[Show abstract][Hide abstract] ABSTRACT: Study design:
Measurement reliability study of adult spinal deformity (ASD) patient radiographs using intra-class coefficients (ICC) and variance.
To compare picture archiving and communication systems (PACS) to dedicated spine measurement software (SMS).
Summary of background data:
Accurate radiographic measurement of sagittal alignment is essential for evaluating ASD. PACS measurements often necessitate rudimentary techniques and estimations of anatomic landmarks and angles. Though SMS has been studied and validated, no studies directly compare PACS to SMS.
Eleven independent observers (7 spine surgeons, 4 researchers) digitally measured 20 ASD radiographs for pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), PI-LL, thoracic kyphosis (TK), and sagittal vertical axis (SVA). Round 1 used PACS basic line/angle tools; Round 2 used a validated SMS that automatically calculates spino-pelvic parameters from 6 user-identified landmarks. Means, coefficient of variance (CV) and intra-class correlation coefficients (ICC) were analyzed.
PACS measurements were significantly greater than SMS (PI, PT, PI-LL: P < 0.0001), though within clinical and measurement margins of error. Excluding TK, the variations in measurement (CV) were significantly greater for PACS (14-34%) vs. SMS (11-23%). Reliability was greater in SMS than PACS for PI, PT, PI-LL, LL, and SVA. The greatest differences in ICC between PACS and SMS were in PI (PACS: 0.647; SMS: 0.810) and PI-LL (PACS: 0.921; SMS: 0.970). Among surgeons, the differences between PACS and SMS were augmented, and SMS had higher ICC than PACS for all parameters (mean ICC 0.931 vs. 0.861). Among surgeons, PI had the lowest reliability (PACS: 0.505; SMS: 0.752) and SVA had the highest (PACS: 0.985; SMS: 0.994).
SMS provides significantly more reliable measurements than PACS, especially among surgeons. Consistent use of SMS in the evaluation and surgical planning of ASD patients appears necessary given the significant differences in values, variance, and reliability between PACS and SMS.
[Show abstract][Hide abstract] ABSTRACT: Background context:
Adult spinal deformity (ASD) patients may gain a MCID in one or more of the HRQOL instruments without surgical intervention. This study identifies baseline characteristics of this subset of non-operative patients and proposes predictors of those most likely to benefit.
Determine factors that affect likelihood of non-operative patients to reach minimum clinically important difference (MCID).
Retrospective review of prospective, multi-center database.
Non-operative ASD patients.
Health-related quality of life measures (HRQOL), including the Scoliosis Research Society (SRS)-22 questionnaire.
Multicenter database of 215 non-operative patients with ASD and minimum 2-year follow-up. Using a multivariate analysis, two groups were compared to identify possible predictors: those that reached an MCID in SRS Pain or Activity (n=86) at 2 years, and those who did not reach MCID (n=129). Subgroup multivariate analysis of patients with a deficit (potential improvement) in both SRS Pain and Activity (n=84) was performed. Data collection was supported by a grant from Depuy for the International Spine Study Group Foundation.
At baseline, the non-operative patients that reached MCID had a significantly lower SRS Pain score (3.0 vs 3.6), smaller thoracolumbar (TL) Cobb angle (29.6° vs. 36.5°; 87 patients with SRS-Schwab classification Lumbar or Double), sacral slope (33.1° vs. 36.4°), and less lumbar lordosis (46.5° vs. 52.8°) (all P<0.05). SRS Pain and TL Cobb were significant predictors of reaching MCID. PI-LL was significant on univariate analysis but not by multivariate (7.5° vs. 2.6°; P=0.14). In the subset of severely disabled patients, worse vertebral obliquity was a predictor for not achieving MCID (P<0.05).
Non-operative ASD patients who achieved an MCID in SRS Activity or Pain had a lower baseline SRS Pain Score and less coronal deformity in the TL region. Greater baseline pain offers significant room for potential improvement, which may be important in identifying ASD patients who have the potential to reach an MCID non-operatively. Coronal deformities in the TL region, and associated vertebral obliquity may negatively impact improvement potential with non-operative care.
The spine journal: official journal of the North American Spine Society 11/2015; DOI:10.1016/j.spinee.2015.10.043 · 2.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: STUDY DESIGN:
Retrospective review of a prospectively collected database.
This study compares patient demographics, incidence of comorbidities, procedure-related complications, and mortality following primary vs. revision adult spinal deformity surgerySummary of Background Data. While adult spinal deformity (ASD) surgery has been extensively investigated, no previous study has provided nationwide estimates of patient characteristics and procedure-related complications for primary vs. revision spinal deformity surgery comparatively.
Nationwide Inpatient Sample data collected between 2001 and 2010 was analyzed. Discharges with procedural codes for anterior and/or posterior thoracic and/or lumbar spinal fusion and refusion were included for patients aged 25+ and 4+ levels fused with any diagnoses specific for scoliosis. Patient demographics, comorbidity and procedure-related complications incidence were determined for primary vs. revision cohorts. Multivariate analysis reported as (OR [95% CI]).
Discharges for 9133 primary and 850 revision cases were identified. Patients differed on the basis of demographic and hospital data. Average comorbidity indices for the cohorts were similar (p = 0.580), as was in-hospital mortality (p = 0.163). The incidence of procedure-related complications was higher for the revision cohort (46.96% vs. 71.97%, p = 0.001). The mean hospital course for the revision cohort was longer (6.37 vs. 7.13 days, p<0.0001). Revisions had an increased risk of complications involving the nervous system (1.34[1.10-1.6]), hematoma/seroma formation (2.31[1.92-2.78]), accidental vessel or nerve puncture (1.44[1.29-1.61]), wound dehiscence (2.18[1.48-3.21]), post-op infection (3.10[2.50-3.85]) and ARDS complications (1.43[1.28-1.60]). The primary cohort had a decreased risk for GI (0.65[0.55-0.76]) and GU complications (0.71[0.51-0.99]).
Relative to primary cases, those undergoing revision correction of spinal deformity have a higher risk of many procedure-related complications with a longer hospital course despite similar baseline comorbidity burden and in-hospital mortality rate. This study provides clinically useful data for surgeons to educate patients at risk for morbidity and mortality and direct future research to improve outcomes.
[Show abstract][Hide abstract] ABSTRACT: Background:
Few reports have focused on treatment of adult cervical deformity (ACD).
To present early complication rates associated with ACD surgery.
A prospective multicenter database of consecutive operative ACD patients was reviewed for early (≤30 days from surgery) complications. Enrollment required at least 1 of the following: cervical kyphosis >10 degrees, cervical scoliosis >10 degrees, C2-7 sagittal vertical axis >4 cm, or chin-brow vertical angle >25 degrees.
Seventy-eight patients underwent surgical treatment for ACD (mean age, 60.8 years). Surgical approaches included anterior-only (14%), posterior-only (49%), anterior-posterior (35%), and posterior-anterior-posterior (3%). Mean numbers of fused anterior and posterior vertebral levels were 4.7 and 9.4, respectively. A total of 52 early complications were reported, including 26 minor and 26 major. Twenty-two (28.2%) patients had at least 1 minor complication, and 19 (24.4%) had at least 1 major complication. Overall, 34 (43.6%) patients had at least 1 complication. The most common complications included dysphagia (11.5%), deep wound infection (6.4%), new C5 motor deficit (6.4%), and respiratory failure (5.1%). One (1.3%) mortality occurred. Early complication rates differed significantly by surgical approach: anterior-only (27.3%), posterior-only (68.4%), and anterior-posterior/posterior-anterior-posterior (79.3%) (P = .007).
This report provides benchmark rates for overall and specific ACD surgery complications. Although the surgical approach(es) used were likely driven by the type and complexity of deformity, there were significantly higher complication rates associated with combined and posterior-only approaches compared with anterior-only approaches. These findings may prove useful in treatment planning, patient counseling, and ongoing efforts to improve safety of care.
3CO, 3-column osteotomiesACD, adult cervical deformityEBL, estimated blood lossISSG, International Spine Study groupSVA, sagittal vertical axis.
[Show abstract][Hide abstract] ABSTRACT: Background:
HGS is a severe deformity most commonly affecting L5-S1 vertebral segment. Treatment available for HGS includes a range of different surgical options: full or partial reduction of translation and/or abnormal alignment and in situ fusion with or without decompression. Various instrumented or non-instrumented constructs are available, and surgical approach varies from anterior/posterior to combined depending on surgeon preference and experience. The aim of this systematic review was to review the literature on lumbosacral high-grade spondylolisthesis (HGS), identify patients at risk for progression to higher-grade slip and evaluate various surgical strategies to report on complications and radiographic and clinical outcomes.
Systematic search of PubMed, Cochrane and Google Scholar for papers relevant to HGS was performed. 19 articles were included after title, abstract, and full-text review and grouped to analyze baseline radiographic parameters and the effect of surgical approach, instrumentation, reduction and decompression on patient radiographic and clinical outcomes.
There is a lack of high-quality studies pertaining to surgical treatment for HGS, and a majority of included papers were Level III or IV based on the JBJS Levels of Evidence Criteria.
Surgical treatment for HGS can vary depending on patient age. There is strong evidence of an association between increased pelvic incidence (PI) and presence of HGS and moderately strong evidence that patients with unbalanced pelvis can benefit from correction of lumbopelvic parameters with partial reduction. Surgeons need to weigh the benefits of fixing the deformity with the risks of potential complications, assessing patient satisfaction as well as their understanding of the possible complications. However, further research is necessary to make more definitive conclusions on surgical treatment guidelines for HGS.
Level of evidence:
International Journal of Spine Surgery 10/2015; 9. DOI:10.14444/2050
[Show abstract][Hide abstract] ABSTRACT: OBJECT A high prevalence of cervical deformity (CD) has been identified among adult patients with thoracolumbar spinal deformity undergoing surgical treatment. The clinical impact of this is uncertain. This study aimed to quantify the differences in patient-reported outcomes among patients with adult spinal deformity (ASD) based on presence of CD prior to treatment. METHODS A retrospective review was conducted of a multicenter prospective database of patients with ASD who underwent surgical treatment with 2-year follow-up. Patients were grouped by the presence of preoperative CD: 1) cervical positive sagittal malalignment (CPSM) C2-7 sagittal vertical axis ≥ 4 cm; 2) cervical kyphosis (CK) C2-7 angle > 0; 3) CPSM and CK (BOTH); and 4) no baseline CD (NONE). Health-related quality of life (HRQOL) scores included the Physical Component Summary and Mental Component Summary (PCS and MCS) scores of the 36-Item Short Form Health Survey (SF-36), Oswestry Disability Index (ODI), Scoliosis Research Society-22 questionnaire (SRS-22), and minimum clinically important difference (MCID) of these scores at 2 years. Standard radiographic measurements were conducted for cervical, thoracic, and thoracolumbar parameters. RESULTS One hundred eighty-two patients were included in this study: CPSM, 45; CK, 37; BOTH, 16; and NONE, 84. Patients with preoperative CD and those without had similar baseline thoracolumbar radiographic measurements and similar correction rates at 2 years. Patients with and without preoperative CD had similar baseline HRQOL and on average both groups experienced some HRQOL improvement. However, those with preoperative CPSM had significantly worse postoperative ODI, PCS, SRS-22 Activity, SRS-22 Appearance, SRS-22 Pain, SRS-22 Satisfaction, and SRS-22 Total score, and were less likely to meet MCID for ODI, PCS, SRS-22 Activity, and SRS-22 Pain scores with the following ORs and 95% CIs: ODI 0.19 (0.07-0.58), PCS 0.17 (0.06-0.47), SRS-22 Activity 0.23 (0.09-0.62), SRS-22 Pain 0.20 (0.08-0.53), and SRS-22 Appearance 0.34 (0.12-0.94). Preoperative CK did not have an effect on outcomes. Interestingly, despite correction of the thoracolumbar deformity, 53.3% and 51.4% of patients had persistent CPSM and persistent CK, respectively. CONCLUSIONS Patients with thoracolumbar deformity without preoperative CD are likely to have greater improvements in HRQOL after surgery than patients with concomitant preoperative CD. Cervical positive sagittal alignment in adult patients with thoracolumbar deformity is strongly associated with inferior outcomes and failure to reach MCID at 2-year follow-up despite having similar baseline HRQOL to patients without CD. This was the first study to assess the impact of concomitant preoperative cervical malalignment in adult patients with thoracolumbar deformity. These results can help surgeons educate patients at risk for inferior outcomes and direct future research to identify an etiology and improve patient outcomes. Investigation into the etiology of the baseline cervical malalignment may be warranted in patients who present with thoracolumbar deformity.
Journal of neurosurgery. Spine 09/2015; DOI:10.3171/2015.3.SPINE141098 · 2.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
Older age has been considered a relative contraindication to complex spinal procedures. Minimally invasive surgery (MIS) techniques to treat patients with adult spinal deformity (ASD) have emerged with the potential benefit of decreased approach-related morbidity.
To determine whether a minimal clinically important difference (MCID) could be achieved in patients aged ≥65 years with ASD who underwent MIS.
Multicenter database of patients who underwent MIS for ASD was queried. Outcome metrics assessed were ODI and VAS scores for back and leg pain. Based on published reports, MCID was defined as a positive change of 12.8 ODI, 1.2 VAS back pain, and 1.6 VAS leg pain.
Forty-two patients were identified. Mean age was 70.3 years, 31 (73.8%) were female. Preoperatively, mean CC, PT, pelvic incidence to lumbar lordosis (PI-LL) mismatch, and SVA were 35°, 24.6°, 14.2°, and 4.7 cm, respectively. Postoperatively, mean CC, PT, PI-LL, and SVA were 18°, 25.4°, 11.9°, and 4.9 cm, respectively. Mean 5.0 levels were treated posteriorly, and mean 4.0 interbody fusions were performed. Mean ODI improved from 47.1 to 25.1. Mean VAS back and leg pain scores improved from 6.8 and 5.9 to 2.7 and 2.7, respectively. Mean follow-up was 32.1 months. For ODI, 64.3% of patients achieved MCID. For VAS back and leg pain, 82.9% and 72.2%, respectively, reached MCID.
MCID represents the threshold where patients feel a meaningful clinical improvement has occurred. Our study results suggest that the majority of elderly patients with modest ASD can achieve MCID with MIS.
World Neurosurgery 09/2015; DOI:10.1016/j.wneu.2015.09.072 · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECT Lenke 1C curves are challenging to manage surgically due to the structural thoracic deformity and nonstructural lumbar curve. Selective thoracic fusion (STF) is considered the standard of care because it preserves motion of the lumbar segment, yet nonselective STF (NSTF) remains prevalent. This study aims to identify baseline patient characteristics that drive treatment and to compare postoperative outcomes for both procedures. METHODS Studies that compared baseline and postoperative demographic data, health-related quality of life (HRQL) questionnaires, and radiographic parameters of patients with Lenke 1C curves undergoing STF or NSTF were identified for meta-analysis. The effect measure is expressed as a mean difference (MD) with 95% CI. A positive MD signifies a greater STF value, or a mean increase within the group. RESULTS One prospective and 6 retrospective case-control studies with sample size of 488 patients (344 STF and 144 NSTF) were identified. Baseline age, sex, and HRQLs were equivalent, except for better scores in the STF group for the Scoliosis Appearance Questionnaire (SAQ): Unrelated to Deformity item (3.47 vs 3.88, p = 0.01) and the Spine Research Society questionnaire, Item 22: Pain (4.13 vs 3.92, p = 0.04). Radiographic findings were significantly worse in NSTF, as measured by the thoracolumbar/lumbar (TL/L) Cobb angle (MD: -4.29°, p < 0.01) and TL/L apical vertebral translation (AVT) (MD: -6.08, p < 0.01). Radiographic findings significantly improved in STF, as measured in the main thoracic (MT) Cobb angle (MD: -27.78°, p < 0.01), TL/L Cobb angle (MD: -16.24°, p < 0.01), MT:TL/L Cobb ratio (MD: -0.21, p < 0.01), coronal balance (MD: 0.47, p = 0.02), and thoracic kyphosis (MD: 7.87°, p < 0.01); and in NSTF in proximal thoracic (PT) Cobb angle (24° vs 14.1°, p < 0.01), MT Cobb angle (53.5° vs 20.5°, p < 0.01), and TL/L Cobb angle (41.6° vs 16.6°, p < 0.01). Postoperative TL/L Cobb angle (23.1° vs 16.6°, p < 0.01) was significantly higher in STF; but PT Cobb angle, MT Cobb angle, and MT:TL/L Cobb ratio are equivalent. CONCLUSIONS Patients with larger lumbar compensatory curves displaying a larger degree of coronal translation, as measured by the TL/L AVT, are more likely to undergo an NSTF. Contrary to established guidelines, larger MT curve magnitudes and MT:TL/L Cobb angle ratios have not been found to influence the decision to pursue a selective thoracic fusion. Although overall both STF and NSTF groups are found to have effective postoperative coronal balance, the STF group has only modest improvements in the lumbar curve position as determined by a relatively unchanged TL/L AVT. Furthermore, surgeons may prefer NSTF in patients who may have a worse overall perception of their spinal deformity as measured by HRQL measures of pain and desire for appearance change.
Journal of neurosurgery. Spine 08/2015; DOI:10.3171/2015.1.SPINE141020 · 2.38 Impact Factor