Prospective multicenter assessment of complication rates associated with adult cervical deformity surgery in 133 patients with minimum 1-year follow-up

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  • 1 Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia;
  • 2 Departments of Neurosurgery and
  • 3 Orthopedic Surgery, Duke University, Durham, North Carolina;
  • 4 Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York;
  • 5 Department of Orthopaedic Surgery, University of California Davis, Sacramento, California;
  • 6 Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York;
  • 7 Scripps Clinic, San Diego, California;
  • 8 Department of Orthopedic Surgery, University of California, San Francisco, California;
  • 9 Department of Orthopedic Surgery, Washington University in St. Louis, Missouri;
  • 10 Department of Orthopedic Surgery, Brown University, Providence, Rhode Island;
  • 11 Department of Orthopedic Surgery, Leatherman Spine Center, Louisville, Kentucky;
  • 12 Department of Orthopedic Surgery, University of Calgary, Alberta, Canada;
  • 13 Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;
  • 14 Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas;
  • 15 Department of Orthopaedic Surgery, Swedish Medical Center, Seattle, Washington;
  • 16 Presbyterian St. Luke’s Medical Center, Denver, Colorado; and
  • 17 Department of Neurological Surgery, University of California, San Francisco, California
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OBJECTIVE

Although surgical treatment can provide significant improvement of symptomatic adult cervical spine deformity (ACSD), few reports have focused on the associated complications. The objective of this study was to assess complication rates at a minimum 1-year follow-up based on a prospective multicenter series of ACSD patients treated surgically.

METHODS

A prospective multicenter database of consecutive operative ACSD patients was reviewed for perioperative (< 30 days), early (30–90 days), and delayed (> 90 days) complications with a minimum 1-year follow-up. Enrollment required at least 1 of the following: cervical kyphosis > 10°, cervical scoliosis > 10°, C2–7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°.

RESULTS

Of 167 patients, 133 (80%, mean age 62 years, 62% women) had a minimum 1-year follow-up (mean 1.8 years). The most common diagnoses were degenerative (45%) and iatrogenic (17%) kyphosis. Almost 40% of patients were active or past smokers, 17% had osteoporosis, and 84% had at least 1 comorbidity. The mean baseline Neck Disability Index and modified Japanese Orthopaedic Association scores were 47 and 13.6, respectively. Surgical approaches were anterior-only (18%), posterior-only (47%), and combined (35%). A total of 132 complications were reported (54 minor and 78 major), and 74 (56%) patients had at least 1 complication. The most common complications included dysphagia (11%), distal junctional kyphosis (9%), respiratory failure (6%), deep wound infection (6%), new nerve root motor deficit (5%), and new sensory deficit (5%). A total of 4 deaths occurred that were potentially related to surgery, 2 prior to 1-year follow-up (1 cardiopulmonary and 1 due to obstructive sleep apnea and narcotic use) and 2 beyond 1-year follow-up (both cardiopulmonary and associated with revision procedures). Twenty-six reoperations were performed in 23 (17%) patients, with the most common indications of deep wound infection (n = 8), DJK (n = 7), and neurological deficit (n = 6). Although anterior-only procedures had a trend toward lower overall (42%) and major (21%) complications, rates were not significantly different from posterior-only (57% and 33%, respectively) or combined (61% and 37%, respectively) approaches (p = 0.29 and p = 0.38, respectively).

CONCLUSIONS

This report provides benchmark rates for ACSD surgery complications at a minimum 1-year (mean 1.8 years) follow-up. The marked health and functional impact of ACSD, the frail population it affects, and the high rates of surgical complications necessitate a careful risk-benefit assessment when contemplating surgery. Collectively, these findings provide benchmarks for complication rates and may prove useful for patient counseling and efforts to improve the safety of care.

ABBREVIATIONS ACSD = adult cervical spine deformity; CCI = Charlson Comorbidity Index; DJK = distal junctional kyphosis; EBL = estimated blood loss; ISSG = International Spine Study Group; 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 = T1 slope minus cervical lordosis.

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Contributor Notes

Correspondence Justin S. Smith: University of Virginia Health System, Charlottesville, VA. jss7f@virginia.edu.

INCLUDE WHEN CITING Published online June 19, 2020; DOI: 10.3171/2020.4.SPINE20213.

Disclosures The International Spine Study Group (ISSG) is funded through research grants from DePuy Synthes, Medtronic, and Globus.

Dr. Smith: consultant for Zimmer Biomet, NuVasive, Stryker/K2M, Cerapedics, DePuy Synthes/ISSG, and Carlsmed; stock ownership in Alphatec; royalties from Zimmer Biomet and NuVasive; and support of non–study-related clinical or research effort from DePuy Synthes/ISSG, AO Spine, and NuVasive. Dr. Shaffrey: consultant for NuVasive, Medtronic, and SI Bone; direct stock ownership in NuVasive; and patent holder with NuVasive, Medtronic, and Zimmer Biomet. Dr. Klineberg: consultant for DePuy Synthes, Stryker, and Medicrea; honoraria from AO Spine; and fellowship grant from AO Spine. Dr. Protopsaltis: consultant for Globus, Stryker K2M, Medicrea, NuVasive, and Innovasis; and royalties from Altus. Dr. Passias: consultant for Medicrea and Spinewave; support of non–study-related clinical or research effort from the Cervical Scoliosis Research Society; speakers bureau for Zimmer and Globus Medical; and other financial or material support from Allosource. Dr. Mundis: consultant for NuVasive, Stryker, Viseon, SeaSpine, and Carlsmed; direct stock ownership in NuVasive, Alphatec, and SeaSpine; patent holder with Stryker; and royalties from NuVasive and Stryker. Dr. Eastlack: consultant for Aesculap, Baxter, NuVasive, SeaSpine, SI Bone, Medtronic, Stryker, and Carevature; direct stock ownership in Spine Innovation, NuVasive, SeaSpine, Alphatec, and SI Bone; ownership in Spine Innovation; patent holder with SeaSpine, Globus, SI Bone, Invuity, and Spine Innovation; support of non–study-related clinical or research effort from SeaSpine, NuVasive, and Medtronic; speakers bureau for Radius; and royalties from NuVasive, SeaSpine, SI Bone, and Aesculap. Dr. Deviren: consultant for NuVasive, Medicrea, Biomet, SeaSpine, and Alphatec. Dr. Kelly: clinical or research support for the study described from DePuy Synthes Spine. Dr. Daniels: consultant for Medicrea, Spineart, Stryker, Orthofix, and Medtronic; and royalties from Medicrea, Spineart, Springer, and Southern Spine. Dr. Gum: employee of Norton Healthcare; consultant for Medtronic, DePuy, Stryker K2M, Acuity, and NuVasive; direct stock ownership in Cingulate Therapeutics; clinical or research support for the study described from Intellirod, Integra, Pfizer, and International Spine Study; patent holder with Medtronic; and royalties from Acuity. Dr. Gupta: consultant for DePuy and Medtronic; royalties from DePuy and Innomed; direct stock ownership in J&J and P&G; honoraria from AO Spine; and travel from Scoliosis Research Society; DePuy, Alphatec, Medtronic, Globus, AO Spine, Medicrea, Mizuho. Dr. Burton: consultant for Bioventus, patent holder with DePuy, and ownership in Progenerative Medical. Dr. Hart: consultant for DePuy, Globus, Medtronic, and Orthofix; royalties from SeaSpine; and support of non–study-related clinical or research effort from ISSLS. Dr. V. Lafage: consultant for Globus Medical; royalties from NuVasive; honoraria from The Permanente Medical Group, DePuy Synthes, and Implanet; and ownership in Nemaris Inc. Mr. R. Lafage: direct stock ownership in Nemaris. Dr. Schwab: consultant for Globus Medical, K2 Medical, and ZimmerBiomet; royalties from Medicrea USA, Medtronic Sofamor Danek USA, and Zimmer Biomet; honoraria from Zimmer Biomet; executive committee of ISSG. Dr. Bess: consultant for Stryker and mirus; direct stock ownership in Carlsmed and Progenitive Medicine; clinical or research support for the study described from DePuy Synthes and ISSGF; patent holder with K2M; royalties from Stryker and NuVaisve; and support of non–study-related clinical or research effort from ISSG. Dr. Ames: employee of UCSF; consultant for DePuy Synthes, Medtronic, Medicrea, and K2M; royalties from Stryker, Biomet Zimmer Spine, DePuy Synthes, NuVasive, Next Orthosurgical, K2M, Meidcrea; research support form Titan Spine, DePuy Synthes, and ISSG; editorial board of Operative Neurosurgery; grant funding from SRS, executive committee of ISSG, and director of Global Spinal Analytics.

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