Results of the AANS membership survey of adult spinal deformity knowledge: impact of training, practice experience, and assessment of potential areas for improved education

Object Adult spinal deformity (ASD) surgery is increasing in the spinal neurosurgeon's practice. Methods A survey of neurosurgeon AANS membership assessed the deformity knowledge base and impact of current training, education, and practice experience to identify opportunities for improved education. Eleven questions developed and agreed upon by experienced spinal deformity surgeons tested ASD knowledge and were subgrouped into 5 categories: 1) radiology/spinopelvic alignment, 2) health-related quality of life, 3) surgical indications, 4) operative technique, and 5) clinical evaluation. Chi-square analysis was used to compare differences based on participant demographic characteristics (years of practice, spinal surgery fellowship training, percentage of practice comprising spinal surgery). Results Responses were received from 1456 neurosurgeons. Of these respondents, 57% had practiced less than 10 years, 20% had completed a spine fellowship, and 32% devoted more than 75% of their practice to spine. The overall correct answer percentage was 42%. Radiology/spinal pelvic alignment questions had the lowest percentage of correct answers (38%), while clinical evaluation and surgical indications questions had the highest percentage (44%). More than 10 years in practice, completion of a spine fellowship, and more than 75% spine practice were associated with greater overall percentage correct (p < 0.001). More than 10 years in practice was significantly associated with increased percentage of correct answers in 4 of 5 categories. Spine fellowship and more than 75% spine practice were significantly associated with increased percentage correct in all categories. Interestingly, the highest error was seen in risk for postoperative coronal imbalance, with a very low rate of correct responses (15%) and not significantly improved with fellowship (18%, p = 0.08). Conclusions The results of this survey suggest that ASD knowledge could be improved in neurosurgery. Knowledge may be augmented with neurosurgical experience, spinal surgery fellowships, and spinal specialization. Neurosurgical education should particularly focus on radiology/spinal pelvic alignment, especially pelvic obliquity and coronal imbalance and operative techniques for ASD.

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Results of the AANS Membership Survey of Adult Spinal Deformity Knowledge: Impact of Training, Practice Experience and Assessment of Potential Areas for Improved Education

The Spine Journal ◽

10.1016/j.spinee.2013.07.093 ◽

2013 ◽

Vol 13 (9) ◽

pp. S25-S26

Author(s):

Aaron Clark ◽

Christopher P. Ames ◽

Malla Keefe ◽

Tyler R. Koski ◽

Michael K. Rosner ◽

...

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

Practice Experience ◽

Training Practice

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Minimally Invasive Spinal Surgery for Adult Spinal Deformity

Neurospine ◽

10.14245/ns.1836022.011 ◽

2018 ◽

Vol 15 (1) ◽

pp. 18-24 ◽

Cited By ~ 18

Author(s):

Junseok Bae ◽

Sang-Ho Lee

Keyword(s):

Minimally Invasive ◽

Spinal Deformity ◽

Spinal Surgery ◽

Adult Spinal Deformity ◽

Minimally Invasive Spinal Surgery

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Can a Minimal Clinically Important Difference Be Achieved in Elderly Patients with Adult Spinal Deformity Who Undergo Minimally Invasive Spinal Surgery?

World Neurosurgery ◽

10.1016/j.wneu.2015.09.072 ◽

2016 ◽

Vol 86 ◽

pp. 168-172 ◽

Cited By ~ 19

Author(s):

Paul Park ◽

David O. Okonkwo ◽

Stacie Nguyen ◽

Gregory M. Mundis ◽

Khoi D. Than ◽

...

Keyword(s):

Minimally Invasive ◽

Elderly Patients ◽

Spinal Deformity ◽

Spinal Surgery ◽

Minimal Clinically Important Difference ◽

Adult Spinal Deformity ◽

Minimally Invasive Spinal Surgery ◽

Clinically Important Difference

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Incidence of Acute, Progressive, and Delayed Proximal Junctional Kyphosis Over an 8-Year Period in Adult Spinal Deformity Patients

Operative Neurosurgery ◽

10.1093/ons/opz128 ◽

2019 ◽

Vol 18 (1) ◽

pp. 75-82 ◽

Cited By ~ 5

Author(s):

Frank A Segreto ◽

Peter G Passias ◽

Renaud Lafage ◽

Virginie Lafage ◽

Justin S Smith ◽

...

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

Management Strategies ◽

Progressive Increase ◽

Small Sample ◽

Annual Incidence ◽

Proximal Junctional Kyphosis ◽

Chi Square Analysis ◽

Junctional Kyphosis

Abstract BACKGROUND Proximal junctional kyphosis (PJK) is a common radiographic complication of adult spinal deformity (ASD) corrective surgery. Although previous literature has reported a 5 to 61% incidence of PJK, these studies are limited by small sample sizes and short-term follow-up. OBJECTIVE To assess the incidence of PJK utilizing a high-powered ASD database. METHODS Retrospective review of a prospective multicenter ASD database. Operative ASD patients > 18 yr old from 2009 to 2017 were included. PJK was defined as ≥ 10° for the sagittal Cobb angle between the inferior upper instrumented vertebra (UIV) endplate and the superior endplate of the UIV + 2. Chi-square analysis and post hoc testing assessed annual and overall incidence of acute (6-wk follow-up [f/u]), progressive (increase in degree of PJK from 6 wk to 1 yr), and delayed (1-yr, 2-yr, and 3-yr f/u) PJK development. RESULTS A total of 1005 patients were included (age: 59.3; 73.5% F; body mass index: 27.99). Overall PJK incidence was 69.4%. Overall incidence of acute PJK was 48.0%. Annual incidence of acute PJK has decreased from 53.7% in 2012 to 31.6% in 2017 (P = .038). Overall incidence of progressive PJK was 35.0%, with stable rates observed from 2009 to 2016 (P = .297). Overall incidence of 1-yr-delayed PJK was 9.3%. Annual incidence of 1-yr-delayed PJK has decreased from 9.2% in 2009 to 3.2% in 2016 (P < .001). Overall incidence of 2-yr-delayed PJK development was 4.3%. Annual incidence of 2-yr-delayed PJK has decreased from 7.3% in 2009 to 0.9% in 2015 (P < .05). Overall incidence of 3-yr-delayed PJK was 1.8%, with stable rates observed from 2009 to 2014 (P = .594). CONCLUSION Although progressive PJK has remained a challenge for physicians over time, significantly lower incidences of acute and delayed PJK in recent years may indicate improving operative decision-making and management strategies.

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Asymmetric Pedicle Subtraction Osteotomy for Adult Spinal Deformity with Coronal Imbalance: Complications, Radiographic and Surgical Outcomes

Operative Neurosurgery ◽

10.1093/ons/opz106 ◽

2019 ◽

Cited By ~ 1

Author(s):

Andrew K Chan ◽

Darryl Lau ◽

Joseph A Osorio ◽

John K Yue ◽

Sigurd H Berven ◽

...

Keyword(s):

Spinal Deformity ◽

Surgical Outcomes ◽

Adult Spinal Deformity ◽

Pedicle Subtraction Osteotomy ◽

Coronal Imbalance

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Adult Spinal Deformity Knowledge in Orthopedic Spine Surgeons: Impact of Fellowship Training, Experience, and Practice Characteristics

Spine Deformity ◽

10.1016/j.jspd.2017.06.003 ◽

2018 ◽

Vol 6 (1) ◽

pp. 60-66 ◽

Cited By ~ 2

Author(s):

Zachary J. Grabel ◽

Robert A. Hart ◽

Aaron J. Clark ◽

Sara Heejung Park ◽

Christopher I. Shaffrey ◽

...

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

Fellowship Training ◽

Training Experience ◽

Practice Characteristics

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Does the Global Alignment and Proportion score overestimate mechanical complications after adult spinal deformity correction?

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20538 ◽

2021 ◽

Vol 34 (1) ◽

pp. 96-102

Author(s):

Griffin R. Baum ◽

Alex S. Ha ◽

Meghan Cerpa ◽

Scott L. Zuckerman ◽

James D. Lin ◽

...

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

External Validation ◽

Global Alignment ◽

Mechanical Complication ◽

Complication Rates ◽

Mechanical Complications ◽

Significant Difference ◽

Chi Square Analysis

OBJECTIVEThe goal of this study was to validate the Global Alignment and Proportion (GAP) score in a cohort of patients undergoing adult spinal deformity (ASD) surgery. The GAP score is a novel measure that uses sagittal parameters relative to each patient’s lumbosacral anatomy to predict mechanical complications after ASD surgery. External validation is required.METHODSAdult ASD patients undergoing > 4 levels of posterior fusion with a minimum 2-year follow-up were included. Six-week postoperative standing radiographs were used to calculate the GAP score, classified into a spinopelvic state as proportioned (P), moderately disproportioned (MD), or severely disproportioned (SD). A chi-square analysis, receiver operating characteristic curve, and Cochran-Armitage analysis were performed to assess the relationship between the GAP score and mechanical complications.RESULTSSixty-seven patients with a mean age of 52.5 years (range 18–75 years) and a mean follow-up of 2.04 years were included. Patients with < 2 years of follow-up were included only if they had an early mechanical complication. Twenty of 67 patients (29.8%) had a mechanical complication. The spinopelvic state breakdown was as follows: P group, 21/67 (31.3%); MD group, 23/67 (34.3%); and SD group, 23/67 (34.3%). Mechanical complication rates were not significantly different among all groups: P group, 19.0%; MD group, 30.3%; and SD group, 39.1% (χ2 = 1.70, p = 0.19). The rates of mechanical complications between the MD and SD groups (30.4% and 39.1%) were less than those observed in the original GAP study (MD group 36.4%–57.1% and SD group 72.7%–100%). Within the P group, the rates in this study were higher than in the original study (19.0% vs 4.0%, respectively).CONCLUSIONSThe authors found no statistically significant difference in the rate of mechanical complications between the P, MD, and SD groups. The current validation study revealed poor generalizability toward the authors’ patient population.

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Impact of an intraoperative coronal spinal alignment measurement technique using a navigational tool for a 3D spinal rod bending system in adult spinal deformity cases

Journal of Neurosurgery Spine ◽

10.3171/2021.3.spine201856 ◽

2021 ◽

pp. 1-9

Author(s):

Masanari Takami ◽

Ryo Taiji ◽

Shunji Tsutsui ◽

Hiroshi Iwasaki ◽

Motohiro Okada ◽

...

Keyword(s):

Radiation Exposure ◽

Measurement Technique ◽

Spinal Deformity ◽

Spinal Surgery ◽

Adult Spinal Deformity ◽

Plumb Line ◽

Spinal Alignment ◽

Coronal Alignment ◽

Absolute Value ◽

Navigational Tool

OBJECTIVE In corrective spinal surgery for adult spinal deformity (ASD), the focus has been on achieving optimal spinopelvic alignment. However, the correction of coronal spinal alignment is equally important. The conventional intraoperative measurement methods currently used for coronal alignment are not ideal. Here, the authors have developed a new intraoperative coronal alignment measurement technique using a navigational tool for a 3D spinal rod bending system (CAMNBS). The purpose of this study was to test the feasibility of using the CAMNBS for coronal spinal alignment and to evaluate its usefulness in corrective spinal surgery for ASD. METHODS In this retrospective cohort study, patients with degenerative lumbar kyphoscoliosis, a Cobb angle ≥ 20°, and lumbar lordosis ≤ 20° who had undergone corrective surgery (n = 67) were included. The pelvic teardrops on both sides, the S1 spinous process, the central point of the apex, a point on the 30-mm cranial (or caudal) side of the apex, and the central point of the upper instrumented vertebra (UIV) and C7 vertebra were registered using the CAMNBS. The positional information of all registered points was displayed as 2D figures on a monitor. Deviation of the UIV plumb line from the central sacral vertical line (UIV-CSVL) and deviation of the C7 plumb line from the CSVL (C7-CSVL) were measured using the 2D figures. Nineteen patients evaluated using the CAMNBS (BS group) were compared with 48 patients evaluated using conventional intraoperative radiography (XR group). The UIV-CSVL measured intraoperatively using the CAMNBS was compared with that measured using postoperative radiography. The prevalence of postoperative coronal malalignment (CM) and the absolute value of postoperative C7-CSVL were compared between the groups on radiographs obtained in the standing position within 4 weeks after surgery. Postoperative CM was defined as the absolute value of C7-CSVL ≥ 30 mm. Further, the measurement time and amount of radiation exposure were measured. RESULTS No significant differences in demographic, sagittal, and coronal parameters were observed between the two groups. UIV-CSVL was 2.3 ± 9.5 mm with the CAMNBS and 1.8 ± 16.6 mm with the radiographs, showing no significant difference between the two methods (p = 0.92). The prevalence of CM was 2/19 (10.5%) in the BS group and 18/48 (37.5%) in the XR group, and absolute values of C7-CSVL were 15.2 ± 13.1 mm in the BS group and 25.0 ± 18.0 mm in the XR group, showing statistically significant differences in both comparisons (p = 0.04 and 0.03, respectively). The CAMNBS method required 3.5 ± 0.9 minutes, while the conventional radiograph method required 13.3 ± 1.5 minutes; radiation exposure was 2.1 ± 1.1 mGy in the BS group and 2.9 ± 0.6 mGy in the XR group. Statistically significant differences were demonstrated in both comparisons (p = 0.0002 and 0.03, respectively). CONCLUSIONS From this study, it was evident that the CAMNBS did not increase postoperative CM compared with that seen using the conventional radiographic method, and hence can be used in clinical practice.

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Risk Factors for Postoperative Coronal Balance in Adult Spinal Deformity Surgery

Global Spine Journal ◽

10.1177/2192568218764904 ◽

2018 ◽

Vol 8 (7) ◽

pp. 690-697 ◽

Cited By ~ 12

Author(s):

Stephen J. Lewis ◽

Sam G. Keshen ◽

So Kato ◽

Taylor E. Dear ◽

Aaron M. Gazendam

Keyword(s):

Spinal Deformity ◽

Statistical Tests ◽

Adult Spinal Deformity ◽

Vertical Axis ◽

Retrospective Case ◽

Sagittal Vertical Axis ◽

Coronal Balance ◽

Coronal Imbalance ◽

Small Series ◽

Spinal Deformity Surgery

Study Design: A retrospective case-control study. Objectives: To determine factors influencing the ability to achieve coronal balance following spinal deformity surgery. Methods: Following institutional ethics approval, the radiographs of 47 patients treated for spinal deformity surgery with long fusions to the pelvis, were retrospectively reviewed. The postoperative measurements included coronal balance, L4 tilt, and L5 tilt, levels fused, apical vertebral translation and maximum Cobb angle. L4 and L5 tilt angles were measured between the superior endplate and the horizontal. Sagittal parameters including thoracic kyphosis, lumbar lordosis, pelvic incidence, and sagittal vertical axis were recorded. Coronal balance was defined as the distance between the central sacral line and the mid body of C7 being ≤40 mm. Surgical factors, including levels fused, use of iliac fixation with and without connectors, use of S2A1 screws, interbody devices, and osteotomies. Statistical tests were performed to determine factors that contribute to postoperative coronal imbalance. Results: Of the 47 patients reviewed, 32 were balanced after surgery and 14 were imbalanced. Coronal balance was 1.30 cm from center in the balanced group compared to 4.83 cm in the imbalanced group ( P < .01). Both L4 and L5 tilt were statistically different between the groups. Gender and the use of transverse connectors differed between the groups but not statistically. Conclusions: In adult spinal deformity patients undergoing primary fusions to the pelvis, the ability to level the coronal tilt of L4 and L5 had the greatest impact on the ability to achieve coronal balance in this small series. A larger prospective series can help validate this important finding.

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