Faculty Bibliography

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: Few studies investigate fractional curve correction after long fusion with transforaminal (TLIF) vs anterior lumbar interbody fusion (ALIF) for adult symptomatic thoracolumbar/lumbar scoliosis (ASLS). PURPOSE: Our objective was to compare fractional correction, health-related quality-of-life (HRQL), and complications associated with L4-S1 TLIF vs ALIF in ASLS operative treatment. STUDY DESIGN/SETTING: Retrospective review of a prospectively collected multicenter consecutive case registry. PATIENT SAMPLE: Database enrollment required age >=18 years, scoliosis >=20, sagittal vertical axis (SVA) >=5cm, pelvic tilt >=25, or thoracic kyphosis >=60. OUTCOME MEASURES: Radiographic correction (including L4-S1 fractional curve), 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 was reviewed. Study inclusion required fractional curve >=10degree, thoracolumbar/lumbar curve >=30degree, index TLIF vs ALIF at L4-L5 and/or L5-S1, and minimum 2-year follow-up. TLIF and ALIF patients were propensity-matched using number and type of interbody fusion at L4-S1.
RESULT(S): Of 135 potentially eligible consecutive patients, 106 (78.5%) achieved minimum 2-year follow-up (age=60.6+/-9.3years, women=85.8%, TLIF=44.3%, ALIF=55.7%). Index operations had 12.2+/-3.6 posterior levels, iliac fixation=86.8%, and TLIF/ALIF at L4-L5 (67.0%) and L5-S1 (84.0%). ALIF had greater cage height (10.9+/-2.1 vs 14.5+/-3.0mm, p=0.001) and lordosis (6.3degree+/-1.6degree vs 17.0degree+/-9.9degree, p=0.001) and longer operative duration (6.7+/-1.5 vs 8.9+/-2.5hrs, p<0.001). Final alignment improved significantly (p<0.05): fractional curve (20.2degree+/-7.0degree to 6.9degree+/-5.2degree), maximum coronal Cobb (55.0degree+/-14.8degree to 23.9degree+/-14.3degree), C7-sagittal vertical axis (5.1+/-6.2 to 2.3+/-5.4cm), pelvic tilt (24.6degree+/-8.1degree to 22.7degree+/-9.5degree), and lumbar lordosis (32.3degree+/-18.8degree to 51.4degree+/-14.1degree). Matched analysis demonstrated comparable fractional correction (TLIF=-13.6degree+/-6.7degree vs ALIF=-13.6degree+/-8.1degree, p=0.982). Final HRQL improved significantly (p<0.05): ODI (42.4+/-16.3 to 24.2+/-19.9), SF-36 Physical Component Summary (PCS, 32.6+/-9.3 to 41.3+/-11.7), SRS-22r (2.9+/-0.6 to 3.7+/-0.7). Matched analysis demonstrated worse ODI (30.9+/-21.1 vs 17.9+/-17.1, p=0.017) and PCS (38.3+/-12.0 vs 45.3+/-10.1, p=0.020) for TLIF at last follow-up (despite no difference in these parameters at baseline). Total complication rate per patient was not different (TLIF=76.6% vs ALIF=71.2%, p=0.530), but significantly more TLIF patients had rod fractures (RF) (TLIF=28.6% vs ALIF=7.1%, p=0.036). Multiple regression demonstrated 1-mm increase in L4-L5 TLIF cage height lead to 2.2degree reduction in L4 coronal tilt (p=0.011), and 1degree increase in L5-S1 ALIF cage lordosis lead to 0.4degree increase in L5-S1 segmental lordosis (p=0.045).
CONCLUSION(S): Operative ASLS treatment with L4-S1 TLIF vs ALIF demonstrated comparable fractional curve correction (66.7% vs 64.8%) despite significantly larger, more lordotic ALIF cages. TLIF cage height had significant impact on leveling L4 coronal tilt, whereas ALIF cage lordosis had significant impact on lumbosacral lordosis restoration. Advantages of TLIF may include reduced operative duration; however, associated HRQL was inferior and more RFs were detected in this study. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Surgeons may preferentially limit fusion levels for younger vs older ASD patients to maintain motion segments and optimize postoperative function. Few data exist comparing the functional impact of upper thoracic (UT) vs thoracolumbar (TL) upper instrumented vertebra (UIV) in younger vs older ASD patients undergoing long fusion to the pelvis. PURPOSE: Evaluate patient reported functional impact of UT vs TL UIV in younger vs older ASD patients undergoing long fusion to the pelvis. 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), estimated blood loss, duration of hospital stay, postoperative complications, revision spine surgery.
METHOD(S): Surgically treated ASD patients prospectively enrolled into a multicenter ASD study were divided into 2 age groups (younger= <65 years, older= > 65 years) and separated according to UIV (TL= L2-T7; UT= T6-T1). Study inclusion criteria; 1) surgery for Lumbar (L), Sagittal (S), or Mixed (M) deformities (as per SRS-Schwab ASD classification), 2) fusion to the pelvis, 3) minimum 5 levels fused, and 4) minimum 2 year postop follow up. Surgery for double major or thoracic scoliosis were excluded. PSM was used to match preop patient demographics, scoliosis, and sagittal spinopelvic parameters including PI-LL, TK, SVS, and TPA. Surgical data evaluated and impact of UIV upon patient reported functional outcomes compared for UT vs TL for younger vs older.
RESULT(S): From 2008-2018, 435 of 717 eligible surgically treated patients were evaluated; younger (n=193; mean age 57.6 years) and older (n=242; mean age 72.3 years), mean levels fused UT=17.4, TL=10.7 (p<0.05). Preop spine deformity, demographics, and performance of osteotomies were similar for matched UT vs TL in younger and older (p>0.05). Surgical blood loss, duration of SICU and hospital stay was greater for UT vs TL in younger and older (p<0.05). UT had more revision surgery than TL due to implant failures in younger (20% vs 3%) and older (16% vs 1%), respectively (p<0.05). Older UT had more major complications than older TL (65% vs 30%). At minimum 2 year postoperative follow up spine deformity correction and all PROMs (including improvements and final values) including SRS-22r activity, SF-36 physical function, SF-36 role physical, SF-36 social function and SF-36 vitality were similar UT vs TL in younger and older (p>0.05).
CONCLUSION(S): Younger ASD patients fused to the pelvis do not report more physical restrictions for UT vs TL UIV compared to older ASD patients, however blood loss, SICU and hospital stay and complications were greater for UT vs TL in younger and older cohorts. When deciding upon UIV for ASD patients, the minimal impact of UT vs TL UIV upon patient reported outcomes must be offset by cognizance of a longer hospital stay and potential for greater postoperative complications for UT fusions especially in older patients. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Cervical alignment and cervical deformity surgery are complex topics. Recently, a score inspired by work on thoracolumbar alignment was developed for cervical alignment (cervical deformity score, CDS). While this score was designed to predict early mechanical failures, its association with patient reported outcomes (PROM) remains unclear. PURPOSE: Investigate the association between PROM, complications, and a newly described cervical deformity score. STUDY DESIGN/SETTING: Retrospective review of prospective multicenter database. PATIENT SAMPLE: A total of 102 adult cervical deformity (CD) patients with at least 1 year follow-up. OUTCOME MEASURES: NDI, neck pain, EQ5D, complication rates.
Method(s): CD patients with baseline and 1-year follow-up were included. Postoperative CDS was constructed using offset from age-adjusted values: SVA [(age -55)*2+25], T1 Slope [(age -55)/4 + 28.7], and TS minus CL [cst: between 26.5 and 14.5degree]. Points were assigned based on the offset from alignment targets and the CDS was the sum of the three individual scores. Association with patient-reported outcomes was investigated using Pearson's correlations. Comparison of CDS between patients with and without complication within 1-year was conducted. Logistical regression controlling for demographic and comorbidities was conducted to identify if CDS was an independent predictor of complications.
Result(s): A total of 102 patients met inclusion criteria (61.7yo+/-10, 66.7% F); 37.6% of them had a history of previous cervical surgery (16.7% previous ACDF, 11.7% previous posterior fusion). Preoperatively, they had elevated disability (NDI: 47.1+/-18.1), pain (NSR Neck: 6.6+/-2.5), myelopathy (mJOA: 13.6+/-2.7) and lower general health (EQ5D: 0.74+/-0.07). They also presented with an overall cervical kyphotic alignment (C2-C7: -6.3degree+/-20.9), a moderate cervical anterior alignment (cSVA: 39mm+/-20; TS-CL: 37.9degree+/-19.4) and a posterior global thoracolumbar alignment (SVA: -3mm+/-68). The median of number of levels fused was 7 [4-9], with 49% treated with a posterior approach and 30.4% with a combined approach; 83.2% received an osteotomy, 44.6% some posterior osteotomy, 16.8% grade 6 or 7. The mean operative time was 368min+/-208, median EBL was 525cc [200 1025], and LOS was 5 days [4 8]. At 1 year, patients improved significantly in terms of disability (NDI: 36.2+/-20.7, 60.8% reached MCID), pain (NSR: 4.1+/-2.9) and general health (EQ5D: 0.79+/-0.08) (all p<0.001). The cervical alignment significantly changed (C2-C7: 7.8+/-14.5m; cSVA: 34mm+/-15; TS-CL: 28.9degree+/-12.6 all p <0.002), with a 1-year CDS of 1.68+/-2.46 (prctl [0 3.25]). There was a significant association between increased CDS and increased disability (r=0.273), pain (r=0.336) and lower general health (r=-0.283). Patient with a lower disability level (NDI<20) had a significantly lower CDS (0.71+/-2.3 vs 2.16+/-2.4 p<0.004). Patients without any complications before 1 year had a lower CDS (0.78+/-2.33 vs 2.18+/-2.40 p=0.005), as did patients without major complications (1.36+/-2.27 vs 2.50+/-.78 p=0.037). Deeper analysis revealed significant differences in terms of CDS for patients experiencing cardiopulmonary, instrumentation and radiographic complications (p<0.05). Multivariate analysis, controlling for age and comorbidities, show 1-year CDS to be a significant predictor of complication (p=0.002, OR=1.409).
Conclusion(s): With better outcomes and lower complication rate, maintaining a proportionate alignment postoperatively can result in superior outcomes following CD surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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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: 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: 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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