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Cole Morrissette, Paul J. Park, Meghan Cerpa, and Lawrence G. Lenke

OBJECTIVE

The objective of this study was to examine the relationship between the mental health domain of the refined 22-item Scoliosis Research Society Outcome Questionnaire (SRS) and various postoperative outcome measures in the adult spinal deformity (ASD) population. Given the scale and involved nature of deformity surgery, some surgeons have proposed that preoperative mental health scores (MHSs) may assist in screening out poor surgical candidates. In this study, the authors aimed to further assess the SRS MHS as a preoperative metric and its association with postoperative outcomes and to comment on its potential use in patient selection and optimization for ASD surgery.

METHODS

The authors conducted a retrospective study of 100 consecutive patients who had undergone primary or revision ASD surgery at a single academic institution between 2015 and 2019. Each patient had a minimum 2-year follow-up. Patients were categorized on the basis of their baseline mental health per the SRS mental health domain, with a score < 4 indicating low baseline mental health (LMH) and a score ≥ 4 indicating high baseline mental health (HMH). Baseline and follow-up SRS and Oswestry Disability Index scores, surgical procedures, lengths of stay, discharge locations, intraoperative or postoperative complications, and other outcome metrics were then compared between the HMH and LMH groups, as well as these groups stratified by an age ≤ 45 and > 45 years.

RESULTS

Among patients aged ≤ 45 and those aged > 45, the LMH group had significantly worse baseline health-related quality-of-life (HRQOL) metrics in nearly all domains. The LMH group also had an increased median estimated blood loss (EBL; 1200 vs 800 ml, p = 0.0026) and longer average surgical duration (8.3 ± 2.8 vs 6.9 ± 2.6 hours, p = 0.014). Both LMH and HMH groups had significant improvements in nearly all HRQOL measures postoperatively. Despite their worse preoperative HRQOL baseline, patients in the LMH group actually improved the most and reached the same HRQOL endpoints as those in the HMH group.

CONCLUSIONS

While patients with lower baseline MHSs may require slightly longer hospital courses or more frequent discharges to rehabilitation facilities, these patients actually attain greater absolute improvements from their preoperative baseline and surprisingly have the same postoperative HRQOL metrics as the patients with high MHSs, despite their poorer starting point. This finding suggests that patients with LMH may be uniquely positioned to substantially benefit from surgical intervention and improve their HRQOL scores and thus should be considered for ASD surgery to an extent similar to patients with HMH.

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Nathan J. Lee, Paul J. Park, Varun Puvanesarajah, William E. Clifton, Kevin Kwan, Cole R. Morrissette, Jaques L. Williams, Michael W. Fields, Eric Leung, Fthimnir M. Hassan, Peter D. Angevine, Christopher E. Mandigo, Joseph M. Lombardi, Zeeshan M. Sardar, Ronald A. Lehman Jr., and Lawrence G. Lenke

OBJECTIVE

There is a paucity of literature on pelvic fixation failure after adult spine surgery in the early postoperative period. The purpose of this study was to determine the incidence of acute pelvic fixation failure in a large single-center study and to describe the lessons learned.

METHODS

The authors performed a retrospective review of adult (≥ 18 years old) patients who underwent spinal fusion with pelvic fixation (iliac, S2-alar-iliac [S2AI] screws) at a single academic medical center between 2015 and 2020. All patients had a minimum of 3 instrumented levels. The minimum follow-up was 6 months after the index spine surgery. Patients with prior pelvic fixation were excluded. Acute pelvic fixation failure was defined as revision of the pelvic screws within 6 months of the primary surgery. Patient demographics and operative, radiographic, and rod/screw parameters were collected. All rods were cobalt-chrome. All iliac and S2AI screws were closed-headed screws.

RESULTS

In 358 patients, the mean age was 59.5 ± 13.6 years, and 64.0% (n = 229) were female. The mean number of instrumented levels was 11.5 ± 5.5, and 79.1% (n = 283) had ≥ 6 levels fused. Three-column osteotomies were performed in 14.2% (n = 51) of patients, and 74.6% (n = 267) had an L5–S1 interbody fusion. The mean diameter/length of pelvic screws was 8.5/86.6 mm. The mean number of pelvic screws was 2.2 ± 0.5, the mean rod diameter was 6.0 ± 0 mm, and 78.5% (n = 281) had > 2 rods crossing the lumbopelvic junction. Accessory rods extended to S1 (32.7%, n = 117) or S2/ilium (45.8%, n = 164). Acute pelvic fixation failure occurred in 1 patient (0.3%); this individual had a broken S2AI screw near the head-neck junction. This 76-year-old woman with degenerative lumbar scoliosis and chronic lumbosacral zone 1 fracture nonunion had undergone posterior instrumented fusion from T10 to pelvis with bilateral S2AI screws (8.5 × 90 mm); i.e., transforaminal lumbar interbody fusion L4–S1. The patient had persistent left buttock pain postoperatively, with radiographically confirmed breakage of the left S2AI screw 68 days after surgery. Revision included instrumentation removal at L2–pelvis and a total of 4 pelvic screws.

CONCLUSIONS

The acute pelvic fixation failure rate was exceedingly low in adult spine surgery. This rate may be the result of multiple factors including the preference for multirod (> 2), closed-headed pelvic screw constructs in which large-diameter long screws are used. Increasing the number of rods and screws at the lumbopelvic junction may be important factors to consider, especially for patients with high risk for nonunion.