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Cervical Deformity Correction Fails to Achieve Age-Adjusted Spinopelvic Alignment Targets

Passias, Peter G; Pierce, Katherine E; Horn, Samantha R; Segar, Anand; Passfall, Lara; Kummer, Nicholas; Krol, Oscar; Bortz, Cole; Brown, Avery E; Alas, Haddy; Segreto, Frank A; Ahmad, Waleed; Naessig, Sara; Buckland, Aaron J; Protopsaltis, Themistocles S; Gerling, Michael; Lafage, Renaud; Schwab, Frank J; Lafage, Virginie
OBJECTIVE:To assess whether surgical cervical deformity (CD) patients meet spinopelvic age-adjusted alignment targets, reciprocal, and lower limb compensation changes. STUDY DESIGN/METHODS:Retrospective review. METHODS:CD was defined as C2-C7 lordosis >10°, cervical sagittal vertical angle (cSVA) >4 cm, or T1 slope minus cervical lordosis (TS-CL) >20°. Inclusion criteria were age >18 years and undergoing surgical correction with complete baseline and postoperative imaging. Published formulas were used to create age-adjusted alignment target for pelvic tilt (PT), pelvic incidence and lumbar lordosis (PI-LL), sagittal vertical angle (SVA), and lumbar lordosis and thoracic kyphosis (LL-TK). Actual alignment was compared with age-adjusted ideal values. Patients who matched ±10-year thresholds for age-adjusted targets were compared with unmatched cases (under- or overcorrected). RESULTS:= 0.269). CONCLUSIONS:In response to worsening CD postoperatively, patients increased in TK and recruited less lower limb compensation. Almost 75% of CD patients did not meet previously established spinopelvic alignment goals, of whom a subset of patients were actually made worse off in these parameters following surgery. This finding raises the question of whether we should be looking at the entire spine when treating CD. LEVEL OF EVIDENCE: 3/METHODS/:
PMID: 35772976
ISSN: 2211-4599
CID: 5281352

Predicting 30-Day Perioperative Outcomes in Adult Spinal Deformity Patients With Baseline Paralysis or Functional Dependence

Alas, Haddy; Ihejirika, Rivka C; Kummer, Nicholas; Passfall, Lara; Krol, Oscar; Bortz, Cole; Pierce, Katherine E; Brown, Avery; Vasquez-Montes, Dennis; Diebo, Bassel G; Paulino, Carl B; De la Garza Ramos, Rafael; Janjua, Muhammad B; Gerling, Michael C; Passias, Peter G
BACKGROUND:Patients undergoing surgical treatment of adult spinal deformity (ASD) are often preoperatively risk stratified using standardized instruments to assess for perioperative complications. Many ASD instruments account for medical comorbidity and radiographic parameters, but few consider a patient's ability to independently accomplish necessary activities of daily living (ADLs). METHODS:Patients ≥18 years undergoing ASD corrective surgery were identified in National Surgical Quality Improvement Program. Patients were grouped by (1) plegic status and (2) dependence in completing ADLs ("totally dependent" = requires total assistance in ADLs, "partially dependent" = uses prosthetics/devices but still requires help, "independent" = requires no help). Quadriplegics and totally dependent patients comprised "severe functional dependence," paraplegics/hemiplegics who are "partially dependent" comprised "moderate functional dependence," and "independent" nonplegics comprised "independent." Analysis of variance with post hoc testing and Kruskal-Wallis tests compared demographics and perioperative outcomes across groups. Logistic regression found predictors of inferior outcomes, controlling for age, sex, body mass index (BMI), and invasiveness. Subanalysis correlated functional dependence with other established metrics such as the modified Frailty Index (mFI) and Charlson Comorbidity Index (CCI). RESULTS:< 0.001). CONCLUSIONS:Severe functional dependence had significantly longer LOS and more never-event complications than moderate or independent groups. Overall, functional dependence may show superiority to traditional metrics in predicting poor perioperative outcomes, such as increased LOS, readmission rate, and risk of surgical site infection and never events. LEVEL OF EVIDENCE: 3/METHODS/:
PMID: 35728828
ISSN: 2211-4599
CID: 5281942

Predictive Analytics for Determining Extended Operative Time in Corrective Adult Spinal Deformity Surgery

Passias, Peter G; Poorman, Gregory W; Vasquez-Montes, Dennis; Kummer, Nicholas; Mundis, Gregory; Anand, Neel; Horn, Samantha R; Segreto, Frank A; Passfall, Lara; Krol, Oscar; Diebo, Bassel; Burton, Doug; Buckland, Aaron; Gerling, Michael; Soroceanu, Alex; Eastlack, Robert; Kojo Hamilton, D; Hart, Robert; Schwab, Frank; Lafage, Virginie; Shaffrey, Christopher; Sciubba, Daniel; Bess, Shay; Ames, Christopher; Klineberg, Eric
BACKGROUND:More sophisticated surgical techniques for correcting adult spinal deformity (ASD) have increased operative times, adding to physiologic stress on patients and increased complication incidence. This study aims to determine factors associated with operative time using a statistical learning algorithm. METHODS:Retrospective review of a prospective multicenter database containing 837 patients undergoing long spinal fusions for ASD. Conditional inference decision trees identified factors associated with skin-to-skin operative time and cutoff points at which factors have a global effect. A conditional variable-importance table was constructed based on a nonreplacement sampling set of 2000 conditional inference trees. Means comparison for the top 15 variables at their respective significant cutoffs indicated effect sizes. RESULTS:66 minutes of increased operative time. Increased operative time also correlated with increased hospital length of stay (LOS), increased estimated intraoperative blood loss (EBL), and inferior 2-year Oswestry Disability Index (ODI) scores. CONCLUSIONS:Procedure location and specific surgeon are the most important factors determining operative time, accounting for operative time increases <2 hours. Surgical approach and number of levels fused were also associated with longer operative times, respectively. Extended operative time correlated with longer LOS, higher EBL, and inferior 2-y ODI outcomes. CLINICAL RELEVANCE/CONCLUSIONS:We further identified the poor outcomes associated with extended operative time during surgical correction of ASD, and attributed the useful predictors of time spent in the operating room, including site, surgeon, surgical approach, and the number of levels fused. LEVEL OF EVIDENCE: 3/METHODS/:
PMID: 35444038
ISSN: 2211-4599
CID: 5218372

A predictive model of perioperative myocardial infarction following elective spine surgery

Passias, Peter G; Pierce, Katherine E; Alas, Haddy; Bortz, Cole; Brown, Avery E; Vasquez-Montes, Dennis; Oh, Cheongeun; Wang, Erik; Jain, Deeptee; O'Connell, Brooke K; Raad, Micheal; Diebo, Bassel G; Soroceanu, Alexandra; Gerling, Michael C
Myocardial infarction (MI), and its predictive factors, has been an understudied complication following spine operations. The objective was to assess the risk factors for perioperative MI in elective spine surgery patients as a retrospective case control study. Elective spine surgery patients with a perioperative MI were isolated in the NSQIP. The relationship between MI and non-MI spine patients was assessed using chi-squared and independent samples t-tests. Univariate/multivariate analyses assessed predictive factors of MI. Logistic regression with stepwise model selection was employed to create a model to predict MI occurrence. The study included 196,523 elective spine surgery patients (57.1 yrs, 48%F, 30.4 kg/m2), and 436 patients with acute MI (Spine-MI). Incidence of MI did not change from 2010 to 2016 (0.2%-0.3%, p = 0.298). Spine-MI patients underwent more fusions than patients without MI (73.6% vs 58.4%, p < 0.001), with an average of 1.03 levels fused. Spine-MI patients also had significantly more SPO (5.0% vs 1.8%, p < 0.001) and 3CO (0.9% vs 0.2%, p < 0.001), but less decompression-only procedures (26.4% vs 41.6%, p < 0.001). Spine-MI underwent more revisions (5.3% vs 2.9%, p = 0.003), had greater invasiveness scores (3.41 vs 2.73, p < 0.001) and longer operative times (211.6 vs 147.3 min, p < 0.001). Mortality rate for Spine-MI patients was 4.6% versus 0.05% (p < 0.001). Multivariate modeling for Spine-MI predictors yielded an AUC of 83.7%, and included history of diabetes, cardiac arrest and PVD, past blood transfusion, dialysis-dependence, low preoperative platelet count, superficial SSI and days from operation to discharge. A model with good predictive capacity for MI after spine surgery now exists and can aid in risk-stratification of patients, consequently improving preoperative patient counseling and optimization in the peri-operative period.
PMID: 34929633
ISSN: 1532-2653
CID: 5099612

Validation of the ACS-NSQIP Risk Calculator: A Machine-Learning Risk Tool for Predicting Complications and Mortality Following Adult Spinal Deformity Corrective Surgery

Pierce, Katherine E; Kapadia, Bhaveen H; Naessig, Sara; Ahmad, Waleed; Vira, Shaleen; Paulino, Carl; Gerling, Michael; Passias, Peter G
OBJECTIVE:To calculate the risk for postoperative complications and mortality after corrective surgery of adult spinal deformity (ASD) patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator (SRC). METHODS:axis. RESULTS:) were identified; 36.9% of procedures involved decompression and 100% involved fusion. The means for individual patient characteristics entered into the online risk calculator interface were as follows: functional status (independent: 94.9%, partially dependent: 4.4%, totally dependent: 0.70%), 1.6% emergent cases, wound class (clean: 94.7%, clean/contaminated: 0.8%, contaminated: 0.5%, dirty/infected: 1.4%), American Society of Anesthesiologists class (I: 2.7%, II: 40.7%, III: 52.1%, IV: 4.6%, V: 0%), 5.1% steroid use for chronic condition, 0.04% ascites within 30 days prior to surgery, 1.73% systemic sepsis within 48 hours of surgery, 0.40% ventilator dependent, 3.2% disseminated cancer, 15.6% diabetes mellitus, 52.8% use of hypertensive medications, 0.3% congestive heart failure , 3% dyspnea, 21.4% history of smoking within 1 year, 4.3% chronic obstructive pulmonary disease, 0.7% dialysis, and 0.1% acute renal failure. Predictive of any 30-day postoperative complications ranged from 2.8 to 18.5% across CPT codes, where the actual rate in the cohort was 11.4%, and demonstrated good predictive performance via Brier score (0.000002, maximum: 0.101). The predicted and observed percentages for each of the 13 outcomes were assessed and their associated Brier scores and Brier maximums were calculated. Mean difference between observed and predicted LOS was 2.375 days (95% CI 9.895-5.145). CONCLUSIONS:The ACS-NSQIP SRC predicts surgical risk in patients undergoing ASD corrective surgery. This tool can be used as a resource in preoperative optimization by deformity surgeons. LEVEL OF EVIDENCE/METHODS:3.
PMID: 35078894
ISSN: 2211-4599
CID: 5154462

Frequency and Implications of Concurrent Complications Following Adult Spinal Deformity Corrective Surgery

Bortz, Cole; Pierce, Katherine E; Brown, Avery; Alas, Haddy; Passfall, Lara; Krol, Oscar; Kummer, Nicholas A; Wang, Erik; O'Connell, Brooke; Wang, Charles; Vasquez-Montes, Dennis; Diebo, Bassel G; Neuman, Brian J; Gerling, Michael C; Passias, Peter G
STUDY DESIGN/METHODS:Retrospective review. OBJECTIVE:Identify co-occurring perioperative complications and associated predictors in a population of patients undergoing surgery for adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA/BACKGROUND:Few studies have investigated the development of multiple, co-occurring complications following ASD-corrective surgery. Preoperative risk stratification may benefit from identification of factors associated with multiple, co-occurring complications. METHODS:Elective ASD patients in National Surgical Quality Improvement Program (NSQIP) 2005 to 2016 were isolated; rates of co-occurring complications and affected body systems were assessed via cross tabulation. Random forest analysis identified top patient and surgical factors associated with complication co-occurrence, using conditional inference trees to identify significant cutoff points. Binary logistic regression indicated effect size of top influential factors associated with complication co-occurrence at each factor's respective cutoff point. RESULTS:Included: 6486 ASD patients. The overall perioperative complication rate was 34.8%; 28.5% of patients experienced one complication, 4.5% experienced two, and 1.8% experienced 3+. Overall, 11% of complication co-occurrences were pulmonary/cardiovascular, 9% pulmonary/renal, and 4% integumentary/renal. By complication type, the most common co-occurrences were transfusion/urinary tract infection (UTI) (24.3%) and transfusion/pneumonia (17.7%). Surgical factors of operative time ≥400 minutes and fusion ≥9 levels were the strongest factors associated with the incidence of co-occurring complications, followed by patient-specific variables like American Society of Anesthesiologists (ASA) physical status classification grade ≥2 and age ≥65 years. Regression analysis further showed associations between increasing complication number and longer length of stay (LOS), (R2 = 0.202, P < 0.001), non-home discharge (R2 = 0.111, P = 0.001), and readmission (R2 = 0.010, P < 0.001). CONCLUSION/CONCLUSIONS:For surgical ASD patients, the overall rate of co-occurring perioperative complications was 6.3%. Body systems most commonly affected by complication co-occurrences were pulmonary and cardiovascular, and common co-occurrences included transfusion/UTI (24.3%) and transfusion/pneumonia (17.7%). Increasing number of perioperative complications was associated with greater LOS, non-home discharge, and readmission, highlighting the importance of identifying risk factors for complication co-occurrences.Level of Evidence: 3.
PMID: 34618707
ISSN: 1528-1159
CID: 5043472

Same Day Surgical Intervention Dramatically Minimizes Complication Occurrence and Optimizes Perioperative Outcomes for Central Cord Syndrome

Bortz, Cole; Dinizio, Mike; Kummer, Nicholas; Brown, Avery; Alas, Haddy; Pierce, Katherine E; Janjua, Muhammad B; Park, Paul; Wang, Charles; Jankowski, Pawel; Hockley, Aaron; Soroceanu, Alex; De la Garza Ramos, Rafael; Sciubba, Daniel M; Frempong-Boadu, Anthony; Vasquez-Montes, Dennis; Diebo, Bassel G; Gerling, Michael C; Passias, Peter G
STUDY DESIGN/METHODS:This was a retrospective cohort study. OBJECTIVE:The aim of this study was to investigate associations between time to surgical intervention and outcomes for central cord syndrome (CCS) patients. BACKGROUND:As surgery is increasingly recommended for patients with neurological deterioration CCS, it is important to investigate the relationship between time to surgery and outcomes. MATERIALS AND METHODS/METHODS:CCS patients were isolated in Nationwide Inpatient Sample database 2005-2013. Patients were grouped by time to surgery: same-day, 1-day delay, 2, 3, 4-7, 8-14, and >14 days. Means comparison tests compared patient factors, perioperative complications, and charges across patient groups. Controlling for age, comorbidities, length of stay, and concurrent traumatic fractures, binary logistic regression assessed surgical timing associated with increased odds of perioperative complication, using same-day as reference group. RESULTS:Included: 6734 CSS patients (64% underwent surgery). The most common injury mechanisms were falls (30%) and pedestrian accidents (7%). Of patients that underwent surgery, 52% underwent fusion, 30% discectomy, and 14% other decompression of the spinal canal. Breakdown by time to procedure was: 39% same-day, 16% 1-day, 10% 2 days, 8% 3 days, 16% 4-7 days, 8% 8-14 days, and 3% >14 days. Timing groups did not differ in trauma status at admission, although age varied: [minimum: 1 d (58±15 y), maximum: >14 d (63±13 y)]. Relative to other groups, same-day patients had the lowest hospital charges, highest rates of home discharge, and second lowest postoperative length of stay behind 2-day delay patients. Patients delayed >14 days to surgery had increased odds of perioperative cardiac and infection complications. Timing groups beyond 3 days showed increased odds of VTE and nonhome discharge. CONCLUSIONS:CCS patients undergoing surgery on the same day as admission had lower odds of complication, hospital charges, and higher rates of home discharge than patients that experienced a delay to operation. Patients delayed >14 days to surgery were associated with inferior outcomes, including increased odds of cardiac complication and infection.
PMID: 34292197
ISSN: 2380-0194
CID: 4948442

The Five-item Modified Frailty Index is Predictive of 30-day Postoperative Complications in Patients Undergoing Spine Surgery

Pierce, Katherine E; Naessig, Sara; Kummer, Nicholas; Larsen, Kylan; Ahmad, Waleed; Passfall, Lara; Krol, Oscar; Bortz, Cole; Alas, Haddy; Brown, Avery; Diebo, Bassel; Schoenfeld, Andrew; Raad, Micheal; Gerling, Michael; Vira, Shaleen; Passias, Peter G
STUDY DESIGN/METHODS:Retrospective cohort study. OBJECTIVE:This study aimed to evaluate the utility of the modified frailty index (mFI-5) in a population of patients undergoing spine surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:The original modified frailty index (mFI-11) published as an American College of Surgeons National Surgical Quality Improvement Program 11-factor index was modified to mFI-5 after variables were removed from recent renditions. METHODS:Surgical spine patients were isolated using current procedural terminology codes. mFI-11 (11) and mFI-5 (5) were calculated from 2005 to 2012. mFI was determined by dividing the factors present by available factors. To assess correlation, Spearman rho was used. Predictive values of indices were generated by binary logistic regression. Patients were stratified into groups by mFI-5: not frail (NF, <0.3), mildly frail (MF, 0.3-0.5), severely frail (SF, >0.5). Means comparison tests analyzed frailty and clinical outcomes. RESULTS:After calculating the mFI-5 and the mFI-11, Spearman rho between the two indices was 0.926(P < 0.001). Each index established significant (all P < 0.001) predictive values for unplanned readmission (11 = odds ratio [OR]: 5.65 [2.92-10.94]; 5 = OR: 3.68 [1.85-2.32]), post-op complications (11 = OR: 8.56 [7.12-10.31]; 5 = OR: 13.32 [10.89-16.29]), and mortality (11 = OR: 41.29 [21.92-77.76]; 5 = OR: 114.82 [54.64-241.28]). Frailty categories by mFI-5 were: 83.2% NF, 15.2% MF, and 1.6% SF. From 2005 to 2016, rates of NF decreased (88.8% to 82.2%, P < 0.001), whereas MF increased (9.2% to 16.2%, P < 0.001), and SF remained constant (2% to 1.6%, P > 0.05). With increase in severity, postoperative rates of morbidities and complications increased. CONCLUSION/CONCLUSIONS:The five-factor National Surgical Quality Improvement Program modified frailty index is an effective predictor of postoperative events following spine surgery. Severity of frailty score by the mFI-5 was associated with increased morbidity and mortality. The mFI-5 within a surgical spine population can reliably predict post-op complications. This tool is less cumbersome than mFI-11 and relies on readily accessible variables at the time of surgical decision-making.Level of Evidence: 3.
PMID: 34160372
ISSN: 1528-1159
CID: 4934032

A Retrospective, Multicenter, Quantitative Analysis of Patients' Baseline Pain Quality (PROMIS-29) Entering into Pain and Spine Practices in the United States (ALIGN)

Pope, Jason E; Fishman, Michael; Chakravarthy, Krishnan; Hanes, Michael; Gerling, Michael; Heros, Robert; Falowski, Steven; Shah, Jay; Orhurhu, Vwaire; Urits, Ivan; Deer, Timothy R
INTRODUCTION/BACKGROUND:Multidisciplinary patient-reported outcomes are a critical part of assessing patients to better understand their well-being during treatment. The use of multidisciplinary patient-reported outcomes is recommended in many areas of medicine. The Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) has been utilized as a common measurement language across universally relevant domains, including pain, mood, sleep, social participation, and function. METHODS:Retrospective analysis of prospectively collected data was performed. Subjects were identified and consecutively enrolled upon entry into chronic pain centers across 24 sites in the United States. The PROMIS-29 v2.1 and the numerical rating scale (NRS) were recorded. The pain impact score and the Health Utilities Index Mark 3 (HUI-3) were calculated. Statistical differences were assessed between genders and among age groups comprising subjects less than 40, 41-60, 61-80, and over 80 years of age. RESULTS:A total of 19,546 patients were assessed over the enrollment period from 2018 to 2020. The PROMIS-29 v2.1 was evaluated across the seven domains, along with the numerical rating sale (NRS). The mean scores of the population for PROMIS SF v1.0 Pain Interference 4a, PROMIS SF v1.0 Sleep Disturbance 4a, PROMIS SF v1.0 Fatigue 4a, PROMIS SF v1.0 Anxiety 4a, PROMIS SF V1.0 Depression 4a, PROMIS SF v2.0 Ability to Participate in Social Roles and Activities 4a, and PROMIS SF v1.0 Physical Function 4a, measuring pain interference, sleep disturbance, fatigue, anxiety, depression, social participation, and physical function, were 64.61, 57.19, 58.50, 53.94, 54.45, 40.06, and 36.23, respectively. Pain intensity was 6.38 on an 11-point NRS scale. The pain impact score (PIS) and health utilities index mark 3 (HUI-3) scores, calculated across the designated age groups, were 33.19 and 0.67, respectively. Statistical differences were observed for the domains of sleep disturbance and physical function for age groups less than 40 and greater than 80 years of age. CONCLUSION/CONCLUSIONS:This data set is the first published normative data set describing the PROMIS-29 assessment in the chronic pain population. The patient population is more homogeneous than expected, and females were found to have higher levels of dysfunction.
PMID: 33624253
ISSN: 2193-8237
CID: 4875152

Esophagopharyngeal perforation and prevertebral abscess after anterior cervical discectomy and fusion: a case report [Case Report]

Shah, Jay K; Romanelli, Filippo; Yang, Jason; Rao, Naina; Gerling, Michael C
Anterior cervical discectomy and fusion (ACDF) represents one of the most commonly performed spine surgeries. Dysphagia secondary to esophageal injury during retraction is one of the most common complications, and usually leads to self-limiting dysphagia. However, actual perforation and violation of the esophageal tissue is much rarer and can lead to delayed deep infections. Prevertebral abscess' are one of the most feared complications after ACDF, as they can lead to severe tissue swelling, osteomyelitis, hardware failure, and even death. Due to their rarity, a gold standard of workup and treatment is still unknown. A healthy 47-year-old female presents 9 months after a C4-C7 ACDF done at an outside institution with a large prevertebral abscess, osteomyelitis, hardware failure, and pseudoarthrosis secondary to esophagopharyngeal defect and prominent hardware. Overall, the patient underwent eight surgeries, and required an extended course of intravenous (IV) antibiotics, multiple diagnostic procedures, and complex soft tissue coverage using an anterolateral thigh free flap. Currently, the patient is doing well 6 months from her last procedure without any complications or plan for future surgery. This was an extremely rare case of a late occurring prevertebral abscess after ACDF. Dysphagia in the late postoperative setting should be evaluated carefully and thoroughly for any esophageal perforation and deep infection. As exemplified in this case, even partial thickness injuries to the esophageal-pharyngeal anatomy due to hardware irrigation can lead to catastrophic complications over time. Safe removal of all hardware anteriorly to avoid continued irritation of the esophagopharyngeal mucosa should be prioritized. If anterior hardware is necessary for stability, implants with the smallest footprint should be utilized. Early collaboration with ENT colleagues should be a priority and can provide crucial diagnostic and therapeutic interventions. Complex closure with a free flap was shown to be an effective way to provide successful definitive soft tissue coverage.
PMID: 34296037
ISSN: 2414-469x
CID: 4948612