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The Case for Operative Efficiency in Adult Spinal Deformity Surgery: Impact of Operative Time on Complications, Length of Stay, Alignment, Fusion Rates, and Patient-Reported Outcomes

Daniels, Alan H; Daher, Mohammad; Singh, Manjot; Balmaceno-Criss, Mariah; Lafage, Renaud; Diebo, Bassel G; Hamilton, David K; Smith, Justin S; Eastlack, Robert K; Fessler, Richard G; Gum, Jeffrey L; Gupta, Munish C; Hostin, Richard; Kebaish, Khaled M; Klineberg, Eric O; Lewis, Stephen J; Line, Breton G; Nunley, Pierce D; Mundis, Gregory M; Passias, Peter G; Protopsaltis, Themistocles S; Buell, Thomas; Scheer, Justin K; Mullin, Jeffrey P; Soroceanu, Alex; Ames, Christopher P; Lenke, Lawrence G; Bess, Shay; Shaffrey, Christopher I; Burton, Douglas C; Lafage, Virginie; Schwab, Frank J; ,
STUDY DESIGN/METHODS:Retrospective review of prospectively collected data. OBJECTIVE:To analyze the impact of operative room (OR) time in adult spinal deformity (ASD) surgery on patient outcomes. BACKGROUND:It is currently unknown if OR time in ASD patients matched for deformity severity and surgical invasiveness is associated with patient outcomes. MATERIALS AND METHODS/METHODS:ASD patients with baseline and two-year postoperative radiographic and patient-reported outcome measures (PROM) data, undergoing a posterior-only approach for long fusion (>L1-Ilium) were included. Patients were grouped into short OR time (<40th percentile: <359 min) and long OR time (>60th percentile: >421 min). Groups were matched by age, baseline deformity severity, and surgical invasiveness. Demographics, radiographic, PROM data, fusion rate, and complications were compared between groups at baseline and two years follow-up. RESULTS:In total, 270 patients were included for analysis: the mean OR time was 286 minutes in the short OR group versus 510 minutes in the long OR group ( P <0.001). Age, gender, percent of revision cases, surgical invasiveness, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt were comparable between groups ( P >0.05). Short OR had a slightly lower body mass index than the short OR group ( P <0.001) and decompression was more prevalent in the long OR time ( P =0.042). Patients in the long group had greater hospital length of stay ( P =0.02); blood loss ( P <0.001); proportion requiring intensive care unit ( P =0.003); higher minor complication rate ( P =0.001); with no significant differences for major complications or revision procedures ( P >0.5). Both groups had comparable radiographic fusion rates ( P =0.152) and achieved improvement in sagittal alignment measures, Oswestry disability index, and Short Form-36 ( P <0.001). CONCLUSION/CONCLUSIONS:Shorter OR time for ASD correction is associated with a lower minor complication rate, a lower estimated blood loss, fewer intensive care unit admissions, and a shorter hospital length of stay without sacrificing alignment correction or PROMs. Maximizing operative efficiency by minimizing OR time in ASD surgery has the potential to benefit patients, surgeons, and hospital systems.
PMID: 37942794
ISSN: 1528-1159
CID: 5633072

Outcomes and survival analysis of adult cervical deformity patients with ten-year follow-up

Passias, Peter G; Tretiakov, Peter S; Das, Ankita; Thomas, Zach; Krol, Oscar; Joujon-Roche, Rachel; Williamson, Tyler; Imbo, Bailey; Owusu-Sarpong, Stephane; Lebovic, Jordan; Diebo, Bassel; Vira, Shaleen; Lafage, Virginie; Schoenfeld, Andrew J
BACKGROUND:Previous studies have demonstrated that adult cervical deformity patients may be at increased risk of death in conjunction with increased frailty or a weakened physiologic state. However, such studies have often been limited by follow-up duration, and longer-term studies are needed to better assess temporal changes in ACD patients and associated mortality risk. PURPOSE/OBJECTIVE:To assess if patients with decreased comorbidities and physiologic burden will be at lessened risk of death for a greater length of time after undergoing adult cervical deformity surgery. STUDY DESIGN/SETTING/METHODS:Retrospective review PATIENT SAMPLE: Two hundred and ninety ACD Patients OUTCOME MEASURES: Morbidity and mortality data. METHODS:). Within 10Y, 12 (18.2% of ACD cohort) expired. At baseline, patients were comparable in age, gender, BMI, and CCI total on average (all p>.05). Furthermore, patients were comparable in BL HRQLs (all p>.05). However, patients who expired between 5Y and 10Y demonstrated higher BL EQ5D and mJOA scores than their earlier expired counterparts at 2Y (p<.021). Furthermore, patients who presented with no CCI markers at BL were significantly more likely to survive until the 5Y-10Y follow-up window. Surgically, the only differences observed between patients who survived until 5Y was in undergoing osteotomy, with longer survival seen in those who did not require it (p=.003). Logistic regression revealed independent predictors of death prior to 5Y to be increased BMI, increased frailty, and increased levels fused (model p<.001). KM analysis found that by Passias et al. frailty, not frail patients had mean survival time of 170.56 weeks, versus 158.00 in frail patients (p=.949). CONCLUSIONS:Our study demonstrates that long-term survival after cervical deformity surgery may be predicted by baseline surgical factors. By optimizing BMI, frailty status, and minimizing fusion length when appropriate, surgeons may be able to further assist ACD patients in increasing their survivability post-operatively.
PMID: 37918570
ISSN: 1878-1632
CID: 5620392

Complication Rates Following Adult Spinal Deformity Surgery: Evaluation of the Category of Complication and Chronology

Lafage, Renaud; Bass, R Daniel; Klineberg, Eric; Smith, Justin S; Bess, Shay; Shaffrey, Christopher; Burton, Douglas C; Kim, Han Jo; Eastlack, Robert; Mundis, Gregory; Ames, Christopher P; Passias, Peter G; Gupta, Munish; Hostin, Richard; Hamilton, Kojo; Schwab, Frank; Lafage, Virginie; ,
OBJECTIVE:Provide benchmarks for the rates of complications by type and timing. STUDY DESIGN/METHODS:Prospective multicenter database. BACKGROUND:Complication rates following adult spinal deformity (ASD) surgery have been previously reported. However, the interplay between timing and complication type warrants further analysis. METHODS:The data for this study were sourced from a prospective, multicenter ASD database. Date and type of complication were collected and classified into three severity groups (minor, major, major leading to reoperation). Only complications occurring before the 2-year visit were retained for analysis. RESULTS:Of the 1260 patients eligible for 2-year follow-up, 997 (79.1%) achieved 2-year follow-up. The overall complication rate was 67.4% (N=672). 247 patients (24.8%) experienced at least one complication on the day of surgery (including intra-operatively), 359 (36.0%) between post-op day 1 and 6 weeks post-op, 271 (27.2%) between 6 weeks and 1 one -year post-op, and finally 162 (16.3%) between 1 year and 2 years post-op. Using Kaplan-Meier survival analysis, the rate of remaining complication-free was estimated at different time points for different severities and types of complications. Stratification by type of complication demonstrated that most of the medical complications occurred within the first 60 days. Surgical complications presented over two distinct timeframes. Operative complications, incision-related complications, and infections occurred early (within 60 d), while implant-related and radiographic complications occurred at a constant rate over the 2-year follow-up period. Neurologic complications had the highest occurrence within the first 60 days but continued to increase up to the 2-year visit. CONCLUSION/CONCLUSIONS:Only one-third of ASD patients remained complication-free by 2 years, and 2 out of 10 patients had a complication requiring a reoperation or revision. Estimation of timing and type of complication associated with surgical treatment may prove useful for more meaningful patient counseling and aid in assessing the cost-effectiveness of treatment.
PMID: 38375636
ISSN: 1528-1159
CID: 5634132

Impact of Hip and Knee Osteoarthritis on Full Body Sagittal Alignment and Compensation for Sagittal Spinal Deformity

Balmaceno-Criss, Mariah; Lafage, Renaud; Alsoof, Daniel; Daher, Mohammad; Hamilton, D Kojo; Smith, Justin S; Eastlack, Robert K; Fessler, Richard G; Gum, Jeffrey L; Gupta, Munish C; Hostin, Richard; Kebaish, Khaled M; Klineberg, Eric O; Lewis, Stephen J; Line, Breton G; Nunley, Pierce D; Mundis, Gregory M; Passias, Peter G; Protopsaltis, Themistocles S; Buell, Thomas; Scheer, Justin K; Mullin, Jeffrey P; Soroceanu, Alex; Ames, Christopher P; Lenke, Lawrence G; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Burton, Douglas C; Diebo, Bassel G; Daniels, Alan H; ,
STUDY DESIGN/METHODS:Retrospective review of prospectively collected data. OBJECTIVE:To investigate the effect of lower extremity osteoarthritis on sagittal alignment and compensatory mechanisms in adult spinal deformity (ASD). BACKGROUND:Spine, hip, and knee pathologies often overlap in ASD patients. Limited data exists on how lower extremity osteoarthritis impacts sagittal alignment and compensatory mechanisms in ASD. METHODS:527 pre-operative ASD patients with full body radiographs were included. Patients were grouped by Kellgren-Lawrence grade of bilateral hips and knees and stratified by quartile of T1-Pelvic Angle (T1PA) severity into low-, mid-, high-, and severe-T1PA. Full body alignment and compensation were compared across quartiles. Regression analysis examined the incremental impact of hip and knee osteoarthritis severity on compensation. RESULTS:The mean T1PA for low-, mid-, high-, and severe-T1PA groups was 7.3°, 19.5°, 27.8°, 41.6°, respectively. Mid-T1PA patients with severe hip osteoarthritis had an increased sagittal vertical axis and global sagittal alignment (P<0.001). Increasing hip osteoarthritis severity resulted in decreased pelvic tilt (P=0.001) and sacrofemoral angle (P<0.001), but increased knee flexion (P=0.012). Regression analysis revealed with increasing T1PA, pelvic tilt correlated inversely with hip osteoarthritis and positively with knee osteoarthritis (r2=0.812). Hip osteoarthritis decreased compensation via sacrofemoral angle (β-coefficient=-0.206). Knee and hip osteoarthritis contributed to greater knee flexion (β-coefficients=0.215, 0.101; respectively). For pelvic shift, only hip osteoarthritis significantly contributed to the model (β-coefficient=0.100). CONCLUSIONS:For the same magnitude of spinal deformity, increased hip osteoarthritis severity was associated with worse truncal and full body alignment with posterior translation of the pelvis. Patients with severe hip and knee osteoarthritis exhibited decreased hip extension and pelvic tilt, but increased knee flexion. This examines sagittal alignment and compensation in ASD patients with hip and knee arthritis and may help delineate whether hip and knee flexion is due to spinal deformity compensation or lower extremity osteoarthritis.
PMID: 38375611
ISSN: 1528-1159
CID: 5634122

Costs of Surgery in Adult Spinal Deformity: Do Higher Cost Surgeries Lead to Better Outcomes?

Joujon-Roche, Rachel; Dave, Pooja; Tretiakov, Peter; Mcfarland, Kimberly; Mir, Jamshaid; Williamson, Tyler K; Imbo, Bailey; Krol, Oscar; Lebovic, Jordan; Schoenfeld, Andrew J; Vira, Shaleen; Lafage, Renaud; Lafage, Virginie; Passias, Peter G
STUDY DESIGN/METHODS:Retrospective. OBJECTIVE:To assess impact of surgical costs on patient reported outcomes in ASD. SUMMARY OF BACKGROUND DATA/BACKGROUND:With increased focus on delivering cost effective healthcare, interventions with high resource utilization, such as adult spinal deformity (ASD) surgery, have received greater scrutiny. METHODS:ASD patients≥18 years with BL and 2Y data were included. Surgical costs were calculated using 2021 average Medicare reimbursement by CPT code. Costs of complications and reoperations were intentionally excluded. Patients were ranked into tertiles by surgical cost: highest surgical costs (HC) and lowest surgical costs (LC). They were propensity score matched (PSM) to account for differences in baseline age and deformity. Bivariate logistic regressions assessed odds of achieving outcomes. RESULTS:421 patients met inclusion (60.7 y, 81.8% female, CCI: 1.6, 27.1 kg/m2), 139 LC and 127 HC patients. After PSM, 102 patients remained in each cost group with an average reimbursement of LC: $12,494 versus HC: $29,248. Matched cohorts had similar demographics and baseline HRQLs. Matched groups had similar baseline SVA (HC: 59.0 vs. LC: 56.7 mm), PI-LL (HC: 13.1 vs. LC: 13.4°), and PT (HC: 25.3 vs. LC: 22.4°). Rates of complications were not significantly different between the cost groups. Compared to LC group, by 2Y HC patients had higher odds of reaching SCB in ODI (OR: 2.356, [1.220, 4.551], P=0.011), in SRS-Total (OR: 2.988, [1.515, 5.895], P=0.002), and in NRS Back (OR: 2.739, [1.105, 6.788], P=0.030). Similar findings were appreciated for HC patients in the setting of Schwab deformity outcome criteria. CONCLUSIONS:Although added cost did not guarantee an ideal outcome, HC patients experienced superior patient reported outcomes compared to LC patients. While cost efficiency remains an important priority for health policy, isolating cost reduction may compromise outcomes and add to future costs of re-intervention, particularly with more severe baseline deformity. LEVEL OF EVIDENCE/METHODS:III.
PMID: 37163657
ISSN: 1528-1159
CID: 5509362

Development of a modified frailty index for adult spinal deformities independent of functional changes following surgical correction: a true baseline risk assessment tool

Passias, Peter G; Pierce, Katherine E; Mir, Jamshaid M; Krol, Oscar; Lafage, Renaud; Lafage, Virginie; Line, Breton; Uribe, Juan S; Hostin, Richard; Daniels, Alan; Hart, Robert; Burton, Douglas; Shaffrey, Christopher; Schwab, Frank; Diebo, Bassel G; Ames, Christopher P; Smith, Justin S; Schoenfeld, Andrew J; Bess, Shay; Klineberg, Eric O; ,
PURPOSE/OBJECTIVE:To develop a simplified, modified frailty index for adult spinal deformity (ASD) patients dependent on objective clinical factors. METHODS:value derived from multivariate forward stepwise regression were including in the modified ASD-FI (clin-ASD-FI). Factors included in the clin-ASD-FI were regressed against mortality, extended length of hospital stay (LOS, > 8 days), revisions, major complications and weights for the clin-ASD-FI were calculated via Beta/Sullivan. Total clin-ASD-FI score was created with a score from 0 to 1. Linear regression correlated clin-ASD-FI with ASD-FI scores and published cutoffs for the ASD-FI were used to create the new frailty cutoffs: not frail (NF: < 0.11), frail (F: 0.11-0.21) and severely frail (SF: > 0.21). Binary logistic regression assessed odds of complication or reop for frail patients. RESULTS:of 0.681, and significant factors were: < 18.5 or > 30 BMI (weight: 0.0625 out of 1), cardiac disease (0.125), disability employment status (0.3125), diabetes mellitus (0.0625), hypertension (0.0625), osteoporosis (0.125), blood clot (0.1875), and bowel incontinence (0.0625). These factors calculated the score from 0 to 1, with a mean cohort score of 0.13 ± 0.14. Breakdown by clin-ASD-FI score: 51.8% NF, 28.1% F, 20.2% SF. Increasing frailty severity was associated with longer LOS (NF: 7.0, F: 8.3, SF: 9.2 days; P < 0.001). Frailty independently predicted occurrence of any complication (OR: 9.357 [2.20-39.76], P = 0.002) and reop (OR: 2.79 [0.662-11.72], P = 0.162). CONCLUSIONS:Utilizing an existing ASD frailty index, we proposed a modified version eliminating the patient-reported components. This index is a true assessment of physiologic status, and represents a superior risk factor assessment compared to other tools for both primary and revision spinal deformity surgery as a result of its immutability with surgery, lack of subjectivity, and ease of use.
PMID: 38305990
ISSN: 2212-1358
CID: 5626942

Patient-Centered Outcomes Following Prone Lateral Single-Position Approach to Same-Day Circumferential Spine Surgery

Passias, Peter G; Williamson, Tyler K; Krol, Oscar; Joujon-Roche, Rachel; Imbo, Bailey; Tretiakov, Peter; Ahmad, Salman; Bennett-Caso, Claudia; Lebovic, Jordan; Owusu-Sarpong, Stephane; Park, Paul; Chou, Dean; Vira, Shaleen; Diebo, Bassel G; Schoenfeld, Andrew J
STUDY DESIGN/METHODS:Retrospective study. OBJECTIVE:Evaluate surgical characteristics and postoperative 2-year results of the PL approach to spinal fusion. SUMMARY OF BACKGROUND DATA/BACKGROUND:Prone-lateral(PL) single positioning has recently gained popularity in spine surgery due to lower blood loss and operative time but has yet to be examined for other notable outcomes, including realignment and patient-reported measures. MATERIALS AND METHODS/METHODS:We included circumferential spine fusion patients with a minimum one-year follow-up. Patients were stratified into groups based on undergoing PL approach versus same-day staged (Staged). Mean comparison tests identified differences in baseline parameters. Multivariable logistic regression, controlling for age, levels fused, and Charlson Comorbidity Index were used to determine the influence of the approach on complication rates, radiographic and patient-reported outcomes up to two years. RESULTS:One hundred twenty-two patients were included of which 72(59%) were same-day staged and 50(41%) were PL. PL patients were older with lower body mass index (both P <0.05). Patients undergoing PL procedures had lower estimated blood loss and operative time (both P <0.001), along with fewer osteotomies (63% vs. 91%, P <0.001). This translated to a shorter length of stay (3.8 d vs. 4.9, P =0.041). PL procedures demonstrated better correction in both PT (4.0 vs. -0.2, P =0.033 and pelvic incidence and lumbar lordosis (-3.7 vs. 3.1, P =0.012). PL procedures were more likely to improve in GAP relative pelvic version (OR: 2.3, [1.5-8.8]; P =0.003]. PL patients suffered lesser complications during the perioperative period and greater improvement in NRS-Back (-6.0 vs. -3.3, P =0.031), with less reoperations (0.0% vs. 4.8%, P =0.040) by two years. CONCLUSIONS:Patients undergoing PL single-position procedures received less invasive procedures with better correction of pelvic compensation, as well as earlier discharge. The prone lateral cohort also demonstrated greater clinical improvement and a lower rate of reoperations by two years following spinal corrective surgery. LEVEL OF EVIDENCE/METHODS:Level-III.
PMID: 36972128
ISSN: 1528-1159
CID: 5624232

Revision-Free Loss of Sagittal Correction Greater Than Three Years After Adult Spinal Deformity Surgery: Who and Why?

Lovecchio, Francis; Lafage, Renaud; Kim, Han Jo; Bess, Shay; Ames, Christopher; Gupta, Munish; Passias, Peter; Klineberg, Eric; Mundis, Gregory; Burton, Douglas; Smith, Justin S; Shaffrey, Christopher; Schwab, Frank; Lafage, Virginie; ,
STUDY DESIGN/METHODS:Multicenter retrospective cohort study. OBJECTIVE:To investigate risk factors for loss of correction within the instrumented lumbar spine after adult spinal deformity surgery. SUMMARY OF BACKGROUND DATA/BACKGROUND:The sustainability of adult spinal deformity surgery remains a health care challenge. Malalignment is a major reason for revision surgery. PATIENTS AND METHODS/METHODS:A total of 321 patients who underwent fusion of the lumbar spine (≥5 levels, LIV pelvis) with a revision-free follow-up of ≥3 years were identified. Patients were stratified by a change in pelvic incidence-lumbar lordosis from 6 weeks to 3 years postoperative as "maintained" versus "loss" >5°. Those with instrumentation failure (broken rod, screw pullout, etc .) were excluded before comparisons. Demographics, surgical data, and radiographic alignment were compared. Repeated measure analysis of variance was performed to evaluate the maintenance of the correction for L1-L4 and L4-S1. Multivariate logistic regression was conducted to identify independent surgical predictors of correction loss. RESULTS:The cohort had a mean age of 64 years, a mean Body Mass Index of 28 kg/m 2 , and 80% females. Eighty-two patients (25.5%) lost >5° of pelvic incidence-lumbar lordosis correction (mean loss 10±5°). After the exclusion of patients with instrumentation failure, 52 losses were compared with 222 maintained. Demographics, osteotomies, 3CO, interbody fusion, use of bone morphogenetic protein, rod material, rod diameter, and fusion length were not significantly different. L1-S1 screw orientation angle was 1.3 ± 4.1 from early postoperative to 3 years ( P = 0.031), but not appreciably different at L4-S1 (-0.1 ± 2.9 P = 0.97). Lack of a supplemental rod (odds ratio: 4.0, P = 0.005) and fusion length (odds ratio 2.2, P = 0.004) were associated with loss of correction. CONCLUSIONS:Approximately, a quarter of revision-free patients lose an average of 10° of their 6-week correction by 3 years. Lordosis is lost proximally through the instrumentation ( i.e. tulip/shank angle shifts and/or rod bending). The use of supplemental rods and avoiding sagittal overcorrection may help mitigate this loss.
PMID: 37847773
ISSN: 1528-1159
CID: 5624282

Patient-specific Cervical Deformity Corrections With Consideration of Associated Risk: Establishment of Risk Benefit Thresholds for Invasiveness Based on Deformity and Frailty Severity

Passias, Peter G; Pierce, Katherine E; Williamson, Tyler K; Lebovic, Jordan; Schoenfeld, Andrew J; Lafage, Renaud; Lafage, Virginie; Gum, Jeffrey L; Eastlack, Robert; Kim, Han Jo; Klineberg, Eric O; Daniels, Alan H; Protopsaltis, Themistocles S; Mundis, Gregory M; Scheer, Justin K; Park, Paul; Chou, Dean; Line, Breton; Hart, Robert A; Burton, Douglas C; Bess, Shay; Schwab, Frank J; Shaffrey, Christopher I; Smith, Justin S; Ames, Christopher P; ,
STUDY DESIGN/SETTING/METHODS:This was a retrospective cohort study. BACKGROUND:Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty. OBJECTIVE:The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity. METHODS:This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely. RESULTS:A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P =0.002], and invasiveness increased with deformity severity ( P <0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P =0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P =0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P =0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group. CONCLUSIONS:Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes.
PMID: 37798829
ISSN: 2380-0194
CID: 5627892

Persistent Lower Extremity Compensation for Sagittal Imbalance After Surgical Correction of Complex Adult Spinal Deformity: A Radiographic Analysis of Early Impact

Williamson, Tyler K; Dave, Pooja; Mir, Jamshaid M; Smith, Justin S; Lafage, Renaud; Line, Breton; Diebo, Bassel G; Daniels, Alan H; Gum, Jeffrey L; Protopsaltis, Themistocles S; Hamilton, D Kojo; Soroceanu, Alex; Scheer, Justin K; Eastlack, Robert; Kelly, Michael P; Nunley, Pierce; Kebaish, Khaled M; Lewis, Stephen; Lenke, Lawrence G; Hostin, Richard A; Gupta, Munish C; Kim, Han Jo; Ames, Christopher P; Hart, Robert A; Burton, Douglas C; Shaffrey, Christopher I; Klineberg, Eric O; Schwab, Frank J; Lafage, Virginie; Chou, Dean; Fu, Kai-Ming; Bess, Shay; Passias, Peter G; ,
BACKGROUND AND OBJECTIVES/OBJECTIVE:Achieving spinopelvic realignment during adult spinal deformity (ASD) surgery does not always produce ideal outcomes. Little is known whether compensation in lower extremities (LEs) plays a role in this disassociation. The objective is to analyze lower extremity compensation after complex ASD surgery, its effect on outcomes, and whether correction can alleviate these mechanisms. METHODS:We included patients with complex ASD with 6-week data. LE parameters were as follows: sacrofemoral angle, knee flexion angle, and ankle flexion angle. Each parameter was ranked, and upper tertile was deemed compensation. Patients compensating and not compensating postoperatively were propensity score matched for body mass index, frailty, and T1 pelvic angle. Linear regression assessed correlation between LE parameters and baseline deformity, demographics, and surgical details. Multivariate analysis controlling for baseline deformity and history of total knee/hip arthroplasty evaluated outcomes. RESULTS:Two hundred and ten patients (age: 61.3 ± 14.1 years, body mass index: 27.4 ± 5.8 kg/m2, Charlson Comorbidity Index: 1.1 ± 1.6, 72% female, 22% previous total joint arthroplasty, 24% osteoporosis, levels fused: 13.1 ± 3.8) were included. At baseline, 59% were compensating in LE: 32% at hips, 39% knees, and 36% ankles. After correction, 61% were compensating at least one joint. Patients undercorrected postoperatively were less likely to relieve LE compensation (odds ratio: 0.2, P = .037). Patients compensating in LE were more often undercorrected in age-adjusted pelvic tilt, pelvic incidence, lumbar lordosis, and T1 pelvic angle and disproportioned in Global Alignment and Proportion (P < .05). Patients matched in sagittal age-adjusted score at 6 weeks but compensating in LE were more likely to develop proximal junctional kyphosis (odds ratio: 4.1, P = .009) and proximal junctional failure (8% vs 0%, P = .035) than those sagittal age-adjusted score-matched and not compensating in LE. CONCLUSION/CONCLUSIONS:Perioperative lower extremity compensation was a product of undercorrecting complex ASD. Even in age-adjusted realignment, compensation was associated with global undercorrection and junctional failure. Consideration of lower extremities during planning is vital to avoid adverse outcomes in perioperative course after complex ASD surgery.
PMID: 38227826
ISSN: 2332-4260
CID: 5626652