Faculty Bibliography

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: Hyperextension of C0-C2 is a painful compensatory mechanism used to maintain horizontal gaze that is analogous to high pelvic tilt to maintain upright posture. The magnitude and impact of relaxation of this hyperextension following CD correction are not well understood. PURPOSE: To investigate whether correction of cervical sagittal malalignment allows for relaxation of C0-C2 hyperextension and improved clinical outcome. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: This study included 65 ACD patients with 1- or 2-year follow-up. OUTCOME MEASURES: Radiographic alignment, range of motion (ROM).
Method(s): CD patients undergoing surgery short of the occiput and the pelvis were included. In addition to the classic alignment parameters, ROM and reserve of extension were calculated across the C2-C7 and C0-C2 segments. After describing the cohort in terms of preoperative information, correlations and hierarchical stepwise regressions investigated the association between C2-C7 correction and change in C0-C2 reserve of extension while controlling for maintenance of horizontal gaze. Stratification by DELTAC2-C7 percentile was conducted followed by paired t-tests to investigate changes in TK, C0-C2 and reserve of extension within each percentile.
Result(s): Sixty-five patients were included (61.8yo+/-9.6, 68%F). At baseline, they presented with a cervical kyphotic alignment (C2-C7: -11.7degree+/-18.2; TS-CL: 38.6degree+/-18.6), a negative global alignment (SVA: -12mm+/-71), and hyperlordosis at C0-C2 (33.2degree+/-11.8). The ROM was 25.7degree+/-17.7 and 21.3degree+/-9.9 at C2-C7 and C0-C2, respectively, with an associated reserve of extension of ~9degree for each segment. Limited C0-C2 ROM and reserve of extension significantly correlated with the Neck Disability Index (r=-0.371 & -0.394) and with decreased general health (r=0.455 & 0.512) (all p<0.005) The mean number of levels treated was 7.0+/-3.1 (24.6% ACDF, 43.1% posterior), with 49.2% of the patients receiving an osteotomy, and 16.9% a 3CO. At 1 year, C2-C7 increased to 5.5degree+/-13.4, SVA became neutral (12mm+/-54), C0-C2 decreased to 27.7degree+/-11.7, and TK increased to -49.4+/-18.1 (all p <0.001). At C2-C7 ROM decreased significantly to 9.5degree+/-14.1, and increased to 27.6degree+/-8.1 at C0-C2 without change in reserve of extension. The horizontal gaze significantly improved (4.5+/-13.3 vs -0.5+/-9.3 p=0.003). Controlling horizontal gaze, change in C2-C7 lordosis significantly correlated with increased TK (r=-0.615, p<0.01), decreased C0-C2 (r=-0.686, p<0.001), and increased C0-C2 reserve of extension (r=0.414, p<0.015). Larger C0-C2 ROM and reserve of extension correlated with decreased in Neck Disability Index (r=-0.571 & -0.470 p<0.05). Stratification by DELTAC2-C7 percentile highlighted the reciprocal change above and below the fusion. Within the lowest percentile (DELTAC2-C7: 2degree+/-9.6), no significant difference was noticed between pre and 1 year, while within the highest percentile (DELTAC2-C7: -42.8+/-14.1), C0-C2 decreased (-9.7degree+/-10.5, p=0.001), TK kyphosis increased (14.3degree+/-7.5, p<0.001) and C0-C2 reserve of extension increased (5.8degree+/-6.4, p=0.026). Subanalysis on patients with available 2-year data (N=42) demonstrated similar trends.
Conclusion(s): Correction of cervical malalignment can significantly impact proximal (C0-C2) and distal (T2-T12) compensation. Restoration of a more natural alignment resulted in an increase of the reserve of extension between C0-C2 and was associated with improved clinical outcomes. 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),

BACKGROUND CONTEXT: Robot-guided lumbar instrumented fusion (RGLF) for accurate pedicle screw placement is increasingly popular. Learning curve (LC) has been reported to be short, but simple comparison of a set number of early to later cases may oversimplify the LC. This study offers an analysis of a single institution LC for RGLF as it relates to increasing case complexity as determined by Spine Surgical Invasive Index (SII) as described by Mirza, and advanced techniques. PURPOSE: To determine if RGLF is related to SII and is more dynamic than previously described. STUDY DESIGN/SETTING: Single-center retrospective cohort study. PATIENT SAMPLE: A total of 346 patients undergoing RGLF at a single institution from 2018 to 2021. OUTCOME MEASURES: Case complexity indicators (levels fused, SII, iliac fixation, single position surgery), radiation dose, procedure/operative time (PTime/OpTime), EBL, LOS, failed registration, robotic mechanical failures, perioperative complications and OR returns.
METHOD(S): All RGLFs at a single institution were included. Outcome measures indicating case complexity (levels fused, SII, iliac fixation, single position surgery) underwent regression analysis to determine risk factors for robot-related complications. Peaks in these characteristics over the course of 346 cases were identified. Outcomes including radiation dose, procedure/operative time (PTime/OpTime), EBL, LOS, failed registration, robotic mechanical failures, perioperative complications, and returns to OR were analyzed in stepwise fashion by each consecutive case using independent samples t-tests and chi-squared analyses as appropriate.
RESULT(S): A total of 346 RGLFs included. No significant changes in demographics over time. SII was an independent risk factor for robot registration and intraoperative mechanical failures on multivariate regression analysis (p<0.001). SII had significant peaks between 10 to 20 cases and 165 to 330 cases. The following outcomes were overcome during a first LC corresponding to an early SII peak: PTime (401.2+/-135.6 vs 361.4+/-99.7 min; p= 0.047), OpTime (326.0+/-129.4 vs 279.4+/-91.9 min; p= 0.034), robot mechanical failures (26.7% vs 10.1%; p=0.046), all postop complications (60.0% vs 29.2%; p=0.037), ileus (9.0% vs 3.3%; p=0.046), urinary complications (6.4% vs 1.9%; p=0.043). A later LC corresponding to a second SII peak saw significant changes in PTime per level (291.1+/-84.7 vs 259.5+/-108.5 min; p=0.017), OpTime per level (223.6+/-70.4 vs 200.9+/-90.7 min; p= 0.038), EBL (316.7+/-264.0 vs 247.4+/-204.6 mL; p=0.035), LOS (3.8+/-2.2 vs 2.7+/-1.1 days; p=0.001), all intraoperative complications (23.8% vs 13.2%; p=0.036), surgical site infections (2.54% vs 10.34%; p=0.022), robot registration failures (8.3% vs 2.1%; p=0.039), new neurological deficits (5.2% vs 0.0%; p=0.050), instrumentation failures (1.7% vs 3.7%; p =0.043), and returns to OR for pedicle screw revision (1.2% vs 8.9%; p=0.046) or for neurological deficit (3.9% vs 0.0%; p=0.050).
CONCLUSION(S): Two learning curves were observed that mirrored significant peaks in SII. The second, more significant, wave of complications was observed with increased surgical complexity. This suggests a longer, more dynamic learning curve than has been previously described. Avoiding surgeries with high SII at the beginning of RGLF experience may prevent early complications. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Cervical deformity (CD) surgery can markedly improve patient quality of life. The longevity of CD correction and the mechanism of alignment deterioration are not well understood. PURPOSE: To investigate preoperative risk factors and failure mechanisms that erode CD corrections and the impact on functional outcomes. STUDY DESIGN/SETTING: Retrospective review of a prospective CD database. PATIENT SAMPLE: This study included 155 operative CD patients with baseline (BL) and 1-year follow-up. OUTCOME MEASURES: Alignment at baseline, 3 months, 6 months and 1 year: cervical sagittal vertical axis (cSVA), C2 Slope (C2S), T1 slope (T1S), C2-C7 lordosis (CL), T1S-CL mismatch (TS-CL), Neck Disability Index (NDI), Modified Japanese Orthopaedic Association score (mJOA).
Method(s): A retrospective review of a prospective database of operative CD patients was analyzed. Patients with baseline, 3-month, 6-month and 1-year cervical radiographs were included. Cervical sagittal vertical axis (cSVA) <4cm was used to categorize patients as well-aligned vs malaligned. Additionally, three subsets were defined as follows: (1) patients who were malaligned preoperatively (cSVA>=4) and remained well aligned at 1 year postoperatively; (2) patients who were well-aligned but experienced alignment deterioration (cSVA>=4cm) up to 1 year postop, and; (3) patients who never attained cSVA <4cm. These groups were compared in terms of demographic factors, surgical factors, baseline radiographic parameters and radiographic and surgical outcomes at baseline and 1 year, using t-tests and X2 tests for continuous and categorical variables, respectively.
Result(s): A total of 155 patients were included (mean age 61.41, 60.9% F). The entire cohort was analyzed at all time points for alignment using cSVA. Among 89 patients with X-rays at every time point, 30 patients (34%) maintained their good alignment correction at 1-year postop. Seventeen patients (19%) experienced alignment deterioration and 42 patients (46%) never reached cSVA <4cm at any time point. Four patients lost their correction at 3 months, 6 patients at 6 months and 8 patients were malaligned by 1 year. The never-aligned cohort was significantly older when compared to those who maintained alignment or those who deteriorated (65.9 vs 61.8 vs 58.8, p=0.038). Patients who never achieved good alignment and those who suffered deterioration had a significantly higher rate of DJK (42.9% vs 47.1% vs 3.3%, p=0.001). Other failure mechanisms in the deterioration group included loss of subjacent spinopelvic compensation and PJK. At baseline, patients with alignment deterioration had a smaller cSVA compared to those who maintained or never reached good alignment (40.5 vs 52.0 and 60.1mm, p=0.001), and less TK (-43.4 vs -55.9 vs -61.4, p=0.049). At 1-year postop, patients with deterioration had worsening of their mJOA score at 6 months compared to those who maintained or never reached proper alignment (2.50 vs 0.04 vs 1.20, p=0.032). There were no significant differences in smokers, BMI, frailty, osteoporosis, levels fused, UIV, LIV, EBL, operative time, rod diameter, rod material, utilization 3-column osteotomy, mean osteotomy grade, in construct (fused) loss of alignment or revision rate between the groups (all p>.05)
Conclusion(s): Cervical deformity correction surgery failed to achieve acceptable sagittal alignment in 46% of patients. In those with successful correction, 36% suffered alignment deterioration within 1 year. Distal junctional kyphosis was the most common failure mechanism leading to loss of correction. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Both frailty and surgical invasiveness are correlated with increased risk of complications following ASD surgery, yet there is no accepted risk-stratification system combining these factors. PURPOSE: The aim of this study is to ascertain data-driven categories defining the risk for 90-day complications following ASD surgery based on frailty and surgical invasiveness. STUDY DESIGN/SETTING: Retrospective review of a multicenter database. PATIENT SAMPLE: A total of 1,272 surgical ASD patients undergoing spinal fusions >=5 levels OUTCOME MEASURES: Ninety-day complication risk, 90-day complication rate, invasiveness thresholds for increased complications.
METHOD(S): Using a prospective, multicenter database, we identified 1,272 surgical ASD patients undergoing posterior spinal fusion of at least five levels. Patients were separated into three frailty groups based on the ASD-FI frailty index. Within each frailty group, stratum-specific likelihood ratio (SSLR) analyses were performed to define frailty-based surgical invasiveness cutoffs associated with increased risk for 90-day complications. Cutoffs generated through SSLR were confirmed with multivariable logistic regression analysis controlling for age, alignment, and ODI.
RESULT(S): Mean age was 60 +/- 14 years, 74% females. Of 1,272 surgical ASD patients, 319 (35%) were nonfrail (NF), 667 (52%) frail (F), and 286 (23%) severely frail (SF). Mean SI was 93 +/- 35. The mean complication rate was 35.4% for NF, 37% for F and 43.6% for SF. SSLR analysis of NF patients produced 2 complication categories: 33% complication rate for SI < 153 and 73% for SI >= 153. NF patients with SI >= 153 had 4.14x higher odds of complications than NF patients with SI <153 (p=0.04). SSLR analysis of F patients produced 3 complication categories: 26% complication rate for SI < 60, 42% for SI of 60 to 179, and 64% for SI >= 180. Relative to F patients with SI < 60, F patients with SI 60 to 179, and SI >= 180 had 2.4x and 6.7x higher odds of complications, respectively (p<0.01 for both). SSLR analysis of SF patients produced 2 complication categories: 35% complication rate for SI < 82 and 49% complication rate for SI >= 82. SF patients with SI >= 82 had 1.77x higher odds of complications than SF patients with SI < 82 (p=0.04).
CONCLUSION(S): Frailer groups were found to have lower SI cutoffs, indicating the less invasiveness surgeries can be performed on frail patients to minimize complication risk. This risk-stratification system is useful for counselling patients regarding their risk of complication. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Deterioration of global coronal alignment (GCA) may be associated with worse outcomes after adult spinal deformity (ASD) surgery. The impact of fusion length and upper instrumented vertebra (UIV) selection for patients with this complication is unclear. PURPOSE: Our objective was to compare outcomes for long sacropelvic fusions with upper-thoracic (UT) vs lower-thoracic (LT) UIV in patients with worsening GCA>=1cm. STUDY DESIGN/SETTING: Retrospective review of a prospectively collected multicenter 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 alignment, HRQL (Oswestry Disability Index [ODI], Short Form-36 [SF-36], Scoliosis Research Society-22 [SRS-22r], numerical rating scale [NRS] back/leg pain scores), and complications.
Method(s): This is a retrospective analysis of a prospective multicenter database of consecutive ASD patients. Index operations involved instrumented fusion from sacropelvis to thoracic spine. Global coronal deterioration was defined as worsening GCA>=1cm from preoperative to 2-year follow-up.
Result(s): Of 875 potentially eligible patients, 560 (64%) had complete 2-year follow-up data, of which 144 (25.7%) demonstrated worse GCA at 2-year postop (UT 35.4%, LT 64.6%). At baseline, UT had younger age (61.6+/-9.9 vs 64.5+/-8.6years, p=0.008), more osteoporosis (35.3% vs 16.1%, p=0.009), and worse scoliosis (51.9+/-22.5degree vs 32.5+/-16.3degree, p<0.001). Index operations were comparable except UT had longer fusions (16.4+/-0.9 vs 9.7+/-1.2 levels, p<0.001) and operative duration (8.6+/-3.2 vs 7.6+/-3.0hrs, p=0.023). At 2-year follow-up, global coronal deterioration averaged 2.7+/-1.4cm (1.9 to 4.6cm, p<0.001), scoliosis improved (39.3+/-20.8degree to 18.0+/-14.8degree, p<0.001), and sagittal spinopelvic alignment improved significantly for all patients. UT maintained smaller positive C7-sagittal vertical axis (SVA) (2.7+/-5.7 vs 4.7+/-5.7cm, p=0.014). Postoperative 2-year health-related quality-of-life (HRQL) was significantly improved from baseline for all patients. Significant HRQL comparisons included: UT had worse SRS-22r Activity (3.2+/-1.0 vs 3.6+/-0.8, p=0.040) and SRS-22r Satisfaction (3.9+/-1.1 vs 4.3+/-0.8, p=0.021). Also, fewer UT patients improved by >=1 minimal clinically important difference in leg pain NRS (41.3% vs 62.7%, p=0.020). Total reported complications (total=208, reoperation=53/major=77/minor=78) had comparable percentages of affected UT vs LT patients, but the percentage of re-operated patients was higher for UT (35.3% vs 18.3%, p=0.023). UT had higher reoperation rates for rod fracture (13.7% vs 2.2%, p=0.006), pseudarthrosis (7.8% vs 1.1%, p=0.006), but not proximal junctional kyphosis (9.8% vs 8.6%, p=0.810).
Conclusion(s): In ASD patients with worse 2-year GCA after long sacropelvic fusion, upper-thoracic UIV was associated with worse 2-year HRQL compared to lower-thoracic UIV. This may suggest residual global coronal malalignment is clinically less tolerated in ASD patients with longer fusions to proximal thoracic spine. These results can inform operative planning and improve patient counseling. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Concerns exist regarding disease transmission and cost associated with postoperative nonroutine discharge. Few data exist evaluating impact of nonroutine vs home discharge on readmissions, complications and patient reported outcome measures (PROMs) for adult spinal deformity (ASD) surgery. PURPOSE: Evaluate 30-day readmissions, 90-day return to surgery, postoperative complications, and postoperative PROMs for matched ASD patients receiving nonroutine discharge vs home discharge following surgery. 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), duration of hospital stay, 30-day readmission, 90-day return to surgery, postoperative complications.
METHOD(S): Surgically treated ASD patients prospectively enrolled in a multicenter ASD study were divided into two discharge disposition groups, nonroutine (NON) and home (HOME). NON was further divided into acute rehab (REHAB) or skilled nursing facility (SNF) discharge. Study inclusion criteria; (1) surgery >=5 levels fused, (2) >=2-year follow-up. PSM was used to match NON vs HOME for age, frailty and total levels fused. 30-day hospital readmission, 90-day return to surgery, postoperative complications, one and minimum 2 year PROM data was compared for NON vs HOME, and REHAB vs SNF vs HOME.
RESULT(S): From 2015 to 2019, 241 of 374 eligible treated patients were evaluated and 158 included in this study after PSM (mean 2.7 year follow-up). NON (n=106) and HOME (n=52) had similar age (67.6 vs 67.6 years), ASD-frailty index (3.9 vs 3.9), levels fused at surgery (13.8 vs 13.7), and preop PROMs, respectively (p>0.05). Duration of hospital stay (9.7 vs 10.4 days), 30-day readmission (6.6% vs 6.6%), 90-day return to surgery (9.4% vs10.4%), total complications/patient (2.0 vs 1.5), major complications/patient (0.8 vs 0.5), were similar NON vs HOME, respectively (p>0.05). At last follow-up, HOME demonstrated better ODI (21.6 vs 28.2), SRS-total (3.8 vs 3.5), and SRS-activity (3.7 vs 3.3) than NON, respectively (p<0.05). Sub-analysis of REHAB (N=63) vs SNF (N=41) vs HOME showed similar findings, including similar 30-day readmissions, 90-day return to surgery, and complications (p>0.05) and improved PROMs for HOME vs REHAB and SNF (p<0.05).
CONCLUSION(S): Analysis of 158 operatively treated ASD patients prospectively enrolled into a multicenter study and matched for age, frailty, and surgery performed demonstrated that postoperative discharge to skilled nursing or acute rehab facilities did not reduce 30-day readmissions, 90-day return to surgery, or postoperative complications. At one and minimum two years postop, patients discharged home had better PROMs scores than nonroutine discharge. These data should be considered in conjunction with postoperative needs and the cost and disease transmission risks for nonroutine discharge. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Both regional cervical and thoracolumbar/spinopelvic (TL) sagittal alignment have been shown to correlate with health-related quality of life (HRQOL). Recently it has been demonstrated that cervical sagittal alignment is associated with HRQOL in patients with TL deformity. It remains unknown if TL alignment parameters are related to cervical HRQOL and complication rates for patients with cervical deformity. PURPOSE: To examine the relationship between cervical and thoracolumbar alignment parameters with HRQOL among patients with adult cervical deformity (CD).
Study Design/Setting: : Retrospective cohort study of a prospective multicenter adult CD database. PATIENT SAMPLE: A total of 119 CD patients. OUTCOME MEASURES: HRQOL (Neck disability Index, NDI, Modified Japanese Orthopaedic Association score, mJOA, EuroQol-5 dimension, EQ5D), radiographic alignment (cervical lordosis, cervical sagittal vertical axis [SVA], T1 slope, T1 slope-cervical lordosis, maximum TL coronal Cobb angle, C7 coronal plumb line, C7-S1 SVA, pelvic tilt [PT], mismatch between pelvic incidence [PI] and lumbar lordosis [LL]), and complications.
Method(s): : Adult (>=18 years old) CD patients (cervical kyphosis >10degree, coronal scoliosis >10degree, cSVA >4cm, TS-CL >10degree, or CBVA >25degree) with min 1-year follow-up. HRQOL and postop complications (any, major, minor, and distal junctional kyphosis [DJK]) were compared between CD patients with preop TL deformity [+TLD] (C7-S1 SVA >5cm and/or PI-LL>10degree) and those without [-TLD]. TL radiographic parameters were correlated with cervical HRQOL.
Result(s): : The mean age was 61.6+/-10.1 years and there were 50 (42.0%) +TLD patients. +TLD patients had statistically similar HRQOL for all metrics at preop, 1 year, and 2 years postop compared with -TLD (p>0.05). However, patients with preop SVA>5cm (n=21, 17.6%) had a significantly worse preop mJOA (11.6+/-2.2 vs 14.2+/-2.3, p<0.0001) and NDI (55.7+/-15.8 vs 44+/-14.8, p=0.03) scores compared to patients with normal preop SVA. Preop SVA directly correlated with preop NDI (r=0.39, p=0.005) and inversely with mJOA (r=-0.46, p=0.001). There were no significant postop correlations between baseline radiographic TL parameters and postop cervical HRQOL (p>0.05). The mean number of fusion levels for +TLD was not statistically different to -TLD patients (8.5+/-2.2 vs 8.5 +/- 3.9, p>0.05) and for the rates of pedicle subtraction osteotomy and vertebral column resection (13.1% vs 12.0%, p>0.05 and 2.6% vs 4.0%, p>0.05, respectively). Postop complication rates were statistically similar between +TLD and -TLD groups for any complication (60% vs 67%, p=0.45), major (20% vs 16%, p=0.56), minor (26% vs 35%p=0.30), and specifically DJK (8% vs 10%, p=0.69).
Conclusion(s): : The incidence of concomitant thoracolumbar deformity in adult cervical deformity patients is 42.0%. +TLD patients have worse preop NDI and mJOA scores. However, this difference is no longer apparent postoperatively. +TLD patients did not have a longer posterior fusion construct nor an increase in 3-column osteotomies. In addition, the complication rates and risk for postop DJK are similar. Although there is a strong association with how the neck affects the back, the converse has less of a relationship. This study provides important information regarding this unique population of adult cervical deformity patients that can help guide clinical decision-making. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Preoperative opioid consumption, poor mental health, and lower socioeconomic status are each associated with worse surgical outcomes for adult spinal deformity (ASD). Little data exits evaluating preoperative morphine milligram equivalent (MME) consumption and preoperative mental health, social function, and socioeconomic status in ASD. PURPOSE: Evaluate the correlations between preoperative daily MME consumption and preoperative depression, anxiety, mental health scores, and socioeconomic status for ASD patients prior to receiving reconstructive ASD surgery. We hypothesized that preoperative MME consumption correlates with preoperative depression, anxiety, poor mental health, poor social function, and poor socioeconomic status in ASD. STUDY DESIGN/SETTING: Preoperative analysis of ASD patients prospectively enrolled into a multicenter study. PATIENT SAMPLE: ASD patients prospectively enrolled into multicenter study. OUTCOME MEASURES: Numeric rating scale (NRS) back and leg pain, Scoliosis Research Society-22r questionnaire (SRS-22r), Edmonton Frailty Index (EFI score), grip strength, Veterans Rand Health Questionnaire (VR-12), Oswestry Disability Index (ODI), daily morphine milligram equivalent consumption (MME), PROMIS-Pain Interference (PROMIS-PI), PROMIS-Physical Function (PROMIS-PF), PROMIS-Depression (DEP), PROMIS-Anxiety (ANX), PROMIS-Satisfaction with Social Roles (SR) and PROMIS-Satisfaction with Discretionary Social Activities (SDA) computer adaptive tests (CATs), Area Deprivation Index (ADI) scores.
METHOD(S): From 2018-2020, ASD patients were prospectively enrolled into a multicenter study. Preoperative MME was calculated. Preoperative PROMIS-DEP, PROMIS-ANX, PROMIS=SR, PROMIS-SDA, PROMIS-PI and PF, SRS-22r total and domain scores, and VR-12 mental component summary (MCS) were calculated. ADI scores were collected to assess socioeconomic status, as previously described. MME data were log transformed and two-tailed Pearson correlation coefficients calculated. Correlation strengths were interpreted according to Cohen. Confidence intervals were created with 1,000 sample bootstrapping.
RESULT(S): A total of 207/207 patients enrolled were evaluated; mean age 61 years (18-81). Preoperative opioid consumption was reported in 38% patients (n=78; mean preoperative MME 22.5 mg, range 1-420 mg). Preoperative MME did not correlate with PROMIS-ANX (p=0.07) and did not correlate with socioeconomic status (ADI; p=0.37). Preoperative MME showed small correlations with PROMIS-DEP (r=0.2, p=0.01), VR-12 MCS (r=-.2, p=0.002), and SRS-Mental Health (r=-0.2, p=0.005). Preoperative MME showed moderate correlations with PROMIS-PI (r=0.4, p<0.0001), PROMIS-PF (r=-0.4, p<0.0001), SRS-Pain (r=-0.5, p<0.0001), SRS-Function (r=-0.4, p<0.0001), PROMIS-SR (r=-0.3, p<0.0001) and PROMIS-SSA (r=-0.4, p<0.0001).
CONCLUSION(S): Prospective evaluation of 207 ASD patients demonstrated minimal to no correlations between preoperative MME consumption and preoperative anxiety, depression or low socioeconomic status. Preoperative MME consumption demonstrated moderate correlations with preoperative pain, physical function, and social function scores. The negative impacts of opioid consumption on physical measures are likely independent of psychosocial variables in ASD. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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