Patient-related and radiographic predictors of inferior health-related quality-of-life measures in adult patients with nonoperative spinal deformity

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  • 1 Division of Spinal Surgery, Departments of Orthopaedic Surgery and Neurosurgery, NYU Medical Center, New York Spine Institute, New York, New York;
  • 2 Department of Orthopaedic Surgery, Denver International Spine Center, Denver, Colorado;
  • 3 Department of Orthopedics, Hospital for Special Surgery, New York, New York;
  • 4 Department of Neurological Surgery, University of California, San Francisco, California;
  • 5 Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, Kansas;
  • 6 Department of Orthopaedic Surgery, Washington University, St. Louis, Missouri;
  • 7 Department of Orthopaedic Surgery, Baylor Scoliosis Center, Dallas, Texas;
  • 8 Department of Orthopaedics, Johns Hopkins University School of Medicine, Baltimore, Maryland;
  • 9 Department of Neurosurgery, Oregon Health & Science University, Portland, Oregon;
  • 10 Spine Institute of Louisiana, Shreveport, Louisiana;
  • 11 Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia; and
  • 12 Department of Orthopaedic Surgery, University of California, Davis, California
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OBJECTIVE

Patients with nonoperative (N-Op) adult spinal deformity (ASD) have inferior long-term spinopelvic alignment and clinical outcomes. Predictors of lower quality-of-life measures in N-Op populations have yet to be sufficiently investigated. The aim of this study was to identify patient-related factors and radiographic parameters associated with inferior health-related quality-of-life (HRQOL) scores in N-Op ASD patients.

METHODS

N-Op ASD patients with complete radiographic and outcome data at baseline and 2 years were included. N-Op patients and operative (Op) patients were propensity score matched for baseline disability and deformity. Patient-related factors and radiographic alignment parameters (pelvic tilt [PT], sagittal vertical axis [SVA], pelvic incidence [PI]–lumbar lordosis [LL] mismatch, mismatch between cervical lordosis and T1 segment slope [TS-CL], cervical-thoracic pelvic angle [PA], and others) at baseline and 2 years were analyzed as predictors for moderate to severe 2-year Oswestry Disability Index (ODI > 20) and failing to meet the minimal clinically importance difference (MCID) for 2-year Scoliosis Research Society Outcomes Questionnaire (SRS) scores (< 0.4 increase from baseline). Conditional inference decision trees identified predictors of each HRQOL measure and established cutoffs at which factors have a global effect. Random forest analysis (RFA) generated 5000 conditional inference trees to compute a variable importance table for top predictors of inferior HRQOL. Statistical significance was set at p < 0.05.

RESULTS

Six hundred sixty-two patients with ASD (331 Op patients and 331 N-Op patients) with complete radiographic and HRQOL data at their 2-year follow-up were included. There were no differences in demographics, ODI, and Schwab deformity modifiers between groups at baseline (all p > 0.05). N-Op patients had higher 2-year ODI scores (27.9 vs 20.3, p < 0.001), higher rates of moderate to severe disability (29.3% vs 22.4%, p = 0.05), lower SRS total scores (3.47 vs 3.91, p < 0.001), and higher rates of failure to reach SRS MCID (35.3% vs 15.7%, p < 0.001) than Op patients at 2 years. RFA ranked the top overall predictors for moderate to severe ODI at 2 years for N-Op patients as follows: 1) frailty index > 2.8, 2) BMI > 35 kg/m, T4PA > 28°, and 4) Charlson Comorbidity Index > 1. Top radiographic predictors were T4PA > 28° and C2–S1 SVA > 93 mm. RFA also ranked the top overall predictors for failure to reach 2-year SRS MCID for N-Op patients, as follows: 1) T12–S1 lordosis > 53°, 2) cervical SVA (cSVA) > 28 mm, 3) C2–S1 angle > 14.5°, 4) TS-CL > 12°, and 5) PT > 23°. The top radiographic predictors were T12–S1 Cobb angle, cSVA, C2–S1 angle, and TS-CL.

CONCLUSIONS

When controlling for baseline deformity in N-Op versus Op patients, subsequent deterioration in frailty, BMI, and radiographic progression over a 2-year follow-up were found to drive suboptimal patient-reported outcome measures in N-Op cohorts as measured by validated ODI and SRS clinical instruments.

ABBREVIATIONS ASD = adult spinal deformity; CCI = Charlson Comorbidity Index; cSVA = cervical SVA; EBL = estimated blood loss; HRQOL = health-related quality of life; LL = lumbar lordosis; MCID = minimal clinically importance difference; N-Op = nonoperative; NRS = numeric rating scale; ODI = Oswestry Disability Index; Op = operative; OR = odds ratio; PA = pelvic angle; PI = pelvic incidence; PRO = patient-reported outcome; PSM = propensity score matching; PT = pelvic tilt; RFA = random forest analysis; SRS-22 = Scoliosis Research Society Outcomes Questionnaire; SVA = sagittal vertical axis; TK = thoracic kyphosis; TS-CL = T1 segment slope–cervical lordosis mismatch.

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Contributor Notes

Correspondence Peter G. Passias: New York Spine Institute, NYU Medical Center, Orthopaedic Hospital, New York, NY. peter.passias@nyumc.org.

INCLUDE WHEN CITING Published online April 2, 2021; DOI: 10.3171/2020.9.SPINE20519.

Disclosures Dr. Passias reports personal consulting fees from Terumo, Spine Wave, Zimmer Biomet, DePuy Synthes, and Medicrea; being on the speakers bureau for Zimmer and Globus Medical; clinical or research support for the study from the Cervical Scoliosis Research Society; and other financial or material support from AlloSource. Dr. Bess reports personal consulting fees from Stryker, Mirus, AlloSource, DePuy, EOS, K2M, and Misonix; intellectual property (IP) royalties from K2M, Stryker, and NuVasive; having direct stock ownership in Progenerative Medicine and Carlsmed; research support from Stryker, ISSG Foundation, AlloSource, Biomet, DePuy, EOS, Globus Medical, K2M, Medtronic Sofamor Danek, NuVasive, and Orthofix; support of non–study-related clinical or research effort from DePuy Synthes, Medtronic, Globus, SI Bone, and the ISSG Foundation; and board/committee membership at the North American Spine Society and Scoliosis Research Society. Mr. Line reports being a consultant for the ISSG. Dr. V. Lafage reports being a consultant for Globus Medical, receiving royalties from NuVasive, and honoraria from The Permanente Medical Group, DePuy Synthes, and Implanet. Mr. R. Lafage reports direct stock ownership in Nemaris. Dr. Ames reports receiving royalties from Stryker, Zimmer Biomet Spine, DePuy Synthes, NuVasive, Next Orthosurgical, K2M, and Medicrea; being a consultant to DePuy Synthes, Medtronic, Medicrea, and K2M; receiving research support from Titan Spine, DePuy Synthes, and ISSG; being on the editorial board of Operative Neurosurgery; receiving grant funding from SRS; being on the executive committee of ISSG; and being the director of Global Spinal Analytics. Dr. Burton reports personal consulting fees from DePuy and Bioventus; IP royalties from DePuy; clinical or research support for the study from ISSG; having direct stock ownership in Progenerative Medical; being on the editorial board of Spine Deformity; board/committee membership at the Scoliosis Research Society; and research support from Bioventus, DePuy, and Pfizer. Dr. Kelly reports non–study-related research support from DePuy. Dr. Kebaish reports personal consulting fees from DePuy, Orthofix, and K2M; IP royalties from DePuy, Stryker, and Orthofix; research support from DePuy; and board/committee membership at the Scoliosis Research Society. Dr. Than reports receiving personal consulting fees from Bioventus and DePuy Synthes, and honoraria from LifeNet Health and DJO. Dr. Nunley reports personal consulting fees from Camber Spine, Centinal Spine, Integrity Spine, K2M, Spineology, LDR Spine, and Vertiflex; IP royalties from Camber Spine, Integrity Spine, K2M, and LDR Spine; stock ownership in Camber Spine, Amedica, Paradigm Spine, and Spineology; and research support from Mesoblast, Organogenesis, Orthofix, Pfizer, Simplify, Spinal Kinetics, Spineology, and K2M. Dr. Shaffrey reports personal consulting fees from Biomet Spine, Medtronic, NuVasive, and Stryker; IP royalties from Medtronic, NuVasive, and Zimmer Biomet; stock ownership in NuVasive; being on the board of directors at Spine Deformity; board membership of the AANS, Cervical Spine Research Society, and Spine; clinical or research support for the study described from the ISSG Foundation; and research support from DePuy, Globus Medical, Medtronic, and Neurosurgery RBC. Dr. Klineberg reports personal consulting fees from DePuy, Stryker, AO Spine, Medtronic/Medicrea, and K2M; and research support and honoraria from AO Spine. Dr. Smith reports personal consulting fees from Zimmer Biomet, NuVasive, Stryker, DePuy Synthes, Carlsmed, K2M, AlloSource, and Cerapedics; IP royalties from Zimmer Biomet and NuVasive; support of non–study-related clinical or research effort from DePuy Synthes, ISSG, and AO Spine; fellowship funding from the NREF and AO Spine; stock ownership in Alphatec; clinical or research support for the study from DePuy Synthes/ISSG; and board membership at the Cervical Spine Research Society, Neurosurgery, and Operative Neurosurgery. Dr. Schwab reports being a consultant for Globus Medical, K2M, and Zimmer Biomet; receiving royalties from Medicrea, Medtronic, and Zimmer Biomet; and being on the executive committee of ISSG.

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