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Alexander A. Theologis, Gregory M. Mundis Jr., Stacie Nguyen, David O. Okonkwo, Praveen V. Mummaneni, Justin S. Smith, Christopher I. Shaffrey, Richard Fessler, Shay Bess, Frank Schwab, Bassel G. Diebo, Douglas Burton, Robert Hart, Vedat Deviren and Christopher Ames

clinically important difference in adult spinal deformity: a comparison of operative and nonoperative treatment . Ochsner J 14 : 67 – 77 , 2014 24688336 22 Manwaring JC , Bach K , Ahmadian AA , Deukmedjian AR , Smith DA , Uribe JS : Management of sagittal balance in adult spinal deformity with minimally invasive anterolateral lumbar interbody fusion: a preliminary radiographic study . J Neurosurg Spine 20 : 515 – 522 , 2014 24628129 10.3171/2014.2.SPINE1347 23 Mundis GM , Akbarnia BA , Phillips FM : Adult deformity correction through

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Cheerag Upadhyaya, John Ziewacs and Praveen Mummaneni

Minimally invasive surgical (MIS) approaches are gaining popularity in many surgical fields. Potential advantages include reduced blood loss, shorter length of stay, and less soft-tissue trauma. Potential disadvantages include inadequate deformity correction, increased fluoroscopy, longer operative times, and decreased posterolateral fusion surface area exposure.

This video demonstrates the key steps in our mini-open transforaminal lumbar interbody fusion (TLIF) using an expandable tubular retractor, placement of cannulated pedicle instrumentation, and subsequent deformity correction. The video demonstrates positioning, surgical opening through a midline incision, a bilateral Wiltse plane tubular approach for the TLIF, placement of bilateral cannulated pedicle screws, and deformity correction.

The video can be found here: http://youtu.be/9GH3qsCGX3E.

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Michael P. Kelly, Lawrence G. Lenke, Jakub Godzik, Ferran Pellise, Christopher I. Shaffrey, Justin S. Smith, Stephen J. Lewis, Christopher P. Ames, Leah Y. Carreon, Michael G. Fehlings, Frank Schwab and Adam L. Shimer

offers better data, as the data are more generalizable to adult deformity surgery as a whole. The results of a cohort including more surgeons likely lend external validity to the conclusions, as opposed to the internally valid conclusions of a smaller research group. 28 Furthermore, one would expect, with greater experience and dissemination of information, that neurological deficits would decline, rather than increase. While possible, it is unlikely that the rate of new neurological deficits has increased over time, thus implying that a flaw in retrospective data

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Neel Anand, Rebecca Rosemann, Bhavraj Khalsa and Eli M. Baron

loss was reported as 1600 ml, with patients receiving a transfusion of 2.4 U on average. Similarly, Shapiro et al. 30 reported outcomes in 16 patients undergoing circumferential deformity correction for adult scoliosis with concurrent low-back pain and spinal stenosis. In patients undergoing combined surgery as an index procedure, they noted a mean blood loss of 3665.7 ml, and they reported a complication rate of 75%. Daubs et al. 15 reported complications in 46 patients with arthrodesis of 5 or more levels undergoing adult deformity correction surgery. Among these

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Virginie Lafage, Frank Schwab, Shaleen Vira, Robert Hart, Douglas Burton, Justin S. Smith, Oheneba Boachie-Adjei, Alexis Shelokov, Richard Hostin, Christopher I. Shaffrey, Munish Gupta, Behrooz A. Akbarnia, Shay Bess and Jean-Pierre Farcy

S pinal deformity in the adult is commonly a 3D pathology. However, evidence points toward the clinical impact of deformity being mostly related to the sagittal plane, with little correlation between coronal deformity and self-reported disability. The Classification of Adult Deformity 20 was primarily built on clinical impact parameters, and it highlights lumbar lordosis as well as global sagittal alignment. Work leading to the classification did not identify a significant clinical impact of coronal plane parameters. 20 Additionally, in the commonly known

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Jean-Christophe Leveque, Vijay Yanamadala, Quinlan D. Buchlak and Rajiv K. Sethi

: 231 – 248 , 2013 23561562 10.1016/j.nec.2012.12.004 51 Mundis GM , Akbarnia BA , Phillips FM : Adult deformity correction through minimally invasive lateral approach techniques . Spine (Phila Pa 1976) 35 ( 26 Suppl ): S312 – S321 , 2010 52 Murray G , Beckman J , Bach K , Smith DA , Dakwar E , Uribe JS : Complications and neurological deficits following minimally invasive anterior column release for adult spinal deformity: a retrospective study . Eur Spine J 24 ( Suppl 3 ): 397 – 404 , 2015 10.1007/s00586-015-3894-1 25850388 53

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Aladine A. Elsamadicy, David T. Lubkin, Amanda R. Sergesketter, Syed M. Adil, Lefko T. Charalambous, Nicolas Drysdale, Theresa Williamson, Joaquin Camara-Quintana, Muhammad M. Abd-El-Barr, C. Rory Goodwin and Isaac O. Karikari

OBJECTIVE

In the United States, healthcare expenditures have been soaring at a concerning rate. There has been an excessive use of postoperative radiographs after spine surgery and this has been a target for hospitals to reduce unnecessary costs. However, there are only limited data identifying the rate of instrumentation changes on radiographs after complex spine surgery involving ≥ 5-level fusions.

METHODS

The medical records of 136 adult (≥ 18 years old) patients with spine deformity undergoing elective, primary complex spinal fusion (≥ 5 levels) for deformity correction at a major academic institution between 2010 and 2015 were reviewed. Patient demographics, comorbidities, and intra- and postoperative complication rates were collected for each patient. The authors reviewed the first 5 subsequent postoperative and follow-up radiographs, and determined whether revision of surgery was performed within 5 years postoperatively. The primary outcome investigated in this study was the rate of hardware changes on follow-up radiographs.

RESULTS

The majority of patients were female, with a mean age of 53.8 ± 20.0 years and a body mass index of 27.3 ± 6.2 kg/m2 (parametric data are expressed as the mean ± SD). The median number of fusion levels was 9 (interquartile range 7–13), with a mean length of surgery of 327.8 ± 124.7 minutes and an estimated blood loss of 1312.1 ± 1269.2 ml. The mean length of hospital stay was 6.6 ± 3.9 days, with a 30-day readmission rate of 14.0%. Postoperative and follow-up change in stability on radiographs (days from operation) included: image 1 (4.6 ± 9.3 days) 0.0%; image 2 (51.7 ± 49.9 days) 3.0%; image 3 (142.1 ± 179.8 days) 5.6%; image 4 (277.3 ± 272.5 days) 11.3%; and image 5 (463.1 ± 525.9 days) 15.7%. The 3rd year after surgery had the highest rate of hardware revision (5.55%), followed by the 2nd year (4.68%), and the 1st year (4.54%).

CONCLUSIONS

This study suggests that the rate of instrumentation changes on radiographs increases over time, with no changes occurring at the first postoperative image. In an era of cost-conscious healthcare, fewer orders for early radiographs after complex spinal fusions (≥ 5 levels) may not impact patient care and can reduce the overall use of healthcare resources.

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Ian G. Dorward and Lawrence G. Lenke

P osterior - only approaches for the correction of adult kyphotic or kyphoscoliotic deformities have become increasingly common in recent years. The reason for this change in practice has been the advent of polysegmental 3-column fixation through the use of pedicle screws, as well as the use of posterior osteotomies to effect greater curve correction without the need for anterior releases or corpectomies. The status of surgical techniques and technology in adult deformity surgery is now such that essentially any kyphotic deformity can be addressed through a

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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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Owoicho Adogwa, Jacob M. Buchowski, Lawrence G. Lenke, Maksim A. Shlykov, Mostafa El Dafrawy, Thamrong Lertudomphonwanit, Mitchel R. Obey, Jonathan Koscso, Munish C. Gupta and Keith H. Bridwell

OBJECTIVE

Pseudarthrosis is a common complication of long-segment fusions after surgery for correction of adult spinal deformity (ASD). Interbody fusions are frequently used at the caudal levels of long-segment spinal deformity constructs as adjuncts for anterior column support. There is a paucity of literature comparing rod fracture rates (proxy for pseudarthrosis) in patients undergoing transforaminal lumbar interbody fusion (TLIF) versus anterior lumbar interbody fusion (ALIF) at the caudal levels of the long spinal deformity construct. In this study the authors sought to compare rod fracture rates in patients undergoing surgery for correction of ASD with TLIF versus ALIF at the caudal levels of long spinal deformity constructs.

METHODS

We reviewed clinical records of patients who underwent surgery for correction of ASD between 2008 and 2014 at a single institution. Data including demographics, comorbidities, and indications for surgery, as well as postoperative variables, were collected for each patient. All patients had a minimum 2-year follow-up. Patients were dichotomized into two groups for comparison on the basis of undergoing a TLIF versus an ALIF procedure at the caudal levels of long spinal deformity constructs. The primary outcome of interest was the rate of rod fractures.

RESULTS

A total of 198 patients (TLIF 133 patients; ALIF 65 patients) underwent a long-segment fusion to the sacrum with iliac fixation. The mean ± standard deviation follow-up period was 62.23 ± 29.26 months. Baseline demographic variables were similar in both patient groups. There were no significant differences between groups in the severity of the baseline sagittal plane deformity (i.e., baseline lumbar-pelvic parameters) or the final deformity correction achieved. Mean total recombinant human bone morphogenetic protein 2 (rhBMP-2) dose for L1–sacrum fusion was significantly higher in the ALIF (100 mg) than in the TLIF (62 mg) group. The overall rod failure rate (cases with rod fracture/total cases) within this case series was 19.19% (38/198); 10.60% (21/198) were unilateral rod fractures and 8.58% (17/198) were bilateral rod fractures. At last clinical follow-up, there were no statistically significant differences in bilateral rod fracture rates between the group of patients who had a TLIF procedure and the group who had an ALIF procedure at the caudal levels of the long spinal deformity constructs (TLIF 10.52% vs ALIF 4.61%, p = 0.11). However, the incidence rate (cases per patient follow-up years) for bilateral rod fractures was significantly higher in the TLIF than in the ALIF cohort (TLIF 2.20% vs ALIF 0.70%, p < 0.0001). The reoperation rate for rod fractures was similar between the patient groups (p = 0.40).

CONCLUSIONS

Although both ALIF and TLIF procedures at the caudal levels of long spinal deformity constructs achieved similar and satisfactory deformity correction, ALIFs were associated with a lower rod fracture incidence rate. There were no differences between groups in the prevalence of rod fracture or revision surgery, however, and both groups had low bilateral rod fracture prevalence and incidence rates. One technique is not clearly superior to the other.