Faculty Bibliography

STUDY DESIGN/METHODS:A national prospective cervical spine surgery registry was developed to archive radiographic studies, patient-reported outcome measures (PROMs), and surgical implant data to assess long-term safety. OBJECTIVE:To describe the design, development, funding, and implementation of a cervical spine data registry for 1000 patients with myelopathy and radiculopathy. SUMMARY OF BACKGROUND DATA/BACKGROUND:While surgery for cervical radiculopathy and myelopathy is safe and effective, there is significant practice variation among spine surgeons. While randomized clinical trials (RCTs) can provide high-quality comparative effectiveness data, RCTs lack the ability to evaluate the safety and effectiveness of various surgical procedures and implants among heterogenous real-world patient populations. The CSRS Registry was designed to collect patient demographics, outcomes, radiographic imaging, surgical approach, and implant data for the purpose of conducting high-quality research. METHODS:Patients with cervical myelopathy or radiculopathy were enrolled in the CSRS National Registry. De-identified patient data, validated PROMs, radiographic data, and implant data were collected from multiple clinical sites across the United States. RESULTS:One thousand patients [mean age, 58 y; 456 (46%) women] were enrolled, with 31% follow-up at 1 year. Five hundred ninety-two patients were diagnosed with radiculopathy, 252 with myelopathy, and 156 with radiculopathy and myelopathy. Patients had significant improvements in their PROMs after surgery. At 1 year, the mean NDI score improved from 37.2 to 20.9 (P<0.001). The mean self-reported P-mJOA score at baseline was 14.2 and improved to 15.2 by 1 year (P<0.001). Baseline CSDI score was 23.6 and improved with a 1-year decrease to an average score of 13.6 (P<0.001). There was significant improvement in PROMIS-10 Physical Health score from 41.0 to 45.9 (n=311; P<0.001) at 1-year follow-up. CONCLUSIONS:The CSRS Registry has successfully collected clinical outcomes data that is being leveraged for comparative effectiveness research and evaluations of the long-term safety and effectiveness of spinal implants.

STUDY DESIGN/METHODS:Prospective, multi-center analysis. OBJECTIVE:Evaluate preoperative and minimum 2-year postoperative health related quality of life (HRQOL) outcomes for adult spine deformity (ASD) using legacy HRQOL measures and computer adaptive testing (CAT) version of the patient reported outcome measurement information system (PROMIS). SUMMARY OF BACKGROUND DATA/BACKGROUND:PROMIS is the NIH recommended measure for patient reported outcomes. No data exists evaluating minimum 2-year ASD surgical outcomes using PROMIS CAT compared to legacy HRQOL measures. METHODS:ASD patients > 18 years of age were enrolled into a prospective, multi-center, observational study. Patients were administered legacy HRQOLs (SRS-22r, ODI, NRS back and leg pain, VR-12) and PROMIS CAT for Pain Interference, Physical Function, Satisfaction with Participation in Social Roles, Satisfaction with Participation in Discretionary Social Activities, Depression, and Anxiety. Preoperative and minimum 2-year postoperative HRQOL scores were compared and ASD PROMIS scores were compared to general population PROMIS values. RESULTS:144 of 190 patients had complete data at minimum 2-year follow-up. Mean preoperative values included: age=62.6 years, scoliosis=34.2°, SVA=74.2mm, PI-LL=16.7. At mean 2.3 year follow-up surgical treatment improved spine alignment (scoliosis=14.7°, SVA=34.5mm, and PI-LL=4.5°; P<0.0001). All legacy HRQOL and PROMIS scores improved from preoperative to minimum 2-year postoperative (P<0.005). Referencing PROMIS scores to normative values demonstrated 50-85% of ASD patients preoperatively reported moderate-severe deficits in all domains. At minimum 2-year postoperative 52-88% of ASD patients reported normal values-mild deficits in all PROMIS domains. PROMIS social health domains demonstrated the greatest improvement. CONCLUSION/CONCLUSIONS:This is the first study evaluating minimum 2-year ASD surgical outcomes using PROMIS CAT. ASD patients demonstrated postoperative improvements in all PROMIS health domains, with the social health domains improving most. The majority of ASD patients reported normal PROMIS values at minimum 2-years postoperative.

STUDY DESIGN/METHODS:Retrospective review. OBJECTIVE:Determine if patients with different degrees of incidence (PI) have the capacity to compensate via pelvic retroversion before initiating lower extremity compensation. SUMMARY OF BACKGROUND DATA/BACKGROUND:Compensatory mechanisms in the spine are thought to help patients with deformities maintain sagittal alignment. Pelvic retroversion and thoracic hypokyphosis are key mechanisms that help maintain balance. When these mechanisms are exhausted, patients often flex their hips and bend their knees. METHODS:This was a retrospective radiographic analysis of the EOS images at a single institution. Various spinal sagittal parameters and lower extremity knee flexion measurements were performed. Patients were subcategorized according to PI. Knee flexion in these groups was correlated with various sagittal parameters to determine whether there were differences when knee flexion occurred based on the PI. RESULTS:Knee flexion was independently correlated with PI, pelvic tilt (PT), PI-lumbar lordosis mismatch (PI-LL), and T1 pelvic inclination angle (TPA) in multiple regression analyses (P < 0.05). In patients with lower PI, knee flexion occurred at a PT of 10-15 degrees, PI-LL mismatch of -5-0 degrees, and TPA of about 10-15 degrees. In those with high PI, knee flexion occurred at a PT of ∼25-30 degrees, PI-LL mismatch of ∼15-20 degrees, and TPA about 25 degrees. Those with a lower PI also more rapidly increased knee flexion with further increases in PI-LL mismatch and TPA compared with those with a higher PI. CONCLUSION/CONCLUSIONS:This study demonstrates that patients with different PI have different capacities to compensate for increasing sagittal plane deformity before initiating knee flexion lower extremity compensation. Those with a lower PI retroverted their pelvis less and begin knee compensation earlier than those with a higher PI. These findings are important for surgical planning in patients with differing PI who are compensating for knee flexion.

STUDY DESIGN/METHODS:Retrospective review of multicenter data. OBJECTIVE:To compare long-term neurologic recovery in patients with and without incidental durotomy (hereafter, "durotomy") after adult spinal deformity surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:Durotomy is a common complication of adult spinal deformity surgery and is typically associated with technical challenges during the procedure. METHODS:Using a prospectively collected database, we included 1452 patients (73% female; mean age, 60±14 y) who underwent adult spinal deformity surgery from 2008-2020 at 22 US centers. We compared patients with and without durotomy with respect to demographic characteristics, surgical variables, and neurologic outcomes at baseline and at 1 and 2 years postoperatively. Multivariate analysis compared neurologic complications and length of stay (LOS) between the groups. P<.05 was considered significant. RESULTS:Durotomy occurred in 121 patients (8.3%). Patients with durotomy were more likely to have undergone revision surgery (P<.001) and had higher Charlson Comorbidity Index values (P=.029) than those who did not. Patients with durotomy had higher estimated blood loss, longer operative time, more frequent 3-column osteotomies, and longer LOS (all, P<.001). Lower-extremity motor scores did not differ between patients with durotomy and those without at 1 and 2 years postoperatively. The incidence of neurologic, medical, and surgical complications did not differ significantly between the 2 groups. Patients with durotomy had a higher rate of inpatient return to the operating room (5.0%) than those without (2.0%) (P=.04). On multivariate analysis, there were no differences between groups in lower-extremity motor scores, neurologic complications, or LOS. CONCLUSIONS:Incidental durotomy during adult spinal deformity surgery was associated with greater intraoperative complexity and transient sensory symptoms but did not adversely affect long-term motor recovery, neurologic complications, or patient-reported outcomes. These findings suggest durotomy is a manageable complication without lasting functional consequences.

STUDY DESIGN/METHODS:Retrospective review of prospectively collected, multicenter data. OBJECTIVE:To assess associations between patient height and weight independently and interactively with the incidence of proximal junctional kyphosis (PJK) after surgical treatment of adult spine deformity. SUMMARY OF BACKGROUND DATA/BACKGROUND:Body mass index has traditionally been used to assess the influence of body composition on surgical outcomes, but the individual effects of height and weight have not been studied in relation to PJK. METHODS:We compared baseline demographic characteristics, radiographic measurements, and perioperative variables between patients who developed PJK after adult spinal deformity surgery between 2008 and 2020 and those who did not. Using a generalized additive model with a logistic link function, we modeled height and weight and their interaction as smooth terms to capture potential nonlinear effects on PJK risk. Multivariate analysis was adjusted for age, history of osteoporosis, upper instrumented vertebra, number of levels fused, and postoperative pelvic incidence minus lumbar lordosis and T1 pelvic angle. RESULTS:Of 904 included patients, the median age was 65 years (interquartile range: 58-71), and 76% were female. PJK developed in 131 patients (14%). Baseline characteristics, including frailty, comorbidities, and radiographic measures, did not differ significantly between the PJK and non-PJK groups. Taller height was a predictor of PJK (P=.03). In contrast, weight was not an independent predictor, and there was no significant interaction between height and weight. The incidence of PJK peaked at a height of approximately 179 cm before plateauing. CONCLUSIONS:Taller height, but not weight, was associated with developing PJK after adult spinal deformity surgery. These findings underscore the importance of considering patient height during surgical planning.

STUDY DESIGN/METHODS:Retrospective cohort analysis. OBJECTIVE:Assess the distribution of Medicare's spinal-deformity-specific diagnosis-related group (DRGs) relative to surgical invasiveness, hospital length of stay (LOS), discharge disposition, 90-day postoperative quality metrics, and reimbursement costs for adult spinal deformity (ASD) operations. SUMMARY OF BACKGROUND DATA/BACKGROUND:Heterogeneity of ASD call into question Medicare's DRGs to accurately capture nuances of ASD surgical episodes of care. METHODS:Adults who underwent thoracic to pelvis instrumentation with associated DRGs were identified from a multicenter database. Demographics, operative details, inpatient course, discharge disposition, 90-day adverse events, and reimbursement costs were compared between spinal deformity-specific DRG codes. Distribution of DRGs for a subset of these patients who fit into one of 6 commonly performed surgical strategies to address ASD was also assessed. RESULTS:Of the 314 patients included for analysis, the majority fell into +CC DRGs, while the minority had +MCC DRGs or no MCC/CC DRG. Within each DRG, there was considerable heterogeneity in regard to patients' ages, ASA, CCI, frailty, surgical invasiveness, postoperative ICU/hospital LOS, discharge disposition, and complication profiles.+MCC DRGs had significantly greater ASA and Edmonton Frailty Scores. While +MCC and +CC had relatively similar surgical invasiveness, +MCC had greater ICU admissions, in-hospital adverse events, and nonhome discharges as well as longer ICU, hospital, and rehab LOS. While reimbursements were significantly higher for +MCC DRG compared with +CC DRGs and DRGs without MCC/CC, there were large ranges in reimbursement within all DRG subgroups.The 7 DRGs varied significantly within and between the subset of 6 commonly performed surgical strategies, although there were no differences in regard to ICU admissions and LOS, hospital LOS, discharge disposition, and number of adverse events (in-hospital, 90-day). CONCLUSIONS:While Medicare's spinal-deformity DRG codes capture average trends in surgical/postoperative episodes of care for ASD patients, each encompasses highly heterogeneous patients and associated surgical operations rendering them unreliable gauges of patient/surgical complexity, early postoperative trajectories, and reimbursement costs. A more granular system is needed to more accurately capture the nuances of ASD operations and their associated quality metrics and reimbursement costs.

STUDY DESIGN/METHODS:Retrospective Multi-Center Study. OBJECTIVE:To investigate how advances in spine realignment have impacted lumbar segmental alignment. SUMMARY OF BACKGROUND DATA/BACKGROUND:The understanding of spine alignment and Adult Spinal Deformity (ASD) management continues to advance. It remains unknown how these advances have influenced lumbar segmental alignment changes in the setting of surgical correction. METHODS:Patients undergoing primary thoracolumbar fusion for ASD were stratified based on enrolment in two distinct multicenter registries; forming an 'Early' (2008-2017) and a 'Late cohort' (2018-present). Patients were further stratified based on pelvic incidence (PI) and Roussouly type. Segmental alignment was determined based on published values of asymptomatic individuals. Pelvic incidence-based alignment and Roussouly-based alignment were determined in alignment with previously published normative values. Means comparisons tests and multivariate analyses compared segmental & regional parameters between groups. RESULTS:1240 patients included (622 EARLY, 618 LATE). The mean age was 61.4±14.5 years, body mass index (BMI) was 28.0±5.8 kg/m2, and Charlson comorbidity index (CCI) was 1.55±1.70. 70.2% of patients were female gender. LATE consistently displayed better L5-S1 alignment across all PI and Roussouly types (P=0.001) However, EARLY demonstrated better L4-5 alignment (P=0.001). Improved alignment in L5-S1, L4-5 and L3-4 was associated with achieving minimum clinically important difference in ODI scores and decreased risk of mechanical complications. Both cohorts demonstrated low rates of matching L4-S1 regional and overall lumbar lordosis L1-S1 alignment, with no differences between both groups. By lordosis distribution index, both groups had predominantly hyperlordotic maldistribution postop, but LATE had more 'Aligned' patients (15.9 vs. 11%, P<0.001). CONCLUSIONS:Over the past 15 years, surgeons appear to be better at restoring ideal lumbar segmental sagittal alignment in ASD patients. However, idealized correction does not appear to be uniform across all lumbar segments, representing an opportunity for further improvement. LEVEL OF EVIDENCE/METHODS:III.

STUDY DESIGN/METHODS:Prospective, multi-center analysis. OBJECTIVE:Evaluate the impact that self-image has upon operative vs. nonoperative treatment choice for adult spine deformity (ASD) patients, and evaluate the association of post-treatment self-image with treatment satisfaction. SUMMARY OF BACKGROUND DATA/BACKGROUND:ASD outcomes traditionally focus upon pain and physical function. Self-image is an important outcome measure for pediatric spine deformity. Little data exists regarding the impact self-image has upon ASD treatment choice and outcomes. METHODS:Factor analysis and decision tree modeling was performed upon ASD patients prospectively enrolled into a multi-center study from 2009-2020. Data elements from physical examination, demographics, spinal alignment, and individual questions from administered PROMs including SRS-22r, ODI, SF-36, and NRS back and leg pain were evaluated for variables that correlated most with (1) patients electing for operative vs. nonoperative treatment and (2) treatment satisfaction at minimum 2-year follow-up. RESULTS:Evaluation of 735 ASD patients demonstrated operatively treated patients (OP; n=548) were older (58.0±15.3 vs. 52.4±16.0 years; P<0.0001), had similar scoliosis (44.9±20.1° vs. 45.5±16.1°; P=0.5555) but worse sagittal malalignment than nonoperatively treated patients (NON; n=187; P<0.0001, respectively). Baseline PROMs were worse for OP vs. NON (P<0.0001). Gradient-boosted decision trees, factor analysis, and logistic regression of demographic, physical examination, radiographic, and PROM variables associated with treatment choice demonstrated self-image (odds ratio=4.5; 95% CI=3.4-6.0; P<0.0001) had the greatest correlation for patients choosing operative treatment. At minimum 2-year follow-up self-image demonstrated the greatest health domain improvement for OP and self-image improvement correlated most with post-treatment satisfaction, while NON demonstrated deterioration of self-image and reported poor treatment satisfaction. CONCLUSION/CONCLUSIONS:Multi-variable evaluation of 735 operative and nonoperative treated ASD patients demonstrated baseline self-image strongly correlated with ASD patients pursuing surgical treatment and postoperative treatment satisfaction. Patient self-image is a critical measure that must be assessed in ASD.

STUDY DESIGN/METHODS:Retrospective review of a prospective, multicenter adult cervical deformity (CD) database. OBJECTIVE:Investigate the prevalence and clinical significance of combined cervical scoliosis (CS) and cervical kyphosis (CK) among patients undergoing surgical management of CD. SUMMARY OF BACKGROUND DATA/BACKGROUND:Although adult CD patients may have both CS and CK, few studies have confirmed prevalence of CK and CS and associated radiographic and clinical findings. MATERIALS AND METHODS/METHODS:Patients undergoing surgery for CD [defined as C2-C7 ≥10° kyphosis, cervical sagittal vertical axis (SVA) >4 cm, or C2-C7 coronal Cobb angle ≥10°] were included. CS was defined as C2-C7 coronal Cobb angle ≥10°. RESULTS:Totally, 114 patients were included (mean age 62.5 yr, 51.8% female). Fourteen patients (12.3%) had combined CS and CK, and 100 patients (87.7%) had CK alone. Preoperative maximum cervical coronal Cobb angle was 3.9° in the CK alone group and 14.6° in the combined CS and CK group. In the combined CS and CK group, this value improved to 8.1° postoperatively ( P =0.0007 vs. preoperative), but CS ≥10° was still present in three patients, with a mean correction percentage of only 48.0% of initial CS.No significant differences were observed between the CK only and combined CS and CK groups with regard to baseline sagittal parameters, change between immediate postoperative and baseline sagittal parameters, surgical approach, age, or baseline HRQOL. Patients with combined CS and CK were more frequently female than patients with CK alone (85.7% vs. 41.2%, P =0.0066). CONCLUSIONS:The vast majority of patients presented with CK alone (88%), and only 12% of adult CD patients had combined CS and CK. Because of the significant residual coronal plane deformity-∼50%-surgical correction should be focused on both coronal and sagittal plane deformity in the combined CS and CK group.

INTRODUCTION/BACKGROUND:The sacroiliac joint (SIJ) is a potential source of pain in the ASD population. Incidence and predictors of preoperative SIJ pain and rates of resolution with surgery in the ASD population are not well understood. METHODS:A prospective, multicenter database of surgically treated ASD patients was queried for baseline SIJ pain at the preoperative assessment. SIJ pain was defined as self-reported back pain in the posterior superior iliac spine region scored ≥4 out of 10 and ≥3 of 5 positive provocative SIJ maneuvers. Demographic data, spinal alignment parameters, and health assessments were assessed using Wilcoxon and χ 2 analysis. Predictors of preoperative SIJ pain were assessed with univariate and multivariate logistic regression. RESULTS:A total of 735 patients were included with a mean (SD) age of 61.3 (15.3) years, BMI of 27.6 (5.4), Edmonton Frailty Score (EFS) of 3.4 (2.5), and Charlson Comorbidity Index (CCI) of 1.1 (1.8). A total of 65% were female and 6% were tobacco users. A total of 411 patients had self-reported PSIS pain and 53 patients (7.2%) had preoperative SIJ pain as assessed by SIJ maneuver testing. SIJ pain was not associated with history of prior lumbosacral fusion ( P =0.23). Patients with SIJ pain had higher BMI (30.0 vs . 27.4, P =0.004), preoperative pain medication usage (92.5% vs . 77.7%, P =0.02), EFS (4.6 vs . 3.3, P <0.001), and CCI (1.6 vs . 1.0, P =0.006) as well as lower L4-S1 lordosis (28.7 vs . 34.5, P =0.02) and greater L1 pelvic angle (14.5 vs . 10.8, P =0.03). After variable selection with univariate regression, multivariate logistic regression identified higher BMI (OR 1.06, P =0.033) as a significant predictor of SIJ pain at preoperative. In the patient cohort with SIJ pain at preoperative, 91.7% reported no SIJ pain at 1-year follow-up. 11/53 (20.8%) patients with baseline pain and SIJ fusion performed concurrently with ASD surgery had 100% resolution of SIJ pain in this cohort; however, there was no significant difference in pain resolution between patients with SIJ fusion and those without ( P =1). CONCLUSION/CONCLUSIONS:We found a lower prevalence of preoperative SIJ pain in ASD patients than what has been historically reported, present in 7.2% of patients. Higher BMI was a predictor of preoperative SIJ pain in this population. ASD surgery led to resolution of SIJ pain in >90% of patients at 1-year follow-up.