Faculty Bibliography

BACKGROUND CONTEXT: Opioid use prior to surgery is associated with worse postop outcomes. Little is known regarding the economic impact that preop opioid use has upon patient preferred health state, quality adjusted life years (QALYs) and the cost/QALY of surgical treatment for adult spinal deformity (ASD). PURPOSE: Compare the health state preference values, QALYs, and cost/QALY for operatively treated ASD patients that used opioids vs did not use opioids prior to surgery. STUDY DESIGN/SETTING: Cost/QALY analysis of operatively treated patients identified from a prospective, multi-center ASD study. PATIENT SAMPLE: Propensity score matched (PSM) cohorts of patients that used opioids (OPIOID) vs nonusers (NON) prior to ASD surgery, at 1- and minimum 2-year follow up. OUTCOME MEASURES: Short Form-36v2 questionnaire (SF-36), SF6D derived from SF-36, hospital costs for operative treatment of ASD based on CMS DRG reimbursements, QALYs, cost/QALY for index surgery, perioperative complications, and 1- and 2-year postop opioid use.
METHOD(S): ASD patients (age>18 years) enrolled into a prospective multicenter ASD database were divided into preop opioid (OPIOID) vs nonopioid (NON) users. PSM was performed to control for confounding demographic, radiographic, and surgical variables. Preop, 1-year, and minimum 2-year postop SF6D values obtained, 1- and 2-year post QALYs were calculated using SF6D change from baseline, hospital costs at the time of index surgery were calculated using CMS DRG reimbursements adjusted for inflation to 2019 US dollars, cost/QALY evaluated at 1- and 2-years postop, perioperative complications, and 1- and 2-year postop opioid use was evaluated for OPIOID vs NON.
RESULT(S): DRG data was available for 182/262 patients meeting inclusion criteria. Following PSM, preoperative demographics, radiographic parameters, surgical treatment, and mean follow up (3.4 vs 3.3 years) were similar for OPIOID (n=68) vs NON (n=114), respectively (p>0.05). OPIOID had longer ICU (49 vs 23 hours) and hospital stay (9.7 vs 6.8 days) than NON, respectively (p<0.05). SF6D was worse for OPIOID at preop (0.521 vs 0.598), 1-year (0.613 vs 0.749), and 2-years postop (0.626 vs 0.749) than NON, respectively (p<0.05). QALYs were worse at 1- (0.567 vs 0.674) and 2-years postop (0.674 vs 0.825) for OPIOID vs NON, respectively (p<0.05). Cost of care at index surgery was greater for OPIOID ($83,363.02) vs NON ($70,281.17). Cost/QALY was higher for OPIOID at 1-year ($150,294.51vs $107,947.19) and 2-years postoperative ($69,615.78 vs $48,761.14) than NON (p<0.05). Perioperative complications were similar for OPIOID vs NON (p>0.05). Continued opioid use at 2-years postop was greater for OPIOID (52.4%) vs NON (8.7%; p>0.05).
CONCLUSION(S): Opioid use prior to ASD surgery is associated with worse patient perceived health state and greater costs to society. After controlling for patient demographics, deformity magnitude, and type of surgery, OPIOID had greater cost of care, despite similar perioperative complication rates. At 2-years postop both OPIOID and NON demonstrated cost effectiveness of index surgery (cost/QALY<$100,000), however the residual cost to society was $21,300 greater for OPIOID vs NON. Over 52% of OPIOD had continued opioid usage at 2-years postop compared to 8.7% of NON. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Emphasis has been placed upon reducing perioperative complications in spinal operations, of which cardiac complications remain among the most devastating for patients. Myocardial infarction (MI), along with its predictive factors, has been an understudied complication. PURPOSE: To assess the incidence and risk factors for perioperative myocardial infarctions in spine surgery patients. STUDY DESIGN/SETTING: Retrospective case control study PATIENT SAMPLE: A total of 196,086 surgical spine patients OUTCOME MEASURES: Predictors of MI following surgical spine intervention METHODS: A patient was categorized as having sustained a postsurgical MI in this study if it occurred intraoperatively or within 30 days of surgery, manifested by documentation of ECG changes accordingly: ST elevation >1mm in two or more contiguous leads, new left bundle branch, new Q-wave in two or more contiguous leads, or new elevation in troponin greater than three times upper level of the reference range. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests, as appropriate. Descriptive statistics, including frequency counts for categorical variables and means and standard deviations, were calculated to summarize demographics and clinical profiles such as spinal diagnoses and comorbidity. Univariate/multivariate analyses were run to assess predictive factors of MI in spine surgery patients. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence.
RESULT(S): Of 196,523 patients (57.1+/-14.2 years, 48% female, 30.4+/-6.5 kg/m2) undergoing elective spine surgery, 436 patients had an acute MI intraoperatively or within 30 days postoperatively (Spine-MI) (69.07+/-10.4 years, 42% female, 30.39+/-6.22 kg/m2). Incidence of MI did not change significantly from 2010 to 2016 (0.2% to 0.3%, p=0.298). Spine-MI patients underwent significantly more fusions than elective spine surgical patients who did not have an MI (73.6% vs 58.4%, p<0.001), with an average of 1.03 levels fused. Spine-MI patients also had significantly more Smith-Peterson osteotomies (5.0% vs 1.8%, p<0.001) and three-column osteotomies (0.9% vs 0.2%, p<0.001), but had far fewer decompression-only procedures (26.4% vs 41.6%, p<0.001). Overall, patients who developed a perioperative MI underwent more revisions compared to all elective spine surgery patients (5.3% vs 2.9%, p=0.003). Spine-MI patients had significantly greater invasiveness scores (3.41 vs 2.73, p<0.001) and total operative time (211.6 vs 147.3 min, p<0.001). The average number of post-operative days until developing an MI was 5.27 days; 9.9% day of operation, 50.8% 1-3 days after, 20.8% 4-7 days 10.9% 8-15 days, 7.6% 16-30 days. Mortality rate for Spine-MI patients was 4.6% versus 0.05% in the entire elective spine surgical population (p<0.001). Multivariate modeling for Spine-MI predictors yielded an AUC of 83.7%, and included history of diabetes mellitus, cardiac arrest and peripheral vascular disease, past blood transfusion, dialysis-dependence, high preoperative platelet count, superficial surgical site infection and days from operation to discharge.
CONCLUSION(S): A model with good predictive capacity to predict MI after spine surgery now exists. Predictive modeling of myocardial infarction following spine operations can aid in risk-stratification of patients, consequently improving preoperative patient counseling and optimization in the peri-operative period. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Frailty has been utilized in cervical deformity (CD) to characterize the influence of preop health state on postop outcomes. Frailty severity may be an important determinant for impaired recovery after CD corrective surgery. No prior studies have examined the associations between increasingly frail states and the trajectory of recovery in CD realignment. PURPOSE: Evaluate postop clinical recovery among CD patients between frailty states undergoing primary procedures STUDY DESIGN/SETTING: Retrospective review of a prospective CD database PATIENT SAMPLE: A total of 106 CD patients. OUTCOME MEASURES: Baseline (BL) to 1-Year(1Y) HRQL Instruments: NDI, mJOA, EQ5D METHODS: Patients>18yrs undergoing surgery for CD (C2-7 Cobb>10degree, coronal Cobb>10degree, cSVA>4cm or TS-CL>10degree, or CBVA>25degree) with HRQL data at BL, 3M and 1Y postop intervals were identified. Patients were stratified by the modified CD frailty index (mCD-FI, Passias et al.) scale from 0-1 (no frailty:<0.3[NF], mild/severe: >0.3[F]). Patients in NF and F groups were propensity score matched (PSM) for TS-CL to control for baseline deformity. Demographics, alignment and Ames-ISSG deformity modifiers were assessed using chi-squared and paired t-tests to compare HRQL outcomes. HRQL outcomes were normalized by dividing BL and postop (3M, 1Y) outcomes by BL for each patient. Normalized scores (y-axis) were plotted against duration of follow-up (x-axis). AUC was calculated for follow-up time intervals; total area for each follow-up interval was divided by cumulative follow-up, determining overall normalized, time-adjusted HRQL outcomes (Integrated Health State [IHS]). IHS was compared between NF and F groups.
RESULT(S): A total of 106 CD patients included (61.7yrs, 66% F, 27.7kg/m2). By frailty group: 52.8% NF, 47.2% F. After PSM for TS-CL (mean: 38.1degree), 38 patients remained in each of the NF and F groups. By surgical approach, 46.1% underwent posterior approach, 19.7% anterior, and 34.2% combined; which was not significant between the frailty groups(p>0.05). At baseline, cervical and spinopelvic radiographic parameters were not significant, except for the C7-S1 SVA (NF: -26.5mm vs F: 15.2mm, p=0.007). According to BL HRQLs, F patients displayed significantly worse NDI scores (NF: 36.8 F: 55.4; p<0.001), mJOA (NF: 14.7, F: 12.7; p=0.002), and EQ5D (NF: 0.78, F: 0.69; p<0.001). All frailty groups exhibited BL to 1Y improvement in NDI, EQ5D and NRS Neck Pain (all p<0.001). After HRQL normalization, F patients had more improvement in mJOA scores at 3M (p=0.065) as well as NDI (p=0.096) and EQ5D (p=0.016). IHS-adjusted HRQL outcomes from BL to 1Y showed a significant difference in EQ5D scores (NF: 1.02, F: 1.07, P=0.016). No significant differences were found in the IHS NDI and mJOA between frailty groups (p>0.05). F patients had more postop major complications (31.3%) compared to the NF (8.9%), p=0.004, though DJK occurrence and reoperation between the groups was not significant.
CONCLUSION(S): While all groups exhibited improved postop disability/pain scores, frail patients recovered better in overall health state. Despite frail patients having more complications, they seem to have overall better patient-reported outcomes, signifying that with frailty severity, patients have more room for improvement postop compared to baseline quality of life. 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 is a complex pathology that often requires challenging surgical intervention for treatment. In patients with osteoporosis, there may be increased risk of complications and reoperations. Our study aimed to evaluate the effect of treating osteoporosis patients with bisphosphonate preoperatively on future reoperations. PURPOSE: Investigate the effect of preoperative bisphosphonate on osteoporosis patients undergoing corrective surgery for adult spinal deformity. STUDY DESIGN/SETTING: Retrospective review of the PearlDiver database between the years 2008-2015. PATIENT SAMPLE: This study included 2,842 adult spinal deformity patients. OUTCOME MEASURES: Ninety-day complications, reoperations.
METHOD(S): Adult spinal deformity patients undergoing a fusion were isolated using ICD-9 CM and CPT codes in the PearlDiver database between the years 2008-2015. Patients were stratified based on diagnosis of osteoporosis and whether there was a filled prescription for bisphosphonate 6 months prior to surgery. ASD patients with osteoporosis and bisphosphonate use who underwent corrective intervention were compared with age- and sex-matched cohorts of osteoporotic and nonosteoporotic controls with no bisphosphonate prescriptions. Means comparison tests compared differences in demographics, comorbidities, 90-day complications, and 2Y reoperation rates. Logistic regression analysis assessed the odds of complication and reoperations controlling for age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was set p<0.05.
RESULT(S): A total of 2,842 operative adult spinal deformity patients were isolated. Four hundred and six patients had osteoporosis and bisphosphonate use, 807 osteoporosis with no bisphosphonate use, and 1,629 non-osteoporosis patients. At baseline, osteoporosis patients had higher rates of obesity, diabetes, hyperlipidemia, and peripheral vascular disease compared to osteoporotic bisphosphonate cohort. There were no differences in 90-day complication rates or 2Y reoperations rates between osteoporosis bisphosphonate users and osteoporosis controls (p>0.05). Compared to nonosteoporotic patients, osteoporosis patients with bisphosphonate use trended toward lower rates of revisions at 1Y (5% vs 7%) and 2Y (7% vs 8%, both p>0.05).
CONCLUSION(S): In a matched cohort, osteoporosis patients treated preoperatively with bisphosphonates trended towards lower rates of revisions two years postoperatively compared to nonosteoporotic controls. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The risk assessment of elective spine fusion patients with a previous history of cardiac intervention, particularly a coronary artery bypass graft (CABG), has been understudied. This study aimed to assess postoperative outcomes of elective spine fusion patients with a prior history of single- to multilevel coronary artery bypass grafting. PURPOSE: Investigate effect of revascularization on 30-day and 90-day outcomes in elective spine fusion patients. STUDY DESIGN/SETTING: Retrospective review of the PearlDiver database between the years 2006-2013. PATIENT SAMPLE: A total of 733,007 elective spine fusion patients. OUTCOME MEASURES: Comorbidity burden, 30-day and 90-day complications (myocardial infarction, pneumonia, sepsis, death, would complications, transfusions), readmission.
METHOD(S): Elective spine fusion patients were isolated with ICD-9 and CPT procedures codes in the PearlDiver database. Patients were stratified by number of coronary arteries grafted during a coronary artery bypass grafting procedure prior to spine fusion: (1) 1-2 grafts (G12); (2) 3-4 grafts (G34); (3) no grafts. Means comparison tests compared differences in demographics, diagnoses, comorbidities, and 30-day complication outcomes. Logistic regression assessed the odds of complication associated with number of arteries grafted, controlling for levels fused, age, sex, and comorbidities (odds ratio [95% confidence interval]).
RESULT(S): A total of 733,007 elective spine fusion patients were isolated;723,606 pts had no grafts, 5,356 were G12, and 4,045 were G34. G12 patients at baseline had higher rates of morbid obesity, PVD, chronic kidney disease, CHF, and COPD (p<0.001). Relative to no graft patients, G12 patients had higher rates of pneumonia, CVA, myocardial infaraction (MI), sepsis, and death 30-days postoperatively (all p<0.05). Compared to no graft patients, G34 had increased rates of pneumonia, CVA, MI, and sepsis 30 days postoperatively. Comparing G12 to G34 pts, there were no significant differences in 30-day major or minor complications (p>0.05). Overall, G34 patients had higher rates of 30-day and 90-day readmissions (p<0.05).
CONCLUSION(S): Compared to patients who had no history of cardiac intervention, patients who had single or multivessel coronary artery bypass graft had an increase in 30-day complications. However, comparing between groups that had 1-2 or 3-4 level grafts, there were no significant differences in major and minor complications 30 days postoperatively. 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: 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: Proximal junctional failure (PJF) is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF. PURPOSE: We hypothesized that lower mean screws per level and decreased rod stiffness would be associated with lower incidence of PJF. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing fusion of >=5 levels, and with LIV at the sacro-pelvis were included. Patients undergoing revision surgery were excluded. In total, 420 patients were analyzed. OUTCOME MEASURES: The primary outcome variable was PJF, defined using previously published radiographic criteria (PJ angle >28degreeand PJ angle >22degree, and >=8mm/>=3mm listhesis at upper thoracic / thoracolumbar levels, respectively).
METHOD(S): The primary independent variables were the mean number of screws per level fused analyzed with a cutoff of 1.8 (determined by ROC analysis) and rod material/diameter. Multivariable logistic regression was utilized to investigate confounding factors, including age, history of osteoporosis, BMI, gender, CCI, preoperative Schwab modifiers, preoperative TPA, postoperative change in lumbar lordosis, upper instrumented vertebra, osteotomy, approach, UIV type (ie, pedicle screw vs other), and number of levels fused.
RESULT(S): Of the total patients, 78.8% were female. PJF occurred in 14.1% of patients. The mean screws per level was 1.7 (SD 0.2), and 57.6% of patients had <1.8 screws per level. PJF occurred in 19.4% vs 9.8% of patients with >=1.8 vs <1.8 screws per level, respectively (p<0.01). In multivariable analysis, patients with <1.8 screws per level exhibited lower odds of PJF (OR 0.39, p<0.01). Rod material and diameter (both p>0.2) were not significantly associated with PJF. Screw density specifically adjacent to the UIV was not related to PJF (p>0.2).
CONCLUSION(S): Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with <1.8 screws per level. Rod diameter and material, however, were not significantly associated with PJF. This finding may be related to construct rigidity. It is possible that residual confounding by other patient and surgeon-specific characteristics may exist. Further biomechanical and clinical studies exploring the relationship between screw density and PJK/PJF are warranted. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Little is known of the impact of myelopathy severity in patients undergoing cervical deformity (CD) on postoperative patient-reported outcomes when stratified by baseline deformity severity. PURPOSE: To investigate the impact of myelopathy severity on outcomes and satisfaction post-operatively over baseline deformity severity. STUDY DESIGN/SETTING: Retrospective cohort study of a single-surgeon CD database PATIENT SAMPLE: A total of 128 CD Patients. OUTCOME MEASURES: HRQL Instruments: Neck Disability Index [NDI], Euro-Qol 5-Dimension questionnaire [EQ5D], meeting the Minimal Clinically Important Difference [MCID]; complications; reoperations METHODS: Included: surgical adult CD patients (C2-C7 Cobb>10degree, CL>10degree, cSVA >4cm, or CBVA>25degree) with baseline and 1-year HRQLs and radiographic follow-up. The modified Japanese Orthopaedic Association scale [mJOA] was utilized to assess baseline myelopathy severity (mJOA=18 was excluded). Moderate myelopathy: 12-17 mJOA scores at baseline; Severe myelopathy: <12 mJOA. Moderate deformity: <=25degree TS-CL at baseline; Severe deformity: >25degree. TS-CL. Groups assessed: (1) severe myelopathy/deformity, (2) severe myelopathy and moderate deformity, (3) moderate myelopathy/deformity, (4) moderate myelopathy and severe deformity. Groups 2 and 4 were compared as mismatched groups. Univariate analyses were performed with a statistical cut-off p<0.050 to determine whether myelopathy severity or deformity severity had a greater impact on patient-reported outcomes.
RESULT(S): A total of 128 CD patients were included (56.5+/-9.2 years, 46% female, 30.4+/-6.4kg/m2). The average Charlson Comorbidity Index (CCI) score was 0.56, 18% current smokers. Cohort surgical factors included, by approach, 27.9% anterior, 47.5% posterior and 24.6% combined (mean levels fused: 5). Mean total operative time was 588.5 minutes, with an EBL of 766.9ccs. Baseline mJOA score was 12.8+/-2.7, with a mean TS-CL of 25.9+/-16.1degree. 30.5% of patients had severe baseline myelopathy, 69.5% Moderate mJOA. By baseline deformity severity, 35.2% were Moderate TS-CL, while 64.8% Severe. By myelopathy/deformity groups: (1) 11.1%, (2) 21%, (3) 34.6%, (4) 33.3%. At baseline, NDI score was the greatest in Group 2 at 69.4 (1: 69.1, 3: 57.1, 4: 52.6, p = 0.011), whereas Group 4 had the lowest EQ5D scores (p<0.001). According to baseline neurologic exam factors were significantly greater in the groups with severe myelopathy (1 and 2, p<0.050). At one year, 55.6% of patients with severe myelopathy and severe deformity (Group 1) met MCID for NDI, while 6.9% of Group 2, 25% Group 3, and 55.6% Group 4, p= 0.002. Mismatch myelopathy/deformity analysis determined that a greater myelopathy over deformity (Group 2) had significantly worse patient reported outcomes compared to Group 4 in terms of 1-year NDI (2: 57 vs 4: 28.1; p=0.004), EQ5D(p=0.028), and NRS Neck (2:5.9, 4:3.6; p=0.046), as well as meeting MCID for NDI (2: 5.9%, 4: 55.6%; p=0.001).
CONCLUSION(S): Patients who present with moderate deformity and severe myelopathy have worse patient-reported outcomes compared to patients classified with severe deformity and moderate myelopathy. In moderate deformity, the myelopathy decompression and symptomatic alleviation plays more of a role, but, most importantly, in severe deformity, decompression is inadequate and realignment is necessary due to cord tension. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: With the increasing emphasis on value-based outcomes in health care, there has been an increased focus on the cost of surgical intervention in patients with adult spinal deformity (ASD). However, there is a paucity of literature on the economic impact of a surgeon's surgical approach for corrective ASD surgery. PURPOSE: To investigate the cost-utility associated with surgical approach. STUDY DESIGN/SETTING: Retrospective cohort study of a prospective multicenter ASD database. PATIENT SAMPLE: This study included 208 ASD patients. OUTCOME MEASURES: Oswestry Disability Index (ODI), SF-6D, cost per quality adjusted life years (QALY).
METHOD(S): ASD patients with no previous history of fusions, complete radiographic, and HRQL data at baseline and 2 years were included. Patients were propensity score matched for age, CCI, levels fused, frailty, SVA, PI-LL and osteotomies. Means comparison tests and ANOVA chi-squared analyses assessed differences in baseline demographic and clinical data between cohorts. Utility data were calculated using ODI converted to SF-6D using published conversion methods. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database incorporating complications, comorbidities (CC), major complications, and comorbidities (MCC) were assessed according to CMS.gov manual definitions. Two-year reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for all services rendered within a 30-day window, including estimates regarding costs of postoperative complications, outpatient health care encounters, revisions and medical related readmissions. After accounting for CC, MCC, length of stay (LOS), revisions, and death, cost per QALY at 2 years and life expectancy were calculated for surgical approach.
RESULT(S): A total of 208 PSM ASD patients were included (62.2yrs, 84% F, 26.9 kg/m²). Patients undergoing a combined approach had a longer LOS (6.55 vs 8.15), greater operative time, and experienced significantly greater blood loss (all p<0.05). Posterior-only approach patients had significantly higher rates of operative complications and revisions within 2 years of index surgery (both p<0.05). Overall, posterior vs combined patients did not significantly differ at baseline ODI (44.3 vs 41.5, p>0.05). Despite initial higher costs of a combined approach, the average cost of ASD surgery at 2 years follow-up for posterior-only approach was greater compared to a combined approach ($72,749 vs $65,073). Furthermore, the cost per QALY was higher for posterior-only patients at 2 years compared to patients undergoing a combined approach ($363,910 vs $333,981). If utility gained is sustained to life expectancy, the cost per QALY was $54,027 for posterior-only and $49,584 for combined.
CONCLUSION(S): In a matched cohort of adult spinal deformity patients, a combined approach trended toward a lower average cost of surgery at 2 years, lower cost per QALY, significantly lower rates of operative complications and revisions. Although improvement after surgical intervention was similar between the two approaches, cost per QALY of posterior-only approach was slightly greater primarily driven by increased operative complications and rates of revisions. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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