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Gregory W. Poorman, Peter G. Passias, Samantha R. Horn, Nicholas J. Frangella, Alan H. Daniels, D. Kojo Hamilton, Hanjo Kim, Daniel Sciubba, Bassel G. Diebo, Cole A. Bortz, Frank A. Segreto, Michael P. Kelly, Justin S. Smith, Brian J. Neuman, Christopher I. Shaffrey, Virginie LaFage, Renaud LaFage, Christopher P. Ames, Robert Hart, Gregory M. Mundis Jr. and Robert Eastlack

OBJECTIVE

Depression and anxiety have been demonstrated to have negative impacts on outcomes after spine surgery. In patients with cervical deformity (CD), the psychological and physiological burdens of the disease may overlap without clear boundaries. While surgery has a proven record of bringing about significant pain relief and decreased disability, the impact of depression and anxiety on recovery from cervical deformity corrective surgery has not been previously reported on in the literature. The purpose of the present study was to determine the effect of depression and anxiety on patients’ recovery from and improvement after CD surgery.

METHODS

The authors conducted a retrospective review of a prospective, multicenter CD database. Patients with a history of clinical depression, in addition to those with current self-reported anxiety or depression, were defined as depressed (D group). The D group was compared with nondepressed patients (ND group) with a similar baseline deformity determined by propensity score matching of the cervical sagittal vertical axis (cSVA). Baseline demographic, comorbidity, clinical, and radiographic data were compared among patients using t-tests. Improvement of symptoms was recorded at 3 months, 6 months, and 1 year postoperatively. All health-related quality of life (HRQOL) scores collected at these follow-up time points were compared using t-tests.

RESULTS

Sixty-six patients were matched for baseline radiographic parameters: 33 with a history of depression and/or current depression, and 33 without. Depressed patients had similar age, sex, race, and radiographic alignment: cSVA, T-1 slope minus C2–7 lordosis, SVA, and T-1 pelvic angle (p > 0.05). Compared with nondepressed individuals, depressed patients had a higher incidence of osteoporosis (21.2% vs 3.2%, p = 0.028), rheumatoid arthritis (18.2% vs 3.2%, p = 0.012), and connective tissue disorders (18.2% vs 3.2%, p = 0.012). At baseline, the D group had greater neck pain (7.9 of 10 vs 6.6 on a Numeric Rating Scale [NRS], p = 0.015), lower mean EQ-5D scores (68.9 vs 74.7, p < 0.001), but similar Neck Disability Index (NDI) scores (57.5 vs 49.9, p = 0.063) and myelopathy scores (13.4 vs 13.9, p = 0.546). Surgeries performed in either group were similar in terms of number of levels fused, osteotomies performed, and correction achieved (baseline to 3-month measurements) (p < 0.05). At 3 months, EQ-5D scores remained lower in the D group (74.0 vs 78.2, p = 0.044), and NDI scores were similar (48.5 vs 39.0, p = 0.053). However, neck pain improved in the D group (NRS score of 5.0 vs 4.3, p = 0.331), and modified Japanese Orthopaedic Association (mJOA) scores remained similar (14.2 vs 15.0, p = 0.211). At 6 months and 1 year, all HRQOL scores were similar between the 2 cohorts. One-year measurements were as follows: NDI 39.7 vs 40.7 (p = 0.878), NRS neck pain score of 4.1 vs 5.0 (p = 0.326), EQ-5D score of 77.1 vs 78.2 (p = 0.646), and mJOA score of 14.0 vs 14.2 (p = 0.835). Anxiety/depression levels reported on the EQ-5D scale were significantly higher in the depressed cohort at baseline, 3 months, and 6 months (all p < 0.05), but were similar between groups at 1 year postoperatively (1.72 vs 1.53, p = 0.416).

CONCLUSIONS

Clinical depression was observed in many of the study patients with CD. After matching for baseline deformity, depression symptomology resulted in worse baseline EQ-5D and pain scores. Despite these baseline differences, both cohorts achieved similar results in all HRQOL assessments 6 months and 1 year postoperatively, demonstrating no clinical impact of depression on recovery up until 1 year after CD surgery. Thus, a history of depression does not appear to have an impact on recovery from CD surgery.

Free access

Ahmed S. Mohamed, Jung Yoo, Robert Hart, Brian T. Ragel, Jayme Hiratzka, D. Kojo Hamilton, Penelope D. Barnes and Alexander C. Ching

Object

The authors evaluated the efficacy of posterior instrumentation for the management of spontaneous spinal infections. Standard surgical management of spontaneous spinal infection is based on debridement of the infected tissue. However, this can be very challenging as most of these patients are medically debilitated and the surgical debridement requires a more aggressive approach to the spine either anteriorly or via an expanded posterior approach. The authors present their results using an alternative treatment method of posterior-only neuro-decompression and stabilization without formal debridement of anterior tissue for treating spontaneous spinal infection.

Methods

Fifteen consecutive patients were treated surgically by 2 of the authors. All patients had osteomyelitis and discitis and were treated postoperatively with intravenous antibiotics for at least 6 weeks. The indications for surgery were failed medical management, progressive deformity with ongoing persistent spinal infection, or neurological deficit. Patients with simple epidural abscess without bony instability were treated with laminectomy and were not included in this series. Fourteen patients were treated with posterior-only decompression and long-segment rigid fixation, without formal debridement of the infected area. One patient was treated with staged anterior and posterior surgery due to delay in treatment related to medical comorbidities. The authors examined as their outcome the ambulatory status and recurrence of deep infection requiring additional surgery or medical treatment.

Results

Of the initial 15 patients, 10 (66%) had a minimum 2-year follow-up and 14 patients had at least 1 year of followup. There were no recurrent spinal infections. There were 3 unplanned reoperations (1 for loss of fixation, 1 for early superficial wound infection, and 1 for epidural hematoma). Nine (60%) of 15 patients were nonambulatory at presentation. At final followup, 8 of 15 patients were independently ambulatory, 6 required an assistive device, and 1 remained nonambulatory.

Conclusions

Long-segment fixation, without formal debridement, resulted in resolution of spinal infection in all cases and in significant neurological recovery in almost all cases. This surgical technique, when combined with aggressive antibiotic therapy and a multidisciplinary team approach, is an effective way of managing serious spinal infections in a challenging patient population.

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Kristina Bianco, Robert Norton, Frank Schwab, Justin S. Smith, Eric Klineberg, Ibrahim Obeid, Gregory Mundis Jr., Christopher I. Shaffrey, Khaled Kebaish, Richard Hostin, Robert Hart, Munish C. Gupta, Douglas Burton, Christopher Ames, Oheneba Boachie-Adjei, Themistocles S. Protopsaltis and Virginie Lafage

Object

Three-column resection osteotomies (3COs) are commonly performed for sagittal deformity but have high rates of reported complications. Authors of this study aimed to examine the incidence of and intercenter variability in major intraoperative complications (IOCs), major postoperative complications (POCs) up to 6 weeks postsurgery, and overall complications (that is, both IOCs and POCs). They also aimed to investigate the incidence of and intercenter variability in blood loss during 3CO procedures.

Methods

The incidence of IOCs, POCs, and overall complications associated with 3COs were retrospectively determined for the study population and for each of 8 participating surgical centers. The incidence of major blood loss (MBL) over 4 L and the percentage of total blood volume lost were also determined for the study population and each surgical center. Complication rates and blood loss were compared between patients with one and those with two osteotomies, as well as between patients with one thoracic osteotomy (ThO) and those with one lumbar or sacral osteotomy (LSO). Risk factors for developing complications were determined.

Results

Retrospective review of prospectively acquired data for 423 consecutive patients who had undergone 3CO at 8 surgical centers was performed. The incidence of major IOCs, POCs, and overall complications was 7%, 39%, and 42%, respectively, for the study population overall. The most common IOC was spinal cord deficit (2.6%) and the most common POC was unplanned return to the operating room (19.4%). Patients with two osteotomies had more POCs (56% vs 38%, p = 0.04) than the patients with one osteotomy. Those with ThO had more IOCs (16% vs 6%, p = 0.03), POCs (58% vs 34%, p < 0.01), and overall complications (67% vs 37%, p < 0.01) than the patients with LSO. There was significant variation in the incidence of IOCs, POCs, and overall complications among the 8 sites (p < 0.01). The incidence of MBL was 24% for the study population, which varied significantly between sites (p < 0.01). Patients with MBL had a higher risk of IOCs, POCs, and overall complications (OR 2.15, 1.76, and 2.01, respectively). The average percentage of total blood volume lost was 55% for the study population, which also varied among sites (p < 0.01).

Conclusions

Given the complexity of 3COs for spinal deformity, it is important for spine surgeons to understand the risk factors and complication rates associated with these procedures. In this study, the overall incidence of major complications following 3CO procedures was 42%. Risks for developing complications included an older age (> 60 years), two osteotomies, ThO, and MBL.