13 research outputs found
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55. Do elderly patients have higher risk of complications and reoperations with MIS deformity surgery?
Evidence suggests that increasing age raises the risk for higher complications with traditional open deformity surgery. The decreased exposure related morbidity associated with minimally invasive surgery (MIS) has the potential to lower the complication profile in older surgical patients.
To evaluate the impact of age on complications and reoperations.
Prospective outcomes registry.
A total of 142 patients.
Complications and reoperations.
Inclusion criteria included age ≥ 18 years, and at least one of the following criteria: coronal curve (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, or thoracic kyphosis (TK) > 60°. Complications (major/minor) and reoperations were collected. A total of 142 patients who underwent circumferential MIS surgery were divided into younger (≤65 yrs, N=45) and older (>65 yrs, N=97) groups. Chi-square and t-test analyses were performed.
Mean age was 57 years (SD±10) in the younger and 73.7yrs (SD±4.8) in the older groups (p<0.001). There were no significant differences in gender (F:76% vs F:66%), BMI (28.2 vs 29.0), frailty (3.7 vs 3.3), interbody levels fused (3.0 vs 3.3), posterior levels fused (4.8 vs 5.6) between younger and older groups, respectively. CCI was significantly lower in the younger (1.64) vs older (2.4) group (p=0.014). Total complications did not differ between younger (48.9%, N=22) and older (47.4%, N=46) patients (p=0.8). Major complications occurred in 11.1% of younger and 7.2% of older patients (p=0.317). Minor complications occurred in 17.8% of younger and 18.6% of older patients (p=0.555). Both major and minor complications occurred in 11.1% of younger and 6.2% of older patients (p=0.242). Reoperations were significantly less in the younger (4.4%, N=2) compared to the older (16.5%, N=16) (p=0.035). Follow-up was 12.8 months in the younger and 12.5 months in the older group.
Despite significantly more comorbidities, total complications were not higher in elderly patients undergoing MIS surgery. However, elderly patients were found to have a higher reoperation rate, with PJK and instrumentation failure/mal-positioning being the most frequent reasons.
This abstract does not discuss or include any applicable devices or drugs
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Factors affecting approach selection for minimally invasive versus open surgery in the treatment of adult spinal deformity: analysis of a prospective, nonrandomized multicenter study
OBJECTIVE Surgical decision-making and planning is a key factor in optimizing outcomes in adult spinal deformity (ASD). Minimally invasive spinal (MIS) strategies for ASD have been increasingly used as an option to decrease postoperative morbidity. This study analyzes factors involved in the selection of either a traditional open approach or a minimally invasive approach to treat ASD in a prospective, nonrandomized multicenter trial. All centers had at least 5 years of experience in minimally invasive techniques for ASD.
METHODS The study enrolled 268 patients, of whom 120 underwent open surgery and 148 underwent MIS surgery. Inclusion criteria included age >= 18 years, and at least one of the following criteria: coronal curve (CC) >= 20 degrees, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25 degrees, or thoracic kyphosis (TK) > 60 degrees. Surgical approach selection was made at the discretion of the operating surgeon. Preoperative significant differences were included in a multivariate logistic regression analysis to determine odds ratios (ORs) for approach selection.
RESULTS Significant preoperative differences (p < 0.05) between open and MIS groups were noted for age (61.9 vs 66.7 years), numerical rating scale (NRS) back pain score (7.8 vs 7), CC (36 degrees vs 26.11, PT (26.4 degrees vs 23 degrees), T1 pelvic angle (TPA; 25.8 degrees vs 21.7 degrees), and pelvic incidence-lumbar lordosis (PI-LL; 19.6 degrees vs 14.9 degrees). No significant differences in BMI (29 vs 28.5 kg/m(2)), NRS leg pain score (5.2 vs 5.7), Oswestry Disability Index (48.4 vs 47.2), Scoliosis Research Society 22-item questionnaire score (2.7 vs 2.8), PI (58.3 degrees vs 57.1 degrees), LL (38.9 degrees vs 42.3 degrees), or SVA (73.8 mm vs 60.3 mm) were found. Multivariate analysis found that age (OR 1.05, p = 0.002), VAS back pain score (OR 1.21, p = 0.016), CC (OR 1.03, p < 0.001), decompression (OR 4.35, p < 0.001), and TPA (OR 1.09, p = 0.023) were significant factors in approach selection.
CONCLUSIONS Increasing age was the primary driver for selecting MIS surgery. Conversely, increasingly severe deformities and the need for open decompression were the main factors influencing the selection of traditional open surgery. As experience with MIS surgery continues to accumulate, future longitudinal evaluation will reveal if more experience, use of specialized treatment algorithms, refinement of techniques, and technology will expand surgeon adoption of MIS techniques for adult spinal deformity
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Role of obesity in less radiographic correction and worse health-related quality-of-life outcomes following minimally invasive deformity surgery
OBJECTIVE Minimally invasive surgery (MIS) for adult spinal deformity (ASD) can offer deformity correction with less tissue manipulation and damage. However, the impact of obesity on clinical outcomes and radiographic correction following MIS for ASD is poorly understood. The goal of this study was to determine the role, if any, that obesity has on radiographic correction and health-related quality-of-life measures in MIS for ASD. METHODS Data were collected from a multicenter database of MIS for ASD. This was a retrospective review of a prospectively collected database. Patient inclusion criteria were age ≥ 18 years and coronal Cobb angle ≥ 20°, pelvic incidence–lumbar lordosis mismatch ≥ 10°, or sagittal vertical axis (SVA) > 5 cm. A group of patients with body mass index (BMI) < 30 kg/m 2 was the control cohort; BMI ≥ 30 kg/m 2 was used to define obesity. Obesity cohorts were categorized into BMI 30–34.99 and BMI ≥ 35. All patients had at least 1 year of follow-up. Preoperative and postoperative health-related quality-of-life measures and radiographic parameters, as well as complications, were compared via statistical analysis. RESULTS A total of 106 patients were available for analysis (69 control, 17 in the BMI 30–34.99 group, and 20 in the BMI ≥ 35 group). The average BMI was 25.24 kg/m 2 for the control group versus 32.46 kg/m 2 (p < 0.001) and 39.5 kg/m 2 (p < 0.001) for the obese groups. Preoperatively, the BMI 30–34.99 group had significantly more prior spine surgery (70.6% vs 42%, p = 0.04) and worse preoperative numeric rating scale leg scores (7.71 vs 5.08, p = 0.001). Postoperatively, the BMI 30–34.99 cohort had worse Oswestry Disability Index scores (33.86 vs 23.55, p = 0.028), greater improvement in numeric rating scale leg scores (−4.88 vs −2.71, p = 0.012), and worse SVA (51.34 vs 26.98, p = 0.042) at 1 year postoperatively. Preoperatively, the BMI ≥ 35 cohort had significantly worse frailty (4.5 vs 3.27, p = 0.001), Oswestry Disability Index scores (52.9 vs 44.83, p = 0.017), and T1 pelvic angle (26.82 vs 20.71, p = 0.038). Postoperatively, after controlling for differences in frailty, the BMI ≥ 35 cohort had significantly less improvement in their Scoliosis Research Society–22 outcomes questionnaire scores (0.603 vs 1.05, p = 0.025), higher SVA (64.71 vs 25.33, p = 0.015) and T1 pelvic angle (22.76 vs 15.48, p = 0.029), and less change in maximum Cobb angle (−3.93 vs −10.71, p = 0.034) at 1 year. The BMI 30–34.99 cohort had significantly more infections (11.8% vs 0%, p = 0.004). The BMI ≥ 35 cohort had significantly more implant complications (30% vs 11.8%, p = 0.014) and revision surgery within 90 days (5% vs 1.4%, p = 0.034). CONCLUSIONS Obese patients who undergo MIS for ASD have less correction of their deformity, worse quality-of-life outcomes, more implant complications and infections, and an increased rate of revision surgery compared with their nonobese counterparts, although both groups benefit from surgery. Appropriate counseling should be provided to obese patients
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Two- and three-year outcomes of minimally invasive and hybrid correction of adult spinal deformity
Previous studies have demonstrated the short-term radiographic and clinical benefits of circumferential minimally invasive surgery (cMIS) and hybrid (i.e., minimally invasive anterior or lateral interbody fusion with an open posterior approach) techniques to correct adult spinal deformity (ASD). However, it is not known if these benefits are maintained over longer periods of time. This study evaluated the 2- and 3-year outcomes of cMIS and hybrid correction of ASD.
A multicenter database was retrospectively reviewed for patients undergoing cMIS or hybrid surgery for ASD. Patients were ≥ 18 years of age and had one of the following: maximum coronal Cobb angle (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic incidence-lumbar lordosis mismatch (PI-LL) ≥ 10°, or pelvic tilt (PT) > 20°. Radiographic parameters were evaluated at the latest follow-up. Clinical outcomes were compared at 2- and 3-year time points and adjusted for age, preoperative CC, levels operated, levels with interbody fusion, presence of L5-S1 anterior lumbar interbody fusion, and upper and lower instrumented vertebral level.
Overall, 197 (108 cMIS, 89 hybrid) patients were included with 187 (99 cMIS, 88 hybrid) and 111 (60 cMIS, 51 hybrid) patients evaluated at 2 and 3 years, respectively. The mean (± SD) follow-up duration for cMIS (39.0 ± 13.3 months, range 22-74 months) and hybrid correction (39.9 ± 16.8 months, range 22-94 months) were similar for both cohorts. Hybrid procedures corrected the CC greater than the cMIS technique (adjusted p = 0.022). There were no significant differences in postoperative SVA, PI-LL, PT, and sacral slope (SS). At 2 years, cMIS had lower Oswestry Disability Index (ODI) scores (adjusted p < 0.001), greater ODI change as a percentage of baseline (adjusted p = 0.006), less visual analog scale (VAS) back pain (adjusted p = 0.006), and greater VAS back pain change as a percentage of baseline (adjusted p = 0.001) compared to hybrid techniques. These differences were no longer significant at 3 years. At 3 years, but not 2 years, VAS leg pain was lower for cMIS compared to hybrid techniques (adjusted p = 0.032). Those undergoing cMIS had fewer overall complications compared to hybrid techniques (adjusted p = 0.006), but a higher odds of pseudarthrosis (adjusted p = 0.039).
In this review of a multicenter database for patients undergoing cMIS and hybrid surgery for ASD, hybrid procedures were associated with a greater CC improvement compared to cMIS techniques. cMIS was associated with superior ODI and back pain at 2 years, but this difference was no longer evident at 3 years. However, cMIS was associated with superior leg pain at 3 years. There were fewer complications following cMIS, with the exception of pseudarthrosis
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Spinal Deformity Complexity Checklist (SDCC) for Minimally Invasive Surgery: Expert Consensus from the Minimally Invasive International Spine Study Group
We developed a spinal deformity complexity checklist (SDCC) to assess the difficulty in performing a circumferential minimally invasive surgery (MIS) for adult spinal deformity (ASD).
A modified Delphi method of panel experts was utilized to construct an SDCC checklist of radiographic and patient-related characteristics that could affect the complexity of surgery via MIS approaches. Ten surgeons with expertise in MIS deformity surgery were queried to develop and refine the SDCC with 3 radiographic categories (X-ray, MRI, CT) and 1 patient-related category. Within each category, characteristics affecting MIS complexity were identified by initial round table discussion. Second-round discussion determined which characteristics substantially impacted complexity the most.
Thirteen characteristics within the X-ray category were determined. Spinopelvic characteristics, endpoints of instrumentation, and prior hardware/fusion were associated with increased complexity. Vertebral body rotation-as reflected by the Nash-Moe grade-added significant complexity. Psoas anatomy and spinal stenosis added the most complexity for the 5 MRI characteristics. Pre-existing fusion added the most complexity for the 3 CT characteristics, Osteoporosis and BMI affected complexity of the 5 patient-related characteristics.
The SDCC is a comprehensive list of pertinent radiographic and patient-related characteristics affecting complexity level for MIS deformity surgery. The value of the SDCC is that it allows rapid assessment of key factors when determining whether MIS surgery can be performed effectively and safely. Patients with scores of 4 in any characteristic should be considered challenging to treat with MIS; open surgery may be a better alternative
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P99. Are two-year reoperation rates different for circumferential minimally invasive surgery (cMIS) vs open ASD surgery? A propensity matched cohort study using a prospective ASD database
As surgical techniques for deformity correction evolve towards minimizing tissue trauma, further clarity is warranted to define differences in complication profiles between cMIS and open surgeries.
To compare cMIS and open surgery reoperation rates and identify contributing etiologies to reoperation in each cohort.
Prospective multicenter observational series.
Database enrollment required age =18 years, adult spinal deformity and circumferential minimally invasive spine surgery.
Reoperation rate, patient reported outcomes (PROMS), spinopelvic parameters, mechanical failures (defined as rod breakage/dislocation, screw breakage/loosening, set screw loosening, proximal/distal junctional kyphosis, pseudoarthrosis) and other factors contributing to re-operation such as wound infection, medial breach, nerve impingement by screw, vertebral body fracture, sagittal/coronal imbalance, and wound infection.
A total of 85 patients (pts) with cMIS for ASD with 2-year follow-up (2YFU) were identified and propensity matched to 85 patients in open cohort. Propensity matching was performed based on pre-operative PT, PI-LL, BMI, and SVA. Patient demographic variables, reoperation rate, and complications contributing to reoperation were compared with uni- and multi-variate analysis at any time in each cohort (33 open, 17 cMIS). PROMS at 2YFU were compared in the reoperated cohorts.
Total of 33 reoperation in the open cohort vs 17 in cMIS were identified. The reoperation rate was significantly higher in the open cohort at 39% (33/85) compared to 20% (17/85) in the cMIS cohort (P= 0.012). The reoperation rate in open cohort related to mechanical failure was 52% (17/33) compared to 35% (6/17) in cMIS cohort (P= 0.43). No significant difference was found in rates of specific etiologies contributing to complications in the cMIS vs open reoperation cohorts under uni- and multivariate analysis. The change in spinopelvic parameters among the two reoperation cohorts at 2YFU were statistically not significant (δCVA, δSVA, δPI-LL, δPT, δLL CA, δTL CA). Under univariate analysis, the following PROMS were similar: ODI, NRS Leg and Back Pain, EQ5D, EQ5D-VAS, SF-36 PCS,SF-36 MCS. However, SRS-22 in open cohort was significantly higher at 2YFU (3.55 ± 0.73 open vs. 3,10 ± 0.56 MIS, p = 0.029).
Findings in our ongoing study show that cMIS procedures were associated with a significantly lower reoperation rate compared to open surgical approaches. PROMS and the change in spinopelvic parameters were similar at 2YFU in both reoperated cohorts (except for SRS-22 favored open cohort).
This abstract does not discuss or include any applicable devices or drugs
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Incremental benefits of circumferential minimally invasive surgery for increasingly frail patients with adult spinal deformity
Circumferential minimally invasive surgery (cMIS) may provide incremental benefits compared with open surgery for patients with increasing frailty status by decreasing peri- and postoperative complications.
Operative patients with adult spinal deformity (ASD) ≥ 18 years old with baseline and 2-year postoperative data were assessed. With propensity score matching, patients who underwent cMIS (cMIS group) were matched with similar patients who underwent open surgery (open group) based on baseline BMI, C7-S1 sagittal vertical axis, pelvic incidence to lumbar lordosis mismatch, and S1 pelvic tilt. The Passias modified ASD frailty index (mASD-FI) was used to determine patient frailty stratification as not frail, frail, or severely frail. Baseline and postoperative factors were assessed using two-way analysis of covariance (ANCOVA) and multivariate ANCOVA while controlling for baseline age, Charlson Comorbidity Index (CCI) score, and number of levels fused.
After propensity score matching, 170 ASD patients (mean age 62.71 ± 13.64 years, 75.0% female, mean BMI 29.25 ± 6.60 kg/m2) were included, split evenly between the cMIS and open groups. Surgically, patients in the open group had higher numbers of posterior levels fused (p = 0.021) and were more likely to undergo three-column osteotomies (p > 0.05). Perioperatively, cMIS patients had lower intraoperative blood loss and decreased use of cell saver across frailty groups (with adjustment for baseline age, CCI score, and levels fused), as well as fewer perioperative complications (p < 0.001). Adjusted analysis also revealed that compared to open patients, increasingly frail patients in the cMIS group were also more likely to demonstrate greater improvement in 1- and 2-year postoperative scores for the Oswestry Disability Index, SRS-36 (total), EQ-5D and SF-36 (all p < 0.05). With regard to postoperative complications, increasingly frail patients in the cMIS group were also noted to experience significantly fewer complications overall (p = 0.036) and fewer major intraoperative complications (p = 0.039). The cMIS patients were also less likely to need a reoperation than their open group counterparts (p = 0.043).
Surgery performed with a cMIS technique may offer acceptable outcomes, with diminishment of perioperative complications and mitigation of catastrophic outcomes, in increasingly frail patients who may not be candidates for surgery using traditional open techniques. However, further studies should be performed to investigate the long-term impact of less optimal alignment in this population