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This document is a reply to a comment on a study about the radiological outcomes of magnetically controlled growing rods (MCGRs) for the treatment of early-onset scoliosis in children. The authors express gratitude for the interest in their study and acknowledge the scrutiny it has received. They discuss the methodology of their study and the analysis of the outcomes, emphasizing the efficacy of MCGRs in achieving satisfactory radiological and clinical results. They also provide radiological statistics of patients treated with MCGRs and discuss the potential limitations and complications of the treatment. Overall, the authors hope that their findings will contribute to advancements in the surgical management of early-onset scoliosis.The given text provides data on various measurements related to thoracic kyphosis and lumbar lordosis in patients before and after graduation surgery. The measurements include the mean and standard deviation of thoracic kyphosis and lumbar lordosis at different stages, as well as comparisons between preoperative and postoperative measurements. The data suggests that there are significant differences in these measurements before and after surgery. However, further analysis is needed to understand the specific implications of these findings.The document provides a table of statistical data related to a study on the correction of spinal deformities. The data includes measurements of preoperative height, length of distraction phase, number of lengthenings per year, and growth rates at different spinal levels. The study was conducted by Pawel Grabala, Munish C. Gupta, Daniel E. Pere [Extracted from the article]

Background: While reimbursement is centered on 90-day outcomes, many patients may still achieve optimal, long-term outcomes following adult spinal deformity (ASD) surgery despite transient short-term complications. Objective: Compare long-term clinical success and cost-utility between patients achieving optimal realignment and suboptimally aligned peers. Study Design/Setting: Retrospective cohort study of a prospectively collected multicenter database. Methods: ASD patients with two-year (2Y) data included. Groups were propensity score matched (PSM) for age, frailty, body mass index (BMI), Charlson Comorbidity Index (CCI), and baseline deformity. Optimal radiographic criteria are defined as meeting low deformity in all three (Scoliosis Research Society) SRS-Schwab parameters or being proportioned in Global Alignment and Proportionality (GAP). Cost-per-QALY was calculated for each time point. Multivariable logistic regression analysis and ANCOVA (analysis of covariance) adjusting for baseline disability and deformity (pelvic incidence (PI), pelvic incidence minus lumbar lordosis (PI-LL)) were used to determine the significance of surgical details, complications, clinical outcomes, and cost-utility. Results: A total of 930 patients were considered. Following PSM, 253 "optimal" (O) and 253 "not optimal" (NO) patients were assessed. The O group underwent more invasive procedures and had more levels fused. Analysis of complications by two years showed that the O group suffered less overall major (38% vs. 52%, p = 0.021) and major mechanical complications (12% vs. 22%, p = 0.002), and less reoperations (23% vs. 33%, p = 0.008). Adjusted analysis revealed O patients more often met MCID (minimal clinically important difference) in SF-36 PCS, SRS-22 Pain, and Appearance. Cost-utility-adjusted analysis determined that the O group generated better cost-utility by one year and maintained lower overall cost and costs per QALY (both p < 0.001) at two years. Conclusions: Fewer late complications (mechanical and reoperations) are seen in optimally aligned patients, leading to better long-term cost-utility overall. Therefore, the current focus on avoiding short-term complications may be counterproductive, as achieving optimal surgical correction is critical for long-term success. [ABSTRACT FROM AUTHOR]

Study Design: Multi-center, prospective, observational cohort. Objective: To compare myelopathic vs. non-myelopathic ambulatory patients in short- and long-term neurologic function, operative treatment, and patient-reported outcomes. Methods: Pediatric deformity patients from 16 centers were enrolled with the following inclusion criteria: aged 10-21 years-old, a Cobb angle ≥100° in either the coronal or sagittal plane or any sized deformity with a planned 3-column osteotomy, and community ambulators. Patients were dichotomized into 2 groups: myelopathic (abnormal preoperative neurologic exam with signs/symptoms of myelopathy) and non-myelopathic (no clinical signs/symptoms of myelopathy). Results: Of 311 patients with an average age of 14.7 ± 2.8 years, 29 (9.3%) were myelopathic and 282 (90.7%) were non-myelopathic. There was no difference in age (P = 0.18), gender (P = 0.09), and Risser Stage (P = 0.06), while more patients in the non-myelopathic group had previous surgery (16.1% vs. 3.9%; P = 0.03). Mean lower extremity motor score (LEMS) in myelopathic patients increased significantly compared to baseline at every postoperative visit: Baseline: 40.7 ± 9.9; Immediate postop: 46.0 ± 7.1, P = 0.02; 1-year: 48.2 ± 3.7, P < 0.001; 2-year: 48.2 ± 7.7, P < 0.001). The non-myelopathic group had significantly higher LEMS immediately postoperative (P = 0.0007), but by 1-year postoperative, there was no difference in LEMS between groups (non-myelopathic: 49.3 ± 3.6, myelopathic: 48.2 ± 3.7, P = 0.10) and was maintained at 2-years postoperative (non-myelopathic: 49.2 ± 3.3, myelopathic: 48.2 ± 5.7, P = 0.09). Both groups improved significantly in all SRS domains compared to preoperative, with no difference in scores in the domains for pain (P = 0.12), self-image (P = 0.08), and satisfaction (P = 0.83) at latest follow-up. Conclusion: In severe spinal deformity pediatric patients presenting with preoperative myelopathy undergoing spinal reconstructive surgery, myelopathic patients can expect significant improvement in neurologic function postoperatively. At 1-year and 2-year postoperative, neurologic function was no different between groups. While non-myelopathic patients had significantly higher postoperative outcomes in SRS mental-health, function, and total-score, both groups had significantly improved outcomes in every SRS domain compared to preoperative. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study. Objectives: Establish simultaneous focal and regional corrective guidelines accounting for reciprocal global and pelvic compensation. Methods: 433 ASD patients (mean age 62.9 yrs, 81.3% F) who underwent corrective realignment (minimum L1-pelvis) were included. Sagittal parameters, and segmental and regional Cobb angles were assessed pre and post-op. Virtual postoperative alignment was generated by combining post-op alignment of the fused spine with the pre-op alignment on the unfused thoracic kyphosis and the pre-op pelvic retroversion. Regression models were then generated to predict the relative impact of segmental (L4-L5) and regional (L1-L4) corrections on PT, SVA (virtual), and TPA. Results: Baseline analysis revealed distal (L4-S1) lordosis of 33 ± 15°, flat proximal (L1-L4) lordosis (1.7 ± 17°), and segmental kyphosis from L2-L3 to T10-T11. Post-op, there was no mean change in distal lordosis (L5-S1 decreased by 2°, and L4-L5 increased by 2°), while the more proximal lordosis increased by 18 ± 16°. Regression formulas revealed that Δ10° in distal lordosis resulted in Δ10° in TPA, associated with Δ100 mm in SVA or Δ3° in PT; Δ10° in proximal lordosis yielded Δ5° in TPA associated with Δ50 mm in SVA; and finally Δ10° in thoraco-lumbar junction yielded Δ2.5° in TPA associated with Δ25 mm in SVA and no impact on PT correction. Conclusions: Overall impact of lumbar lordosis restoration is critically determined by location of correction. Distal correction leads to a greater impact on global alignment and pelvic retroversion. More specifically, it can be assumed that 1° L4-S1 lordosis correction produces 1° change in TPA / 10 mm change in SVA and 0.5° in PT. [ABSTRACT FROM AUTHOR]

Background Context: Sagittal spinopelvic alignment has been associated with patient-reported outcome measures and mechanical complication rates. Recently, it was claimed that linear numerical values of pelvic tilt and lumbar lordosis measurements may be misleading for patients that have different magnitudes of pelvic incidence. The use of "relative" measurements embedded in a weighted scoring of Global Alignment and Proportion (GAP) was proposed.Purpose: The purpose was to evaluate the GAP scorein an independent database.Study Design/setting: Retrospective Cohort Study PATIENT SAMPLE: Adult spinal deformity patients who underwent ≥7 levels posterior fusion to the pelvis between 2004 and 2014 were included.Outcome Measures: Mechanical Complication Rates.Methods: Demographic, clinical, surgical and radiographic patient characteristics were recorded. Cochran-Armitage tests were used to compare mechanical complication rates in GAP categories. Uni and multivariable logistic regression analyses were used to obtain crude and adjusted Odds Ratios, of predictor (GAP categories) and the outcome (mechanical complication), and Risk Ratios were calculated. The diagnostic performance of the GAP score was tested using the area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value and accuracy in predicting mechanical complications.Results: A total of 322 patients (285F, 37M) with a mean age of 58.2±9.6 were analyzed. Mean follow-up was 69.7 months (range 24 to 177). Mechanical complications occurred in 52.2% of the patients. Mechanical complication rates in proportioned (GAP-P), moderately (GAP-MD) and severely disproportioned (GAP-SD) patients were 21.8%, 55.1%, and 70.4%, respectively. AUC for the GAP score, at 2 years, was 0.682 (95% CI, 0.624 to 0.741, p<.001). AUC at minimum 5 years follow-up was similar at 0.708, while AUC at minimum 7- and 12-year follow-up were 78.5 and 90.7, respectively. Having a postoperative spinopelvic alignment of GAP-MD and GAP-SD resulted in 2.5 and 3.2 folds of relative risk in incurring a mechanical complication when compared to having a proportioned spinopelvic state, respectively.Conclusions: This study reports an association between the GAP Score and mechanical complications in an independent database. Increased association was noted as the years of follow-up increased. Aiming to achieve proportionate GAP Score postoperatively seems to be a viable option as lower GAP scores were associated with lower rates of mechanical complications, and vice versa. [ABSTRACT FROM AUTHOR]

Purpose: AI algorithms have shown promise in medical image analysis. Previous studies of ASD clusters have analyzed alignment metrics—this study sought to complement these efforts by analyzing images of sagittal anatomical spinopelvic landmarks. We hypothesized that an AI algorithm would cluster preoperative lateral radiographs into groups with distinct morphology. Methods: This was a retrospective review of a multicenter, prospectively collected database of adult spinal deformity. A total of 915 patients with adult spinal deformity and preoperative lateral radiographs were included. A 2 × 3, self-organizing map—a form of artificial neural network frequently employed in unsupervised classification tasks—was developed. The mean spine shape was plotted for each of the six clusters. Alignment, surgical characteristics, and outcomes were compared. Results: Qualitatively, clusters C and D exhibited only mild sagittal plane deformity. Clusters B, E, and F, however, exhibited marked positive sagittal balance and loss of lumbar lordosis. Cluster A had mixed characteristics, likely representing compensated deformity. Patients in clusters B, E, and F disproportionately underwent 3-CO. PJK and PJF were particularly prevalent among clusters A and E. Among clusters B and F, patients who experienced PJK had significantly greater positive sagittal balance than those who did not. Conclusions: This study clustered preoperative lateral radiographs of ASD patients into groups with highly distinct overall spinal morphology and association with sagittal alignment parameters, baseline HRQOL, and surgical characteristics. The relationship between SVA and PJK differed by cluster. This study represents significant progress toward incorporation of computer vision into clinically relevant classification systems in adult spinal deformity. Level of Evidence IV: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding. [ABSTRACT FROM AUTHOR]

Purpose: Analysis of interactions of spinal alignment metrics may uncover novel alignment parameters, similar to PI-LL. This study utilized a data-driven approach to hypothesis generation by testing all possible division interactions between spinal alignment parameters.Methods: This study was a retrospective cohort analysis. In total, 1439 patients with baseline ODI were included for hypothesis generation. In total, 666 patients had 2-year postoperative follow-up and were included for validation. All possible combinations of division interactions between baseline metrics were assessed with linear regression against baseline ODI.Results: From 247 raw alignment metrics, 32,398 division interactions were considered in hypothesis generation. Conceptually, the TPA divided by PI is a measure of the relative alignment of the line connecting T1 to the femoral head and the line perpendicular to the sacral endplate. The mean TPA/PI was 0.41 at baseline and 0.30 at 2 years postoperatively. Higher TPA/PI was associated with worse baseline ODI (p < 0.0001). The change in ODI at 2 years was linearly associated with the change in TPA/PI (p = 0.0172). The optimal statistical grouping of TPA/PI was low/normal (≤ 0.2), medium (0.2-0.4), and high (> 0.4). The R-squared for ODI against categorical TPA/PI alone (0.154) was directionally higher than that for each of the individual Schwab modifiers (SVA: 0.138, PI-LL 0.111, PT 0.057).Conclusion: This study utilized a data-driven approach for hypothesis generation and identified the spino-pelvic ratio (TPA divided by PI) as a promising measure of sagittal spinal alignment among ASD patients. Patients with SPR > 0.2 exhibited inferior ODI scores.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Purpose: The thoracolumbar junction (TLJ) has not been explored in regard to its contribution to global sagittal alignment. This study aims to define novel sagittal parameters of the TLJ and to assess their roles within global sagittal alignment.Methods: Included for cross-sectional, retrospective analysis were asymptomatic volunteers and symptomatic patients who had undergone operation for adult spinal deformity. Unique sagittal parameters of the TLJ were measured using the midline of the T12-L1 disk space: The TLJ orientation [TLJO; thoracolumbar tilt (TLT) and slope (TLS)]. Thoracic kyphosis (TK; T5-12), C7-S1 sagittal vertical axis (SVA), lumbar lordosis (LL; L1-S1), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI) were measured. Continuous variables were compared using the independent t test. Pearson correlations examined relationships between the parameters in each group. The asymptomatic TK was calculated using the measurement of the asymptomatic volunteer's TLJO by linear regression.Results: One hundred fifteen asymptomatic volunteers and 127 symptomatic patients were included. Only LL among the lumbopelvic parameters correlated with TK (asymptomatic volunteers: r = - 0.42; symptomatic patients: r = - 0.40). All the pelvic parameters have no direct correlation with TK in both groups. TLJO had stronger correlation with TK [asymptomatic volunteers: r = - 0.68 (TLS), r = 0.41 (TLT); symptomatic patients: r = - 0.56 (TLS), r = 0.44 (TLT)] than the lumbopelvic parameters. TLS correlated with LL (asymptomatic volunteers: r = 0.78; symptomatic patients: r = 0.73). Most pelvic parameters correlated with TLJO except for PI. The asymptomatic TK was estimated by the derived formula: 20.847 + TLS × (- 1.198).Conclusion: The TLJO integrates the status of the lumbopelvic sagittal parameters and simultaneously correlates with thoracic and global sagittal alignment. These slides can be retrieved under Electronic Supplementary Material. [ABSTRACT FROM AUTHOR]

Purpose: To identify the effect of complications and reoperation on the recovery process following adult spinal deformity (ASD) surgery by examining health-related quality of life (HRQOL) measures over time via an integrated health state analysis (IHS).Methods: A retrospective review of a multicenter, prospective ASD database was conducted. Complication number, type, and need for reoperation (REOP) or not (NOREOP) were recorded. Patients were stratified as having no complication (NOCOMP), any complication (COMP), only minor complications (MINOR) and any major complications (MAJOR). HRQOL measures included Oswestry Disability Index (ODI), Short Form-36 (SF-36), and Scoliosis Research Society-22 (SRS22) at baseline, 6 weeks, 1 and 2 years postoperatively. All HRQOL scores were normalized to each patient's baseline scores and an IHS was then calculated.Results: 149 patients were included. COMP, MINOR, and MAJOR had significantly lower normalized SRS mental scores at 1 and 2 years than NOCOMP (p < 0.05). REOP had significantly worse normalized 1 and 2 year mental component score (MCS), SRS mental, and total score than NOCOMP (p < 0.05). COMP, MINOR, and MAJOR all had significantly lower SRS mental IHSs than NOCOMP (p < 0.05). REOP had significantly lower IHSs for MCS and SRS satisfaction than NOREOP (p < 0.05). REOP had a significantly lower MCS and SRS mental IHS than NOCOMP (p < 0.05).Conclusion: An IHS analysis suggests there was a significantly protracted mental recovery phase associated with patients that had at least one complication, as well as either a minor and major complication. The addition of a reoperation also adversely affected the mental recovery as well as overall satisfaction. [ABSTRACT FROM AUTHOR]

Purpose: The goal of the present study was to compare the outcomes of operative and non-operative patients with adult spinal deformity (ASD) over 75 years of age.Methods: A retrospective review of a multicenter prospective adult spinal deformity database was conducted examining patients with ASD over the age of 75 years. Demographics, comorbidities, operation-related variables, complications, radiographs, and Health-related quality of life (HRQOL) measures collected included Oswestry Disability Index, Short Form-36, and Scoliosis Research Society-22 preoperatively, and at 1 and 2 years later. Minimum clinically important difference (MCID) was calculated and also compared.Results: 27 patients (12 operative, 15 non-operative) were studied. There were no significant differences (p > 0.05) between operative and non-operative patients for age, body mass-index, and comorbidities, but operative patients had worse baseline HRQOL than non-operative patients. Operative patients had a significant improvement in radiographic parameters in 2-year HRQOL, whereas non-operative patients did not (p > 0.05). Operative patients were significantly more likely to reach MCID (range 41.7-81.8 vs. 0-33.3 %, p < 0.05). In the surgical group, 9 (75 %) patients had at least 1 complication (24 total complications).Conclusions: In the largest series to date comparing operative and non-operative management of adult spinal deformity in elderly patients greater than 75 years of age, reconstructive surgery provides significant improvements in pain and disability over a 2-year period. Furthermore, operative patients were more likely to reach MCID than non-operative patients. When counseling elderly patients with ASD, such data may be helpful in the decision-making process regarding treatment. [ABSTRACT FROM AUTHOR]

Rod failure and pseudarthrosis are common complications following the surgical treatment of adult spinal defomity (ASD). Many strategies have been employed in mitigating these problems, such as interbody fusion, multiple rods, use of more effective biologics, and optimizing spinal alignment. We aimed to study the frequency and type of rod failures in a large ASD population over time. To study the frequency and type of rod failures in a large ASD population over time. Retrospective review of prospective data. This study included 647 adult spinal deformity patients surgically treated between 2008 and 2018. Rod failures. ASD patients with a fusion extended from minimum L1 to pelvis and min 2-year follow-up were included. Radiographs and records were examined to identify characteristics of the rod failures: timing, unilateral vs bilateral, vertebral level, unilateral progressing to bilateral failure, revision and failure rates over time. Among the study population, 647/1052 patients met inclusion criteria (age: 64±10 yrs., 78% F, BMI: 28.3±5.7, Mean follow-up: 37 months ±13). Surgeries for these patients were performed from 2008 to 2018. The UIV was T7 or above in 306 and T8 or below in 338 patients, most frequent UIV: T4 (121) and T10 (208). A total of 146 patients had a 3COs; 435 had interbody fusion with 187 ALIF, 202 TLIF,135 XLIF; 286 patients had BMP use post only and 203 had BMP use interbody and posteriorly. Overall rod failure rate was 135/647 (21%), of which 9.3% occurred before by 2 years postop. Mean days to failure was 795 day +/- 485 (Median 733). Most frequent failures were in the lower lumbar spine L3-4 (32) 24%, L4-5 (34) 25% and L5-S1 (44) 32%. Of the 97 Unilateral failures, 35 (36.1%) were revised and only 8 progressed to bilateral failure of which 6/8 were revised; 46 Bilateral failure, 24 (52.2%) were revised.Kaplan-Meier analysis shows a survival rate of 89.7% at 2 years with decrease of 5% per year. No significant difference was found between the first 5 years and last 5 years. Comparison of primary vs revision index procedures did not reveal any differences in time to failure nor time to revision. Use of BMP improved survival rate to 91.2% compared to no BMP 83.4% at 2 years. Rod failures remain a common complication when treating ASD with a rate of 21%. Among those rod failures, 9.3% occurred within 2 years. The most frequent sites of failure were in the lower lumbar spine. Unilateral failures underwent a lower rate of revision than bilateral. BMP increased rod survivability. Kaplan-Meier analysis demonstrated a survival rate of 89.7% at 2 years with a decrease of 5% per year. The failure rate has not improved when comparing the first 5 years. to last 5 years. We must continue to seek solutions to improve rod durability challenges to improve long-term outcomes. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background: Few studies have examined threshold improvements in health-related quality of life (HRQOL) by measuring minimal clinically important differences (MCIDs) in treatment of adult spinal deformity. We hypothesized that patients undergoing operative treatment would be more likely to achieve MCID threshold improvement compared with those receiving nonoperative care, although a subset of nonoperative patients may still reach threshold. Methods: We analyzed a multicenter, prospective, consecutive case series of 464 patients: 225 nonoperative and 239 operative. To be included in the study, patients had to have adult spinal deformity, be older than 18 years, and have both baseline and 1-year follow-up HRQOL measures (Oswestry Disability Index [ODI], Short Form-36 [SF-36] health survey, and Scoliosis Research Society-22 [SRS-22] questionnaire). We compared the percentages of patients achieving established MCID thresholds between operative and nonoperative groups using risk ratios (RR) with a 95% confidence interval (CI). Results: Compared to nonoperative patients, surgical patients demonstrated significant mean improvement (P<0.01) and were more likely to achieve threshold MCID improvement across all HRQOL scores (ODI RR¼7.37 [CI 4.45, 12.21], SF-36 physical component score RR¼2.96 [CI 2.11, 4.15], SRS Activity RR ¼ 3.16 [CI 2.32, 4.31]). Furthermore, operative patients were more likely to reach threshold MCID improvement in 2 or more HRQOL measures simultaneously and were less likely to deteriorate. Conclusion: Patients in both the operative and nonoperative treatment groups demonstrated improvement in at least one HRQOL measure at 1 year. However, surgical treatment was more likely to result in threshold improvement and more likely to lead to simultaneous improvement across multiple measures of ODI, SF-36, and SRS-22. Although a subset of nonoperative patients achieved threshold improvement, nonoperative patients were significantly less likely to improve in multiple HRQOL measures and more likely to sustain MCID deterioration or no change. [ABSTRACT FROM AUTHOR]

Purpose: Major peri-operative complications for adult spinal deformity (ASD) surgery remain common. However, risk factors have not been clearly defined. Our objective was to identify patient and surgical parameters that correlate with the development of major peri-operative complications with ASD surgery. Methods: This is a multi-center, retrospective, consecutive, case-control series of surgically treated ASD patients. All patients undergoing surgical treatment for ASD at eight centers were retrospectively reviewed. Each center identified 10 patients with major peri-operative complications. Randomization tables were used to select a comparably sized control group of patients operated during the same time period that they did not suffer major complications. The two groups were analyzed for differences in clinical and surgical factors. Analysis was restricted to non-instrumentation related complications. Results: At least one major complication occurred in 80 of 953 patients (8.4 %), including 72 patients with non-instrumentation related complications. There were no significant differences between the complications and control groups based on the demographics, ASA grade, co-morbidities, body mass index, prior surgeries, pre-operative anemia, smoking, operative time or ICU stay ( p > 0.05). Hospital stay was significantly longer for the complications group (14.4 vs. 7.9 days, p = 0.001). The complications group had higher percentages of staged procedures (46 vs. 37 %, p = 0.011) and combined anterior-posterior approaches (56 vs. 32 %, p = 0.011) compared with the control group. Conclusion: The major peri-operative complication rate was 8.4 % for 953 surgically treated ASD patients. Significantly higher rates of complications were associated with staged and combined anterior-posterior surgeries. None of the patient factors assessed were significantly associated with the occurrence of major peri-operative complications. Improved understanding of risk profiles and procedure-related parameters may be useful for patient counseling and efforts to reduce complication rates. [ABSTRACT FROM AUTHOR]

The opioid crisis in the US has created a backlash from the government and third- party payors with headlines appearing daily in the media. We sought to understand the current opioid prescribing practices of adult spinal deformity surgeons in this difficult environment. We wanted to investigate the opioid prescribing practices of surgeons from neurosurgical and orthopedic disciplines treating adult spinal deformity Survey of the prescribing practices of surgeons treating adult spinal deformity. A total of 33 surgeons: 20 orthopedist and 13 neurosurgeons. Survey of opioid prescribing practices. A questionnaire was given to adult deformity surgeons with varied years of practice. Years in practice and residency specialty (ortho vs neuro) were noted. Various questions regarding prescribing practice were asked. Descriptive statistics were performed to show the prevalence of the different prescribing practices among the cohort. A total of 33 surgeons (20 ortho, 13 neuro) returned the survey. Years in practice were as follows: <5yrs, 4 (12.1%); 5-10yrs, 5 (15.2%); 10-15yrs,12 (36.4%); 15-20yrs, 8 (24.2%); and >20yrs, 4 (12.1%). The following questions were asked: Do you actively wean patients off narcotic medications before surgery? {Yes=18 (54.5%) [Neuro=4 (31%) and Ortho=14 (70%) (p=0.0270)]; No=15 (45.5%)}; Do you require them to be completely off of the narcotics? {Yes=0 No=33 (100%)}; Do you prescribe opioids to your patients postoperatively? {Yes=30 (90.9%) No=3 (9.1%)}; If no, who does? {Pain Management=2; Fellows=1 (Japan)}; If yes, do you have a cut-off time point postoperatively after which you no longer primarily prescribe narcotics? {Yes=28 (84.8%), No=2 (6.1%), N/A=3 (9.1%)}; If yes, how long do you prescribe? {6 weeks=5 (15.2%), 2 months=1 (3.0%), 3 months=19 (57.6%), 6 months=3 (9.1%), 1 year= None, indefinitely=2 (6.1%), N/A=3 (9.1%)}; Do you actively attempt to wean your patients off of opioids postoperatively? {Yes=30 (90.9%) [Neuro=10 (77%) and Ortho=20 (100%) (p=0.0242)], No=3 (9.1%)}. Differences between the group of surgeons in their training background of neurosurgery vs orthopedics was significantly different in actively weaning patients off narcotics either before or after surgery. Surgeons operating on adult deformity patients in 2018 are limiting the amount of narcotics given to surgical patients preoperatively and postoperatively. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Surgical treatment of severe pediatric deformity can be extremely challenging due to difficulties with instrumentation placement in small patients, stress on implants due to correction of severe deformities, and use of three column osteotomies. We investigated the instrumentation and fusion related complications in these complex spine deformity surgical cases. The purpose of this study was to evaluate the frequency and timing of revisions related to instrumentation or fusion in patients with severe pediatric deformity. Prospective observational multicenter cohort of severe pediatric deformity patients treated surgically. Patients with a minimum spinal deformity curve of 100° or who were scheduled for a VCR procedure were prospectively enrolled at 17 sites. Patient who had reached a minimum of 2 years postoperative were included for analysis. Postoperative complications associated with instrumentation and/or fusion, time of revisions and complications from index surgery Patients with severe spinal deformity (>100° or planned VCR) were included with a min. Two year f/u from 17 centers. Complications with or without revision due to pseudoarthrosis, instrumentation failure, infection requiring instrumentation removal and progression of deformity were all analyzed. A total of 228 of 312 patients had a min of 2 yrs f/u. Of these, 29 pts (13%) had complications associated with instrumentation or fusion. A total of 22 patients (10%) had 27 revisions. The average time for all revisions was 16 mos (0-36) after index surgery; 3 patients were revised 2x and 1 pt 3x. The 27 revisions included 5 patients with loss of fixation, revised an ave. of 21 mos po (1-35). Four patients with pseudarthrosis were revised an average of 21 mos po (13-28). One patient was revised for prominent instrumentation at 27 mos po, and 5 patients for deep infection between 1-27 mos, average 15 mos. Eight patients had revisions for deformity progression at an ave of 13 mos (1-36). One patient was revised for a malpositioned screw a few days po, and 1 at 12 mos po for implant/instrumentation failure. Eight patients had complications that did not require revision. These included 1 with prominent implants, 1 with a malpositioned screw in the disc space, 3 had progressive deformity including PJK , 1 patient for implant prominence, 1 for loss of fixation, and 2 implant failures. Pediatric patients with severe spinal deformity are at significant risk for revision surgery at a rate of 13% within 2 years. The average time for revision surgery was 16 mos po but was necessary as long 36 months after index surgery. Long term follow-up is necessary to evaluate failures in this patient population. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Abstract: We are now entering an exciting new era in spinal surgery where the inherent osteoinductive capacity of the body has been harnessed for bone formation for therapeutic purposes. Recombinant bone morphogenetic proteins have been extensively studied in both the pre-clinical and clinical arena for spinal fusion with considerable success. The challenges facing spine surgeons now is the development of site-specific carriers and optimal doses for these growth factors. This review highlights the recent advances in this regard. [Copyright &y& Elsevier]

Abstract: Background context: Multiple studies involving the outcomes of anterior interbody cages have been published, but the majority were by authors who designed the cage. No outcome studies with Bagby and Kuslich (BAK) cages implanted by a single-surgeon have either 3 years of follow-up or at least 25 patients. Purpose: To determine the 3- to 6-year clinical outcomes, including fusion rate, revision rate, complications and functional status of patients who underwent placement of anterior, stand-alone BAK cages by a single surgeon. Study design: This is a retrospective cohort study of patients who underwent anterior, stand-alone BAK cage placement by a single surgeon with a minimum of 3 years of follow-up. Patient sample: A total of 46 consecutive patients who underwent placement of anterior BAK cages from 1997 to 1999 were the study group. Outcome measures: Complications, fusion rate, revision rate, Prolo scores, Oswestry scores, pain scores, patient satisfaction. Methods: A retrospective review of charts of patients undergoing anterior stand-alone placement of BAK cages over the study period were reviewed. Demographic data were collected, and postoperative radiographs and clinic notes were reviewed. Patients were then contacted to complete a survey to determine Prolo and Oswestry scores, workers'' compensation status and general satisfaction with the procedure. Patients were also asked to undergo repeat radiographs of their lumbar spine to determine if the operative levels had fused. Results: Follow-up was available on 33 of 46 patients (72%). At least 10 patients (22%) required revision surgery. Ten patients (22%) had 14 total complications not requiring revision surgery. Seventy percent of patients had a fair or poor outcome as assessed by the Prolo rating system, and 58% of patients had at least “severe disability” according to the Oswestry outcome scale. Fifty percent of patients were satisfied with their surgery. Conclusions: This single-surgeon series of stand-alone BAK cages demonstrates significantly worse clinical outcomes than has been previously reported. The use of stand-alone BAK cages for degenerative disc disease should be reconsidered given the large number of patients with unacceptable outcomes. [Copyright &y& Elsevier]

Study Design. A retrospective cohort study of a prospectively collected multicenter adult spinal deformity (ASD) database. Objective. The aim of this study was to compare staged procedures to same-day interventions and identify the optimal time interval between staged surgeries for the treatment of ASD. Background. Surgical intervention for ASD is an invasive and complex procedure that surgeons often elect to perform on different days (staging). Yet, there remains a paucity of literature on the timing and effects of the interval between stages. Materials and Methods. ASD patients with 2-year data undergoing an anterior/posterior (A/P) fusion to the ilium were included. Propensity score matching was performed for the number of levels fused, number of interbody devices, surgical approaches, number of osteotomies/three-column osteotomy, frailty, Oswestry Disability Index, Charlson Comorbidity Index, revisions, sagittal vertical axis, pelvic incidence--lumbar lordosis, and upper instrumented vertebrae to create balanced cohorts of same-day and staged surgical patients. Staged patients were stratified by intervening time-period between surgeries, using quartiles. Results. A total of 176 propensity score--matched patients were included. The median interval between A/P staged procedures was 3 days. Staged patients had greater operative time and lower intensive care unit stays postoperatively (P<0.05). At 2 years, staged compared with same-day showed a greater improvement in T1 slope --cervical lordosis, C2 sacral slope, and SRS-Schwab sagittal vertical axis (P<0.05). Staged patients had higher rates of minimal clinically important difference for 1-year SRS-Appearance and 2-year Physical Component Summary scores. Assessing different intervals of staging, patients at the 75th percentile interval showed greater improvement in 1-year SRS-Pain and SRS-Total postoperative as well as SRSActivity, Pain, Satisfaction, and Total scores (P<0.05) compared with patients in lower quartiles. Compared with the 25th percentile, patients reaching the 50th percentile interval were associated with increased odds of improvement in Global Alignment and Proportion score proportionality [9.3 (1.6-53.2), P=0.01]. Conclusions. This investigation is among the first to compare multicenter staged and same-day surgery A/P ASD patients fused to ilium using propensity matching. Staged procedures resulted in significant improvement radiographically, reduced intensive care unit admissions, and superior patient-reported outcomes compared with same-day procedures. An interval of at least 3 days between staged procedures is associated with superior outcomes in terms of Global Alignment and Proportion score proportionality. [ABSTRACT FROM AUTHOR]

Objective. Provide benchmarks for the rates of complications by type and timing. Study Design. Prospective multicenter database. Background. Complication rates following adult spinal deformity (ASD) surgery have been previously reported. However, the interplay between timing and complication type warrants further analysis. Methods. The data for this study were sourced from a prospective, multicenter ASD database. The date and type of complication were collected and classified into three severity groups (minor, major, and major leading to reoperation). Only complications occurring before the two-year visit were retained for analysis. Results. Of the 1260 patients eligible for two-year follow-up, 997 (79.1%) achieved two-year follow-up. The overall complication rate was 67.4% (N=672). 247 patients (24.8%) experienced at least one complication on the day of surgery (including intraoperatively), 359 (36.0%) between postoperative day 1 and six weeks postoperatively, 271 (27.2%) between six weeks and one-year postoperatively, and finally 162 (16.3%) between one year and two years postoperatively. Using Kaplan-Meier survival analysis, the rate of remaining complication-free was estimated at different time points for different severities and types of complications. Stratification by type of complication demonstrated that most of the medical complications occurred within the first 60 days. Surgical complications presented over two distinct timeframes. Operative complications, incision-related complications, and infections occurred early (within 60 d), while implant-related and radiographic complications occurred at a constant rate over the two-year follow-up period. Neurological complications had the highest occurrence within the first 60 days but continued to increase up to the two-year visit. Conclusion. Only one-third of ASD patients remained complication- free by two years, and 2 of 10 patients had a complication requiring a reoperation or revision. An estimation of the timing and type of complications associated with surgical treatment may prove useful for more meaningful patient counseling and aid in assessing the cost-effectiveness of treatment. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective review of a prospective multicenter adult spinal deformity (ASD) study. Objective. The aim of this study was to evaluate 30-day readmissions, 90-day return to surgery, postoperative complications, and patient-reported outcomes (PROs) for matched ASD patients receiving nonhome discharge (NON), including acute rehabilitation (REHAB), and skilled nursing facility (SNF), or home (HOME) discharge following ASD surgery. Summary of Background Data. Postoperative disposition following ASD surgery frequently involves nonhome discharge. Little data exists for longer term outcomes for ASD patients receiving nonhome discharge versus patients discharged to home. Materials and Methods. Surgically treated ASD patients prospectively enrolled into a multicenter study were assessed for NON or HOME disposition following hospital discharge. NON was further divided into REHAB or SNF. Propensity score matching was used to match for patient age, frailty, spine deformity, levels fused, and osteotomies performed at surgery. Thirty-day hospital readmissions, 90-day return to surgery, postoperative complications, and 1-year and minimum 2-year postoperative PROs were evaluated. Results. A total of 241 of 374 patients were eligible for the study. NON patients were identified and matched to HOME patients. Following matching, 158 patients remained for evaluation; NON and HOME had similar preoperative age, frailty, spine deformity magnitude, surgery performed, and duration of hospital stay (P>0.05). Thirty-day readmissions, 90-day return to surgery, and postoperative complications were similar for NON versus HOME and similar for REHAB (N =64) versus SNF (N = 42) versus HOME (P>0.05). At 1-year and minimum 2-year follow-up, HOME demonstrated similar to better PRO scores including Oswestry Disability Index, Short-Form 36v2 questionnaire Mental Component Score and Physical Component Score, and Scoliosis Research Society scores versus NON, REHAB, and SNF (P< 0.05). Conclusions. Acute needs must be considered following ASD surgery, however, matched analysis comparing 30-day hospital readmissions, 90-day return to surgery, postoperative complications, and PROs demonstrated minimal benefit for NON, REHAB, or SNF versus HOME at 1- and 2-year follow-up, questioning the risk and cost/benefits of routine use of nonhome discharge. [ABSTRACT FROM AUTHOR]

The era of using biologic enhancers for augmenting spinal fusion has arrived. Clear understanding of the complex biologic processes involved along with a critical view of the preclinical and clinical data is needed. This article reviews the data to date regarding OP-1 and spinal fusion. [ABSTRACT FROM AUTHOR]

Sagittal spino-pelvic alignment has been associated with patient-reported outcome measures and mechanical complication rates. Linear numerical values of pelvic tilt and lumbar lordosis measurements with different pelvic incidences may be misleading. The use of "relative" measurements embedded in a weighted scoring of Global Alignment and Proportion (GAP) has been described. The purpose of our study was to evaluate the validity of the GAP score in an independent database. The purpose of our study was to evaluate the validity of the GAP score in an independent database. Retrospective review of an independent adult spinal deformity data base from a single center. Adult spinal deformity patients from a single center who had >5 level fusion to the pelvis between 2004-2014. Demographic, clinical, surgical and radiographic parameters. ASD patients who underwent ≥5 levels fusion to the pelvis between 2004 to 2014 were included. Demographic, clinical, surgical and radiographic patient characteristics were recorded. Cochran-Armitage tests were used to determine mechanical complication trends across GAP categories. Uni /multivariable logistic regression analyses were used to obtain crude and adjusted odds ratios of predictor (GAP categories) and the outcome (mechanical complication). The diagnostic performance of the GAP score was tested using the area under the receiver operating characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value and accuracy in predicting mechanical complications. A total of 338 out of 657 patients (295F, 43M) with a mean age of 58±9.6 met the inclusion criteria. Mean follow-up was 55 months (24-138). Every mechanical complication was included from minor proximal compression fracture and iliac screw disengagement. Most common complications were rod failure in 25.4% (86/338) patients, 23 patients (6.8%) implant complication at the L-S junction, PJF in 45 patients (13.3%) and PJK in 20 pts (5.9%). Mechanical complication in proportioned (GAP-P), moderately (GAP-MD) and severely disproportioned (GAP-SD) patients were 23.8%, 55.7% and 66.1%, respectively. AUC for the GAP score was 0.653 (95% CI, 0.59 to 0.71, p<0.001). GAP Score demonstrated 60.5% sensitivity, 76.2% specificity, 89.1% positive predictive value, 37.4% negative predictive value and 64.2% accuracy in predicting mechanical complications. Postoperative alignment of GAP-MD and GAP-SD resulted in 3.6 and 4.6 folds of more odds in incurring a mechanical complication compared to proportioned GAP. This study validates the efficacy of GAP Score in predicting mechanical complications in an independent database. A trend was observed in which lower GAP scores were associated with lower rates of mechanical complications. Both the crude and adjusted odds ratios were high, showing the extent of effectiveness of this predictive tool. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective review of prospectively collected data. Objective. To analyze the impact of operative room (OR) time in adult spinal deformity (ASD) surgery on patient outcomes. Background. It is currently unknown if OR time in ASD patients matched for deformity severity and surgical invasiveness is associated with patient outcomes. Materials and Methods. ASD patients with baseline and two-year postoperative radiographic and patient-reported outcome measures (PROM) data, undergoing a posterior-only approach for long fusion (> L1-Ilium) were included. Patients were grouped into short OR time (< 40th percentile: <359 min) and long OR time ( >60th percentile: > 421 min). Groups were matched by age, baseline deformity severity, and surgical invasiveness. Demographics, radiographic, PROM data, fusion rate, and complications were compared between groups at baseline and two years follow-up. Results. In total, 270 patients were included for analysis: the mean OR time was 286 minutes in the short OR group versus 510 minutes in the long OR group (P<0.001). Age, gender, percent of revision cases, surgical invasiveness, pelvic incidence minus lumbar lordosis, sagittal vertical axis, and pelvic tilt were comparable between groups (P>0.05). Short OR had a slightly lower body mass index than the short OR group (P<0.001) and decompression was more prevalent in the long OR time (P=0.042). Patients in the long group had greater hospital length of stay (P= 0.02); blood loss (P<0.001); proportion requiring intensive care unit (P=0.003); higher minor complication rate (P=0.001); with no significant differences for major complications or revision procedures (P> 0.5). Both groups had comparable radiographic fusion rates (P=0.152) and achieved improvement in sagittal alignment measures, Oswestry disability index, and Short Form-36 (P<0.001). Conclusion. Shorter OR time for ASD correction is associated with a lower minor complication rate, a lower estimated blood loss, fewer intensive care unit admissions, and a shorter hospital length of stay without sacrificing alignment correction or PROMs. Maximizing operative efficiency by minimizing OR time in ASD surgery has the potential to benefit patients, surgeons, and hospital systems. [ABSTRACT FROM AUTHOR]

Study Design. Retrospective study. Objective. Evaluate surgical characteristics and postoperative 2-year results of the PL approach to spinal fusion. Summary of Background Data. Prone-lateral(PL) single positioning has recently gained popularity in spine surgery due to lower blood loss and operative time but has yet to be examined for other notable outcomes, including realignment and patientreported measures. Materials and Methods. We included circumferential spine fusion patients with a minimum one-year follow-up. Patients were stratified into groups based on undergoing PL approach versus sameday staged (Staged). Mean comparison tests identified differences in baseline parameters. Multivariable logistic regression, controlling for age, levels fused, and Charlson Comorbidity Index were used to determine the influence of the approach on complication rates, radiographic and patient-reported outcomes up to two years. Results. One hundred twenty-two patients were included of which 72(59%) were same-day staged and 50(41%) were PL. PL patients were older with lower body mass index (both P<0.05). Patients undergoing PL procedures had lower estimated blood loss and operative time (both P<0.001), along with fewer osteotomies (63% vs. 91%, P<0.001). This translated to a shorter length of stay (3.8 d vs. 4.9, P=0.041). PL procedures demonstrated better correction in both PT (4.0 vs. 0.2, P= 0.033 and pelvic incidence and lumbar lordosis (3.7 vs. 3.1, P=0.012). PL procedures were more likely to improve in GAP relative pelvic version (OR: 2.3, [1.5--8.8]; P=0.003]. PL patients suffered lesser complications during the perioperative period and greater improvement in NRSBack (6.0 vs. 3.3, P=0.031), with less reoperations (0.0% vs. 4.8%, P=0.040) by two years. Conclusions. Patients undergoing PL single-position procedures received less invasive procedures with better correction of pelvic compensation, as well as earlier discharge. The prone lateral cohort also demonstrated greater clinical improvement and a lower rate of reoperations by two years following spinal corrective surgery. [ABSTRACT FROM AUTHOR]

Study Design. Multicenter retrospective cohort study. Objective. To investigate risk factors for loss of correction within the instrumented lumbar spine after adult spinal deformity surgery. Summary of Background Data. The sustainability of adult spinal deformity surgery remains a health care challenge. Malalignment is a major reason for revision surgery. Patients and Methods. A total of 321 patients who underwent fusion of the lumbar spine ( ≥5 levels, LIV pelvis) with a revisionfree follow-up of ≥3 years were identified. Patients were stratified by a change in pelvic incidence--lumbar lordosis from 6 weeks to 3 years postoperative as "maintained" versus "loss" > 5°. Those with instrumentation failure (broken rod, screw pullout, etc.) were excluded before comparisons. Demographics, surgical data, and radiographic alignment were compared. Repeated measure analysis of variance was performed to evaluate the maintenance of the correction for L1-L4 and L4-S1. Multivariate logistic regression was conducted to identify independent surgical predictors of correction loss. Results. The cohort had amean age of 64 years, amean BodyMass Index of 28 kg/m2, and 80% females. Eighty-two patients (25.5%) lost >5° of pelvic incidence--lumbar lordosis correction (mean loss 10±5°). After the exclusion of patients with instrumentation failure, 52 losses were compared with 222 maintained. Demographics, osteotomies, 3CO, interbody fusion, use of bone morphogenetic protein, rod material, rod diameter, and fusion length were not significantly different. L1-S1 screw orientation angle was 1.3 ± 4.1 from early postoperative to 3 years (P = 0.031), but not appreciably different at L4-S1 (0.1 ± 2.9 P = 0.97). Lack of a supplemental rod (odds ratio: 4.0, P = 0.005) and fusion length (odds ratio 2.2, P = 0.004) were associated with loss of correction. Conclusions. Approximately, a quarter of revision-free patients lose an average of 10° of their 6-week correction by 3 years. Lordosis is lost proximally through the instrumentation (i.e. tulip/ shank angle shifts and/or rod bending). The use of supplemental rods and avoiding sagittal overcorrection may help mitigate this loss. [ABSTRACT FROM AUTHOR]

Pedicle subtraction osteotomy (PSO) is a surgical technique to restore lumbar lordosis in patients with rigid sagittal deformity. Herein, we report on outcomes of a surgical technique utilizing a 4-rod PSO with satellite rods. A retrospective study was performed for a cohort of patients who underwent 4-rod PSO revision surgery for sagittal deformity. Procedures were performed by one surgeon at 2 different academic centers between 2004–2018. Alignment outcomes and complications specifically for revision surgeries in previously fused spines were assessed. 40 patients underwent PSO with the satellite rod technique (n = 29 at L3, 72.5%; n = 7 at L4, 17.5%). Mean PSO angle was 28.7 ± 7.6°. Two patients (5%) had rod fracture necessitating revision surgery at 32 and 34 months. Three patients (7.5%) developed proximal junctional kyphosis (PJK), but none required revision. No patients developed pseudoarthrosis. Mean preoperative sagittal vertical axis (SVA) was 13.5 ± 7.3 cm, which decreased to 4.8 ± 7.3 cm (P = 0.002) postoperatively. Mean preoperative pelvic incidence-lumbar lordosis (PI-LL) mismatch improved from 35.9 ± 16.6° preoperatively to 11.8 ± 14.6° postoperatively (P < 0.001). Mean preoperative pelvic tilt (PT) improved from 34.7 ± 9.8° preoperatively to 30.1 ± 9.0° (P = 0.026) postoperatively. Mean global alignment and proportion (GAP) score improved from 10 ± 2 preoperatively to 8 ± 2 postoperatively (P < 0.001), which was still considered severely disproportioned. Rod failure rate after PSO with the 4-rod satellite configuration was low. SVA, PI-LL mismatch, and PT significantly improved for these previously-fused patients. Mean GAP score also improved, but was still considered severely disproportioned, likely due to the inability of PSO to correct low LL or PT in previously-fused spines. [ABSTRACT FROM AUTHOR]

• A total of 18.6% of surgically treated adult spinal deformity patients indicated they were unsure or would not undergo surgery again. • Patients indicating they were unsure or wound not have surgery again had more postoperative complications requiring surgery than patients indicating they would have surgery again. • Patients indicating they were unsure or wound not have surgery again had worse postoperative PROs and fewer percentages reaching minimal clinically important difference for SRS-22r and ODI than patients indicating they would have surgery again. • At minimum 2 year follow up 93.0% of patients indicating they would have surgery again reported they were satisfied with the results of their back management compared 82.3% of unsure if they would have the same surgery again and 72.4% of patients that wound not have surgery again (p<.05). • Surgeons accurately identified patients indicating they would have surgery again (91.1%) but poorly identified patients indicating they wound not have surgery again (13.8%; p<.05). Adult spinal deformity (ASD) surgery can improve patient pain and physical function but is associated with high complication rates and long postoperative recovery. Accordingly, if given a choice, patients may indicate they would not undergo ASD surgery again. Evaluate surgically treated ASD patients to assess if given the option (1) would surgically treated ASD patients choose to undergo the same ASD surgery again, (2) would the treating surgeon perform the same ASD surgery again and if not why, (3) evaluate for consensus and/or discrepancies between patient and surgeon opinions for willingness to perform/receive the same surgery, and (4) evaluate for associations with willingness to undergo or not undergo the same surgery again and patient demographics, patient reported outcomes, and postoperative complications. Retrospective review of a prospective ASD study. Surgically treated ASD patients enrolled into a multicenter prospective study. Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form-36v2 questionnaire (SF-36) physical component summary (PCS) and mental component summary (MCS), Oswestry Disability Index (ODI), numeric pain rating for back pain (NRS back) and leg pain (NRS leg), minimal clinically important difference (MCID) for SRS-22r domains and ODI, intraoperative and postoperative complications, surgeon and patient satisfaction with surgery. Surgically treated ASD patients prospectively enrolled into a multicenter study were asked at minimum 2-year postoperative, if, based upon their hospital and surgical experiences and surgical recovery experiences, would the patient undergo the same surgery again. Treating surgeons were then matched to their corresponding patients, blinded to the patients' preoperative and postoperative patient reported outcome measures, and interviewed and asked if (1) the surgeon believed that the corresponding patient would undergo the surgery again, (2) if the surgeon believed the corresponding patient was improved by the surgery and (3) if the surgeon would perform the same surgery on the corresponding patient again, and if not why. ASD patients were divided into those indicating they would (YES), would not (NO) or were unsure (UNSURE) if they would have same surgery again. Agreement between patient and surgeon willingness to receive/perform the same surgery was assessed and correlations between patient willingness for same surgery, postoperative complications, spine deformity correction, patient reported outcomes (PROs). A total of 580 of 961 ASD patients eligible for study were evaluated. YES (n=472) had similar surgical procedures performed, similar duration of hospital and ICU stay, similar spine deformity correction and similar postoperative spinal alignment as NO (n=29; p>.05). UNSURE (n=79) had greater preoperative depression and opioid use rates, UNSURE and NO had more postoperative complications requiring surgery, and UNSURE and NO had fewer percentages of patients reaching postoperative MCID for SRS-22r domains and MCID for ODI than YES (p<.05). Comparison of patient willingness to receive the same surgery versus surgeon perceptions on patient's willingness to receive the same surgery demonstrated surgeons accurately identified YES (91.1%) but poorly identified NO (13.8%; p<.05). If given a choice, 18.6% of surgically treated ASD patients indicated they were unsure or would not undergo the surgery again. ASD patients indicating they were unsure or would not undergo ASD surgery again had greater preoperative depression, greater preoperative opioid use, worse postoperative PROs, fewer patients reaching MCID, more complications requiring surgery, and greater postoperative opioid use. Additionally, patients that indicated they would not have the same surgery again were poorly identified by their treating surgeons compared to patients indicating they would be willing to receive the same surgery again. More research is needed to understand patient expectations and improve patient experiences following ASD surgery. [ABSTRACT FROM AUTHOR]

Background Context: Previous research on rates of spinal detection showed a low frequency of patients (5%) experienced delays and additional screening going through airport security. With continuous technology advances in screenings and the rise in cobalt chrome implantation, updated data on patient experiences was needed.Purpose: 1) Assess the rates of detection and additional screening by traditional metal detectors and full body scanners in patients with metal spinal implants, 2) Compare the rates of detection of various metal types (Titanium and cobalt-chrome, titanium only, and stainless steel) STUDY DESIGN: Retrospective PATIENT SAMPLE: All spine surgical follow-ups over survey period.Outcome Measures: Self-reported open questionnaire; frequency of airport screening, patients' feelings and attitudes towards screening.Methods: Patients were surveyed in the outpatient setting on exposure to metal detectors (Traditional and full-body scanners) after spinal surgery with metallic implants at a single institution. A total of 182 patients were identified and consented. The medical records were reviewed for details on implant material and location.Results: Mean age at surgery was 53 years (range=12-88) with a mean 5.9 levels fused (range 2-20). Mean time from surgery to survey was 34 months (range=2-351) and number of airport screenings was 5.8 (range=0-54). The most common implants were titanium/cobalt-chrome (Ti/CoCr) (n=96, 53%) and titanium only (n=72, 40%). Overall, 40% of patients reported a detector alert at an airport requiring processing delay and additional screening: 86% from full body scanners, 54% from traditional metal detectors, and 41% of patients reporting both. Full body scanners were more likely to detect implants compared to traditional metal detectors (OR 5.1, p<.0001). No significant difference in number of screenings between patients who set off detectors and patients who did not (p=.185). Twenty percent of patients reported trouble at non-airport locations with detectors due to their spinal implants, with 70% of these patients reporting additional manual screenings. There was no correlation between levels spanned by the construct and number of times detected by traditional metal detectors or full body scanners, and no significant difference between levels spanned by constructs, or construct locations, in patients who set off detectors and those who did not. There was no significant difference between Ti/CoCr vs. titanium or other constructs in positive screenings. Subanalysis of fusions <5 levels demonstrated Ti/CoCr implants did not have an impact on positive screenings vs. other metal types (OR 0.88, p=.756). Interestingly, there was a significant difference in age and the positive screenings (p=.0025). Patients 60+ years of age had statistically significant greater positive screening than patients 0 to 40 years and 41 to 60 years. This data raises the possibility the presence of total joint arthroplasties (Mean age of patients with arthroplasty 65.5 years, range 50-88) likely play a significant role in the frequency of positive screenings.Conclusions: 40% of patients had their spinal implants detected at airports and 20% reported detections at other non-airport locations. Full body scanners detect spinal implants more frequently compared to traditional metal detectors (86% vs. 54% of detections, respectively). There was no difference in rate of airport and non-airport detection in patients with cobalt chrome implants compared to other materials. The presence of total joint arthroplasties likely has a significant contribution to the detector alerts. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study.Objective: Determine whether screws per level and rod material/diameter are associated with incidence of proximal junctional kyphosis (PJF).Summary Of Background Data: PJF is a common and particularly adverse complication of adult spinal deformity (ASD) surgery. There is evidence that the rigidity of posterior spinal constructs may impact risk of PJF.Methods: Patients with ASD and 2-year minimum follow-up were included. Only patients undergoing primary fusion of more than or equal to five levels with lower instrumented vertebrae (LIV) at the sacro-pelvis were included. Screws per level fused was analyzed with a cutoff of 1.8 (determined by receiver operating characteristic curve (ROC) analysis). Multivariable logistic regression was utilized, controlling for age, body mass index (BMI), 6-week postoperative change from baseline in lumbar lordosis, number of posterior levels fused, sex, Charlson comorbidity index, approach, osteotomy, upper instrumented vertebra (UIV), osteoporosis, preoperative TPA, and pedicle screw at the UIV (as opposed to hook, wire, etc.).Results: In total, 504 patients were included. PJF occurred in 12.7%. The mean screws per level was 1.7, and 56.8% of patients had less than 1.8 screws per level. No differences were observed between low versus high screw density groups for T1-pelvic angle or magnitude of lordosis correction (both P > 0.15). PJF occurred in 17.0% versus 9.4% of patients with more than or equal to 1.8 versus less than 1.8 screws per level, respectively (P < 0.05). In multivariable analysis, patients with less than 1.8 screws per level exhibited lower odds of PJF (odds ratio (OR) 0.48, P < 0.05), and a continuous variable for screw density was significantly associated with PJF (OR 3.87 per 0.5 screws per level, P < 0.05). Rod material and diameter were not significantly associated with PJF (both P > 0.1).Conclusion: Among ASD patients undergoing long-segment primary fusion to the pelvis, the risk of PJF was lower among patients with less than 1.8 screws per level. This finding may be related to construct rigidity. Residual confounding by other patient and surgeon-specific characteristics may exist. Further biomechanical and clinical studies exploring this relationship are warranted.Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective review of prospectively collected multicenter registry data.Objective: To identify rates and timing of postoperative complications in adult spinal deformity (ASD) patients, the impact of complication type and timing on health related quality of life (HRQoL) outcomes, and the impact of complication timing on readmission and reoperation rates. Better understanding of complication timing and impact on HRQoL may improve patient selection, preoperative counseling, and postoperative complication surveillance.Summary Of Background Data: ASD is common and associated with significant disability. Surgical correction is often pursued, but is associated with high complication rates. The International Spine Study Group, AO Spinal Deformity Forum, and European Spine Study Group have developed a new complication classification system for ASD (ISSG-AO spine complications classification system).Methods: The ISSG-AO spine complications classification system was utilized to assess complications occurring over the 2-year postoperative time period amongst a multicenter, prospectively enrolled cohort of patients who underwent surgery for ASD. Kaplan-Meier survival curves were established for each complication type. Propensity score matching was performed to adjust for baseline disability and comorbidities. Associations between each complication type and HRQoL, and reoperation/readmission and complication timing, were assessed.Results: Of 584 patients meeting inclusion criteria, cardiopulmonary, gastrointestinal, infection, early adverse events, and operative complications contributed to a rapid initial decrease in complication-free survival. Implant-related, radiographic, and neurologic complications substantially decreased long-term complication-free survival. Only radiographic and implant-related complications were significantly associated with worse 2-year HRQoL outcomes. Need for readmission and/or reoperation was most frequent among those experiencing complications after postoperative day 90.Conclusion: Surgeons should recognize that long-term complications have a substantial negative impact on HRQoL, and should carefully monitor for implant-related and radiographic complications over long-term follow-up.Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective review of prospectively collected multicenter registry data.Objective: The aim of this study was to determine whether surgical variables and complications as graded by treatment severity impact postoperative hospital length of stay (LOS).Summary Of Background Data: Surgical treatment can substantially improve quality of life for patients with adult spinal deformity (ASD). However, surgical treatment is associated with high complication rates, which may impact hospital LOS. Classifying complications by severity of subsequent treatment may allow surgeons to better understand complications and predict their impact on important outcome metrics, including LOS.Methods: Patients enrolled in a multicenter, prospectively enrolled database for ASD were assessed for study inclusion. Complications were graded based on intervention severity. Associations between LOS, complication intervention severity, and surgical variables (fusion length, use of interbody fusion, use of major osteotomy, primary versus revision surgery, same day vs. staged surgery, and surgical approach), were assessed. Two multivariate regression models were constructed to assess for independent associations with LOS.Results: Of 1183 patients meeting inclusion criteria, 708 did not and 475 did experience a perioperative complication during their index hospitalization, with 660 and 436 included in the final cohorts, respectively. Among those with complications, intervention severities included 14.9% with no intervention, 68.6% with minor, 8.9% with moderate, and 7.6% with severe interventions. Multivariate regression modeling demonstrated that length of posterior fusion, use of major osteotomy, staged surgery, and severity of intervention for complications were significantly associated with LOS.Conclusion: Careful selection of surgical factors may help reduce hospital LOS following surgery for ASD. Classification of complications by treatment severity can help surgeons better understand and predict the implications of complications, in turn assisting with surgical planning and patient counseling.Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective review of a prospective multicenter cervical deformity database.Objective: To examine the differences in sagittal alignment correction between three positioning methods in cervical spinal deformity surgery (CD).Summary Of Background Data: Surgical correction for CD is technically demanding and various techniques are utilized to achieve sagittal alignment objectives. The effect of different patient positioning techniques on sagittal alignment correction following CD remains unknown.Methods: Patients with sagittal deformity who underwent a posterior approach (with and without anterior approach) with an upper instrumented vertebra of C6 or above. Patients with Grade 5, 6, or 7 osteotomies were excluded. Positioning groups were Mayfield skull clamp, bivector traction, and halo ring. Preoperative lower surgical sagittal curve (C2-C7), C2-C7 sagittal vertical axis (cSVA), cervical scoliosis, T1 slope minus cervical lordosis (TS-CL), T1 slope (T1S), chin-brow vertebral angle (CBVA), C2-T3 curve, and C2-T3 SVA was assessed and compared with postoperative radiographs. Segmental changes were analyzed using the Fergusson method.Results: Eighty patients (58% female) with a mean age of 60.6 ± 10.5 years (range, 31-83) were included. The mean postoperative C2-C7 lordosis was 7.8° ± 14 and C2-C7 SVA was 34.1 mm ± 15. There were overall significant changes in cervical alignment across the entire cohort, with improvements in T1 slope (P < 0.001), C2-C7 (P < 0.001), TS-CL (P < 0.001), and cSVA (P = 0.006). There were no differences postoperatively of any radiographic parameter between positioning groups (P > 0.05). The majority of segmental lordotic correction was achieved at C4-5-6 (mean 6.9° ± 11). Additionally, patients who had bivector traction applied had had significantly more segmental correction at C7-T1-T2 compared with Mayfield and halo traction (4.2° vs. 0.3° vs. -1.7° respectively, P < 0.027).Conclusion: Postoperative cervical sagittal correction or alignment was not affected by patient position. The majority of segmental correction occurred at C4-5-6 across all positioning methods, while bivector traction had the largest corrective ability at the cervicothoracic junction.Level of Evidence: 4. [ABSTRACT FROM AUTHOR]

Study Design: Prospective analysis of example cases.Objective: The aim of this study was to analyze the accuracy and repeatability of a new comprehensive classification system for capturing complications data in adult spinal deformity.Summary Of Background Data: Complications are common in adult spinal deformity surgery. However, no consensus exists on the definition or classification of complications in adult spinal deformity surgery. The lack of consensus significantly limits understanding of complications' effects on outcomes in surgery for adult spinal deformity.Methods: Using a Delphi method, members of the International Spine Study Group, AO Spine, and the European Spine Study Group collaborated to develop an adult spinal deformity classification system. The multidomain classification system accounts for medical complications (cancer, cardiopulmonary, central nervous system, gastrointestinal, infectious, musculoskeletal, renal) and surgical complications (implant complications, radiographic complications, neurologic events, intraoperative events, and wound complications). Seventeen individuals ("event readers"), including spine surgeons, trainees, and research coordinators, used the new classification system two separate times to analyze complications in ten example cases. The accuracy and repeatability of the classification system were subsequently calculated based on the providers' responses for the example cases.Results: The 10 example cases included 22 complications. Nearly 95% of complications were captured by >95% of the event readers. The system demonstrated good repeatability of 86.9% between the first and second set of responses provided by event readers.Conclusion: The ISSG-AO Multi-Domain Spinal Deformity Complication Classification System for Adult Spinal Deformity demonstrated good accuracy and repeatability among both surgeons and research coordinators in capturing complications in adult spinal deformity surgery. The ISSG-AO system may be applied to help better understand the impact of complications on outcomes and costs in adult spinal deformity surgery.Level of Evidence: 5. [ABSTRACT FROM AUTHOR]

Patients with ASD show complex and highly variable disease. The decision to manage patients operatively is largely subjective and varies based on surgeon training and experience. We sought to develop models capable of accurately discriminating between patients receiving operative versus nonoperative treatment based only on baseline radiographic and clinical data at enrollment. This study was a retrospective analysis of a multicenter consecutive cohort of patients with ASD. A total of 1503 patients were included, divided in a 70:30 split for training and testing. Patients receiving operative treatment were defined as those undergoing surgery up to 1 year after their baseline visit. Potential predictors included available demographics, past medical history, patient-reported outcome measures, and premeasured radiographic parameters from anteroposterior and lateral films. In total, 321 potential predictors were included. Random forest, elastic net regression, logistic regression, and support vector machines (SVMs) with radial and linear kernels were trained. Of patients in the training and testing sets, 69.0% (n = 727) and 69.1% (n = 311), respectively, received operative management. On evaluation with the testing dataset, performance for SVM linear (area under the curve =0.910), elastic net (0.913), and SVM radial (0.914) models was excellent, and the logistic regression (0.896) and random forest (0.830) models performed very well for predicting operative management of patients with ASD. The SVM linear model showed 86% accuracy. This study developed models showing excellent discrimination (area under the curve >0.9) between patients receiving operative versus nonoperative management, based solely on baseline study enrollment values. Future investigations may evaluate the implementation of such models for decision support in the clinical setting. [ABSTRACT FROM AUTHOR]

The Lumbar Stiffness Disability Index (LSDI) assesses impact of lumbar stiffness on activities of daily living. We hypothesized that patients <60 years old would perceive greater lumbar stiffness–related functional limitation following fusion for adult spinal deformity. Patients completed the LSDI and Scoliosis Research Society 22 Questionnaire, Revised (SRS-22r) preoperatively and at 2 years postoperatively. The primary independent variable was patient age <60 versus ≥60. Multivariable regression analyses were used. Analysis included 267 patients. Patients <60 years old (51.3%) and ≥60 years old (48.7%) were evenly represented. In bivariable analysis, patients age <60 exhibited lower LSDI at baseline versus patients age ≥60 (25.7 vs. 35.5, β −9.8, P < 0.0001), but a directionally smaller difference at 2 years (26.4 vs. 32.3, β −5.8, P = 0.0147). LSDI was associated with lower SRS-22r total score among both age groups at baseline and 2 years (all P < 0.0001); the association was stronger among patients age <60 versus ≥60 at 2 years. LSDI was associated with SRS-22r satisfaction scores at 2 years among patients age <60 (P < 0.0001), but not patients age ≥60 (P = 0.2250). The difference in SRS-22r satisfaction per unit LSDI between patients <60 years old and ≥60 years old was significant (P = 0.0021). Among patients with adult spinal deformity managed operatively, higher LSDI was associated with inferior SRS-22r total score and satisfaction at 2 years postoperatively. The association between increased LSDI and worse patient-reported outcome measures was greater among patients age <60 versus ≥60. Preoperative counseling is needed for patients age <60 undergoing adult spinal deformity surgery regarding effects that lumbar stiffness may have on postoperative function and satisfaction. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective analysis of a prospective registry OBJECTIVE.: To investigate associations of preoperative narcotic use with outcomes after adult spinal deformity (ASD) surgery.Summary Of Background Data: We hypothesized that preoperative narcotic use would predict longer hospital stays, greater postoperative narcotic use, and greater disability 2 years after ASD surgery.Methods: A multicenter database of surgical ASD patients was analyzed retrospectively for patients with self-reported data on preoperative narcotic use. Patients were categorized as using narcotics daily or non-daily (including those who used no narcotics), according to self-report. Outcomes were prolonged length of hospital stay (LOS) (>7 days); length of intensive care unit (ICU) stay; and daily narcotic use and Oswestry Disability Index (ODI) scores 2 years postoperatively. Groups were compared by demographic characteristics, pain, disability, radiographic deformity, and surgical invasiveness. Multivariate logistic and linear regression were used to determine associations between preoperative narcotic use and outcomes.Results: Of 575 patients who met the inclusion criteria, 425 (74%) had complete 2-year follow-up data. Forty-four percent reported daily preoperative narcotic use. Compared with non-daily users, daily narcotic users were older, had more comorbidities, more severe back pain, higher ODI scores, longer operative times, and worse preoperative malalignment and were more likely to undergo 3-column osteotomy (all, P < 0.05). Daily narcotic use independently predicted prolonged LOS (odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.1-2.9), longer ICU stay (difference = 16 hours, 95% CI = 1.9-30 hours), and daily narcotic use 2 years postoperatively (OR = 6.9, 95% CI = 3.7-13), as well as worse 2-year ODI score (difference = 4.5, 95% CI: 0.7-8.3, P = 0.021).Conclusion: Daily narcotic use before ASD surgery was associated with prolonged LOS, longer ICU stays, and increased risk of daily narcotic use and greater disability 2 years postoperatively.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background Context: Risk factors associated with rod fracture (RF) following adult spinal deformity (ASD) surgery fused to the sacrum remain debatable, and the impact of RF on patient-reported outcomes (PROs) after ASD surgery has not been investigated.Purpose: We aimed to evaluate the prevalence of and risk factors for RF and determine PROs changes associated with RF after ASD surgery fused to the sacrum.Study Design/setting: A retrospective single-center cohort study was performed.Patient Sample: Patients undergoing long-construct posterior spinal fusions to the sacrum performed at a single institution by two senior spine surgeons from 2004 to 2014 were included.Outcome Measures: Patient demographics, radiographic parameters, and surgical factors were assessed for risk factors associated with RF. Oswestry Disability Index (ODI) and Scoliosis Research Society-30 (SRS-30) scores were assessed at baseline, 1 year postoperatively, and latest follow-up.Methods: Inclusion criteria were ASD patients age >18 who had ≥5 vertebrae instrumented and fused posteriorly to the sacrum and either development of RF or no development of RF with minimum 2-year follow-up. Patient characteristics, operative data, radiographic parameters, and PROs were analyzed at baseline and follow-up. Separate Cox proportional hazard models based on rod material and diameter were used to determine factors associated with RF.Results: Five hundred twenty-six patients (80%) were available for analysis. RF occurred in 97 (18.4%) patients (unilateral RF n=61 [63%]; bilateral RF n=36 [37%]). Risk factors for fracture of 5.5 mm cobalt chromium (CC) instrumentation (CC 5.5 model) included preoperative sagittal vertical axis (hazard ratio [HR] 1.07, 95% confidence interval [95% CI] 1.02-1.14 per 1-cm increase), preoperative thoracolumbar kyphosis (HR 1.02, 95% CI 1.01-1.04 per 1-degree increase), and number of levels fused for patients who received rhBMP-2 <12 mg per level fused (HR 1.48, 95% CI 1.20-1.82 per 1-level increase). Implants that were 5.5-mm CC constructs were at a higher risk for fracture than 6.35-mm stainless steel (SS) constructs (HR 8.49, 95% CI 4.26-16.89). The RF group had less overall improvement in SRS Satisfaction (0.93 vs. 1.32; p=.007) and SRS Self-image domain scores (0.72 vs. 1.02; p=.01). The bilateral RF group had less overall improvement in ODI (8.1 vs. 15.8; p=.02), SRS Subscore (0.51 vs. 0.85; p=.03), and SRS Pain domain scores (0.48 vs. 0.95; p=.02) compared with the non-RF group at final follow-up.Conclusions: The prevalence of all RF after index procedures was 18.4%, 37% for bilateral RF. Greater preoperative sagittal vertical axis, greater preoperative thoracolumbar kyphosis, increased number of vertebrae fused for patients who received rhBMP-2 <12 mg per level fused, and CC 5.5-mm rod were associated with RF. Less improvement in patient satisfaction and self-image was noted in the RF group. Furthermore, bilateral RF significantly affected PROs as measured by ODI and SRS Subscore at final follow-up. [ABSTRACT FROM AUTHOR]

Adult spinal deformity (ASD) is a complex pathology associated with high complication rates. Although complication rates have been previously reported, the interplay between timing and type of complications has not been fully analyzed. Provide benchmarks for the rates of complications by type and timing. Prospective multicenter database. Operatively treated ASD patients with 2-year follow-up. Rates of medical complications (cardiac, GI, infection, pulmonary, renal) and surgical complications (implant-related, operative, neurologic, radiographic) within 2 years postsurgery In the context of a prospective multicenter ASD database, standardized forms were used to collect data on surgery-related complications. Onsite research coordinators and central auditing helped ensure data capture completeness. Inclusion criteria were age >18 years, ASD and minimum 2-year follow-up. Date and type of complication were collected and classified into three severity groups (minor, major, major leading to reoperation). Only complications occurring before the 2-year visit were retained for analysis. A total of 997 out of 1,260 patients eligible for 2-year follow-up (79.1%) were captured. The mean age at the time of surgery was 60.4yo±14.3, 76.3% were female and 50.5% had a history of previous spine surgery. The vast majority of patients (98.9%) had treatment including a posterior procedure, 57.9% had decompression, 71.2% had at least one osteotomy, and 18.1% had a 3-column osteotomy. Interbody fusion (IBF) was used in 64.0%: 48.7% posterior (TLIF or PLIF), 38.3% anterior (ALIF) and 23.2% lateral (LLIF). The mean ASD surgical invasiveness index was 88.8±36.1; 66.3% of the patients were admitted postop to the ICU, with a median overall length of hospital stay of 7 days (IQR 5 to 9). The overall complication rate was 67.4% (N=672). A total of 247 patients (24.8%) experienced at least one complication the day of surgery (including intraoperatively), 359 (36.0%) between POD1 and 6-weeks postoperatively, 271 (27.2%) between 6 weeks and 1-year postoperatively, and finally 162 (16.3%) between 1- and 2-years postoperatively. Using Kaplan-Meier survival analysis, the rate of remaining complication-free was estimated at 70.9% by POD1, 59.0% by POD7, 51.4% by 30 days, 47.4% by 3 months, and 33.6% by 2-years postoperatively. Breakdown by severity of remaining complication-free revealed the following rates for minor | major | reop: by POD1= 87.3% | 90.1% | 97.4%; by POD7=78.4% | 86.8% | 95.8%; by 3 months= 71.6% | 81.0% | 86.7%; by 6 months = 70.3% | 80.1% | 86.7%; and by 2-years postop=64.5% | 75.1% | 77.0%. Stratification by type of complication demonstrated that most of the medical complications occurred within the first 60 days. Surgical complications followed two types of behavior: operative, wound and infection occurred early (within 60 days), while implant-related and radiographic complications happened at a constant rate over the 2-year period. Neurologic complications had a high occurrence with the first 60 days, followed by a continuous increase up to the 2-year visit. Only one-third of ASD patients remained complication-free 2-years postoperatively. Two patients out of ten had a complication requiring a reoperation/revision. Estimation of timing and type of complication associated with surgical treatment is crucial when counseling patients and planning treatment cost-effectiveness. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Previous reports indicate postoperative complications have minimal impact on long-term outcomes after ASD surgery. Little data has evaluated the impact of complications on specific heath domains during postoperative period. To evaluate the impact of specific complications on patient reported health domains compared to patients with no complications. Prospective, multicenter, propensity score matched analysis. ASD patients enrolled into a prospective multi-center study. Oswestry Disability Index, Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form-36v2 questionnaire (SF-36), postoperative complications. Surgically treated ASD patients enrolled into a multicenter study were assessed for postoperative complications requiring surgery including wound (WOUND), pseudoarthrosis (PSEUDO), neurologic (NEURO) and malalignment (MAL) and matched to patients with no complications (NOCOMP) using inverse probability weighting for demographic, radiographic and surgical variables. Health domains for SRS-22r, and SF-36 were evaluated at regular time intervals, domain scores normalized to the date of revision surgery, and compared to patients with no complications at minimum 2-year follow-up. A total of 566 of 1130 were analyzed, average 3.6 yrs (range: 1.9 to 9). WOUND (n=12) compared to NOCOMP (n=390) had worse SF-36 physical function(21.7 vs 27.4), social function(19.6 vs 28.9), general health (-7.3 vs 8.9) and vitality (-0.9 vs 26.6,p < 0.05). PSEUDO (n=64) was worse than NOCOMP for SRS-22r function, 1.4 vs 2.1, and SF-36 social function, (17.1 vs 28.9) (p < 0.05). NEURO (n=28) was worse than NOCOMP for SRS-22r (0.9 vs 2.1), SF-36 bodily pain (14.7 vs 35.7) and social function (13.4 vs 28.9) (p < 0.05). MAL (n=72) was worse than NOCOMP for SRS-22r pain, (2.7 vs 3.4), function (1.2 vs 2.1), self-image (3.0 vs 3.9), SF-36 bodily pain (27.6 vs 35.7), physical function (18.7 vs 27.4), and social function (11.6 vs 28.9) (p < 0.05). Counter to previous reports, specific postoperative complications requiring surgery uniquely impact specific health domains, resulting in worse patient reported quality of life compared to ASD patients with no complications. Social function was negatively impacted for all complications, while wound complications negatively impacted patient perceived general health and vitality and patients with malalignment requiring surgery reported worse self-image. These data highlight new findings that postoperative complications have a negative impact on specific aspects of ASD quality of life that can undermine the potential benefits of ASD surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

As adult spinal deformity (ASD) prevalence increases in our ever-aging population there is a concomitant increase in poor bone quality. ASD surgery is expensive and carries a high complication profile. It is important to optimize modifiable preoperative risk factors, such as osteopenia or osteoporosis. Additional diagnostic modalities such as a DEXA can add cost, delay diagnosis, and can be an additional insurance hurdle. Some studies suggest HU's can be utilized as a proxy for frailty, but it is unclear if this is useful in risk stratification. Our goal was to evaluate the relationship between bone health as measured by HU's and PJK and identify a HU threshold in which PJK risk is increased. We hypothesize that HU will correlate with occurrence of PJK after ASD surgery. Retrospective review of a prospective, multicenter ASD database. Of 1,330 pts eligible, 997 (74.9%) had complete 2Y follow-up. Of these, 605 meet inclusion criteria with 110 (18.18%) patients having a PJK. Development of PJK within 2 years of surgery. Operative ASD patients (scoliosis >20, SVA>5cm, PT>25, or TK>60) with available baseline (BL) and 2-year (2Y) radiographic and HRQL data were included if they had a preop CT. HU were measured from axial views within the cancellous body (x3) at both L1 and UIV with the mean value calculated for each. Threshold linear regression with Bayesian information criteria was utilized to identify optimal cut-offs of risk factors for PJK. Multivariable analysis (MVA) controlled for PJK prophylaxis and surgeon. Additionally, risk factors identified were controlled against each other. Threshold regression identified that cut-offs of <125 HU for UIV, >63 years for age, >0.31 for ASD-FI, and >47° for preoperative T4-12 thoracic kyphosis, and <10 levels fused were predictive of PJK on bivariate analysis (P<0.05 for all). On MVA, age > 63 years old (OR 4.7; P = 0.003), female gender (OR 3.33; P=0.035), HU at UIV vertebrae <125 (2.83; P=0.008), ASD-FI >0.31 (OR 4.02; P=0.011), TK > 46° (OR 3.75; P=0.003), and < 10 levels fused (OR 3.31; P=0.0310) were associated with increased odds of PJK. Bone health as measured by HU appears to be an independent predictor of PJK after ASD surgery, specifically values <125 at the UIV. It also parallels frailty in prediction of PJK and can potentially be used as a proxy for frailty assessment. This can be easily measured and could help with risk stratification in the future. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Prior studies assessed the association between underlying neurological condition and worse outcomes following spinal surgery with recent emphasis of self-reported loss of balance (Imbalance) by Uribe et al. To investigate if patients with self-reported loss of balance have poorer outcomes following adult spinal deformity (ASD) surgery. Retrospective review of prospectively collected database. ASD patients with baseline and 2-year radiographic and patient-reported outcome measure (PROM) data were included. Demographics, radiographic outcomes, complications, and PROM were compared from baseline to 2-year follow up. Patients undergoing a long spinal fusion with no prior history of spine surgery were retained. Patients were grouped according to imbalance and unsteady gait. The groups were propensity matched by age, PI-LL, and surgical invasiveness score. Demographics, radiographic, complications and PROM were compared from baseline to 2-year post-op. A total of 212 patients were reported (106 patients in each group). The mean age (64 vs 63 years), BMI (27.2 vs 27.0 kg/m2), and gender (76% vs 87% female) were not significantly different for patients with imbalance and without imbalance respectively (all p >0.05). Patients in the imbalance group had a higher Frailty Index Score compared to patients without imbalance (3.74 vs 2.33, p <0.001). At baseline, the sagittal profile for both groups were comparable with regard to PT, PI-LL, and SVA. Patients with loss of balance had a significantly lower thoracic Cobb angle (25.27° vs 37.45°, p <0.001) and lumbar Cobb angle (37.03° vs 45.53°, p=0.004), although the global coronal alignment was similar (imbalance:41.51 mm vs 34.25 mm, p=0.155). Patients with imbalance had worse PROM measures, including ODI (45.15 vs 36.62), SF-36 Mental Component Score (44.04 vs 51.76), SF-36 Physical Component Score (30.17 vs 35.10), and SRS-22 Mental domain score (3.28 vs 3.80) (p <0.001 for all). Postoperatively, patients with imbalance had less PT correction (-1.45° vs -3.60°, p=0.039) for a comparable correction in their PI-LL (-11.93° vs-15.08°, p=0.144) by 2-year follow-up. Both groups demonstrated similar improvements in their coronal plane deformity. Imbalance patients had higher rates of radiographic PJK at 2-year follow-up (26.4% vs 14.2%, p=0.026). Furthermore, patients with reported imbalance have significantly higher rate of implant related complications (47.2% vs 34.0%, p=0.05). After controlling for age, baseline sagittal parameters, PI-LL correction and Charlson Comorbidity Index, patients with imbalance had 2.2 times increased odds of sustaining PJK by 2 years. Patients with a self-reported loss of balance and unsteady gait have significantly worse baseline frailty and PROMs, represented by poorer mental health and physical function. Although those patients had higher rates of PJK and implant-related complications, surgical intervention significantly improved their quality of life. Despite the improvement, they remained with lower PROMs by 2-year follow-up. Therefore, in the clinic setting and with limited institutional access to Frailty scores, asking patients if they have loss of balance or unsteady gait is a simple yet powerful question which may trigger their preoperative risk stratification and optimization. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Identifying the components needed for an optimal adult spinal deformity (ASD) surgical outcome could help inform surgeons and improve ASD treatment. However, defining the components that create an optimal outcome for ASD surgery is challenging because outcome metrics depend on multiple perspectives. A patient may receive a technically successful complication-free surgery but may report dissatisfaction with the treatment outcome. Conversely, a patient may incur multiple postoperative complications with high societal cost but report satisfaction with the surgical outcome. (1) Define an "optimal" ASD surgical outcome by integrating outcome metrics from multiple perspectives, and (2) identify the patient-specific and surgical components of ASD treatment that surgeons can employ to improve ASD surgery by creating a model that predicts a multi-perspective "optimal" surgical outcome. Prospective, multicenter analysis. ASD patients enrolled into a prospective multicenter study. Scoliosis Research Society-22r questionnaire (SRS-22r), Oswestry Disability Index (ODI), postoperative complications. Surgically treated ASD patients prospectively enrolled into a multicenter study from 2009-2018 were assessed at minimum 2-year follow-up for optimal outcome defined as (1) no major postoperative complication or complication requiring surgery, (2) patient reached MCID for ODI and SRS-22r subscore, and (3) patient satisfied and indicates would have the surgery again. Demographic, radiographic, PROM and surgical variables were assessed for associations with optimal outcome. Multivariate regression models were built based on level of upper instrumented vertebra (UIV) to identify variables that created a best fit predictive model for optimal outcome by R2 maximization and AIC/BIC minimization. Of 1291 patients, 788 (mean 3.5 years follow-up), were eligible for study and evaluated. Optimal outcome patients (OP; n=196) had less preoperative opioid use (47.5% vs 56.8%) and fewer histories of prior spine surgery (65.4% vs 77.3%) than nonoptimal outcome (NO; n=592), respectively (p 0.05). Creation of the best fit predictive model for optimal outcome demonstrated synergy between several modifiable variables including preoperative BMI and opioid and tobacco use, final SVA and scoliosis, and use of supplemental rods and PJF prophylaxis. Refining the model for specific surgeries based upon UIV demonstrated increased synergistic impact of the modifiable variables and predictive accuracy (thoracolumbar UIV R2 =0.41; upper thoracic UIV R2 =0.77). No single surgical or radiographic variable is independently predictive of an a priori defined multiperspective optimal outcome following ASD surgery. However, predictive modeling identified preoperative BMI, opioid and tobacco use, final SVA and scoliosis, and use of supplemental rods and PJF prophylaxis as variables surgeons can optimize and/or employ that act synergistically to predict an optimal ASD surgical outcome. Future research will focus on development of predictive models that highlight the synergistic effects of patient specific and interventional variables to improve surgical outcomes. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Despite studies reporting the efficacy of BMP to promote surgical spinal fusion, hospital systems and third-party payors continue to deny use of BMP, claiming high cost and lack of long term follow up. Perform a propensity score matched analysis of complications and cost-effectiveness for surgically treated adult spinal deformity (ASD) patients receiving BMP vs no BMP. Prospective, multicenter, propensity score matched analysis. ASD patients enrolled into a prospective multicenter study. Numeric rating scale (NRS) back and leg pain, Scoliosis Research Society-22r questionnaire (SRS-22r), Short Form-36v2 questionnaire (SF-36), Oswestry Disability Index (ODI), cost of care, cost/QALY, postoperative complications. Surgically treated ASD patients prospectively enrolled into a multicenter study from 2009-2018 were assessed for receiving BMP or NOBMP (iliac crest bone graft and allograft only) at the time of surgery. BMP and NOBMP cohorts were propensity score matched (PSM) for age, BMI, frailty, total levels fused, fusion to the pelvis, osteotomies, interbody fusion and supplemental rod use. Postoperative alignment, complications, rod fractures, patient-reported outcomes (PROMs), cost of care (based on DRG reimbursements adjusted to 2021 US dollars), were evaluated at minimum 3-year follow-up, and cost/QALY calculated at 1-,2-, and minimum 3-year follow-up. Of 888 patients, 483 (mean 4.2 years follow-up, range 2.9 to 8.8) were evaluated. Mean BMP dosage was 27.6 mg total (range 1 to 200), 2.2 mg/level posterior (range 0 to 25) and 1.7 mg/level interbody (range 0 to 18). BMP (n=407) had similar demographics, osteotomies, total and interbody levels fused, preop PROMs, follow-up duration, and pre- and postoperative spinal alignment as NOBMP (n=76; p>0.05). BMP had fewer implant failures (0.17/patient vs 0.33/patient; p 0.05). At last follow-up, BMP had better SF-36 social function (46.7 vs 43.9) and SF-36 mental component scores (51.5. vs 47.8) than NOBMP (p <0.05, respectively). BMP had lower mean total cost of care/patient ($78,679.61 vs $103,388.78) and lower cost/QALY ($22,455.48 vs $32,947.68) at last follow-up vs NOBMP, respectively (p < 0.05). Revision surgery rates were similar for BMP vs NOBMP (0.32 vs 0.42/patient, p=0.11); however, costs of revision surgery were less for BMP ($11,114.33) vs NOBMP ($22,912.53, p <0.05). Propensity score matched analysis demonstrated BMP use in ASD surgery at mean 4-year follow-up was associated with decreased implant fracture rates, lower treatment costs and better cost/QALY than NOBMP. Hospital systems, administrators and third-party payors should consider that the initial cost of BMP use at index surgery may be offset by decreased total cost of care and improve cost/QALY for ASD patients. Bone morphogenetic protein: Investigational. [ABSTRACT FROM AUTHOR]

Background Context: Recombinant human bone morphogenetic protein 2 (rhBMP-2) plays a pivotal role in complex spine surgery. Despite its limited approval, the off-label use of rhBMP-2 is prevalent, particularly in transforaminal lumbar interbody fusions (TLIFs).Purpose: To determine the effectiveness and safety of rhBMP-2 use in TLIF procedures versus autograft.Study Design: Retrospective cohort study.Patient Sample: Patients older than 18 years undergoing spine surgery for lumbar degenerative spine disease at a single academic institution.Outcome Measures: Clinical outcome was determined according to patient records. Radiographic outcome was determined according to plain X-rays and computed tomography (CT).Methods: A retrospective study from 1997 to 2014 was conducted on 191 adults undergoing anterior-posterior instrumented spinal fusion with TLIF at a single academic institution. Patient data were gathered from operative notes, follow-up clinic notes, and imaging studies to determine complications and fusion rates. One hundred eighty-seven patients fit the criteria, which included patients with a minimum of one TLIF, and had a minimum 2-year radiographic and clinical follow-up. Patients were further classified into a BMP group (n=83) or non-BMP group (n=104). Three logistic regression models were run using rhBMP-2 exposure as the independent variable. The respective outcome variables were TLIF-related complications (radiculitis, seroma, osteolysis, and ectopic bone), surgical complications, and all complications.Results: Bone morphogenetic protein (n=83) and non-BMP (n=104) groups had similar baseline demographics (sex, diabetes, pre-existing cancer). On average, the BMP and non-BMP groups were similarly aged (51.9 vs. 47.9 years, p>.05), but the BMP group had a shorter follow-up time (3.03 vs. 4.06 years; p<.001) and fewer smokers (8 vs. 21 patients; p<.048). The fusion rate for the BMP and non-BMP groups was 92.7% and 92.3%, respectively. The pseudoarthrosis rate was 7.5% (14 of 187 patients). Radiculitis was observed in seven patients in the BMP group (8.4%) and two patients in the non-BMP group (1.9%). Seroma was observed in two patients in the BMP group (2.4%) and none in the non-BMP group. No deep infections were observed in the BMP group, and in one patient in the non-BMP group (0.96%). Although patients exposed to BMP were at a significantlygreater risk of developing radiculitis and seroma (odds ratio [OR]=4.53, confidence interval [CI]=1.42-14.5), BMP exposure was not a significant predictor of surgical complications (OR=0.32, CI=0.10-1.00) or overall complications (OR=1.11, CI=0.53-2.34). The outcome of TLIF-related complications was too rare and the confidence interval too wide for practical significance of the first model.Conclusion: Evidence supports the hypothesis that off-label use of rhBMP-2 in TLIF procedures is relatively effective for achieving bone fusion at rates similar to patients receiving autograft. Patients exhibited similar complication rates between the two groups, with the BMP group exhibiting slightly higher rates of radiculitis and seroma. [ABSTRACT FROM AUTHOR]

Adult spinal deformity (ASD) patients undergoing surgery risk neurological decline following surgery. However, surgery may be the key in improving outcomes in patients starting with lower extremity motor deficits at baseline (BL). We aim to analyze the improvement in neurological outcomes of ASD patients undergoing spinal reconstruction with BL and 6-week postoperative lower extremity motor scores (LEMS). The aim of this study is to analyze the improvement in neurological outcomes of adult patients undergoing deformity surgery with baseline abnormal LEMS. Multicenter, prospective cohort. A total of 205 patients were included in the study. Patient and procedural factors that lead to the improvement in neurological outcomes of adult patients undergoing deformity surgery with baseline abnormalLEMS. ASD patients ages = 18 were prospectively studied from 2018-2021. All patients underwent an instrumented PSF with a few also having an ASF of the lumbar spine. Patients were dichotomized based on BL LEMS (NML = 50, ABML < 50). The ABNML group was then dichotomized based on whether LEMS improved overall from BL or experienced no change or declined by first postoperative follow-up (PO) and various factors were analyzed and compared using standard statistical tests. Of the 205 patients evaluated, 134 (65.4%) were NML and 71 were ABNML (34.3%) at BL. Among the 71 patients with ABML LEMS at BL, 49% (N=35) improved to NML levels, 21% (N=15) improved from BL levels but not to NML, 20% (N=14) remained the same, and 10% (N=7) declined further at 6week PO. Compared to ABNML patients with no change or a decline in LEMS at first PO, patients who improved overall (70%; N=50) had significantly more decompressions performed (86% vs 57%; p=0.0092), and had more PCOs performed intraoperatively (90% vs 62%, p=0.0074). There were no statistical differences between the groups in age, BL LEMS, BMI, total instrumented vertebrae (TIV), EBL, and OR time. Overall, the number of patients with NML LEMS at 6 weeks PO increased by 7.5% (65.4% to 70.2%; p<.0001). Seventy percent of patients with ABML LEMS at BL improved their motor strength by the first PO visit, while 30% stayed the same or declined. ABNML patients who improved from BL had significantly more decompressions performed and, surprisingly, more PCOs performed. Interestingly, patient factors between the two groups demonstrated no statistical differences further highlighting that improvement may be influenced by the differences in surgical techniques. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Several studies have suggested that Hounsfield units (HU) in the spine are associated with increased complications for adult spinal deformity (ASD) patients. The aim of this study is to assess whether there exists a threshold for HU that is associated with increased blood loss following ASD surgery. We hypothesize that HU below thresholds on spinal CT are predictive of increased blood loss during surgery and implant complications within 90 days after surgery for ASD. Retrospective analysis. ASD patients who had HU measured in the spine were identified from a multicenter database. High Intraoperative blood loss and implant complications within 90 days of surgery. HU at L1, upper instrumented vertebrae (UIV) and total averages were assessed. Threshold linear regression with Bayesian information criteria was utilized to identify optimal cut-offs for predicting high blood loss (>2100mL, top 25% by volume) or any implant complications within 90 days. Implant complications included loosening, breakage and dislocation of rods or screws. Multivariable logistic regression was utilized controlling for age, gender, comorbidity, osteotomy and levels fused. Of 527 patients included, the mean age was 61±14. Mean L1 HU was 154.59±87, UIV HU was 175.1±304, and total average HU was 165±168. There were 59 patients with high blood loss (mean 5,026±233ml) and 467 with low blood loss (1,331±39.5ml). Threshold regression analysis identified that a cut-off of =140.33 was optimal for predicting high blood loss and =99.75 total average HU was optimal for predicting implant complications within 90 days of surgery. On multivariable analysis, L1 HU less than 140 was associated with 1.57x higher odds of high blood loss (P=0.032). Total average HU less than 100 was associated with a 3.6x higher odds of having an implant related failure within 90 days of surgery (P=0.035). In this prospective multi-center study, Those with L1 HU=140 had a 1.52x higher odds of high blood loss. Patients with an average HUof =100 have 3.6x higher odds of implant related complication within 90 days of surgery. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]