Faculty Bibliography

BACKGROUND: Prior studies have observed similar health-related quality of life (HRQL) in revisions and nonrevision (NR) patients following adult spinal deformity (ASD) correction. However, a novel comparison approach may allow better comparisons in spine outcomes groups. OBJECTIVE: To determine if ASD revisions for radiographic and implant-related complications undergo a different recovery than NR patients. METHODS: Inclusion: ASD patients with complete HRQL (Oswestry Disability Index, Short-Form-36 version 2 (SF-36), Scoliosis Research Society [SRS]-22) at baseline, 6 wk, 1 yr, 2 yr. Generated revision groups: nonrevision (NR), revised-complete data (RC; with follow-up 2 yr after revision), and revised-incomplete data (RI; without 2-yr follow-up after revision). In a traditional analysis, analysis of variance (ANOVA) compared baseline HRQLs to follow-up changes. In a novel approach, integrated health state was normalized at baseline using area under curve analysis before ANOVA t-tests compared follow-up statuses. RESULTS: Two hundred fifty-eight patients were included with 50 undergoing reoperations (19.4%). Rod fractures (n = 15) and proximal joint kyphosis (n = 9) were most common. In standard HRQL analysis, comparing RC index surgery and RC revision surgery HRQLS revealed no significant differences throughout the 2-yr follow-up from either the initial index or revision procedure. Using normalized HRQL/integrated health state, RI displayed worse scores in SF-36 Physical Component Score, SRS activity, and SRS appearance relative to NR (P < .05), indicating less improvement over the 2-yr period. RC were significantly worse than RI in SF-36 Mental Component Score, SRS mental, SRS satisfaction, and SRS total (P < .05). CONCLUSION: ASD patients indicated for revisions for radiographic and implant-related complications differ significantly in their overall 2-yr recovery compared to NR, using a normalized integrated health state method. Traditional methods for analyzing revision patients' recovery kinetics may overlook delayed improvements.

BACKGROUND: Proximal junctional kyphosis (PJK) following adult spinal deformity (ASD) surgery is a well-documented complication, but associations between radiographic PJK and cervical malalignment onset remain unexplored. OBJECTIVE: To study cervical malalignment in ASD surgical patients that develop PJK. METHODS: Retrospective review of prospective multicenter database. Inclusion: primary ASD patients (>/=5 levels fused, upper instrumented vertebra [UIV] at T2 or above, and 1-yr minimum follow-up) without baseline cervical deformity (CD), defined as >/=2 of the following criteria: T1 slope minus cervical lordosis < 20 degrees , cervical sagittal vertical axis < 4 cm, C2-C7 cervical lordosis < 10 degrees . PJK presence (<10 degrees change in UIV and UIV + 2 kyphosis) and angle were identified 1 yr postoperative. Propensity score matching between PJK and nonPJK groups controlled for baseline alignment. Preoperative and 1-yr postoperative cervical alignment were compared between PJK and nonPJK patients. RESULTS: One hundred sixty-three patients without baseline CD (54.9 yr, 83.9% female) were included. PJK developed in 60 (36.8%) patients, with 27 (45%) having UIV above T7. PJK patients had significantly greater baseline T1 slope in unmatched and propensity score matching comparisons (P < .05). At 1 yr postoperative, PJK patients had significantly higher T1 slope (P < .001), C2-T3 Cobb (P = .04), and C2-T3 sagittal vertical axis (P = .02). New-onset CD rate in PJK patients was 15%, and 16.5% in nonPJK patients (P > .05). Increased PJK magnitude was associated with increasing T1 slope and C2-T3 SVA (P < .05). CONCLUSION: Patients who develop PJK following surgical correction of ASD have a 15% incidence of development of new-onset CD. Patients developing PJK following surgical correction of ASD tend to have an increased preoperative T1 slope. Increased progression of C2-T3 Cobb angle and C2-T3 SVA are associated with development of PJK following surgical correction of thoracolumbar deformity.

BACKGROUND CONTEXT/BACKGROUND:With advances in the understanding of adult spinal deformity (ASD), more complex osteotomy and fusion techniques are being implemented with increasing frequency. Patients undergoing ASD corrections infrequently require extended acute care, longer inpatient stays, and are discharged to supervised care. Given the necessity of value-based health care, identification of clinical indicators for adverse discharge disposition in ASD surgeries is paramount. PURPOSE/OBJECTIVE:On nationwide and surgeon-created databases, identify predictors of adverse discharge disposition after ASD surgeries and view corresponding differences in charges. STUDY DESIGN/SETTING/METHODS:Retrospective analysis of patients on the National Surgical Quality Improvement Program (NSQIP) database and cost data from Medicare PearlDiver Database. PATIENT SAMPLE/METHODS:Patients undergoing thoracolumbar surgery for correction of ASD. OUTCOME MEASURES/METHODS:Primary: Discharge disposition home vs. not home. Secondary: Cost differences across discharge groups. METHODS:Patients on NSQIP undergoing thoracolumbar ASD-corrective surgery with a primary diagnosis of scoliosis (ICD-9 code 737.x), and over the age of 18 were isolated. Predictors (demographic, clinical, and complications) of not-home (NH; rehab or skilled nursing facility) discharge were analyzed using binary logistic regression controlling for levels fused, decompressions, osteotomies, and revisions. Average 30-day and 90-day costs of care were reported in home, rehab, and skilled nursing facility discharge groups in patients undergoing 8+ level thoracolumbar fusion. RESULTS:1,978 patients undergoing lumbar ASD-corrective surgery were included for analysis (average age: 59.3 years, sex: 64% female). Average length of stay was 6.58 days. Upon multivariate regression analysis, age over 60 years (OR: 0.28 CI: 0.22-0.34) and female sex (p=0.003) were independent predictors of adverse discharge status. Partially dependent pre-operational functional status, defined as reliance on another person to complete some activities of daily living, increased likelihood of adverse discharge disposition (OR:0.57 CI:0.35-0.90). Despite controlling for all clinical variables except for the ones specific to each analysis, Smith-Petersen osteotomy (OR:0.51 CI:0.40-0.64), interbody device placement (OR:0.80 CI:0.64-0.98) and fixation to the iliac (OR:0.54 CI:0.41-0.70) both increased likelihood of adverse discharge. Complications most associated with adverse discharge were UTIs (OR:0.34 CI:0.21-0.57) and blood transfusions (OR:0.42 CI:0.34-0.52). Relative to home-discharge, 30-day costs of care were +$21,061 more expensive in rehab discharges, but not different in skilled nursing facility discharges (+$5,791, p=0.177). 90-day costs of care were $23,815 in rehab discharges (p<0.001), but again not different in skilled nursing facility discharges (+$6,091, p=0.212). CONCLUSIONS:Discharge destination to rehabilitation has a significant impact on cost of thoracolumbar adult spinal deformity surgeries. Patient selection can predict patients at higher risk for discharges to rehab or skilled nursing facility.

CD development secondary to PJK was recently documented in adult spinal deformity patients after surgical correction for thoracolumbar ASD. This study analyzes surgical management of patients with CD secondary to proximal junctional kyphosis (PJK) versus patients with primary CD. Retrospective review of multicenter cervical deformity (CD) database. CD defined as at least one of the following: C2-C7 coronal Cobb > 10°, cervical lordosis (CL) > 10°, cervical sagittal vertical axis (cSVA) > 4cm, CBVA > 25°. Patients were grouped into those with PJK (UIV +2 < -10°) prior to cervical surgery versus who don't (Non-PJK). Independent t-tests and chi-squared tests compared radiographic, clinical, and surgical metrics between PJK and non-PJK groups. Of 123 eligible CD patients, 26(21.1%) had radiographic PJK prior to cervical surgery. PJK patients had significantly greater T2-T12 thoracic kyphosis (-58.8° vs -45.0°, p = 0.002), cSVA (49.1 mm vs 38.9 mm, p = 0.020), T1 Slope (42.6° vs 28.4°, p < 0.001), TS-CL (44.1° vs 35.6°, p = 0.048), C2-T3 SVA (98.8 mm vs 75.8 mm, p = 0.015), C2 Slope (45.4° vs 36.0°, p = 0.043), and CTPA (6.4° vs 4.6°, p = 0.005). Comparing their surgeries, the PJK group had significantly more levels fused (10.7 vs 7.4, p = 0.01). There was significantly greater blood loss in PJK patients (1158 ± 1063vs 738 ± 793 cc, p = 0.028); operative time, surgical approach, and BMP-2 use were similar (all p > 0.05). PJK patients experienced higher rates of complications 30 and 90 days post-operatively (23.1% vs. 5.2%, p = 0.004; 30.8% vs. 19.6%, p = 0.026), and more instrumentation failure 30 days postoperatively (7.8% vs. 1.0%, p = 0.004). Patients with cervical deformity secondary to PJK had worse baseline CD, despite no differences in HRQL or demographics. Surgical correction of CD associated with PJK required more invasive surgery and had higher complication rates than non-PJK patients, despite achieving similar clinical outcomes.

Background/UNASSIGNED:Informed patient selection and counseling is key in improving surgical outcomes. Understanding the impact that certain baseline variables can have on postoperative outcomes is essential in optimizing treatment for certain symptoms, such as radiculopathy from cervical spine pathologies. The aim was to identify baseline characteristics that were related to improved or worsened postoperative outcomes for patients undergoing surgery for cervical spine radiculopathic pain. Methods/UNASSIGNED:Retrospective review of prospectively collected data. Patient Sample: Surgical cervical spine patients with a diagnosis classification of "degenerative." Diagnoses included in the "degenerative" category were those that caused radiculopathy: cervical disc herniation, cervical stenosis, and cervical spondylosis without myelopathy. Baseline variables considered as predictors were: (1) age, (2) body mass index (BMI), (3) gender, (4) history of cervical spine surgery, (5) baseline Neck Disability Index (NDI) score, (6) baseline SF-36 Physical Component Summary (PCS) scores, (7) baseline SF-36 Mental Component Summary (MCS) scores, (8) Visual Analog Scale (VAS) Arm score, and (9) VAS Neck. Outcome Measures: Improvement in NDI (≥50%), VAS Arm/Neck (≥50%), SF-36 PCS/MCS (≥10%) scores at 2-years postoperative. An arm-to-neck ratio (ANR) was also generated from baseline VAS scores. Univariate and multivariate analyses evaluated predictors for 2-year postoperative outcome improvements, controlling for surgical complications and technique. Results/UNASSIGNED:= .025). Multivariate analysis for neck disability revealed higher baseline SF-36 PCS (odds ratio [OR] 1.053) and MCS (OR 1.028) were associated with over 50% improvements. Higher baseline NDI were reduced odds of postoperative neck pain improvement (OR 0.958). Arm pain greater than neck pain at baseline was associated with both increased odds of postoperative arm pain improvement (OR 1.707) and SF36 PCS improvement (OR 1.495). Conclusions/UNASSIGNED:This study identified specific symptom locations and health-related quality of life (HRQL) scores, which were associated with postoperative pain and disability improvement. In particular, baseline arm pain greater than neck pain was determined to have the greatest impact on whether patients met at least 50% improvement in their upper body pain score. These findings are important for clinicians to optimize patient outcomes through effective preoperative counseling.

Background/UNASSIGNED:The rate of mortality in surgical procedures involving the lumbar spine has historically been low, and as a result, there has been difficulty providing accurate quantitative mortality rates to patients in the preoperative planning phase. Awareness of these mortality rates is essential in reducing postoperative complications and improving outcomes. Additionally, mortality rates can be influenced by procedure type and patient profile, including demographics and comorbidities. The purpose of this study is to assess rates and risk factors associated with mortality in surgical procedures involving the lumbar spine using a large national database. Methods/UNASSIGNED:< .05 differences relative to the overall cohort. Results/UNASSIGNED:Mortality for all patients requiring surgery of the lumbar spine was 0.13%. Mortality based on procedure type was 0.105% for simple fusions, 0.321% for complex fusions, and 0.081% for decompression only. Increased mortality was observed demographically in patients who were male (odds ratio [OR]: 1.75; 95% confidence interval [CI]: 1.51-2.03), black (OR: 1.40; CI: 1.10-1.79), ages 65-74 (OR: 1.46; CI: 1.25-1.70), and age 75+ (OR: 2.70; CI: 2.30-3.17). Comorbidities associated with the greatest increase in mortality were mild (OR: 10.04; CI: 7.76-13.01) and severe (OR: 26.47; CI: 16.03-43.70) liver disease and congestive heart failure (OR: 4.57; CI: 3.77-5.53). The complications with the highest mortality rates were shock (OR: 20.67; CI: 13.89-30.56) and pulmonary embolism (OR: 20.15; CI: 14.01-29.00). Conclusions/UNASSIGNED:From 2003 to 2012, the overall mortality rate in 803,949 lumbar spine surgery patients was 0.13%. Risk factors that were significantly associated with increased mortality rates were male gender, black race, and ages 65-74 and 75+. Comorbidities associated with an increased mortality rate were mild and severe liver disease and congestive heart failure. Inpatient complications with the highest mortality rates were shock and pulmonary embolism. These findings can be helpful to surgeons providing preoperative counseling for patients considering elective lumbar procedures and for allocating resources to treat and prevent perioperative complications leading to mortality. Level of Evidence/UNASSIGNED:3.

STUDY DESIGN/METHODS:Retrospective analysis OBJECTIVE.: To compare long-term outcomes between patients with and without mental health comorbidities who are undergoing surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA/BACKGROUND:Recent literature reveals that one in three patients admitted for surgical treatment for ASD has comorbid mental health disorder. Currently, impacts of baseline mental health status on long-term outcomes following ASD surgery have not been thoroughly investigated. METHODS:Patients admitted from 2009-2013 with diagnoses of ASD who underwent ≥4-level thoracolumbar fusion with minimum two-year follow-up were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System (SPARCS). Patients were stratified by fusion length (Short: 4-8-level; Long: ≥9 level). Patients with comorbid mental health disorder (MHD) at time of admission were selected for analysis (MHD) and compared against those without MHD (no-MHD). Univariate analysis compared demographics, complications, readmissions and revisions between cohorts for each fusion length. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: fusion length, age, female gender, and Deyo score). RESULTS:6,020 patients (MHD: n = 1,631; no-MHD: n = 4,389) met inclusion criteria. Mental health diagnoses included disorders of depression (59.0%), sleep (28.0%), anxiety (24.0%), and stress (2.3%). At two-year follow-up, MHD patients with short fusion had significantly higher complication rates (p = 0.001). MHD patients with short or long fusion also had significantly higher rates of any readmission and revision (all p ≤ 0.002). Regression modeling revealed that comorbid MHD was a significant predictor of any complication (OR: 1.17, p = 0.01) and readmission (OR: 1.32, p < 0.001). MHD was the strongest predictor of any revision (OR: 1.56, p < 0.001). Long fusion most strongly predicted any complication (OR: 1.87, p < 0.001). CONCLUSIONS:ASD patients with comorbid depressive, sleep, anxiety, and stress disorders were more likely to experience surgical complications and revision at minimum of two years following spinal fusion surgery. Proper patient counseling and psychological screening/support is recommended to complement ASD treatment. LEVEL OF EVIDENCE/METHODS:3.