Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery

BACKGROUND: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications. OBJECTIVE: Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers. STUDY DESIGN/SETTING: Retrospective cohort study of a prospectively collected multicenter database. METHODS: ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility. RESULTS: A total of 930 patients were considered. Following PSM, 253 optimal (O) and 253 not optimal (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, CONCLUSIONS: Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Top 50 most-cited articles on craniovertebral junction surgery

Background: Craniovertebral junction is a complex anatomical location posing unique challenges to the surgical management of its pathologies. We aimed to identify the fifty most-cited articles that are dedicated to this field. Methods: A keyword search using the Thomson Reuters Web of Knowledge was conducted to identify articles relevant to the field of craniovertebral junction surgery. The articles were reviewed based on title, abstract, and methods, if necessary, and then ranked based on the total number of citations to identify the fifty most-cited articles. Characteristics of the articles were determined and analyzed. Results: The earliest top-cited article was published in 1948. When stratified by decade, 1990s was the most productive with 16 articles. The most-cited article was by Anderson and Dalonzo on a classification of odontoid fractures. By citation rate, the most-cited article was by Herms and Melcher who described Goel's technique of atlantoaxial fixation using C1 lateral mass screws and C2 pedicle screws with rod fixation. Atlantoaxial fixation was the most common topic. The United States, Barrow Neurological Institute, and VH Sonntag were the most represented country, institute, and author, respectively. The significant majority of articles were designed as case series providing level IV evidence. Conclusion: Using citation analysis, we have provided a list of the most-cited articles representing important contributions of various authors from many institutions across the world to the field of craniovertebral junction surgery

Long-term clinical outcomes following surgical management of cervical spine fractures in elderly patients

Background: To date, no studies have compared the outcomes of surgical management of cervical fractures in patients<75 to those of patients≥75. Given the possibility of increased frailty in “older” elderly patients, it is important to consider how the outcomes of surgery compare in these two patient groups. Objective: In this study, we aim to determine if the outcomes of surgical management of cervical fractures differ when comparing patients<75 to patients≥75. Methods: A retrospective review was conducted of a prospectively maintained database of 107 elderly patients who experienced cervical spine trauma between 2007 and 2014. Chi-square analysis and Fisher exact tests were performed to compare two groups on a number clinical outcome measures. Results: There are no statistically significant differences when patients<75 with patients≥75 on a number of clinical outcome measures. Selected outcomes include length of stay, likelihood of death during admission, likelihood of death following discharge, likelihood of developing mental status decline following discharge, post-operative neurologic improvements, and long-term functional status. Conclusions: Patients≥75 have statistically similar outcomes following surgical management of cervical spine fractures when compared to patients<75. This may be due to ongoing improvements in both surgical and medical methodologies in spine trauma care. These results indicate that surgical management of cervical fractures in elderly patients is beneficial without regard to age, and should not be withheld for fear of poor outcomes in “older” elderly patients. Keywords: Cervical, Elderly, Fracture, Morbidity, Outcomes, Spine, Traum

Curve Laterality for Lateral Lumbar Interbody Fusion in Adult Scoliosis Surgery: The Concave Versus Convex Controversy

BACKGROUND: Minimally invasive lateral lumbar interbody fusion (LLIF) is an effective adjunct in adult degenerative scoliosis (ADS) surgery. LLIF approaches performed from the concavity or convexity have inherent approach-related risks and benefits. OBJECTIVE: To analyze LLIF approach-related complications and radiographic and clinical outcomes in patients with ADS. METHODS: A multicenter retrospective review of a minimally invasive adult spinal deformity database was queried with a minimum of 2-yr follow-up. Patients were divided into 2 groups as determined by the side of the curve from which the LLIF was performed: concave or convex. RESULTS: No differences between groups were noted in demographic, and preoperative or postoperative radiographic parameters (all P >.05). There were 8 total complications in the convex group (34.8%) and 21 complications in the concave group (52.5%; P =.17). A subgroup analysis was performed in 49 patients in whom L4-5 was in the primary curve and not in the fractional curve. In this subset of patients, there were 6 complications in the convex group (31.6%) compared to 19 in the concave group (63.3%; P < .05) and both groups experienced significant improvements in coronal Cobb angle, Oswestry Disability Index, and Visual Analog Scale score with no difference between groups. CONCLUSION: Patients undergoing LLIF for ADS had no statistically significant clinical or operative complication rates regardless of a concave or convex approach to the curve. Clinical outcomes and coronal plane deformity improved regardless of approach side. However, in cases wherein L4-5 is in the primary curve, approaching the fractional curve at L4-5 from the concavity may be associated with a higher complication rate compared to a convex approach

Reoperation rates in minimally invasive, hybrid and open surgical treatment for adult spinal deformity with minimum 2-year follow-up

Minimally invasive surgical (MIS) techniques are gaining popularity in the treatment of adult spinal deformity (ASD). The premise is that MIS techniques will lead to equivalent outcomes and a reduction in perioperative complications when compared with open techniques. Potential issues with MIS techniques are a limited capacity to correct lumbar lordosis, unknown long-term efficacy, and the potential need for revision surgery. This study compares reoperation rates and reasons for reoperation following MIS, hybrid, and open surgery for ASD through multicenter database analysis. We retrospectively analyzed a prospective multicenter ASD database comparing open and MIS correction techniques. Inclusion criteria were: age > 18 years with minimum 20° coronal lumbar Cobb angle, a minimum of three levels fused, and minimum 2-year follow-up. Patients were propensity matched for preoperative sagittal vertebral axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), and number of levels fused. We included 189 patients from three propensity-matched subgroups of 63 patients each: (1) MIS: lateral or transforaminal lumbar interbody fusion (LIF) and percutaneous pedicle instrumentation, (2) Hybrid: MIS LIF with open posterior segmental fixation (PSF), and (3) OPEN: open posterior fixation ± osteotomies. With propensity matching, there were significant differences between groups in pre-op SVA or PI-LL (p > 0.05). The MIS group had significantly fewer levels fused (5.4) (0-14) than the OPEN group (7.4) (p = 0.002) (0-17). The rate of revision surgery was significantly different between the groups with a higher rate of revision (27 %) amongst the HYB group versus MIS = 11.1 %, and OPEN = 12.0 %. The most common reason for reoperation in the OPEN and HYB groups was a postoperative neurological deficit (7.9 and 11.1 %), respectively. The most common reason for reoperation in the MIS group was pseudoarthrosis (7.9 %). Reoperation rates were not statistically different among the MIS, and OPEN surgical groups, but differed significantly on multivariate analysis with HYB group. The incidence of reoperations was twice as high in the Hybrid group compared to OPEN and MIS

A new piece of the puzzle to understand cervical sagittal alignment: Utilizing a novel angle δ to describe the relationship among T1 vertebral body slope, cervical lordosis, and cervical sagittal alignment

Cervical alignment has become increasingly important in the planning of spine surgery. A relationship between the slope of T1 (T1S), the cervical lordosis (CL), and the overall cervical sagittal vertical axis (cSVA) has previously been demonstrated, but the exact nature of this relationship is poorly understood. In this study, we derive theoretical and empirical equations to better understand how T1S and CL affect cSVA. The first equation was developed on a theoretical basis using inherent trigonometric relationships of the cervical spine. By treating the cervical spine as the arc of a circumference, and by taking into account the cervical height (CH), the geometric relationship between theT1S, CL, and cSVA was described via a trigonometric identity utilizing a novel angle δ subtended by the CH and cSVA (δ = T1S-CL/2). The second equation was developed on an empiric basis by performing a multiple linear regression on data obtained from a retrospective review of a large multicenter deformity database. The theoretical equation determined that the value of cSVA could be expressed as: cSVA = CH ∗ tan(π/180 ∗ (T 1S − CL/2)) . The empirical equation determined that value of cSVA could be expressed as: cSVA = (1.1 ∗ T 1) − (0.43 ∗ CL) + 6.69. In both, the sagittal alignment of the head over the shoulders is directly proportional to the T1S and inversely proportional to CL/2. These 2 equations may allow surgeons to better understand how the CL compensates for the T1S, to accurately predict the postoperative cSVA, and to customize cervical interbody grafts by taking into consideration each individual patient’s specific cervical spine parameters.Fil: Goldschmidt, Ezequiel Darío. Univeristy of Pittsburgh. School of Medicine; Estados UnidosFil: Angriman, Federico. Hospital Italiano; ArgentinaFil: Agarwal, Nitin. Univeristy of Pittsburgh. School of Medicine; Estados UnidosFil: Trevisan, Marcos Alberto. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Instituto de Física de Buenos Aires. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Instituto de Física de Buenos Aires; Argentina. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Departamento de Física; ArgentinaFil: Zhou, James. Univeristy of Pittsburgh. School of Medicine; Estados UnidosFil: Chen, Katherine. Univeristy of Pittsburgh. School of Medicine; Estados UnidosFil: Gerszten, Peter C.. Univeristy of Pittsburgh. School of Medicine; Estados UnidosFil: Kanter, Adam S.. Univeristy of Pittsburgh. School of Medicine; Estados UnidosFil: Okonkwo, David O.. Univeristy of Pittsburgh. School of Medicine; Estados UnidosFil: Passias, Peter. New York Spine Institute; Estados UnidosFil: Scheer, Justin. University of California; Estados UnidosFil: Protopsaltis, Themistocles. NYU Langone Medical Center; Estados UnidosFil: Lafage, Virginie. Hospital for Special Surgery; Estados UnidosFil: Lafage, Renaud. Hospital for Special Surgery; Estados UnidosFil: Schwab, Frank. Hospital for Special Surgery; Estados UnidosFil: Bess, Shay. NYU Langone Medical Center; Estados UnidosFil: Ames, Christopher. University of California; Estados UnidosFil: Smith, Justin S.. University of Virginia; Estados UnidosFil: Shaffrey, Christopher I.. University of Virginia; Estados UnidosFil: Miller, Emily. University Johns Hopkins; Estados UnidosFil: Jain, Amit. University Johns Hopkins; Estados UnidosFil: Neuman, Brian. University Johns Hopkins; Estados UnidosFil: Sciubba, Daniel M.. University Johns Hopkins; Estados UnidosFil: Burton, Douglas. University of Kansas; Estados UnidosFil: Hamilton, D. Kojo. Univeristy of Pittsburgh. School of Medicine; Estados Unido

P125. Enhanced cost utility in adult deformity corrections can be achieved by application of contemporary age-adjusted realignment criteria

Studies have evaluated outcomes for sagittal age-adjusted alignment score (SAAS) in adult spinal deformity (ASD) corrective surgery, yet no study to date evaluated its cost-utility. Our study aims to evaluate the cost-utility and cost-effectiveness of age-adjusted alignment targets. Retrospective cohort study. Adult Spinal Deformity. Cost-utility. We included ASD patients undergoing primary surgery fused from at least L1 and proximal, to the sacrum, with a minimum of 5-year follow-up. Published methods to determine costs were utilized based on CMS.gov definitions and the average DRG reimbursement rates. Utility was calculated using quality-adjusted life years (QALY) utilizing the Oswestry Disability Index (ODI) converted to Short-Form Six-Dimension (SF-6D), with a 3% discount applied for its decline with life expectancy. Cost-utility (CU) was determined by dividing the cost by the utility gained five years postoperatively. The cost-effectiveness (CE) threshold of $150,000 was used. Patients were categorized based on whether they met SAAS (M) [SAAS score of -1 to 1], were under-corrected (U) [1]. Baseline variances amongst SAAS groups and meeting CE were adjusted using ANCOVA and controlled using multivariable logistic regression. A total of 231 patients were included (Age 64.5, 68$98,000, with a utility gained at 5Y of 0.52. The cost per QALY at 5Y was $248,300 at 5Y, with 39% meeting CE. The mean SAAS score preoperatively was -2.0±4.6, and postoperatively was 1.5±3.8. Postoperative SAAS categories: 29.2% M, 23.6% U, 47.2% O. O cohort was older and had lower BMI, with no difference in frailty, CCI, osteoporosis rates, and baseline HRQLs. Furthermore, O had lower baseline deformity in PT, PI-LL, SVA, TPA, and PI (all p.05). U had worse patient-reported outcomes at the last follow-up (ODI: 31 U, M 20, O 22, p=.1). Univariate and multivariable analysis depicted no difference in CU and CE for SAAS categories, even when extrapolating utility to life expectancy. SAAS score of >5 was found to be significant for CU and CE, with CU being 30% higher in those overcorrected at that score (p<.05). Comparative analysis for each incremental decrease in SAAS score found those with a score of <-4 having 20% higher CU (p=.04). In those overcorrected, lower age (OR: 0.910 [0.845-0.981], p=0.013) and baseline deformity in TPA was predictive of achieving CE (OR: 0.905 [0.822-0.996], p=0.04). While in those under-corrected, lower frailty (OR: 0.555 [0.344-0.894], p=0.016) and baseline deformity in PT (OR: 0.390 [0.183-0.831], p=0.015) was predictive. ASD corrective surgery improves patient outcomes and has favorable cost-utility in most patients. However, patients were significantly less likely to achieve cost-effectiveness and have a higher cost utility if the age-adjusted alignment was under-corrected by 1 SD and overcorrected by 1.5 SD. This abstract does not discuss or include any applicable devices or drugs

Are We Focused on the Wrong Early Postoperative Quality Metrics? Optimal Realignment Outweighs Perioperative Risk in Adult Spinal Deformity Surgery.

BACKGROUND: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications. OBJECTIVE: Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers. STUDY DESIGN/SETTING: Retrospective cohort study of a prospectively collected multicenter database. METHODS: ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility. RESULTS: A total of 930 patients were considered. Following PSM, 253 optimal (O) and 253 not optimal (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, CONCLUSIONS: Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success