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Adam S. Kanter, Christopher I. Shaffrey, Praveen Mummaneni, Michael Y. Wang and Juan S. Uribe

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Pierce D. Nunley, Gregory M. Mundis Jr., Richard G. Fessler, Paul Park, Joseph M. Zavatsky, Juan S. Uribe, Robert K. Eastlack, Dean Chou, Michael Y. Wang, Neel Anand, Kelly A. Frank, Marcus B. Stone, Adam S. Kanter, Christopher I. Shaffrey, Praveen V. Mummaneni and the International Spine Study Group

OBJECTIVE

The aim of this study was to educate medical professionals about potential financial impacts of improper diagnosis-related group (DRG) coding in adult spinal deformity (ASD) surgery.

METHODS

Medicare’s Inpatient Prospective Payment System PC Pricer database was used to collect 2015 reimbursement data for ASD procedures from 12 hospitals. Case type, hospital type/location, number of operative levels, proper coding, length of stay, and complications/comorbidities (CCs) were analyzed for effects on reimbursement. DRGs were used to categorize cases into 3 types: 1) anterior or posterior only fusion, 2) anterior fusion with posterior percutaneous fixation with no dorsal fusion, and 3) combined anterior and posterior fixation and fusion.

RESULTS

Pooling institutions, cases were reimbursed the same for single-level and multilevel ASD surgery. Longer stay, from 3 to 8 days, resulted in an additional $1400 per stay. Posterior fusion was an additional $6588, while CCs increased reimbursement by approximately $13,000. Academic institutions received higher reimbursement than private institutions, i.e., approximately $14,000 (Case Types 1 and 2) and approximately $16,000 (Case Type 3). Urban institutions received higher reimbursement than suburban institutions, i.e., approximately $3000 (Case Types 1 and 2) and approximately $3500 (Case Type 3). Longer stay, from 3 to 8 days, increased reimbursement between $208 and $494 for private institutions and between $1397 and $1879 for academic institutions per stay.

CONCLUSIONS

Reimbursement is based on many factors not controlled by surgeons or hospitals, but proper DRG coding can significantly impact the financial health of hospitals and availability of quality patient care.

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Michael Y. Wang, Stacie Tran, G. Damian Brusko, Robert Eastlack, Paul Park, Pierce D. Nunley, Adam S. Kanter, Juan S. Uribe, Neel Anand, David O. Okonkwo, Khoi D. Than, Christopher I. Shaffrey, Virginie Lafage, Gregory M. Mundis Jr., Praveen V. Mummaneni and the MIS-ISSG Group

OBJECTIVE

The past decade has seen major advances in techniques for treating more complex spinal disorders using minimally invasive surgery (MIS). While appealing from the standpoint of patient perioperative outcomes, a major impediment to adoption has been the significant learning curve in utilizing MIS techniques.

METHODS

Data were retrospectively analyzed from a multicenter series of adult spinal deformity surgeries treated at eight tertiary spine care centers in the period from 2008 to 2015. All patients had undergone a less invasive or hybrid approach for a deformity correction satisfying the following inclusion criteria at baseline: coronal Cobb angle ≥ 20°, sagittal vertical axis (SVA) > 5 cm, or pelvic tilt > 20°. Analyzed data included baseline demographic details, severity of deformity, surgical metrics, clinical outcomes (numeric rating scale [NRS] score and Oswestry Disability Index [ODI]), radiographic outcomes, and complications. A minimum follow-up of 2 years was required for study inclusion.

RESULTS

Across the 8-year study period, among 222 patients, there was a trend toward treating increasingly morbid patients, with the mean age increasing from 50.7 to 62.4 years (p = 0.013) and the BMI increasing from 25.5 to 31.4 kg/m2 (p = 0.12). There was no statistical difference in the severity of coronal and sagittal deformity treated over the study period. With regard to radiographic changes following surgery, there was an increasing emphasis on sagittal correction and, conversely, less coronal correction. There was no statistically significant difference in clinical outcomes over the 8-year period, and meaningful improvements were seen in all years (ODI range of improvement: 15.0–26.9). Neither were there statistically significant differences in major complications; however, minor complications were seen less often as the surgeons gained experience (p = 0.064). Operative time was decreased on average by 47% over the 8-year period.

Trends in surgical practice were seen as well. Total fusion construct length was unchanged until the last year when there was a marked decrease in conjunction with a decrease in interbody levels treated (p = 0.004) while obtaining a higher degree of sagittal correction, suggesting more selective but powerful interbody reduction methods as reflected by an increase in the lateral and anterior column resection techniques being utilized.

CONCLUSIONS

The use of minimally invasive methods for adult spinal deformity surgery has evolved over the past decade. Experienced surgeons are treating older and more morbid patients with similar outcomes. A reliance on selective, more powerful interbody approaches is increasing as well.

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Praveen V. Mummaneni, Christopher I. Shaffrey, Lawrence G. Lenke, Paul Park, Michael Y. Wang, Frank La Marca, Justin S. Smith, Gregory M. Mundis Jr., David O. Okonkwo, Bertrand Moal, Richard G. Fessler, Neel Anand, Juan S. Uribe, Adam S. Kanter, Behrooz Akbarnia and Kai-Ming G. Fu

Object

Minimally invasive surgery (MIS) is an alternative to open deformity surgery for the treatment of patients with adult spinal deformity. However, at this time MIS techniques are not as versatile as open deformity techniques, and MIS techniques have been reported to result in suboptimal sagittal plane correction or pseudarthrosis when used for severe deformities. The minimally invasive spinal deformity surgery (MISDEF) algorithm was created to provide a framework for rational decision making for surgeons who are considering MIS versus open spine surgery.

Methods

A team of experienced spinal deformity surgeons developed the MISDEF algorithm that incorporates a patient's preoperative radiographic parameters and leads to one of 3 general plans ranging from MIS direct or indirect decompression to open deformity surgery with osteotomies. The authors surveyed fellowship-trained spine surgeons experienced with spinal deformity surgery to validate the algorithm using a set of 20 cases to establish interobserver reliability. They then resurveyed the same surgeons 2 months later with the same cases presented in a different sequence to establish intraobserver reliability. Responses were collected and tabulated. Fleiss' analysis was performed using MATLAB software.

Results

Over a 3-month period, 11 surgeons completed the surveys. Responses for MISDEF algorithm case review demonstrated an interobserver kappa of 0.58 for the first round of surveys and an interobserver kappa of 0.69 for the second round of surveys, consistent with substantial agreement. In at least 10 cases there was perfect agreement between the reviewing surgeons. The mean intraobserver kappa for the 2 surveys was 0.86 ± 0.15 (± SD) and ranged from 0.62 to 1.

Conclusions

The use of the MISDEF algorithm provides consistent and straightforward guidance for surgeons who are considering either an MIS or an open approach for the treatment of patients with adult spinal deformity. The MISDEF algorithm was found to have substantial inter- and intraobserver agreement. Although further studies are needed, the application of this algorithm could provide a platform for surgeons to achieve the desired goals of surgery.

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Praveen V. Mummaneni, Paul Park, Christopher I. Shaffrey, Michael Y. Wang, Juan S. Uribe, Richard G. Fessler, Dean Chou, Adam S. Kanter, David O. Okonkwo, Gregory M. Mundis Jr., Robert K. Eastlack, Pierce D. Nunley, Neel Anand, Michael S. Virk, Lawrence G. Lenke, Khoi D. Than, Leslie C. Robinson, Kai-Ming Fu and the International Spine Study Group (ISSG)

OBJECTIVE

Minimally invasive surgery (MIS) can be used as an alternative or adjunct to traditional open techniques for the treatment of patients with adult spinal deformity. Recent advances in MIS techniques, including advanced anterior approaches, have increased the range of candidates for MIS deformity surgery. The minimally invasive spinal deformity surgery (MISDEF2) algorithm was created to provide an updated framework for decision-making when considering MIS techniques in correction of adult spinal deformity.

METHODS

A modified algorithm was developed that incorporates a patient’s preoperative radiographic parameters and leads to one of 4 general plans ranging from basic to advanced MIS techniques to open deformity surgery with osteotomies. The authors surveyed 14 fellowship-trained spine surgeons experienced with spinal deformity surgery to validate the algorithm using a set of 24 cases to establish interobserver reliability. They then re-surveyed the same surgeons 2 months later with the same cases presented in a different sequence to establish intraobserver reliability. Responses were collected and analyzed. Correlation values were determined using SPSS software.

RESULTS

Over a 3-month period, 14 fellowship-trained deformity surgeons completed the surveys. Responses for MISDEF2 algorithm case review demonstrated an interobserver kappa of 0.85 for the first round of surveys and an interobserver kappa of 0.82 for the second round of surveys, consistent with substantial agreement. In at least 7 cases, there was perfect agreement between the reviewing surgeons. The mean intraobserver kappa for the 2 surveys was 0.8.

CONCLUSIONS

The MISDEF2 algorithm was found to have substantial inter- and intraobserver agreement. The MISDEF2 algorithm incorporates recent advances in MIS surgery. The use of the MISDEF2 algorithm provides reliable guidance for surgeons who are considering either an MIS or an open approach for the treatment of patients with adult spinal deformity.

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Khoi D. Than, Paul Park, Kai-Ming Fu, Stacie Nguyen, Michael Y. Wang, Dean Chou, Pierce D. Nunley, Neel Anand, Richard G. Fessler, Christopher I. Shaffrey, Shay Bess, Behrooz A. Akbarnia, Vedat Deviren, Juan S. Uribe, Frank La Marca, Adam S. Kanter, David O. Okonkwo, Gregory M. Mundis Jr., Praveen V. Mummaneni and the International Spine Study Group

OBJECTIVE

Minimally invasive surgery (MIS) techniques are increasingly used to treat adult spinal deformity. However, standard minimally invasive spinal deformity techniques have a more limited ability to restore sagittal balance and match the pelvic incidence–lumbar lordosis (PI-LL) than traditional open surgery. This study sought to compare “best” versus “worst” outcomes of MIS to identify variables that may predispose patients to postoperative success.

METHODS

A retrospective review of minimally invasive spinal deformity surgery cases was performed to identify parameters in the 20% of patients who had the greatest improvement in Oswestry Disability Index (ODI) scores versus those in the 20% of patients who had the least improvement in ODI scores at 2 years' follow-up.

RESULTS

One hundred four patients met the inclusion criteria, and the top 20% of patients in terms of ODI improvement at 2 years (best group, 22 patients) were compared with the bottom 20% (worst group, 21 patients). There were no statistically significant differences in age, body mass index, pre- and postoperative Cobb angles, pelvic tilt, pelvic incidence, levels fused, operating room time, and blood loss between the best and worst groups. However, the mean preoperative ODI score was significantly higher (worse disability) at baseline in the group that had the greatest improvement in ODI score (58.2 vs 39.7, p < 0.001). There was no difference in preoperative PI-LL mismatch (12.8° best vs 19.5° worst, p = 0.298). The best group had significantly less postoperative sagittal vertical axis (SVA; 3.4 vs 6.9 cm, p = 0.043) and postoperative PI-LL mismatch (10.4° vs 19.4°, p = 0.027) than the worst group. The best group also had better postoperative visual analog scale back and leg pain scores (p = 0.001 and p = 0.046, respectively).

CONCLUSIONS

The authors recommend that spinal deformity surgeons using MIS techniques focus on correcting a patient's PI-LL mismatch to within 10° and restoring SVA to < 5 cm. Restoration of these parameters seems to impact which patients will attain the greatest degree of improvement in ODI outcomes, while the spines of patients who do the worst are not appropriately corrected and may be fused into a fixed sagittal plane deformity.

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Paul Park, Kai-Ming Fu, Praveen V. Mummaneni, Juan S. Uribe, Michael Y. Wang, Stacie Tran, Adam S. Kanter, Pierce D. Nunley, David O. Okonkwo, Christopher I. Shaffrey, Gregory M. Mundis Jr., Dean Chou, Robert Eastlack, Neel Anand, Khoi D. Than, Joseph M. Zavatsky, Richard G. Fessler and the International Spine Study Group

OBJECTIVE

Achieving appropriate spinopelvic alignment in deformity surgery has been correlated with improvement in pain and disability. Minimally invasive surgery (MIS) techniques have been used to treat adult spinal deformity (ASD); however, there is concern for inadequate sagittal plane correction. Because age can influence the degree of sagittal correction required, the purpose of this study was to analyze whether obtaining optimal spinopelvic alignment is required in the elderly to obtain clinical improvement.

METHODS

A multicenter database of ASD patients was queried. Inclusion criteria were age ≥ 18 years; an MIS component as part of the index procedure; at least one of the following: pelvic tilt (PT) > 20°, sagittal vertical axis (SVA) > 50 mm, pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°, or coronal curve > 20°; and minimum follow-up of 2 years. Patients were stratified into younger (< 65 years) and older (≥ 65 years) cohorts. Within each cohort, patients were categorized into aligned (AL) or mal-aligned (MAL) subgroups based on postoperative radiographic measurements. Mal-alignment was defined as a PI-LL > 10° or SVA > 50 mm. Pre- and postoperative radiographic and clinical outcomes were compared.

RESULTS

Of the 185 patients, 107 were in the younger cohort and 78 in the older cohort. Based on postoperative radiographs, 36 (33.6%) of the younger patients were in the AL subgroup and 71 (66.4%) were in the MAL subgroup. The older patients were divided into 2 subgroups based on alignment; there were 26 (33.3%) patients in the AL and 52 (66.7%) in the MAL subgroups. Overall, patients within both younger and older cohorts significantly improved with regard to postoperative visual analog scale (VAS) scores for back and leg pain and Oswestry Disability Index (ODI) scores. In the younger cohort, there were no significant differences in postoperative VAS back and leg pain scores between the AL and MAL subgroups. However, the postoperative ODI score of 37.9 in the MAL subgroup was significantly worse than the ODI score of 28.5 in the AL subgroup (p = 0.019). In the older cohort, there were no significant differences in postoperative VAS back and leg pain score or ODI between the AL and MAL subgroups.

CONCLUSIONS

MIS techniques did not achieve optimal spinopelvic alignment in most cases. However, age appears to impact the degree of sagittal correction required. In older patients, optimal spinopelvic alignment thresholds did not need to be achieved to obtain similar symptomatic improvement. Conversely, in younger patients stricter adherence to optimal spinopelvic alignment thresholds may be needed.

https://thejns.org/doi/abs/10.3171/2018.4.SPINE171153

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Paul Park, Khoi D. Than, Praveen V. Mummaneni, Pierce D. Nunley, Robert K. Eastlack, Juan S. Uribe, Michael Y. Wang, Vivian Le, Richard G. Fessler, David O. Okonkwo, Adam S. Kanter, Neel Anand, Dean Chou, Kai-Ming G. Fu, Alexander F. Haddad, Christopher I. Shaffrey, Gregory M. Mundis Jr. and the International Spine Study Group

OBJECTIVE

Surgical decision-making and planning is a key factor in optimizing outcomes in adult spinal deformity (ASD). Minimally invasive spinal (MIS) strategies for ASD have been increasingly used as an option to decrease postoperative morbidity. This study analyzes factors involved in the selection of either a traditional open approach or a minimally invasive approach to treat ASD in a prospective, nonrandomized multicenter trial. All centers had at least 5 years of experience in minimally invasive techniques for ASD.

METHODS

The study enrolled 268 patients, of whom 120 underwent open surgery and 148 underwent MIS surgery. Inclusion criteria included age ≥ 18 years, and at least one of the following criteria: coronal curve (CC) ≥ 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 25°, or thoracic kyphosis (TK) > 60°. Surgical approach selection was made at the discretion of the operating surgeon. Preoperative significant differences were included in a multivariate logistic regression analysis to determine odds ratios (ORs) for approach selection.

RESULTS

Significant preoperative differences (p < 0.05) between open and MIS groups were noted for age (61.9 vs 66.7 years), numerical rating scale (NRS) back pain score (7.8 vs 7), CC (36° vs 26.1°), PT (26.4° vs 23°), T1 pelvic angle (TPA; 25.8° vs 21.7°), and pelvic incidence–lumbar lordosis (PI-LL; 19.6° vs 14.9°). No significant differences in BMI (29 vs 28.5 kg/m2), NRS leg pain score (5.2 vs 5.7), Oswestry Disability Index (48.4 vs 47.2), Scoliosis Research Society 22-item questionnaire score (2.7 vs 2.8), PI (58.3° vs 57.1°), LL (38.9° vs 42.3°), or SVA (73.8 mm vs 60.3 mm) were found. Multivariate analysis found that age (OR 1.05, p = 0.002), VAS back pain score (OR 1.21, p = 0.016), CC (OR 1.03, p < 0.001), decompression (OR 4.35, p < 0.001), and TPA (OR 1.09, p = 0.023) were significant factors in approach selection.

CONCLUSIONS

Increasing age was the primary driver for selecting MIS surgery. Conversely, increasingly severe deformities and the need for open decompression were the main factors influencing the selection of traditional open surgery. As experience with MIS surgery continues to accumulate, future longitudinal evaluation will reveal if more experience, use of specialized treatment algorithms, refinement of techniques, and technology will expand surgeon adoption of MIS techniques for adult spinal deformity.

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Juan S. Uribe, Armen R. Deukmedjian, Praveen V. Mummaneni, Kai-Ming G. Fu, Gregory M. Mundis Jr., David O. Okonkwo, Adam S. Kanter, Robert Eastlack, Michael Y. Wang, Neel Anand, Richard G. Fessler, Frank La Marca, Paul Park, Virginie Lafage, Vedat Deviren, Shay Bess and Christopher I. Shaffrey

Object

It is hypothesized that minimally invasive surgical techniques lead to fewer complications than open surgery for adult spinal deformity (ASD). The goal of this study was to analyze matched patient cohorts in an attempt to isolate the impact of approach on adverse events.

Methods

Two multicenter databases queried for patients with ASD treated via surgery and at least 1 year of follow-up revealed 280 patients who had undergone minimally invasive surgery (MIS) or a hybrid procedure (HYB; n = 85) or open surgery (OPEN; n = 195). These patients were divided into 3 separate groups based on the approach performed and were propensity matched for age, preoperative sagittal vertebral axis (SVA), number of levels fused posteriorly, and lumbar coronal Cobb angle (CCA) in an attempt to neutralize these patient variables and to make conclusions based on approach only. Inclusion criteria for both databases were similar, and inclusion criteria specific to this study consisted of an age > 45 years, CCA > 20°, 3 or more levels of fusion, and minimum of 1 year of follow-up. Patients in the OPEN group with a thoracic CCA > 75° were excluded to further ensure a more homogeneous patient population.

Results

In all, 60 matched patients were available for analysis (MIS = 20, HYB = 20, OPEN = 20). Blood loss was less in the MIS group than in the HYB and OPEN groups, but a significant difference was only found between the MIS and the OPEN group (669 vs 2322 ml, p = 0.001). The MIS and HYB groups had more fused interbody levels (4.5 and 4.1, respectively) than the OPEN group (1.6, p < 0.001). The OPEN group had less operative time than either the MIS or HYB group, but it was only statistically different from the HYB group (367 vs 665 minutes, p < 0.001). There was no significant difference in the duration of hospital stay among the groups. In patients with complete data, the overall complication rate was 45.5% (25 of 55). There was no significant difference in the total complication rate among the MIS, HYB, and OPEN groups (30%, 47%, and 63%, respectively; p = 0.147). No intraoperative complications were reported for the MIS group, 5.3% for the HYB group, and 25% for the OPEN group (p < 0.03). At least one postoperative complication occurred in 30%, 47%, and 50% (p = 0.40) of the MIS, HYB, and OPEN groups, respectively. One major complication occurred in 30%, 47%, and 63% (p = 0.147) of the MIS, HYB, and OPEN groups, respectively. All patients had significant improvement in both the Oswestry Disability Index (ODI) and visual analog scale scores after surgery (p < 0.001), although the MIS group did not have significant improvement in leg pain. The occurrence of complications had no impact on the ODI.

Conclusions

Results in this study suggest that the surgical approach may impact complications. The MIS group had significantly fewer intraoperative complications than did either the HYB or OPEN groups. If the goals of ASD surgery can be achieved, consideration should be given to less invasive techniques.

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Paul Park, Michael Y. Wang, Virginie Lafage, Stacie Nguyen, John Ziewacz, David O. Okonkwo, Juan S. Uribe, Robert K. Eastlack, Neel Anand, Raqeeb Haque, Richard G. Fessler, Adam S. Kanter, Vedat Deviren, Frank La Marca, Justin S. Smith, Christopher I. Shaffrey, Gregory M. Mundis Jr. and Praveen V. Mummaneni

OBJECT

Minimally invasive surgery (MIS) techniques are becoming a more common means of treating adult spinal deformity (ASD). The aim of this study was to compare the hybrid (HYB) surgical approach, involving minimally invasive lateral interbody fusion with open posterior instrumented fusion, to the circumferential MIS (cMIS) approach to treat ASD.

METHODS

The authors performed a retrospective, multicenter study utilizing data collected in 105 patients with ASD who were treated via MIS techniques. Criteria for inclusion were age older than 45 years, coronal Cobb angle greater than 20°, and a minimum of 1 year of follow-up. Patients were stratified into 2 groups: HYB (n = 62) and cMIS (n = 43).

RESULTS

The mean age was 60.7 years in the HYB group and 61.0 years in the cMIS group (p = 0.910). A mean of 3.6 interbody fusions were performed in the HYB group compared with a mean of 4.0 interbody fusions in the cMIS group (p = 0.086). Posterior fusion involved a mean of 6.9 levels in the HYB group and a mean of 5.1 levels in the cMIS group (p = 0.003). The mean follow-up was 31.3 months for the HYB group and 38.3 months for the cMIS group. The mean Oswestry Disability Index (ODI) score improved by 30.6 and 25.7, and the mean visual analog scale (VAS) scores for back/leg pain improved by 2.4/2.5 and 3.8/4.2 for the HYB and cMIS groups, respectively. There was no significant difference between groups with regard to ODI or VAS scores. For the HYB group, the lumbar coronal Cobb angle decreased by 13.5°, lumbar lordosis (LL) increased by 8.2°, sagittal vertical axis (SVA) decreased by 2.2 mm, and LL–pelvic incidence (LL-PI) mismatch decreased by 8.6°. For the cMIS group, the lumbar coronal Cobb angle decreased by 10.3°, LL improved by 3.0°, SVA increased by 2.1 mm, and LL-PI decreased by 2.2°. There were no significant differences in these radiographic parameters between groups. The complication rate, however, was higher in the HYB group (55%) than in the cMIS group (33%) (p = 0.024).

CONCLUSIONS

Both HYB and cMIS approaches resulted in clinical improvement, as evidenced by decreased ODI and VAS pain scores. While there was no significant difference in degree of radiographic correction between groups, the HYB group had greater absolute improvement in degree of lumbar coronal Cobb angle correction, increased LL, decreased SVA, and decreased LL-PI. The complication rate, however, was higher with the HYB approach than with the cMIS approach.