Publications by authors named "Haddy Alas"

51 Publications

Does Matching Roussouly Spinal Shape and Improvement in SRS-Schwab Modifier Contribute to Improved Patient-reported Outcomes?

Spine (Phila Pa 1976) 2021 Sep;46(18):1258-1263

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

Study Design: Retrospective review.

Objective: The aim of this study was to evaluate outcomes of matching Roussouly and improving in Schwab modifier following adult spinal deformity (ASD) surgery.

Summary Of Background Data: The Roussouly Classification system of sagittal spinal shape and the SRS-Schwab classification system have become important indicators of spine deformity. No previous studies have examined the outcomes of matching both Roussouly type and improving in Schwab modifiers postoperatively.

Methods: Surgical ASD patients with available baseline (BL) and 1 year (1Y) radiographic data were isolated in the single-center spine database. Patients were classified by their "theoretical" and "current" Roussouly types as previously published. Patients were considered a "Match" if their theoretical and current Roussouly types were the same, or a "Mismatch" if the types differed. Patients were noted as improved if they were Roussouly "Mismatch" preoperatively, and "Match" at 1Y postop. Schwab modifiers at BL were categorized as follows: no deformity (0), moderate deformity (+), and severe deformity (++) for PT, SVA, and PI-LL. Improvement in SRS-Schwab was defined as a decrease in any modifier severity at 1Y.

Results: 103 operative ASD patients (61.8 years, 63.1% female, 30 kg/m2) were included. At baseline, breakdown of "current" Roussouly type was: 28% Type 1, 25.3% Type 2, 32.0% Type 3, 14.7% Type 4. 65.3% of patients were classified as Roussouly "Mismatch" at BL. Breakdown of BL Schwab modifier severity: PT (+: 41.7%, ++: 49.5%), SVA (+: 20.3%, ++: 50%), PI-LL (+: 25.2%, ++: 46.6%). At 1 year postop, 19.2% of patients had Roussouly "Match". Analysis of Schwab modifiers showed that 12.6% improved in SVA, 42.7% in PI-LL, and 45.6% in PT. Count of patients who both had a Roussouly type "Match" at 1Y and improved in Schwab modifier severity: nine PT (8.7%), eight PI-LL (7.8%), and two SVA (1.9%). There were two patients (1.9%) who met their Roussouly type and improved in all three Schwab. 1Y matched Roussouly patients improved more in health-related quality of life scores (minimal clinically important difference [MCID] for Oswestry Disability Index [ODI], EuroQol-5D-3L [EQ5D], Visual Analogue Score Leg/Back Pain), compared to mismatched, but was not significant (P > 0.05). Match Roussouly and improvement in PT Schwab met MCID for EQ5D more (P = 0.050). Matched Roussouly and improvement in SVA Schwab met MCID for ODI more (P = 0.024).

Conclusion: Patients who both matched Roussouly sagittal spinal type and improved in SRS-Schwab modifiers had superior patient-reported outcomes. Utilizing both classification systems in surgical decision-making can optimize postop outcomes.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003999DOI Listing
September 2021

Increasing Cost Efficiency in Adult Spinal Deformity Surgery: Identifying Predictors of Lower Total Costs.

Spine (Phila Pa 1976) 2021 Aug 13. Epub 2021 Aug 13.

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 Orthopedic Surgery, University of Virginia School of Medicine, Charlottesville, VA Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas Department of Orthopaedic Surgery, Norton Leatherman Spine Center, Louisville, KY, USA Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas, USA Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore, MD, USA 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 Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC Department of Orthopaedic Surgery, University of California, Davis, Davis, CA.

Study Design: Retrospective study of a prospective multicenter database.

Objective: The purpose of this study was to identify predictors of lower total surgery costs at 3 years for Adult Spinal Deformity (ASD) patients.

Summary Of Background Data: ASD surgery involves complex deformity correction.

Methods: Inclusion criteria: surgical ASD (scoliosis≥20°, SVA≥5 cm, PT≥25°, or thoracic kyphosis ≥60°) patients >18 years. Total costs for surgery were calculated using the PearlDiver database. Cost per quality adjusted life year was assessed. A Conditional Variable Importance Table used non-replacement sampling set of 20,000 Conditional Inference trees to identify top factors associated with lower cost surgery for low (LSVA), moderate (MSVA), and high (HSVA) SRS Schwab SVA grades.

Results: 316/322 ASD patients met inclusion criteria. At 3Y follow up, the potential cost of ASD surgery ranged from $57,606.88 to $116,312.54. The average costs of surgery at 3 years was found to be $72,947.87, with no significant difference in costs between deformity groups (p > 0.05). There were 152 LSVA patients, 53 MSVA patients, and 111 HSVA patients. For all patients, the top predictors of lower costs were frailty scores <0.19, BL SRS Activity >1.5, baseline (BL) ODI <50 (all p < 0.05). For LSVA patients, no history of osteoporosis, SRS Activity scores >1.5, age <64, were the top predictors of lower costs (all p < 0.05). Among MSVA patients, ASD invasiveness scores <94.16, no past history of cancer, and frailty scores <0.3 trended towards lower total costs (p = 0.071, p = 0.210). For HSVA, no history of smoking and BMI <27.8 trended towards lower costs (both p = 0.060).

Conclusions: ASD surgery has the potential for improved cost efficiency, as costs ranged from $57,606.88 to $116,312.54. Predictors of lower costs included higher baseline SRS activity, decreased frailty, and not having depression. Additionally, predictors of lower costs were identified for different baseline deformity profiles, allowing for the optimization of cost efficiency for all patients.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004201DOI Listing
August 2021

Same Day Surgical Intervention Dramatically Minimizes Complication Occurrence and Optimizes Perioperative Outcomes for Central Cord Syndrome.

Clin Spine Surg 2021 Jul 21. Epub 2021 Jul 21.

Department of Orthopaedics, NYU Langone Orthopedic Hospital, New York, NY Department of Pediatric Neurosurgery, UT Southwestern Medical Center, Dallas, TX Department of Neurologic Surgery, University of Michigan, Ann Arbor, MI Department of Orthopaedic Surgery, University of Calgary, Calgary, AB, Canada Department of Neurological Surgery Montefiore Medical Center/Albert Einstein College of Medicine Bronx, NY Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD Deparment of Orthopedic Surgery, SUNY Downstate, New York, NY.

Study Design: This was a retrospective cohort study.

Objective: The aim of this study was to investigate associations between time to surgical intervention and outcomes for central cord syndrome (CCS) patients.

Background: As surgery is increasingly recommended for patients with neurological deterioration CCS, it is important to investigate the relationship between time to surgery and outcomes.

Materials And Methods: CCS patients were isolated in Nationwide Inpatient Sample database 2005-2013. Patients were grouped by time to surgery: same-day, 1-day delay, 2, 3, 4-7, 8-14, and >14 days. Means comparison tests compared patient factors, perioperative complications, and charges across patient groups. Controlling for age, comorbidities, length of stay, and concurrent traumatic fractures, binary logistic regression assessed surgical timing associated with increased odds of perioperative complication, using same-day as reference group.

Results: Included: 6734 CSS patients (64% underwent surgery). The most common injury mechanisms were falls (30%) and pedestrian accidents (7%). Of patients that underwent surgery, 52% underwent fusion, 30% discectomy, and 14% other decompression of the spinal canal. Breakdown by time to procedure was: 39% same-day, 16% 1-day, 10% 2 days, 8% 3 days, 16% 4-7 days, 8% 8-14 days, and 3% >14 days. Timing groups did not differ in trauma status at admission, although age varied: [minimum: 1 d (58±15 y), maximum: >14 d (63±13 y)]. Relative to other groups, same-day patients had the lowest hospital charges, highest rates of home discharge, and second lowest postoperative length of stay behind 2-day delay patients. Patients delayed >14 days to surgery had increased odds of perioperative cardiac and infection complications. Timing groups beyond 3 days showed increased odds of VTE and nonhome discharge.

Conclusions: CCS patients undergoing surgery on the same day as admission had lower odds of complication, hospital charges, and higher rates of home discharge than patients that experienced a delay to operation. Patients delayed >14 days to surgery were associated with inferior outcomes, including increased odds of cardiac complication and infection.
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http://dx.doi.org/10.1097/BSD.0000000000001234DOI Listing
July 2021

Bariatric surgery diminishes spinal diagnoses in a morbidly obese population: A 2-year survivorship analysis of cervical and lumbar pathologies.

J Clin Neurosci 2021 Aug 8;90:135-139. Epub 2021 Jun 8.

Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA, USA.

The effects of bariatric surgery on diminishing spinal diagnoses have yet to be elucidated in the literature. The purpose of this study was to assess the rate in which various spinal diagnoses diminish after bariatric surgery. This was a retrospective analysis of the NYSID years 2004-2013. Patient linkage codes allow identification of multiple and return inpatient stays within the time-frame analyzed (720 days). Time from bariatric surgery until the patient's respective spinal diagnosis was no longer present was considered a loss of previous spinal diagnosis (LOD). Included: 4,351 bariatric surgery pts with a pre-op spinal diagnosis. Cumulative LOD rates at 90-day, 180-day, 360-day, and 720-day f/u were as follows: lumbar stenosis (48%,67.6%,79%,91%), lumbar herniation (61%,77%,86%,93%), lumbar spondylosis (47%,65%,80%,93%), lumbar spondylolisthesis (37%,58%,70%,87%), lumbar degeneration (37%,56%,72%,86%). By cervical region: cervical stenosis (48%,70%,84%,94%), cervical herniation (39%,58%,74%,87%), cervical spondylosis (46%, 70%,83%, 94%), cervical degeneration (44%,64%,78%,89%). Lumbar herniation pts saw significantly higher 90d-LOD than cervical herniation pts (p < 0.001). Cervical vs lumbar degeneration LOD rates did not differ @90d (p = 0.058), but did @180d (p = 0.034). Cervical and lumbar stenosis LOD was similar @90d & 180d, but cervical showed greater LOD by 1Y (p = 0.036). In conclusion, over 50% of bariatric patients diagnosed with a cervical or lumbar pathology before weight-loss surgery no longer sought inpatient care for their respective spinal diagnosis by 180 days post-op. Lumbar herniation had significantly higher LOD than cervical herniation by 90d, whereas cervical degeneration and stenosis resolved at higher rates than corresponding lumbar pathologies by 180d and 1Y f/u, respectively.
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http://dx.doi.org/10.1016/j.jocn.2021.05.012DOI Listing
August 2021

Increased cautiousness in adolescent idiopathic scoliosis patients concordant with syringomyelia fails to improve overall patient outcomes.

J Craniovertebr Junction Spine 2021 Apr-Jun;12(2):197-201. Epub 2021 Jun 10.

Department of Orthopedics and Neurological Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.

Background: Adolescent idiopathic scoliosis (AIS) is a common cause of spinal deformity in adolescents. AIS can be associated with certain intraspinal anomalies such as syringomyelia (SM). This study assessed the rate o f SM in AIS patients and compared trends in surgical approach and postoperative outcomes in AIS patients with and without SM.

Methods: The database was queried using ICD-9 codes for AIS patients from 2003-2012 (737.1-3, 737.39, 737.8, 737.85, and 756.1) and SM (336.0). The patients were separated into two groups: AIS-SM and AIS-N. Groups were compared using -tests and Chi-squared tests for categorical and discrete variables, respectively.

Results: Totally 77,183 AIS patients were included in the study (15.2 years, 64% F): 821 (1.2%) - AIS-SM (13.7 years, 58% F) and 76,362 - AIS-N (15.2 years, 64% F). The incidence of SM increased from 2003-2012 (0.9 to 1.2%, = 0.036). AIS-SM had higher comorbidity rates (79 vs. 56%, < 0.001). Comorbidities were assessed between AIS-SM and AIS-N, demonstrating significantly more neurological and pulmonary in AIS-SM patients. 41.2% of the patients were operative, 48% of AIS-SM, compared to 41.6% AIS-N. AIS-SM had fewer surgeries with fusion (anterior or posterior) and interbody device placement. AIS-SM patients had lower invasiveness scores (2.72 vs. 3.02, = 0.049) and less LOS (5.0 vs. 6.1 days, = 0.001). AIS-SM patients underwent more routine discharges (92.7 vs. 90.9%). AIS-SM had more nervous system complications, including hemiplegia and paraplegia, brain compression, hydrocephalous and cerebrovascular complications, all < 0.001. After controlling for respiratory, renal, cardiovascular, and musculoskeletal comorbidities, invasiveness score remained lower for AIS-SM patients ( < 0.001).

Conclusions: These results indicate that patients concordant with AIS and SM may be treated more cautiously (lower invasiveness score and less fusions) than those without SM.
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http://dx.doi.org/10.4103/jcvjs.jcvjs_25_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214240PMC
June 2021

Redefining cervical spine deformity classification through novel cutoffs: An assessment of the relationship between radiographic parameters and functional neurological outcomes.

J Craniovertebr Junction Spine 2021 Apr-Jun;12(2):157-164. Epub 2021 Jun 10.

Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado, USA.

Purpose: The aim is to investigate the relationship between cervical parameters and the modified Japanese Orthopedic Association scale (mJOA).

Materials And Methods: Surgical adult cervical deformity (CD) patients were included in this retrospective analysis. After determining data followed a parametric distribution through the Shapiro-Wilk Normality ( = 0.15, > 0.05), Pearson correlations were run for radiographic parameters and mJOA. For significant correlations, logistic regressions were performed to determine a threshold of radiographic measures for which the correlation with mJOA scores was most significant. mJOA score of 14 and <12 reported cut-off values for moderate (M) and severe (S) disability. New modifiers were compared to an existing classification using Spearman's rho and logistic regression analyses to predict outcomes up to 2 years.

Results: A total of 123 CD patients were included (60.5 years, 65%F, 29.1 kg/m). For significant baseline factors from Pearson correlations, the following thresholds were predicted: MGS (M:-12 to-9° and 0°-19°, = 0.020; S: >19° and <-12°, χ= 4.291, = 0.036), TS-CL (M: 26°to 45°, = 0.201; S: >45°, χ= 7.8, = 0.005), CL (M:-21° to 3°, χ= 8.947, = 0.004; S: <-21°, χ= 9.3, = 0.009), C2-T3 (M: -35° to -25°, χ= 5.485, = 0.046; S: <-35°, χ= 4.1, = 0.041), C2 Slope (M: 33° to 49°, = 0.122; S: >49°, χ= 5.7, = 0.008), and Frailty (Mild: 0.18-0.27, = 0.129; Severe: >0.27, = 0.002). Compared to existing Ames- International Spine Study Group classification, the novel thresholds demonstrated significant predictive value for reoperation and mortality up to 2 years.

Conclusions: Collectively, these radiographic values can be utilized in refining existing classifications and developing collective understanding of severity and surgical targets in corrective surgery for adult CD.
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http://dx.doi.org/10.4103/jcvjs.jcvjs_22_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214235PMC
June 2021

The Five-item Modified Frailty Index is Predictive of 30-day Postoperative Complications in Patients Undergoing Spine Surgery.

Spine (Phila Pa 1976) 2021 Jul;46(14):939-943

Departments of Orthopedic and Neurologic Surgery, NYU Langone Orthopedic Hospital; New York Spine Institute, New York, NY.

Study Design: Retrospective cohort study.

Objective: This study aimed to evaluate the utility of the modified frailty index (mFI-5) in a population of patients undergoing spine surgery.

Summary Of Background Data: The original modified frailty index (mFI-11) published as an American College of Surgeons National Surgical Quality Improvement Program 11-factor index was modified to mFI-5 after variables were removed from recent renditions.

Methods: Surgical spine patients were isolated using current procedural terminology codes. mFI-11 (11) and mFI-5 (5) were calculated from 2005 to 2012. mFI was determined by dividing the factors present by available factors. To assess correlation, Spearman rho was used. Predictive values of indices were generated by binary logistic regression. Patients were stratified into groups by mFI-5: not frail (NF, <0.3), mildly frail (MF, 0.3-0.5), severely frail (SF, >0.5). Means comparison tests analyzed frailty and clinical outcomes.

Results: After calculating the mFI-5 and the mFI-11, Spearman rho between the two indices was 0.926(P < 0.001). Each index established significant (all P < 0.001) predictive values for unplanned readmission (11 = odds ratio [OR]: 5.65 [2.92-10.94]; 5 = OR: 3.68 [1.85-2.32]), post-op complications (11 = OR: 8.56 [7.12-10.31]; 5 = OR: 13.32 [10.89-16.29]), and mortality (11 = OR: 41.29 [21.92-77.76]; 5 = OR: 114.82 [54.64-241.28]). Frailty categories by mFI-5 were: 83.2% NF, 15.2% MF, and 1.6% SF. From 2005 to 2016, rates of NF decreased (88.8% to 82.2%, P < 0.001), whereas MF increased (9.2% to 16.2%, P < 0.001), and SF remained constant (2% to 1.6%, P > 0.05). With increase in severity, postoperative rates of morbidities and complications increased.

Conclusion: The five-factor National Surgical Quality Improvement Program modified frailty index is an effective predictor of postoperative events following spine surgery. Severity of frailty score by the mFI-5 was associated with increased morbidity and mortality. The mFI-5 within a surgical spine population can reliably predict post-op complications. This tool is less cumbersome than mFI-11 and relies on readily accessible variables at the time of surgical decision-making.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003936DOI Listing
July 2021

Frailty Severity Impacts Development of Hospital-acquired Conditions in Patients Undergoing Corrective Surgery for Adult Spinal Deformity.

Clin Spine Surg 2021 Aug;34(7):E377-E381

Department of Orthopaedic and Neurologic Surgery, NYU Langone Orthopedic Hospital, New York Spine Institute.

Study Design: This was a retrospective cohort study of a national dataset.

Purpose: The purpose of this study was to consider the influence of frailty on the development of hospital-acquired conditions (HACs) in adult spinal deformity (ASD).

Summary Of Background Data: HACs frequently include reasonably preventable complications. Eleven events are identified as HACs by the Affordable Care Act. In the surgical ASD population, factors leading to HACs are important to identify to optimize health care.

Methods: Patients 18 years and older undergoing corrective surgery for ASD identified in the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP). The relationship between HACs and frailty as defined by the NSQIP modified 5-factor frailty index (mFI-5) were assessed using χ2 and independent sample t tests. The mFI-5 is assessed on a scale 0-1 [not frail (NF): <0.3, mildly frail (MF): 0.3-0.5, and severely frail (SF): > 0.5]. Binary logistic regression measured the relationship between frailty throughout HACs.

Results: A total of 9143 ASD patients (59.1 y, 56% female, 29.3 kg/m2) were identified. Overall, 37.6% of procedures involved decompression and 100% fusion. Overall, 6.5% developed at least 1 HAC, the most common was urinary tract infection (2.62%), followed by venous thromboembolism (2.10%) and surgical site infection (1.88%). According to categorical mFI-5 frailty, 82.1% of patients were NF, 16% MF, and 1.9% SF. Invasiveness increased with mFI-5 severity groups but was not significant (NF: 3.98, MF: 4.14, SF: 4.45, P>0.05). Regression analysis of established factors including sex [odds ratio (OR): 1.22; 1.02-146; P=0.030], diabetes mellitus (OR: 0.70; 0.52-0.95; P=0.020), total operative time (OR: 1.01; 1.00-1.01; P<0.001), body mass index (OR: 1.02; 1.01-1.03; P=0.008), and frailty (OR: 8.44; 4.13-17.26; P<0.001), as significant predictors of HACs. Overall, increased categorical frailty severity individually predicted increased total length of stay (OR: 1.023; 1.015-1.030; P<0.001) and number of complications (OR: 1.201; 1.047-1.379; P=0.009).

Conclusions: For patients undergoing correction surgery for ASD, the incidence of HACs increased with worsening frailty score. Such findings suggest the importance of medical optimization before surgery for ASD.
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http://dx.doi.org/10.1097/BSD.0000000000001219DOI Listing
August 2021

Predictors of serious, preventable, and costly medical complications in a population of adult spinal deformity patients.

Spine J 2021 Sep 8;21(9):1559-1566. Epub 2021 May 8.

Department of Orthopaedic Surgery, University of California Davis, Davis, CA, USA.

Background Context: In 2008, the Centers for Medicare and Medicaid Services (CMS) established a list of hospital-acquired conditions (HACs) with significant deleterious effects on both patients and providers. Adult spinal deformity (ASD) surgery is complex and highly invasive, and as such may result in significant morbidity including these HACs.

Purpose: Identify predictors for developing the most common HACs among adult spinal deformity (ASD) patients undergoing corrective surgery.

Study Design/setting: Retrospective analysis.

Patient Sample: One thousand one hundred and seventy-one ASD patients.

Outcome Measures: HACs, Health-Related Quality of Life scores(HRQLs), Reoperation, Integrated Health State (IHS) METHODS: ASD pts undergoing surgery (>18 years, scoliosis ≥20°, SVA ≥5 cm, PT ≥25° and/or TK >60°) with complete data at BL and up to 2 years post-op were included. Patients were stratified by presence of >1 HAC, defined as at least one superficial/deep SSI, UTI, DVT, or PE within a 30-day post-op window. Random forest analysis generated 5,000 Conditional Inference Trees to compute a variable importance table for top predictors of HACs. An area-under-the-curve (AUC) methodology compared normalized HRQL scores between groups to determine an IHS with 2-year follow-up.

Results: Total of 1,171 pts (59.8 years, 76.2%F, 28.1kg/m) underwent corrective ASD surgery, with 1,053 pts in the non-HAC group and 118 in the HAC group. Of these pts, 25.4% had UTI, 15.4% DVT, 19.2% superficial SSI, 20.8% deep SSI, and 19.2% PE. HAC pts were on average older (63.5 vs 59.3, p=.004) and more often frail (51.3 vs 39.7%, p=.021) than non-HAC pts. Postop LOS and reoperation were most associated with HAC groups: [1] LOS >7 days [2] reoperation. Patient-related predictors of HACs were [3] age >50 yerr, [4] frailty, and [13] BMI >31. Procedure-related predictors of HACs were [5] operative-time >405 minutes, [6] levels fused >9, EBL >1450 mL, and [11] decompression. BL radiographic predictors were [7] PT >20°, [9] PI-LL>6°, [10] TL Cobb angle >15°, [12] SVA C7-S1 >29 mm. No differences were observed between groups with regards to IHS ODI (0.73 vs 0.74, p=.863), SRS (1.3 vs1.3, p=.374), NRS Back (0.6 vs 0.6, p=.158). HAC had higher rates of reoperation than non-HAC (0.08 vs 0.01, p=.066), and any HAC within 30-days of index was a significant predictor of reoperation (OR: 2.448 [1.94-3.09], p<.001).

Conclusions: In a population of ASD patients, HACs were associated with length of stay, reoperation, age, and frailty. Radiographic parameters such as pelvic tilt >20°, PI-LL >6°, & SVA >29 mm also increased odds of HACs, and should raise postoperative awareness for HAC development.
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http://dx.doi.org/10.1016/j.spinee.2021.04.020DOI Listing
September 2021

The Patient-Reported Outcome Measurement Information System (PROMIS) Better Reflects the Impact of Length of Stay and the Occurrence of Complications Within 90 Days Than Legacy Outcome Measures for Lumbar Degenerative Surgery.

Int J Spine Surg 2021 Feb 12;15(1):82-86. Epub 2021 Feb 12.

Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York.

Background: The Patient-Reported Outcome Measurement Information System (PROMIS) and legacy outcome measures like the Oswestry Disability Index (ODI) have not been compared for their sensitivity in reflecting the impact of perioperative complications and length of stay (LOS) in a surgical thoracolumbar population. The purpose of this study is to assess the strength of PROMIS and ODI scores as they correlate with LOS and complication outcomes of surgical thoracolumbar patients.

Methods: Retrospective cohort study. Included: patients ≥18 years undergoing thoracolumbar surgery with available preoperative and 3-month postoperative ODI and PROMIS scores. Pearson correlation assessed the linear relationships between LOS, complications, and scores for PROMIS (physical function, pain intensity, pain interference) and ODI. Linear regression predicted the relationship between complication incidence and scores for ODI and PROMIS.

Results: Included: 182 patients undergoing thoracolumbar surgery. Common diagnoses were stenosis (62.1%), radiculopathy (48.9%), and herniated disc (47.8%). Overall, 58.3% of patients underwent fusion, and 50.0% underwent laminectomy. Patients showed preoperative to postoperative improvement in ODI (50.2 to 39.0), PROMIS physical function (10.9 to 21.4), pain intensity (92.4 to 78.3), and pain interference (58.4 to 49.8, all < .001). Mean LOS was 2.7 ± 2.8 days; overall complication rate was 16.5%. Complications were most commonly cardiac, neurologic, or urinary (all 2.2%). Whereas preoperative to postoperative changes in ODI did not correlate with LOS, changes in PROMIS pain intensity ( = 0.167, = .024) and physical function ( = -0.169, = .023) did. Complications did not correlate with changes in ODI or PROMIS score; however, postoperative scores for physical function ( = -0.205, = .005) and pain interference ( = 0.182, = .014) both showed stronger correlations with complication occurrence than ODI ( = 0.143, = .055). Regression analysis showed postoperative physical function ( = 0.037, = .005) and pain interference ( = 0.028, = .014) could predict complications; ODI could not.

Conclusions: PROMIS domains of physical function and pain interference better reflected perioperative complications and LOS than the ODI. These results suggest PROMIS may offer more utility as an outcomes assessment instrument.

Level Of Evidence: 3.
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http://dx.doi.org/10.14444/8011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931701PMC
February 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

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

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

A Simpler, Modified Frailty Index Weighted by Complication Occurrence Correlates to Pain and Disability for Adult Spinal Deformity Patients.

Int J Spine Surg 2020 Dec;14(6):1031-1036

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

Background: The Miller et al adult spinal deformity frailty index (ASD-FI) correlates with complication risk; however, its development was not rooted in clinical outcomes, and the 40 factors needed for its calculation limit the index's clinical utility. The present study aimed to develop a simplified, weighted frailty index for ASD patients METHODS: This study is a retrospective review of a single-center database. Component ASD-FI parameters contributing to overall ASD-FI score were assessed via Pearson correlation. Top significant, clinically relevant factors were regressed against ASD-FI score to generate the modified ASD-FI (mASD-FI). Component mASD-FI factors were regressed against incidence of medical complications, and factor weights were calculated from regression of these coefficients. Total mASD-FI score ranged from 0 to 21, and was calculated by summing weights of expressed parameters. Linear regression and published ASD-FI cutoffs generated corresponding mASD-FI frailty cutoffs: not frail (NF, <7), frail (7-12), severely frail (SF, >12). Analysis of variance assessed the relationship between frailty category and validated baseline measures of pain and disability at baseline.

Results: The study included 50 ASD patients. Eight factors were included in the mASD-FI. Overall mean mASD-FI score was 5.7 ± 5.2. Combined, factors comprising the mASD-FI showed a trend of predicting the incidence of medical complications (Nagelkerke = 0.558; Cox & Snell = 0.399; = .065). Breakdown by frailty category is NF (70%), frail (12%), and SF (18%). Increasing frailty category was associated with significant impairments in measures of pain and disability: Oswestry Disability Index (NF: 23.4; frail: 45.0; SF: 49.3; < .001), SRS-22r (NF: 3.5; frail: 2.6; SF: 2.4; = .001), Pain Catastrophizing Scale (NF: 41.9; frail: 32.4; SF: 27.6; < .001), and NRS Leg Pain (NF: 2.3; frail: 7.2; SF: 5.6; = .001).

Conclusions: This study modifies an existing ASD frailty index and proposes a weighted, shorter mASD-FI. The mASD-FI relies less on patient-reported variables, and it weights component factors by their contribution to adverse outcomes. Because increasing mASD-FI score is associated with inferior clinical measures of pain and disability, the mASD-FI may serve as a valuable tool for preoperative risk assessment.
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http://dx.doi.org/10.14444/7154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872408PMC
December 2020

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

Spine (Phila Pa 1976) 2021 Aug;46(16):1087-1096

Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO.

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 measures at 3Y. Decision tree analysis assessed invasiveness risk-benefit cutoff points, above which experiencing complications or reoperations and not reaching MCID were higher. Significance was set to P < 0.05.

Results: Overall, 195 of 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 health-related quality of life at 3Y established an invasiveness cutoff 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 cutoff 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).

Conclusion: Increasing invasiveness is associated with increased odds of major complications and reoperations. Risk-benefit cutoffs 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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http://dx.doi.org/10.1097/BRS.0000000000003977DOI Listing
August 2021

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

J Clin Neurosci 2021 Feb 28;84:42-45. Epub 2020 Dec 28.

Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA. Electronic address:

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).
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http://dx.doi.org/10.1016/j.jocn.2020.11.049DOI Listing
February 2021

A cost utility analysis of treating different adult spinal deformity frailty states.

J Clin Neurosci 2020 Oct 27;80:223-228. Epub 2020 Aug 27.

Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA. Electronic address:

The aim of this study was to investigate the cost utility of treating non-frail versus frail or severely frail adult spinal deformity (ASD) patients. 79 surgical ASD patients >18 years with available frailty and ODI data at baseline and 2-years post-surgery (2Y) were included. Utility data was calculated using the ODI converted to the SF-6D. QALYs utilized a 3% discount rate to account for decline to life expectancy (LE). Costs were calculated using the PearlDiver database. ICER was compared between non-operative (non-op.) and operative (op.) NF and F/SF patients at 2Y and LE. When compared to non-operative ASD, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2Y, and $68,311.35 vs. $47,764.61 for NF and F/SF at LE. Frail and severely frail patients had lower cost per QALY compared to not frail patients at 2Y and life expectancy, and had lower ICER values when compared to a non-operative cohort of ASD patients. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. Furthermore, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow up times, these findings support the cost effectiveness of ASD surgery at all frailty states.
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http://dx.doi.org/10.1016/j.jocn.2020.07.047DOI Listing
October 2020

A cost benefit analysis of increasing surgical technology in lumbar spine fusion.

Spine J 2021 02 15;21(2):193-201. Epub 2020 Oct 15.

Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.

Background Context: Numerous advances have been made in the field of spine fusion, such as minimally invasive (MIS) or robotic-assisted spine surgery. However, it is unknown how these advances have impacted the cost of care.

Purpose: Compare the economic outcomes of lumbar spine fusion between open, MIS, and robot-assisted surgery patients.

Study Design/setting: Retrospective review of a single center spine surgery database.

Patient Sample: Three hundred sixty propensity matched patients.

Outcome Measures: Costs, EuroQol-5D (EQ5D), cost per quality adjusted life years (QALY).

Methods: Inclusion criteria: surgical patients >18 years undergoing lumbar fusion surgery. Patients were categorized into 3 groups based on procedure type: open, MIS, or robotic. Open patients undergoing poster spinal fusion were considered as the control group. MIS patients included those undergoing transforaminal or lateral lumbar interbody fusion with percutaneous screws. Robotic patients were those undergoing robot-assisted fusion. Propensity score matching was performed between all groups for the number of levels fused. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims for ICD-9 codes. For robotic cases, costs were reflective of operational fees and initial purchase cost. Complications and comorbidities and major complications and comorbidities were assessed according to CMS.gov manual definitions. QALYs and cost per QALY were calculated using a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs per QALY were calculated for both 1 year and life expectancy, assuming no loss of benefit. A 10,000 trial Monte Carlo simulation with probabilistic sensitivity analysis (PSA) assessed our model parameters and costs.

Results: Three hundred sixty propensity matched patients (120 open, 120 MIS, 120 robotic) met inclusion criteria. Descriptive statistics for the cohort were: age 58.8±13.5, 50% women, BMI 29.4±6.3, operative time 294.4±119.0, LOS 4.56±3.31 days, estimated blood loss 515.9±670.0 cc, and 2.3±2.2 average levels fused. Rates of post-op complications were significantly higher in robotic cases versus open and MIS (43% vs. 21% and 22% for open and MIS, p<.05). However, revision rates were comparable between all groups (3% open, 3% MIS, 5% robotic, p>.05). After factoring in complications, revisions, and purchasing and operating fees, the costs of robotic cases was significantly higher than both open and MIS surgery ($60,047.01 vs. $42,538.98 open and $41,471.21 MIS). In a subanalysis of 42 patients with baseline (BL) and 1Y EQ5D data, the cost per QALY at 1Y for open, MIS, and robot-assisted cases was $296,624.48, $115,911.69, and $592,734.30. If utility gained was sustained to life expectancy, the cost per QALY was $14,905.75, $5,824.71, $29,785.64 for open, MIS, and robot-assisted cases. Results of the PSA were consistent with MIS surgery having the most incremental cost effectiveness when compared to open and robotic surgery.

Conclusions: Numerous advances have been made in the field of spine surgery, however, there has been limited discussion of the effect these advances have on economic outcomes. When matched for levels fused, robot-assisted surgery patients had significantly higher rates of complications and 30% higher costs of surgery compared to minimally invasive and open spine surgery patients. While 1 year economic outcomes were not optimal for robotic surgery cases, the projected costs per QALYs at life expectancy were well below established acceptable thresholds. The above findings may be reflective of an educational learning curve and emerging surgical technologies undergoing progressive refinement.
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http://dx.doi.org/10.1016/j.spinee.2020.10.012DOI Listing
February 2021

Sports-related Cervical Spine Fracture and Spinal Cord Injury: A Review of Nationwide Pediatric Trends.

Spine (Phila Pa 1976) 2021 Jan;46(1):22-28

Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Langone Medical Center, NY Spine Institute, New York, NY.

Study Design: Retrospective cohort study.

Objective: Assess trends in sports-related cervical spine trauma using a pediatric inpatient database.

Summary Of Background Data: Injuries sustained from sports participation may include cervical spine trauma such as fractures and spinal cord injury (SCI). Large database studies analyzing sports-related cervical trauma in the pediatric population are currently lacking.

Methods: The Kid Inpatient Database was queried for patients with external causes of injury secondary to sports-related activities from 2003 to 2012. Patients were further grouped for cervical spine injury (CSI) type, including C1-4 and C5-7 fracture with/without spinal cord injury (SCI), dislocation, and SCI without radiographic abnormality (SCIWORA). Patients were grouped by age into children (4-9), pre-adolescents (Pre, 10-13), and adolescents (14-17). Kruskall-Wallis tests with post-hoc Mann-Whitney U's identified differences in CSI type across age groups and sport type. Logistic regression found predictors of TBI and specific cervical injuries.

Results: A total of 38,539 patients were identified (12.76 years, 24.5% F). Adolescents had the highest rate of sports injuries per year (P < 0.001). Adolescents had the highest rate of any type of CSI, including C1-4 and C5-7 fracture with and without SCI, dislocation, and SCIWORA (all P < 0.001). Adolescence increased odds for C1-4 fracture w/o SCI 3.18×, C1-4 fx w/ SCI by 7.57×, C5-7 fx w/o SCI 4.11×, C5-7 w/SCI 3.63×, cervical dislocation 1.7×, and cervical SCIWORA 2.75×, all P < 0.05. Football injuries rose from 5.83% in 2009 to 9.14% in 2012 (P < 0.001), and were associated with more SCIWORA (1.6% vs. 1.0%, P = 0.012), and football injuries increased odds of SCI by 1.56×. Concurrent TBI was highest in adolescents at 58.4% (pre: 26.6%, child: 4.9%, P < 0.001), and SCIWORA was a significant predictor for concurrent TBI across all sports (odds ratio: 2.35 [1.77-3.11], P < 0.001).

Conclusion: Adolescent athletes had the highest rates of upper/lower cervical fracture, dislocation, and SCIWORA. Adolescence and SCIWORA were significant predictors of concurrent TBI across sports. The increased prevalence of CSI with age sheds light on the growing concern for youth sports played at a competitive level, and supports recently updated regulations aimed at decreasing youth athletic injuries.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003718DOI Listing
January 2021

Radiographic benefit of incorporating the inflection between the cervical and thoracic curves in fusion constructs for surgical cervical deformity patients.

J Craniovertebr Junction Spine 2020 Apr-Jun;11(2):131-138. Epub 2020 Jun 5.

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

Purpose: The aim is to assess the relationship between cervicothoracic inflection point and baseline disability, as well as the relationship between clinical outcomes and pre- to postoperative changes in inflection point.

Methods: Cervical deformity (CD) patients with baseline and 3-month (3M) postoperative radiographic, clinical, and inflection data were grouped by region of inflection point: C6 or above, C6-C7 to C7-T1, T1, or below. Inflection was defined as: Distal-most level where cervical lordosis (CL) changes to thoracic kyphosis (TK). Differences in alignment and patient factors across pre- and postoperative inflection point groups were assessed, as were outcomes by the inclusion of inflection in the CD-corrective fusion construct.

Results: A total of 108 patients were included. Preoperative inflection breakdown: C6 or above (42%), C6-C7 to C7-T1 (44%), T1 or below (15%). Surgery was associated with a caudal migration of inflection by 3M: C6 or above (8%), C6-C7 to C7-T1 (58%), T1 or below (33%). For patients with preoperative inflection T1 or below, the inclusion of inflection in the fusion construct was associated with improvements in horizontal gaze (McGregor's Slope included: -11.3° vs. not included: 1.6°, = 0.038). The inclusion of preoperative inflection in fusion was associated with the superior cervical sagittal vertical axis (cSVA) changes for C6-C7 to C7-T1 patients (-5.2 mm vs. 3.2 mm, = 0.018). The location of postoperative inflection was associated with variation in 3M alignment: Inflection C6 or above was associated with less Pelvic Tilt (PT), PT and a trend of larger cSVA. Location of inflection or inclusion in fusion was not associated with reoperation or distal junctional kyphosis.

Conclusions: Incorporating the inflection point between CL and TK in the fusion construct was associated with superior restoration of cervical alignment and horizontal gaze for surgical CD patients.
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http://dx.doi.org/10.4103/jcvjs.JCVJS_57_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7462144PMC
June 2020

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

Bull Hosp Jt Dis (2013) 2020 Sep;78(3):157-162

Purpose: 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: 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.
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September 2020

Complication Risk in Primary and Revision Minimally Invasive Lumbar Interbody Fusion: A Comparable Alternative to Conventional Open Techniques?

Global Spine J 2020 Aug 5;10(5):619-626. Epub 2019 Aug 5.

NYU Langone Orthopedic Hospital, New York, NY, USA.

Study Design: Retrospective cohort study of prospective patients undergoing minimally invasive lumbar fusion at a single academic institution.

Objective: To assess differences in perioperative outcomes between primary and revision MIS (minimally invasive surgical) lumbar interbody fusion patients and compare with those undergoing corresponding open procedures.

Methods: Patients ≥18 years old undergoing lumbar interbody fusion were grouped by surgical technique: MIS or open. Patients within each group were propensity score matched for comorbidities and levels fused. Patient demographics, surgical factors, and perioperative complication incidences were compared between primary and revision cases using means comparison tests, as appropriate.

Results: Of the 214 lumbar interbody fusion patients included after propensity score matching, 44 (21%) cases were MIS, and 170 (79%) were open. For MIS patients, there were no significant differences between primary and revision cases in estimated blood loss (EBL; 344 vs 299 cm, = .682); however, primary cases had longer operative times (301 vs 246 minutes, = .029). There were no differences in length of stay (LOS), intensive care unit LOS, readmission, and intraoperative or postoperative complications (all > .05). For open patients, there were no differences between primary and revision cases in EBL ( > .05), although revisions had longer operative times (331 vs 278 minutes, = .018) and more postoperative complications (61.7% vs 23.8%, < .001). MIS revision procedures were shorter than open revisions (182 vs 213 minutes, = .197) with significantly less EBL (294 vs 965 cm, < .001), shorter inpatient and intensive care unit LOS, and fewer postoperative complications (all < .05).

Conclusions: Clinical outcomes of revision MIS lumbar interbody fusion were similar to those of primary surgery. Additionally, MIS techniques were associated with less EBL, shorter LOS, and fewer perioperative complications than corresponding open revisions.
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http://dx.doi.org/10.1177/2192568219867289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359676PMC
August 2020

Ossification of the Posterior Longitudinal Ligament in Cervical Spine Cases Trends in Surgical Treatments and Outcomes in the US from 2005 to 2013.

Bull Hosp Jt Dis (2013) 2020 Jun;78(2):108-114

Background: Ossification of the posterior longitudinal ligament (OPLL) is characterized by ectopic bone formation within the ligament and can elicit cervical spinal canal stenosis. Surgical treatment for OPLL is debated in the literature. This study examined nationwide data to estimate the prevalence of cervical OPLL (C-OPLL) and investigated trends in surgical treatment and outcomes.

Methods: A retrospective cross-sectional study was conducted of the National Inpatient Sample (NIS) database for patients with a diagnosis code for C-OPLL (ICD-9-CM 723.7) from 2005 to 2013. NIS supplied hospital- and yearadjusted weights allowed for accurate assessment of prevalence. Descriptive statistics assessed patient demographics, comorbidities, surgical factors, and complications. Trends were analyzed using chi-squared, ANOVA, and independent sample t-tests.

Results: A total of 4,601 C-OPLL discharges were identified (56.7 years, 43% female). The prevalence of C-OPLL has increased from 0.7/100,000 in 2005 to 2.1/100,000 in 2013. Among hospitalized C-OPLL patients, 89.1% underwent surgery, with 62.1% undergoing an anterior-only (A) approach, 21.5% posterior-only (P), and 16.4% combined (AP). Rates of anterior- and decompression-only surgeries have declined since 2005, from 67.5% to 44.4% and 21.6% to 14.8%, respectively (p < 0.001 for both). Corpectomy rates have dramatically increased, from 3.6% to 27.2% (p < 0.001). Overall complication rates have increased 2.5% since 2005 (p < 0.001) with higher rates of dysphagia (0.7%) and dural tears (5.6%) associated with A-only surgeries (p < 0.001 for both). The overall mortality rate was 0.8%, with P surgery associated with the highest rate, 1.6% (p = 0.002).

Conclusions: The rate of hospitalization for C-OPLL has increased over the last decade as have morbidity rates for C-OPLL discharges. Anterior-only surgeries were associated with higher complication rates. Surgical rates have remained constantsince 2005, butrates of anterior-only and decompression-only procedures have decreased in favor of posterior-only and combined-approach surgeries.
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June 2020

Readmission in elective spine surgery: Will short stays be beneficial to patients.

J Clin Neurosci 2020 Aug 29;78:170-174. Epub 2020 Apr 29.

Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA. Electronic address:

There has been limited discussion as to whether spine surgery patients are benefiting from shorter in-patient hospital stays or if they are incurring higher rates of readmission and complications secondary to shortened length of stays. Included in this study were 237,446 spine patients >18yrs and excluding infection. Patients with Clavien Grade 5 complications in 2015 had the lowest mean time to readmission after initial surgery in all years at 12.44 ± 9.03 days. Pearson bivariate correlations between LOS ≤ 1 day and decreasing days to readmission was the strongest in 2016.). Logistic regression analysis found that LOS ≤ 1 day showed an overall increase in the odds of hospital readmission from 2012 to 2016 (2.29 [2.00-2.63], 2.33 [2.08-2.61], 2.35 [2.11-2.61], 2.27 [2.06-2.49], 2.33 [2.14-2.54], all p < 0.001).
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http://dx.doi.org/10.1016/j.jocn.2020.04.083DOI Listing
August 2020

Hospital-acquired conditions occur more frequently in elective spine surgery than for other common elective surgical procedures.

J Clin Neurosci 2020 Jun 21;76:36-40. Epub 2020 Apr 21.

Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY, USA. Electronic address:

Hospital-acquired conditions (HACs) have been the focus of recent initiatives by the Centers for Medicare and Medicaid Services in an effort to improve patient safety and outcomes. Spine surgery can be complex and may carry significant comorbidity burden, including so called "never events." The objective was to determine the rates of common HACs that occur within 30-days post-operatively for elective spine surgeries and compare them to other common surgical procedures. Patients: >18 y/o undergoing elective spine surgery were identified in the American College of Surgeons' NSQIP database from 2005 to 2013. Patients were stratified by whether they experienced >1 HAC, then compared to those undergoing other procedures including bariatric surgery, THA and TKA. Of the 90,551 spine surgery patients, 3021 (3.3%) developed at least one HAC. SSI was the most common (1.4%), followed by UTI (1.3%), and VTE (0.8%). Rates of HACs in spine surgery were significantly higher than other elective procedures including bariatric surgery (2.8%) and THA (2.8%) (both p < 0.001). Spine surgery and TKA patients had similar rates of HACs(3.3% vs 3.4%, p = 0.287), though spine patients experienced higher rates of SSI (1.4%vs0.8%, p < 0.001) and UTI (1.3%vs1.1%, p < 0.001) but lower rates of VTE (0.8%vs1.6%, p < 0.001). Spine surgery patients had lower rates of HACs overall (3.3%vs5.9%) when compared to cardiothoracic surgery patients (p < 0.001). When compared to other surgery types, spine procedures were associated with higher HACs than bariatric surgery patients and knee and hip arthroplasties overall but lower HAC rates than patients undergoing cardiothoracic surgery.
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http://dx.doi.org/10.1016/j.jocn.2020.04.067DOI Listing
June 2020

Comparative outcomes of operative relative to medical management of spondylodiscitis accounting for frailty status at presentation.

J Clin Neurosci 2020 May 12;75:134-138. Epub 2020 Mar 12.

Division of Spinal Surgery, Departments of Orthopaedic and Neurological Surgery, NYU Langone Medical Center, NY Spine Institute, New York, NY, United States. Electronic address:

Purpose: Investigate outcomes in a spondylodiscitis (SD) patient cohort undergoing operative and medical treatment or medical treatment alone, accounting for frailty status at presentation.

Methods: Patients >18 years old undergoing treatment for SD were retrospectively analyzed. The diagnosis of SD was made through a combination of clinical findings, MRI/CT findings, and blood/tissue cultures. Those who failed to respond to antibiotics, had deteriorating markers, or developed neurologic compromise were considered operative candidates. Patients were stratified based on operative (Op, operative plus medical management) or conservative (Cons, medical only) treatment. Univariate analyses identified differences in outcome measures across treatment groups. Conditional forward regression equations, controlling for patient age, identified predictors of increased mortality and inferior outcomes.

Results: 116 patients with SD were included. 73 underwent Cons treatment and 43 were Op. Op patients were significantly younger (62.9vs70.7yrs; p < 0.001) and less frail (1.09vs1.85; p < 0.006) than Cons patients, with significantly higher WCC and ESR. Cons pts had higher rates of isolated SD, but Op pts had higher rates of SD with associated SEA, VOM, psoas abscess, and para-vertebral abscess (all p < 0.05). Op pts had significantly lower 30-day mortality than Cons pts (2.3%vs17.8%, p = 0.016), and trended lower 1Y mortality (11.6%vs20.5%, p = 0.310) with similar SD recurrence rates (11.6%vs16.4%, p = 0.592). Patients with an mFI > 3 had significantly higher 30-day mortality (30.4% vs 7.5%, p = 0.003) and trended higher 1-year mortality regardless of intervention.

Conclusions: Operative intervention was associated with lower 30-day mortality significantly and 1-year mortality compared to conservative treatment, while an increased mFI was associated with higher short-term mortality.
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http://dx.doi.org/10.1016/j.jocn.2020.03.003DOI Listing
May 2020

Bariatric Surgery Population at Significantly Increased Risk of Spinal Disorders and Surgical Intervention Compared With Morbidly Obese Patients.

Clin Spine Surg 2020 05;33(4):E158-E161

Department of Orthopaedic Surgery, Hospital for Special Surgery, Manhattan, NY.

Introduction: Obesity is associated with acceleration of musculoskeletal degenerative diseases and functional impairment secondary to spinal disorders. Bariatric surgery (BS) is an increasingly common treatment for severe obesity but can affect bone and mineral metabolism. The effect of BS on degenerative spinal disorders is yet to be fully described. The aim of our study was to analyze changes in bariatric patients' risk for spinal degenerative diseases and spinal surgery.

Methods: Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years (2004-2013) using patient linkage codes. The incidence of degenerative spinal diagnoses and spinal surgery was queried using International Classification of Diseases, Ninth Revision (ICD)-9 codes for morbidly obese patients (ICD-9 278.01) with and without a history of BS. The incidence of degenerative spinal diagnoses and spinal surgery was determined using χ tests for independence. Logistic testing controlled for age, sex, and comorbidity burden.

Results: A total of 18,176 patients were identified in the NYSID database with a history of BS and 146,252 patients were identified as morbidly obese without a history of BS. BS patients have a significantly higher rate of spinal diagnoses than morbidly obese patients without BS (19.3% vs. 8.1%, P<0.001). Bariatric patients were more likely to have spinal diagnoses and procedures than nonbariatric obese patients (P<0.001). This was mostly observed in lumbar spinal stenosis (5.0%), cervical disk herniation (3.3%), lumbar disk degeneration (3.4%), lumbar spondylolisthesis (2.9%), lumbar spondylosis (1.9%), and cervical spondylosis with myelopathy (2.0%). Spine procedure rates are higher for bariatric patients than nonbariatric overall (25.6% vs. 2.3, P<0.001) and for fusions and decompressions (P<0.001). When controlling for age, sex, and comorbidities (and diagnosis rate with regards to procedure rates), these results persist, with BS patients having a higher likelihood of spinal diagnoses and procedures. In addition, bariatric patients had a lower comorbidity burden than morbidly obese patients without a history of BS.

Conclusions: Morbidly obese BS patients have a dramatically higher incidence of spinal diagnoses and procedures, relative to morbidly obese patients without BS. Further study is necessary to determine if there is a pathophysiological mechanism underlying this higher risk of spinal disease and intervention in bariatric patients, and the effect of BS on these rates following treatment.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000000960DOI Listing
May 2020

Operative fusion of patients with metabolic syndrome increases risk for perioperative complications.

J Clin Neurosci 2020 Feb 30;72:142-145. Epub 2019 Dec 30.

Department of Orthopaedic and Neurologic Surgery, NYU Langone Medical Center/NYU School of Medicine, New York Spine Institute, New York, NY, USA. Electronic address:

Metabolic syndrome is a clustering of clinical findings defined in the literature including hypertension, high glucose, abdominal obesity, high triglyceride, and low high-density lipoprotein cholesterol levels. The purpose of this study was to assess perioperative outcomes in patients undergoing spine fusion surgery with (MetS) and without (no-MetS) a history of metabolic syndrome. Included: Patients ≥18 yrs old undergoing spine fusion procedures diagnosed with MetS components with BL and 1-year follow-up were isolated in a single-center database. Patients in the two groups were propensity score matched for levels fused. 250 spine fusion patients (58 yrs, 52.2%F, 39.0 kg/m) with an average CCI of 1.92 were analyzed. 125 patients were classified with MetS (60.2 yrs, 52%F, CCI: 3.2). MetS patients were significantly older (p = 0.012). MetS patients underwent significantly more open (Met-S: 78.4% vs No-MetS: 45.6%, p < 0.001) and posterior approached procedures (Met-S: 60.8% vs No-MetS: 47.2%, p = 0.031). Mean operative time: 272.4 ± 150 min (MetS: 288.1 min vs. no-MetS: 259.7; p = 0.089). Average length of stay: 4.6 days (MetS: 5.27 vs no-MetS: 3.95; p = 0.095). MetS patients had more post-operative complications (29.6% vs. 18.4%; p = 0.038), specifically neuro (6.4% vs 2.4%), pulmonary (4% vs. 1.6%), and urinary (4.8% vs 2.4%) complications. Binary logistic regression analyses found that MetS was an independent risk factor for post-operative complications (OR: 1.865 [1.030-3.375], p = 0.040). With longer surgeries and greater open-exposure types, MetS patients were at greater risk for complications, despite controlling for total number of levels fused. Surgeons should be aware of the increased threat to spine surgery patients with metabolic syndrome in order to optimize surgical decision-making.
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http://dx.doi.org/10.1016/j.jocn.2019.12.043DOI Listing
February 2020

Obesity negatively affects cost efficiency and outcomes following adult spinal deformity surgery.

Spine J 2020 04 23;20(4):512-518. Epub 2019 Dec 23.

Division of Spinal Surgery, Departments of Orthopaedic and Neurosurgery, NYU Medical Center, NY Spine Institute, New York, NY, USA. Electronic address:

Background Context: Obesity has risen to epidemic proportions within the United States. As the rates of obesity have increased, so has its prevalence among patients undergoing adult spinal deformity (ASD) surgery. The effect of obesity on the cost efficiency of corrective procedures for ASD has not been effectively evaluated.

Purpose: To investigate differences in cost efficiency of ASD surgery for patients stratified by body mass index (BMI).

Study Design/setting: Retrospective review of a single-center ASD database.

Patient Sample: Five hundred five ASD patients.

Outcome Measures: Complications, revisions, costs, EuroQol-5D (EQ5D), quality-adjusted life years (QALYs), cost per QALY.

Methods: ASD patients (scoliosis≥20°, SVA≥5 cm, PT≥25°, or TK ≥60°) ≥18, undergoing ≥4 level fusions were included. Patients were stratified into NIH-defined obesity groups based on their preoperative BMI: underweight 18.5< (U), normal 18.5 to 24.9 (N), overweight 25.0 to 29.9 (O), obese I 30.0 to 34.9 (OI), obese II 35.0 to 39.9 (OII), and obesity class III 40.0+ (OIII). Total surgery costs for each ASD obesity group were calculated. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims. Overall complications and major complications were assessed according to CMS definitions. QALYs and cost per QALY for obesity groups were calculated using an annual 3% discount up to life expectancy (78.7 years).

Results: In all, 505 patients met inclusion criteria. Baseline demographics and surgical details were: age 60.8±14.8, 67.6% female, BMI 28.8±7.30, 81.0% posterior approach, 18% combined approach, 10.1±4.2 levels fused, op time 441.2±146.1 minutes, EBL 1903.8±1594.7 cc, and LOS 8.7±10.7 days. There were 17 U, 154 N patients, 151 O patients, 100 OI, 51 OII, and 32 OIII patients. Revision rates by obesity group were: 0% U, 3% N patients, 3% O patients, 5% OI, 4% OII, and 6% for OIII patients. The total surgery costs by obesity group were: $48,757.86 U, $49,688.52 N, $47,219.93 O, $50,467.66 OI, $51,189.47 OII, and $53,855.79 OIII. In an analysis of patients with baseline and 1 Y EQ5D follow-up, the cost per QALY by obesity group was: $153,737.78 U, $229,222.37 N, $290,361.68 O, $493,588.47 OI, $327,876.21 OII, and $171,680.00 OIII. If that benefit was sustained to life expectancy, the cost per QALY was $8,588.70 U, $12,805.72 N, $16,221.32 O, $27,574.77 OI, $18,317.11 OII, and $9,591.06 for OIII.

Conclusions: Among adult spinal deformity patients, those with BMIs in the obesity I, obesity II, or obesity class III range had more expensive total surgery costs. When assessing 1 year cost per QALY, obese patients had costs 32% higher than nonobese patients ($224,440.61 vs. $331,048.23). Further research is warranted on the utility of optimizing modifiable preoperative health factors for patients undergoing corrective adult spinal deformity surgery.
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http://dx.doi.org/10.1016/j.spinee.2019.12.012DOI Listing
April 2020
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