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Passias PG, Passfall L, Tretiakov PS, Das A, Onafowokan OO, Smith JS, Lafage V, Lafage R, Line B, Gum J, Kebaish KM, Than KD, Mundis G, Hostin R, Gupta M, Eastlack RK, Chou D, Forman A, Diebo B, Daniels AH, Protopsaltis T, Hamilton DK, Soroceanu A, Pinteric R, Mummaneni P, Kim HJ, Anand N, Ames CP, Hart R, Burton D, Schwab FJ, Shaffrey C, Klineberg EO, Bess S. Have We Made Advancements in Optimizing Surgical Outcomes and Enhancing Recovery for Patients With High-Risk Adult Spinal Deformity Over Time? Oper Neurosurg (Hagerstown) 2025; 28:617-626. [PMID: 39589896 DOI: 10.1227/ons.0000000000001420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/19/2024] [Indexed: 11/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The spectrum of patients requiring adult spinal deformity (ASD) surgery is highly variable in baseline (BL) risk such as age, frailty, and deformity severity. Although improvements have been realized in ASD surgery over the past decade, it is unknown whether these carry over to high-risk patients. We aim to determine temporal differences in outcomes at 2 years after ASD surgery in patients stratified by BL risk. METHODS Patients ≥18 years with complete pre- (BL) and 2-year (2Y) postoperative data from 2009 to 2018 were categorized as having undergone surgery from 2009 to 2013 [early] or from 2014 to 2018 [late]. High-risk [HR] patients met ≥2 of the criteria: (1) ++ BL pelvic incidence and lumbar lordosis or SVA by Scoliosis Research Society (SRS)-Schwab criteria, (2) elderly [≥70 years], (3) severe BL frailty, (4) high Charlson comorbidity index, (5) undergoing 3-column osteotomy, and (6) fusion of >12 levels, or >7 levels for elderly patients. Demographics, clinical outcomes, radiographic alignment targets, and complication rates were assessed by time period for high-risk patients. RESULTS Of the 725 patients included, 52% (n = 377) were identified as HR. 47% (n = 338) had surgery pre-2014 [early], and 53% (n = 387) underwent surgery in 2014 or later [late]. There was a higher proportion of HR patients in Late group (56% vs 48%). Analysis by early/late status showed no significant differences in achieving improved radiographic alignment by SRS-Schwab, age-adjusted alignment goals, or global alignment and proportion proportionality by 2Y (all P > .05). Late/HR patients had significantly less poor clinical outcomes per SRS and Oswestry Disability Index (both P < .01). Late/HR patients had fewer complications (63% vs 74%, P = .025), reoperations (17% vs 30%, P = .002), and surgical infections (0.9% vs 4.3%, P = .031). Late/HR patients had lower rates of early proximal junctional kyphosis (10% vs 17%, P = .041) and proximal junctional failure (11% vs 22%, P = .003). CONCLUSION Despite operating on more high-risk patients between 2014 and 2018, surgeons effectively reduced rates of complications, mechanical failures, and reoperations, while simultaneously improving health-related quality of life.
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Affiliation(s)
- Peter G Passias
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, New York Spine Institute, New York , New York , USA
| | - Lara Passfall
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, New York Spine Institute, New York , New York , USA
| | - Peter S Tretiakov
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, New York Spine Institute, New York , New York , USA
| | - Ankita Das
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, New York Spine Institute, New York , New York , USA
| | - Oluwatobi O Onafowokan
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, New York Spine Institute, New York , New York , USA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville , Virginia , USA
| | - Virginie Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York , New York , USA
| | - Renaud Lafage
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York , New York , USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver , Colorado , USA
| | - Jeffrey Gum
- Norton Leatherman Spine Center, Louisville , Kentucky , USA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, Johns Hopkins Medical Center, Baltimore , Maryland , USA
| | - Khoi D Than
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham , North Carolina , USA
| | - Gregory Mundis
- Division of Orthopaedic Surgery, Scripps Clinic, San Diego Center for Spinal Disorders, La Jolla , California , USA
| | - Richard Hostin
- Department of Orthopaedic Surgery, Southwest Scoliosis Center, Dallas , Texas , USA
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St. Louis , Missouri , USA
| | - Robert K Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, Louisiana Jolla , California , USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco , California , USA
| | - Alexa Forman
- New York Spine Institute for Scoliosis and Spinal Deformity, Westbury , New York , USA
| | - Bassel Diebo
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence , Rhode Island , USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence , Rhode Island , USA
| | - Themistocles Protopsaltis
- Division of Spinal Surgery/Departments of Orthopaedic and Neurosurgery, NYU Medical Center, New York Spine Institute, New York , New York , USA
| | - D Kojo Hamilton
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh , Pennsylvania , USA
| | - Alex Soroceanu
- Department of Orthopaedic Surgery, University of Calgary, Calgary , Alberta , Canada
| | - Raymarla Pinteric
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver , Colorado , USA
| | - Praveen Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco , California , USA
| | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York , New York , USA
| | - Neel Anand
- Department of Orthopedic Surgery, Cedars-Sinai Health Center, Los Angeles , California , USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco , California , USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle , Washington , USA
| | - Douglas Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City , Kansas , USA
| | - Frank J Schwab
- Department of Orthopaedics, Lenox Hill Hospital, Northwell Health, New York , New York , USA
| | - Christopher Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham , North Carolina , USA
| | - Eric O Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Davis , California , USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver , Colorado , USA
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Ragborg L, Tøndevold N, Karbo T, Dragsted C, Svardal-Stelmer R, Valentin L, Dahl B, Gehrchen M. Two-Year Radiological Outcome of Adult Spinal Deformity Treated with Lumbar Pedicle Subtraction Osteotomy or Posterior Lumbar Interbody Fusion: A Propensity Score-Matched Analysis. World Neurosurg 2025; 194:123618. [PMID: 39732455 DOI: 10.1016/j.wneu.2024.123618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Accepted: 12/19/2024] [Indexed: 12/30/2024]
Abstract
OBJECTIVE The purpose of this retrospective cohort study was to compare the 2-year radiological outcome and revision rates in patients with adult spinal deformity treated with either pedicle subtraction osteotomy (PSO) or posterior lumbar interbody fusion (PLIF), when PLIF was used to improve sagittal balance. METHODS In 2016, PLIF was introduced at our institution as an alternative method when restoring lumbar lordosis. We analyzed 2 cohorts of patients with adult spinal deformity undergoing either PSO in 2010-2015 or PLIF in 2016-2020, retrospectively. The rate of mechanical failure was analyzed using competing risk analysis. RESULTS We included 141 patients (111 PSO and 30 PLIF). After propensity score matching, 60 patients undergoing PSO and 30 patients undergoing PLIF were included. Baseline demographics were comparable between groups but radiographic parameters differed significantly on Sacral Slope; 23 ± 13 versus 28 ± 10, and segmental lordosis; 7 ± 14° versus. 14 ± 13° (P-value < 0.05) for PSO and PLIF, respectively. Postoperatively, PSO patients had a larger global lordosis; 54 ± 12 versus 48 ± 14 and segmental lordosis of 33 ± 10 versus 26 ± 10 (P-value < 0.05), than PLIF patients. Competing risk analysis showed a cumulative incidence of revision surgery of 38.3% (95% CI 28-43) versus 16.7 (95% CI 3-30), (P-value < 0.05) for PSO, and PLIF at 2-year follow-up. CONCLUSIONS A significantly lower revision rate was seen for patients undergoing PLIF compared with PSO at a 2-year follow-up. A satisfactory sagittal correction was obtained for both groups regardless of the procedure. Thus, PLIF could be a viable option in selected cases.
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Affiliation(s)
- Lærke Ragborg
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Niklas Tøndevold
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ture Karbo
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Casper Dragsted
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Robert Svardal-Stelmer
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Valentin
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Benny Dahl
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Frerich JM, Dibble CF, Park C, Bergin SM, Goodwin CR, Abd-El-Barr MM, Shaffrey CI, Than KD. Proximal Lumbar Anterior Column Realignment for Iatrogenic Sagittal Plane Adult Spinal Deformity Correction: A Retrospective Case Series. World Neurosurg 2025; 193:884-892. [PMID: 39489337 DOI: 10.1016/j.wneu.2024.10.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 10/24/2024] [Accepted: 10/25/2024] [Indexed: 11/05/2024]
Abstract
BACKGROUND Anterior column realignment (ACR) is a powerful minimally invasive surgery technique to restore sagittal alignment in adult spinal deformity (ASD). This can accomplish similar segmental lordosis restoration as 3-column osteotomy with less blood loss and comparable complication rates. ACR can be performed at adjacent disease segments in the proximal lumbar spine in revision cases. However, two thirds of physiologic lordosis occurs between L4-S1, and concerns remain about altered lumbar morphology. We evaluated patients who underwent proximal lumbar ACR for iatrogenic flatback deformity. METHODS A total of 19 consecutive patients who underwent L1-2 or L2-3 ACR were retrospectively analyzed. All patients were treated with lateral minimally invasive surgery interbody technique, followed by posterior reconstruction with Smith-Peterson osteotomy. Preoperative and postoperative radiographic and clinical outcomes were obtained. RESULTS Mean follow-up was 19 months. All but 1 patient had a history of prior lumbar or lumbo-sacral fusion. Sagittal vertical axis and pelvic incidence-lumbar lordosis decreased from 11.9 cm to 6.1 cm (P < 0.0001) and 34.2° to 12.8° (P < 0.0001). Segmental lordosis increased from -2.7° to 21.9° (P < 0.0001). Proximal lumbar lordosis increased from -0.4° to 22.6° (P < 0.0001), and lordosis distribution index decreased from 79.5% to 48.9% (P < 0.0001). Mean Oswestry Disability Index and numeric pain rating scale back pain scores decreased from 58.0 to 36.2 (P = 0.0041) and 7.9 to 3.4 (P < 0.0001), respectively. Patient-Reported Outcomes Measurement Information System Physical and Mental Health T-scores increased from 34.1 to 43.3 (P = 0.0049) and 40.4 to 45.0 (P = 0.0993), respectively. Major complication rate was 15.8%. One patient required revision for mechanical failure. There were no permanent neurological or vascular injuries. CONCLUSIONS Proximal lumbar ACR plus Smith-Peterson osteotomy can achieve sagittal correction with low major complication rates in patients with ASD and prior distal fusion. Differentially increasing proximal lumbar lordosis and lowering lumbar distribution index did not have deleterious effects on radiographic or clinical outcomes. Further work is needed to understand the effect of proximal ACR in the surgical management of ASD.
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Affiliation(s)
- Jason M Frerich
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Christopher F Dibble
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christine Park
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Stephen M Bergin
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muhammad M Abd-El-Barr
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Khoi D Than
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
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Kankam SB, Zarei M, Moghadam N, Roohollahi F, Moosavi M, Yaseen Khan FM, Besharaty S, Abbaspour MJ, Rostami M. The Advantages of 4-rod Construct over the 2-rod Techniques in Adult Spinal Deformity Patients who Underwent Pedicle Subtraction Osteotomy: A Multicenter Retrospective Comparative Study. World Neurosurg 2024; 183:e530-e539. [PMID: 38159604 DOI: 10.1016/j.wneu.2023.12.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/25/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE In this retrospective study we compared clinicoradiologic outcomes and complication profiles of the traditional 2-rod construct versus the 4-rod construct in patients with adult spinal deformity (ASD) who underwent pedicle subtraction osteotomy (PSO). METHODS We performed a retrospective review of 208 ASD patients at 2 referral centers who underwent lumbar PSO and long fusion from thoracic to the pelvis. Two different techniques, including the 4-rod construct and the traditional 2-rod technique, were used at the PSO level. Clinicoradiologic outcomes and complication profiles of the patients were documented and compared statistically between the groups. RESULTS The 4-rod construct was associated with statistically lower rates of rod fracture (44.8% vs. 26.4%, P < 0.01), pedicular screw loosening at the PSO level (25.3% vs. 14.0%, P = 0.04), and reoperation (49.4% vs. 33.9%, P = 0.02). Radiologically, the 4-rod construct was associated with higher degree of lumbar lordosis (LL) (-37.4°vs. -26.8°; P < 0.01) and improved pelvic tilt (PT) (-17.2° vs. -9.9°; P < 0.01) and sacral vertical axis (SVA) corrections (-211.5° vs. -192.2°; P = 0.04). Overall, the 4-rod construct was associated with improved quality of life (P = 0.04) and statistically lower Oswestry Disability Index score at 12 months postoperatively (P < 0.01). CONCLUSIONS Our results showed that the 4-rod construct was associated with statistically lower rates of rod fracture and pedicular screw loosening at the osteotomy level, higher degree of LL correction and improved PT and SVA than the 2-rod technique. The 4-rod construct was also associated with improved quality of life and Oswestry Disability Index and lower complication profiles.
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Affiliation(s)
- Samuel Berchi Kankam
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohammad Zarei
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran; Department of Orthopedic Surgery, Imam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Navid Moghadam
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Faramarz Roohollahi
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran; Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mersad Moosavi
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Furqan Mohammed Yaseen Khan
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran; Department of Orthopedic Surgery, Imam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Saied Besharaty
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohsen Rostami
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran; Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Gendreau JL, Nguyen A, Brown NJ, Pennington Z, Lopez AM, Patel N, Chakravarti S, Kuo C, Camino-Willhuber G, Albano S, Osorio JA, Oh MY, Pham MH. External Validation of the Global Alignment and Proportion Score as Prognostic Tool for Corrective Surgery in Adult Spinal Deformity: A Systematic Review and Meta-Analysis. World Neurosurg 2023; 177:e600-e612. [PMID: 37393993 DOI: 10.1016/j.wneu.2023.06.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/22/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Since its proposal, the Global Alignment and Proportion (GAP) score has been the topic of several external validation studies, which have yielded conflicting results. Given the lack of consensus regarding this prognostic tool, the authors aim to assess the accuracy of GAP scores for predicting mechanical complications following adult spinal deformity correction surgery. METHODS A systematic search was performed using PubMed, Embase, and Cochrane Library for the purpose of identifying all studies evaluating the GAP score as a predictive tool for mechanical complications. GAP scores were pooled using a random-effects model to compare patients reporting mechanical complications after surgery versus those reporting no complications. Where receiver operator curves were provided, the area under the curve (AUC) was pooled. RESULTS A total of 15 studies featuring 2092 patients were selected for inclusion. Qualitative analysis using Newcastle-Ottawa criteria revealed moderate quality among all included studies (5.99/9). With respect to sex, the cohort was predominantly female (82%). The pooled mean age among all patients in the cohort was 58.55 years, with a mean follow-up of 33.86 months after surgery. Upon pooled analysis, we found that mechanical complications were associated with higher mean GAP scores, albeit minimal (mean difference = 0.571 [ 95% confidence interval: 0.163-0.979]; P = 0.006, n = 864). Additionally, age (P = 0.136, n = 202), fusion levels (P = 0.207, n = 358), and body mass index (P = 0.616, n = 350) were unassociated with mechanical complications. Pooled AUC revealed poor discrimination overall (AUC = 0.69; n = 1206). CONCLUSIONS GAP scores may have a minimal-to-moderate predictive capability for mechanical complications associated with adult spinal deformity correction.
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Affiliation(s)
- Julian L Gendreau
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | - Andrew Nguyen
- College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Nolan J Brown
- Department of Neurosurgery, University of California Irvine, Orange, California, USA.
| | - Zach Pennington
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander M Lopez
- Department of Neurosurgery, University of California Irvine, Orange, California, USA
| | - Neal Patel
- School of Medicine, Mercer University, Savannah, Georgia, USA; Department of Neurosurgery, University of California San Diego, La Jolla, California, USA
| | - Sachiv Chakravarti
- Department of Biomedical Engineering, Johns Hopkins Whiting School of Engineering, Baltimore, Maryland, USA
| | - Cathleen Kuo
- Department of Neurosurgery, University of California Irvine, Orange, California, USA
| | | | - Stephen Albano
- Department of Neurosurgery, University of California Irvine, Orange, California, USA
| | - Joseph A Osorio
- Department of Neurosurgery, University of California San Diego, La Jolla, California, USA
| | - Michael Y Oh
- Department of Neurosurgery, University of California Irvine, Orange, California, USA
| | - Martin H Pham
- Department of Neurosurgery, University of California San Diego, La Jolla, California, USA
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Chen Y, Yang H, Xie N, Zhang S, Zou X, Deng C, Wang B, Li H, Ma X. Could extended laminectomy effectively prevent spinal cord injury due to spinal shortening after 3-column osteotomy? BMC Musculoskelet Disord 2023; 24:658. [PMID: 37592275 PMCID: PMC10436457 DOI: 10.1186/s12891-023-06751-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/25/2023] [Indexed: 08/19/2023] Open
Abstract
OBJECTIVE To explore whether the laminectomy extension can effectively prevent spinal cord injury (SCI) due to spinal shortening after 3-column osteotomy in goat models. METHODS A total of twenty healthy goats were included and done with 3-column osteotomy of T13 and L1 under the somatosensory evoked potential (SSEP) monitoring. The samples were divided into two groups. The first group underwent regular laminectomy while the second group underwent an extended laminectomy with an extra 10 mm-lamina cranial to L2. The SSEP measured after 3-column osteotomy was set as the baseline, and the SSEP decreased by 50% from the baseline amplitude and/or delayed by 10% relative to the baseline peak latency was set as positive results, which indicated spinal cord injury. The vertebral column was gradually shortened until the SSEP monitoring just did not show a positive result. The height of the initial osteotomy gap (the distance from the lower endplate of T12 to the upper endplate of L2), the shortened distance (△H), the number of spinal cord angulated and the changed angle of the spinal cord (△α) were measured and recorded in each group. Neurological function was evaluated by the Tarlov scores on day 2 postoperatively. RESULTS All the goats except one of the first group due to changes in the SSEP during the osteotomy were included and analyzed. In the first group, the height of the initial osteotomy segment and the safe shortening distances were 61.6 ± 2.6 mm and 35.2 ± 2.6 mm, respectively; the spinal cord of 5 goats was angulated (46.4 ± 6.6°), the other four goats were kinked and not angulated. In the second group, the height of the initial osteotomy segment and the safe shortening distances were 59.8 ± 1.5 mm and 43.3 ± 1.2 mm, respectively, and the spinal cord of ten goats were angulated (97.6 ± 7.2°). There was no significant difference in the height of the initial osteotomy segment between the two groups by using Independent-Samples T-Test, P = 0.095 (P > 0.05); there were significant difference in the safe shortening distance and the changed angle of the spinal cord between the two groups by using Independent-Samples T-Test (both [Formula: see text]H and [Formula: see text]α of P < 0.001), the difference between their mean were 8.1 mm and 51.2°. Significant difference was found in the number of spinal cord angulation between the two groups through Fisher's exact test (5/9 vs. 10/10, P = 0.033). CONCLUSIONS An additional resection of 10 mm-lamina cranial to L2 showed the satisfactory effect in alleviating SCI after 3-column osteotomy. Timely and appropriate extend laminectomy could be a promising therapeutic strategy for SCI attributable to facilitating spinal cord angulation rather than spinal cord kinking and increasing the safe shortening distance.
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Affiliation(s)
- Yuyue Chen
- Department of Orthopedics, General Hospital of Southern Theatre Command, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Haozhi Yang
- Department of Orthopedics, General Hospital of Southern Theatre Command, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Ningling Xie
- Department of Orthopedics, General Hospital of Southern Theatre Command, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Shuang Zhang
- Department of Orthopedics, General Hospital of Southern Theatre Command, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Xiaobao Zou
- Department of Orthopedics, General Hospital of Southern Theatre Command, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Chenfu Deng
- Department of Orthopedics, General Hospital of Southern Theatre Command, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Binbin Wang
- Department of Orthopedics, General Hospital of Southern Theatre Command, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Hengrui Li
- Department of Orthopedics, General Hospital of Southern Theatre Command, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China
| | - Xiangyang Ma
- Department of Orthopedics, General Hospital of Southern Theatre Command, 111 Liuhua Road, Guangzhou, 510010, People's Republic of China.
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Cho JH, Lau D, Ashayeri K, Deviren V, Ames CP. Association Between the Bone Density of Posterior Fusion Mass and Mechanical Complications After Thoracolumbar Three-Column Osteotomy for Adult Spinal Deformity. Spine (Phila Pa 1976) 2023; 48:672-682. [PMID: 36940248 DOI: 10.1097/brs.0000000000004625] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 02/28/2023] [Indexed: 03/22/2023]
Abstract
STUDY DESIGN Retrospective comparative study. OBJECTIVE To assess the relationship of fusion mass bone density on computed tomography (CT) and the development of rod fractures (RFs) and proximal junctional kyphosis (PJK). SUMMARY OF BACKGROUND DATA Few studies have evaluated the relationship of fusion mass bone density to mechanical complications. MATERIALS AND METHODS A retrospective review of adult spinal deformity patients who underwent thoracolumbar three-column osteotomy from 2007 to 2017 was performed. All patients underwent routine 1-year CT imaging and had at least 24 months follow-up. Posterior fusion mass bone density was evaluated by measuring hounsfield unit (HU) on CT in three different regions [upper instrumented vertebra (UIV), lower instrumented vertebra, and osteotomy site], and were compared between patients with and without mechanical complications. RESULTS A total of 165 patients (63.2 years, 33.5% male) were included. Overall PJK rate was 18.8%, and 35.5% of these underwent PJK revision. There was significantly lower density of posterior fusion mass at the UIV in patients who experienced PJK compared with patients without PJK (431.5HU vs. 537.4HU, P =0.026). Overall RF rate was 34.5% and 61.4% of these underwent revision for RFs. Among 57 patients with RFs, 71.9% had pseudarthrosis. Fusion mass density did not differ between patients with or without RFs. However, in RF patients with pseudarthrosis, there was significantly higher bone mass density near the osteotomy compared with those without pseudarthrosis (515.7HU vs. 354.2HU, P =0.012). There were no differences in radiographic sagittal measures between the patients with and without RF or PJK. CONCLUSIONS Patients with PJK tend to have less dense posterior fusion mass at the UIV. Fusion mass density does not correlate with RF, but greater bone density near the osteotomy was correlated with accompanying pseudarthrosis in patients with RFs. Assessing density of posterior fusion mass on CT may be helpful in assessing risk for PJK and provide insight as to the causes of RFs.
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Affiliation(s)
- Jae Hwan Cho
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Darryl Lau
- Department of Neurological Surgery, New York University, New York, NY
| | - Kimberly Ashayeri
- Department of Neurological Surgery, New York University, New York, NY
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, CA
| | - Christopher P Ames
- Derpatment of Neurological Surgery, University of California, San Francisco, CA
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Alshabab BS, Lafage R, Smith JS, Kim HJ, Mundis G, Klineberg E, Shaffrey C, Daniels A, Ames C, Gupta M, Burton D, Hostin R, Bess S, Schwab F, Lafage V. Evolution of Proximal Junctional Kyphosis and Proximal Junctional Failure Rates Over 10 Years of Enrollment in a Prospective Multicenter Adult Spinal Deformity Database. Spine (Phila Pa 1976) 2022; 47:922-930. [PMID: 35472089 DOI: 10.1097/brs.0000000000004364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/18/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to investigate the evolution of proximal junctional kyphosis (PJK) rate over 10-year enrollment period within a prospective database. SUMMARY OF BACKGROUND DATA PJK is a common complication following adult spinal deformity (ASD) surgery and has been intensively studied over the last decade. METHODS Patients with instrumentation extended to the pelvis and minimum 2-year follow-up were included. To investigate evolution of PJK/proximal junctional failure (PJF) rate, a moving average of 321 patients was calculated across the enrollment period. Logistic regression was used to investigate the association between the date of surgery (DOS) and PJK and/or PJF. Comparison of PJK/PJF rates, demographics, and surgical strategies was performed between the first and second half of the cohort. RESULTS A total of 641 patients met inclusion criteria (age: 64±10 years, 78.2% female, body mass index: 28.3±5.7). The overall rate of radiographic PJK at 2 years was 47.9%; 12.9% of the patients developed PJF, with 31.3% being revised within 2-year follow-up. Stratification by DOS produced two halves. Between these two periods, rate of PJK and PJF demonstrated nonsignificant decrease (50.3%-45.5%, P =0.22) and (15.0%-10.9%, P =0.12), respectively. Linear interpolation suggested a decrease of 1.2% PJK per year and 1.0% for PJF. Patients enrolled later in the study were older and more likely to be classified as pure sagittal deformity ( P <0.001). There was a significant reduction in the use of three-column osteotomies ( P <0.001), an increase in anterior longitudinal ligament release ( P <0.001), and an increase in the use of PJK prophylaxis (31.3% vs 55.1%). Logistical regression demonstrated no significant association between DOS and radiographic PJK ( P =0.19) or PJF ( P =0.39). CONCLUSION Despite extensive research examining risk factors for PJK/PJF and increasing utilization of intraoperative PJK prophylaxis techniques, the rate of radiographic PJK and/or PJF did not significantly decrease across the 10-year enrollment period of this ASD database.
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Affiliation(s)
- Basel Sheikh Alshabab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Renaud Lafage
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA
| | - Han Jo Kim
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Eric Klineberg
- Department of Orthopedic Surgery, University of California, Davis, Sacramento, CA
| | | | - Alan Daniels
- Department of Orthopedic Surgery, Brown University, Providence, RI
| | - Christopher Ames
- Department of Neurosurgery, University of California School of Medicine, San Francisco, CA
| | - Munish Gupta
- Department of Orthopedic Surgery, Washington University, St Louis, MO
| | - Douglas Burton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | - Richard Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO
| | - Frank Schwab
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
| | - Virginie Lafage
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, NY
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9
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Yilgor C, Kindan P, Yucekul A, Zulemyan T, Alanay A. Osteotomies for the Treatment of Adult Spinal Deformities: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202205000-00010. [PMID: 35613311 DOI: 10.2106/jbjs.rvw.21.00226] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Spinal osteotomies are powerful deformity correction techniques that may be associated with serious complications. » The anatomical spinal osteotomy classification system proposes 6 grades of resection corresponding to different anatomic bone, disc, facet, and ligament interventions. » Surgeons should be aware of the nuances of 3-column osteotomies with regard to spinal level selection, construct composition, and posterior column reconstruction and closure techniques. » There is a global tendency toward avoiding 3-column osteotomies as much as possible because of the growing evidence regarding the effectiveness of posterior column osteotomies and halo-gravity traction.
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Affiliation(s)
- Caglar Yilgor
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Peri Kindan
- Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Altug Yucekul
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Tais Zulemyan
- Comprehensive Spine Center, Acibadem University Maslak Hospital, Istanbul, Turkey
| | - Ahmet Alanay
- Department of Orthopedics and Traumatology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
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10
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Mao S, Li S, Ma Y, Shi BL, Liu Z, Zhu ZZ, Qiao J, Qiu Y. How to rectify the convex coronal imbalance in patients with unstable dystrophic scoliosis secondary to type I neurofibromatosis: experience from a case series. BMC Musculoskelet Disord 2022; 23:368. [PMID: 35443648 PMCID: PMC9020035 DOI: 10.1186/s12891-022-05321-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 04/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There was a paucity of valid information on how to rectify the convex coronal imbalance effectively in dystrophic scoliosis secondary to Type I neurofibromatosis (DS-NF1), while postoperative inadvertent aggravation of CCI occurred regularly resulting in poor patient satisfaction. We aimed to identify the risk factors for persistent postoperative CCI in DS-NF1, and to optimize the coronal rebalancing strategies based on the lessons learned from this rare case series. METHODS NF1-related scoliosis database was reviewed and those with significant CCI (> 3 cm) were identified, sorted and the outcomes of surgical coronal rebalance were analyzed to identify the factors being responsible for failure of CCI correction. RESULTS CCI with dystrophic thoracolumbar/lumbar apex was prone to remain uncorrected (7 failure cases in 11) when compared to those with thoracic apex (0 failure cases in 4) (63.6% vs. 0.0%, p = 0.077). Further comparison between those with and without post-op CCI showed a higher correction of main curve Cobb angle (65.9 ± 9.1% vs. 51.5 ± 37.3%, p = 0.040), more tilted instrumentation (10.3 ± 3.6° vs. 3.2 ± 3.1°, p = 0.001) and reverse tilt and translation of upper instrumented vertebra (UIV) to convex side (8.0 ± 2.3° vs. -3.4 ± 5.9°, p < 0.001; 35.4 ± 6.9 mm vs. 12.3 ± 13.1 mm, p = 0.001) in the uncorrected imbalanced group. Multiple linear regression analysis revealed that △UIV translation (pre- to post-operation) (β = 0.832; p = 0.030) was significantly correlated with the correction of CBD. CONCLUSION Thoracolumbar/lumbar CCI in dystrophic scoliosis was prone to suffer high risk of persistent post-op CCI. Satisfying coronal rebalance should avoid UIV tilt and translation to the convex side, tilted morphology of instrumentation and over correction maneuvers for main curve, the upper hemi-curve region in particular.
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Affiliation(s)
- Saihu Mao
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China.
| | - Song Li
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Yanyu Ma
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Ben-Long Shi
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Zhen Liu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Ze-Zhang Zhu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Jun Qiao
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
| | - Yong Qiu
- Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Zhongshan Road 321, Nanjing, 210008, China
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11
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Varshneya K, Stienen MN, Medress ZA, Fatemi P, Pendharkar AV, Ratliff JK, Veeravagu A. Risk Factors for Revision Surgery After Primary Adult Thoracolumbar Deformity Surgery. Clin Spine Surg 2022; 35:E94-E98. [PMID: 33443943 DOI: 10.1097/bsd.0000000000001124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE The aim was to identify the risk factors for revision surgery within 2 years of patients undergoing primary adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA Previous literature reports estimate 20% of patients undergoing thoracolumbar ASD correction undergo reoperation within 2 years. There is limited published data regarding specific risk factors for reoperation in ASD surgery in the short term and long term. METHODS The authors queried the MarketScan database in order to identify patients who were diagnosed with a spinal deformity and underwent ASD surgery from 2007 to 2015. Patient-level factors and revision risk were investigated during 2 years after primary ASD surgery. Patients under the age of 18 years and those with any prior history of trauma or tumor were excluded from this study. RESULTS A total 7422 patients underwent ASD surgery during 2007-2015 in the data set. Revision rates were 13.1% at 90 days, 14.5% at 6 months, 16.7% at 1 year, and 19.3% at 2 years. In multivariate multiple logistic regression analysis, obesity [adjusted odds ratio (OR): 1.58, P<0.001] and tobacco use (adjusted OR: 1.38, P=0.0011) were associated with increased odds of reoperation within 2 years. Patients with a combined anterior-posterior approach had lower odds of reoperation compared with those with posterior only approach (adjusted OR: 0.66, P=0.0117). CONCLUSIONS Obesity and tobacco are associated with increased odds of revision surgery within 2 years of index ASD surgery. Male sex and combined surgical approach are associated with decreased odds of revision surgery.
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Affiliation(s)
- Kunal Varshneya
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Martin N Stienen
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
- Department of Neurosurgery, University Hospital Zurich and Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Zachary A Medress
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Parastou Fatemi
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Arjun V Pendharkar
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - John K Ratliff
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
| | - Anand Veeravagu
- Neurosurgery AI Laboratory and Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA
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12
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Lyu Q, Lau D, Haddad AF, Deviren V, Ames CP. Multiple-rod constructs and use of bone morphogenetic protein-2 in relation to lower rod fracture rates in 141 patients with adult spinal deformity who underwent lumbar pedicle subtraction osteotomy. J Neurosurg Spine 2022; 36:235-245. [PMID: 34560633 DOI: 10.3171/2021.3.spine201968] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to compare rod fracture (RF) rates among three types of rod constructs (RCs) following lumbar pedicle subtraction osteotomy (PSO) for adult spinal deformity (ASD). METHODS A retrospective review of consecutive patients with adult spinal deformity who were treated with lumbar PSO between 2007 and 2017 was performed. The minimum follow-up was 2 years. Three RCs were compared: standard (2 main rods), satellite (2 main rods with satellite rod), and nested (2 main rods and 2 short rods spanning osteotomy). Outcomes examined included RF rate, time to RF, pseudarthrosis, and reoperation. Multivariate analysis was used. RESULTS A total of 141 patients were included 55 with standard, 23 with satellite, and 63 with nested RCs. The mean age was 65.2 years and 34.8% of patients were male. Radiographic preoperative and postoperative results were as follows: sagittal vertical axis (11.0 vs 3.9 cm), lumbar lordosis (28.5° vs 57.1°), pelvic tilt (30.6° vs 21.0°), pelvic incidence (61.5° vs 60.0°), distance between central sacral vertical line and C7 plumb line (2.2 vs 1.5 cm), and scoliosis (18.9° vs 11.3°). The average time to RF was 12.4 months. Overall RF, bilateral RF, pseudarthrosis, and reoperation rates were 22.7%, 5.0%, 20.6%, and 17.7%, respectively. Standard RCs had a significantly higher RF (36.4% vs 13.0% vs 14.3%, p = 0.008), bilateral RF (35.0% vs 0.0% vs 0.0%, p = 0.021), pseudarthrosis (34.5% vs 8.7% vs 12.7%, p = 0.004), and reoperation (30.9% vs 4.3% vs 11.1%, p = 0.004) rates. Satellite RCs (OR 0.21, p = 0.015), nested RCs (OR 0.24, p = 0.003), and bone morphogenetic protein-2 (OR 0.28, p = 0.005) were independently associated with lower odds of RF. CONCLUSIONS Use of multiple rods in the satellite RC and nested RC groups was associated with lower rates of RF, pseudarthrosis, and reoperations following lumbar PSO. Bone morphogenetic protein-2 was associated with a reduction in RF rate as well.
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Affiliation(s)
- Qiunan Lyu
- 1Department of Orthopedic Surgery, The First Peoples' Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan, China
- 2Department of Neurological Surgery, University of California, San Francisco; and
| | - Darryl Lau
- 2Department of Neurological Surgery, University of California, San Francisco; and
| | - Alexander F Haddad
- 2Department of Neurological Surgery, University of California, San Francisco; and
| | - Vedat Deviren
- 3Department of Orthopedic Surgery, University of California, San Francisco, California
| | - Christopher P Ames
- 2Department of Neurological Surgery, University of California, San Francisco; and
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13
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Lau D, Joshi RS, Haddad AF, Deviren V, Ames CP. Incidence and Risk Factors of Mechanical Complications After Posterior-Based Osteotomies for Correction of Moderate to Severe Adult Cervical Deformity: 1-Year and 2-Year Follow-up. Neurosurgery 2022; 90:207-214. [PMID: 34995272 DOI: 10.1227/neu.0000000000001781] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 09/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Rigid cervical deformity (CD) requires multilevel and/or high-grade osteotomies and long-construct fusions to achieve adequate correction. The incidence of mechanical complications (MCs) remains incompletely studied. OBJECTIVE To define the incidence and risk factors for MC. METHODS A retrospective review of consecutive patients with CD who underwent correction from 2010 to 2018 was performed. Inclusion criteria were cervical kyphosis >20° and/or cervical sagittal vertical axis (cSVA) >4 cm. MCs (junctional kyphosis/failure, pseudarthrosis, and implant failure) and reoperation at 1 and 2 yr were examined. RESULTS Eighty-three patients were included. The mean age was 63.4 yr, and 61.0% were female. Fifty-three percent underwent 3-column osteotomies. After surgery, cervical parameters were significantly improved: cSVA (6.2 vs 3.8 cm, P < .001), cervical lordosis (6.3 vs -8.3°, P < .001), cervical scoliosis (CS) (6.5 vs 2.2°, P < .001), and T1 slope (41.7 vs 36.3°, P = .007). The MC rate was 28.9%: junctional (18.1%), implant (16.9%), and pseudarthrosis (10.8%). MC rates at 1 and 2 yr were 14.5% and 25.5%, respectively: junctional (9.6% and 17.6%), implant (9.6% and 17.6%), and pseudarthrosis (2.4% and 7.8%). The overall reoperation rate was 24.1%: 14.5% at 1 yr and 19.6% at 2 yr. Body mass index (BMI) (P = .015) and preoperative CS (P = .040) were independently associated with higher odds of MC. Receiver operating characteristic curves defined CS >5° to be the threshold of risk for MCs and reoperation. CONCLUSION Correction of CD is effective by posterior-based osteotomes, but MCs are relatively high at 1 and 2 yr. BMI >30 and preoperative CS >5° predispose patients for MC and reoperation.
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Affiliation(s)
- Darryl Lau
- Department of Neurological Surgery, New York University, New York, New York, USA
| | - Rushikesh S Joshi
- Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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14
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Lafage R, Fong AM, Klineberg E, Smith JS, Bess S, Shaffrey CI, Burton D, Kim HJ, Elysee J, Mundis GM, Passias P, Gupta M, Hostin R, Schwab F, Lafage V. Complication rate evolution across a 10-year enrollment period of a prospective multicenter database. J Neurosurg Spine 2021:1-11. [PMID: 35349975 DOI: 10.3171/2021.10.spine21795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adult spinal deformity is a complex pathology that benefits greatly from surgical treatment. Despite continuous innovation, little is known regarding continuous changes in surgical techniques and the complications rate. The objective of the current study was to investigate the evolution of the patient profiles and surgical complications across a single prospective multicenter database. METHODS This study is a retrospective review of a prospective, multicenter database of surgically treated patients with adult spinal deformity (thoracic kyphosis > 60°, sagittal vertical axis > 5 cm, pelvic tilt > 25°, or Cobb angle > 20°) with a minimum 2-year follow-up. Patients were stratified into 3 equal groups by date of surgery. The three groups' demographic data, preoperative data, surgical information, and complications were then compared. A moving average of 320 patients was used to visualize and investigate the evolution of the complication across the enrollment period. RESULTS A total of 928/1260 (73.7%) patients completed their 2-year follow-up, with an enrollment rate of 7.7 ± 4.1 patients per month. Across the enrollment period (2008-2018) patients became older (mean age increased from 56.7 to 64.3 years) and sicker (median Charlson Comorbidity Index rose from 1.46 to 2.08), with more pure sagittal deformity (type N). Changes in surgical treatment included an increased use of interbody fusion, more anterior column release, and a decrease in the 3-column osteotomy rate, shorter fusion, and more supplemental rods and bone morphogenetic protein use. There was a significant decrease in major complications associated with a reoperation (from 27.4% to 17.1%) driven by a decrease in radiographic failures (from 12.3% to 5.2%), despite a small increase in neurological complications. The overall complication rate has decreased over time, with the lowest rate of any complication (51.8%) during the period from August 2014 to March 2017. Major complications associated with reoperation decreased rapidly in the 2014-2015. Major complications not associated with reoperation had the lowest level (21.0%) between February 2014 and October 2016. CONCLUSIONS Despite an increase in complexity of cases, complication rates did not increase and the rate of complications leading to reoperation decreased. These improvements reflect the changes in practice (supplemental rod, proximal junctional kyphosis prophylaxis, bone morphogenetic protein use, anterior correction) to ensure maintenance of status or improved outcomes.
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Affiliation(s)
- Renaud Lafage
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Alex M Fong
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Eric Klineberg
- 2Department of Orthopedic Surgery, School of Medicine, University of California, Davis, California
| | - Justin S Smith
- 3Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Shay Bess
- 4Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | | | - Douglas Burton
- 6Department of Orthopedics, University of Kansas Medical Center, Kansas City, Kansas
| | - Han Jo Kim
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Jonathan Elysee
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Peter Passias
- 8Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, New York
| | - Munish Gupta
- 9Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri; and
| | - Richard Hostin
- 10Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, Texas
| | - Frank Schwab
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- 1Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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15
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Zuckerman SL, Lai CS, Shen Y, Kerolus MG, Ha AS, Buchanan IA, Lee NJ, Leung E, Cerpa M, Lehman RA, Lenke LG. Be Prepared: Preoperative Coronal Malalignment Often Leads to More Extensive Surgery Than Sagittal Malalignment During Adult Spinal Deformity Surgery. Neurospine 2021; 18:570-579. [PMID: 34610688 PMCID: PMC8497231 DOI: 10.14245/ns.2142384.192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/25/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate the effect of coronal alignment on: (1) surgical invasiveness and operative complexity and (2) postoperative complications.
Methods A retrospective, cohort study of adult spinal deformity patients was conducted. Alignment groups were: (1) neutral alignment (NA): coronal vertical axis (CVA) ≤ 3 cm and sagittal vertical axis (SVA) ≤ 5 cm; (2) coronal malalignment (CM) only: CVA > 3 cm; (3) Sagittal malalignment (SM) only: SVA > 5 cm; and (4) coronal and sagittal malalignment (CCSM): CVA > 3 cm and SVA > 5 cm.
Results Of 243 patients, alignment groups were: NA 115 (47.3%), CM 48 (19.8%), SM 38 (15.6%), and CCSM 42 (17.3%). Total instrumented levels (TILs) were highest in CM (14.5±3.7) and CCSM groups (14±4.0) (p<0.001). More 3-column osteotomies (3COs) were performed in SM (21.1%) and CCSM (28.9%) groups than CM (10.4%) (p=0.003). CM patients had more levels instrumented (p=0.029), posterior column osteotomies (PCOs) (p<0.001), and TLIFs (p=0.002) than SM patients. CCSM patients had more TLIFs (p=0.012) and higher estimated blood loss (EBL) (p=0.003) than SM patients. CVA displayed a stronger relationship with TIL (p=0.002), EBL (p<0.001), and operative time (p<0.001) than SVA, which had only one significant association with EBL (p=0.010). Both SM/CCSM patients had higher readmissions (p=0.003) and reoperations (p<0.001) than CM patients.
Conclusion Amount of preoperative CM was a better predictor of surgical invasiveness than the amount of SM, despite 3COs more commonly performed in SM patients. CM patients had more instrumented levels, PCOs, and TLIFs than SM patients.
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Affiliation(s)
- Scott L Zuckerman
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Christopher S Lai
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Yong Shen
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Mena G Kerolus
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Alex S Ha
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Ian A Buchanan
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Nathan J Lee
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Eric Leung
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Meghan Cerpa
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Ronald A Lehman
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
| | - Lawrence G Lenke
- Department of Orthopaedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA
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16
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Bari TJ, Hallager DW, Hansen LV, Dahl B, Gehrchen M. Reducing revision rates following Pedicle Subtraction Osteotomy surgery: a single-center experience of trends over 7 years in patients with Adult Spinal Deformity. Spine Deform 2021; 9:803-815. [PMID: 33400231 DOI: 10.1007/s43390-020-00256-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/08/2020] [Indexed: 11/30/2022]
Abstract
STUDY DESIGN This is a single-center, retrospective study. OBJECTIVE To assess if implemented changes to clinical practice have reduced mechanical complications following pedicle subtraction osteotomy (PSO) surgery. Adult spinal deformity (ASD) is increasing in prevalence with concurrent increasing demands for surgical treatment. The most extensive technique, PSO, allows for major correction of rigid deformities. However, surgery-related complications have been reported in rates up to 77% and especially mechanical complications occur at unsatisfactory frequencies. METHODS We retrospectively included all patients undergoing PSO for ASD between 2010 and 2016. Changes to clinical practice were introduced continuously in the study period, including rigorous patient selection; inter-disciplinary conferences; implant-material; number of surgeons; surgeon experience; and perioperative standardized protocols for pain, neuromonitoring and blood-loss management. Postoperative complications were recorded in the 2-year follow-up period. Competing risk survival analysis was used to assess cumulative incidence of revision surgery due to mechanical complications. The Mann-Kendall test was used for analysis of trends. RESULTS We included 185 patients undergoing PSO. The level of PSO changed over the study period (P < 0.01) with L3 being the most common level in 2010 compared to L4 in 2016. Both preoperative and surgical corrections of sagittal vertical axis were larger towards the end of the study period. The 2-year revision rate due to mechanical failure steadily declined over the study period from 52% in 2010 to 14% for patients treated in 2016, although without statistically significant trend (P = 0.072). In addition, rates of mechanical complications steadily declined over the study period and significant decreasing trends were observed in time trend analyses of overall complications, major complications and rod breakage. CONCLUSIONS We observed decreased risks of revision surgery due to mechanical complications following PSO in patients with ASD over a 7-year period. We attribute these improvements to advancements in patient selection, surgical planning and techniques, surgeon experience and more standardized perioperative care. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tanvir Johanning Bari
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Dennis Winge Hallager
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Lars Valentin Hansen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Benny Dahl
- Department of Orthopedics and Scoliosis Surgery, Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin St, Houston, TX, 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
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17
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Barone G, Giudici F, Martinelli N, Ravier D, Muzzi S, Minoia L, Zagra A, Scaramuzzo L. Mechanical Complications in Adult Spine Deformity Surgery: Retrospective Evaluation of Incidence, Clinical Impact and Risk Factors in a Single-Center Large Series. J Clin Med 2021; 10:jcm10091811. [PMID: 33919280 PMCID: PMC8122265 DOI: 10.3390/jcm10091811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/06/2021] [Accepted: 04/19/2021] [Indexed: 11/16/2022] Open
Abstract
The advancement of deformity-specific implants and surgical techniques has improved the surgical treatment of Adult Spine Deformity (ASD), allowing surgeons to treat more complex deformities. Simultaneously, high rates of medical and surgical complications have been reported. The aim of this study is to describe the risk factors, the rate and the clinical impact of mechanical complications in ASD surgery. A retrospective review of a large, single-center database of consecutive ASD patients was conducted. Inclusion criteria were as follows: Cobb coronal curve > 20° or alteration of at least one of sagittal vertical axis (SVA > 40 mm), thoracic kyphosis (TK > 60°), pelvic tilt (PT > 20°) and pelvic incidence minus lumbar lordosis mismatch (PI-LL > 10°), at least four levels of posterior instrumented fusion and 2-year follow-up. At the baseline and at each follow-up end point, the authors collected clinical and radiographic outcomes and recorded any mechanical complications that occurred. One hundred and two patients were enrolled. Clinical outcomes significantly were improved at the last follow-up (mean 40.9 months). Postoperative mechanical complications occurred in 15 patients (14.7%); proximal junctional disease was the most common complication (60%) and the revision rate was 53.3%. Patients who experienced mechanical complications were older (61.2 vs. 54.8 years, p = 0.04); they had also a higher rate of pelvic fusion and posterior-only approach, a lower LL (−37.9 vs. −46.2, p = 0.02) and a higher PT (26.3 vs. 19.8, p = 0.009), TK (41.8 vs. 35.7, p = 0.05), PI–LL (12.9 vs. 5.4, p = 0.03) and Global Alignment and Proportion score (6.9 vs. 4.3, p = 0.01). This study showed a significant improvement in pain and disability after ASD surgery. Regarding the risk of developing a mechanical complication, not only postoperative radiographic parameters affected the risk but also patient age and surgical features.
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18
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Kwan KYH, Lenke LG, Shaffrey CI, Carreon LY, Dahl BT, Fehlings MG, Ames CP, Boachie-Adjei O, Dekutoski MB, Kebaish KM, Lewis SJ, Matsuyama Y, Mehdian H, Qiu Y, Schwab FJ, Cheung KMC. Are Higher Global Alignment and Proportion Scores Associated With Increased Risks of Mechanical Complications After Adult Spinal Deformity Surgery? An External Validation. Clin Orthop Relat Res 2021; 479:312-320. [PMID: 33079774 PMCID: PMC7899533 DOI: 10.1097/corr.0000000000001521] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 09/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Global Alignment and Proportion (GAP) score, based on pelvic incidence-based proportional parameters, was recently developed to predict mechanical complications after surgery for spinal deformities in adults. However, this score has not been validated in an independent external dataset. QUESTIONS/PURPOSES After adult spinal deformity surgery, is a higher GAP score associated with (1) an increased risk of mechanical complications, defined as rod fractures, implant-related complications, proximal or distal junctional kyphosis or failure; (2) a higher likelihood of undergoing revision surgery to treat a mechanical complication; and (3) is a lower (more proportioned) GAP score category associated with better validated outcomes scores using the Oswestry Disability Index (ODI), Scoliosis Research Society-22 (SRS-22) and the Short Form-36 questionnaires? METHODS A total of 272 patients who had undergone corrective surgeries for complex spinal deformities were enrolled in the Scoli-RISK-1 prospective trial. Patients were included in this secondary analysis if they fulfilled the original inclusion criteria by Yilgor et al. From the original 272 patients, 14% (39) did not satisfy the radiographic inclusion criteria, the GAP score could not be calculated in 14% (37), and 24% (64) did not have radiographic assessment at postoperative 2 years, leaving 59% (159) for analysis in this review of data from the original trial. A total of 159 patients were included in this study,with a mean age of 58 ± 14 years at the time of surgery. Most patients were female (72%, 115 of 159), the mean number of levels involved in surgery was 12 ± 4, and three-column osteotomy was performed in 76% (120 of 159) of patients. The GAP score was calculated using parameters from early postoperative radiographs (between 3 and 12 weeks) including pelvic incidence, sacral slope, lumbar lordosis, lower arc lordosis and global tilt, which were independently obtained from a computer software based on centralized patient radiographs. The GAP score was categorized as proportional (scores of 0 to 2), moderately disproportional (scores of 3 to 6), or severely disproportional (scores higher than 7 to 13). Receiver operating characteristic area under curve (AUC) was used to assess associations between GAP score and risk of mechanical complications and risk of revision surgery. An AUC of 0.5 to 0.7 was classified as "no or low associative power", 0.7 to 0.9 as "moderate" and greater than 0.9 as "high". We analyzed differences in validated outcome scores between the GAP categories using Wilcoxon rank sum test. RESULTS At a minimum of 2 years' follow-up, a higher GAP score was not associated with increased risks of mechanical complications (AUC = 0.60 [95% CI 0.50 to 0.70]). A higher GAP score was not associated with a higher likelihood of undergoing a revision surgery to treat a mechanical complication (AUC = 0.66 [95% 0.53 to 0.78]). However, a moderately disproportioned GAP score category was associated with better SF-36 physical component summary score (36 ± 10 versus 40 ± 11; p = 0.047), better SF-36 mental component summary score (46 ± 13 versus 51 ± 12; p = 0.01), better SRS-22 total score (3.4 ± 0.8 versus 3.7 ± 0.7, p = 0.02) and better ODI score (35 ± 21 versus 25 ± 20; p = 0.003) than severely disproportioned GAP score category. CONCLUSION Based on the findings of this external validation study, we found that alignment targets based on the GAP score alone were not associated with increased risks of mechanical complications and mechanical revisions in patients with complex adult spinal disorders. Parameters not included in the original GAP score needed to be considered to reduce the likelihood of mechanical complications. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Kenny Yat Hong Kwan
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Lawrence G Lenke
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Christopher I Shaffrey
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Leah Y Carreon
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Benny T Dahl
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Michael G Fehlings
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Christopher P Ames
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Oheneba Boachie-Adjei
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Mark B Dekutoski
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Khaled M Kebaish
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Stephen J Lewis
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Yukihiro Matsuyama
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Hossein Mehdian
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Yong Qiu
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Frank J Schwab
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
| | - Kenneth Man Chee Cheung
- K. Y. H. Kwan, The University of Hong Kong, Pokfulam, Hong Kong
- L. G. Lenke, Columbia University Medical Center, New York, NY, USA
- C. I. Shaffrey, University of Virginia Medical Center, Charlottesville, VA, USA
- L. Y. Carreon, Norton Leatherman Spine Center, Louisville, KY, USA
- B. T. Dahl, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- B. T. Dahl, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
- M. G. Fehlings, S. J. Lewis, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
- C. P. Ames, University of California San Francisco, San Francisco, CA, USA
- O. Boachie-Adjei, The Foundation of Orthopedics and Complex Spine Hospital, Pantang West, Republic of Ghana
- M. B. Dekutoski, Marshfield Clinic Eau Claire Center, Eau Claire, WI, USA
- K. M. Kebaish, Johns Hopkins University, Baltimore, MD, USA
- Y. Matsuyama, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- H. Mehdian, University Hospital, Queen's Medical Centre, Nottingham, UK
- Y. Qiu, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
- F. J. Schwab, Hospital for Special Surgery, New York, NY, USA
- K. M. C. Cheung, The University of Hong Kong, Pokfulam, Hong Kong
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Mechanical revision following pedicle subtraction osteotomy: a competing risk survival analysis in 171 consecutive adult spinal deformity patients. Spine Deform 2021; 9:191-205. [PMID: 32875546 DOI: 10.1007/s43390-020-00195-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 08/25/2020] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To report the incidence of revision surgery due to mechanical failure following pedicle subtraction osteotomy (PSO) in adult spinal deformity (ASD) patients. PSO allow major surgical correction of ASD, although; the risk of mechanical complications remains considerable. Previous reports have been based on smaller cohorts or multicenter databases and none have utilized competing risk (CR) survival analysis. METHODS All ASD patients undergoing PSO surgery from 2010 to 2015 at a single, tertiary institution were included. Demographics, long standing radiographs as well as intra- and postoperative complications were registered for all. A CR-model was used to estimate the incidence of revision surgery due to mechanical failure and two predefined multivariable models were used to assess radiographic prediction of failure and reported as odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS A total of 171 patients were included with 2-year follow-up available for 91% (mean [IQR]: 35 [24-50] months). Mechanical failure occurred in 111 cases (65%) at any time in follow-up, the most frequent being rod breakage affecting 81 patients (47%). Cumulative incidence of revision surgery due to mechanical failure was estimated to 34% at 2 years and 58% at 5 years. A multivariable proportional odds model with death as competing risk showed significantly increased odds of revision with fusion to the sacrum (OR: 5.42; 95% CI 1.89-15.49) and preoperative pelvic tilt (PT) > 20° (OR: 2.41; 95% CI 1.13-5.16). History of previous surgery, number of instrumented vertebra, as well as postoperative SRS-Schwab modifiers and Global Alignment and Proportion score were not associated with significant effects on odds of revision. CONCLUSIONS In a consecutive single-center cohort of patients undergoing PSO for ASD, we found an estimated incidence of revision surgery due to mechanical failure of 34% 2 years postoperatively. Fusion to the sacrum and preoperative PT > 20° were associated with elevated risks of revision. LEVEL OF EVIDENCE Prognostic III.
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Medical optimization of modifiable risk factors before thoracolumbar three-column osteotomies: an analysis of 195 patients. Spine Deform 2020; 8:1039-1047. [PMID: 32323168 DOI: 10.1007/s43390-020-00114-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/04/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To determine the rate of preoperative modifiable laboratory abnormalities (both major and minor) and the association with early postoperative medical and surgical complications. METHODS All patients undergoing thoracolumbar three-column osteotomy between 2013 and 2016 with preoperative laboratory data were identified. Potential preoperative modifiable laboratory abnormalities (major and minor) were assessed including hyponatremia (sodium < 130 and < 135 mEq/L), anemia (hematocrit < 25% and < 30%), renal insufficiency (creatinine ≥ 1.8 and ≥ 1.2 mg/dL), coagulopathy (INR ≥ 1.8 and ≥ 1.2), and hypoalbuminemia (albumin < 2.5 and < 3.5 g/dL). Multivariate logistic regression was used to determine associations with 30-day complications after controlling for possible confounding factors. RESULTS A total of 195 patients were identified. The rates of major and minor preoperative laboratory abnormalities were 7.7% and 31.3%, respectively. The rates of serious medical, minor medical, and surgical complications over 30-days were 6.7%, 21.5%, and 10.3%, respectively. In multivariate analysis the presence of major preoperative laboratory abnormalities had a significant association with serious medical complications (odds ratio [OR] 77.8, P < 0.001), and minor medical complications (OR 13.3, P < 0.001), but not surgical complications (P = 0.243). The presence of minor preoperative laboratory abnormalities had a significant association with serious medical complications (OR 10.4, P = 0.041) and minor medical complications (OR 2.4, P = 0.045), but not surgical complications (P = 0.490). CONCLUSIONS While major laboratory abnormalities had a strong association with complications, even minor modifiable laboratory abnormalities had a significant association with both serious and minor medical complications.
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Lee KH, Kim KT, Kim YC, Lee JW, Ha KY. Radiographic findings for surgery-related complications after pedicle subtraction osteotomy for thoracolumbar kyphosis in 230 patients with ankylosing spondylitis. J Neurosurg Spine 2020; 33:366-372. [PMID: 32413867 DOI: 10.3171/2020.3.spine191355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the rate of and the risk factors for surgery-related complications demonstrated on radiography after pedicle subtraction osteotomy (PSO) for thoracolumbar kyphosis in patients with ankylosing spondylitis (AS). METHODS The authors retrospectively reviewed the medical records of 230 consecutive patients with thoracolumbar kyphosis due to AS who had undergone 1-level PSO at a single institution in the period from 2010 to 2017. The causes of surgery-related complications were divided into two types: surgical/technical failure and mechanical failure. RESULTS The patients consisted of 20 women and 210 men, with an average age of 43.4 years. The average follow-up period was 39.0 months. The preoperative sagittal vertical axis was 18.5 ± 69.3 cm, which improved to 4.9 ± 4.6 cm after PSO. Of the 77 patients (33.5%) who experienced minor or major surgery-related complications, 56 had complications related to surgical/technical failure (overall incidence 24.3%) and 21 had complications related to mechanical failure (overall incidence 9.1%). Fourteen patients (6.1%) underwent reoperation. However, among the 77 patients with complications, the rate of revision surgery was 18.2%. The most common radiological complications were as follows: sagittal translation in 24 patients, coronal imbalance in 20, under-correction in 8, delayed union in 8, and distal junctional failure and kyphosis in 8. The most common causes of reoperation were coronal imbalance in 4 patients, symptomatic malposition of pedicle screws in 3, and distal junctional failure in 3. Delayed union was statistically correlated with posterior sagittal translation (p = 0.007). CONCLUSIONS PSO can provide acceptable radiographic outcomes for the correction of thoracolumbar kyphosis in patients with AS. However, a high incidence of surgery-related complications related to mechanical failure and surgical technique can develop. Thorough radiographic investigation before and during surgery is needed to determine whether complete ossification occurs along the anterior and posterior longitudinal ligaments of the spine.
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Affiliation(s)
- Keun-Ho Lee
- 1Department of Orthopaedic Surgery, Kangdong Sacred Heart Hospital, College of Medicine, Hallym University, Seoul; and
| | - Ki-Tack Kim
- 2Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Yong-Chan Kim
- 2Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Joong-Won Lee
- 2Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Kee-Yong Ha
- 2Department of Orthopaedic Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
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Korovessis P, Mpountogianni E, Syrimpeis V, Tsekouras V, Baikousis A. Three-level lumbar Ponte osteotomies with less invasive pelvic fixation improve spinal balance, quality of life and decrease disability in adult and elderly women with moderate adult spinal deformity. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:3006-3017. [PMID: 32621077 DOI: 10.1007/s00586-020-06523-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/24/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE To report on quality of life and radiological changes of Ponte osteotomies (POs) with long fixation for primary and revision surgery, in elderly women with adult spinal deformity (ASD). METHODS Sixty-seven (67) women, aged 69 ± 7 years, received 3 POs, spinopelvic fixation plus TLIFs. Forty-nine (73%) patients received primary and 18 (27%) revision surgery. Survivorship analysis was made for unplanned revision surgery for broken rods (BR); proximal junction failure (PJF); and deep wound infection (DWI). ODI and SF-36 were used for disability (ODI) and quality of life (SF-36) evaluation. RESULTS In total, 201 lumbar POs were made and 9.55 ± 3 levels fused. All patients were available 49 ± 11 months postoperatively. Postoperatively, SVA, CSVL, PI-LL, scoliosis, PT and T9-spinopelvic inclination were reduced, while LL and SS were increased significantly. At the final visit, PI-LL ≤ 10° was achieved in 26 (39.4%) patients; ≤ 15° in 51 (76%) patients, while all 67 patients showed a PI-LL ≤ 20°. Unplanned reoperation was performed in 11 (16.4%) patients: for BR in 5 (7.5%); for PJF in 3 (4.5%) and for DWI in 3 (4.5%) patients, respectively. With end point the reoperation for any reason the survival ± SE was 67.8% ± 0.1; for PJF 89.6 ± 0.065; and for BR 76% ± 0.1 in the final evaluation. There was no difference in survival between the primary and revision surgery groups (P = 0.568). ODI and SF-36 scores were improved postoperatively. CONCLUSIONS Three-segment lumbar POs offered and maintained sufficient improvement of lumbar lordosis along with restoration of the sagittal and coronal spinal alignment, improvement of quality of life and disability of female adult and elderly population after primary and revision surgery for ASD.
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Affiliation(s)
- Panagiotis Korovessis
- Orthopaedics Department, "Agios Andreas" General Hospital of Patras, Tsertidou 1, 26223, Patras, Greece.
| | - Evangelia Mpountogianni
- Orthopaedics Department, "Agios Andreas" General Hospital of Patras, Tsertidou 1, 26223, Patras, Greece
| | - Vasileios Syrimpeis
- Orthopaedics Department, "Agios Andreas" General Hospital of Patras, Tsertidou 1, 26223, Patras, Greece
| | - Vassilis Tsekouras
- Orthopaedics Department, "Agios Andreas" General Hospital of Patras, Tsertidou 1, 26223, Patras, Greece
| | - Andreas Baikousis
- Orthopaedics Department, "Agios Andreas" General Hospital of Patras, Tsertidou 1, 26223, Patras, Greece
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Raad M, Puvanesarajah V, Harris A, El Dafrawy MH, Khashan M, Jain A, Hassanzadeh H, Kebaish KM. The learning curve for performing three-column osteotomies in adult spinal deformity patients: one surgeon's experience with 197 cases. Spine J 2019; 19:1926-1933. [PMID: 31310816 DOI: 10.1016/j.spinee.2019.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/18/2019] [Accepted: 07/10/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Three-column osteotomy (3CO) is used to correct rigid adult spinal deformity. It presents risk of complications because it involves extensive osseous resection and spinal destabilization. PURPOSE Our purpose was to characterize the learning curve for performing 3CO in adult spinal deformity patients. DESIGN Retrospective review. PATIENT SAMPLE A surgical registry at a tertiary care center was used to identify 238 cases of 3CO for correction of adult spinal deformity by 1 surgeon between 2005 and 2014. Patients with at least 1 year of clinical and radiographic follow-up were included (n=197; mean duration of follow-up, 43 months; range, 12-121). OUTCOME MEASURES We quantified associations between surgeon experience and (1) estimated blood loss per vertebral level fused (EBL/VLF), (2) incidence of new neurologic deficits, (3) incidence of reoperation for instrumentation failure, (4) operative time in minutes, and (5) magnitude of correction at the level of the osteotomy. METHODS The learning curve for binary outcomes was demonstrated using a LOWESS smoother plot of the probability of occurrence. Change in risk was calculated using a generalized linear model with link identity and binomial family. The learning curve for continuous variables was demonstrated using a scatter plot and a line of best fit based on linear regression analysis. Alpha=0.05. RESULTS EBL/VLF decreased by a mean of 19.7 mL (95% confidence interval [CI]: 11.3-28.1) with each 10 cases (decrease of 388 mL/level fused by the end of the study period). The risk of a neurologic deficit declined by 7.98% (95% CI: 7.98%, 7.99%) with every 100 cases. The risk of reoperation declined by 1.99% (95% CI: 0.83%, 3.17%) with every 10 cases until the 100th case. After that point, there was no significant change in the probability of reoperation (p>.05). The magnitude of correction and operative time did not change with increasing surgeon experience (p>.05). CONCLUSION Incidence of reoperation for instrumentation failure, incidence of new neurologic deficits, and estimated blood loss improved with increasing surgeon experience at performing 3CO. Most outcomes, except the risk of reoperation, improved through the last case.
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Affiliation(s)
- Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Andrew Harris
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | | | - Morsi Khashan
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Amit Jain
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD.
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Yang H, Wang B, Zou X, Ge S, Chen Y, Zhang S, Ni L, Li H, Yang J, Ma X. Safe Limit of Shortening of the Spinal Cord in Thoracolumbar Bivertebral Column Resections: An Experimental Study in Goats. World Neurosurg 2019; 134:e589-e595. [PMID: 31678449 DOI: 10.1016/j.wneu.2019.10.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To clarify the safe limit of shortening of the spinal cord in thoracolumbar bivertebral column resection in a goat model. METHODS Ten healthy goats were selected for the experiment. Radiographs were taken before surgery to measure the height of T13, L1, and the initial osteotomy segment (distance from the lower end plate of T12 to the upper end plate of L2). A procedure of thoracolumbar bivertebral column resection (T13 and L1) was completed under the monitoring of somatosensory evoked potential (SSEP) monitoring. The SSEP measured after vertebral resection was set as the baseline. SSEPs decreased by 50% from the baseline amplitude and/or delayed by 10% relative to the baseline peak latency were set as positive results, indicating spinal cord injury. The initial height of the osteotomy gap was measured first and the spinal column was gradually shortened until the SSEP monitoring did not show a positive result. Then the height of the osteotomy gap was recorded again. The safe limit of shortening was measured and recorded when any morphologic change of the spinal cord was observed. Hindlimb function was evaluated by the Tarlov scores on day 2 postoperatively. RESULTS The safe limit of shortening of the spinal cord in thoracolumbar bivertebral columns resection was 35.2 ± 2.6 mm, which was roughly equal to 127.6% of the mean osteotomy vertebral height and 57.1% of the initial osteotomy gap height. Pearson correlation test showed that the safe limit of shortening of the spinal cord was correlated with the height of T13, the height of L1, the mean height of T13 and L1, and the height of the initial osteotomy gap. CONCLUSIONS The safe limit of shortening distance of the bivertebral column resection was roughly equal to 127.6% of the mean osteotomy vertebral height and 57.1% of the initial osteotomy gap height with good correlation. Moreover, the safe limit of shortening distance of the bivertebral column resection was longer than that in single vertebral column resection. Increasing the number of vertebrae resected may prevent spinal cord injury because of excessive shortening.
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Affiliation(s)
- Haozhi Yang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China; Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, People's Republic of China
| | - Binbin Wang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
| | - Xiaobao Zou
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China; Graduate School, Southern Medical University, Guangzhou, People's Republic of China
| | - Su Ge
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
| | - Yuyue Chen
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
| | - Shuang Zhang
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China; Graduate School, Southern Medical University, Guangzhou, People's Republic of China
| | - Ling Ni
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
| | - Hengrui Li
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China
| | - Jincheng Yang
- Department of Orthopedics, Southern Medical University Nanfang Hospital, Guangzhou, People's Republic of China
| | - Xiangyang Ma
- Department of Orthopedics, General Hospital of Southern Theatre Command of PLA, Guangzhou, People's Republic of China; Graduate School, Southern Medical University, Guangzhou, People's Republic of China.
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Steinmetz L, Vasquez-Montes D, Johnson BC, Buckland AJ, Goldstein JA, Bendo JA, Errico TJ, Fischer CR. Modifiable and nonmodifiable factors associated with patient satisfaction in spine surgery and other orthopaedic subspecialties: A retrospective survey analysis. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Raman T, Varlotta C, Vasquez-Montes D, Buckland AJ, Errico TJ. The use of tranexamic acid in adult spinal deformity: is there an optimal dosing strategy? Spine J 2019; 19:1690-1697. [PMID: 31202836 DOI: 10.1016/j.spinee.2019.06.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/20/2019] [Accepted: 06/11/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT ASD (Adult spinal deformity) surgery often entails complex osteotomies and realignment procedures, particularly in the setting of rigid deformities. Although previous studies have established the efficacy of tranexamic acid (TXA), data evaluating the widely variable dosing regimens remains sparse. PURPOSE To improve understanding of blood loss and transfusion requirements for low-dose and high-dose TXA regimens for adult spinal deformity (ASD) surgery. STUDY DESIGN/SETTING This is a retrospective cohort study of 318 ASD patients who received TXA. Outcome measures include estimated blood loss (EBL), perioperative transfusion requirement, and complications. METHODS A retrospective review was conducted on 318 ASD patients: 258 patients received a low-dose regimen of TXA (10 or 20 mg/kg loading dose with a 1 or 2 mg/kg/h maintenance dose) and 60 patients received a high-dose regimen of TXA (40 mg/kg loading dose with a 1 mg/kg/h maintenance dose, 30 mg/kg loading dose with a 10 mg/kg/h maintenance dose, or 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose). RESULTS Compared with the low-dose TXA group, the high-dose TXA group had significantly decreased EBL (1402 vs. 1793 mL, p=.009), blood volume lost (30.3 vs. 39.4%, p=.01), intraoperative packed red blood cell (pRBC) transfusion (0.9 vs. 1.6 U, p<.0001), and intraoperative platelet transfusion (0 vs. 0.1 U, p<.0001). High-dose TXA was predictive of 515 cc less EBL (p=.002), 11.4% less blood volume lost (p=.004), and 1 U pRBC less transfused intraoperatively (p<.0001) than the low-dose TXA group. The high-dose TXA group had a higher incidence of postop atrial fibrillation (5 vs. 0%, p<.0001) and myocardial infarction (1.7 vs. 0%, p=.04). CONCLUSIONS Varying dosing regimens of TXA are utilized for ASD surgery, with a prevailing theme of dosing ambiguity. These data demonstrate that high-dose TXA is more effective than low-dose TXA in reducing blood loss and blood product transfusion requirement in ASD surgery. Importantly, rates of MI and postop AF were higher in the high-dose TXA group.
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Affiliation(s)
- Tina Raman
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.
| | - Chris Varlotta
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Dennis Vasquez-Montes
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Aaron J Buckland
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Thomas J Errico
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
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Pitter FT, Lindberg-Larsen M, Pedersen AB, Dahl B, Gehrchen M. Revision Risk After Primary Adult Spinal Deformity Surgery: A Nationwide Study With Two-Year Follow-up. Spine Deform 2019; 7:619-626.e2. [PMID: 31202380 DOI: 10.1016/j.jspd.2018.10.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/06/2018] [Accepted: 10/21/2018] [Indexed: 11/15/2022]
Abstract
STUDY DESIGN Cohort study. OBJECTIVES To report the two-year revision risk following primary adult spinal deformity (ASD) surgery, describe reasons for revisions, and assess risk factors for revision surgery. SUMMARY OF BACKGROUND DATA Revision risk following primary ASD surgery has been reported to vary between 7% and 26%, but with loss to follow-up as a considerable challenge. METHODS Patients ≥18 years of age undergoing primary instrumented surgery for ASD in Denmark during 2006-2014 were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Complete two-year follow-up on revision surgery for each patient was achieved. Medical records were reviewed to determine reasons for revisions. Overall comorbidity was summarized using the Charlson Comorbidity Index (CCI) based on DNPR data; low comorbidity (CCI 0); medium comorbidity (CCI 1-2); and high comorbidity (CCI ≥3). Risk factors for revision were assessed in a Cox regression model. RESULTS A total of 553 patients were identified. Of these, 19.9% were revised within the two-year follow-up and 7.2% of patients were revised more than once. Median time to revision was 308 days (interquartile range 105-508). The most common reason for revision was implant failure (38.2%) followed by infection (11.8%). Increased age (hazard ratio [HR] = 1.13, 95% confidence interval [CI] 1.01-1.26, per 10 years increment) and high comorbidity burden (HR = 2.10, 95% CI 1.16-3.79) were associated with increased revision risk. Risk of revision increased from 2006 to 2014; hence, year of primary surgery (with 2006 as reference) was associated with increased revision risk (HR = 1.09, 95% CI 1.01-1.18). CONCLUSIONS The revision risk within 2 years after primary ASD surgery was 19.9% nationwide in Denmark, and implant failure was the most common reason for revision. Increased comorbidity and age were separately associated with increased risk of revision. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Frederik T Pitter
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9-2100, København Ø, Denmark.
| | - Martin Lindberg-Larsen
- Department of Orthopedic Surgery and Traumatology, Odense University Hospital, J.B. Winsløvsvej 4-5000, Odense C, Denmark
| | - Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45-8200, Aarhus N, Denmark
| | - Benny Dahl
- Department of Orthopedic Surgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX 77030, USA
| | - Martin Gehrchen
- Spine Unit, Department of Orthopedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Blegdamsvej 9-2100, København Ø, Denmark
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Safaee MM, Dalle Ore CL, Zygourakis CC, Deviren V, Ames CP. Estimating a price point for cost-benefit of bone morphogenetic protein in pseudarthrosis prevention for adult spinal deformity surgery. J Neurosurg Spine 2019; 30:814-821. [PMID: 30849745 DOI: 10.3171/2018.12.spine18613] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 12/17/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Bone morphogenetic protein (BMP) is associated with reduced rates of pseudarthrosis and has the potential to decrease the need for revision surgery. There are limited data evaluating the cost-benefit of BMP for pseudarthrosis-related prevention surgery in adult spinal deformity. METHODS The authors performed a single-center retrospective review of 200 consecutive patients with adult spinal deformity. Demographic data and costs of BMP, primary surgery, and revision surgery for pseudarthrosis were collected. Patients with less than 12 months of follow-up or with infection, tumor, or neuromuscular disease were excluded. RESULTS One hundred fifty-one patients (107 [71%] women) with a mean age of 65 years met the inclusion criteria. The mean number of levels fused was 10; BMP was used in 98 cases (65%), and the mean follow-up was 23 months. Fifteen patients (10%) underwent surgical revision for pseudarthrosis; BMP use was associated with an 11% absolute risk reduction in the rate of reoperation (17% vs 6%, p = 0.033), with a number needed to treat of 9.2. There were no significant differences in age, sex, upper instrumented vertebra, or number of levels fused in patients who received BMP. In a multivariate model including age, sex, number of levels fused, and the upper instrumented vertebra, only BMP (OR 0.250, 95% CI 0.078-0.797; p = 0.019) was associated with revision surgery for pseudarthrosis. The mean direct cost of primary surgery was $87,653 ± $19,879, and the mean direct cost of BMP was $10,444 ± $4607. The mean direct cost of revision surgery was $52,153 ± $26,985. The authors independently varied the efficacy of BMP, cost of BMP, and cost of reoperation by ± 50%; only reductions in the cost of BMP resulted in a cost savings per 100 patients. Using these data, the authors estimated a price point of $5663 in order for BMP to be cost-neutral. CONCLUSIONS Use of BMP was associated with a significant reduction in the rates of revision surgery for pseudarthrosis. At its current price, the direct in-hospital costs for BMP exceed the costs associated with revision surgery; however, this likely underestimates the true value of BMP when considering the savings associated with reductions in rehabilitation, therapy, medication, and additional outpatient costs.
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Affiliation(s)
| | | | - Corinna C Zygourakis
- 2Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Vedat Deviren
- 3Orthopedic Surgery, University of California, San Francisco, California; and
| | - Christopher P Ames
- Departments of1Neurological Surgery and
- 3Orthopedic Surgery, University of California, San Francisco, California; and
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Pumberger M, Schmidt H, Putzier M. Spinal Deformity Surgery: A Critical Review of Alignment and Balance. Asian Spine J 2018; 12:775-783. [PMID: 30060389 PMCID: PMC6068412 DOI: 10.31616/asj.2018.12.4.775] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/12/2017] [Indexed: 12/01/2022] Open
Abstract
Correction of the overall coronal and/or sagittal plane deformities is one of the main predictors of successful spinal surgery. In routine clinical practice, spinal alignment is assessed using several spinal and pelvic parameters, such as pelvic incidence and tilt, sacral slope, lumbar lordosis, thoracic kyphosis, and sagittal vertical axis. Standard values have been defined for all these parameters, and the formulas of correction have been set for determining the surgical strategy. However, several factors can potentially bias these formulas. First, all standard values are measured using conventional plain radiographs and are, therefore, prone to bias. The radiologist, measuring surgeon, and patient are possible confounding influencing factors. Second, spino-pelvic compensatory effects and biomechanically relevant structures for the patient’s posture, including ligaments, tendons, and muscles, have received minimal consideration in the literature. Therefore, even in cases of appropriately planned deformity correction surgeries, complications, revision rates, and surgical outcomes significantly vary. This study aimed to illustrate the current clinical weaknesses of the assessment of spinal alignment and the importance of holistically approaching the musculoskeletal system for any spinal deformity surgery. We believe that our detailed insights regarding spinal, sagittal, and coronal alignments as well as the considerations of an individual’s spinal balance will contribute toward improvement in routine patient care.
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Affiliation(s)
- Matthias Pumberger
- Spine Department, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg School for Regenerative Therapies, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Hendrik Schmidt
- Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Putzier
- Spine Department, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Ailon T, Hamilton DK, Klineberg E, Daniels AH, Lafage V, Bess S, Burton DC, Gupta M, Schwab F, Ames CP, Smith JS, Shaffrey CI, Hart RA. Radiographic Fusion Grade Does Not Impact Health-Related Quality of Life in the Absence of Instrumentation Failure for Patients Undergoing Posterior Instrumented Fusion for Adult Spinal Deformity. World Neurosurg 2018; 117:e1-e7. [PMID: 29709744 DOI: 10.1016/j.wneu.2018.04.127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Pseudarthrosis and rod fracture (RF) remain significant concerns after fusion for adult spinal deformity (ASD). Although a radiographic system of fusion grade has been proposed, the correlation between fusion grade and health-related quality of life measures (HRQoL) is not known. METHODS In a retrospective review of a prospectively collected clinical database, patients that underwent ≥5-level posterior instrumented arthrodesis for ASD were evaluated. Fusion grade was determined on plain films using the Lenke criteria. Patients were grouped as 1) complete fusion (grade I or II at all levels), 2) incomplete fusion (grade 3 or 4 at any level), 3) rod fracture without revision (RF), and 4) rod fracture with revision (RFR). Outcome measures were the Oswestry Disability Index, Medical Outcomes Study 36-Item Short-Form Health Survey Physical and Mental Component Summaries, Scoliosis Research Society-22r total, and Lumbar Stiffness and Disability Index. RESULTS There were 205 (85%) patients who achieved the minimum 2-year follow-up and were included. Complete fusion was achieved in 115 patients (56.1%), 55% patients (26.8%) had incomplete fusion, and 35% patients (17.1%) had RF. Of the 35 patients with RF, 19 (17.1%; 19/205) underwent revision while 16 (7.8%; 16/205) had RF without revision. HRQoL measures were significantly worse in the RFR group, whereas no significant differences were found between groups 1, 2, and 3. CONCLUSIONS Radiographic fusion grade after ASD surgery did not significantly impact HRQoL in the absence of RF. RFR was associated with significantly worse clinical outcomes. Fusion grade may be less predictive of clinical outcomes than the occurrence of RF.
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Affiliation(s)
- Tamir Ailon
- Swedish Neurosciences Institute, Seattle, Washington, USA
| | | | - Erik Klineberg
- Swedish Neurosciences Institute, Seattle, Washington, USA
| | - Alan H Daniels
- Swedish Neurosciences Institute, Seattle, Washington, USA
| | | | - Shay Bess
- Swedish Neurosciences Institute, Seattle, Washington, USA
| | | | - Munish Gupta
- Swedish Neurosciences Institute, Seattle, Washington, USA
| | - Frank Schwab
- Swedish Neurosciences Institute, Seattle, Washington, USA
| | | | - Justin S Smith
- Swedish Neurosciences Institute, Seattle, Washington, USA
| | | | - Robert A Hart
- Swedish Neurosciences Institute, Seattle, Washington, USA.
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- Swedish Neurosciences Institute, Seattle, Washington, USA
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102 lumbar pedicle subtraction osteotomies: one surgeon’s learning curve. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:652-660. [DOI: 10.1007/s00586-018-5481-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/16/2018] [Indexed: 10/18/2022]
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Redaelli A, Berjano P, Aebi M. Focal disorders of the spine with compensatory deformities: how to define them. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:59-69. [PMID: 29383486 DOI: 10.1007/s00586-018-5501-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/22/2018] [Accepted: 01/24/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE In this paper, the authors propose classifying the epiphenomenon of spinal deformity in two different categories: structural deformity, when the main driver of the observed deformity is a fixed and stiff alteration of the spinal segments, and compensatory deformity, which includes cases where the observed deformity is due to focal abnormalities. This last category comprises, but is not limited to, spinal stenosis, spondylolisthesis, disc herniation, infection or tumor, hip disease or neurological disease (such as Parkinson's disease). METHOD Narrative review article. RESULTS We analyzed the focal diseases of the spine that may cause a compensatory deformity inducing adaptation in the unaffected part of the spine. CONCLUSION The compensatory mechanisms involved in adaptive deformity represent an attempt to maintain a global alignment, to escape from pain or to control body posture. These slides can be retrieved under Electronic Supplementary material.
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Affiliation(s)
- Andrea Redaelli
- IRCCS Istituto Ortopedico Galeazzi, Gspine4, via Riccardo Galeazzi 4, 20161, Milan, Italy.
| | - Pedro Berjano
- IRCCS Istituto Ortopedico Galeazzi, Gspine4, via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Max Aebi
- IRCCS Istituto Ortopedico Galeazzi, Gspine4, via Riccardo Galeazzi 4, 20161, Milan, Italy
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Ferrero E, Liabaud B, Henry JK, Ames CP, Kebaish K, Mundis GM, Hostin R, Gupta MC, Boachie-Adjei O, Smith JS, Hart RA, Obeid I, Diebo BG, Schwab FJ, Lafage V. Sagittal alignment and complications following lumbar 3-column osteotomy: does the level of resection matter? J Neurosurg Spine 2017; 27:560-569. [DOI: 10.3171/2017.3.spine16357] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThree-column osteotomy (3CO) is a demanding technique that is performed to correct sagittal spinal malalignment. However, the impact of the 3CO level on pelvic or truncal sagittal correction remains unclear. In this study, the authors assessed the impact of 3CO level and postoperative apex of lumbar lordosis on sagittal alignment correction, complications, and revisions.METHODSIn this retrospective study of a multicenter spinal deformity database, radiographic data were analyzed at baseline and at 1- and 2-year follow-up to quantify spinopelvic alignment, apex of lordosis, and resection angle. The impact of 3CO level and apex level of lumbar lordosis on the sagittal correction was assessed. Logistic regression analyses were performed, controlling for cofounders, to investigate the effects of 3CO level and apex level on intraoperative and postoperative complications as well as on the need for subsequent revision surgery.RESULTSA total of 468 patients were included (mean age 60.8 years, mean body mass index 28.1 kg/m2); 70% of patients were female. The average 3CO resection angle was 25.1° and did not significantly differ with regard to 3CO level. There were no significant correlations between the 3CO level and amount of sagittal vertical axis or pelvic tilt correction. The postoperative apex level significantly correlated with greater correction of pelvic tilt (2° per more caudal level, R = −0.2, p = 0.006). Lower-level 3CO significantly correlated with revisions for pseudarthrosis (OR = 3.88, p = 0.001) and postoperative motor deficits (OR = 2.02, p = 0.026).CONCLUSIONSIn this study, a more caudal lumbar 3CO level did not lead to greater sagittal vertical axis correction. The postoperative apex of lumbar lordosis significantly impacted pelvic tilt. 3CO levels that were more caudal were associated with more postoperative motor deficits and revisions.
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Affiliation(s)
- Emmanuelle Ferrero
- 1Hôpital Européen Georges-Pompidou, APHP, Paris V University, Paris, France
- 2Department of Orthopaedic Surgery, Spine Division, Hospital for Special Surgery, New York, New York
| | - Barthelemy Liabaud
- 2Department of Orthopaedic Surgery, Spine Division, Hospital for Special Surgery, New York, New York
| | - Jensen K. Henry
- 2Department of Orthopaedic Surgery, Spine Division, Hospital for Special Surgery, New York, New York
| | - Christopher P. Ames
- 3Department of Neurosurgery, University of California, San Francisco Medical Center, San Francisco, California
| | - Khaled Kebaish
- 4Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Munish C. Gupta
- 7Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | | | - Justin S. Smith
- 9Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert A. Hart
- 10Department of Orthopedic Surgery, University of Oregon Health Sciences Center, Portland, Oregon; and
| | - Ibrahim Obeid
- 11Centre Hospitalier Universitaire de Bordeaux, France
| | - Bassel G. Diebo
- 2Department of Orthopaedic Surgery, Spine Division, Hospital for Special Surgery, New York, New York
| | - Frank J. Schwab
- 2Department of Orthopaedic Surgery, Spine Division, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- 2Department of Orthopaedic Surgery, Spine Division, Hospital for Special Surgery, New York, New York
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Yilgor C, Sogunmez N, Boissiere L, Yavuz Y, Obeid I, Kleinstück F, Pérez-Grueso FJS, Acaroglu E, Haddad S, Mannion AF, Pellise F, Alanay A. Global Alignment and Proportion (GAP) Score: Development and Validation of a New Method of Analyzing Spinopelvic Alignment to Predict Mechanical Complications After Adult Spinal Deformity Surgery. J Bone Joint Surg Am 2017; 99:1661-1672. [PMID: 28976431 DOI: 10.2106/jbjs.16.01594] [Citation(s) in RCA: 395] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The restoration of normal sagittal alignment is a critical goal in adult spinal deformity surgery to achieve favorable outcomes and prevent mechanical complications. Schwab sagittal modifiers have been accepted as targets for appropriate alignment, but addressing these targets does not always prevent high mechanical complication or revision rates. This may be because the linear absolute numerical parameters do not cover the whole pelvic incidence spectrum and the distribution of lordosis, pelvic anteversion, and negative malalignment are not considered as potential causes of failure. The aim of the present study was to develop and validate a score based on pelvic-incidence-based proportional parameters to better predict mechanical complications. METHODS Two hundred and twenty-two patients (168 women and 54 men) followed for ≥2 years after posterior fusion at ≥4 levels were included in the study. The mean age (and standard deviation) was 52.2 ± 19.3 years (range, 18 to 84 years), and the mean duration of follow-up was 28.8 ± 8.2 months (range, 24 to 62 months). The global alignment and proportion (GAP) score was developed and validated in groups of patients randomly assigned to derivation (n = 148, 66.7%) and validation (n = 74, 33.3%) cohorts. GAP score parameters were relative pelvic version (the measured minus the ideal sacral slope), relative lumbar lordosis (the measured minus the ideal lumbar lordosis), lordosis distribution index (the L4-S1 lordosis divided by the L1-S1 lordosis multiplied by 100), relative spinopelvic alignment (the measured minus the ideal global tilt), and an age factor. Proximal and distal junctional kyphosis and/or failure, rod breakage, and other implant-related complications were considered mechanical complications. The predictive accuracy of the GAP score was analyzed using receiver operating characteristic (ROC) analyses. Associations between GAP categories and mechanical complications and revisions were analyzed using Cochran-Armitage tests. RESULTS In the validation cohort, 32 patients (43%) experienced mechanical complications and 17 (23%) underwent mechanical revision. The area under curve for the GAP score predicting mechanical complications was 0.92 (standard error [SE] = 0.034, p < 0.001, 95% [confidence interval [CI] = 0.85 to 0.98). Postoperatively, patients with a proportioned spinopelvic state according to the GAP score had a mechanical complication rate of 6% while those with a moderately or severely disproportioned spinopelvic state had rates of 47% and 95%, respectively. CONCLUSIONS The GAP score is a new pelvic-incidence-based proportional method of analyzing the sagittal plane that predicts mechanical complications in patients undergoing surgery for adult spinal deformity. Setting surgical goals according to the GAP score may decrease the prevalence of mechanical complications.
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Affiliation(s)
- Caglar Yilgor
- 1Department of Orthopedics and Traumatology, Acibadem University, Istanbul, Turkey 2Spine Research Unit, Comprehensive Spine Center, Acibadem Maslak Hospital, Istanbul, Turkey 3Spine Surgery Unit, Bordeaux University Hospital, Bordeaux, France 4Department of Biostatistics, Ankara University, Ankara, Turkey 5Spine Center Division, Department of Orthopedics and Neurosurgery (F.K.), and Spine Center Division, Department of Research and Development (A.F.M.), Schulthess Klinik, Zurich, Switzerland 6Spine Surgery Unit, Hospital Universitario La Paz, Madrid, Spain 7Ankara ARTES Spine Center, Ankara, Turkey 8Spine Surgery Unit, Hospital Vall d'Hebron, Barcelona, Spain
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Ramieri A, Miscusi M, Domenicucci M, Raco A, Costanzo G. Surgical management of coronal and sagittal imbalance of the spine without PSO: a multicentric cohort study on compensated adult degenerative deformities. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:442-449. [PMID: 28303383 DOI: 10.1007/s00586-017-5042-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Sagittal imbalance of severe adult degenerative deformities requires surgical correction to improve pain, mobility and quality of life. Our aim was a harmonic and balanced spine, treating a series of adult degenerative thoracolumbar and lumbar kyphoscoliosis by a non posterior subtraction osteotomy technique. METHODS We operated 22 painful thoracolumbar and lumbar compensated degenerative deformities by anterior (ALIF), extreme lateral (XLIF) and transforaminal (TLIF) interbody fusion and grade 2 osteotomy (SPO) to restore lumbar lordosis and mobilize the coronal curve. Two-stage surgery, first anterior and after 2 or 3 weeks posterior, was proposed when the Oswestry Disability Index (ODI) was equal to or greater than 50% and VAS more than 5. All patients were submitted to X-ray and clinical screening during pre, post-operative and follow-up periods. RESULTS We performed 5 ALIFs, 39 XLIFs, 8 TLIFs, 32 SPOs. No major complications were recorded and complication rate was 18% after lateral fusion and 22.7% after posterior approach. Pelvic tilt, lumbar lordosis, sagittal vertical axis and thoracic kyphosis improved (p < 0.05). Clinical follow-up (mean 20.5; range 18-24) was satisfactory in all cases, except for two due to sacroiliac pain. Mean preoperative VAS was 7.7 (range 6-10), while ODI was 67% on average (range 50-78). After two-stage surgery, VAS and ODI decreased, respectively, to 2.4 (range 2-4) and 31% (range 25-45), while their values were 4 (range 2-6) and 35% (range 20-55) at the final follow-up. CONCLUSION Current follow-up does not allow definitive conclusions. However, the surgical approach adopted in this study seems promising, improving balance and clinical condition of adult patients with a compensated sagittal degenerative imbalance of the thoracolumbar spine.
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Affiliation(s)
- Alessandro Ramieri
- Orthopaedics, Don Gnocchi Foundation, ONLUS, Milan, Italy.
- , Via M. Caviglia, 30, Rome, Italy.
| | | | - Maurizio Domenicucci
- Department Neurology and Psychiatry, Neurosurgery, Sapienza Rome University, Rome, Italy
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Seki S, Hirano N, Kawaguchi Y, Nakano M, Yasuda T, Suzuki K, Watanabe K, Makino H, Kanamori M, Kimura T. Teriparatide versus low-dose bisphosphonates before and after surgery for adult spinal deformity in female Japanese patients with osteoporosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2121-2127. [PMID: 28116510 DOI: 10.1007/s00586-017-4959-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 12/08/2016] [Accepted: 01/15/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Complications of adult spinal deformity surgery are problematic in osteoporotic individuals. We compared outcomes between Japanese patients treated perioperatively with teriparatide vs. low-dose bisphosphonates. METHODS Fifty-eight osteoporotic adult Japanese female patients were enrolled and assigned to perioperative teriparatide (33 patients) and bisphosphonate (25 patients) groups in non-blinded fashion. Pre- and post-operative X-ray and computed tomography imaging were used to assess outcome, and rates were compared between the groups and according to age. Pain scores and Oswestry Disability Indices (ODI) were calculated before and 2 years after surgery. RESULTS Adjacent vertebral fractures and implant failure, fusion failure, and poor pain and ODI outcomes were significantly more common in the bisphosphonates group than the teriparatide group. CONCLUSIONS Perioperative administration of teriparatide is more effective than that of low-dose bisphosphonates in preventing complications and maintaining fusion rates in osteoporotic Japanese females with spinal deformities undergoing surgery.
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Affiliation(s)
- Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
| | - Norikazu Hirano
- Department of Orthopaedic Surgery, Toyama Rosai Hospital, Toyama, 937-0042, Japan
| | - Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Masato Nakano
- Department of Orthopaedic Surgery, Takaoka City Hospital, Toyama, 933-8550, Japan
| | - Taketoshi Yasuda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Kayo Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Kenta Watanabe
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Hiroto Makino
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Masahiko Kanamori
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Tomoatsu Kimura
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
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Novel Index to Quantify the Risk of Surgery in the Setting of Adult Spinal Deformity: A Study on 10,912 Patients From the Nationwide Inpatient Sample. Clin Spine Surg 2017; 30:E993-E999. [PMID: 28169941 DOI: 10.1097/bsd.0000000000000509] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective review of the Nationwide Inpatient Sample from 2001 to 2010, a prospectively collected national database. OBJECTIVE Structure an index to quantify adult spinal deformity (ASD) surgical risk based on risk factors for medical complications, surgical complications, revisions (R), mortality (M) rates, and length of hospital stay. SUMMARY OF BACKGROUND DATA Evidence supporting ASD surgery cost-effectiveness and anticipating surgical risk is critical to evaluate the risk/benefit balance of such treatment for patients. MATERIALS AND METHODS Discharges ages 25+, 4+ levels fused, diagnoses specific for scoliosis, and refusions. Five multivariate models determined independent risk factors that increased the risk of ≥1 for medical complications, surgical complications, R, M, and length of hospital stay. Models controlled for age, sex, race, revision status, surgical approach, levels fused, and osteotomy utilization. Odds ratios (ORs) were weighted using Nationwide Inpatient Sample weight files and based on their predictive category: 2 times for revision predictors and 4 times for mortality predictors. Predictors with OR≥1.5 were considered clinically relevant. Fifty points were distributed among the predictors based on their accumulative OR to establish a risk index. RESULTS A total of 10,912 ASD discharges were identified (mean age: 62 y; 73% females; 14% revision cases). The structured risk index incorporated the following factors based on accumulative ORs: pulmonary circulation disorder (42.05), drug abuse (21.86), congestive heart failure (15.25), neurological disorder (17.31), alcohol abuse (13.24), renal failure (11.64), age>65 (12.28), coagulopathy (11.65), level +9 (6.7), revision (3.35), and osteotomy (3). These risk factors were scored: 14, 7, 5, 5, 4, 4, 4, 4, 2, 1, 1, respectively. Three risk thresholds were proposed: mild (0-10), moderate (10-20), severe >20/50 points. CONCLUSIONS This study proposes an index to quantify the possible risk of morbidity before ASD surgery that will help patients, health insurance companies, and socioeconomic studies in assessing surgical risk/benefits. LEVEL OF EVIDENCE Level III.
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After 9 Years of 3-Column Osteotomies, Are We Doing Better? Performance Curve Analysis of 573 Surgeries With 2-Year Follow-up. Neurosurgery 2017; 83:69-75. [DOI: 10.1093/neuros/nyx338] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/16/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
In spinal deformity treatment, the increased utilization of 3-column (3CO) osteotomies reflects greater comfort and better training among surgeons. This study aims to evaluate the longitudinal performance and adverse events (complications or revisions) for a multicenter group following a decade of 3CO.
OBJECTIVE
To investigate if performance of 3CO surgeries improves with years of practice.
METHODS
Patients who underwent 3CO for spinal deformity with intra/postoperative and revision data collected up to 2 yr were included. Patients were chronologically divided into 4 even groups. Demographics, baseline deformity/correction, and surgical metrics were compared using Student t-test. Postoperative and revision rates were compared using Chi-square analysis.
RESULTS
Five hundred seventy-three patients were stratified into: G1 (n = 143, 2004-2008), G2 (n = 142, 2008-2009), G3 (n = 144, 2009-2010), G4 (n = 144 2010-2013). The most recent patients were more disabled by Oswestry disability index (G4 = 49.2 vs G1 = 38.3, P = .001), and received a larger osteotomy resection (G4 = 26° vs G1 = 20°, P = .011) than the earliest group. There was a decrease in revision rate (45%, 35%, 33%, 30%, P = .039), notably in revisions for pseudarthrosis (16.7% G1 vs 6.9% G4, P = .007). Major complication rates also decreased (57%, 50%, 46%, 39%, P = .023) as did excessive blood loss (>4 L, 27.2 vs 16.7%, P = .023) and bladder/bowel deficit (4.2% vs 0.7% P = .002). Successful outcomes (no complications or revision) significantly increased (P = .001).
CONCLUSION
Over 9 yr, 3COs are being performed on an increasingly disabled population while gaining a greater correction at the osteotomy site. Revisions and complication rate decreased while success rate improved during the 2-yr follow-up period.
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Radiographic Predictors for Mechanical Failure After Adult Spinal Deformity Surgery: A Retrospective Cohort Study in 138 Patients. Spine (Phila Pa 1976) 2017; 42:E855-E863. [PMID: 27879571 DOI: 10.1097/brs.0000000000001996] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study at a single institution. OBJECTIVE We aimed at estimating the rate of revision procedures and identify radiographic predictors of mechanical failure after adult spinal deformity surgery. SUMMARY OF BACKGROUND DATA Mechanical failure rates after adult spinal deformity surgery range 12% to 37% in literature. Although the importance of spinal and spino-pelvic alignment is well documented for surgical outcome and ideal alignment has been proposed as sagittal vertical axis (SVA) < 5 cm, pelvic tilt < 20° and lumbar lordosis (LL) = pelvic incidence ± 9°, the role of radiographic sagittal spine parameters and alignment targets as predictors for mechanical failure remains uncertain. METHODS A consecutive cohort of adult spinal deformity patients who underwent corrective surgery with at least 5 levels of instrumentation between January 2008 and December 2012 at a single tertiary spine unit were followed for at least 2 years. Time to death or failure was recorded and cause-specific Cox regressions were applied to evaluate predictors for mechanical failure or death. RESULTS A total of 138 patients with median age of 61 years were included for analysis. Follow up ranged 2.1 to 6.8 years. In total 47% had revision and estimated failure rates were 16% at 1 year increasing to 56% at 5 years. A multivariate analysis adjusting for age at surgery showed increased hazard of failure from LL change > 30°, postoperative TK > 50°, and SS ≤30°. LL change was mostly because of 3-column osteotomy and ending the instrumentation at L5 or S1 increased the hazard of failure more than 6 fold compared with more cranial lumbar levels. CONCLUSION Mechanical failure rate was 47% after adult spinal deformity corrective surgery. LL change > 30°, postoperative TK > 50°, and postoperative SS ≤30° were independent radiographic predictors associated with increased hazard of failure. LEVEL OF EVIDENCE 4.
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Bao H, Yan P, Qiu Y, Liu Z, Zhu F. Coronal imbalance in degenerative lumbar scoliosis: Prevalence and influence on surgical decision-making for spinal osteotomy. Bone Joint J 2017; 98-B:1227-33. [PMID: 27587525 DOI: 10.1302/0301-620x.98b9.37273] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 05/06/2016] [Indexed: 11/05/2022]
Abstract
AIMS There is a paucity of information on the pre-operative coronal imbalance in patients with degenerative lumbar scoliosis (DLS) and its influence on surgical outcomes. PATIENTS AND METHODS A total of 284 DLS patients were recruited into this study, among whom 69 patients were treated surgically and the remaining 215 patients conservatively Patients were classified based on the coronal balance distance (CBD): Type A, CBD < 3 cm; Type B, CBD > 3 cm and C7 Plumb Line (C7PL) shifted to the concave side of the curve; Type C, CBD > 3 cm and C7PL shifted to the convex side. RESULTS A total of 99 of the 284 (34.8%) patient presented with a pre-operative coronal imbalance (mean CBD: 48.5, standard deviation 18.7 mm). More patients with a Type B malalignment were observed than with a Type C malalignment (62 versus 37). A total of 21 pf the 69 (30.4%) surgically treated patients had a post-operative coronal imbalance, which was found to be more prevalent in Type C patients (p < 0.001). At follow-up, less improvement was observed in terms of Short Form-36 Physical Component Score and visual analogue score for back pain (p = 0.034 and 0.025, respectively) in Type C patients. CONCLUSION This study shows that patients with Type C coronal malalignment may be at greater risk of post-operative coronal imbalance following posterior osteotomy. Cite this article: Bone Joint J 2016;98-B:1227-33.
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Affiliation(s)
- H Bao
- Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - P Yan
- Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Y Qiu
- Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - Z Liu
- Nanjing Drum Tower Hospital, 321 Zhongshan Road, Nanjing, 210008, China
| | - F Zhu
- Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong, China
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Scheer JK, Osorio JA, Smith JS, Schwab F, Lafage V, Hart RA, Bess S, Line B, Diebo BG, Protopsaltis TS, Jain A, Ailon T, Burton DC, Shaffrey CI, Klineberg E, Ames CP. Development of Validated Computer-based Preoperative Predictive Model for Proximal Junction Failure (PJF) or Clinically Significant PJK With 86% Accuracy Based on 510 ASD Patients With 2-year Follow-up. Spine (Phila Pa 1976) 2016; 41:E1328-E1335. [PMID: 27831987 DOI: 10.1097/brs.0000000000001598] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective review of large, multicenter adult spinal deformity (ASD) database. OBJECTIVE The aim of this study was to build a model based on baseline demographic, radiographic, and surgical factors that can predict clinically significant proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). SUMMARY OF BACKGROUND DATA PJF and PJK are significant complications and it remains unclear what are the specific drivers behind the development of either. There exists no predictive model that could potentially aid in the clinical decision making for adult patients undergoing deformity correction. METHODS Inclusion criteria: age ≥18 years, ASD, at least four levels fused. Variables included in the model were demographics, primary/revision, use of three-column osteotomy, upper-most instrumented vertebra (UIV)/lower-most instrumented vertebra (LIV) levels and UIV implant type (screw, hooks), number of levels fused, and baseline sagittal radiographs [pelvic tilt (PT), pelvic incidence and lumbar lordosis (PI-LL), thoracic kyphosis (TK), and sagittal vertical axis (SVA)]. PJK was defined as an increase from baseline of proximal junctional angle ≥20° with concomitant deterioration of at least one SRS-Schwab sagittal modifier grade from 6 weeks postop. PJF was defined as requiring revision for PJK. An ensemble of decision trees were constructed using the C5.0 algorithm with five different bootstrapped models, and internally validated via a 70 : 30 data split for training and testing. Accuracy and the area under a receiver operator characteristic curve (AUC) were calculated. RESULTS Five hundred ten patients were included, with 357 for model training and 153 as testing targets (PJF: 37, PJK: 102). The overall model accuracy was 86.3% with an AUC of 0.89 indicating a good model fit. The seven strongest (importance ≥0.95) predictors were age, LIV, pre-operative SVA, UIV implant type, UIV, pre-operative PT, and pre-operative PI-LL. CONCLUSION A successful model (86% accuracy, 0.89 AUC) was built predicting either PJF or clinically significant PJK. This model can set the groundwork for preop point of care decision making, risk stratification, and need for prophylactic strategies for patients undergoing ASD surgery. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Justin K Scheer
- University of California, San Diego, School of Medicine, La Jolla, CA
| | - Joseph A Osorio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | - Frank Schwab
- Spine Service, Hospital for Special Surgery, New York, NY
| | | | - Robert A Hart
- Department of Orthopaedic Surgery, Oregon Health & Science University, Portland, OR
| | - Shay Bess
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Breton Line
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Bassel G Diebo
- Spine Service, Hospital for Special Surgery, New York, NY
| | | | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD
| | - Tamir Ailon
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS
| | | | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
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Buckland AJ, Vira S, Oren JH, Lafage R, Harris BY, Spiegel MA, Diebo BG, Liabaud B, Protopsaltis TS, Schwab FJ, Lafage V, Errico TJ, Bendo JA. When is compensation for lumbar spinal stenosis a clinical sagittal plane deformity? Spine J 2016; 16:971-81. [PMID: 27063925 DOI: 10.1016/j.spinee.2016.03.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 02/05/2016] [Accepted: 03/31/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Degenerative lumbar stenosis (DLS) patients have been reported to lean forward in an attempt to provide neural decompression. Spinal alignment in patients with DLS may resemble that of adult spinal deformity (ASD). No previous studies have compared and contrasted the compensatory mechanisms of DLS and ASD patients. PURPOSE This study aimed to determine the differences in compensatory mechanisms between DLS and ASD patients with increasing severity of sagittal spinopelvic malalignment. Contrasting these compensatory mechanisms may help determine at what severity sagittal malalignment represents a clinical sagittal deformity rather than a compensation for neural compression. STUDY DESIGN/SETTING This is a retrospective clinical and radiological review. PATIENT SAMPLE Baseline x-rays in patients without spinal instrumentation, with the clinical radiological and diagnoses of DLS or ASD, were assessed for patterns of spinopelvic compensatory mechanisms. Patients were stratified by sagittal vertical axis (SVA) according to the Scoliosis Research Society-Schwab [SRS-Schwab] classification. OUTCOME MEASURES Radiographic spinopelvic parameters were measured in the DLS and ASD groups, including SVA, pelvic incidence-lumbar lordosis mismatch (PI-LL), T1 spinopelvic inclination (T1SPi), T1 pelvic angle (TPA), and pelvic tilt (PT). METHODS The two diagnosis cohorts were propensity-matched for PI and age. Each group contained 125 patients and was stratified according to the SRS-Schwab classification. Regional spinopelvic,lower limb, and global alignment parameters were assessed to identify differences in compensatory mechanisms between the two groups with differing degrees of deformity. No funding was provided by any third party in relation to carrying out this study or preparing the manuscript. RESULTS With mild to moderate malalignment (SRS-Schwab groups "0," or "+" for PT, PI-LL, or SVA), DLS patients permit anterior truncal inclination and recruit posterior pelvic shift instead of pelvic tilt to maintain balance, while providing relief of neurologic symptoms. Adult spinal deformity patients with mild to moderate deformity recruit pelvic tilt earlier than DLS patients. With moderate to severe malalignment, no significant difference was found in compensatory mechanisms between DLS and ASD patients. CONCLUSIONS Patients with DLS permit mild to moderate deformity without recruiting compensatory mechanisms of PT, reducing truncal inclination and thoracic hypokyphosis to achieve neural decompression. However, with moderate to severe deformity, their desire for upright posture overrides the desire for neural decompression, evident by the adaptation of compensatory mechanisms similar to that of ASD patients.
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Affiliation(s)
- Aaron J Buckland
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA.
| | - Shaleen Vira
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Jonathan H Oren
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Renaud Lafage
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Bradley Y Harris
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Matthew A Spiegel
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Barthelemy Liabaud
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Themistocles S Protopsaltis
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Frank J Schwab
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Virginie Lafage
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - Thomas J Errico
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
| | - John A Bendo
- Department of Orthopaedic Surgery, New York University Langone Medical Center, c/- Spine Research Center, 306 E. 15th St, New York, NY 10003, USA
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Ferrero E, Simon AL, Magrino B, Ould-Slimane M, Guigui P. Double-level degenerative spondylolisthesis: what is different in the sagittal plane? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:2546-52. [DOI: 10.1007/s00586-016-4384-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 01/08/2016] [Accepted: 01/10/2016] [Indexed: 10/22/2022]
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Teli MGA. Importance of balance and profile in adult spinal reconstruction. World J Orthop 2015; 6:413-415. [PMID: 26085982 PMCID: PMC4458491 DOI: 10.5312/wjo.v6.i5.413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/21/2015] [Accepted: 05/06/2015] [Indexed: 02/06/2023] Open
Abstract
Long before its current understanding, the concept of balance was common among spine surgeons dealing with deformities, but it was a hard one to transfer to clinical practice. Thanks to the pioneering work of Duval-Beaupere and followers, the idea of balancing the sagittal contour of the spine has gained scientific status and is now in the armamentarium of the skilled surgeon as the single most important tool to achieve superior clinical results in adult spinal deformity surgery.
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Unanticipated revision surgery in adult spinal deformity: an experience with 815 cases at one institution. Spine (Phila Pa 1976) 2014; 39:B36-44. [PMID: 24979146 DOI: 10.1097/brs.0000000000000463] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE This study reviewed the overall prevalence and indications of revision surgical procedures for adult scoliosis in a single institution. In this largest single-institution series, revision surgery in adult scoliosis was required for a relatively low proportion of cases (7.61%). The main indications were implant breakage, deformity progression, and infection. SUMMARY OF BACKGROUND DATA Spine fusion is considered as the final therapeutic intervention in the management of adult scoliosis. However, reports on the repeat surgical intervention of adult scoliosis predate the use of advanced instrumentation systems. METHODS The scoliosis database of our center was searched, and all cases with index spinal fusion surgical procedures performed for adult scoliosis from 1998 to 2011 with the follow-up period of more than 2 years were identified. The clinical data and radiographs of patients were reviewed to provide information on the indication of initial operation and any subsequent revision surgery. A total of 815 patients were identified, with a mean age of 30.49 years (range, 20-76 yr). The mean follow-up periods were 6.4 years (range, 2-15 yr) for the entire cohort and 7.6 years (range, 2.5-12 yr) for the subset of the cohort requiring revision. RESULTS The patients exhibiting multiple reasons for revision were classified under primary reason and subjected to subsequent analysis. Among the 815 patients, 62 (7.61%) underwent at least 1 revision surgery. The most common reasons for revision were implant breakage (23/62; 37.1%), deformity progression (10/62; 16.1%), and infection (9/62; 14.5%). The other indications were pseudarthrosis (n = 8), implant dislodgement (n = 6), junctional kyphosis (n = 5), and neurological deficit (n = 1). Revision rate was significantly higher in patients older than 40 years (15.23% vs. 5.87%), in patients with degenerative or congenital scoliosis (15.12% vs. 12.82%), or in patients with hybrid constructs (12.12% vs. 5.82%). CONCLUSION In this largest single-institution series, revision surgery after index spinal fusion in patients with adult scoliosis was required for a relatively low proportion of surgical cases (7.61%). The main indications for revision were implant breakage, deformity progression, and infection.
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Diebo BG, Henry J, Lafage V, Berjano P. Sagittal deformities of the spine: factors influencing the outcomes and complications. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24 Suppl 1:S3-15. [DOI: 10.1007/s00586-014-3653-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 11/01/2014] [Accepted: 11/01/2014] [Indexed: 10/24/2022]
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