Faculty Bibliography

BACKGROUND CONTEXT: Recombinant human bone morphogenetic protein 2 (BMP) is increasingly utilized in minimally invasive (MIS) transforaminal lumbar interbody fusions (TLIF) in order to increase rate of fusion by promoting bone growth through the induction of osteoblast differentiation, awhile reducing morbidity related to iliac crest autograft. Despite these benefits, BMP use is still controversial due to its pro-inflammatory mechanism of action and potential to cause radiculitis. PURPOSE: To assess whether BMP is a risk factor for postoperative radiculitis in TLIF. STUDY DESIGN/SETTING: Single-center retrospective cohort study. PATIENT SAMPLE: A total of 397 TLIFs from June 2012 to December 2018. OUTCOME MEASURES: Perioperative clinical characteristics, post-operative risk of radiculitis and complication, and future reoperation rates.
METHOD(S): Patients >= 18 years-old undergoing elective single-level TLIFs from 2012 to 2018 were included. Outcome measures included perioperative clinical characteristics, postoperative risk of radiculitis and complication, and future reoperation rates. Radiculitis was defined the delayed onset of radicular symptoms postoperatively in patients whom had initial resolution of radicular symptoms immediately postoperatively, in the absence of persistent neurological compression on postoperative imaging. Statistical analyses included independent t-tests and chi-square analysis. Propensity score matching was utilized to control for demographic differences between the groups. Independent predictors for post-operative radiculitis were assessed by multivariate logistic regression. Significance set at p<0.05.
RESULT(S): A total of 397 cases were included in the study (59.33 +/- 13.49 mean age, 28.98 +/- 6.29 mean BMI, 52.90% female, 2.29 +/- 1.92 average Charleston comorbidity Index). There were 223 open procedures and 174 MIS. For the entire cohort, 238 cases utilized BMP and 159 did not, with 102 MIS pairing with BMP use. The MIS TLIFs had a higher percentage of BMP use than open TLIFs (58.6% vs 25.7%, p<0.001), lower estimated blood loss (212.28 +/- 193.79 mL vs 410.91 +/- 337.98 mL, p<0.001) higher fluoroscopy dosage (52.43 +/- 48.61mGy vs 16.77 +/- 27.84mGy, p<0.001), and a lower length of stay (3.20 +/- 2.55 days vs 4.11 +/- 2.52 days, p<0.001). There were no other differences in perioperative clinical characteristics. There was a significantly higher rate of postoperative radiculitis in the MIS TLIFs compared to open (12.6% vs 6.8%, p=0.046) and use of BMP compared to no BMP (13.2% vs 6.7%, p=0.029). There was a 15.7% radiculitis rate when MIS was paired with BMP use. There were no other notable differences in complication rates or rates of reoperation. Individually, MIS had a 12.6% radiculitis rate (p=0.046) and BMP use had a 13.2% rate (p=0.029). Propensity score match controlled for the significant difference in CCI between the MIS and open groups (N=168 each). Multivariate regression indicated that MIS (p=0.314) and BMP (p=0.109) were not independent predictors individually when controlling for age, gender, and BMI. When technique was paired with biologic use the regression revealed MIS + BMP is a risk factor of post-operative radiculitis (2.265(4.753-1.079), p=0.031).
CONCLUSION(S): While BMP and MIS technique were not independent risk factors for postoperative radiculitis, there is an increased risk of radiculitis when using BMP in MIS TLIF. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Amidst a current US opioid epidemic, it is important to understand factors that contribute to long-term or sustained opioid use after elective spine surgery. Recent reports have reported up to 25% of opioid-naive patients are taking opioids at 2-year follow-up after adult spinal deformity (ASD) surgery. This suggests ASD surgery, or at least the postoperative course, could be a significant factor contributing to long-term or sustained opioid use. ln Asian countries, opioids are rarely prescribed for postoperative pain. Potentially, there is a significant cultural difference that can play a role in patient expectations in the postoperative period leading to long-term opioid use. PURPOSE: To compare long-term or sustained (2-years) opioid use after ASD surgery between American and Japanese Cohorts STUDY DESIGN/SETTING: Propensity-matched comparison of American and Japanese ASD patients PATIENT SAMPLE: Patients from two (United States vs Japanese) prospective, multicenter ASD databases were compared OUTCOME MEASURES: Baseline and 2-year opioid use and SRS-22 domains were compared METHODS: We propensity matched 127 JPN to 619 US ASD patients based on age, sex, BMI, 3-column osteotomy, pelvic fixation, number of levels fused and preoperative SVA. Pre-op and 2-year postoperative opioid use was determined using responses to SRS22R Q11 and grouped into 3 categories (none, weekly, or daily). We have previously validated the use of SRS22R Q11 as an accurate measure for opioid use by comparing to a prospective study specifically designed to study opioid use and postoperative outcomes in ASD.
RESULT(S): From each cohort, 34 cases were successfully matched, with no difference in baseline parameters, including baseline opioid use (p=0.095), between the cohorts. The relatively low numbers in each cohort arise from difficulty matching a lower BMI and lower baseline opioid use in the JPN cohort. At 2-years postop, 22 US (65%) vs 31 JPN (91%) reported no opioid use, 1 US (3%) vs 0 JPN (0%) reported weekly use, and 11 US (32%) vs 3 JPN (9%) reported daily use (p=0.009). There was no difference in 2-year SRS-22 Self-image and Mental Health between the two groups while US patients had better Satisfaction (4.29 vs 3.84, p=0.032) but lower Function scores (3.52 vs 3.90, p=0.029).
CONCLUSION(S): In propensity-matched ASD cohorts, 35% of US patients were still using opioids 2 years after surgery compared to 9% of JPN patients, with the most taking opioids daily. Further studies are needed to identify sources of this variability. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Due to inherent patient and surgical factors, some adult spinal deformity patients are at higher risk of larger blood loss. This is associated with increased risk of complications, coagulopathy, and higher requirements for blood component replacement intraoperatively. The medical team should be aware of expected blood loss in order to adequately plan patient monitoring and blood product requirements. PURPOSE: This study aims to develop and validate a model based on patient characteristics and surgical strategies to predict which patients undergoing adult spinal deformity surgery are at greater risk of massive intra-operative blood loss. STUDY DESIGN/SETTING: Retrospective analysis of a multicenter prospective database. PATIENT SAMPLE: Surgical ASD patients undergoing long fusions (>5 levels). OUTCOME MEASURES: Massive intraoperative blood loss (>7% of a patient's ideal body weight), ICU stay, complications.
METHOD(S): Surgical adult spinal deformity patients undergoing long fusions (> 5 levels) were analyzed. Massive blood loss was defined as an intraoperative blood loss over 7% of a patients' ideal body weight, in accordance to the anesthesia literature. The impact of mEBL on complications and ICU stay was assessed through multivariate poisson and logistic regression, adjusting for baseline patient demographics and magnitude of surgery. Multivariate logistic regression modeling was used to build a prediction model of mEBL. Potential predictors were identified using univariate analysis. The model was built using a combination of backward elimination and bootstrap selection. Model fit was assessed using the Hosmer-Lemeshow test and the ROC curve. Split sample internal cross-validation was performed.
RESULT(S): A total of 1,205 patients met inclusion criteria, and mEBL occurred in 7.8% (94/1205) of cases. In this cohort, mEBL was an independent risk factor for major complications (IRR 2.89, p=0.0001), and postoperative ICU stay (OR 4.68, p=0.001). Predictors of mEBL included: revision surgery (OR 1.66, p=0.05), performing a three-column osteotomy (OR 2.65, p=0.0001), number of levels fused (OR 1.19, p=0.0001), number of levels decompressed (OR 1.15, p=0.004), and number of LLIF interbodies (OR 0.69, p=0.066). The predictive model had a good discrimination (ROC curve 0.76), and good calibration (Hosmer-Lemeshow p=0.39), which held true when performing split-sample cross-validation.
CONCLUSION(S): We built and validated a model to predict massive intra operative blood loss in ASD surgery. In this model, baseline patient demographics and elements of the surgical strategy are used to predict which patients are at greater risk for massive blood loss. This tool would be of particular help to the anesthesia team, allowing to identify preoperatively which patients are at greater risk and plan intraoperative care and fluid management accordingly. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Following cervical deformity (CD) corrective surgery, durability remains a challenge and distal junctional kyphosis (DJK) is an important risk for a surgeon to consider. DJK is the result from fixation failure, adjacent level fracture or spondylolisthesis. The timing of DJK onset has yet to be investigated. PURPOSE: To determine the timing of DJK development following CD corrective surgery. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: A total of 139 CD patients. OUTCOME MEASURES: Early/Late DJK Development, Severe DJK, Symptomatic DJK.
METHOD(S): Included: surgical CD patients (C2-C7 Cobb>10degree, CL>10degree, cSVA>4cm, or CBVA>25degree) without preop DJK. DJK angle was defined as the change in kyphosis between lower-most instrumented vertebra (LIV) and LIV-2 from preop to postop (<-10). X2 analysis and post-hoc testing assessed annual and overall incidence of early (3M follow-u) and late (DJK development at 6M, 1Y, 2Y) DJK development among operative patients. Differences between early and late DJK (development after 3 months) were assessed. Pearson correlations determined significant variables associated with development of early versus late DJK. Severe DJK was defined as DJK angle <-20degree. DJK was considered symptomatic if associated with reoperation or the previously published thresholds of NDI>24 or mJOA<14. The natural progression of the disease was predicted with the use of a Kaplan-Meier survivorship analysis.
RESULT(S): A total of 139 patients without preop DJK were included (16 re-op) (61.8yrs, 62.3%F, 29.1kg/m2). Surgical characteristics: 20.1% anterior approach, 42.4% posterior, 36.7% combined (levels fused: 7.6). Incidence of DJK from 2013-2018: 23%. Early: 9.4%, late: 10.1% (6M delayed: 3.6%, 1Y delayed: 6.5%, 2Y delayed: 2.2%). No differences were observed between op and reop for development of early or late DJK at all f/u (p>0.050). Presence of upgoing plantar response at baseline neuro exam, C2-C7 angle, T1-C2 angle, CBVA and combined approach correlated with development of early DJK. For late DJK: history of tumor and pulmonary disease, pelvic incidence, T10-L2 angle, and L4 pelvic angle. Apex of the secondary driver was significantly lower in the Late group (mean early: T2/3; late: T10; p=0.023). 3M radiographically, Early DJK patients had greater TK (-57.9degree vs -40degree, p=0.024, while L4PA remained larger in the late DJK group (14.5degree, p=0.009). Between early and late groups, 41.7% of early DJK patients met criteria for severe DJK, while 0% of Late DJK patient were severe(p=0.010); symptomatic DJK between the two groups was not significant (p=0.941). Kaplan-Meier survivorship analysis determined patients within the cohort to have a 91.1% cumulative probability of maintaining non-DJK status by 3-month follow-up, 85.9% at 6-month, 80% at 1-year, and 77.0% by 2-year follow-up.
CONCLUSION(S): Patients undergoing CD corrective surgery have incidence of early and incidence of late DJK. While the majority of DJK development occurs within the first 6 months, late DJK occurs and differs in presentation and etiologic factors. Early DJK occurrence is more likely to be severe radiographically, associated with neurological decline, and is more strongly related to biomechanical factors such as use of a combined approach at the time of surgery. Contrarily, although equally likely to be symptomatic as reflected in loss of clinical gains from surgery, late DJK is more likely mild radiographically and associated with suboptimal cervical realignment and lack of addressing secondary drivers, likely related to negative compensatory mechanisms. Customized prophylactic approaches for both occurrences is mandated. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Scoliosis Research Society established appropriateness criteria for surgery for degenerative lumbar scoliosis (DLS) in order to improve and unify clinical decision making. Though utilized and validated in various cohorts, an appropriateness criteria has yet to be developed in a cervical deformity (CD) population. PURPOSE: To modify the DLS Appropriateness criteria to be utilized in a CD cohort. STUDY DESIGN/SETTING: Retrospective review of a single-surgeon CD database PATIENT SAMPLE: A total of 100 CD patients. OUTCOME MEASURES: Appropriateness criteria.
METHOD(S): CD patients>18yrs were included. Each patient was scored based upon the SRS-appropriateness criteria, comprised of clinical or radiographic characteristics and was modified for a cervical deformity cohort: (1) Severity of Symptoms [NDI], (2) Severity of Myelopathy[mJOA.], (3) Progression of Deformity, (4) Global Sagittal Malalignment [Schwab modifiers], (5) Severity of Risk Factors, (6) Degree of the T1S-CL curvature. For the category 'progression', radiographs were only available at one preoperative time point, and we were unable to include this in the total score. Based upon certain combinations of criteria, patients were stratified into Appropriate and Not Appropriate.
RESULT(S): A total of 100 patients were included (61yrs, 62% F, 29.5kg/m²). Assessment of the categories of Appropriateness of CD surgery: (1) Symptoms: 6% None to Mild, 94% Moderate to Severe; (2) Myelopathy: 16% None to Mild, 45% Moderate, 39% Severe; (3) All were grouped No Progression in the present study; (4) 19% demonstrated Global Malalignment (+/++Schwab), 81% did not; (5) Risk Factors: 27% had None to Mild, 63% Moderate, 10% Severe; (6) Curvature TS-CL demonstrated 88.6% of patients Severe (>20degree). Not Appropriate: None to Mild (NDI <28), with (1) None to Moderate myelopathy (mJOA >12) and Severe Risk Factors (2) None to Mild myelopathy (15-18) and No Progression or Imbalance (3) Moderate myelopathy (mJOA 12-15) and None to Moderate Risk Factors and no Progression, or imbalance and TSCL <25degree. Appropriate: Moderate to Severe Symptoms (NDI >=30), with (1) Severe myelopathy (mJOA<12) and Any Risk Factors (2) Moderate myelopathy and None to Moderate Risk Factors (3) Moderate myelopathy with Severe Risk Factors, Progression AND Imbalance (4) None to Mild myelopathy and None to Moderate Risk Factors and Progression OR imbalance (5) None to Mild myelopathy with None to Moderate Risk Factors and TSCL >25degree. In the present cohort, 94% were deemed Appropriate for surgery, 6% Not Appropriate. Less Appropriate patients demonstrated higher rates of postop dysphagia complications (17% vs 2%), met MCID for NDI less (0% vs 30.9%), and had more occurrences of DJK (16.7% vs 6.4%) by 2 years, p<0.05.
CONCLUSION(S): In light of the heterogeneity and uncertainty surrounding CD, this study developed CD appropriateness criteria, using established methodology, for surgeons to consider in the preoperative decision-making that correlate well with major postop occurrences. Application of the appropriateness criteria for CD may optimize patient selection and reduce the incidence of unwarranted surgery, although future validation is necessary. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Hospital acquired conditions (HACs) were established in the Affordable Care Act, and are defined as reasonably preventable complications that are nonreimbursable. In high risk patient populations for HACs, such as frail surgical spine patients, preoperative evaluation should consider modifiable factors. PURPOSE: To identify if optimizing the modifiable factors in the frailty index reduce the risk of developing HACs in population of surgical spine patients. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: This study included 196,523 elective spine surgery patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). OUTCOME MEASURES: Modifiable patient frailty factors: hypertension and diabetes mellitus; rates of HACs, superficial or deep surgical site infection (SSI), deep venous thromboembolism (VTE) and urinary tract infection (UTI), across frailty scores.
METHOD(S): Patients >18 years who underwent elective spine surgery were identified in ACS-NSQIP database from 2005-2016. HACs identified: SSI, VTE, and UTI. Patient frailty was assessed utilizing the modified NSQIP 5-factor frailty index. The modified frailty score (mFI-5) is assessed on a scale between 0 and 1 (no frailty [NF] <0.3, mild frailty [MF] 0.3-0.5, severe frailty [SF] >0.5). Descriptive analysis quantified rates of patient characteristics, operative details, and HAC prevalence. Stepwise linear regression models determined significant predictors of baseline frailty using controllable patient factors. HACs were compared between 'optimized' and 'non-optimized' frailty status in the cohort. Level of significance was set to P<0.05.
RESULT(S): A total of 196,523 patients (57+/-14.2 years, 30.4 kg/m², 48%F) met inclusion criteria. Overall, 5,720 (2.9%) of patients developed an HAC, the most common was an SSI (1.3%), followed by UTI (1.1%). When stratified by the mFI-5 frailty severity groups at baseline, 83.6% of patients were categorized NF, 15.1% MF and 1.3% SF. Within the frailty severity groups, prevalence of overall HACs increased significantly (NF: 2.64%, MF: 4.17%, 5.93%, p<0.001). Rates of all individual postoperative HACs assessed also increased with greater baseline frailty severity: SSI (NF: 1.14%, MF: 1.93%, SF: 2.39%, p<0.001), UTI (NF: 0.91%, MF: 1.66%, SF: 2.85%, p<0.001), VTE (NF: 0.68%, MF: 0.80%, SF: 1.16%, p=0.002). Stepwise linear regression models determined that diabetes mellitus (beta = 0.493) and hypertension (beta = 0.679) were the most significant predictors for increased baseline frailty by way of the mFI-5 NSQIP index (Final model: R2= 0.897). Of total patients, 47.2% had the optimal modifiable frailty factors (no history of diabetes or hypertension). The optimal frailty patients had significantly less overall incidence of SSI (2.03% vs 2.5%, p<0.001), UTI (0.65% vs 1.4%, p<0.001), DVT (0.56% vs 0.84%, p<0.001), and any overall HAC (2.18% vs 3.56%, p<0.001).
CONCLUSION(S): Stepwise linear regression models determined that hypertension and diabetes account for 89.7% of variance in baseline mFI-5 score. Patients with these optimal controllable factors had reduced incidence of all hospital acquired conditions. In order to optimize hospital resources and treatment outcomes, physicians and patients should be aware of the modifiable factors that contribute to a patient's frailty that can ultimately impact acquiring HACs. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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Background/UNASSIGNED:Changes in spinopelvic and lower extremity alignment between standing and relaxed sitting have important clinical implications with regard to stability of total hip arthroplasty. This study aimed to analyze the effect of body mass index (BMI) on lumbopelvic alignment and motion at the hip joint. Methods/UNASSIGNED:A retrospective review of patients who underwent full-body stereoradiographs in standing and relaxed sitting for total hip arthroplasty planning was conducted. Spinopelvic parameters measured included spinopelvic tilt (SPT), pelvic incidence (PI), lumbar lordosis (LL), PI minus LL (PI-LL), proximal femoral shaft angle (PFSA), and standing-to-sitting hip range of motion. Propensity score matching controlled for age, gender, PI, and hip ostoarthritis grade. Patients were stratified into normal (NORMAL; BMI, 18.5-24.9), overweight (OW; 25.0-29.9), and obese (OB; 30.0-34.9) groups. Alignment parameters were compared using one-way analysis of variance. Results/UNASSIGNED:< .001). Conclusions/UNASSIGNED:Significant differences in sitting and standing-to-sitting change in lumbopelvic alignment based on BMI suggest obese patients recruit more posterior spinopelvic tilt when sitting to compensate for soft-tissue impingement that occurs anterior to the hip joint and limiting hip flexion.

BACKGROUND CONTEXT: Traditionally, adult spinal deformity (ASD) has been treated with long segment fusions with the goal of restoring sagittal and coronal alignment. Long segment fusions can be associated with high rates of complications and morbidity. Some patients are reluctant to undergo large procedures. Others have comorbidities excluding them as good surgical candidates for long fusions. PURPOSE: To compare baseline and postoperative HRQL and radiographic outcomes and revisions and complications in small vs longer fusions for ASD. STUDY DESIGN/SETTING: Retrospective analysis of a prospective, multicenter database PATIENT SAMPLE: Surgical ASD patients OUTCOME MEASURES: ODI, SF36-PCS, SRS22, NRS back and leg pain.
METHOD(S): A prospective database of operative ASD patients who completed two year follow up was analyzed. Prior thoracolumbar fusions were excluded. Patients were divided into short fusions (SF: 3 levels) and long fusions (LF: 36 levels). LF and SF patients were compared in baseline alignment. Propensity matching (PSM) controlling for baseline alignment (TPA and maximum coronal cobb) was performed to compare SF and LF in HRQL improvement, postop alignment and complications. Subanalysis of SF identified which patients were more likely to have successful surgery. The level of significance was p<0.05.
RESULT(S): A total of 298 patients met inclusion criteria (SF n=20, mean levels fused 2.13; LF n=275, mean fusion levels 12.33). Prior to PSM, LF had greater PT, coronal cobb, and TPA. Following PSM, LF had better improvements in PILL (20.8 vs 3.37), PT (8.57 vs 0.21), TPA (8.68 vs 2.07), and coronal cobb (17.3 vs 5.33) all p<0.005. There were no differences in 2y HROL improvement, satisfaction or reoperations. SF had fewer complications (OR 0.15, p=0.018). In the SF group, the deformities were 15% sagittal, 40% coronal, and 45% combined. In the sagittal group, 67% of surgery aimed at deformity correction but 67% of these required revision long fusion surgery. In the coronal group, 38% of surgery aimed at deformity correction with no revisions. In the combined group. 67% of surgery aimed at deformity correction but 11% of these required revision long fusion surgery.
CONCLUSION(S): This study shows that a more limited fusion could be an alternative to the more traditional long segment fusion in carefully selected patients with adult spinal deformity since there were fewer complications but similar short-term (2-year) satisfaction rates and HRQL improvements. Patients undergoing long fusions had better improvements in alignment. The majority of sagittal only deformities undergoing short fusions required revision surgery. The durability of short fusions in the setting of ASD needs to be investigated with long term studies. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Revision surgery is often necessary for adult spinal deformity (ASD) patients. Satisfaction with management is an important component of HRQOL. PURPOSE: We hypothesized that patients who underwent multiple revision surgeries following adult spinal deformity correction would exhibit lower satisfaction scores. STUDY DESIGN/SETTING: Retrospective cohort study of a prospectively collected multicenter database of ASD patients. PATIENT SAMPLE: A total of 668 patients undergoing ASD surgery and eligible for minimum 2-year follow-up were included. OUTCOME MEASURES: SRS-22r satisfaction score.
METHOD(S): Visits were stratified by occurrence prior to the index surgery (period 0), after the index surgery only (period 1) (ie, never underwent revision or had not yet undergone revision), after first revision only (period 2), and after second revision only (period 3). Patients were further stratified by prior spine surgery before their index surgery. SRS-22r satisfaction scores were evaluated at all periods using multiple linear regression adjusting for age, gender, and CCI.
RESULT(S): In total, 46.6% had 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, satisfaction increased from period 0 to 1 (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 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, 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 between visits in periods 1, 2, and 3 (all p>0.3). among patients with multiple revisions, 40% experienced rod fracture, 40% PJK, and 33% pseudarthrosis.
CONCLUSION(S): ASD patients exhibit decreased satisfaction with subsequent revision. Among patients undergoing primary surgery in our database, this effect is additive for multiple revisions. These results have important implications for surgeons, patients, insurers, hospital administrators, and policymakers. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Prior studies have demonstrated potential benefits of adult spinal deformity (ASD) surgery, but less outcomes data exist for operative ASD patients with severe scoliotic curves (thoracic [TH] curve >=75degree, thoracolumbar [TL] curve >=50degree, or lumbar [LL] curve >=50degree). Also, the surgical complication profile is less clear for this subset of patients with severe scoliotic deformity and warrants focused investigation. PURPOSE: The objective of the current study was to assess treatment outcomes and complication rates associated with ASD surgery in patients with severe scoliosis. STUDY DESIGN/SETTING: Retrospective review of a prospectively collected multicenter consecutive case registry PATIENT SAMPLE: Enrollment required: age >=18 yrs, scoliosis >=20degree, sagittal vertical axis (SVA) >=5cm, pelvic tilt >=25degree, and/or thoracic kyphosis >=60degree. OUTCOME MEASURES: Standard coronal and sagittal spinopelvic deformity measurements and health-related quality of life (HRQL) outcomes, which included Oswestry Disability Index (ODI), Short Form-36 (SF-36) scores, and Scoliosis Research Society-22 (SRS-22) scores.
METHOD(S): Using a prospective multicenter database, we identified surgically treated ASD patients with severe scoliosis (TH Cobb >=75degree or TL/LL Cobb >=50degree) and minimum 2-yr follow-up. Demographic data, surgical characteristics, radiographic alignment measurements, HRQL outcomes and associated complications were analyzed.
RESULT(S): Of 178 patients, 146 (82%, mean age 54 yrs, 92% women, 88 TL, 50 LL, 8 TH) had minimum 2-yr follow-up (mean=3.1 yrs). Almost 30% had prior spine fusion, 6% were active or past smokers, 16% had osteoporosis and 77% had at least 1 comorbidity. Surgical details included: posterior-only (58%) or anterior-posterior approach (42%), SPO (65%), 3CO (14%), TLIF (23%), ALIF (37%), sacropelvic fixation (76%), upper thoracic UIV (64%) and mean posterior fusion length of 13.2 levels. Postoperative coronal alignment improved significantly for all patients (global coronal alignment 3.8 to 2.8 cm, p< 0.001; TH Cobb 38degree to 24degree, p<0.001; TL Cobb 61degree to 30degree, p<0.001; LL Cobb 50degree to 24degree, p<0.001; Fractional Cobb 20degree to 7degree, p<0.001). Overall sagittal alignment also improved significantly (p<0.05), most notably for severe lumbar curves (C7-S1 SVA 6.7 to 2.5 cm, p<0.001; PI-LL 18degreeto 3degree, p<0.001). Overall HRQL improved significantly, including ODI (39 to 26, p<0.001), SF-36 PCS (35 to 41, p<0.001) and SRS-22r (2.9 to 3.8, p<0.001). A total of 191 complications were reported (92 minor/99 major), and 94 (64%) patients had at least one complication. The most common complications included dural tear (12%), pleural effusion (12%), rod fracture (11%), radiculopathy (8%) and proximal junctional kyphosis (7%). 34 reoperations were performed in 27 (18%) patients, with most common indications of rod fracture/pseudarthrosis (8), deep wound infection (6) and neurological deficit (5).
CONCLUSION(S): Surgery for severe adult scoliosis is associated with significant improvement in radiographic alignment and HRQL measures. Although associated complication rates are high, these appear to be comparable to reports of less severe scoliosis. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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