Operative treatment outcomes for adult cervical deformity: a prospective multicenter assessment with mean 3-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 G. LinePresbyterian St. Luke’s Medical Center, Denver, Colorado;

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Virginie LafageDepartment of Orthopedic Surgery, Lennox 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 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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Khaled 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, 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, Lennox 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

Adult cervical deformity (ACD) has high complication rates due to surgical complexity and patient frailty. Very few studies have focused on longer-term outcomes of operative ACD treatment. The objective of this study was to assess minimum 2-year outcomes and complications of ACD surgery.

METHODS

A multicenter, prospective observational study was performed at 13 centers across the United States to evaluate surgical outcomes for ACD. Demographics, complications, radiographic parameters, and patient-reported outcome measures (PROMs; Neck Disability Index, modified Japanese Orthopaedic Association, EuroQol-5D [EQ-5D], and numeric rating scale [NRS] for neck and back pain) were evaluated, and analyses focused on patients with ≥ 2-year follow-up.

RESULTS

Of 169 patients with ACD who were eligible for the study, 102 (60.4%) had a minimum 2-year follow-up (mean 3.4 years, range 2–8.1 years). The mean age at surgery was 62 years (SD 11 years). Surgical approaches included anterior-only (22.8%), posterior-only (39.6%), and combined (37.6%). PROMs significantly improved from baseline to last follow-up, including Neck Disability Index (from 47.3 to 33.0) and modified Japanese Orthopaedic Association score (from 12.0 to 12.8; for patients with baseline score ≤ 14), neck pain NRS (from 6.8 to 3.8), back pain NRS (from 5.5 to 4.8), EQ-5D score (from 0.74 to 0.78), and EQ-5D visual analog scale score (from 59.5 to 66.6) (all p ≤ 0.04). More than half of the patients (n = 58, 56.9%) had at least one complication, with the most common complications including dysphagia, distal junctional kyphosis, instrumentation failure, and cardiopulmonary events. The patients who did not achieve 2-year follow-up (n = 67) were similar to study patients based on baseline demographics, comorbidities, and PROMs. Over the course of follow-up, 23 of the total 169 enrolled patients were reported to have died. Notably, these represent all-cause mortalities during the course of follow-up.

CONCLUSIONS

This multicenter, prospective analysis demonstrates that operative treatment for ACD provides significant improvement of health-related quality of life at a mean 3.4-year follow-up, despite high complication rates and a high rate of all-cause mortality that is reflective of the overall frailty of this patient population. To the authors’ knowledge, this study represents the largest and most comprehensive prospective effort to date designed to assess the intermediate-term outcomes and complications of operative treatment for ACD.

ABBREVIATIONS

ACD = adult cervical deformity; CSM = cervical spondylotic myelopathy; DJK = distal junctional kyphosis; EQ-5D = EuroQol-5D; HRQL = health-related quality of life; mJOA = modified Japanese Orthopaedic Association; NDI = Neck Disability Index; NRS = numeric rating scale; PROMs = patient-reported outcome measures; VAS = visual analog scale; VCR = vertebral column resection; 3CO = 3-column osteotomy.
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Illustrations from Hagan et al. (pp 843–850). © Albert Telfeian, published with permission.

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