Decompensation of un-fused vertebrae is a potential complication of spinal instrumentation performed for adolescent idiopathic scoliosis (AIS). This can result in problems requiring revision surgery. ...The purpose of this study was to compare patients who decompensated in the sagittal/coronal plane and those who do not and to identify risk factors.
The Spinal Deformity Study Group data-base for AIS identified 908 patients at 2 years post-op. Coronal measures analyzed included coronal balance (CB), coronal position of the lower instrumented vertebra (CPL) and LIV tilt angle (LTA). Sagittal measures included sagittal balance (SB) and distal-junctional kyphosis (DJK). The incidence of decompensation at 2 years was: CB-16.83%, LTA-37.53%, CPL-21.17%, negative SB-51.88%, positive SB-7.62%, DJK-6.8%. Decompensated patients were compared to those who were not using preoperative, and 4-16 weeks post-op values.
Numerous significant differences were found between patients who decompensated at 2 years and those who did not. CB was significantly influenced by larger height/weight, increased Cobb, preexisting CB and a thoracic LIV. In addition to other factors LTA decompensation was more likely to occur in JIS. CPL was associated with pelvic-obliquity and thoracic LIV. Post-operative sagittal balance could be predicted by pre-operative sagittal balance. DJK was also associated with larger weight and preoperative sagittal measures.
Less correction in sagittal/coronal planes is a risk factor for decompensation. Curve correction was significant in predicting coronal decompensation. Failure to control sagittal alignment was a risk factor in sagittal decompensation.
Frailty is a baseline measure of disability that transcends age alone and has been determined a strong predictor of outcomes following adult spinal deformity (ASD) surgery. This postop impact calls ...for investigation of unique adjustment of Global Alignment and Proportion (GAP) scores accounting for frailty. This adjustment in spinal proportion may help surgical planning for individualized, optimal postop outcomes.
Modify the GAP score with frailty to optimize outcomes in surgical ASD patients.
Retrospective review of a single-surgeon comprehensive ASD database
A total of 140 ASD patients
Frailty-adjusted GAP scores; Health Related Quality of Life scores (HRQLs): ODI, SRS-22
Surgical ASD patients (SVA≥5cm, PT≥25°, or TK ≥60°, >3 levels fused) ≥18 years old with available baseline (BL) radiographic data were isolated in the single-center Comprehensive Spine Quality Database (Quality). Patients were dichotomized by the ASD frailty index, F (Not Frail, Frail). Linear regression analysis established radiographic equations for frailty-adjusted GAP Scores at baseline and 2-years involving relative pelvic version, relative lumbar lordosis, lordosis distribution index, relative spinopelvic alignment, and an age factor to formulate a sagittal plane score. Patients were restratified into frailty-adjusted proportionality groups: Proportional (<5.8), Moderately Disproportional (MD) (5.8-7), Severely Disproportional (SD) (>7). Frailty-adjusted GAP proportionality at 2-years were compared to adjusted-BL to determine whether patients improved, deteriorated or remained the same in their spine proportion.
A total of 140 patients were included (55.5±16.4 yrs, 77.5% female, 25.2±4.7 kg/m2). BL frailty: 32.8% not frail, 67.2% frail. Primary analyses demonstrated correlation between BL frailty score and BL and 2-year GAP scores(P<0.001). Linear regression analysis(p<0.001) developed a frailty-adjusted GAP threshold equation: 4.4 + 0.93*(frailty score). Adjusted-baseline scores were taken and re-stratified based distribution and placed 26.4% of patients in Proportional, 26.6% MD, and 44% SD. BL adjusted GAP scores by frailty group: 5.3 Not Frail, 7.5 Frail; p<0.001. At 2-years, GAP scores were grouped into the frailty-adjusted proportionality groups: 66.2% Proportional, 10.8% MD, and 23.1% SD. Patients who were 2-year MD/SD underwent significantly more reoperations (>33.5%) compared to Proportional (12.8%), p=0.015. SD 2-year patients developed increased PJK at the 1-year mark (40%, Proportional: 13.9%, MD:7.1%, p=0.003), as well as had worse 2-year ODI and SRS-22 satisfaction scores(p<0.050). 47.5% improved in GAP (63.4% of frail patients), 12.3% deteriorated, and 40.2% remained in the same proportionality group at 2-year follow up.
Significant associations exist between frailty and spinal proportion. By adjusting the GAP proportionality groups accounting for baseline frailty contributed to improved outcomes and minimized reoperations. The adjusted GAP groups appeal for less rigorous spine proportion goals in severely frail patients.
This abstract does not discuss or include any applicable devices or drugs.
Spinal fusion is increasingly considered for management of patients with osteoporosis (OP) and degenerative disc disease (DDD). Little data is available regarding long-term outcomes in OP patients ...undergoing short-segment, lumbar fusion for DDD.
Analyze the impact of OP on long-term outcomes in patients who have had 2-3-level lumbar fusions for degenerative disc disease.
Retrospective review of the New York State Statewide Planning and Research Cooperative System (NYS SPARCS) database.
Patients with DDD undergoing 2-3-level lumbar fusion.
Frequency of 2-year medical and surgical complications and reoperations.
Utilizing SPARCS, all patients from 2009-2011 with ICD-9 codes for DDD who underwent 2-3-level lumbar fusion were identified. Patients with bone mineralization disorders, systemic and endocrine disorders affecting bone quality were excluded. Surgical indications of trauma, systemic disease(s), and infection were excluded. Patients with and without OP were compared for demographics, hospital-related parameters, and 2-year complications and reoperations. Logistic regression models were utilized to identify predictors of complications.
A total of 29,028 patients (OP=1,353 (4.7%), No-OP=27,675) were included. OP patients were older (66.9 vs 52.6 years) as well as more often female (85.1% vs 48.4%) and white (82.8% vs 73.5%), all p<0.001. Deyo index did not differ between groups. LOS and total charges were higher for OP patients (4.9 vs 4.1 days; $74,484 vs $73,724), all p<0.001. Medical complications were higher for OP patients: acute renal failure (8.9% vs 4.7%), and deep vein thromboses (3.4% vs 1.6%), all p<0.01. OP patients also had higher rates of implant-related (3.4% vs 1.9%) and wound complications (9.8% vs 5.9%) (p<0.01). Preoperative OP was associated with 2-year medical and surgical complications (OR=1.62, 1.66; p<0.001). Patients with OP had greater odds of reoperations (OR=1.34).
Patients with OP undergoing 2-3-level lumbar fusion for DDD were at higher risk of 2-year medical and surgical complications, and 3.4% of OP patients experienced implant-related complication. These findings highlight the importance of rigorous preoperative metabolic workup prior to spinal surgery.
This abstract does not discuss or include any applicable devices or drugs.
Evidence on long-term surgical recovery in adult spinal deformity (ASD) patients who are both frail and have an invasive procedure is limited.
This study aims to evaluate frail and invasive patients ...with 5-year recovery kinetics. We hypothesize that patients who are both frail and have invasive surgeries will have adverse postoperative recovery kinetics
Retrospective review.
A total of 133 ASD patients with complete HRQOL data at preoperative, 1-year, 2-year, 5-year follow-up were included.
Integrated Health State Scores (IHS) in Oswestry Disability Index (ODI), Short-form 36 (SF-36) physical (PCS) and mental (MCS) component score, and Scoliosis Research Society (SRS)-22r measures
ASD-FI scores were used to stratify non-frail (0.3) patients. ASD-SR scores were used to stratify low invasive (90) surgeries. Using ASD-FI and ASD-SR, patients were separated into four cohorts: non-frail low invasive (NFLI), frail low invasive (FLI), non-frail high invasive (NFHI), and frail high invasive (FHI). HRQOLs at 1 year, 2 years, and 5 years were normalized against preoperative values. AUC was calculated across time points to generate an integrated health state score (IHS). Multivariable linear regression was used to compare IHS scores of FLI, NFHI, and FHI to NFLI while controlling for age, gender, comorbidity, and radiographic alignment.
Of 633 eligible ASD patients, 339 had 5-year follow-up. Of those, 125 patients with complete HRQOL data at preoperative, 1-year, 2-year, and 5-year visits were included; 27.2% (34) were NFLI, 20.0% (25) were FLI, 26.4% (33) were NFHI, and 26.4% (33) were FHI. Using NFLI as the referent, FLI and NFHI did not have differences in ODI, MCS, PCS or SRS-22r IHS scores (P >0.05). On multivariable analysis of integrated health scores, FHI had higher MCS (7.6 vs 5.47; P=0.0188), SRS activity (6.97 vs 5.67; P=0.0004), SRS pain (8.49 vs 6.4; P=0.001), SRS appearance (8.97 vs 6.81; P=0.0014), SRS satisfaction (11.71 vs 7.97; P=0.0033), and SRS total (7.49 vs. 6.09; P=0.0002), indicating more improved recovery over a 5-year period. Patients who were FHI had higher rates of complications (P <0.05).
Despite having more complications, patients who were frail and underwent more invasive surgeries were more likely to have greater overall improvement in activity, pain, and satisfaction over a 5-year period relative to preoperative baseline. Our results suggest that frailty in combination with invasiveness do not hinder long-term postoperative recovery kinetics, in comparison to frailty or invasiveness alone.
This abstract does not discuss or include any applicable devices or drugs.
Evidence on long-term maintenance of health status in adult spinal deformity (ASD) patients who improve above MCID threshold (MCID+) at 2 years following surgery is limited.
This study aims to: (1) ...evaluate whether patients who reached MCID+ status at two years postoperatively will maintain MCID+ status at 5 years, (2) identify risk factors associated with maintaining MCID+ status, and (3) Assess whether maintaining MCID+ status at 5 years is associated with satisfaction with surgery.
Retrospective review.
Patients who underwent adult spinal deformity (ASD) surgery with minimum 5-year follow-up who achieved 2-year MCID in ODI were identified.
Maintenance of MCID+ status at 5 years for Oswestry Diability Index (ODI).
Patients who maintained MCID+ status at 5 years and those who did not formed the comparison groups. Multivariable logistic regression, controlling for age, complications after two years and two-year alignment, was used to identify risk factors associated with the inability to maintain MCID+ status. In a separate multivariable logistic regression, whether maintaining MCID+ status was associated with 5-year surgical satisfaction was assessed.
Of 633 eligible patients, 339 had 5-year data. Of 133 with both 2- and 5-year data, 70 who achieved 2-year MCID in ODI were included. 30% (21) failed to maintain MCID+ status at 5 years. Preoperatively, 33% (23) were narcotic users, 47% (33) were frail and mean surgical invasiveness was 96.6±36.02. On multivariable logistic regression, preoperative variables were assessed: CCI > 3 (OR 5.75; p=0.026), ASA grade > 2 (OR 5.25; p=0.015), anemia (OR 19.74; p=0.009), and cancer (OR 6.46; p=0.015) were associated with increased odds of failure to maintain MCID+ status at 5-year follow-up. Patients who failed to maintain MCID+ status at 5 years had a higher odds of being unsatisfied with the surgery (OR 15.66; p=0.001). Frailty and surgical invasiveness had no significant impact on MCID+ status at 5 years.
Preoperative comorbid conditions significantly impact patient's long-term ability to maintain the positive gains in health-related quality of life measures from the surgery. Surgeons should continue to monitor and treat the chronic conditions to ensure maintenance of long-term recovery.
This abstract does not discuss or include any applicable devices or drugs.
Tranexamic acid (TXA) is commonly used to lower blood loss in ASD surgery. Despite widespread use of TXA in ASD surgery, there is a lack of consensus regarding the optimal dosing intraoperatively.
...This study aims to assess differences in blood loss and complications between high-dose, medium-dose, and low-dose TXA regimens. Complex ASD patients who receive high-dose TXA will have decreased blood loss compared to those who receive low-dose TXA.
Retrospective Review.
A total of 265 ASD patients in a multi-center prospective study were retrospectively analyzed.
Blood loss (ml), Major Blood Loss (>90th percentile ml), units transfused intraoperatively, units transfused perioperatively.
Patients were separated into three cohorts by TXA regimen: 1) low-dose patients had =20mg/kg loading dose with =2mg/kg/hr maintenance dose 2) medium-dose patients had 20-50 mg/kg loading dose with 2-5 mg/kg/hr maintenance dose. 3) high-dose patients had =50mg/kg loading dose with =5mg/kg/hr maintenance dose. Major or minor blood loss was defined as above or below the 90th percentile of our cohort respectively. Multivariable analysis controlled for levels fused, BMI, platelets, Hgb, OR time, 3CO, and radiographic alignment.
Fifty-four (20%) patients received low-dose regimen, 133 (50%) received medium-dose and 80 (30%) received high dose. Mean blood loss was 1,551±1,295 ml, intraoperative units RBCs 1.52±2, and perioperative units RBCs 2.3±2.3. Mean major blood loss was 4,566±1,516ml and minor blood loss 1,236±755ml. Compared to the low-dose group, patients in the high-dose group had 77.8% decreased odds of major blood loss (OR 0.222; P=0.007), decreased blood loss (Coef. -540.92ml; P=0.019), units transfused intraoperatively (Coef. -.739 units; P < 0.001), and units transfused perioperatively (Coef. -0.328 units; P=0.025). Compared to medium-dose group, the high-dose group had less units transfused intraoperatively (Coef. -.59 units; P < 0.001) and perioperatively (Coef. -.42 units; P < 0.001) with no difference in blood loss. There was no difference between the medium and low dose groups in blood loss or units transfused. There was no association between high-dose TXA regimen and increased rates of DVT, PE, or any medical complication before six weeks. No patients had a seizure.
In this multicenter prospectively collected database, ASD patients receiving high-dose intraoperative TXA have decreased odds of major blood loss, less RBC transfusions intraoperatively and 540ml less blood loss compared to low dose TXA, without additional risk of seizure or thromboembolic complications.
This abstract does not discuss or include any applicable devices or drugs.
Both cervical and thoracolumbar deformity surgeries are often complex and invasive, with a fairly comorbid patient population. However, few studies have assessed the mortality rates, frailty, and ...invasiveness between the two populations.
The aim of this study was to determine the incidence density of all-cause mortality as well as the 30-day and 90-day mortality rates. Secondary objectives were to ascertain causes of death, frailty of patients, and invasiveness of surgeries. We hypothesize that the mortality rates and causes of death associated with cervical deformity surgery will be higher than those for thoracolumbar deformity surgery.
Retrospective review.
A total of 146 cervical deformity and 1,380 thoracolumbar patients were included.
Outcomes included: mortality incidence density, 30- and 90-day mortality rates.
Using two prospective, multicenter databases, we identified cervical and thoracolumbar deformity patients. Clinical parameters, surgical parameters and all-cause mortality were analyzed. Incidence density was calculated based on the equation: 100 × (number of deaths)/(sum of total years of follow-up for all patients).
DB1-CD: Death was reported for 23 patients (15.7%). Mean age 61.43 ± 10.45, 34% of individuals frail (CD-FI) and mean invasiveness (CD-SR) was 79 ± 96. The mean time to death 25.46 ± 18.86 months. The mortality incidence density 8.75 deaths/year/1,000 patients. The 30-day mortality rate was 0.68% (1/146), 90-day mortality rate 1.3% (2/146). The three most common causes of death: pneumonia (9.68%), congestive heart failure (6.45%) and myocardial infarction (6.45%). DB2-TL: death was reported for 38 patients (2.75%). Mean age 60.5 ± 14.24, 58% of individuals frail (ASD-FI), and mean invasiveness (ASD-SR) 92.7±34.7. Mean time to death 29.68 ± 20.26 months. Average follow-up 1.82 ± 1.5 years. The mortality incidence density was 1.5 deaths/year/1,000 patients. The 30-day mortality ratewas 072% (1/1,380) and 90-day mortality rate 0.22% (3/1,380). The three most common causes of death: pneumonia (13.16%), myocardial infarction (10.53%) and malignancy (7.89%). There were no intraoperative deaths.
Cervical deformity patients had significantly more deaths per year (8.75 cervical vs 1.5 thoracolumbar) per 1,000 patients than thoracolumbar deformity surgeries. Pneumonia and myocardial infarction were common causes of death in both cervical and thoracolumbar deformity surgery patients. No deaths occurred during surgery.
This abstract does not discuss or include any applicable devices or drugs.
A previous study by Pellisé et al identified that a lowest instrumented vertebrae (LIV) at the pelvis, frailty, and sagittal deformity (global sagittal alignment SVA, lordosis gap PI-LL, T1 sagittal ...tilt T1Slope) were strong preoperative predictors of major complications. In addition to the preoperative predictors, blood loss and surgical time were strong predictors that occur operatively. It is unknown whether being at risk by these criteria has an effect on cost of surgery.
To determine whether previously established risk stratification criteria will reduce operative costs.
Retrospective cohort study of a prospectively collected multicenter ASD database.
This study included 952 ASD patients.
Health-related quality of life measures (HRQLs), quality adjusted life years (QALYs), utility gained, ODI, total cost.
Adult spinal deformity (ASD) patients with complete baseline (BL) and 2-year (2Y) HRQLs and radiographic data were included. Frailty score, sagittal deformity measures, blood loss, and surgical time were divided into tertiles, with the highest tertile being high risk. Published methods converted ODI to SF-6D. QALYs utilized a 3% discount rate for residual decline to life expectancy (LE, 78.7 years). Cost was calculated using the PearlDiver database and assessed for complications/major complications and comorbidities according to CMS.gov definitions. Cost per QALY at 2Y and LE were calculated for additive risk factors (LIV at pelvis, high frailty, any high sagittal deformity measure, high blood loss, high surgical time). These costs represented national averages of Medicare pay-scales for services within a 30-day window including length of stay and death differentiated by complication/comorbidity, revision, and surgical approach. Internal cost data were based on individual patient DRG codes.
Of 926 patients included, 118 did not meet any risk criteria, 171 met 1, 207 met 2, 151 met 3, 56 met 4, and 3 met 5 (these 3 patients were excluded due to small sample size). There was a significant trend (R2=0.897) in terms of national average cost at 2-years with increasing amount of risk measures met, as cost increased by $11,566 with each additional risk factor. Amount of risk factors met had a positive correlation to baseline ODI (0: 30.89; 1: 39.66; 2: 46.96; 3: 51.59; 4: 54.69; p<0.001) and 2Y ODI (0: 18.06; 1: 22.55; 2: 27.53; 3: 34.23; 4: 38.54; p<0.001). When analyzing initial surgical cost by DRG code, there was a $3,844 increase in cost per risk factor (R2=0.8703). Patients meeting 2 risk factors had the highest ODI improvement from BL to 2Y (p=0.06). QALYs gained at LE decreased by 0.0756 per risk factor (R2=0.8153). National average cost per QALY at 2Y increased by $45,852 per risk factor (R2=0.4151), and cost per QALY at LE increased by $15,759 per risk factor (R2=0.8822).
Increasing risk factors involving frailty, baseline deformity, and operative factors reduce cost effectiveness by increasing total cost and reducing QALYs. Preoperative or intraoperative measures to reduce a patient's amount of applicable risk factors would concurrently reduce operative cost and improve cost-effectiveness. Awareness of non-modifiable risk factors may also help educate surgical approach.
This abstract does not discuss or include any applicable devices or drugs.
