Faculty Bibliography

Study Design/UNASSIGNED:Prospective cohort study. Objectives/UNASSIGNED:Most studies of dysphagia in the cervical spine have focused on a degenerative patient population; the rate of dysphagia following surgery for cervical deformity (CD) is unknown. This study aims to investigate if surgery for cervical deformity results in postoperative dysphagia. Methods/UNASSIGNED:tests, and bivariate Pearson correlations were performed. Results/UNASSIGNED:= .53). Surgical variables, including estimated blood loss (EBL), anterior or posterior fusion levels, steroid use, preoperative traction, staged surgery, surgical approach, anterior corpectomy, posterior osteotomy, and UIV (upper instrumented vertebrae) location, showed no impact on postoperative SWAL-QoL. Correction of cervical kyphosis was not correlated to 3-month SWAL-QoL scores or the change in SWAL-QoL scores. Conclusions/UNASSIGNED:While patients undergoing surgery for cervical deformity had swallowing dysfunction at baseline, we did not observe a significant decline in SWAL-QoL scores at 3 months. Patients with prior cervical surgery and higher BMI had a lower baseline SWAL-QoL. There were no surgical or radiographic variables correlated to a change in SWAL-QOL score.

MINI: A retrospective analysis of the impact of PD on long-term outcomes following adult spinal deformity surgery with two-year follow-up surveillance in New York. PD patients experienced comparable overall complication and revision rates to a propensity score-matched patient cohort without PD from the general population undergoing thoracolumbar fusion surgery.

BACKGROUND:Patients undergoing multilevel spine surgery are at risk for delayed extubation. OBJECTIVE:To evaluate the impact of type and volume of intraoperative fluids administered during multilevel thoracic and/or lumbar spine surgery on postoperative extubation status. METHODS:Retrospective evaluation of medical records of patients ≥ 18 yr undergoing ≥ 4 levels of thoracic and/or lumbar spine fusions was performed. Patients were organized according to postoperative extubation status: immediate (IMEX; in OR/PACU) or delayed (DEX; outside OR/PACU). Propensity score matched (PSM) analysis was performed to compare IMEX and DEX groups. Volume, proportion, and ratios of intraoperative fluids administered were evaluated for the associated impact on extubation status. RESULTS:A total of 246 patients (198 IMEX, 48 DEX) were included. PSM analysis demonstrated that increased administration of non-cell saver blood products (NCSB) and increased ratio of crystalloid: colloids infused were independently associated with delayed extubation. With increasing EBL, IMEX had a proportionate reduction in crystalloid infusion (R = -0.5, P < .001), while the proportion of crystalloids infused remained relatively unchanged for DEX (R = -0.27; P = .06). Twenty-six percent of patients receiving crystalloid: colloid ratio > 3:1 had DEX compared to none of those receiving crystalloid: colloid ratio ≤ 3:1 (P = .009). DEX had greater cardiac and pulmonary complications, surgical site infections and prolonged intensive care unit and hospital stay (P < .05). CONCLUSION/CONCLUSIONS:PSM analysis of patients undergoing multilevel thoracic and/or lumbar spine fusion demonstrated that increased administration of crystalloid to colloid ratio is independently associated with delayed extubation. With increasing EBL, a proportionate reduction of crystalloids facilitates early extubation.

BACKGROUND:Limited data are available to objectively define what constitutes a "good" versus a "bad" recovery for operative cervical deformity (CD) patients. Furthermore, the recovery patterns of primary versus revision procedures for CD is poorly understood. OBJECTIVE:To define and compare the recovery profiles of CD patients undergoing primary or revision procedures, utilizing a novel area-under-the-curve normalization methodology. METHODS:CD patients undergoing primary or revision surgery with baseline to 1-yr health-related quality of life (HRQL) scores were included. Clinical symptoms and HRQL were compared among groups (primary/revision). Normalized HRQL scores at baseline and follow-up intervals (3M, 6M, 1Y) were generated. Normalized HRQLs were plotted and area under the curve was calculated, generating one number describing overall recovery (Integrated Health State). Subanalysis identified recovery patterns through 2-yr follow-up. RESULTS:Eighty-three patients were included (45 primary, 38 revision). Age (61.3 vs 61.9), gender (F: 66.7% vs 63.2%), body mass index (27.7 vs 29.3), Charlson Comorbidity Index, frailty, and osteoporosis (20% vs 13.2%) were similar between groups (P > .05). Primary patients were more preoperatively neurologically symptomatic (55.6% vs 31.6%), less sagittally malaligned (cervical sagittal vertical axis [cSVA]: 32.6 vs 46.6; T1 slope: 28.8 vs 36.8), underwent more anterior-only approaches (28.9% vs 7.9%), and less posterior-only approaches (37.8% vs 60.5%), all P < .05. Combined approaches, decompressions, osteotomies, and construct length were similar between groups (P > .05). Revisions had longer op-times (438.0 vs 734.4 min, P = .008). Following surgery, complication rate was similar between groups (66.6% vs 65.8%, P = .569). Revision patients remained more malaligned (cSVA, TS-CL; P < .05) than primary patients until 1-yr follow-up (P > .05). Normalized HRQLs determined primary patients to exhibit less neck pain (numeric rating scale [NRS]) and myelopathy (modified Japanese Orthopaedic Association) symptoms through 1-yr follow-up compared to revision patients (P < .05). These differences subsided when following patients through 2 yr (P > .05). Despite similar 2-yr HRQL outcomes, revision patients exhibited worse neck pain (NRS) Integrated Health State recovery (P < .05). CONCLUSION/CONCLUSIONS:Despite both primary and revision patients exhibiting similar HRQL outcomes at final follow-up, revision patients were in a greater state of postoperative neck pain for a greater amount of time.

STUDY DESIGN/METHODS:This is a retrospective review of prospective multicenter cervical deformity (CD) database. OBJECTIVE:Assess the impact of complication type and Clavien complication (Cc) grade on clinical outcomes of surgical CD patients BACKGROUND:: Validated for general surgery, the Clavien-Dindo complication classification system allows for broad comparison of postoperative complications; however, the applicability of this system is unclear in CD-specific populations. METHODS:Surgical CD patients above 18 years with baseline and postoperative clinical data were included. Primary outcomes were complication type (renal, infection, cardiac, pulmonary, gastrointestinal, neurological, musculoskeletal, implant-related, radiographic, operative, wound) and Cc grade (I, II, III, IV, V). Secondary outcomes were estimated blood loss (EBL), length of stay (LOS), reoperation, and health-related quality of life (HRQL) score. The univariate analysis assessed the impact of complication type and Cc grade on improvement markers and 1-year postoperative HRQL outcomes. RESULTS:In total, 153 patients (61±10 y, 61% female) underwent surgery for CD (8.1±4.6 levels fused; surgical approach included 48% posterior, 18% anterior, 34% combined). Overall, 63% of patients suffered at least 1 complication. Complication breakdown by type: renal (2.0%), infection (5.2%), cardiac (7.2%), pulmonary (3.9%), gastrointestinal (2.0%), neurological (26.1%), musculoskeletal (0.0%), implant-related (3.9%), radiographic (16.3%), operative (7.8%), and wound (5.2%). Of complication types, only operative complications were associated with increased EBL (P=0.004), whereas renal, cardiac, pulmonary, gastrointestinal, neurological, radiographic, and wound infections were associated with increased LOS (P<0.050). Patients were also assessed by Cc grade: I (28%), II (14.3%), III (16.3%), IV (6.5%), and V (0.7%). Grades I and V were associated with increased EBL (both P<0.050); Cc grade V was the only complication not associated with increased LOS (P=0.610). Increasing complication severity was correlated with increased risk of reoperation (r=0.512; P<0.001), but not inferior 1-year HRQL outcomes (all P>0.05). CONCLUSIONS:Increasing complication severity, assessed by the Clavien-Dindo classification system, was not associated with increased EBL, inpatient LOS, or inferior 1-year postoperative HRQL outcomes. Only operative complications were associated with increased EBL. These results suggest a need for modification of the Clavien system to increase applicability and utility in CD-specific populations.

STUDY DESIGN:Retrospective review of a prospectively collected database. OBJECTIVES:This preliminary investigation sought to identify the quality of care adolescent idiopathic scoliosis (AIS) patients from our large, underserved community had received before presenting at this institution's clinic. SUMMARY OF BACKGROUND DATA:AIS affects 1% to 4% of children between ages 10 and 16. Barriers to health care for patients in underserved populations have not been well studied. METHODS:Patients who visited a single surgeon's clinic for primary AIS between June 2016 and January 2017 were enrolled. Patients had 36-inch full-spine radiographs and completed a survey of demographics, prior AIS care received (screening, bracing, etc), socioeconomic parameters, and patient-reported outcomes (PROs; Scoliosis Research Society [SRS]-30 Questionnaire and Body Image Disturbance Questionnaire [BIDQ]). Parametric and nonparametric analyses were used and percentages and mean/median values were reported. RESULTS:47 patients (age: 15 ± 3 years; 82.7% female) were included. Overall, 25.5% of patients reported a family history of scoliosis, and 42.6% had no prior knowledge of scoliosis. Per Scoliosis Research Society (SRS) recommendations, 15 patients required observation (main Cobb angle: <25°), 22 patients were eligible for bracing (25°-45°), and 10 patients were surgical candidates (>45°). In addition, 21.3% of all patients were never screened for scoliosis; of these, 50% had a main scoliosis curve >25°. Seventy percent of surgical candidates never wore a brace, and 59.3% of screened patients who were eligible for bracing were not braced at initial presentation. Patients who were left unbraced when eligible exhibited worse BIDQ scores (1.7 vs. 1.4, p < .05). CONCLUSIONS:One of five children in our population was never screened for scoliosis, and nearly three of five children did not receive optimal care as recommended by SRS. AIS patients in our inner-city populations are potentially at risk of continuing to experience a significant disadvantage in health care access. LEVEL OF EVIDENCE:Level IV case series.

STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:The goals of this study were to (1) evaluate pre-operative bone quality assessment and intervention practice over time and (2) review the current evidence for bone evaluation in spine fusion surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:Deformity spine surgery has demonstrated improved quality of life in patients however its cost has made it controversial. If pre-operative bone quality can be optimized then potentially these treatments could be more durable however, at present, no clinical practice guidelines have been published by professional spine surgical organizations. METHODS:A retrospective cohort review was performed on patients who underwent a minimum five-level primary or revision fusion. Pre-operative bone quality metrics were evaluated over time from 2012 - 2017 to find potential trends. Sub-group analysis was conducted based on age, gender, pre-operative diagnosis, and spine fusion region. RESULTS:Patient characteristics including pre-operative rates of pseudarthrosis and junctional failure did not change. An increasing trend of physician bone health documentation was noted (p = 0.045) but changes in other metrics were not significant. A gender bias favored females who had higher rates of pre-operative DXA studies (p = 0.001), Vitamin D 25-OH serum labs (p = 0.005), Vitamin D supplementation (p = 0.022), calcium supplementation (p < 0.001), antiresorptive therapy (p = 0.016), and surgeon clinical documentation of bone health (p = 0.008) compared to men. CONCLUSION/CONCLUSIONS:Our spine surgeons have increased documentation of bone health discussions but this has not affected bone quality interventions. A discrepancy exists favoring females over males in nearly all pre-operative bone quality assessment metrics. Pre-operative vitamin D level and BMD assessment should be considered in patients undergoing long fusion constructs however the data for bone anabolic and resorptive agents has less support. Clinical practice guidelines on pre-operative bone quality assessment spine patients should be defined. LEVEL OF EVIDENCE/METHODS:4.

Introduction/UNASSIGNED:The aim of this study was to evaluate the association of available cervical alignment components through the Ames cervical deformity (CD) classification parameters with the Patient-Reported Outcomes Measurement Information System (PROMIS) physical health domain metrics. Methods/UNASSIGNED:Surgical CD patients (C2-C7 Cobb >10° or C2-C7 sagittal vertical axis [cSVA] >4 cm or T1 slope minus cervical lordosis (TS-CL) >15°) ≥18 years with available baseline (BL) radiographic and PROMIS were isolated in a single-center spine database. Patients were classified according to the Ames CD modifiers for cSVA and TS-CL (low deformity [Low], moderate deformity [Mod], and severe deformity [Sev]). Descriptives and univariate analyses compared population-weighted PROMIS scores for Pain Intensity (PI), Physical Function (PF), and Pain Interference (Int) across CD modifiers. Conditional tree analysis with logistic regression sampling determined the threshold of PROMIS scores for which the correlation with Ames radiographic cutoffs was most significant. Reported cutoff values for Mod (cSVA: 4-8 cm; TS-CL: 15-20°) and Sev (cSVA: >8 cm; TS-CL: >20°) disabilities were used. Results/UNASSIGNED:, Charlson Comorbidity Index: 1.19). BL cSVA modifier by severity: 83.2% Low, 16.8% Mod. No patients met criteria for severe cSVA. BL TS-CL modifier by severity: 18.8% Low, 22.1% Mod, 59.1% Sev. Mean baseline PROMIS scores were as follows: PI score: 89.6 ± 15.4, PF score: 11.9 ± 13.1, Int score: 56.9 ± 6.8. PI did not differ between cSVA and TS-CL severity. Mod cSVA patients and Mod/Sev TS-CL modifier groups trended toward lower PF scores and higher Int scores. A PI score of >96 (odds ratio [OR]: 0.658 [0.303-1.430]), a PF score of <14 (OR: 1.864 [0.767-4.531]), and an Int score of > 57.4 (OR: 1.878 [0.889-3.967]) were predictors of Mod cSVA. A PI score of >87 (OR: 1.428 [0.767-2.659]), a PF score of <14 (OR: 1.551 [0.851-2.827]), and an Int score of >56.5 (OR: 1.689 [0.967-2.949]) were predictors of Sev TS-CL. Conclusions/UNASSIGNED:PROMIS physical health domains were related to the Ames CD classification. Certain BL PROMIS thresholds can be connected to the severity of CD.

Introduction/UNASSIGNED:Correction of cervical deformity (CD) often involves different types of osteotomies to address sagittal malalignment. This study assessed the relationship between osteotomy grade and vertebral level on alignment and clinical outcomes. Methods/UNASSIGNED:Retrospective review of a multi-center prospectively collected CD database. CD was defined as at least one of the following: C2-C7 Cobb >10°, cervical lordosis (CL) >10°, C2-C7 sagittal vertical axis (cSVA) >4 cm, and chin-brow vertical angle > 25°. Patients were evaluated for level and type of cervical osteotomy. Results/UNASSIGNED:= 0.058) due to lever arm effect. Conclusions/UNASSIGNED:CD patients undergoing osteotomies in the cervical and upper thoracic spine experienced improvement in TS--CL and C2 slope. In the upper thoracic spine, multiple minor osteotomies achieved similar alignment changes to major osteotomies at a single level, while a major osteotomy focused at T2 had the greatest overall impact in cervicothoracic and global alignment in CD patients.

Hypothesis/UNASSIGNED:Reciprocal changes in the upper cervical spine correlate with adult TL deformity modifiers. Design/UNASSIGNED:This was a retrospective review. Introduction/UNASSIGNED:The upper cervical spine has remarkable adaptability to wide ranges of thoracolumbar (TL) deformity. Methods/UNASSIGNED:assessed changes in BL upper cervical parameters (C0-2, C0 slope, McGregor's Slope [MGS], and CBVA) across groups. Results/UNASSIGNED:< 0.001). Conclusions/UNASSIGNED:Our study suggests that upper cervical alignment remains relatively stable through most broad variations of adult TL deformity. Changes in SVA correlated most with upper cervical changes.