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Study design Retrospective review of a prospective multicenter database evaluating surgical adult spinal deformity (ASD) patients. Objective This study aims to identify risk factors for medical complications in ASD patients undergoing surgery. Summary of background data ASD surgery is known for its high complication rate. This study examines baseline patient characteristics for predictors of medical complications in surgical ASD patients. Methods Intra and perioperative medical complications were included. Medical complications were: infection, pneumonia, urinary tract infection, c-difficile, sepsis, stroke, delirium, deep venous thrombosis, pulmonary embolism, myocardial infarction, arrhythmia, congestive heart failure, pneumothorax, atelectasis, adult respiratory distress syndrome, bowel obstruction, ileus, and renal failure. Potential predictors were identified using univariate testing. Multivariate Poisson regression was used to determine independent predictors of medical complications. Health-related quality of life (HRQL) was measured using the Oswestry Disability Index and SF-36. Multivariate repeated measures mixed models were used to examine HRQL. Results Four hundred forty-eight patients were included. The incidence of patients with at least one medical complication was 26.8%. Potential predictors included: age, BMI, anemia, arthritis, depression, cardiac history, hypertension, lung disease, history of PVD, Charlson Comorbidity Index, ASA, smoking, sex, and the number of years with spine problems. Independent predictors identified on multivariate logistic regression modeling included hypertension (IRR 2.43 P = 0.0001), smoking (IRR 2.49 P = 0.0001), and number of years with spine problems (IRR 1.23 P = 0.03). Despite medical complications, patients experienced significant improvements in HRQL, as measured by the SF-36 (P = 0.0001) and oswestry disability index (P = 0.0001). The rate of improvement and overall improvement compared with baseline were not statistically different than that of patients who did not experience medical complications. Conclusion Risk factors for the development of postoperative medical complications after correction of ASD include smoking, hypertension, and duration of symptoms. Patients who have one or more of these risk factors should be identified and informed during informed consent of their increased risks. They should be optimized preoperatively, and followed closely during the postoperative period. Level of evidence 3. more...

Introduction Les objectifs principaux du traitement chirurgical du spondylolisthesis degeneratif sont la decompression radiculaire et la stabilisation segmentaire. Avec l’idee qu’un manque de lordose regional postoperatoire puisse etre un facteur de risque de syndrome adjacent, l’importance de la restauration de la lordose segmentaire a recemment ete soulignee. A ce jour, aucun guide ne permet de predire de facon pragmatique le realignement spinopelvien dans les fusions courtes. L’objectif de cette etude etait de developper une formule permettant de predire les changements d’alignement des segments non fusionnes lors de la modification de l’alignement du segment L4S1. Materiel et methodes Une etude retrospective multicentrique incluant des patients souffrant de spondylolisthesis de bas grade a ete menee. Tous les patients ont eu une fusion courte entre L4 et S1. Une analyse radiographique preoperatoire, postoperatoire et au dernier recul etait realisee. L’analyse comprenait la lordose segmentaire L4S1 et l’adequation entre la lordose lombaire L1S1 et l’incidence pelvienne (IP-LL). Une analyse de correlation et une regression lineaire permettaient de predire l’IP-LL postoperatoire en se basant sur la lordose L4S1. Une formule simplifiee a ete developpee et testee en comparaison a la formule initiale. Resultats Un total de 83 patients a ete inclus dans l’etude (âge 62 ans). Il n’y avait pas de changement radiographique entre le pre et le postoperatoire. Au dernier recul, seul l’IP-LL etait significativement amelioree (6,3 vs. 4,5, p = 0,049). Il y avait une correlation entre les changements de IP-LL et les changements de L4S1 (ΔL4S1) en postoperatoire et au dernier recul (p Discussion Cette etude a permis de developper une formule predisant precisement l’alignement postoperatoire (IP-LL) dans les fusions courtes. Cette formule est simple d’utilisation et peut etre appliquee en pratique courante. A partir des objectifs de realignement et en fonction de l’alignement preoperatoire, la lordose segmentaire L4S1 peut ainsi etre planifiee. Conclusion Cet outil constitue une aide precieuse dans la planification des fusions courtes, en particulier chez les patients avec un spondylolisthesis pour lesquels la restauration de l’equilibre sagittal pourrait permettre de diminuer le risque de syndrome adjacent. more...

STUDY DESIGN Prospective observational study. OBJECTIVE This study aims to quantify the incidence of intraoperative waste in spine surgery and to examine the efficacy of an educational program directed at surgeons to induce a reduction in the intraoperative waste. SUMMARY OF BACKGROUND DATA Spine procedures are associated with high costs. Implants are a main contributor of these costs. Intraoperative waste further exacerbates the high cost of surgery. METHODS Data were collected during a 25-month period from one academic medical center (15-month observational period, 10-month post-awareness program). The total number of spine procedures and the incidence of intraoperative waste were recorded prospectively. Other variables recorded included the type of product wasted, cost associated with the product or implant wasted, and reason for the waste. RESULTS Intraoperative waste occurred in 20.2% of the procedures prior to the educational program and in 10.3% of the procedures after the implementation of the program (P < 0.0001). Monthly costs associated with surgical waste were, on average, $17680 prior to the awareness intervention and $5876 afterwards (P = 0.0006). Prior to the intervention, surgical waste represented 4.3% of total operative spine budget. After the awareness program this proportion decrease to an average of 1.2% (P = 0.003). CONCLUSION Intraoperative waste in spine surgery exacerbates the already costly procedures. Extrapolation of this data to the national level leads to an annual estimate of $126,722,000 attributable to intraoperative spine waste. A simple educational program proved to be and continues to be effective in making surgeons aware of the import of their choices and the costs related to surgical waste. more...

OBJECT Adult spinal deformity (ASD) surgery is known for its high complication rate. This study examined the impact of obesity on complication rates, infection, and patient-reported outcomes in patients undergoing surgery for ASD. METHODS This study was a retrospective review of a multicenter prospective database of patients with ASD who were treated surgically. Patients with available 2-year follow-up data were included. Obesity was defined as having a body mass index (BMI) ≥ 30 kg/m2. Data collected included complications (total, minor, major, implant-related, radiographic, infection, revision surgery, and neurological injury), estimated blood loss (EBL), operating room (OR) time, length of stay (LOS), and patient-reported questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], and Scoliosis Research Society [SRS]) at baseline and at 6 weeks, 1 year, and 2 years postoperatively. The impact of obesity was studied using multivariate modeling, accounting for confounders. RESULTS Of 241 patients who satisfied inclusion criteria, 175 patients were nonobese and 66 were obese. Regression models showed that obese patients had a higher overall incidence of major complications (IRR 1.54, p = 0.02) and wound infections (odds ratio 4.88, p = 0.02). Obesity did not increase the number of minor complications (p = 0.62), radiographic complications (p = 0.62), neurological complications (p = 0.861), or need for revision surgery (p = 0.846). Obesity was not significantly correlated with OR time (p = 0.23), LOS (p = 0.9), or EBL (p = 0.98). Both groups experienced significant improvement overtime, as measured on the ODI (p = 0.0001), SF-36 (p = 0.0001), and SRS (p = 0.0001) questionnaires. However, the overall magnitude of improvement was less for obese patients (ODI, p = 0.0035; SF-36, p = 0.0012; SRS, p = 0.022). Obese patients also had a lower rate of improvement over time (SRS, p = 0.0085; ODI, p = 0.0001; SF-36, p = 0.0001). CONCLUSIONS This study revealed that obese patients have an increased risk of complications following ASD correction. Despite these increased complications, obese patients do benefit from surgical intervention; however, their improvement in health-related quality of life (HRQL) is less than that of nonobese patients. more...

To describe reciprocal changes in cervical alignment after adult spinal deformity (ASD) correction and subsequent development of proximal junctional kyphosis (PJK). This study also investigated these changes using two novel global sagittal angular parameters, cervical–thoracic pelvic angle (CTPA) and the T1 pelvic angle (TPA). Multicenter, retrospective consecutive case series of ASD patients undergoing thoracolumbar three-column osteotomy (3CO) with fusion to the pelvis. Radiographs were analyzed at baseline and 1 year post-operatively. Patients were substratified into upper thoracic (UT; UIV T6 and above) and lower thoracic (LT; UIV below T6). PJK was defined by >10° angle between UIV and UIV + 2 and >10° change in the angle from baseline to post-op. PJK developed in 29 % (78 of 267) of patients. CTPA was linearly correlated with cervical plumbline (CPL) as a measure of cervical sagittal alignment (R = 0.826, p more...

Background Adult spinal deformity (ASD) surgery is known for its high complication rate. Obesity is known to be a risk factor for increased complications in orthopedic procedures, but its specific effect in adult spinal deformity (ASD) surgery is not well understood. This study looks at the impact of obesity on complications and HRQOL in adult spinal deformity surgery. Methods Retrospective review of a multicenter prospective database of operative ASD patients. Obesity was defined by a BMI &#8805 + 30. Outcomes included complications (total, minor, major, implant related, radiographic, infection, revision, and neurologic injury), blood loss (EBL), operative time, length of stay (LOS), and patient reported questionnaires (ODI, SF-36, SRS). The impact of obesity was studied using multivariate Poisson, linear, or logistic regression modeling. Models accounted for confounders, as determined by univariate analysis and expert opinion. Results In total, 395 patients were identified (284 non-obese, 112 obese), with 2-year follow up on 225 patients. Regression models showed that obesity increased the risk of overall complications (IRR 1.28, P = 0.01), major complications (IRR 1.57, P = 0.005), and wound infection (OR 4.74, P = 0.006). Absolute weight, but not BMI, increased the incidence of implant-related complications (weight – IRR 1.12 per 10 kg increase in weight P = 0.05, BMI P = 0.69) Obesity did not increase the number of minor complications ( P = 0.33), radiographic complications ( P = 0.75), neurologic complications ( P = 0.48) or need for revision surgery ( P = 0.74). Obesity was not significantly associated with OR time ( P = 0.15), LOS ( P = 0.9) or EBL ( P = 0.38). Both groups experienced significant improvement over time, as measured on the ODI ( P = 0.0001), SF-36 ( P = 0.0001), and SRS ( P = 0.0001). However, the overall improvement was less for obese patients (SRS P = 0.02, ODI P = 0.003, SF-36 P = 0.001). They also had a lower rate of improvement over time (SRS P = 0.008, ODI P = 0.0001 SF-36 P = 0.0001). Conclusions This study reveals that obese patients have an increased risk of complications following ASD correction. Despite increased complications, obese patients do benefit from ASD surgery, however their improvement in HRQOL is less than that of non-obese patients. more...

Introduction Adults with spinal deformity typically present with pain and disability. Our objective was to compare outcomes for op and nonop treatment for ASD based on a prospective, multicenter patient population. Patients and Methods This is a multicenter, prospective analysis of consecutive patients with ASD electing for op or non-op care at enrollment. Inclusion criteria are age > 18 years and ASD. Propensity scores were used to match an op and nonop patients based on baseline (BL) ODI, SRS22, maximum thoracolumbar/lumbar Cobb angle, pelvic incidence to lumbar lordosis mismatch (PI–LL), and leg pain numeric rating scale (NRS) score. Results A total of 689 patients met criteria, including 286 op and 403 non-op, with mean ages of 53 and 55 years, minimum 2-year follow-up rates of 86 and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At BL, compared with nonop, op patients had significantly worse HRQL based on ODI, SRS22, SF36, and leg and back pain NRS ( p 0.11). Overall, 97 matched op–non-op pairs were identified based on propensity scores. At last follow-up, the 97 matched op patients had significant improvement in all HRQL measures assessed ( p 0.20). Paired op–non-op analysis demonstrated the op patients to have significantly better HRQL scores at follow-up for all measures assessed ( p Conclusion Op treatment for ASD can provide significant improvement of HRQL measures at minimum 2-year follow-up. In contrast, non-op treatment appears to at best maintain presenting levels of pain and disability. more...

Introduction A high prevalence of residual cervical deformity (CD) has been identified following surgical treatment of adult spinal deformity (ASD). Development of the new onset CD is less understood and its clinical impact unclear. This study quantifies the incidence of new onset CD after ASD surgery, identifies predictors of development, and determines the impact outcomes. Materials and Methods Retrospective review of a prospective multicenter database yielded 215 patients (pts) with complete 2-year follow-up and full length X-rays including the cervical spine. CD was defined by T1S–CL > 20 degrees, C2C7 SVA > 40 mm, or C2C7 kyphosis > 10 degrees. Univariate analysis was performed using t tests or tests of proportion. Multivariate logistic regression was used to determine independent predictors of new CD. The impact of CD on health-related quality of life (HRQL) and satisfaction was measured using repeated measures mixed models or logistic regression as appropriate, accounting for potential confounders. Results Of the 215, 88 pts with ASD did not have CD at baseline and 42 of them (47.7%) developed CD at 2 years' postoperatively. Univariate analysis revealed that pts who developed new CD in the postoperative period had a higher incidence of diabetes (14.29 vs. 2.17%, p = 0.036) increased preoperative C2C7 SVA ( p = 0.04) and C2 slope ( p = 0.038) and smaller diameter rods used at surgery ( p = 0.0328). Independent predictors of new CD at 2 years included diabetes (OR, 10.49; p = 0.046) and increased preoperative TS–CL (OR, 1.08/deg, p = 0.027). Ending instrumentation below T4 was a negative predictor of CD (OR, 0.31; p = 0.019). Pts with and without CD experienced improvements in 2-year SF-36 ( p = 0.0001), ODI ( p = 0.0001), and SRS ( p = 0.0001). Rates and overall improvement were similar. CD was not associated with decreased satisfaction ( p = 0.28). Conclusion Overall, 47.7% of pts without preoperative CD develop new postoperative CD after ASD surgery. Independent predictors of new onset CD at 2 years include diabetes, higher preoperative TS–CL, and ending instrumentation above T4. Significant improvements in HRQL scores occurred despite the development of postoperative CD. more...

Introduction A high prevalence of cervical deformity (CD) has been identified among adult spinal deformity (ASD) patients undergoing surgical treatment. The clinical impact of this is uncertain. This study aims to quantify the difference in patient-reported outcomes among ASD patients based on presence of CD before treatment. Material and Methods Retrospective review of a multicenter prospective database of surgical ASD patients with 2-year follow-up. CD was defined as: C2C7 SVA > 4 cm, cervical kyphosis (CK) C2C7angle > 0. Univariate testing was performed using t-tests, or tests of proportion. Multivariate models determined impact of preoperative CD on health-related quality of life (HRQL) scores (SF-36, ODI, and SRS) and obtaining minimally clinically important difference (MCID) at 2 years. Results A total of 235 patients met the criteria, of which 65 with preoperative C2C7 SVA > 4 cm, 57 with CK. Patients with and without CD saw improvements in 2-year HRQL scores ( p 4 cm had worse ODI, PCS, SRS activity, appearance, pain, and total, and were less likely to meet MCID for ODI, PCS, SRS activity, and pain scores (odds ratio 0.39 for ODI CI 0.19:0.81 p Conclusion Despite experiencing significant improvements in HRQL scores, preoperative CD in ASD patients is a strong predictor of inferior outcomes and failure to reach MCID at 2-year follow-up. This information will help surgeons educate patients at risk for inferior outcomes and direct future research to improve patient outcomes. more...

Background Antifibrinolytic therapy (AF) has been shown to be effective in preventing blood loss in some settings. Its effect in patients undergoing adult spinal deformity (ASD) surgery remains unclear. This study looks at the use of antifibrinolytic therapy in adult spinal deformity surgery and its effect on major and minor perioperative complications, blood product utilization, vascular events and postoperative fusion. Methods A multicenter prospective consecutive database of surgical ASD patients was reviewed. Complications were divided into intra-operative and perioperative (within 6 weeks). Parameters of blood product utilization included the rate of transfusion, and the units of PRBCs and FFP transfused. Thromboembolic events included stroke, deep venous thrombosis (DVT) and pulmonary embolus (PE). Fusion rates at 2 years were measured on AP and lateral radiographs at using the Lenke classification. The impact of AF use on complications, blood product utilization, vascular events and fusion rates was studied using multivariate logistic, ordinal logistic, or poisson regression, as appropriate. Models accounted for confounders as determined by univariate analysis and expert opinion. Results In total, 403 patients were included, 137 patients received aminocaproic acid (ACA), 81 received tranexamic acid (TXA), 185 received no AF, 227 patients had two-year radiographic data. The use of AF was associated with a decrease in transfusion (ACA OR 0.38 P = 0.043, TXA 0.31 P = 0.047), a decrease in the number of units of PRBCs transfused (ACA IRR 0.45 P = 0.0005, TXA IRR 0.7 P = 0.0005), and a decrease in the number of FFP transfused (ACA IRR 0.65 P = 0.003, TXA IRR 0.67 P = 0.006). The use of TXA (but not ACA) was associated with a decrease the incidence of major perioperative complications compared to no AF (IRR 0.37, P = 0.019). AF use was not associated with an increase in thromboembolic events. The use of AF did not impact the fusion rates at 2 years. Conclusions The use of TXA or ACA was associated with increased minor intra-operative complications. TXA was associated with decreased major perioperative complications. AF was associated with decreased utilization of blood products without an increased rate of thromboembolic events. Given the observational nature of this study, transfusion threshold was not standardized across the study sites. Future studies with rigid criteria for transfusion should be prospectively performed to better evaluate AF use in ASD. more...