Faculty Bibliography

BACKGROUND:Few reports focus on adults with severe scoliosis. OBJECTIVE:To report surgical outcomes and complications for adults with severe scoliosis. METHODS:A multicenter, retrospective review was performed on operatively treated adults with severe scoliosis (minimum coronal Cobb: thoracic [TH] ≥ 75°, thoracolumbar [TL] ≥ 50°, lumbar [L] ≥ 50°). RESULTS:Of 178 consecutive patients, 146 (82%; TH = 8, TL = 88, L = 50) achieved minimum 2-yr follow-up (mean age = 53.9 ± 13.2 yr, 92% women). Operative details included posterior-only (58%), 3-column osteotomy (14%), iliac fixation (72%), and mean posterior fusion = 13.2 ± 3.7 levels. Global coronal alignment (3.8 to 2.8 cm, P = .001) and maximum coronal Cobb improved significantly (P ≤.020): TH (84º to 57º; correction = 32%), TL (67º to 35º; correction = 48%), L (61º to 29º; correction = 53%). Sagittal alignment improved significantly (P < .001), most notably for L: C7-sagittal vertical axis 6.7 to 2.5 cm, pelvic incidence-lumbar lordosis mismatch 18º to 3º. Health-related quality-of-life (HRQL) improved significantly (P < .001), most notably for L: Oswestry Disability Index (44.4 ± 20.5 to 26.1 ± 18.3), Short Form-36 Physical Component Summary (30.2 ± 10.8 to 39.9 ± 9.8), and Scoliosis Research Society-22r Total (2.9 ± 0.7 to 3.8 ± 0.7). Minimal clinically important difference and substantial clinical benefit thresholds were achieved in 36% to 75% and 29% to 51%, respectively. Ninety-four (64%) patients had ≥1 complication (total = 191, 92 minor/99 major, most common = rod fracture [13.0%]). Fifty-seven reoperations were performed in 37 (25.3%) patients, with most common indications deep wound infection (11) and rod fracture (10). CONCLUSION/CONCLUSIONS:Although results demonstrated high rates of complications, operative treatment of adults with severe scoliosis was associated with significant improvements in mean HRQL outcome measures for the study cohort at minimum 2-yr follow-up.

Background/UNASSIGNED:To optimize quality of life in patients with cervical deformity (CD), there may be alignment targets to be prioritized. Objective/UNASSIGNED:To prioritize the cervical parameter targets for alignment. Methods/UNASSIGNED:°) were excluded. Patients assessed: Meeting Minimal Clinically Important Difference (MCID) for NDI (<-15 ΔNDI). Ratios of correction were found for regional parameters categorized by Primary Ames Driver (C or CT). Decision tree analysis assessed cut-offs for differences associated with meeting NDI MCID at 1Y. Results/UNASSIGNED:TS-CL. Conclusions/UNASSIGNED:Certain ratios of correction of cervical parameters contribute to improving neck disability. Prioritizing these radiographic alignment parameters may help optimize patient-reported outcomes for patients undergoing CD surgery.

Introduction/UNASSIGNED:Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), though patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD-corrective surgery with regards to HK and hyperlordosis (HL). Materials and Methods/UNASSIGNED:Operative CD patients (C2-C7 Cobb >10°, cervical lordosis [CL] >10°, cervical sagittal vertical axis [cSVA] >4 cm, chin-brow vertical angle >25°) with baseline (BL) and 1Y radiographic data. Patients were stratified based on BL C2-7 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 1 SD were considered the control group. Results/UNASSIGNED:< 0.001), however postoperative differences in McGregor's slope and C0-C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary computed tomography (38.1%), upper thoracic (23.8%), and C (14.3%) drivers. Conclusions/UNASSIGNED:Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1Y postoperative, perhaps due to undercorrection compared to kyphotic etiologies.

Introduction/UNASSIGNED:Osteotomies are commonly performed to correct sagittal malalignment in cervical deformity (CD). However, the risks and benefits of performing a major osteotomy for cervical deformity correction have been understudied. The objective of this retrospective cohort study was to investigate the risks and benefits of performing a major osteotomy for CD correction. Methods/UNASSIGNED:-tests and Chi-squared tests were used to assess differences between MAJ and MIN. A sub-analysis compared patients with flexible versus rigid CL. Results/UNASSIGNED:> 0.05). Conclusions/UNASSIGNED:Cervical deformity patients who underwent a major osteotomy had similar clinical outcomes at 3-months but worse outcomes at 1-year as compared to minor osteotomies, likely due to differences in baseline deformity. Patients with rigid deformities who underwent a major osteotomy had higher complication rates and worse clinical improvement despite similar realignment at 1 year.

Background/UNASSIGNED:For cervical deformity (CD) surgery, goals include realignment, improved patient quality of life, and improved clinical outcomes. There is limited research identifying patients most likely to achieve all three. Objective/UNASSIGNED:The objective is to create a model predicting good 1-year postoperative realignment, quality of life, and clinical outcomes following CD surgery using baseline demographic, clinical, and radiographic factors. Methods/UNASSIGNED:Retrospective review of a multicenter CD database. CD patients were defined as having one of the following radiographic criteria: Cervical sagittal vertical axis (cSVA) >4 cm, cervical kyphosis/scoliosis >10°° or chin-brow vertical angle >25°. The outcome assessed was whether a patient achieved both a good radiographic and clinical outcome. The primary analysis was stepwise regression models which generated a dataset-specific prediction model for achieving a good radiographic and clinical outcome. Model internal validation was achieved by bootstrapping and calculating the area under the curve (AUC) of the final model with 95% confidence intervals. Results/UNASSIGNED:Seventy-three CD patients were included (61.8 years, 58.9% F). The final model predicting the achievement of a good overall outcome (radiographic and clinical) yielded an AUC of 73.5% and included the following baseline demographic, clinical, and radiographic factors: mild-moderate myelopathy (Modified Japanese Orthopedic Association >12), no pedicle subtraction osteotomy, no prior cervical spine surgery, posterior lowest instrumented vertebra (LIV) at T1 or above, thoracic kyphosis >33°°, T1 slope <16 and cSVA <20 mm. Conclusions/UNASSIGNED:Achievement of a positive outcome in radiographic and clinical outcomes following surgical correction of CD can be predicted with high accuracy using a combination of demographic, clinical, radiographic, and surgical factors, with the top factors being baseline cSVA <20 mm, no prior cervical surgery, and posterior LIV at T1 or above.

BACKGROUND:Operative treatment of adult spinal deformity (ASD) can be very challenging with high complication rates. It is well established that patients benefit from such treatment; however, the surgical outcomes for patients with severe sagittal deformity have not been reported. OBJECTIVE:To report the outcomes of patients undergoing surgical correction for severe sagittal deformity. METHODS:Retrospective review of a prospective, multicenter ASD database. Inclusion criteria: operative patients age ≥18, sagittal vertical axis (SVA) ≥15 cm, mismatch between pelvic incidence and lumbar lordosis (PI-LL) ≥30°, and/or lumbar kyphosis ≥5° with minimum 2 yr follow-up. Health-related quality of life (HRQOL) scores including minimal clinically important difference (MCID)/substantial clinical benefit (SCB), sagittal and coronal radiographic values, demographic, frailty, surgical, and complication data were collected. Comparisons between 2 yr postoperative and baseline HRQOL/radiographic data were made. P < .05 was significant. RESULTS:A total of 138 patients were included from 502 operative patients (54.3% Female, Average (Avg) age 63.3 ± 11.5 yr). Avg operating room (OR) time 386.2 ± 136.5 min, estimated blood loss (EBL) 1829.8 ± 1474.6 cc. A total of 71(51.4%) had prior fusion. A total of 89.9% were posterior fusion only. Mean posterior levels fused 11.5 ± 4.1. A total of 44.9% had a 3-column osteotomy. All 2 yr postoperative radiographic parameters were significantly improved compared to baseline (P < .001 for all). All 2yr HRQOL measures were significantly improved compared to baseline (P < .004 for all). A total of 46.6% to 73.8% of patients met either MCID/SCB for all HRQOL. A total of 74.6% of patients had at least 1 complication, 11.6% had 4 or more complications, 33.3% had minimum 1 major complication, and 42(30.4%) had a postop revision. CONCLUSION/CONCLUSIONS:Patients with severe sagittal malalignment benefit from surgical correction at 2 yr postoperative both radiographically and clinically despite having a high complication rate.

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/BACKGROUND:The COVID-19 pandemic caused nationwide suspensions of elective surgeries due to reallocation of resources to the care of COVID-19 patients. Following resumption of elective cases, a significant proportion of patients continued to delay surgery, with many yet to reschedule, potentially prolonging their pain and impairment of function and causing detrimental long-term effects. PURPOSE/OBJECTIVE:The aim of this study was to examine differences between patients who have and have not rescheduled their spine surgery procedures originally cancelled due to the COVID-19 pandemic, and to evaluate the reasons for continued deferment of spine surgeries even after the lifting of the mandated suspension of elective surgeries. STUDY DESIGN/SETTING/METHODS:Retrospective case series at a single institution PATIENT SAMPLE: Included were 133 patients seen at a single institution where spine surgery was canceled due to a state-mandated suspension of elective surgeries from March to June, 2020. OUTCOME MEASURES/METHODS:The measures assessed included preoperative diagnoses and neurological dysfunction, surgical characteristics, reasons for surgery deferment, and PROMIS scores of pain intensity, pain interference, and physical function. METHODS:Patient electronic medical records were reviewed. Patients who had not rescheduled their canceled surgery as of January 31, 2021, and did not have a reason noted in their charts were called to determine the reason for continued surgery deferment. Patients were divided into three groups: early rescheduled (ER), late rescheduled (LR), and not rescheduled (NR). ER patients had a date of surgery (DOS) prior to the city's Phase 4 reopening on July 20, 2020; LR patients had a DOS on or after that date. Statistical analysis of the group findings included analysis of variance with Tukey's honestly significant difference (HSD) post-hoc test, independent samples T-test, and chi-square analysis with significance set at p≤.05. RESULTS:Out of 133 patients, 47.4% (63) were in the ER, 15.8% (21) in the LR, and 36.8% (49) in the NR groups. Demographics and baseline PROMIS scores were similar between groups. LR had more levels fused (3.6) than ER (1.6), p= .018 on Tukey HSD. NR (2.1) did not have different mean levels fused than LR or ER, both p= >.05 on Tukey HSD. LR had more three column osteotomies (14.3%) than ER and (1.6%) and NR (2.0%) p=.022, and fewer lumbar microdiscectomies (0%) compared to ER (20.6%) and NR (10.2%), p=.039. Other surgical characteristics were similar between groups. LR had a longer length of stay than ER (4.2 vs 2.4, p=.036). No patients in ER or LR had a nosocomial COVID-19 infection. Of NR, 2.0% have a future surgery date scheduled and 8.2% (4) are acquiring updated exams before rescheduling. 40.8% (20; 15.0% total cohort) continue to defer surgery over concern for COVID-19 exposure and 16.3% (8) for medical comorbidities. 6.1% (3) permanently canceled for symptom improvement. 8.2% (4) had follow-up recommendations for non-surgical management. 4.1% (2) are since deceased. CONCLUSION/CONCLUSIONS:Over 1/3 of elective spine surgeries canceled due to COVID-19 have not been performed in the 8 months from when elective surgeries resumed in our institution to the end of the study. ER patients had less complex surgeries planned than LR. NR patients continue to defer surgery primarily over concern for COVID-19 exposure. The toll on the health of these patients as a result of the delay in treatment and on their lives due to their inability to return to normal function remains to be seen.

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: Few studies investigate segmental lordosis restoration after long fusion with anterior (ALIF) vs transforaminal lumbar interbody fusion (TLIF) for adults with flatback deformity. PURPOSE: Our objective was to compare segmental lordosis restoration, health-related quality-of-life (HRQL), and complications associated with L4-S1 ALIF vs TLIF in operative treatment of flatback deformity. STUDY DESIGN/SETTING: Retrospective review of a prospectively collected multicenter consecutive case registry. PATIENT SAMPLE: Database enrollment required age >=18 years, scoliosis >=20degree, sagittal vertical axis (SVA) >=5cm, pelvic tilt >=25degree, or thoracic kyphosis >=60degree. OUTCOME MEASURES: Radiographic correction (including L4-S1 segmental lordosis), HRQL (Oswestry Disability Index [ODI], Short Form-36 [SF-36] scores, Scoliosis Research Society-22 [SRS-22r] scores), and complications.
Method(s): Prospective multicenter data were reviewed. Study inclusion required pelvic incidence to lumbar lordosis mismatch >=10degree (flatback), index ALIF vs TLIF at L4-L5 and/or L5-S1, and minimum 2-year follow-up. Cage details (height and lordosis) were also assessed.
Result(s): Of 222 consecutive patients, 157 (71%) achieved 2-year follow-up (age=63+/-10years, women=82%, ALIF=43%, TLIF=57%). Index operations had 12+/-3 posterior levels, iliac fixation=93%, and ALIF/TLIF at L4-L5 (66%) and L5-S1 (85%). ALIF vs TLIF cages were similar in height, but cage lordosis was greater for ALIF: L4-L5 (9degree+/-5degree vs 7degree+/-2degree, p=0.025) and L5-S1 (14degree+/-9degree vs 7degree+/-3degree, p<0.001). ALIF (vs TLIF) was associated with significantly more L4-S1 segmental lordosis at last follow-up (37degree+/-11degree vs 31degree+/-9degree, p<0.001) despite similar baseline measurement (32degree+/-15degree vs 31degree+/-14degree, p=0.705). Multiple regression demonstrated 1degree increase in L4-L5 ALIF cage lordosis led to 0.9degree increase in L4-L5 segmental lordosis (p=0.014), and 1degree increase in L5-S1 ALIF cage lordosis led to 0.5degree increase in L5-S1 segmental lordosis (p=0.005). For all patients, final alignment improved significantly (p<0.05): T12-S1 lordosis (25degree+/-17degree to 48degree+/-13degree), L4-S1 lordosis (32degree+/-14degree to 34degree+/-10degree),