Acute Reciprocal Changes Distant from the Site of Spinal Osteotomies Affect Global Postoperative Alignment

Introduction. Three-column vertebral resections are frequently applied to correct sagittal malalignment; their effects on distant unfused levels need to be understood. Methods. 134 consecutive adult PSO patients were included (29 thoracic, 105 lumbar). Radiographic analysis included pre- and postoperative regional curvatures and pelvic parameters, with paired independent t-tests to evaluate changes. Results. A thoracic osteotomy with limited fusion leads to a correction of the kyphosis and to a spontaneous decrease of the unfused lumbar lordosis (−8°). When the fusion was extended, the lumbar lordosis increased (+8°). A lumbar osteotomy with limited fusion leads to a correction of the lumbar lordosis and to a spontaneous increase of the unfused thoracic kyphosis (+13°). When the fusion was extended, the thoracic kyphosis increased by 6°. Conclusion. Data from this study suggest that lumbar and thoracic resection leads to reciprocal changes in unfused segments and requires consideration beyond focal corrections

Cost-utility of revisions for cervical deformity correction warrants minimization of reoperations.

Background: Cervical deformity (CD) surgery has become increasingly more common and complex, which has also led to reoperations for complications such as distal junctional kyphosis (DJK). Cost-utility analysis has yet to be used to analyze CD revision surgery in relation to the cost-utility of primary CD surgeries. The aim of this study was to determine the cost-utility of revision surgery for CD correction. Methods: Retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: C2-C7 Cobb \u3e10°, cervical lordosis (CL) \u3e10°, cervical sagittal vertical axis (cSVA) \u3e4 cm, chin-brow vertical angle (CBVA) \u3e25°. Quality-adjusted life year (QALY) were calculated by EuroQol Five-Dimensions questionnaire (EQ-5D) and Neck Disability Index (NDI) mapped to SF-6D index and utilized a 3% discount rate to account for residual decline to life expectancy (men: 76.9 years, women: 81.6 years). Medicare reimbursement at 30 days assigned costs for index procedures (9+ level posterior fusion, 4-8 level posterior fusion with anterior fusion, 2-3 level posterior fusion with anterior fusion, 4-8 level anterior fusion) and revision fusions (2-3 level, 4-8 level, or 9+ level posterior refusion). Cost per QALY gained was calculated. Results: Eighty-nine CD patients were included (61.6 years, 65.2% female). CD correction for these patients involved a mean 7.7±3.7 levels fused, with 34% combined approach surgeries, 49% posterior-only and 17% anterior-only, 19.1% three-column osteotomy. Costs for index surgeries ranged from $20,001-55,205, with the average cost for this cohort of$44,318 and cost per QALY of $27,267. Eleven revision surgeries (mean levels fused 10.3) occurred up to 1-year, with an average cost of$41,510. Indications for revisions were DJK (5/11), neurologic impairment [4], infection [1], prominent/painful instrumentation [1]. Average QALYs gained was 1.62 per revision patient. Cost was $28,138 per QALY for reoperations. Conclusions: CD revisions had a cost of$28,138 per QALY, in addition to the $27,267 per QALY for primary CD surgeries. For primary CD patients, CD surgery has the potential to be cost effective, with the caveats that a patient livelihood extends long enough to have the benefits and durability of the surgery is maintained. Efforts in research and surgical technique development should emphasize minimization of reoperation causes just as DJK that significantly affect cost utility of these surgeries to bring cost-utility to an acceptable range

Comparison of Best Versus Worst Clinical Outcomes for Adult Cervical Deformity Surgery.

Study Design: Retrospective cohort study. Objective: Factors that predict outcomes for adult cervical spine deformity (ACSD) have not been well defined. To compare ACSD patients with best versus worst outcomes. Methods: This study was based on a prospective, multicenter observational ACSD cohort. Best versus worst outcomes were compared based on Neck Disability Index (NDI), Neck Pain Numeric Rating Scale (NP-NRS), and modified Japanese Orthopaedic Association (mJOA) scores. Results: Of 111 patients, 80 (72%) had minimum 1-year follow-up. For NDI, compared with best outcome patients (n = 28), worst outcome patients (n = 32) were more likely to have had a major complication ( Conclusions: Factors distinguishing best and worst ACSD surgery outcomes included patient, surgical, and radiographic factors. These findings suggest areas that may warrant greater awareness to optimize patient counseling and outcomes

Scoliosis Research Society survey: brace management in adolescent idiopathic scoliosis

Purpose: While the Scoliosis Research Society (SRS) has established criteria for brace initiation in adolescent idiopathic scoliosis (AIS), there are no recommendations concerning other management issues. As the BrAIST study reinforced the utility of bracing, the SRS Non-Operative Management Committee decided to evaluate the consensus or discord in AIS brace management. Methods: 1200 SRS members were sent an online survey in 2017, which included 21 items concerning demographics, bracing indications, management, and monitoring. Free-text responses were analyzed and collated into common themes. Data were analyzed using Microsoft Excel 2013. Results: Of 218 respondents; 207 regularly evaluate and manage patients with AIS, and 205 currently prescribe bracing. 99% of respondents use bracing for AIS and the majority (89%) use the published SRS criteria, or a modified version, to initiate bracing. 85% do not use brace monitoring and 66% use both %-Cobb correction and fit criteria to evaluate brace adequacy. In contrast, other aspects of brace management demonstrated a high degree of practice variability. This was seen with a radiographic assessment of maturity level, hours prescribed, timing and frequency of radiographic evaluation, the use of nighttime bracing only, and the method and timing of brace discontinuation. Conclusion: Although there is consensus in brace management amongst SRS members with respect to brace initiation and evaluation of adequacy, there is striking variability in how bracing for AIS is used. This variability may impact the overall efficacy of brace treatment and may be decreased with more robust guidelines from the SRS. Level of evidence: III.</p

Proximal Junctional Kyphosis: Inter- and Intraobserver Reliability of Radiographic Measurements in Adult Spinal Deformity.

STUDY DESIGN: Reliability study of radiographic measures of proximal junctional kyphosis (PJK) in patients with adult spinal deformity (ASD). OBJECTIVE: To assess impacts of level of proximal endpoint and vertebral fracture on reliability of measurement of junctional kyphosis. SUMMARY OF BACKGROUND DATA: Radiographic assessment is important in determining management of patients with PJK or proximal junctional failure (PJF). No study to date has evaluated the reliability of radiographic measurement of the junctional kyphotic angle after surgery for ASD. METHODS: Postoperative radiographs from 52 patients with ASD were divided into four categories based on the level of the upper instrumented vertebra (UIV) and the presence or absence of PJF: upper thoracic without failure (UT), thoracolumbar without failure (TL), upper thoracic with PJF (UTF), and thoracolumbar with PJF (TLF). Nine surgeon reviewers performed radiographic measurements of kyphosis between UIV+2 and UIV twice at least 4 weeks apart. Intraclass correlation coefficients (ICC) were calculated to determine inter- and intraobserver reliability. RESULTS: Interobserver reliability for measurements of UT, TL, UTF, and TLF were all almost perfect with ICC scores of 0.917, 0.965, 0.956, and 0.882, and 0.932, 0.975, 0958, and 0.989, for sessions 1 and 2, respectively. Similarly, ICCs for kyphosis measurements for the TL and TLF group had almost perfect agreement with means of 0.898 (range: 0.817-0.969) and 0.976 (range: 0.931-0.995), respectively. ICCs for measurements for the UT and UTF groups all had substantial or almost perfect agreement with means of 0.801 (range: 0.662-0.942) and 0.879 (range: 0.760-0.988), respectively. CONCLUSION: The present study demonstrates high inter- and intraobserver reliability of PJK measurement following instrumented fusion for ASD, independent of the presence or absence of PJF. Although slightly lower for upper thoracic than for thoracolumbar proximal endpoints, all ICCs consistently reached at least substantial agreement and near perfect agreement for most. LEVEL OF EVIDENCE: 4

Likelihood of reaching minimal clinically important difference in adult spinal deformity: a comparison of operative and nonoperative treatment.

BackgroundFew studies have examined threshold improvements in health-related quality of life (HRQOL) by measuring minimal clinically important differences (MCIDs) in treatment of adult spinal deformity. We hypothesized that patients undergoing operative treatment would be more likely to achieve MCID threshold improvement compared with those receiving nonoperative care, although a subset of nonoperative patients may still reach threshold.MethodsWe analyzed a multicenter, prospective, consecutive case series of 464 patients: 225 nonoperative and 239 operative. To be included in the study, patients had to have adult spinal deformity, be older than 18 years, and have both baseline and 1-year follow-up HRQOL measures (Oswestry Disability Index [ODI], Short Form-36 [SF-36] health survey, and Scoliosis Research Society-22 [SRS-22] questionnaire). We compared the percentages of patients achieving established MCID thresholds between operative and nonoperative groups using risk ratios (RR) with a 95% confidence interval (CI).ResultsCompared to nonoperative patients, surgical patients demonstrated significant mean improvement (P&lt;0.01) and were more likely to achieve threshold MCID improvement across all HRQOL scores (ODI RR = 7.37 [CI 4.45, 12.21], SF-36 physical component score RR = 2.96 [CI 2.11, 4.15], SRS Activity RR = 3.16 [CI 2.32, 4.31]). Furthermore, operative patients were more likely to reach threshold MCID improvement in 2 or more HRQOL measures simultaneously and were less likely to deteriorate.ConclusionPatients in both the operative and nonoperative treatment groups demonstrated improvement in at least one HRQOL measure at 1 year. However, surgical treatment was more likely to result in threshold improvement and more likely to lead to simultaneous improvement across multiple measures of ODI, SF-36, and SRS-22. Although a subset of nonoperative patients achieved threshold improvement, nonoperative patients were significantly less likely to improve in multiple HRQOL measures and more likely to sustain MCID deterioration or no change