Perioperative outcomes associated with thoracolumbar 3-column osteotomies for adult spinal deformity patients with rheumatoid arthritis

OBJECTIVESpinal deformity causing spinal imbalance is directly correlated to pain and disability. Prior studies suggest adult spinal deformity (ASD) patients with rheumatoid arthritis (RA) have more complex deformities and are at higher risk for complications. In this study the authors compared outcomes of ASD patients with RA following thoracolumbar 3-column osteotomies to outcomes of a matched control cohort.METHODSAll patients with RA who underwent 3-column osteotomy for thoracolumbar deformity correction performed by the senior author from 2006 to 2016 were identified retrospectively. A cohort of patients without RA who underwent 3-column osteotomies for deformity correction was matched based on multiple clinical factors. Data regarding demographics and surgical approach, along with endpoints including perioperative outcomes, reoperations, and incidence of proximal junctional kyphosis (PJK) were reviewed. Univariate analyses were used to compare patients with RA to matched controls.RESULTSEighteen ASD patients with RA were identified, and a matched cohort of 217 patients was generated. With regard to patients with RA, 11.1% were male and the mean age was 68.1 years. Vertebral column resection (VCR) was performed in 22.2% and pedicle subtraction osteotomy (PSO) in 77.8% of patients. Mean case length was 324.4 minutes and estimated blood loss (EBL) was 2053.6 ml. Complications were observed in 38.9% of patients with RA and 29.0% of patients without RA (p = 0.380), with a trend toward increased medical complications (38.9% vs 21.2%, p = 0.084). Patients with RA had a significantly higher incidence of deep vein thrombosis (DVT)/pulmonary embolism (PE) (11.1% vs 1.8%, p = 0.017) and wound infections (16.7% vs 5.1%, p = 0.046). PJK occurred in 16.7% of patients with RA, and 33.3% of RA patients underwent reoperation. Incidence rates of PJK and reoperation in matched controls were 12.9% and 25.3%, respectively (p = 0.373, p = 0.458). At follow-up, mean sagittal vertical axis (SVA) was 6.1 cm in patients with RA and 4.5 cm in matched controls (p = 0.206).CONCLUSIONSFindings from this study suggest that RA patients experience a higher incidence of medical complications, specifically DVT/PE. Preoperative lower-extremity ultrasounds, inferior vena cava (IVC) filter placement, and/or early initiation of DVT prophylaxis in RA patients may be indicated. Perioperative complications, morbidity, and long-term outcomes are otherwise similar to non-RA patients.

Download Full-text

Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery

Journal of Neurosurgery Spine ◽

10.3171/2015.11.spine151036 ◽

2016 ◽

Vol 25 (1) ◽

pp. 1-14 ◽

Cited By ~ 130

Author(s):

Justin S. Smith ◽

Eric Klineberg ◽

Virginie Lafage ◽

Christopher I. Shaffrey ◽

Frank Schwab ◽

...

Keyword(s):

Patient Care ◽

Spinal Deformity ◽

Perioperative Complications ◽

Adult Spinal Deformity ◽

Vena Cava ◽

Complication Rates ◽

Inclusion Criteria ◽

Patient Counseling ◽

Delayed Complications

OBJECTIVE Although multiple reports have documented significant benefit from surgical treatment of adult spinal deformity (ASD), these procedures can have high complication rates. Previously reported complications rates associated with ASD surgery are limited by retrospective design, single-surgeon or single-center cohorts, lack of rigorous data on complications, and/or limited follow-up. Accurate definition of complications associated with ASD surgery is important and may serve as a resource for patient counseling and efforts to improve the safety of patient care. The authors conducted a study to prospectively assess the rates of complications associated with ASD surgery with a minimum 2-year follow-up based on a multicenter study design that incorporated standardized data-collection forms, on-site study coordinators, and regular auditing of data to help ensure complete and accurate reporting of complications. In addition, they report age stratification of complication rates and provide a general assessment of factors that may be associated with the occurrence of complications. METHODS As part of a prospective, multicenter ASD database, standardized forms were used to collect data on surgery-related complications. On-site coordinators and central auditing helped ensure complete capture of complication data. Inclusion criteria were age older than 18 years, ASD, and plan for operative treatment. Complications were classified as perioperative (within 6 weeks of surgery) or delayed (between 6 weeks after surgery and time of last follow-up), and as minor or major. The primary focus for analyses was on patients who reached a minimum follow-up of 2 years. RESULTS Of 346 patients who met the inclusion criteria, 291 (84%) had a minimum 2-year follow-up (mean 2.1 years); their mean age was 56.2 years. The vast majority (99%) had treatment including a posterior procedure, 25% had an anterior procedure, and 19% had a 3-column osteotomy. At least 1 revision was required in 82 patients (28.2%). A total of 270 perioperative complications (145 minor; 125 major) were reported, with 152 patients (52.2%) affected, and a total of 199 delayed complications (62 minor; 137 major) were reported, with 124 patients (42.6%) affected. Overall, 469 complications (207 minor; 262 major) were documented, with 203 patients (69.8%) affected. The most common complication categories included implant related, radiographic, neurological, operative, cardiopulmonary, and infection. Higher complication rates were associated with older age (p = 0.009), greater body mass index (p ≤ 0.031), increased comorbidities (p ≤ 0.007), previous spine fusion (p = 0.029), and 3-column osteotomies (p = 0.036). Cases in which 2-year follow-up was not achieved included 2 perioperative mortalities (pulmonary embolus and inferior vena cava injury). CONCLUSIONS This study provides an assessment of complications associated with ASD surgery based on a prospective, multicenter design and with a minimum 2-year follow-up. Although the overall complication rates were high, in interpreting these findings, it is important to recognize that not all complications are equally impactful. This study represents one of the most complete and detailed reports of perioperative and delayed complications associated with ASD surgery to date. These findings may prove useful for treatment planning, patient counseling, benchmarking of complication rates, and efforts to improve the safety and cost-effectiveness of patient care.

Download Full-text

Classifying Complications: Assessing Adult Spinal Deformity 2-Year Surgical Outcomes

Global Spine Journal ◽

10.1177/2192568220937473 ◽

2020 ◽

Vol 10 (7) ◽

pp. 896-907

Author(s):

Eric O. Klineberg ◽

Peter G. Passias ◽

Gregory W. Poorman ◽

Cyrus M. Jalai ◽

Abiola Atanda ◽

...

Keyword(s):

Postoperative Complications ◽

Postoperative Complication ◽

Spinal Deformity ◽

Surgical Outcomes ◽

Perioperative Complications ◽

Adult Spinal Deformity ◽

Complication Rates ◽

Estimated Blood Loss ◽

Patient Reported ◽

The Impact

Study Design: Retrospective review of prospective database. Objective: Complication rates for adult spinal deformity (ASD) surgery vary widely because there is no accepted system for categorization. Our objective was to identify the impact of complication occurrence, minor-major complication, and Clavien-Dindo complication classification (Cc) on clinical variables and patient-reported outcomes. Methods: Complications in surgical ASD patients with complete baseline and 2-year data were considered intraoperatively, perioperatively (<6 weeks), and postoperatively (>6 weeks). Primary outcome measures were complication timing and severity according to 3 scales: complication presence (yes/no), minor-major, and Cc score. Secondary outcomes were surgical outcomes (estimated blood loss [EBL], length of stay [LOS], reoperation) and health-related quality of life (HRQL) scores. Univariate analyses determined complication presence, type, and Cc grade impact on operative variables and on HRQL scores. Results: Of 167 patients, 30.5% (n = 51) had intraoperative, 48.5% (n = 81) had perioperative, and 58.7% (n = 98) had postoperative complications. Major intraoperative complications were associated with increased EBL ( P < .001) and LOS ( P = .0092). Postoperative complication presence and major postoperative complication were associated with reoperation ( P < .001). At 2 years, major perioperative complications were associated with worse ODI, SF-36, and SRS activity and appearance scores ( P < .02). Increasing perioperative Cc score and postoperative complication presence were the best predictors of worse HRQL outcomes ( P < .05). Conclusion: The Cc Scale was most useful in predicting changes in patient outcomes; at 2 years, patients with raised perioperative Cc scores and postoperative complications saw reduced HRQL improvement. Intraoperative and perioperative complications were associated with worse short-term surgical and inpatient outcomes.

Download Full-text

Intracranial pressure monitoring during adult spinal deformity correction in a patient with critical venous occlusive disease and superior vena cava syndrome: A technical note

Surgical Neurology International ◽

10.4103/2152-7806.180771 ◽

2016 ◽

Vol 7 (1) ◽

pp. 47

Author(s):

DKojo Hamilton ◽

Alp Ozpinar ◽

JesseJ Liu ◽

ZacharyJ Tempel ◽

PhillipA Choi ◽

...

Keyword(s):

Intracranial Pressure ◽

Spinal Deformity ◽

Superior Vena Cava Syndrome ◽

Superior Vena ◽

Adult Spinal Deformity ◽

Vena Cava ◽

Deformity Correction ◽

Technical Note ◽

Pressure Monitoring ◽

Vena Cava Syndrome

Download Full-text

Evaluation of complications and neurological deficits with three-column spine reconstructions for complex spinal deformity: a retrospective Scoli-RISK-1 study

Neurosurgical FOCUS ◽

10.3171/2014.2.focus1419 ◽

2014 ◽

Vol 36 (5) ◽

pp. E17 ◽

Cited By ~ 50

Author(s):

Michael P. Kelly ◽

Lawrence G. Lenke ◽

Christopher I. Shaffrey ◽

Christopher P. Ames ◽

Leah Y. Carreon ◽

...

Keyword(s):

Risk Factors ◽

Blood Loss ◽

Spinal Deformity ◽

Perioperative Complications ◽

Neurological Deficits ◽

Neurological Injury ◽

Medical Complications ◽

Medical Complication ◽

Estimated Blood Loss ◽

Surgical Data

Object The goal in this study was to evaluate the risk factors for complications, including new neurological deficits, in the largest cohort of patients with adult spinal deformity to date. Methods The Scoli-RISK-1 inclusion criteria were used to identify eligible patients from 5 centers who were treated between June 1, 2009, and June 1, 2011. Records were reviewed for patient demographic information, surgical data, and reports of perioperative complications. Neurological deficits were recorded as preexisting or as new deficits. Patients who underwent 3-column osteotomies (3COs) were compared with those who did not (posterior spinal fusion [PSF]). Between-group comparisons were performed using independent samples t-tests and chi-square analyses. Results Two hundred seven patients were identified—75 who underwent PSF and 132 treated with 3CO. In the latter group, patients were older (58.9 vs 49.4 years, p < 0.001), had a higher body mass index (29.0 vs 25.8, p = 0.029), smaller preoperative coronal Cobb measurements (33.8° vs 56.4°, p < 0.001), more preoperative sagittal malalignment (11.7 cm vs 5.4 cm, p < 0.001), and similar sagittal Cobb measurements (45.8° vs 57.7°, p = 0.113). Operating times were similar (393 vs 423 minutes, p = 0.130), although patients in the 3CO group sustained higher estimated blood loss (2120 vs 1700 ml, p = 0.066). Rates of new neurological deficits were similar (PSF: 6.7% vs 3CO: 9.9%, p = 0.389), and rates of any perioperative medical complication were similar (PSF: 46.7% vs 3CO: 50.8%, p = 0.571). Patients who underwent vertebral column resection (VCR) were more likely to sustain medical complications than those treated with pedicle subtraction osteotomy (73.7% vs 46.9%, p = 0.031), although new neurological deficits were similar (15.8% vs 8.8%, p = 0.348). Regression analysis did not reveal significant predictors of neurological injury or complication from collected data. Conclusions Despite higher estimated blood loss, rates of all complications (49.3%) and new neurological deficits (8.7%) did not vary for patients who underwent complex reconstruction, whether or not a 3CO was performed. Patients who underwent VCR sustained more medical complications without an increase in new neurological deficits. Prospective studies of patient factors, provider factors, and refined surgical data are needed to define and optimize risk factors for complication and neurological deficits.

Download Full-text

P.089 A comparison of perioperative complication rates in adult spinal deformity correction with one versus two surgeons

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2017.173 ◽

2017 ◽

Vol 44 (S2) ◽

pp. S36-S36

Author(s):

K Parvez ◽

J Hsu ◽

Z Ivanishvilli ◽

S Boisvert ◽

M Warren ◽

...

Keyword(s):

Blood Loss ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Radicular Pain ◽

Complication Rates ◽

Perioperative Morbidity ◽

Hardware Failure ◽

Estimated Blood Loss ◽

One Year

Background: Morbidity can be high in the management of adult spinal deformity patients. Complications include blood loss (EBL), durotomy, radicular pain, and postoperative hardware failure. Utilization of one versus two spinal surgeons in spinal deformity correction reduces overall perioperative morbidity is unclear. Methods: All procedures were performed by surgeons at a single institution between January 2012-2015. Patients were followed for a minimum of one year and maximum of four years. We retrospectively reviewed 60 cases of adult spinal deformity. Our cohort was divided into 1 versus 2 surgeons (12 vs 48 cases). We analyzed these cases for estimated blood loss and peri-operative complications. Results: Cases involving long thoracic to pelvis correction (T3-T6) was 20.8% in the 2 surgeons group and 8.3% in the 1 surgeon group. The EBL >3.0 L for 1 versus 2 surgeon groups were 25% and 41.6% respectively. Major complications in the 1 versus 2 surgeon group were 25% and 47.9% and the revision rates were 25% versus 37.5%. The percentage of minor complications in the 1 versus 2 surgeon group was 33.3% versus 14.6%. Conclusions: Utilizing two surgeons did not reduce complication rates. Procedures performed by two surgeons were more extensive deformity corrections. The extent of correction is the likely explanation for differing complication rates.

Download Full-text

Instrumentation techniques to prevent proximal junctional kyphosis and proximal junctional failure in adult spinal deformity correction—a systematic review of biomechanical studies

The Spine Journal ◽

10.1016/j.spinee.2021.01.011 ◽

2021 ◽

Author(s):

Remco J.P. Doodkorte ◽

Timon F.G. Vercoulen ◽

Alex K. Roth ◽

Rob A. de Bie ◽

Paul C. Willems

Keyword(s):

Systematic Review ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Proximal Junctional Kyphosis ◽

Proximal Junctional Failure ◽

Junctional Kyphosis

Download Full-text

Predictors of Serious, Preventable, and Costly Medical Complications in a Population of Adult Spinal Deformity Patients

The Spine Journal ◽

10.1016/j.spinee.2021.04.020 ◽

2021 ◽

Author(s):

Haddy Alas ◽

Peter G Passias ◽

Avery E Brown ◽

Katherine E Pierce ◽

Cole Bortz ◽

...

Keyword(s):

Spinal Deformity ◽

Adult Spinal Deformity ◽

Medical Complications

Download Full-text

Fluctuations in Spinal Cord Perfusion During Adult Spinal Deformity Correction Identify Neurologic Changes: Proof of Concept

World Neurosurgery ◽

10.1016/j.wneu.2015.08.067 ◽

2016 ◽

Vol 85 ◽

pp. 365.e1-365.e6 ◽

Cited By ~ 5

Author(s):

Jay D. Turner ◽

Robert K. Eastlack ◽

Zaman Mirzadeh ◽

Stacie Nguyen ◽

Jeff Pawelek ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Deformity ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Proof Of Concept

Download Full-text

Strategies for prevention of rod fracture in adult spinal deformity: cobalt chrome rod, accessory rod technique, and lateral lumbar interbody fusion

Journal of Neurosurgery Spine ◽

10.3171/2020.8.spine201037 ◽

2021 ◽

pp. 1-10

Author(s):

Ki Young Lee ◽

Jung-Hee Lee ◽

Kyung-Chung Kang ◽

Sang-Kyu Im ◽

Hae Seong Lim ◽

...

Keyword(s):

Spinal Deformity ◽

Interbody Fusion ◽

Sagittal Alignment ◽

Adult Spinal Deformity ◽

Deformity Correction ◽

Lumbar Interbody Fusion ◽

Patient Factors ◽

Rod Fracture ◽

Cobalt Chrome

OBJECTIVERestoring the proper sagittal alignment in adult spinal deformity (ASD) can improve radiological and clinical outcomes, but pseudarthrosis including rod fracture (RF) is a common problematic complication. The purpose of this study was to analyze the methods for reducing the incidence of RF in deformity correction of ASD.METHODSThe authors retrospectively selected 178 consecutive patients (mean age 70.8 years) with lumbar degenerative kyphosis (LDK) who underwent deformity correction with a minimum 2-year follow-up. Patients were classified into the non-RF group (n = 131) and the RF group (n = 47). For predicting the crucial factors of RF, patient factors, radiographic parameters, and surgical factors were analyzed.RESULTSThe overall incidence of RF was 26% (47/178 cases), occurring in 42% (42/100 cases) of pedicle subtraction osteotomy (PSO), 7% (5/67 cases) of lateral lumbar interbody fusion (LLIF) with posterior column osteotomy, 18% (23/129 cases) of cobalt chrome rods, 49% (24/49 cases) of titanium alloy rods, 6% (2/36 cases) placed with the accessory rod technique, and 32% (45/142 cases) placed with the 2-rod technique. There were no significant differences in the incidence of RF regarding patient factors between two groups. While both groups showed severe sagittal imbalance before operation, lumbar lordosis (LL) was more kyphotic and pelvic incidence (PI) minus LL (PI-LL) mismatch was greater in the RF group (p < 0.05). Postoperatively, while LL and PI-LL did not show significant differences between the two groups, LL and sagittal vertical axis correction were greater in the RF group (p < 0.05). Nonetheless, at the last follow-up, the two groups did not show significant differences in radiographic parameters except thoracolumbar junctional angles. As for surgical factors, use of the cobalt chrome rod and the accessory rod technique was significantly greater in the non-RF group (p < 0.05). As for the correction method, PSO was associated with more RFs than the other correction methods, including LLIF (p < 0.05). By logistic regression analysis, PSO, preoperative PI-LL mismatch, and the accessory rod technique were crucial factors for RF.CONCLUSIONSGreater preoperative sagittal spinopelvic malalignment including preoperative PI-LL mismatch was the crucial risk factor for RF in LDK patients 65 years or older. For restoring and maintaining sagittal alignment, use of the cobalt chrome rod, accessory rod technique, or LLIF was shown to be effective for reducing RF in ASD surgery.

Download Full-text