Publications by authors named "Shay Bess"

310 Publications

Lateral Thoracolumbar Listhesis as an Independent Predictor of Disability in Adult Scoliosis Patients: Multivariable Assessment Before and After Surgical Realignment.

Neurosurgery 2021 Sep 11. Epub 2021 Sep 11.

Swedish Neuroscience Institute, Seattle, Washington, USA.

Background: Lateral (ie, coronal) vertebral listhesis may contribute to disability in adult scoliosis patients.

Objective: To assess for a correlation between lateral listhesis and disability among patients with adult scoliosis.

Methods: This was a retrospective multi-center analysis of prospectively collected data. Patients eligible for a minimum of 2-yr follow-up and with coronal plane deformity (defined as maximum Cobb angle ≥20º) were included (n = 724). Outcome measures were Oswestry Disability Index (ODI) and leg pain numeric scale rating. Lateral thoracolumbar listhesis was measured as the maximum vertebral listhesis as a percent of the superior endplate across T1-L5 levels. Linear and logistic regression was utilized, as appropriate. Multivariable analyses adjusted for demographics, comorbidities, surgical invasiveness, maximum Cobb angle, and T1-PA. Minimally clinically important difference (MCID) in ODI was defined as 12.8.

Results: In total, 724 adult patients were assessed. The mean baseline maximum lateral thoracolumbar listhesis was 18.3% (standard deviation 9.7%). The optimal statistical grouping for lateral listhesis was empirically determined to be none/mild (<6.7%), moderate (6.7-15.4%), and severe (≥15.4%). In multivariable analysis, listhesis of moderate and severe vs none/mild was associated with worse baseline ODI (none/mild = 33.7; moderate = 41.6; severe = 43.9; P < .001 for both comparisons) and leg pain NSR (none/mild = 2.9, moderate = 4.0, severe = 5.1, P < .05). Resolution of severe lateral listhesis to none/mild was independently associated with increased likelihood of reaching MCID in ODI at 2 yr postoperatively (odds ratio 2.1 95% confidence interval 1.2-3.7, P = .0097).

Conclusion: Lateral thoracolumbar listhesis is associated with worse baseline disability among adult scoliosis patients. Resolution of severe lateral listhesis following deformity correction was independently associated with increased likelihood of reaching MCID in ODI at 2-yr follow-up.
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http://dx.doi.org/10.1093/neuros/nyab356DOI Listing
September 2021

Association of findings on preoperative extension lateral cervical radiography with osteotomy type, approach, and postoperative cervical alignment after cervical deformity surgery.

J Neurosurg Spine 2021 Sep 3:1-6. Epub 2021 Sep 3.

1Department of Orthopaedic Surgery, UC Davis Medical Center, Sacramento, California.

Objective: The authors' objective was to determine whether preoperative lateral extension cervical spine radiography can be used to predict osteotomy type and postoperative alignment parameters after cervical spine deformity surgery.

Methods: A total of 106 patients with cervical spine deformity were reviewed. Radiographic parameters on preoperative cervical neutral and extension lateral radiography were compared with 3-month postoperative radiographic alignment parameters. The parameters included T1 slope, C2 slope, C2-7 cervical lordosis, cervical sagittal vertical axis, and T1 slope minus cervical lordosis. Associations of radiographic parameters with osteotomy type and surgical approach were also assessed.

Results: On extension lateral radiography, patients who underwent lower grade osteotomy had significantly lower T1 slope, T1 slope minus cervical lordosis, cervical sagittal vertical axis, and C2 slope. Patients who achieved more normal parameters on extension lateral radiography were more likely to undergo surgery via an anterior approach. Although baseline parameters were significantly different between neutral lateral and extension lateral radiographs, 3-month postoperative lateral and preoperative extension lateral radiographs were statistically similar for T1 slope minus cervical lordosis and C2 slope.

Conclusions: Radiographic parameters on preoperative extension lateral radiography were significantly associated with surgical approach and osteotomy grade and were similar to those on 3-month postoperative lateral radiography. These results demonstrated that extension lateral radiography is useful for preoperative planning and predicting postoperative alignment.
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http://dx.doi.org/10.3171/2021.3.SPINE202156DOI Listing
September 2021

Reaching the medicare allowable threshold in adult spinal deformity surgery: multicenter cost analysis comparing actual direct hospital costs versus what the government will pay.

Spine Deform 2021 Sep 1. Epub 2021 Sep 1.

Presbyterian/St. Luke's Medical Center, Rocky Mountain Hospital for Children, Denver, CO, USA.

Study Design: Retrospective multicenter cost analysis.

Objective: To (1) determine if index episode of care (iEOC) costs of Adult Spinal Deformity (ASD) surgeries are below the Medicare Allowable (MA) threshold, and (2) identify variables that can predict iEOC cases that are below MA. Previous studies have suggested that actual direct hospital cost of Adult Spinal Deformity (ASD) surgery is higher than Medicare Allowable (MA) rates, which has become the benchmark reimbursement target for hospital accounting systems.

Methods: From a prospective, multicenter ASD surgical database, patients undergoing long instrumented fusions (> 5 level) with cost data were identified. iEOC cost was calculated utilizing actual direct hospital cost. MA rates were calculated using hospital specific, year-appropriate CMS Inpatient Pricer Payment System. Recursive partitioning identified potentially modifiable variables that can predict iEOC cost < MA.

Results: Administrative direct cost data from 210 patients were obtained from 4 of 11 centers. Ninety-five (45%) patients had iEOC cost < MA. There was significant variation across the four centers in both iEOC cost ($56,788-$78,878, p < 0.0001) and reimbursement ($40,623-$91,351, p < 0.0001) across deformity-specific DRGs (453,454,456,457). Academic centers were more likely to have iEOC costs < MA (67.2% vs 8.9%, p < 0.0001). Recursive partitioning (r = 0.309) identified rhBMP-2 use of < 24 mg, sagittal plane deformity, a combined anterior/posterior approach, and an SF36-MCS < 39 as predictive for iEOC cost < MA. Performing an anterior/posterior approach reimburses between 14.7% and 121.1% more (2.2-fold) than posterior-only approach. This change in DRG allows iEOC cost to be more likely below the MA threshold.

Conclusion: There is significant institutional (private vs academic) variation in ASD reimbursement. BMP use, deformity type, approach, and baseline mental health impact ASD surgery cost being below Medicare reimbursement. ASD surgeries with anterior/posterior approaches are in DRGs that can potentially reimburse 2.2-fold the posterior-only surgery, making it more likely to fall below the MA threshold.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s43390-021-00405-4DOI Listing
September 2021

Sagittal age-adjusted score (SAAS) for adult spinal deformity (ASD) more effectively predicts surgical outcomes and proximal junctional kyphosis than previous classifications.

Spine Deform 2021 Aug 30. Epub 2021 Aug 30.

Department of Orthopedics, Hospital for Special Surgery, 525 E 71st St., Belaire 4E, New York, NY, 10021, USA.

Background: Several methodologies have been proposed to determine ideal ASD sagittal spinopelvic alignment (SRS-Schwab classification) global alignment and proportion (GAP) score, patient age-adjusted alignment). A recent study revealed the ability and limitations of these methodologies to predict PJK. The aim of the study was to develop a new approach, inspired by SRS classification, GAP score, and age-alignment to improve the evaluation of the sagittal plane.

Method: A multi-center ASD database was retrospectively evaluated for surgically treated ASD patients with complete fusion of the lumbar spine, and minimum 2 year follow-up. The Sagittal age-adjusted score (SAAS) methodology was created by assigning numerical values to the difference between each patient's postoperative sagittal alignment and ideal alignment defined by previously reported age generational norms for PI-LL, PT, and TPA. Postoperative HRQOL and PJK severity between each SAAS categories were evaluated.

Results: 409 of 667 (61.3%) patients meeting inclusion criteria were evaluated. At 2 year SAAS score showed that 27.0% of the patients were under-corrected, 51.7% over-corrected, and 21.3% matched their age-adjusted target. SAAS score increased as PJK worsened (from SAAS = 0.2 for no-PJK, to 4.0 for PJF, p < 0.001). Post-operatively, HRQOL differences between SAAS groups included ODI, SRS pain, and SRS total.

Conclusion: Inspired by SRS classification, the concept of the GAP score, and age-adjusted alignment targets, the results demonstrated significant association with PJK and patient reported outcomes. With a lower rate of failure and better HRQOL, the SAAS seems to represent a "sweet spot" to optimize HRQOL while mitigating the risk of mechanical complications.
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http://dx.doi.org/10.1007/s43390-021-00397-1DOI Listing
August 2021

Global coronal decompensation and adult spinal deformity surgery: comparison of upper-thoracic versus lower-thoracic proximal fixation for long fusions.

J Neurosurg Spine 2021 Aug 27:1-13. Epub 2021 Aug 27.

18Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.

Objective: Deterioration of global coronal alignment (GCA) may be associated with worse outcomes after adult spinal deformity (ASD) surgery. The impact of fusion length and upper instrumented vertebra (UIV) selection on patients with this complication is unclear. The authors' objective was to compare outcomes between long sacropelvic fusion with upper-thoracic (UT) UIV and those with lower-thoracic (LT) UIV in patients with worsening GCA ≥ 1 cm.

Methods: This was a retrospective analysis of a prospective multicenter database of consecutive ASD patients. Index operations involved instrumented fusion from sacropelvis to thoracic spine. Global coronal deterioration was defined as worsening GCA ≥ 1 cm from preoperation to 2-year follow-up.

Results: Of 875 potentially eligible patients, 560 (64%) had complete 2-year follow-up data, of which 144 (25.7%) demonstrated worse GCA at 2-year postoperative follow-up (35.4% of UT patients vs 64.6% of LT patients). At baseline, UT patients were younger (61.6 ± 9.9 vs 64.5 ± 8.6 years, p = 0.008), a greater percentage of UT patients had osteoporosis (35.3% vs 16.1%, p = 0.009), and UT patients had worse scoliosis (51.9° ± 22.5° vs 32.5° ± 16.3°, p < 0.001). Index operations were comparable, except UT patients had longer fusions (16.4 ± 0.9 vs 9.7 ± 1.2 levels, p < 0.001) and operative duration (8.6 ± 3.2 vs 7.6 ± 3.0 hours, p = 0.023). At 2-year follow-up, global coronal deterioration averaged 2.7 ± 1.4 cm (1.9 to 4.6 cm, p < 0.001), scoliosis improved (39.3° ± 20.8° to 18.0° ± 14.8°, p < 0.001), and sagittal spinopelvic alignment improved significantly in all patients. UT patients maintained smaller positive C7 sagittal vertical axis (2.7 ± 5.7 vs 4.7 ± 5.7 cm, p = 0.014). Postoperative 2-year health-related quality of life (HRQL) significantly improved from baseline for all patients. HRQL comparisons demonstrated that UT patients had worse Scoliosis Research Society-22r (SRS-22r) Activity (3.2 ± 1.0 vs 3.6 ± 0.8, p = 0.040) and SRS-22r Satisfaction (3.9 ± 1.1 vs 4.3 ± 0.8, p = 0.021) scores. Also, fewer UT patients improved by ≥ 1 minimal clinically important difference in numerical rating scale scores for leg pain (41.3% vs 62.7%, p = 0.020). Comparable percentages of UT and LT patients had complications (208 total, including 53 reoperations, 77 major complications, and 78 minor complications), but the percentage of reoperated patients was higher among UT patients (35.3% vs 18.3%, p = 0.023). UT patients had higher reoperation rates of rod fracture (13.7% vs 2.2%, p = 0.006) and pseudarthrosis (7.8% vs 1.1%, p = 0.006) but not proximal junctional kyphosis (9.8% vs 8.6%, p = 0.810).

Conclusions: In ASD patients with worse 2-year GCA after long sacropelvic fusion, UT UIV was associated with worse 2-year HRQL compared with LT UIV. This may suggest that residual global coronal malalignment is clinically less tolerated in ASD patients with longer fusion to the proximal thoracic spine. These results may inform operative planning and improve patient counseling.
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http://dx.doi.org/10.3171/2021.2.SPINE201938DOI Listing
August 2021

Orthopedic disease burden in adult patients with symptomatic lumbar scoliosis: results from a prospective multicenter study.

J Neurosurg Spine 2021 Aug 20:1-9. Epub 2021 Aug 20.

3Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri.

Objective: Although the health impact of adult symptomatic lumbar scoliosis (ASLS) is substantial, these patients often have other orthopedic problems that have not been previously quantified. The objective of this study was to assess disease burden of other orthopedic conditions in patients with ASLS based on a retrospective review of a prospective multicenter cohort.

Methods: The ASLS-1 study is an NIH-sponsored prospective multicenter study designed to assess operative versus nonoperative treatment for ASLS. Patients were 40-80 years old with ASLS, defined as a lumbar coronal Cobb angle ≥ 30° and Oswestry Disability Index ≥ 20, or Scoliosis Research Society-22 questionnaire score ≤ 4.0 in pain, function, and/or self-image domains. Nonthoracolumbar orthopedic events, defined as fractures and other orthopedic conditions receiving surgical treatment, were assessed from enrollment to the 4-year follow-up.

Results: Two hundred eighty-six patients (mean age 60.3 years, 90% women) were enrolled, with 173 operative and 113 nonoperative patients, and 81% with 4-year follow-up data. At a mean (± SD) follow-up of 3.8 ± 0.9 years, 104 nonthoracolumbar orthopedic events were reported, affecting 69 patients (24.1%). The most common events were arthroplasty (n = 38), fracture (n = 25), joint ligament/cartilage repair (n = 13), and cervical decompression/fusion (n = 7). Based on the final adjusted model, patients with a nonthoracolumbar orthopedic event were older (HR 1.44 per decade, 95% CI 1.07-1.94), more likely to have a history of tobacco use (HR 1.63, 95% CI 1.00-2.66), and had worse baseline leg pain scores (HR 1.10, 95% CI 1.01-1.19).

Conclusions: Patients with ASLS have high orthopedic disease burden, with almost 25% having a fracture or nonthoracolumbar orthopedic condition requiring surgical treatment during the mean 3.8 years following enrollment. Comparisons with previous studies suggest that the rate of total knee arthroplasty was considerably greater and the rates of total hip arthroplasty were at least as high in the ASLS-1 cohort compared with the similarly aged general US population. These conditions may further impact health-related quality of life and outcomes assessments of both nonoperative and operative treatment approaches in patients with ASLS.
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http://dx.doi.org/10.3171/2021.1.SPINE201911DOI Listing
August 2021

Multicenter assessment of outcomes and complications associated with transforaminal versus anterior lumbar interbody fusion for fractional curve correction.

J Neurosurg Spine 2021 Aug 20:1-14. Epub 2021 Aug 20.

18Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.

Objective: Few studies have compared fractional curve correction after long fusion between transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) for adult symptomatic thoracolumbar/lumbar scoliosis (ASLS). The objective of this study was to compare fractional correction, health-related quality of life (HRQL), and complications associated with L4-S1 TLIF versus those of ALIF as an operative treatment of ASLS.

Methods: The authors retrospectively analyzed a prospective multicenter adult spinal deformity database. Inclusion required a fractional curve ≥ 10°, a thoracolumbar/lumbar curve ≥ 30°, index TLIF or ALIF performed at L4-5 and/or L5-S1, and a minimum 2-year follow-up. TLIF and ALIF patients were propensity matched according to the number and type of interbody fusion at L4-S1.

Results: Of 135 potentially eligible consecutive patients, 106 (78.5%) achieved the minimum 2-year follow-up (mean ± SD age 60.6 ± 9.3 years, 85% women, 44.3% underwent TLIF, and 55.7% underwent ALIF). Index operations had mean ± SD 12.2 ± 3.6 posterior levels, 86.6% of patients underwent iliac fixation, 67.0% underwent TLIF/ALIF at L4-5, and 84.0% underwent TLIF/ALIF at L5-S1. Compared with TLIF patients, ALIF patients had greater cage height (10.9 ± 2.1 mm for TLIF patients vs 14.5 ± 3.0 mm for ALIF patients, p = 0.001) and lordosis (6.3° ± 1.6° for TLIF patients vs 17.0° ± 9.9° for ALIF patients, p = 0.001) and longer operative duration (6.7 ± 1.5 hours for TLIF patients vs 8.9 ± 2.5 hours for ALIF patients, p < 0.001). In all patients, final alignment improved significantly in terms of the fractional curve (20.2° ± 7.0° to 6.9° ± 5.2°), maximum coronal Cobb angle (55.0° ± 14.8° to 23.9° ± 14.3°), C7 sagittal vertical axis (5.1 ± 6.2 cm to 2.3 ± 5.4 cm), pelvic tilt (24.6° ± 8.1° to 22.7° ± 9.5°), and lumbar lordosis (32.3° ± 18.8° to 51.4° ± 14.1°) (all p < 0.05). Matched analysis demonstrated comparable fractional correction (-13.6° ± 6.7° for TLIF patients vs -13.6° ± 8.1° for ALIF patients, p = 0.982). In all patients, final HRQL improved significantly in terms of Oswestry Disability Index (ODI) score (42.4 ± 16.3 to 24.2 ± 19.9), physical component summary (PCS) score of the 36-item Short-Form Health Survey (32.6 ± 9.3 to 41.3 ± 11.7), and Scoliosis Research Society-22r score (2.9 ± 0.6 to 3.7 ± 0.7) (all p < 0.05). Matched analysis demonstrated worse ODI (30.9 ± 21.1 for TLIF patients vs 17.9 ± 17.1 for ALIF patients, p = 0.017) and PCS (38.3 ± 12.0 for TLIF patients vs 45.3 ± 10.1 for ALIF patients, p = 0.020) scores for TLIF patients at the last follow-up (despite no differences in these parameters at baseline). The rates of total complications were similar (76.6% for TLIF patients vs 71.2% for ALIF patients, p = 0.530), but significantly more TLIF patients had rod fracture (28.6% of TLIF patients vs 7.1% of ALIF patients, p = 0.036). Multiple regression analysis demonstrated that a 1-mm increase in L4-5 TLIF cage height led to a 2.2° reduction in L4 coronal tilt (p = 0.011), and a 1° increase in L5-S1 ALIF cage lordosis led to a 0.4° increase in L5-S1 segmental lordosis (p = 0.045).

Conclusions: Operative treatment of ASLS with L4-S1 TLIF versus ALIF demonstrated comparable mean fractional curve correction (66.7% vs 64.8%), despite use of significantly larger, more lordotic ALIF cages. TLIF cage height had a significant impact on leveling L4 coronal tilt, whereas ALIF cage lordosis had a significant impact on restoration of lumbosacral lordosis. The advantages of TLIF may include reduced operative duration and hospitalization; however, associated HRQL was inferior and more rod fractures were detected in the TLIF patients included in this study.
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http://dx.doi.org/10.3171/2020.11.SPINE201915DOI Listing
August 2021

Does Achieving Global Spinal Alignment Lead to Higher Patient Satisfaction and Lower Disability in Adult Spinal Deformity?

Spine (Phila Pa 1976) 2021 Aug;46(16):1105-1110

Spine service, Hospital for Special Surgery, New York, NY.

Study Design: Multicenter retrospective review of prospective database.

Objective: The aim of this study was to investigate potential associations between postoperative alignment and satisfaction.

Summary Of Background Data: Achieving high satisfaction is the main goal of any treatment, including adult spinal deformity (ASD) surgery. Despite being one of the key elements, literature is sparse regarding postoperative factors influencing patient satisfaction.

Methods: ASD patients with 2-year follow-up were retrospectively reviewed. Patients without revision after the index procedure were stratified according to deformity type: sagittal (T1 pelvic angle >22°), coronal (C7 plumb line [C7PL] >5 cm or MaxCobb >50°), or mixed. Bivariate correlation between satisfaction and postoperative data was conducted on the entire cohort as well as by type of preoperative deformity. Multivariate regression controlling for pre-op alignment and demographic information was used to identify independent predictors of 2Y satisfaction.

Results: A total of 509 patients were included in the analysis (58.7 ± 14.8, 80% females). The quality of life significantly improved between pre- and 2-year (ΔOswestry Disability Index [ODI]: 17.6, p < 0.001). At 2 years, SRS22 satisfaction was 4.27 ± 0.89 (median 4.5). Significant associations were found between satisfaction and disability (ODI, r = -0.50) and global coronal (C7PL r = -0.15) and sagittal (sagittal vertical axis [SVA], r = -0.10) alignment (all p < 0.01) but not with the coronal clavicle angle. Stratification by preoperative deformity revealed significant associations between satisfaction and SVA for sagittal deformity only, C7PL and MaxCobb for coronal only, and C7PL for combined deformity. In the multivariate analysis controlling for demographic and pre-op deformity, 2-year ODI and 2-year C7PL were independent predictors of satisfaction. Multilinear regression demonstrated 2-year SVA, pre-op ODI and patient's age were the independent predictors 2-year ODI.

Conclusion: The ability to restore global alignment depends on the severity of the preoperative deformity as well as the correction of the main aspect of the deformity. Achieving global coronal and sagittal alignment is an independent predictor of both satisfaction and disability at 2 years post-op. Patients who continue to be disabled are also not satisfied.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004002DOI Listing
August 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

Examination of Adult Spinal Deformity Patients Undergoing Surgery with Implanted Spinal Cord Stimulators and Intrathecal Pumps.

Spine (Phila Pa 1976) 2021 Jul 23. Epub 2021 Jul 23.

Department of Orthopaedics, Warren Alpert Medical School, Brown University, Providence, RI Warren Alpert Medical School, Brown University, Providence, RI Brown University, Providence, RI Hospital for Special Surgery, New York, NY University of Pittsburgh Medical Center, Pittsburgh, PA Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY University of Virginia Health System, Charlottesville, VA Duke University, Durham, NC Washington University, St. Louis, MO University of California-Davis, Sacramento, CA Norton Leatherman Spine Center, Louisville, KY Scripp's Clinic, La Jolla, CA Johns Hopkins University, Baltimore, MD University of Calgary Spine Program, University of Calgary, Alberta Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, TX University of Kansas Hospital, Kansas City, KS Denver International Spine Center, Denver, CO University of California-San Francisco, CA Swedish Neuroscience Institute, Seattle, WA.

Study Design: Retrospective cohort study of a prospectively collected multi-center database of adult spinal deformity (ASD) patients.

Objective: We hypothesized that patients undergoing ASD surgery with and without previous SCS/ITP would exhibit increased complication rates but comparable improvement in HRQOL.

Summary Of Background Data: ASD patients sometimes seek pain management with spinal cord stimulators (SCS) or intrathecal medication pumps (ITP) prior to spinal deformity correction. Few studies have examined outcomes in this patient population.

Methods: Patients undergoing ASD surgery and eligible for 2-year follow-up were included. Pre-operative radiographs were reviewed for the presence of SCS/ITP. Outcomes included complications, ODI, SF-36 MCS, and SRS-22r. Propensity score matching was utilized.

Results: In total, out of 1,034 eligible ASD patients, a propensity score-matched cohort of 60 patients (30 with SCS/ITP, 30 controls) was developed. SCS/ITP were removed intra-operatively in most patients (56.7%, n = 17). The overall complication rate was 80.0% versus 76.7% for SCS/ITP versus control (p > 0.2), with similarly non-significant differences for intraoperative and infection complications (all p > 0.2). ODI was significantly higher among patients with SCS/ITP at baseline (59.2 versus 47.6, p = 0.0057) and at 2-year follow-up (44.4 versus 27.7, p = 0.0295). The magnitude of improvement, however, did not significantly differ (p = 0.45). Similar results were observed for SRS-22r pain domain. Satisfaction did not differ between groups at either baseline or follow-up (p > 0.2). No significant difference was observed in the proportion of patients with SCS/ITP versus control reaching MCID in ODI (47.6% versus 60.9%, p = 0.38). Narcotic usage was more common among patients with SCS/ITP at both baseline and follow-up (p < 0.05).

Conclusions: ASD patients undergoing surgery with SCS/ITP exhibited worse preoperative and post-operative ODI and SRS-22r pain domain; however, the mean improvement in outcome scores was not significantly different from patients without stimulators or pumps. No significant differences in complications were observed between patients with versus without SCS/ITP.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004176DOI Listing
July 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

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

J Clin Neurosci 2021 Jul 21;89:297-304. Epub 2021 May 21.

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

This retrospective cohort study describes adult cervical deformity(ACD) patients with Ames-ACD classification at baseline(BL) and 1-year post-operatively and assesses the relationship of improvement in Ames modifiers with clinical outcomes. Patients ≥ 18yrs with BL and post-op(1-year) radiographs were included. Patients were categorized with Ames classification by primary deformity descriptors (C = cervical; CT = cervicothoracic junction; T = thoracic; S = coronal) and alignment/myelopathy modifiers(C2-C7 Sagittal Vertical Axis[cSVA], T1 Slope-Cervical Lordosis[TS-CL], Horizontal Gaze[Horiz], mJOA). Univariate analysis evaluated demographics, clinical intervention, and Ames deformity descriptor. Patients were evaluated for radiographic improvement by Ames classification and reaching Minimal Clinically Important Differences(MCID) for mJOA, Neck Disability Index(NDI), and EuroQuol-5D(EQ5D). A total of 73 patients were categorized: C = 41(56.2%), CT = 18(24.7%), T = 9(12.3%), S = 5(6.8%). By Ames modifier 1-year improvement, 13(17.8%) improved in mJOA, 26(35.6%) in cSVA grade, 19(26.0%) in Horiz, and 15(20.5%) in TS-CL. The overall proportion of patients without severe Ames modifier grades at 1-year was as follows: 100% cSVA, 27.4% TS-CL, 67.1% Horiz, 69.9% mJOA. 1-year post-operatively, severe myelopathy(mJOA = 3) prevalence differed between Ames-ACD descriptors (C = 26.3%, CT = 15.4%, T = 0.0%, S = 0.0%, p = 0.033). Improvement in mJOA modifier correlated with reaching 1-year NDI MCID in the overall cohort (r = 0.354,p = 0.002). For C descriptors, cSVA improvement correlated with reaching 1-year NDI MCID (r = 0.387,p = 0.016). Improvement in more than one radiographic Ames modifier correlated with reaching 1-year mJOA MCID (r = 0.344,p = 0.003) and with reaching more than one MCID for mJOA, NDI, and EQ-5D (r = 0.272,p = 0.020). In conclusion, improvements in radiographic Ames modifier grades correlated with improvement in 1-year postoperative clinical outcomes. Although limited in scope, this analysis suggests the Ames-ACD classification may describe cervical deformity patients' alignment and outcomes at 1-year.
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http://dx.doi.org/10.1016/j.jocn.2021.05.007DOI Listing
July 2021

Outcomes of Surgical Treatment for 138 Patients With Severe Sagittal Deformity at a Minimum 2-Year Follow-up: A Case Series.

Oper Neurosurg (Hagerstown) 2021 Aug;21(3):94-103

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

Background: Operative treatment of adult spinal deformity (ASD) can be very challenging with high complication rates. It is well established that patients benefit from such treatment; however, the surgical outcomes for patients with severe sagittal deformity have not been reported.

Objective: To report the outcomes of patients undergoing surgical correction for severe sagittal deformity.

Methods: Retrospective review of a prospective, multicenter ASD database. Inclusion criteria: operative patients age ≥18, sagittal vertical axis (SVA) ≥15 cm, mismatch between pelvic incidence and lumbar lordosis (PI-LL) ≥30°, and/or lumbar kyphosis ≥5° with minimum 2 yr follow-up. Health-related quality of life (HRQOL) scores including minimal clinically important difference (MCID)/substantial clinical benefit (SCB), sagittal and coronal radiographic values, demographic, frailty, surgical, and complication data were collected. Comparisons between 2 yr postoperative and baseline HRQOL/radiographic data were made. P < .05 was significant.

Results: A total of 138 patients were included from 502 operative patients (54.3% Female, Average (Avg) age 63.3 ± 11.5 yr). Avg operating room (OR) time 386.2 ± 136.5 min, estimated blood loss (EBL) 1829.8 ± 1474.6 cc. A total of 71(51.4%) had prior fusion. A total of 89.9% were posterior fusion only. Mean posterior levels fused 11.5 ± 4.1. A total of 44.9% had a 3-column osteotomy. All 2 yr postoperative radiographic parameters were significantly improved compared to baseline (P < .001 for all). All 2yr HRQOL measures were significantly improved compared to baseline (P < .004 for all). A total of 46.6% to 73.8% of patients met either MCID/SCB for all HRQOL. A total of 74.6% of patients had at least 1 complication, 11.6% had 4 or more complications, 33.3% had minimum 1 major complication, and 42(30.4%) had a postop revision.

Conclusion: Patients with severe sagittal malalignment benefit from surgical correction at 2 yr postoperative both radiographically and clinically despite having a high complication rate.
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http://dx.doi.org/10.1093/ons/opab153DOI Listing
August 2021

Use of rhBMP-2 for adult spinal deformity surgery: patterns of usage and changes over the past decade.

Neurosurg Focus 2021 06;50(6):E4

7Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York.

Objective: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been shown to increase fusion rates; however, cost, limited FDA approval, and possible complications impact its use. Decisions regarding rhBMP-2 use and changes over time have not been well defined. In this study, the authors aimed to assess changes in rhBMP-2 use for adult spinal deformity (ASD) surgery over the past decade.

Methods: A retrospective review of the International Spine Study Group prospective multicenter database was performed to identify ASD patients treated surgically from 2008 to 2018. For assessment of rhBMP-2 use over time, 3 periods were created: 2008-2011, 2012-2015, and 2016-2018.

Results: Of the patients identified, 1180 met inclusion criteria, with a mean age 60 years and 30% of patients requiring revision surgery; rhBMP-2 was used in 73.9% of patients overall. The mean rhBMP-2 dose per patient was 23.6 mg. Patients receiving rhBMP-2 were older (61 vs 58 years, p < 0.001) and had more comorbidities (Charlson Comorbidity Index 1.9 vs 1.4, p < 0.001), a higher rate of the Scoliosis Research Society-Schwab pelvic tilt modifier (> 0; 68% vs 62%, p = 0.026), a greater deformity correction (change in pelvic incidence minus lumbar lordosis 15° vs 12°, p = 0.01), and more levels fused (8.9 vs 7.9, p = 0.003). Over the 3 time periods, the overall rate of rhBMP-2 use increased and then stabilized (62.5% vs 79% vs 77%). Stratified analysis showed that after an overall increase in rhBMP-2 use, only patients who were younger than 50 years, those who were smokers, those who received a three-column osteotomy (3CO), and patients who underwent revision sustained an increased rate of rhBMP-2 use between the later two periods. No similar increases were noted for older patients, nonsmokers, primary surgery patients, and patients without a 3CO. The total rhBMP-2 dose decreased over time (26.6 mg vs 24.8 mg vs 20.7 mg, p < 0.001). After matching patients by preoperative alignment, 215 patients were included, and a significantly lower rate of complications leading to revision surgery was observed within the 2012-2015 period compared with the 2008-2011 (21.4% vs 13.0%, p = 0.029) period, while rhBMP-2 was increasingly used (80.5% vs 66.0%, p = 0.001). There was a trend toward a lower rate of pseudarthrosis for patients in the 2012-2015 period, but this difference did not reach statistical significance (7% vs 4.2%, p = 0.283).

Conclusions: The authors found that rhBMP-2 was used in the majority of ASD patients and was more commonly used in those with greater deformity correction. Additionally, over the last 10 years, rhBMP-2 was increasingly used for ASD patients, but the dose has decreased.
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http://dx.doi.org/10.3171/2021.3.FOCUS2164DOI Listing
June 2021

Cervicothoracic Versus Proximal Thoracic Lower Instrumented Vertebra Have Comparable Radiographic and Clinical Outcomes in Adult Cervical Deformity.

Global Spine J 2021 May 20:21925682211017478. Epub 2021 May 20.

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

Study Design: Comparative cohort study.

Objective: Factors that influence the lower instrumented vertebra (LIV) selection in adult cervical deformity (ACD) are less reported, and outcomes in the cervicothoracic junction (CTJ) and proximal thoracic (PT) spine are unclear.

Methods: A prospective ACD database was analyzed using the following inclusion criteria: LIV between C7 and T5, upper instrumented vertebra at C2, and at least a 1-year follow-up. Patients were divided into CTJ (LIV C7-T2) and PT groups (LIV T3-T5) based on LIV levels. Demographics, operative details, radiographic parameters, and the health-related quality of life (HRQOL) scores were compared.

Results: Forty-six patients were included (mean age, 62 years), with 22 and 24 patients in the CTJ and PT groups, respectively. Demographics and surgical parameters were comparable between the groups. The PT group had a significantly higher preoperative C2-C7 sagittal vertical axis (cSVA) (46.9 mm vs 32.6 mm, = 0.002) and T1 slope minus cervical lordosis (45.9° vs 36.0°, = 0.042) than the CTJ group and was more likely treated with pedicle-subtraction osteotomy (33.3% vs 0%, = 0.004). The PT group had a larger correction of cSVA (-7.7 vs 0.7 mm, = 0.037) and reciprocal change of increased T4-T12 kyphosis (8.6° vs 0.0°, = 0.001). Complications and reoperations were comparable. The HRQOL scores were not different preoperatively and at 1-year follow-up.

Conclusions: The selection of PT LIV in cervical deformities was more common in patients with larger baseline deformities, who were more likely to undergo pedicle-subtraction osteotomy. Despite this, the complications and HRQOL outcomes were comparable at 1-year follow-up.
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http://dx.doi.org/10.1177/21925682211017478DOI Listing
May 2021

State-of-the-art reviews predictive modeling in adult spinal deformity: applications of advanced analytics.

Spine Deform 2021 Sep 18;9(5):1223-1239. Epub 2021 May 18.

Department of Neurological Surgery, University of California, San Francisco, 400 Parnassus Avenue, A850, San Francisco, CA, 94143, USA.

Adult spinal deformity (ASD) is a complex and heterogeneous disease that can severely impact patients' lives. While it is clear that surgical correction can achieve significant improvement of spinopelvic parameters and quality of life measures in adults with spinal deformity, there remains a high risk of complication associated with surgical approaches to adult deformity. Over the past decade, utilization of surgical correction for ASD has increased dramatically as deformity correction techniques have become more refined and widely adopted. Along with this increase in surgical utilization, there has been a massive undertaking by spine surgeons to develop more robust models to predict postoperative outcomes in an effort to mitigate the relatively high complication rates. A large part of this revolution within spine surgery has been the gradual adoption of predictive analytics harnessing artificial intelligence through the use of machine learning algorithms. The development of predictive models to accurately prognosticate patient outcomes following ASD surgery represents a dramatic improvement over prior statistical models which are better suited for finding associations between variables than for their predictive utility. Machine learning models, which offer the ability to make more accurate and reproducible predictions, provide surgeons with a wide array of practical applications from augmenting clinical decision making to more wide-spread public health implications. The inclusion of these advanced computational techniques in spine practices will be paramount for improving the care of patients, by empowering both patients and surgeons to more specifically tailor clinical decisions to address individual health profiles and needs.
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http://dx.doi.org/10.1007/s43390-021-00360-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8363545PMC
September 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

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 08 15;30(8):2157-2166. 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
August 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

Factors influencing upper-most instrumented vertebrae selection in adult spinal deformity patients: qualitative case-based survey of deformity surgeons.

J Spine Surg 2021 Mar;7(1):37-47

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

Background: The decision upper-most instrumented vertebrae (UIV) in a multi-level fusion procedure can dramatically influence outcomes of corrective spine surgery. We aimed to create an algorithm for selection of UIV based on surgeon selection/reasoning of sample cases.

Methods: The clinical/imaging data for 11 adult spinal deformity (ASD) patients were presented to 14 spine deformity surgeons who selected the UIV and provided reasons for avoidance of adjacent levels. The UIV chosen was grouped into either upper thoracic (UT, T1-T6), lower thoracic (LT, T7-T12), lumbar or cervical. Disagreement between surgeons was defined as ≥3 not agreeing. We performed a descriptive analysis of responses and created an algorithm for choosing UIV then applied this to a large database of ASD patients.

Results: Surgeons agreed in 8/11 cases on regional choice of UIV. T10 was the most common UIV in the LT region (58%) and T3 was the most common UIV in the UT region (44%). The most common determinant of UIV in the UT region was proximal thoracic kyphosis and presence of coronal deformity. The most common determinant of UIV in the LT region was small proximal thoracic kyphosis. Within the ASD database (236 patients), when the algorithm called for UT fusion, patients fused to TL region were more likely to develop proximal junctional kyphosis (PJK) at 1 year post-operatively (76.9% . 38.9%, P=0.025).

Conclusions: Our algorithm for selection of UIV emphasizes the role of proximal and regional thoracic kyphosis. Failure to follow this consensus for UT fusion was associated with twice the rate of PJK.
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http://dx.doi.org/10.21037/jss-20-598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8024758PMC
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

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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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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February 2021

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

Neurosurgery 2021 05;88(6):1121-1127

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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May 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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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
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