Faculty Bibliography

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

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

Introduction/UNASSIGNED:Patients with symptomatic cervical deformity (CD) requiring surgical correction often present with hyperkyphosis (HK), though patients with hyperlordotic curves may require surgery as well. Few studies have investigated differences in CD-corrective surgery with regards to HK and hyperlordosis (HL). Materials and Methods/UNASSIGNED:Operative CD patients (C2-C7 Cobb >10°, cervical lordosis [CL] >10°, cervical sagittal vertical axis [cSVA] >4 cm, chin-brow vertical angle >25°) with baseline (BL) and 1Y radiographic data. Patients were stratified based on BL C2-7 lordosis (CL) angle: those >1 standard deviation (SD) from the mean (-6.96° ±21.47°) were hyperlordotic (>14.51°) or hyperkyphotic (≤28.43°) depending on directionality. Patients within 1 SD were considered the control group. Results/UNASSIGNED:< 0.001), however postoperative differences in McGregor's slope and C0-C2 were not significant. HK drivers of deformity were primarily C (90%), whereas HL had primary computed tomography (38.1%), upper thoracic (23.8%), and C (14.3%) drivers. Conclusions/UNASSIGNED:Hyperlodotic patients trended higher revision rates with greater radiographic malalignment at 1Y postoperative, perhaps due to undercorrection compared to kyphotic etiologies.

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

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

STUDY DESIGN/METHODS:Retrospective review. OBJECTIVE:The aim of this study was to evaluate outcomes of matching Roussouly and improving in Schwab modifier following adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:The Roussouly Classification system of sagittal spinal shape and the SRS-Schwab classification system have become important indicators of spine deformity. No previous studies have examined the outcomes of matching both Roussouly type and improving in Schwab modifiers postoperatively. METHODS:Surgical ASD patients with available baseline (BL) and 1 year (1Y) radiographic data were isolated in the single-center spine database. Patients were classified by their "theoretical" and "current" Roussouly types as previously published. Patients were considered a "Match" if their theoretical and current Roussouly types were the same, or a "Mismatch" if the types differed. Patients were noted as improved if they were Roussouly "Mismatch" preoperatively, and "Match" at 1Y postop. Schwab modifiers at BL were categorized as follows: no deformity (0), moderate deformity (+), and severe deformity (++) for PT, SVA, and PI-LL. Improvement in SRS-Schwab was defined as a decrease in any modifier severity at 1Y. RESULTS:103 operative ASD patients (61.8 years, 63.1% female, 30 kg/m2) were included. At baseline, breakdown of "current" Roussouly type was: 28% Type 1, 25.3% Type 2, 32.0% Type 3, 14.7% Type 4. 65.3% of patients were classified as Roussouly "Mismatch" at BL. Breakdown of BL Schwab modifier severity: PT (+: 41.7%, ++: 49.5%), SVA (+: 20.3%, ++: 50%), PI-LL (+: 25.2%, ++: 46.6%). At 1 year postop, 19.2% of patients had Roussouly "Match". Analysis of Schwab modifiers showed that 12.6% improved in SVA, 42.7% in PI-LL, and 45.6% in PT. Count of patients who both had a Roussouly type "Match" at 1Y and improved in Schwab modifier severity: nine PT (8.7%), eight PI-LL (7.8%), and two SVA (1.9%). There were two patients (1.9%) who met their Roussouly type and improved in all three Schwab. 1Y matched Roussouly patients improved more in health-related quality of life scores (minimal clinically important difference [MCID] for Oswestry Disability Index [ODI], EuroQol-5D-3L [EQ5D], Visual Analogue Score Leg/Back Pain), compared to mismatched, but was not significant (P > 0.05). Match Roussouly and improvement in PT Schwab met MCID for EQ5D more (P = 0.050). Matched Roussouly and improvement in SVA Schwab met MCID for ODI more (P = 0.024). CONCLUSION/CONCLUSIONS:Patients who both matched Roussouly sagittal spinal type and improved in SRS-Schwab modifiers had superior patient-reported outcomes. Utilizing both classification systems in surgical decision-making can optimize postop outcomes.Level of Evidence: 3.

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

STUDY DESIGN/METHODS:Retrospective review of a prospectively enrolled multicenter Adult Spinal Deformity (ASD) database. OBJECTIVE:Investigate invasiveness and outcomes of ASD surgery by frailty state. SUMMARY OF BACKGROUND DATA/BACKGROUND:The ASD Invasiveness Index incorporates deformity-specific components to assess correction magnitude. Intersections of invasiveness, surgical outcomes, and frailty state are understudied. METHODS:ASD patients with baseline and 3-year (3Y) data were included. Logistic regression analyzed the relationship between increasing invasiveness and major complications or reoperations and meeting minimal clinically important differences (MCID) for health-related quality-of-life measures at 3Y. Decision tree analysis assessed invasiveness risk-benefit cutoff points, above which experiencing complications or reoperations and not reaching MCID were higher. Significance was set to P < 0.05. RESULTS:Overall, 195 of 322 patients were included. Baseline demographics: age 59.9 ± 14.4, 75% female, BMI 27.8 ± 6.2, mean Charlson Comorbidity Index: 1.7 ± 1.7. Surgical information: 61% osteotomy, 52% decompression, 11.0 ± 4.1 levels fused. There were 98 not frail (NF), 65 frail (F), and 30 severely frail (SF) patients. Relationships were found between increasing invasiveness and experiencing a major complication or reoperation for the entire cohort and by frailty group (all P < 0.05). Defining a favorable outcome as no major complications or reoperation and meeting MCID in any health-related quality of life at 3Y established an invasiveness cutoff of 63.9. Patients below this threshold were 1.8[1.38-2.35] (P < 0.001) times more likely to achieve favorable outcome. For NF patients, the cutoff was 79.3 (2.11[1.39-3.20] (P < 0.001), 111 for F (2.62 [1.70-4.06] (P < 0.001), and 53.3 for SF (2.35[0.78-7.13] (P = 0.13). CONCLUSION/CONCLUSIONS:Increasing invasiveness is associated with increased odds of major complications and reoperations. Risk-benefit cutoffs for successful outcomes were 79.3 for NF, 111 for F, and 53.3 for SF patients. Above these, increasing invasiveness has increasing risk of major complications or reoperations and not meeting MCID at 3Y.Level of Evidence: 3.

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: ASD is a complex pathology that benefits greatly from surgical treatment despite being associated with high rates of complications. Despite continuous innovation, little is known regarding the association between changes in surgical techniques and complications. PURPOSE: To investigate the evolution of patient profiles and surgical complications across a single prospective multicenter database. STUDY DESIGN/SETTING: Retrospective review of prospective data. PATIENT SAMPLE: This study included 947 adult spinal deformity patients surgically treated between 2008 and 2018. OUTCOME MEASURES: Complication types and rates.
METHOD(S): Surgical ASD patients (TK >60degree, SVA >5cm, PT >25degree or Cobb angle >20degree) with minimum 2-year follow-up were included and stratified into 3 equal groups by date of surgery. Demographic, preoperative data, surgical information, and complications were compared across time using a moving average of 316 patients to delineate those enrolled at the beginning of the study (Early) from the most recent one (Late).
RESULT(S): Among the total, 947/1260 (67%) patients completed their 2-year follow-up with an enrollment rate of 7.7+/-4.1 patients per month. Compared to the Early phase (Oct 2008 and Nov 2012), patients enrolled more recently (Jan 2016 to Jan 2018) were older (Age: 56.7+/-15yovs 64.3+/-12.3), sicker (CCI: 1.46+/-1.6 vs 2.08+/-1.78), more disabled (ODI: 42.6+/-19.4 vs 45.7+/-15.3; PCS: 32.8+/-10.4 vs 29.7+/-8.5), with more pronounced sagittal deformity (SRS-Schwab type N: 26.3% vs 50.9%: PI-LL modifier ++: 37.1% vs 46.8%) (all p<0.05). Changes in surgical treatment included an increase use of IBF (61% vs 69.9%), more ACR/3CO use (21% vs 37%) and a decrease in 3CO rate (21% vs 12%), shorter fusion (11.2+/-4 vs 9.8+/-5), more supplemental rods (0.3% vs 26.9%) and BMP use (64.1% vs 80.1%) (all p<0.05), but no significant difference in invasiveness (91.2+/-37.1 vs 86.0+/-36.9 p=0.06). LOS decrease by 1 day, EBL by 500 cc and rate of ICU stay decrease from 71% to 53% (all p <0.001). There was no significant difference in overall complication rate (73% vs 67.4% p=0.14) despite a significant decrease in major complications requiring a reoperation (27.6% vs17.4% p=0.002) driven by a decrease in implant (8.3% vs 4.1% p=0.032) and radiographic failures (12.7% vs 5.7% p=0.002). Rate of major operative complication decreased (11.8% vs 6.7% p=0.028) while rate of major radiographic complication increased (0.6% vs 5.7% p<0.001) leading to a stable rate of major complications without reoperation (28.3% vs 27.9% p=0.92). No significant difference in minor complication rate (38.7% vs 34.2% p=0.24) The moving average analysis revealed a steady decrease in major complications associated to a reoperation (from 28% to 17%). The lowest peak of major complications (21%) occurred between Feb 2014 and Oct 2016, and the lowest overall complication rate (62%) occurred between July 2014 and Feb 2017.
CONCLUSION(S): Despite an increase in patient complexity including older, more medical morbidities and larger deformities, complication rates did not increase and the rate of complications requiring surgery decreased over time. These findings likely reflect evolutions in practice improvement including use of supplemental rods, PJK prophylaxis, BMP use, and targeting age-appropriate deformity corrections. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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