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Identifying Subsets of Patients With Adult Spinal Deformity Who Maintained a Positive Response to Nonoperative Management

Passias, Peter G; Ahmad, Waleed; Tretiakov, Peter; Krol, Oscar; Segreto, Frank; Lafage, Renaud; Lafage, Virginie; Soroceanu, Alex; Daniels, Alan; Gum, Jeffrey; Line, Breton; Schoenfeld, Andrew J; Vira, Shaleen; Hart, Robert; Burton, Douglas; Smith, Justin S; Ames, Christopher P; Shaffrey, Christopher; Schwab, Frank; Bess, Shay
BACKGROUND:Adult spinal deformity (ASD) represents a major cause of disability in the elderly population in the United States. Surgical intervention has been shown to reduce disability and pain in properly indicated patients. However, there is a small subset of patients in whom nonoperative treatment is also able to durably maintain or improve symptoms. OBJECTIVE:To examine the factors associated with successful nonoperative management in patients with ASD. METHODS:We retrospectively evaluated a cohort of 207 patients with nonoperative ASD, stratified into 3 groups: (1) success, (2) no change, and (3) failure. Success was defined as a gain in minimal clinically importance difference in both Oswestry Disability Index and Scoliosis Research Society-Pain. Logistic regression model and conditional inference decision trees established cutoffs for success according to baseline (BL) frailty and sagittal vertical axis. RESULTS:In our cohort, 44.9% of patients experienced successful nonoperative treatment, 22.7% exhibited no change, and 32.4% failed. Successful nonoperative patients at BL were significantly younger, had a lower body mass index, decreased Charlson Comorbidity Index, lower frailty scores, lower rates of hypertension, obesity, depression, and neurological dysfunction (all P < .05) and significantly higher rates of grade 0 deformity for all Schwab modifiers (all P < .05). Conditional inference decision tree analysis determined that patients with a BL ASD-frailty index ≤ 1.579 (odds ratio: 8.3 [4.0-17.5], P < .001) were significantly more likely to achieve nonoperative success. CONCLUSION:Success of nonoperative treatment was more frequent among younger patients and those with less severe deformity and frailty at BL, with BL frailty the most important determinant factor. The factors presented here may be useful in informing preoperative discussion and clinical decision-making regarding treatment strategies.
PMID: 36942962
ISSN: 1524-4040
CID: 5534942

Improvement in some Ames-ISSG cervical deformity classification modifier grades may correlate with clinical improvement

Horn, Samantha R; Passias, Peter G; Passfall, Lara; Lafage, Renaud; Smith, Justin S; Poorman, Gregory W; Steinmetz, Leah M; Bortz, Cole A; Segreto, Frank A; Diebo, Bassel; Hart, Robert; Burton, Douglas; Shaffrey, Christopher I; Sciubba, Daniel M; Klineberg, Eric O; Protopsaltis, Themistocles S; Schwab, Frank J; Bess, Shay; Lafage, Virginie; Ames, Christopher
This retrospective cohort study describes adult cervical deformity(ACD) patients with Ames-ACD classification at baseline(BL) and 1-year post-operatively and assesses the relationship of improvement in Ames modifiers with clinical outcomes. Patients ≥ 18yrs with BL and post-op(1-year) radiographs were included. Patients were categorized with Ames classification by primary deformity descriptors (C = cervical; CT = cervicothoracic junction; T = thoracic; S = coronal) and alignment/myelopathy modifiers(C2-C7 Sagittal Vertical Axis[cSVA], T1 Slope-Cervical Lordosis[TS-CL], Horizontal Gaze[Horiz], mJOA). Univariate analysis evaluated demographics, clinical intervention, and Ames deformity descriptor. Patients were evaluated for radiographic improvement by Ames classification and reaching Minimal Clinically Important Differences(MCID) for mJOA, Neck Disability Index(NDI), and EuroQuol-5D(EQ5D). A total of 73 patients were categorized: C = 41(56.2%), CT = 18(24.7%), T = 9(12.3%), S = 5(6.8%). By Ames modifier 1-year improvement, 13(17.8%) improved in mJOA, 26(35.6%) in cSVA grade, 19(26.0%) in Horiz, and 15(20.5%) in TS-CL. The overall proportion of patients without severe Ames modifier grades at 1-year was as follows: 100% cSVA, 27.4% TS-CL, 67.1% Horiz, 69.9% mJOA. 1-year post-operatively, severe myelopathy(mJOA = 3) prevalence differed between Ames-ACD descriptors (C = 26.3%, CT = 15.4%, T = 0.0%, S = 0.0%, p = 0.033). Improvement in mJOA modifier correlated with reaching 1-year NDI MCID in the overall cohort (r = 0.354,p = 0.002). For C descriptors, cSVA improvement correlated with reaching 1-year NDI MCID (r = 0.387,p = 0.016). Improvement in more than one radiographic Ames modifier correlated with reaching 1-year mJOA MCID (r = 0.344,p = 0.003) and with reaching more than one MCID for mJOA, NDI, and EQ-5D (r = 0.272,p = 0.020). In conclusion, improvements in radiographic Ames modifier grades correlated with improvement in 1-year postoperative clinical outcomes. Although limited in scope, this analysis suggests the Ames-ACD classification may describe cervical deformity patients' alignment and outcomes at 1-year.
PMID: 34119284
ISSN: 1532-2653
CID: 4907162

Predictive model for achieving good clinical and radiographic outcomes at one-year following surgical correction of adult cervical deformity

Passias, Peter Gust; Horn, Samantha R; Oh, Cheongeun; Poorman, Gregory W; Bortz, Cole; Segreto, Frank; Lafage, Renaud; Diebo, Bassel; Scheer, Justin K; Smith, Justin S; Shaffrey, Christopher I; Eastlack, Robert; Sciubba, Daniel M; Protopsaltis, Themistocles; Kim, Han Jo; Hart, Robert A; Lafage, Virginie; Ames, Christopher P
Background/UNASSIGNED:For cervical deformity (CD) surgery, goals include realignment, improved patient quality of life, and improved clinical outcomes. There is limited research identifying patients most likely to achieve all three. Objective/UNASSIGNED:The objective is to create a model predicting good 1-year postoperative realignment, quality of life, and clinical outcomes following CD surgery using baseline demographic, clinical, and radiographic factors. Methods/UNASSIGNED:Retrospective review of a multicenter CD database. CD patients were defined as having one of the following radiographic criteria: Cervical sagittal vertical axis (cSVA) >4 cm, cervical kyphosis/scoliosis >10°° or chin-brow vertical angle >25°. The outcome assessed was whether a patient achieved both a good radiographic and clinical outcome. The primary analysis was stepwise regression models which generated a dataset-specific prediction model for achieving a good radiographic and clinical outcome. Model internal validation was achieved by bootstrapping and calculating the area under the curve (AUC) of the final model with 95% confidence intervals. Results/UNASSIGNED:Seventy-three CD patients were included (61.8 years, 58.9% F). The final model predicting the achievement of a good overall outcome (radiographic and clinical) yielded an AUC of 73.5% and included the following baseline demographic, clinical, and radiographic factors: mild-moderate myelopathy (Modified Japanese Orthopedic Association >12), no pedicle subtraction osteotomy, no prior cervical spine surgery, posterior lowest instrumented vertebra (LIV) at T1 or above, thoracic kyphosis >33°°, T1 slope <16 and cSVA <20 mm. Conclusions/UNASSIGNED:Achievement of a positive outcome in radiographic and clinical outcomes following surgical correction of CD can be predicted with high accuracy using a combination of demographic, clinical, radiographic, and surgical factors, with the top factors being baseline cSVA <20 mm, no prior cervical surgery, and posterior LIV at T1 or above.
PMID: 34728988
ISSN: 0974-8237
CID: 5038072

Pelvic Incidence Affects Age-adjusted Alignment Outcomes in a Population of Adult Spinal Deformity

Passias, Peter G; Bortz, Cole A; Segreto, Frank A; Horn, Samantha R; Pierce, Katherine E; Manning, Jordan; Vasquez-Montes, Dennis; Diebo, Bassel; Lafage, Renaud; Lafage, Virginie
STUDY DESIGN/METHODS:A single-center retrospective cohort study. OBJECTIVE:The objective of this study was to assess the effects of patient height and pelvic incidence (PI) on age-adjusted alignment outcomes of surgical adult spinal deformity (ASD) patients. SUMMARY OF BACKGROUND DATA/BACKGROUND:Patient height and PI have yet to be evaluated for their individual effects on achieving age-adjusted alignment targets. METHODS:Surgical ASD patients were grouped by percentile (low: <25th; normative: 25th-75th; high: >75th) for height and PI. Correction groups were generated at postoperative follow-up for actual alignment compared with age-adjusted ideal values for pelvic tilt (PT), pelvic incidence minus lumbar lordosis mismatch (PI-LL), and sagittal vertical axis, and PI-adjusted ideal alignment values for sacral slope (SS), as derived from clinically relevant formulas. Means comparison tests assessed differences in rates of matching ideal alignment (±10 y threshold for age-adjusted targets; -7 to 5 degrees measured minus ideal for SS) across height and PI groups. RESULTS:Breakdown of all included 198 patients by PI group: low (25%, 38±11 degrees), normative (50%, 57±5 degrees), high (25%, 75±7 degrees). Breakdown of patient height groups: low (25%, 1.52±0.04 m), normative (50% 1.64±0.05 m), and high (25%, 1.79±0.06 m). Overall, 29% of patients met postoperative age-adjusted alignment targets for PT, 23% for PI-LL, and 25% for sagittal vertical axis. Overall, 26% of patients met PI-adjusted SS alignment. There were no differences across patient height groups in rates of achieving adjusted alignment target (all P>0.05). Patients with high PI reached age-adjusted ideal alignment for PT at a lower rate (16%) than patients with normative (33%) or low PI (33%, P=0.056). Of patients that matched at least 1 ideal alignment target, those with high PI showed inferior preoperative to postoperative changes in EuroQol 5-dimension questionnaire as compared with normative and low PI patients (P=0.015). CONCLUSIONS:Patients with high PI reached ideal postoperative age-adjusted PT alignment at a lower rate than patients with normative and low PI. Height had no impact on postoperative age-adjusted alignment outcomes. Current postoperative ideal alignment targets may warrant an adjustment to account for PI.
PMID: 32568861
ISSN: 2380-0194
CID: 4529202

Patients with psychiatric diagnoses have increased odds of morbidity and mortality in elective orthopedic surgery

Brown, Avery; Alas, Haddy; Bortz, Cole; Pierce, Katherine E; Vasquez-Montes, Dennis; Ihejirika, Rivka C; Segreto, Frank A; Haskel, Jonathan; Kaplan, Daniel James; Segar, Anand H; Diebo, Bassel G; Hockley, Aaron; Gerling, Michael C; Passias, Peter G
Psychiatric diagnoses (PD) present a significant burden on elective surgery patients and may have potentially dramatic impacts on outcomes. As ailments of the spine can be particularly debilitating, the effect of PD on outcomes was compared between elective spine surgery patients and other common elective orthopedic surgery procedures. This study included 412,777 elective orthopedic patients who were concurrently diagnosed with PD within the years 2005 to 2016. 30.2% of PD patients experienced a post-operative complication, compared to 25.1% for non-PD patients (p < 0.001). Mood Disorders (bipolar or depressive disorders) were the most commonly diagnosed PD for all elective Orthopedic procedures, followed by anxiety, then dementia (p < 0.001). Logistic regression analysis found PD to be a significant predictor of higher cost to charge ratio (CCR), length of stay (LOS), and death (all p < 0.001). Between, hand, elbow, and shoulder specialties, spine patients had the highest odds of increased CCR and unfavorable discharge, and the second highest odds of death (all p < 0.001).
PMID: 33485597
ISSN: 1532-2653
CID: 4766722

Effect of age-adjusted alignment goals and distal inclination angle on the fate of distal junctional kyphosis in cervical deformity surgery

Passias, Peter Gust; Horn, Samantha R; Lafage, Virginie; Lafage, Renaud; Smith, Justin S; Line, Breton G; Protopsaltis, Themistocles S; Soroceanu, Alex; Bortz, Cole; Segreto, Frank A; Ahmad, Waleed; Naessig, Sara; Pierce, Katherine E; Brown, Avery E; Alas, Haddy; Kim, Han Jo; Daniels, Alan H; Klineberg, Eric O; Burton, Douglas C; Hart, Robert A; Schwab, Frank J; Bess, Shay; Shaffrey, Christopher I; Ames, Christopher P
Background/UNASSIGNED:Age-adjusted alignment targets in the context of distal junctional kyphosis (DJK) development have yet to be investigated. Our aim was to assess age-adjusted alignment targets, reciprocal changes, and role of lowest instrumented level orientation in DJK development in cervical deformity (CD) patients. Methods/UNASSIGNED:CD patients were evaluated based on lowest fused level: cervical (C7 or above), upper thoracic (UT: T1-T6), and lower thoracic (LT: T7-T12). Age-adjusted alignment targets were calculated using published formulas for sagittal vertical axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), pelvic tilt (PT), T1 pelvic angle (TPA), and LL-thoracic kyphosis (TK). Outcome measures were cervical and global alignment parameters: Cervical SVA (cSVA), cervical lordosis, C2 slope, C2-T3 angle, C2-T3 SVA, TS-CL, PI-LL, PT, and SVA. Subanalysis matched baseline PI to assess age-adjusted alignment between DJK and non-DJK. Results/UNASSIGNED:< 0.05). The distribution of over/under corrected patients and the offset between actual and ideal alignment for SVA, PT, TPA, PI-LL, and LL-TK were similar between DJK and non-DJK patients. DJK patients requiring reoperation had worse postoperative changes in all cervical parameters and trended toward larger offsets for global parameters. Conclusion/UNASSIGNED:CD patients with severe baseline malalignment went on to develop postoperative DJK. Age-adjusted alignment targets did not capture differences in these populations, suggesting the need for cervical-specific goals.
PMID: 33850384
ISSN: 0974-8237
CID: 4875702

Atlantoaxial dislocation with congenital "sandwich fusion" in the craniovertebral junction: a retrospective case series of 70 patients

Tian, Yinglun; Xu, Nanfang; Yan, Ming; Passias, Peter G; Segreto, Frank A; Wang, Shenglin
BACKGROUND:In the setting of congenital C1 occipitalization and C2-3 fusion, significant strain is placed on the atlantoaxial joint. Vertebral fusion both above and below the atlantoaxial joint (i.e., a "sandwich") creates substantial instability. We retrospectively report on a case series of "sandwich fusion" atlantoaxial dislocation (AAD), describing the associated clinical characteristics and detailing surgical treatment. To the best of our knowledge, the present study is the largest investigation to date of this congenital subgroup of AAD. METHODS:Seventy consecutive patients with sandwich fusion AAD, from one senior surgeon, were retrospectively reviewed. The clinical features and the surgical treatment results were assessed using descriptive statistics. No funding sources or potential conflict of interest-associated biases exist. RESULTS:The mean patient age was 42.2 years (range: 5-77 years); 36 patients were male, and 34 were female. Fifty-eight patients (82.9%) had myelopathy, with Japanese Orthopaedic Association (JOA) scores ranging 4-16 (mean: 12.9). Cranial neuropathy was involved in 10 cases (14.3%). The most common presentation age group was 31 to 40 years (24 cases, 34.3%). Radiological findings revealed brainstem and/or cervical-medullar compression (58 cases, 82.9%), syringomyelia (16 cases, 22.9%), Chiari malformation (12 cases, 17.1%), cervical spinal stenosis (10 cases, 14.3%), high scapula deformity (1 case, 1.4%), os odontoideum (1 case, 1.4%), and dysplasia of the atlas (1 case, 1.4%). Computed tomography angiography was performed in 27 cases, and vertebral artery (VA) anomalies were identified in 14 cases (51.9%). All 70 patients underwent surgical treatment, without spinal cord or VA injury. Four patients (5.7%) suffered complications, including 1 wound infection, 1 screw loosening, and 2 cases of bulbar paralysis. In the 58 patients with myelopathy, the mean JOA score increased from 12.9 to 14.5. The average follow-up time was 50.5 months (range: 24-120 months). All 70 cases achieved solid atlantoaxial fusion at the final follow-up. CONCLUSIONS:Sandwich fusion AAD, a unique subgroup of AAD, has distinctive clinical features and associated malformations such as cervical-medullar compression, syringomyelia, and VA anomalies. Surgical treatment of AAD was associated with myelopathy improvement and minimal complication occurrence.
PMID: 33287792
ISSN: 1471-2474
CID: 4712442

Tethered Cord Syndrome in the United States Cluster Analysis of Presenting Anomalies and Associated

Horn, Samantha; Moses, Michael; Vasquez-Montes, Dennis; Hockley, Aaron; Poorman, Gregory; Bortz, Cole; Segreto, Frank; Brown, Avery; Pierce, Katherine; Alas, Haddy; Ihejirika, Yael; Moon, John; Varlotta, Christopher; Ge, David; Vira, Shaleen; Diebo, Bassel; De la Garza Ramos, Rafael; Lafage, Renaud; Lafage, Virginie; Sciubba, Daniel; Raad, Micheal; Nikas, Dimitrios; Passias, Peter
PURPOSE/OBJECTIVE:Tethered cord syndrome (TCS) is an occult spinal dysraphism that includes low lying conus, tight filum terminale, lipomeningomyelocele, split cord malformations, dermal sinus tracts, and dermoids. This congenital disorder has been associated with musculoskeletal, neurological, and gastrointestinal abnormalities. This study presents a retrospective review of the prospectively collected data of TCS patients and their concurrent diagnoses or associated anomalies. METHODS:The National Inpatient Sample (NIS) database from 2003 to 2012 was used for data collection. Hospital- and year-adjusted weights allowed for accurate assessment of the incidence of TCS, as well as cardiac and gastrointestinal (GI) and genitourinary (GU) anomalies. K-means clustering analysis was run to discover patterns of concurrent cardiac, GI, GU, and other system anomalies in TCS patients. RESULTS:A total of 13,470 discharges with a diagnosis of TCS were identified in the NIS database, and at least one additional anomaly was identified in 40.7% of TCS patients. The most common secondary anomalies by system were: spine (24.48%), cardiac (6.27%), and urinary (5.37%). For patients with multiple anomalies, the most common combinations were GI and cardiac (4.55%), urinary and GI (4.26%), and urinary and cardiac (4.19%). The most common spinal association was spina bifida (13.65%). The most common neurological or musculoskeletal anomaly was any VACTERL association (13.45%). The top relation in GI and GU anomalies was cervix and female genitalia anomalies (69.1%). The most common specific anomalies were spina bifida, large intestine atresia, Rubenstein-Taybi syndrome, and atrial and ventral septal defects. CONCLUSION/CONCLUSIONS:This study provides a nationwide prospective on congenital anomalies and concurrent conditions present in tethered cord syndrome patients in the United States and demonstrates that 40.7% of TCS patients have at least one associated anomaly. The most common congenital anomalies studied were spina bifida, urogenital with or without cardiac septal defects, and cystourethral anomaly or cystic kidney disease with or without large intestinal atresia.
PMID: 32857021
ISSN: 2328-5273
CID: 4586972

107. Effect of osteoporosis and bisphosphonate on reoperations in adult spinal deformity [Meeting Abstract]

Ahmad, W; Bell, J; Pierce, K E; Naessig, S; Segreto, F A; Vira, S N; Lafage, V; Paulino, C B; Schoenfeld, A J; Diebo, B G; Hassanzadeh, H; Passias, P G
BACKGROUND CONTEXT: Adult spinal deformity is a complex pathology that often requires challenging surgical intervention for treatment. In patients with osteoporosis, there may be increased risk of complications and reoperations. Our study aimed to evaluate the effect of treating osteoporosis patients with bisphosphonate preoperatively on future reoperations. PURPOSE: Investigate the effect of preoperative bisphosphonate on osteoporosis patients undergoing corrective surgery for adult spinal deformity. STUDY DESIGN/SETTING: Retrospective review of the PearlDiver database between the years 2008-2015. PATIENT SAMPLE: This study included 2,842 adult spinal deformity patients. OUTCOME MEASURES: Ninety-day complications, reoperations.
METHOD(S): Adult spinal deformity patients undergoing a fusion were isolated using ICD-9 CM and CPT codes in the PearlDiver database between the years 2008-2015. Patients were stratified based on diagnosis of osteoporosis and whether there was a filled prescription for bisphosphonate 6 months prior to surgery. ASD patients with osteoporosis and bisphosphonate use who underwent corrective intervention were compared with age- and sex-matched cohorts of osteoporotic and nonosteoporotic controls with no bisphosphonate prescriptions. Means comparison tests compared differences in demographics, comorbidities, 90-day complications, and 2Y reoperation rates. Logistic regression analysis assessed the odds of complication and reoperations controlling for age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was set p<0.05.
RESULT(S): A total of 2,842 operative adult spinal deformity patients were isolated. Four hundred and six patients had osteoporosis and bisphosphonate use, 807 osteoporosis with no bisphosphonate use, and 1,629 non-osteoporosis patients. At baseline, osteoporosis patients had higher rates of obesity, diabetes, hyperlipidemia, and peripheral vascular disease compared to osteoporotic bisphosphonate cohort. There were no differences in 90-day complication rates or 2Y reoperations rates between osteoporosis bisphosphonate users and osteoporosis controls (p>0.05). Compared to nonosteoporotic patients, osteoporosis patients with bisphosphonate use trended toward lower rates of revisions at 1Y (5% vs 7%) and 2Y (7% vs 8%, both p>0.05).
CONCLUSION(S): In a matched cohort, osteoporosis patients treated preoperatively with bisphosphonates trended towards lower rates of revisions two years postoperatively compared to nonosteoporotic controls. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
ISSN: 1878-1632
CID: 4597322

22. Risk of surgical intervention is nearly normalized following coronary artery bypass grafting in spinal surgery with key exceptions [Meeting Abstract]

Ahmad, W; Bell, J; Pierce, K E; Naessig, S; Segreto, F A; Vira, S N; Lafage, V; Paulino, C B; Schoenfeld, A J; Diebo, B G; Hassanzadeh, H; Passias, P G
BACKGROUND CONTEXT: The risk assessment of elective spine fusion patients with a previous history of cardiac intervention, particularly a coronary artery bypass graft (CABG), has been understudied. This study aimed to assess postoperative outcomes of elective spine fusion patients with a prior history of single- to multilevel coronary artery bypass grafting. PURPOSE: Investigate effect of revascularization on 30-day and 90-day outcomes in elective spine fusion patients. STUDY DESIGN/SETTING: Retrospective review of the PearlDiver database between the years 2006-2013. PATIENT SAMPLE: A total of 733,007 elective spine fusion patients. OUTCOME MEASURES: Comorbidity burden, 30-day and 90-day complications (myocardial infarction, pneumonia, sepsis, death, would complications, transfusions), readmission.
METHOD(S): Elective spine fusion patients were isolated with ICD-9 and CPT procedures codes in the PearlDiver database. Patients were stratified by number of coronary arteries grafted during a coronary artery bypass grafting procedure prior to spine fusion: (1) 1-2 grafts (G12); (2) 3-4 grafts (G34); (3) no grafts. Means comparison tests compared differences in demographics, diagnoses, comorbidities, and 30-day complication outcomes. Logistic regression assessed the odds of complication associated with number of arteries grafted, controlling for levels fused, age, sex, and comorbidities (odds ratio [95% confidence interval]).
RESULT(S): A total of 733,007 elective spine fusion patients were isolated;723,606 pts had no grafts, 5,356 were G12, and 4,045 were G34. G12 patients at baseline had higher rates of morbid obesity, PVD, chronic kidney disease, CHF, and COPD (p<0.001). Relative to no graft patients, G12 patients had higher rates of pneumonia, CVA, myocardial infaraction (MI), sepsis, and death 30-days postoperatively (all p<0.05). Compared to no graft patients, G34 had increased rates of pneumonia, CVA, MI, and sepsis 30 days postoperatively. Comparing G12 to G34 pts, there were no significant differences in 30-day major or minor complications (p>0.05). Overall, G34 patients had higher rates of 30-day and 90-day readmissions (p<0.05).
CONCLUSION(S): Compared to patients who had no history of cardiac intervention, patients who had single or multivessel coronary artery bypass graft had an increase in 30-day complications. However, comparing between groups that had 1-2 or 3-4 level grafts, there were no significant differences in major and minor complications 30 days postoperatively. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
ISSN: 1878-1632
CID: 4597332