Faculty Bibliography

OBJECTIVE Depression and anxiety have been demonstrated to have negative impacts on outcomes after spine surgery. In patients with cervical deformity (CD), the psychological and physiological burdens of the disease may overlap without clear boundaries. While surgery has a proven record of bringing about significant pain relief and decreased disability, the impact of depression and anxiety on recovery from cervical deformity corrective surgery has not been previously reported on in the literature. The purpose of the present study was to determine the effect of depression and anxiety on patients' recovery from and improvement after CD surgery. METHODS The authors conducted a retrospective review of a prospective, multicenter CD database. Patients with a history of clinical depression, in addition to those with current self-reported anxiety or depression, were defined as depressed (D group). The D group was compared with nondepressed patients (ND group) with a similar baseline deformity determined by propensity score matching of the cervical sagittal vertical axis (cSVA). Baseline demographic, comorbidity, clinical, and radiographic data were compared among patients using t-tests. Improvement of symptoms was recorded at 3 months, 6 months, and 1 year postoperatively. All health-related quality of life (HRQOL) scores collected at these follow-up time points were compared using t-tests. RESULTS Sixty-six patients were matched for baseline radiographic parameters: 33 with a history of depression and/or current depression, and 33 without. Depressed patients had similar age, sex, race, and radiographic alignment: cSVA, T-1 slope minus C2-7 lordosis, SVA, and T-1 pelvic angle (p > 0.05). Compared with nondepressed individuals, depressed patients had a higher incidence of osteoporosis (21.2% vs 3.2%, p = 0.028), rheumatoid arthritis (18.2% vs 3.2%, p = 0.012), and connective tissue disorders (18.2% vs 3.2%, p = 0.012). At baseline, the D group had greater neck pain (7.9 of 10 vs 6.6 on a Numeric Rating Scale [NRS], p = 0.015), lower mean EQ-5D scores (68.9 vs 74.7, p < 0.001), but similar Neck Disability Index (NDI) scores (57.5 vs 49.9, p = 0.063) and myelopathy scores (13.4 vs 13.9, p = 0.546). Surgeries performed in either group were similar in terms of number of levels fused, osteotomies performed, and correction achieved (baseline to 3-month measurements) (p < 0.05). At 3 months, EQ-5D scores remained lower in the D group (74.0 vs 78.2, p = 0.044), and NDI scores were similar (48.5 vs 39.0, p = 0.053). However, neck pain improved in the D group (NRS score of 5.0 vs 4.3, p = 0.331), and modified Japanese Orthopaedic Association (mJOA) scores remained similar (14.2 vs 15.0, p = 0.211). At 6 months and 1 year, all HRQOL scores were similar between the 2 cohorts. One-year measurements were as follows: NDI 39.7 vs 40.7 (p = 0.878), NRS neck pain score of 4.1 vs 5.0 (p = 0.326), EQ-5D score of 77.1 vs 78.2 (p = 0.646), and mJOA score of 14.0 vs 14.2 (p = 0.835). Anxiety/depression levels reported on the EQ-5D scale were significantly higher in the depressed cohort at baseline, 3 months, and 6 months (all p < 0.05), but were similar between groups at 1 year postoperatively (1.72 vs 1.53, p = 0.416). CONCLUSIONS Clinical depression was observed in many of the study patients with CD. After matching for baseline deformity, depression symptomology resulted in worse baseline EQ-5D and pain scores. Despite these baseline differences, both cohorts achieved similar results in all HRQOL assessments 6 months and 1 year postoperatively, demonstrating no clinical impact of depression on recovery up until 1 year after CD surgery. Thus, a history of depression does not appear to have an impact on recovery from CD surgery.

BACKGROUND CONTEXT: Complication rates for adult cervical deformity are poorly characterized given the complexity and heterogeneity of cases. PURPOSE: To compare peri-operative complication rates following adult cervical deformity corrective surgery between a prospective multi-center database for cervical deformity patients (PCD) and Nationwide Inpatient Sample (NIS). STUDY DESIGN/SETTING: Retrospective review of prospective databases. PATIENT SAMPLE: 11,501 adult cervical deformity patients (11,379 patients from NIS and 122 patients from PCD database). OUTCOME MEASURES: Peri-operative medical and surgical complications. METHODS: The NIS was queried (2001-2013) for cervical deformity discharges for patients >/=18yrs undergoing cervical fusions using ICD-9 coding. Patients >/=18 years from the PCD database (2013-2015) were selected. Equivalent complications were identified and rates were compared. Bonferroni correction (p<0.004) was used for Pearson chi2. Binary logistic regression was used to evaluate differences in complication rates between databases. RESULTS: 11,379 NIS patients and 122 PCD patients were identified. PCD patients were older (62.49 vs. 55.15,p<0.001) but displayed similar gender distribution. Intra-operative complication rate was higher in PCD (39.3%) compared to NIS (9.2%,p<0.001). PCD had an increased risk of reporting overall complications than NIS (OR:2.81, CI:1.81-4.38). Only device-related complications were greater in NIS (7.1% vs. 1.1%,p=0.007). PCD patients displayed higher rates of the following complications: peripheral vascular (0.8% vs. 0.1%,p=0.001), GI (2.5% vs. 0.2%,p<0.001), infection (8.2% vs. 0.5%,p<0.001), dural tear (4.1% vs. 0.6%, p<0.001), and dysphagia (9.8% vs. 1.9%,p<0.001). GU, wound, and DVT complications were similar between databases (p>0.004). Based on surgical approach, PCD reported higher GI and neurologic complication rates for combined anterior/posterior procedures (p<0.001). For posterior-only procedures, NIS had more device-related complications (12.4% vs. 0.1%,p=0.003), while PCD had more infections (9.3% vs. 0.7%,p<0.001). CONCLUSIONS: Analysis of the surgeon-maintained cervical database revealed higher overall and individual complication rates and higher data granularity. The nationwide database may underestimate ACD patient complications particularly in regards to peri-operative surgical details due to coding and deformity generalizations. The surgeon-maintained database captures the surgical details, but may underestimate some medical complications.

OBJECTIVE Using 2 complication-reporting methods, the authors investigated the incidence of major medical complications and mortality in elderly patients after surgery for adult spinal deformity (ASD) during a 2-year follow-up period. METHODS The authors queried a multicenter, prospective, surgeon-maintained database (SMD) to identify patients 65 years or older who underwent surgical correction of ASD from 2008 through 2014 and had a minimum 2 years of follow-up (n = 153). They also queried a Centers for Medicare & Medicaid Services claims database (MCD) for patients 65 years or older who underwent fusion of 8 or more vertebral levels from 2005 through 2012 (n = 3366). They calculated cumulative rates of the following complications during the first 6 weeks after surgery: cerebrovascular accident, congestive heart failure, deep venous thrombosis, myocardial infarction, pneumonia, and pulmonary embolism. Significance was set at p < 0.05. RESULTS During the perioperative period, rates of major medical complications were 5.9% for pneumonia, 4.1% for deep venous thrombosis, 3.2% for pulmonary embolism, 2.1% for cerebrovascular accident, 1.8% for myocardial infarction, and 1.0% for congestive heart failure. Mortality rates were 0.9% at 6 weeks and 1.8% at 2 years. When comparing the SMD with the MCD, there were no significant differences in the perioperative rates of major medical complications except pneumonia. Furthermore, there were no significant intergroup differences in the mortality rates at 6 weeks or 2 years. The SMD provided greater detail with respect to deformity characteristics and surgical variables than the MCD. CONCLUSIONS The incidence of most major medical complications in the elderly after surgery for ASD was similar between the SMD and the MCD and ranged from 1% for congestive heart failure to 5.9% for pneumonia. These complications data can be valuable for preoperative patient counseling and informed consent.

OBJECTIVE It is becoming increasingly necessary for surgeons to provide evidence supporting cost-effectiveness of surgical treatment for cervical spine pathology. Anticipating surgical risk is critical in accurately evaluating the risk/benefit balance of such treatment. Determining the risk and cost-effectiveness of surgery, complications, revision procedures, and mortality rates are the most significant limitations. The purpose of this study was to determine independent risk factors for medical complications (MCs), surgical complications (SCs), revisions, and mortality rates following surgery for patients with cervical spine pathology. The most relevant risk factors were used to structure an index that will help quantify risk and anticipate failure for such procedures. METHODS The authors of this study performed a retrospective review of the National Inpatient Sample (NIS) database for patients treated surgically for cervical spine pathology between 2001 and 2010. Multivariate models were performed to calculate the odds ratio (OR) of the independent risk factors that led to MCs and repeated for SCs, revisions, and mortality. The models controlled for age (< and > 65 years old), sex, race, revision status (except for revision analysis), surgical approach, number of levels fused/re-fused (2-3, 4-8, >/= 9), and osteotomy utilization. ORs were weighted based on their predictive category: 2 times for revision surgery predictors and 4 times for mortality predictors. Fifty points were distributed among the predictors based on their cumulative OR to establish a risk index. RESULTS Discharges for 362,989 patients with cervical spine pathology were identified. The mean age was 52.65 years, and 49.47% of patients were women. Independent risk factors included medical comorbidities, surgical parameters, and demographic factors. Medical comorbidities included the following: pulmonary circulation disorder, coagulopathy, metastatic cancer, renal failure, congestive heart failure, alcohol abuse, neurological disorder, nonmetastatic cancer, liver disease, rheumatoid arthritis/collagen vascular diseases, and chronic blood loss/anemia. Surgical parameters included posterior approach to fusion/re-fusion, >/= 9 levels fused/re-fused, corpectomy, 4-8 levels fused/re-fused, and osteotomy; demographic variables included age >/= 65 years. These factors increased the risk of at least 1 of MC, SC, revision, or mortality (risk of death). A total of 50 points were distributed among the factors based on the cumulative risk ratio of every factor in proportion to the total risk ratios. CONCLUSIONS This study proposed an index to quantify the potential risk of morbidity and mortality prior to surgical intervention for patients with cervical spine pathology. This index may be useful for surgeons in patient counseling efforts as well as for health insurance companies and future socioeconomics studies in assessing surgical risks and benefits for patients undergoing surgical treatment of the cervical spine.

BACKGROUND CONTEXT: Patients with degenerative lumbar stenosis (DLS) adopt a forward flexed posture in an attempt to decompress neural elements. The relationship between sagittal alignment and severity of lumbar stenosis has not previously been studied. PURPOSE: We hypothesized that patients with increasing radiological severity of lumbar stenosis will exhibit worsening sagittal alignment. STUDY DESIGN: This is a cross-sectional study. PATIENT SAMPLE: Our sample consists of patients who have DLS. OUTCOME MEASURES: Standing pelvic, regional, lower extremity and global sagittal alignment, and health-related quality of life (HRQoL) were the outcome measures. METHODS: Patients with DLS were identified from a retrospective clinical database with corresponding full-body stereoradiographs. Exclusion criteria included coronal malalignment, prior spine surgery, spondylolisthesis>Grade 1, non-degenerative spinal pathology, or skeletal immaturity. Central stenosis severity was graded on axial T2-weighted magnetic resonance imaging (MRI) from L1-S1. Foraminal stenosis and supine lordosis was graded on sagittal T1-weighted images. Standing pelvic, regional, lower extremity, and global sagittal alignment were measured using validated software. The HRQoL measures were also analyzed in relation to severity of stenosis. RESULTS: A total of 125 patients were identified with DLS on appropriate imaging. As central stenosis grade increased, patients displayed significantly increasing standing T1 pelvic angle, pelvic tilt, sagittal vertical axis, and pelvic incidence-lumbar lordosis (p<.05). No significant difference wasfound in pelvic incidence, supine lordosis, thoracic kyphosis, or T1 spinopelvic inclination between central stenosis groups. Despite similar supine lordosis between stenosis groups, patients with Grades 2 and 3 stenosis had less standing lordosis, suggesting antalgic posturing. Upper lumbar (L1-L3) stenosis predicted worse alignment than lower lumbar (L4-S1) stenosis. Increasing severity of foraminal stenosis was associated with reduced lumbar lordosis; however, no significant postural difference in lordosis, thoracolumbar, or lower extremity compensatory mechanisms were noted between foraminal stenosis groups. Stenosis grading did not predict worsening HRQoLs in central or foraminal stenosis. CONCLUSIONS: Severity of central lumbar stenosis as graded on MRI correlates with severity of sagittal malalignment. These findings support theories of sagittal malalignment as a compensatory mechanism for central lumbar stenosis.

STUDY DESIGN: Retrospective analysis of prospective data from the degenerative spondylolisthesis (DS) arm of the Spine Patient Outcomes Research Trial. OBJECTIVE: To identify risk factors for reoperation in patients treated surgically for DS and compare outcomes between patients who underwent reoperation with non-reoperative patients. SUMMARY OF BACKGROUND DATA: Several studies have examined outcomes following surgery for DS, but few have identified risk factors for reoperation. METHOD: Analysis included patients with neurogenic claudication (>12 weeks), clinical neurological signs, spinal stenosis, and DS on standing lateral x-rays. Univariate and multivariate analyses were used to investigate patient characteristics and risk factors. Treatment effects (TE) were calculated and compared between study groups. RESULTS: Of 406 patients, 72% underwent instrumented fusion, 21% non-instrumented fusion, and 7% decompression alone. At 8 years, the reoperation rate was 22%, of which 28% occurred within one year, 54% within 2 years, 70% within 4 years, and 86% within 6 years. The reasons for reoperation included recurrent stenosis or progressive spondylolisthesis (45%), complications such as hematoma, dehiscence, or infection (36%), or new condition (14%). Re-operative patients were younger (62.2 vs 65.3, p = 0.008). Significant risk factors were use of antidepressants (p = 0.008, HR 2.08) or having no neurogenic claudication upon enrollment (p = 0.02, HR 1.82). Patients who were smokers, diabetics, obese, or on workman's compensation were not at greater risk for reoperation. At eight year follow-up, scores for SF-36 bodily pain (BP), ODI, and stenosis frequency index were better in non-re-operative patients. TE favored non-re-operative patients for SF-36 BP, physical function, ODI, stenosis bothersomeness index and satisfaction with symptoms (p < 0.001). CONCLUSION: The incidence of reoperation for patients with DS was 22% eight years following surgery. Patients with a history of no neurogenic claudication and patients taking antidepressants were more likely to undergo reoperation. Outcomes scores and TE were more favorable in non-re-operative patients. LEVEL OF EVIDENCE: 2.

OBJECTIVE: To report the outcome of adult spinal deformity (ASD) in patients with rod fracture (RF) after thoracolumbar fusion. METHODS: Retrospective review of prospective, multicenter database. Operative patients with ASD >/=18 years old with RF after ASD surgery and with a minimum 6-month follow-up after RF were included. Health-related quality of life scores and radiographic alignment were compared with nonparametric paired and independent testing (P < 0.05). RESULTS: A total of 51 of 343 patients with ASD (14.9%) sustained a RF, of whom 44 (86.3%) had at least 6-month follow up after RF (mean age = 61.2 years, mean body mass index = 29.6 kg/m2). Mean total follow-up was 37.8 months (range 24.5-66.7 months). Interbody fusion was used in 26 cases of RF (59.1%) (transforaminal lumbar interbody fusion, n = 17 [65.4%], anterior lumbar interbody fusion, n = 5 [19.2%]). RF was symptomatic in 26 of 44 (59.1%) of patients and discovered incidentally in 18 of 44 patients (40.9%). Overall, 28 RFs were revised (63.6%); 12 of 23 (52.2%) unilateral RF and 16 of 21 (76.2%) bilateral RF at last follow-up. Revision patients were significantly more likely to be symptomatic at the time of RF detection (78.6% vs. 25.0%, P = 0.0006), and had significantly worse Oswestry Disability Index and Scoliosis Research Society-22r pain scores. CONCLUSIONS: RFs were detected in 14.9% of patients with ASD and were most common at the L4-L5 and L5-S1 levels. Approximately 63.6% of patients underwent revision surgery. The decision to perform revision surgery may be based predominantly on symptoms referable to the RF, pain, and perceived disability, as radiographic parameters at the time of RF did not differ significantly between patients who did and did not undergo revision.

STUDY DESIGN: Retrospective study OBJECTIVE:: To propose radiographic characteristics of patients with cervical disability and to investigate the relevant parameters when assessing cervical alignment. SUMMARY OF BACKGROUND DATA: Although cervical kyphosis is traditionally recognized as presentation of cervical deformity, an increasing number of studies demonstrated that cervical kyphosis may not equal cervical deformity. Therefore, several other differentiating criteria for cervical deformity should be investigated and supported with quality of life scores. METHODS: A database of full-body radiographs was retrospectively reviewed. Patients without previous cervical surgery, with a well aligned thoracolumbar profile (defined as T1 pelvis angle (TPA) <15 degrees ) and with an available Neck Disability Index (NDI) score were reviewed in this study. Subjects were stratified into an asymptomatic (64 subjects with NDI15, VAS neck>3, or VAS arm>3). Independent t-tests were performed to investigate differences between two groups. Logistic regressions and principle component analyses were then performed. RESULTS: NDI averaged 5.43 in asymptomatic group, significantly smaller than symptomatic group (5.43 vs. 41.25). T-test revealed that C2-C7 SVA, McGregor slope (McGS) and the slope of line of sight (SLS were significantly different while C2C7 angle (Cervical curvature, CC) did not show statistical difference (P = 0.09). Logistic regressions were performed using the significantly different parameters as well as CC. Results identified C2-C7 SVA and SLS as independent risk factors for low HRQoL. The principle component analysis, lead to a new factor (0.55 x C2C7 SVA + 0.34 x C0C2 + 0.77 x CC) with strong correlations with NDI, VAS and EQ5D measurements. CONCLUSION: The traditional concept of cervical kyphosis should not be regarded as a standalone criterion of cervical deformity. The most clinically relevant components of cervical analysis are the C2-C7 SVA, C0C2 angle and C2C7 angle. In addition, the three components should be assessed in together in harmony and not individually. LEVEL OF EVIDENCE: 4.