Cervical Deformity Patients Have Baseline Swallowing Dysfunction but Surgery Does Not Increase Dysphagia at 3 Months: Results From a Prospective Cohort Study.

Study designProspective cohort study.ObjectivesMost studies of dysphagia in the cervical spine have focused on a degenerative patient population; the rate of dysphagia following surgery for cervical deformity (CD) is unknown. This study aims to investigate if surgery for cervical deformity results in postoperative dysphagia.MethodsPatients with CD undergoing surgery from 2013 to 2015 were prospectively enrolled to evaluate dysphagia. Demographic, operative, and radiographic variables were analyzed. The Quality of Life in Swallowing Disorders (SWAL-QoL) was used to measure dysphagia. Paired t test, independent t tests, and bivariate Pearson correlations were performed.ResultsA total of 88 CD patients, aged 61.52 ± 10.52 years, were enrolled. All patients (100%) had 3-month SWAL-QoL for analysis. The baseline preoperative SWAL-QoL was 78.35. This is roughly the same level of dysphagia as an anterior cervical discectomy patient that is 3 weeks removed from surgery. Increasing body mass index (BMI) was correlated with decreased SWAL-QoL score (r = -0.30, P = .001). Age, gender, smoking, and Charlson Comorbidity Index (CCI) showed no significant correlations with preoperative SWAL-QoL. Patients with prior cervical surgery had a lower preoperative SWAL-QoL (P = .04). While 11 patients had acute postoperative dysphagia, CD surgery did not result in lower SWAL-QoL at 3 months (77.26 vs 78.35, P = .53). Surgical variables, including estimated blood loss (EBL), anterior or posterior fusion levels, steroid use, preoperative traction, staged surgery, surgical approach, anterior corpectomy, posterior osteotomy, and UIV (upper instrumented vertebrae) location, showed no impact on postoperative SWAL-QoL. Correction of cervical kyphosis was not correlated to 3-month SWAL-QoL scores or the change in SWAL-QoL scores.ConclusionsWhile patients undergoing surgery for cervical deformity had swallowing dysfunction at baseline, we did not observe a significant decline in SWAL-QoL scores at 3 months. Patients with prior cervical surgery and higher BMI had a lower baseline SWAL-QoL. There were no surgical or radiographic variables correlated to a change in SWAL-QOL score

Cervical, Thoracic, and Spinopelvic Compensation After Proximal Junctional Kyphosis (PJK): Does Location of PJK Matter?

Study Design:Retrospective case series. Objective:Compensatory changes above a proximal junctional kyphosis (PJK) have not been defined. Understanding these mechanisms may help determine optimal level selection when performing revision for PJK. This study investigates how varying PJK location changes proximal spinal alignment. Methods:Patients were grouped by upper instrumented vertebrae (UIV): lower thoracic (LT; T8-L1) or upper thoracic (UT; T1-7). Alignment parameters were compared. Correlation analysis was performed between PJK magnitude and global/cervical alignment. Results:A total of 369 patients were included; mean age of 63 years, body mass index 28, and 81% female, LT (n = 193) versus UT (n = 176). The rate of radiographic PJK was 49%, higher in the LT group (55% vs 42%, P = .01). The UT group displayed significant differences in all cervical radiographic parameters (P < .05) between PJK versus non-PJK patients, while the LT group displayed significant differences in T1S and C2-T3 sagittal vertical axis (SVA) (CTS). In comparing UT versus LT patients, UT had more posterior global alignment (smaller TPA [T1 pelvic angle], SVA, and larger PT [pelvic tilt]) and larger anterior cervical alignment (greater cSVA [cervical SVA], T1S-CL [T1 slope-cervical lordosis] mismatch, CTS) compared to LT. Correlation analysis of PJK magnitude and location demonstrated a correlation with increases in CL, T1S, and CTS in the UT group. In the LT group, PT increased with PJK angle (r = 0.17) and no significant correlations were noted to SVA, cSVA, or T1S-CL. Conclusions:PJK location influences compensation mechanisms of the cervical and thoracic spine. LT PJK results in increased PT and CL with decreased CTS. UT PJK increases CL to counter increases in T1S with continued T1S-CL mismatch and elevated cSVA

The posterior use of BMP-2 in cervical deformity surgery does not result in increased early complications: A prospective multicenter study

Study designProspective cohort study.ObjectivesTo describe the rate of short-term complications following the posterior use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in cervical deformity (CD) surgery.MethodsCD patients from 2013 to 2015 were enrolled in a prospective, multicenter database. Patients were divided into those receiving rhBMP-2 (BMP) and no rhBMP-2 (NOBMP). The relationship between BMP use, demographic variables surgical variables, radiographic parameters and complications was evaluated.ResultsA total of 100 patients (47 BMP, 53 NOBMP) were included. Follow-up time averaged 7.6 months (range 3-12 months). An average of 13.6mg of BMP was used per person with 1.49 mg per level. Compared with the NOBMP group, patients in the BMP group were older (P = .03). BMP was more commonly used in patients that and had longer prior fusions (6.0 vs 2.5, P < .01). There were no differences between groups with regards to a history of surgery, Charlson Comorbidity Index, estimated blood loss, operation time, fusion levels, and surgical approach. The maintenance of radiographic parameters at 6-month follow-up was similar. There were no differences in terms of total complication incidence, total complications per person, major complications per person or any specific complication. Linear regression and Pearson correlation analysis did not reveal any strong r2 values (r2 = 0.09, 0.08, 0.06) between the use of BMP and complications (major or operative).ConclusionsBMP use was not directly associated with an increased incidence of early complications in this prospective cohort of operative adult CD patients. Its use was associated with increased number of levels instrumented and fused

Clinically Significant Thromboembolic Disease in Adult Spinal Deformity Surgery: Incidence and Risk Factors in 737 Patients.

Study Design:Retrospective cohort study. Objectives:Describe the rate and risk factors for venous thromboembolic events (VTEs; defined as deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in adult spinal deformity (ASD) surgery. Methods:ASD patients with VTE were identified in a prospective, multicenter database. Complications, revision, and mortality rate were examined. Patient demographics, operative details, and radiographic and clinical outcomes were compared with a non-VTE group. Multivariate binary regression model was used to identify predictors of VTE. Results:A total of 737 patients were identified, 32 (4.3%) had VTE (DVT = 14; PE = 18). At baseline, VTE patients were less likely to be employed in jobs requiring physical labor (59.4% vs 79.7%, P < .01) and more likely to have osteoporosis (29% vs 15.1%, P = .037) and liver disease (6.5% vs 1.4%, P = .027). Patients with VTE had a larger preoperative sagittal vertical axis (SVA; 93 mm vs 55 mm, P < .01) and underwent larger SVA corrections. VTE was associated with a combined anterior/posterior approach (45% vs 25%, P = .028). VTE patients had a longer hospital stay (10 vs 7 days, P < .05) and higher mortality rate (6.3% vs 0.7%, P < .01). Multivariate analysis demonstrated osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE (r2 = .11, area under the curve = 0.74, P < .05). Conclusions:The incidence of VTE in ASD is 4.3% with a DVT rate of 1.9% and PE rate of 2.4%. Osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE. Patients with VTE had a higher mortality rate compared with non-VTE patients

Dural tears in adult deformity surgery: Incidence, risk factors, and outcomes

Study Design: Retrospective cohort study. Objectives: Describe the rate of dural tears (DTs) in adult spinal deformity (ASD) surgery. Describe the risk factors for DT and the impact of this complication on clinical outcomes. Methods: Patients with ASD undergoing surgery between 2008 and 2014 were separated into DT and non-DT cohorts; demographics, operative details, radiographic, and clinical outcomes were compared. Statistical analysis included Results: A total of 564 patients were identified. The rate of DT was 10.8% (n = 61). Patients with DT were older (61.1 vs 56.5 years, Conclusions: The rate of DT was 10.8% in an ASD cohort. This is similar to rates of DT reported following surgery for degenerative pathology. A history of prior spine surgery, decompression, interbody fusion, and osteotomies are all associated with an increased risk of DT, but decompression is the only independent risk factor for DT

Cervical Deformity Patients Have Baseline Swallowing Dysfunction but Surgery Does Not Increase Dysphagia at 3 Months: Results From a Prospective Cohort Study.

Study designProspective cohort study.ObjectivesMost studies of dysphagia in the cervical spine have focused on a degenerative patient population; the rate of dysphagia following surgery for cervical deformity (CD) is unknown. This study aims to investigate if surgery for cervical deformity results in postoperative dysphagia.MethodsPatients with CD undergoing surgery from 2013 to 2015 were prospectively enrolled to evaluate dysphagia. Demographic, operative, and radiographic variables were analyzed. The Quality of Life in Swallowing Disorders (SWAL-QoL) was used to measure dysphagia. Paired t test, independent t tests, and bivariate Pearson correlations were performed.ResultsA total of 88 CD patients, aged 61.52 ± 10.52 years, were enrolled. All patients (100%) had 3-month SWAL-QoL for analysis. The baseline preoperative SWAL-QoL was 78.35. This is roughly the same level of dysphagia as an anterior cervical discectomy patient that is 3 weeks removed from surgery. Increasing body mass index (BMI) was correlated with decreased SWAL-QoL score (r = -0.30, P = .001). Age, gender, smoking, and Charlson Comorbidity Index (CCI) showed no significant correlations with preoperative SWAL-QoL. Patients with prior cervical surgery had a lower preoperative SWAL-QoL (P = .04). While 11 patients had acute postoperative dysphagia, CD surgery did not result in lower SWAL-QoL at 3 months (77.26 vs 78.35, P = .53). Surgical variables, including estimated blood loss (EBL), anterior or posterior fusion levels, steroid use, preoperative traction, staged surgery, surgical approach, anterior corpectomy, posterior osteotomy, and UIV (upper instrumented vertebrae) location, showed no impact on postoperative SWAL-QoL. Correction of cervical kyphosis was not correlated to 3-month SWAL-QoL scores or the change in SWAL-QoL scores.ConclusionsWhile patients undergoing surgery for cervical deformity had swallowing dysfunction at baseline, we did not observe a significant decline in SWAL-QoL scores at 3 months. Patients with prior cervical surgery and higher BMI had a lower baseline SWAL-QoL. There were no surgical or radiographic variables correlated to a change in SWAL-QOL score

Clinically Significant Thromboembolic Disease in Adult Spinal Deformity Surgery: Incidence and Risk Factors in 737 Patients.

Study designRetrospective cohort study.ObjectivesDescribe the rate and risk factors for venous thromboembolic events (VTEs; defined as deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in adult spinal deformity (ASD) surgery.MethodsASD patients with VTE were identified in a prospective, multicenter database. Complications, revision, and mortality rate were examined. Patient demographics, operative details, and radiographic and clinical outcomes were compared with a non-VTE group. Multivariate binary regression model was used to identify predictors of VTE.ResultsA total of 737 patients were identified, 32 (4.3%) had VTE (DVT = 14; PE = 18). At baseline, VTE patients were less likely to be employed in jobs requiring physical labor (59.4% vs 79.7%, P < .01) and more likely to have osteoporosis (29% vs 15.1%, P = .037) and liver disease (6.5% vs 1.4%, P = .027). Patients with VTE had a larger preoperative sagittal vertical axis (SVA; 93 mm vs 55 mm, P < .01) and underwent larger SVA corrections. VTE was associated with a combined anterior/posterior approach (45% vs 25%, P = .028). VTE patients had a longer hospital stay (10 vs 7 days, P < .05) and higher mortality rate (6.3% vs 0.7%, P < .01). Multivariate analysis demonstrated osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE (r2 = .11, area under the curve = 0.74, P < .05).ConclusionsThe incidence of VTE in ASD is 4.3% with a DVT rate of 1.9% and PE rate of 2.4%. Osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE. Patients with VTE had a higher mortality rate compared with non-VTE patients

Alignment Targets, Curve Proportion and Mechanical Loading: Preliminary Analysis of an Ideal Shape Toward Reducing Proximal Junctional Kyphosis.

Study designRetrospective cohort study.ObjectiveInvestigate risk factors for PJK including theoretical kyphosis, mechanical loading at the UIV and age adjusted offset alignment.Methods373 ASD patients (62.7 yrs ± 9.9; 81%F) with 2-year follow up and UIV of at least L1 and LIV of sacrum were included. Images of patients without PJK, with PJK and with PJF were compared using standard spinopelvic parameters before and after the application of the validated virtual alignment method which corrects for the compensatory mechanisms of PJK. Age-adjusted offset, theoretical thoracic kyphosis and mechanical loading at the UIV were then calculated and compared between groups. A subanalysis was performed based on the location of the UIV (upper thoracic (UT) vs. Lower thoracic (LT)).ResultsAt 2-years 172 (46.1%) had PJK, and 21 (5.6%) developed PJF. As PJK severity increased, the post-operative global alignment became more posterior secondary to increased over-correction of PT, PI-LL, and SVA (all P < 0.005). Also, a larger under correction of the theoretical TK (flattening) and a smaller bending moment at the UIV (underloading of UIV) was found. Multivariate analysis demonstrated that PI-LL and bending moment offsets from normative values were independent predictors of PJK/PJF in UT group; PT and bending moment difference were independent predictors for LT group.ConclusionsSpinopelvic over correction, under correction of TK (flattening), and under loading of the UIV (decreased bending moment) were associated with PJK and PJF. These differences are often missed when compensation for PJK is not accounted for in post-operative radiographs

Cervical, Thoracic, and Spinopelvic Compensation After Proximal Junctional Kyphosis (PJK): Does Location of PJK Matter?

Study designRetrospective case series.ObjectiveCompensatory changes above a proximal junctional kyphosis (PJK) have not been defined. Understanding these mechanisms may help determine optimal level selection when performing revision for PJK. This study investigates how varying PJK location changes proximal spinal alignment.MethodsPatients were grouped by upper instrumented vertebrae (UIV): lower thoracic (LT; T8-L1) or upper thoracic (UT; T1-7). Alignment parameters were compared. Correlation analysis was performed between PJK magnitude and global/cervical alignment.ResultsA total of 369 patients were included; mean age of 63 years, body mass index 28, and 81% female, LT (n = 193) versus UT (n = 176). The rate of radiographic PJK was 49%, higher in the LT group (55% vs 42%, P = .01). The UT group displayed significant differences in all cervical radiographic parameters (P < .05) between PJK versus non-PJK patients, while the LT group displayed significant differences in T1S and C2-T3 sagittal vertical axis (SVA) (CTS). In comparing UT versus LT patients, UT had more posterior global alignment (smaller TPA [T1 pelvic angle], SVA, and larger PT [pelvic tilt]) and larger anterior cervical alignment (greater cSVA [cervical SVA], T1S-CL [T1 slope-cervical lordosis] mismatch, CTS) compared to LT. Correlation analysis of PJK magnitude and location demonstrated a correlation with increases in CL, T1S, and CTS in the UT group. In the LT group, PT increased with PJK angle (r = 0.17) and no significant correlations were noted to SVA, cSVA, or T1S-CL.ConclusionsPJK location influences compensation mechanisms of the cervical and thoracic spine. LT PJK results in increased PT and CL with decreased CTS. UT PJK increases CL to counter increases in T1S with continued T1S-CL mismatch and elevated cSVA

Dural Tears in Adult Deformity Surgery: Incidence, Risk Factors, and Outcomes.

Study designRetrospective cohort study.ObjectivesDescribe the rate of dural tears (DTs) in adult spinal deformity (ASD) surgery. Describe the risk factors for DT and the impact of this complication on clinical outcomes.MethodsPatients with ASD undergoing surgery between 2008 and 2014 were separated into DT and non-DT cohorts; demographics, operative details, radiographic, and clinical outcomes were compared. Statistical analysis included t tests or χ2 tests as appropriate and a multivariate analysis.ResultsA total of 564 patients were identified. The rate of DT was 10.8% (n = 61). Patients with DT were older (61.1 vs 56.5 years, P = .005) and were more likely to have had prior spine surgery (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.2-3.3, P = .007). DT patients had higher pelvic tilt, lower lumbar lordosis, and greater pelvic-incidence lumbar lordosis mismatch than non-DT patients (P < .05). DT patients had longer operative times (424 vs 375 minutes, P = .008), were more likely to undergo interbody fusions (OR = 2.0, 95% CI = 1.1-3.6, P = .021), osteotomies (OR = 2.2, 95% CI = 1.1-4.0, P = .012), and decompressions (OR = 2.3, 95% CI = 1.3-4.3, P = .003). In our multivariate analysis, only decompressions were associated with an increased risk of DT (OR = 3.2, 95% CI = 1.4-7.6, P = .006). There were no significant differences in patient outcomes at 2 years.ConclusionsThe rate of DT was 10.8% in an ASD cohort. This is similar to rates of DT reported following surgery for degenerative pathology. A history of prior spine surgery, decompression, interbody fusion, and osteotomies are all associated with an increased risk of DT, but decompression is the only independent risk factor for DT