Robert A. Hart

Oregon Health and Science University, Portland, Oregon, United States

Are you Robert A. Hart?

Claim your profile

Publications (239)444.45 Total impact


  • No preview · Article · Oct 2015
  • Source

    Full-text · Conference Paper · Oct 2015

  • No preview · Article · Oct 2015
  • Source

    Full-text · Conference Paper · Oct 2015

  • No preview · Article · Oct 2015
  • Source

    Full-text · Conference Paper · Oct 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Few reports have focused on treatment of adult cervical deformity (ACD). Objective: To present early complication rates associated with ACD surgery. Methods: 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. Results: 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). Conclusion: 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. Abbreviations: 3CO, 3-column osteotomiesACD, adult cervical deformityEBL, estimated blood lossISSG, International Spine Study groupSVA, sagittal vertical axis.
    No preview · Article · Oct 2015 · Neurosurgery
  • Source

    Full-text · Conference Paper · Oct 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECT The goal of this study was to examine the effectiveness of preoperative autologous blood donation (PABD) in adult spinal deformity (ASD) surgery. METHODS Patients undergoing single-stay ASD reconstructions were identified in a multicenter database. Patients were divided into groups according to PABD (either PABD or NoPABD). Propensity weighting was used to create matched cohorts of PABD and NoPABD patients. Allogeneic (ALLO) exposure, autologous (AUTO) wastage (unused AUTO), and complication rates were compared between groups. RESULTS Four hundred twenty-eight patients were identified as meeting eligibility criteria. Sixty patients were treated with PABD, of whom 50 were matched to 50 patients who were not treated with PABD (NoPABD). Nearly one-third of patients in the PABD group (18/60, 30%) did not receive any autologous transfusion and donated blood was wasted. In 6 of these cases (6/60, 10%), patients received ALLO blood transfusions without AUTO. In 9 cases (9/60, 15%), patients received ALLO and AUTO blood transfusions. Overall rates of transfusion of any type were similar between groups (PABD 70% [42/60], NoPABD 75% [275/368], p = 0.438). Major and minor in-hospital complications were similar between groups (Major PABD 10% [6/60], NoPABD 12% [43/368], p = 0.537; Minor PABD 30% [18/60], NoPABD 24% [87/368], p = 0.499). When controlling for potential confounders, PABD patients were more likely to receive some transfusion (OR 15.1, 95% CI 2.1-106.7). No relationship between PABD and ALLO blood exposure was observed, however, refuting the concept that PABD is protective against ALLO blood exposure. In the matched cohorts, PABD patients were more likely to sustain a major perioperative cardiac complication (PABD 8/50 [16%], NoPABD 1/50 [2%], p = 0.046). No differences in rates of infection or wound-healing complications were observed between cohorts. CONCLUSIONS Preoperative autologous blood donation was associated with a higher probability of perioperative transfusions of any type in patients with ASD. No protective effect of PABD against ALLO blood exposure was observed, and no risk of perioperative infectious complications was observed in patients exposed to ALLO blood only. The benefit of PABD in patients with ASD remains undefined.
    No preview · Article · Sep 2015 · Journal of neurosurgery. Spine
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Study Design. A multicenter, prospective review of surgical patients with adult spine deformity. Objective. Assessment of the incidence, risk factor, and impact of radiographical and implant-related complications (RIC) on health-related quality of life measures. Summary of Background Data. This study provides assessment of the incidence of RIC in adult spinal deformity surgery and impact of these complications on need for reoperation. Risk factors for development of RIC are also assessed, as well as the impact of these complications on health-related quality of life (HRQOL) outcomes measures. Methods. A multicenter, prospective database of surgical patients with adult spinal deformity was reviewed. All patients with complete 2-year follow-up were included. HRQOL was measured using the Oswestry Disability Index, General Health Survey (36-Item Short Form Health Survey [SF-36]), and Scoliosis Research Society-22 (SRS-22r) at baseline, 6 weeks, 1 year, and 2 years postoperatively. Univariate testing was performed as appropriate. Multivariate logistic regression modeling was used to determine independent predictors of RIC. Multivariate repeated-measures mixed models were used to examine HRQOL, accounting for confounders. Results. A total of 245 patients met inclusion criteria. The incidence of RIC was 31.7% and 52.6% of those patients required reoperation. Rod breakage accounted for 47% of the implant-related complications, and proximal junctional kyphosis accounted for 54.5% of radiographical complications. Univariate analysis identified the following potential risk factors for RIC: weight, American Society of Anesthesiologists score, revision, stopping the fusion in the lower thoracic spine, worse SRS-Schwab classification modifiers (pelvic tilt++, pelvic incidence minus lumbar lordosis++, sagittal vertical axis++), higher T1 spinopelvic inclination, and higher T1 slope. Independent predictors of RIC as identified on multivariate logistic regression included American Society of Anesthesiologists (odds ratio: 1.75, P = 0.029) and sagittal vertical axis modifier ++ (odds ratio 3.43, P = 0.0001). The RIC and no RIC groups each experienced significant improvement over time, as measured on the Oswestry Disability Index (P = 0.0001), SF-36 (P = 0.0001), and SRS-22r (P = 0.0001). However, the rate of improvement over time was less for patients with RIC (SRS-22r P = 0.043, SF-36 P = 0.0001). Conclusion. This study identified that nearly one-third of patients undergoing adult spinal deformity surgery experienced a radiographical or implant-related complication, and that just more than one-half of these patients experiencing complication required a reoperation within 2 years of surgery. These complications significantly affected HRQOL measures. Baseline patient characteristics and parameters of the SRS-Schwab classification can be used to help identify those patients at greater risk.
    Full-text · Article · Sep 2015 · Spine
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: STUDY DESIGN: Retrospective review of a multicenter, prospective adult spinal deformity (ASD) database. OBJECTIVE: The objective was to evaluate the impact of stiffness on activities of daily living (ADL) after instrumented total lumbar fusions to the pelvis; specifically between patients with the upper-most instrumented vertebra (UIV) within the upper thoracic (UT) versus the thoracolumbar (TL) region. SUMMARY OF BACKGROUND DATA: The Lumbar Stiffness Disability Index (LSDI) has been validated and used in clinical studies as a self-reported outcomes tool; however, the impact of stiffness on the 10 specific ADLs comprising the LSDI has not been evaluated. METHODS: A retrospective comparison of prospectively collected pre- and 2-year minimum postoperative answers to the 10 questions comprising the LSDI among patients with ASD was conducted. Cohorts were defined based on the UIV as UT (T1-T6) or TL (T9-L1). RESULTS: 134 patients were included (UT:64, TL:70). Both groups had statistically similar changes in all individual LSDI scores at 2 years versus preoperative values (P > 0.05l) with the exception of questions #2 (Bend through your waist to put socks and shoes on) and #8 (bathe lower half of body) in which UT reported increased difficulty (P < 0.05). Both groups had statistically similar individual LSDI question scores with the exception of 2-year question #4 (hygiene after toileting) in which UT had a significantly worse score (P < 0.05). CONCLUSION: Patients with ASD undergoing instrumented total lumbar fusions to the ilium report limited changes from baseline in the ability to perform the 10 ADL functions of the LSDI and had limited differences in final scores regardless of whether the UIV was in the UT or TL region. Domains showing the greatest change from baseline involved dressing or bathing the lower half of the body among patients with UT. The only domain for which UT had greater impairment was in performing personal hygiene functions after toileting.
    Full-text · Article · Sep 2015 · Spine
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECT Despite the complexity of cervical spine deformity (CSD) and its significant impact on patient quality of life, there exists no comprehensive classification system. The objective of this study was to develop a novel classification system based on a modified Delphi approach and to characterize the intra- and interobserver reliability of this classification. METHODS Based on an extensive literature review and a modified Delphi approach with an expert panel, a CSD classification system was generated. The classification system included a deformity descriptor and 5 modifiers that incorporated sagittal, regional, and global spinopelvic alignment and neurological status. The descriptors included: “C,” “CT,” and “T” for primary cervical kyphotic deformities with an apex in the cervical spine, cervicothoracic junction, or thoracic spine, respectively; “S” for primary coronal deformity with a coronal Cobb angle ≥ 15°; and “CVJ” for primary craniovertebral junction deformity. The modifiers included C2–7 sagittal vertical axis (SVA), horizontal gaze (chin-brow to vertical angle [CBVA]), T1 slope (TS) minus C2–7 lordosis (TS–CL), myelopathy (modified Japanese Orthopaedic Association [mJOA] scale score), and the Scoliosis Research Society (SRS)-Schwab classification for thoracolumbar deformity. Application of the classification system requires the following: 1) full-length standing posteroanterior (PA) and lateral spine radiographs that include the cervical spine and femoral heads; 2) standing PA and lateral cervical spine radiographs; 3) completed and scored mJOA questionnaire; and 4) a clinical photograph or radiograph that includes the skull for measurement of the CBVA. A series of 10 CSD cases, broadly representative of the classification system, were selected and sufficient radiographic and clinical history to enable classification were assembled. A panel of spinal deformity surgeons was queried to classify each case twice, with a minimum of 1 intervening week. Inter- and intrarater reliability measures were based on calculations of Fleiss k coefficient values. RESULTS Twenty spinal deformity surgeons participated in this study. Interrater reliability (Fleiss k coefficients) for the deformity descriptor rounds 1 and 2 were 0.489 and 0.280, respectively, and mean intrarater reliability was 0.584. For the modifiers, including the SRS-Schwab components, the interrater (round 1/round 2) and intrarater reliabilities (Fleiss k coefficients) were: C2–7 SVA (0.338/0.412, 0.584), horizontal gaze (0.779/0.430, 0.768), TS-CL (0.721/0.567, 0.720), myelopathy (0.602/0.477, 0.746), SRS-Schwab curve type (0.590/0.433, 0.564), pelvic incidence-lumbar lordosis (0.554/0.386, 0.826), pelvic tilt (0.714/0.627, 0.633), and C7-S1 SVA (0.071/0.064, 0.233), respectively. The parameter with the poorest reliability was the C7–S1 SVA, which may have resulted from differences in interpretation of positive and negative measurements. CONCLUSIONS The proposed classification provides a mechanism to assess CSD within the framework of global spinopelvic malalignment and clinically relevant parameters. The intra- and interobserver reliabilities suggest moderate agreement and serve as the basis for subsequent improvement and study of the proposed classification.
    Full-text · Article · Aug 2015 · Journal of Neurosurgery Spine
  • [Show abstract] [Hide abstract]
    ABSTRACT: Various surgical factors affect the incidence of postoperative medical complications following elective spinal arthrodesis. Due to the inter-relatedness of these factors, it is difficult for clinicians to accurately risk stratify individual patients. Our goal was to develop a scoring system that predicts the rate of major medical complications in patients with significant preoperative medical comorbidities, as a function of the four perioperative parameters that are most closely associated with the invasiveness of the surgical intervention. Level 2, Prognostic Retrospective Study PATIENT SAMPLE: 281 patients with American Society of Anesthesiologists (ASA) scores 3-4 undergoing elective thoracic/lumbar spine fusion surgeries from 2007 - 2011 OUTCOME MEASURES: Physiologic risk factors, number of levels fused, complications, operative time, intraoperative fluids, estimate blood loss METHODS: Risk factors were recorded, and patients who suffered major medical complications within the 30-day postoperative period were identified. We used Chi-Square tests to identify factors that affect the medical complication rate. These factors were ranked and scored by quartiles. The quartile scores were combined to form a single composite score. We determined the major medical complication rate for each composite score, and divided the cohort into quartiles again based on score. A Pearson linear regression analysis was used to compare the incidence of complications to the score. No outside sources of funding were used for this study, and the authors acknowledge no potential conflicts of interest. The number of fused levels, operative time, volume of intraoperative fluids, and EBLinfluenced the complication rate of ASA 3-4 patients. The composite score was Powered by Editorial Manager® and Preprint Manager® from Aries Systems Corporation determined by the sum of the quartile ranking of these four factors. This score predicted the complication rate in a linear fashion ranging from 7.6% for the lowest risk group to 34.7% the highest group (r=0.998, p<0.001). The four factors, though not independent of one another, taken together proved to be strongly predictive of the major medical complication rate. This score can be used guide medical management of thoracic/lumbar spinal arthrodesis patients with pre-existing medical co-morbidities. Copyright © 2015 Elsevier Inc. All rights reserved.
    No preview · Article · Aug 2015 · The spine journal: official journal of the North American Spine Society
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Operative management of adult spinal deformity (ASD) repeatedly demonstrates improvements in health-related quality of life over nonoperative treatment. However, little is reported regarding the quality-adjusted life-year (QALY) improvements following surgical correction of ASD. The purpose of this study was to evaluate the QALY increases following the operative treatment of ASD compared with nonoperative treatment. Inclusion criteria: =18 years, ASD. Health utility values were calculated from SF-6D scores and used to calculate QALYs gained or lost at a minimum 2 years from the baseline utility value. A subanalysis was conducted on the available patients in the cohort with complete 1-, 2-, and 3-year SF-36 scores to establish a trend in QALY changes. Three hundred sixty-five operative (OP) and 469 nonoperative (NONOP) patients were eligible for 2-year follow-up, and 479 patients were included (OP: 258 (70.7%), NONOP: 221 (47.1%). OP had significantly worse health utility values (0.545 ± 0.118 vs 0.657 ± 0.114, P < .0001), and larger QALY gained (0.139 ± 0.253 vs -0.004 ± 0.209, P < .0001). OP had lower QALY at minimum 2 years (1.28 ± 0.330 vs 1.39 ± 0.374, P = .0014). One hundred seventy-nine patients (OP: 106, NONOP: 73) had complete 1-, 2-, and 3-year SF-36 scores and were included in the subanalysis. Of these patients, both groups had statistically similar mean QALYs at all time points (OP vs NONOP, P > .05): 1 year (0.648 ± 0.102 vs 0.645 ± 0.090), 2 year (1.32 ± 0.232 vs 1.27 ± 0.204), and 3 year (1.97 ± 0.379 vs 1.93 ± 0.303). OP patients had a significantly larger increase in QALYs (from baseline) at 1, 2, and 3 years compared with NONOP (Figure): 1 year (0.084 ± 0.113 vs 0.011 ± 0.086, P < .0001), 2 year (0.179 ± 0.240 vs 0.005 ± 0.186, P < .0001), and 3 year (0.258 ± 0.354 vs 0.020 ± 0.258, P < .0001). The operative treatment of ASD results in significant increases in QALYs gained at minimum 2 years postoperatively as well as at the 1-, 2-, and 3-year time points compared with nonoperative management.
    Full-text · Conference Paper · Aug 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Study design. Cross-sectional analysis Objective. To compare Lumbar Stiffness Disability Index (LSDI) scores between asymptomatic adults and patients with spinal deformity. Summary of Background Data. The LSDI was designed and validated as a tool to assess functional impacts of lumbar spine stiffness and diminished spinal flexibility. Baseline disability levels of adult spinal deformity (ASD) patients are high as measured by multiple validated outcome tools. Baseline lumbar stiffness-related disability has not been assessed in adults with and without spinal deformity. Methods. The LSDI and Scoliosis Research Society-22r (SRS-22r) were submitted to a group of asymptomatic adult volunteers. Additionally, a multi-center cross-sectional cohort analysis of ASD patients from 10 centers was conducted. Baseline LSDI and SRS-22r were completed for both operatively and non-operatively treated deformity patients. Results. The LSDI was completed by 176 asymptomatic volunteers and 693 ASD patients. Mean LSDI score for asymptomatic volunteers was 3.4 +/- 6.3 out of a maximum score of 100, with significant correlation between increasing age and higher (worse) LSDI score (r = 0.30, p = 0.0001). Of the spinal deformity patients undergoing analysis, 301 subsequently underwent surgery and 392 were subsequently treated non-operatively. Operative patients had significantly higher preoperative LSDI scores than both non-operative patients and asymptomatic volunteers (29.9 vs. 17.3 vs. 3.4, p<0.0001 for both). For ASD patients, significant correlations were found between LSDI and SRS-22 Pain and Function subscales (r = -0.75, and -0.76, respectively; p<0.0001 for both). Conclusion. LSDI scores are low among asymptomatic volunteers, although stiffness-related disability increases with increasing age. ASD patients report substantial stiffness-related disability even prior to surgical fusion. Stiffness-related disability correlates with pain and function related disability measures among spinal deformity patients. Copyright
    Full-text · Article · Aug 2015 · Spine
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECT Adult spinal deformity (ASD) surgery is known for its high complication rate. This study examined the impact of obesity on complication rates, infection, and patient-reported outcomes in patients undergoing surgery for ASD. METHODS This study was a retrospective review of a multicenter prospective database of patients with ASD who were treated surgically. Patients with available 2-year follow-up data were included. Obesity was defined as having a body mass index (BMI) ≥ 30 kg/m(2). Data collected included complications (total, minor, major, implant-related, radiographic, infection, revision surgery, and neurological injury), estimated blood loss (EBL), operating room (OR) time, length of stay (LOS), and patient-reported questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], and Scoliosis Research Society [SRS]) at baseline and at 6 weeks, 1 year, and 2 years postoperatively. The impact of obesity was studied using multivariate modeling, accounting for confounders. RESULTS Of 241 patients who satisfied inclusion criteria, 175 patients were nonobese and 66 were obese. Regression models showed that obese patients had a higher overall incidence of major complications (IRR 1.54, p = 0.02) and wound infections (odds ratio 4.88, p = 0.02). Obesity did not increase the number of minor complications (p = 0.62), radiographic complications (p = 0.62), neurological complications (p = 0.861), or need for revision surgery (p = 0.846). Obesity was not significantly correlated with OR time (p = 0.23), LOS (p = 0.9), or EBL (p = 0.98). Both groups experienced significant improvement overtime, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001). CONCLUSIONS This study revealed that obese patients have an increased risk of complications following ASD correction. Despite these increased complications, obese patients do benefit from surgical intervention; however, their improvement in health-related quality of life (HRQL) is less than that of nonobese patients.
    Full-text · Article · Jul 2015 · Journal of neurosurgery. Spine
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Study Design. Retrospective review of a multicenter, prospective adult spinal deformity (ASD) databaseObjective. We hypothesized that increased age and increased pre-operative disability would negatively impact both the length of time needed to achieve maximal recovery and the amount of functional improvement achieved. In order to gauge the recovery process, a normalization process was used to calculate an integrated health state (IHS) over the 2-year post-operative period. Elderly ASD patients generally have worse baseline health-related quality of life (HRQOL) measures than younger patients. Current methods of reporting outcomes are limited perhaps diminishing the health impact of the entire postoperative recovery experience. Inclusion criteria included ≥18yrs and ASD. Patient groups: young (≤45 years), middle (46-64), elderly (≥65) as well as by baseline Oswestry Disability Index (ODI) scores: MILD (0-30), MEDIUM (31-49), and HIGH (≥50). Collected HRQOL measures included ODI, Short Form-36(PCS/MCS), and Scoliosis Research Society-22 (SRS22) at baseline, 6wks, 1 and 2-years post-operative. All HRQOL measures were normalized to each patient's baseline scores. A 2-year IHS was calculated for each individual patient the means compared between groups. 149 patients were included (≤45:32, 46-64:67, ≥65:50). All groups significantly improved in all HRQOL at 2-years compared to baseline (p<0.05) except for MCS, ODI, and SRS activity for the ≤45 group (p>0.05). Normalized IHS HRQOL for young patients was worse than elderly for ODI, PCS, MCS, SRS activity, pain and total over the 2-year recovery period from index surgery. The MILD ODI group had significantly worse 2-year IHS values than the HIGH group for all HRQOL measured (p<0.05) except SRS appearance and satisfaction (p>0.05). Contrary to our hypothesis, an integrated health state analysis suggested that the recovery process was significantly better for elderly patients than young patients and better for patients with high baseline disability.
    Full-text · Article · Jul 2015 · Spine
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECT Although recent studies suggest that average clinical outcomes are improved following surgery for selected adult spinal deformity (ASD) patients, these outcomes span a broad range. Few studies have specifically addressed factors that may predict favorable clinical outcomes. The objective of this study was to compare patients with ASD with best versus worst clinical outcomes following surgical treatment to identify distinguishing factors that may prove useful for patient counseling and optimization of clinical outcomes. METHODS This is a retrospective review of a prospectively collected, multicenter, database of consecutively enrolled patients with ASD who were treated operatively. Inclusion criteria were age > 18 years and ASD. For patients with a minimum of 2-year follow-up, those with best versus worst outcomes were compared separately based on Scoliosis Research Society-22 (SRS-22) and Oswestry Disability Index (ODI) scores. Only patients with a baseline SRS-22 ≤ 3.5 or ODI ≥ 30 were included to minimize ceiling/floor effects. Best and worst outcomes were defined for SRS-22 (≥ 4.5 and ≤ 2.5, respectively) and ODI (≤ 15 and ≥ 50, respectively). RESULTS Of 257 patients who met the inclusion criteria, 227 (88%) had complete baseline and 2-year follow-up SRS-22 and ODI outcomes scores and radiographic imaging and were analyzed in the present study. Of these 227 patients, 187 had baseline SRS-22 scores ≤ 3.5, and 162 had baseline ODI scores ≥ 30. Forthe SRS-22, best and worst outcomes criteria were met at follow-up for 25 and 27 patients, respectively. For the ODI, best and worst outcomes criteria were met at follow-up for 43 and 51 patients, respectively. With respect to the SRS-22, compared with best outcome patients, those with worst outcomes had higher baseline SRS-22 scores (p < 0.0001), higher prevalence of baseline depression (p < 0.001), more comorbidities (p = 0.012), greater prevalence of prior surgery (p = 0.007), a higher complication rate (p = 0.012), and worse baseline deformity (sagittal vertical axis [SVA], p = 0.045; pelvic incidence [PI] and lumbar lordosis [LL] mismatch, p = 0.034). The best-fit multivariate model for SRS-22 included baseline SRS-22 (p = 0.033), baseline depression (p = 0.012), and complications (p = 0.030). With respect to the ODI, compared with best outcome patients, those with worst outcomes had greater baseline ODI scores (p < 0.001), greater baseline body mass index (BMI; p = 0.002), higher prevalence of baseline depression (p < 0.028), greater baseline SVA (p = 0.016), a higher complication rate (p = 0.02), and greater 2-year SVA (p < 0.001) and PI-LL mismatch (p = 0.042). The best-fit multivariate model for ODI included baseline ODI score (p < 0.001), 2-year SVA (p = 0.014) and baseline BMI (p = 0.037). Age did not distinguish best versus worst outcomes for SRS-22 or ODI (p > 0.1). CONCLUSIONS Few studies have specifically addressed factors that distinguish between the best versus worst clinical outcomes for ASD surgery. In this study, baseline and perioperative factors distinguishing between the best and worst outcomes for ASD surgery included several patient factors (baseline depression, BMI, comorbidities, and disability), as well as residual deformity (SVA), and occurrence of complications. These findings suggest factors that may warrant greater awareness among clinicians to achieve optimal surgical outcomes for patients with ASD.
    Full-text · Article · Jun 2015 · Journal of neurosurgery. Spine
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECT Although recent studies suggest that average clinical outcomes are improved following surgery for selected adult spinal deformity (ASD) patients, these outcomes span a broad range. Few studies have specifically addressed factors that may predict favorable clinical outcomes. The objective of this study was to compare patients with ASD with best versus worst clinical outcomes following surgical treatment to identify distinguishing factors that may prove useful for patient counseling and optimization of clinical outcomes. METHODS This is a retrospective review of a prospectively collected, multicenter, database of consecutively enrolled patients with ASD who were treated operatively. Inclusion criteria were age > 18 years and ASD. For patients with a minimum of 2-year follow-up, those with best versus worst outcomes were compared separately based on Scoliosis Research Society-22 (SRS-22) and Oswestry Disability Index (OD!) scores. Only patients with a baseline SRS-22 (<=) 3.5 or ODI >= 30 were included to minimize ceiling/floor effects. Best and worst outcomes were defined for SRS-22 >= 4.5 and <= 2.5, respectively) and ODI (<= 15 and 50, respectively). RESULTS Of 257 patients who met the inclusion criteria, 227 (88%) had complete baseline and 2-year follow-up SRS-22 and ODI outcomes scores and radiographic imaging and were analyzed in the present study. Of these 227 patients, 187 had baseline SRS-22 scores <= 3.5, and 162 had baseline ODI scores >= 30. For the SRS-22, best and worst outcomes criteria were met at follow-up for 25 and 27 patients, respectively. For the ODI, best and worst outcomes criteria were met at follow-up for 43 and 51 patients, respectively. With respect to the SRS-22, compared with best outcome patients, those with worst outcomes had higher baseline SRS-22 scores (p < 0.0001), higher prevalence of baseline depression (p < 0.001), more comorbidities (p = 0.012), greater prevalence of prior surgery (p = 0.007), a higher complication rate (p = 0.012), and worse baseline deformity (sagittal vertical axis [SVA], p = 0.045; pelvic incidence [Pl] and lumbar lordosis [LL] mismatch, p = 0.034). The best-fit multivariate model for SRS-22 included baseline SRS-22 (p = 0.033), baseline depression (p = 0.012), and complications (p = 0.030). With respect to the ODI, compared with best outcome patients, those with worst outcomes had greater baseline ODI scores (p <0.001), greater baseline body mass index (BMI; p = 0.002), higher prevalence of baseline depression (p < 0.028), greater baseline SVA (p = 0.016), a higher complication rate (p = 0.02), and greater 2-year SVA (p <0.001) and PI-LL mismatch (p = 0.042). The best-fit multivariate model for ODI included baseline ODI score (p < 0.001), 2-year SVA (p = 0.014) and baseline BMI (p = 0.037). Age did not distinguish best versus worst outcomes for SRS-22 or ODI (p > 0.1). CONCLUSIONS Few studies have specifically addressed factors that distinguish between the best versus worst clinical outcomes for ASD surgery. In this study, baseline and perioperative factors distinguishing between the, best and worst outcomes for ASD surgery included several patient factors (baseline depression, BMI, comorbidities, and disability), as well as residual deformity (SVA), and occurrence of complications. These findings suggest factors that may warrant greater awareness among clinicians to achieve optimal surgical outcomes for patients with ASD.
    Full-text · Article · Jun 2015 · Journal of Neurosurgery Spine
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Study Design Systematic review. Clinical Questions (1) Has the proportion and number of randomized controlled trials (RCTs) as an indicator of quality of evidence regarding lumbar fusion increased over the past 10 years? (2) Is there a difference in the proportion of RCTs among the four primary fusion diagnoses (degenerative disk disease, spondylolisthesis, deformity, and adjacent segment disease) over the past 10 years? (3) Is there a difference in the type and quality of clinical outcomes measures reported among RCTs over time? (4) Is there a difference in the type and quality of adverse events measures reported among RCTs over time? (5) Are there changes in fusion surgical approach and techniques over time by diagnosis over the past 10 years? Methods Electronic databases and reference lists of key articles were searched from January 1, 2004, through December 31, 2013, to identify lumbar fusion RCTs. Fusion studies designed specifically to evaluate recombinant human bone morphogenetic protein-2 or other bone substitutes, revision surgery studies, nonrandomized comparison studies, case reports, case series, and cost-effectiveness studies were excluded. Results Forty-two RCTs between January 1, 2004, and December 31, 2013, met the inclusion criteria and form the basis for this report. There were 35 RCTs identified evaluating patients diagnosed with degenerative disk disease, 4 RCTs evaluating patients diagnosed with degenerative spondylolisthesis, and 3 RCTs evaluating patients with a combination of degenerative disk disease and degenerative spondylolisthesis. No RCTs were identified evaluating patients with deformity or adjacent segment disease. Conclusions This structured review demonstrates that there has been an increase in the available clinical database of RCTs using patient-reported outcomes evaluating the benefit of lumbar spinal fusion for the diagnoses of degenerative disk disease and degenerative spondylolisthesis. Gaps remain in the standardization of reportage of adverse events in such trials, as well as uniformity of surgical approaches used. Finally, continued efforts to develop higher-quality data for other surgical indications for lumbar fusion, most notably in the presence of adult spinal deformity and revision of prior surgical fusions, appear warranted.
    Preview · Article · Jun 2015 · Global Spine Journal

Publication Stats

2k Citations
444.45 Total Impact Points

Institutions

  • 2000-2015
    • Oregon Health and Science University
      • • Department of Orthopaedics & Rehabilitation
      • • Department of Surgery
      Portland, Oregon, United States
  • 2014
    • University of California, San Francisco
      • Department of Neurological Surgery
      San Francisco, California, United States
    • Brown University
      Providence, Rhode Island, United States
    • Otto-von-Guericke-Universität Magdeburg
      Magdeburg, Saxony-Anhalt, Germany
  • 2013-2014
    • University of Oregon
      Eugene, Oregon, United States
    • University of Virginia
      • Department of Neurosurgery
      Charlottesville, VA, United States
  • 2010
    • Clemenceau Medical Center
      Beyrouth, Beyrouth, Lebanon
  • 2005
    • University of Kentucky
      Lexington, Kentucky, United States