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: Recent studies suggest that for patients with neck pain, both psychological and physical symptoms need to be addressed. Psychological distress risk factors are associated with poor outcomes in the fear avoidance model, where individuals passively cope through avoidance behaviors and disuse. Cognitive behavioral therapy (CBT) works to address risk factors through education about pain, modification of maladaptive beliefs, and increasing patient's self-efficacy. PURPOSE: Determine the effectiveness of brief psychological intervention on outcomes in cervical spine surgery. STUDY DESIGN/SETTING: Prospective, blind, and placebo-controlled trial. PATIENT SAMPLE: A total of 35 symptomatic Cervical Degenerative Disorders patients. OUTCOME MEASURES: Distress and Risk Assessment Method (DRAM), Fear Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), Outcome Expectation Question (OEQ). Neck Disability Index (NDI), modified Japanese Orthopedic Association (mJOA), Visual Analog Scale (VAS), EuroQol Five Dimensions (EQ5D).
METHOD(S): Thirty-five patients age >18 with symptomatic cervical degenerative disease have been enrolled in the study. If patients met psychological distress criteria, they were in the treatment group: DRAM >17 and <33, FABQ >49/66, PCS >30/52 or OEQ <=2 (randomized to CBT or placebo). CBT and sham treatment groups had 6 sessions prior to surgery. The control group had no intervention prior to surgery. Baseline and 3M changes were assessed for all outcome measures.
RESULT(S): A total of 35 patients were enrolled (age 53.9 years, BMI 28.7 kg/m2). Twenty-two patients met psychological distress criteria and were randomized into a treatment group (13 CBT vs. 9 placebo). Thirteen patients were in the control group, with 5 having too high of DRAM scores to be CBT candidates. At enrollment, the average DRAM score was 34.55 +/- 13.87, with the DRAM observational group, Placebo, and CBT groups all having higher scores than control patients (45.6 vs 13.4, P<0.001). Treatment patients had higher baseline FABQ scores than controls (45.9 vs 20.4, P=0.004). The overall OEQ score was 3.78+/-1.18, with all control patients scoring a 5 and CBT and Placebo patients answering 3-4 out of 5 on the scale. At 3M post op, all groups showed improved outcomes in all measurements. Between CBT, placebo, and control patients, CBT patients exhibited greater postop improvement in all psychological questionnaires compared to non treatment groups (DRAM: 34.9 a30.8 CBT, 35.2 a22.4 placebo, 11 a10 no risk controls, FABQ: 40.8 a35.2 CBT, 38.3 a37.8 placebo, 19 a21 no risk controls, PCS: 31.8 a17.4 CBT, 32.8 a11.6 placebo, 15 a6 no risk controls, OEQ: Disagree aStrongly Agree CBT, Disagree aAgree placebo, Strongly Agree aStrongly Agree, no risk controls).
CONCLUSION(S): Preliminary results of this randomized controlled study on cervical degenerative surgery patients showed that patients who received cognitive behavioral treatment before surgery had better improvement in all psychological related questionnaires compared to non treatment patients. Long-term follow up will assess the changes in psychological and pain related outcomes in these groups to assess the impact of psychological intervention for at risk patients. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: For surgical adult spinal deformity (ASD) patients, incorporating restoration of appropriate Roussouly Classificaion shape into surgical planning may improve outcomes. With the introduction and use of the SRS-Schwab ASD classification system, it is important to compare the utility of both classification frameworks as they relate to surgical outcomes. PURPOSE: Compare outcomes of surgical ASD patients classified by both Roussouly and Schwab systems. STUDY DESIGN/SETTING: Retrospective review of prospective ASD database. PATIENT SAMPLE: A total of 515 ASD patients. OUTCOME MEASURES: Complications; Health-related quality of life (HRQL): ODI, SF-36 PCS, SRS-22r.
METHOD(S): ASD patients with pre- and 2-year postop (2Y) radiographic/HRQL data were grouped by "theoretical" Roussouly type (Type 1: PI<45degree, LL apex below L4; Type 2: PI<45degree, LL apex above L4-L5 space; Type 3: 45degree60degree) and "current" Roussouly type (1: SS<35degree, LL apex below L4; 2: PI<35degree, LL apex above L4-L5 space; 3: 35degree45degree), as published. Means comparison tests assessed outcomes of those that mismatched "theoretical" and "current" types at both pre- and 2Y intervals (mismatched) to those of preoperative mismatched patients that matched at 2-years (matched). Subanalysis assessed outcomes of patients that improved in Schwab modifiers, and patients that both improved in both Schwab modifiers and matched Roussouly type by 2Y.
RESULT(S): Included 515 ASD patients (59+/-14yrs, 80%F). The overall cohort showed moderate preoperative global and lumbo-pelvic deformity: SVA(64mm+/-73), PT(25degree+/-11), PI-LL(16degree+/-21). Preoperative breakdown of "current" Roussouly types: Type 1 (10%), Type 2 (54%), Type 3 (24%), Type 4 (12%). Preoperative mismatch between "current" and "theoretical" types was 60%. By 2Y, 16% of patients matched Roussouly types. Matched and Mismatched groups did not differ in rates of reaching MCID for any HRQL metrics by 2Y(all p>0.1). Reop, PJK and complications did not differ between matched and mismatched(all p>0.1), though mismatched patients showed a trend of increased instrumentation failure(17% vs 26%, p=0.080). By 2Y, 28% of patients improved in PT Schwab modifier, 37% in SVA, and 46% in PI-LL. Patients that improved in PT modifier had lower instrumentation failure rates (16% vs 24%) and higher rates of reaching 2Y MCID for ODI (58% vs 48%) and SRS Activity (75% vs 64%) than patients that did not improve. Patients that both Matched Roussouly at 2Y and improved in all Schwab modifiers met MCID for ODI and SRS Activity at higher rates than patients that did not. Roussouly Match patients that improved in Schwab PT met SRS Activity MCID at a higher rate, and had less renal, infection, and neurologic complications than patients that did not. Roussouly Match patients that improved in Schwab SVA also had superior SF-36 scores and fewer cardiopulmonary complications(all p<0.05).
CONCLUSION(S): For surgical ASD patients, isolated restoration of sagittal spinal shape per the Roussouly system was not associated with superior clinical outcomes or complications by 2 years. In contrast, improvement in PT, per the SRS-Schwab system, was associated with substantial improvement in low-back disability by 2 years. Collectively, patients that both matched Roussouly sagittal type and improved in Schwab modifiers had superior complication and patient-reported outcomes by 2 years. These results suggest that concurrent consideration of both existing systems may offer utility in establishing optimal realignment targets. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: MHD prevalence in patients with substance abuse history has been well-described. However, the impact of current or historical substance abuse/dependence in adolescent idiopathic scoliosis (AIS) patients on risk of subsequent development of new-onset mental health disorders (MHDs) is unknown. PURPOSE: This study evaluated the: (1) demographics and (2) new-onset diagnosis of MHD among AIS patients with baseline substance abuse/dependence. The goal of this study was to determine whether substance abuse among AIS patients increases the odds of subsequent new-onset development of a MHD. STUDY DESIGN/SETTING: Retrospective review of prospectively collected data. PATIENT SAMPLE: Using the NYS Statewide Planning and Research Cooperative System (SPARCS), we identified age, gender, race, and Charlson/Deyo-index propensity-score matched cohorts of AIS patients with or without prior/current substance abuse. AIS patients with comorbid substance abuse were included from 2009-11, with minimum 2-year follow-up. A total of 386 AIS patients (n=193 in each group) were included. OUTCOME MEASURES: Demographic information, length of stay, hospital charges, new-onset MHD diagnosis at 2-year follow-up METHODS: The NYS Statewide Planning and Research Cooperative System was reviewed to identify all 10-25 year-old AIS patients with prior or concurrent substance abuse (AIS-Sub: alcohol, tobacco, cannabis, amphetamine, opioid or polysubstance) from 2009-11 to ensure two-year follow-up. Patients with prior or concurrent MHD(s) were excluded. AIS-Sub were 1:1 propensity score-matched by age, sex, race and Charlson/Deyo index to AIS patients without substance abuse (AIS-NoSub). Cohorts were compared for subsequent incidence/development of individual and overall MHDs (depressive, anxiety, stress, sleep and/or eating disorder). Binary stepwise logistic regressions were utilized to calculate odds ratios (OR) of developing individual or any MHDs based on baseline substance abuse.
RESULT(S): A total of 386 AIS patients were included (n=193 each in AIS-Sub and AIS-NoSub). AIS-Sub and AIS-NoSub patients had comparable age (both 20.8 years), sex (62.2 vs 62.7% male), race (54.9 vs 52.8% white), insurance (55.4 v 45.6% Medicaid), and Charlson-Deyo (0.29 vs 0.37) respectively. AIS-Sub patients had higher rates of new-onset subsequent overall MHDs (16.1% vs 3.6%), with only depressive disorder higher among individual MHDs (10.9% vs 0.5%), both p<0.001. Baseline substance abuse independently predicted subsequent diagnosis of overall MHD (OR=6.8). Among individual MHDs, baseline substance abuse predicted development of new-onset depressive disorder (OR=47.0), all p<=0.002; it did not predict development of anxiety, stress, sleep, or eating disorders.
CONCLUSION(S): AIS patients with prior or current substance abuse/dependence were at increased two-year risk of developing any new-onset MHD, specifically depressive disorders. This data may guide preoperative screening and optimization efforts for scoliosis surgeons, as MHDs have been associated with poor outcomes following spine surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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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: Novel analyses of clinical outcomes following cervical deformity (CD) corrective surgery use an area-under-the-curve (AUC) method to assess health-related quality of life (HRQL) metrics throughout the surgical recovery process. It remains unclear how demographics, preop parameters, and surgical decisions are associated with superior recovery. PURPOSE: Identify demographic, surgical and radiographic factors that predict superior recovery kinetics. STUDY DESIGN/SETTING: Retrospective review of a prospective CD database. PATIENT SAMPLE: A total of 98 CD patients. OUTCOME MEASURES: Baseline (BL) to 1-year (1Y) HRQL Instruments: Neck Disability Index (NDI).
METHOD(S): CD database criteria:C2-7 Cobb angle>10degree, coronal Cobb angle >10degree, cSVA>4cm or TS-CL>10degree, or CBVA>25degree. Following univariate analyses, the AUC normalization method was utilized by dividing all reported BL and postoperative(3M, 1Y) outcome measures by the BL score. Normalized scores(y-axis) were plotted against follow-up time interval(x-axis). Total area was calculated for all follow-up, divided by cumulative follow-up length, determining overall, time-adjusted HRQL recovery (Integrated Health State[IHS]). IHS NDI scores were stratified by quartile, the uppermost 25% were categorized as having "superior" recovery kinetics (SRK) vs "normal" recovery kinetics (NRK). BL demographic, clinical and surgical information were used to predict SRK using generalized linear modeling.
RESULT(S): A total of 98 patients included(62+/-10yrs, 28+/-6kg/m2, 65%F). Mean CCI: 0.95, 6% smokers, and 31% history of smoking. Surgical approach: combined(33%), posterior(49%), anterior(18%). Average posterior levels fused: 8.7, anterior levels fused: 3.6, EBL: 915.9ccs, op time: 495min. According to the Ames CD classification at BL: cSVA (53.2% minor deformity and 46.8% moderate), TS-CL (9.8% minor, 4.3% moderate, 85.9% marked), and horizontal gaze (27.4% minor, 46.6% moderate, 26% marked). Relative to BL NDI scores (mean: 47), normalized postop NDI scores showed decrease in disability at 3M(0.9+/-0.5, p=0.260) and a further decrease at 1Y (0.78+/-0.41, p<0.001). As assessed with normalized NDI scores, patients showed significant improvement in neck disability from BL to 1Y postoperative (p<0.001). NDI IHS scores demonstrated correlation with age (p=0.011), gender (p=0.042), anterior approach only (p=0.042), posterior approach (p=0.042). After grouping by quartile, patients with greater BL PT (SRK:25.6degree, NRK:17degree, p=0.002), PI-LL (SRK:8.4degree, NRK:-2.8degree, p=0.009), and anterior approach (SRK:34.8%, NRK:13.3%; p=0.020) correlated strongly with SRK. A total of 69.4% of patients met MCID for NDI (CONCLUSION(S): Superior recovery kinetics following cervical deformity surgery was predicted with high accuracy using a combination of baseline patient reported factors(VAS EQ5D, swallow sleep, and mJOA scores) and radiographic factors(TK, T10-T12, T12-S1, L1-S1). Patients and health care providers should be aware of these factors in order to improve surgical decision-making, in an effort to reduce postop neck disability. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Reciprocal changes in cervical alignment occur with incremental degrees of adult spinal deformity (ASD) severity, or across different sagittal morphotypes as described respectively by Schwab and Roussouly systems. The extent to which these systems relate changes in the upper cervical spine remains underexplored. PURPOSE: To investigate quantitative anatomical relationships with regards to abnormal alignment in the upper cervical spine. STUDY DESIGN/SETTING: Retrospective review of a prospective multicenter ASD database. PATIENT SAMPLE: A total of 343 patients who met criteria for ASD. OUTCOME MEASURES: Cervical alignment parameters (C2-C7 angle, C2 slope, McGregor's Slope, CBVA when available, segmental tilt), Ostrow Disability Index (ODI) METHODS: Patients >18 years with ASD (scoliosis>=20degree, SVA>=5cm, PT>=25degree, or thoracic kyphosis >=60degree) and complete radiographic data at baseline (BL) & 1-year (1Y) were identified. Patients were grouped by BL PI and apex of LL into component types of the Roussouly classification system (Type 1: PI<45degree & LL apex below L4; Type 2: PI<45degree & LL apex above L4; Type 3: 45degree65degree). Patients were categorized by increasing severity of SRS-Schwab modifiers at BL (0, +, ++) and further grouped by anatomical malalignment, moving cranially (P: pelvic only; LP: lumbopelvic; TL: thoracolumbopelvic; C: subaxial & thoracolumbo-pelvic). Analysis of variance (ANOVA) tests assessed differences in BL upper cervical alignment parameters (C0-C2, C0 slope, McGregor's slope, CBVA) and ODI scores across Roussouly and Schwab modifier groups.
RESULT(S): A total of 343 ASD patients were analyzed. Schwab modifiers at BL were as follows: SVA (0: 45.8%, +: 20.3%, ++: 33.9%), PI-LL (0: 42.3%, +: 20.7%, ++: 37.0%), PT (0: 38.6%, +: 36.2%, ++: 25.3%). By Roussouly classification, 4.2% were Type 1, 19.3% were Type 2, 43.1% were Type 3, and 33.3% were Type 4. Moving cranially up the spine, Group P (10.6%), Group LP (54.7%) and Group TL (8.5%) did not differ in C0-C2 angle, C0 slope, MGS or CBVA (all P>0.05). Group C (26.2%) had a significantly smaller C0-C2 angle, and more negative MGS, C0 slope, and CBVA than non-cervical groups. By Roussouly type, Type 1 trended slightly higher CBVA and MGS than types 2-4 without statistical significance (all P>0.05). No differences in CL, C0-C2, or C0S were found between Types 1-4 (all P>0.05). McGregor's slope (r=-0.131, P=0.015), CBVA (r=-0.473, P<0.001) and C0 slope (r=-0.099, P=0.042) correlated most strongly with SVA compared to other Schwab modifiers. We found SVA>34mm predicted a 1 unit(degree) decrease in MGS (OR: 0.970 [0.948 - 0.993], p=0.010), while cSVA>51mm predicted a 1 unit increase in MGS (OR: 1.25[1.12-1.38], p<0.001). Group P had the lowest BL disability compared to other Groups, while Roussouly Type 1 correlated with higher BL disability compared to Type 2 (46.1 vs 37.4, P=0.007).
CONCLUSION(S): Our present study suggests that upper cervical alignment remains relatively stable through most broad variations of adult thoracolumbar deformity. Changes in SVA correlated most with upper cervical changes compared to other TL modifiers. Incremental trends in upper cervical alignment changes were observed as TL deformity extended cranially, with greatest variation in pts who also had subaxial malalignment. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Osteoporosis (OP) is a common condition affecting nearly 200 million individuals globally. Similarly, adult spinal deformity has a peak prevalence of 65% of the adult population. While bone health is instrumental in orthopaedic surgery, few studies have described the long-term outcomes of osteoporosis following surgery for ASD. PURPOSE: We sought to evaluate the impact of OP on two-year postoperative complication rates when compared to patients without OP. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Utilizing the New York State Statewide Planning and Research Cooperative System (SPARCS), we identified all patients who underwent >=4-level fusion with ICD-9 codes diagnostic for ASD (progressive idiopathic scoliosis and degenerative lumbar disease) from 2009-2011 with >=2-year follow-up. Patients with osteoporosis (OP) and without OR were identified following exclusions. OUTCOME MEASURES: Patient demographics, hospital-related parameters, postoperative complications and reoperations.
METHOD(S): Using SPARCS, we identified all patients who underwent >=4-level fusion with ICD-9 codes diagnostic for ASD (progressive idiopathic scoliosis and degenerative lumbar disease) from 2009-2011 for >=2-year minimum follow-up. Patients with osteoporosis (OP) and without OP were identified. Any patients with bone mineralization disorders (osteomalacia, rickets, hyperparathyroidism [primary, secondary, tertiary], vitamin D deficiency) and other systemic (fibrous dysplasia, sickle cell disease, renal osteodystrophy) and endocrine disorders (thyroid hypo- or hyperfunctioning disorders, adrenal insufficiency, adrenal hyperplastic syndromes) affecting bone quality or production were excluded, as were patients with surgical indications of trauma, systemic disease, infection, or cancer. The two cohorts were compared for demographics, hospital-related parameters, and 2-year postoperative complications and reoperations. Multivariate binary stepwise logistic regressions was utilized to identify significant predictors of these outcomes (covariates: OP, age, sex, race, and Charlson/Deyo).
RESULT(S): A total of 6,132 patients were identified (OP, n=490 (7.99%); No-OP, n=5,642). OP patients were older (67.6 vs 56.7 years), more often female (83.7% vs 46.2%) and white (84.3% vs 79.1%), and had higher comorbidity scores (Charlson/Deyo: 0.72 vs 0.61), all p<0.05. Patients with OP incurred higher hospital charges ($122,801 vs $108,649) and length of stay (6.7 days vs 5.8 days), both p<0.001. OP patients had higher rates of postop wound complications (13.5% vs 10.6%), acute renal failure (12.2% vs 7.90%), pseudarthrosis (3.7% vs 1.4%), blood transfusions (54.3% vs 34.6%), pneumonia (10.4% vs 6.1%), and implant-related complications (22.4% vs 14.5%); all p<=0.047. Patients in OP and no-OP cohorts experienced similar rates of postop PE, DVT, acute myocardial infarction, pneumonia, UTIs, dural tears, and CNS complications. Regression revealed that while controlling for demographics and comorbidities, OP is independently associated with increased odds of 2-year medical complications (OR=1.46), surgical complications (OR=1.55), and reoperations (OR=1.46); all p<=0.024.
CONCLUSION(S): Osteoporosis was associated with two-year postoperative complications in ASD patients. Aside from being an etiology of ASD due to vertebral fracture, osteoporosis should be considered as a comorbidity that needs to be optimized and managed perioperatively. Furthermore, this data is a call to every spine surgeon to consider metabolic bone disorders screening prior to any spinal deformity surgery. 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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