Faculty Bibliography

There exist no population-based examinations of stereotactic radiosurgery (SRS) of the spine. To address this, spinal SRS was analyzed using the New Jersey State Ambulatory Surgery and Services Database (SASD) and Nationwide Inpatient Sample (NIS) over 10-year periods. The SASD is a state-specific ambulatory surgery and outpatient database, while the NIS database comprises approximately 20% of all nonfederal hospital inpatient admissions and discharges in the United States. Only patients receiving SRS for at least one spinal lesion were included (ICD-9-CM=92.3x; diagnosis codes=63620,63621). 4,194,207 patients were contained in the New Jersey SASD from 2003-2012, of whom fewer than 0.0003% received SRS of any sort, with none receiving SRS of the spine. Of the 78,686,628 patients contained in the NIS, only 16 (0.00002%) received radiosurgery, none of whom received SRS of the spine. In conclusion, a decade-long analysis of the NIS and SASD from the most densely populated state in the United States revealed that no patients received spinal SRS with virtually none receiving SRS of any sort. Given the improbability of these findings, it is much more likely that neither the NIS nor SASD can accurately capture patients receiving SRS. Accurate characterization of the incidence and usage of spinal SRS will require databases less reliant on ICD-9 coding than the SASD or NIS.

BACKGROUND: Few reports have focused on treatment of adult cervical deformity (ACD). OBJECTIVE: To present early complication rates associated with ACD surgery. METHODS: A prospective multicenter database of consecutive operative ACD patients was reviewed for early (<=30 days from surgery) complications. Enrollment required at least 1 of the following: cervical kyphosis >10 degrees, cervical scoliosis >10 degrees, C2-7 sagittal vertical axis >4 cm, or chin-brow vertical angle >25 degrees. RESULTS: Seventy-eight patients underwent surgical treatment for ACD (mean age, 60.8 years). Surgical approaches included anterior-only (14%), posterior-only (49%), anterior-posterior (35%), and posterior-anterior-posterior (3%). Mean numbers of fused anterior and posterior vertebral levels were 4.7 and 9.4, respectively. A total of 52 early complications were reported, including 26 minor and 26 major. Twenty-two (28.2%) patients had at least 1 minor complication, and 19 (24.4%) had at least 1 major complication. Overall, 34 (43.6%) patients had at least 1 complication. The most common complications included dysphagia (11.5%), deep wound infection (6.4%), new C5 motor deficit (6.4%), and respiratory failure (5.1%). One (1.3%) mortality occurred. Early complication rates differed significantly by surgical approach: anterior-only (27.3%), posterior-only (68.4%), and anterior-posterior/posterior-anterior- posterior (79.3%) (P = .007). CONCLUSION: This report provides benchmark rates for overall and specific ACD surgery complications. Although the surgical approach(es) used were likely driven by the type and complexity of deformity, there were significantly higher complication rates associated with combined and posterior-only approaches compared with anterior-only approaches. These findings may prove useful in treatment planning, patient counseling, and ongoing efforts to improve safety of care.

BACKGROUND CONTEXT: Radiographic parameters including sagittal balance, coronal balance, and lumbar lordosis have been increasingly implicated as potential determinants or markers of functioning in patients with scoliosis. In an effort to stratify disease severity preoperatively and assess response to treatment for patients undergoing spine surgery, several patientreported functional measures have been employed including the Scoliosis Research Society Questionnaire (SRS-30), Oswestry Disability Index (ODI) and the Short Form Health Survey (SF-12). The degree to which radiographic and functional measures of spinal disease correlate and interact remains unclear. PURPOSE: The purpose of this study was to assess the correlation between SRS-30, ODI, and SF-12 scores and radiographic alignment measures in adult patients with scoliosis. STUDY DESIGN/SETTING: Retrospective review of a prospectively maintained multi-institution database. PATIENT SAMPLE: A total of 1850 adult patients seen in consultation for scoliosis. OUTCOME MEASURES: ODI, SRS-30, SF12-PCS, SF12-MCS. Pelvic incidence, pelvic obliquity, lumbar lordosis, absolute values of sagittal (C7- sacrum) and coronal balance. METHODS: The relationship of four patient-reported outcomes (PROM) as well as five radiographic measures was assessed. Given the large sample size, nearly all correlations were statistically significant, but many were clinically meaningless. We focused our analysis on those variables with a univariate correlation >=0.20. To assess the relevant impact, these variables were then entered into a linear model adjusting for baseline demographic variables of body mass index (BMI), gender, pain location, smoking status, and number of comorbidities. Additionally, lumbar lordosis was separated into clinically relevant groups, and a one-way ANCOVA (analysis of covariance), controlling for the above variables, was used to assess the impact on PROMs. RESULTS: The absolute value of the correlations between the four PROMs was at least 0.20; all results were moderate, between 0.20 and 0.36, with the exception of ODI and PCS at -0.70. Neither the MCS or SRS-30 had any meaningful correlation with any radiographic measures with no correlation coefficient reaching 0.10. The ODI and PCS had similar correlations with sagittal balance (0.22 and -0.20, respectively) and the ODI had a significant correlation with lordosis (0.28). ODI scores increased 0.90 (0.62- 1.16) points for each centimeter of imbalance, and decreased 0.11 (0.08- 0.14) for each degree of lordosis. When comparing patients with 10 cm of sagittal imbalance to those with 5 cm or less, the effect in favor of 5 cm or less was: ODI-14.34 (-9.47, -19.22); SRS-30 0.48 (0.80, 0.17); PCS 7.89 (4.67, 11.12); MCS 0.29 (-0.45, 0.63). CONCLUSIONS: Outcomes commonly used in assessing patients with scoliosis have statistically significant but clinically small correlations, with the exception of the ODI and PCS, both of which focus on pain and function. Lumbar lordosis and sagittal balance were significant predictors of selfreported pain and function. Patients with greater than 10 cm of sagittal imbalance had significantly worse scores in three of four measures when compared to those with less than 5 cm of imbalance