Faculty Bibliography

BACKGROUND CONTEXT: Following cervical deformity (CD) corrective surgery, durability remains a challenge and distal junctional kyphosis (DJK) is an important risk for a surgeon to consider. DJK is the result from fixation failure, adjacent level fracture or spondylolisthesis. The timing of DJK onset has yet to be investigated. PURPOSE: To determine the timing of DJK development following CD corrective surgery. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: A total of 139 CD patients. OUTCOME MEASURES: Early/Late DJK Development, Severe DJK, Symptomatic DJK.
METHOD(S): Included: surgical CD patients (C2-C7 Cobb>10degree, CL>10degree, cSVA>4cm, or CBVA>25degree) without preop DJK. DJK angle was defined as the change in kyphosis between lower-most instrumented vertebra (LIV) and LIV-2 from preop to postop (<-10). X2 analysis and post-hoc testing assessed annual and overall incidence of early (3M follow-u) and late (DJK development at 6M, 1Y, 2Y) DJK development among operative patients. Differences between early and late DJK (development after 3 months) were assessed. Pearson correlations determined significant variables associated with development of early versus late DJK. Severe DJK was defined as DJK angle <-20degree. DJK was considered symptomatic if associated with reoperation or the previously published thresholds of NDI>24 or mJOA<14. The natural progression of the disease was predicted with the use of a Kaplan-Meier survivorship analysis.
RESULT(S): A total of 139 patients without preop DJK were included (16 re-op) (61.8yrs, 62.3%F, 29.1kg/m2). Surgical characteristics: 20.1% anterior approach, 42.4% posterior, 36.7% combined (levels fused: 7.6). Incidence of DJK from 2013-2018: 23%. Early: 9.4%, late: 10.1% (6M delayed: 3.6%, 1Y delayed: 6.5%, 2Y delayed: 2.2%). No differences were observed between op and reop for development of early or late DJK at all f/u (p>0.050). Presence of upgoing plantar response at baseline neuro exam, C2-C7 angle, T1-C2 angle, CBVA and combined approach correlated with development of early DJK. For late DJK: history of tumor and pulmonary disease, pelvic incidence, T10-L2 angle, and L4 pelvic angle. Apex of the secondary driver was significantly lower in the Late group (mean early: T2/3; late: T10; p=0.023). 3M radiographically, Early DJK patients had greater TK (-57.9degree vs -40degree, p=0.024, while L4PA remained larger in the late DJK group (14.5degree, p=0.009). Between early and late groups, 41.7% of early DJK patients met criteria for severe DJK, while 0% of Late DJK patient were severe(p=0.010); symptomatic DJK between the two groups was not significant (p=0.941). Kaplan-Meier survivorship analysis determined patients within the cohort to have a 91.1% cumulative probability of maintaining non-DJK status by 3-month follow-up, 85.9% at 6-month, 80% at 1-year, and 77.0% by 2-year follow-up.
CONCLUSION(S): Patients undergoing CD corrective surgery have incidence of early and incidence of late DJK. While the majority of DJK development occurs within the first 6 months, late DJK occurs and differs in presentation and etiologic factors. Early DJK occurrence is more likely to be severe radiographically, associated with neurological decline, and is more strongly related to biomechanical factors such as use of a combined approach at the time of surgery. Contrarily, although equally likely to be symptomatic as reflected in loss of clinical gains from surgery, late DJK is more likely mild radiographically and associated with suboptimal cervical realignment and lack of addressing secondary drivers, likely related to negative compensatory mechanisms. Customized prophylactic approaches for both occurrences is mandated. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Traditional iliac (IS) and S2-alar-iliac (S2AI) pelvic fixation methods have unique technical characteristics in their application, and result in varied biomechanical and anatomic impact. These differences may lead to variance in lumbopelvic fixation failure types and rates. PURPOSE: We intended to evaluate the influence of type of iliac fixation utilized for adult spinal deformity (ASD) correction on the frequency and manner of lumbopelvic fixation failure. STUDY DESIGN/SETTING: Retrospective review of prospective, multicenter ASD database. PATIENT SAMPLE: This study included 410 patients. OUTCOME MEASURES: HRQL (ODI, SF-36, NRS), rod fracture, screw fracture, screw loosening, revision surgery, pseudarthrosis METHODS: Inclusion criteria included ASD (coronal Cobb>=20degree, sagittal vertical axis (SVA) >=5cm, pelvic tilt >=25degree and/or thoracic kyphosis >60degree) >= 18 years old, 2yr follow-up, and >5 level fusion with pelvic fixation. Cohort subdivided by type of pelvic fixation (IS vs S2AI). Loosening was defined by lucency around the screw shank on radiographs. Univariate testing was performed using t-tests and chi-squared tests. Multivariate logistic regression, accounting for significant confounders, was used to examine differences between the two groups for screw loosening/fracture, rod fracture, and revision surgery. Level of significance = p<0.05.
RESULT(S): Of the total of 1422 patients, 410 met inclusion criteria (IS=287, S2AI=131). The two groups had similar age, BMI, baseline co-morbidities, and number of levels fused (p>0.05), as well as similar baseline HRQLs (SF-36, ODI, SRS-22, NRS leg and back, p>0.05) and deformity (PT, PI-LL, SVA, p>0.05). Patients in the IS group had a higher proportion of unilateral fixation compared to S2AI group (12.9% vs 5.6%; p=0.001). The overall pelvic fixation failure rate (screw loosening/screw fracture/rod fracture) was 29.4%. Loosening of pelvic fixation occurred in 13.4% of patients, and was more prevalent in the S2AI fixation group (OR 2.74, p=0.001). The rate of S1 screw loosening was 2.9%, and more likely to occur in the S2AI group (OR 4.17, p=0.045). The rate of pelvic fixation fracture in the overall cohort was 2.3%, with no difference between groups (p=0.37). Rod fracture occurred in 14.1% below L4, with a trend toward less occurrence in the S2AI group (OR 0.47, p=0.06). Revision surgery was required in 22.7% of our cohort, with no difference between groups (p=0.449). Patients with failure of the pelvic fixation had less improvement in their HRQL at 2years (PCS 7.69 vs 10.46 p=0.028; SRS 0.83 vs 1.03 p=0.019; ODI 12.91 vs 19.77 p=0.0016).
CONCLUSION(S): Pelvic fixation is commonly used in long segment adult spinal deformity surgery to improve the rate of L5-S1 fusion and protect from construct failure at the lumbosacral junction. Our results demonstrate a substantial rate of pelvic fixation hardware issues following ASD correction. Lumbopelvic fixation failure occurred at a rate of 29.4% following surgical correction of ASD that involved iliac fixation and was associated with diminished clinical outcomes. Additionally, S2AI screws were more likely to demonstrate loosening, but less commonly associated with rod fractures. Patients who experienced failure of their pelvic fixation had less improvement in their HRQL two years postoperatively. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The literature reports age and frailty as strong predictors of outcomes following spine surgery. This postop impact calls for investigation of unique adjustment parameters accounting for the two factors. Grasping the concordance of surgical factors with age and frailty may help surgical planning for individualized, optimal postop outcomes. PURPOSE: Modify the age-adjusted alignment goals with frailty to optimize outcomes in surgical adult spinal deformity (ASD) patients. STUDY DESIGN/SETTING: Retrospective review of a prospective, multicenter spine database PATIENT SAMPLE: A total of 853 patients OUTCOME MEASURES: Age-frailty-adjusted alignment goals (AF); optimal outcomes METHODS: Included: ASD patients with baseline (BL) frailty and ODI scores, radiographic parameters (PT, SVA, PILL, TPA). Patients were dichotomized by the ASD frailty index (not frail, frail). Linear regression analysis established normative radiographic thresholds, utilizing previously published age(A) specific (<35, 35-55, 45-54, 55-64, 65-74, >=75y/o) US-Normative ODI values converted from SF-36 PCS, in conjunction with frailty score. Patients met AF goals if 1-year postop alignment was within one standard deviation (+1SD Overcorrected [Over]; -1SD Undercorrected [Under]).
RESULT(S): A total of 853 patients were included (57.4+/-15yrs, 80%female, 27.2+/-5.9kg/m2). BL frailty: 438 not frail (51.3%), 308 frail (46.8%). Primary analyses demonstrated correlation between BL frailty score, PT, PILL, TPA, SVA, ODI (P<0.001). Linear regression analysis (R: 0.420-0.517,p<0.001) developed AF specific alignment threshold equations: (PT=5.7+0.25[A]+0.86[F]+0.073[ODI]), (SVA=-63.85 +1.23[A]+93.48[F]+0.52[ODI]), (PI-LL=-21.35+0.83[A]+22.89[F]+ 0.083[ODI]), (TPA=-2.91+0.30[A]+10.12[F]+ 0.097[ODI]). Thresholds increased with age and frailty for all four parameters. Patients<35 years and not frail predicted PT:13.3degree, SVA: -13.3mm, PI-LL: -6.6degree, TPA: 7.5degree, while patients>=75 and frail increased in all thresholds (PT: 29.1degree, SVA: 96.9mm, PI-LL: 25.6degree, TPA: 29.6degree). 38.1% patients matched PT ABF, 43.8% SVA, 38.6% PI-LL, and 45.3% TPA. Match PT patients had less PJK incidence 3mos-2yrs (Match:51% vs O/U:55.9%; p=0.173), as well as SVA (Match: 45.5% vs O/U: 60.8%; p<0.001), PI-LL (Match: 42.9% vs O/U: 61%; p<0.01), and TPA (Match: 49.5% vs O/U: 57.8%; p=0.015). PT Match group met MCID for SRS-22 Pain more (p=0.005), while SVA, PILL and TPA Match met MCID for ODI, PCS, and SRS-22 more (p<0.05). Match SVA and TPA had less overall LOS(p<0.01).
CONCLUSION(S): Incorporating frailty with age-specific goals influenced SVA, PT, PILL and TPA. Use of these modified goals is more sensitive to response to surgery than age and contribute to superior clinical and complication outcomes. Specific alignment thresholds accounting for age and frailty appeal for less rigorous alignment goals in older and severely frail patients. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Operative treatment of adult spinal deformity (ASD) can be very challenging with high complication rates. Despite these challenges it's well established that pts benefit from such treatment. However, the surgical outcomes for pts with mild scoliosis and age appropriate sagittal alignment have not been reported. PURPOSE: To determine if patients (pts) with mild scoliosis and age appropriate sagittal alignment have favorable outcomes following surgical correction. STUDY DESIGN/SETTING: Retrospective review of a prospective, multicenter ASD database. PATIENT SAMPLE: ASD patients: operative pts age>=18, and all preoperartive pelvic tilt (PT), mismatch between pelvic incidence and lumbar lordosis (PI-LL), and C7 sagittal vertical axis (SVA) within established age adjusted parameters with minimum 2-year follow up. A subanalysis for pts with max coronal cobb angle 10-30degree (mild scoli) was done. OUTCOME MEASURES: Health-related quality of life (HRQOL) scores: Oswestry Disability Index (ODI), Short form-36(SF36), Scoliosis Research Society (SRS22), back/leg pain numerical rating scale (NRS) and minimum clinically important difference (MCID)/substantial clinical benefit (SCB). Radiographic values: max coronal cobb angle, coronal C7 plumb line, PT, PI-LL, thoracic kyphosis (TK), SVA. Demographic, frailty, surgical and complications data were collected.
METHOD(S): Two-year and baseline HRQOL/radiographic data were compared.
RESULT(S): A total of 103 pts were included from 667 operative patients (89.3% female, avg age 59.8+/-13.1yrs). Of the 103 pts, 29 (28.2%) had max preop coronal cobb angle 10-30degree. Two-year max coronal cobb angle and C7 coronal plumb were significantly improved compared to baseline (p<0.001 for both the overall cohort and mild scoli). All 2yr HRQOL measures were significantly improved compared to baseline(p<0.001) for both groups. 33.3-81.5%% of mild scoli pts met either MCID/SCB for all HRQOL. In mild scoli pts, 62.1% had min one complication, 27.6% had a major complication with 24.1% requiring a revision.
CONCLUSION(S): Pts with mild scoliosis and sagittal alignment within age appropriate parameters benefit from surgical correction at 2 years postop both radiographically and clinically including 81.5% meeting MCID for SRS pain despite having high complication rates. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: To make the 40-factor adult spinal deformity frailty index (ASD-FI) more practical for use in clinical setting, a recent study proposed a modified, 8-factor frailty index (mASD-FI). The mASD-FI quantifies frailty of ASD patients on a scale from 0 to 21, with higher scores indicating greater frailty. While the mASD-FI has been shown to correlate with preoperative pain and disability, its relationship with postoperative outcomes has not been investigated. PURPOSE: Assess the relationship between mASD-FI score and clinical outcomes after ASD-corrective surgery. STUDY DESIGN/SETTING: Retrospective cohort study PATIENT SAMPLE: A total of 509 ASD patients OUTCOME MEASURES: Length of stay (LOS), complications, health-related quality of life (HRQL) questionnaires: ODI, SRS-22r, EQ-5D, SF-36 Physical Component Score (PCS).
METHOD(S): ASD patients (scoliosis>=20degree, SVA>=5cm, PT>=25degree, or TK >=60degree) with available mASD-FI scores and HRQL data at pre- and 2-years postop intervals were included. Patients were stratified by mASD-FI score using published cutoffs: not frail (<7), frail (7-12), severely frail (>12). Analysis of variance (ANOVA) assessed differences in demographics, surgical factors, and HRQL across frailty groups. Linear regression assessed the relationship between mASD-FI score and postop clinical outcomes (LOS, HRQL scores). Binary logistic regression assessed the relationship between frailty category and odds of complication or reoperation (results presented: odds ratio [95% confidence interval]).
RESULT(S): A total of 509 ASD patients were included (59+/-14yrs, 79%F, BMI: 27.7+/-6.0 kg/m2). The overall cohort presented with moderate baseline deformity: SVA (83.7mm+/-71), PT (12.7degree+/-10.8), PI-LL (43.1degree+/-21.1). Mean preop mASD-FI score was 7.2+/-5.0, and breakdown by frailty category was: not frail (50.3%), frail (34.0%), severely frail (15.7%). Preop age, BMI, and Charlson Comorbidity Index score all increased across increasing frailty categories (all p<0.001); however, fusion length (p=0.247) and rates of osteotomy (p=0.731) did not. At baseline, increasing frailty was associated with inferior ODI, EQ-5D, SRS-22r, SF-36 PCS, and NRS Back and Leg pain scores (all p<0.001). Following surgery, length of stay increased with increasing frailty category (6.9 days, 7.9 days, 9.6 days, p<0.001). Complication rates increased with frailty (57.6%, 64.4%, 78.7%, p<0.001). Increasing frailty was also associated with inferior postoperative outcomes for ODI (19.9, 31.8, 41.2), SRS (3.9, 3.6, 3.2), EQ-5D (0.84, 0.80, 0.74), and SF-36 PCS (44.2, 36.5, 32.6, all p<0.001). Higher preop mASD-FI scores predicted inferior postoperative scores for ODI (R2=0.193), SRS (R2=0.132), EQ-5D (R2=0.156) and SF-36 (R2=0.198). Controlling for complication incidence, baseline mASD-FI score still predicted postop scores for ODI, SRS, EQ-5D, and SF-36 (all p<0.001). Frailty also predicted higher odds of revision surgery (1.6 [1.1-2.5]) and complication (2.2 [1.5-3.2]), including infection (2.1 [1.1-3.9]), wound (2.0 [1.3-3.0]), and implant-related (2.2 [1.4-3.5]) complications. Severe frailty was associated with even greater odds of revision (2.0 [1.1-3.4]) and complication (2.8 [1.5-5.0]), including infection (2.5 [1.3-5.0]) and radiographic (2.3 [1.4-3.8]) complications. Operative treatment was associated with significant pre- to postop changes in frailty (7.2+/-5.0 to 4.9+/-4.4, p<0.001).
CONCLUSION(S): Greater preoperative frailty, as assessed by mASD-FI score, was associated with significantly greater LOS and inferior postoperative health-related quality of life across multiple outcomes assessment instruments. Frailty status was associated with increased odds of reoperation, complication, and infection. Severely frail patients showed the greatest risk of experiencing an adverse event. These results suggest the mASD-FI may have utility as a preoperative risk assessment tool. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Frailty is an increasingly recognized characteristic that has been validated across many studies as influencing operative risk. Utilization of frailty indices can allow for its identification of which spine patients may be too high risk for surgical intervention. This may be especially useful when it comes to surgeries that are minimally invasive and are supposed to have decrease perioperative outcomes. PURPOSE: Identify MIS techniques effects in postoperative outcomes in TLIF patients. STUDY DESIGN/SETTING: Retrospective review of a prospective database. PATIENT SAMPLE: TLIF spine patients. OUTCOME MEASURES: Complications, length of stay (LOS), estimated blood loss (EBL).
METHOD(S): Pts that underwent a lumbar spine procedure in a single-center Comprehensive Spine Quality Database. Pts were stratified based on procedural approach (Open [OP] and Minimally invasive Surgery [MIS]). Frailty was then calculated for each resultant group by using 30 variables with a validated method. Based on these scores, pts were categorized no frailty [NF]: <0.09, frail [F]: 0.09-0.18, and severe frailty [SF] >0.18. Groups were then controlled for surgical invasiveness. Chi-squared tests identified the relationship between complications and length of stay among various frailty states given surgical approach (OP vs MIS). These patients were propensity score matched for levels fused. Hospital acquired complications (HACs) were identified based on frailty groups through the use of chi-squared and t-tests for other surgical factors. A logistic regression analysis identified the association between frailty status and surgical, regarding postoperative (postop) outcomes.
RESULT(S): A total of 1,300 TLIF spine patients were isolated (59yrs, 29.3kg/m2). After PSM for levels fused, there were 338 pts for both MIS and OP. MIS pts were older (56.1 vs 53.3; p<0.05) than Op pts and had similar BMI's (29.1 vs 29.7; respectively). However, OP received more posterior approaches and less anterior approaches than MIS pts (p<0.05). By surgical factors: MIS and OP patients had similar LOS (3 vs 2.9days) and EBL (282.8 vs 251.5cc) but differed by Op time (195.7 vs 247.1; p<0.05) respectively. Further breakdown by frailty displayed statistical significance between MIS and OP patients with MIS pts having more F (16% vs 12%) and SF pts (4.3% vs 1.9%) than OP (all p<0.05). FMIS patients had lower postop neurologic complications as compared to FOP pts (4.63% vs 14.8%). However, SFMIS patiens had more post-operative complications than SFOP pts (55.2% vs 23.1%) and increased a pt's likelihood of being SFMIS by 5.4x's (all p<0.05).
CONCLUSION(S): This study displays that when frailty status is taken into account, TLIF MIS patients benefit from this procedure type when analyzed against neurologic complications. However, these patients were seen to suffer more from postop complications but did not differ on any other specific complications or surgical variables. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Thoracolumbar malalignment is often seen in patients presenting with cervical deformities. For operative cervical deformity (CD) patients, it is unknown whether certain thoracolumbar parameters play a large role in poor outcomes (complications, distal junctional kyphosis, reoperation) and whether addressment of such parameters is warranted. PURPOSE: To investigate the impact of cervical to thoracolumbar ratios on poor outcomes in CD corrective surgery. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: 110 CD patients. OUTCOME MEASURES: Radiographic parameters: regionally and globally; complications; distal junctional kyphosis (DJK); reoperations; health-related quality-of-life (HRQLs): NDI, EQ5D, mJOA.
METHOD(S): Included: surgical CD pts (C2-C7 Cobb >10degree, CL>10degree, cSVA >4cm, or CBVA >25degree) with full baseline and 1-year data. Patients were assessed for ratios of preop cervical and global parameters including: C2 slope/T1 slope, TS-CL/PI-LL, cSVA/SVA. Deformity classification ratios of cervical (Ames-ISSG) to spinopelvic (SRS-Schwab) were investigated: cSVA modifier/SVA modifier, TS-CL modifier/PI-LL modifier. Cervical to thoracic ratios included C2-C7 lordosis/T4-T12 kyphosis. Correlations assessed the relationship between ratios and poor outcome (major complication, reoperation, HRQL decline or failure to meet MCID). Decision tree analysis through multiple iterations of multivariate regressions assessed cut-offs for ratios for acquiring suboptimal outcomes.
RESULT(S): A total of 110 cervical deformity patients were included in the present analysis (61.5+/-9.9 years, 66% female, 28.8+/-7.5 kg/m2). By approach, 18.2% underwent anterior-only procedures, 46.4% posterior, and 35.4% combined. Average levels fused: 7.7+/-3.7 levels (anterior: 3.5, posterior: 8.5). The average preoperative radiographic ratios assessed included a C2 slope/T1 slope 1.56, TS-CL/PI-LL of 11.1, cSVA/SVA of 5.4, CL/TK of 0.26. Ames-ISSG and SRS-Schwab modifier ratios of cSVA/SVA 0.1 and TS-CL/PI-LL of 0.35. Pearson correlations demonstrated a significant relationship between major complications and the baseline TS-CL/PI-LL with a cutoff of >12.72 (p=0.034), >0.482 Ames TS-CL/Schwab PI-LL modifiers (p=0.019), and the CL/TK ratios (>0.814, p=0.050). Reoperation had a significant correlation with the TS-CL/PI-LL (>5.819, p=0.009) and the cSVA/SVA (>3.79, p=0.002) ratios. Postoperative DJK had a correlation with the C2 slope/T1 slope (>1.59, p=0.017) and CL/TK (>0.692, p=0.0629) ratios. Not meeting MCID for NDI correlated with the CL/TK ratio (>1.402, p=0.016) and not meeting MCID for EQ5D correlated with the Ames TS-CL/Schwab PI-LL (>0.564, p=0.010).
CONCLUSION(S): Consideration of the ratio of distal regional to global alignment is a critical determinant of outcomes in cervical deformity corrective surgery. Several key ratios of cervical to global alignment were found to correlate with the occurrence of suboptimal realignment parameters, or poor clinical outcomes. A larger cervical lordosis to thoracic kyphosis was most representative of this risk, which predicted a complication, DJK, and not meeting MCID for NDI. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: There have been few investigations into national trends in the use or outcomes of patients treated with robotic assisted surgery. PURPOSE: To evaluate if incorporation of robotic assisted procedures will lead to a rise in suboptimal outcomes. STUDY DESIGN/SETTING: Retrospective review of a national patient database between 2010-2016. PATIENT SAMPLE: A total of 4,109 weighted hospital discharges. OUTCOME MEASURES: Length of stay, complications, invasiveness.
METHOD(S): Inclusion criteria: elective spine surgery procedures as defined by ICD-9-CM and ICD-10-CM codes. Descriptive statistics assessed demographic information for the cohort. Rates of open and MIS robot assisted procedures were assessed, as well as trends in postoperative complications, and length of stay. Propensity score matching was performed between robotic spine surgery patients and non-robotic spine surgery patients for levels fused. Regression analysis was used to assess robot assisted procedures as a predictor of complications and extended LOS (LOS above 75th percentile), unfavorable discharge, and death during hospitalization.
RESULT(S): A total of 4,109 discharges were included. The overall trends in robotic surgery show a significant increase from 2010 to 2016, increasing from 11 recorded cases to 1,535 in 2016 (p<0.001). The majority of cases were open, however, an increasing percentage of cases have been MIS (8% in 2010 vs 12% in 2016, p<0.001). Average length of stay has significantly decreased from 9.5 days in 2010 to 4.4 days in 2016 (p<0.001). Postoperative hardware complications have significantly decreased from a high of 15.6% of cases in 2011 to 0.3% of cases in 2016, as well as DVTs (9.4% in 2011 vs 0% in 2016, both p<0.001). However, overall complication rates have increased, from 25% in 2011 to 29.3% in 2016 (p<0.001). In an analysis of invasiveness matched non-robot assisted patients, robot assisted surgery was not predictive of extended LOS, unfavorable discharge, total post-operative complications, or death during hospitalization (all p>0.05). Robot assisted surgery was predictive of bleeding complications (hemorrhage and hematoma) compared to non-robot surgery patients (OR: 2.05 [1.10-3.82], p=0.02).
CONCLUSION(S): Robot assisted surgery is an increasing implemented technique in spine surgery, with a significant rise from 2010 to 2016. However, during that period there has been a concurrent rise in postoperative complications. Invasiveness matched robot assisted patients were at significantly higher odds of bleeding complications compared to non-robotic patients. 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 Outcome Measurement Information System (PROMIS) aims to offer a valid, reliable and efficient means of capturing spine surgery patient clinical outcomes. To date, few studies have compared PROMIS and legacy outcome measures like the Oswestry Disability Index (ODI) for their sensitivity in reflecting the impact of perioperative complications and length of stay. PURPOSE: Assess differences between PROMIS and ODI scores as they relate to length of stay and complication outcomes of surgical thoracolumbar patients. STUDY DESIGN/SETTING: Retrospective review of single institution clinical data and patient-reported outcome measures. PATIENT SAMPLE: A total of 182 patients undergoing thoracolumbar surgery. OUTCOME MEASURES: Length of stay (LOS), perioperative complications.
METHOD(S): Patients >18 years undergoing thoracolumbar surgery with available pre- and 3-month postoperative ODI and PROMIS scores were included. Pearson bivariate correlation assessed the linear relationships between clinical outcomes (including length of stay, complications) and scores for both PROMIS (Physical Function, Pain Intensity, Pain Interference) and ODI. Linear regression predicted the relationship between perioperative complication incidence and postop scores for ODI and PROMIS. Significance was set p<0.05.
RESULT(S): Included: 182 patients (55.2+/-16.1 years, 44.5% female, 29.5+/-6.3 kg/m2) undergoing thoracolumbar surgery. Among the most common diagnoses were stenosis (62.1%), radiculopathy (48.9%), herniated disc (47.8%), and degenerative spondylolisthesis (25.3%). Overall, 58.3% of patients underwent fusion (mean fusion length: 2.6+/-2.9 levels), 50% underwent laminectomy, 82.9% of cases involved posterior-only approach, 17.6% combined, and 0.5% anterior-only. Patients showed significant pre- to postoperative improvement in both ODI (50.2 to 39.0) and PROMIS Physical Function (10.9 to 21.4), Pain Intensity (92.4 to 78.3) and Pain Interference (58.4 to 49.8, all p<0.001). Mean LOS was 2.7+/-2.8 days. The overall complication rate was 16.5%, and by type, complications were most commonly cardiac, neurologic, or urinary (all 2.2%). Whereas LOS showed no relationship with pre- to postop changes in ODI (p=0.179), changes in PROMIS Pain Intensity (r=0.167, p=0.024) and Physical Function (r=-0.169) both correlated with LOS. Complication occurrence was not correlated with pre- to postoperative changes in ODI or PROMIS (all p>0.05); however, 3-month postoperative scores for Physical Function (r=-0.205, p=0.005) and Pain Interference (r=0.182, p=0.014) both showed stronger correlations with complication occurrence than ODI (r=0.143, p=0.055). Regression analysis showed that while perioperative complication incidence could not predict postoperative ODI (p>0.05), complication occurrence predicted Physical Function (R2=0.037, p=0.005) and Pain Interference (R2=0.028, p=0.014) scores.
CONCLUSION(S): The PROMIS domains of Physical Function and Pain Interference better reflected perioperative complications and length of stay as compared to the legacy patient reported outcome ODI. These results suggest PROMIS may offer more utility as an outcomes assessment instrument. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Due to the complexity and invasiveness of deformity correction, poor outcomes are often associated. Currently, it is unknown what factors predict an outcome which operation may not be warranted (reoperation, major complications, clinical deterioration). PURPOSE: To investigate what patient factors justify determining a patient ineligible for a deformity correction. STUDY DESIGN/SETTING: Retrospective review of a prospective, consecutively enrolled adult spinal deformity (ASD) database. PATIENT SAMPLE: Operative patients with complete 2-year HRQL and radiographic data were included. OUTCOME MEASURES: HRQLs: Oswestry Disability Index (ODI), complications; reoperations.
METHOD(S): Patients >18yrs undergoing surgery for ASD (scoliosis >=20degree, SVA >=5cm, PT >=25degree, or TK >=60degree). An unsatisfactory outcome was defined by the following categories met at 2Y: (1) clinical: deteriorating in ODI at 2Y follow-up (2) complications/reop: having a reoperation and major complication were deemed unacceptable for surgery (NoOp). Baseline demographic, clinical and radiographic information were utilized through univariate/multivariate analyses to assess predictive factors of NoOp patients in adult spinal deformity patients. Multivariate regression with backward model selection was employed to create a model for when not to operate.
RESULT(S): A total of 633 ASD patients (59.9 years, 79% F, 27.7 kg/m2, CCI: 1.74) were included. By approach, 0.6% were anterior, 69.7% posterior and 29.5% combined approaches, with a total number of levels fused as 7.5+/-2.1. Baseline severe Schwab modifier incidence (++): 39.2% PI-LL, 28.8% SVA, 28.9% PT. 15.5% of patients deteriorated in ODI by 2 years, while 7.6% underwent a reoperation and had a major complication. This categorized 11 (1.7%) of patients in the total cohort as NoOp. NoOp patients had were more comorbid in terms of arthritis (73%) heart disease (36%) and kidney disease (18%), p<0.001. Surgically, NoOp patients had an overall greater EBL (4431ccs), underwent more osteotomies (91%), specifically Ponte (36%) and Three Column Osteotomies (55%), which occurred more at L2(91%). NoOp patients underwent more PLIFs (45%) and had more blood transfusion units (2641ccs), all p<0.050. The multivariate regression predicting the NoOp ASD group determined a combination of a baseline DRAM score in the 75th percentile, having arthritis and kidney disease, a baseline right lower extremity motor score <=3, cSVA >65mm, C2 slope >30.2degree, CTPA >5.5degree for an R2 value of 0.535 (p<0.001).
CONCLUSION(S): When addressing adult spine deformities, a negative outcome of clinical deterioration, major complications, and reoperations are exceedingly rare, but do occur. This tends to occur in severely comorbid patients with major baseline psychological distress scores, severe neurologic dysfunction and concomitant cervical malalignment not addressed at surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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