The impact of baseline cervical malalignment on the development of proximal junctional kyphosis following surgical correction of thoracolumbar adult spinal deformity.

OBJECTIVE: The objective of this study was to identify the effect of baseline cervical deformity (CD) on proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) in patients with adult spinal deformity (ASD). METHODS: This study was a retrospective analysis of a prospectively collected, multicenter database comprising ASD patients enrolled at 13 participating centers from 2009 to 2018. Included were ASD patients aged \u3e 18 years with concurrent CD (C2-7 kyphosis \u3c -15°, T1S minus cervical lordosis \u3e 35°, C2-7 sagittal vertical axis \u3e 4 cm, chin-brow vertical angle \u3e 25°, McGregor\u27s slope \u3e 20°, or C2-T1 kyphosis \u3e 15° across any three vertebrae) who underwent surgery. Patients were grouped according to four deformity classification schemes: Ames and Passias CD modifiers, sagittal morphotypes as described by Kim et al., and the head versus trunk balance system proposed by Mizutani et al. Mean comparison tests and multivariable binary logistic regression analyses were performed to assess the impact of these deformity classifications on PJK and PJF rates up to 3 years following surgery. RESULTS: A total of 712 patients with concurrent ASD and CD met the inclusion criteria (mean age 61.7 years, 71% female, mean BMI 28.2 kg/m2, and mean Charlson Comorbidity Index 1.90) and underwent surgery (mean number of levels fused 10.1, mean estimated blood loss 1542 mL, and mean operative time 365 minutes; 70% underwent osteotomy). By approach, 59% of the patients underwent a posterior-only approach and 41% underwent a combined approach. Overall, 277 patients (39.1%) had PJK by 1 year postoperatively, and an additional 189 patients (26.7%) developed PJK by 3 years postoperatively. Overall, 65 patients (9.2%) had PJF by 3 years postoperatively. Patients classified as having a cervicothoracic deformity morphotype had higher rates of early PJK than flat neck deformity and cervicothoracic deformity patients (p = 0.020). Compared with the head-balanced patients, trunk-balanced patients had higher rates of PJK and PJF (both p \u3c 0.05). Examining Ames modifier severity showed that patients with moderate and severe deformity by the horizontal gaze modifier had higher rates of PJK (p \u3c 0.001). CONCLUSIONS: In patients with concurrent cervical and thoracolumbar deformities undergoing isolated thoracolumbar correction, the use of CD classifications allows for preoperative assessment of the potential for PJK and PJF that may aid in determining the correction of extending fusion levels

A Risk Benefit Analysis of Increasing Surgical Invasiveness Relative to Frailty Status in Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective review of a prospectively enrolled multicenter Adult Spinal Deformity (ASD) database. OBJECTIVE: Investigate invasiveness and outcomes of ASD surgery by frailty state. SUMMARY OF BACKGROUND DATA: The ASD Invasiveness Index incorporates deformity-specific components to assess correction magnitude. Intersections of invasiveness, surgical outcomes, and frailty state are understudied. METHODS: ASD patients with baseline and 3-year (3Y) data were included. Logistic regression analyzed the relationship between increasing invasiveness and major complications or reoperations and meeting minimal clinically important differences (MCID) for health-related quality of life (HRQL) measures at 3Y. Decision tree analysis assessed invasiveness risk-benefit cut-off points, above which experiencing complications or reoperations and not reaching MCID were higher. Significance was set to p \u3c 0.05. RESULTS: Overall, 195/322 patients were included. Baseline demographics: age 59.9 ± 14.4, 75% female, BMI 27.8 ± 6.2, mean Charlson Comorbidity Index: 1.7 ± 1.7. Surgical information: 61% osteotomy, 52% decompression, 11.0 ± 4.1 levels fused. There were 98 not frail (NF), 65 frail (F), and 30 severely frail (SF) patients. Relationships were found between increasing invasiveness and experiencing a major complication or reoperation for the entire cohort and by frailty group (all p \u3c 0.05). Defining a favorable outcome as no major complications or reoperation and meeting MCID in any HRQL at 3Y established an invasiveness cut-off of 63.9. Patients below this threshold were 1.8[1.38-2.35] (p \u3c 0.001) times more likely to achieve favorable outcome. For NF patients, the cut-off was 79.3 (2.11[1.39-3.20] (p \u3c 0.001), 111 for F (2.62 [1.70-4.06] (p \u3c 0.001), and 53.3 for SF (2.35[0.78-7.13] (p = 0.13). CONCLUSIONS: Increasing invasiveness is associated with increased odds of major complications and reoperations. Risk-benefit cut-offs for successful outcomes were 79.3 for NF, 111 for F, and 53.3 for SF patients. Above these, increasing invasiveness has increasing risk of major complications or reoperations and not meeting MCID at 3Y.Level of Evidence: 3

Cardiovascular risk associated with high sodium-containing drugs: A systematic review.

Excess dietary sodium is associated with increased blood pressure (BP). Some drugs are associated with high sodium intake (in particular effervescent tablets), but the cardiovascular risk associated with such high sodium-containing drugs (HSCD) is largely underevaluated.To summarize the evidence for a potential cardiovascular risk associated with exposure to HSCD, and to highlight possible risk factors associated with this iatrogenic issue; in general and/or specific populations.We conducted a systematic review, by searching electronic databases including MEDLINE, EMBASE, Web of Science, CENTRAL and grey literature between 1960 and 2015. We included studies that reported modification of cardiovascular parameters or incidence/prevalence of cardiovascular outcomes, between a group of subjects exposed to HSCD relative to a non-exposed group. The threshold used to identify HSCD was 391 mg/day. We did not consider studies evaluating exposure to sodium as an active ingredient or those focusing on dialysis solutions or enteral/parenteral nutrition. Study quality was assessed using the EPHPP tool.A total of eight studies met our inclusion criteria. Four reported results for short-term exposure to HSCD (≤ 7 days) on BP fluctuations. One study reported an elevation of BP (associated sodium intake: 1,656 mg/day). Four studies evaluated a long-term exposure (≥ 2 years or discontinuation of a chronic treatment). Two studies reported iatrogenic risk. For these studies, drug associated sodium intake was high (> 1,500 mg/day) in patients with comorbidities (in particular, diabetes mellitus and hypertension).Despite numerous study limitations, this systematic review suggests three potential synergistic risk factors for cardiovascular complications after exposure to HSCD: a high sodium intake (≥ 1,500 mg/day), a long duration of exposure, and the presence of comorbidities. Further studies are required to characterize this iatrogenic risk.PROSPERO CRD42016047086

Risk-benefit assessment of major versus minor osteotomies for flexible and rigid cervical deformity correction.

Introduction: Osteotomies are commonly performed to correct sagittal malalignment in cervical deformity (CD). However, the risks and benefits of performing a major osteotomy for cervical deformity correction have been understudied. The objective of this retrospective cohort study was to investigate the risks and benefits of performing a major osteotomy for CD correction. Methods: Patients stratified based on major osteotomy (MAJ) or minor (MIN). Independent Results: 137 CD patients were included (62 years, 65% F). 19.0% CD patients underwent a MAJ osteotomy. After propensity score matching for cSVA, 52 patients were included. About 19.0% CD patients underwent a MAJ osteotomy. MAJ patients had more minor complications ( Conclusions: Cervical deformity patients who underwent a major osteotomy had similar clinical outcomes at 3-months but worse outcomes at 1-year as compared to minor osteotomies, likely due to differences in baseline deformity. Patients with rigid deformities who underwent a major osteotomy had higher complication rates and worse clinical improvement despite similar realignment at 1 year