Faculty Bibliography

BACKGROUND CONTEXT: Circumferentially minimally invasive (cMIS) correction techniques of adult scoliosis have advanced, but it is unclear how outcomes compare to open correction. PURPOSE: To compare health related quality of life (HRQL) measures and surgical parameters between the two modalities. STUDY DESIGN/SETTING: Retrospective review of prospective multicenter adult spinal deformity database. PATIENT SAMPLE: Inclusion criteria are age >18, and one of the following: PT>25, PI-LL>10, or SVA>5 cm. OUTCOME MEASURES: NRS leg, ODI, SF-12, EQ5D, SRS-22.
METHOD(S): A prospective database was retrospectively reviewed. Inclusion criteria were age >18, and one of the following: PT>25, PI-LL>10, or SVA>5 cm. Patients were grouped as cMIS (percutaneous screws) or OPEN. Propensity matching was used to create two equal groups controlling for: age, BMI, preop (PI-LL, PI, TPA), and number of posterior levels fused.
RESULT(S): A total of 154 (77 cMIS, 77 OPEN) patients were included after matching for age, BMI, PI-LL (15 vs 17degree), PI (54degree vs 54degree), TPA (21degree vs 22degree), and mean number of levels fused (6 vs 6), for cMIS and OPEN, respectively. 3-column osteotomies were excluded. Baseline and postop ODI, SRS total, EQ5D were not different between MIS and OPEN (p=0.50, 0.45, 0.33). Maximum Cobb angles were similar for OPEN and cMIS, respectively, at baseline (26.3degree, 25.9degree, p=0.85) and at 1-yr postop (17.5degree, 15.0degree, p=0.17). Patients reaching minimal clinically important difference (MCID) were 58.3% for OPEN and 64.4% for cMIS (p=0.31) at 1 year. At 1 year, no difference was observed between PI-LL, SVA, PT, or Cobb (p=0.71, 0.46, 0.9, 0.20). OPEN vs MIS had greater EBL (1.36L vs 0.524L, p<0.05), fewer levels of interbody fusion (1.87 vs 3.46, p<0.05), but shorter OR time (356 vs 452min, p=0.003). Revision surgery rates between the two cohorts were not different (p=0.097).
CONCLUSION(S): When comparing cMIS to OPEN adult scoliosis correction with propensity matching, HRQL improvement, spino-pelvic parameters, revision surgery rates, and patients reaching MCID were not different between cohorts. However, cMIS had lower blood loss with comparable results in well-selected patients, but longer OR time. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Neurologic complications following adult spinal deformity (ASD) are common and may play a role in the outcomes for our patients. Neurologic complications may include radiculopathy, sensory deficit or motor weakness. The impact that these specific complications have on HRQL is unknown. PURPOSE: Neurologic complications are common following ASD. Understanding their impact on Health-related quality of life (HRQL) measures is critical. STUDY DESIGN/SETTING: Retrospective cohort study of prospective ASD database. PATIENT SAMPLE: Retrospective cohort study, 733 patients. OUTCOME MEASURES: Neurologic complications, HRQL scores.
METHOD(S): ASD patients (>18yrs, scoliosis >=20degree, SVA >=5cm, PT >=25degree and/or TK >60degree). Inclusion criteria was HRQL at baseline (BL) and 1 year, and lower extremity motor score (LEMS) at BL, 6-week and 1-year ODI, SRS22r and SF36 were determined at BL and 1yr LEMS was calculated from 0-50, with 50 designated as normal motor function. Patients were divided into 4 groups: pLEMS (perfect, no deficit), dLEMS (new postop deficit that returned to normal at 1 year), iLEMS (deficit improved from abnormal baseline), and wLEMS (new postop deficit persistent at one year).
RESULT(S): A total of 733 patients were eligible, with 95 (12.96%) reporting neurologic complications (NC). Impact of any NC vs no complication at 1yr was significant for ODI (5.1), PCS (3.6) and SRSpain (0.2) at 1 year (p<0.001 all). For NC vs any other complication, there was still a decrease in ODI (3.9) and PCS (2.4) at 1 year (p<0.01). NC subtype: radiculopathy caused worse outcomes for (4.3) and SRS pain (0.3) (p<0.05), sensory deficit caused worse SRSmental (0.5) (p<0.05), but no HRQL change was detected for motor deficit at 1 year. PLEMS (456/733) had improvement in all HRQL, and these improvements were not different with or w/o NC, or non-NC. Compared to pLEMS w/o complication, dLEMS (62/733) and iLEMS (147/733) were statically similar, however wLEMS (68/733) had worse ODI (7.1), SRStotal (0.3), activity (0.3), mental (0.3), pain (0.3) (p<0.05 all).
CONCLUSION(S): Neurologic complications that occur following ASD have a significant effect on HRQLs. The magnitude of effect is driven by radiculopathy and by lower extremity motor score. LEMS scores that remain normal, return back to normal or improve have similar outcomes, while patients that have continued weakness remain statistically worse at 1 year. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Recent studies have suggested that for patients with chronic neck pain, both psychological and physical symptoms need to be addressed. Studies have shown that psychological distress is associated with poor outcomes in these patients. The fear avoidance model has been used to explain how maladaptive thoughts and behaviors contribute to chronicity and disability. Cognitive behavioral therapy (CBT) addresses these 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 psychological outcomes in cervical spine surgery. STUDY DESIGN/SETTING: Prospective, blind, and placebo-controlled trial. PATIENT SAMPLE: A total of 42 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).
METHOD(S): Forty-two 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 Placebo treatment groups had 6 sessions prior to surgery. The control group had no intervention prior to surgery. Baseline and 1-year (1Y) changes were assessed for all outcome measures.
RESULT(S): Forty-two patients were enrolled (53.6 years, BMI 29.4 kg/m2); 23 patients met psychological distress criteria and were randomized into a treatment group (14 CBT vs 9 placebo). Ten patients were in the control group, with nine exceeding DRAM scores to be CBT candidates. At enrollment, the CBT group had greater EQ5D scores (CBT: 10.8, Placebo: 9.5, Control: 7.5, DRAM:8.7) while the Placebo group had greater PCS scores (Placebo: 33.1, CBT: 32.4, Control:18.6, DRAM: 30.8; all p<0.05). From BL to 1Y postop, the CBT patients improved in all psychological-related questionnaires (NDI: 29.2 to 2, PCS: 32.4 to 20.7, FABQ:41.3 to 32.3, mJOA: 2.3 to 3.4, DRAM:12.9 to 16.6). Placebo patients also improved post-operatively, but to a lesser degree in NDI (26.6 to 2), PCS (33.1 to 28.3), and worsened in FABQ (40.4 to 54.1), mJOA(12.5 to 11.8), and DRAM (36.6 to 31.6). In contrast, patients in the control group showed improvement to a much lesser degree than CBT and Placebo patients (NDI: 18.1 to 2, PCS:18.6 to 3.2, FABQ:26.2 to 17.6, mJOA: 15.3 to 16.4). DRAM patients showed minimal changes in psychological- and spine-related questionnaires. Comparing treatment groups at 1Y, CBT pts had significantly lower FABQ scores than Placebo pts (32.3 vs 54.1; p<0.05). CBT pts also had better DRAM scores than the control group at 1Y (30.3 vs 11.4; p=0.03).
CONCLUSION(S): Cognitive behavior treatment can be beneficial in patients undergoing cervical surgery as it was identified in our study to minimize fear avoidance beliefs more than the Placebo group. This type of professional treatment has also shown a steady improvement in all psychological questionnaires and spine related neck disability from baseline to 1-year postoperatively. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Miller et al. adult spinal deformity frailty index (ASD-FI) correlates with increased complication risk after surgery; however, its development is rooted in health related quality of life metrics (HRQLs) that may be subjective, and the 40 factors needed for its calculation limit the index's utility in a clinical setting. PURPOSE: Develop a simplified, modified frailty index for ASD patients STUDY DESIGN/SETTING: Retrospective cohort study PATIENT SAMPLE: A total of 531 ASD patients OUTCOME MEASURES: HRQLs, length of stay (LOS) METHODS: ASD patients (scoliosis>=20degree, SVA>=5cm, PT>=25degree, or TK >=60degree) with baseline (BL) and 2-year HRQL follow up. HRQL components were removed from the FI and top contributors to the ASD-FI score of the remaining were assessed via Pearson correlation, and included in forward multiple stepwise regressions. Factors with the largest R2 value were including in the modified, ASD-FI (clin-ASD-FI). Factors included in the clin-ASD-FI were regressed against mortality, extended length of hospital stay (>8 days), revisions, major complications and weights for the clin-ASD-FI were calculated via Beta/Sullivan. Total clin-ASD-FI score was created with a score from 0 to 1. Linear regression correlated the clin-ASD-FI with ASD-FI scores and published cut-offs for the ASD-FI were used to create the new frailty cutoffs: not frail (NF: < 0.11), frail (F: 0.11-0.21) and severely frail (SF: >0.21). Binary logistic regression assessed odds of complication or reop for frail patients. Logistic regressions were run to determine whether the clin-ASD-FI is superior to previously utilized measures predicting risk (age, ASA, previous FI, and CCI) for complications and reop.
RESULT(S): A total of 531 ASD patients (59.5yrs, 79.5%F). The final stepwise regression model R2 of 0.681: <18.5 or >20 BMI (weight: 0.0625 out of 1), cardiac disease (0.125), disability employment status (0.3125), diabetes mellitus (0.0625), hypertension (0.0625), osteoporosis (0.125), blood clot (0.1875), and bowel incontinence (0.0625). These factors calculated the score from 0 to 1, with a mean cohort score of 0.13+/-0.14. Breakdown by clin-ASD-FI score: 51.8% NF, 28.1% F, 20.2% SF. Increasing frailty severity was associated with longer LOS (NF: 7.0, F: 8.3, SF: 9.2 days; p<0.001). When assessing BL HRQL status between the new clin-ASD-FI groups, ODI, EQ5D, SRS, PCS, MCS, NRS-Back, and NRS-Neck were worse with increasing categorical frailty (all p<0.001). Frailty independently predicted occurrence of any complication (9.357[2.20-39.76], p=0.002) and reop (2.79[0.662-11.72], p=0.162). Specific complications predicted included infection, neurologic, operative, radiographic, and wound complications (OR: 1.69-5, all p<0.001). Chi-square and p-values for the historical risk predictors of complications are as follows: Age(complication: 1.01[1-1.03] p=0.052; reop: 0.999[0.984-1.01] p=0.866), ASA(complication: 1.102[1.20-2.18], p=0.002; reop: 1.31[0.927-1.84], p=0.177), previous frailty index(complication: 8.57[1.66-44.17], p=0.010; reop=2.629[0.498-16.06], p=0.241), CCI(complication: 1.24[1.10-1.40], p<0.001; reop: 1.06[0.943-1.20], p=0.320).
CONCLUSION(S): Utilizing an existing ASD frailty index, we proposed a modified version eliminating the patient-reported components. This index is a true assessment of physiologic status, and represents a superior risk factor to other risk assessment tools for baseline and revision spinal deformity surgery as a result of its immutability with surgery, lack of subjectivity, and ease of use. Future studies should explore external validation of the proposed frailty index. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Spinal fusion is increasingly considered for management of patients with osteoporosis (OP) and degenerative disc disease (DDD). Little data is available regarding long-term outcomes in OP patients undergoing short-segment, lumbar fusion for DDD. PURPOSE: Analyze the impact of OP on long-term outcomes in patients who have had 2-3-level lumbar fusions for degenerative disc disease. STUDY DESIGN/SETTING: Retrospective review of the New York State Statewide Planning and Research Cooperative System (NYS SPARCS) database. PATIENT SAMPLE: Patients with DDD undergoing 2-3-level lumbar fusion. OUTCOME MEASURES: Frequency of 2-year medical and surgical complications and reoperations.
METHOD(S): Utilizing SPARCS, all patients from 2009-2011 with ICD-9 codes for DDD who underwent 2-3-level lumbar fusion were identified. Patients with bone mineralization disorders, systemic and endocrine disorders affecting bone quality were excluded. Surgical indications of trauma, systemic disease(s), and infection were excluded. Patients with and without OP were compared for demographics, hospital-related parameters, and 2-year complications and reoperations. Logistic regression models were utilized to identify predictors of complications.
RESULT(S): A total of 29,028 patients (OP=1,353 (4.7%), No-OP=27,675) were included. OP patients were older (66.9 vs 52.6 years) as well as more often female (85.1% vs 48.4%) and white (82.8% vs 73.5%), all p<0.001. Deyo index did not differ between groups. LOS and total charges were higher for OP patients (4.9 vs 4.1 days; $74,484 vs $73,724), all p<0.001. Medical complications were higher for OP patients: acute renal failure (8.9% vs 4.7%), and deep vein thromboses (3.4% vs 1.6%), all p<0.01. OP patients also had higher rates of implant-related (3.4% vs 1.9%) and wound complications (9.8% vs 5.9%) (p<0.01). Preoperative OP was associated with 2-year medical and surgical complications (OR=1.62, 1.66; p<0.001). Patients with OP had greater odds of reoperations (OR=1.34).
CONCLUSION(S): Patients with OP undergoing 2-3-level lumbar fusion for DDD were at higher risk of 2-year medical and surgical complications, and 3.4% of OP patients experienced implant-related complication. These findings highlight the importance of rigorous preoperative metabolic workup prior to spinal surgery. 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: For patients with coronary artery disease, the two most common options for intervention are a cardiac stent or a coronary artery bypass graft. Although less invasive, stents may pose a long-term risk for patients undergoing further invasive procedures such as elective spine surgery. This study aimed to provide surgeons with insight on possible major complications for elective spine surgery patients with a history of coronary artery disease. PURPOSE: Investigate outcomes of elective spine fusion patients with prior history of cardiac intervention STUDY DESIGN/SETTING: Retrospective review of the PearlDiver database between the years 2006-2013 PATIENT SAMPLE: A total of 731,173 elective spine fusion patients OUTCOME MEASURES: Comorbidity burden, 30-day and 90-day complications, readmission METHODS: Elective spine fusion patients were isolated with ICD-9 and CPT procedures codes in the PearlDiver database. Patients were stratified by having previous history of a coronary stent (Stent), coronary artery bypass graft (CABG), and no previous heart procedure (No-HP). Means comparison tests (chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, and comorbidities. Logistic regression assessed the odds of 30-day and 90-day postoperative (postop) complications associated with each heart procedure (Odds Ratio [95% confidence interval]). Statistical significance was set p<0.05.
RESULT(S): A total of 731,173 elective spine fusion patients were included. Overall, 8,401 pts underwent a CABG, 24,037 patients Stent, and 698,735 had No-HP prior to spine fusion surgery. Compared to Stent and No-HP patients, CABG patients had higher rates of morbid obesity, chronic kidney disease and diabetes (p<0.001 for all). Stent patients had higher rates of peripheral vascular disease, hypertension, and hyperlipidemia (all p<0.001). Within 30 days postoperatively of index surgery, CABG patients had significantly higher complication rates including pneumonia, cerebrovascular accident (CVA), myocardial infarction (MI), sepsis, and death compared to No-HP (all p<0.001). Stent patients vs No-HF also had higher 30-day postoperative complication rates including pneumonia, CVA, MI, sepsis, and death. Adjusting for age, comorbidities and sex, Stent was significantly predictive of a MI 30-days post-op (OR: 1.90 [1.53-2.34], P<0.001). Additionally, Stent patients compared to CABG patients had 1.99x greater odds of a MI within 30-days (OR: 1.99 [1.26-3.31], p=0.005) and 2.02x greater odds of readmission within 90-days postop (OR: 2.2 [1.53-2.71, p<0.001).
CONCLUSION(S): With regards to spine surgery, coronary artery bypass graft remains the gold standard for risk reduction. Stenting does not appear to minimize risk as significantly as CABG. When assessing patients with a history of coronary artery disease for elective spine fusion surgery, surgeons should be cautious of the significant risk of major complications associated with stents compared to coronary artery bypass grafting. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Adult spinal deformity (ASD) surgery is complex and may lead to new-onset cervical malalignment and/or proximal junctional kyphosis (PJK). Roussouly et al describes variations in baseline thoracolumbar (TL) shape (Types 1-4), which have been shown to differentially influence surgical ASD outcomes. The effect of morphological shape on patterns of postoperative CD development remains underexplored. PURPOSE: Stratify patients by Roussouly type and assess patterns of conversion from baseline (BL) cervical alignment to postoperative cervical deformity (CD) in patients undergoing thoracolumbar ASD surgery. STUDY DESIGN/SETTING: Retrospective review of a prospective multicenter database of ASD patients. PATIENT SAMPLE: A total of 266 surgical ASD patients. OUTCOME MEASURES: Rate and timing of conversion to CD, rate of PJK, radiographic alignment parameters.
METHOD(S): Operative ASD patients with complete radiographic data at baseline, 6W, 1Y, 2Y, & 3Y intervals were included. Patients were grouped by baseline PI and apex of LL into component types of the Roussouly classification system utilizing pelvic incidence as published by Pizones et al. Patients with no BL CD were postoperatively stratified by Ames CD criteria (TS-CL>20 degree, cSVA>40mm), where CD was defined as fulfilling >1 criteria. Follow-up intervals were established post-ASD surgery, with 6W postop defined as "Early," 6W-1Y "Intermediate," 1-2Y "Late," and 2-3Y "Long." Univariate and Cox regression analyses identified CD conversion rate and PJK rate (<-10degree change in UIV and UIV+2) across Roussouly types 1-4.
RESULT(S): A total of 266 surgical ASD patients (59.7yrs, 77.4% F) with complete radiographic data were included. By Roussouly classification, 9% were Type 1, 15.8% Type 2, 46.6% Type 3, and 28.6% Type 4. 28.6% of ASD patients converted to postop CD (Early: 14.3%, Intermediate: 5.3%, Late: 4.1%, Long: 4.9%). There were no significant differences in CD conversion rate across Roussouly types (1: 33.3%; 2: 28.6%; 3: 26.6%; 4: 30.3%, P=0.895). Types 2 (41.7%), 3 (60.6%), and 4 (43.5%) had their peak rates of conversion in the Early (<6w) window compared to other follow-up intervals, whereas Type 1 patients had a peak rate (50%) between 6w-1Y. Type 2 patients had higher rates of later CD conversion (>1 year) than other types (50% vs 28.1%, P=0.135), while Type 1 patients trended higher rates of earlier CD conversion (<1 year) than other types (33.8% vs 12.5%, P=0.220); these patterns did not reach statistical significance. Across Roussouly Types, among patients who converted to CD, Type 4 had significantly higher rates of ++ SRS-Schwab PT and greater TPA at BL (both p<0.05). Type 4 patients had the highest rate of concurrent PJK with CD conversion (60.9%) compared to Type 1 (50%), Type 2 (50%), or Type 3 (54.5%) (P>0.05). There were no significant change in ODI, PCS, or SRS total among Roussouly Types in patients that converted to CD (p>0.05). Random forest analysis determined the top surgical (levels fused), radiographic (TS-CL), and demographic (frailty) factors associated with CD conversion.
CONCLUSION(S): Baseline thoracolumbar shape as described by the Roussouly classification has a differential effect on timing to CD conversion, though overall rates of CD conversion after TL-ASD correction were similar across Types 1-4. Type 1 patients with a lower apex of lumbar lordosis trended earlier conversion, while Type 2 patients with a higher apex of LL trended conversion beyond 1-year postop. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Chiari malformations (CM) are congenital or acquired hind brain anomalies with resultant cerebellar tonsillar herniation through the foramen magnum. Chiari I malformation consists of herniation of the cerebellar tonsils into the foramen magnum thus crowding the craniocervcial junction. Surgical management is variable among these type 1 patients(pts) based on their presenting symptoms. PURPOSE: Identify complication rates following CM surgery. STUDY DESIGN/SETTING: Retrospective cohort study of (Kids' Inpatient Database) KID. PATIENT SAMPLE: Chiari Malformation Type I. OUTCOME MEASURES: Complication rates, fusion, decompression, duroplasty, laminectomy, LOS, Readmission.
METHOD(S): The KID database was queried for diagnoses of operative Chiari Malformation from 2003-2012 by ICD-9 codes (348.4). Differences in preoperative demographics (age/BMI) and perioperative complication rates between patient cohorts were assessed using Pearson's chi-squared tests and T-tests when necessary. Binary logistic regression were utilized to find significant factors associated with complication rate. Decision tree analysis was utilized for continuous variables predictive of complication rate. Certain surgical procedures were analyzed for their relationship with post-operative outcomes.
RESULT(S): A total of 13,812 CM-1 patients were isolated (10.12 yrs, 0.62 CCI). Of these pts, 8.2% (1,128) received a complication. From 2003 to 2012, the rate of complications for CM-1 pts decreased significantly (9.6%-5.1%) along with surgical rate (33.3%-28.6%), despite the increase in CM diagnosis (36.3%-42.3%; all p<0.05). CM-1 pts who had a complication were younger (9.73+/-6.8 yrs vs 10.2+/-6.3 yrs) and had a lower invasiveness score (0.35+/-1.0 vs 0.41+/-1.0), however; they had a larger CCI (1.10+/-1.6 vs 0.6+/-1.3) than those who did not have a complication (all p<0.05). The most prevalent comorbidities for these pts were cerebrovascular (16.67%), malignancy (11.6%), pulmonary (9.6%), and renal (7.1%; all p<0.05). CM-1 pts who experienced complications had a concurrent diagnosis of syringomyelia (7.1%) and also Scoliosis (3.2%; all p<0.05). CM-1 pts who did not have a complication had a greater surgical rate than those that had a complication (76.4% vs 23.6% p<0.05). Having an interbody instrument, having an invasiveness score>4.25 and receiving a fusion greater than 4 levels were all significant factors associated with receiving a complication postoperatively (p<0.05). The most common complication was nervous system related (2.8%), anemia (2.4%), and acute respiratory distress (2.1%). CM-1 pts that underwent a fusion (3.4% vs 2.1%) had greater complication rates as well as those that underwent a craniotomy (23.2% vs 19.1%; all p<0.05). However, CM-1 pts who underwent a decompression had lower postop complications (21.3% vs 28.9%; all p<0.05). A total of 13,812 CM-1 patients isolated (10.12 yrs, 0.62 CCI). Of these pts, 8.2% (1,128) received a complication. From 2003 to 2012, the rate of complications for CM-1 pts decreased significantly (9.6%-5.1%) along with surgical rate (33.3%-28.6%), despite the increase in CM diagnosis (36.3%-42.3%; all p<0.05). CM-1 pts who had a complication were younger (9.73+/-6.8yrs vs 10.2+/-6.3yrs) and had a lower invasiveness score (0.35+/-1.0 vs 0.41+/-1.0), however; they had a larger CCI (1.10+/-1.6 vs 0.6+/-1.3) than those who did not have a complication (all p<0.05). The most prevalent comorbidities for these pts were cerebrovascular (16.67%), malignancy (11.6%), pulmonary (9.6%), and renal (7.1%; all p<0.05). CM-1 pts who experienced complications had a concurrent diagnosis of syringomyelia (7.1%) and also Scoliosis (3.2%; all p<0.05). CM-1 pts who did not have a complication had a greater surgical rate than those that had a complication (76.4% vs 23.6% p<0.05). Having an interbody instrument, having an invasiveness score>4.25 and receiving a fusion greater than 4 levels were all significant factors associated with receiving a complication postoperatively (p<0.05). The most common complication was nervous system related (2.8%), anemia (2.4%), and acute respiratory distress (2.1%). CM-1 pts that underwent a fusion (3.4% vs 2.1%) had greater complication rates as well as those that underwent a craniotomy (23.2% vs 19.1%; all p<0.05). However, CM-1 pts that underwent a decompression had lower postop complications (21.3% vs 28.9%; all p<0.05).
CONCLUSION(S): Treatment of Chiari malformation has been identified to have improved from 2003 to 2012 with increased identification of diagnosis and decreased complications. Chiari patients undergoing fusions and craniotomies are at a greater risk of postoperative complications especially when the instrumented fusions are performed on >4 levels. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The age-adjusted alignment ideal alignment was proposed in order reduce the occurrence of proximal junctional kyphosis (PJK) in an adult spinal deformity (ASD) population. The normative postoperative age ideal value for the mismatch between pelvic incidence and lumbar lordosis (PI-LL) has yet to be related to the global alignment and proportion (GAP) score postop proportionality. PURPOSE: To assess the impact of normative age-adjusted PI-LL and proportionality via GAP score on postoperative patient-reported outcomes. STUDY DESIGN/SETTING: Retrospective review of single-surgeon adult spinal deformity (ASD) database PATIENT SAMPLE: 140 ASD patients. OUTCOME MEASURES: Health-related quality-of-life (HRQLs); SRS-22r; PJK.
METHOD(S): ASD patients with baseline (BL) and 2-year postoperative (2Y) radiographic and HRQL data were included. Age-adjusted correction groups generated at postoperative follow-up for actual alignment compared to age-adjusted values for PI-LL-adjusted ideal values (matched, overcorrected, undercorrected). GAP Score in the literature includes the four parameters, and an age factor to formulate a sagittal plane score out of 13 (proportional, moderately disproportional [MD], severely disproportional [SD]). GAP improvement scores were noted as less at 2Y compared to BL. Patients were grouped by age-adjusted and 2Y GAP results: Match PI-LL/Proportional GAP, Match PI-LL/Disproportional GAP, Unmatch PI-LL/Proportional GAP, Unmatch PI-LL/Disproportional GAP. Means comparison and chi-squared ANOVA analyses assessed the outcomes between age-adjusted and GAP groups.
RESULT(S): Included: 140 ASD patients (55.5+/-16.4 years, 81% female, 25.2+/-4.7kg/m2). At BL, mean sacral slope: 30.7degree, pelvic tilt: 23degree, pelvic incidence: 53.5degree, PI-LL: 13.3degree, SVA: 61.6 mm, and L1-S1: 40.4degree. BL GAP proportionality: 17.8% proportional, 27.1% MD, 55% SD. PI-LL by baseline GAP proportionality groups: -6.4degree Proportional, -4.6degree MD, 26.8degree SD, p<0.001. Baseline ODI increased significantly with GAP proportionality: 27.3 Proportional, 32.3 MD, 37.4 SD, p=0.050. Assessment of 2Y age-adjusted PI-LL alignment found that 20.3% of patients Matched, 45.1% Overcorrected, and 34.6% Undercorrected. By 2Y GAP results, 32.3% were proportional, 38.5% MD, 29.5% SD (40.5% of patients improved, while 48.5% remained the same, and 11.1% deteriorated in their GAP proportionality). Categorized by the PI-LL age-adjusted/GAP groups: 2.3% Match PI-LL/Proportional GAP, 13.1% Match PI-LL/Disproportional GAP, 30% Unmatch PI-LL/Proportional GAP, 54.6% Unmatch PI-LL/Disproportional GAP. Patients who Unmatched PI-LL/Disproportional in GAP had significantly worse postoperative SRS-Pain scores (1.80 vs 3.53-3.86), SRS-Appearance (3.30 vs 3.69-4.29) and SRS-22 Total scores (2.84 vs 3.80-4.12), all p<0.050. Unmatch PI-LL/Disproportional patients developed PJK at a significantly higher rate by 6-months (66.7% vs 11.8-15.4%), p<0.050. Outcomes were not different between Match PI-LL/Disproportional GAP and Unmatch PI-LL/Proportional GAP groups.
CONCLUSION(S): Collectively over or undercorrecting in age-adjusted mismatch pelvic incidence and lumbar lordosis and becoming disproportional in spinal shape at 2 years led to increased postoperative proximal junctional kyphosis and significantly worse patient-reported outcomes. Surgeons should be wary of the double mal-correction when utilizing these complex realignment schemas. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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