Faculty Bibliography

PURPOSE/OBJECTIVE:Clinical trials have studied the effects of curve magnitude and flexibility, age, and skeletal immaturity on the outcomes of VBT. No studies have assessed the effect of Lenke curve type on the outcomes of VBT. This study compares outcomes in patients who underwent VBT with Lenke type 1, 3, 5, and 6 curves. METHODS:Single center retrospective review of patients undergoing mini-open thoracoscopic-assisted two row vertebral body tethering (2RVBT) for the correction of AIS with a minimum 2-year follow-up were included. Patients were grouped by Lenke type, which yielded 4 groups; types 1, 3, 5, or 6. Analysis included preoperative demographic parameters, as well as radiographic and clinical outcome measures. RESULTS:156 2RVBT (Lenke 1, N = 61; Lenke 3, N = 35; Lenke 5, N = 37; Lenke 6, N = 23) patients met inclusion criteria. The mean preoperative apex Cobb angle in the Lenke type 1, 3, 5, and 6 groups were 50.2 ± 9.1, 50.5 ± 10.1, 45.0 ± 8.6, and 49.0 ± 10.8, respectively. This corrected to 21.2 ± 10.2, 19.2 ± 8.5, 13.6 ± 7.2, 18.5 ± 8.3 in Lenke type 1, 3, 5, and 6 groups, respectively, demonstrating that Lenke type 5 saw greatest correction following 2RVBT. With regards to revision recommendation following tether breakage, Lenke type 3 curves were most frequently indicated for fusion, whereas Lenke type 1 curves were most frequently not indicated for revision surgery. CONCLUSION/CONCLUSIONS:Lenke type 5 curves are the most amenable to correction via 2RVBT, as evident by their lower post-operative apex Cobb angles and lowest rate of recommendation for revision to posterior spinal fusion.

STUDY DESIGN/METHODS:Single-center retrospective cohort study. OBJECTIVE:To compare the correction of fractional curve and L5 tilt in 2RVBT versus PSF with LIV in the lumbar spine. SUMMARY OF BACKGROUND DATA/BACKGROUND:Vertebral body tethering, an AIS fusion-alternative, avoids rigid constructs, allowing for lower instrumented vertebra (LIV) selection. Single-tether constructs break, but mini-open thoracoscopic assistant double-row vertebral body tethering (2RVBT) reduces this. Limited comparative studies exist with posterior spinal fusion (PSF). METHODS:Retrospective analysis of AIS correction surgeries with lumbar LIV using preoperative and minimum 2-year postoperative imaging. Patients were divided into 2RVBT or PSF groups. Data included age, Riser, UIV, LIV, instrumented levels, and revision rates. Radiographic analyses included preoperative and postoperative main curve Cobb (MCC), secondary curve Cobb (SCC), fractional curve Cobb (FCC), and L5 tilt. RESULTS:Ninety-nine patients participated (49 in 2RVBT, 50 in PSF). Preoperatively, secondary CC differed significantly (2RVBT: 44.6±10.4 degrees vs. PSF: 39.5±11.8 degrees, P=0.026), but not L5 tilt, MCC, or FCC. Postoperatively, MCC (2RVBT: 25.7±12.3 degrees vs. PSF: 19.5±7.4 degrees, P=0.003) and SCC (2RVBT: 18.0±8.4 degrees vs. PSF: 14.5±6.6 degrees, P=0.012) varied. Preoperative to postoperative changes in MCC (2RVBT: -32.0±11.3 degrees vs. PSF: -37.2±13.3 degrees, P=0.044) and L5 tilt (-13.8±9.0 degrees vs. PSF: -8.1±6.8 degrees, P=0.001) differed. Revision rates were similar (2RVBT: 2.0%, PSF: 4.0%, P=0.57). In 2RVBT, 3 tethers broke, 1 revision occurred for a broken tether, and 1 pleural effusion needed thoracocentesis. In PSF, 1 superficial infection needed surgery, and 1 revision was for add-on phenomenon. After PSM for Lenke classification, 54 patients remained (27 in each group). At 2 years, 2RVBT showed less MCC correction (-30.8±11.8 degrees vs. -38.9±11.9 degrees, P=0.017), but greater L5 tilt correction (-14.6±10.0 degrees vs. -7.5±6.0 degrees, P=0.003). CONCLUSIONS:This study with a minimum 2-year radiographic follow-up demonstrates that 2RVBT results in greater L5 tilt correction when compared with posterior spinal fusion after PSM for Lenke classification and similar rates of revision surgery. LEVEL OF EVIDENCE/METHODS:Level III.

BACKGROUND:Recombinant human bone morphogenetic protein 2 (rhBMP-2, or BMP for short) is a popular biological product used in spine surgeries to promote fusion and avoid the morbidity associated with iliac crest autograft. BMP's effect on pseudarthrosis in transforaminal lumbar interbody fusion (TLIF) remains unknown. OBJECTIVE:To assess the rates of pseudarthrosis in single-level TLIF with and without concurrent use of BMP. METHODS:analyses, and perioperative characteristics were analyzed by multiple logistic regression. RESULTS:= 0.002) increased the risk of reoperation for pseudarthrosis. CONCLUSIONS:BMP use did not reduce the rate of pseudarthrosis or the number of reoperations for pseudarthrosis in single-level TLIFs. Diabetes with end-organ damage was a significant risk factor for pseudarthrosis. CLINICAL RELEVANCE/CONCLUSIONS:BMP is frequently used "off-label" in transforaminal lumbar interbody fusion; however, little data exists to demonstrate its safety and efficacy in this procedure.

STUDY DESIGN/METHODS:Retrospective analysis. OBJECTIVES/OBJECTIVE:To evaluate resolution of radiculopathy in one-level lumbar fusion with indirect or direct decompression techniques. METHODS:< .05. RESULTS:116 patients were included: 58 direct decompression (DD) (mean 53.9y, 67.2% female) and 58 indirect decompression (ID) (mean 54.6y, 61.4% female). DD patients experienced greater blood loss than ID. Additionally, DD patients were 4.7 times more likely than ID patients to experience full resolution of radiculopathy at 3 months post-op. By 6 months, DD patients demonstrated larger reductions in VAS score. With regard to motor function, DD patients had improved motor score associated with the L5 dermatome at 6 months relative to ID patients. CONCLUSIONS:Direct decompression was associated with greater resolution of radiculopathy in the near post-operative term, with no differences at long term follow-up when compared with indirect decompression. In particularly debilitated patients, these findings may influence surgeons to perform a direct decompression to achieve more rapid resolution of radiculopathy symptoms.

STUDY DESIGN/METHODS:Retrospective. OBJECTIVE:The objective of this study is to describe the rate of postoperative morbidity before and after two-year (2Y) follow-up for patients undergoing surgical correction of adult spinal deformity (ASD). SUMMARY OF BACKGROUND DATA/BACKGROUND:Advances in modern surgical techniques for deformity surgery have shown promising short-term clinical results. However, the permanence of radiographic correction, mechanical complications, and revision surgery in ASD surgery remains a clinical challenge. Little information exists on the incidence of long-term morbidity beyond the acute postoperative window. METHODS:ASD patients with complete baseline and five-year (5Y) health-related quality of life and radiographic data were included. The rates of adverse events, including proximal junctional kyphosis (PJK), proximal junctional failure (PJF), and reoperations up to 5Y were documented. Primary and revision surgeries were compared. We used logistic regression analysis to adjust for demographic and surgical confounders. RESULTS:Of 118 patients eligible for 5Y follow-up, 99(83.9%) had complete follow-up data. The majority were female (83%), mean age 54.1 years and 10.4 levels fused and 14 undergoing three-column osteotomy. Thirty-three patients had a prior fusion and 66 were primary cases. By 5Y postop, the cohort had an adverse event rate of 70.7% with 25 (25.3%) sustaining a major complication and 26 (26.3%) receiving reoperation. Thirty-eight (38.4%) developed PJK by 5Y and 3 (4.0%) developed PJF. The cohort had a significantly higher rate of complications (63.6% vs. 19.2%), PJK (34.3% vs. 4.0%), and reoperations (21.2% vs. 5.1%) before 2Y, all P <0.01. The most common complications beyond 2Y were mechanical complications. CONCLUSIONS:Although the incidence of adverse events was high before 2Y, there was a substantial reduction in longer follow-up indicating complications after 2Y are less common. Complications beyond 2Y consisted mostly of mechanical issues.

STUDY DESIGN/METHODS:Retrospective Cohort Study. OBJECTIVE:Assess whether modifying spinal alignment goals to accommodate frailty considerations will decrease mechanical complications and maximize clinical outcomes. SUMMARY OF BACKGROUND DATA/BACKGROUND:The Global Alignment and Proportion(GAP) score was developed to assist in reducing mechanical complications, but has had less success predicting such events in external validation. Higher frailty and many of its components have been linked to development of implant failure. Therefore, modifying the GAP score with frailty may strengthen its ability to predict mechanical complications. METHODS:We included 412 surgical ASD patients with two-year(2Y) follow-up. Frailty was quantified using the ASD modified Frailty Index(mASD-FI). Outcomes: proximal junctional kyphosis(PJK) and failure(PJF), major mechanical complications, and 'Best Clinical Outcome'(BCO), defined as ODI<15 and SRS-22 Total>4.5. Logistic regression analysis established a six-week score based on GAP score,frailty and ODI US-Norms. Logistic regression followed by conditional inference tree(CIT) analysis generated categorical thresholds. Multivariable logistic regression analysis controlling for confounders was used to assess the performance of the frailty modified GAP score. RESULTS:Baseline frailty categories: 57% Not Frail,30% frail,14% severely frail. Overall, 39% of patients developed PJK, 8% PJF, 21% mechanical complications, 22% underwent reoperation, and 15% met BCO. The modified ASD-FI demonstrated correlation with developing PJF, mechanical complications, undergoing reoperation, and meeting BCO at 2Y(all P<0.05). Regression analysis generated the following equation: Frailty-Adjusted Realignment Score(FAR Score) =0.49*mASD-FI + 0.38*GAP Score. Thresholds for the FAR score(0-13): Proportioned:<3.5,Moderately Disproportioned:3.5-7.5,Severely Disproportioned:>7.5. Multivariable logistic regression assessing FAR Score demonstrated associations with mechanical complications, reoperation, and meeting Best Clinical Outcome by two years(all P<0.05), whereas the original GAP score was only significant for reoperation. CONCLUSION/CONCLUSIONS:This study demonstrated adjusting alignment goals in adult spinal deformity surgery for a patient's baseline frailty status and disability may be useful in minimizing the risk of complications and adverse events, outperforming the original GAP score in terms of prognostic capacity. LEVEL OF EVIDENCE/METHODS:III.

INTRODUCTION/BACKGROUND:Complex surgery for adult spinal deformity has high rates of complications, reoperations, and readmissions. Preoperative discussions of high-risk operative spine patients at a multidisciplinary conference may contribute to decreased rates of these adverse outcomes through appropriate patient selection and surgical plan optimization. With this goal, we implemented a high-risk case conference involving orthopedic and neurosurgery spine, anesthesia, intraoperative monitoring neurology, and neurological intensive care. METHODS:Included in this retrospective review were patients ≥ 18 years old meeting one of the following high-risk criteria: 8 + levels fused, osteoporosis with 4 + levels fused, three column osteotomy, anterior revision of the same lumbar level, or planned significant correction for severe myelopathy, scoliosis (> 75˚), or kyphosis (> 75˚). Patients were categorized as Before Conference (BC): surgery before 2/19/2019 or After Conference (AC): surgery after 2/19/2019. Outcome measures include intraoperative and postoperative complications, readmissions, and reoperations. RESULTS:263 patients were included (96 AC, 167 BC). AC was older than BC (60.0 vs 54.6, p = 0.025) and had lower BMI (27.1 vs 28.9, p = 0.047), but had similar CCI (3.2 vs 2.9 p = 0.312), and ASA Classification (2.5 vs 2.5, p = 0.790). Surgical characteristics, including levels fused (10.6 vs 10.7, p = 0.839), levels decompressed (1.29 vs 1.25, p = 0.863), 3 column osteotomies (10.4% vs 18.6%, p = 0.080), anterior column release (9.4% vs 12.6%, p = 0.432), and revision cases (53.1% vs 52.4%, p = 0.911) were similar between AC and BC. AC had lower EBL (1.1 vs 1.9L, p < 0.001) and fewer total intraoperative complications (16.7% vs 34.1%, p = 0.002), including fewer dural tears (4.2% vs 12.6%, p = 0.025), delayed extubations (8.3% vs 22.8%%, p = 0.003), and massive blood loss (4.2% vs 13.2%, p = 0.018). Length of stay (LOS) was similar between groups (7.2 vs 8.2 days, 0.251). AC had a lower incidence of deep surgical site infections (SSI, 1.0% vs 6.6%, p = 0.038), but a higher rate of hypotension requiring vasopressor therapy (18.8% vs 4.8%, p < 0.001). Other postoperative complications were similar between groups. AC had lower rates of reoperation at 30 (2.1% vs 8.4%, p = 0.040) and 90 days (3.1 vs 12.0%, p = 0.014) and lower readmission rates at 30 (3.1% vs 10.2%, p = 0.038) and 90 days (6.3 vs 15.0%, p = 0.035). On logistic regression, AC patients had higher odds of hypotension requiring vasopressor therapy and lower odds of delayed extubation, intraoperative RBC, and intraoperative salvage blood. CONCLUSIONS:Following implementation of a multidisciplinary high-risk case conference, 30- and 90-day reoperation and readmission rates, intraoperative complications, and postoperative deep SSIs decreased. Hypotensive events requiring vasopressors increased, but did not result in longer LOS or greater readmissions. These associations suggest a multidisciplinary conference may help improve quality and safety for high-risk spine patients. particularly through minimizing complications and optimizing outcomes in complex spine surgery.

Background: Identify the external applicability of the American College of Surgeons"™ National Surgical Quality Improvement Program (NSQIP) risk calculator in the setting of adult spinal deformity (ASD) and subsets of patients based on deformity and frailty status. Methods: ASD patients were isolated in our single-center database and analyzed for the shared predictive variables displayed in the NSQIP calculator. Patients were stratified by frailty (not frail <0.03, frail 0.3"“0.5, severely frail >0.5), deformity [T1 pelvic angle (TPA) > 30, pelvic incidence minus lumbar lordosis (PI-LL) > 20], and reoperation status. Brier scores were calculated for each variable to validate the calculator"™s predictability in a single center"™s database (Quality). External validity of the calculator in our ASD patients was assessed via Hosmer-Lemeshow test, which identified whether the differences between observed and expected proportions are significant. Results: A total of 1606 ASD patients were isolated from the Quality database (48.7 years, 63.8% women, 25.8 kg/m²); 33.4% received decompressions, and 100% received a fusion. For each subset of ASD patients, the calculator predicted lower outcome rates than what was identified in the Quality database. The calculator showed poor predictability for frail, deformed, and reoperation patients for the category "any complication" because they had Brier scores closer to 1. External validity of the calculator in each stratified patient group identified that the calculator was not valid, displaying P values >0.05. Conclusion: The NSQIP calculator was not a valid calculator in our single institutional database. It is unable to comment on surgical complications such as return to operating room, surgical site infection, urinary tract infection, and cardiac complications that are typically associated with poor patient outcomes. Physicians should not base their surgical plan solely on the NSQIP calculator but should consider multiple preoperative risk assessment tools.

Background: The number of elderly patients undergoing adult spinal deformity (ASD) surgery has increased with the advent of new techniques and more nuanced understanding of global malalignment as patients age. The relationship between inpatient physical activity after ASD surgery and postoperative complications in elderly patients has not been reported; thus, we sought to investigate this relationship. Methods: We performed a medical record review of 185 ASD patients older than 65 years (age: 71.5 ± 4.7; body mass index: 30.0 ± 6.1, American Society of Anesthesiologists: 2.7 ± 0.5, and levels fused: 10.5 ± 3.4). We derived the number of feet walked over the first 3 days after surgery from physical therapy documentation and evaluated for association with 90-day perioperative complications. Patients who sustained an incidental durotomy were excluded from the study. Results: The 185 patients were divided into groups based on whether they were among the 50th percentile for number of feet walked (62 ft). Walking less than 62 ft after ASD surgery was associated with higher incidence of postoperative complications (54.3%, P = 0.05), cardiac complications (34.8%, P = 0.03), pulmonary complications (21.7%, P = 0.01), and ileus (15.2%, P = 0.03). Patients who developed any postoperative complication (106 ± 172 vs 211 ± 279 ft, P = 0.001), ileus (26 ± 49 vs 174 ± 248 ft, P = 0.001), deep venous thrombosis (23 ± 30 vs 171 ± 247 ft, P = 0.001), and cardiac complications (58 ± 94 vs 192 ± 261 ft) walked less than patients who did not. Conclusion: Elderly patients who walked less than 62 ft in the first 3 days after ASD surgery have a higher rate of postoperative complications, specifically pulmonary and ileus compared with those patients who walked more. Steps walked after ASD surgery may be a helpful and practical addition to the surgeon"™s armamentarium for monitoring the recovery of their patients. Clinical Relevence: Monitoring the steps walked by patients after ASD surgery can be a practical and useful tool for surgeons to track and improve their patients"™ recovery.

STUDY DESIGN/METHODS:Retrospective analysis of outcomes in cervical spine and shoulder arthroscopy patients. OBJECTIVE:The objective of this study is to assess differential improvements in health-related quality of life for cervical spine surgery compared with shoulder surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:An understanding of outcome differences between different types of orthopedic surgeries is helpful in counseling patients about expected postoperative recovery. This study compares outcomes in patients undergoing cervical spine surgery with arthroscopic shoulder surgery using computer-adaptive Patient-reported Outcome Information System scores. MATERIALS AND METHODS/METHODS:Patients undergoing cervical spine surgery (1-level or 2-level anterior cervical discectomy and fusion, cervical disc replacement) or arthroscopic shoulder surgery (rotator cuff repair±biceps tenodesis) were grouped. Patient-reported Outcome Information System scores of physical function, pain interference, and pain intensity at baseline and at 3, 6, and 12 months were compared using paired t tests. RESULTS:Cervical spine (n=127) and shoulder (n=91) groups were similar in sex (25.8% vs. 41.8% female, P=0.731) but differed in age (51.6±11.6 vs. 58.60±11.2, P<0.05), operative time (148.3±68.6 vs. 75.9±26.9 min, P<0.05), American Society of Anesthesiologists (ASAs) (2.3±0.6 vs. 2.0±0.5, P=0.001), smoking status (15.7% vs. 4.4%, P=0.008), and length of stay (1.1±1.0 vs. 0.3±0.1, P=0.000). Spine patients had worse physical function (36.9 ±12.6 vs. 49.4±8.6, P<0.05) and greater pain interference (67.0±13.6 vs. 61.7±4.8, P=0.001) at baseline. Significant improvements were seen in all domains by 3 months for both groups, except for physical function after shoulder surgery. Spine patients had greater physical function improvements at all timepoints (3.33 vs. -0.43, P=0.003; 4.81 vs. 0.08, P=0.001; 6.5 vs. -5.24, P=<0.05). Conversely, shoulder surgery patients showed better 6-month improvement in pain intensity over spine patients (-8.86 vs. -4.46, P=0.001), but this difference resolved by 12 months. CONCLUSIONS:Cervical spine patients had greater relative early improvement in physical function compared with shoulder patients, whereas pain interference and intensity did not significantly differ between the 2 groups after surgery. This will help in counseling patients about relative difference in recovery and improvement between the 2 surgery types. LEVEL OF EVIDENCE/METHODS:III.