Faculty Bibliography

BACKGROUND CONTEXT: Although epidural steroid injection (ESI) has been shown to provide adequate pain relief for degenerative spondylolisthesis patients in treatment regimens up to months, it remains unclear whether the use of ESI affects the rate of crossover from nonoperative to operative management. PURPOSE: Investigate the relationship between epidural steroid injections and rates of surgical crossover for degenerative spondylolisthesis patients. STUDY DESIGN/SETTING: Retrospective review of prospectively collected data from 13 spine centers. PATIENT SAMPLE: Degenerative spondylolisthesis patients from both the randomized and concurrent observational cohorts of the Spine Patient Outcomes Research Trial (SPORT). OUTCOME MEASURES: Primary: Surgical crossover rates. Secondary: health related quality of life outcome (HRQL) measures (SF-36, ODI, Sciatica and Leg Pain Bothersomeness Indices), self-reported improvement METHODS: Included: surgical candidates >18yrs with degenerative spondylolisthesis. Excluded: patients receiving ESI before enrollment. Those who received ESI within 3 months of enrollment (ESI) and those who did not (no-ESI) were compared for differences in baseline characteristics. Outcomes at 1-year, 2-year, 3-year, and 4-year intervals following enrollment were assessed within operative and nonoperative groups using longitudinal mixed-effect models with random subject intercept term to account for correlations between repeated measurements. Treatment comparisons were performed at follow-up intervals. Area under the curve analysis for all time points assessed global significance of treatment.
RESULT(S): Included: 266 patients (192 no-ESI, 74 ESI). Patient groups did not differ in age, sex, BMI, or comorbidity burden (all p>0.05). No-ESI had greater baseline SF-36 body-pain scores (38+/-20 vs 30+/-16, p=0.002) and self-reported surgical preference (38% vs 11%, p<0.001). There were no differences in surgical rates within 4-years of enrollment between no-ESI and ESI patients (61% vs 62%, p=0.97). Surgical ESI and no-ESI patients did not differ in op-time, blood loss, rates of decompression, multilevel fusion or levels decompressed (all p>0.05). Surgical ESI and no-ESI patients showed no differences in postoperative HRQL changes at any follow-up interval, or in 4-year average HRQL outcomes. Non-operative no-ESI patients showed greater 4-year average improvement in SF-36 body pain (no-ESI: 17.8, ESI: 7.8, p=0.004) and physical function (no-ESI: 13.1, ESI: 4.3, p=0.005) than non-operative ESI patients. These improvements in SF-36 body pain were greater for non-operative no-ESI patients at 1-year (p=0.002) and 3-years (p=0.005); improvements in SF-36 physical function were greater for non-operative no-ESI patients at 1-year (p=0.030) and 2-years (p=0.002). Of patients that were initially non-operative, there was no difference between ESI and no-ESI groups in surgical crossover rates (ESI: 52%, no-ESI: 39%, p=0.15). For operative patients, crossover rates to non-operative treatment did not differ between ESI and no-ESI groups (ESI: 23%, no-ESI: 16%, p=0.38).
CONCLUSION(S): For surgical degenerative spondylolisthesis patients, there was no relationship between ESI and improved clinical outcomes over a 4-year study. For nonoperative patients, ESI was associated with inferior pain reduction through 3 years of follow-up; however, this was confounded by higher levels of baseline pain. ESI showed little relationship with surgical crossover. FDA DEVICE/DRUG STATUS: Unavailable from authors at time of publication.
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BACKGROUND CONTEXT: The shared decision-making (SDM) process is an opportunity to deliver answers to frequently asked questions (FAQs) in adult spinal deformity (ASD) surgery. PURPOSE: Our goal was to present a concise list of answers to these FAQs to aid in SDM counseling. STUDY DESIGN/SETTING: Retrospective analysis of a prospective multi-center ASD database. PATIENT SAMPLE: Adult spinal deformity patients undergoing surgical correction enrolled into a prospective, multicenter surgical database from 2008-2016. OUTCOME MEASURES: Health related quality of life (HRQOL) outcome measures were collected such as Oswestry Disability Index (ODI), SF-36 PCS, and SF-36 MCS.
METHOD(S): Adult patients undergoing >= 5 level fusion with minimum 2-year follow up were included. We purposely included all deformity types (heterogeneity) to provide general applicability. We compiled a list of FAQs by patients undergoing ASD surgery and utilized a retrospective analysis to provide answers. All responses are reported as either means or reaching minimal clinically important difference (MCID) at the 2-year follow-up interval.
RESULT(S): Out of 689 ASD patients eligible for 2-year follow-up, 521 (76%) had complete follow-up. The majority were female (77%) with mean age of 58.5 years and BMI of 27.5. Mean levels fused were 11.3 with 52% being primary vs 48% revision surgeries. Will my pain improve? Back (7.2 to 3.6) and leg (4.7 to 2.6) pain were both reduced by ~50%. Will my activity level improve? A total of 63.9% reached MCID for SRS-22r activity. Will I feel better about myself? A total of 71.2% reached MCID for SRS-22r appearance. Is there a chance I'm worse? A total of 4.1% of patients were worse (ODI). What is the likelihood I have a complication? A total of 52.9% of patients have at least 1 complication and 29.6% have a major complication. Will I need another surgery? A total of 29.6% of patients have a reoperation within 2 years. Will I regret having surgery? A total of 32% would not choose the same treatment. Will I get a blood transfusion? A total of 79.1% of patients receive a blood transfusion. How long will I stay in the hospital? Study showed 9.9 days. Will I have to go to the ICU? A total of 79.1% of patients require an ICU stay. Will I be able to return to work? A total of 71% returned to full-time work at 2 years. Will I be taller after surgery? Yes, 1.4cm was the average
CONCLUSION(S): The above list provides concise, practical answers to FAQs encountered in the SDM process while counseling patients for ASD surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Proximal junctional kyphosis (PJK) is a devastating complication of adult spinal deformity (ASD) surgery. Optimal alignment specifications to maximize quality of life while limiting PJK have yet to be defined. Previous studies have primarily examined sagittal vertical axis (SVA) to determine likelihood of PJK. More recently, other alignment parameters such as thoracic-pelvic angles (TPAs) and age-adjusted alignment have been examined. PURPOSE: The goal of this study is to examine the relationship between GAP, TPAs, and bracing with likelihood of developing PJK. STUDY DESIGN/SETTING: A retrospective chart review was conducted to identity ASD patients with at least 1 year of radiographic follow up. PATIENT SAMPLE: Patients who underwent fusions to the pelvis and >4 levels fused from 2013 to 2018 and have 1-year postoperative alignment x-rays were included. OUTCOME MEASURES: The rate of radiographic PJK (change of 10-20degree) and severe PJK (change>20degree) was determined for each group. Reoperation rates were also collected.
METHOD(S): Surgical records were reviewed to determine patient sample. Chart and X-ray review were conducted to determine spinopelvic alignment parameters, GAP scores, bracing, and reoperation. X-rays were reviewed up to one year postoperatively in order to determine PJK.
RESULT(S): A total of 81 patients were included (mean 64y 63%F); baseline and 1-year postoperative alignment did not differ between PJK and no PJK patients. There was no PJK in 53.1%, 30.9% had PJK from 10-20degree, and 16% had sPJK. Of these, 7 patients had revision surgery: 1 for PJK and 1 for rod fracture. Postop bracing was used in 54% of patients. There was no difference in sPJK according to brace use. At baseline, 79% of patients had severely disproportioned GAP, 16% moderate, 5% proportioned. Of severely disproportioned, 63% had no change in GAP at 1 year. Improved GAP was not associated with sPJK (improved: 22% vs no change: 18%, p=.72). Greater correction of the UIV-PA was associated with a larger PJK angle change (R=.26) as was the 1 year T1-UIV angle (R=.30), both p<.05.GAP change was not correlated with PJKA change. The magnitude of T1PA correction was not associated with sPJK, p>.05.
CONCLUSION(S): There was no correlation between PJK and GAP alone or change in GAP; it is notable that these patients tended to be disproportioned pre and postop. Greater correction of UIV-PA and larger postop T1-UIV was associated with greater PJKA change; suggesting that the greater alignment correction led to greater likelihood of it failing. Our data suggest bracing was not effective in preventing PJK. These parameters may help surgeons understand alignment targets in ASD. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Surgical correction of cervical deformity (CD) can improve a patient's functional status, but is often associated with suboptimal radiographic and clinical outcomes. Although prior studies have demonstrated a high prevalence of thoracolumbar deformity among CD patients, correction of the cervical deformity often fails to address global malalignment, which may contribute to the high rates of treatment failure. The relationship between global alignment and successful CD correction remains unclear. PURPOSE: To investigate whether spinopelvic alignment (SPA) is associated with outcomes following CD correction STUDY DESIGN/SETTING: Retrospective review of a prospective CD database PATIENT SAMPLE: A total of 97 patients with CD. OUTCOME MEASURES: One-year cervical alignment, Neck Disability Index (NDI) scores, distal junctional kyphosis (DJK).
METHOD(S): A database of operative CD patients was analyzed. Inclusion criteria: cSVA>4cm or C2-slope>20degree. Failure was defined as: 1-year cSVA >4cm, NDI change20degree). Failed surgeries were compared with respect to pelvic angles (TPA, T10PA, C2PA), C2-pelvic tilt (CPT), and pelvic incidence (PI). Age- and PI-specific alignment targets were calculated for TPA and T10PA.
RESULT(S): A total of 97 CD patients were included (mean 62+/-11y, 62%F). At 1 year 57% had alignment failure, 39% failed to reach NDI MCID and 12% developed DJK. 66% had baseline thoracolumbar malalignment (>1 +Schwab modifier). Alignment failure was associated with worse BL cervical alignment and higher rate of DJK (16% vs 2%), all p<.05; it was not associated with achieving NDI MCID. Failed alignment patients had greater BL C2PA (21degree vs 16degree) as did patients reaching NDI MCID(21degree vs 15degree), both p<.05. BL C2PA was not associated with DJK. On average, DJK patients had a BL TPA 6degree less than optimal (vs no DJK=-0.03degree) and smaller BL T10PA (-0.2degree vs 7degree). T1PA/T10PA was not associated with alignment failure or NDI improvement. Alignment failure patients had higher BL CPT(53degree vs 36degree) and 76% with a CPT>48.5 reached NDI MCID(<48.5=56%), both p<.05. PI was not associated with any outcomes. Failed alignment was associated with worse 1y C2PA (23vs16degree, p<.05).
CONCLUSION(S): Two-thirds of CD patients had concurrent TL deformity. Patients with failed alignment had worse BL CA, but successful cervical realignment was not associated with NDI improvement. This study demonstrates that SPA is associated with radiographic and clinical outcomes following CD correction. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Risk factors have been identified for complications following adult spinal deformity (ASD) surgery; however, the risk of complications following ASD surgery in relation to the degree of surgical invasiveness is unknown. Understanding the relationship between surgical invasiveness and risk of major complications is important to patients and surgeons for estimating these risks based upon the planned surgical treatment. PURPOSE: To define a surgical invasiveness threshold that predicts increased likelihood of major complications following surgical treatment of ASD. STUDY DESIGN/SETTING: Retrospective review of a prospective multicenter database PATIENT SAMPLE: Five hundred seventy-four of 760 (76%) eligible ASD patients (>5 levels fused) were identified in a multicenter database with complete 2-year follow-up OUTCOME MEASURES: Our primary outcome was development of a major complication at any time point in the postoperative period METHODS: Surgical invasiveness was calculated according to the previously published and validated ASD Surgical and Radiographic (ASD-SR) score, which assigns point values to 13 operative and radiographic factors. Youden's index was used to identify the highest predicted probability cut-off of developing a major complication to be an ASD-SR of 90. Using this value, patients were divided into quartiles (Q1: ASD-SR 0-65; Q2: ASD-SR 66-89; Q3: ASD-SR 90-119; Q4: ASD-SR 120+). Odds of developing a major complication were analyzed after controlling for baseline frailty and radiographic deformity.
RESULT(S): Mean age of patients was 59 +/- 14 years, 79% females. Mean levels fused were 11.2 +/- 4.3. The overall risk of a major complication was 17% in Q1, 21% in Q2, 35% in Q3 and 33% in Q4 (p<0.001). Comparing the odds of a major complication by adjacent quartiles demonstrated a significant increase between Q2 and Q3 (OR 1.8, 95% CI 1.03, 2.98), while the risk of increasing invasiveness from Q1 to Q2, and Q3 to Q4 were not significant (p<0.05). Similarly, patients above an ASD-SR cutoff point of 90 (Q3/Q4) were 1.9 times more likely to have a major complication than patients with a surgical invasiveness below this threshold (Q1/Q2) (OR 1.9, 95% CI 1.3 - 2.9). There were no significant differences in the odds of having a minor complication or inpatient medical complication between invasiveness groups (all p>0.05). The mean ASD-SR scores above and below the ASD-SR threshold of 90 were 120.7 +/- 25.4 and 63.4 +/- 16.8, respectively. Example of a patient with an ASD-SR of 63 (low invasiveness): T11-Pelvis, 6 Smith-Peterson Osteotomies, -.9cm change in SVA, +1degree change in TK, + 43degree change in PT. Example of a patient with an ASD-SR of 121 (high invasiveness): T8-Pelvis, 3-column osteotomy, -2.3cm change in SVA, -5degree change in TK, +38degree change in PT.
CONCLUSION(S): ASD patients have an increased risk of major complications above an ASD-SR score of 90, while the risk of minor complications and inpatient medical complications is not significantly increased. The ASD-SR score can be used as a tool to counsel patients regarding these increased risks. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The impact of worsening activities of daily living (ADL) such as spine-related financial difficulty and attending work/school have not been studied as potential independent predictors of failing nonoperative management of adult spinal deformity (ASD). PURPOSE: To identify which specific ADLs assessed with the Scoliosis Research Society 22r (SRS-22r) can identify patients with ASD who are likely to fail nonoperative management. STUDY DESIGN/SETTING: Prospective, observational study. PATIENT SAMPLE: A total of 482 patients initially selected for nonoperative treatment of ASD patients were identified from a multicenter database. Of these, 55 (11%) had eventual crossover to operative intervention. Propensity score matching (PSM) was performed using age, gender and baseline Oswestry Disability Index (ODI) to create matched cohorts of 46 crossover (CX) and 46 noncrossover (NC) patients. OUTCOME MEASURES: Our primary outcome was crossover to operative treatment among patients who were originally intended to be treated nonoperatively.
METHOD(S): Scoliosis Research Society (SRS-22r) questionnaire was administered at baseline, 6-weeks, 6-months and both 1 and 2 years. Change in overall score, subdomains and responses to specific questions over time were classified as increasing, decreasing or unchanged in relation to baseline. Kaplan-Meier curves were produced for time to crossover among patients by change in SRS-22r domains, and compared using log-rank test. Significant was set at 0.05.
RESULT(S): NC and CX groups were similar among age, baseline ODI, and SVA (p>0.05). Patients had a mean age 55 +/- 15 years; ODI of 35 +/- 15; SVA of 3.5 +/- 5.9cm. Mean time to crossover was 1.7 +/- 1.4yrs. Decline in SRS-22r Total and Activity domains were associated with increased risk of failing nonoperative management (p=0.005, p=0.006), while decline in SRS-22r pain, appearance and mental health domains were not significantly associated with failure. Analysis of specific ADLs within the activity domain showed worsening financial hardship, level of activity and going out with friends/family to be associated with failure, while work/school activity and doing household chores were not.
CONCLUSION(S): Decline in SRS-22r Activity is the primary SRS-22r domain independently associated with failing nonoperative management of ASD. Within this domain, worsening physical activity, spine-related financial hardship and decreasing time with family/friends drive patients to undergo surgery, while the ability to perform household chores and attend work/school are not independently associated with failing nonoperative management. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Returning to full-time work postoperatively is important to employed adults undergoing surgical treatment of adult spinal deformity (ASD). It is important for both patients and providers to have realistic expectations of returning to work after surgery, and to understand the extent to which more invasive surgery may modify a patient's return to work. PURPOSE: Our purpose was to identify the frequency of employed ASD patients who are working full-time postoperatively, and the impact of surgical invasiveness on the percentage of patients who are working full time postoperatively at various time points. STUDY DESIGN/SETTING: Retrospective review of a prospective, multicenter database. PATIENT SAMPLE: A total of 255 ASD patients were identified in a multicenter database who were employed prior to surgery and eligible for 2-year follow-up. Of these patients, 188 (74%) had 2-year follow-up or returned to work at any point within 2 years postoperatively and were included in the final cohort. OUTCOME MEASURES: Our primary outcome was returning to full-time work following surgery.
METHOD(S): Working full-time was defined as reporting 75-100% of normal work/school activity per question 9 of the Scoliosis Research Society Version 22-revised (SRS-22r) questionnaire. Surgical invasiveness was measured according to the ASD Surgical and Radiographical (ASD-SR) invasiveness index, a tool that has been developed and validated to measure the invasiveness of ASD surgery. Patients were separated into high invasiveness (HI) or low invasiveness (LI) groups for ASD-SR scores above and below 100, respectively based on previously established invasiveness categories. Chi-squared and fisher exact test were used to compare categorical variables.
RESULT(S): Mean age of patients was 51 +/- 15 years of age, 79% females. Overall, 69% of these employed patients were working full-time preoperatively, 15% were working full-time at 6-weeks, 70% at 6 months, 83% at 1-year and 84% at 2-years. The percentage of patients working full time was significantly improved at 2-years compared to preoperatively (p<0.001). The difference in patients returning to full-time work in HI and LI groups was significantly different at 6-weeks (5% in high invasiveness vs 19% with low invasiveness, p=0.03), and this difference decreased to non-significant levels at 6-months, 1-year and 2-years (p>0.05).
CONCLUSION(S): The majority of employed adults will return to full-time work following ASD surgery. More patients are working full time at 2-years postoperatively compared to preoperatively, and patients with higher invasiveness surgery may have a delay in return-to-work in the immediate postoperative period. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Age specific alignment targets have been shown to optimize outcomes and minimizing the risks of mechanical failure like proximal junctional kyphosis (PJK). Recently, PI has been shown to be an important determinant of spinal alignment but the role of PI and age-optimal alignment has not been analyzed simultaneously with respect to PJK and clinical outcomes. Previous PJK studies have used SVA to measure over- or undercorrection, however in patients with PJK, SVA underestimates the overcorrection because of patient compensation and the PJK itself increases the SVA. The T1 Pelvic Angle (TPA) has been proposed as useful perioperative planning parameter; using the component of TPA within the fusion (T10PA) allows for measuring spinopelvic alignment separate from that of the unfused thoracic spine and any PJK that may occur postoperatively. PURPOSE: To identify age- and PI-optimal alignment targets using a component angle of TPA within the fusion to define over and under-correction and their relationship to PJK and clinical outcomes. STUDY DESIGN/SETTING: Retrospective analysis of a prospective, multicenter database PATIENT SAMPLE: Operative ASD patients OUTCOME MEASURES: SF36-PCS, PJK METHODS: A prospective database of operative ASD patients was analyzed. Patients with fusions to the pelvis and UIV above T11 were included in the PJK analysis. Alignment within the fusion was correlated with clinical outcomes and PI. SF36-PCS normative data were used to compute PI- and age-optimal alignment for each patient. Over-, under- and optimally-corrected groups were determined using intervals from optimal alignment within the fusion to define the group boundaries. The rate of severe PJK (change>20degree) was determined for each group.
RESULT(S): A total of 1052 patients met inclusion criteria. Alignment within the fusion correlated with SF36-PCS and PI. At 6 weeks, 40.7% were optimally-corrected vs 39.4% overcorrected vs 20.9% undercorrected. The overall rate of PJK was 13.6%. Overcorrected patients had the highest PJK rate (18.1%) compared with optimally (11.3%) and undercorrected (9.5%), p<.05; and overcorrected patients had a trend towards more PJK revisions (2.1% vs 1.2% vs 0%, p=.09). All groups improved in HRQL from baseline to 1 year (all p<.05) but undercorrected patients had the worst 1-year SF36-PCS offset relative to normative patients of equivalent age (-8.1) vs optimal (-6.1) and overcorrected (-4.5), p<0.05.
CONCLUSION(S): A component angle of TPA within the fusion, separate from the PJK, was used to determine age and PI-optimal alignment. Correcting ASD patients to optimal alignment within the fusion produced clinical outcome improvements with the lowest rates of PJK. This age and PI-specific approach to spinal alignment within the fusion provides ASD correction targets for surgeons that can be used intraoperatively. Future studies are warranted to verify the reliability of such intraoperative spinopelvic measurements. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Miller et al adult spinal deformity frailty index (ASD-FI) correlates with increased complication risk after surgery; however, its development was not rooted in clinical outcomes, and the 40 factors needed for its calculation limit the index's utility in a clinical setting. PURPOSE: Develop a simplified, weighted frailty index for ASD patients. STUDY DESIGN/SETTING: Retrospective review of prospective ASD database. PATIENT SAMPLE: A total of 50 ASD patients. OUTCOME MEASURES: Health-related quality of life questionnaires: Oswestry Disability Index (ODI), SRS-22r, pain catastrophizing scale, Numerif Rating Scale (NRS) for Leg Pain.
METHOD(S): ASD patients (scoliosis>=20degree, SVA>=5cm, PT>=25degree, or TK >=60degree) with baseline ASD-FI component factors. Component ASD-FI parameters contributing to overall ASD-FI score were assessed via Pearson correlation. Top significant, clinically relevant factors were regressed against ASD-FI score to generate the modified ASD-FI (mASD-FI). Factors comprising the mASD-FI were regressed against the incidence of medical complications; weights for mASD-FI factors were calculated from these regression coefficients via the beta/Sullivan method. Total mASD-FI score was calculated by summing weights of expressed parameters, resulting in a score ranging from 0 to 21. Linear regression correlated ASD-FI and mASD-FI scores, and previously published ASD-FI cutoffs were used to generate corresponding mASD-FI frailty cutoffs: not frail (NF,<7), frail (7-12), severely frail (SF,>12). Analysis of variance assessed the relationship between increasing frailty category and validated baseline measures of patient pain and disability.
RESULT(S): Included: 50 ASD patients (52+/-20yrs, 78% female). All the following preoperative factors correlated with ASD-FI score (all p<0.039), and combined, accounted for 85.0% (p<0.001) of the variation in ASD-FI score: BMI <18.5 kg/m2 or >30 kg/m2 (weight: 5), depression (weight: 5), difficulty climbing stairs (3), presence of >3 medical comorbidities (2), leg weakness (2), difficulty getting dressed (1), bladder incontinence (1), and patient-reported deterioration in health within the past year (1). These factors were used to calculate the overall population's mean mASD-FI score: 5.7+/-5.2. Combined, these factors comprising the mASD-FI showed a trend of predicting the incidence of medical complications (Nagelkerke R2=0.558, Cox & Snell R2=0.399, p=0.065). Overall patient breakdown by mASD-FI frailty category: NF (70%), frail (12%), SF (18%). Increasing frailty category was associated with significant impairments in validated measures of disability, including ODI score (NF: 23.4, frail: 45.0, SF: 49.3, p<0.001), SRS-22r score (NF: 3.5, frail: 2.6, SF: 2.4, p=0.001), pain catastrophizing scale score (NF: 41.9, frail: 32.4, SF: 27.6, p<0.001), and NRS Leg Pain (NF: 2.3, frail: 7.2, SF: 5.6, p=0.001).
CONCLUSION(S): This study modifies an existing ASD frailty index and proposes a weighted, shorter mASD-FI. The mASD-FI relies less on patient-reported variables, and weights component factors by their contribution to adverse outcomes. As increasing mASD-FI score is associated with inferior clinical measures of pain and disability, the mASD-FI may serve as a valuable tool for preoperative risk assessment. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Chronic opioid use is an emergent public health issue in the United States. Opioids are regularly prescribed to patients with adult spinal deformity (ASD) for postoperative pain. Therefore, the potential for chronic postoperative opioid use is a significant concern for patients undergoing surgery for ASD. It is important to patients, surgeons and policymakers to understand preoperative risk factors for prolonged opioid use in ASD patients who were not using opioids regularly prior to surgery. PURPOSE: To demonstrate demographic and surgical factors associated with increased risk of chronic opioid use following surgery in ASD patients who were not regularly using opioids preoperatively. STUDY DESIGN/SETTING: Retrospective review of a multicenter database. PATIENT SAMPLE: A total of 760 ASD patients were identified in a multicenter database eligible for 2-year follow-up. Of these patients, 547 (72%) had complete baseline and 2-year responses to question 11 of the Scoliosis Research Society version 22r (SRS-22r), which allowed us to categorize patients into opioid users and non-opioid users. Of these, 251/547 patients (46%) were not using opioids regularly prior to surgery and included in our analysis. OUTCOME MEASURES: Our primary outcome was chronic postoperative opioid use, and secondary outcome was patient satisfaction.
METHOD(S): Among patients who were not using opioids regularly prior to surgery, those reporting routine opioid use at 1 or 2-year follow-up were classified as CU (chronic user), while patients reporting no opioid use at both 1 and 2 years after surgery were classified as NC (no chronic use). Odds of CU vs NC were examined in relation to factors of interest, controlling for history of previous substance use disorder and baseline radiographic deformity. Satisfaction was assessed using the satisfaction domain of the SRS-22r.
RESULT(S): Mean age of patients was 55 +/- 17 years, 78% females. Overall, patients were using opioids until 3.2 +/- 7.7 months postoperatively. A total of 176 patients (78%) were classified as NC and 51 (22%) CU. Factors associated with significantly increased odds of CU compared with NC included smoking (OR 3.44, 95% CI: 1.06 - 11.11; p=0.039), and each additional point worse on the back pain Numeric Rating Scale (NRS) (OR 1.24, 95% CI: 1.06 - 1.46; p=0.008) SRS-22r Activity domain (OR 1.99, 95% CI: 1.27 - 3.09; p=0.002) and SRS-22r Mental Health domain (OR 1.50, 95% CI: 1.06 - 2.11; p=0.022). Notable factors that were not significantly associated with chronic use included gender, C7-S1 sagittal vertical axis, prior spine surgery, elderly age, number of levels fused, 3-column osteotomy and at least one major complication (p>0.05). CU had worse SRS-22r satisfaction scores at 2 years compared with NC (4.33 +/-.93 vs 3.80 +/- 0.17, p=0.001).
CONCLUSION(S): The majority of opioid nonusers prior to ASD surgery will not become chronic users following surgery. Factors associated with chronic opioid use include smoking, higher baseline back pain, worse preoperative functional status, and worse mental health. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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