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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.

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Hai V. Le, Joseph B. Wick, Renaud Lafage, Gregory M. Mundis Jr., Robert K. Eastlack, Shay Bess, Douglas C. Burton, Christopher P. Ames, Justin S. Smith, Peter G. Passias, Munish C. Gupta, Virginie Lafage, Eric O. Klineberg, and

OBJECTIVE

The authors’ objective was to determine whether preoperative lateral extension cervical spine radiography can be used to predict osteotomy type and postoperative alignment parameters after cervical spine deformity surgery.

METHODS

A total of 106 patients with cervical spine deformity were reviewed. Radiographic parameters on preoperative cervical neutral and extension lateral radiography were compared with 3-month postoperative radiographic alignment parameters. The parameters included T1 slope, C2 slope, C2–7 cervical lordosis, cervical sagittal vertical axis, and T1 slope minus cervical lordosis. Associations of radiographic parameters with osteotomy type and surgical approach were also assessed.

RESULTS

On extension lateral radiography, patients who underwent lower grade osteotomy had significantly lower T1 slope, T1 slope minus cervical lordosis, cervical sagittal vertical axis, and C2 slope. Patients who achieved more normal parameters on extension lateral radiography were more likely to undergo surgery via an anterior approach. Although baseline parameters were significantly different between neutral lateral and extension lateral radiographs, 3-month postoperative lateral and preoperative extension lateral radiographs were statistically similar for T1 slope minus cervical lordosis and C2 slope.

CONCLUSIONS

Radiographic parameters on preoperative extension lateral radiography were significantly associated with surgical approach and osteotomy grade and were similar to those on 3-month postoperative lateral radiography. These results demonstrated that extension lateral radiography is useful for preoperative planning and predicting postoperative alignment.

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Renaud Lafage, Justin S. Smith, Alex Moy Fong, Basel Sheikh Alshabab, Themistocles Protopsaltis, Eric O. Klineberg, Gregory Mundis Jr., Peter G. Passias, Munish Gupta, Christopher I. Shaffrey, Han Jo Kim, Shay Bess, Frank Schwab, Christopher P. Ames, Virginie Lafage, and

OBJECTIVE

Hyperextension of C0–2 is a debilitating compensatory mechanism used to maintain horizontal gaze, analogous to high pelvic tilt in the lumbopelvic complex to maintain an upright posture. This study aims to investigate the impact of cervical deformity (CD) correction on this hyperextension. The authors hypothesize that correction of cervical sagittal malalignment allows for relaxation of C0–2 hyperextension and improved clinical outcomes.

METHODS

A retrospective review was conducted of a multicenter database of patients with CD undergoing spinal realignment and fusion caudal to C2 and cephalad to the pelvis. Range of motion (ROM) and reserve of extension (ROE) were calculated across C2–7 and C0–2. The association between C2–7 correction and change in C0–2 ROE was investigated while controlling for horizontal gaze, followed by stratification into ΔC2–7 percentiles.

RESULTS

Sixty-five patients were included (mean age 61.8 ± 9.6 years, 68% female). At baseline, patients had cervical kyphosis (C2–7, −11.7° ± 18.2°; T1 slope–cervical lordosis mismatch, 38.6° ± 18.6°), negative global alignment (sagittal vertical axis [SVA] −12.8 ± 71.2 mm), and hyperlordosis at C0–2 (mean 33.2° ± 11.8°). The mean ROM was 25.7° ± 17.7° and 21.3° ± 9.9° at C2–7 and C0–2, respectively, with an ROE of approximately 9° for each segment. Limited C0–2 ROM and ROE correlated with the Neck Disability Index (r = −0.371 and −0.394, p < 0.01). The mean number of levels fused was 7.0 ± 3.1 (24.6% anterior, 43.1% posterior), with 87.7% undergoing at least an osteotomy. At 1 year, mean C2–7 increased to 5.5° ± 13.4°, SVA became neutral (11.5 ± 54.8 mm), C0–2 hyperlordosis decreased to 27.8° ± 11.7°, and thoracic kyphosis (TK) increased to −49.4° ± 18.1° (all p < 0.001). Concurrently, mean C0–2 ROM increased to 27.6° ± 8.1° and C2–7 ROM decreased significantly to 9.0° ± 12.3° without a change in ROE. Controlling for horizontal gaze, change in C2–7 lordosis significantly correlated with increased TK (r = −0.617, p < 0.001), decreased C0–2 (r = −0.747, p < 0.001), and increased C0–2 ROE (r = 0.550, p = 0.002).

CONCLUSIONS

CD correction can significantly impact cephalad and caudal compensation in the upper cervical and thoracic spine. Restoration of cervical alignment resulted in increased C0–2 ROE and TK and was also associated with improved clinical outcome.

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Justin K. Scheer, Jessica A. Tang, Justin S. Smith, Eric Klineberg, Robert A. Hart, Gregory M. Mundis Jr., Douglas C. Burton, Richard Hostin, Michael F. O'Brien, Shay Bess, Khaled M. Kebaish, Vedat Deviren, Virginie Lafage, Frank Schwab, Christopher I. Shaffrey, Christopher P. Ames, and the International Spine Study Group

Object

Complications and reoperation for surgery to correct adult spinal deformity are not infrequent, and many studies have analyzed the rates and factors that influence the likelihood of reoperation. However, there is a need for more comprehensive analyses of reoperation in adult spinal deformity surgery from a global standpoint, particularly focusing on the 1st year following operation and considering radiographic parameters and the effects of reoperation on health-related quality of life (HRQOL). This study attempts to determine the prevalence of reoperation following surgery for adult spinal deformity, assess the indications for these reoperations, evaluate for a relation between specific radiographic parameters and the need for reoperation, and determine the potential impact of reoperation on HRQOL measures.

Methods

A retrospective review was conducted of a prospective, multicenter, adult spinal deformity database collected through the International Spine Study Group. Data collected included age, body mass index, sex, date of surgery, information regarding complications, reoperation dates, length of stay, and operation time. The radiographic parameters assessed were total number of levels instrumented, total number of interbody fusions, C-7 sagittal vertical axis, uppermost instrumented vertebra (UIV) location, and presence of 3-column osteotomies. The HRQOL assessment included Oswestry Disability Index (ODI), 36-Item Short Form Health Survey physical component and mental component summary, and SRS-22 scores. Smoking history, Charlson Comorbidity Index scores, and American Society of Anesthesiologists Physical Status classification grades were also collected and assessed for correlation with risk of early reoperation. Various statistical tests were performed for evaluation of specific factors listed above, and the level of significance was set at p < 0.05.

Results

Fifty-nine (17%) of a total of 352 patients required reoperation. Forty-four (12.5%) of the reoperations occurred within 1 year after the initial surgery, including 17 reoperations (5%) within 30 days.

Two hundred sixty-eight patients had a minimum of 1 year of follow-up. Fifty-three (20%) of these patients had a 3-column osteotomy, and 10 (19%) of these 53 required reoperation within 1 year of the initial procedure. However, 3-column osteotomy was not predictive of reoperation within 1 year, p = 0.5476). There were no significant differences between groups with regard to the distribution of UIV, and UIV did not have a significant effect on reoperation rates. Patients needing reoperation within 1 year had worse ODI and SRS-22 scores measured at 1-year follow-up than patients not requiring operation.

Conclusions

Analysis of data from a large multicenter adult spinal deformity database shows an overall 17% reoperation rate, with a 19% reoperation rate for patients treated with 3-column osteotomy and a 16% reoperation rate for patients not treated with 3-column osteotomy. The most common indications for reoperation included instrumentation complications and radiographic failure. Reoperation significantly affected HRQOL outcomes at 1-year follow-up. The need for reoperation may be minimized by carefully considering spinal alignment, termination of fixation, and type of surgical procedure (presence of osteotomy). Precautions should be taken to avoid malposition or instrumentation (rod) failure.

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Taemin Oh, Justin K. Scheer, Justin S. Smith, Richard Hostin, Chessie Robinson, Jeffrey L. Gum, Frank Schwab, Robert A. Hart, Virginie Lafage, Douglas C. Burton, Shay Bess, Themistocles Protopsaltis, Eric O. Klineberg, Christopher I. Shaffrey, Christopher P. Ames, and the International Spine Study Group

OBJECTIVE

Patients with adult spinal deformity (ASD) experience significant quality of life improvements after surgery. Treatment, however, is expensive and complication rates are high. Predictive analytics has the potential to use many variables to make accurate predictions in large data sets. A validated minimum clinically important difference (MCID) model has the potential to assist in patient selection, thereby improving outcomes and, potentially, cost-effectiveness.

METHODS

The present study was a retrospective analysis of a multiinstitutional database of patients with ASD. Inclusion criteria were as follows: age ≥ 18 years, radiographic evidence of ASD, 2-year follow-up, and preoperative Oswestry Disability Index (ODI) > 15. Forty-six variables were used for model training: demographic data, radiographic parameters, surgical variables, and results on the health-related quality of life questionnaire. Patients were grouped as reaching a 2-year ODI MCID (+MCID) or not (−MCID). An ensemble of 5 different bootstrapped decision trees was constructed using the C5.0 algorithm. Internal validation was performed via 70:30 data split for training/testing. Model accuracy and area under the curve (AUC) were calculated. The mean quality-adjusted life years (QALYs) and QALYs gained at 2 years were calculated and discounted at 3.5% per year. The QALYs were compared between patients in the +MCID and –MCID groups.

RESULTS

A total of 234 patients met inclusion criteria (+MCID 129, −MCID 105). Sixty-nine patients (29.5%) were included for model testing. Predicted versus actual results were 50 versus 40 for +MCID and 19 versus 29 for −MCID (i.e., 10 patients were misclassified). Model accuracy was 85.5%, with 0.96 AUC. Predicted results showed that patients in the +MCID group had significantly greater 2-year mean QALYs (p = 0.0057) and QALYs gained (p = 0.0002).

CONCLUSIONS

A successful model with 85.5% accuracy and 0.96 AUC was constructed to predict which patients would reach ODI MCID. The patients in the +MCID group had significantly higher mean 2-year QALYs and QALYs gained. This study provides proof of concept for using predictive modeling techniques to optimize patient selection in complex spine surgery.

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Mathieu Bannwarth, Justin S. Smith, Shay Bess, Eric O. Klineberg, Christopher P. Ames, Gregory M. Mundis Jr., Han Jo Kim, Renaud Lafage, Munish C. Gupta, Douglas C. Burton, Christopher I. Shaffrey, Frank J. Schwab, Virginie Lafage, and and the International Spine Study Group (ISSG)

OBJECTIVE

Recombinant human bone morphogenetic protein–2 (rhBMP-2) has been shown to increase fusion rates; however, cost, limited FDA approval, and possible complications impact its use. Decisions regarding rhBMP-2 use and changes over time have not been well defined. In this study, the authors aimed to assess changes in rhBMP-2 use for adult spinal deformity (ASD) surgery over the past decade.

METHODS

A retrospective review of the International Spine Study Group prospective multicenter database was performed to identify ASD patients treated surgically from 2008 to 2018. For assessment of rhBMP-2 use over time, 3 periods were created: 2008–2011, 2012–2015, and 2016–2018.

RESULTS

Of the patients identified, 1180 met inclusion criteria, with a mean age 60 years and 30% of patients requiring revision surgery; rhBMP-2 was used in 73.9% of patients overall. The mean rhBMP-2 dose per patient was 23.6 mg. Patients receiving rhBMP-2 were older (61 vs 58 years, p < 0.001) and had more comorbidities (Charlson Comorbidity Index 1.9 vs 1.4, p < 0.001), a higher rate of the Scoliosis Research Society–Schwab pelvic tilt modifier (> 0; 68% vs 62%, p = 0.026), a greater deformity correction (change in pelvic incidence minus lumbar lordosis 15° vs 12°, p = 0.01), and more levels fused (8.9 vs 7.9, p = 0.003). Over the 3 time periods, the overall rate of rhBMP-2 use increased and then stabilized (62.5% vs 79% vs 77%). Stratified analysis showed that after an overall increase in rhBMP-2 use, only patients who were younger than 50 years, those who were smokers, those who received a three-column osteotomy (3CO), and patients who underwent revision sustained an increased rate of rhBMP-2 use between the later two periods. No similar increases were noted for older patients, nonsmokers, primary surgery patients, and patients without a 3CO. The total rhBMP-2 dose decreased over time (26.6 mg vs 24.8 mg vs 20.7 mg, p < 0.001). After matching patients by preoperative alignment, 215 patients were included, and a significantly lower rate of complications leading to revision surgery was observed within the 2012–2015 period compared with the 2008–2011 (21.4% vs 13.0%, p = 0.029) period, while rhBMP-2 was increasingly used (80.5% vs 66.0%, p = 0.001). There was a trend toward a lower rate of pseudarthrosis for patients in the 2012–2015 period, but this difference did not reach statistical significance (7% vs 4.2%, p = 0.283).

CONCLUSIONS

The authors found that rhBMP-2 was used in the majority of ASD patients and was more commonly used in those with greater deformity correction. Additionally, over the last 10 years, rhBMP-2 was increasingly used for ASD patients, but the dose has decreased.

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Amit Jain, Hamid Hassanzadeh, Varun Puvanesarajah, Eric O. Klineberg, Daniel M. Sciubba, Michael P. Kelly, D. Kojo Hamilton, Virginie Lafage, Aaron J. Buckland, Peter G. Passias, Themistocles S. Protopsaltis, Renaud Lafage, Justin S. Smith, Christopher I. Shaffrey, Khaled M. Kebaish, and the International Spine Study Group

OBJECTIVE

Using 2 complication-reporting methods, the authors investigated the incidence of major medical complications and mortality in elderly patients after surgery for adult spinal deformity (ASD) during a 2-year follow-up period.

METHODS

The authors queried a multicenter, prospective, surgeon-maintained database (SMD) to identify patients 65 years or older who underwent surgical correction of ASD from 2008 through 2014 and had a minimum 2 years of follow-up (n = 153). They also queried a Centers for Medicare & Medicaid Services claims database (MCD) for patients 65 years or older who underwent fusion of 8 or more vertebral levels from 2005 through 2012 (n = 3366). They calculated cumulative rates of the following complications during the first 6 weeks after surgery: cerebrovascular accident, congestive heart failure, deep venous thrombosis, myocardial infarction, pneumonia, and pulmonary embolism. Significance was set at p < 0.05.

RESULTS

During the perioperative period, rates of major medical complications were 5.9% for pneumonia, 4.1% for deep venous thrombosis, 3.2% for pulmonary embolism, 2.1% for cerebrovascular accident, 1.8% for myocardial infarction, and 1.0% for congestive heart failure. Mortality rates were 0.9% at 6 weeks and 1.8% at 2 years. When comparing the SMD with the MCD, there were no significant differences in the perioperative rates of major medical complications except pneumonia. Furthermore, there were no significant intergroup differences in the mortality rates at 6 weeks or 2 years. The SMD provided greater detail with respect to deformity characteristics and surgical variables than the MCD.

CONCLUSIONS

The incidence of most major medical complications in the elderly after surgery for ASD was similar between the SMD and the MCD and ranged from 1% for congestive heart failure to 5.9% for pneumonia. These complications data can be valuable for preoperative patient counseling and informed consent.

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Alexander A. Theologis, Tamir Ailon, Justin K. Scheer, Justin S. Smith, Christopher I. Shaffrey, Shay Bess, Munish Gupta, Eric O. Klineberg, Khaled Kebaish, Frank Schwab, Virginie Lafage, Douglas Burton, Robert Hart, Christopher P. Ames, and The International Spine Study Group

OBJECTIVE

The objective of this study was to isolate whether the effect of a baseline clinical history of depression on outcome is independent of associated physical disability and to evaluate which mental health screening tool has the most utility in determining 2-year clinical outcomes after adult spinal deformity (ASD) surgery.

METHODS

Consecutively enrolled patients with ASD in a prospective, multicenter ASD database who underwent surgical intervention with a minimum 2-year follow-up were retrospectively reviewed. A subset of patients who completed the Distress and Risk Assessment Method (DRAM) was also analyzed. The effects of categorical baseline depression and DRAM classification on the Oswestry Disability Index (ODI), SF-36, and Scoliosis Research Society questionnaire (SRS-22r) were assessed using univariate and multivariate linear regression analyses. The probability of achieving ≥ 1 minimal clinically important difference (MCID) on the ODI based on the DRAM’s Modified Somatic Perceptions Questionnaire (MSPQ) score was estimated.

RESULTS

Of 267 patients, 66 (24.7%) had self-reported preoperative depression. Patients with baseline depression had significantly more preoperative back pain, greater BMI and Charlson Comorbidity Indices, higher ODIs, and lower SRS-22r and SF-36 Physical/Mental Component Summary (PCS/MCS) scores compared with those without self-reported baseline depression. They also had more severe regional and global sagittal malalignment. After adjusting for these differences, preoperative depression did not impact 2-year ODI, PCS/MCS, or SRS-22r totals (p > 0.05). Compared with those in the “normal” DRAM category, “distressed somatics” (n = 11) had higher ODI (+23.5 points), lower PCS (−10.9), SRS-22r activity (−0.9), and SRS-22r total (−0.8) scores (p ≤ 0.01), while “distressed depressives” (n = 25) had lower PCS (−8.4) and SRS-22r total (−0.5) scores (p < 0.05). After adjusting for important covariates, each additional point on the baseline MSPQ was associated with a 0.8-point increase in 2-year ODI (p = 0.03). The probability of improving by at least 1 MCID in 2-year ODI ranged from 77% to 21% for MSPQ scores 0–20, respectively.

CONCLUSIONS

A baseline clinical history of depression does not correlate with worse 2-year outcomes after ASD surgery after adjusting for baseline differences in comorbidities, health-related quality of life, and spinal deformity severity. Conversely, DRAM improved risk stratification of patient subgroups predisposed to achieving suboptimal surgical outcomes. The DRAM’s MSPQ was more predictive than MCS and SRS mental domain for 2-year outcomes and may be a valuable tool for surgical screening.

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Alex Soroceanu, Justin S. Smith, Darryl Lau, Michael P. Kelly, Peter G. Passias, Themistocles S. Protopsaltis, Jeffrey L. Gum, Virginie Lafage, Han-Jo Kim, Justin K. Scheer, Munish Gupta, Gregory M. Mundis Jr., Eric O. Klineberg, Douglas Burton, Shay Bess, Christopher P. Ames, and the International Spine Study Group

OBJECTIVE

It is being increasingly recognized that adult cervical deformity (ACD) is correlated with significant pain, myelopathy, and disability, and that patients who undergo deformity correction gain significant benefit. However, there are no defined thresholds of minimum clinically important difference (MCID) in Neck Disability Index (NDI) and modified Japanese Orthopaedic Association (mJOA) scores.

METHODS

Patients of interest were consecutive patients with ACD who underwent cervical deformity correction. ACD was defined as C2–7 sagittal Cobb angle ≥ 10° (kyphosis), C2–7 coronal Cobb angle ≥ 10° (cervical scoliosis), C2–7 sagittal vertical axis ≥ 4 cm, and/or chin-brow vertical angle ≥ 25°. Data were obtained from a consecutive cohort of patients from a multiinstitutional prospective database maintained across 13 sites. Distribution-based MCID, anchor-based MCID, and minimally detectable measurement difference (MDMD) were calculated.

RESULTS

A total of 73 patients met inclusion criteria and had sufficient 1-year follow-up. In the cohort, 42 patients (57.5%) were female. The mean age at the time of surgery was 62.23 years, and average body mass index was 29.28. The mean preoperative NDI was 46.49 and mJOA was 13.17. There was significant improvement in NDI at 1 year (46.49 vs 37.04; p = 0.0001). There was no significant difference in preoperative and 1-year mJOA (13.17 vs 13.7; p = 0.12). Using multiple techniques to yield MCID thresholds specific to the ACD population, the authors obtained values of 5.42 to 7.48 for the NDI, and 1.00 to 1.39 for the mJOA. The MDMD was 6.4 for the NDI, and 1.8 for the mJOA. Therefore, based on their results, the authors recommend using an MCID threshold of 1.8 for the mJOA, and 7.0 for the NDI in patients with ACD.

CONCLUSIONS

The ACD-specific MCID thresholds for NDI and mJOA are similar to the reported MCID following surgery for degenerative cervical disease. Additional studies are needed to verify these findings. Nonetheless, the findings here will be useful for future studies evaluating the success of surgery for patients with ACD undergoing deformity correction.

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Ferran Pellisé, Miquel Serra-Burriel, Alba Vila-Casademunt, Jeffrey L. Gum, Ibrahim Obeid, Justin S. Smith, Frank S. Kleinstück, Shay Bess, Javier Pizones, Virginie Lafage, Francisco Javier S. Pérez-Grueso, Frank J. Schwab, Douglas C. Burton, Eric O. Klineberg, Christopher I. Shaffrey, Ahmet Alanay, Christopher P. Ames, and

OBJECTIVE

The reported rate of complications and cost of adult spinal deformity (ASD) surgery, associated with an exponential increase in the number of surgeries, cause alarm among healthcare payers and providers worldwide. The authors conjointly analyzed the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and health-related quality of life [HRQOL] outcomes) since 2010.

METHODS

This is an observational prospective longitudinal cohort study. Patients underwent surgery between January 2010 and December 2016, with > 2 years of follow-up data. Demographic, surgical, radiological, and HRQOL (i.e., Oswestry Disability Index, SF-36, Scoliosis Research Society-22r) data obtained preoperatively and at 3, 6, 12, and 24 months after surgery were evaluated. Trends and changes in indicators were analyzed using local regression (i.e., locally estimated scatterplot smoothing [LOESS]) and adjusted odds ratio (OR).

RESULTS

Of the 2286 patients included in the 2 registries, 1520 underwent surgery between 2010 and 2016. A total of 1151 (75.7%) patients who were treated surgically at 23 centers in 5 countries met inclusion criteria. Patient recruitment increased progressively (2010–2011 vs 2015–2016: OR 1.64, p < 0.01), whereas baseline clinical characteristics (age, American Society of Anesthesiologists class, HRQOL scores, sagittal deformity) did not change. Since 2010 there has been a sustained reduction in major and minor postoperative complications observed at 90 days (major: OR 0.59; minor: OR 0.65; p < 0.01); at 1 year (major: OR 0.52; minor: 0.75; p < 0.01); and at 2 years of follow-up (major: OR 0.4; minor: 0.80; p < 0.01) as well as in the 2-year reintervention rate (OR 0.41, p < 0.01). Simultaneously, there has been a slight improvement in the correction of sagittal deformity (i.e., pelvic incidence–lumbar lordosis mismatch: OR 1.11, p = 0.19) and a greater gain in quality of life (i.e., Oswestry Disability Index 26% vs 40%, p = 0.02; Scoliosis Research Society-22r, self-image domain OR 1.16, p = 0.13), and these are associated with a progressive reduction of surgical aggressiveness (number of fused segments: OR 0.81, p < 0.01; percent pelvic fixation: OR 0.66, p < 0.01; percent 3-column osteotomies: OR 0.63, p < 0.01).

CONCLUSIONS

The best available data show a robust global improvement in quality metrics in ASD surgery over the last decade. Surgical complications and reoperations have been reduced by half, while improvement in disability increased and correction rates were maintained, in patients with similar baseline characteristics.