Purpose
Pan Lumbar Arthodesis (PLA) are often required for Adult Spinal Deformity (ASD) correction, reducing significantly the compensatory capacity in case of postoperative sagittal malalignment. ...Few papers have investigated outcomes and complications in this vulnerable subset of patients. The objective of this study was to assess revision surgery rate for PLA in ASD, its risk factors and impact on clinical outcomes.
Methods
Retrospective multicenter review of prospective ASD data from 7 hospitals covering Europe and Asia. ASD patients included in two prospective databases having a posterior instrumentation spanning the whole lumbar region with more than 2-years of follow-up were reviewed. Demographic, surgical, radiographic parameters and Health-Related Quality of Life (HRQoL) scores were analyzed. Univariate and multivariate regression models analyzed risk factors for revision surgery as well as surgical outcomes. Patients with Early versus Late and PJK versus Non-PJK mechanical complications were also compared.
Results
Out of 1359 ASD patients included in the database 589 (43%) had a PLA and 357 reached 2-years mark. They were analyzed and compared to non-PLA patients. Average age was 67 and 82% were females. 100 Patients (28.1%) needed 114 revision surgeries (75.4% for mechanical failures). Revised patients were more likely to have a nerve system disorder, higher BMI and worst immediate postoperative alignment (as measured by GAP Parameters). These risk factors were also associated with earlier mechanical complications and PJK. Deformity and HRQoL parameters were comparable at baseline. Non-revised patients had significantly better clinical outcomes at 2-years (SRS 22 scores, ODI, Back pain). Multivariate analysis could identify nerve system disorder (OR 4.8; CI 1.8–12.6;
p
= 0.001), postoperative sagittal alignment (GAP Score) and high BMI (OR 1.07; CI 1.01–1.13;
p
= 0.004) as independent risk factors for revisions.
Conclusions
Revision surgery due to mechanical failures is relatively common after PLA leading to worse clinical outcomes. Prevention strategies should focus on individualized restoration of sagittal alignment and better weight control to decrease stress on these rigid constructs in non-compliant spines. Nerve system disorders independently increase revision risk in PLA.
Level of evidence II
Prognosis.
Purpose
There is scarce information regarding the effectiveness of postoperative braces in decreasing mechanical complications and reinterventions following adult deformity surgery.
Methods
...Retrospective matched cohort study from a prospective adult deformity multicenter database. We selected operated patients, fused to the pelvis, > 6 instrumented levels, and minimum 2 year follow-up. Three hundred and eighty patients were separated into two groups (Brace—3 months TLSO—vs No Brace) and then matched controlling for age, gender and frailty. We studied demographic, intraoperative, and postoperative spinopelvic parameters. Both groups were compared regarding complications and reinterventions in the first 2 postoperative years, using univariate and multivariate logistic regression analysis.
Results
We finally analyzed 359 matched patients, mean age of 65.3 ± 8.9 years, frailty-index (0.43 ± 0.15), and mostly females (84%). 224 patients wore a postoperative brace (B) and 135 didn’t (NoB). They showed no difference in intraoperative variables and postoperative spinopelvic alignment. They differed (
P
< 0.05) in: Pelvic incidence (B:58° ± 13 vs NoB:54.5° ± 13); BMI (B:25.8 ± 4 vs NoB:27.4 ± 5); upper instrumented vertebra (B:81.7% T8-L1 vs NoB:72.6% T8-L1), and the use of multiple rods (B:47.3% vs NoB:18.5%). Univariate analysis showed a higher rate of mechanical complications and reinterventions when not using a brace. As well as higher NRS—back and leg pain at 6 weeks. However, multivariate analysis selected the use of multiple rods as the only independent factor protecting against mechanical complications (OR: 0.38; CI 95% 0.22–0.64) and reinterventions (OR: 0.41; CI 95% 0.216–0.783).
Conclusion
After controlling for potential confounders, our study could not identify the protective effect of postoperative braces preventing mechanical complications and reinterventions in the first two postoperative years.
Purpose
Health-related quality of life (HRQL) instruments are essential in value-driven health care, but patients often have more specific, personal priorities when seeking surgical care. The ...Scoliosis Research Society-22R (SRS-22R), an HRQL instrument for spinal deformity, provides summary scores spanning several health domains, but these may be difficult for patients to utilize in planning their specific care goals. Our objective was to create preoperative predictive models for responses to individual SRS-22R questions at 1 and 2 years after adult spinal deformity (ASD) surgery to facilitate precision surgical care.
Methods
Two prospective observational cohorts were queried for ASD patients with SRS-22R data at baseline and 1 and 2 years after surgery. In total, 150 covariates were used in training machine learning models, including demographics, surgical data and perioperative complications. Validation was accomplished via an 80%/20% data split for training and testing, respectively. Goodness of fit was measured using area under receiver operating characteristic (AUROC) curves.
Results
In total, 561 patients met inclusion criteria. The AUROC ranged from 56.5 to 86.9%, reflecting successful fits for most questions. SRS-22R questions regarding pain, disability and social and labor function were the most accurately predicted. Models were less sensitive to questions regarding general satisfaction, depression/anxiety and appearance.
Conclusions
To the best of our knowledge, this is the first study to explicitly model the prediction of individual answers to the SRS-22R questionnaire at 1 and 2 years after deformity surgery. The ability to predict individual question responses may prove useful in preoperative counseling in the age of individualized medicine.
Graphic abstract
These slides can be retrieved under Electronic Supplementary Material.
Purpose
To assess the ability of the recently developed adult spinal deformity frailty index (ASD-FI) to predict odds of perioperative complications, odds of reoperation, and length of hospital stay ...after adult spinal deformity (ASD) surgery using a database other than the one used to create the index.
Methods
We used the ASD-FI to calculate frailty scores for 266 ASD patients who had minimum postoperative follow-up of 2 years in the European Spine Study Group (ESSG) database. Patients were enrolled from 2012 through 2013. Using ASD-FI scores, we categorized patients as not frail (NF) (< 0.3 points), frail (0.3–0.5 points), or severely frail (SF) (> 0.5 points). Multivariable logistic regression, adjusted for preoperative and surgical factors such as operative time and blood loss, was performed to determine the relationship between ASD-FI category and odds of major complications, odds of reoperation, and length of hospital stay.
Results
We categorized 135 patients (51%) as NF, 90 patients (34%) as frail, and 41 patients (15%) as SF. Overall mean ASD-FI score was 0.29 (range 0–0.8). The adjusted odds of experiencing a major intraoperative or postoperative complication (OR 4.5, 95% CI 2.0–10) or having a reoperation (OR 3.9, 95% CI 1.7–8.9) were higher for SF patients compared with NF patients. Mean hospital stay was 2.1 times longer (95% CI 1.8–2.4) for SF patients compared with NF patients.
Conclusions
Greater patient frailty, as measured by the ASD-FI, is associated with longer hospital stays and greater odds of major complications and reoperation.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Posterior thoracic osteotomies Pellisé, Ferran; Vila-Casademunt, Alba
European journal of orthopaedic surgery & traumatology
24, Številka:
Suppl 1
Journal Article
Recenzirano
Spinal osteotomies are used to treat partially flexible and fixed deformities. Fixed thoracic spinal deformities have been traditionally treated with anterior release and posterior correction with ...fusion. In recent decades, it has been shown that posterior-only osteotomies might be sufficient to achieve proper deformity correction with lower complication rates than with combined anterior and posterior procedures. Different types of osteotomies have been described to treat spinal deformities through a single posterior approach. These include posterior column osteotomies such as the Smith-Petersen osteotomy and the Ponte osteotomy, and three-column osteotomies such as the pedicle subtraction osteotomy, the posterior vertebral column resection and the posterior vertebral column decancellation. In general, three-column osteotomies are most commonly performed in the lumbar spine, where the vast majority of reports have focused on. They can also be performed in the thoracic spine in the setting of rigid thoracic deformity. A progressive increase in complications has been reported with more aggressive osteotomies. The aim of this article was to describe the most common posterior spinal osteotomies used to treat adult thoracic spinal deformities, with special emphasis on the technical aspects, complications and outcomes, based on current publications and European Spine Study Group (ESSG) data.
Purpose
Sagittal malalignment is a risk factor for mechanical complications after surgery for adult spinal deformity (ASD). Spinal loads, modulated by sagittal alignment, may explain this ...relationship. The aims of this study were to investigate the relationships between: (1) postoperative changes in loads at the proximal segment and realignment, and (2) absolute postoperative loads and postoperative alignment measures.
Methods
A previously validated musculoskeletal model of the whole spine was applied to study a clinical sample of 205 patients with ASD. Based on clinical and radiographic data, pre-and postoperative patient-specific alignments were simulated to predict loads at the proximal segment adjacent to the spinal fusion.
Results
Weak-to-moderate associations were found between pre-to-postop changes in lumbar lordosis, LL (
r
= − 0.23,
r
= − 0.43;
p
< 0.001), global tilt, GT (
r
= 0.26,
r
= 0.38;
p
< 0.001) and the Global Alignment and Proportion score, GAP (
r
= 0.26,
r
= 0.37;
p
< 0.001), and changes in compressive and shear forces at the proximal segment. GAP score parameters, thoracic kyphosis measurements and the slope of upper instrumented vertebra were associated with changes in shear. In patients with T10-pelvis fusion, moderate-to-strong associations were found between postoperative sagittal alignment measures and compressive and shear loads, with GT showing the strongest correlations (
r
= 0.75,
r
= 0.73,
p
< 0.001).
Conclusions
Spinal loads were estimated for patient-specific full spinal alignment profiles in a large cohort of patients with ASD pre-and postoperatively. Loads on the proximal segments were greater in association with sagittal malalignment and malorientation of proximal vertebra. Future work should explore whether they provide a causative mechanism explaining the associated risk of proximal junction complications.
Purpose
Major complications are a concern following ASD surgery. Even when properly managed and resolved, they may still have a relevant impact on HRQL. We aimed to investigate the impact of resolved ...early major complications on 2-year outcome after ASD surgery.
Methods
Two groups of consecutive surgical patients were extracted from a prospective multicentre database. Major complication group (MCG) included patients with any major complication, resolved within 6 months after surgery. Patients with further major complications during follow-up were excluded. Control group (CG) included patients with no major complications over the entire follow-up. Analysis of covariance adjusting for preoperative baseline values was used to compare improvements in HRQL measures at 2 years.
Results
One hundred and seventy-five patients met the inclusion criteria and had complete HRQL data at 2 years (24 MCG, 151 CG). MCG patients were older and had more severe deformity and poorer baseline HRQL. There were 27 resolved major complications at 6 months needing 19 additional surgeries (18 revisions, 1 cholecystectomy). At 2 years, and after adjusting for preoperative data, outcome in MCG patients was as follows: scores were 5.98 (SE 3.03) points higher for the ODI (
p
= 0.05), 0.36 (SE 0.13) lower SRS-22 function (
p
= 0.01), 4.07 (SE 1.93) lower SF-36 PCS (
p
= 0.04), and 0.16 (SE 0.13) lower SRS-22 subtotal (
p
= 0.22).
Conclusion
The results indicate that patients experiencing major complications after ASD surgery have significantly less functional improvement (SRS-22 function, ODI, SF-36 PCS) than their complication-free counterparts, even when complications were considered resolved, and the outcome was measured after an 18-month complication-free period.
Graphical abstract
These slides can be retrieved under Electronic Supplementary Material.
Surgery appears to yield better results in adult spinal deformity treatment when fixed minimum clinically important difference values are used to define success. Our objective was to analyze ...utilities and improvement provided by surgical versus nonsurgical treatment at 2 years using Oswestry Disability Index with treatment-specific minimum clinically important difference values.
From a multicenter database including 1452 patients, 698 with 2 years of follow-up were analyzed. Mean age of patients was 50.95 ± 19.44 years; 580 patients were women, and 118 were men. The surgical group comprised 369 patients, and the nonsurgical group comprised 329 patients. The surgical group was subcategorized into no complications (192 patients), minor complications (97 patients) and major complications (80 patients) groups to analyze the effect of complications on results. Minimum clinically important differences using Oswestry Disability Index were 14.31, 14.96, and 2.48 for overall, surgical, and nonsurgical groups. Utilities were calculated by visual analog scale mapping.
Surgical treatment provided higher utility (0.583) than nonsurgical treatment (0.549) that was sensitive to complications, being 0.634, 0.564, and 0.497 in no, minor, and major complications. Probabilities of improvement, unchanged, and deterioration were 38.3%, 39.2%, and 22.5% for surgical treatment and 39.4%, 10.5%, and 50.1% for nonsurgical treatment. Improvement in the surgical group was also sensitive to complications with rates of 40.1%, 39.3%, and 33.3%.
Our results suggest that surgical treatment has less disease burden and less chance of deterioration, but equal chances for improvement at 2 years of follow-up. As it appears to be a better modality in the absence of complications, future efforts need be directed to decreasing the complication rates.
Purpose
The impact of deep surgical site infection (SSI) on surgical outcomes after adult spinal deformity (ASD) surgery is still unclear. We aimed to study the morbidity of SSI in ASD and its impact ...on deformity correction and functional outcome.
Methods
Prospective multicenter matched-cohort study including consecutively enrolled ASD patients. Patients developing SSI were matched to similar controls in terms of age, gender, ASA, primary or revision, extent of fusion, and use of tri-columnar osteotomies. Preoperative parameters, surgical variables, and complications were recorded. Deformity parameters and Health Related Quality of Life (HRQoL) scores were obtained preoperatively and at 6, 12, and 24 months. Independent
t
test and Fischer’s exact test were used for comparisons.
Results
444 surgical ASD patients with more than 2 years of follow-up were identified. 20 sustained an acute SSI and 60 controls were accordingly matched. No differences were observed between groups in preoperative radiological and HRQoL variables confirming comparable groups. SSI patients had longer hospital stay and more mechanical complications including proximal junctional kyphosis. Infection was associated with more unrelated complications and revisions. Deformity correction was maintained equally at the different time intervals. One death was related to SSI. SSI patients had worse overall HRQoL status at 1 year and were less likely to experience improvement. However, no significant differences were recorded thereafter.
Conclusion
SSI significantly affects the first postoperative year after posterior ASD surgery. It is associated with more complications, unrelated revisions, and worst quality of life. However it’s negative impact seems to be diluted by the second postoperative year as differences in HRQoL scores between the two groups decrease.
Graphical abstract
These slides can be retrieved under Electronic Supplementary material.
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