Faculty Bibliography

Metabolic syndrome is a clustering of clinical findings defined in the literature including hypertension, high glucose, abdominal obesity, high triglyceride, and low high-density lipoprotein cholesterol levels. The purpose of this study was to assess perioperative outcomes in patients undergoing spine fusion surgery with (MetS) and without (no-MetS) a history of metabolic syndrome. Included: Patients ≥18 yrs old undergoing spine fusion procedures diagnosed with MetS components with BL and 1-year follow-up were isolated in a single-center database. Patients in the two groups were propensity score matched for levels fused. 250 spine fusion patients (58 yrs, 52.2%F, 39.0 kg/m²) with an average CCI of 1.92 were analyzed. 125 patients were classified with MetS (60.2 yrs, 52%F, CCI: 3.2). MetS patients were significantly older (p = 0.012). MetS patients underwent significantly more open (Met-S: 78.4% vs No-MetS: 45.6%, p < 0.001) and posterior approached procedures (Met-S: 60.8% vs No-MetS: 47.2%, p = 0.031). Mean operative time: 272.4 ± 150 min (MetS: 288.1 min vs. no-MetS: 259.7; p = 0.089). Average length of stay: 4.6 days (MetS: 5.27 vs no-MetS: 3.95; p = 0.095). MetS patients had more post-operative complications (29.6% vs. 18.4%; p = 0.038), specifically neuro (6.4% vs 2.4%), pulmonary (4% vs. 1.6%), and urinary (4.8% vs 2.4%) complications. Binary logistic regression analyses found that MetS was an independent risk factor for post-operative complications (OR: 1.865 [1.030-3.375], p = 0.040). With longer surgeries and greater open-exposure types, MetS patients were at greater risk for complications, despite controlling for total number of levels fused. Surgeons should be aware of the increased threat to spine surgery patients with metabolic syndrome in order to optimize surgical decision-making.

OBJECTIVE:In the setting of a previous proximal fusion, an asymmetric 3-column osteotomy (3CO) can provide tremendous deformity correction. Our goal was to evaluate outcomes and complications of asymmetric 3CO through the proximal fusion mass, for coronal malalignment in patients with previous long thoracic fusion for adolescent idiopathic scoliosis. METHODS:This was a retrospective case series. Thirteen individuals with a history of a long thoracic fusion underwent asymmetric 3CO for persistent coronal malalignment. Clinical chart review was conducted to determine perioperative complications and radiographs evaluated for alignment. RESULTS:Thirteen patients (age: 57.8 ± 12.2 years; 0 male, 13 female) completed a mean follow-up of 42.4 months. There was significant improvement in coronal and sagittal alignment, and pelvic incidence-lumbar lordosis postoperatively (P < 0.05). One patient developed lower-extremity weakness requiring revision decompression 72 hours postoperatively; the weakness subsequently resolved. One patient had a foot drop postoperatively. At final follow-up, 12 of 13 patients had grade 1 fusion at the osteotomy site; 1 patient had a grade 2 fusion. None of the patients developed a pseudarthrosis, or superficial or deep infections. CONCLUSIONS:Patients with a history of previous thoracic fusion for adolescent idiopathic scoliosis and coronal malalignment may develop painful degeneration of the segments caudal to the fusion as adults. In this setting, extension of fusion to the sacropelvis alone may worsen the patient's coronal alignment. An asymmetric 3CO may be considered at the proximal fusion mass to achieve realignment objectives, with an acceptable complication rate and an expected improvement in outcomes.

BACKGROUND CONTEXT/BACKGROUND:ASD (Adult spinal deformity) surgery often entails complex osteotomies and realignment procedures, particularly in the setting of rigid deformities. While previous studies have established the efficacy of tranexamic acid (TXA), data evaluating the widely variable dosing regimens remains sparse. PURPOSE/OBJECTIVE:To improve understanding of blood loss and transfusion requirements for low-dose and high-dose TXA regimens for adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTING/METHODS:This is a retrospective cohort study of 318 ASD patients who received TXA. Outcome measures include estimated blood loss (EBL), perioperative transfusion requirement, and complications. METHODS:A retrospective review was conducted on 318 ASD patients: 258 patients received a low-dose regimen of TXA (10 or 20 mg/kg loading dose with a 1 or 2 mg/kg/h maintenance dose) and 60 patients received a high-dose regimen of TXA (40 mg/kg loading dose with a 1 mg/kg/h maintenance dose, 30 mg/kg loading dose with a 10 mg/kg/h maintenance dose, or 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose). RESULTS:Compared with the low-dose TXA group, the high-dose TXA group had significantly decreased EBL (1402 vs. 1793 mL, p=0.009), blood volume lost (30.3 vs. 39.4%, p=0.01), intraoperative packed red blood cell (pRBC) transfusion (0.9 vs 1.6 U, p<0.0001), and intraoperative platelet transfusion (0 versus 0.1 U, p<0.0001). High-dose TXA was predictive of 515 cc less EBL (p=0.002), 11.4% less blood volume lost (p=0.004), and 1 U pRBC less transfused intraoperatively (p<0.0001) than the low-dose TXA group. The high-dose TXA group had a higher incidence of postop atrial fibrillation (AF) (5 vs 0%, p<0.0001) and myocardial infarction (MI) (1.7 vs. 0%, p=0.04). CONCLUSIONS:Varying dosing regimens of TXA are utilized for ASD surgery, with a prevailing theme of dosing ambiguity. These data demonstrate that high-dose TXA is more effective than low-dose TXA in reducing blood loss and blood product transfusion requirement in ASD surgery. Importantly, rates of MI and postop AF were higher in the high-dose TXA group.

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: The Adult Spinal Deformity Frailty Index (ASD-FI), a validated modality for quantifying frailty, stratifies patients into categories not frail (NF), frail (F) and severely frail (SF). However, the cost of treating each frailty state is unknown. PURPOSE: Investigate the cost utility of treating not frail versus frail or severely frail ASD patients. STUDY DESIGN/SETTING: Retrospective review of a prospective single center adult spinal deformity database. PATIENT SAMPLE: A total of 79 operative and non operative ASD patients >=18 years old, with baseline and 2Y ASD-FI and Oswestry Disability Index (ODI) scores. OUTCOME MEASURES: ODI, SF-6D, Cost per quality adjusted life years (QALY), Incremental Cost Effectiveness, Ratio (ICER).
METHOD(S): Inclusion criteria was surgical ASD (scoliosis>=20degree, SVA>=5cm, PT>=25degree, or thoracic kyphosis >=60degree) patients >18 years with available frailty and ODI data at BL and 2-years post op. Independent T-Tests assessed baseline radiographic differences in PT, PI-LL, and Schwab SVA modifier status between NF vs. F/SF patients. Utility data was calculated using the ODI converted to the SF-6D using published conversion methods. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database. After accounting for complications, LOS, revisions, and death, cost per QALY at 2Y and life expectancy were calculated for NF, and F/SF patients. ICER was compared between non op and operative NF and F/SF patients at 2Y and life expectancy.
RESULT(S): Seventy-nine ASD patients met inclusion criteria. Descriptive statistics for the cohort were: age 51.0+/-6.8, 76% women, BMI 26.7+/-6.8, 54% osteotomy, 54% decompression, and 11.6+/-4.2 average levels fused. At BL, there were 48 NF, 26 F, and 4 SF pts. The average BL frailty for NF pts was 0.13+/-0.08, 0.39+/-0.06 for F, and 0.59+/-0.08 for SF pts. There were no differences in PT, PI-LL, or severe SVA Schwab modifier grades between NF or F/SF pts (all p>0.05). At 2-year follow up, there was no difference in the average cost of ASD surgery, $91,068.98 for NF patients and $90,888.53 for F/SF pts (p>0.05). The cost per QALY was higher for NF pts at 2 years vs F/SF pts ($464,239.62 vs. $321,107.89, p<0.05). If the utility gained was sustained to life expectancy, the cost per QALY was $70,796.43 for NF and $48,968.88 for F/SF (p<0.05). When compared to non op ASD pts, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2 years, and $68,311.35 vs. $47,764.61 for NF and F/SF at life expectancy.
CONCLUSION(S): Frail and severely frail patients had lower cost per QALY compared to not frail patients at 3 years and life expectancy. In addition, when compared to a non operative cohort of ASD patients, frail and severely frail patients had lower ICER values. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. In addition, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow-up times, these findings support the cost effectiveness of ASD surgery at all frailty states. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Patient-Reported Outcomes Measurement Information System (PROMIS) is a comprehensive self-report measurement tool with patient functions, symptoms, behaviors, and mental health outcomes. Little work has been done correlating PROMIS physical health domain metrics with established adult spinal deformity (ASD) classifications such as SRS-Schwab. PURPOSE: To correlate sagittal alignment components via the SRS-Schwab classification system with established PROMIS domains in a cohort of ASD patients. STUDY DESIGN/SETTING: Retrospective review of a single-center stereoradiographic database. PATIENT SAMPLE: A total of 41 ASD patients with complete baseline radiographic and PROMIS data. OUTCOME MEASURES: PROMIS physical health domain metrics (Pain Intensity [PI], Physical Function [PF], Pain Interference [Interference]), SRS-Schwab modifiers (SVA, PI-LL, PT) METHODS: Surgical ASD patients (SVA>=5cm, PT>=25degree or TK >=60degree) >=18 years old with available baseline (BL) radiographic and PROMIS data were isolated in the single-center comprehensive Spine Quality Database (Quality). Patients were classified according to SRS-Schwab deformity modifiers(0,+,++) for SVA, PI-LL and PT. Descriptives and univariate analyses compared population-weighted PROMIS scores for PI, PF and Interference across ASD deformity modifiers. Conditional Tree Analysis (CTA) with logistic regression sampling established cut-off points for PROMIS scores predicting severe malalignment (++) at BL compared to mild or moderate (0,+).
RESULT(S): A total of 41 patients (58.95 yrs,75.6%F,29.1kg/m2) met inclusion criteria. BL SRS modifiers were as follows: SVA 51.2%, 2.4%, 46.3% (0,+,++); PI-LL 27.3%, 12.1%, 60.6%(0,+,++); PT 18.2%, 36.4%, 45.5% (0,+,++). Mean cohort PI score was 94.2+/-6.0, mean PF score 8.95+/-10.1, mean Inter score 57.84+/-5.46. PF and Interference differed significantly across low and high SVA groups, with low SVA having significantly higher PF (13.50 vs 3.68,p<0.001) and lower Inter (59.62 vs 56.30, p=0.05). PI did not differ across SVA groups (p>0.05). Low PI-LL pts had significantly higher PF than pts with ++PI-LL (19.3 vs 4.15,p=0.001) and trended lower PI and Inter without significance. No significant differences in PI, PF or Inter were found across PT groups (all p>0.05). CTA found a PI score>98 or PF score <6 were independent predictors of Severe (++) SVA as opposed to Mild/Moderate SVA. For example, a PF score<6 increased odds of ++SVA by at least 2.7x compared to 0/+SVA. Similarly, significant thresholds for PI (>98) and PF (<8) scores were found for ++PI-LL, but not ++PT (p>0.05). Pain Interference did not predict SRS metrics to a significant degree (all p>0.05).
CONCLUSION(S): Inferior PROMIS scores of pain intensity and physical function predicted increasingly severe SRS sagittal modifiers at baseline, specifically severe sagittal vertical axis and lumbopelvic mismatch. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Roussouly Classification system of sagittal spinal shape and the SRS-Schwab adult spinal deformity (ASD) classification system have become important indicators of spine deformity. No prior studies have examined the outcomes of matching both Roussouly type and improving in Schwab modifiers postoperatively. PURPOSE: Evaluate outcomes of matching Roussouly Type and improving in Schwab modifier following ASD surgery. STUDY DESIGN/SETTING: Retrospective review of single-center ASD database. PATIENT SAMPLE: A total of 103 ASD patients. OUTCOME MEASURES: Roussouly types, Schwab modifiers, Health Related Quality of Life scores(HRQLs): Minimal Clinical Important Difference for ODI, EQ5D, VAS Leg &Back Pain.
METHOD(S): Surgical ASD patients (SVA>=5cm, PT>=25degree, or TK >=60degree, >3 levels fused) >=18 years old with available baseline (BL) radiographic data at baseline (BL) and 1-year (1Y) were isolated in the single-center Comprehensive Spine Quality Database (Quality). Patients were grouped by two Roussouly types: (1)"theoretical" Roussouly type(Type 1: PI<45degree, LL apex below L4; Type 2: PI<45degree, LL apex above L4 L4-L5 space; Type 3: 45degree60degree); (2) "current" Roussouly type (1: SS<35degree, LL apex below L4; 2: PI<35degree, LL apex above L4-L5 space; 3: 35degree45degree), as previously published. One year (1Y) matched Roussouly: preoperative mismatched (Between 'actual' and 'theoretical' patients that matched at 1Y. Schwab modifiers at BL were identified: non-, moderate and severe deformity (0, +, ++) for PT, SVA, and PI-LL. Schwab improvement was defined as a decrease in a modifier at one year.
RESULT(S): A total of 103 ASD patients (61.8yrs, 63.1%F, 30kg/m2). By surgical approach, 79.6% posterior, 10.7% combined, 2.9% anterior). Average levels fused: 4.6. BL breakdown of 'current; Roussouly type: 28% Type 1, 25.3% Type 2, 32.0% Type 3, 14.7% Type 4. BL Roussouly mismatch: 65.3%. Breakdown BL Schwab modifiers: PT (0: 8.7%, +: 41.7%, ++: 49.5%), SVA (0: 29.7%, +: 20.3%, ++: 50%), PI-LL mismatch (0: 28.2%, +: 25.2%, ++: 46.6%). At one year, 19.2% of patients matched Roussouly target type, while according to Schwab modifiers, 12.6% improved in SVA, 42.7% in PI-LL, and 45.6% in PT. Patients who both met Roussouly type and improved in a Schwab by the modifiers: 9 PT (8.7%), 8 PI-LL (7.8%), 2 SVA (1.9%). There were 2 patients (1.9%) who met their Roussouly type and improved in all 3 Schwab modifiers. One year (1Y) matched Roussouly patients improved more in HRQLs (MCID for ODI, EQ5D, VAS Leg/Back Pain), when compared to mismatched Roussouly, but was not significant(P>0.05). Match Roussouly and improvement in PT Schwab met MCID for EQ5D significantly more (33.3% vs 10.6%, p=0.050). Matched Roussouly and PI-LL Schwab had more patients meet MCID for all HRQLs, yet none were significant, p>0.05. Matched Roussouly and improvement in SVA Schwab met MCID for ODI significantly more (p=0.024).
CONCLUSION(S): Patients who both matched Roussouly sagittal spinal type and improved in SRS-Schwab modifiers had superior patient-reported outcomes at 1-year. Utilizing both classification systems in surgical decision making can optimize postop patient outcomes. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Antifibrinolytic agents are used during ASD surgery to minimize blood loss and transfusion requirements. Tranexamic acid (TXA) reduces the risk of blood loss and transfusion after ASD surgery, but there persists concern for prothrombotic effects, myocardial infarction, stroke, and postoperative neurologic events including seizures. PURPOSE: To investigate perioperative blood loss and transfusion after TXA for ASD surgery. STUDY DESIGN/SETTING: Retrospective review of prospectively collected single center database. PATIENT SAMPLE: 469 patients who received TXA, and 354 patients who did not receive TXA. OUTCOME MEASURES: Perioperative blood loss and blood product transfusion rate, and complications.
METHOD(S): Using a single-institution multi-surgeon database, we performed a retrospective review of patients undergoing ASD surgery from 2011-2018. We identified 469 patients who received TXA, and 354 patients who did not receive TXA. We investigated perioperative blood loss and blood product transfusion rate, and complications occurring after surgery.
RESULT(S): There was no significant difference in age, BMI, or frailty between the TXA (age: 45 +/- 23, BMI: 25 +/- 6) and non-TXA group (age: 47 +/- 24, BMI: 26 +/- 7). The prevalence of coronary artery disease, chronic kidney disease, and history of pulmonary embolism was higher in the non-TXA group, presumably due to surgeon preoperative screening, with no difference in other medical comorbidities. There were more revision surgeries and pelvic fixation procedures in the TXA group, with no other differences in surgical complexity. The group that received TXA had significantly lower EBL (1693 +/- 1343 mL vs 2009 +/- 1892 mL, p=0.019), and were transfused less platelets intraoperatively (.07 +/-.3 U vs 0.25 +/- 0.86 U, p=0.012). There was no difference in rates of perioperative pRBC transfusion between the groups. The most common complications in both groups were ileus and urinary retention. There was no difference in rate of thrombotic, cardiac, or renal complications, or seizures between the two groups. There was no significant difference in 90-day complication, readmission, or revision rates.
CONCLUSION(S): Among patients undergoing ASD surgery, TXA was associated with a lower estimated blood loss, without a higher risk for any morbid event. To our knowledge, this is the largest study to date to evaluate the safety of TXA for ASD surgery. FDA DEVICE/DRUG STATUS: Unavailable from authors at time of publication.
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BACKGROUND CONTEXT: Persistent lumbopelvic malalignment following ASD-corrective surgery may impair quality of life and result in persistent pathologic compensation in the lower extremities. Patient-specific age- and BMI-adjusted alignment targets have been proposed to improve alignment outcomes; however, it is unclear whether reaching these postop targets reduces rates of pelvic nonresponse following surgery. PURPOSE: Assess the relationship between pelvic nonresponse to ASD-corrective surgery and persistent lower-extremity compensation. STUDY DESIGN/SETTING: Single center retrospective review. PATIENT SAMPLE: Fifty-eight ASD patients. OUTCOME MEASURES: Sagittal alignment.
METHOD(S): Included: surgical ASD patients with full-spine X-ray imaging at pre- and early postop follow-up (<1Y). Patients were grouped by postop improvement in PT, per SRS-Schwab Classification: those who did not improve (pelvic nonresponders, PNR), and those that did improve (pelvic responders, PR). Groups were propensity score matched for preop PT, and assessed for differences in demographics, surgical factors, and alignment (sagittal spinal and lower extremity) with means comparison tests. Rates of persistent postop lower extremity compensation (defined as no improvement in lower extremity alignment) were compared between groups. Subanalysis assessed the relationship between reaching postop age- and BMI-specific alignment targets and rates of pelvic nonresponse.
RESULT(S): Following propensity score matching, PNR (N=29) and PR (N=29) patients did not differ in age, sex, BMI or preop sagittal spinal alignment (all p>0.05); however, PNR patients presented with less knee flexion (9degree vs 14degree, p=0.043). Groups did not differ in levels fused (10.8 vs 10.8, p=0.974) or osteotomy (93% vs 92%, p=0.902). Postop, PNR patients had inferior lumbopelvic alignment in PT (30degree vs 17degree), PI-LL (17degree vs 3degree), and greater global malalignment for TPA (27degree vs 15degree, all p<0.001). For PNR patients, these changes in alignment were accompanied by greater compensatory anterior hip extension (53mm vs 31mm, p=0.021). PNR patients also showed greater pre- to postop increases in sacrofemoral angle (2degree vs -5degree), and smaller decreases in hip extension (-24mm vs -64mm), pelvic femoral angle (-1.4degree vs -3.8degree), and global sagittal angle (-3.5degree vs -8degree, all p<0.005), indicating persistent lower extremity compensation. PNR patients had higher rates of persistent postop lower extremity compensation for sacrofemoral angle (68% vs 25%), ankle flexion (64% vs 33%), and pelvic shift (28% vs 4%, all p<0.034). PNR and PR groups did not differ in rates of reaching age- and BMI specific ideal postop alignment for PT, SVA, TPA, or PI-LL (all p>0.05). For patients with severe preop SVA deformity, overcorrection relative to ideal postop PT targets was associated with lower rates of pelvic non-response (under: 12%, match: 18%, over: 71%, p<0.001). Lower rates of nonresponse were observed for patients with severe preop PT deformity overcorrected relative to ideal postop PI-LL (under: 0%, match: 30%, over: 70%, p=0.016).
CONCLUSION(S): Pelvic nonresponders following ASD-corrective surgery had higher rates of persistent compensatory action in the lower extremities. Patients with severe preop PT deformity who were surgically overcorrected with respect to ideal PI-LL had lower rates of postop pelvic nonresponse, indicating that for severely malalignmed patients, existing alignment targets may need to be adjusted to optimize alignment outcomes. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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Introduction/UNASSIGNED:Correction of cervical deformity (CD) often involves different types of osteotomies to address sagittal malalignment. This study assessed the relationship between osteotomy grade and vertebral level on alignment and clinical outcomes. Methods/UNASSIGNED:Retrospective review of a multi-center prospectively collected CD database. CD was defined as at least one of the following: C2-C7 Cobb >10°, cervical lordosis (CL) >10°, C2-C7 sagittal vertical axis (cSVA) >4 cm, and chin-brow vertical angle > 25°. Patients were evaluated for level and type of cervical osteotomy. Results/UNASSIGNED:= 0.058) due to lever arm effect. Conclusions/UNASSIGNED:CD patients undergoing osteotomies in the cervical and upper thoracic spine experienced improvement in TS--CL and C2 slope. In the upper thoracic spine, multiple minor osteotomies achieved similar alignment changes to major osteotomies at a single level, while a major osteotomy focused at T2 had the greatest overall impact in cervicothoracic and global alignment in CD patients.