Faculty Bibliography

MINI: 172 patients underwent a primary TLIF. Those receiving <250 total MME (44%) as an inpatient had a 3.73 (odds ratio) times smaller probability of requiring opioids at 6 month follow-up. Patients who received >500 total MME (27%) had a 4.84 times greater probability of requiring opioids at 6 month follow-up.

BACKGROUND CONTEXT/BACKGROUND:ASD (Adult spinal deformity) surgery often entails complex osteotomies and realignment procedures, particularly in the setting of rigid deformities. While previous studies have established the efficacy of tranexamic acid (TXA), data evaluating the widely variable dosing regimens remains sparse. PURPOSE/OBJECTIVE:To improve understanding of blood loss and transfusion requirements for low-dose and high-dose TXA regimens for adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTING/METHODS:This is a retrospective cohort study of 318 ASD patients who received TXA. Outcome measures include estimated blood loss (EBL), perioperative transfusion requirement, and complications. METHODS:A retrospective review was conducted on 318 ASD patients: 258 patients received a low-dose regimen of TXA (10 or 20 mg/kg loading dose with a 1 or 2 mg/kg/h maintenance dose) and 60 patients received a high-dose regimen of TXA (40 mg/kg loading dose with a 1 mg/kg/h maintenance dose, 30 mg/kg loading dose with a 10 mg/kg/h maintenance dose, or 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose). RESULTS:Compared with the low-dose TXA group, the high-dose TXA group had significantly decreased EBL (1402 vs. 1793 mL, p=0.009), blood volume lost (30.3 vs. 39.4%, p=0.01), intraoperative packed red blood cell (pRBC) transfusion (0.9 vs 1.6 U, p<0.0001), and intraoperative platelet transfusion (0 versus 0.1 U, p<0.0001). High-dose TXA was predictive of 515 cc less EBL (p=0.002), 11.4% less blood volume lost (p=0.004), and 1 U pRBC less transfused intraoperatively (p<0.0001) than the low-dose TXA group. The high-dose TXA group had a higher incidence of postop atrial fibrillation (AF) (5 vs 0%, p<0.0001) and myocardial infarction (MI) (1.7 vs. 0%, p=0.04). CONCLUSIONS:Varying dosing regimens of TXA are utilized for ASD surgery, with a prevailing theme of dosing ambiguity. These data demonstrate that high-dose TXA is more effective than low-dose TXA in reducing blood loss and blood product transfusion requirement in ASD surgery. Importantly, rates of MI and postop AF were higher in the high-dose TXA group.

STUDY DESIGN/METHODS:Secondary analysis of prospective multicenter cohort OBJECTIVE.: To assess effect of serious adverse events (SAEs) on 2- and 4-year patient-reported outcomes measures (PROMs) in patients surgically treated for adult symptomatic lumbar scoliosis (ASLS) SUMMARY OF BACKGROUND DATA.: Operative treatment for ASLS can improve health-related quality of life (HRQL), but has high rates of SAEs. How these SAEs effect HRQL remains unclear. METHODS:The ASLS study assessed operative versus nonoperative ASLS treatment, with randomized and observational arms. Patients were 40- to 80-years-old with ASLS, defined as lumbar coronal Cobb ≥30° and Oswestry Disability Index (ODI) ≥20 or Scoliosis Research Society-22 (SRS-22) ≤4.0 in pain, function and/or self-image domains. SRS-22 subscore and ODI were compared between operative patients with and without a related SAE and nonoperative patients using an as-treated analysis combining randomized and observational cohorts. RESULTS:286 patients were enrolled, and 2- and 4-year follow-up rates were 90% and 81%, respectively, although at the time of data extraction not all patients were eligible for 4-year follow-up. A total of 97 SAEs were reported among 173 operatively treated patients. The most common were implant failure/pseudarthrosis (n = 25), proximal junctional kyphosis/failure (n = 10), and minor motor deficit (n = 8). At 2 years patients with an SAE improved less than those without an SAE based on SRS-22 (0.52 vs 0.79, p = 0.004) and ODI (-11.59 vs -17.34, p = 0.021). These differences were maintained at 4-years for both SRS-22 (0.51 vs 0.86, p = 0.001) and ODI (-10.73 vs -16.69, p = 0.012). Despite this effect, patients sustaining an operative SAE had greater PROM improvement than nonoperative patients (p<0.001). CONCLUSIONS:Patients affected by SAEs following surgery for ASLS had significantly less improvement of PROMs at 2- and 4-year follow-up versus those without an SAE. Regardless of SAE occurrence, operatively treated patients had significantly greater improvement in PROMs than those treated nonoperatively. LEVEL OF EVIDENCE/METHODS:2.

BACKGROUND:Interplay between degenerative hip and spine conditions (Hip-Spine Syndrome [HiSS]) warrants effective communication between respective surgeons. We identified radiographic parameters to distinguish a subset of patients with HiSS by evaluating hip osteoarthritis (HOA) in patients with and without spinopelvic malalignment, categorizing patients into respective HiSS types, and comparing radiographic parameters. METHODS:All patients with full-body orthogonal radiography from 2013 to 2016 were reviewed (n = 1,389). Using sagittal/coronal hip radiographs, HOA (Kellgren-Lawrence Grade) was noted, and pelvic incidence-lumbar lordosis mismatch (PI-LL) > 10° was considered spinal malalignment. Patients groups included non-HiSS (PI-LL ≤ 10°/Grade 0/n = 444), Hip (PI-LL ≤ 10°/Grade 3-4/n = 78), Spine (PI-LL > 10°/Grade 0/n = 297), or Hip-Spine (PI-LL > 10°/Grade 3-4/n = 30). Parameters were compared using ANOVA with post-hoc Bonferroni analysis. RESULTS:HiSS Hip type patients had less hip extension capability compared with non-HiSS, Spine, and Hip-Spine type patients, reflected by lowest pelvic tilt (PT)/sagittal retroversion (11.3° versus 16.5°/29.2°/25.2°, respectively) and less hip extension per sacrofemoral angle (10.1° versus 19.5°/28.4°/23.1°, respectively) (P < 0.001), as well as 4.7° increase in anterior tilt/sagittal anteversion compared with age-matched individuals. Hip-Spine type patients had less pelvic retroversion than Spine type patients (P = 0.045); these differences were greater when referenced to age-matched individuals (P < 0.001). Hip-Spine type patients had less hip extension than Spine type patients (P = 0.013). Hip type patients had greater knee flexion than non-HiSS type patients (6.4° versus 2.6°; P < 0.001). Moreover, Hip-Spine type patients had comparable lower extremity alignment compared with Spine type patients, except for greater posterior pelvic shift. CONCLUSION/CONCLUSIONS:Our novel HiSS categorization used established classification methods and supported PT use to potentially improve the ability to discern HiSS types/pathologies in a subset of patients with HOA and spinal sagittal malalignment. HOA grade 3 to 4 with PT <15° are categorized as Hip type and those with PT >25° are Hip-Spine type with sagittal malalignment, which may impact acetabular arthroplasty component placement.

Study Design/UNASSIGNED:Retrospective study of consecutive patients at a single institution.Objective: Examine the effect of minimally invasive surgery (MIS) versus open transforaminal lumbar interbody fusion (TLIF) surgery on long-term postoperative narcotic consumption. Objective/UNASSIGNED:Examine the effect of minimally invasive versus open TLIF on short-term postoperative narcotic consumption. Methods/UNASSIGNED:Differences between MIS and open TLIF, including inpatient opioid and nonopioid analgesic use, discharge opioid use, and postdischarge duration of narcotic usage were compared using appropriate statistical methods. Results/UNASSIGNED:= .018) compared with MIS TLIF. Conclusion/UNASSIGNED:Patients undergoing MIS TLIF required less inpatient opioids and had a decreased incidence of opioid dependence at 3-month follow-up. Patients with preoperative opioid use undergoing MIS TLIF are less likely to require long-term opioids.

BACKGROUND:Congenital abnormalities when present, according to VACTERL theory, occur nonrandomly with other congenital anomalies. This study estimates the prevalence of congenital spinal anomalies, and their concurrence with other systemic anomalies. METHODS:A retrospective cohort analysis on Health care Cost and Utilization Project's Kids Inpatient Database (KID), years 2000, 2003, 2006, 2009 was performed. ICD-9 coding identified congenital anomalies of the spine and other body systems. OUTCOME MEASURES/METHODS:Overall incidence of congenital spinal abnormalities in pediatric patients, and the concurrence of spinal anomaly diagnoses with other organ system anomalies. Frequencies of congenital spine anomalies were estimated using KID hospital-and-year-adjusted weights. Poisson distribution in contingency tables tabulated concurrence of other congenital anomalies, grouped by body system. RESULTS:Of 12,039,432 patients, rates per 100,000 cases were: 9.1 hemivertebra, 4.3 Klippel-Fiel, 56.3 Chiari malformation, 52.6 tethered cord, 83.4 spina bifida, 1.2 absence of vertebra, and 6.2 diastematomyelia. Diastematomyelia had the highest concurrence of other anomalies: 70.1% of diastematomyelia patients had at least one other congenital anomaly. Next, 63.2% of hemivertebra, and 35.2% of Klippel-Fiel patients had concurrent anomalies. Of the other systems deformities cooccuring, cardiac system had the highest concurrent incidence (6.5% overall). In light of VACTERL's definition of a patient being diagnosed with at least 3 VACTERL anomalies, hemivertebra patients had the highest cooccurrence of ≥3 anomalies (31.3%). With detailed analysis of hemivertebra patients, secundum ASD (14.49%), atresia of large intestine (10.2%), renal agenesis (7.43%) frequently cooccured. CONCLUSIONS:Congenital abnormalities of the spine are associated with serious systemic anomalies that may have delayed presentations. These patients continue to be at a very high, and maybe higher than previously thought, risk for comorbidities that can cause devastating perioperative complications if not detected preoperatively, and full MRI workups should be considered in all patients with spinal abnormalities. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND:Congenital scoliosis (CS) is associated with more rigid, complex deformities relative to adolescent idiopathic scoliosis (AIS) which theoretically increases surgical complications. Despite extensive literature studying AIS patients, few studies have been performed on CS patients. The purpose of this study was to evaluate complications associated with spinal fusions for CS and AIS. METHODS:A retrospective review of the Kid's Inpatient Database (KID) years 2000 to 2009 was performed. Inclusion: patients under 20 years with ICD-9 diagnosis codes for idiopathic scoliosis (IS-without concomitant congenital anomalies) and CS, undergoing spinal fusion from the KID years 2000 to 2009. Two analyses were performed according to age below 10 years and 10 years and above. Univariate analysis described differences in demographics, comorbidities, intraoperative complications, and clinical values between groups. Binary logistic regression controlling for age, sex, race, and invasiveness predicted complications risk in CS (odds ratios; 95% confidence interval). RESULTS:In total, 25,131 patients included (IS, n=22443; CS, n=2688). For patients under age 10, CS patients underwent 1 level shorter fusions (P<0.001), had fewer comorbidities (P<0.001), and sustained similar complication incidence. In the 10 and over age analysis, CS patients similarly had shorter fusions, but greater comorbidities, and significantly more complications (odds ratio, 1.6; confidence interval, 1.4-1.8). CONCLUSIONS:CS patients have higher in-hospital complication rates. With more comorbidities, these patients have increased risk of sustaining procedure-related complications such as shock, infection, and Adult Respiratory Distress Syndrome. These data help to counsel patients and their families before spinal fusion. LEVEL OF EVIDENCE/METHODS:Level III-retrospective review of a prospectively collected database.

BACKGROUND CONTEXT: Antifibrinolytic agents are used during ASD surgery to minimize blood loss and transfusion requirements. Tranexamic acid (TXA) reduces the risk of blood loss and transfusion after ASD surgery, but there persists concern for prothrombotic effects, myocardial infarction, stroke, and postoperative neurologic events including seizures. PURPOSE: To investigate perioperative blood loss and transfusion after TXA for ASD surgery. STUDY DESIGN/SETTING: Retrospective review of prospectively collected single center database. PATIENT SAMPLE: 469 patients who received TXA, and 354 patients who did not receive TXA. OUTCOME MEASURES: Perioperative blood loss and blood product transfusion rate, and complications.
METHOD(S): Using a single-institution multi-surgeon database, we performed a retrospective review of patients undergoing ASD surgery from 2011-2018. We identified 469 patients who received TXA, and 354 patients who did not receive TXA. We investigated perioperative blood loss and blood product transfusion rate, and complications occurring after surgery.
RESULT(S): There was no significant difference in age, BMI, or frailty between the TXA (age: 45 +/- 23, BMI: 25 +/- 6) and non-TXA group (age: 47 +/- 24, BMI: 26 +/- 7). The prevalence of coronary artery disease, chronic kidney disease, and history of pulmonary embolism was higher in the non-TXA group, presumably due to surgeon preoperative screening, with no difference in other medical comorbidities. There were more revision surgeries and pelvic fixation procedures in the TXA group, with no other differences in surgical complexity. The group that received TXA had significantly lower EBL (1693 +/- 1343 mL vs 2009 +/- 1892 mL, p=0.019), and were transfused less platelets intraoperatively (.07 +/-.3 U vs 0.25 +/- 0.86 U, p=0.012). There was no difference in rates of perioperative pRBC transfusion between the groups. The most common complications in both groups were ileus and urinary retention. There was no difference in rate of thrombotic, cardiac, or renal complications, or seizures between the two groups. There was no significant difference in 90-day complication, readmission, or revision rates.
CONCLUSION(S): Among patients undergoing ASD surgery, TXA was associated with a lower estimated blood loss, without a higher risk for any morbid event. To our knowledge, this is the largest study to date to evaluate the safety of TXA for ASD surgery. FDA DEVICE/DRUG STATUS: Unavailable from authors at time of publication.
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BACKGROUND CONTEXT: Sagittal malalignment has been discussed extensively in adult spinal deformity (ASD) literature, while coronal malalignment (CM) and fractional curve (FC) have received less attention. As a result, little guidance currently exists for surgical indications in managing CM, despite it being a relatively common occurrence that can considerably impact patient wellbeing. Patients with CM significantly affected by FC are at particular risk for continued CM postoperatively, along with its complications. PURPOSE: Assess types of approach to fusion of the fractional curve in ASD surgery and their relation to coronal alignment and sagittal alignment. STUDY DESIGN/SETTING: Retrospective review at single institution. PATIENT SAMPLE: A total of 82 ASD patients undergoing primary spinal fusion of 4 or more levels to sacrum or pelvis. OUTCOME MEASURES: Baseline (BL), 1-year (Y1) postoperatively and BL-Y1 difference (DELTABL-Y1) in magnitudes of FC, coronal alignment (CA) and sagittal alignment (SA) parameters: pelvic incidence-LL (PI-LL), cervical sagittal vertical axis (cSVA), T1 pelvic angle (TPA).
METHOD(S): Patients >=18 years old undergoing primary >=4-level fusion to sacrum/pelvis between October 2011 and January 2018 with minimum 6-month follow-up included. Chart review performed for operative dates and details and patient follow-up information. Coronal and sagittal parameters measured using deformity measuring software program. FC measured as segmental angle between L4 and S1. CA measured as distance between C7 plumb line and central sacral vertical line. CA>=20mm designated as CM, per guidelines in literature. Chi-squared test used to compare percentages and ANOVA used to compare means, with significance set at p<0.05.
RESULT(S): A total of 82 patients studied (68.3%F, age 62.6+/-13.3, BMI 28.1+/-6.6, Charlson comorbidity index 0.80+/-1.16). Nine patients (10.98%) had anterior-posterior fusion (AP), 41 (50%) posterior-only fusion with interbody device (PIB), 32 (39.02%) PSF without interbody (PSF). Twenty-three patients (28.04%) had FC>=15degree at BL, 7 (8.54%) at Y1. Forty-one patients (50%) had CM at BL, 35 (42.68%) at Y1. AP fusion patients had least levels fused (6.4 AP, 11.4 PIB, 11.8 PSF, p<0.001). No difference in revision by approach (55.56% AP, 24.39% PIB, 28.13% PSF, p=0.179). Approach type was not associated with different BL, Y1 or DELTABL-Y1 alignment parameters for FC, CA or SA. Mean FC 9.89degree at BL, 6.91degree at Y1 and DELTABL-Y1 difference 5.77degree, no difference between approach groups (p=0.361, 0.127, 0.550, respectively). Mean value for CA 33.62mm at BL, 21.15mm at Y1 and DELTABL-Y1 difference 23.23mm, no difference between approach groups (p=0.087, 0.153, 0.206, respectively). Mean PI-LL 25.21degree at BL, 11.1degree at Y1 and DELTABL-Y1 difference -13.7degree, no difference between approach groups (p=0.503, 0.600, 0.356, respectively). Mean cSVA 27.53degree at BL, 28.85degree at Y1 and DELTABL-Y1 difference 1.29degree, no difference between approach groups (p=0.364, 0.099, 0.141, respectively). Mean TPA 28.37degree at BL, 21.12degree at Y1 and DELTABL-Y1 difference -6.63degree, no difference between approach groups (p=0.066, 0.248, 0.138, respectively).
CONCLUSION(S): Fusion to the sacrum/pelvis improves sagittal alignment, fractional curve and coronal alignment in most patients. However, while fractional curve and sagittal alignment are better corrected, coronal malalignment, particularly more severe malalignment at baseline, tends to persist postoperatively. Type of approach and use of interbody device does not appear to significantly impact these results. This should be considered in preoperative planning for patients with coronal deformity. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Cerebral palsy (CP) can be described as a "static encephalopathy with progressive musculoskeletal pathology." Nonambulant children (GMFCS IV&V) have high rates of both spastic hip disease and neuromuscular scoliosis. Adult sagittal spinal deformity correction is known to cause acetabular retroversion and reduced pelvic tilt, resulting in increased rates of prosthetic hip dislocation; however, the role of spinal alignment on hip status in CP remains unknown. PURPOSE: To identify surgical factors and postoperative spinal alignment parameters that are associated with worsening postoperative hip status (WHS) (ie, subluxation, dislocation or resection) after spinal fusion. STUDY DESIGN/SETTING: Prospective multicenter outcomes study of nonambulant CP patients (GMFCS IV&V) requiring spinal fusion. PATIENT SAMPLE: A total of 142 operative CP patients with preoperative, 6-week, 1Y, 2Y and 5Y postoperative follow-up. OUTCOME MEASURES: Postoperative spinal alignment parameters associations with WHS up to 5Y postoperatively.
METHOD(S): WHS was defined by permutations of baseline and 1Y, 2Y and 5Y hip status of left and right hips by a change from either a normal hip at baseline (BL) that became subluxated, dislocated or resected at postop intervals; or if a subluxated hip at BL became dislocated or resected at postop intervals. Hip status up to 5Y postop was analyzed according to age, sex, coronal spinal alignment (major curve Cobb, pelvic obliquity), sagittal spinal alignment (thoracic kyphosis, T12-S1 lumbar lordosis, C7-S1 sagittal vertical axis), Risser score, hip position at rest, upper and lower- instrumented vertebrae (UIV&LIV), levels fused and fusion to the sacrum. Potential cutoff values for alignment parameters at which the relationship with hip status was determined using receiver operating characteristic (ROC) curves. Logistic regression was used to determine odds ratios for predictors of WHS.
RESULT(S): Of 142 patients (mean age 13.7+/-2.5, 48.3% female), 36 (25.4%) had WHS postoperatively. 7 had reoperation of their spinal fusion, 3 for loose screws/bolts and 4 for prominent instrumentation. ROC curve analysis and multivariate logistic regression demonstrated that the only spino-pelvic alignment parameter that significantly correlated with WHS was lumbar hyperlordosis (T12-L5) >60degree (p=.015), OR=2.61 (CI 1.19-5.75). Assessment of all patients demonstrated an increase in pre- to postop LL. Change in LL pre- to postoperative was no different between groups (p=.643), however the WHS group was more lordotic at baseline and postop (pre 44degree, post 58degree) compared to the no change group (pre 36degree, post 50degree). Age at surgery (p=0.214), sex (p=0.955), Risser score (p=0.205), major coronal cobb angle (p=0.907), thoracic kyphosis (p=0.717), global sagittal alignment (C7-S1 SVA p=0.320), levels fused (p=0.064), fusion to the sacrum (p=.548), coronal pelvic obliquity (p=0.652), or hip position at rest (adducted/abducted/neutral; p=.284) were not associated with WHS. Reoperation was not associated with WHS (p=.304).
CONCLUSION(S): Postoperative hyperlordosis (>60degree) is the only determined risk for WHS at 5Y after spinal fusion in nonambulant patients with cerebral palsy (GMFCS IV&V). WHS likely relates to anterior pelvic tilt and functional acetabular retroversion due to hyperlordosis, as well as loss of protective lumbo-pelvic motion causing anterior femoracetabular impingement. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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