Proximal junctional failure (PJF) should be distinguished from proximal junctional kyphosis, which is a recurrent deformity with limited clinical impact. PJF includes mechanical failure, and is a ...significant complication following adult spinal deformity surgery with potential for neurologic injury and increased need for surgical revision. Risk factors for PJF include age, severity of sagittal plane deformity, and extent of operative sagittal plane realignment. Techniques for avoiding PJF will likely require refinements in both perioperative and surgical strategies.
Abstract Background context Whereas the costs of primary surgery, revisions, and selected complications for adult spinal deformity (ASD) have been individually reported in the literature, the total ...costs over several years after surgery have not been assessed. The determinants of such costs are also not well understood in the literature. Purpose This study analyzes the total hospital costs and operating room (OR) costs of ASD surgery through extended follow-up. Study design/setting Single-center retrospective analysis of consecutive surgical patients. Patient sample Four hundred eighty-four consecutive patients undergoing surgical treatment for ASD from January 2005 through January 2011 with minimum three levels fused. Outcome measures Costs were collected from hospital administrative data on the total hospital costs incurred for the operation and any related readmissions, expressed in 2010 dollars and discounted at 3.5% per year. Detailed data on OR costs, including implants and biologics, were also collected. Methods We performed a series of paired t tests and Wilcoxon signed-rank tests for differences in total hospital costs over different follow-up periods. The goal of these tests was to identify a time period over which average costs plateau and remain relatively constant over time. Generalized linear model regression was used to estimate the effect of patient and surgical factors on hospital inpatient costs, with different models estimated for different follow-up periods. A similar regression analysis was performed separately for OR costs and all other hospital costs. Results Patients were predominantly women (n=415 or 86%) with an average age of 48 (18–82) years and an average follow-up of 4.8 (2–8) years. Total hospital costs averaged $120,394, with primary surgery averaging $103,143 and total readmission costs averaging $67,262 per patient with a readmission (n=130 or 27% of all patients). Operating room costs averaged $70,514 per patient, constituting the majority (59%) of total hospital costs. Average total hospital costs across all patients significantly increased (p<.01) after primary surgery, from $111,807 at 1-year follow-up to $126,323 at 4-year follow-up. Regression results also revealed physician preference as the largest determinant of OR costs, accounting for $14,780 of otherwise unexplained OR cost differences across patients, with no significant physician effects on all other non-OR costs (p<.05). Conclusions The incidence of readmissions increased the average cost of ASD surgery by more than 70%, illustrating the financial burden of revisions/reoperations; however, the cost burden resulting from readmissions appeared to taper off within 5 years after surgery. The estimated impact of physician preference on OR costs also highlights the variation in current practice and the opportunity for large cost reductions via a more standardized approach in the use of implants and biologics.
Abstract Objective Although previous reports suggest that surgery can improve the pain and disability of cervical spinal deformity (CSD), techniques are not standardized. Our objective was to assess ...for consensus on recommended surgical plans for CSD treatment. Methods 18 CSD cases were assembled, including a clinical vignette, cervical imaging (x-rays, CT/MRI), and full-length standing x-rays. Fourteen deformity surgeons (10 orthopedic, 4 neurosurgery) were queried regarding recommended surgical plan. Results There was marked variation in treatment plans across all deformity types. Even for the least complex deformities (moderate mid-cervical apex kyphosis), there was lack of agreement on approach (50% combined anterior-posterior, 25%, anterior-only, 25% posterior-only), number of anterior (range: 2-6) and posterior (range: 4-16) fusion levels, and types of osteotomies. As the kyphosis apex moved caudally (cervical-thoracic junction/upper thoracic spine) and for cases with chin-on-chest kyphosis, >80% of surgeons agreed on a posterior-only approach and >70% recommended a pedicle subtraction osteotomy (PSO) or vertebral column resection (VCR), but the range in number of anterior (4-8) and posterior (4-27) fusion levels was exceptionally broad. Cases of cervical/cervical-thoracic scoliosis had the least agreement for approach (48% posterior-only, 33% combined anterior-posterior, 17% anterior-posterior-anterior or posterior-anterior-posterior, 2% anterior-only) and had broad variation in number of anterior (2-5) and posterior (6-19) fusion levels, and recommended osteotomies (41% PSO/VCR). Conclusions Among a panel of deformity surgeons, there was marked lack of consensus on recommended surgical approach, osteotomies and fusion levels for CSD. Further study is warranted to assess whether specific surgical treatment approaches are associated with better outcomes.
Abstract Background Context Adult spinal deformity (ASD) patients may gain minimal clinically important difference (MCID) in one or more of the health-related quality-of-life instruments without ...surgical intervention. The present study identifies the baseline characteristics of this subset of nonoperative patients and proposes predictors of those most likely to benefit. Purpose The study aims to determine the factors that affect likelihood of nonoperative patients to reach MCID. Study Design/Setting This is a retrospective review of a prospective, multicenter database. Patient Sample The study includes nonoperative ASD patients. Outcome Measures Health-related quality-of-life measures, including the Scoliosis Research Society (SRS)-22 questionnaire, were used. Methods The study used a multicenter database of 215 nonoperative patients with ASD and with minimum 2-year follow-up. Using a multivariate analysis, two groups were compared to identify possible predictors: those who reached MCID in the SRS pain or activity (N=86) at 2 years and those who did not reach MCID (N=129). A subgroup multivariate analysis of patients with a deficit (potential improvement) in both SRS pain and activity (N=84) was performed. Data collection was supported by a grant from DePuy for the International Spine Study Group Foundation. Results At baseline, the nonoperative patients who reached MCID had a significantly lower SRS pain score (3.0 vs. 3.6), smaller thoracolumbar Cobb (TL Cobb) angle (29.6° vs. 36.5°; 87 patients with SRS-Schwab classification of lumbar or double), lower sacral slope (33.1° vs. 36.4°), and less lumbar lordosis (46.5° vs. 52.8°) (all p<.05). The SRS pain and TL Cobb were significant predictors for reaching MCID. The pelvic incidence minus lumbar lordosis (PI−LL) was significant on univariate analysis but not on multivariate analysis (7.5° vs. 2.6°; p=.14). In the subset of severely disabled patients, worse vertebral obliquity was a predictor for not achieving MCID (p<.05). Conclusions Nonoperative ASD patients who achieved MCID in SRS activity or pain had a lower baseline SRS pain score and less coronal deformity in the TL region. Greater baseline pain offers significant room for potential improvement, which may be important in identifying ASD patients who have the potential to reach MCID nonoperatively. Coronal deformities in the TL region and associated vertebral obliquity may negatively impact potential for improvement in nonoperative care.
Abstract Background Context Current metrics to assess a patient's health-related quality-of-life (HRQOL) may not reflect a true change in a patient's specific perception of what is most important to ...them. Purpose To describe the initial experience of a Patient Generated Index (PGI) in which patients create their own outcome domains. Study Design Single center prospective study Patient Sample Adult spinal deformity (ASD) patients Outcome Measures Oswestry Disability Index (ODI), Short-Form 36 (SF36:PCS/MCS), Scoliosis research society 22r (SRS22r), and PGI Methods ODI, SF36, SRS22r, and PGI were administered preoperatively and postoperatively at 6wks, 3mo, 6mo, and 1 and 2yrs. PGI correlations with ODI, SF36, SRS Total score, free text frequency analysis of PGI exact response with text in ODI/SRS22r questionnaires, and the responsiveness (effect size; ES) of the HRQOL metrics were analyzed. No funding was used for this study and there are no conflicts of interest. Results 59 patients with 209 clinical encounters produced 370 PGI written response topics that included affect/emotions, relationships, activities of daily life, personal care, work, and hobbies. Mean preoperative PGI score was 18.6±13.5 (0-71.7 out of 100best) and mean scores significantly improved at every postoperative time point (p<0.05). Preoperative PGI scores significantly correlated with preoperative ODI (r=-0.28,p=0.03), MCS (r=0.48,p<0.01), and SRS Total (r=0.57,p<0.01). Postoperative PGI scores correlated with all HRQOL measures (p<0.0001): ODI (r=-0.65), PCS (r=0.50), MCS (r=0.55), and SRS Total (r=0.63). PGI responses exactly matched ODI and SRS22r text 47.8% and 35.4%, respectively, and 63.2% and 58.9% respectively for categories. PGI ES at minimum 1-year follow-up was -2.39, indicating substantial responsiveness (|ES|>0.8). ES for ODI, SRS22r total and SF-36 PCS and MCS, were 2.16, -2.06, -2.05, and -0.80, respectively. Conclusions PGI is easy to administer and offers additional information about the patient's perspective not captured in standard HRQOL metrics. PGI scores correlated with all of the standard HRQOL scores and were more responsive than ODI, SF-36, and SRS22r suggesting that the PGI may be a step closer to one HRQOL measure that better encompasses concerns and goals of the individual patients.
Abstract Background context Over the past decade, the number of Adult Spinal Deformity (ASD) surgeries has more than doubled in the United States. The complex surgeries needed to manage ASD are ...associated with significant resource utilization and high cost making them a primary target for increased scrutiny . Accordingly, it is important to not only demonstrate value in ASD surgery as clinical effectiveness but also to translate outcome assessment to cost-effectiveness. Purpose To compare the difference between Medicare allowable rates and the actual, direct hospital costs for ASD surgeries. Study design Longitudinal cohort Patient sample Consecutive patients enrolled in an ASD database from a single institution Outcome measures Short Form -6D Methods Consecutive patients enrolled in an ASD database from a single institution from 2008–2013 were identified. Direct hospital costs were collected from hospital administrative records for the entire inpatient episode of surgical care. Medicare allowable rates were calculated for the same inpatient stays using the year-appropriate Center for Medicare-Medicaid Services Inpatient Pricer Payment System Tool. The SF-6D, a utility index derived from the SF-36v1, was used to determine quality-adjusted life-years (QALY).Costs and QALYs were discounted at 3.5% annually. Results Of 580 surgical ASD patients eligible for two-year follow up, 346 (60%) had complete baseline and 2-year data, and 60 were Medicare beneficiaries comprising the cohort for this study. Mean SF-6D gained was 0.10 during year one after surgery and 0.02 at year two; resulting in a cumulative SF-6D gain of 0.12 over two years. Mean Medicare allowable rates over the two years was $82,050 (range, $42,383 to $220,749) and mean direct costs were $99,114 (range, $28,447 to $217,717). Mean cost/QALY over two years was $683,750 using Medicare allowable rates $825,950 using direct costs. This difference of $17,181 between the two cost calculation represents a 17% difference, which was statistically significant (p <0.001). Conclusion There is a significant difference in direct hospital costs versus Medicare allowable rates in ASD surgery and in turn, there is a similar difference in the cost/QALY calculation. Utilizing Medicare allowable rates not only underestimates (17%) the cost- of ASD surgery, but it creates inaccurate and unrealistic expectations for researchers and policymakers.
Given the substantial growth in frequency and expense of spine deformity surgery, and the general economic landscape of the health care system, health economics research has an important role in the ...literature on adult spinal deformity (ASD). The purpose of this article is to provide an update on the current state of health economics studies in the ASD literature and to introduce areas in which health economics might play some additional role in future research on ASD.
Abstract Background context Existing literature on adult spinal deformity (ASD) offers little guidance regarding an evidence-based approach to care. To optimize the value of medical treatment, a ...thorough understanding of the cost of surgical treatment for ASD is required. Purpose To evaluate four clinically and radiographically distinct groups of ASD and identify and compare the cost of surgical treatment among the groups. Study design/setting Multicenter retrospective study of consecutive surgeries for ASD. Patient sample Three hundred twenty-five consecutive ASD patients treated between 2008 and 2010. Outcome measures Cost data were collected from hospital administrative records on the direct costs (DCs) incurred for the episode of surgical care, excluding overhead. Methods Based on preoperative radiographs and history, patients were categorized into one of four diagnostic categories of deformity: primary idiopathic scoliosis (PIS), primary degenerative scoliosis (PDS), primary sagittal plane deformity (PSPD), and revision (R). Analysis of variance and generalized linear model regressions were used to analyze the DCs of surgery and to assess differences in costs across the four diagnostic categories considered. Results Significant differences were observed in DC of surgery for different categories of ASD, with surgical treatment for PDS the most expensive followed in decreasing order by PSPD, PIS, and R (p<.01). Results further revealed a significant positive relationship between age and DC (p<.01) and a significant positive relationship between length of stay and DC (p<.01). Among PIS patients, for every incremental increase in levels fused, the expected DC increased by $3,997 (p=.00). Fusion to pelvis also significantly increased the DC of surgery for patients aged 18 to 29 years (p<.01) and 30 to 59 years (p<.01) but not for 60 years or more (p=.86). Conclusions There is an increasing DC of surgery with increasing age, length of hospital stay, length of fusion, and fusions to the pelvis. Revision surgery is the least expensive surgery on average and should therefore not preclude its consideration from a pure cost perspective.
Adult spinal deformity (ASD) surgery seeks to reduce disability and improve quality of life through restoration of spinal alignment. In particular, correction of sagittal malalignment is correlated ...with patient outcome. Inadequate correction of sagittal deformity is not infrequent. The present study assessed surgeons' ability to accurately predict postoperative alignment.
Seventeen cases were presented with preoperative radiographic measurements, and a summary of the operation as performed by the treating physician. Surgeon training, practice characteristics, and use of surgical planning software was assessed. Participants predicted if the surgical plan would lead to adequate deformity correction and attempted to predict postoperative radiographic parameters including sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence to lumbar lordosis mismatch (PI-LL), thoracic kyphosis (TK).
Seventeen surgeons participated: 71% within 0 to 10 years of practice; 88% devote >25% of their practice to deformity surgery. Surgeons accurately judged adequacy of the surgical plan to achieve correction to specific thresholds of SVA 69% ± 8%, PT 68% ± 9%, and PI-LL 68% ± 11% of the time. However, surgeons correctly predicted the actual postoperative radiographic parameters only 42% ± 6% of the time. They were more successful at predicting PT (61% ± 10%) than SVA (45% ± 8%), PI-LL (26% ± 11%), or TK change (35% ± 21%; p < .05). Improved performance correlated with greater focus on deformity but not number of years in practice or number of three-column osteotomies performed per year.
Surgeons failed to correctly predict the adequacy of the proposed surgical plan in approximately one third of presented cases. They were better at determining whether a surgical plan would achieve adequate correction than predicting specific postoperative alignment parameters. Pelvic tilt and SVA were predicted with the greatest accuracy.
Abstract Background For patients with adult spinal deformity (ASD), surgical treatment may improve their health-related quality of life. This study investigates when the greatest improvement in ...outcomes occurs and whether incremental improvements in patient-reported outcomes during the first postoperative year predict outcomes at 3 years. Methods Using a multicenter registry, we identified 84 adults with ASD treated surgically from 2008 through 2012 with complete 3-year follow-up. Pairwise t tests and multivariate regression were used for analysis. Significance was set at P < 0.01. Results Mean Oswestry Disability Index (ODI) and Scoliosis Research Society-22r total (SRS-22r) scores improved by 13 and 0.8 points, respectively, from preoperatively to 3 years (both P < 0.001). From preoperatively to 6 weeks postoperatively, ODI scores worsened by 5 points (P = 0.049) and SRS-22r scores improved by 0.3 points (P < 0.001). Between 6 weeks and 1 year, ODI and SRS-22r scores improved by 19 and 0.5 points, respectively (both P < 0.001). Incremental improvements during the first postoperative year predicted 3-year outcomes in ODI and SRS-22r scores (adjusted R2 = 0.52 and 0.42, respectively). There were no significant differences in the measured or predicted 3-year ODI (P = 0.991) or SRS-22r scores (P = 0.986). Conclusion In surgically treated patients with ASD, the greatest improvements in outcomes occurred between 6 weeks and 1 year postoperatively. A model with incremental improvements from baseline to 6 weeks and from 6 weeks to 1 year can be used to predict ODI and SRS-22r scores at 3 years.
