Outcomes of operative treatment for adult spinal deformity: a prospective multicenter assessment with mean 4-year follow-up

Elias EliasDepartment of Neurosurgery, University of Virginia, Charlottesville, Virginia;

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Shay BessPresbyterian St. Luke’s Medical Center, Denver, Colorado;

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Breton LinePresbyterian St. Luke’s Medical Center, Denver, Colorado;

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Virginie LafageDepartment of Orthopedic Surgery, Lenox Hill Hospital, New York, New York;

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Renaud LafageDepartment of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;

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Eric KlinebergDepartment of Orthopaedic Surgery, University of California, Davis, Sacramento, California;

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Han Jo KimDepartment of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;

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Peter G. PassiasDepartment of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York;

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Zeina NasserNeuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Hadath, Lebanon;

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Jeffrey L. GumLeatherman Spine Center, Louisville, Kentucky;

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Khal KebaishDepartment of Orthopedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland;

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Robert EastlackScripps Clinic, San Diego, California;

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Alan H. DanielsDepartment of Orthopedic Surgery, Brown University, Providence, Rhode Island;

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Gregory Mundis Jr.Scripps Clinic, San Diego, California;

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Richard HostinDepartment of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas;

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Themistocles S. ProtopsaltisDepartment of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York;

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Alex SoroceanuDepartment of Orthopedic Surgery, University of Calgary, Alberta, Canada;

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D. Kojo HamiltonDepartment of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania;

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Michael P. KellyDepartment of Orthopedic Surgery, Rady Children’s Hospital, San Diego, California;

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Munish GuptaDepartment of Orthopedic Surgery, Washington University, St. Louis, Missouri;

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Robert HartDepartment of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington;

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Frank J. SchwabDepartment of Orthopedic Surgery, Lenox Hill Hospital, New York, New York;

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Douglas BurtonDepartment of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;

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Christopher P. AmesDepartment of Neurological Surgery, University of California, San Francisco, California; and

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Christopher I. ShaffreyDepartments of Neurosurgery and Orthopedic Surgery, Duke University, Durham, North Carolina

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Justin S. SmithDepartment of Neurosurgery, University of Virginia, Charlottesville, Virginia;

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OBJECTIVE

The current literature has primarily focused on the 2-year outcomes of operative adult spinal deformity (ASD) treatment. Longer term durability is important given the invasiveness, complications, and costs of these procedures. The aim of this study was to assess minimum 3-year outcomes and complications of ASD surgery.

METHODS

Operatively treated ASD patients were assessed at baseline, follow-up, and through mailings. Patient-reported outcome measures (PROMs) included scores on the Oswestry Disability Index (ODI), Scoliosis Research Society–22r (SRS-22r) questionnaire, mental component summary (MCS) and physical component summary (PCS) of the SF-36, and numeric rating scale (NRS) for back and leg pain. Complications were classified as perioperative (≤ 90 days), delayed (90 days to 2 years), and long term (≥ 2 years). Analyses focused on patients with minimum 3-year follow-up.

RESULTS

Of 569 patients, 427 (75%) with minimum 3-year follow-up (mean ± SD [range] 4.1 ± 1.1 [3.0–9.6] years) had a mean age of 60.8 years and 75% were women. Operative treatment included a posterior approach for 426 patients (99%), with a mean ± SD 12 ± 4 fusion levels. Anterior lumbar interbody fusion was performed in 35 (8%) patients, and 89 (21%) underwent 3-column osteotomy. All PROMs improved significantly from baseline to last follow-up, including scores on ODI (45.4 to 30.5), PCS (31.0 to 38.5), MCS (45.3 to 50.6), SRS-22r total (2.7 to 3.6), SRS-22r activity (2.8 to 3.5), SRS-22r pain (2.3 to 3.4), SRS-22r appearance (2.4 to 3.5), SRS-22r mental (3.4 to 3.7), SRS-22r satisfaction (2.7 to 4.1), NRS for back pain (7.1 to 3.8), and NRS for leg pain (4.8 to 3.0) (all p < 0.001). Degradations in some outcome measures were observed between the 2-year and last follow-up evaluations, but the magnitudes of these degradations were modest and arguably not clinically significant. Overall, 277 (65%) patients had at least 1 complication, including 185 (43%) perioperative, 118 (27%) delayed, and 56 (13%) long term. Notably, the 142 patients who did not achieve 3-year follow-up were similar to the study patients in terms of demographic characteristics, deformities, and baseline PROMs and had similar rates and types of complications.

CONCLUSIONS

This prospective multicenter analysis demonstrated that operative ASD treatment provided significant improvement of health-related quality of life at minimum 3-year follow-up (mean 4.1 years), suggesting that the benefits of surgery for ASD remain durable at longer follow-up. These findings should prove useful for counseling, cost-effectiveness assessments, and efforts to improve the safety of care.

ABBREVIATIONS

ASD = adult spinal deformity; BMI = body mass index; CCI = Charlson Comorbidity Index; GCA = global coronal alignment; HRQOL = health-related quality of life; MCID = minimal clinically important difference; MCS = mental component summary; NRS = numeric rating scale; ODI = Oswestry Disability Index; PCS = physical component summary; PI-LL = pelvic incidence to lumbar lordosis mismatch; PROM = patient-reported outcome measure; PT = pelvic tilt; SRS-22r = Scoliosis Research Society–22r; SVA = sagittal vertical axis; TK = thoracic kyphosis.
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Images from de Andrada Pereira et al. (pp 525–534).

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