Thomas J. Buell and Justin S. Smith
Justin S. Smith, Thomas J. Buell, Christopher I. Shaffrey, Han Jo Kim, Eric Klineberg, Themistocles Protopsaltis, Peter Passias, Gregory M. Mundis Jr., Robert Eastlack, Vedat Deviren, Michael P. Kelly, Alan H. Daniels, Jeffrey L. Gum, Alex Soroceanu, Munish Gupta, Doug Burton, Richard Hostin, Robert Hart, Virginie Lafage, Renaud Lafage, Frank J. Schwab, Shay Bess and Christopher P. Ames
Although surgical treatment can provide significant improvement of symptomatic adult cervical spine deformity (ACSD), few reports have focused on the associated complications. The objective of this study was to assess complication rates at a minimum 1-year follow-up based on a prospective multicenter series of ACSD patients treated surgically.
A prospective multicenter database of consecutive operative ACSD patients was reviewed for perioperative (< 30 days), early (30–90 days), and delayed (> 90 days) complications with a minimum 1-year follow-up. Enrollment required at least 1 of the following: cervical kyphosis > 10°, cervical scoliosis > 10°, C2–7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°.
Of 167 patients, 133 (80%, mean age 62 years, 62% women) had a minimum 1-year follow-up (mean 1.8 years). The most common diagnoses were degenerative (45%) and iatrogenic (17%) kyphosis. Almost 40% of patients were active or past smokers, 17% had osteoporosis, and 84% had at least 1 comorbidity. The mean baseline Neck Disability Index and modified Japanese Orthopaedic Association scores were 47 and 13.6, respectively. Surgical approaches were anterior-only (18%), posterior-only (47%), and combined (35%). A total of 132 complications were reported (54 minor and 78 major), and 74 (56%) patients had at least 1 complication. The most common complications included dysphagia (11%), distal junctional kyphosis (9%), respiratory failure (6%), deep wound infection (6%), new nerve root motor deficit (5%), and new sensory deficit (5%). A total of 4 deaths occurred that were potentially related to surgery, 2 prior to 1-year follow-up (1 cardiopulmonary and 1 due to obstructive sleep apnea and narcotic use) and 2 beyond 1-year follow-up (both cardiopulmonary and associated with revision procedures). Twenty-six reoperations were performed in 23 (17%) patients, with the most common indications of deep wound infection (n = 8), DJK (n = 7), and neurological deficit (n = 6). Although anterior-only procedures had a trend toward lower overall (42%) and major (21%) complications, rates were not significantly different from posterior-only (57% and 33%, respectively) or combined (61% and 37%, respectively) approaches (p = 0.29 and p = 0.38, respectively).
This report provides benchmark rates for ACSD surgery complications at a minimum 1-year (mean 1.8 years) follow-up. The marked health and functional impact of ACSD, the frail population it affects, and the high rates of surgical complications necessitate a careful risk-benefit assessment when contemplating surgery. Collectively, these findings provide benchmarks for complication rates and may prove useful for patient counseling and efforts to improve the safety of care.
Alex Soroceanu, Justin S. Smith, Darryl Lau, Michael P. Kelly, Peter G. Passias, Themistocles S. Protopsaltis, Jeffrey L. Gum, Virginie Lafage, Han-Jo Kim, Justin K. Scheer, Munish Gupta, Gregory M. Mundis Jr., Eric O. Klineberg, Douglas Burton, Shay Bess, Christopher P. Ames and the International Spine Study Group
It is being increasingly recognized that adult cervical deformity (ACD) is correlated with significant pain, myelopathy, and disability, and that patients who undergo deformity correction gain significant benefit. However, there are no defined thresholds of minimum clinically important difference (MCID) in Neck Disability Index (NDI) and modified Japanese Orthopaedic Association (mJOA) scores.
Patients of interest were consecutive patients with ACD who underwent cervical deformity correction. ACD was defined as C2–7 sagittal Cobb angle ≥ 10° (kyphosis), C2–7 coronal Cobb angle ≥ 10° (cervical scoliosis), C2–7 sagittal vertical axis ≥ 4 cm, and/or chin-brow vertical angle ≥ 25°. Data were obtained from a consecutive cohort of patients from a multiinstitutional prospective database maintained across 13 sites. Distribution-based MCID, anchor-based MCID, and minimally detectable measurement difference (MDMD) were calculated.
A total of 73 patients met inclusion criteria and had sufficient 1-year follow-up. In the cohort, 42 patients (57.5%) were female. The mean age at the time of surgery was 62.23 years, and average body mass index was 29.28. The mean preoperative NDI was 46.49 and mJOA was 13.17. There was significant improvement in NDI at 1 year (46.49 vs 37.04; p = 0.0001). There was no significant difference in preoperative and 1-year mJOA (13.17 vs 13.7; p = 0.12). Using multiple techniques to yield MCID thresholds specific to the ACD population, the authors obtained values of 5.42 to 7.48 for the NDI, and 1.00 to 1.39 for the mJOA. The MDMD was 6.4 for the NDI, and 1.8 for the mJOA. Therefore, based on their results, the authors recommend using an MCID threshold of 1.8 for the mJOA, and 7.0 for the NDI in patients with ACD.
The ACD-specific MCID thresholds for NDI and mJOA are similar to the reported MCID following surgery for degenerative cervical disease. Additional studies are needed to verify these findings. Nonetheless, the findings here will be useful for future studies evaluating the success of surgery for patients with ACD undergoing deformity correction.
Zoher Ghogawala, Shekar Kurpad, Asdrubal Falavigna, Michael W. Groff, Daniel M. Sciubba, Jau-Ching Wu, Paul Park, Sigurd Berven, Daniel J. Hoh, Erica F. Bisson, Michael P. Steinmetz, Marjorie C. Wang, Dean Chou, Charles A. Sansur, Justin S. Smith and Luis M. Tumialán
Thomas J. Buell, Ulas Yener, Tony R. Wang, Avery L. Buchholz, Chun-Po Yen, Mark E. Shaffrey, Christopher I. Shaffrey and Justin S. Smith
Sacral insufficiency fracture after lumbosacral (LS) arthrodesis is an uncommon complication. The objective of this study was to report the authors’ operative experience managing this complication, review pertinent literature, and propose a treatment algorithm.
The authors analyzed consecutive adult patients treated at their institution from 2009 to 2018. Patients who underwent surgery for sacral insufficiency fractures after posterior instrumented LS arthrodesis were included. PubMed was queried to identify relevant articles detailing management of this complication.
Nine patients with a minimum 6-month follow-up were included (mean age 73 ± 6 years, BMI 30 ± 6 kg/m2, 56% women, mean follow-up 35 months, range 8–96 months). Six patients had osteopenia/osteoporosis (mean dual energy x-ray absorptiometry hip T-score −1.6 ± 0.5) and 3 received treatment. Index LS arthrodesis was performed for spinal stenosis (n = 6), proximal junctional kyphosis (n = 2), degenerative scoliosis (n = 1), and high-grade spondylolisthesis (n = 1). Presenting symptoms of back/leg pain (n = 9) or lower extremity weakness (n = 3) most commonly occurred within 4 weeks of index LS arthrodesis, which prompted CT for fracture diagnosis at a mean of 6 weeks postoperatively. All sacral fractures were adjacent or involved S1 screws and traversed the spinal canal (Denis zone III). H-, U-, or T-type sacral fracture morphology was identified in 7 patients. Most fractures (n = 8) were Roy-Camille type II (anterior displacement with kyphosis). All patients underwent lumbopelvic fixation via a posterior-only approach; mean operative duration and blood loss were 3.3 hours and 850 ml, respectively. Bilateral dual iliac screws were utilized in 8 patients. Back/leg pain and weakness improved postoperatively. Mean sacral fracture anterolisthesis and kyphotic angulation improved (from 8 mm/11° to 4 mm/5°, respectively) and all fractures were healed on radiographic follow-up (mean duration 29 months, range 8–90 months). Two patients underwent revision for rod fractures at 1 and 2 years postoperatively. A literature review found 17 studies describing 87 cases; potential risk factors were osteoporosis, longer fusions, high pelvic incidence (PI), and postoperative PI-to–lumbar lordosis (LL) mismatch.
A high index of suspicion is needed to diagnose sacral insufficiency fracture after LS arthrodesis. A trial of conservative management is reasonable for select patients; potential surgical indications include refractory pain, neurological deficit, fracture nonunion with anterolisthesis or kyphotic angulation, L5–S1 pseudarthrosis, and spinopelvic malalignment. Lumbopelvic fixation with iliac screws may be effective salvage treatment to allow fracture healing and symptom improvement. High-risk patients may benefit from prophylactic lumbopelvic fixation at the time of index LS arthrodesis.
Rebecca M. Burke, Thomas J. Buell, Dominic M. Maggio, Ulas Yener, Chun-Po Yen, Christopher I. Shaffrey and Justin S. Smith
Adolescent idiopathic scoliosis patients treated with spinal fusion may develop adjacent segment disease and curve progression into adulthood. Revision operations can be challenging, especially for adult patients treated with outdated instrumentation such as sublaminar hooks and/or wires. The authors demonstrate revision lumbar spine surgery in a 38-year-old female with scoliosis progression from junctional degeneration below a prior T5–L3 posterior instrumented arthrodesis with a hook-and-rod wire system. They also demonstrate safe application of an ultrasonic bone scalpel for completion of a Smith-Petersen osteotomy. The patient provided written, informed consent for all material presented in this case demonstration.
The video can be found here: https://youtu.be/3PmaFtNcqKc.
Justin S. Smith, Christopher I. Shaffrey, Michael Wang, Mohamad Bydon and Lawrence Lenke
Alexandria C. Marino, Thomas J. Buell, Rebecca M. Burke, Tony R. Wang, Chun-Po Yen, Christopher I. Shaffrey and Justin S. Smith
Three-column osteotomies (3COs) can achieve significant alignment correction when revising fixed sagittal plane deformities; however, the technique is associated with high complication rates. The authors demonstrate staged anterior-posterior surgery with L5–S1 ALIF (below a prior L3–5 fusion) and multilevel Smith-Petersen osteotomies to circumvent the morbidity associated with 3CO. The patient was a 67-year-old male with three prior lumbar surgeries who presented with back and leg pain. Imaging demonstrated lumbar flat back deformity and sagittal imbalance. The narrated video details key radiological measurements, operative planning and rationale, surgical steps, and outcomes. The patient provided written, informed consent for publication of this illustrative case.
The video can be found here: https://youtu.be/wv4W9D9fUPc.
Alan H. Daniels, Daniel B. C. Reid, Wesley M. Durand, D. Kojo Hamilton, Peter G. Passias, Han Jo Kim, Themistocles S. Protopsaltis, Virginie Lafage, Justin S. Smith, Christopher I. Shaffrey, Munish Gupta, Eric Klineberg, Frank Schwab, Douglas Burton, Shay Bess, Christopher P. Ames, Robert A. Hart and the International Spine Study Group
Optimal patient selection for upper-thoracic (UT) versus lower-thoracic (LT) fusion during adult spinal deformity (ASD) correction is challenging. Radiographic and clinical outcomes following UT versus LT fusion remain incompletely understood. The purposes of this study were: 1) to evaluate demographic, radiographic, and surgical characteristics associated with choice of UT versus LT fusion endpoint; and 2) to evaluate differences in radiographic, clinical, and health-related quality of life (HRQOL) outcomes following UT versus LT fusion for ASD.
Retrospective review of a prospectively collected multicenter ASD database was performed. Patients with ASD who underwent fusion from the sacrum/ilium to the LT (T9–L1) or UT (T1–6) spine were compared for demographic, radiographic, and surgical characteristics. Outcomes including proximal junctional kyphosis (PJK), reoperation, rod fracture, pseudarthrosis, overall complications, 2-year change in alignment parameters, and 2-year HRQOL metrics (Lumbar Stiffness Disability Index, Scoliosis Research Society-22r questionnaire, Oswestry Disability Index) were compared after controlling for confounding factors via multivariate analysis.
Three hundred three patients (169 LT, 134 UT) were evaluated. Independent predictors of UT fusion included greater thoracic kyphosis (odds ratio [OR] 0.97 per degree, p = 0.0098), greater coronal Cobb angle (OR 1.06 per degree, p < 0.0001), and performance of a 3-column osteotomy (3-CO; OR 2.39, p = 0.0351). While associated with longer operative times (ratio 1.13, p < 0.0001) and greater estimated blood loss (ratio 1.31, p = 0.0018), UT fusions resulted in greater sagittal vertical axis improvement (−59.5 vs −41.0 mm, p = 0.0035) and lower PJK rates (OR 0.49, p = 0.0457). No significant differences in postoperative HRQOL measures, reoperation, or overall complication rates were detected between groups (all p > 0.1).
Greater deformity and need for 3-CO increased the likelihood of UT fusion. Despite longer operative times and greater blood loss, UT fusions resulted in better sagittal correction and lower 2-year PJK rates following surgery for ASD. While continued surveillance is necessary, this information may inform patient counseling and surgical decision-making.
Dana L. Cruz, Ethan W. Ayres, Matthew A. Spiegel, Louis M. Day, Robert A. Hart, Christopher P. Ames, Douglas C. Burton, Justin S. Smith, Christopher I. Shaffrey, Frank J. Schwab, Thomas J. Errico, Shay Bess, Virginie Lafage and Themistocles S. Protopsaltis
Neck and back pain are highly prevalent conditions that account for major disability. The Neck Disability Index (NDI) and Oswestry Disability Index (ODI) are the two most common functional status measures for neck and back pain. However, no single instrument exists to evaluate patients with concurrent neck and back pain. The recently developed Total Disability Index (TDI) combines overlapping elements from the ODI and NDI with the unique items from each. This study aimed to prospectively validate the TDI in patients with spinal deformity, back pain, and/or neck pain.
This study is a retrospective review of prospectively collected data from a single center. The 14-item TDI, derived from ODI and NDI domains, was administered to consecutive patients presenting to a spine practice. Patients were assessed using the ODI, NDI, and EQ-5D. Validation of internal consistency, test-retest reproducibility, and validity of reconstructed NDI and ODI scores derived from TDI were assessed.
A total of 252 patients (mean age 55 years, 56% female) completed initial assessments (back pain, n = 115; neck pain, n = 52; back and neck pain, n = 55; spinal deformity, n = 55; and no pain/deformity, n = 29). Of these patients, 155 completed retests within 14 days. Patients represented a wide range of disability (mean ODI score: 36.3 ± 21.6; NDI score: 30.8 ± 21.8; and TDI score: 34.1 ± 20.0). TDI demonstrated excellent internal consistency (Cronbach’s alpha = 0.922) and test-retest reliability (intraclass correlation coefficient = 0.96). Differences between actual and reconstructed scores were not clinically significant. Subanalyses demonstrated TDI’s ability to quantify the degree of disability due to back or neck pain in patients complaining of pain in both regions.
The TDI is a valid and reliable disability measure in patients with back and/or neck pain and can capture each spine region’s contribution to total disability. The TDI could be a valuable method for total spine assessment in a clinical setting, and its completion is less time consuming than that for both the ODI and NDI.