analysis (p=0.038). On subanalysis of 124 robot-guided anterior-posterior lumbar fusion (RG APLF), L1 HU was an independent risk factors for registration failure (p=0.007) and approached significance for mechanical failures (p=0.051). ROC analysis revealed a cutoff of L1 HU of 148.55 for mechanical failures (area under the curve = 0.778). Levels fused (1.41+/-0.69 vs 2.00+/-0.54; p=0.018) was a significant risk factor for pedicle screw malpositioning on univariate analysis.
CONCLUSION(S): In all RGLFs, IFW was a risk factor for robot-related complications. In RG APLF, low L1 HU was a risk factor. Robot-related complications may be avoided by placing pedicle screws prior to interbody and by using caution in patients with poor bone quality. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Adult spinal deformity (ASD) surgery is costly and carries a high complication rate. It is therefore very important to optimize value (cost-per-QALY) or cost-utility in ASD surgery. To identify targets for improvement, we compared the influence of patient factors, measured by frailty, vs surgical factors, measured by surgical invasiveness (SI), on 2-year cost-utility. Patient frailty is an approximation of baseline patient health status, whereas SI represents extensiveness of the surgical intervention. Data comparing the relative importance of these aggregate measures on cost-utility are limited. Additionally, this analysis can serve to help identify the most impactful modifiable factors in the value equation. PURPOSE: The aim of this study was to assess whether frailty or SI is a more important determinant of 2-year cost-utility in ASD surgery. STUDY DESIGN/SETTING: Prospective, multicenter study. PATIENT SAMPLE: ASD patients with >4-level fusion and eligible for minimum 2-year follow-up were included. OUTCOME MEASURES: Two-year cost-per-QALY.
METHOD(S): Index and total episode of care (EOC; iEOC; tEOC) cost was calculated using Medicare's inpatient prospective payment system (IPPS) for MS-DRGs 453-460. All costs were adjusted for inflation to 2020 US dollar values. QALYs gained were calculated using baseline, 1-year, and 2-year SF-6D scores. A discount rate of 3% was assumed. Cost-per-QALY was determined by calculating total EOC per cumulative QALY at two years. Patients were categorized as not-frail (NF, <0.3), frail (F, 0.3<= to <0.5), and severely frail (SF, >0.5). SI was categorized as low-SI (SI<90) and high-SI (SI>90). A generalized linear model with gamma error distribution and log link was used to estimate the association between frailty and SI on cost-per-QALY. All analyses were controlled for gender and blood loss. Other variables commonly adjusted for (ie, age, levels fused) were intentionally not controlled for in this analysis to avoid collinearity with either frailty or SI.
RESULT(S): DRG data for index and revision surgery was available for 505/889 patients. Mean age was 62.5+12.4years, 76% were women, and 91% were Caucasian. Of the total patients,72% demonstrated positive gain in QALY at 2 years (0.12+0.09, p<0.001) compared to baseline. The mean iEOC was $72,717, tEOC was $86,066, and cost-per-QALY was $52,357. Eighty-nine patients had 114 (range 1-5) revisions (17.6%) compared to 416 without. The tEOC in revision group was $151,913 compared to $71,978 in the non-revision group with 2-year cost-per-QALY 98,262 compared to 42,537, respectively. On adjusted analysis, F and SF patients compared to NF patients had significantly higher cost-per-QALY (p<0.0001 for all comparisons) regardless of the surgical invasiveness. However, SI was not significantly associated with cost-per-QALY regardless of patient's frailty.
CONCLUSION(S): Increasing levels of frailty were associated with significantly and incrementally higher values of 2-year cost-per-QALY in both low and high SI groups. However, within each frailty group, the high and low SI groups had equivalent cost-per-QALY. Frailty appears to be a better determinant of 2-year cost-per-QALY compared to surgical invasiveness. Surgeons should place more importance on modifiable patient factors compared to surgical factors to improve or optimize 2-year cost-utility in ASD surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: ASD surgery is associated with postoperative improvements in patient pain and function but is also associated with high complication rates and long recovery. Accordingly, if given a choice, patients may indicate they would not undergo surgery again. PURPOSE: At minimum two years postop, evaluate 1) surgically treated ASD patients for willingness to receive/not receive the same surgery, 2) surgeon willingness to perform/not perform the same surgery, 3) surgeon opinion if the corresponding patient would indicate they would/would not have the same surgery again. STUDY DESIGN/SETTING: Analysis of patient vs surgeon willingness to perform/receive surgery for ASD patients enrolled into a prospective, multicenter study. PATIENT SAMPLE: Surgically treated ASD patients prospectively enrolled into multicenter study. OUTCOME MEASURES: Numeric rating scale (NRS) back and leg pain, Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form-36v2 questionnaire (SF-36), Oswestry Disability Index (ODI), estimated blood loss, duration of hospital stay, postoperative complications, revision spine surgery, patient and surgeon willingness to perform surgery.
Method(s): Surgically treated ASD patients, prospectively enrolled into a multicenter study from 2009-2018, were asked at minimum 2 years postop, using SRS-22r question 22 if, based upon their surgical and recovery experience, they would undergo the same surgery. Surgeons were matched to their corresponding patients and the surgeons asked if 1) surgeon would perform the same surgery on the patient and why/why not, 2) surgeon believed the patient would undergo the same surgery and why/why not. Patients were divided into those that indicated they would (yes) or not (no) have same surgery. Agreement between patient and surgeon willingness for same surgery was assessed and correlations between willingness for same surgery and postop complications, deformity improvement, and PROMs evaluated.
Result(s): Of 961 patients eligible for study, 580 were evaluated. The no group (n=108, 18.6%) had similar levels fused, osteotomies, duration of hospital and SICU stay, and major complications as the yes group. (n=472; 81.4%; p>0.05). No group members were younger (58.5 vs 61.6 years), more frail (ASD frailty scale 3.9 vs 3.3), and at minimum 2-years postop had more complications requiring surgery and worse postop improvements for all PROMs including ODI (3.8 vs 18.9), SF-36 PCS (1.8 vs 10) and SRS-22r total (0.4 vs 0.9), pain (0.5 vs 1.2), activity (0.2 vs0.7), and self-image (0.6 vs 1.3) than the yes group, respectively (p<0.05). MCID was reached in 28-56% of no group vs 62- 81% of yes group. Patient willingness to receive surgery varied by surgical institution (70% to 89%; p<0.05). Surgeons accurately identified yes group (91%) but poorly identified the no group (22%; p<0.05).
Conclusion(s): ASD patient willingness to undergo same surgery is important for counseling. Unwillingness for same surgery was associated with PROMs, MCID and complications requiring surgery. Surgeons were poorly able to identify patients unwilling to undergo the same surgery. More research is needed to understand patient experiences recovering from ASD surgeries. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Surgeons may preferentially limit fusion levels for younger vs older ASD patients to maintain motion segments and optimize postoperative function. Few data exist comparing the functional impact of upper thoracic (UT) vs thoracolumbar (TL) upper instrumented vertebra (UIV) in younger vs older ASD patients undergoing long fusion to the pelvis. PURPOSE: Evaluate patient reported functional impact of UT vs TL UIV in younger vs older ASD patients undergoing long fusion to the pelvis. STUDY DESIGN/SETTING: Propensity score matched (PSM) analysis of ASD patients prospectively enrolled into a multicenter study. PATIENT SAMPLE: Surgically treated ASD patients prospectively enrolled into multicenter study. OUTCOME MEASURES: Numeric rating scale (NRS) back and leg pain, Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form-36v2 questionnaire (SF-36), Oswestry Disability Index (ODI), estimated blood loss, duration of hospital stay, postoperative complications, revision spine surgery.
METHOD(S): Surgically treated ASD patients prospectively enrolled into a multicenter ASD study were divided into 2 age groups (younger= <65 years, older= > 65 years) and separated according to UIV (TL= L2-T7; UT= T6-T1). Study inclusion criteria; 1) surgery for Lumbar (L), Sagittal (S), or Mixed (M) deformities (as per SRS-Schwab ASD classification), 2) fusion to the pelvis, 3) minimum 5 levels fused, and 4) minimum 2 year postop follow up. Surgery for double major or thoracic scoliosis were excluded. PSM was used to match preop patient demographics, scoliosis, and sagittal spinopelvic parameters including PI-LL, TK, SVS, and TPA. Surgical data evaluated and impact of UIV upon patient reported functional outcomes compared for UT vs TL for younger vs older.
RESULT(S): From 2008-2018, 435 of 717 eligible surgically treated patients were evaluated; younger (n=193; mean age 57.6 years) and older (n=242; mean age 72.3 years), mean levels fused UT=17.4, TL=10.7 (p<0.05). Preop spine deformity, demographics, and performance of osteotomies were similar for matched UT vs TL in younger and older (p>0.05). Surgical blood loss, duration of SICU and hospital stay was greater for UT vs TL in younger and older (p<0.05). UT had more revision surgery than TL due to implant failures in younger (20% vs 3%) and older (16% vs 1%), respectively (p<0.05). Older UT had more major complications than older TL (65% vs 30%). At minimum 2 year postoperative follow up spine deformity correction and all PROMs (including improvements and final values) including SRS-22r activity, SF-36 physical function, SF-36 role physical, SF-36 social function and SF-36 vitality were similar UT vs TL in younger and older (p>0.05).
CONCLUSION(S): Younger ASD patients fused to the pelvis do not report more physical restrictions for UT vs TL UIV compared to older ASD patients, however blood loss, SICU and hospital stay and complications were greater for UT vs TL in younger and older cohorts. When deciding upon UIV for ASD patients, the minimal impact of UT vs TL UIV upon patient reported outcomes must be offset by cognizance of a longer hospital stay and potential for greater postoperative complications for UT fusions especially in older patients. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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