Publications by authors named "Christopher Ames"

522 Publications

Quantitative Analysis of Neural Foramina in the Lumbar Spine: An Imaging Informatics and Machine Learning Study.

Radiol Artif Intell 2019 Mar 6;1(2):180037. Epub 2019 Mar 6.

Departments of Neurosurgery (B.G., J.B., D.V., C. Ahn, M.E., M.A., D.B., L.M.), Radiological Sciences (J.P.V., N.S., A.B.), and Electrical Engineering (S.M.), University of California, Los Angeles, 300 Stein Plaza, Suite 554E, Los Angeles, CA 90095; and Department of Neurosurgery, University of California, San Francisco, San Francisco, Calif (C. Ames).

Purpose: To use machine learning tools and leverage big data informatics to statistically model the variation in the area of lumbar neural foramina in a large asymptomatic population.

Materials And Methods: By using an electronic health record and imaging archive, lumbar MRI studies in 645 male (mean age, 50.07 years) and 511 female (mean age, 48.23 years) patients between 20 and 80 years old were identified. Machine learning algorithms were used to delineate lumbar neural foramina autonomously and measure their areas. The relationship between neural foraminal area and patient age, sex, and height was studied by using multivariable linear regression.

Results: Neural foraminal areas correlated directly with patient height and inversely with patient age. The associations involved were statistically significant ( < .01).

Conclusion: By using machine learning and big data techniques, a linear model encoding variation in lumbar neural foraminal areas in asymptomatic individuals has been established. This model can be used to make quantitative assessments of neural foraminal areas in patients by comparing them to the age-, sex-, and height-adjusted population averages.© RSNA, 2019
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http://dx.doi.org/10.1148/ryai.2019180037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8017393PMC
March 2019

Operative versus nonoperative treatment for adult symptomatic lumbar scoliosis at 5-year follow-up: durability of outcomes and impact of treatment-related serious adverse events.

J Neurosurg Spine 2021 Apr 30:1-13. Epub 2021 Apr 30.

2Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri.

Objective: Although short-term adult symptomatic lumbar scoliosis (ASLS) studies favor operative over nonoperative treatment, longer outcomes are critical for assessment of treatment durability, especially for operative treatment, because the majority of implant failures and nonunions present between 2 and 5 years after surgery. The objectives of this study were to assess the durability of treatment outcomes for operative versus nonoperative treatment of ASLS, to report the rates and types of associated serious adverse events (SAEs), and to determine the potential impact of treatment-related SAEs on outcomes.

Methods: The ASLS-1 (Adult Symptomatic Lumbar Scoliosis-1) trial is an NIH-sponsored multicenter prospective study to assess operative versus nonoperative ASLS treatment. Patients were 40-80 years of age and had ASLS (Cobb angle ≥ 30° and Oswestry Disability Index [ODI] ≥ 20 or Scoliosis Research Society [SRS]-22 subscore ≤ 4.0 in the Pain, Function, and/or Self-Image domains). Patients receiving operative and nonoperative treatment were compared using as-treated analysis, and the impact of related SAEs was assessed. Primary outcome measures were ODI and SRS-22.

Results: The 286 patients with ASLS (107 with nonoperative treatment, 179 with operative treatment) had 2-year and 5-year follow-up rates of 90% (n = 256) and 74% (n = 211), respectively. At 5 years, compared with patients treated nonoperatively, those who underwent surgery had greater improvement in ODI (mean difference -15.2 [95% CI -18.7 to -11.7]) and SRS-22 subscore (mean difference 0.63 [95% CI 0.48-0.78]) (p < 0.001), with treatment effects (TEs) exceeding the minimum detectable measurement difference (MDMD) for ODI (7) and SRS-22 subscore (0.4). TEs at 5 years remained as favorable as 2-year TEs (ODI -13.9, SRS-22 0.52). For patients in the operative group, the incidence rates of treatment-related SAEs during the first 2 years and 2-5 years after surgery were 22.38 and 8.17 per 100 person-years, respectively. At 5 years, patients in the operative group who had 1 treatment-related SAE still had significantly greater improvement, with TEs (ODI -12.2, SRS-22 0.53; p < 0.001) exceeding the MDMD. Twelve patients who received surgery and who had 2 or more treatment-related SAEs had greater improvement than nonsurgically treated patients based on ODI (TE -8.34, p = 0.017) and SRS-22 (TE 0.32, p = 0.029), but the SRS-22 TE did not exceed the MDMD.

Conclusions: The significantly greater improvement of operative versus nonoperative treatment for ASLS at 2 years was durably maintained at the 5-year follow-up. Patients in the operative cohort with a treatment-related SAE still had greater improvement than patients in the nonoperative cohort. These findings have important implications for patient counseling and future cost-effectiveness assessments.
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http://dx.doi.org/10.3171/2020.9.SPINE201472DOI Listing
April 2021

Lowest Instrumented Vertebra Selection to S1 or Ilium Versus L4 or L5 in Adult Spinal Deformity: Factors for Consideration in 349 Patients With a Mean 46-Month Follow-Up.

Global Spine J 2021 Apr 28:21925682211009178. Epub 2021 Apr 28.

Spine Service, Hospital for Special Surgery, New York, NY, USA.

Study Design: Retrospective cohort study.

Objective: To compare the outcomes of patients with adult spinal deformity (ASD) following spinal fusion with the lowest instrumented vertebra (LIV) at L4/L5 versus S1/ilium.

Methods: A multicenter ASD database was evaluated. Patients were categorized into 2 groups based on LIV levels-groups L (fusion to L4/L5) and S (fusion to S1/ilium). Both groups were propensity matched by age and preoperative radiographic alignments. Patient demographics, operative details, radiographic parameters, revision rates, and health-related quality of life (HRQOL) scores were compared.

Results: Overall, 349 patients had complete data, with a mean follow-up of 46 months. Patients in group S (n = 311) were older and had larger sagittal and coronal plane deformities than those in group L (n = 38). After matching, 28 patients were allocated to each group with similar demographic, radiographic, and clinical parameters. Sagittal alignment restoration at postoperative week 6 was significantly better in group S than in group L, but it was similar in both groups at the 2-year follow-up. Fusion to S1/ilium involved a longer operating time, higher PJK rates, and greater PJK angles than that to L4/L5. There were no significant differences in the complication and revision rates between the groups. Both groups showed significant improvements in HRQOL scores.

Conclusions: Fusion to S1/ilium had better sagittal alignment restoration at postoperative week 6 and involved higher PJK rates and greater PJK angles than that to L4/L5. The clinical outcomes and rates of revision surgery and complications were similar between the groups.
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http://dx.doi.org/10.1177/21925682211009178DOI Listing
April 2021

Artificial intelligence clustering of adult spinal deformity sagittal plane morphology predicts surgical characteristics, alignment, and outcomes.

Eur Spine J 2021 Apr 15. Epub 2021 Apr 15.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Alpert Medical School, Providence, Rhode Island, 1 Kettle Point Avenue, East Providence, RI, 02914, USA.

Purpose: AI algorithms have shown promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics-this study sought to complement these efforts by analyzing images of sagittal anatomical spinopelvic landmarks. We hypothesized that an AI algorithm would cluster preoperative lateral radiographs into groups with distinct morphology.

Methods: This was a retrospective review of a multicenter, prospectively collected database of adult spinal deformity. A total of 915 patients with adult spinal deformity and preoperative lateral radiographs were included. A 2 × 3, self-organizing map-a form of artificial neural network frequently employed in unsupervised classification tasks-was developed. The mean spine shape was plotted for each of the six clusters. Alignment, surgical characteristics, and outcomes were compared.

Results: Qualitatively, clusters C and D exhibited only mild sagittal plane deformity. Clusters B, E, and F, however, exhibited marked positive sagittal balance and loss of lumbar lordosis. Cluster A had mixed characteristics, likely representing compensated deformity. Patients in clusters B, E, and F disproportionately underwent 3-CO. PJK and PJF were particularly prevalent among clusters A and E. Among clusters B and F, patients who experienced PJK had significantly greater positive sagittal balance than those who did not.

Conclusions: This study clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology and association with sagittal alignment parameters, baseline HRQOL, and surgical characteristics. The relationship between SVA and PJK differed by cluster. This study represents significant progress toward incorporation of computer vision into clinically relevant classification systems in adult spinal deformity.

Level Of Evidence Iv: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.
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http://dx.doi.org/10.1007/s00586-021-06799-zDOI Listing
April 2021

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

J Craniovertebr Junction Spine 2021 Jan-Mar;12(1):65-71. Epub 2021 Mar 4.

Department of Neurological Surgery, University of California, San Francisco, CA, USA.

Background: 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: 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: Seventy-six CD patients included. By 1Y, 20 patients developed DJK. Non-DJK patients had 27% cervical lowest instrumented vertebra (LIV), 68% UT, and 5% LT. DJK patients had 25% cervical, 50% UT, and 25% LT. There were no baseline or 1Y differences for PI, PI-LL, SVA, TPA, or PT for actual and age-adjusted targets. DJK patients had worse baseline cSVA and more severe 1Y cSVA, C2-T3 SVA, and C2 slope ( < 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: 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.
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http://dx.doi.org/10.4103/jcvjs.JCVJS_170_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8035585PMC
March 2021

Patient-related and radiographic predictors of inferior health-related quality-of-life measures in adult patients with nonoperative spinal deformity.

J Neurosurg Spine 2021 Apr 2:1-7. Epub 2021 Apr 2.

3Department of Orthopedics, Hospital for Special Surgery, New York, New York.

Objective: Patients with nonoperative (N-Op) adult spinal deformity (ASD) have inferior long-term spinopelvic alignment and clinical outcomes. Predictors of lower quality-of-life measures in N-Op populations have yet to be sufficiently investigated. The aim of this study was to identify patient-related factors and radiographic parameters associated with inferior health-related quality-of-life (HRQOL) scores in N-Op ASD patients.

Methods: N-Op ASD patients with complete radiographic and outcome data at baseline and 2 years were included. N-Op patients and operative (Op) patients were propensity score matched for baseline disability and deformity. Patient-related factors and radiographic alignment parameters (pelvic tilt [PT], sagittal vertical axis [SVA], pelvic incidence [PI]-lumbar lordosis [LL] mismatch, mismatch between cervical lordosis and T1 segment slope [TS-CL], cervical-thoracic pelvic angle [PA], and others) at baseline and 2 years were analyzed as predictors for moderate to severe 2-year Oswestry Disability Index (ODI > 20) and failing to meet the minimal clinically importance difference (MCID) for 2-year Scoliosis Research Society Outcomes Questionnaire (SRS) scores (< 0.4 increase from baseline). Conditional inference decision trees identified predictors of each HRQOL measure and established cutoffs at which factors have a global effect. Random forest analysis (RFA) generated 5000 conditional inference trees to compute a variable importance table for top predictors of inferior HRQOL. Statistical significance was set at p < 0.05.

Results: Six hundred sixty-two patients with ASD (331 Op patients and 331 N-Op patients) with complete radiographic and HRQOL data at their 2-year follow-up were included. There were no differences in demographics, ODI, and Schwab deformity modifiers between groups at baseline (all p > 0.05). N-Op patients had higher 2-year ODI scores (27.9 vs 20.3, p < 0.001), higher rates of moderate to severe disability (29.3% vs 22.4%, p = 0.05), lower SRS total scores (3.47 vs 3.91, p < 0.001), and higher rates of failure to reach SRS MCID (35.3% vs 15.7%, p < 0.001) than Op patients at 2 years. RFA ranked the top overall predictors for moderate to severe ODI at 2 years for N-Op patients as follows: 1) frailty index > 2.8, 2) BMI > 35 kg/m2, T4PA > 28°, and 4) Charlson Comorbidity Index > 1. Top radiographic predictors were T4PA > 28° and C2-S1 SVA > 93 mm. RFA also ranked the top overall predictors for failure to reach 2-year SRS MCID for N-Op patients, as follows: 1) T12-S1 lordosis > 53°, 2) cervical SVA (cSVA) > 28 mm, 3) C2-S1 angle > 14.5°, 4) TS-CL > 12°, and 5) PT > 23°. The top radiographic predictors were T12-S1 Cobb angle, cSVA, C2-S1 angle, and TS-CL.

Conclusions: When controlling for baseline deformity in N-Op versus Op patients, subsequent deterioration in frailty, BMI, and radiographic progression over a 2-year follow-up were found to drive suboptimal patient-reported outcome measures in N-Op cohorts as measured by validated ODI and SRS clinical instruments.
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http://dx.doi.org/10.3171/2020.9.SPINE20519DOI Listing
April 2021

Adult Spinal Deformity Surgery and Frailty: A Systematic Review.

Global Spine J 2021 Mar 26:21925682211004250. Epub 2021 Mar 26.

McGill University Faculty of Medicine, Scoliosis and Spinal Research Unit, Montreal, Quebec, Canada.

Study Design: Systematic review.

Objectives: Adult spinal deformity (ASD) can be a debilitating condition with a profound impact on patients' health-related quality of life (HRQoL). Many reports have suggested that the frailty status of a patient can have a significant impact on the outcome of the surgery. The present review aims to identify all pre-operative patient-specific frailty markers that are associated with postoperative outcomes following corrective surgery for ASD of the lumbar and thoracic spine.

Methods: A systematic review of the literature was performed to identify findings regarding pre-operative markers of frailty and their association with postoperative outcomes in patients undergoing ASD surgery of the lumbar and thoracic spine. The search was performed in the following databases: PubMed, Embase, Cochrane and CINAHL.

Results: An association between poorer performance on frailty scales and worse postoperative outcomes. Comorbidity indices were even more frequently employed with similar patterns of association between increased comorbidity burden and postoperative outcomes. Regarding the assessment of HRQoL, worse pre-operative ODI, SF-36, SRS-22 and NRS were shown to be predictors of post-operative complications, while ODI, SF-36 and SRS-22 were found to improve post-operatively.

Conclusions: The findings of this review highlight the true breadth of the concept of "frailty" in ASD surgical correction. These parameters, which include frailty scales and various comorbidity and HRQoL indices, highlight the importance of identifying these factors preoperatively to ensure appropriate patient selection while helping to limit poor postoperative outcomes.
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http://dx.doi.org/10.1177/21925682211004250DOI Listing
March 2021

Timing of conversion to cervical malalignment and proximal junctional kyphosis following surgical correction of adult spinal deformity: a 3-year radiographic analysis.

J Neurosurg Spine 2021 Mar 19:1-9. Epub 2021 Mar 19.

2Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York.

Objective: The goal of this study was to assess the conversion rate from baseline cervical alignment to postoperative cervical deformity (CD) and the corresponding proximal junctional kyphosis (PJK) rate in patients undergoing thoracolumbar adult spinal deformity (ASD) surgery.

Methods: The operative records of patients with ASD with complete radiographic data beginning at baseline up to 3 years were included. Patients with no baseline CD were postoperatively stratified by Ames CD criteria (T1 slope-cervical lordosis mismatch [TS-CL] > 20°, cervical sagittal vertical axis [cSVA] > 40 mm), where CD was defined as fulfilling one or more of the Ames criteria. Severe CD was defined as TS-CL > 30° or cSVA > 60 mm. Follow-up intervals were established after ASD surgery, with 6 weeks postoperatively defined as early; 6 weeks-1 year as intermediate; 1-2 years as late; and 2-3 years as long-term. Descriptive analyses and McNemar tests identified the CD conversion rate, PJK rate (< -10° change in uppermost instrumented vertebra and the superior endplate of the vertebra 2 levels superior to the uppermost instrumented vertebra), and specific alignment parameters that converted.

Results: Two hundred sixty-six patients who underwent ASD surgery (mean age 59.7 years, 77.4% female) met the inclusion criteria; 103 of these converted postoperatively, and the remaining 163 did not meet conversion criteria. Thirty-eight patients converted to CD early, 26 converted at the intermediate time point, 29 converted late, and 10 converted in the long-term. At conversion, the early group had the highest mean TS-CL at 25.4° ± 8.5° and the highest mean cSVA at 33.6 mm-both higher than any other conversion group. The long-term group had the highest mean C2-7 angle at 19.7° and the highest rate of PJK compared to other groups (p = 0.180). The early group had the highest rate of conversion to severe CD, with 9 of 38 patients having severe TS-CL and only 1 patient per group converting to severe cSVA. Seven patients progressed from having only malaligned TS-CL at baseline (with normal cSVA) to CD with both malaligned TS-CL and cSVA by 6 weeks. Conversely, only 2 patients progressed from malaligned cSVA to both malaligned cSVA and TS-CL. By 1 year, the former number increased from 7 to 26 patients, and the latter increased from 2 to 20 patients. The revision rate was highest in the intermediate group at 48.0%, versus the early group at 19.2%, late group at 27.3%, and long-term group at 20% (p = 0.128). A higher pelvic incidence-lumbar lordosis mismatch, lower thoracic kyphosis, and a higher thoracic kyphosis apex immediately postoperatively significantly predicted earlier rather than later conversion (all p < 0.05). Baseline lumbar lordosis, pelvic tilt, and sacral slope were not significant predictors.

Conclusions: Patients with ASD with normative cervical alignment who converted to CD after thoracolumbar surgery had varying radiographic findings based on timing of conversion. Although the highest number of patients converted within 6 weeks postoperatively, patients who converted in the late or long-term follow-up intervals had higher rates of concurrent PJK and greater radiographic progression.
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http://dx.doi.org/10.3171/2020.8.SPINE20320DOI Listing
March 2021

Appropriate Risk Stratification and Accounting for Age-Adjusted Reciprocal Changes in the Thoracolumbar Spine Reduces the Incidence and Magnitude of Distal Junctional Kyphosis in Cervical Deformity Surgery.

Spine (Phila Pa 1976) 2021 Mar 11. Epub 2021 Mar 11.

Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA Department of Orthopedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA Department of Orthopaedic Surgery, Rocky Mountain Scoliosis and Spine, Denver, CO Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA Department of Orthopedic Surgery, University of California, Davis, Davis, CA, USA Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA San Diego Center for Spinal Disorders, La Jolla, CA, USA Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA.

Study Design: Retrospective cohort study of a prospective cervical deformity (CD) database.

Objective: Identify factors associated with Distal Junctional Kyphosis (DJK); assess differences across DJK types.

Summary Of Background Data: DJK may develop as compensation for mal-correction of sagittal deformity in the thoracic curve. There is limited understanding of DJK drivers, especially for different DJK types.

Methods: Included: patients with pre- and postoperative clinical/radiographic data. Excluded: patients with previous fusion to L5 or below. DJK was defined per surgeon note or DJK angle (kyphosis from LIV to LIV-2)<-10°, and pre- to postoperative change in DJK angle by<-10°. Age-specific target LL-TK alignment was calculated as published. Offset from target LL-TK was correlated to DJK magnitude and inclination. DJK types: severe (DJK<-20°), progressive (DJK increase>4.4°), symptomatic (reoperation or published disability thresholds of NDI ≥ 24 or mJOA≤14). Random forest identified factors associated with DJK. Means comparison tests assessed differences.

Results: Included: 136 CD patients (61 ± 10yrs, 61%F). DJK rate was 30%. Postop offset from ideal LL-TK correlated with greater DJK angle (r = 0.428) and inclination of the distal end of the fusion construct (r = 0.244, both p < 0.02). Seven of the top 15 factors associated with DJK were radiographic, four surgical, and four clinical. Breakdown by type: severe (22%), progressive (24%), symptomatic (61%). Symptomatic had more posterior osteotomies than asymptomatic (p = 0.018). Severe had worse NDI and upper-cervical deformity (CL, C2 slope, C0-C2), as well as more posterior osteotomies than non-severe (all p < 0.01). Progressive had greater malalignment both globally and in the cervical spine (all p < 0.03) than static. Each type had varying associated factors.

Conclusion: Offset from age-specific alignment is associated with greater DJK and more anterior distal construct inclination, suggesting DJK may develop due to inappropriate realignment. Preoperative clinical and radiographic factors are associated with symptomatic and progressive DJK, suggesting the need for preoperative risk stratification.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004033DOI Listing
March 2021

Accuracy of Rod Contouring to Desired Angles With and Without a Template: Implications for Achieving Desired Spinal Alignment and Outcomes.

Global Spine J 2021 Feb 25:2192568221998371. Epub 2021 Feb 25.

Department of Neurosurgery, 2358University of Virginia, Charlottesville, VA, USA.

Study Design: Biomechanical Study.

Objective: The search for optimal spinal alignment has led to the development of sophisticated formulas and software for preoperative planning. However, preoperative plans are not always appropriately executed since rod contouring during surgery is often subjective and estimated by the surgeon. We aimed to assess whether rods contoured to specific angles with a French rod bender using a template guide will be more accurate than rods contoured without a template.

Methods: Ten experienced spine surgeons were requested to contour two 125 × 5.5 mm Ti64 rods to 40°, 60° and 80° without templates and then 2 more rods using 2D metallic templates with the same angles. Rod angles were then measured for accuracy and compared.

Results: Average angles for rods bent without a template to 40°, 60° and 80° were 60.2°, 78.9° and 97.5°, respectively. Without a template, rods were overbent by a mean of 18.9°. When using templates of 40°, 60° and 80°, mean bend angles were 41.5°, 59.1° and 78.7°, respectively, with an average underbend of 0.2°. Differences between the template and non-template groups for each target angle were all significant (p < 0.001).

Conclusions: Without the template, surgeons tend to overbend rods compared to the desired angle, while surgeons improved markedly with a template guide. This tendency to overbend could have significant impact on patient outcomes and risk of proximal junctional failure and warrants further research to better enable surgeons to more accurately execute preoperative alignment plans.
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http://dx.doi.org/10.1177/2192568221998371DOI Listing
February 2021

Baseline Frailty Status Influences Recovery Patterns and Outcomes Following Alignment Correction of Cervical Deformity.

Neurosurgery 2021 Feb 20. Epub 2021 Feb 20.

Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.

Background: Frailty severity may be an important determinant for impaired recovery after cervical spine deformity (CD) corrective surgery.

Objective: To evaluate postop clinical recovery among CD patients between frailty states undergoing primary procedures.

Methods: Patients >18 yr old undergoing surgery for CD with health-related quality of life (HRQL) data at baseline, 3-mo, and 1-yr postoperative were identified. Patients were stratified by the modified CD frailty index scale from 0 to 1 (no frailty [NF] <0.3, mild/severe fraily [F] >0.3). Patients in NF and F groups were propensity score matched for TS-CL (T1 slope [TS] minus angle between the C2 inferior end plate and the C7 inferior end plate [CL]) to control for baseline deformity. Area under the curve was calculated for follow-up time intervals determining overall normalized, time-adjusted HRQL outcomes; Integrated Health State (IHS) was compared between NF and F groups.

Results: A total of 106 CD patients were included (61.7 yr, 66% F, 27.7 kg/m2)-by frailty group: 52.8% NF, 47.2% F. After propensity score matching for TS-CL (mean: 38.1°), 38 patients remained in each of the NF and F groups. IHS-adjusted HRQL outcomes from baseline to 1 yr showed a significant difference in Euro-Qol 5 Dimension scores (NF: 1.02, F: 1.07, P = .016). No significant differences were found in the IHS Neck Disability Index (NDI) and modified Japanese Orthopedic Association between frailty groups (P > .05). F patients had more postop major complications (31.3%) compared to the NF (8.9%), P = .004, though DJK occurrence and reoperation between the groups was not significant.

Conclusion: While all groups exhibited improved postop disability and pain scores, frail patients experienced greater amount of improvement in overall health state compared to baseline disability. This signifies that with frailty severity, patients have more room for improvement postop compared to baseline quality of life.
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http://dx.doi.org/10.1093/neuros/nyab039DOI Listing
February 2021

Predictors of Superior Recovery Kinetics in Adult Cervical Deformity Correction: An Analysis Using a Novel Area Under the Curve Methodology.

Spine (Phila Pa 1976) 2021 05;46(9):559-566

Department of Neurosurgery, University of Virginia, Charlottesville, VA.

Study Design: Retrospective review of a prospective database.

Objective: The aim of this study was to identify demographic, surgical, and radiographic factors that predict superior recovery kinetics following cervical deformity (CD) corrective surgery.

Summary Of Background Data: Analyses of CD corrective surgery use area under the curve (AUC) to assess health-related quality of life (HRQL) metrics throughout recovery.

Methods: Outcome measures were baseline (BL) to 1-year (1Y) health-related quality of life (HRQL) (Neck Disability Index [NDI]). CD criteria were C2-7 Cobb angle >10°, coronal Cobb angle >10°, C2-C7 sagittal vertical axis (cSVA) >4 cm, TS-CL >10°, or chin-brow vertical angle >25°. AUC normalization divided BL and postoperative outcomes by BL. Normalized scores (y axis) were plotted against follow-up (x axis). AUC was calculated and divided by cumulative follow-up length to determine overall, time-adjusted recovery (Integrated Health State [IHS]). IHS NDI was stratified by quartile, uppermost 25% being "Superior" Recovery Kinetics (SRK) versus "Normal" Recovery Kinetics (NRK). BL demographic, clinical, and surgical information predicted SRK using generalized linear modeling.

Results: Ninety-eight patients included (62 ± 10 years, 28 ± 6 kg/m2, 65% females, Charlson Comorbidity Index: 0.95), 6% smokers, 31% smoking history. Surgical approach was: combined (33%), posterior (49%), anterior (18%). Posterior levels fused: 8.7, anterior: 3.6, estimated blood loss: 915.9ccs, operative time: 495 minutes. Ames BL classification: cSVA (53.2% minor deformity, 46.8% moderate), TS-CL (9.8% minor, 4.3% moderate, 85.9% marked), horizontal gaze (27.4% minor, 46.6% moderate, 26% marked). Relative to BL NDI (Mean: 47), normalized NDI decreased at 3 months (0.9 ± 0.5, P = 0.260) and 1Y (0.78 ± 0.41, P < 0.001). NDI IHS correlated with age (P = 0.011), sex (P = 0.042), anterior approach (P = 0.042), posterior approach (P = 0.042). Greater BL pelvic tilt (PT) (SRK: 25.6°, NRK: 17°, P = 0.002), pelvic incidence-lumbar lordosis (PI-LL) (SRK: 8.4°, NRK: -2.8°, P = 0.009), and anterior approach (SRK: 34.8%, NRK: 13.3%; P = 0.020) correlated with SRK. 69.4% met MCID for NDI (<Δ-15) and 63.3% met substantial clinical benefit for NDI (<Δ-10); 100% of SRK met both MCID and substantial clinical benefit. The predictive model for SRK included (AUC = 88.1%): BL visual analog scale (VAS) EuroQol five-dimensional descriptive system (EQ5D) (odds rario [OR] 0.96, 95% confidence interval [CI]: 0.92-0.99), BL swallow sleep score (OR: 1.04, 95% CI: 1.01-1.06), BL PT (OR: 1.12, 95% CI: 1.03-1.22), BL modified Japanese Orthopedic Association scale (mJOA) (OR: 1.5, 95% CI: 1.07-2.16), BL T4-T12, BL T10-L2, BL T12-S1, and BL L1-S1.

Conclusion: Superior recovery kinetics following CD surgery was predicted with high accuracy using BL patient-reported (VAS EQ5D, swallow sleep, mJOA) and radiographic factors (PT, TK, T10-L2, T12-S1, L1-S1). Awareness of these factors can improve decision-making and reduce postoperative neck disability.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003971DOI Listing
May 2021

Surgical outcomes in rigid versus flexible cervical deformities.

J Neurosurg Spine 2021 Feb 12:1-9. Epub 2021 Feb 12.

13Department of Neurological Surgery, University of California, San Francisco, California.

Objective: Cervical deformity (CD) patients have severe disability and poor health status. However, little is known about how patients with rigid CD compare with those with flexible CD. The main objectives of this study were to 1) assess whether patients with rigid CD have worse baseline alignment and therefore require more aggressive surgical corrections and 2) determine whether patients with rigid CD have similar postoperative outcomes as those with flexible CD.

Methods: This is a retrospective review of a prospective, multicenter CD database. Rigid CD was defined as cervical lordosis (CL) change < 10° between flexion and extension radiographs, and flexible CD was defined as a CL change ≥ 10°. Patients with rigid CD were compared with those with flexible CD in terms of cervical alignment and health-related quality of life (HRQOL) at baseline and at multiple postoperative time points. The patients were also compared in terms of surgical and intraoperative factors such as operative time, blood loss, and number of levels fused.

Results: A total of 127 patients met inclusion criteria (32 with rigid and 95 with flexible CD, 63.4% of whom were females; mean age 60.8 years; mean BMI 27.4); 47.2% of cases were revisions. Rigid CD was associated with worse preoperative alignment in terms of T1 slope minus CL, T1 slope, C2-7 sagittal vertical axis (cSVA), and C2 slope (C2S; all p < 0.05). Postoperatively, patients with rigid CD had an increased mean C2S (29.1° vs 22.2°) at 3 months and increased cSVA (47.1 mm vs 37.5 mm) at 1 year (p < 0.05) compared with those with flexible CD. Patients with rigid CD had more posterior levels fused (9.5 vs 6.3), fewer anterior levels fused (1 vs 2.0), greater blood loss (1036.7 mL vs 698.5 mL), more 3-column osteotomies (40.6% vs 12.6%), greater total osteotomy grade (6.5 vs 4.5), and mean osteotomy grade per level (3.3 vs 2.1) (p < 0.05 for all). There were no significant differences in baseline HRQOL scores, the rate of distal junctional kyphosis, or major/minor complications between patients with rigid and flexible CD. Both rigid and flexible CD patients reported significant improvements from baseline to 1 year according to the numeric rating scale for the neck (-2.4 and -2.7, respectively), Neck Disability Index (-8.4 and -13.3, respectively), modified Japanese Orthopaedic Association score (0.1 and 0.6), and EQ-5D (0.01 and 0.05) (p < 0.05). However, HRQOL changes from baseline to 1 year did not differ between rigid and flexible CD patients.

Conclusions: Patients with rigid CD have worse baseline cervical malalignment compared with those with flexible CD but do not significantly differ in terms of baseline disability. Rigid CD was associated with more invasive surgery and more aggressive corrections, resulting in increased operative time and blood loss. Despite more extensive surgeries, rigid CD patients had equivalent improvements in HRQOL compared with flexible CD patients. This study quantifies the importance of analyzing flexion-extension images, creating a prognostic tool for surgeons planning CD correction, and counseling patients who are considering CD surgery.
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http://dx.doi.org/10.3171/2020.8.SPINE191185DOI Listing
February 2021

Surgical Planning for Adult Spinal Deformity: Anticipated Sagittal Alignment Corrections According to the Surgical Level.

Global Spine J 2021 Feb 11:2192568220988504. Epub 2021 Feb 11.

Spine Service, Hospital for Special Surgery, New York, NY, USA.

Study Design: Retrospective cohort study.

Objectives: Establish simultaneous focal and regional corrective guidelines accounting for reciprocal global and pelvic compensation.

Methods: 433 ASD patients (mean age 62.9 yrs, 81.3% F) who underwent corrective realignment (minimum L1-pelvis) were included. Sagittal parameters, and segmental and regional Cobb angles were assessed pre and post-op. Virtual postoperative alignment was generated by combining post-op alignment of the fused spine with the pre-op alignment on the unfused thoracic kyphosis and the pre-op pelvic retroversion. Regression models were then generated to predict the relative impact of segmental (L4-L5) and regional (L1-L4) corrections on PT, SVA (virtual), and TPA.

Results: Baseline analysis revealed distal (L4-S1) lordosis of 33 ± 15°, flat proximal (L1-L4) lordosis (1.7 ± 17°), and segmental kyphosis from L2-L3 to T10-T11. Post-op, there was no mean change in distal lordosis (L5-S1 decreased by 2°, and L4-L5 increased by 2°), while the more proximal lordosis increased by 18 ± 16°. Regression formulas revealed that Δ10° in distal lordosis resulted in Δ10° in TPA, associated with Δ100 mm in SVA or Δ3° in PT; Δ10° in proximal lordosis yielded Δ5° in TPA associated with Δ50 mm in SVA; and finally Δ10° in thoraco-lumbar junction yielded Δ2.5° in TPA associated with Δ25 mm in SVA and no impact on PT correction.

Conclusions: Overall impact of lumbar lordosis restoration is critically determined by location of correction. Distal correction leads to a greater impact on global alignment and pelvic retroversion. More specifically, it can be assumed that 1° L4-S1 lordosis correction produces 1° change in TPA / 10 mm change in SVA and 0.5° in PT.
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February 2021

Patient-Reported Outcomes After Complex Adult Spinal Deformity Surgery: 5-Year Results of the Scoli-Risk-1 Study.

Global Spine J 2021 Feb 9:2192568220988276. Epub 2021 Feb 9.

University of Virginia, Charlottesville, VA, USA.

Study Design: Prospective cohort.

Objective: To prospectively evaluate PROs up to 5-years after complex ASD surgery.

Methods: The Scoli-RISK-1 study enrolled 272 ASD patients undergoing surgery from 15 centers. Inclusion criteria was Cobb angle of >80°, corrective osteotomy for congenital or revision deformity, and/or 3-column osteotomy. The following PROs were measured prospectively at intervals up to 5-years postoperative: ODI, SF36-PCS/MCS, SRS-22, NRS back/leg. Among patients with 5-year follow-up, comparisons were made from both baseline and 2-years postoperative to 5-years postoperative. PROs were analyzed using mixed models for repeated measures.

Results: Seventy-seven patients (28.3%) had 5-year follow-up data. Comparing baseline to 5-year data among these 77 patients, significant improvement was seen in all PROs: ODI (45.2 vs. 29.3, < 0.001), SF36-PCS (31.5 vs. 38.8, < 0.001), SF36-MCS (44.9 vs. 49.1, = 0.009), SRS-22-total (2.78 vs. 3.61, < 0.001), NRS-back pain (5.70 vs. 2.95, < 0.001) and NRS leg pain (3.64 vs. 2.62, = 0.017). In the 2 to 5-year follow-up period, no significant changes were seen in any PROs. The percentage of patients achieving MCID from baseline to 5-years were: ODI (62.0%) and the SRS-22r domains of function (70.4%), pain (63.0%), mental health (37.5%), self-image (60.3%), and total (60.3%). Surprisingly, mean values ( > 0.05) and proportion achieving MCID did not differ significantly in patients with major surgery-related complications compared to those without.

Conclusions: After complex ASD surgery, significant improvement in PROs were seen at 5-years postoperative in ODI, SF36-PCS/MCS, SRS-22r, and NRS-back/leg pain. No significant changes in PROs occurred during the 2 to 5-year postoperative period. Those with major surgery-related complications had similar PROs and proportion of patients achieving MCID as those without these complications.
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http://dx.doi.org/10.1177/2192568220988276DOI Listing
February 2021

Alignment, Classification, Clinical Evaluation, and Surgical Treatment for Adult Cervical Deformity: A Complete Guide.

Neurosurgery 2021 03;88(4):864-883

Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.

Adult cervical deformity management is complex and is a growing field with many recent advancements. The cervical spine functions to maintain the position of the head and plays a pivotal role in influencing subjacent global spinal alignment and pelvic tilt as compensatory changes occur to maintain horizontal gaze. There are various types of cervical deformity and a variety of surgical options available. The major advancements in the management of cervical deformity have only been around for a few years and continue to evolve. Therefore, the goal of this article is to provide a comprehensive review of cervical alignment parameters, deformity classification, clinical evaluation, and surgical treatment of adult cervical deformity. The information presented here may be used as a guide for proper preoperative evaluation and surgical treatment in the adult cervical deformity patient.
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http://dx.doi.org/10.1093/neuros/nyaa582DOI Listing
March 2021

A Risk Benefit Analysis of Increasing Surgical Invasiveness Relative to Frailty Status in Adult Spinal Deformity Surgery.

Spine (Phila Pa 1976) 2021 Feb 3. Epub 2021 Feb 3.

Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles, CA San Diego Center for Spinal Disorders, La Jolla, CA Department of Orthopaedic Surgery, Johns Hopkins School of Medicine, Baltimore, MD Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado. Department of Orthopedics and Neurosurgery, Duke University Medical Center, Durham, NC Department of Orthopaedic Surgery, University of California, Davis, Davis, CA Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA.

Study Design: Retrospective review of a prospectively enrolled multicenter Adult Spinal Deformity (ASD) database.

Objective: Investigate invasiveness and outcomes of ASD surgery by frailty state.

Summary Of Background Data: The ASD Invasiveness Index incorporates deformity-specific components to assess correction magnitude. Intersections of invasiveness, surgical outcomes, and frailty state are understudied.

Methods: ASD patients with baseline and 3-year (3Y) data were included. Logistic regression analyzed the relationship between increasing invasiveness and major complications or reoperations and meeting minimal clinically important differences (MCID) for health-related quality of life (HRQL) measures at 3Y. Decision tree analysis assessed invasiveness risk-benefit cut-off points, above which experiencing complications or reoperations and not reaching MCID were higher. Significance was set to p < 0.05.

Results: Overall, 195/322 patients were included. Baseline demographics: age 59.9 ± 14.4, 75% female, BMI 27.8 ± 6.2, mean Charlson Comorbidity Index: 1.7 ± 1.7. Surgical information: 61% osteotomy, 52% decompression, 11.0 ± 4.1 levels fused. There were 98 not frail (NF), 65 frail (F), and 30 severely frail (SF) patients. Relationships were found between increasing invasiveness and experiencing a major complication or reoperation for the entire cohort and by frailty group (all p < 0.05). Defining a favorable outcome as no major complications or reoperation and meeting MCID in any HRQL at 3Y established an invasiveness cut-off of 63.9. Patients below this threshold were 1.8[1.38-2.35] (p < 0.001) times more likely to achieve favorable outcome. For NF patients, the cut-off was 79.3 (2.11[1.39-3.20] (p < 0.001), 111 for F (2.62 [1.70-4.06] (p < 0.001), and 53.3 for SF (2.35[0.78-7.13] (p = 0.13).

Conclusions: Increasing invasiveness is associated with increased odds of major complications and reoperations. Risk-benefit cut-offs for successful outcomes were 79.3 for NF, 111 for F, and 53.3 for SF patients. Above these, increasing invasiveness has increasing risk of major complications or reoperations and not meeting MCID at 3Y.Level of Evidence: 3.
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February 2021

Alignment Targets, Curve Proportion and Mechanical Loading: Preliminary Analysis of an Ideal Shape Toward Reducing Proximal Junctional Kyphosis.

Global Spine J 2021 Jan 29:2192568220987188. Epub 2021 Jan 29.

Spine Service, 25062Hospital for Special Surgery, New York, NY, USA.

Study Design: Retrospective cohort study.

Objective: Investigate risk factors for PJK including theoretical kyphosis, mechanical loading at the UIV and age adjusted offset alignment.

Methods: 373 ASD patients (62.7 yrs ± 9.9; 81%F) with 2-year follow up and UIV of at least L1 and LIV of sacrum were included. Images of patients without PJK, with PJK and with PJF were compared using standard spinopelvic parameters before and after the application of the validated virtual alignment method which corrects for the compensatory mechanisms of PJK. Age-adjusted offset, theoretical thoracic kyphosis and mechanical loading at the UIV were then calculated and compared between groups. A subanalysis was performed based on the location of the UIV (upper thoracic (UT) vs. Lower thoracic (LT)).

Results: At 2-years 172 (46.1%) had PJK, and 21 (5.6%) developed PJF. As PJK severity increased, the post-operative global alignment became more posterior secondary to increased over-correction of PT, PI-LL, and SVA (all < 0.005). Also, a larger under correction of the theoretical TK (flattening) and a smaller bending moment at the UIV (underloading of UIV) was found. Multivariate analysis demonstrated that PI-LL and bending moment offsets from normative values were independent predictors of PJK/PJF in UT group; PT and bending moment difference were independent predictors for LT group.

Conclusions: Spinopelvic over correction, under correction of TK (flattening), and under loading of the UIV (decreased bending moment) were associated with PJK and PJF. These differences are often missed when compensation for PJK is not accounted for in post-operative radiographs.
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http://dx.doi.org/10.1177/2192568220987188DOI Listing
January 2021

Costs and utility of post-discharge acute inpatient rehabilitation following adult spinal deformity surgery.

Spine Deform 2021 May 5;9(3):817-822. Epub 2021 Jan 5.

Department of Neurological Surgery, UCSF, San Francisco, CA, USA.

Purpose: Evaluate costs and functional utility of post-discharge rehabilitation after surgery for adult spinal deformity (ASD).

Methods: Retrospective analysis of ASD patients who underwent operation at a single center and discharged to one rehabilitation facility. Operative details and costs were obtained for index inpatient encounter. Rehabilitation data included: direct costs, length of stay, and patient function, as assessed by Functional Independence Measure (FIM) instrument.

Results: Of 937 operations, 391 (41.7%) were discharged to rehabilitation. Ninety-patients (9.6%; 95 care episodes; average age 70.5 ± 10.6 years) were discharged to rehabilitation. Inpatient length of stay was 8.2 ± 2.6 days. Operative details: posterior levels fused 13.6 ± 3.6, PCOs/patient 7 ± 3.7, forty-two 3-column osteotomies, and 11 inter-body fusions. Direct costs were $90,738 ± $24,166 for index hospitalizations and $38,808 ± $14,752 for rehabilitation. Patients spent 11.7 ± 4.0 days in rehabilitation. Direct cost per day in hospital ($11,758 ± $3390) was significantly greater than rehabilitation ($3338 ± $2131) (p < 0.05). Significant improvements in function while in rehabilitation were observed (admit FIM: 66 ± 14 vs. discharge FIM: 94 ± 14). Charlson Comorbidity Index was the only independent predictor of rehabilitation direct costs. Conclusion Post-discharge inpatient rehabilitation following operations for ASD is associated with a direct cost of $38,808 per case. While rehabilitation resulted in significant functional improvements, it came at significant economic expense ($3.7 million) that accounted for 30% of costs for 95 episodes of care. For 100 operatively treated patients (assuming 41% discharge rate to rehab), rehabilitation results in an additional price premium of $1,674,872.
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http://dx.doi.org/10.1007/s43390-020-00251-wDOI Listing
May 2021

Multilevel Pedicle Subtraction Osteotomy for Correction of Severe Rigid Adult Spinal Deformities: A Case Series, Indications, Considerations, and Literature Review.

Oper Neurosurg (Hagerstown) 2021 Mar;20(4):343-354

Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.

Background: Rigid and ankylosed thoracolumbar spinal deformities require three-column osteotomy (3CO) to achieve adequate correction. For severe and multiregional deformities, multilevel 3CO is required but its use and outcomes are rarely reported.

Objective: To describe the use of multilevel pedicle subtraction osteotomy (PSO) in adult spinal deformity (ASD) patients with severe, rigid, and ankylosed multiregional deformity.

Methods: Retrospective review of 5 ASD patients who underwent multilevel PSO for the correction of severe fixed deformity and review the literature regarding the use of multilevel PSO.

Results: Five patients presented with spinal imbalance secondary to regional and multiregional spinal deformities involving the thoracolumbar spine. All patients underwent a single-stage two-level noncontiguous PSO, and 2 of the patients underwent a staged third PSO to treat deformity involving a separate spinal region. Significant radiographic correction was achieved with normalization of spinal alignment and parameters. Two-level PSO was able to provide greater than 80 degrees of sagittal plane correction in both the lumbar and thoracic spine. Two patients experienced new postoperative weakness which recovered to preoperative baseline at 3 to 6 mo follow-up. At most recent follow-up, 4 of the 5 patients gained significant pain relief and had improved functionality.

Conclusion: Noncontiguous multilevel PSO is a formidable surgical technique. Additional risk (compared to single-level 3CO) comes in the form of greater blood loss and higher risk for postoperative weakness. Nonetheless, multilevel PSO is feasible and effective for correcting severe multiplanar and multiregional ASD, and patients gain significant benefits in increased functionality and pain relief.
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http://dx.doi.org/10.1093/ons/opaa419DOI Listing
March 2021

Depression Symptoms Are Associated with Poor Functional Status Among Operative Spinal Deformity Patients.

Spine (Phila Pa 1976) 2021 04;46(7):447-456

Department of Orthopedics, Hospital for Special Surgery, New York, NY.

Study Design: Retrospective review of prospective multicenter database.

Objective: The aim of this study was to investigate how preoperative mental status affects preoperative and postoperative disability and health scores in adult spinal deformity (ASD) patients.

Summary Of Background Data: The relationship between health-related quality of life (HRQOL) and depression has previously been documented. However, the influence of depression on clinical outcomes among ASD patients is not well understood.

Methods: ASD patients with minimum 2-year follow-up were stratified based on preoperative mental health measured by Short Form 36 (SF-36) mental component score (MCS). Patients with MCS in the 25th and 75th percentile of the cohort were designated as having low and high MCS, respectively. After matching by preoperative demographics and deformity, pre- and post-HRQOL were compared between the two groups. Further analysis was performed to identify individualized questions on the SF-36 that could potentially screen for patients with low MCS.

Results: Five hundred thirteen patients were assessed (58.4 years' old, 79% women, mean MCS 45.5). Thresholds for low and high MCS cohorts were 35.0 and 57.3, respectively. After matching by preoperative alignment, low MCS patients had worse Oswestry Disability Index (ODI) (52.3 ± 17.0 vs. 35.7 ± 14.6, P < 0.001) and Scoliosis Research Society-22R scores for all domains (all P < 0.001) compared to high MCS patients. Similar results were maintained at 2-year postop, with low MCS patients having a worse ODI (35.2 ± 20.2 vs. 19.7 ± 18.6, P < 0.001) and MCS (42.4 ± 13.5 vs. 58.6 ± 7.1, P < 0.001). Despite similar preoperative Physical Component Score (PCS), low MCS patients were less likely to reach MCID for PCS (46.1% vs. 70.6%, P < 0.01) and had a lower satisfaction at 2-year follow-up (3.88 ± 1.07 vs. 4.39 ± 0.94, P < 0.001). Questions 5a, 9d, and 9f on the SF-36 were found to be independent predictors of low MCS.

Conclusion: ASD patients with low MCS are more likely to experience functional limitations before and after surgery and are less likely to be satisfied postoperatively, even when similar clinical goals are achieved. Incorporating psychological factors may assist in decision making.Level of Evidence: 3.
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April 2021

Improvement in SRS-22R Self-Image Correlate Most with Patient Satisfaction after 3-Column Osteotomy.

Spine (Phila Pa 1976) 2020 Dec 17;Publish Ahead of Print. Epub 2020 Dec 17.

Norton Leatherman Spine Center, 210 East Gray Street, Louisville, KY 40202 Inova Loudoun Hospital, Lansdowne, VA 2017 Sarah Cannon Research Institute, Nashville, TN 37203 Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas Department of Orthopaedic Surgery, Washington University, St Louis, Missouri Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York Department of Neurosurgery, University of Virginia, Charlottesville, Virginia Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland Department of Orthopaedic Surgery, Spine Division, Duke University Medical Center Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas Department of Neurological Surgery, University of California, San Francisco, San Francisco, California Presbyterian/St. Luke's Medical Center, Rocky Mountain Hospital for Children, Denver, Colorado International Spine Study Group Foundation, Brighton, Colorado.

Study Design: Longitudinal Cohort.

Objectives: To examine the relationship between patient satisfaction, Patient Reported Outcome Measures (PROMs) and radiographic parameters in Adult Spine Deformity (ASD) patients undergoing 3 Column Osteotomies (3CO).

Summary Of Background Data: Identifying factors that influence patient satisfaction in ASD is important. Evidence suggests SRS22R Self-Image domain correlates with patient satisfaction in patients with ASD.

Methods: This is a retrospective review of ASD patients enrolled in a prospective, multicenter database undergoing a 3CO with complete SRS22R pre-op and minimum 2-years postop. Spearman correlations were used to evaluate associations between the 2-yr SRS Satisfaction score and changes in SRS22R domain scores, Oswestry Disability Index (ODI), and radiographic parameters.

Results: Of 135 patients eligible for 2-year follow-up, 98 patients (73%) had complete pre- and 2-yr postop data. The cohort was mostly female (69%) with mean BMI of 29.7 kg/m2 and age of 61.0 yrs. Mean levels fused was 12.9 with EBL of 2695cc and OR time of 407 minutes; 27% were revision surgeries. There was a statistically significant improvement between pre- and 2-year post-op PROMs and all radiographic parameters except Coronal Vertical Axis. The majority of patients had an SRS Satisfaction score of ≥ 3.0 (90%) or ≥ 4.0 (68%), consistent with a moderate ceiling effect. Correlations of patient satisfaction was significant for Pain (0.43, p < 0.001), Activity (0.39, p < 0.001), Mental (0.38, p = 0.001) Self-Image (0.52, p < 0.001). ODI and SF-36 PCS had a moderate correlation as well, with MCS being weak. There was no statistically significant correlations between any radiographic or operative parameters and patient satisfaction.

Conclusion: There was statistically significant improvement in all PROMs and radiographic parameters, except CVA at 2-years in ASD patients undergoing 3CO. Improvement in SRS Self-Image domain has the strongest correlation with patient satisfaction.Level of Evidence: 3.
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December 2020

Evaluating the Clinical Utility and Cost of Imaging Strategies in Adults with Newly Diagnosed Primary Intradural Spinal Tumors.

World Neurosurg 2021 Mar 13;147:e239-e246. Epub 2020 Dec 13.

Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA. Electronic address:

Objective: In patients with new primary intradural spinal tumors, the best screening strategy for additional central nervous system (CNS) lesions is unclear. The goal of this study was to document the rate of additional CNS tumors in these patients.

Methods: Adults with primary intradural spinal tumors were retrospectively reviewed. Imaging strategy at diagnosis was classified as focused spine (cervical, thoracic, or lumbar), total spine, or complete neuraxis (brain and total spine). Tumor pathology, genetic syndromes, and presence of additional CNS lesions at diagnosis or follow-up were collected.

Results: The study comprised 319 patients with mean age of 51 years and mean follow-up of 41 months. In 151 patients with focused spine imaging, 3 (2.0%) were found to have new lesions with 2 (1.4%) requiring treatment. In 35 patients with total spine imaging, there were no additional lesions. In 133 patients with complete neuraxis imaging, 4 (3.0%) were found to have new lesions with 2 (1.5%) requiring treatment. There was no difference in the identification of new lesions (P = 0.542) or new lesions requiring treatment (P = 0.772) across imaging strategies. Among patients without genetic syndromes, rates of new lesions requiring treatment were 1.4% for focused spine, 0% for total spine, and 2.2% for complete neuraxis (P = 0.683). There were no cases of delayed identification causing risk to life or neurological function. Complete neuraxis imaging carried an increased charge of $4420 per patient.

Conclusions: Among patients without an underlying genetic syndrome, the likelihood of identifying additional CNS lesions requiring treatment is low. In appropriate cases, focused spine imaging may be a more cost-effective strategy.
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March 2021

Impact of New Motor Deficit on HRQOL After Adult Spinal Deformity Surgery: Subanalysis From Scoli Risk 1 Prospective Study.

Spine (Phila Pa 1976) 2021 Apr;46(7):E450-E457

Department of Neurosurgery and Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA.

Study Design: International, multicenter, prospective, longitudinal observational cohort.

Objective: To assess how new motor deficits affect patient reported quality of life scores after adult deformity surgery.

Summary Of Background Data: Adult spinal deformity surgery is associated with high morbidity, including risk of new postoperative motor deficit. It is unclear what effect new motor deficit has on Health-related Quality of Life scores (HRQOL) scores.

Methods: Adult spinal deformity patients were enrolled prospectively at 15 sites worldwide. Other inclusion criteria included major Cobb more than 80°, C7-L2 curve apex, and any patient undergoing three column osteotomy. American Spinal Injury Association (ASIA) scores and standard HRQOL scores were recorded pre-op, 6 weeks, 6 months, and 2 years.

Results: Two hundred seventy two complex adult spinal deformity (ASD) patients enrolled. HRQOL scores were worse for patients with lower extremity motor score (LEMS). Mean HRQOL changes at 6 weeks and 2 years compared with pre-op for patients with motor worsening were: ODI (+12.4 at 6 weeks and -4.7 at 2 years), SF-36v2 physical (-4.5 at 6 weeks and +2.3 at 2 years), SRS-22r (0.0 at 6 weeks and +0.4 at 2 years). Mean HRQOL changes for motor-neutral patients were: ODI (+0.6 at 6 weeks and -12.1 at 2 years), SF-36v2 physical (-1.6 at 6 weeks and +5.9 at 2 years), and SRS-22r (+0.4 at 6 weeks and +0.7 at 2 years). For patients with LEMS improvement, mean HRQOL changes were: ODI (-0.6 at 6 weeks and -16.3 at 2 years), SF-36v2 physical (+1.0 at 6 weeks and +7.0 at 2 years), and SRS-22r (+0.5 at 6 weeks and +0.9 at 2 years).

Conclusion: In the subgroup of deformity patients who developed a new motor deficit, total HRQOLs and HRQOL changes were negatively impacted. Patients with more than 2 points of LEMS worsening had the worst changes, but still showed overall HRQOL improvement at 6 months and 2 years compared with pre-op baseline.Level of Evidence: 3.
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April 2021

A Comparison of Three Different Positioning Techniques on Surgical Corrections and Postoperative Alignment in Cervical Spinal Deformity (CD) Surgery.

Spine (Phila Pa 1976) 2021 May;46(9):567-570

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY.

Study Design: Retrospective review of a prospective multicenter cervical deformity database.

Objective: To examine the differences in sagittal alignment correction between three positioning methods in cervical spinal deformity surgery (CD).

Summary Of Background Data: Surgical correction for CD is technically demanding and various techniques are utilized to achieve sagittal alignment objectives. The effect of different patient positioning techniques on sagittal alignment correction following CD remains unknown.

Methods: Patients with sagittal deformity who underwent a posterior approach (with and without anterior approach) with an upper instrumented vertebra of C6 or above. Patients with Grade 5, 6, or 7 osteotomies were excluded. Positioning groups were Mayfield skull clamp, bivector traction, and halo ring. Preoperative lower surgical sagittal curve (C2-C7), C2-C7 sagittal vertical axis (cSVA), cervical scoliosis, T1 slope minus cervical lordosis (TS-CL), T1 slope (T1S), chin-brow vertebral angle (CBVA), C2-T3 curve, and C2-T3 SVA was assessed and compared with postoperative radiographs. Segmental changes were analyzed using the Fergusson method.

Results: Eighty patients (58% female) with a mean age of 60.6 ± 10.5 years (range, 31-83) were included. The mean postoperative C2-C7 lordosis was 7.8° ± 14 and C2-C7 SVA was 34.1 mm ± 15. There were overall significant changes in cervical alignment across the entire cohort, with improvements in T1 slope (P < 0.001), C2-C7 (P < 0.001), TS-CL (P < 0.001), and cSVA (P = 0.006). There were no differences postoperatively of any radiographic parameter between positioning groups (P > 0.05). The majority of segmental lordotic correction was achieved at C4-5-6 (mean 6.9° ± 11). Additionally, patients who had bivector traction applied had had significantly more segmental correction at C7-T1-T2 compared with Mayfield and halo traction (4.2° vs. 0.3° vs. -1.7° respectively, P < 0.027).

Conclusion: Postoperative cervical sagittal correction or alignment was not affected by patient position. The majority of segmental correction occurred at C4-5-6 across all positioning methods, while bivector traction had the largest corrective ability at the cervicothoracic junction.Level of Evidence: 4.
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May 2021

Multicenter assessment of surgical outcomes in adult spinal deformity patients with severe global coronal malalignment: determination of target coronal realignment threshold.

J Neurosurg Spine 2020 Dec 4:1-14. Epub 2020 Dec 4.

18Department of Neurological Surgery, University of California, San Francisco, California.

Objective: The impact of global coronal malalignment (GCM; C7 plumb line-midsacral offset) on adult spinal deformity (ASD) treatment outcomes is unclear. Here, the authors' primary objective was to assess surgical outcomes and complications in patients with severe GCM, with a secondary aim of investigating potential surgical target coronal thresholds for optimal outcomes.

Methods: This is a retrospective analysis of a prospective multicenter database. Operative patients with severe GCM (≥ 1 SD above the mean) and a minimum 2-year follow-up were identified. Demographic, surgical, radiographic, health-related quality of life (HRQOL), and complications data were analyzed.

Results: Of 691 potentially eligible operative patients (mean GCM 4 ± 3 cm), 80 met the criteria for severe GCM ≥ 7 cm. Of these, 62 (78%; mean age 63.7 ± 10.7 years, 81% women) had a minimum 2-year follow-up (mean follow-up 3.3 ± 1.1 years). The mean ASD-Frailty Index was 3.9 ± 1.5 (frail), 50% had undergone prior fusion, and 81% had concurrent severe sagittal spinopelvic deformity with GCM and C7-S1 sagittal vertical axis (SVA) positively correlated (r = 0.313, p = 0.015). Surgical characteristics included posterior-only (58%) versus anterior-posterior (42%) approach, mean fusion of 13.2 ± 3.8 levels, iliac fixation (90%), 3-column osteotomy (36%), operative duration of 8.3 ± 3.0 hours, and estimated blood loss of 2.3 ± 1.7 L. Final alignment and HRQOL significantly improved (p < 0.01): GCM, 11 to 4 cm; maximum coronal Cobb angle, 43° to 20°; SVA, 13 to 4 cm; pelvic tilt, 29° to 23°; pelvic incidence-lumbar lordosis mismatch, 31° to 5°; Oswestry Disability Index, 51 to 37; physical component summary of SF-36 (PCS), 29 to 37; 22-Item Scoliosis Research Society Patient Questionnaire (SRS-22r) Total, 2.6 to 3.5; and numeric rating scale score for back and leg pain, 7 to 4 and 5 to 3, respectively. Residual GCM ≥ 3 cm was associated with worse SRS-22r Appearance (p = 0.04) and SRS-22r Satisfaction (p = 0.02). The minimal clinically important difference and/or substantial clinical benefit (MCID/SCB) was met in 43%-83% (highest for SRS-22r Appearance [MCID 83%] and PCS [SCB 53%]). The severity of baseline GCM (≥ 2 SD above the mean) significantly impacted postoperative SRS-22r Satisfaction and MCID/SCB improvement for PCS. No significant partial correlations were demonstrated between GCM or SVA correction and HRQOL improvement. There were 89 total complications (34 minor and 55 major), 45 (73%) patients with ≥ 1 complication (most commonly rod fracture [19%] and proximal junctional kyphosis [PJK; 18%]), and 34 reoperations in 22 (35%) patients (most commonly for rod fracture and PJK).

Conclusions: Study results demonstrated that ASD surgery in patients with substantial GCM was associated with significant radiographic and HRQOL improvement despite high complication rates. MCID improvement was highest for SRS-22r Appearance/Self-Image. A residual GCM ≥ 3 cm was associated with a worse outcome, suggesting a potential coronal realignment target threshold to assist surgical planning.
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December 2020

Implementation of Outpatient Minimally Invasive Lumbar Decompression at an Academic Medical Center without Ambulatory Surgery Centers: A Cost Analysis and Systematic Review.

World Neurosurg 2021 Feb 26;146:e961-e971. Epub 2020 Nov 26.

Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA. Electronic address:

Background: Lumbar decompressions are increasingly performed at ambulatory surgery centers (ASCs). We sought to compare costs of open and minimally invasive (MIS) lumbar decompressions performed at a university without dedicated ASCs.

Methods: Lumbar decompressions performed at a tertiary academic hospital or satellite university hospital dedicated to outpatient surgery were retrospectively reviewed. Care pathways were same-day, overnight observation, or inpatient admission. Patient demographics, American Society of Anesthesiologists classification, Charlson Comorbidity Index, surgical characteristics, 30-day readmission, and costs were collected. A systematic review of lumbar decompression cost literature was performed.

Results: A total of 354 patients, mean age 55 years with 128 women (36.2%), were reviewed. There was no significant difference in age, gender, body mass index, American Society of Anesthesiologists classification, or Charlson Comorbidity Index between patients treated with open and minimally invasive surgery. Open decompression was associated with higher total cost ($21,280 vs. $14,407; P < 0.001); however, this was driven by care pathway and length of stay. When stratifying by care pathway, there was no difference in total cost between open versus minimally invasive surgery among same-day ($10,609 vs. $11,074; P = 0.556), overnight observation ($14,097 vs. $13,992; P = 0.918), or inpatient admissions ($24,507 vs. $27,929; P = 0.311).

Conclusions: When accounting for care pathway, the cost of open and MIS decompression were no different. Transition from a tertiary academic hospital to a university hospital specializing in outpatient surgery was not associated with lower costs. Academic departments may consider transitioning lumbar decompressions to a dedicated ASC to maximize cost savings; however, additional studies are needed.
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February 2021

Neurological Complications and Recovery Rates of Patients With Adult Cervical Deformity Surgeries.

Global Spine J 2020 Nov 23:2192568220975735. Epub 2020 Nov 23.

Department of Neurological Surgery, University of California, San Francisco, CA, USA.

Study Design: Retrospective cohort study.

Objective: This study aims to report the incidence, risk factors, and recovery rate of neurological complications (NC) in patients with adult cervical deformity (ACD) who underwent corrective surgery.

Methods: ACD patients undergoing surgery from 2013 to 2015 were enrolled in a prospective, multicenter database. Patients were separated into 2 groups according to the presence of neurological complications (NC vs no-NC groups). The types, timing, recovery patterns, and interventions for NC were recorded. Patients' demographics, surgical details, radiographic parameters, and health-related quality of life (HRQOL) scores were compared.

Results: 106 patients were prospectively included. Average age was 60.8 years with a mean of 18.2 months follow-up. The overall incidence of NC was 18.9%; of these, 68.1% were major complications. Nerve root motor deficit was the most common complication, followed by radiculopathy, sensory deficit, and spinal cord injury. The proportion of complications occurring within 30 days of surgery was 54.5%. The recovery rate from neurological complication was high (90.9%), with most of the recoveries occurring within 6 months and continuing even after 12 months. Only 2 patients (1.9%) had continuous neurological complication. No demographic or preoperative radiographic risk factors could be identified, and anterior corpectomy and posterior foraminotomy were found to be performed less in the NC group. The final HRQOL outcome was not significantly different between the 2 groups.

Conclusions: Our data is valuable to surgeons and patients to better understand the neurological complications before performing or undergoing complex cervical deformity surgery.
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November 2020

Cost Analysis of Outpatient Anterior Cervical Discectomy and Fusion at an Academic Medical Center without Dedicated Ambulatory Surgery Centers.

World Neurosurg 2021 Feb 17;146:e940-e946. Epub 2020 Nov 17.

Department of Neurological Surgery, University of California, San Francisco, California, USA. Electronic address:

Background: Anterior cervical discectomy and fusion (ACDF) are increasingly performed at ambulatory surgical centers (ASCs). Academic centers lacking dedicated ASCs must perform these at large university hospitals, which pose unique challenges to cost savings and efficiency.

Objective: To describe the safety and cost of outpatient ACDF at a major academic medical center without a dedicated ASC.

Methods: ACDFs performed from 2015 to 2018 were retrospectively reviewed. Cases were performed at the major tertiary university hospital or a satellite university hospital dedicated to outpatient surgery. Patient demographics, surgical characteristics, perioperative complications, fusion at 12 months, and cost were collected.

Results: A total of 470 patients were included. The mean age was 56 years, with 255 women (54.3%). When comparing same-day discharge, overnight observation, or inpatient admission, there were no differences in age, gender, or number of levels fused. Same-day and overnight observation cases were associated with shorter procedure duration and less estimated blood loss. There were no differences in perioperative complications, 30-day readmissions, or fusion at 12 months. Direct and total costs were lowest for same-day cases, followed by overnight observation and inpatient admissions (P < 0.001).

Conclusion: Academic centers without dedicated ASCs can safely perform ACDF as a same-day or overnight observation procedure with significant reductions in cost. The lack of a dedicated ASC should not preclude academic centers from allocating appropriately selected patients into same-day or overnight observation care pathways. This strategy can improve resource utilization and preserve precious hospital resources for the most critically ill patients while also allowing these centers to build viable outpatient spine practices.
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February 2021