Faculty Bibliography

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: 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: ASD is a vague and heterogeneous label applied to adults afflicted with varying types, severities, and etiologies of spine deformities. We hypothesized that ASD patients with a history of spine fusion and associated spine deformity (revision=R) have distinct pathognomonic differences from ASD patients with no history of spine fusion (primary=P). PURPOSE: Evaluate baseline differences for revision vs primary ASD patients including demographics, radiographic spine deformity, functional measures, opiate consumption and patient-reported outcome measures (PROMs), prior to receiving reconstructive ASD surgery. 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 (SSA) computer adaptive tests (CATs).
METHOD(S): From 2018-2020, patients age >18 years were enrolled in a multicenter prospective study evaluating surgical treatment for ASD. Patients were dichotomized according to R vs P, and preop demographics, grip strength, frailty, daily MME consumption, physical examination, radiographic measures, and PROMs data were compared.
RESULT(S): A total of 204/204 enrolled patients were evaluated; R (n=99), P (n= 105). R and P had similar age, Charleson Comorbidity Index (CCI) and gender distribution (p>0.05). R had greater daily MME consumption (35mg vs 15mg), were more frail (EFI score 4 vs 2), and had greater incidence of motor deficits (54% vs 37%) than P, respectively (p<0.05). R differed radiographically from P in 11/15 measurements, as nearly all sagittal parameters were worse for R (SVA=139mm vs 57mm; PI-LL=26degree vs 12degree; PT= 28.2degree vs 20.7degree), while P had greater scoliosis (50.6degree vs 20.3degree), respectively (p<0.05). Nearly all PROM measures were worse for R vs P, including disability (ODI=48 vs 38), pain measures (PROMIS PI=66.9 vs 61.9; NRS-Back=7.0 vs 6.0), physical function (PROMIS-PF=32.8 vs 36.8, SRS-Activity=2.6 vs 3.2), social function (PROMIS-SSA= 40.4 vs 45.4), depression (PROMIS-DEP=51.1 vs 48.8), and self-image (SRS-Appearance=2.2 vs 2.6).
CONCLUSION(S): Revision ASD patients are distinctly different from primary ASD patients. Despite having similar preop age, gender and CCI, R were more frail, consumed more opiates, and reported greater pain, disability, function, and worse mental health than P. R had greater sagittal deformities while P had worse coronal deformities. Future analysis of ASD patients should distinguish between revision and primary patients to avoid confounding analyses. 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: 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: 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: 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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OBJECTIVE/UNASSIGNED: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 on patients with this complication is unclear. The authors' objective was to compare outcomes between long sacropelvic fusion with upper-thoracic (UT) UIV and those with lower-thoracic (LT) UIV in patients with worsening GCA ≥ 1 cm. METHODS:This was 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 ≥ 1 cm from preoperation to 2-year follow-up. RESULTS: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 postoperative follow-up (35.4% of UT patients vs 64.6% of LT patients). At baseline, UT patients were younger (61.6 ± 9.9 vs 64.5 ± 8.6 years, p = 0.008), a greater percentage of UT patients had osteoporosis (35.3% vs 16.1%, p = 0.009), and UT patients had worse scoliosis (51.9° ± 22.5° vs 32.5° ± 16.3°, p < 0.001). Index operations were comparable, except UT patients 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 ± 3.0 hours, p = 0.023). At 2-year follow-up, global coronal deterioration averaged 2.7 ± 1.4 cm (1.9 to 4.6 cm, p < 0.001), scoliosis improved (39.3° ± 20.8° to 18.0° ± 14.8°, p < 0.001), and sagittal spinopelvic alignment improved significantly in all patients. UT patients maintained smaller positive C7 sagittal vertical axis (2.7 ± 5.7 vs 4.7 ± 5.7 cm, p = 0.014). Postoperative 2-year health-related quality of life (HRQL) significantly improved from baseline for all patients. HRQL comparisons demonstrated that UT patients had worse Scoliosis Research Society-22r (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) scores. Also, fewer UT patients improved by ≥ 1 minimal clinically important difference in numerical rating scale scores for leg pain (41.3% vs 62.7%, p = 0.020). Comparable percentages of UT and LT patients had complications (208 total, including 53 reoperations, 77 major complications, and 78 minor complications), but the percentage of reoperated patients was higher among UT patients (35.3% vs 18.3%, p = 0.023). UT patients had higher reoperation rates of rod fracture (13.7% vs 2.2%, p = 0.006) and pseudarthrosis (7.8% vs 1.1%, p = 0.006) but not proximal junctional kyphosis (9.8% vs 8.6%, p = 0.810). CONCLUSIONS:In ASD patients with worse 2-year GCA after long sacropelvic fusion, UT UIV was associated with worse 2-year HRQL compared with LT UIV. This may suggest that residual global coronal malalignment is clinically less tolerated in ASD patients with longer fusion to the proximal thoracic spine. These results may inform operative planning and improve patient counseling.

OBJECTIVE:Few studies have compared fractional curve correction after long fusion between transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) for adult symptomatic thoracolumbar/lumbar scoliosis (ASLS). The objective of this study was to compare fractional correction, health-related quality of life (HRQL), and complications associated with L4-S1 TLIF versus those of ALIF as an operative treatment of ASLS. METHODS:The authors retrospectively analyzed a prospective multicenter adult spinal deformity database. Inclusion required a fractional curve ≥ 10°, a thoracolumbar/lumbar curve ≥ 30°, index TLIF or ALIF performed at L4-5 and/or L5-S1, and a minimum 2-year follow-up. TLIF and ALIF patients were propensity matched according to the number and type of interbody fusion at L4-S1. RESULTS:Of 135 potentially eligible consecutive patients, 106 (78.5%) achieved the minimum 2-year follow-up (mean ± SD age 60.6 ± 9.3 years, 85% women, 44.3% underwent TLIF, and 55.7% underwent ALIF). Index operations had mean ± SD 12.2 ± 3.6 posterior levels, 86.6% of patients underwent iliac fixation, 67.0% underwent TLIF/ALIF at L4-5, and 84.0% underwent TLIF/ALIF at L5-S1. Compared with TLIF patients, ALIF patients had greater cage height (10.9 ± 2.1 mm for TLIF patients vs 14.5 ± 3.0 mm for ALIF patients, p = 0.001) and lordosis (6.3° ± 1.6° for TLIF patients vs 17.0° ± 9.9° for ALIF patients, p = 0.001) and longer operative duration (6.7 ± 1.5 hours for TLIF patients vs 8.9 ± 2.5 hours for ALIF patients, p < 0.001). In all patients, final alignment improved significantly in terms of the fractional curve (20.2° ± 7.0° to 6.9° ± 5.2°), maximum coronal Cobb angle (55.0° ± 14.8° to 23.9° ± 14.3°), C7 sagittal vertical axis (5.1 ± 6.2 cm to 2.3 ± 5.4 cm), pelvic tilt (24.6° ± 8.1° to 22.7° ± 9.5°), and lumbar lordosis (32.3° ± 18.8° to 51.4° ± 14.1°) (all p < 0.05). Matched analysis demonstrated comparable fractional correction (-13.6° ± 6.7° for TLIF patients vs -13.6° ± 8.1° for ALIF patients, p = 0.982). In all patients, final HRQL improved significantly in terms of Oswestry Disability Index (ODI) score (42.4 ± 16.3 to 24.2 ± 19.9), physical component summary (PCS) score of the 36-item Short-Form Health Survey (32.6 ± 9.3 to 41.3 ± 11.7), and Scoliosis Research Society-22r score (2.9 ± 0.6 to 3.7 ± 0.7) (all p < 0.05). Matched analysis demonstrated worse ODI (30.9 ± 21.1 for TLIF patients vs 17.9 ± 17.1 for ALIF patients, p = 0.017) and PCS (38.3 ± 12.0 for TLIF patients vs 45.3 ± 10.1 for ALIF patients, p = 0.020) scores for TLIF patients at the last follow-up (despite no differences in these parameters at baseline). The rates of total complications were similar (76.6% for TLIF patients vs 71.2% for ALIF patients, p = 0.530), but significantly more TLIF patients had rod fracture (28.6% of TLIF patients vs 7.1% of ALIF patients, p = 0.036). Multiple regression analysis demonstrated that a 1-mm increase in L4-5 TLIF cage height led to a 2.2° reduction in L4 coronal tilt (p = 0.011), and a 1° increase in L5-S1 ALIF cage lordosis led to a 0.4° increase in L5-S1 segmental lordosis (p = 0.045). CONCLUSIONS:Operative treatment of ASLS with L4-S1 TLIF versus ALIF demonstrated comparable mean fractional curve correction (66.7% vs 64.8%), despite use of significantly larger, more lordotic ALIF cages. TLIF cage height had a significant impact on leveling L4 coronal tilt, whereas ALIF cage lordosis had a significant impact on restoration of lumbosacral lordosis. The advantages of TLIF may include reduced operative duration and hospitalization; however, associated HRQL was inferior and more rod fractures were detected in the TLIF patients included in this study.

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.