Faculty Bibliography
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885
The Impact of Peri-operative Enhanced Recovery After Surgery Protocols on Outcomes Following Adult Cervical Deformity Surgery
STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVES/OBJECTIVE:To assess the impact of Enhanced recovery after surgery (ERAS) protocols on peri-operative course in adult cervical deformity (ACD) corrective surgery. METHODS:Patients ≥18 yrs with complete pre-(BL) and up to 2-year (2Y) radiographic and clinical outcome data were stratified by enrollment in an ERAS protocol that commenced in 2020. Differences in demographics, clinical outcomes, radiographic alignment targets, peri-operative factors and complication rates were assessed via means comparison analysis. Logistic regression analysed differences while controlling for baseline disability and deformity. RESULTS:= .025). CONCLUSIONS:Enhanced recovery after surgery programs in ACD surgery demonstrate significant benefit in terms of peri-operative outcomes for patients.
PMCID:11571307
PMID: 38647538
ISSN: 2192-5682
CID: 5755842
Impact of congestive heart failure on patients undergoing lumbar spine fusion for adult spine deformity
BACKGROUND/UNASSIGNED:With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks. PURPOSE/UNASSIGNED:The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients. STUDY DESIGN/SETTING/UNASSIGNED:This was a retrospective cohort study of the PearlDiver database. PATIENT SAMPLE/UNASSIGNED:We enrolled 670,526 patients undergoing spine fusion surgery. OUTCOME MEASURES/UNASSIGNED:Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs. METHODS/UNASSIGNED:< 0.05. RESULTS/UNASSIGNED:= 0.013). CONCLUSIONS/UNASSIGNED:When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF.
PMCID:11029109
PMID: 38644919
ISSN: 0974-8237
CID: 5755802
Canadian journal of surgery = Journal canadien de chirurgie. 2024:67(6suppl1):S17-S76.DOI: 10.1503/cjs.011424
Canadian Spine Society: 24th Annual Scientific Conference, Wednesday, February 28 - Saturday, March 2, Fairmont Chateau Whistler, Whistler, B.C., Canada
PMID: 39537311
ISSN: 1488-2310
CID: 5753252
Fractional curve following adult idiopathic scoliosis correction: impact of curve magnitude on postoperative outcomes
OBJECTIVE:The goal of this study was to assess the impact of fractional curve (FC) severity on curve progression and postoperative outcomes in patients undergoing adult idiopathic scoliosis (AdIS) correction. METHODS:Patients with AdIS who had preoperative coronal plane deformity and who had undergone thoracolumbar fusion with a lowermost instrumented vertebra (LIV) between L1 and L4 were included. Patients were stratified by 6-week postoperative FC severity (small FC, ≤ 40th percentile, large FC, ≥ 60th percentile of the entire cohort; calculated as the Cobb angle between LIV and S1) and age groups. Preoperative to 2-year postoperative changes in FC were evaluated using Student t-tests. Demographics, spinopelvic alignment, patient-reported outcome measures (PROMs), and complications were compared using chi-square tests for categorical variables and Student t-tests for quantitative variables. Multivariate regression analyses, accounting for age, sex, frailty, and 6-week postoperative LIV, were also performed when feasible to assess the impact of FC on 2-year postoperative outcomes. RESULTS:In total, 86 patients, with 34 in the group with small FCs and 34 in the group with large FCs, were examined (18 were in the group with medium FC). The mean age (36.4 years for those with small FCs vs 36.0 years for those with large FCs, p > 0.05) was similar. Preoperatively, spinopelvic parameters and PROMs were comparable (p > 0.05). Two years postoperatively, higher postoperative FC was associated with larger thoracolumbar deformity (i.e., higher thoracolumbar/lumbar/lumbosacral Cobb angles) and lower perceived lumbar stiffness (p < 0.05); however, other PROMs and complications, including revisions, were comparable (p > 0.05). Bidirectional change in postoperative FC was associated with a lower C7 pelvic angle and lower C7 plumb line (R2 = -0.03, 95% CI -0.05 to 0.00, p = 0.050). Across all patients, the mean FC improved from baseline to 6 weeks postoperatively (from 18.1° to 6.5°, p < 0.001) but changed minimally from 6 weeks to 2 years postoperatively (from 6.5° to 6.5°, p = 0.942). After stratification, the cohort with small FCs exhibited a relative increase (from 1.6° to 3.5°, p < 0.001), whereas the cohort with large FCs noted a nonsignificant change (from 11.9° to 9.8°, p = 0.121) in FC over time. CONCLUSIONS:Following surgery for AdIS, larger residual lumbosacral FCs were not correlated with adverse events or poor outcomes at 2 years postoperatively. FCs may improve or worsen over time to drive improvement in global coronal balance surgery, but are not associated with adverse outcomes or reoperation during the first 2 years after surgery.
PMID: 39546796
ISSN: 1547-5646
CID: 5753892
Treatment of adult spine deformity: A retrospective comparison of bone morphogenic protein and bone marrow aspirate with bone allograft
UNLABELLED:BACKGROUND : The use of bone morphogenic protein (BMP-2) in adult spine deformity (ASD) surgery remains controversial more than two decades following its approval for clinical application in spine surgery. This study was performed to assess outcomes in patients undergoing ASD surgery with BMP application compared with a combination of bone marrow aspirate, cancellous bone chips and i-Factor. METHODS:This was a retrospective cohort study. ASD patients were stratified by use of intra-operative BMP (BMP +) or not (BMA + I) and surveyed for the development of complications and mechanical failure. Quality of life gained following the procedure was evaluated using quality-adjusted life years (QALYs). Cost was calculated using the PearlDiver database and CMS definitions. Multivariable analyses (ANCOVA) and logistic regression were used to adjust for confounding. RESULTS:512 patients were included (60% BMP +). At baseline, BMP + patients were older (62.5 vs 60.8 years, p < 0.010). Radiographic and quality-of-life metrics did not differ at follow up timepoints (all p > 0.05). BMP use was associated with higher supplemental rod use (OR: 7.0, 1.9 - 26.2, p = 0.004), greater number of levels fused (OR: 1.1, 1.03 - 1.17, p = 0.003) and greater neurological complications (OR: 5.0, 1.3 - 18.7, p = 0.017). Controlling for rod use and levels fused, BMP use was not associated with a lower risk of mechanical complications (OR 0.3, 95% CI: 0.2 - 3.0, p = 0.353), rod breakage (OR: 3.3, 0.6 - 18.7, p = 0.182) or implant failure (OR: 0.3, 0.04 - 1.51). At 2 years, the BMP + cohort exhibited higher overall costs ($108,062 vs $95,144, p = 0.002), comparable QALYs (0.163 vs 0.171, p = 0.65) and higher cost per QALY (p = 0.001) at two years. CONCLUSIONS:In this analysis, BMP-2 application was not associated with superior outcomes when compared to a less costly biologic alternative (bone marrow aspirate + cancellous bone chips + i-Factor) following ASD surgery. The use of BMP-2 in ASD surgery appears to have reduced cost-efficacy at two years postoperatively.
PMID: 39528828
ISSN: 0942-0940
CID: 5752742
Frail patients require instrumentation of a more proximal vertebra for a successful outcome after surgery for adult spine deformity
AIMS/UNASSIGNED:The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD). METHODS/UNASSIGNED:Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes. RESULTS/UNASSIGNED:(SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than 'not frail' patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV. CONCLUSION/UNASSIGNED:Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally.
PMID: 39481445
ISSN: 2049-4408
CID: 5747342
Determining the utility of three-column osteotomies in revision surgery compared with primary surgeries in the thoracolumbar spine: a retrospective cohort study in the United States
STUDY DESIGN/UNASSIGNED:Retrospective cohort study. PURPOSE/UNASSIGNED:To determine the incidence and success of three-column osteotomies (3COs) performed in primary and revision adult spine deformity (ASD) corrective surgeries. OVERVIEW OF LITERATURE/UNASSIGNED:3COs are often required to correct severe, rigid ASD presentations. However, controversy remains on the utility of 3COs, particularly in primary surgery. METHODS/UNASSIGNED:Patients ASD having 2-year data were included and divided into 3CO and non-3CO (remaining ASD cohort) groups. For the subanalysis, patients were stratified based on whether they were undergoing primary (P3CO) or revision (R3CO) surgery. Multivariate analysis controlling for age, Charlson comorbidity index, body mass index, baseline pelvic incidence-lumbar lordosis, and fused levels evaluated the complication rates and radiographic and patient-reported outcomes between the 3CO and non-3CO groups. RESULTS/UNASSIGNED:Of the 436 patients included, 20% had 3COs. 3COs were performed in 16% of P3COs and 51% of R3COs. Both 3CO groups had greater severity in deformity and disability at baseline; however, only R3COs improved more than non-3COs. Despite greater segmental correction, 3COs had much lower rates of aligning in the lumbar distribution index (LDI), higher mechanical complications, and more reoperations when performed below L3. When comparing P3COs and R3COs, baseline lumbopelvic and global alignments, as well as disability, were different. The R3CO group had greater clinical improvements and global correction (both p<0.04), although the P3CO group achieved alignment in LDI more often (odds ratio, 3.9; 95% confidence interval, 1.3-6.2; p=0.006). The P3CO group had more neurological complications (30% vs. 13%, p=0.042), whereas the R3CO tended to have higher mechanical complication rates (25% vs. 15%, p=0.2). CONCLUSIONS/UNASSIGNED:3COs showed greater improvements in realignment while failing to demonstrate the same clinical improvement as primaries without a 3CO. Overall, when suitably indicated, a 3CO offers superior utility for achieving optimal realignment across primary and revision surgeries for ASD correction.
PMID: 39434234
ISSN: 1976-1902
CID: 5739662
Defining modern iatrogenic flatback syndrome: examination of segmental lordosis in short lumbar fusion patients undergoing thoracolumbar deformity correction
PURPOSE/OBJECTIVE:Understanding the mechanism and extent of preoperative deformity in revision procedures may provide data to prevent future failures in lumbar spinal fusion patients. METHODS:ASD patients without prior spine surgery (PRIMARY) and with prior short (SHORT) and long (LONG) fusions were included. SHORT patients were stratified into modes of failure: implant, junctional, malalignment, and neurologic. Baseline demographics, spinopelvic alignment, offset from alignment targets, and patient-reported outcome measures (PROMs) were compared across PRIMARY and SHORT cohorts. Segmental lordosis analyses, assessing under-, match, or over-correction to segmental and global lordosis targets, were performed by SRS-Schwab coronal curve type and construct length. RESULTS:Among 785 patients, 430 (55%) were PRIMARY and 355 (45%) were revisions. Revision procedures included 181 (23%) LONG and 174 (22%) SHORT corrections. SHORT modes of failure included 27% implant, 40% junctional, 73% malalignment, and/or 28% neurologic. SHORT patients were older, frailer, and had worse baseline deformity (PT, PI-LL, SVA) and PROMs (NRS, ODI, VR-12, SRS-22) compared to primary patients (p < 0.001). Segmental lordosis analysis identified 93%, 88%, and 62% undercorrected patients at LL, L1-L4, and L4-S1, respectively. SHORT patients more often underwent 3-column osteotomies (30% vs. 12%, p < 0.001) and had higher ISSG Surgical Invasiveness Score (87.8 vs. 78.3, p = 0.006). CONCLUSIONS:Nearly half of adult spinal deformity surgeries were revision fusions. Revision short fusions were associated with sagittal malalignment, often due to undercorrection of segmental lordosis goals, and frequently required more invasive procedures. Further initiatives to optimize alignment in lumbar fusions are needed to avoid costly and invasive deformity corrections. LEVEL OF EVIDENCE/METHODS:IV: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
PMID: 39443371
ISSN: 1432-0932
CID: 5740002
Factors Associated With the Maintenance of Cost-effectiveness at Five Years in Adult Spinal Deformity Corrective Surgery
STUDY DESIGN/METHODS:Retrospective cohort. OBJECTIVE:To evaluate factors associated with the long-term durability of cost-effectiveness (CE) in ASD patients. BACKGROUND:A substantial increase in costs associated with the surgical treatment for adult spinal deformity (ASD) has given precedence to scrutinize the value and utility it provides. METHODS:We included 327 operative ASD patients with five-year (5 yr) follow-up. Published methods were used to determine costs based on CMS.gov definitions and were based on the average DRG reimbursement rates. The utility was calculated using quality-adjusted life-years (QALY) utilizing the Oswestry Disability Index (ODI) converted to Short-Form Six-Dimension (SF-6D), with a 3% discount applied for its decline in life expectancy. The CE threshold of $150,000 was used for primary analysis. RESULTS:Major and minor complication rates were 11% and 47%, respectively, with 26% undergoing reoperation by five years. The mean cost associated with surgery was $91,095±$47,003, with a utility gain of 0.091±0.086 at one years, QALY gained at 2 years of 0.171±0.183, and at five years of 0.42±0.43. The cost per QALY at two years was $414,885, which decreased to $142,058 at five years.With the threshold of $150,000 for CE, 19% met CE at two years and 56% at five years. In those in which revision was avoided, 87% met cumulative CE till life expectancy. Controlling analysis depicted higher baseline CCI and pelvic tilt (PT) to be the strongest predictors for not maintaining durable CE to five years [CCI OR: 1.821 (1.159-2.862), P =0.009] [PT OR: 1.079 (1.007-1.155), P =0.030]. CONCLUSIONS:Most patients achieved cost-effectiveness after four years postoperatively, with 56% meeting at five years postoperatively. When revision was avoided, 87% of patients met cumulative cost-effectiveness till life expectancy. Mechanical complications were predictive of failure to achieve cost-effectiveness at two years, while comorbidity burden and medical complications were at five years.
PMID: 38462731
ISSN: 1528-1159
CID: 5737602
Predictors of pelvic tilt normalization: a multicenter study on the impact of regional and lower-extremity compensation on pelvic alignment after complex adult spinal deformity surgery
OBJECTIVE:The objective was to determine the degree of regional decompensation to pelvic tilt (PT) normalization after complex adult spinal deformity (ASD) surgery. METHODS:Operative ASD patients with 1 year of PT measurements were included. Patients with normalized PT at baseline were excluded. Predicted PT was compared to actual PT, tested for change from baseline, and then compared against age-adjusted, Scoliosis Research Society-Schwab, and global alignment and proportion (GAP) scores. Lower-extremity (LE) parameters included the cranial-hip-sacrum angle, cranial-knee-sacrum angle, and cranial-ankle-sacrum angle. LE compensation was set as the 1-year upper tertile compared with intraoperative baseline. Univariate analyses were used to compare normalized and nonnormalized data against alignment outcomes. Multivariable logistic regression analyses were used to develop a model consisting of significant predictors for normalization related to regional compensation. RESULTS:In total, 156 patients met the inclusion criteria (mean ± SD age 64.6 ± 9.1 years, BMI 27.9 ± 5.6 kg/m2, Charlson Comorbidity Index 1.9 ± 1.6). Patients with normalized PT were more likely to have overcorrected pelvic incidence minus lumbar lordosis and sagittal vertical axis at 6 weeks (p < 0.05). GAP score at 6 weeks was greater for patients with nonnormalized PT (0.6 vs 1.3, p = 0.08). At baseline, 58.5% of patients had compensation in the thoracic and cervical regions. Postoperatively, compensation was maintained by 42% with no change after matching in age-adjusted or GAP score. The patients with nonnormalized PT had increased rates of thoracic and cervical compensation (p < 0.05). Compensation in thoracic kyphosis differed between patients with normalized PT at 6 weeks and those with normalized PT at 1 year (69% vs 35%, p < 0.05). Those who compensated had increased rates of implant complications by 1 year (OR [95% CI] 2.08 [1.32-6.56], p < 0.05). Cervical compensation was maintained at 6 weeks and 1 year (56% vs 43%, p = 0.12), with no difference in implant complications (OR 1.31 [95% CI -2.34 to 1.03], p = 0.09). For the lower extremities at baseline, 61% were compensating. Matching age-adjusted alignment did not eliminate compensation at any joint (all p > 0.05). Patients with nonnormalized PT had higher rates of LE compensation across joints (all p < 0.01). Overall, patients with normalized PT at 1 year had the greatest odds of resolving LE compensation (OR 9.6, p < 0.001). Patients with normalized PT at 1 year had lower rates of implant failure (8.9% vs 19.5%, p < 0.05), rod breakage (1.3% vs 13.8%, p < 0.05), and pseudarthrosis (0% vs 4.6%, p < 0.05) compared with patients with nonnormalized PT. The complication rate was significantly lower for patients with normalized PT at 1 year (56.7% vs 66.1%, p = 0.02), despite comparable health-related quality of life scores. CONCLUSIONS:Patients with PT normalization had greater rates of resolution in thoracic and LE compensation, leading to lower rates of complications by 1 year. Thus, consideration of both the lower extremities and thoracic regions in surgical planning is vital to preventing adverse outcomes and maintaining pelvic alignment.
PMID: 38215449
ISSN: 1547-5646
CID: 5728882
