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Background and Objectives: For patients with surgical adult spinal deformity (ASD), our understanding of alignment has evolved, especially in the last 20 years. Determination of optimal restoration of alignment and spinal shape has been increasingly studied, yet the assessment of how these alignment schematics have incrementally added benefit to outcomes remains to be evaluated., Methods: Patients with ASD with baseline and 2-year were included, classified by 4 alignment measures: Scoliosis Research Society (SRS)-Schwab, Age-Adjusted, Roussouly, and Global Alignment and Proportion (GAP). The incremental benefits of alignment schemas were assessed in chronological order as our understanding of optimal alignment progressed. Alignment was considered improved from baseline based on SRS-Schwab 0 or decrease in severity, Age-Adjusted ideal match, Roussouly current (based on sacral slope) matching theoretical (pelvic incidence-based), and decrease in proportion. Patients separated into 4 first improving in SRS-Schwab at 2-year, second Schwab improvement and matching Age-Adjusted, third two prior with Roussouly, and fourth improvement in all four. Comparison was accomplished with means comparison tests and χ 2 analyses., Results: Sevenhundredthirty-two. patients met inclusion. SRS-Schwab BL: pelvic incidence-lumbar lordosis mismatch (++:32.9%), sagittal vertical axis (++: 23%), pelvic tilt (++:24.6%). 640 (87.4%) met criteria for first, 517 (70.6%) second, 176 (24%) third, and 55 (7.5%) fourth. The addition of Roussouly (third) resulted in lower rates of mechanical complications and proximal junctional kyphosis (48.3%) and higher rates of meeting minimal clinically important difference (MCID) for physical component summary and SRS-Mental ( P < .05) compared with the second. Fourth compared with the third had higher rates of MCID for ODI (44.2% vs third: 28.3%, P = .011) and SRS-Appearance (70.6% vs 44.8%, P < .001). Mechanical complications and proximal junctional kyphosis were lower with the addition of Roussouly ( P = .024), while the addition of GAP had higher rates of meeting MCID for SRS-22 Appearance ( P = .002) and Oswestry Disability Index ( P = .085)., Conclusion: Our evaluation of the incremental benefit that alignment schemas have provided in ASD corrective surgery suggests that the addition of Roussouly provided the greatest reduction in mechanical complications, while the incorporation of GAP provided the most significant improvement in patient-reported outcomes., (Copyright © Congress of Neurological Surgeons 2024. All rights reserved.)

Purpose: To develop a simplified, modified frailty index for adult spinal deformity (ASD) patients dependent on objective clinical factors., Methods: ASD patients with baseline (BL) and 2-year (2Y) follow-up were included. Factors with the largest R 2 value derived from multivariate forward stepwise regression were including in the modified ASD-FI (clin-ASD-FI). Factors included in the clin-ASD-FI were regressed against mortality, extended length of hospital stay (LOS, > 8 days), revisions, major complications and weights for the clin-ASD-FI were calculated via Beta/Sullivan. Total clin-ASD-FI score was created with a score from 0 to 1. Linear regression correlated clin-ASD-FI with ASD-FI scores and published cutoffs for the ASD-FI were used to create the new frailty cutoffs: not frail (NF: < 0.11), frail (F: 0.11-0.21) and severely frail (SF: > 0.21). Binary logistic regression assessed odds of complication or reop for frail patients., Results: Five hundred thirty-one ASD patients (59.5 yrs, 79.5% F) were included. The final model had a R 2 of 0.681, and significant factors were: < 18.5 or > 30 BMI (weight: 0.0625 out of 1), cardiac disease (0.125), disability employment status (0.3125), diabetes mellitus (0.0625), hypertension (0.0625), osteoporosis (0.125), blood clot (0.1875), and bowel incontinence (0.0625). These factors calculated the score from 0 to 1, with a mean cohort score of 0.13 ± 0.14. Breakdown by clin-ASD-FI score: 51.8% NF, 28.1% F, 20.2% SF. Increasing frailty severity was associated with longer LOS (NF: 7.0, F: 8.3, SF: 9.2 days; P < 0.001). Frailty independently predicted occurrence of any complication (OR: 9.357 [2.20-39.76], P = 0.002) and reop (OR: 2.79 [0.662-11.72], P = 0.162)., Conclusions: Utilizing an existing ASD frailty index, we proposed a modified version eliminating the patient-reported components. This index is a true assessment of physiologic status, and represents a superior risk factor assessment compared to other tools for both primary and revision spinal deformity surgery as a result of its immutability with surgery, lack of subjectivity, and ease of use., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Study Design/setting: This was a retrospective cohort study., Background: Little is known of the intersection between surgical invasiveness, cervical deformity (CD) severity, and frailty., Objective: The aim of this study was to investigate the outcomes of CD surgery by invasiveness, frailty status, and baseline magnitude of deformity., Methods: This study included CD patients with 1-year follow-up. Patients stratified in high deformity if severe in the following criteria: T1 slope minus cervical lordosis, McGregor's slope, C2-C7, C2-T3, and C2 slope. Frailty scores categorized patients into not frail and frail. Patients are categorized by frailty and deformity (not frail/low deformity; not frail/high deformity; frail/low deformity; frail/high deformity). Logistic regression assessed increasing invasiveness and outcomes [distal junctional failure (DJF), reoperation]. Within frailty/deformity groups, decision tree analysis assessed thresholds for an invasiveness cutoff above which experiencing a reoperation, DJF or not achieving Good Clinical Outcome was more likely., Results: A total of 115 patients were included. Frailty/deformity groups: 27% not frail/low deformity, 27% not frail/high deformity, 23.5% frail/low deformity, and 22.5% frail/high deformity. Logistic regression analysis found increasing invasiveness and occurrence of DJF [odds ratio (OR): 1.03, 95% CI: 1.01-1.05, P =0.002], and invasiveness increased with deformity severity ( P <0.05). Not frail/low deformity patients more often met Optimal Outcome with an invasiveness index <63 (OR: 27.2, 95% CI: 2.7-272.8, P =0.005). An invasiveness index <54 for the frail/low deformity group led to a higher likelihood of meeting the Optimal Outcome (OR: 9.6, 95% CI: 1.5-62.2, P =0.018). For the frail/high deformity group, patients with a score <63 had a higher likelihood of achieving Optimal Outcome (OR: 4.8, 95% CI: 1.1-25.8, P =0.033). There was no significant cutoff of invasiveness for the not frail/high deformity group., Conclusions: Our study correlated increased invasiveness in CD surgery to the risk of DJF, reoperation, and poor clinical success. The thresholds derived for deformity severity and frailty may enable surgeons to individualize the invasiveness of their procedures during surgical planning to account for the heightened risk of adverse events and minimize unfavorable outcomes., Competing Interests: P.G.P.: Allosource: Other financial or material support; Cervical Scoliosis Research Society: Research support; Globus Medical: Paid presenter or speaker; Medtronic: Paid consultant; Royal Biologics: Paid consultant; Spine: Editorial or governing board; SpineWave: Paid consultant; Terumo: Paid consultant; Zimmer: Paid presenter or speaker. V.L.: DePuy, A Johnson & Johnson Company: Paid presenter or speaker; European Spine Journal : Editorial or governing board; Globus Medical: Paid consultant; International Spine Study Group: Board or committee member; Nuvasive: IP royalties; Scoliosis Research Society: Board or committee member; The Permanente Medical Group: Paid presenter or speaker. R.F.: Nemaris: Stock or stock options. H.J.K.: AAOS: Board or committee member; Alphatec Spine: Paid consultant; AO SPINE: Board or committee member; Cervical Spine Research Society: Board or committee member; HSS Journal , Asian Spine Journal : Editorial or governing board; ISSGF: Research support; K2M: IP royalties; Scoliosis Research Society: Board or committee member; Zimmer: IP royalties. A.H.D.: EOS: Paid consultant; Medicrea: Paid consultant; Medtronic Sofamor Danek: Paid consultant; Novabone: Paid consultant; Orthofix Inc.: Paid consultant; Research support; Southern Spine: IP royalties; Spineart: IP royalties; Paid consultant; Springer: Publishing royalties, financial or material support; Stryker: Paid consultant. J.L.G.: Acuity: IP royalties; Paid consultant; Alan L. & Jacqueline B. Stuart Spine Research: Research support; Cerapedics: Research support; Cingulate Therapeutics: Stock or stock Options; DePuy, A Johnson & Johnson Company: Paid presenter or speaker; Global Spine Journal —Reviewer: Editorial or governing board; Intellirod Spine Inc.: Research support; K2M /Stryker: Board or committee member; MAZOR Surgical Technologies: Paid consultant; Medtronic: Board or committee member; Paid consultant; Research support; Norton Healthcare: Research support; Nuvasive: IP royalties; Paid consultant; Pfizer: Research support; Scoliosis Research Society: Research support; Spine Deformity —Reviewer: Editorial or governing board; Stryker: Paid consultant; Paid presenter or speaker; Texas Scottish Rite Hospital: Research support; The Spine Journal —Reviewer: Editorial or governing board. T.S.P.: Altus: IP royalties; Globus Medical: Paid consultant; Medicrea: Paid consultant; Medtronic: Paid consultant; Nuvasive: Paid consultant; Spine Align: Stock or stock Options; Stryker: Paid consultant; Torus Medical: Stock or stock Options. G.M.M.: Carlsmed: Paid consultant; ISSGF: Research support; K2M: IP royalties; Nuvasive: IP royalties; Paid consultant; Research support; Scoliosis Research Society: Board or committee member; SeaSpine: Paid consultant; Stryker: Paid consultant; Viseon: Paid consultant. R.K.E.: Aesculap/B.Braun: Paid consultant; Alphatec Spine: Stock or stock Options; Baxter: Paid consultant; Biedermann-Motech: Paid consultant; Carevature: Paid consultant; Stock or stock Options; Globus Medical: IP royalties; Invuity: Stock or stock Options; Medtronic: Paid consultant; Nocimed: Stock or stock Options; Nuvasive: IP royalties; Paid consultant; Research support; Stock or stock Options; Radius: Paid presenter or speaker; San Diego Spine Foundation: Board or committee member; Scoliosis Research Society: Board or committee member; Seaspine: IP royalties; Paid consultant; Stock or stock Options; SI Bone: IP royalties; Paid consultant; Society of Lateral Access Surgery: Board or committee member; Spine Innovations: Stock or stock Options; Stryker: Paid consultant. K.H.: European Spine Journal : Editorial or governing board; Nuvasive: Research support. E.O.K.: AO Spine: Paid presenter or speaker; Research support; DePuy, A Johnson & Johnson Company: Paid consultant; Medicrea: Paid consultant; Medtronic: Paid consultant; Stryker: Paid consultant. B.G.L.: ISSGF: Paid consultant. R.A.H.: American Orthopaedic Association: Board or committee member; Cervical Spine Research Society: Board or committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Paid presenter or speaker; Globus Medical: IP royalties; Paid consultant; Paid presenter or speaker; International Spine Study Group: Board or committee member; ISSLS Textbook of the Lumbar Spine: Editorial or governing board; Medtronic: Paid consultant; Paid presenter or speaker; North American Spine Society: Board or committee member; Orthofix Inc.: Paid consultant; Paid presenter or speaker; Scoliosis Research Society: Board or committee member; SeaSpine: IP royalties; Spine Connect: Stock or stock Options; Western Ortho Assn: Board or committee member. D.C.B.: Bioventus: Research support; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Pfizer: Research support; Progenerative Medical: Stock or stock Options; Scoliosis Research Society: Board or committee member; Spine Deformity : Editorial or governing board. P.V.M.: AANS/CNS Spine Section and Scoliosis Research Society: Board or committee member; American Association of Neurological Surgeons: Board or committee member; Cervical Spine Research Society: Board or committee member; Congress of Neurological Surgeons: Board or committee member; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Global Spine Journal : Editorial or governing board; Globus Medical: Paid consultant; International Spine Study Group: Research support; Neurosurgery: Editorial or governing board; NREF: Research support; Spinal Deformity: Editorial or governing board; Spinicity/ISD: Stock or stock Options; Springer: Publishing royalties, financial or material support; Stryker: Paid consultant; Taylor and Francis: Publishing royalties, financial or material support; Thieme: Publishing royalties, financial or material support; World Neurosurgery: Editorial or governing board. P.P.: AANS Spine Section: Board or committee member; Cerapedics: Research support; DePuy, A Johnson & Johnson Company: Research support; Globus Medical: IP royalties; Paid consultant; ISSG: Research support; Journal of Neurosurgery Spine : Editorial or governing board; Neurosurgery: Editorial or governing board; North American Spine Society: Board or committee member; Nuvasive: Paid consultant; Operative Neurosurgery: Editorial or governing board; Scoliosis Research Society: Board or committee member; SI-Bone: Research support. F.J.S.: DePuy, A Johnson & Johnson Company: Research support; Globus Medical: Paid consultant; Paid presenter or speaker; K2M: IP royalties; Paid consultant; Paid presenter or speaker; Medicrea: Paid consultant; Medtronic: Paid consultant; Medtronic Sofamor Danek: IP royalties; Paid presenter or speaker; Nuvasive: Research support; Scoliosis Research Society: Board or committee member; Spine Deformity : Editorial or governing board; Stryker: Research support; VP of International Spine Society Group (ISSG): Board or committee member; Zimmer: IP royalties; Paid consultant; Paid presenter or speaker. D.C.: Globus Medical: IP royalties; Paid consultant. C.I.S.: AANS: Board or committee member; Cervical Spine Research Society: Board or committee member; DePuy, A Johnson & Johnson Company: Paid presenter or speaker; Research support; Globus Medical: Research support; Medtronic: Other financial or material support; Paid consultant; Medtronic Sofamor Danek: IP royalties; Paid presenter or speaker; Research support; Neurosurgery RRC: Board or committee member; Nuvasive: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Stock or stock Options; Proprio: Paid consultant; Scoliosis Research Society: Board or committee member; SI Bone: IP royalties; Spinal Deformity: Editorial or governing board; Spine: Editorial or governing board. R.S.B.: allosource: Paid consultant; Research support; Biomet: Research support; DePuy, A Johnson & Johnson Company: Paid consultant; Research support; EOS: Research support; Globus Medical: Research support; k2 medical: IP royalties; Paid consultant; Paid presenter or speaker; Research support; Medtronic Sofamor Danek: Research support; North American Spine Society: Board or committee member; Nuvasive: IP royalties; Research support; Orthofix Inc.: Research support; Scoliosis Research Society: Board or committee member; Stryker: IP royalties; Paid presenter or speaker. C.P.A.: Biomet Spine: IP royalties; DePuy, A Johnson & Johnson Company: IP royalties; Paid consultant; Research support; Global Spine Analytics—Director: Other financial or material support; International Spine Study Group (ISSG): Research support; International Spine Study Group (ISSG)—Executive Committee: Other financial or material support; K2M: IP royalties; Paid consultant; Medicrea: IP royalties; Paid consultant; Medtronic: Paid consultant; Next Orthosurgical: IP royalties; Nuvasive: IP royalties; Operative Neurosurgery—Editorial Board: Other financial or material support; Scoliosis Research Society (SRS)—Grant Funding: Other financial or material support; Stryker: IP royalties; Titan Spine: Research support. J.S.S.: Alphatec Spine: Stock or stock Options; Carlsmed: Paid consultant; Cerapedics: Paid consultant; DePuy: Research support; DePuy, A Johnson & Johnson Company: Paid consultant; Journal of Neurosurgery Spine : Editorial or governing board; Neurosurgery: Editorial or governing board; Nuvasive: IP royalties; Paid consultant; Research support; Operative Neurosurgery: Editorial or governing board; Scoliosis Research Society: Board or committee member; Spine Deformity : Editorial or governing board; Stryker: Paid consultant; Thieme: Publishing royalties, financial or material support; Zimmer: IP royalties; paid consultant. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design/setting: Retrospective single-center study., Background: The global alignment and proportion score is widely used in adult spinal deformity surgery. However, it is not specific to the parameters used in adult cervical deformity (ACD)., Purpose: Create a cervicothoracic alignment and proportion (CAP) score in patients with operative ACD., Methods: Patients with ACD with 2-year data were included. Parameters consisted of relative McGregor's Slope [RMGS = (MGS × 1.5)/0.9], relative cervical lordosis [RCL = CL - thoracic kyphosis (TK)], Cervical Lordosis Distribution Index (CLDI = C2 - Apex × 100/C2 - T2), relative pelvic version (RPV = sacral slope - pelvic incidence × 0.59 + 9), and a frailty factor (greater than 0.33). Cutoff points were chosen where the cross-tabulation of parameter subgroups reached a maximal rate of meeting the Optimal Outcome. The optimal outcome was defined as meeting Good Clinical Outcome criteria without the occurrence of distal junctional failure (DJF) or reoperation. CAP was scored between 0 and 13 and categorized accordingly: ≤3 (proportioned), 4-6 (moderately disproportioned), >6 (severely disproportioned). Multivariable logistic regression analysis determined the relationship between CAP categories, overall score, and development of distal junctional kyphosis (DJK), DJF, reoperation, and Optimal Outcome by 2 years., Results: One hundred five patients with operative ACD were included. Assessment of the 3-month CAP score found a mean of 5.2/13 possible points. 22.7% of patients were proportioned, 49.5% moderately disproportioned, and 27.8% severely disproportioned. DJK occurred in 34.5% and DJF in 8.7%, 20.0% underwent reoperation, and 55.7% achieved Optimal Outcome. Patients severely disproportioned in CAP had higher odds of DJK [OR: 6.0 (2.1-17.7); P =0.001], DJF [OR: 9.7 (1.8-51.8); P =0.008], reoperation [OR: 3.3 (1.9-10.6); P =0.011], and lower odds of meeting the optimal outcome [OR: 0.3 (0.1-0.7); P =0.007] by 2 years, while proportioned patients suffered zero occurrences of DJK or DJF., Conclusion: The regional alignment and proportion score is a method of analyzing the cervical spine relative to global alignment and demonstrates the importance of maintaining horizontal gaze, while also matching overall cervical and thoracolumbar alignment to limit complications and maximize clinical improvement., Competing Interests: P.G.P.: Allosource: other financial or material support; Cervical Scoliosis Research Society: research support; Globus Medical: paid presenter or speaker; Medicrea: paid consultant; Royal Biologics: paid consultant; SpineWave: paid consultant; Terumo: paid consultant; Zimmer: paid presenter or speaker. R.L.: Nemaris: stock or stock options. V.L.: DePuy, A Johnson & Johnson Company: paid presenter or speaker; European Spine Journal : editorial or governing board; Globus Medical: paid consultant; International Spine Study Group: board or committee member; Nuvasive: IP royalties; Scoliosis Research Society: Board or committee member; The Permanente Medical Group: paid presenter or speaker. The remaining authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)