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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

Machine learning clustering of adult spinal deformity patients identifies four prognostic phenotypes: a multicenter prospective cohort analysis with single surgeon external validation

Mohanty, Sarthak; Hassan, Fthimnir M; Lenke, Lawrence G; Lewerenz, Erik; Passias, Peter G; Klineberg, Eric O; Lafage, Virginie; Smith, Justin S; Hamilton, D Kojo; Gum, Jeffrey L; Lafage, Renaud; Mullin, Jeffrey; Diebo, Bassel; Buell, Thomas J; Kim, Han Jo; Kebaish, Khalid; Eastlack, Robert; Daniels, Alan H; Mundis, Gregory; Hostin, Richard; Protopsaltis, Themistocles S; Hart, Robert A; Gupta, Munish; Schwab, Frank J; Shaffrey, Christopher I; Ames, Christopher P; Burton, Douglas; Bess, Shay; ,
BACKGROUND CONTEXT/BACKGROUND:Among adult spinal deformity (ASD) patients, heterogeneity in patient pathology, surgical expectations, baseline impairments, and frailty complicates comparisons in clinical outcomes and research. This study aims to qualitatively segment ASD patients using machine learning-based clustering on a large, multicenter, prospectively gathered ASD cohort. PURPOSE/OBJECTIVE:To qualitatively segment adult spinal deformity patients using machine learning-based clustering on a large, multicenter, prospectively gathered cohort. STUDY DESIGN/SETTING/METHODS:Machine learning algorithm using patients from a prospective multicenter study and a validation cohort from a retrospective single center, single surgeon cohort with complete 2-year follow up. PATIENT SAMPLE/METHODS:About 805 ASD patients; 563 patients from a prospective multicenter study and 242 from a single center to be used as a validation cohort. OUTCOME MEASURES/METHODS:To validate and extend the Ames-ISSG/ESSG classification using machine learning-based clustering analysis on a large, complex, multicenter, prospectively gathered ASD cohort. METHODS:We analyzed a training cohort of 563 ASD patients from a prospective multicenter study and a validation cohort of 242 ASD patients from a retrospective single center/surgeon cohort with complete two-year patient-reported outcomes (PROs) and clinical/radiographic follow-up. Using k-means clustering, a machine learning algorithm, we clustered patients based on baseline PROs, Edmonton frailty, age, surgical history, and overall health. Baseline differences in clusters identified using the training cohort were assessed using Chi-Squared and ANOVA with pairwise comparisons. To evaluate the classification system's ability to discern postoperative trajectories, a second machine learning algorithm assigned the single-center/surgeon patients to the same 4 clusters, and we compared the clusters' two-year PROs and clinical outcomes. RESULTS:K-means clustering revealed four distinct phenotypes from the multicenter training cohort based on age, frailty, and mental health: Old/Frail/Content (OFC, 27.7%), Old/Frail/Distressed (OFD, 33.2%), Old/Resilient/Content (ORC, 27.2%), and Young/Resilient/Content (YRC, 11.9%). OFC and OFD clusters had the highest frailty scores (OFC: 3.76, OFD: 4.72) and a higher proportion of patients with prior thoracolumbar fusion (OFC: 47.4%, OFD: 49.2%). ORC and YRC clusters exhibited lower frailty scores and fewest patients with prior thoracolumbar procedures (ORC: 2.10, 36.6%; YRC: 0.84, 19.4%). OFC had 69.9% of patients with global sagittal deformity and the highest T1PA (29.0), while YRC had 70.2% exhibiting coronal deformity, the highest mean coronal Cobb Angle (54.0), and the lowest T1PA (11.9). OFD and ORC had similar alignment phenotypes with intermediate values for Coronal Cobb Angle (OFD: 33.7; ORC: 40.0) and T1PA (OFD: 24.9; ORC: 24.6) between OFC (worst sagittal alignment) and YRC (worst coronal alignment). In the single surgeon validation cohort, the OFC cluster experienced the greatest increase in SRS Function scores (1.34 points, 95%CI 1.01-1.67) compared to OFD (0.5 points, 95%CI 0.245-0.755), ORC (0.7 points, 95%CI 0.415-0.985), and YRC (0.24 points, 95%CI -0.024-0.504) clusters. OFD cluster patients improved the least over 2 years. Multivariable Cox regression analysis demonstrated that the OFD cohort had significantly worse reoperation outcomes compared to other clusters (HR: 3.303, 95%CI: 1.085-8.390). CONCLUSION/CONCLUSIONS:Machine-learning clustering found four different ASD patient qualitative phenotypes, defined by their age, frailty, physical functioning, and mental health upon presentation, which primarily determines their ability to improve their PROs following surgery. This reaffirms that these qualitative measures must be assessed in addition to the radiographic variables when counseling ASD patients regarding their expected surgical outcomes.
PMID: 38365004
ISSN: 1878-1632
CID: 5636072

Functional Alignment Within the Fusion in Adult Spinal Deformity (ASD) Improves Outcomes and Minimizes Mechanical Failures

Ani, Fares; Ayres, Ethan W; Soroceanu, Alex; Mundis, Gregory M; Smith, Justin S; Gum, Jeffrey L; Daniels, Alan H; Klineberg, Eric O; Ames, Christopher P; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Protopsaltis, Themistocles S; ,
STUDY DESIGN/METHODS:Retrospective review of an adult deformity database. OBJECTIVE:To identify Pelvic Incidence (PI) and age-appropriate physical function alignment targets using a component angle of T1- Pelvic Angle (TPA) within the fusion to define correction and their relationship to proximal junctional kyphosis (PJK) and clinical outcomes. SUMMARY OF BACKGROUND DATA/BACKGROUND:In preoperative planning, a patient's PI is often utilized to determine alignment target. In a trend toward more patient specific planning, age-specific alignment has been shown to reduce the risk of mechanical failures. PI and age have not been analyzed with respect to defining a functional alignment. METHODS:A database of patients with operative adult spinal deformity (ASD) was analyzed. Patients fused to the pelvis and upper-instrumented vertebrae (UIV) above T11 were included. Alignment within the fusion correlated with clinical outcomes and PI. Short form 36-physical Component score (SF36-PCS) normative data and PI were used to compute functional alignment for each patient. Over-, under-, and functionally corrected groups were determined using T10-pelvic angle (T10PA). RESULTS:1052 patients met inclusion criteria. T10PA correlated with SF36-PCS and PI (R=0.601). At 6 weeks, 40.7% were functionally corrected, 39.4% were overcorrected, and 20.9% were under-corrected. The PJK incidence rate was 13.6%. Overcorrected patients had the highest PJK rate (18.1%) compared with functionally (11.3%) and under-corrected (9.5%) patients (P<0.05). Overcorrected patients had a trend toward more PJK revisions. All groups improved in HRQL; however, under-corrected patients had the worst 1-year SF36-PCS offset relative to normative patients of equivalent age (-8.1) vs. functional (-6.1) and overcorrected (-4.5), P<0.05. CONCLUSIONS:T10PA was used to determine functional alignment, an alignment based on PI and age-appropriate physical function. Correcting patients to functional alignment produced improvements in clinical outcomes, with the lowest rates of PJK. This patient specific approach to spinal alignment provides ASD correction targets that can be used intraoperatively.
PMID: 37698284
ISSN: 1528-1159
CID: 5594012

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

Are insufficient corrections a major factor in distal junctional kyphosis? A simulated analysis of cervical deformity correction using in-construct measurements

Ani, Fares; Sissman, Ethan; Woo, Dainn; Soroceanu, Alex; Mundis, Gregory; Eastlack, Robert K; Smith, Justin S; Hamilton, D Kojo; Kim, Han Jo; Daniels, Alan H; Klineberg, Eric O; Neuman, Brian; Sciubba, Daniel M; Gupta, Munish C; Kebaish, Khaled M; Passias, Peter G; Hart, Robert A; Bess, Shay; Shaffrey, Christopher I; Schwab, Frank J; Lafage, Virginie; Ames, Christopher P; Protopsaltis, Themistocles S
OBJECTIVE:The present study utilized recently developed in-construct measurements in simulations of cervical deformity surgery in order to assess undercorrection and predict distal junctional kyphosis (DJK). METHODS:A retrospective review of a database of operative cervical deformity patients was analyzed for severe DJK and mild DJK. C2-lower instrumented vertebra (LIV) sagittal angle (SA) was measured postoperatively, and the correction was simulated in the preoperative radiograph in order to match the C2-LIV by using the planning software. Linear regression analysis that used C2 pelvic angle (CPA) and pelvic tilt (PT) determined the simulated PT that matched the virtual CPA. Linear regression analysis was used to determine the C2-T1 SA, C2-T4 SA, and C2-T10 SA that corresponded to DJK of 20° and cervical sagittal vertical axis (cSVA) of 40 mm. RESULTS:Sixty-nine cervical deformity patients were included. Severe and mild DJK occurred in 11 (16%) and 22 (32%) patients, respectively; 3 (4%) required DJK revision. Simulated corrections demonstrated that severe and mild DJK patients had worse alignment compared to non-DJK patients in terms of cSVA (42.5 mm vs 33.0 mm vs 23.4 mm, p < 0.001) and C2-LIV SVA (68.9 mm vs 57.3 mm vs 36.8 mm, p < 0.001). Linear regression revealed the relationships between in-construct measures (C2-T1 SA, C2-T4 SA, and C2-T10 SA), cSVA, and change in DJK (all R > 0.57, p < 0.001). A cSVA of 40 mm corresponded to C2-T4 SA of 10.4° and C2-T10 SA of 28.0°. A DJK angle change of 10° corresponded to C2-T4 SA of 5.8° and C2-T10 SA of 20.1°. CONCLUSIONS:Simulated cervical deformity corrections demonstrated that severe DJK patients have insufficient corrections compared to patients without DJK. In-construct measures assess sagittal alignment within the fusion separate from DJK and subjacent compensation. They can be useful as intraoperative tools to gauge the adequacy of cervical deformity correction.
PMID: 38364226
ISSN: 1547-5646
CID: 5636022

Single-Position Prone Lateral Lumbar Interbody Fusion Increases Operative Efficiency and Maintains Safety in Revision Lumbar Spinal Fusion

Buckland, Aaron J; Proctor, Dylan; Thomas, J Alex; Protopsaltis, Themistocles S; Ashayeri, Kimberly; Braly, Brett A
STUDY DESIGN/METHODS:Multi-centre retrospective cohort study. OBJECTIVE:To evaluate the feasibility and safety of the single-position prone lateral lumbar interbody fusion (LLIF) technique for revision lumbar fusion surgery. BACKGROUND CONTEXT/BACKGROUND:Prone LLIF (P-LLIF) is a novel technique allowing for placement of a lateral interbody in the prone position and allowing posterior decompression and revision of posterior instrumentation without patient repositioning. This study examines perioperative outcomes and complications of single position P-LLIF against traditional Lateral LLIF (L-LLIF) technique with patient repositioning. METHOD/METHODS:A multi-centre retrospective cohort study involving patients undergoing 1-4 level LLIF surgery was performed at 4 institutions in the USA and Australia. Patients were included if their surgery was performed via either: P-LLIF with revision posterior fusion; or L-LLIF with repositioning to prone. Demographics, perioperative outcomes, complications, and radiological outcomes were compared using independent samples t-tests and chi-squared analyses as appropriate with significance set at P <0.05. RESULTS:101 patients undergoing revision LLIF surgery were included, of which 43 had P-LLIF and 58 had L-LLIF. Age, BMI and CCI were similar between groups. The number of posterior levels fused (2.21 P-LLIF vs. 2.66 L-LLIF, P =0.469) and number of LLIF levels (1.35 vs. 1.39, P =0.668) was similar between groups. Operative time was significantly less in the P-LLIF group (151 vs. 206 min, P =0.004). EBL was similar between groups (150 mL P-LLIF vs. 182 mL L-LLIF, P =0.31) and there was a trend toward reduced length of stay in the P-LLIF group (2.7 vs. 3.3 d, P =0.09). No significant difference was demonstrated in complications between groups. Radiographic analysis demonstrated no significant differences in preoperative or postoperative sagittal alignment measurements. CONCLUSION/CONCLUSIONS:P-LLIF significantly improves operative efficiency when compared to L-LLIF for revision lumbar fusion. No increase in complications was demonstrated by P-LLIF or trade-offs in sagittal alignment restoration. LEVEL OF EVIDENCE/METHODS:Level IV.
PMID: 37134133
ISSN: 1528-1159
CID: 5544902

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

Lumbar Lordosis Redistribution and Segmental Correction in Adult Spinal Deformity (ASD): Does it Matter?

Diebo, Bassel G; Balmaceno-Criss, Mariah; Lafage, Renaud; Daher, Mohammad; Singh, Manjot; Hamilton, D Kojo; Smith, Justin S; Eastlack, Robert K; Fessler, Richard; Gum, Jeffrey L; Gupta, Munish C; Hostin, Richard; Kebaish, Khaled M; Lewis, Stephen; Line, Breton G; Nunley, Pierce D; Mundis, Gregory M; Passias, Peter G; Protopsaltis, Themistocles S; Turner, Jay; Buell, Thomas; Scheer, Justin K; Mullin, Jeffery; Soroceanu, Alex; Ames, Christopher P; Bess, Shay; Shaffrey, Christopher I; Lenke, Lawrence G; Schwab, Frank J; Lafage, Virginie; Burton, Douglas C; Daniels, Alan H; ,
STUDY DESIGN/METHODS:Retrospective analysis of prospectively collected data. OBJECTIVE:Evaluate the impact of correcting to normative segmental lordosis values on post-operative outcomes. BACKGROUND:Restoring lumbar lordosis magnitude is crucial in adult spinal deformity surgery, but the optimal location and segmental distribution remains unclear. METHODS:Patients were grouped based on offset to normative segmental lordosis values, extracted from recent publications. Matched patients were within 10% of the cohort's mean offset, less than or over 10% were under- and over-corrected. Surgical technique, PROMs, and surgical complications were compared across groups at baseline and 2-year. RESULTS:510 patients with an average age of 64.6, mean CCI 2.08, and average follow-up of 25 months. L4-5 was least likely to be matched (19.1%), while L4-S1 was the most likely (24.3%). More patients were overcorrected at proximal levels (T10-L2; Undercorrected, U: 32.2% vs. Matched, M: 21.7% vs. Overcorrected, O: 46.1%) and undercorrected at distal levels (L4-S1: U: 39.0% vs. M: 24.3% vs. O: 36.8%). Postoperative ODI was comparable across correction groups at all spinal levels except at L4-S1 and T10-L2/L4-S1, where overcorrected patients and matched were better than undercorrected (U: 32.1 vs. M: 25.4 vs. O: 26.5, P=0.005; U: 36.2 vs. M: 24.2 vs. O: 26.8, P=0.001; respectively). Patients overcorrected at T10-L2 experienced higher rates of proximal junctional failure (PJF) (U: 16.0% vs. M: 15.6% vs. O: 32.8%, P<0.001) and had greater posterior inclination of the upper instrumented vertebra (UIV) (U: -9.2±9.4° vs. M: -9.6±9.1° vs. O: -12.2±10.0°, P<0.001), whereas undercorrection at these levels led to higher rates of revision for implant failure (U: 14.2% vs. M: 7.3% vs. O: 6.4%, P=0.025). CONCLUSIONS:Patients undergoing fusion for adult spinal deformity suffer higher rates of PJF with overcorrection and increased rates of implant failure with undercorrection based on normative segmental lordosis. LEVEL OF EVIDENCE/METHODS:IV.
PMID: 38270393
ISSN: 1528-1159
CID: 5625212

The Importance of Incorporating Proportional Alignment in Adult Cervical Deformity Corrections Relative to Regional and Global Alignment: Steps Toward Development of a Cervical-Specific Score

Passias, Peter G; Williamson, Tyler K; Pierce, Katherine E; Schoenfeld, Andrew J; Krol, Oscar; Imbo, Bailey; Joujon-Roche, Rachel; Tretiakov, Peter; Ahmad, Salman; Bennett-Caso, Claudia; Mir, Jamshaid; Dave, Pooja; McFarland, Kimberly; Owusu-Sarpong, Stephane; Lebovic, Jordan A; Janjua, Muhammad Burhan; de la Garza-Ramos, Rafael; Vira, Shaleen; Diebo, Bassel; Koller, Heiko; Protopsaltis, Themistocles S; Lafage, Renaud; Lafage, Virginie
STUDY DESIGN/SETTING/METHODS:Retrospective single-center study. BACKGROUND:The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD). PURPOSE/OBJECTIVE:Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD. METHODS:Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years. RESULTS:One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF. CONCLUSION/CONCLUSIONS:The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement.
PMID: 37796161
ISSN: 1528-1159
CID: 5613142