Faculty Bibliography

BACKGROUND:Adult spinal deformity (ASD) surgery can entail complex reconstructive procedures. It is unclear whether there is any effect of case start time on outcomes. We sought to evaluate the effects of case start time and day of the week on 90-day complication, readmission, and revision rates after ASD surgery. METHODS:This is a retrospective study of 1040 ASD patients from a single institution. We collected start times and day of the week for cases from 2011 to 2018. Early start was designated as any case starting either before or at 7:30 am or between 7:30 and 11 am; late start was designated as any case starting at 11 am or later. Outcome measures include 90-day complication, revision, and readmission rates. RESULTS:= 0.046). CONCLUSIONS:A late OR start time was predictive of increased risk for neurologic complication, 90-day readmission, and unplanned reoperation. The well-established protocols for first start OR times for elective ASD surgery may decrease outcome risk and reduce variability in complication rates. CLINICAL RELEVANCE/CONCLUSIONS:Understanding the impact of start time on outcomes and complications after ASD surgery is helpful for surgeons in preoperative planning and for institutions and hospitals' allocation of operating room staff and resources. LEVEL OF EVIDENCE/METHODS:3.

STUDY DESIGN/METHODS:Retrospective review of a single-center spine database. OBJECTIVE:Investigate the intersections of chronological age and physiological age via frailty to determine the influence of surgical invasiveness on patient outcomes. SUMMARY OF BACKGROUND DATA/BACKGROUND:Frailty is a well-established factor in preoperative risk stratification and prediction of postoperative outcomes. The surgical profile of operative adult spinal deformity (ASD) patients who present as elderly and not frail has yet to be investigated. Our aim was to examine the surgical profile and outcomes of ASD patients who were not frail and elderly. METHODS:Included: ASD patients≥18 years old, ≥4 levels fused, with baseline(BL) and follow up data. Patients were categorized by ASD frailty index: Not Frail[NF], Frail[F], Severely Frail [SF]. An elderly patient was defined as ≥70 years. Patients were grouped into NF/elderly and F/elderly. SRS-Schwab modifiers were assessed at baseline and 1-year(0, +, ++). Logistic regression analysis assessed the relationship between increasing invasiveness, no reoperations, or major complications, and improvement in SRS-Schwab modifiers[Good Outcome]. Decision tree analysis assessed thresholds for an invasiveness risk/benefit cutoff point. RESULTS:598 ASD pts included(55.3yrs, 59.7%F, 28.3 kg/m2). 29.8% of patients were above age 70. At baseline, 51.3% of patients were NF, 37.5% F, and 11.2% SF. 66(11%) of patients were NF and elderly. 24.2% of NF-Elderly patients improved in SRS-Schwab by 1-year and had no reoperation or complication postoperatively. Binary regression analysis found a relationship between worsening SRS-Schwab, postop complication, and reoperation with invasiveness score(OR: 1.056[1.013-1.102], p = 0.011). Risk/benefit cut-off was 10(p = 0.004). Patients below this threshold were 7.9[2.2-28.4] times more likely to have a Good Outcome. 156 patients were elderly and F/SF with 16.7% having Good Outcome, with a risk/benefit cut-off point of <8 (4.4[2.2-9.0], p < 0.001). CONCLUSIONS:Frailty status impacted the balance of surgical invasiveness relative to operative risk in an inverse manner, while the opposite was seen amongst elderly patients with a frailty status less than their chronologic age. Surgeons should perhaps consider incorporation of frailty status over age status when determining realignment plans in patients of advanced age.Level of Evidence: ???

BACKGROUND:Interbody fusion at the caudal levels of long constructs for adult spinal deformity (ASD) surgery is used to promote fusion and secure a solid foundation for maintenance of deformity correction. We sought to evaluate long-term pseudarthrosis, rod fracture, and revision rates for TLIF performed at the base of a long construct for ASD. METHODS:We reviewed 316 patients who underwent TLIF as a component of ASD surgery for medical comorbidities, surgical characteristics, and rate of unplanned reoperation for pseudarthrosis or instrumentation failure at the TLIF level. Fusion grading was assessed after revision surgery for pseudarthrosis at the TLIF level. RESULTS:Rate of pseudarthrosis at the TLIF level was 9.8% (31/316), and rate of rod fractures was 7.9% (25/316). The rate of revision surgery at the TLIF level was 8.9% (28/316), and surgery was performed at a mean of 20.4 ± 16 months from the index procedure. Current smoking status (odds ratio 3.34, P = 0.037) was predictive of pseudarthrosis at the TLIF site. At a mean follow-up of 43 ± 12 months after revision surgery, all patients had achieved bony union at the TLIF site. CONCLUSIONS:At 3-year follow-up, the rate of pseudarthrosis after TLIF performed at the base of a long fusion for ASD was 9.8%, and the rate of revision surgery to address pseudarthrosis and/or rod fracture was 8.9%. All patients were successfully treated with revision interbody fusion or posterior augmentation of the fusion mass, without need for further revision procedures at the TLIF level.

PURPOSE/OBJECTIVE:To evaluate the effectiveness of the use of topical tranexamic acid (tTXA) in spinal deformity correction in AIS patients METHODS: Sixty consecutive operative AIS patients were reviewed from a single institution and divided into two groups with similar demographics. Standardized peri-operative blood salvage techniques were utilized in all 60 patients. In the latter 30 patients, tTXA soaked sponges (1 g mixed in 500 ml Normal Saline) was utilised for wound packing during the entire surgical procedure compared to dry sponges as used in the former 30 patients. Both the groups were compared for the magnitude of deformity corrected, EBL per level fused, total EBL, blood transfused, drain output and peri-operative events. RESULTS:Sixty AIS patients (mean age 14.4 yrs, 43 females, mean BMI 21.5, mean levels 10.7) were included. Both groups achieved similar change in Coronal Cobb correction. The EBVL (Estimated blood volume loss) % lost in the topical TXA group was 38% less than the control group (11.2 vs. 18.3%, p = 0.006). Similarly, the EBL/level was significantly lower in the topical TXA group (41 ± 30 ml vs. 57 ± 26 ml, p = 0.03). Three of 30 patients in the control group required at least 1 unit of blood transfusion, whereas only 1 patient in the topical TXA group required transfusion (10 vs. 3.3%, p = 0.001). No differences were noted in post-operative drain output, change in hemoglobin levels, and peri-operative complication rates. CONCLUSION/CONCLUSIONS:When used as an adjunct to the conventional blood salvage techniques in spinal deformity correction procedures, the use of tTXA resulted in reduced operative blood loss, and blood transfusion requirements.

BACKGROUND:Cerebral palsy (CP) is a static encephalopathy with progressive musculoskeletal pathology. Non-ambulant children (GMFCS IV and V) with CP have high rates of spastic hip disease and neuromuscular scoliosis. The effect of spinal fusion and spinal deformity on hip dislocation following total hip arthroplasty has been well studied, however in CP this remains largely unknown. This study aimed to identify factors associated with worsening postoperative hip status (WHS) following corrective spinal fusion in children with GMFCS IV and V CP. METHODS:Retrospective review of GMFSC IV and V CP patients in a prospective multicenter database undergoing spinal fusion, with 5 years follow-up. WHS was determined by permutations of baseline (BL), 1 year, 2 years, and 5 years hip status and defined by a change from an enlocated hip at BL that became subluxated, dislocated or resected post-op, or a subluxated hip that became dislocated or resected. Hip status was analyzed against patient demographics, hip position, surgical variables, and coronal and sagittal spinal alignment parameters. Cutoff values for parameters at which the relationship with hip status was significant was determined using receiver operating characteristic curves. Logistic regression determined odds ratios for predictors of WHS. RESULTS:Eighty four patients were included. 37 (44%) had WHS postoperatively. ROC analysis and logistic regression demonstrated that the only spinopelvic alignment parameter that significantly correlated with WHS was lumbar hyperlordosis (T12-L5) > 60° (p = 0.028), OR = 2.77 (CI 1.10-6.94). All patients showed an increase in pre-to-postop LL. Change in LL pre-to-postop was no different between groups (p = 0.318), however the WHS group was more lordotic at BL and postop (pre44°/post58° vs pre32°/post51° in the no change group). Age, sex, Risser, hip position, levels fused, coronal parameters, global sagittal alignment (SVA), thoracic kyphosis, and reoperation were not associated with WHS. CONCLUSION/CONCLUSIONS:Postoperative hyperlordosis(> 60°) is a risk factor for WHS at 5 years after spinal fusion in non-ambulant CP patients. WHS likely relates to anterior pelvic tilt and functional acetabular retroversion due to hyperlordosis, as well as loss of protective lumbopelvic motion causing anterior femoracetabular impingement. LEVEL OF EVIDENCE/METHODS:III.

STUDY DESIGN/METHODS:Bibliometric literature review. OBJECTIVE:The aim of this study was to recognize and analyze the most frequently cited manuscripts published in the journal Spine. SUMMARY OF BACKGROUND DATA/BACKGROUND:Although the journal Spine is considered a premiere location for distributing influential spine research, no previous study has evaluated which of their publications have had the most impact. Knowledge and appreciation of the most influential Spine publications can guide and inspire future research endeavors. METHODS:Using the Scopus database, the 100 most cited articles published in Spine were accessed. The frequency of citations, year of publication, country of origin, level-of-evidence (LOE), article type, and contributing authors/institutions were recorded. The 10 most cited articles (per year) from the past decade were also determined. RESULTS:"Guidelines For The Process Of Cross-Cultural Adaptation Of Self-Report Measures" by Beaton DE was the most cited article with 2960 citations. 2000 to 2009 (n = 46) was the most productive period. A LOE of III (n = 35) followed by II (n = 34) were the most common. Deyo RA (n = 8), Bombardier C (n = 6), and Waddell G (n = 6) produced the most articles. University of Washington (n = 8) and University of Toronto (n = 8) ranked first for institutional output. Clinical Outcome (n = 28) was the most recurring article topic. The United States (n = 51) ranked first for country of origin. CONCLUSION/CONCLUSIONS:Using citation analysis as an objective proxy for influence, certain publications can be distinguished from others due to their lasting impact and recognition from peers. Of the top cited Spine publications, many pertained to clinical outcomes (28%) and had a LOE of I, II, or III (60%). Although older publications have had longer time to accrue citations, those in the most recent decade comprise this list almost 2:1. Knowledge of these "classic" publications allows for a better overall understanding of the diagnosis, management, and future direction of spine health care.Level of Evidence: 3.

OBJECTIVE:The goal of this study was to reliably predict sagittal and coronal spinal alignment with clinical photographs by using markers placed at easily localized anatomical landmarks. METHODS:A consecutive series of patients with adult spinal deformity were enrolled from a single center. Full-length standing radiographs were obtained at the baseline visit. Clinical photographs were taken with reflective markers placed overlying C2, S1, the greater trochanter, and each posterior-superior iliac spine. Sagittal radiographic parameters were C2 pelvic angle (CPA), T1 pelvic angle (TPA), and pelvic tilt. Coronal radiographic parameters were pelvic obliquity and T1 coronal tilt. Linear regressions were performed to evaluate the relationship between radiographic parameters and their photographic "equivalents." The data were reanalyzed after stratifying the cohort into low-body mass index (BMI) (< 30) and high-BMI (≥ 30) groups. Interobserver and intraobserver reliability was assessed for clinical measures via intraclass correlation coefficients (ICCs). RESULTS:A total of 38 patients were enrolled (mean age 61 years, mean BMI 27.4 kg/m2, 63% female). All regression models were significant, but sagittal parameters were more closely correlated to photographic parameters than coronal measurements. TPA and CPA had the strongest associations with their photographic equivalents (both r2 = 0.59, p < 0.001). Radiographic and clinical parameters tended to be more strongly correlated in the low-BMI group. Clinical measures of TPA and CPA had high intraobserver reliability (all ICC > 0.99, p < 0.001) and interobserver reliability (both ICC > 0.99, p < 0.001). CONCLUSIONS:The photographic measures of spinal deformity developed in this study were highly correlated with their radiographic counterparts and had high inter- and intraobserver reliability. Clinical photography can not only reduce radiation exposure in patients with adult spinal deformity, but also be used to assess deformity when full-spine radiographs are unavailable.

OBJECTIVE:Although short-term adult symptomatic lumbar scoliosis (ASLS) studies favor operative over nonoperative treatment, longer outcomes are critical for assessment of treatment durability, especially for operative treatment, because the majority of implant failures and nonunions present between 2 and 5 years after surgery. The objectives of this study were to assess the durability of treatment outcomes for operative versus nonoperative treatment of ASLS, to report the rates and types of associated serious adverse events (SAEs), and to determine the potential impact of treatment-related SAEs on outcomes. METHODS:The ASLS-1 (Adult Symptomatic Lumbar Scoliosis-1) trial is an NIH-sponsored multicenter prospective study to assess operative versus nonoperative ASLS treatment. Patients were 40-80 years of age and had ASLS (Cobb angle ≥ 30° and Oswestry Disability Index [ODI] ≥ 20 or Scoliosis Research Society [SRS]-22 subscore ≤ 4.0 in the Pain, Function, and/or Self-Image domains). Patients receiving operative and nonoperative treatment were compared using as-treated analysis, and the impact of related SAEs was assessed. Primary outcome measures were ODI and SRS-22. RESULTS:The 286 patients with ASLS (107 with nonoperative treatment, 179 with operative treatment) had 2-year and 5-year follow-up rates of 90% (n = 256) and 74% (n = 211), respectively. At 5 years, compared with patients treated nonoperatively, those who underwent surgery had greater improvement in ODI (mean difference -15.2 [95% CI -18.7 to -11.7]) and SRS-22 subscore (mean difference 0.63 [95% CI 0.48-0.78]) (p < 0.001), with treatment effects (TEs) exceeding the minimum detectable measurement difference (MDMD) for ODI (7) and SRS-22 subscore (0.4). TEs at 5 years remained as favorable as 2-year TEs (ODI -13.9, SRS-22 0.52). For patients in the operative group, the incidence rates of treatment-related SAEs during the first 2 years and 2-5 years after surgery were 22.38 and 8.17 per 100 person-years, respectively. At 5 years, patients in the operative group who had 1 treatment-related SAE still had significantly greater improvement, with TEs (ODI -12.2, SRS-22 0.53; p < 0.001) exceeding the MDMD. Twelve patients who received surgery and who had 2 or more treatment-related SAEs had greater improvement than nonsurgically treated patients based on ODI (TE -8.34, p = 0.017) and SRS-22 (TE 0.32, p = 0.029), but the SRS-22 TE did not exceed the MDMD. CONCLUSIONS:The significantly greater improvement of operative versus nonoperative treatment for ASLS at 2 years was durably maintained at the 5-year follow-up. Patients in the operative cohort with a treatment-related SAE still had greater improvement than patients in the nonoperative cohort. These findings have important implications for patient counseling and future cost-effectiveness assessments.

STUDY DESIGN/UNASSIGNED:Retrospective study. OBJECTIVES/UNASSIGNED:Our goal was to evaluate the rate of rod fracture and persistent pseudarthrosis in cohorts of patients treated with a dual rod or multiple-rod construct in revision surgery for pseudarthrosis. METHODS/UNASSIGNED:A dual rod construct was used in 23 patients, and a multiple rod construct in 24 patients, spanning the pseudarthrosis level. Two-year fusion grading, and rates of pseudarthrosis and implant failure, were assessed. RESULTS/UNASSIGNED:There were no differences in patient or surgical characteristics between the groups: (2- rod construct: Age 60 ± 14, Levels 10 ± 5, 3-column osteotomy:17%; multiple-rod construct: Age: 62 ± 11, Levels 9 ± 4, 3-column osteotomy:30%). Patients in the multiple rod construct were transfused a greater volume of packed red blood cells (pRBCs) intraoperatively (2.6 ± 2.9 vs. 1.1 ± 1.5 U, p < 0.0001). At 2 year follow up there was no difference in fusion grades at the previous level of pseudarthrosis, the rate of rod fracture or pseudarthrosis between the 2 groups, or rate of reoperation for pseudarthrosis, rod fracture, wound infection, hardware prominence, or PJK/PJF. CONCLUSIONS/UNASSIGNED:Our data demonstrate no difference in fusion grade, or rates of rod fracture and revision at 2 years, after utilizing a dual rod versus multiple rod construct in revision surgery for pseudarthrosis. The low complication rates seen with either configuration warrant further investigation of the optimal instrumentation configuration.

BACKGROUND:Adult sagittal spinal deformity (SSD) leads to the recruitment of compensatory mechanisms to maintain standing balance. After regional spinal compensation is exhausted, lower extremity compensation is recruited. Knee flexion, ankle flexion, and sacrofemoral angle increase to drive pelvic shift posterior and increase pelvic tilt. We aim to describe 2 summary angles termed ankle-pelvic angle (APA) and global lower extremity angle (GLA) that incorporate all aspects of lower extremity and pelvic compensation in a comprehensive measurement that can simplify radiographic analysis. METHODS:Full-body sagittal stereotactic radiographs were retrospectively collected and digitally analyzed. Spinal and lower extremity alignment were quantified with existing measures. Two angles-APA and GLA-were drawn as geometrically complementary angles to T1-pelvic angle (TPA) and global sagittal axis (GSA), respectively. Regression analysis was used to represent the predictive relationship between TPA and APA and between GSA and GLA. RESULTS:= .005). CONCLUSIONS:TPA and GSA are measures of global spinal alignment and APA and GLA, respectively, and are geometrically complementary angles that vary proportionately to SSD and balance the body. APA and GLA increase in SSD patients with lower extremity compensation and decrease with corrective surgery. LEVEL OF EVIDENCE/METHODS:4. CLINICAL RELEVANCE/CONCLUSIONS:APA and GLA offer a concise and simple method of communicating pelvic and lower extremity compensation.