Predicting the combined occurrence of poor clinical and radiographic outcomes following cervical deformity corrective surgery

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OBJECTIVE

Cervical deformity (CD) correction is clinically challenging. There is a high risk of developing complications with these highly complex procedures. The aim of this study was to use baseline demographic, clinical, and surgical factors to predict a poor outcome following CD surgery.

METHODS

The authors performed a retrospective review of a multicenter prospective CD database. CD was defined as at least one of the following: cervical kyphosis (C2–7 Cobb angle > 10°), cervical scoliosis (coronal Cobb angle > 10°), C2–7 sagittal vertical axis (cSVA) > 4 cm, or chin-brow vertical angle (CBVA) > 25°. Patients were categorized based on having an overall poor outcome or not. Health-related quality of life measures consisted of Neck Disability Index (NDI), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scale scores. A poor outcome was defined as having all 3 of the following categories met: 1) radiographic poor outcome: deterioration or severe radiographic malalignment 1 year postoperatively for cSVA or T1 slope–cervical lordosis mismatch (TS-CL); 2) clinical poor outcome: failing to meet the minimum clinically important difference (MCID) for NDI or having a severe mJOA Ames modifier; and 3) complications/reoperation poor outcome: major complication, death, or reoperation for a complication other than infection. Univariate logistic regression followed by multivariate regression models was performed, and internal validation was performed by calculating the area under the curve (AUC).

RESULTS

In total, 89 patients with CD were included (mean age 61.9 years, female sex 65.2%, BMI 29.2 kg/m2). By 1 year postoperatively, 18 (20.2%) patients were characterized as having an overall poor outcome. For radiographic poor outcomes, patients’ conditions either deteriorated or remained severe for TS-CL (73% of patients), cSVA (8%), horizontal gaze (34%), and global SVA (28%). For clinical poor outcomes, 80% and 60% of patients did not reach MCID for EQ-5D and NDI, respectively, and 24% of patients had severe symptoms (mJOA score 0–11). For the complications/reoperation poor outcome, 28 patients experienced a major complication, 11 underwent a reoperation, and 1 had a complication-related death. Of patients with a poor clinical outcome, 75% had a poor radiographic outcome; 35% of poor radiographic and 37% of poor clinical outcome patients had a major complication. A poor outcome was predicted by the following combination of factors: osteoporosis, baseline neurological status, use of a transition rod, number of posterior decompressions, baseline pelvic tilt, T2–12 kyphosis, TS-CL, C2–T3 SVA, C2–T1 pelvic angle (C2 slope), global SVA, and number of levels in maximum thoracic kyphosis. The final model predicting a poor outcome (AUC 86%) included the following: osteoporosis (OR 5.9, 95% CI 0.9–39), worse baseline neurological status (OR 11.4, 95% CI 1.8–70.8), baseline pelvic tilt > 20° (OR 0.92, 95% CI 0.85–0.98), > 9 levels in maximum thoracic kyphosis (OR 2.01, 95% CI 1.1–4.1), preoperative C2–T3 SVA > 5.4 cm (OR 1.01, 95% CI 0.9–1.1), and global SVA > 4 cm (OR 3.2, 95% CI 0.09–10.3).

CONCLUSIONS

Of all CD patients in this study, 20.2% had a poor overall outcome, defined by deterioration in radiographic and clinical outcomes, and a major complication. Additionally, 75% of patients with a poor clinical outcome also had a poor radiographic outcome. A poor overall outcome was most strongly predicted by severe baseline neurological deficit, global SVA > 4 cm, and including more of the thoracic maximal kyphosis in the construct.

ABBREVIATIONS AUC = area under the curve; CBVA = chin-brow vertical angle; CD = cervical deformity; CL = C2–7 lordosis; cSVA = C2–7 SVA; MCID = minimum clinically important difference; mJOA = modified Japanese Orthopaedic Association; NDI = Neck Disability Index; PI-LL = mismatch between pelvic incidence and lumbar lordosis; PT = pelvic tilt; SVA = sagittal vertical axis; TS-CL = mismatch between T1 slope and CL.
Article Information

Contributor Notes

Correspondence Peter G. Passias: New York Spine Institute, NYU Langone Medical Center–Orthopaedic Hospital, New York, NY. peter.passias@nyumc.org.INCLUDE WHEN CITING Published online November 1, 2019; DOI: 10.3171/2019.7.SPINE18651.Disclosures The ISSG is funded through research grants from DePuy Synthes, which supported the current work.Ms. Horn: consultant for Medicrea and SpineWave; scientific advisory board and speaking/teaching for Allosource, Zimmer Biomet, and Globus; and support of non–study-related clinical or research effort from CSFS and Aesculap. Dr. Lafage: direct stock ownership in Nemaris Inc.; speaking/teaching arrangements with AOSpine and DePuy Spine; and support of non–study-related clinical or research effort from DePuy Spine, NuVasive, K2M, and Stryker paid through ISSG and grants from SRS and NASS. Dr. Smith: consultant for K2M, AlloSource, Cerapedics, Zimmer Biomet, and NuVasive; support of non–study-related clinical or research effort from DePuy/Synthes/ISSG; royalties from Zimmer Biomet; and fellowship funding from NREF and AOSpine. Mr. Line: consultant for ISSG and AlloSource. Dr. Anand: consultant for Medtronic, direct stock ownership in Medtronic and Globus Medical, patent holder with Medtronic, and royalties from Globus Medical. Dr. Deviren: consultant for NuVasive, SeaSpine, Medicrea, Pfizer, Biomet, Guidepoint, and Alphatec and royalties from NuVasive. Dr. Mummaneni: consultant for Stryker; employee of UCSF, royalties from DePuy, honorarium from Globus, ownership in ISD/Spinicity, and grants from AANS/CNS/AOSpine and NREF. Dr. Daniels: consultant for Spineart, Stryker, and Orthofix and royalties from Springer. Dr. Park: consultant for Globus, NuVasive, Medtronic, and Allosource and royalties from Globus. Dr. Nunley: consultant for K2M; direct stock ownership in Amedica, Paradigm, and Spineology; patent holder with K2M and LDR/Zimmer Biomet; speakers bureau for K2M and LDR/Zimmer Biomet; Dr. Klineberg: consultant for DePuy Synthes, Stryker, Springer, Trevena, and Allosource; honoraria from K2M and AOSpine; and fellowship grant from AOSpine. Dr. Burton: consultant for Allosource and support of non–study-related clinical or research effort from Pfizer and DePuy. Dr. Schwab: consultant for MSD, K2M, Zimmer Biomet, NuVasive, and Medicrea; direct stock ownership in Nemaris Inc.; patent holder with MSD and K2M; support of non–study-related clinical or research effort from DePuy Spine, Stryker, K2M, and NuVasive (paid through ISSG); and speaking/teaching arrangements with MSD, K2M, NuVasive, and Zimmer Biomet. Dr. Bess: consultant for K2M and Allosource; royalties from K2M; and support of non–study-related clinical or research effort from K2M, Innovasis, NuVasive, DePuy, and Stryker. Dr. Shaffrey: consultant for Medtronic and NuVasive; direct stock ownership in NuVasive; and patent holder with Medtronic, NuVasive, and Zimmer Biomet. Dr. Ames: employee of UCSF; consultant for Medtronic, Stryker, Medicrea, K2M, and DePuy Synthes; and royalties from Stryker, Biomet Spine; DePuy Synthes; NuVasive; and Next Orthosurgical.
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References
  • 1

    Ames CPBlondel BScheer JKSchwab FJLe Huec JCMassicotte EM: Cervical radiographical alignment: comprehensive assessment techniques and potential importance in cervical myelopathy. Spine (Phila Pa 1976) 38 (22 Suppl 1):S149S1602013

    • Search Google Scholar
    • Export Citation
  • 2

    Ames CPSmith JSEastlack RBlaskiewicz DJShaffrey CISchwab F: Reliability assessment of a novel cervical spine deformity classification system. J Neurosurg Spine 23:6736832015

    • Search Google Scholar
    • Export Citation
  • 3

    Carreon LYPuno RMDimar JR IIGlassman SDJohnson JR: Perioperative complications of posterior lumbar decompression and arthrodesis in older adults. J Bone Joint Surg Am 85:208920922003

    • Search Google Scholar
    • Export Citation
  • 4

    Cauley JAFullman RLStone KLZmuda JMBauer DCBarrett-Connor E: Factors associated with the lumbar spine and proximal femur bone mineral density in older men. Osteoporos Int 16:152515372005

    • Search Google Scholar
    • Export Citation
  • 5

    Champain SBenchikh KNogier AMazel CGuise JDSkalli W: Validation of new clinical quantitative analysis software applicable in spine orthopaedic studies. Eur Spine J 15:9829912006

    • Search Google Scholar
    • Export Citation
  • 6

    Hart RAPrendergast MA: Spine surgery for lumbar degenerative disease in elderly and osteoporotic patients. Instr Course Lect 56:2572722007

    • Search Google Scholar
    • Export Citation
  • 7

    Kim DHVaccaro AR: Osteoporotic compression fractures of the spine; current options and considerations for treatment. Spine J 6:4794872006

    • Search Google Scholar
    • Export Citation
  • 8

    Kim WJLee ESJeon SHYalug I: Correction of osteoporotic fracture deformities with global sagittal imbalance. Clin Orthop Relat Res 443:75932006

    • Search Google Scholar
    • Export Citation
  • 9

    Miller EKAilon TNeuman BJKlineberg EOMundis GMJ JrSciubba DM: Assessment of a novel adult cervical deformity frailty index as a component of preoperative risk stratification. World Neurosurg 109:e800e8062018

    • Search Google Scholar
    • Export Citation
  • 10

    O’Brien MFKuklo TRBlanke KMLenke LG (eds): Spinal Deformity Study Group Radiographic Measurement Manual. Winter Park, FL: Medtronic Sofamor Danek2008

    • Search Google Scholar
    • Export Citation
  • 11

    Park SBChung CK: Strategies of spinal fusion on osteoporotic spine. J Korean Neurosurg Soc 49:3173222011

  • 12

    Passias PGBortz CHorn SSegreto FPoorman GJalai C: Drivers of cervical deformity have a strong influence on achieving optimal radiographic and clinical outcomes at 1 year after cervical deformity surgery. World Neurosurg 112:e61e682018

    • Search Google Scholar
    • Export Citation
  • 13

    Passias PGOh CJalai CMWorley NLafage RScheer JK: Predictive model for cervical alignment and malalignment following surgical correction of adult spinal deformity. Spine (Phila Pa 1976) 41:E1096E11032016

    • Search Google Scholar
    • Export Citation
  • 14

    Passias PGSoroceanu AScheer JYang SBoniello ASmith JS: Magnitude of preoperative cervical lordotic compensation and C2-T3 angle are correlated to increased risk of postoperative sagittal spinal pelvic malalignment in adult thoracolumbar deformity patients at 2-year follow-up. Spine J 15:175617632015

    • Search Google Scholar
    • Export Citation
  • 15

    Passias PGVasquez-Montes DPoorman GWProtopsaltis THorn SRBortz CA: Predictive model for distal junctional kyphosis after cervical deformity surgery. Spine J 18:218721942018

    • Search Google Scholar
    • Export Citation
  • 16

    Protopsaltis TSStekas N: Response to the Letter to the Editor regarding "Analysis of Successful vs. Failed Radiographic Outcomes Following Cervical Deformity Surgery." Spine (Phila Pa 1976) 43:E981E9822018

    • Search Google Scholar
    • Export Citation
  • 17

    Rillardon LLevassor NGuigui PWodecki PCardinne LTemplier A: [Validation of a tool to measure pelvic and spinal parameters of sagittal balance.] Rev Chir Orthop Reparatrice Appar Mot 89:2182272003 (French)

    • Search Google Scholar
    • Export Citation
  • 18

    Scheer JKAmes CPDeviren V: Assessment and treatment of cervical deformity. Neurosurg Clin N Am 24:2492742013

  • 19

    Scheer JKPassias PGSorocean AMBoniello AJMundis GMJ JrKlineberg E: Association between preoperative cervical sagittal deformity and inferior outcomes at 2-year follow-up in patients with adult thoracolumbar deformity: analysis of 182 patients. J Neurosurg Spine 24:1081152016

    • Search Google Scholar
    • Export Citation
  • 20

    Scheer JKTang JASmith JSAcosta FL JrProtopsaltis TSBlondel B: Cervical spine alignment, sagittal deformity, and clinical implications: a review. J Neurosurg Spine 19:1411592013

    • Search Google Scholar
    • Export Citation
  • 21

    Smith JSKlineberg EShaffrey CILafage VSchwab FJProtopsaltis T: Assessment of surgical treatment strategies for moderate to severe cervical spinal deformity reveals marked variation in approaches, osteotomies, and fusion levels. World Neurosurg 91:2282372016

    • Search Google Scholar
    • Export Citation
  • 22

    Smith JSLafage VSchwab FJShaffrey CIProtopsaltis TKlineberg E: Prevalence and type of cervical deformity among 470 adults with thoracolumbar deformity. Spine (Phila Pa 1976) 39:E1001E10092014

    • Search Google Scholar
    • Export Citation
  • 23

    Smith JSLine BBess SShaffrey CIKim HJMundis G: The health impact of adult cervical deformity in patients presenting for surgical treatment: comparison to United States population norms and chronic disease states based on the EuroQuol-5 Dimensions questionnaire. Neurosurgery 80:7167252017

    • Search Google Scholar
    • Export Citation
  • 24

    Smith JSRamchandran SLafage VShaffrey CIAilon TKlineberg E: Prospective multicenter assessment of early complication rates associated with adult cervical deformity surgery in 78 patients. Neurosurgery 79:3783882016

    • Search Google Scholar
    • Export Citation
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