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Anthony J. Boniello, Saqib Hasan, Sun Yang, Cyrus M. Jalai, Nancy Worley and Peter G. Passias

OBJECT

Lenke 1C curves are challenging to manage surgically due to the structural thoracic deformity and nonstructural lumbar curve. Selective thoracic fusion (STF) is considered the standard of care because it preserves motion of the lumbar segment, yet nonselective STF (NSTF) remains prevalent. This study aims to identify baseline patient characteristics that drive treatment and to compare postoperative outcomes for both procedures.

METHODS

Studies that compared baseline and postoperative demographic data, health-related quality of life (HRQL) questionnaires, and radiographic parameters of patients with Lenke 1C curves undergoing STF or NSTF were identified for meta-analysis. The effect measure is expressed as a mean difference (MD) with 95% CI. A positive MD signifies a greater STF value, or a mean increase within the group.

RESULTS

One prospective and 6 retrospective case-control studies with sample size of 488 patients (344 STF and 144 NSTF) were identified. Baseline age, sex, and HRQLs were equivalent, except for better scores in the STF group for the Scoliosis Appearance Questionnaire (SAQ): Unrelated to Deformity item (3.47 vs 3.88, p = 0.01) and the Spine Research Society questionnaire, Item 22: Pain (4.13 vs 3.92, p = 0.04). Radiographic findings were significantly worse in NSTF, as measured by the thoracolumbar/lumbar (TL/L) Cobb angle (MD: −4.29°, p < 0.01) and TL/L apical vertebral translation (AVT) (MD: −6.08, p < 0.01). Radiographic findings significantly improved in STF, as measured in the main thoracic (MT) Cobb angle (MD: −27.78°, p < 0.01), TL/L Cobb angle (MD: −16.24°, p < 0.01), MT:TL/L Cobb ratio (MD: −0.21, p < 0.01), coronal balance (MD: 0.47, p = 0.02), and thoracic kyphosis (MD: 7.87°, p < 0.01); and in NSTF in proximal thoracic (PT) Cobb angle (24° vs 14.1°, p < 0.01), MT Cobb angle (53.5° vs 20.5°, p < 0.01), and TL/L Cobb angle (41.6° vs 16.6°, p < 0.01). Postoperative TL/L Cobb angle (23.1° vs 16.6°, p < 0.01) was significantly higher in STF; but PT Cobb angle, MT Cobb angle, and MT:TL/L Cobb ratio are equivalent.

CONCLUSIONS

Patients with larger lumbar compensatory curves displaying a larger degree of coronal translation, as measured by the TL/L AVT, are more likely to undergo an NSTF. Contrary to established guidelines, larger MT curve magnitudes and MT:TL/L Cobb angle ratios have not been found to influence the decision to pursue a selective thoracic fusion. Although overall both STF and NSTF groups are found to have effective postoperative coronal balance, the STF group has only modest improvements in the lumbar curve position as determined by a relatively unchanged TL/L AVT. Furthermore, surgeons may prefer NSTF in patients who may have a worse overall perception of their spinal deformity as measured by HRQL measures of pain and desire for appearance change.

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Peter G. Passias, Bassel G. Diebo, Bryan J. Marascalchi, Cyrus M. Jalai, Samantha R. Horn, Peter L. Zhou, Karen Paltoo, Olivia J. Bono, Nancy Worley, Gregory W. Poorman, Vincent Challier, Anant Dixit, Carl Paulino and Virginie Lafage

OBJECTIVE

It is becoming increasingly necessary for surgeons to provide evidence supporting cost-effectiveness of surgical treatment for cervical spine pathology. Anticipating surgical risk is critical in accurately evaluating the risk/benefit balance of such treatment. Determining the risk and cost-effectiveness of surgery, complications, revision procedures, and mortality rates are the most significant limitations. The purpose of this study was to determine independent risk factors for medical complications (MCs), surgical complications (SCs), revisions, and mortality rates following surgery for patients with cervical spine pathology. The most relevant risk factors were used to structure an index that will help quantify risk and anticipate failure for such procedures.

METHODS

The authors of this study performed a retrospective review of the National Inpatient Sample (NIS) database for patients treated surgically for cervical spine pathology between 2001 and 2010. Multivariate models were performed to calculate the odds ratio (OR) of the independent risk factors that led to MCs and repeated for SCs, revisions, and mortality. The models controlled for age (< and > 65 years old), sex, race, revision status (except for revision analysis), surgical approach, number of levels fused/re-fused (2–3, 4–8, ≥ 9), and osteotomy utilization. ORs were weighted based on their predictive category: 2 times for revision surgery predictors and 4 times for mortality predictors. Fifty points were distributed among the predictors based on their cumulative OR to establish a risk index.

RESULTS

Discharges for 362,989 patients with cervical spine pathology were identified. The mean age was 52.65 years, and 49.47% of patients were women. Independent risk factors included medical comorbidities, surgical parameters, and demographic factors. Medical comorbidities included the following: pulmonary circulation disorder, coagulopathy, metastatic cancer, renal failure, congestive heart failure, alcohol abuse, neurological disorder, nonmetastatic cancer, liver disease, rheumatoid arthritis/collagen vascular diseases, and chronic blood loss/anemia. Surgical parameters included posterior approach to fusion/re-fusion, ≥ 9 levels fused/re-fused, corpectomy, 4–8 levels fused/re-fused, and osteotomy; demographic variables included age ≥ 65 years. These factors increased the risk of at least 1 of MC, SC, revision, or mortality (risk of death). A total of 50 points were distributed among the factors based on the cumulative risk ratio of every factor in proportion to the total risk ratios.

CONCLUSIONS

This study proposed an index to quantify the potential risk of morbidity and mortality prior to surgical intervention for patients with cervical spine pathology. This index may be useful for surgeons in patient counseling efforts as well as for health insurance companies and future socioeconomics studies in assessing surgical risks and benefits for patients undergoing surgical treatment of the cervical spine.

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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.