Browse

You are looking at 1 - 10 of 23 items for

  • By Author: Kim, Han Jo x
Clear All
Restricted access

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Restricted access

Han Jo Kim, Sohrab Virk, Jonathan Elysee, Peter Passias, Christopher Ames, Christopher I. Shaffrey, Gregory Mundis Jr., Themistocles Protopsaltis, Munish Gupta, Eric Klineberg, Justin S. Smith, Douglas Burton, Frank Schwab, Virginie Lafage, Renaud Lafage and the International Spine Study Group

OBJECTIVE

Cervical deformity (CD) is difficult to define due to the high variability in normal cervical alignment based on postural- and thoracolumbar-driven changes to cervical alignment. The purpose of this study was to identify whether patterns of sagittal deformity could be established based on neutral and dynamic alignment, as shown on radiographs.

METHODS

This study is a retrospective review of a prospective, multicenter database of CD patients who underwent surgery from 2013 to 2015. Their radiographs were reviewed by 12 individuals using a consensus-based method to identify severe sagittal CD. Radiographic parameters correlating with health-related quality of life were introduced in a two-step cluster analysis (a combination of hierarchical cluster and k-means cluster) to identify patterns of sagittal deformity. A comparison of lateral and lateral extension radiographs between clusters was performed using an ANOVA in a post hoc analysis.

RESULTS

Overall, 75 patients were identified as having severe CD due to sagittal malalignment, and they formed the basis of this study. Their mean age was 64 years, their body mass index was 29 kg/m2, and 66% were female. There were significant correlations between focal alignment/flexibility of maximum kyphosis, cervical lordosis, and thoracic slope minus cervical lordosis (TS-CL) flexibility (r = 0.27, 0.31, and −0.36, respectively). Cluster analysis revealed 3 distinct groups based on alignment and flexibility. Group 1 (a pattern involving a flat neck with lack of compensation) had a large TS-CL mismatch despite flexibility in cervical lordosis; group 2 (a pattern involving focal deformity) had focal kyphosis between 2 adjacent levels but no large regional cervical kyphosis under the setting of a low T1 slope (T1S); and group 3 (a pattern involving a cervicothoracic deformity) had a very large T1S with a compensatory hyperlordosis of the cervical spine.

CONCLUSIONS

Three distinct patterns of CD were identified in this cohort: flat neck, focal deformity, and cervicothoracic deformity. One key element to understanding the difference between these groups was the alignment seen on extension radiographs. This information is a first step in developing a classification system that can guide the surgical treatment for CD and the choice of fusion level.

Free access

Samantha R. Horn, Peter G. Passias, Cheongeun Oh, Virginie Lafage, Renaud Lafage, Justin S. Smith, Breton Line, Neel Anand, Frank A. Segreto, Cole A. Bortz, Justin K. Scheer, Robert K. Eastlack, Vedat Deviren, Praveen V. Mummaneni, Alan H. Daniels, Paul Park, Pierce D. Nunley, Han Jo Kim, Eric O. Klineberg, Douglas C. Burton, Robert A. Hart, Frank J. Schwab, Shay Bess, Christopher I. Shaffrey, Christopher P. Ames and the International Spine Study Group

OBJECTIVE

Cervical deformity (CD) correction is clinically challenging. There is a high risk of developing complications with these highly complex procedures. The aim of this study was to use baseline demographic, clinical, and surgical factors to predict a poor outcome following CD surgery.

METHODS

The authors performed a retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: cervical kyphosis (C2–7 Cobb angle > 10°), cervical scoliosis (coronal Cobb angle > 10°), C2–7 sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical angle (CBVA) > 25°. Patients were categorized based on having an overall poor outcome or not. Health-related quality of life measures consisted of Neck Disability Index (NDI), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scale scores. A poor outcome was defined as having all 3 of the following categories met: 1) radiographic poor outcome: deterioration or severe radiographic malalignment 1 year postoperatively for cSVA or T1 slope–cervical lordosis mismatch (TS-CL); 2) clinical poor outcome: failing to meet the minimum clinically important difference (MCID) for NDI or having a severe mJOA Ames modifier; and 3) complications/reoperation poor outcome: major complication, death, or reoperation for a complication other than infection. Univariate logistic regression followed by multivariate regression models was performed, and internal validation was performed by calculating the area under the curve (AUC).

RESULTS

In total, 89 patients with CD were included (mean age 61.9 years, female sex 65.2%, BMI 29.2 kg/m2). By 1 year postoperatively, 18 (20.2%) patients were characterized as having an overall poor outcome. For radiographic poor outcomes, patients’ conditions either deteriorated or remained severe for TS-CL (73% of patients), cSVA (8%), horizontal gaze (34%), and global SVA (28%). For clinical poor outcomes, 80% and 60% of patients did not reach MCID for EQ-5D and NDI, respectively, and 24% of patients had severe symptoms (mJOA score 0–11). For the complications/reoperation poor outcome, 28 patients experienced a major complication, 11 underwent a reoperation, and 1 had a complication-related death. Of patients with a poor clinical outcome, 75% had a poor radiographic outcome; 35% of poor radiographic and 37% of poor clinical outcome patients had a major complication. A poor outcome was predicted by the following combination of factors: osteoporosis, baseline neurological status, use of a transition rod, number of posterior decompressions, baseline pelvic tilt, T2–12 kyphosis, TS-CL, C2–T3 SVA, C2–T1 pelvic angle (C2 slope), global SVA, and number of levels in maximum thoracic kyphosis. The final model predicting a poor outcome (AUC 86%) included the following: osteoporosis (OR 5.9, 95% CI 0.9–39), worse baseline neurological status (OR 11.4, 95% CI 1.8–70.8), baseline pelvic tilt > 20° (OR 0.92, 95% CI 0.85–0.98), > 9 levels in maximum thoracic kyphosis (OR 2.01, 95% CI 1.1–4.1), preoperative C2–T3 SVA > 5.4 cm (OR 1.01, 95% CI 0.9–1.1), and global SVA > 4 cm (OR 3.2, 95% CI 0.09–10.3).

CONCLUSIONS

Of all CD patients in this study, 20.2% had a poor overall outcome, defined by deterioration in radiographic and clinical outcomes, and a major complication. Additionally, 75% of patients with a poor clinical outcome also had a poor radiographic outcome. A poor overall outcome was most strongly predicted by severe baseline neurological deficit, global SVA > 4 cm, and including more of the thoracic maximal kyphosis in the construct.

Restricted access

Michael P. Kelly, Michael A. Kallen, Christopher I. Shaffrey, Justin S. Smith, Douglas C. Burton, Christopher P. Ames, Virginie Lafage, Frank J. Schwab, Han Jo Kim, Eric O. Klineberg, Shay Bess and the International Spine Study Group

OBJECTIVE

After using PROsetta Stone crosswalk tables to calculate Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) scores, the authors sought to examine 1) correlations with Scoliosis Research Society–22r (SRS-22r) scores, 2) responsiveness to change, and 3) the relationship between baseline scores and 2-year follow-up scores in adult spinal deformity (ASD).

METHODS

PROsetta Stone crosswalk tables were used to converted SF-36 scores to PROMIS scores for pain and physical function in a cohort of ASD patients with 2-year follow-up. Spearman correlations were used to evaluate the relationship of PROMIS scores with SRS-22r scores. Effect size (ES) and adjusted standardized response mean (aSRM) were used to assess responsiveness to change. Linear regression was used to evaluate the association between baseline scores and 2-year follow-up scores.

RESULTS

In total, 425 (425/625, 68%) patients met inclusion criteria. Strong correlations (all |r| > 0.7, p < 0.001) were found between baseline and 2-year PROMIS values and corresponding SRS-22r domain scores. PROMIS-PI showed a large ES (1.09) and aSRM (0.88), indicating good responsiveness to change. PROMIS-PF showed a moderate ES (0.52) and moderate aSRM (0.69), indicating a moderate responsiveness to change. Patients with greater baseline pain complaints were associated with greater pain improvement at 2 years for both SRS-22r Pain (B = 0.39, p < 0.001) and PROMIS-PI (B = 0.45, p < 0.001). Higher functional scores at baseline were associated with greater average improvements in both SRS-22r Activity (B = 0.62, p < 0.001) and PROMIS-PF (B = 0.40, p < 0.001).

CONCLUSIONS

The authors found strong correlations between the SRS-22r Pain and Activity domains with corresponding PROMIS-PI and -PF scores. Pain measurements showed similar and strong ES and aSRM while the function measurements showed similar, moderate ES and aSRM at 2-year follow-up. These data support further exploration of the use of PROMIS–computer adaptive test instruments in ASD.

Free access

Francis Lovecchio, Jeffrey G. Stepan, Ajay Premkumar, Michael E. Steinhaus, Maria Sava, Peter Derman, Han Jo Kim and Todd Albert

OBJECTIVE

Patients with lumbar spine pathology are at high risk for opioid misuse. Standardizing prescribing practices through an institutional intervention may reduce the overprescribing of opiates, leading to a decrease in the risk for opioid misuse and the number of pills available for diversion. Without quantitative data on the “minimum necessary quantity” of opioids appropriate for postdischarge prescriptions, the optimal method for changing existing prescribing practices is unknown. The purpose of this study was to determine whether mandatory provider education and prescribing guidelines could modify prescriber behavior and lead to a decreased amount of opioids prescribed at hospital discharge following lumbar spine surgery.

METHODS

Qualified staff were required to attend a mandatory educational conference, and a consensus method among the spine service was used to publish qualitative prescribing guidelines. Prescription data for 2479 patients who had undergone lumbar spine surgery were captured and compared based on the timing of surgery. The preintervention group consisted of 1177 patients who had undergone spine surgery in the period before prescriber education and guidelines (March 1, 2016–November 1, 2016). The postintervention group consisted of 1302 patients who had undergone spine surgery after the dissemination of the guidelines (February 1, 2017–October 1, 2017). Surgeries were classified as decompression or fusion procedures. Patients who had undergone surgeries for infection and patients on long-acting opioids were excluded.

RESULTS

For all lumbar spine surgeries (decompression and fusion), the mean amount of opioids prescribed at discharge was lower after the educational program and distribution of prescribing guidelines (629 ± 294 oral morphine equivalent [OME] preintervention vs 490 ± 245 OME postintervention, p < 0.001). The mean number of prescribed pills also decreased (81 ± 26 vs 66 ± 22, p < 0.001). Prescriptions for 81 or more tablets dropped from 65.5% to 25.5%. Tramadol was prescribed more frequently after prescriber education (9.9% vs 18.6%, p < 0.001). Refill rates within 6 weeks were higher after the institutional intervention (7.6% vs 12.4%, p < 0.07).

CONCLUSIONS

Qualitative guidelines and prescriber education are effective in reducing the amount of opioids prescribed at discharge and encouraging the use of weaker opioids. Coupling provider education with prescribing guidelines is likely synergistic in achieving larger reductions. The sustainability of these changes is yet to be determined.

Full access

Renaud Lafage, Ibrahim Obeid, Barthelemy Liabaud, Shay Bess, Douglas Burton, Justin S. Smith, Cyrus Jalai, Richard Hostin, Christopher I. Shaffrey, Christopher Ames, Han Jo Kim, Eric Klineberg, Frank Schwab, Virginie Lafage and the International Spine Study Group

OBJECTIVE

The surgical correction of adult spinal deformity (ASD) often involves modifying lumbar lordosis (LL) to restore ideal sagittal alignment. However, corrections that include large changes in LL increase the risk for development of proximal junctional kyphosis (PJK). Little is known about the impact of cranial versus caudal correction in the lumbar spine on the occurrence of PJK. The goal of this study was to investigate the impact of the location of the correction on acute PJK development.

METHODS

This study was a retrospective review of a prospective multicenter database. Surgically treated ASD patients with early follow-up evaluations (6 weeks) and fusions of the full lumbosacral spine were included. Radiographic parameters analyzed included the classic spinopelvic parameters (pelvic incidence [PI], pelvic tilt [PT], PI−LL, and sagittal vertical axis [SVA]) and segmental correction. Using Glattes’ criteria, patients were stratified into PJK and noPJK groups and propensity matched by age and regional lumbar correction (ΔPI−LL). Radiographic parameters and segmental correction were compared between PJK and noPJK patients using independent t-tests.

RESULTS

After propensity matching, 312 of 483 patients were included in the analysis (mean age 64 years, 76% women, 40% with PJK). There were no significant differences between PJK and noPJK patients at baseline or postoperatively, or between changes in alignment, with the exception of thoracic kyphosis (TK) and ΔTK. PJK patients had a decrease in segmental lordosis at L4-L5-S1 (−0.6° vs 1.6°, p = 0.025), and larger increases in segmental correction at cranial levels L1-L2-L3 (9.9° vs 7.1°), T12-L1-L2 (7.3° vs 5.4°), and T11-T12-L1 (2.9° vs 0.7°) (all p < 0.05).

CONCLUSIONS

Although achievement of an optimal sagittal alignment is the goal of realignment surgery, dramatic lumbar corrections appear to increase the risk of PJK. This study was the first to demonstrate that patients who developed PJK underwent kyphotic changes in the L4–S1 segments while restoring LL at more cranial levels (T12–L3). These findings suggest that restoring lordosis at lower lumbar levels may result in a decreased risk of developing PJK.

Full access

Blake N. Staub, Renaud Lafage, Han Jo Kim, Christopher I. Shaffrey, Gregory M. Mundis Jr., Richard Hostin, Douglas Burton, Lawrence Lenke, Munish C. Gupta, Christopher Ames, Eric Klineberg, Shay Bess, Frank Schwab, Virginie Lafage and the International Spine Study Group

OBJECTIVE

Numerous studies have attempted to delineate the normative value for T1S−CL (T1 slope minus cervical lordosis) as a marker for both cervical deformity and a goal for correction similar to how PI-LL (pelvic incidence–lumbar lordosis) mismatch informs decision making in thoracolumbar adult spinal deformity (ASD). The goal of this study was to define the relationship between T1 slope (T1S) and cervical lordosis (CL).

METHODS

This is a retrospective review of a prospective database. Surgical ASD cases were initially analyzed. Analysis across the sagittal parameters was performed. Linear regression analysis based on T1S was used to provide a clinically applicable equation to predict CL. Findings were validated using the postoperative alignment of the ASD patients. Further validation was then performed using a second, normative database. The range of normal alignment associated with horizontal gaze was derived from a multilinear regression on data from asymptomatic patients.

RESULTS

A total of 103 patients (mean age 54.7 years) were included. Analysis revealed a strong correlation between T1S and C0–7 lordosis (r = 0.886), C2–7 lordosis (r = 0.815), and C0–2 lordosis (r = 0.732). There was no significant correlation between T1S and T1S−CL. Linear regression analysis revealed that T1S−CL assumed a constant value of 16.5° (R2 = 0.664, standard error 2°). These findings were validated on the postoperative imaging (mean absolute error [MAE] 5.9°). The equation was then applied to the normative database (MAE 6.7° controlling for McGregor slope [MGS] between −5° and 15°). A multilinear regression between C2–7, T1S, and MGS demonstrated a range of T1S−CL between 14.5° and 26.5° was necessary to maintain horizontal gaze.

CONCLUSIONS

Normative CL can be predicted via the formula CL = T1S − 16.5° ± 2°. This implies a threshold of deformity and aids in providing a goal for surgical correction. Just as pelvic incidence (PI) can be used to determine the ideal LL, T1S can be used to predict ideal CL. This formula also implies that a kyphotic cervical alignment is to be expected for individuals with a T1S < 16.5°.

Free access

David B. Bumpass, Lawrence G. Lenke, Jeffrey L. Gum, Christopher I. Shaffrey, Justin S. Smith, Christopher P. Ames, Shay Bess, Brian J. Neuman, Eric Klineberg, Gregory M. Mundis Jr., Frank Schwab, Virginie Lafage, Han Jo Kim, Douglas C. Burton, Khaled M. Kebaish, Richard Hostin, Renaud Lafage, Michael P. Kelly and for the International Spine Study Group

OBJECTIVE

Adolescent spine deformity studies have shown that male patients require longer surgery and have greater estimated blood loss (EBL) and complications compared with female patients. No studies exist to support this relationship in adult spinal deformity (ASD). The purpose of this study was to investigate associations between sex and complications, deformity correction, and health-related quality of life (HRQOL) in patients with ASD. It was hypothesized that male ASD patients would have greater EBL, longer surgery, and more complications than female ASD patients.

METHODS

A multicenter ASD cohort was retrospectively queried for patients who underwent primary posterior-only instrumented fusions with a minimum of 5 levels fused. The minimum follow-up was 2 years. Primary outcomes were EBL, operative time, intra-, peri-, and postoperative complications, radiographic correction, and HRQOL outcomes (Oswestry Disability Index, SF-36, and Scoliosis Research Society-22r Questionnaire). Poisson multivariate regression was used to control for age, comorbidities, and levels fused.

RESULTS

Ninety male and 319 female patients met the inclusion criteria. Male patients had significantly greater mean EBL (2373 ml vs 1829 ml, p = 0.01). The mean operative time, transfusion requirements, and final radiographic measurements did not differ between sexes. Similarly, changes in HRQOL showed no significant differences. Finally, there were no sex differences in the incidence of complications (total, major, or minor) at any time point after controlling for age, body mass index, comorbidities, and levels fused.

CONCLUSIONS

Despite higher EBL, male ASD patients did not experience more complications or require less deformity correction at the 2-year follow-up. HRQOL scores similarly showed no sex differences. These findings differ from adolescent deformity studies, and surgeons can counsel patients that sex is unlikely to influence the outcomes and complication rates of primary all-posterior ASD surgery.

Full access

Justin S. Smith, Christopher I. Shaffrey, Eric Klineberg, Virginie Lafage, Frank Schwab, Renaud Lafage, Han Jo Kim, Richard Hostin, Gregory M. Mundis Jr., Munish Gupta, Barthelemy Liabaud, Justin K. Scheer, Bassel G. Diebo, Themistocles S. Protopsaltis, Michael P. Kelly, Vedat Deviren, Robert Hart, Doug Burton, Shay Bess and Christopher P. Ames

OBJECTIVE

Although 3-column osteotomy (3CO) can provide powerful alignment correction in adult spinal deformity (ASD), these procedures are complex and associated with high complication rates. The authors' objective was to assess complications associated with ASD surgery that included 3CO based on a prospectively collected multicenter database.

METHODS

This study is a retrospective review of a prospectively collected multicenter consecutive case registry. ASD patients treated with 3CO and eligible for 2-year follow-up were identified from a prospectively collected multicenter ASD database. Early (≤ 6 weeks after surgery) and delayed (> 6 weeks after surgery) complications were collected using standardized forms and on-site coordinators.

RESULTS

Of 106 ASD patients treated with 3CO, 82 (77%; 68 treated with pedicle subtraction osteotomy [PSO] and 14 treated with vertebral column resection [VCR]) had 2-year follow-up (76% women, mean age 60.7 years, previous spine fusion in 80%). The mean number of posterior fusion levels was 12.9, and 17% also had an anterior fusion. A total of 76 early (44 minor, 32 major) and 66 delayed (13 minor, 53 major) complications were reported, with 41 patients (50.0%) and 45 patients (54.9%) affected, respectively. Overall, 64 patients (78.0%) had at least 1 complication, and 50 (61.0%) had at least 1 major complication. The most common complications were rod breakage (31.7%), dural tear (20.7%), radiculopathy (9.8%), motor deficit (9.8%), proximal junctional kyphosis (PJK, 9.8%), pleural effusion (8.5%), and deep wound infection (7.3%). Compared with patients who did not experience early or delayed complications, those who had these complications did not differ significantly with regard to age, sex, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, smoking status, history of previous spine surgery or spine fusion, or whether the 3CO performed was a PSO or VCR (p ≥ 0.06). Twenty-seven (33%) patients had 1–11 reoperations (total of 44 reoperations). The most common indications for reoperation were rod breakage (n = 14), deep wound infection (n = 15), and PJK (n = 6). The 24 patients who did not achieve 2-year follow-up had a mean of 0.85 years of follow-up, and the types of early and delayed complications encountered in these 24 patients were comparable to those encountered in the patients that achieved 2-year follow-up.

CONCLUSIONS

Among 82 ASD patients treated with 3CO, 64 (78.0%) had at least 1 early or delayed complication (57 minor, 85 major). The most common complications were instrumentation failure, dural tear, new neurological deficit, PJK, pleural effusion, and deep wound infection. None of the assessed demographic or surgical parameters were significantly associated with the occurrence of complications. These data may prove useful for surgical planning, patient counseling, and efforts to improve the safety and cost-effectiveness of these procedures.