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STUDY DESIGN Survey based on complication scenarios. OBJECTIVE To assess and compare perceived potential impacts of various perioperative adverse events by both surgeons and patients. SUMMARY OF BACKGROUND DATA Incidence of adverse events after adult spinal deformity surgery remains substantial. Patient-centered outcomes tools measuring the impact of these events have not been developed. An important first step is to assess the perceptions of surgeons and patients regarding the impact of these events on surgical outcome and quality of life. METHODS Descriptions of 22 potential adverse events of surgery (heart attack, stroke, spinal cord injury, nerve root injury, cauda equina injury, blindness, dural tear, blood transfusion, deep vein thrombosis, pulmonary embolism, superficial infection, deep infection, lung failure, urinary tract infection, nonunion, adjacent segment disease, persistent deformity, implant failure, death, renal failure, gastrointestinal complications, and sexual dysfunction) were presented to 14 spinal surgeons and 16 adult patients with spinal deformity. Impact scores were assigned to each complication on the basis of perceptions of overall severity, satisfaction with surgery, and effect on quality of life. Impact scores were compared between surgeons and patients with a Wilcoxon/Kruskal-Wallis test. RESULTS Mean impact scores varied from 0.9 (blood transfusion) to 10.0 (death) among surgeons and 2.3 (urinary tract infection) to 9.2 (stroke) among patients. Patients' scores were consistently higher (P < 0.05) than surgeons in all 3 categories for 6 potential adverse events: stroke, lung failure, heart attack, pulmonary embolism, dural tear, and blood transfusion. Three additional complications (renal failure, non-union, and deep vein thrombosis) were rated higher in 1 or 2 categories by patients. CONCLUSION There was substantial variation in how both surgeons and patients perceived impacts of various adverse events after spine surgery. Patients generally perceived the impact of adverse events to be greater than surgeons. Patient-centered descriptions of adverse events would provide a more complete description of surgical outcomes.

STUDY DESIGN Cross-Sectional Cohort Study OBJECTIVE.: To describe age-stratified normative values of novel occipitocervical, cervical, and cervicothoracic alignment parameters. SUMMARY OF BACKGROUND DATA Full-body radiographic images obtained without stitching or vertical distortion represent an ideal method to evaluate occipitocervical alignment and horizontal gaze. METHODS One hundred twenty adults with no back or neck symptoms were recruited. Age, sex, body mass index, Neck Disability Index (NDI), and Oswestry Disability Index scores were recorded. Radiographic parameters measured included: center sacral vertebral line, chin brow vertical angle (CBVA), orbital tilt (OrT), orbital slope, occipital slope (OS), occipital incidence, occiput-C2 (O-C2) lordosis, cervical lordosis (C2-C7, CL), T1 slope (TS), neck tilt, thoracic inlet angle (TIA), cervicothoracic kyphosis (C6-T4), and C2-C7 sagittal vertical axis (C2-7 SVA). Interobserver reliability was calculated for all measurements (intraclass correlation coefficient, ICC). A Pearson correlation was used to determine relationships between variables. RESULTS A total of 115 patients were analyzed; average age as 50.1 years (range 22-78). All measured variables had an ICC >0.6. CL (r = -0.33, P

STUDY DESIGN Cross-sectional cohort study. OBJECTIVE Describe age-stratified normative values of traditional and novel sagittal alignment parameters. SUMMARY OF BACKGROUND DATA Full-body radiographic techniques can capture coronal and sagittal standing images from the occiput to the foot without stitching or vertical distortion. This provides an ideal method to evaluate measures of global alignment. METHODS Adults with no back or neck symptoms were recruited. Age, body mass index, Neck Disability Index, and Oswestry Disability Index scores were recorded. The following parameters were measured: center sacral vertebral line, Occiput-C2 (O-C2) lordosis, cervical lordosis (C2-C7, CL), thoracic kyphosis (T2-12, TK), T2-T5 kyphosis, T5-T12 kyphosis, thoracolumbar kyphosis (T10-L2), lumbar lordosis (L1-S1, LL), sacral slope, pelvic tilt, pelvic incidence (PI), knee flexion angle, global sagittal angle, T1-pelvis angle, C2-S1 sagittal vertical axis (SVA), C7-S1 SVA, Basion-C7 SVA, B-S1 SVA and Basion to the center of the femoral head SVA and PI minus LL. Comparisons of sagittal alignment parameters between different age groups were performed. A Pearson correlation was used to determine relationships. RESULTS One hundred fifteen volunteers had imaging suitable for analysis; average age as 50.1 years (range 22-78), average body mass index was 28, average Neck Disability Index was 3.4 ± 4.4, and average Oswestry Disability Index was 1.7 ± 4.9. CL (r = -0.34, P = 0.001), T1-pelvis angle (r = 0.44, P

STUDY DESIGN Multi-center, retrospective review. OBJECTIVE Identify age associated clinical and radiographic features correlating with AS treatment. SUMMARY OF BACKGROUND DATA Little information exists about factors determining treatment for adult scoliosis (AS). Existing studies have not evaluated age stratified differences. METHODS Multicenter, retrospective review of 290 patients treated for AS. Patients divided into operative (OP) or nonoperative (NON), and age stratified into 3 groups (G1 = 65 years). Demographic and spinopelvic radiographic parameters evaluated. Health-related quality of life (HRQL) measures included SRS-22, Oswestry Disability Index (ODI), visual analog pain scale. RESULTS Treatment groups (OP, n = 137; NON, n = 153) demonstrated similar age (OP = 52.7 years; NON = 55.5 years; P > 0.05) and comorbidities. OP had larger thoracic curves than NON (OP = 51 degrees, NON = 45 degrees; P < 0.05). OP had worse HRQL scores than NON (SRS = 2.95 vs. 3.12, P < 0.05; ODI = 33.4 vs. 28.7, P < 0.05; visual analog pain scale = 6.9 vs. 5.6, P < 0.05, respectively). Age stratification of OP demonstrated larger curves in G1 and G2 versus G3, progressively worsening sagittal imbalance in older age groups, and worse HRQL scores in G3 versus G1 and G2. Age stratification of NON demonstrated worsening sagittal imbalance with age, however, other radiographic values and HRQL scores were similar between all NON age groups. Treatment stratification of age groups demonstrated G1-OP had greater deformity than G1-NON (mean thoracic curve: G1-OP = 53 degrees, G1-NON = 43 degrees; P < 0.05) but similar HRQL values. Whereas G2 and G3-OP had similar radiographic coronal and sagittal values as G2 and G3-NON, but worse HRQL scores. CONCLUSION Counter to previous reports, age, comorbidities, and sagittal balance did not influence treatment modality for AS. Operative treatment for younger patients was driven by increased coronal plane deformity. Conversely, pain and disability mandated treatment for older patients, independent of radiographic measures. These findings suggest that AS patients do not become uniformly disabled with age, and that disability can not be solely predicted by radiographic findings. These data should be considered when considering treatment for AS.

Study Design. Retrospective review. Objective. To determine if Anterior/Posterior Combined approach spine surgery is associated with an increased risk of pulmonary embolism (PE) compared to Posterior Only approach surgery. Summary of Background Data. Combined anterior/posterior approach spine surgery is associated with a significantly increased risk for PE. However, it is uncertain if there is any difference in risk between combined approaches versus a posterior-only approach. Methods. A prospective cohort of patients who underwent anterior/ posterior combined approach spine surgery from January 2002 to January 2006 was compared to a retrospective cohort of consecutive patients who underwent posterior only approach spine surgery from September2007 to September 2008. Patient demographics, medical history, body-mass indexes, type of surgery, length of surgery, transfusions, and instrumented vertebral levels were collected from hospital and office records. Hospital records were used to identify patients who developed PE based on diagnosis by spiral CT scan.CT scans were only performed when a patient's clinical picture raised suspicion of PE. Fisher exact test for significance, X 2 test and odds ratios were used for analysis. Results. A total of 119 patients were included in the study: 63 patients underwent posterior approach spine surgery and 66 patients underwent combined anterior/posterior approach surgery. One patient (1.6%) developed PE after posterior approach surgery while 5 patients (7.5%) developed PE in the combined approach group.Those undergoing combined approaches were 5.08 times more likely to suffer from PE, but this increase was not significant (P = 0.208). Overall, increased risk for PE was associated with the number of levels fused (P = 0.006), total blood loss (P = 0.029), and number of units transfused (P = 0.030). The combined approach was associated with older age (P < 0.001), higher BMI (P = 0.023), more instrumented vertebrae (P < 0.001), greater total blood loss (P < 0.001) and cell saver infusion (P = 0.004) compared to the posterior only approach. Conclusion. Combined anterior/posterior approach spine surgery is associated with an increased risk for pulmonary embolism compared to posterior only approaches. However, regardless of the surgical approach, risk factors for PE common in both groups were operative time, total blood loss, number of levels fused, and the number of units transfused. Patients who undergo spine surgery with prolonged operative times and greater blood loss should be recognized as higher risk patients.

STUDY DESIGN The posterolateral rabbit spinal fusion model was used to assess the effect of intermittent parathyroid hormone on spinal fusion outcomes. OBJECTIVE To test the hypothesis that intermittent parathyroid hormone (PTH) improves spinal fusion outcomes in the rabbit posterolateral spinal fusion model. SUMMARY OF BACKGROUND DATA Spinal fusion is the definitive management for spinal deformity or instability, yet despite current technology, 5% to 40% of lumbar fusions result in pseudarthrosis. Animal studies have demonstrated enhanced fracture healing with the use of PTH, but the effect of PTH on spinal fusion is poorly described. METHODS Forty-four male New Zealand white rabbits underwent bilateral posterolateral spine fusion (L5-L6 level). Twenty-two rabbits received daily subcutaneous injections of PTH (1-34) (10 microg/kg) and 22 received an injection of saline fluid. All were killed 6 weeks after surgery. L5-L6 vertebral segments were removed and analyzed with manual bending, faxitron radiography, microCT, and histomorphometry. RESULTS Manual bending identified fusion in 30% (control) versus 81% (PTH) animals (P < 0.001). A radiographic scoring system ("0" = no bone formation, "5" = full fusion) resulted in an average score of 3.36 (control) versus 4.51 (PTH) (P < 0.001). MicroCT analysis demonstrated a median mass of 3.5 cc (control) (range, 2.25-5.40 cc) versus 6.03 cc (PTH) (range, 4.34-10.58 cc) (P < 0.001). Histology showed a median percentage bone area of 14.3% (control) (n = 12) versus 29.9% (PTH) (n = 15) (P < 0.001). The median percentage cartilage was 2.7% (control) (n = 5) versus 26.6% (PTH) (n = 5) (P < 0.01). Osteoclast quantification revealed median values of 140.5 (control) (n = 6) and 345.0 (PTH) (n = 8) (P < 0.001) respectively, and the percentage of osteoblasts revealed a median value of 31.4% (control) (n = 6) versus 64.4% (PTH) (n = 8) (P < 0.001). CONCLUSION Intermittent PTH administration increased posterolateral fusion success in rabbits. Fusion bone mass and histologic determinants were also improved with PTH treatment. PTH has promise for use as an adjunctive agent to improve spinal fusion in clinical medicine.