Faculty Bibliography

BACKGROUND CONTEXT: Prior studies assessed the association between underlying neurological condition and worse outcomes following spinal surgery with recent emphasis of self-reported loss of balance (Imbalance) by Uribe et al. PURPOSE: To investigate if patients with self-reported loss of balance have poorer outcomes following adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTING: Retrospective review of prospectively collected database. PATIENT SAMPLE: ASD patients with baseline and 2-year radiographic and patient-reported outcome measure (PROM) data were included. OUTCOME MEASURES: Demographics, radiographic outcomes, complications, and PROM were compared from baseline to 2-year follow up.
METHOD(S): Patients undergoing a long spinal fusion with no prior history of spine surgery were retained. Patients were grouped according to imbalance and unsteady gait. The groups were propensity matched by age, PI-LL, and surgical invasiveness score. Demographics, radiographic, complications and PROM were compared from baseline to 2-year post-op.
RESULT(S): A total of 212 patients were reported (106 patients in each group). The mean age (64 vs 63 years), BMI (27.2 vs 27.0 kg/m2), and gender (76% vs 87% female) were not significantly different for patients with imbalance and without imbalance respectively (all p >0.05). Patients in the imbalance group had a higher Frailty Index Score compared to patients without imbalance (3.74 vs 2.33, p <0.001). At baseline, the sagittal profile for both groups were comparable with regard to PT, PI-LL, and SVA. Patients with loss of balance had a significantly lower thoracic Cobb angle (25.27degree vs 37.45degree, p <0.001) and lumbar Cobb angle (37.03degree vs 45.53degree, p=0.004), although the global coronal alignment was similar (imbalance:41.51 mm vs 34.25 mm, p=0.155). Patients with imbalance had worse PROM measures, including ODI (45.15 vs 36.62), SF-36 Mental Component Score (44.04 vs 51.76), SF-36 Physical Component Score (30.17 vs 35.10), and SRS-22 Mental domain score (3.28 vs 3.80) (p <0.001 for all). Postoperatively, patients with imbalance had less PT correction (-1.45degree vs -3.60degree, p=0.039) for a comparable correction in their PI-LL (-11.93degree vs-15.08degree, p=0.144) by 2-year follow-up. Both groups demonstrated similar improvements in their coronal plane deformity. Imbalance patients had higher rates of radiographic PJK at 2-year follow-up (26.4% vs 14.2%, p=0.026). Furthermore, patients with reported imbalance have significantly higher rate of implant related complications (47.2% vs 34.0%, p=0.05). After controlling for age, baseline sagittal parameters, PI-LL correction and Charlson Comorbidity Index, patients with imbalance had 2.2 times increased odds of sustaining PJK by 2 years.
CONCLUSION(S): Patients with a self-reported loss of balance and unsteady gait have significantly worse baseline frailty and PROMs, represented by poorer mental health and physical function. Although those patients had higher rates of PJK and implant-related complications, surgical intervention significantly improved their quality of life. Despite the improvement, they remained with lower PROMs by 2-year follow-up. Therefore, in the clinic setting and with limited institutional access to Frailty scores, asking patients if they have loss of balance or unsteady gait is a simple yet powerful question which may trigger their preoperative risk stratification and optimization. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The ACS-NSQIP and SpineSage are both easy to use and readily available online perioperative risk calculators The ACS-NSQIP calculator predicts perioperative complications after surgery, but lacks more spine-specific predictors. The SpineSage platform was developed as a tool built for predicting complications in spine surgery. While a limited number of studies have shown it be predictive of both overall and major medical complications in spine surgery, large external validation studies are limited and none have directly compared NSQIP against SpineSage in the same cohort of spine surgery patients. PURPOSE: Assess the ACS-NSQIP Risk Calculator and SpineSage informatics platform for prediction of perioperative complications in spine surgery STUDY DESIGN/SETTING: Retrospective. PATIENT SAMPLE: A total of 440 patients undergoing thoracolumbar spine with or without fusion. OUTCOME MEASURES: Any complication, serious complication, pneumonia, cardiac, dural tear, SSI, UTI, VTE, reoperation, death and LOS METHODS: Each patient was entered into the ACS-NSQIP and SpineSage calculators and predicted risk for specific complications were directly compared to actual risks. Paired t-tests compared the differences between calculators and their predictability of complications. Patients were ranked based on risk predicted for each complication and the highest tertile for each was isolated. Multivariate regression controlling for age and gender was used to determine if the highest tertile for each risk calculator had predictability in complications following spine surgery.
RESULT(S): Mean LOS 4.2+3 days, EBL 444+300 mL, operative time 256+240 min, and levels instrumented 2.1+2.3. When assessing the four complications predicted by SpineSage there were significant differences in three of the four variables, as SpineSage underpredicted the risk of all and serious-complications (p.5). Both calculator tertiles were trending towards significance for major medical complications (SpineSage: OR: 2.0, [0.94-4.23], p=.073; ACS-NSQIP: OR: 1.8,[0.96-3.48],p=.067). When examining any medical risk, only ACS NSQIP had significant predictability for any medical complication (OR: 2.1, [1.3-3.3]; p=.003).
CONCLUSION(S): Similar to previous studies, the ACS-NSQIP score underpredicted most complications, with the exception of LOS and death. In contrast to previous studies, our data suggest SpineSage was not predictive of actual rates of complications. As both calculators are highly accessible and provide at least some objective perioperative risk data points, we recommend them as a guiding tool but not as an absolute endpoint for clinical decision making as they may be inaccurate and insensitive. Further, higher powered studies elucidating the findings in this study should be conducted. Additionally, the assessment of these calculators for a specific subset of patients, such as deformity, degenerative or pediatrics, can further help guide clinicians regarding the utility of these calculators for their particular patient populations. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Prophylaxis usage has been established in literature as an important component of minimizing the risk of proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) development. However, literature is scarce on the effects of prophylaxis in patients who have achieved adequate postoperative alignment and those who maintained poor alignment postoperatively. PURPOSE: To investigate how PJK prophylaxis impacts rates of PJK and PJF with and without ideal alignment and the associated cost/cost-effectiveness. STUDY DESIGN/SETTING: Retrospective cohort study of a prospective adult thoracolumbar deformity database. PATIENT SAMPLE: This study included 1,541 patients. OUTCOME MEASURES: Radiographic alignment, patient-reported outcome measures (ODI), cost per QALY.
METHOD(S): Operative adult spinal deformity patients (scoliosis >20degree, SVA>5cm, PT>25degree, or TK>60degree) with an UIV at L1 or below and available baseline (BL) and 2-year (2Y) radiographic and HRQL data were included. "Matched" and "unmatched" alignment refers to the age-adjusted alignment criteria. PJK prophylaxis was defined by usage of cement, hooks or tethers. PJF was defined as PJK with reoperation. Costs were calculated using the PearlDiver database, accounting for additional costs of prophylaxis when applicable, through estimates from Medicare pay scales for services within a 30-day window, including estimates regarding costs of postoperative complications, outpatient healthcare encounters, revisions and medical related readmissions. QALY was calculated using SF6D.
RESULT(S): A total of 738 ASD patients or below met inclusion criteria (59.9yrs+/-14.0, 79%F, BMI: 27.7 kg/m2 +/-6.0, CCI: 1.8 +/-1.7). Surgically, patients had a mean level fused of 11.1+/-4.4, LOS of 7.9 days+/-4.4, EBL of 1577 mL, operative time of 377 min, with 63% undergoing an osteotomy. Forty percent of patients had PJK prophylaxis. Controlling for age, CCI, BL osteoporosis, levels fused, usage of 3CO, UIV, BL SVA and BL PI-LL, patients who were matched postoperatively in PT, SVA, or PI-LL had lowered PJF rates (OR:.5, 95% CI:.28-.86, p=.01) with prophylaxis. Among those unmatched in either SVA, PILL, or PT by 6W, prophylaxis significantly reduced the rates of PJK and PJF as well (p <0.05). ANCOVA controlling for age, CCI, BL osteoporosis, levels fused, usage of 3CO, UIV, BL SVA and BL PI-LL shows patients with ideal age-adjusted alignment and prophylaxis resulted in a lower cost per QALY by 2Y ($399,948 vs $514,228, p <.001). Similarly, in unmatched patients, prophylaxis resulted in a substantially lower cost per QALY by 2Y ($466,409 vs 672, 024, p <.001), primarily due to decreased costs of reoperation and greater improvements in QALY among prophylaxis cohorts.
CONCLUSION(S): Despite additional surgical cost, optimization of radiographic realignment in conjunction with utilization of proximal junctional failure prophylactic techniques achieves ideal cost utility, predominately due to the minimization of mechanical failure related reoperations. Even among those not achieving optimal alignment, junctional prophylactic measures improved cost utility, emphasizing its critical role of minimization of junctional failures to achieve cost efficiency in adult spinal deformity surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND:Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations. RESEARCH QUESTION/OBJECTIVE:Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease? MATERIALS AND METHODS/METHODS:Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses. RESULTS:). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all p<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs 17.6;p<0.001) and PCS (27.4 vs 19.3;p<0.001). DISCUSSION AND CONCLUSION/CONCLUSIONS:Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated. LEVEL OF EVIDENCE/METHODS:Level III.

Background/UNASSIGNED:Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), although patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD corrective surgery with regard to HK and hyperlordosis (HL). Objective/UNASSIGNED:The objective of the study is to evaluate patterns in treatment for CD patients with baseline (BL) HK and HL and understand how extreme curvature of the spine may influence surgical outcomes. Materials and Methods/UNASSIGNED:Operative CD patients with BL and 1-year (1Y) radiographic data were included in the study. Patients were stratified based on BL C2-C7 lordosis (CL) angle: those >1 standard deviation (SD) from the mean (-6.96 ± 21.47°) were hyperlordotic (>14.51°) or hyperkyphotic (<-28.43°) depending on directionality. Patients within 1SD were considered control group. Results/UNASSIGNED:< 0.001), however, postoperative differences in MGS and C0-C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary CT (38.1%), UT (23.8%), and C (14.3%) drivers. Conclusions/UNASSIGNED:Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1-year postoperative, perhaps due to undercorrection compared to kyphotic etiologies.

BACKGROUND:As corrective surgery for cervical deformity (CD) increases, so does the rate of complications and reoperations. To minimize suboptimal postoperative outcomes, it is important to develop a tool that allows for proper preoperative risk stratification. OBJECTIVE:To develop a prognostic utility for identification of risk factors that lead to the development of major complications and unplanned reoperations. METHODS:CD patients age 18 years or older were stratified into 2 groups based on the postoperative occurrence of a revision and/or major complication. Multivariable logistic regressions identified characteristics that were associated with revision or major complication. Decision tree analysis established cutoffs for predictive variables. Models predicting both outcomes were quantified using area under the curve (AUC) and receiver operating curve characteristics. RESULTS:A total of 109 patients with CD were included in this study. By 1 year postoperatively, 26 patients experienced a major complication and 17 patients underwent a revision. Predictive modeling incorporating preoperative and surgical factors identified development of a revision to include upper instrumented vertebrae > C5, lowermost instrumented vertebrae > T7, number of unfused lordotic cervical vertebrae > 1, baseline T1 slope > 25.3°, and number of vertebral levels in maximal kyphosis > 12 (AUC: 0.82). For developing a major complication, a model included a current smoking history, osteoporosis, upper instrumented vertebrae inclination angle < 0° or > 40°, anterior diskectomies > 3, and a posterior Smith Peterson osteotomy (AUC: 0.81). CONCLUSION/CONCLUSIONS:Revisions were predicted using a predominance of radiographic parameters while the occurrence of major complications relied on baseline bone health, radiographic, and surgical characteristics.

STUDY DESIGN/METHODS:Retrospective cohort. OBJECTIVE:To describe the 2-year outcomes for patients undergoing surgical correction of cervical deformity. BACKGROUND:Adult cervical deformity (CD) has been shown to compromise health-related quality of life. While advances in spinal realignment have shown promising short-term clinical results in this parameter, the long-term outcomes of CD corrective surgery remain unclear. METHODS:Operative CD patients >18 years with 2-year (2Y) HRQL/radiographic data were included. Improvement in radiographic, neurologic and HRQL outcomes were reported. Patients with a prior cervical fusion and patients with the greatest and smallest change based on NDI, NRS neck, mJOA were compared using multivariable analysis controlling for age, and frailty, and invasiveness. RESULTS:158 patients were included in this study. By 2Y, 96.3% of patients improved in Ames cSVA modifier, 34.2% in TS-CL, 42.0% in Horizontal gaze modifier, and 40.9% in SVA modifier. Additionally, 65.5% of patients improved in Passias CL modifier, 53.3% in TS-CL modifier, 100% in C2-T3 modifier, 88.9% in C2S modifier, and 81.0% in MGS modifier severity by 2Y. The cohort significantly improved from BL to 2Y in NDI, NRS Neck, and mJOA, all P<0.05. 59.3% of patients met MCID for NDI, 62.3% for NRS Neck, and 37.3% for mJOA. 97 patients presented with at least one neurologic deficit at BL and 63.9% no longer reported that deficit at follow-up. There were 45 (34.6%) cases of DJK (∆DJKA>10° between LIV and LIV-2), of which 17 were distal junctional failure (DJF-DJK requiring reoperation). Patients with the greatest beneficial change were less likely to have had a complication in the 2-year follow-up period. CONCLUSION/CONCLUSIONS:Correction of cervical deformity results in notable clinical and radiographic improvement with most patients achieving favorable outcomes after two years. However, complications including distal junctional kyphosis or failure remain prevalent.

OBJECTIVE:Revision surgery is often necessary for adult spinal deformity (ASD) patients. Satisfaction with management is an important component of health-related quality of life. The authors hypothesized that patients who underwent multiple revision surgeries following ASD correction would exhibit lower self-reported satisfaction scores. METHODS:This was a retrospective cohort study of 668 patients who underwent ASD surgery and were eligible for a minimum 2-year follow-up. Visits were stratified by occurrence prior to the index surgery (period 0), after the index surgery only (period 1), after the first revision only (period 2), and after the second revision only (period 3). Patients were further stratified by prior spine surgery before their index surgery. Scoliosis Research Society-22 (SRS-22r) health-related quality-of-life satisfaction subscore and total satisfaction scores were evaluated at all periods using multiple linear regression and adjustment for age, sex, and Charlson Comorbidity Index. RESULTS:In total, 46.6% of the study patients had undergone prior spine surgery before their index surgery. The overall revision rate was 21.3%. Among patients with no spine surgery prior to the index surgery, SRS-22r satisfaction scores increased from period 0 to 1 (from 2.8 to 4.3, p < 0.0001), decreased after one revision from period 1 to 2 (4.3 to 3.9, p = 0.0004), and decreased further after a second revision from period 2 to 3 (3.9 to 3.3, p = 0.0437). Among patients with spine surgery prior to the index procedure, SRS-22r satisfaction increased from period 0 to 1 (2.8 to 4.2, p < 0.0001) and decreased from period 1 to 2 (4.2 to 3.8, p = 0.0011). No differences in follow-up time from last surgery were observed (all p > 0.3). Among patients with multiple revisions, 40% experienced rod fracture, 40% proximal junctional kyphosis, and 33% pseudarthrosis. CONCLUSIONS:Among patients undergoing ASD surgery, revision surgery is associated with decreased satisfaction, and multiple revisions are associated with additive detriment to satisfaction among patients initially undergoing primary surgery. These findings have direct implications for preoperative patient counseling and establishment of postoperative expectations.

BACKGROUND:Frailty is influential in determining operative outcomes, including complications, in patients with cervical deformity (CD). OBJECTIVE:To assess whether frailty status limits the highest achievable outcomes of patients with CD. METHODS:Adult patients with CD with 2-year (2Y) data included. Frailty stratification: not frail (NF) <0.2, frail (F) 0.2 to 0.4, and severely frail (SF) >0.4. Analysis of covariance established estimated marginal means based on age, invasiveness, and baseline deformity, for improvement, deterioration, or maintenance in Neck Disability Index (NDI), Modified Japanese Orthopaedic Association (mJOA), and Numerical Rating Scale Neck Pain. RESULTS:One hundred twenty-six patients with CD included 29 NF, 83 F, and 14 SF. The NF group had the highest rates of deterioration and lowest rates of improvement in cervical Sagittal Vertical Axis and horizontal gaze modifiers. Two-year improvements in NDI by frailty: NF: -11.2, F: -16.9, and SF: -14.6 (P = .524). The top quartile of NF patients also had the lowest 1-year (1Y) NDI (7.0) compared with F (11.0) and SF (40.5). Between 1Y and 2Y, 7.9% of patients deteriorated in NDI, 71.1% maintained, and 21.1% improved. Between 1Y and 2Y, SF had the highest rate of improvement (42%), while NF had the highest rate of deterioration (18.5%). CONCLUSION/CONCLUSIONS:Although frail patients improved more often by 1Y, SF patients achieve most of their clinical improvement between 1 and 2Y. Frailty is associated with factors such as osteoporosis, poor alignment, neurological status, sarcopenia, and other medical comorbidities. Similarly, clinical outcomes can be affected by many factors (fusion status, number of pain generators within treated levels, integrity of soft tissues and bone, and deformity correction). Although accounting for such factors will ultimately determine whether frailty alone is an independent risk factor, these preliminary findings may suggest that frailty status affects the clinical outcomes and improvement after CD surgery.