Incidence and risk factors of iatrogenic coronal malalignment after adult spinal deformity surgery: a single-center experience

2021 ◽  
pp. 1-10
Author(s):  
Scott L. Zuckerman ◽  
Christopher S. Lai ◽  
Yong Shen ◽  
Nathan J. Lee ◽  
Mena G. Kerolus ◽  
...  
Keyword(s):  
Risk Factors ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Vertical Axis ◽  
Pelvic Obliquity ◽  
Major Complications ◽  
Patient Reported ◽  
Sagittal Malalignment ◽  
The Mean ◽  
Coronal Malalignment

OBJECTIVE The authors’ objectives were: 1) to evaluate the incidence and risk factors of iatrogenic coronal malalignment (CM), and 2) to assess the outcomes of patients with all three types of postoperative CM (iatrogenic vs unchanged/worsened vs improved but persistent). METHODS A single-institution, retrospective cohort study was performed on adult spinal deformity (ASD) patients who underwent > 6-level fusion from 2015 to 2019. Iatrogenic CM was defined as immediate postoperative C7 coronal vertical axis (CVA) ≥ 3 cm in patients with preoperative CVA < 3 cm. Additional subcategories of postoperative CM were unchanged/worsened CM, which was defined as immediate postoperative CVA within 0.5 cm of or worse than preoperative CVA, and improved but persistent CM, which was defined as immediate postoperative CVA that was at least 0.5 cm better than preoperative CVA but still ≥ 3 cm; both groups included only patients with preoperative CM. Immediate postoperative radiographs were obtained when the patient was discharged from the hospital after surgery. Demographic, radiographic, and operative variables were collected. Outcomes included major complications, readmissions, reoperations, and patient-reported outcomes (PROs). The t-test, Kruskal-Wallis test, and univariate logistic regression were performed for statistical analysis. RESULTS In this study, 243 patients were included, and the mean ± SD age was 49.3 ± 18.3 years and the mean number of instrumented levels was 13.5 ± 3.9. The mean preoperative CVA was 2.9 ± 2.7 cm. Of 153/243 patients without preoperative CM (CVA < 3 cm), 13/153 (8.5%) had postoperative iatrogenic CM. In total, 43/243 patients (17.7%) had postoperative CM: iatrogenic CM (13/43 [30.2%]), unchanged/worsened CM (19/43 [44.2%]), and improved but persistent CM (11/43 [25.6%]). Significant risk factors associated with iatrogenic CM were anxiety/depression (OR 3.54, p = 0.04), greater preoperative sagittal vertical axis (SVA) (OR 1.13, p = 0.007), greater preoperative pelvic obliquity (OR 1.41, p = 0.019), lumbosacral fractional (LSF) curve concavity to the same side of the CVA (OR 11.67, p = 0.020), maximum Cobb concavity opposite the CVA (OR 3.85, p = 0.048), and three-column osteotomy (OR 4.34, p = 0.028). In total, 12/13 (92%) iatrogenic CM patients had an LSF curve concavity to the same side as the CVA. Among iatrogenic CM patients, mean pelvic obliquity was 3.1°, 4 (31%) patients had pelvic obliquity > 3°, mean preoperative absolute SVA was 8.0 cm, and 7 (54%) patients had preoperative sagittal malalignment. Patients with iatrogenic CM were more likely to sustain a major complication during the 2-year postoperative period than patients without iatrogenic CM (12% vs 33%, p = 0.046), yet readmission, reoperation, and PROs were similar. CONCLUSIONS Postoperative iatrogenic CM occurred in 9% of ASD patients with preoperative normal coronal alignment (CVA < 3 cm). ASD patients who were most at risk for iatrogenic CM included those with preoperative sagittal malalignment, increased pelvic obliquity, LSF curve concavity to the same side as the CVA, and maximum Cobb angle concavity opposite the CVA, as well as those who underwent a three-column osteotomy. Despite sustaining more major complications, iatrogenic CM patients did not have increased risk of readmission, reoperation, or worse PROs.

scholarly journals Be Prepared: Preoperative Coronal Malalignment Often Leads to More Extensive Surgery Than Sagittal Malalignment During Adult Spinal Deformity Surgery

Neurospine ◽  
2021 ◽  
Vol 18 (3) ◽  
pp. 570-579
Author(s):  
Scott L. Zuckerman ◽  
Christopher S. Lai ◽  
Yong Shen ◽  
Mena G. Kerolus ◽  
Alex S. Ha ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Vertical Axis ◽  
Sagittal Vertical Axis ◽  
Estimated Blood Loss ◽  
Spinal Deformity Surgery ◽  
Sagittal Malalignment ◽  
Coronal Malalignment ◽  
Neutral Alignment ◽  
Extensive Surgery

Objective: To evaluate the effect of coronal alignment on: (1) surgical invasiveness and operative complexity and (2) postoperative complications.Methods: A retrospective, cohort study of adult spinal deformity patients was conducted. Alignment groups were: (1) neutral alignment (NA): coronal vertical axis (CVA) ≤ 3 cm and sagittal vertical axis (SVA) ≤ 5 cm; (2) coronal malalignment (CM) only: CVA > 3 cm; (3) Sagittal malalignment (SM) only: SVA > 5 cm; and (4) coronal and sagittal malalignment (CCSM): CVA > 3 cm and SVA > 5 cm.Results: Of 243 patients, alignment groups were: NA 115 (47.3%), CM 48 (19.8%), SM 38 (15.6%), and CCSM 42 (17.3%). Total instrumented levels (TILs) were highest in CM (14.5 ± 3.7) and CCSM groups (14 ± 4.0) (p < 0.001). More 3-column osteotomies (3COs) were performed in SM (21.1%) and CCSM (28.9%) groups than CM (10.4%) (p = 0.003). CM patients had more levels instrumented (p = 0.029), posterior column osteotomies (PCOs) (p < 0.001), and TLIFs (p = 0.002) than SM patients. CCSM patients had more TLIFs (p = 0.012) and higher estimated blood loss (EBL) (p = 0.003) than SM patients. CVA displayed a stronger relationship with TIL (p = 0.002), EBL (p < 0.001), and operative time (p < 0.001) than SVA, which had only one significant association with EBL (p = 0.010). Both SM/CCSM patients had higher readmissions (p = 0.003) and reoperations (p < 0.001) than CM patients.Conclusion: Amount of preoperative CM was a better predictor of surgical invasiveness than the amount of SM, despite 3COs more commonly performed in SM patients. CM patients had more instrumented levels, PCOs, and TLIFs than SM patients.

scholarly journals Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative?

2021 ◽  
pp. 219256822110193
Author(s):  
Scott L. Zuckerman ◽  
Christopher S. Lai ◽  
Yong Shen ◽  
Meghan Cerpa ◽  
Nathan J. Lee ◽  
...  
Keyword(s):  
Clinical Improvement ◽  
Adult Spinal Deformity ◽  
Minimum Clinically Important Difference ◽  
Time Interval ◽  
Symptom Scale ◽  
Patient Reported ◽  
Chi Squared ◽  
Sagittal Malalignment ◽  
Coronal Malalignment ◽  
Patients Experience

Objective: Evaluate clinical improvement as measured by patient-reported outcomes (PROs) during the 1 to 2-year interval. Study Design: Retrospective Cohort. Methods: A single-institution registry of ASD patients undergoing surgery was queried for patients with ≥6 level fusions. Demographics and radiographic variables were collected. PROs collected were the ODI and SRS-22r scores at: preoperative, 1-year and 2-years. Outcome measures of clinical improvement during the 1-2 year time interval were: 1) group medians, 2) percent minimum clinically important difference (MCID), and 3) percent minimal symptom scale (MSS)(ODI < 20 or SRS-pain + function >8). Wilcoxon rank-sum tests, chi-squared tests, Kruskal-Wallis tests, and logistic regression were performed. Results: 157 patients undergoing ASD surgery with minimum of 1-year follow-up were included. Mean age was 53.2 and mean instrumented levels was 13.1. Preoperative alignment was: Neutral Alignment (NA) 49%, Coronal Malalignment (CM) 17%, Sagittal Malalignment (SM 17%), and Combined Coronal/Sagittal Malalignment (CCSM) 18%. Preoperative to 1-year, and preoperative to 2-years, all ODI/SRS-22r significantly improved ( P < .001). In all patients, the only significant improvement in PROs between 1-and 2-year postoperative were those reaching ODI MCID (69% 1-year vs. 84% 2-years; P < .001). Subgroup analysis: ≥55 years had an improved median ODI (18 vs. 8; P = .047) and an improved percent achieving ODI MCID (73% vs. 84%, P = .048). CCSM patients experienced significant improvement in SRS-appearance score (75% vs. 100%; P = .050), along with those with severe preoperative SM >7.5 cm (73% vs. 100%; P = .032). Conclusions: Most ASD patients experience the majority of PRO improvement by 1-year postoperative. However, subsets of patients that may continue to improve up to 2-years postoperative include patients ≥55 years, combined coronal/sagittal malalignment, and those with severe sagittal malalignment ≥7.5 cm.

Postoperative Coronal Malalignment is Associated with Significantly Poor Patient Reported Outcomes in Operatively Treated Adult Spinal Deformity

2015 ◽  
Vol 15 (10) ◽  
pp. S148-S149 ◽  
Author(s):  
International Spine Study Group ◽  
Amit Jain ◽  
Christopher P. Ames ◽  
Brian J. Neuman ◽  
Daniel M. Sciubba ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Patient Reported Outcomes ◽  
Adult Spinal Deformity ◽  
Poor Patient ◽  
Patient Reported ◽  
Coronal Malalignment

scholarly journals Postoperative Cervical Deformity in 215 Thoracolumbar Adult Spinal Deformity Patients: Prevalence, Risk Factors, and Impact on Patient-Reported Outcome and Satisfaction at 2-Year Follow-Up

2015 ◽  
Vol 5 (1_suppl) ◽  
pp. s-0035-1554517-s-0035-1554517
Author(s):  
Peter Passias ◽  
Justin Smith ◽  
Alex Soroceanu ◽  
Anthony Boniello ◽  
Justin Scheer ◽  
...  
Keyword(s):  
Risk Factors ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Patient Reported Outcome ◽  
Cervical Deformity ◽  
Patient Reported

Prospective multicenter assessment of risk factors for rod fracture following surgery for adult spinal deformity

2014 ◽  
Vol 21 (6) ◽  
pp. 994-1003 ◽  
Author(s):  
Justin S. Smith ◽  
Ellen Shaffrey ◽  
Eric Klineberg ◽  
Christopher I. Shaffrey ◽  
Virginie Lafage ◽  
...  
Keyword(s):  
Risk Factors ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Full Length ◽  
Consecutive Series ◽  
Inclusion Criteria ◽  
The Mean ◽  
Spine Radiographs ◽  
Rod Fracture

Object Improved understanding of rod fracture (RF) following adult spinal deformity (ASD) surgery could prove valuable for surgical planning, patient counseling, and implant design. The objective of this study was to prospectively assess the rates of and risk factors for RF following surgery for ASD. Methods This was a prospective, multicenter, consecutive series. Inclusion criteria were ASD, age > 18 years, ≥5 levels posterior instrumented fusion, baseline full-length standing spine radiographs, and either development of RF or full-length standing spine radiographs obtained at least 1 year after surgery that demonstrated lack of RF. ASD was defined as presence of at least one of the following: coronal Cobb angle ≥20°, sagittal vertical axis (SVA) ≥5 cm, pelvic tilt (PT) ≥25°, and thoracic kyphosis ≥60°. Results Of 287 patients who otherwise met inclusion criteria, 200 (70%) either demonstrated RF or had radiographic imaging obtained at a minimum of 1 year after surgery showing lack of RF. The patients' mean age was 54.8 ± 15.8 years; 81% were women; 10% were smokers; the mean body mass index (BMI) was 27.1 ± 6.5; the mean number of levels fused was 12.0 ± 3.8; and 50 patients (25%) had a pedicle subtraction osteotomy (PSO). The rod material was cobalt chromium (CC) in 53%, stainless steel (SS), in 26%, or titanium alloy (TA) in 21% of cases; the rod diameters were 5.5 mm (in 68% of cases), 6.0 mm (in 13%), or 6.35 mm (in 19%). RF occurred in 18 cases (9.0%) at a mean of 14.7 months (range 3–27 months); patients without RF had a mean follow-up of 19 months (range 12–24 months). Patients with RF were older (62.3 vs 54.1 years, p = 0.036), had greater BMI (30.6 vs 26.7, p = 0.019), had greater baseline sagittal malalignment (SVA 11.8 vs 5.0 cm, p = 0.001; PT 29.1° vs 21.9°, p = 0.016; and pelvic incidence [PI]–lumbar lordosis [LL] mismatch 29.6° vs 12.0°, p = 0.002), and had greater sagittal alignment correction following surgery (SVA reduction by 9.6 vs 2.8 cm, p < 0.001; and PI-LL mismatch reduction by 26.3° vs 10.9°, p = 0.003). RF occurred in 22.0% of patients with PSO (10 of the 11 fractures occurred adjacent to the PSO level), with rates ranging from 10.0% to 31.6% across centers. CC rods were used in 68% of PSO cases, including all with RF. Smoking, levels fused, and rod diameter did not differ significantly between patients with and without RF (p > 0.05). In cases including a PSO, the rate of RF was significantly higher with CC rods than with TA or SS rods (33% vs 0%, p = 0.010). On multivariate analysis, only PSO was associated with RF (p = 0.001, OR 5.76, 95% CI 2.01–15.8). Conclusions Rod fracture occurred in 9.0% of ASD patients and in 22.0% of PSO patients with a minimum of 1-year follow-up. With further follow-up these rates would likely be even higher. There was a substantial range in the rate of RF with PSO across centers, suggesting potential variations in technique that warrant future investigation. Due to higher rates of RF with PSO, alternative instrumentation strategies should be considered for these cases.

scholarly journals Association between bicortical screw fixation at upper instrumented vertebra and risk for upper instrumented vertebra fracture

2017 ◽  
Vol 26 (5) ◽  
pp. 638-644 ◽  
Author(s):  
Young-Seop Park ◽  
Seung-Jae Hyun ◽  
Ho Yong Choi ◽  
Ki-Jeong Kim ◽  
Tae-Ahn Jahng
Keyword(s):  
Spinal Deformity ◽  
Pelvic Incidence ◽  
Screw Fixation ◽  
Adult Spinal Deformity ◽  
Vertical Axis ◽  
Sagittal Vertical Axis ◽  
The Mean ◽  
Upper Instrumented Vertebra ◽  
Bicortical Screw

OBJECTIVEThe aim of this study was to investigate the risk of upper instrumented vertebra (UIV) fractures associated with UIV screw fixation (unicortical vs bicortical) and polymethylmethacrylate (PMMA) augmentation after adult spinal deformity surgery.METHODSA single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥ 4 levels (that is, the lower instrumented vertebra at the sacrum or pelvis and the UIV of the thoracolumbar spine [T9–L2]) were retrospectively reviewed. Age, sex, follow-up duration, sagittal UIV angle immediately postoperatively including several balance-related parameters (lumbar lordosis [LL], pelvic incidence, and sagittal vertical axis), bone mineral density, UIV screw fixation type, UIV PMMA augmentation, and UIV fracture were evaluated. Patients were divided into 3 groups: Group U, 15 patients with unicortical screw fixation at the UIV; Group P, 16 with bicortical screw fixation and PMMA augmentation at the UIV; and Group B, 21 with bicortical screw fixation without PMMA augmentation at the UIV.RESULTSThe mean number of levels fused was 6.5 ± 2.5, 7.5 ± 2.5, and 6.5 ± 2.5; the median age was 50 ± 29, 72 ± 6, and 59 ± 24 years; and the mean follow-up was 31.5 ± 23.5, 13 ± 6, and 24 ± 17.5 months in Groups U, P, and B, respectively (p > 0.05). There were no significant differences in balance-related parameters (LL, sagittal vertical axis, pelvic incidence–LL, and so on) among the groups. UIV fracture rates in Groups U (0%), P (31.3%), and B (42.9%) increased in sequence by group (p = 0.006). UIV bicortical screw fixation increased the risk for UIV fracture (OR 5.39; p = 0.02).CONCLUSIONSBicortical screw fixation at the UIV is a major risk factor for early UIV compression fracture, regardless of whether a thoracolumbosacral orthosis is used. To reduce the proximal junctional failure, unicortical screw fixation at the UIV is essential in adult spinal deformity correction surgery.

scholarly journals Clinically Significant Thromboembolic Disease in Adult Spinal Deformity Surgery: Incidence and Risk Factors in 737 Patients

2017 ◽  
Vol 8 (3) ◽  
pp. 224-230 ◽  
Author(s):  
Han Jo Kim ◽  
Sravisht Iyer ◽  
Basel G. Diebo ◽  
Michael P. Kelly ◽  
Daniel Sciubba ◽  
...  
Keyword(s):  
Risk Factors ◽  
Mortality Rate ◽  
Spinal Deformity ◽  
Adult Spinal Deformity ◽  
Area Under The Curve ◽  
Vertical Axis ◽  
Sagittal Vertical Axis ◽  
Venous Thromboembolic Events ◽  
Venous Thromboembolic ◽  
Spinal Deformity Surgery

Study Design: Retrospective cohort study. Objectives: Describe the rate and risk factors for venous thromboembolic events (VTEs; defined as deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) in adult spinal deformity (ASD) surgery. Methods: ASD patients with VTE were identified in a prospective, multicenter database. Complications, revision, and mortality rate were examined. Patient demographics, operative details, and radiographic and clinical outcomes were compared with a non-VTE group. Multivariate binary regression model was used to identify predictors of VTE. Results: A total of 737 patients were identified, 32 (4.3%) had VTE (DVT = 14; PE = 18). At baseline, VTE patients were less likely to be employed in jobs requiring physical labor (59.4% vs 79.7%, P < .01) and more likely to have osteoporosis (29% vs 15.1%, P = .037) and liver disease (6.5% vs 1.4%, P = .027). Patients with VTE had a larger preoperative sagittal vertical axis (SVA; 93 mm vs 55 mm, P < .01) and underwent larger SVA corrections. VTE was associated with a combined anterior/posterior approach (45% vs 25%, P = .028). VTE patients had a longer hospital stay (10 vs 7 days, P < .05) and higher mortality rate (6.3% vs 0.7%, P < .01). Multivariate analysis demonstrated osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE ( r2 = .11, area under the curve = 0.74, P < .05). Conclusions: The incidence of VTE in ASD is 4.3% with a DVT rate of 1.9% and PE rate of 2.4%. Osteoporosis, lack of physical labor, and increased SVA correction were independent predictors of VTE. Patients with VTE had a higher mortality rate compared with non-VTE patients.

scholarly journals Development of a Preoperative Adult Spinal Deformity Comorbidity Score That Correlates With Common Quality and Value Metrics: Length of Stay, Major Complications, and Patient-Reported Outcomes

2019 ◽  
pp. 219256821989495
Author(s):  
Daniel Sciubba ◽  
Amit Jain ◽  
Khaled M. Kebaish ◽  
Brian J. Neuman ◽  
Alan H. Daniels ◽  
...  
Keyword(s):  
Spinal Deformity ◽  
Patient Reported Outcomes ◽  
Adult Spinal Deformity ◽  
Index Score ◽  
Charlson Comorbidity Index Score ◽  
Health State ◽  
Comorbidity Score ◽  
Scoliosis Research Society ◽  
Major Complications ◽  
Patient Reported

Study Design: Retrospective review of a multicenter prospective registry. Objectives: Our goal was to develop a method to risk-stratify adult spinal deformity (ASD) patients on the basis of their accumulated health deficits. We developed a novel comorbidity score (CS) specific to patients with ASD based on their preoperative health state and investigated whether it was associated with major complications, length of hospital stay (LOS), and self-reported outcomes after ASD surgery. Methods: We identified 273 operatively treated ASD patients with 2-year follow-up. We assessed associations between major complications and age, comorbidities, Charlson Comorbidity Index score, and Oswestry Disability Index score. Significant factors were used to construct the ASD-CS. Associations of ASD-CS with major complications, LOS, and patient-reported outcomes were analyzed. Results: Major complications increased significantly with ASD-CS ( P < .01). Compared with patients with ASD-CS of 0, the odds of major complications were 2.8-fold higher ( P = .068) in patients with ASD-CS of 1 through 3; 4.5-fold higher ( P < .01) in patients with ASD-CS of 4 through 6; and 7.5-fold higher ( P < .01) in patients with ASD-CS of 7 or 8. Patients with ASD-CS of 7 or 8 had the longest mean LOS (10.7 days) and worst mean Scoliosis Research Society–22r total score at baseline; however, they experienced the greatest mean improvement (0.98 points) over 2 years. Conclusions: The ASD-CS is significantly associated with major complications, LOS, and patient-reported outcomes in operatively treated ASD patients.

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